EAR NOSE THROAT

INDEX
S. No. Topics Pg. Nos.

1 Anatomy 123-135
2 Larynx Carcinoma 135-138
3 Facial Nerve Palsy 138-142
4 Otosclerosis 142-144
5 Acotic Nueroma 144-145
6 Cholesteatoma 145-146
7 Chronic Suppurative Otitis Media 146-156
8 Deafness 156-159
9 Nasopharyngeal Cancer 160-161
10 Meniere’s Disease 161-164
11 Nasopharyngeal Angiofibroma 164-165
12 Vocal Cord Paralysis 165-169
13 CSF Rhinorrhea 169-170
14 Epistaxis 171-172
15 Tonsillitis Tonsillectomy 172-174
16 Sinus Carcinoma 175
17 Tracheostomy 175-178
18 DNS 178-180
19 Epiglottitis 180-181
20 Glomus Tumor 181-182
21 Laryngitis Pachyderma 182
22 Laryngomalacia 183
23 Malignant Otitis Externa 183
121
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 EAR NOSE THROAT
INDEX
S. No. Topics Pg. Nos.

24 Myringotomy Mastoidectomy Adenoidectomy 183-185

25 Papilloma 185
26 Vocal Nodule 186
27 Antrochoanal and Ethmoidal Polypi 187-188
28 Tuberculosis of Larynx 189
29 Sinusitis 189-191
30 Laryngomalacia 192
31 Allergic Fungal Sinusitis 192
32 Allergic Rhinitis 193
33 Laryngocele 193
34 Atrophic Rhinitis 193-194
35 Bronchoscopy 194
36 Laboratory Tests of Vestibular Function 194-195
37 Dysphonia Plica Ventricularis 195-196
38 Functional Aphonia 196
39 Puberphonia 196
40 Rhinolalia Clausa and Rhinolalia Aperta 196
41 Nasal Syphilis 196-197
42 Rhinophyma 197
43 Rhinoscleroma 197
44 Rhinosporiodiosis 198
45 Mucormycosis 198
46 Water/Stenver and Radiologic Views of PNS 198

122
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 TOPIC 1 - ANATOMY
n The external ear
m Auricle or Pinna
n The entire pinna, except its lobule, and the outer
part of external acoustic canal are made up of
yellow elastic cartilage covered with skin.
n Incisura terminalis
l There is no cartilage between the tragus and
crus of the helix, and this area is called the
incisura terminalis
l An incision made in this area will not cut
through the cartilage and is used for
endaural approach in surgery of the external auditory
canal or the mastoid
n Cartilage from the tragus, perichondrium
from the tragus or concha, and fat from
the lobule are frequently used for reconstructive
surgery of the middle ear.
n The conchal cartilage has also been used to
correct the depressed nasal bridge
n composite grafts of the skin and cartilage
from the pinna are sometimes used for repair
of defects of nasal ala
m External Acoustic (Auditory) Canal
n It measures about 24 mm along its posterior
wall.
n It is not a straight tube
n its outer part is directed upwards, backwards
and medially while its inner part is directed
downwards, forwards and medially.
n Therefore, to see the tympanic membrane, the
pinna has to be pulled upwards, backwards
and laterally so as to bring the two parts in
alignment.
n The canal is divided into two parts: cartilaginous
and bony.
l Cartilaginous Part
„ It forms outer one-third (8 mm) of the
canal.
„ It has two deficiencies-the “fissures of
Santorini” in this part of the cartilage and
through them the parotid or superficial mastoid
infections can appear in the canal, or vice versa.
„ The skin, covering the cartilaginous
canal is thick and contains ceruminous and
pilosebaceous glands which secrete wax.
„ Hair is only confined to the outer canal
„ furuncles (staphylococcal infection of hair
follicles) are seen only in the outer one
third of the canal.
l Bony Part
„ It forms inner two-thirds (16 mm).
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„ Skin lining the bony canal is thin and
continuous over the tympanic membrane.
„ It is devoid of hair and ceruminous glands.
„ Isthmus
® About 6 mm lateral to tympanic
membrane, the bony meatus presents a
narrowing called the isthmus.
® Foreign bodies lodged medial to the
isthmus, get impacted, and are difficult
to remove.
„ Antero-inferior part of the deep meatus,
beyond the isthmus, presents a recess
called the anterior recess which acts as a
cesspool for discharge and debris in
cases of exter nal and middle ear
infections.
„ Foramen of Huschke
® Antero-inferior part of the bony canal may
present a deficiency (foramen of
ENT
Huschke) in children up to the age of
four or sometimes in adults, permitting
infections to and from the parotid.
n Posterosuperior part of deeper canal near the
tympanic membrane is related to the mastoid
antrum. “Sagging” of this area may be
noticed in acute mastoiditis
n Tympanic Membrane or the Drumhead
m It is obliquely set and as a result, its posterosuperior
part is more lateral than its antero-inferior part.
m It is 9-10 mm tall, 8-9 mm wide and 0.1 mm thick.
m Tympanic membrane can be divided into two
ANATOMY
parts:
n Pars Tensa
l It forms most of tympanic membrane.
l Its periphery is thickened to form a
fibrocartilaginous ring called the annulus
tympanicus which fits in the tympanic sulcus.
l Umbo
„ The central part of pars tensa is tented
inwards at the level of the tip of
malleus and is called the umbo.
„ A bright cone of light can be seen
radiating from the tip of malleus to the
periphery in the anteroinferior quadrant
l Pars Flaccida (Shrapnel’s Membrane)
„ This is situated above the lateral process of
malleus between the notch of Rivinus and
the anterior and posterior malleal folds
(earlier called the malleolar folds).
„ It is not so taut and may appear slightly
pinkish.
n Tympanic membrane consists of three layers:
123
 l Outer epithelial layer, which is continuous with
the skin lining the meatus.
l Inner mucosal layer, which is continuous with
the mucosa of the middle ear.
l Middle fibrous layer, which encloses the
handle of malleus
m Nerve Supply of the External Ear
n Pinna
l Greater auricular nerve (C2,3) supplies most of
the medial surface of pinna and only
posterior part of the lateral surface
l Lesser occipital (C2) supplies upper part of
medial surface.
l Auriculotemporal (V3) supplies tragus, crus
of helix and the adjacent part of the
helix.
l Auricular branch of vagus (CN X), also called
Arnold’s nerve, supplies the concha and
corresponding eminence on the medial
ENT
surface.(MCQ)
„ cough response caused while cleaning the
ear canal is mediated by stimulation of
Arnold’s nerve (MCQ)
l Facial nerve, which is distributed with fibres
of auricular branch of vagus, supplies the
concha and retroauricular groove.
n External Auditory Canal
l Anterior wall and roof: auriculotemporal (V3).
l Posterior wall and floor: auricular branch of vagus
(CN X).
ANATOMY
l Posterior wall of the auditory canal also receives
sensory fibres of CN VII through auricular
branch of vagus (Hitzelberger sign).
n Tympanic Membrane (MCQ)
l Anterior half of lateral surface:
auriculotemporal (V3).
l Posterior half of lateral surface: auricular branch
of vagus (CN X).
l Medial surface: Tympanic branch of CN IX
(Jacobson’s nerve).
THE MIDDLE EAR
n The middle ear extends much beyond the limits of
tympanic membrane which forms its lateral boundary
and is sometimes divided into
m mesotympanum (lying opposite the pars tensa),
n narrowest part of middle ear (MCQ)
m epitympanum or the attic (lying above the pars tensa
but medial to Shrapnell’s membrane and the bony lateral
attic wall),
m hypotympanum (lying below the level of pars tensa)
n Middle ear can be likened to a six-sided box with a
roof, a floor, medial, lateral, anterior and posterior walls
m The roof
124
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n is formed by a thin plate of bone called tegmen
tympani.
n It also extends posteriorly to form the roof
of the aditus and antrum.
n It separates tympanic cavity from the middle
cranial fossa.
m The floor
n is also a thin plate of bone which separates
tympanic cavity from the jugular bulb.
n Sometimes, it is congenitally deficient
m The anterior wall
n has a thin plate of bone which separates the
cavity from internal carotid artery.
n It also has two openings; the lower one for
the eustachian tube and the upper one for the canal
of tensor tympani muscle.
m The posterior wall
n lies close to the mastoid air cells.
n It presents a bony projection called the pyramid
through the summit of which appears the
tendon of the stapedius muscle to get
attachment to the neck of stapes.
n Aditus, an opening through which attic
communicates with the antrum, lies above the
pyramid.
n Facial nerve runs in the posterior wall just
behind the pyramid.
n Facial recess or the posterior sinus
l is a depression in the posterior wall lateral to the
pyramid.
l It is bounded medially by the vertical part
of VIIth nerve, laterally by the chorda
tympani and above, by the fossa incudis
l Surgically, facial recess is important, as direct
access can be made through this into the middle ear
without disturbing posterior canal wall (intact
canal wall technique).
m The medial wall
n is formed by the labyrinth.
n It presents a bulge called promontory which
is due to the basal coil of cochlea (MCQ)
n oval window into which is fixed the footplate of
stapes(MCQ)
n round window or the fenestra cochleae
which is covered by the secondary tympanic
membrane.
n Canal for facial nerve
l Above the oval window is the canal for
facial nerve.
l Its bony covering may sometimes be
congenitally dehiscent and the nerve may
lie exposed making it very vulnerable to injuries
or infection.
 l Above the canal for facial nerve is the
prominence of lateral semicircular canal.
n Processus cochleariformis
l Just anterior to the oval window, the medial wall
presents a hook-like projection called the
processus cochleariformis.
l The tendon of tensor tympani takes a turn
here to get attachment to the neck of malleus.
l The cochleariform process also marks the
level of the genu of the facial nerve which
is an important landmark for surgery of the
facial nerve.
n It is possible to see some structures of the middle
ear through the normal tympanic membrane, e.g.
the long process of incus, incudostapedial joint and the round
window.
n Mastoid Antrum
m It is a large, air-containing space in the upper
part of mastoid and communicates with the attic
through the aditus.
m Its roof is formed by the tegmen antri that
separates it from the middle cranial fossa.
m The lateral wall of antrum is formed by a plate
of bone which is on an average 1.5 cm thick in
the adult. It is marked externally on the surface of
mastoid by suprameatal (MacEwen’s) triangle
m Aditus ad Antrum
n Aditus is an opening through which the attic
communicates with the antrum.
n The bony prominence of the horizontal
canal lies on its medial side
n fossa incudis, to which is attached the short process
of incus, lies laterally. Facial nerve courses just
below the aditus.
m Korner’s septum.
n Mastoid develops from the squamous and petrous
bones.
n The petrosquamosal suture may persist as a
bony plate-the Korner’s septum, separating
superficial squamosal cells from the deep
petrosal cells.
n Korner’s septum is surgically important as it may
cause difficulty in locating the antrum and
the deeper cells; and thus may lead to incomplete
removal of disease at mastoidectomy
n Mastoid antrum cannot be reached unless the
Korner’s septum has been removed
m Ossicles of the Middle Ear
n There are three ossicles in the middle ear-the
malleus, incus and stapes.
n The lateral process of Malleus forms a knob-
like projection on the outer surface of the tympanic
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membrane and gives attachment to the anterior
and posterior malleal (malleolar) folds.
n The footplate of stapes is held in the oval window
by annular ligament.
n The ossicles conduct sound energy from the
tympanic membrane to the oval window
and then to the inner ear fluid
l Tensor tympani (MCQ)
® attaches to the neck of malleus
® tenses the tympanic membrane
® tensor tympani develops from the 1st
arch
® supplied by a branch of mandibular
nerve (V3).
l Stapedius (MCQ)
® attaches to the neck of stapes
® helps to dampen very loud sounds
® prevents noise trauma to the inner ear.
® Stapedius is a 2nd arch muscle
ENT
® supplied by a branch of CN VII
m Tympanic Plexus ( MCQ)
l It lies on the promontory
l formed by
® tympanic branch of glossopharyngeal
® sympathetic fibres from the plexus
round the internal carotid artery.
l Tympanic plexus supplies innervation to the
® medial surface of the tympanic
membrane
® tympanic cavity
® mastoid air cells
ANATOMY
® bony eustachian tube
l It also carries secretomotor fibres for the
parotid gland.
l Section of tympanic branch of glossopharyngeal
nerve can be carried out in the middle ear in
cases of Frey’s syndrome.
l Course of secretomotor fibres to the
parotid:(MCQ)
® Inferior salivary nucleus g CN IX
gTympanic branch g Tympanic plexus
g Lesser petrosal nerve gOtic ganglion
g Auriculotemporal nerve g Parotid
gland.
m Chorda Tympani Nerve :(MCQ)
l It is a branch of the facial nerve
l enters the middle ear through posterior
canaliculus
l runs on the medial surface of the tympanic
membrane between the handle of malleus and
long process of incus, above the
attachment of tendon of tensor tympani.
125
 l It carries taste from anterior two-thirds of
tongue
l It supplies secretomotor fibres to the
submaxillary and sublingual salivary glands.
m Lining of the Middle Ear (MCQ)
l eustachian tube
„ is lined by ciliated epithelium
„ which is pseudostratified columnar in the
cartilaginous part
„ columnar in the bony part with several
mucous glands in the submucosa.
l Tympanic cavity
„ is lined by ciliated columnar epithelium
in its anterior and inferior part
„ which changes to cuboidal type in the
posterior part.
l Epitympanum and mastoid air cells
n lined by flat, nonciliated epithelium.
m Blood Supply of Middle Ear
ENT
l Middle ear is supplied by six arteries, out
of which two are the main
„ Anterior tympanic branch of maxillary
artery which supplies tympanic membrane.
„ Stylomastoid branch of posterior
auricular artery which supplies middle ear
and mastoid air cells.
l Four minor vessels are:
„ Petrosal branch of middle meningeal
„ Superior tympanic branch of middle
meningeal artery
ANATOMY
„ Branch of artery of pterygoid canal
„ Tympanic branch of internal carotid.
m Veins drain into pterygoid venous plexus and
superior petrosal sinus.
m Lymphatic Drainage of Ear
l Lymphatics from the middle ear drain into
retropharyngeal and parotid nodes
l Lymphatics from the eustachian tube drain
into retropharyngeal group
Lymphatic Damage of Ear
Area Nodes
Concha, tragus, Preauricular and
fossa triangularis and parotid nodes
external cartilaginous canal
Lobule and antitragus Infra-auricular nodes
Helix and antihelix Post-auricular nodes,
deep jugular and spinal
accessory nodes
Middle ear and Retropharyngeal nodes
eustachian tube ¦ upper jugular chain
126 Inner ear No lymphatics
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n The internal ear or the labyrinth
m It consists of a bony and a membranous
labyrinth.
m The membranous labyrinth is filled with a clear
fluid called endolymph
m the space between membranous and bony labyrinths is filled
with perilymph
m Bony Labyrinth
l It consists of three parts: the vestibule, the
semicircular canals and the cochlea.
l Vestibule
„ is the central chamber of the labyrinth.
„ In its lateral wall lies the oval window.
„ The inside of its medial wall presents two
recesses,
® spherical recess, which lodges the saccule
® elliptical recess which lodges the utricle.
„ Below the elliptical recess is the opening of
aqueduct of vestibule through which passes
the endolymphatic duct.
„ In the posterosuperior part of vestibule are
the five openings of semicircular canals
l Semicircular canals
„ the lateral, posterior and superior
„ lie in planes at right angles to one another.
„ Each canal has an
® ampullated end which opens
independently into the vestibule
® nonampullated end.
» The non-ampullated ends of
posterior and superior canals unite
to form a common channel called the
crus commune.
® the three canals open into the vestibule
by five openings
l Cochlea
„ The bony cochlea is a coiled tube making
2.5 to 2.75 turns round a central pyramid
of bone called the modiolus (MCQ).
„ The base of modiolus is directed towards
internal acoustic meatus and transmits vessels
and nerves to the cochlea.
„ What is osseous spiral lamina
® Around the modiolus and winding
spirally like the thread of a screw, is a
thin plate of bone called osseous spiral
lamina.
® It divides the bony cochlea
incompletely
® It gives attachment to the basilar
membrane.
 „The bony bulge in the medial wall of æ It receives the five openings of
middle ear-the promontory, is due to the the three semicircular ducts.
basal coil of the cochlea. (MCQ) æ The sensory epithelium of the
l The bony cochlea contains three utricle is called the macula and is
compartments: concerned with linear
„ scala vestibuli, acceleration and deceleration.
„ scala tympani, (MCQ)
„ scala media or the membranous cochlea » The saccule
(MCQ) æ also lies in the bony vestibule
l The scala vestibuli and scala tympani are filled anterior to the utricle and opposite
with perilymph the stapes footplate.
l scala vestibuli and scala tympani communicate æ Its sensory epithelium is also
with each other at the apex of cochlea through called the macula
an opening called helicotrema. æ In Meniere’s disease, the distended
l Scala vestibuli is closed by the footplate of saccule lies against the stapes footplate
stapes which separates it from the air-filled and can be surgically
middle ear. (MCQ) decompressed by perforating
l The scala tympani is closed by secondary the footplate. (MCQ)
tympanic membrane (MCQ) „ Semicircular ducts

ENT
l The scala tympani is also connected with » They are three in number
the subarachnoid space through the » They open in the utricle.
aqueduct of cochlea (MCQ) » The ampullated end of each duct
m Membranous Labyrinth contains a thickened ridge of
l It consists of the cochlear duct, the utricle and neuroepithelium called crista
saccule, the three semicircular ducts, and the ampullaris.
endolymphatic duct and sac » Angular acceleration is sensed by—
l Cochlear duct Semicircular canals (MCQ)
® Also called membranous cochlea or „ Endolymphatic duct and sac
the scala media. » Endolymphatic duct is formed by the
® It is a blind coiled tube. union of two ducts, one each from
® It appears triangular on cross-section the saccule and the utricle.

ANATOMY
® its three walls are formed by: » It passes through the vestibular
ö the basilar membrane, aqueduct.
¼ which supports the organ of corti, » Its terminal part is dilated to form
ö the Reissner’s membrane endolymphatic sac which lies
¼ which separates it from the scala between the two layers of dura on
vestibuli, the posterior surface of the petrous
ö the striavascularis (MCQ) bone.
¼ which contains vascular epithelium » Endolymphatic sac is exposed for
¼ concerned with secretion of drainage or shunt operation in
endolymph. Meniere’s disease.(MCQ)
® Cochlear duct is connected to the n Perilymph and Endolymph.
saccule by ductus reuniens „ Perilymph
® The length of basilar membrane » resembles extracellular fluid (MCQ)
increases as we proceed from the » rich in Na+ ions.
basal coil to the apical coil. » It fills the space between the bony and
» It is for this reason that higher the membranous labyrinth.
frequencies of sound are heard at » It communicates with CSF through
the basal coil while lower ones are the aqueduct of cochlea which opens
heard at the apical coil.(MCQ) into the scala tympani near the round
„ Utricle and saccule window.
» The utricle » There are two views regarding the
formation of perilymph:
127
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 It is a filterate of blood serum
æ ischaemic damage can occur to these organs
and is formed by capillaries of the causing either cochlear or vestibular symptoms
spiral ligament
æ it is a direct continuation of Labyrinthine artery
CSF and reaches the labyrinth via (from anterior-inferior
aqueduct of cochlea. cerebellar artery)
„ Endolymph
Common cochlear Anterior vestibular artery
» fills the entire membranous labyrinth
(to utricle and lateral and
» resembles intracellular fluid
superior canals)
» rich in K+ ions.
Vestibulocochlear Main cochlear artery
» It is secreted by the secretory cells artery (to cochlea, 80%)
of the stria vascularis of the cochlea
and by the dark cells (present in the Cochlear branch Posterior vestibular artery
utricle and also near the ampullated
ends of semicircular ducts). n Anatomy of Nose
» There are two views regarding its flow m Upper one-third of the external nose is bony while
æ Longitudinal, lower two-thirds are cartilaginous.
ì endolymph from the cochlea m Inferior turbinate
reaches saccule, utricle and n a separate bone
ENT

endolymphatic duct and gets
absorbed through
endolymphatic sac which lies
in the subdural space
æ radial,
ì endolymph is secreted by
stria vascularis and also gets
absorbed by the stria vascularis.
n below it, into the inferior meatus, opens the
nasolacrimal duct guarded at its terminal end
by a mucosal valve called Hasner’s valve.(MCQ)
m Middle turbinate
n is an ethmoturbinal-a part of ethmoid bone.
n Its attachment is not straight but in an S-shaped
manner
m Middle meatus (MCQ)

Composition of inner ear fluids n Uncinate process

l a hook-like structure running in from
Endolymph Perilymph CSF
anterosuperior to posteroinferior direction.
ANATOMY

Na+ (mEq/L) 5 140 152 n Hiatus semilunaris

K+ (mEq/L) 144 10 4 l the gap between the bulla ethmoidalis and
Protein (mg/dL) 126 200-400 20-50 Uncinate process is called hiatus semilunaris
Glucose (mg/dL) 10-40 85 70 (inferior)
n Infundibulum
n Blood Supply of Labyrinth l The space limited medially by the uncinate
m The entire labyrinth receives its arterial supply
process and frontal process of maxilla and
through labyrinthine artery (MCQ) sometimes lacrimal bone, and laterally by the
l a branch of anterior-inferior cerebellar
lamina papyracea is called infundibulum.
artery l Natural ostium of the maxillary sinus is
l but sometimes from the basilar.
situated in the lower part of infundibulum
m Venous drainage is through three veins, namely i
l internal auditory vein,
l vein of cochlear aqueduct
l vein of vestibular aqueduct
m Veins ultimately drain into inferior petrosal sinus
and lateral venous sinus.
m Blood supply to the inner ear is independent
of blood supply to middle ear and bony otic
capsule, and there is no cross circulation between
the two.
m Blood supply to cochlea and vestibular
labyrinth is segmental, therefore, independent
128
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 m Nerve Supply
n They are:
l Anterior ethmoidal nerve.
„ supplies anterior and superior part of the nasal
cavity (lateral wall and septum)
® Branches of sphenopalatine ganglion.
ö Most of the posterior two-thirds of
nasal cavity (both septum and lateral
wall) is supplied
® Branches of infra-orbital nerve.
n Autonomic nerves
l Parasympathetic nerve fibres
„ supply the nasal glands and control nasal
secretion.
„ They come from greater superficial
petrosal nerve, travel in the nerve of
pterygoid canal (vidian nerve) and reach
the sphenopalatine ganglion where they relay
before reaching the nasal cavity.
„ They also supply the blood vessels of nose
and cause vasodilation.
l Sympathetic nerve fibres
„ come from upper two thoracic segments
of spinal cord, pass through superior
cervical ganglion, travel in deep petrosal
nerve and join the parasympathetic fibres
of greater petrosal nerve to form the nerve
of pterygoid canal (vidian nerve).
„ They reach the nasal cavity without relay in
the sphenopalatine ganglion. Their
stimulation causes vasoconstriction.
l Excessive rhinorrhea in cases of vasomotor
and allergic rhinitis can be controlled by
section of the vidian nerve(MCQ)
m Lymphatic Drainage
n Lymphatics from the external nose and
anterior part of nasal cavity drain into
submandibular lymph nodes
n Lymphatics from the rest of nasal cavity drain
into upper jugular nodes either directly or through
the retropharyngeal nodes.
n Lymphatics of the upper part of nasal
cavity communicate with subarachnoid space
along the olfactory nerves.
Anatomy of paranasal sinuses
n Clinically, paranasal sinuses have been divided into
two groups:
m Anterior group.
n This includes maxillary, frontal and anterior
ethmoidal.
l They all open in the middle meatus
l theirostia lie anterior to basal lamella of
middle turbinate.
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m Posterior groups.
n posterior ethmoidal sinuses
l opens into the superior meatus (MCQ)
n sphenoid sinus
l open in sphenoethmoidal recess.
n Maxillary Sinus (Antrum of Highmore)
m It is the largest of paranasal sinuses (MCQ)
m has a capacity of 15 ml in an adult.
m the roots of all the molars are in close relation to the
floor of maxillary sinus separated from it by a thin
lamina of bone or even no bone at all.
m Oroantral fistulae can result from extraction of
any of these teeth. (MCQ)
m Dental infection is also an important cause of
maxillary sinusitis.
m Ostium of the maxillary sinus
n situated high up in medial wall
n opens in the posterior part of ethmoidal
infundibulum into the middle meatus.
ENT
n It is unfavourably situated for natural
drainage.
m Roof of the maxillary sinus is formed by the floor
of the orbit
n Frontal Sinus
m Frontal sinus may be absent on one or both sides
m Opening of frontal sinus is situated in its floor
and leads into the middle meatus directly or through
a canal called frontonasal duct. (MCQ)
n Ethmoidal Sinuses (Ethmoid Air Cells)
m Their number varies from 3 to 18.
m Clinically, ethmoidal cells are divided into
ANATOMY
n anterior ethmoid group which opens into the
middle meatus
n posterior ethmoid group which opens into the
superior meatus and sphenoethmoidal recess.
m lamina papyracea (MCQ)
n The thin paper-like lamina of bone (lamina
papyracea)
n Separates ethmoid air cells from the orbit
n can be easily destroyed leading to spread of
ethmoidal infections into the orbit.
m Optic nerve forms close relationship with the
posterior ethmoidal cells and is at risk during ethmoid
surgery
n Sphenoid Sinus
m Ostium of the sphenoid sinus
n is situated in the upper part of its anterior wall
n drains into sphenoethmoidal recess.
m Relations of the sphenoid sinus are for trans-
sphenoidal hypophysectomy..
n In the anterior part
l roof is related to the olfactory tract, optic
chiasma and frontal lobe
129
 l lateral wall is related to the optic nerve,
internal carotid artery and maxillary
nerve
n In the posterior part
l roof is related to pituitary gland in the sella
turcica
l each lateral wall is related to cavernous sinus,
internal carotid artery and CN III, IV,
VI and all the divisions of V
n Development of Paranasal Sinuses (MCQ)
m At birth, only the maxillary and ethmoidal sinuses are
present and are large enough to be clinically
significant.
m Radiologically,
n maxillary sinuses can be identified at 4-5 months
n ethmoids at 1 year
n frontals at 6 years
n sphenoids at 4 years
ENT

DEVELOPMENT AND GROWTH OF PARANASAL SINUSES

Status at birth Growth First radiologic
evidence
Maxillary Present at birth Rapid growth from birth to 3 years and from 7-12 years. 4-5 months
Adult size - 15 years after birth
Ethmoid Present at birth Reach adult size by 12 years 1 year
Anterior group:
5 x 2x 2 mm.
Posterior group:
5 x 4 x 2 mm.
ANATOMY

Frontal Not present Invades frontal bone at the age of 4 years. Size increases until teens 6 years
Sphenoid Not present Reaches sella turcica by the age of 7 years, dorsum sellae by late teens 4 years
and basisphenoid by adult age.
Reaches full size between 15 years to adult age.

130
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n Lymphatic Drainage of Oral Cavity
m Lips Lower
n Medial portion of lower lip drains into
submental
n lateral portion to submandibular nodes
m Upper Lip:
n Drain into preauricular, infraparotid and
submandibular nodes.
m Buccal mucosa
n Submental and submandibular nodes.
m Floor of mouth
n Anterior portion of floor of mouth drains
into submandibular nodes.
l Lymphatics from this area also cross the
midline.
n Posterior portion drains into upper deep cervical
nodes.
m Tongue
n Tip of tongue drains into submental and
jugulo-omohyoid nodes
n lateral portion drains into ipsilateral,
submandibular and deep cervical nodes.
n Central portion and base drain into deep
cervical nodes of both sides.
Pharynx
n The epithelium is ciliated columnar in the nasopharynx
and stratified squamous elsewhere.
n Killian’s Dehiscence
m Inferior constrictor muscle has two parts;
n thyropharyngeus with oblique fibres and
n cricopharyngeus with transverse fibres.
m Between these two parts exists a potential gap
called Killian’s dehiscence.
m It is also called the “gateway of tears” as
perforation can occur at this site during
oesophagoscopy. (MCQ)
m This is also the site for herniation of pharyngeal
mucosa in cases of pharyngeal pouch
n Waldeyer’s Ring
m Scattered throughout the pharynx in its
subepithelial layer is the lymphoid tissue which
is aggregated at places to form masses,
collectively called Waldeyer’s ring.
m The masses are:
n Nasopharyngeal tonsil or the adenoids
n Palatine tonsils or simply the tonsils
n Lingual tonsil
n Tubal tonsils (in fossa of Rosenmuller)
n Lateral pharyngeal bands
n Nodules (in posterior pharyngeal wall).
n Pharyngeal Spaces
m There are two potential spaces in relation to the
pharynx where abscesses can form.
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n Retropharyngeal space
l situated behind the pharynx
l extend from the base of skull to the bifurcation
of trachea
n Parapharyngeal space
l situated on the side of pharynx
l It contains carotid vessels, jugular vein,
last four cranial nerves and cervical
sympathetic chain(MCQ)
n Nasopharynx (Epipharynx)
m Lateral wall.
n Each lateral wall presents the pharyngeal opening
of eustachian tube
n situated 1.25 cm behind the posterior end of inferior
turbinate.
n It is bounded above and behind by an elevation
called torus tubarius raised by the cartilage of
the tube.
n Above and behind the tubal elevation is a recess
ENT
called fossa of Rosenmuller it is the
commonest site for origin of carcinoma.
m Nasopharyngeal Tonsil (Adenoids)
n It increases in size up to the age of six years
and then gradually atrophies.(MCQ)
m Thornwaldt’s disease
n Nasopharyngeal Bursa
l It is an epithelial-lined median recess found within
the adenoid mass
l It represents the attachment of notochord
to the phar yngeal entoder m during
embryonic life.
ANATOMY
n An abscess can form in the bursa
(Thornwaldt’s disease).
m Rathke’s Pouch
n It is reminiscent of the buccal mucosal
invagination, to form the anterior lobe of
pituitary.
n A craniopharyngioma may arise from it.
m Tubal Tonsil
n When enlarged due to infection, it causes eustachian
tube occlusion.
m Sinus of Morgagni
n It is a space between the base of the skull
and upper free border of superior
constrictor muscle.
n Through it enters (i) the eustachian tube, (ii) the
levator veli palatini, (iii) tensor veli palatini and (iv)
ascending palatine artery-branch of the facial artery
m Passavant’s Ridge
n It is a mucosal ridge raised by fibres of
palatopharyngeus.
n It encircles the posterior and lateral walls of
nasopharyngeal isthmus.
131
 n Soft palate, during its contraction, makes firm
contact with this ridge to cut off nasopharynx
from the oropharynx during the deglutition
or speech.
n nasopharynx is lined by pseudostratified ciliated
columnar epithelium.
n Lymphatic Drainage of nasopharynx
m Lymphatics of the nasopharynx, including those
of the adenoids and pharyngeal end of eustachian
tube
m drain into upper deep cervical nodes
m either directly or indirectly through
retropharyngeal and parapharyngeal lymph
nodes.
m They also drain into spinal accessory chain of
nodes in the posterior triangle of the neck.
m Lymphatics of the nasopharynx may also cross
midline to drain into contralateral lymph nodes.
n Hypopharynx (Laryngopharynx)
ENT
m Hypopharynx is the lowest part of the pharynx
n lies behind and partly on the sides of the larynx.
n Its superior limit is the plane passing from
the body of hyoid bone to the posterior
pharyngeal wall
n inferior limit is lower border of cricoid cartilage
where hypopharynx becomes continuous with
oesophagus.
n Hypopharynx lies opposite the 3rd, 4th, 5th,
6th cervical vertebrae.
m Clinically, it is subdivided into three regions-the
ANATOMY
pyriform sinus, post-cricoid region and the posterior
pharyngeal wall.
m Pyriform sinus (fossa).
n Foreign bodies may lodge in the pyriform fossa.
n Internal laryngeal nerve
l runs submucosally in the lateral wall of the
sinus
l is easily accessible for local anaesthesia.
l through this nerve that pain is referred to the
ear in carcinoma of the pyriform sinus.
n Pyriform sinus is richly supplied by
lymphatics which exit through the thyrohyoid
membrane and drain into the upper jugular
chain.
n Rich lymphatic network of pyriform fossae
explains the high frequency with which nodal
metastases are seen in carcinoma of this
region.
m Post-cricoid region.
n It is a common site for carcinoma in females
suffering from Plummer-Vinson syndrome
n Adenoids
132
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m The nasopharyngeal tonsil, commonly called
“adenoids”
m is situated at the junction of the roof and posterior
wall of the nasopharynx.
m It is composed of vertical ridges of lymphoid
tissue separated by deep clefts
m It is covered by ciliated columnar epithelium
(MCQ)
m Unlike palatine tonsils, adenoids have no crypts
and no capsule.
m Adenoid growth
n Adenoid tissue is present at birth
n shows physiological enlargement up to the age of
six years
n it tends to atrophy at puberty and almost
completely disappears by the age of 20.
m Adenoids receive their blood supply from:
(MCQ)
m Ascending palatine branch of facial.
m Ascending pharyngeal branch of external
carotid.
m Pharyngeal branch of the third part of maxillary
artery.
m Ascending cervical branch of inferior thyroid
artery of thyrocervical trunk.
m Lymphatics from the adenoid drain into upper
jugular nodes directly or indirectly via
retropharyngeal and parapharyngeal nodes.
n Larynx
m The larynx lies in front of the hypopharynx
opposite the third to sixth cervical vertebrae.
m It moves vertically and in anteroposterior direction during
swallowing and phonation. It can also be passively
moved from side to side producing a
characteristic grating sensation called laryngeal
crepitus.
m In an adult, the larynx ends at the lower border
of C6 vertebra
m Laryngeal Cartilages
n Larynx has 3 unpaired and 3 paired cartilages.
l Unpaired: Thyroid, cricoid, epiglottis.
l Paired: Arytenoid, corniculate(of Santorini),
cuneiform(of Wrisberg).(MCQ)
m Thyroid cartilage
n It is the largest of all laryngeal cartilages
n Its two alae meet anteriorly forming an angle
of 90° in males and 120° in females. (MCQ)
n Vocal cords are attached to the middle of thyroid
angle.
n Cricothyrotomy.
l Most of laryngeal foreign bodies are arrested
above the vocal cords, i.e. above the middle
of thyroid cartilage
 l an effective airway can be provided by
piercing the cricothyroid membrane-a
procedure called cricothyrotomy.
q Cricoid
m It is the only cartilage forming a complete ring
q Epiglottis
m It is a leaf-like, yellow, elastic cartilage (MCQ)
m Forms anterior wall of laryngeal inlet.
m Pre-epiglottic space
n Anterior surface of epiglottis is separated from
thyrohyoid membrane and upper part of
thyroid cartilage by a potential space filled
with fat-the pre-epiglottic space.
n The space may be invaded in carcinoma of
supraglottic larynx or the base of tongue.
q Arytenoid cartilages
m They are paired.
m Each arytenoid cartilage is pyramidal in shape.
m It has
n a muscular process, directed laterally to give
attachment to intrinsic laryngeal muscles
n a vocal process directed anteriorly, giving
attachment to vocal cord
n and an apex which supports the corniculate
cartilage.
q Type of cartilage
m Thyroid, cricoid and most of the arytenoid
cartilages are hyaline cartilages
m epiglottis, corniculate, cuneiform and tip of
arytenoid near the corniculate cartilage are
fibroelastic in nature.
m Hyaline cartilages can undergo ossification
n it begins at the age of 25 years in thyroid, a
little later in cricoid and arytenoids
n is complete by 65 years of age.
q Laryngeal Joints
m Cricoarytenoid joint, Cricothyroid joint
m They are synovial joint surrounded by capsular

ENT
n a base which articulates with cricoid cartilage ligament.(MCQ)

Muscles of Larynx
1. Intrinsic muscles they may act on vocal cords or laryngeal inlet.
(a) Acting on vocal cords (Figs 55.4 and 55.5)
Abductors : Posterior cricoarytenoid
Adductors : Lateral cricoarytenoid
Interarytenoid (transverse arytenoid)
Thyroarytenoid (external part)
Tensors : Cricothyroid

(b) Acting on laryngeal Inlet (Fig.55.5)
Openers of laryngeal inlet :
Closers of laryngeal inlet :
ANATOMY
Vocalis (internal part of thyroarytenoid)
Thyroepiglottic (part of thyroarytenoid)
Interarytenoid (oblique part) Aryepiglottic
(posterior oblique part of interarytenoids)

133
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 n Cavity of the Larynx
m Glottis (MCQ)
n Anteroposteriorly, glottis is about 24 mm in
men and 16 mm in women.
n It is the narrowest part of laryngeal cavity.
n Anterior two-thirds of glottis are formed by
membranous cords while posterior one-third by
vocal processes of arytenoids.
m Mucous Membrane of the Larynx
n It lines the larynx and is loosely attached
except over the posterior surface of epiglottis, true
vocal cords and corniculate and cuneiform cartilages.
n Epithelium of the mucous membrane is
ciliated columnar type except over the vocal cords
and upper part of the vestibule where it is stratified
squamous type. (MCQ)
n Mucous glands are distributed all over the
mucous lining and are particularly numerous on
the posterior surface of epiglottis, posterior part of the
ENT
n Superior laryngeal nerve
m a branch of vagus
m is 4th arch nerve
m supplies cricothyroid and constrictors of
pharynx.
n Recurrent laryngeal nerve
m 6th arch nerve
m supplies all the intrinsic muscles of larynx.(MCQ)
n Paediatric larynx (MCQ)
m Infant’s larynx is positioned high in the neck
n opposite C3 or C4 (level of vocal cords) at rest
and reaches C1 or C2 during swallowing.
n This high position allows the epiglottis to meet
soft palate and make a nasopharyngeal channel
for nasal breathing during suckling.
n The milk feed passes separately over the dorsum
of tongue and the side of epiglottis, thus
allowing breathing and feeding to go on
simultaneously.

aryepiglottic folds and in the saccules.
n There are no mucous glands in the vocal folds
(MCQ)
n Lymphatic Drainage of larynx
m Supraglottic larynx
n drained by lymphatics that go to upper deep
cervical nodes.
m Infraglottic larynx
n drained by lymphatics that go to prelaryngeal
and pretracheal nodes and thence to lower
deep cervical and mediastinal nodes.
ANATOMY
m Laryngeal cartilages are soft and collapse easily.
n Epiglottis is omega-shaped and arytenoids
relatively large covering significant portion of
the posterior glottis.(MCQ)
m Thyroid cartilage in an infant is flat.
n It also overlaps the cricoid cartilage and is in
turn overlapped by the hyoid bone.
n Thus cricothyroid and thyrohyoid spaces are
narrow and not easily discernible as landmarks when
performing tracheostomy.
m Infant’s larynx is small and conical.

m There are practically no lymphatics in vocal
cords, hence carcinoma of this site rarely shows
lymphatic metastases. (MCQ)
n Reinke’s space
m Under the epithelium of vocal cords is a potential space
with scanty subepithelial connective tissues.
m Oedema of this space causes fusiform swelling
of the membranous cords (Reinke’s oedema).
Embryological development
n The diameter of cricoid cartilage is smaller than the
size of glottis, making subglottis the
narrowest part.(MCQ)
n It has a bearing in the selection of paediatric
endotracheal tube.
n In adults, subglottic-glottic dimensions are
approximately same and larynx is cylindrical.
m Submucosal tissues of infant’s larynx are
comparatively loose
n easily undergo oedematous change with trauma or

Epiglottis Hypobranchial inflammation leading to obstruction.

eminence m Infant’s larynx shows two spurts in growth.

Upper part of thyroid cartilage 4th arch n In the first three years of life larynx grows in

Lower part of thyroid cartilage width and length, and thus obviates the need for
Cricoid cartilage any airway surgery in certain congenital anomalies.
Corniculate cartilage 6th arch n The second spurt in growth occurs during

Cuneiform cartilage adolescence when the thyroid angle develops.

Intrinsic muscles of larynx m The length of vocal cords then increases

Upper part of body of hyoid bone leading to voice changes associated with puberty
Lesser cornua of hyoid bone 2nd arch n With growth of the neck, larynx gradually

Stylohyoid ligament descends to adult; the vocal cords lying

Lower part of body of hyoid bone 3rd arch opposite C5.
134
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 n In childhood, vocal cord is 6 mm in females
and 8 mm in males.
n It increases to 15-19 mm in adult female and
17-23 in adult male.(MCQ)
TOPIC 2 - LARYNX CARCINOMA
Cancer Larynx
n It is 10 times more common in males than in females
(MCQ)
n mostly seen in the age group of 40-70 years (MCQ)
n Risk factors in laryngeal cancer.
m Both tobacco and alcohol
n Cigarette smoke contains benzopyrene –
carcinogenic
n Combination of alcohol and smoking
increases the risk 15-folds compared to each factor
alone (2-3 folds).
m Previous radiation to neck for benign lesions or
laryngeal papilloma may induce laryngeal carcinoma.
(MCQ)
m Occupational exposure to asbestos, mustard gas
and petroleum products related to the genesis
of laryngeal cancer
n Anatomy
m Supraglottis
n Suprahyoid epiglottis (both lingual and laryngeal
surfaces)
n Infrahyoid epiglottis
n Aryepiglottic folds (laryngeal aspect only)
n Arytenoids
n Ventricular bands (or false cords)
m Glottis
n True vocal cords including anterior and posterior
commissure
m Subglottis
n Subglottis up to lower border of cricoid
cartilage
n TNM Classification and Staging
m Tumor Size
n Supraglottis
l T1- Tumour limited to one subsite of
supraglottis with normal vocal cord mobility
l T2 -Tumour invades mucosa of more than
one adjacent subsite of supraglottis or
glottis or region outside the supraglottis
(e.g., mucosa of base of tongue, vallecula,
medial wall of pyriform sinus) without
fixation of the larynx
l T3 - Tumour limited to larynx with vocal
cord fixation and/or invades any of the
following: postcricoid area, pre-epiglottic
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tissues, paraglottic space and/or minor
thyroid cartilage invasion
l T4a -Tumour invades through the thyroid
cartilage and/or invades tissues beyond
the larynx (e.g., trachea, soft tissues of neck
including deep extrinsic muscle of tongue,
strap muscles, thyroid or oesophagus)
l T4b -Tumour invades prevertebral space,
encases carotid arter y or invades
mediastinal structures
n Glottis
l T1- Tumour limited to vocal cord(s) (may
involve anterior or posterior commissures)
with normal mobility
l T1a -Tumour limited to one vocal cord
l T1b -Tumour involves both vocal cords
l T2- Tumour extends to supraglottis and/
or subglottis, and/or with impaired vocal
cord mobility
ENT
l T3 Tumour limited to the larynx with vocal
cord fixation and/or invades paraglottic
space and/or minor thyroid cartilage erosion
l T4a- Tumour invades through thyroid
cartilage and/or invades tissues beyond the
larynx (e.g., trachea, soft tissues of neck
including deep extrinsic muscles of the tongue,
strap muscles, thyroid, or oesophagus)
l T4b- Tumour invades prevertebral space,
LARYNX CARCINOMA
encases carotid artery or invades mediastinal
structures
n Subglottis
l T1- Tumour limited to the subglottis
l T2 -Tumour extends to vocal cord(s) with
normal or impaired mobility
l T3 -Tumour limited to larynx with vocal cord
fixation
l T4a- Tumour invades cricoid or thyroid
cartilage and/or invades tissues beyond the
larynx (e.g., trachea, soft tissues of neck
including deep extrinsic muscle of
tongue, strap muscles, thyroid or
oesophagus)
l T4b -Tumour invades prevertebral space,
encases carotid artery or invades mediastinal
structures
m Regional lymph nodes (N)
n NX- Regional lymph nodes cannot be assessed
n N0 -No regional lymph node metastasis
n N1 -Metastasis in a single ipsilateral lymph
node, 3 cm or less in greatest dimension
n N2 -Metastasis in a single ipsilateral lymph
node, more than 3 cm but not more than 6 cm in
greatest dimension, or multiple ipsilateral
135
 lymph nodes, none more than 6 cm in greatest
dimension, or bilateral or contralateral lymph
nodes, none more than 6 cm in greatest dimension.
n N2a -Metastasis in a single ipsilateral lymph
node more than 3 cm but not more than 6 cm in
greatest dimension
n N2b- Metastasis in multiple ipsilateral lymph
nodes, none more than 6 cm in greatest dimension
n N2c- Metastasis in bilateral or contralateral
lymph nodes, none more than 6 cm in greatest
dimension
n N3 -Metastasis in a lymph node more than 6
cm in greatest dimension
m Distant metastasis (M)
n MX -Distant metastasis cannot be assessed
n M0 -No distant metastasis
n M1- Distant metastasis
n Histopathology
m About 90-95% of laryngeal malignancies are
ENT
squamous cell carcinoma.(MCQ)
m Cordal lesions are often well-differentiated while
supraglottic ones are anaplastic.
n Supraglottic Cancer
m Majority of lesions are seen on epiglottis, false
cords followed by aryepiglottic folds, in that order.
m spread locally and invade the adjoining areas, i.e.
vallecula, base of tongue and pyriform fossa.
LARYNX CARCINOMA
m Cancer of infrahyoid epiglottis and anterior
ventricular band may extend into pre-epiglottic space
and penetrate the thyroid cartilage.
m Nodal metastases occur early.(MCQ)
m Upper and middle jugular nodes are often
involved.
m Bilateral metastases may be seen in cases of
epiglottic cancer.
m Supraglottic growths are often silent.
m Hoarseness is a late symptom.
m Throat pain, dysphagia and referred pain in
the ear or mass of lymph nodes in the neck
may be the presenting features. (MCQ)
m Weight loss, respiratory obstruction, halitosis
are late features.
n Glottic Cancer
m In vast majority of cases, laryngeal cancer
originates in the glottic region. (MCQ)
m Free edge and upper surface of vocal cord in its anterior
and middle third is the most frequent site (MCQ)
m Fixation of vocal cord
n indicates spread of disease to thyroarytenoid
muscle
n is a bad prognostic sign.
136
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mThere are few lymphatics in vocal cords and
nodal metastasis are practically never seen in cordal lesions
(MCQ)
m Hoarseness of voice is an early sign because lesions
of cord affect its vibratory capacity.(MCQ)
n It is because of this that glottic cancer is
detected early.
m Increase in size of growths with accompanying
oedema or cord fixation may cause stridor and
laryngeal obstruction.
n Subglottic Cancer (1-2%)
m The earliest presentation of subglottic cancer
may be stridor or laryngeal obstruction but this is often
late
m by this time disease has already spread
sufficiently to encroach the airway.
n Diagnosis of Laryngeal Cancer
m Any patient in cancer age group having persistent
or gradually increasing hoarseness of voice for 3 weeks
must have laryngeal examination to exclude cancer
m Supravital staining and biopsy
n Toluidine blue is applied to the laryngeal lesion
n Carcinoma-in-situ and superficial
carcinomas take up the dye while leukoplakia
does not. Thus, it helps to select the area for
biopsy in a leukoplakic patch.
Treatment of Laryngeal Cancer (Very important
MCQ area)
m Treatment consists of:
n Radiotherapy
n Surgery
l conservation laryngeal surgery
l total laryngectomy
m Combined therapy.
m Radiotherapy
n Curative radiotherapy is reserved for early
lesions which neither impair cord mobility nor invade
cartilage or cervical nodes. (MCQ)
n Cancer of the vocal cord without
impairment of its mobility gives a 90% cure
rate after irradiation and has the advantage of
preservation of voice. Superficial exophytic
lesions, especially of the tip of epiglottis,
and aryepiglottic folds give 70-90% cure rate.
n Radiotherapy does not give good results in
lesions with fixed cords, subglottic
extension, cartilage invasion, and nodal
metastases. These lesions require surgery.
n Surgery
m Conservation surgery
n Conservation surgery includes:
 l Excision of vocal cord after splitting the larynx
(cordectomy via laryngofissure),
l Excision of vocal cord and anterior commissure region
(partial frontolateral laryngectomy),
l Excision of supraglottis, i.e. epiglottis,
aryepiglottic folds, false cords and ventricle
„ a sort of transverse section of larynx
above the vocal cords (partial horizontal
laryngectomy).
m Total laryngectomy
n The entire larynx including the hyoid bone, pre-
epiglottic space, strap muscles, and one or
more rings of trachea are removed.
n Phar yngeal wall is repaired and lower
tracheal stump sutured to the skin for breathing.
n patient was left with no voice and a
permanent tracheostome
n Laryngectomy may be combined with block
dissection for nodal metastasis.
n Total laryngectomy is indicated in the following
conditions:
l T3 lesions (i.e. with cord fixed)
l All T4 lesions
l Invasion of thyroid or cricoid cartilage
l Bilateral arytenoid cartilage involvement
l Lesions of posterior commissure
l Failure after radiotherapy or conservation
surgery
l Transglottic cancers, i.e. tumours involving
supraglottis and glottis across the ventricle,
causing fixation of the vocal cord.
n It is contraindicated in patients with distant
metastasis.
m Combined therapy
n Surgical ablation may be combined with pre-
or post-operative radiation
l decrease the incidence of recurrence.
l Pre-operative radiation may also render fixed
nodes resectable.
n Glottic Carcinoma
m Carcinoma-in-situ
n It is best treated by transoral endoscopic CO2
laser.
n If laser is not available, stripping of vocal cord
is done under microscope and tissue subjected
to biopsy.
n If biopsy shows invasive carcinoma, give
radiotherapy.
n If biopsy confirms only carcinoma in situ,
treatment is regular follow-up.
m Invasive carcinoma
n T1-carcinoma-
l Radiotherapy is the treatment of choice.
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l If radiotherapy is refused or not available,
excision of cord by endoscopic CO2 laser or
laryngofissure is performed.
n T1-carcinoma with extension to anterior
commissure.
l Radiotherapy is the best choice.
l In the absence of this, frontolateral partial
laryngectomy is done with regular follow-
up.
l If it fails, total laryngectomy is performed.
n T1-carcinoma with extension to arytenoid.
l Treatment is same as above but surgery is
preferred.
n T2N0
l It implies tumour of the glottic region, i.e.
vocal cord(s), anterior commissure and/or
vocal process of the arytenoid with extension
to supraglottic or subglottic regions but with
no lymph node involvement.
ENT
l Treatment depends on two factors
„ Is mobility of vocal cord normal or
impaired?
„ Is there involvement of anterior
commissure and/or arytenoid?
l If cord is mobile and anterior commissure
and arytenoid is not involved, radiotherapy
gives good results.
l If disease recurs, total laryngectomy is
LARYNX CARCINOMA
performed.
l Some surgeons will still consider partial
vertical laryngectomy to preserve voice in such
radiation-failed cases.
l If anterior commissure and/or arytenoid
is involved or cord mobility is impaired
„ radiothemrapy is not preferred
„ because radiotherapy leads to perichondritis
which would entail total laryngectomy.
„ In such cases, some form of conservation
surgery such as vertical
hemilaryngectomy or frontolateral
laryngectomy is done to preserve the
voice
l In N0 neck, in T2 carcinoma, chances of
occult nodal metastasis are less than 25%,
therefore prophylactic neck dissection is not done.
l However, if radiation is considered the mode
of treatment, for the primary, upper neck
nodes are included in the radiation field.
l Cord mobility is important in determining
the outcome of T2 lesions.
„ Normal cord mobility suggests growth is only
limited to the surface.
137
 „ Impaired mobility indicates deeper invasion l treated by supraglottic laryngectomy with
into intrinsic laryngeal muscles or paraglottic space or without neck dissection
and thus poor response to radiation. n If lung function is poor

l Invasion of paraglottic or subglottic space is also l radiotherapy can be given to the primary and

associated with undetected invasion of the nodes.

laryngeal cartilages and hence poor survival m T3 and T4 lesions

results. n often require total laryngectomy with neck

l With radiation, cure rate of T2 lesions, dissection and post-operative radiotherapy

„ with normal cord mobility, is 86% to neck
„ it drops to 63% if cord mobility is impaired n Vocal Rehabilitation After Total Laryngectomy
n T3 and T4 glottic carcinomas m Oesophageal speech (MCQ)

l best treated by total laryngectomy. m Electrolarynx.

l It is combined with neck dissection if nodes m Transoral pneumatic device.

are palpable. m Tracheo-oesophageal speech

n T4 lesions m Blom-Singer or Panje prosthesis are being used to

l treated by combined therapy, i.e. surgery with shunt air from trachea to the oesophagus.
FACIAL NERVE PALSY

post-operative radiotherapy or only palliative

treatment. TOPIC 3 - FACIAL NERVE PALSY

T2NO cancer n Anatomy of Facial Nerve

m Nucleus of Facial Nerve
Ü Ü
n Motor nucleus of the nerve is situated in the
Cord mobile Cord mobility impaired
pons. (MCQ)
Ü or n It receives fibres from the precentral gyrus.
n Upper part of the nucleus which innervates
Radiotheraphy to the Involvement of anterior
primary including commissure or arytenoid forehead muscles receives fibres from both the
radiation to upper cerebral hemispheres (MCQ)
n Lower part of nucleus which supplies lower
neck nodes
LARYNX CARCINOMA

face gets only crossed fibres from one

Failure hemisphere.
n The function of forehead is preserved in
Failure Ü
Conservation Conservation supranuclear lesions because of bilateral
laryngectomy laryngectomy innervation.
n Facial nucleus also receives fibres from the

Failure Failure thalamus

l provides involuntary control to facial muscles.
Ü Ü l The emotional movements such as smiling
Total laryngectomy Total laryngectomy and crying are thus preserved in supranuclear
± neck dissection ± neck dissection palsies because of these fibres from the
thalamus (MCQ)
n Subglottic cancer
m Early lesions T1 and T2 are treated by radiotherapy.
n Course of facial nerve
m Motor fibres take origin from the nucleus of
m T3 and T4 lesions require total laryngectomy and post-
operative radiation. VIIth nerve
m hook round the nucleus of VIth nerve and are
m Radiation portal should also include superior
mediastinum. joined by the sensory root (nerve of Wrisberg).
m Facial ner ve leaves the brainstem at
n Supraglottic cancer
m T1 lesions
pontomedullary junction, travels through
n respond well to radiation.
posterior cranial fossa and enters the internal
n can also be excised with CO2 laser.
acoustic meatus.
m At the lateralmost part of meatus, the nerve enters
m T2 lesions
n if lung function is good.
the bony facial canal, traverses the temporal
bone and comes out of the stylomastoid
138 foramen.
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 m Here it crosses the styloid process and divides
into terminal branches.
m The course of the nerve can thus be divided
into:
n Intracranial part
l From pons to internal acoustic meatus (15-
17 mm).
n Intratemporal part
l From inter nal acoustic meatus to
stylomastoid foramen.
l It is further divided into:
„ Meatal segment.
® Within internal acoustic meatus (8-10
mm).
„ Labyrinthine segment.
® From fundus of meatus to the geniculate
ganglion where nerve takes a turn
posteriorly forming a “genu”.
® The nerve in the labyrinthine segment has
the narrowest diameter (0.61-0.68 mm)
and the bony canal in this segment is also
the narrowest. (MCQ)
® This is also the shortest segment of
the nerve-only 4.0 mm.(MCQ)
® Thus oedema or inflammation can easily
compress the nerve and cause paralysis.
„ Tympanic or horizontal segment.
® From geniculate ganglion to just above
the pyramidal eminence.
® It lies above the oval window and below the
lateral semicircular canal (11.0 mm).
„ Mastoid or vertical segment.
® From the pyramid to stylomastoid
foramen.
® Between the tympanic and mastoid
segments is the second genu of the
nerve (13.0 mm).
n Extracranial part
l From stylomastoid foramen to the
termination of its peripheral branches.
n Branches of Facial Nerve (High yield MCQ Topic)
m Greater superficial petrosal nerve (MCQ)
n It arises from geniculate ganglion
n carries secretomotor fibres to lacrimal gland and
the glands of nasal mucosa.
m Nerve to stapedius
n It arises at the level of second genu
n supplies the stapedius muscle.
m Chorda tympani (MCQ)
n It arises from the middle of vertical segment
n passes between the incus and neck of malleus
n leaves the tympanic cavity through petrotympanic
fissure.
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n It carries secretomotor fibres to submandibular
and sublingual glands and brings taste from anterior
two-thirds of tongue.(MCQ)
m Communicating branch
n It joins auricular branch of vagus
n it supplies the concha, retroauricular groove,
posterior meatus and the outer surface of
tympanic membrane.
m Posterior auricular nerve
n It supplies muscles of pinna, occipital belly of
occipitofrontalis and communicates with auricular
branch of vagus.
m Muscular branches to stylohyoid and posterior
belly of digastric.(MCQ)
m Peripheral branches
n These are the temporal, zygomatic, buccal,
mandibular and cervical and together form
pes anserinus (goose-foot). (MCQ)
n They supply all the muscles of facial expression.
ENT
n Blood supply of Facial Nerve
m Anterior-inferior cerebellar artery
n supplies the nerve in CP angle
m labyrinthine artery
n branch of anterior inferior cerebellar artery
n supplies the nerve in internal auditory canal
m superficial petrosal artery
n a branch of middle meningeal artery
n which supplies geniculate ganglion and the
adjacent region;
FACIAL NERVE PALSY
m stylomastoid artery
n branch of posterior auricular artery
n which supplies the mastoid segment.
n Bell’s Palsy (High yield MCQ Subtopic)
m Sixty to seventy-five percent of facial paralysis is due to
Bell’s palsy.
m idiopathic, peripheral facial paralysis or paresis of
acute onset.
m Both sexes are affected with equal frequency.
m incidence rises with increasing age.
m A positive family history is present in 6-8% of
patients.
m Risk of Bell’s palsy is more in
n diabetics (angiopathy)
n pregnant women (retention of fluid).
m Aetiology
n Viral infection
l HSV, herpes zoster or the Epstein-Barr virus
n Vascular ischaemia
n Hereditary
l The fallopian canal is narrow because of
hereditary predisposition
n Autoimmune disorder
139
 m Clinical Features n Eighty-five to ninety percent of the patients
n Onset is sudden. recover fully.
n Patient is unable to close his eye. n Melkersson’s Syndrome
n On attempting to close the eye, eyeball turns up m an idiopathic disorder
and out (Bell’s phenomenon). m consisting of a triad of facial paralysis, swelling of lips
n Saliva dribbles from the angle of and fissured tongue.
mouth.(MCQ) m Paralysis may be recurrent.
n Face becomes asymmetrical. n Recurrent facial palsy
n Tears flow down from the eye (epiphora). m Recurrent facial palsy is seen in
n Pain in the ear may precede or accompany the n Bell’s palsy (3-10% cases),
nerve paralysis. n Melkersson’s syndrome
n noise intolerance (stapedial paralysis). (MCQ) n Diabetes
n loss of taste (involvement of chorda tympani). n sarcoidosis
n Paralysis may be complete or incomplete. n tumours.
n Bell’s palsy is recurrent in 3-10% of patients. n Bilateral facial paralysis
m Diagnosis m seen in
n Nerve excitability tests are done daily or on n Guillain-Barré syndrome
alternate days and compared with the normal n sarcoidosis,
side to monitor nerve degeneration.(MCQ) n sickle cell disease
ENT

m Treatment n acute leukaemia

n Eye must be protected against exposure
keratitis.
n Physiotherapy or massage of the facial
muscles (MCQ)
l gives psychological support to the patient.
l It has not been shown to influence recovery.
l Active facial movements are encouraged
n bulbar palsy,
n leprosy
n Herpes Zoster Oticus (Ramsay-Hunt Syndrome)
(MCQ)
m There is facial paralysis along with vesicular rash in
the external auditory canal and pinna
m There may also be anaesthesia of face, giddiness and

n Steroids (MCQ) hearing impairment due to involvement of Vth and

l Their utility has not been proved beyond VIIIth nerves
FACIAL NERVE PALSY

doubt in carefully controlled studies. n Fractures of Temporal Bone (High yield MCQ
Prednisolone is the drug of choice Topic)
l Patient is seen on the 5th day. m Facial palsy is seen more often in transverse

„ If paralysis is incomplete or is recovering, dose is fractures (50%).(MCQ) Delayed onset paralysis

tapered during the next 5 days. is treated conservatively like Bell’s palsy
„ If paralysis remains complete, the same dose is m Immediate onset paralysis may require surgery

continued for another 10 days and in the form of decompression, re-anastomosis of cut ends or
thereafter tapered in next 5 days. (total cable
of 20 days). m nerve graft (MCQ)

l Steroids have been found useful to prevent

incidence of
„ Synkinesis
„ crocodile tears
„ shorten the recovery time of facial paralysis.
l Steroids can be combined with acyclovir
for Herpes zoster oticus or Bell’s palsy.
n Surgical treatment (MCQ)
l Nerve decompression relieves pressure on
the nerve fibres and thus improves the
microcirculation of the nerve.
l Vertical and tympanic segments of nerve
are decompressed.
m Prognosis
140
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 • Differeces in longitudinal and transverse fractures of temporal bone
Longitudinal Transverse

• Frequency More common (80%) Less common (20%)

• Type of Parietal blow Occipital blow
Injury
• Fracture line Runs parallel to long axis of petrous pyramid. Runs across the petrous Starts at foramen magnum
Starts at squamous part of temporal bone or jugular foramen towards the foramen spinosum
to end at foramen lacerum
• Bleeding Common, due to injury to tegmen and Absent because tympanic membrane is intact.
from ear tympanic membrane Haemotympanum may be seen
• C.S.F. Present, often mixed with blood Absent or unmanifested
otorrhoea
• Structures Tegmen, ossicles and tympanic membrane Labyrinth or CN VIII
injured
• Hearing loss Conductive Sensorineural
• Vertigo Less often; due to concussion Severe, due to injury to labyrinth or CN VIII
• Facial Less (20%), delayed onset. Nerve is injured Most common (50%). Immediate onset. Injury
paralysis in tympanic segment, distal to geniculate ganglion to nerve in meatal or labyrinthine segment

ENT
proximal to geniculate ganglion.

n Systemic diseases and facial paralysis n Schirmer’s test

m Peripheral facial paralysis is mostly of idiopathic
variety but always needs exclusion of diabetes,
hypothyroidism, leukaemia, sarcoidosis, periarteritis nodosa,
Wegener’s granulomatosis, leprosy, syphilis and demyelinating
disease
n Localisation of facial lesion (High yield MCQ
Topic)
l It compares lacrimation of the two sides.
l Decreased lacrimation indicates lesion
proximal to the geniculate ganglion as the
secretomotor fibres to lacrimal gland
leave at the geniculate ganglion via
greater superficial petrosal nerve.(MCQ)
n Stapedial reflex (MCQ)

FACIAL NERVE PALSY

m Central Facial Paralysis l Stapedial reflex is lost in lesions above the
n It is caused by cerebrovascular accidents nerve to stapedius.
(haemorrhage, thrombosis or embolism), l It is tested by tympanometry.
tumour or an abscess. n Taste test
n It causes paralysis of only the lower half of l Impairment of taste indicates lesion above the
face on the contralateral side. Forehead chorda tympani.(MCQ)
movements are retained due to bilateral n Submandibular salivary flow test
innervation of frontalis muscle. l It also measures function of chorda
n Involuntary emotional movements and the tympani.
tone of facial muscles are also retained. m Topographical localisation of VIIth nerve
m Peripheral Facial Paralysis lesions.
n All the muscles of the face on the involved n Suprageniculate or transgeniculate lesion.
side are paralysed. l Secretomotor fibres to the lacrimal gland leave at
n Patient is unable to frown, close the eye, purse the lips the geniculate ganglion
or whistle. l interrupted in lesions situated at/or proximal
n A lesion at the level of nucleus is identified to geniculate ganglion.
by associated paralysis of VIth nerve. n Suprastapedial lesions
n A lesion at cerebellopontine angle is identified l cause loss of stapedial reflex and taste but
by the presence of vestibular and auditory defects preserve lacrimation
and involvement of other cranial nerves such as n Infrastapedial lesions
Vth, IXth, Xth and XIth. l cause loss of taste but preserve stapedial reflex
m Topodiagnostic Tests for Lesions in and lacrimation.
Intratemporal Part n Infrachordal lesions
l cause loss of facial motor function only.
141
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 n Complications following facial paralysis TOPIC 4 - OTOSCLEROSIS
m Crocodile tears (gustatory lacrimation)
n There is unilateral lacrimation with mastication.
n otospongiosis, is a primary disease of the bony
n This is due to faulty regeneration of
labyrinth
parasympathetic fibres which now supply n one or more foci of irregularly laid spongy bone
lacrimal gland instead of the salivary glands. replace part of normally dense enchondral layer of
n It can be treated by section of greater
bony otic capsule.
superficial petrosal nerve or tympanic n Most often, otosclerotic focus involves the stapes
neurectomy. region leading to stapes fixation and conductive deafness.
m Frey’s syndrome (gustatory sweating)
(MCQ)
n There is sweating and flushing of skin over the parotid
n Aetiology
m Anatomical basis.
area during mastication.
n Bony labyrinth is made of enchondral bone which
n It results from parotid surgery.
n in this hard bone, there are areas of cartilage
n Hemifacial spasm
m It is characterised by repeated, uncontrollable twitchings of
rests which due to certain non-specific factors,
facial muscles on one side are activated to form a new spongy bone.
n One such area is the fissula ante fenestram
m It is of two types
n Idiopathic
lying in front of the oval window-the site of
n secondary,
predilection for stapedial type of
otospongiosis. (MCQ)
ENT

l acoustic neuroma
m Heredity.
l congenital cholesteatoma
n About 50% of otosclerotics have positive
l glomus tumour.
m Many cases of hemifacial spasm are due to irritation
family history (MCQ)
n it is an autosomal dominant trait with incomplete
of the nerve because of a vascular loop at the cerebellopontine
angle. penetrance and a variable expressivity. (MCQ)
m Race.
m Microvascular decompression through posterior fossa
n White races are affected more than
craniotomy has met with high success rate in these cases
m Botulinum toxin has been used in the affected
Negros.(MCQ)
n It is common in Indians but rare among
muscle.
OTOSCLEROSIS

Chinese and Japanese.

m Sex.
n Females are affected twice as often as males
(MCQ)
n but in India, otosclerosis seems to
predominate in males.
m Age of onset.
n Deafness usually starts between 20 and 30 years
of age
n rare before 10 and after 40 years.
m Effect of other factors.
n Deafness due to otosclerosis may be initiated
or made worse by pregnancy (MCQ)
n Similarly, deafness may increase during
l Menopause
l after an accident
l a major operation.
m van der Hoeve syndrome
n The triad of symptoms of osteogenesis
imperfecta, otosclerosis and blue sclera,
is called.
n osteogenesis imperfecta and otosclerosis and
both are due to genes encoding type I
collagen.
142
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 m Viral infection.
n measle virus.
n Types of Otosclerosis
m Stapedial otosclerosis
n causes stapes fixation and conductive deafness
n most common variety. (MCQ)
n lesion starts just in front of the oval window in an
area called ‘fissula ante fenestram’. This is the
site of predilection (anterior focus).
m Cochlear otosclerosis
n involves region of round window or other areas in
the otic capsule
n may cause sensorineural hearing loss (MCQ)
m Histologic otosclerosis
n This type of otosclerosis remains asymptomatic
n causes neither conductive nor sensorineural
hearing loss.
n Pathology
m Grossly, otosclerotic lesion appears chalky white,
greyish or yellow.
m Sometimes, it is red in colour due to increased
vascularity, in which case, the otosclerotic focus is
active and rapidly progressive.
m Microscopically, spongy bone appears in the
normally dense enchondral layer of otic capsule.
m In immature active lesions, there are
n numerous marrow and vascular spaces with plenty of
osteoblasts and osteoclasts
n a lot of cement substance which stains blue
(blue mantles) with haematoxylin-eosin stain.
m Mature foci show
n less vascularity and laying of more bone
n more of fibrillar substance than cementum
n stained red
n Symptoms
m Hearing loss
n This is the presenting symptom
n usually starts in twenties.
n It is painless and progressive with insidious
onset.
n Often it is bilateral conductive type.(MCQ)
m Paracusis willisii (MCQ)
n An otosclerotic patient hears better in noisy
than quiet surroundings.
n This is because a normal person will raise his
voice in noisy surroundings.
m Tinnitus
n It is more commonly seen in cochlear otosclerosis
and in active lesions.
m Vertigo
n It is an uncommon symptom.
m Speech
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n Patient has a monotonous, well modulated soft
speech.(MCQ)
Treatment
Sodium fluoride (MCQ)
hasten the maturity of active focus and arrest further
cochlear loss,
n Surgical
m Stapedectomy with a placement of prosthesis is
the treatment of choice.(MCQ)
n fixed otosclerotic stapes is removed and a
prosthesis inserted between the incus and oval window
n Prosthesis employed may be a teflon piston,
stainless steel piston, platinum teflon or
titanium teflon piston
n In 90% of patients, there is good improvement in
hearing after stapedectomy.
m Selection of patients for stapes surgery
n Hearing threshold should be 30 dB or worse
(It is this level when patient starts feeling socially
ENT
handicapped).
n Average air-bone gap should be at least 15
dB with Rinne negative for 256 and 512
Hz.(MCQ)
n Speech discrimination score should be 60%
or more.
m Absolute Contraindications to stapes surgery
n The only hearing ear.
n Associated Meniere’s disease.
l When there is history of vertigo with clinical
OTOSCLEROSIS
evidence of Meniere’s disease in an otosclerotic
patient, there are more chances of sensorineural
hearing loss after stapedectomy.
n Young children.
l Recurrent eustachian tube dysfunction is
common in children.
l It can displace the prosthesis or cause acute otitis
media.
l Also the growth of otosclerotic focus is
faster in children leading to reclosure of oval
window.
n Professional athletes, high construction
workers, divers, and frequent air-travellers.
l Stapes surgery has the risk to cause post-operative
vertigo and/or dizziness and thus interfere with
their profession
l frequent air pressure changes may damage the
hearing or cause severe vertigo.
n Those who work in noisy surroundings.
l After stapedectomy, they would be more
vulnerable to get sensorineural hearing loss due to
noise trauma.
m Relative contraindications for Stapedectomy
n Otitis externa
143
 n tympanic membrane perforation
n exostosis
m Stapedectomy is avoided during
pregnancy.(MCQ)
m Stapedectomy is preferably done under local
anaesthesia.
m Complications of Stapedectomy
n 2% of patients — suffer sensorineural loss.
n Slowly progressive high frequency loss
n One in 200 patients may get a totally “dead”
ear.
m Hearing aid
n Patients who refuse surgery or are unfit for
surgery can use hearing aid.
TOPIC 5 - ACOTIC NUEROMA
n Acoustic neuroma constitutes 80% of all
cerebellopontine angle tumours
ENT
n It is a benign, encapsulated, extremely slow-
growing tumour of the 8th nerve.
n Microscopically, it consists of elongated spindle
cells with rod-shaped nuclei lying in rows or
palisades.
n Bilateral tumours are seen in patients with
neurofibromatosis
n The tumour almost always arises from the
Schwann cells of the vestibular nerve
ACOTIC NUEROMA
n As it expands, it causes widening and erosion of the
canal
n in cerebellopontine angle , grows anterosuperiorly
to involve Vth nerve or inferiorly to involve the
IXth, Xth and XIth cranial nerves.
m Depending on the size, the tumour is classified as:
n Intracanalicular (when it is confined to internal
auditory canal)
n Small size (up to 1.5 cm)
n Medium size (1.5 to 4 cm)
n Large size (over 4 cm)
m Tumour is mostly seen in age group of 40-60 years.
m Both sexes are equally affected.
m Cochle-ovestibular symptoms
n They are the earliest symptoms when tumour
is still intracanalicular
n Progressive unilateral sensorineural hearing
loss, often accompanied by tinnitus, is the
presenting symptom in majority of cases.
n There is marked difficulty in understanding
speech, out of proportion to the pure tone hearing
loss. This feature is characteristic of acoustic
neuroma.
n Some patients may get sudden hearing loss.
144
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m Vestibular symptoms are imbalance or
unsteadiness.
n True vertigo is seldom seen.
m Cranial nerve involvement
n Vth nerve is the earliest nerve to be involved.
l There is reduced corneal sensitivity,
numbness or paraesthesia of face.
l Involvement of this nerve indicates that the
tumour is roughly 2.5 cm in diameter and
occupies the cerebellopontine angle.
n VIIth nerve.
l Sensory fibres are affected early.
l There is hypoaesthesia of posterior meatal wall
(Hitzelberger’s sign),
l loss of taste (as tested by electrogustometry)
l reduced lacrimation on Schirmer’s test.
l Motor fibres are more resistant and are
affected late.
l Delayed blink reflex may be an early
manifestation.
n IXth and Xth nerves.
l There is dysphagia and hoarseness due to
palatal, pharyngeal and laryngeal paralysis.
l Other cranial nerves. XIth and XIIth, IIIrd,
IVth and VIth are affected when tumour is
very large.
n Brainstem involvement
m There is ataxia, weakness and numbness of
the arms and legs with exaggerated tendon
reflexes. They are seen when long motor and
sensory tracts are involved.
n Cerebellar involvement
m Pressure symptoms on cerebellum are seen in large
tumours.
n Raised intracranial tension
m This is also a late feature..
n Investigations and Diagnosis
m Attempts should be made to diagnose the tumour
when it is still intracanalicular.
n This is possible when all cases of unilateral
sensorineural hearing loss with tinnitus or
imbalance are carefully evaluated.
m Audiological tests
n Pure tone audiometry will show sensorineural
hearing loss, more marked in high frequencies.
n Speech audiometry shows poor speech
discrimination and this is disproportionate to pure
tone hearing loss.
n Roll-over phenomenon, i.e. reduction of
discrimination score when loudness is increased beyond a
particular limit is most commonly observed.
n Recruitment phenomenon is absent.
 n Short Increment Sensitivity Index (SISI)
test will show a score of 0-20% in 70-90% of
cases.
n Threshold tone decay test shows retrocochlear
type of lesion.
m Stapedial reflex decay test
m Vestibular tests
n Caloric test will show diminished or absent
response in 96% of patients.
n When tumour is very small, caloric test may
be normal.
m Radiological tests
l Plain X-rays (transorbital, Stenver’s,
Towne’s and submentovertical views) give
positive findings in 80% of patients.
m CT scan.
l A tumour that projects even 0.5 cm into
the posterior fossa can be detected by a CT
scan.
l If combined with intrathecal air, even the
intrameatal tumour can be detected
m MRI with gadolinium contrast.
l It is superior to CT scan and is the gold
standard for diagnosis of acoustic
neuroma.
l Intracanalicular tumour, of even a few
millimetres, can be easily diagnosed by this
method.
m Vertebral angiography.
l This is helpful to differentiate acoustic
neuroma from other tumours of
cerebellopontine angle when doubt exists.
m Evoked response audiometry (BERA)
l It is very useful in the diagnosis of
retrocochlear lesions.
l In the presence of VIIIth nerve tumour, a
delay of >0.2 msec in wave V between two
ears is significant
m Treatment
l Surgery
„ Surgical removal of the tumour is the
treatment of choice.
l Radiotherapy
„ Conventional radiotherapy by external
beam has no role in the treatment of
acoustic neuromas due to low tolerance of
the central nervous system to radiation.
„ X-knife or Gamma knife surgery. It is a
form of stereo-tactic radiotherapy where
radiation energy is converged on the
tumour, thus minimising its effect on the
surrounding normal tissue.
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„This causes arrest of the growth of the
tumour and also reduction in its size.
„ It can be used in patients who refuse
surgery or have contraindications to surgery
or in those with a residual tumour.
„ X-knife surgery is done through linear
accelerator and gamma knife through a
Cobalt-60 source.
m Cyber knife:
„ It is totally frameless and more accurate.
„ It uses real-time image guidance technology
through computer controlled robotics.
TOPIC 6 - CHOLESTEATOMA
Cholesteatoma
n Normally, middle ear cleft is lined by
ACOTIC NUEROMA
m ciliated columnar in the anterior and inferior part
m cuboidal in the middle part
m pavement-like in the attic.
n The middle ear is no where lined by keratinising
squamous epithelium.
n It is the presence of keratinising squamous epithelium in
the middle ear or mastoid that constitutes a
cholesteatoma. (MCQ)
n In other words, cholesteatoma is a “skin in the
wrong place”.
n The term cholesteatoma is a misnomer
CHOLESTEATOMA
m it neither contains cholesterol crystals (MCQ)
m nor is it a tumour to merit the suffix “oma”. (MCQ)
n The cholesteatoma is classified into:
m Congenital
m Acquired, primary
m Acquired, secondary (MCQ)
n Congenital cholesteatoma
m It arises from the embryonic epidermal cell rests
in the middle ear cleft or temporal bone.
m Congenital cholesteatoma occurs at three important
sites:
n middle ear
n petrous apex
n cerebellopontine angle
m Clinical presentation of congenital cholesteatoma
n white mass behind an intact tympanic
membrane
n causes conductive hearing loss.
n discovered on routine examination of children or at
the time of myringotomy.
n also spontaneously rupture through the
tympanic membrane and present with a
discharging ear indistinguishable from a case of
chronic suppurative otitis media (CSOM).
n Primary acquired cholesteatoma
145
 m there is no history of previous otitis media or a
pre-existing perforation.
m Theories on its genesis are:
n Invagination of pars flaccida.
l Persistent negative pressure in the attic causes
a retraction pocket which accumulates keratin
debris.
CHRONIC SUPPURATIVE OTITIS MEDIA
TOPIC 7 -
CHRONIC SUPPURATIVE OTITIS MEDIA
Chronic suppurative otitis media
n a long-standing infection of a part or whole of the
middle ear cleft characterised by ear discharge and a
permanent perforation.

l When infected, the keratin mass expands n Permanent perforation

towards the middle ear.
l Thus, attic perforation is in fact the proximal
end of an expanding invaginated sac.
n Basal cell hyperplasia.
l There is proliferation of the basal layer of
pars flaccida induced by subclinical
childhood infections.
l Expanding cholesteatoma then breaks
through pars flaccida forming an attic
perforation.(MCQ)
n Squamous metaplasia.
l Normal pavement epithelium of attic undergoes
metaplasia to keratinising squamous epithelium due
to subclinical infections
n Secondary acquired cholesteatoma
m In these cases, there is already a pre-existing
perforation in pars tensa.
m This is often associated with posterosuperior
marginal perforation or sometimes large central
perforation
n Expansion of Cholesteatoma and Destruction
CHOLESTEATOMA
m A perforation becomes permanent when its edges
are covered by squamous epithelium
m it does not heal spontaneously.
n Single most important cause of hearing impairment
in rural population
n Types of CSOM
m Tubotympanic
n Also called the safe or benign type
n it involves anteroinferior part of middle ear
cleft, i.e. eustachian tube and mesotympanum
n is associated with a central perforation.
n There is no risk of serious complications.
m Atticoantral
n Also called unsafe or dangerous type
n it involves posterosuperior part of the cleft
(i.e. attic, antrum and mastoid)
n it is associated with an attic or a marginal
perforation.
n The disease is often associated with a bone-
eroding process such as cholesteatoma, granulations
or osteitis.

of Bone n Risk of complications is high in this variety.

m An attic cholesteatoma may extend
n backwards into the aditus, antrum and mastoid;
n downwards into the mesotympanum
n medially, it may surround the incus and/or head
of malleus. (MCQ)
m Cholesteatoma may cause destruction of
n ear ossicles
n erosion of bony labyrinth
n canal of facial nerve
n sinus plate or tegmen tympani
n The peak incidence occurs in the second decade
n Most common presentation ear discharge or
hearing loss or both in the affected ear.(MCQ)
n If a patient presents with ear discharge and hearing
loss, the diagnosis is cholesteatoma until the disease
is definitely excluded.
n Appearence of tympanic membrane
m posterior and superior parts of the tympanic
membrane are most commonly affected.
m If the cholesteatoma has been dry, the
cholesteatoma may present the appearance of ‘wax
over the attic’.
146
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 Difference between atticoantral and tubotympanic type of CSOM

Tubotympanic or safe type Atticoantral or unsafe type

Discharge Profuse, mucoid, odourless Scanty, purulent, foul-smelling
Perforation Central Attic or marginal
Granulations Uncommon Common
Polyp Pale Red and fleshy
Cholesteatoma Absent present
Complications Rare Common
Audiogram Mild to moderate conductive deafness Conductive or mixed deafness

n Tubotympanic Type CSOM l Patients are instructed to keep water out of

m Ear discharge the ear during bathing, swimming and hair
n It is non-offensive, mucoid or wash.
mucopurulent, constant or intermittent. l Hard nose-blowing can also push the
n The discharge appears mostly infection from nasopharynx to middle ear and

l at time of upper respiratory tract infection
l on accidental entry of water into the ear.
m Hearing loss
n It is conductive type
n severity varies but rarely exceeds 50 dB.
n What is round window shielding effect
l Sometimes, the patient reports of a
paradoxical effect, i.e. hears better in the presence
ENT
should be avoided.
n Surgical treatment
l Aural polyp or granulations, if present, should
be removed before local treatment with
antibiotics.
l An aural polyp should never be avulsed
as it may be arising from the stapes, facial nerve
or horizontal canal and thus lead to facial paralysis

CHRONIC SUPPURATIVE OTITIS MEDIA

of discharge than when the ear is dry.
l This is due to “round window shielding
effect” produced by discharge which helps to
maintain phase differential.
l In the dry ear with perforation, sound
waves strike both the oval and round windows
simultaneously, thus cancelling each other’s effect
n In long standing cases, cochlea may suffer
damage , hearing loss becomes mixed type.
m Perforation
n Always central
m Middle ear mucosa
n It is seen when the perforation is large.
n Normally, it is pale pink and moist
m Treatment
n Aural toilet
n Ear drops
l Antibiotic ear drops containing neomycin,
polymyxin, chloromycetin or gentamicin
are used.
l They are combined with steroids which
have local anti-inflammatory effect.
l Acid pH helps to eliminate pseudomonas
infection, and irrigations with 1.5% acetic acid
are useful.
n Precautions
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or labyrinthitis.
n Reconstructive surgery
l Once ear is dry, myringoplasty with or
without ossicular reconstruction can be
done to restore hearing. (MCQ)
n Atticoantral Type CSOM
m It involves posterosuperior part of middle ear
cleft (attic, antrum and posterior tympanum and
mastoid)
m associated with cholesteatoma
m the disease is also called unsafe or dangerous
type.
m Atticoantral diseases is associated with the
following pathological processes:
n Cholesteatoma
n Osteitis and granulation tissue
l Osteitis involves outer attic wall and
posterosuperior margin of the tympanic
ring.
l A mass of granulation tissue surrounds the
area of osteitis
l A fleshy red polypus may be seen filling the
meatus.
n Ossicular necrosis
l It is common in atticoantral disease.
147
 n Cholesteatoma causes destruction in the area of attic
l hearing loss is always greater than in disease
of tubotympanic type. and antrum (key area), better seen in lateral view.
m CT scan temporal bone
n Cholesterol granuloma
n CT scan of temporal bone gives more
l It is a mass of granulation tissue with
foreign body giant cells surrounding the information and is preferred to X-ray mastoids.
m Features Indicating Complications in CSOM
cholesterol crystals.
n Pain
l It is a reaction to long-standing retention of
l Pain is uncommon in uncomplicated CSOM.
secretions or haemorrhage
l Its presence is considered serious as it may
l When present in the mesotympanum,
behind an intact drum, the latter appears indicate
„ extradural, perisinus or brain abscess.
blue.
„ otitis externa associated with a discharging
n Who is cholesteatoma hearer
l Occasionally, the cholesteatoma bridges the gap
ear.
n Vertigo
caused by the destroyed ossicles, and hearing
l It indicates erosion of lateral semicircular canal
loss is not apparent (cholesteatoma
hearer). which may progress to labyrinthitis or
n Symptoms
meningitis.
l Fistula test should be performed in all cases.
m Ear discharge
n Persistent headache
n Usually scanty, but always foul-smelling due to
ENT

l It is suggestive of an intracranial complication.

bone destruction.
n Facial weakness
n Total cessation of discharge from an ear
l indicates erosion of facial canal.
which has been active till recently should be
n A listless child refusing to take feeds and easily
viewed seriously, because
l perforation in these cases might be sealed
going to sleep indicate extradural abscess
n Fever, nausea and vomiting —intracranial
by crusted discharge
l inf lammator y mucosa or a polyp,
infection
n Irritability and neck rigidity -- meningitis
obstructing the free flow of discharge.
n Diplopia - Gradenigo’s syndrome
CHRONIC SUPPURATIVE OTITIS MEDIA

l Pus, in these cases, may find its way

n Ataxia - labyrinthitis or cerebellar abscess
internally and cause complications.
n Abscess round the ear — mastoiditis
m Hearing loss
m Treatment
n Hearing is normal when
n Surgical
l ossicular chain is intact
l It is the mainstay of treatment.
l when cholesteatoma, having destroyed the
n Canal wall down procedures.
ossicles, bridges the gap caused by destroyed
l They leave the mastoid cavity open into the
ossicles (cholesteatoma hearer).
n Hearing loss is mostly conductive but
external auditory canal so that the diseased area
sensorineural element may be added. is fully exteriorised.
l The commonly performed operations for
m Bleeding
n It may occur from granulations or the polyp when
atticoantral disease are
„ Atticotomy
cleaning the ear.
„ modified radical mastoidectomy
n Signs
„ radical mastoidectomy
m Perforation
n Canal wall up procedures.
n It is either attic or posterosuperior marginal
l Here disease is removed by combined approach
type.
m Retraction pocket
through the meatus and mastoid but retaining
n An invagination of tympanic membrane is
the posterior bony meatal wall intact
l an open mastoid cavity is avoided
seen in the attic or posterosuperior area of pars
l It gives dry ear
tensa.
l It permits easy reconstruction of hearing
m Cholesteatoma
n Investigations
mechanism.
l However, there is danger of leaving some
m X-ray mastoids
n They are useful to indicate a low-lying dura or an
cholesteatoma behind. Incidence of residual
148 anteposed sigmoid sinus.
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 or recurrent cholesteatoma in these cases
is very high
l long-term follow-up is essential.
l Some surgeon’s even advise routine re-
exploration in all cases after 6 months or
so.
l Canal wall up procedures are advised only in
selected cases
„ Combined-approach or intact canal
wall mastoidectomy
® disease is removed both permeatally, and
through cortical mastoidectomy
„ Posterior tympanotomy approach,
® a window is created between the mastoid and
middle ear, through the facial recess, to
reach sinus tympani
n Hearing can be restored by myringoplasty or
tympanoplasty

ENT
• Comparison of canal wall up and canal wall down procedures
Canal wall up procedure Canal wall down procedure

Meatus Normal appearance Widely open meatus communicating with mastoid

Dependence Does not require routine cleaning Dependence on doctor for cleaning mastoid cavity once or
twice a year
Recurrence of Highrate of recurrent or residual Low rate of recurrence or residual disease and thus a safe
residual disease cholesteatoma procedure

CHRONIC SUPPURATIVE OTITIS MEDIA

Second look Requires second look surgey after Not required
Surgery 6 months or so to rule out cholesteatoma
Patients limitations No limitation. Patient allowed swimming Swimming can lead to infection of mastoid cavity and
it is thus curtailed
Auditory Easy to wear a hearing aid if needed Problems in fitting a hearing aid due to large meatus and
rehabilitation mastoid cavity which sometimes gets infected

149
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 Complications of Suppurative Otitis Media ® They are similar to that of acute
n Classification suppurative otitis media.
m Intratemporal (Within the Confines of Temporal ® In a case of acute middle ear infection,

Bone) it is the change in the character of these

n Mastoiditis symptoms which is significant and a
n Petrositis pointer to the development of acute
n Facial paralysis mastoiditis.
n Labyrinthitis. ® Pain behind the ear.

m Intracranial » Pain is seen in acute otitis media but it

n Extradural abscess subsides with establishment of

n Subdural abscess perforation or treatment with antibiotics.
n Meningitis » It is the persistence of pain,

n Brain abscess increase in its intensity or

n Lateral sinus thrombophlebitis recurrence of pain, once it had
n Otitic hydrocephalus. subsided. These are significant pointers
n Sequelae of Otitis Media - direct result of middle ear of pain.
infection ® Fever.

m Perforation of tympanic membrane » It is the persistence or recurrence

m Ossicular erosion of fever in a case of acute otitis media,

ENT

m Atelectasis and adhesive otitis media in spite of adequate antibiotic treatment

m Tympanosclerosis that points to the development of
m Cholesteatoma formation mastoiditis.
m Conductive hearing loss due to ossicular erosion ® Ear discharge.

or fixation » In mastoiditis, discharge becomes

m Sensorineural hearing loss profuse and increases in purulence

m Speech impairment » Any persistence of discharge beyond

m Learning disabilities three weeks, in a case of acute otitis

n Acute Mastoiditis media, points to mastoiditis.
CHRONIC SUPPURATIVE OTITIS MEDIA

m Inflammation of mucosal lining of antrum and „ Signs

mastoid air cell system ® Mastoid tenderness.

m Aetiology » This is an important sign.

l Acute mastoiditis usually accompanies or » Tenderness is elicited by pressure over

follows acute suppurative otitis media the middle of mastoid process, at

l the determining factors its tip, posterior border or the root
„ high virulence of organisms of zygoma.
„ lowered resistance of the patient due to » Tenderness elicited over the

measles, exanthematous fevers, poor suprameatal triangle may not be

nutrition
„ diabetes
l Acute mastoiditis is often seen in mastoids
with well-developed air cell system.
l Children are affected more.
diagnostic of acute mastoiditis as it is seen
even in cases of the acute otitis media
due to inflammation of mastoid
antrum (antritis).
® Ear discharge.

l Beta-haemolytic streptococcus is the most » Mucopurulent or purulent

common causative organism discharge
n Pathology » often pulsatile (light-house effect),

„ Two main pathological processes are » seen coming through a central

responsible: perforation of pars tensa.

® Production of pus under tension. ® Sagging of posterosuperior meatal

® Hyperaemic decalcification and osteoclastic wall.

resorption of bony walls. » It is due to periosteitis of bony party wall

n Clinical Features between the antrum and deeper

„ Symptoms posterosuperior part of bony canal.
® Perforation of tympanic membrane.
150
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 » Usually, a small perforation is seen in pars
tensa with congestion of the rest of
tympanic membrane.
» Perforation may sometimes appear as
a nipple-like protrusion
» An absolutely nor mal looking
tympanic membrane excludes possibility
of acute mastoiditis
® Swelling over the mastoid.
» Initially, there is oedema of periosteum,
imparting a smooth “ironed out”
feel over the mastoid.
» Later retroauricular sulcus becomes
obliterated
» pinna is pushed forward and downwards.
» When pus bursts through bony cortex,
a subperiosteal fluctuant abscess
is formed
® Hearing loss.
» Conductive type of hearing loss is
always present.
® General findings.
» Patient appears ill and toxic with
low-grade fever.
» In children, fever is high with a rise
in pulse rate.
n Investigations
„ X-ray mastoid
® There is clouding of air cells due to
collection of exudate in them.
® Bony partitions between air cells
become indistinct, but the sinus plate
is seen as a distinct outline.
n Treatment
„ Myringotomy
® Early cases of acute mastoiditis respond
to conser vative treatment with
antibiotics alone or combined with
myringotomy.
„ Cortical mastoidectomy(MCQ)
® It is indicated when there is:
» Subperiosteal abscess.
» Sagging of posterosuperior meatal
wall.
» Positive reservoir sign, i.e. meatus
immediately fills with pus after it has
been mopped out.
» No change in condition of patient or
it worsens in spite of adequate
medical treatment for 48 hours
» Mastoiditis, leading to
complications, e.g. facial paralysis,
labyrinthitis, intracranial complications, etc.
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® Aim of cortical mastoidectomy is to
exenterate all the mastoid air cells and remove
any pockets of pus.
® Adequate antibiotic treatment must be continued
at least for 5 days following
mastoidectomy.
n Complications of Acute Mastoiditis
m Subperiosteal abscess
m Labyrinthitis
m Facial paralysis
m Petrositis
m Extradural abscess
m Subdural abscess
m Meningitis
m Brain abscess
m Lateral sinus thrombophlebitis
m Otitic hydrocephalous.(MCQ)
n Abscesses in Relation to Mastoid Infection
m Postauricular abscess
ENT
n This is the commonest abscess that forms
over the mastoid. (MCQ)
n Pinna is displaced forwards, outwards and downwards.
n In infants and children, abscess forms over
the MacEwen’s triangle; pus in these cases
travels along the vascular channels of lamina
cribrosa.
m Zygomatic abscess
CHRONIC SUPPURATIVE OTITIS MEDIA
n It occurs due to infection of zygomatic air cells
situated at the posterior root of zygoma.
n Swelling appears in front of and above the
pinna
n There is associated oedema of the upper
eyelid.
n In these cases, pus collects either superficial
or deep to the temporalis muscle.
m Bezold abscess (MCQ)
n It can occur following acute coalescent
mastoiditis when pus breaks through the thin
medial side of the tip of the mastoid
n presents as a swelling in the upper part of
neck.
n The abscess may
l lie deep to sternocleidomastoid, pushing
the muscle outwards
l follow the posterior belly of digastric and
present as a swelling between the tip of
mastoid and angle of jaw,
l be present in upper part of posterior
triangle,
l reach the parapharyngeal space
l track down along the carotid vessels
n Clinical features
l Onset is sudden.
151
 l There is pain, fever, a tender swelling in
the neck and torticollis.
l Patient gives history of purulent otorrhoea.
l A Bezold abscess should be differentiated
from:
„ acute upper jugular lymphadenitis.
„ abscess or a mass in the lower part of the
parotid gland.
„ an infected branchial cyst.
„ parapharyngeal abscess.
„ jugular vein thrombosis.
n A CT scan of the mastoid and swelling of
the neck may establish the diagnosis.
n Treatment
l Cortical mastoidectomy for coalescent
mastoiditis
l exploration of the tip for a fistulous
opening into the soft tissues of the neck.
l Drainage of the neck abscess through a
ENT
separate incision and putting a drain in the
dependent part.
l Administration of intravenous antibiotics
m Meatal abscess (Luc’s abscess) (MCQ)
n In this case, pus breaks through the bony wall
between the antrum and external osseous
meatus.
n Swelling is seen in deep part of bony meatus.
n Abscess may burst into the meatus.
CHRONIC SUPPURATIVE OTITIS MEDIA
m Behind the mastoid (Citelli’s abscess) (MCQ)
n Abscess is formed behind the mastoid more
towards the occipital bone unlike
postauricular mastoid abscess which forms
over the mastoid
n Some authors consider Citelli’s abscess.as abscess
of the digastric triangle, which is formed by
tracking of pus from the mastoid tip,
m Parapharyngeal or retropharyngeal abscess
n This results from infection of the peritubal
cells due to acute coalescent mastoiditis.
n Petrositis
m Spread of infection from middle ear and
mastoid to the petrous part of temporal bone is called
petrositis.
m It may be associated with
n acute coalescent mastoiditis
n latent mastoiditis
n chronic middle ear infections.
m Clinical Features
n Gradenigo’s syndrome consists of a triad of
(MCQ)
l external rectus palsy (VIth nerve palsy)
l deep-seated ear or retro-orbital pain (Vth nerve
involvement)
152
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l persistent ear discharge.
n Persistent ear discharge with or without deep-seated
pain in spite of an adequate cortical or modified
radical mastoidectomy also points to
petrositis.
n Fever, headache, vomiting and sometimes neck rigidity
may also be associated.
n Some patients may get facial paralysis and recurrent
vertigo due to involvement of facial and
statoacoustic nerves.
m Diagnosis of petrous apicitis requires both CT
scan and MRI.
n CT scan of temporal bone will show bony
details of the petrous apex and the air cells
n MRI helps to differentiate diploic marrow
containing apex from fluid or pus.
m Treatment
n Cortical, modified radical or radical
mastoidectomy is often required if not already
done.
n The fistulous tract should be found out, which
is then curetted and enlarged to provide free drainage.
l Tract of posterosuperior cells starts in the
Trautmann’s triangle or the attic.
l Tract of anterior cells is situated near the
tympanic opening of eustachian tube
n Most cases of acute petrositis can now be
cured with antibacterial therapy alone.
n Facial Paralysis
m It can occur as a complication of both acute and
chronic otitis media.
m Acute Otitis Media
n Facial nerve function fully recovers if acute
otitis media is controlled with systemic
antibiotics.
n Myringotomy or cortical mastoidectomy
may sometimes be required.(MCQ)
m Chronic Otitis Media
n Facial paralysis in chronic otitis media either
results from cholesteatoma or from
penetrating granulation tissue.
n Treatment is urgent exploration of the
middle ear and mastoid.
n Labyrinthitis (MCQ)
m There are three types of labyrinthitis:
n Circumscribed labyrinthitis
n Diffuse serous labyrinthitis
n Diffuse suppurative labyrinthitis
m Circumscribed Labyrinthitis (Fistula of
Labyrinth)
n There is thinning or erosion of bony capsule
of labyrinth, usually of the horizontal
semicircular canal.
 n The causes are:
l Chronic suppurative otitis media with
cholesteatoma is the most common cause.
l Neoplasms of middle ear, e.g. carcinoma or
glomus tumour.
l Surgical or accidental trauma to labyrinth.
n Clinical features
l A part of membranous labyrinth is exposed
and becomes sensitive to pressure changes.
l Patient complains of transient vertigo
l often induced by pressure on tragus, cleaning the
ear or while performing Valsalva manoeuvre.
l It is diagnosed by “fistula test” which can
be performed in two ways.
„ Pressure on tragus.
® Sudden inward pressure is applied on
the tragus.
® Nystagmus may also be induced with
quick component towards the ear
under test.
„ Siegle’s speculum.
® When positive pressure is applied to ear
canal, patient complains of vertigo
usually with nystagmus.
® The quick component of nystagmus
would be towards the affected ear
(ampullopetal displacement of cupula).
l Ampullopetal flow of endolymph (as also
ampullopetal displacement of cupula)
whether in rotation, caloric or fistula test
causes nystagmus to same side.
l If negative pressure is applied, again it
would induce vertigo and nystagmus but this
time the quick component of nystagmus would be
directed to the (opposite) healthy side due to
ampullofugal displacement of cupula.
n Treatment
l In chronic suppurative otitis media or
cholesteatoma, mastoid exploration is often
required to eliminate the cause.
l Systemic antibiotic therapy
m Diffuse Serous Labyrinthitis
n It is diffuse intralabyrinthine inflammation
without pus formation
n it is a reversible condition if treated early.
n Aetiology
l Most often it arises from pre-existing
circumscribed labyrinthitis associated with
chronic middle ear suppuration or
cholesteatoma.
l In acute infections of middle ear
l It can follow stapedectomy or fenestration
operation.
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n Quick component of nystagmus is towards
the affected ear.
n Myringotomy is done if labyrinthitis has
followed acute otitis media and the drum is
bulging
n Cortical mastoidectomy (in acute
mastoiditis) or modified radical
mastoidectomy (in chronic middle ear
infection or cholesteatoma) will often be
required to treat the source of infection. (MCQ)
m Diffuse Suppurative Labyrinthitis
n This is diffuse pyogenic infection of the labyrinth
n permanent loss of vestibular and cochlear
functions.
n It usually follows serous labyrinthitis,
n Spontaneous nystagmus with its quick
component towards the healthy side.
n Patient is markedly toxic.
n There is total loss of hearing.
ENT
n Relief from vertigo is seen after 3-6 weeks due
to adaptation.
Intracranial complications of otitis media
n Extradural Abscess
m It is collection of pus between the bone and dura.
m It may occur both in acute and chronic
infections of middle ear.
m Presence is suspected when there is: (MCQ)
CHRONIC SUPPURATIVE OTITIS MEDIA
n Persistent headache on the side of otitis media.
n Severe pain in the ear.
n General malaise with low-grade fever.
n Pulsatile purulent ear discharge.
n Disappearance of headache with free flow
of pus from the ear (spontaneous abscess
drainage).
m Diagnosis is made on contrast-enhanced CT or
MRI.
m Treatment - Cortical or modified radical or
radical mastoidectomy
n Subdural Abscess
m This is collection of pus between dura and
arachnoid.
m Signs and symptoms of subdural abscess are due
to
l meningeal irritation
l thrombophlebitis of cortical veins of cerebrum
„ aphasia, hemiplegia, hemianopia.
l raised intracranial tension.
m Treatment
l Lumbar puncture should not be done as it
can cause herniation of the cerebellar tonsils.
l It is a neurological emergency.
l A series of burr holes or a craniotomy is
done to drain subdural empyema.
153
 Intravenous antibiotics are administered to
control infection.
n Meningitis
m Corticosteroids combined with antibiotic
therapy further helps to reduce neurological or
audiological complications.
m Meningitis following acute otitis media may
require myringotomy or cortical mastoidectomy.
m Meningitis following chronic otitis media with
cholesteatoma will require radical or modified radical
mastoidectomy.
n Otogenic Brain Abscess (MCQ)
m Fifty percent of brain abscesses in adults and 25%
in children are otogenic in origin.
m In adults, abscess usually follows chronic
suppurative otitis media with cholesteatoma
m in children, it is usually the result of acute otitis
media.
m Cerebral abscess is seen twice as frequently as
ENT
cerebellar abscess.
n Cerebral abscess develops as a result of
l direct extension of middle ear infection
through the tegmen
l by retrograde thrombophlebitis, in which
case the tegmen will be intact.
n Often it is associated with extradural abscess.
m Cerebellar abscess
n develops
CHRONIC SUPPURATIVE OTITIS MEDIA
l as a direct extension through the
Trautmann’s triangle
l by retrograde thrombophlebitis.
n This is often associated with extradural abscess,
perisinus abscess, sigmoid sinus thrombophlebitis or
labyrinthitis.
m Clinical Features
n Temporal lobe abscess
l Nominal aphasia.
„ If abscess involves dominant hemisphere,
i.e. left hemisphere in right-handed persons
„ patient fails to tell the names of common objects
such as key, pen, etc. but can demonstrate
their use.
l Homonymous hemianopia.
„ This is due to pressure on the optic radiations.
„ The defect is usually in the upper, but
sometimes in the lower quadrants.
l Contralateral motor paralysis.
„ In the usual upward spread of abscess, face is
involved first followed by the arm and
leg.
„ Inward spread, towards internal capsule, involves
the leg first followed by the arm and
the face.
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l Epileptic fits.
„ Involvement of uncinate gyrus causes
hallucinations of taste, and small and
involuntary smacking movements of lips
and tongue
l Pupillary changes and oculomotor palsy.
„ It indicates transtentorial herniation.
n Cerebellar abscess
l Headache involves suboccipital region and
may be associated with neck rigidity.
l Spontaneous nystagmus is common and
irregular and generally to the side of lesion.
l Ipsilateral hypotonia and weakness.
l Ipsilateral ataxia. Patient staggers to the side
of lesion.
l Past-pointing and intention tremor can be
elicited by finger nose test.
l Dysdiadokokinesia. Rapid pronation and
supination of the forearm shows slow and
irregular movements on the affected side.
m CT scan
n is the single most important means of
investigation and helps to find the site and size
of an abscess
n It also reveals associated complications such as
extradural abscess, sigmoid sinus thrombosis, etc.
m Treatment
n Chloramphenicol and third generation cephalosporins are
usually effective. Bacteroides fragilis, an
obligate anaerobe, often seen in brain abscess,
responds to metronidazole.
n Aminoglycoside antibiotics, e.g. gentamicin, may be
required if infection suspected is pseudomonas
or proteus.
n Raised intracranial tension can be lowered
by dexamethasone or mannitol 20%
n Lateral Sinus Thrombophlebitis (Syn. Sigmoid
Sinus Thrombosis)
m It is an inflammation of inner wall of lateral
venous sinus with formation of a thrombus.
m Clinical Features
n Hectic Picket-fence type of fever with rigors
l This is due to septicaemia, often coinciding
with release of septic emboli into blood
stream.
l Clinical picture resembles malaria but lacks
regularity.(MCQ)
l In between the bouts of fever, patient is alert with
a sense of well-being.
n Headache
l In early stage, it may be due to perisinus abscess
and is mild.
 l Later, it may be severe when intracranial pressure
rises due to venous obstruction.
n Progressive anaemia and emaciation
n Griesinger’s sign (MCQ)
l This is due to thrombosis of mastoid emissary vein.
l Oedema appears over the posterior part of
mastoid.
n Papilloedema
l Its presence depends on obstruction to
venous return.
l It is often seen when right sinus (which is
larger than left) is thrombosed or when
clot extends to superior sagittal sinus.
m Tobey-Ayer test (MCQ)
n This is to record CSF pressure by manometer
and to see the effect of manual compression of one
or both jugular veins.
n Compression of vein on the thrombosed side
produces no effect while compression of vein on
healthy side produces rapid rise in CSF pressure
which will be equal to bilateral compression of
jugular veins.
m Crowe-Beck test
n Pressure on jugular vein of healthy side produces
engorgement of retinal veins (seen by
ophthalmoscopy) and supraorbital veins.
n Engorgement of veins subside on release of
pressure.
m Tenderness along jugular vein
n This is seen when thrombophlebitis extends along
the jugular vein.
n There may be associated enlargement and
inflammation of jugular chain of lymph
nodes and torticollis.
m Investigations
n X-ray mastoids
l clouding of air cells (acute mastoiditis)
l destruction of bone (cholesteatoma).
n Contrast-enhanced CT scan can show sinus
thrombosis by typical delta sign.
l It is a triangular area with rim enhancement, and
central low density area is seen in posterior
cranial fossa on axial cuts.
n MR imaging
l better delineates thrombus.
l “Delta sign” may also be seen on contrast-
enhanced MRI.
l MR venography is useful to assess
progression or resolution of thrombus.
m Complications
n Septicaemia and pyaemic abscesses in lung,
bone, joints or subcutaneous tissue.
n Meningitis and subdural abscess.
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n Cerebellar abscess.
n Thrombosis of jugular bulb and jugular vein
with involvement of IXth, Xth and XIth cranial
nerves.
n Cavernous sinus thrombosis. There would
be chemosis, proptosis, fixation of eyeball and
papilloedema.
n Otitic hydrocephalus, when thrombus
extends to sagittal sinus via confluens of sinuses.
m Treatment
n Mastoidectomy and exposure of sinus
n Ligation of internal jugular vein
n Anticoagulant therapy
n Otitic Hydrocephalus
m It is characterised by raised intracranial pressure with
normal CSF findings. It is seen in children and
adolescents with acute or chronic middle ear
infections.
m Mechanism
ENT
n Lateral sinus thrombosis accompanying
middle ear infection causes obstruction to venous
return.
n If thrombosis extends to superior sagittal
sinus, it will also impede the function of arachnoid
villi to absorb CSF
m Clinical Features
n Severe headache, sometimes intermittent, is
CHRONIC SUPPURATIVE OTITIS MEDIA
the presenting feature. It may be accompanied
by nausea and vomiting.
n Diplopia due to paralysis of VIth cranial nerve.
n Blurring of vision due to papilloedema or
optic atrophy.
n Papilloedema may be 5-6 diopters, sometimes
with patches of exudates and haemorrhages.
n Nystagmus due to raised intracranial tension.
m Lumbar puncture.
n CSF pressure exceeds 300 mm of water (normal
70-120 mm H2O).
n It is otherwise normal in cell, protein and sugar content
and is bacteriologically sterile.
m Treatment
n The aim is to reduce CSF pressure to prevent optic
atrophy and blindness. This is achieved
medically by acetazolamide and
corticosteroids and repeated lumbar
puncture or placement of a lumbar drain.
n Sometimes, draining CSF into the peritoneal
cavity (lumboperitoneal shunt) is necessary.
n TUBERCULAR OTITIS MEDIA
m In most of the cases, infection is secondary to
pulmonary tuberculosis
m infection reaches the middle ear through eustachian
tube.
155
 m Disease is mostly seen in children and young m Fixation of ossicles, e.g. otosclerosis,
adults. tympanosclerosis, adhesive otitis media
m Clinical Features (MCQ) m Eustachian tube blockage, e.g. retracted tympanic
n Painless ear discharge membrane, serous otitis media.
l Earache is characteristically absent in cases of
tubercular otitis media. (MCQ) Average Hearing Loss Seen in Different Lesions of
l Discharge is often foul-smelling because of Conductive Apparatus
the underlying bone destruction. 1. Complete obstruction of ear canal: 30 dB
n Perforation
2. Perforation of tympanic membrane 10-40 dB
(it varies and is directly proportional
l Multiple perforations, 2 or 3 in number,
to the size of perforation) :
are seen in pars tensa and form a classical 3. Ossicular interruption with intact drum : 54 dB
sign of disease. 4. Ossicular interruption with perforation : 38 dB
n Hearing loss 5. Malleus fixation : 10-25 dB
l There is severe hearing loss, out of 6. Closure of oval window : 60 dB
proportion to symptoms.
Note here that ossicular interruption with intact drum causes more
l Mostly conductive
loss than ossicular interruption with perforated drum.
n Facial paralysis (MCQ)
l It is a common complication
Sensorineural hearing loss
n The characteristics of sensorineural hearing loss are:
ENT

TOPIC 8 - DEAFNESS
m A positive Rinne test, i.e. air AC > BC.
m Weber lateralised to better ear.
m Bone conduction reduced on Schwabach and
Hearing Loss
absolute bone conduction tests.
Organic Non-organic m More often involving high frequencies.
m No gap between air and bone conduction curve

Conductive Sensarineural on audiometry (Fig. 5.6).

m Loss may exceed 60 dB.
Sensory (cochlear) Neural m Speech discrimination is poor.
m There is difficulty in hearing in the presence of
Peripheral Central
DEAFNESS

noise.
(VIIIth nerve) (Central auditory pathways) n Common causes of acquired SNHL include:
m Infections of labyrinth-viral, bacterial or
Conductive hearing loss spirochaetal,
n The characteristics of conductive hearing loss m Trauma to labyrinth or VIIIth nerve, e.g. fractures
are: of temporal bone or concussion of labyrinth or
m Negative Rinne test, i.e. BC > AC. ear surgery,
m Weber lateralised to poorer ear. m Noise-induced hearing loss,
m Normal absolute bone conduction. m Ototoxic drugs,
m Low frequencies affected more. m Presbycusis,
m Audiometry shows bone conduction better than m Meniere’s disease
air conduction with air-bone gap. m Acoustic neuroma
m Greater the air-bone gap, more is the conductive m Sudden hearing loss,
loss m Familial progressive SNHL,
m Loss is not more than 60 dB. m Systemic disorders, e.g. diabetes, hypothyroidism, kidney
m Speech discrimination is good. disease, autoimmune disorders, multiple sclerosis, blood
n Acquired causes of conductive hearing loss dyscrasia
m Perforation of tympanic membrane, traumatic or infective n Viral labyrinthitis
m Fluid in the middle ear, e.g. acute otitis media, serous m Measles, mumps and cytomegaloviruses are
otitis media or haemotympanum well documented to cause labyrinthitis.
m Mass in middle ear, e.g. benign or malignant tumour n Syphilitic hearing loss
m Disruption of ossicles, e.g. trauma to ossicular chain, m Sensorineural hearing loss is caused both by
chronic suppurative otitis media, congenital and acquired syphilis.
cholesteatoma
156
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 m Clinical picture simulate Meniere’s disease.
m Hennebert’s sign.
n A positive fistula sign in the absence of a
fistula.
n This is due to fibrous adhesions between the
stapes footplate and the membranous labyrinth.
m Tullio phenomenon in which loud sounds produce
vertigo.
n Familial Progressive Sensorineural Hearing Loss
m progressive degeneration of the cochlea starting
in late childhood or early adult life.
m Hearing loss is bilateral
m flat or basin-shaped audiogram but an excellent
speech discrimination.
n Drugs and Ototoxicity
m Aminoglycoside antibiotics
n Streptomycin, gentamicin and tobramycin
are primarily vestibulotoxic (MCQ)
n They selectively destroy type I hair cells of
the crista ampullaris
n Neomycin, kanamycin, amikacin,
sisomycin and dihydrostreptomycin are
cochleotoxic. (MCQ)
n They cause selective destruction of outer hair
cells (MCQ)
n Damage start at the basal coil and progressing
onto the apex of cochlea.
m Diuretics
n Furosemide and ethacrynic acid are called loop
diuretics
n cause oedema and cystic changes in the stria
vascularis of the cochlear duct
m Salicylates
n Symptoms of salicylate ototoxicity
l tinnitus
l bilateral sensorineural hearing loss
particularly affecting higher frequencies.
n Hearing loss due to salicylates is reversible
after the drug is discontinued.
m Quinine
n Ototoxic effects of quinine are due to
vasoconstriction in the small vessels of the
cochlea and stria vascularis.
n Ototoxic symptoms due to quinine are tinnitus
and sensorineural hearing loss, both of which
are reversible.
n Congenital deafness and hypoplasia of
cochlea have been reported in children whose
mothers received this drug during the first
trimester of pregnancy.
m Chloroquine
n Effect is similar to that of quinine
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m Cytotoxic drugs
n Nitrogen mustard, cisplatin and carboplatin can cause
cochlear damage.
n They affect the outer hair cells of cochlea.
m Deferoxamine (Desferrioxamine)
n It is an iron-chelating substance
n Like cisplatin and aminoglycosides, deferoxamine also
causes high frequency sensorineural hearing
loss.
m Topical ear drops
n Deafness has occurred with the use of
chlorhexidine which was used in the
preparation of ear canal before surgery or use
of ear drops containing amino-glycoside
antibiotics, e.g. neomycin, framycetin and
gentamicin.
n Noise Trauma
m Hearing loss associated with exposure to noise is
seen in boiler makers, iron-and coppersmiths
ENT
and artillery men.
m A frequency of 2000 to 3000 Hz causes more
damage than lower or higher frequencies;
m Continuous noise is more harmful;
m A noise of 90 dB (A) SPL, 8 hours a day for 5
days per week is the maximum safe limit as
recommended by Ministry of Labour, Govt. of
India-Model Rules under Factories Act
m No exposure in excess of 115 dB (A) is to be
permitted.
m No impulse noise of intensity greater than 140
DEAFNESS
dB (A) is permitted.
m The audiogram in NIHL
n shows a typical notch, at 4 kHz, both for air
and bone conduction (MCQ)
n It is usually symmetrical on both sides.
m At early stage, patient complains of high pitched
tinnitus and difficulty in hearing in noisy
surroundings but no difficulty in day to day hearing.
m As the duration of noise exposure increases,
the notch deepens and also widens to involve lower
and higher frequencies.
m Hearing impairment becomes clinically apparent
to the patient when the frequencies of 500, 1000
and 2000 Hz (the speech frequencies) are also
affected.
m NIHL causes damage to hair cells, starting in the
basal turn of cochlea.
m Outer hair cells are affected before the inner hair
cells.
m Persons who have to work at places where noise
is above 85 dB (A) should have pre-employment
and then annual audiograms for early detection.
m Ear protectors (ear plugs or ear muffs)
157
 n should be used where noise levels exceed 85 dB
(A).
n They provide protection up to 35 dB.
m 5 dB rule of time-intensity states that “any rise of
5 dB noise level will reduce the permitted noise exposure
time to half ”.
n Sudden Hearing Loss
m sensorineural hearing loss that has developed
over a period of hours or a few days
m Mostly it is unilateral.
m Aetiology
n Most often — idiopathic variety
n three aetiological factors are considered-viral,
vascular or the rupture of cochlear
membranes.
n Spontaneous perilymph fistulae may form
in the oval or round window.
n Other aetiological factors
l Infections
ENT
l Low molecular weight dextran
„ It decreases blood viscosity.
„ It is contraindicated in cardiac failure and
bleeding disorders.
l Hyperbaric oxygen therapy
m Prognosis
n Fortunately, about half the patients of
idiopathic sensorineural hearing loss recover
spontaneously within 15 days.
n Chances of recovery are poor after 1 month.
n Severe hearing loss and that associated with
vertigo have poor prognosis. Younger patients
below 40 and those with moderate losses have
better prognosis.
n Presbycusis
m Sensorineural hearing loss
m associated with physiological aging process in
the ear is called presbycusis. It usually manifests
at the age of 65 years

„ Mumps, herpes zoster, meningitis, m Four pathological types of presbycusis have

encephalitis, syphilis, otitis media. been identified.
l Trauma n Sensory
„ Head injury, ear operations, noise trauma, l This is characterised by degeneration of the
barotrauma, spontaneous rupture of organ of corti
cochlear membranes. l starting at the basal coil and progressing
l Vascular gradually to the apex.
„ Haemorrhage (leukaemia), embolism or l Higher frequencies are affected but speech
thrombosis of labyrinthine or cochlear artery discrimination remains good.
or their vasospasm. n Neural
„ They may be associated with diabetes, l This is characterised by degeneration of the
DEAFNESS

hypertension, polycythaemia, cells of spiral ganglion

macroglobinaemia or sickle cell trait. l start at the basal coil and progressing to the apex.
l Ear (otologic) l manifests with high tone loss but speech
„ Meniere’s disease, Cogan’s syndrome, large discrimination is poor and out of proportion to
vestibular aqueduct. the pure tone loss.
l Toxic n Strial or metabolic
„ Ototoxic drugs, insecticides. l This is characterised by atrophy of stria
l Neoplastic vascularis in all turns of cochlea
„ Acoustic neuroma. Metastases in l It runs in families.
cerebellopontine angle, carcinomatous l Audiogram is flat
neuropathy. l but speech discrimination is good.
l Miscellaneous n Cochlear conductive
„ Multiple sclerosis, hypothyroidism, l This is due to stiffening of the basilar membrane
sarcoidosis. thus affecting its movements. Audiogram is
l Psychogenic. sloping type.
m Management m Patients of presbycusis have great difficulty in
n Treatment is empirical and consists of: hearing in the presence of background noise
l Bed rest. though they may hear well in quiet
l Steroid therapy surroundings.
l Inhalation of carbogen (5% CO2 + 95% O2) m They may complain of speech being heard but
„ It increases cochlear blood flow and not understood.
improves oxygenation.
l Vasodilator drugs.
158
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 m Recruitment phenomenon is positive and all the delivered to two ears simultaneously, only
sounds suddenly become intolerable when the ear which receives tone of greater intensity will
volume is raised. hear it.
m Tinnitus is another bothersome problem and in n Acoustic reflex threshold
some it is the only complaint. l Normally, stapedial reflex is elicited at 70-100
m Patients of presbycusis can be helped by a hearing dB SL.
aid. l If patient claims total deafness but the
m They should also have lessons in speech reading reflex can be elicited, it indicates NOHL.
through visual cues. Curtailment of smoking n Electric response audiometry (ERA)
and stimulants like tea and coffee may help to l It is very useful in NOHL and can establish
decrease tinnitus. hearing acuity of the person to within 5-10 dB of
n Non-organic hearing loss (NOHL) actual thresholds.
m In this type of hearing loss, there is no organic
lesion. Category Hearing acuity
m It is either due to malingering or is psychogenic. Mild impairment Morethan 30 but not
m Malingering - usually there is a motive to claim some
morethan 45dB in better
compensation for being exposed to industrial noises,
ear.
head injury or ototoxic medication.
Serious impairment Morethan 45 but not
m Patient may present with any of the three clinical
morethan 60 dB in

ENT
situations:
n Total hearing loss in both ears
better ear.
n total loss in only one ear Severe impairment Morethan 60 but not
n exaggerated loss in one or both ears. morethan 90 dB in
m Malingering vs Organic hearing loss better ear
n High index of suspicion
l Suspicion further rises when the patient makes Degree of Hearing Loss (WHO classification)
exaggerated efforts to hear, Degree of Hearing Loss
„ frequently making requests to repeat
1. Mild 26-40 dB
the question
2. Moderate 41-55 dB
„ placing a cupped hand to the ear.

DEAFNESS
3. Moderately severe 56-70 dB
n Inconsistent results on repeat pure tone and
4. Severe 71-91 dB
speech audiometry tests
5. Profound Morethan 91 dB
n Normally, the result of repeat tests are within
6. Total
±5 dB.
n A variation greater than 15 dB is diagnostic
of NOHL.
n Absence of shadow curve
l Normally, a shadow curve can be obtained
while testing bone conduction, if the healthy ear
is not masked. This is due to transcranial
transmission of sound to the healthy ear.
l Absence of this cur ve in a patient
complaining of unilateral deafness is diagnostic
of NOHL.
n Inconsistency in PTA and SRT
l Normally, pure tone average (PTA) of three
speech frequencies (500, 1000 and 2000 Hz)
is within 10 dB of SRT.
l An SRT better than PTA by more than 10 dB
points to NOHL.
n Stenger test
l Principle involved is that, if a tone of two
intensities, one greater than the other, is
159
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 TOPIC 9 - NASOPHARYNGEAL CANCER
Nasopharyngeal cancer
n Nasopharyngeal cancer is most common in China
particularly in southern states and Taiwan.
m Burning of incense or wood (polycyclic
hydrocarbon),
m use of preserved salted fish (nitrosamines)
m vitamin C deficient diet (vitamin C blocks
nitrosification of amines and is thus protective)
n Nasopharyngeal cancer is uncommon in India except
in the North East region
n Aetiology
n Chinese have a higher genetic susceptibility
n Epstein-Barr virus is closely associated with
nasopharyngeal cancer. (MCQ)
n Pathology
n Squamous cell carcinoma is the most
common (85%).
ENT
„ CN VI paralysis is the most common of
Cranial nerve palsies.
„ Squint and diplopia due to involvement
of CN VI
„ Ophthalmoplegia (CN III, IV and VI)
„ facial pain and reduced corneal reflex may
(invasion of CN V through foramen
lacerum) occur.
„ Tumours may directly invade the orbit
leading to exophthalmos and blindness
(CN II at the apex of the orbit).
„ Involvement of IXth, Xth and XIth cranial
nerves may occur, constituting jugular
foramen syndrome.
® Usually, this is due to pressure of enlarged
lateral retropharyngeal lymph nodes
on these nerves in the neck.
„ CN XII may be involved due to extension
of growth to hypoglossal canal. Horner’s

n Grossly, the tumour presents in three forms:
l Proliferative
„ When a polypoid tumour fills the
nasopharynx, it causes obstructive nasal symptoms.l Nasopharyngeal cancer can cause conductive
l Ulcerative
„ Epistaxis is the common symptom.
l Infiltrative
„ Growths infiltrate submucosally.
n Spread of nasopharyngeal carcinoma
NASOPHARYNGEAL CANCER
syndrome may occur due to involvement of
cervical sympathetic chain. (MCQ)
l Trotter’s tria
deafness (eustachian tube blockage),
ipsilateral temporoparietal neuralgia
(involvement of CN V) and palatal paralysis
(CN X)-collectively called Trotter’s triad.(MCQ)
n Cervical nodal metastases (MCQ)

n The commonest site of origin is fossa of l This may be the only manifestation of
Rosenmuller in the lateral wall of nasopharynx. (MCQ) nasopharyngeal cancer.
n It can spread into the cranium through l Cervical lymphadenopathy (most common)
foramen lacerum and cause involvement of (60-90%)
various cranial nerves. l A lump of nodes is found between the angle
n Lymph node involvement is common because of jaw and the mastoid
of rich lymphatic network in the nasopharynx. l some nodes along the spinal accessory in
n Clinical Features the posterior triangle of neck.
n It is mostly seen in fifth to seventh decades l Nodal metastases are seen in 75% of the
n Males are three times more prone than females. patients
n Symptomatology is divided into four main groups: l when first seen, about half of them with
l Nasal bilateral nodes.
„ Nasal obstruction, nasal discharge, denasal n Distant metastases involve bone, lung, liver
speech (rhinolalia clausa) and epistaxis.(MCQ) and other sites.
l Otologic WHO Classification
n
„ Due to obstruction of eustachian tube,
Present WHO terminology
there is conductive hearing loss, serous or suppurative
Type I (25%) Squamous cell carcinoma
otitis media. (MCQ)
Type II (12%) Non-keratinising carcinoma
„ Tinnitus and dizziness may occur.
-Without lymphoid stroma
„ Presence of unilateral serous otitis media in an
-With lymphoid stroma
adult should raise suspicion of
Type III (63%) Undifferentiated carcinoma
nasopharyngeal growth. (MCQ)
-Without lymphoid stroma
l Ophthalmoneurologic
-With lymphoid stroma
„ Nearly all the cranial nerves may be
involved.
160
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 m Type III is the most common in North America.
m type II and type III
n are associated with higher titres of EB virus
n have higher local control rates with radiotherapy.
Staging
m In nasopharyngeal carcinoma, N. classification
is different from that of other mucosal cancers
of the head and neck.
n Enlarged nodes in the lower neck
(supraclavicular fossa) places them in N3
category.
n Less weightage is given to nodes in upper neck.
n Nodes even up to 6 cm size are still
categorised as N1 as against N2 at other sites.
m Supraclavicular fossa or Ho’s triangle
n defined as area of neck lying between three
points:
l medial end of clavicle
l lateral end of clavicle
l the point where neck meets the shoulder
n Enlarged node(s) in this triangle, irrespective
of the size, are categorised as N3
m Treatment
n Irradiation is the treatment of choice. (MCQ)
n Supervoltage therapy using large ports which
include cervical nodes, delivering a tumour dose
of 6000-7000 rads, is employed.
n Radical neck dissection is required for
persistent nodes when primary has been controlled.
n Recurrent or residual tumour
l requires a second course of external radiation or
intracavitary implants (brachytherapy).
l also been treated with cryosurgery through
a palatal fenestration or in selected cases
by skull base surgery.
n Chemotherapy
l Some stages III and IV cancers of
nasopharynx
„ can be cured by radiotherapy alone
„ cure rate is doubled when chemotherapy
is combined with radiotherapy.
l Cisplatin or cisplatin with 5-FU have been
used
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TOPIC 10 - MENIERE’S DISEASE
n Meniere’s Disease, also called endolymphatic
hydrops
n a disorder of the inner ear where the endolymphatic
system is distended with endolymph.
n Pathology
m The main pathology mainly affect the cochlear
duct (scala media) and the saccule, and to a
lesser extent the utricle and semicircular canals.
m Cochlear duct is distended with endolymph pushing
the Reissner’s membrane into scala vestibuli.
m Distension of membranous labyrinth leads to
rupture of Reissner’s membrane and thus mixing of
perilymph with endolymph, which is thought to bring
about an attack of vertigo.
m Vasomotor disturbance
n There is sympathetic over-activity resulting in spasm
of internal auditory artery and/or its
branches
ENT
n interfere with the function of cochlear or
vestibular sensory neuroepithelium. This is
responsible for deafness and vertigo.
n Anoxia of capillaries of stria vascularis also
causes increased permeability, with transudation of
fluid and increased production of endolymph.
m Allergy
n Nearly 50% of patients with Meniere’s disease
MENIERE’S DISEASE
have concomitant inhalant and/or food allergy.
m Sodium and water retention
m Hypothyroidism
n Clinical Features
m commonly seen in the age group of 35-60 years.
(MCQ)
m Males are affected more than females.(MCQ)
m Usually, disease is unilateral (MCQ)
m Cardinal symptoms of Meniere’s disease are:
(MCQ)
n Episodic vertigo
n Fluctuating hearing loss
n Tinnitus
n Sense of fullness or pressure in the involved ear.
m Vertigo
n It comes in attacks.
n The onset is sudden.
n Attacks come in clusters, with periods of
spontaneous remission lasting for weeks,
months or years.
n Usually, an attack is accompanied by nausea and
vomiting with ataxia and nystagmus.
n Severe attacks may be accompanied by other
symptoms of vagal disturbances such as
abdominal cramps, diarrhoea, cold sweats, pallor and
bradycardia. 161
 n Usually, there is no warning symptom of an n Rinne test is positive, absolute bone
oncoming attack of vertigo conduction is reduced in the affected ear and
n Tullio phenomenon. Weber is lateralised to the better ear.
l It is a condition where loud sounds or noise produce n Investigations
vertigo m Pure tone audiometry

l due to the distended saccule lying against n There is sensorineural hearing loss.

the stapes footplate. n In early stages, lower frequencies are affected

l This phenomenon is also seen when there are and the curve is of rising type.
three functioning windows in the ear, e.g. n When higher frequencies are involved curve

a fenestration of horizontal canal in the presence of a becomes flat or a falling type

mobile stapes. m Speech audiometry

m Hearing loss (MCQ) n Discrimination score is usually 55-85% between

n It usually accompanies vertigo or may precede it. the attacks but discrimination ability is much
n Hearing improves after the attack and may be impaired during and immediately following
normal during the periods of remission. an attack.
n This fluctuating nature of hearing loss is quite m Special audiometry tests

characteristic of the disease. (MCQ) n They indicate the cochlear nature of disease

n Distortion of sound. and thus help to differentiate from retrocochlear

l A tone of a particular frequency may lesions, e.g. acoustic neuroma
ENT

appear normal in one ear and of higher pitch in the l Recruitment test is positive.

other leading to diplacusis. l SISI (short increment sensitivity index)

l Music appears discordant. test.

l Intolerance to loud sounds. „ SISI score is better than 70% in two-thirds

l Patients of Meniere’s disease cannot tolerate of the patients (Normal 15%).

amplification of sound due to recruitment l Tone decay test.

phenomenon. „ Normally, there is decay of less than 20 dB.

l They are poor candidates for hearing m Electrocochleography

n It shows changes diagnostic of Meniere’s
MENIERE’S DISEASE

aids.(MCQ)
m Tinnitus (MCQ) disease.
n It is low-pitched roaring type, and is aggravated n Normally, ratio of summating potential (SP)

during acute attacks. Sometimes, it has a hissing to action potential (AP) is 30%.
character. n In Meniere’s disease, SP/AP ratio is greater than

n It may persist during periods of remission. 30%

n Change in intensity and pitch of tinnitus may m Caloric test

be the warning symptom of attack. n It shows reduced response on the affected side in

m Sense of fullness or pressure 75% of cases.

n Like other symptoms, it also fluctuates. n Often, it reveals a canal paresis on the affected side

n It may accompany or precede an attack of vertigo. (most common)

m Other features m Glycerol test

n Patients of Meniere’s disease often show signs n Glycerol is a dehydrating agent.

of emotional upset due to apprehension of n When given orally, it reduces endolymph

the repetition of attacks pressure and thus causes an improvement in hearing.

n Examination m Audiogram in early Meniere’s disease

m Otoscopy n Hearing loss is sensorineural and more in lower

n No abnormality is seen in the tympanic frequencies-the rising curve. As the disease

membrane. progresses, middle and higher frequencies get
m Nystagmus involved and audiogram becomes flat or falling
n It is seen only during acute attack. type (B & C).
n The quick component of nystagmus is towards
the unaffected ear.
m Tuning fork tests
n They indicate sensorineural hearing loss.

162
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 Normal Cochlear lesion Retrocochlear lesion
• Pure tone audiogram Normal Sensorineural hearing loss Sensorineural hearing loss
• Speech discrimination score 90-100% Below 90% Very poor
• Roll over phenomenon Absent Absent Present
• Recruitment Absent Present Absent
• SISI score 0-15% Over 70% 0-20%
• Threshold tone decay test 0-15 dB Lessthan 25 dB Above 25 dB
• Stapedial reflex Present Present Absent
• Stapedial reflex decay (page 109) Normal Normal Abnormal
• E.R.A Normal interval Normal interval Wave V delayed or absent
between wave I & V between wave I & V
n Variants of Meniere’s Disease n Avoid over-indulgence in coffee, tea and
m Cochlear hydrops alcohol
n Here, only the cochlear symptoms and signs of n Avoid stress and bring a change in life-style
Meniere’s disease are present. n Avoid activities requiring good body balance
n Vertigo is absent n Professions such as flying, under-water diving
n increased endolymph pressure is confined to or working at great heights should be
the cochlea only avoided.
n there is block at the level of ductus reuniens, m Management of Acute Attack

ENT
m Vestibular hydrops n Vestibular sedatives
n Patient gets typical attacks of episodic vertigo while l to relieve vertigo.
cochlear functions remain normal. l dimenhydrinate, promethazine or
m Drop attacks (Tumarkin’s otolithic crisis) prochlorperazine
n In this, there is a sudden drop attack without loss of l Diazepam
consciousness. l atropine, 0.4 mg, given subcutaneously.
n There is no vertigo or fluctuations in hearing loss. n Vasodilators
n Patient gets a feeling of having been pushed to the l Inhalation of carbogen (5% CO2 with 95%

MENIERE’S DISEASE
ground or poleaxed O2).
n Possible mechanism is deformation of the l It is a good cerebral vasodilator and improves
otolithic membrane of the utricle or saccule labyrinthine circulation.
due to changes in the endolymphatic pressure. n Histamine drip.
m Lermoyez syndrome l Histamine diphosphate, given as i.v. drip
n Here symptoms of Meniere’s disease are seen m Management of Chronic Phase
in reverse order. n Vestibular sedatives
n First there is progressive deterioration of hearing, n Vasodilators
followed by an attack of vertigo, at which time l Nicotinic acid
the hearing recovers. l Betahistine
m Meniere’s Disease vs Meniere’s Syndrome „ given orally, also increases labyrinthine blood
n Meniere’s disease is an idiopathic condition flow by releasing histamine in the body.
n Meniere’s syndrome, results from n Diuretics
l trauma (head injury or ear surgery), l Sometimes, diuretic Furosemide, 40
l viral infections (following measles or mumps) n Propantheline bromide
l syphilis (congenital or late acquired), n Elimination of allergen
l Cogan’s syndrome, n Hormones
l otosclerosis or autoimmune disorders. l Hypothyroidism should be treated with
n Treatment replacement therapy given.
m General Measures n Intratympanic gentamicin therapy
n Reassurance (chemical labyrinthectomy).
n Cessation of smoking m Surgical Treatment
l Nicotine causes vasospasm. n Conservative procedures

n Low salt diet l Decompression of endolymphatic sac. (MCQ)

n Avoid excessive intake of water l Endolymphatic shunt operation.

163
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 l Sacculotomy (Fick’s operation).
l Section of vestibular nerve.
l Ultrasonic destruction of vestibular
labyrinth.
„ Cochlear function is preserved.
n Destructive procedures
l They totally destroy cochlear and vestibular
function and are thus used only when
cochlear function is not serviceable.
l Labyrinthectomy.
„ Membranous labyrinth is completely
l Intermittent low pressure pulse therapy
[Meniett device therapy )
„ Intermittent positive pressure waves can be
delivered through an instrument called
Meniett device
„ A prerequisite for such a therapy is to perform
a myringotomy and insert a ventilation tube so that
the device when coupled to the external ear
ENT
canal can deliver pressure waves to the
round window membrane via the
ventilation tube.
„ Pressure waves pass through the perilymph and
cause reduction in endolymph pressure
by redistributing it through various
communication channels such as the
endolymphatic sac or the blood.
NASOPHARYNGEAL ANGIOFIBROMA
164
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TOPIC 11 -
NASOPHARYNGEAL ANGIOFIBROMA
Nasophar yngeal Fibroma (Juvenile
Nasopharyngeal Angiofibroma)
n it is the commonest of all benign tumours of
nasopharynx.
n Aetiology
m tumour is predominantly seen in adolescent males in
the second decade of life . (MCQ)
m it is thought to be testosterone dependent
n Site of Origin and Growth (MCQ)
m arise from the posterior part of nasal cavity close
to the superior margin of sphenopalatine foramen.
m It runs behind the posterior wall of maxillary
sinus which is pushed forward as the tumour grows.
n Pathology
m made up of vascular and fibrous tissues
m Mostly, the vessels are just endothelium-lined
spaces with no muscle coat. This accounts for the
severe bleeding as the vessels lose the ability to
contract
m also the bleeding cannot be controlled by
application of adrenaline.
n Extensions of Nasopharyngeal Fibroma
m Orbits giving rise to proptosis and “frog-face
deformity”.
m Cranial cavity. Middle cranial fossa is the most
common.
n Clinical Features
m seen almost exclusively in males in the age group
of 10-20 years.
m Profuse and recurrent epistaxis.
n This is the most common presentation. (MCQ)
m Progressive nasal obstruction and denasal speech
due to mass in the postnasal space.
m Conductive hearing loss and serous otitis
media due to obstruction of eustachian tube.
m Mass in the nasopharynx.
n Tumour is sessile, lobulated or smooth and
obstructs one or both choanae.
n It is pink or purplish in colour.
n Consistency is firm but digital palpation
should never be done until at the time of
operation.
n Investigations
m CT scan of the head with contrast
enhancement
n now the investigation of choice (MCQ)
n Anterior bowing of the posterior wall of
maxillary sinus (often called the antral sign or
Holman-Miller sign) is pathognomic of
angiofibroma.(MCQ).
n Magnetic resonance imaging (MRI)
m complementary to CT scans, when soft tissue
extensions are present intracranially, in the
infratemporal fossa or into the orbit.
n Carotid angiography
m shows extension of tumour ,its vascularity and feeding
vessels.
m It is done when embolisation is planned before
operation.
n Diagnosis
m It is mostly based on clinical picture.
m Biopsy of the tumour
n is attended with profuse bleeding
n is therefore, avoided.
n Treatment
m Surgery
n Surgical excision is now the treatment of
choice. (MCQ)
n Transpalatal approach is employed for
tumours confined to nasopharynx.
n Lateral rhinotomy approach
l gives wide exposure
l generally preferred for the tumour and its
extensions.
n There may be about 2 litres of blood loss
during surgery
n A course of oestrogen therapy (stilboestrol)
may reduce vascularity of tumour.
n How to reduce blood loss at surgery.
l Pre-operative radiation
l Cryotherapy of the tumour
l embolisation of the feeding vessels
n Recurrence of tumour after surgical removal
is not uncommon.
m Radiotherapy
n Radiotherapy has been used as a primary mode
of treatment
n Radiotherapy is also used for intracranial
extension of disease when tumour derives
its blood supply from the internal carotid system.
n Recurrent angiofibromas have also been
treated by intensity modulated radiotherapy-a newer
mode of treatment.
m Hormonal (MCQ)
n Since the tumour occurs in young males at
puberty, hormonal therapy as the primary
or adjunctive treatment has been used.
n Diethylstilboestrol and flutamide have been
used.
m Chemotherapy
n Recurrent and residual lesions have been treated
by chemotherapy, doxorubicin, vincristine
and dacarbazine in combination.
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TOPIC 12 - VOCAL CORD PARALYSIS
Laryngeal Paralysi
n Nerve Supply of Larynx
m Motor
n All the muscles which move the vocal cord
(abductors, adductors or tensors) are supplied by
the recurrent lar yngeal nerve except the
cricothyroid muscle. (MCQ)
n Cricothyroid receives its innervation from the
external laryngeal nerve-a branch of superior
laryngeal nerve.
m Sensory
n Above the vocal cords, larynx is supplied by
internal laryngeal nerve-a branch of superior
laryngeal
n Below the vocal cords , larynx is supplied by
recurrent laryngeal nerve.
m Recurrent laryngeal nerve
ENT
n Right recurrent laryngeal nerve
l arises from the vagus at the level of
subclavian artery
l hooks around of subclavian artery and then
ascends between the trachea and oesophagus.
n Left recurrent laryngeal nerve
l arises from the vagus in the mediastinum at
the level of arch of aorta
VOCAL CORD PARALYSIS
l loops around arch of aorta and then ascends
into the neck in the tracheo-oesophageal
groove.
l left recurrent laryngeal nerve has a much
longer course which makes it more prone
to paralysis compared to the right one
m Superior laryngeal nerve
n It arises from inferior ganglion of the vagus
n descends behind internal carotid artery
n at the level of greater cornua of hyoid bone,
divides into external and internal branches.
l The external branch supplies cricothyroid
muscle
l the internal branch pierces the thyrohyoid
membrane and supplies sensory innervation
to the larynx and hypopharynx.(MCQ)
n Causes of Vocal cord paralysis
m Supranuclear : Rare.
m Nuclear
n There is involvement of nucleus ambiguus in
the medulla.
n The causes are vascular, neoplastic, motor neurone
disease, polio, and syringobulbia.
n In nuclear lesions, there would be associated
paralysis of other cranial nerves and neural
pathways. 165
 m High vagal lesions
n Vagus nerve may be involved in the skull, at the
exit from jugular foramen or in
parapharyngeal space
m Low vagal or recurrent laryngeal nerve
m Systemic causes
n Diabetes, syphilis, diphtheria, typhoid,
streptococcal or viral infections, lead poisoning.
m Idiopathic In about 30% of cases, cause remains
obscure.
Causes of combined paralysis (high vagal lesions)
Intracranial Tumours of posterior fossa
Basal meningitis (tubercular)
Skull base Fractures
Nasopharyngeal cancer
Glomus tumour
Neck Penetrating injury
ENT

Parapharyngeal tumours
Metastatic nodes
Lymphoma

Position of the vocal cord in health and disease

Position of the Situation in
VOCAL CORD PARALYSIS

cord Location of the cord from midline Health Disease

Median Midline • Phonation • RLN Paralysis
Paramedian 1.5 mm • Strong whisper • RLN Paralysis
Intermediate 3.5 mm. This is neutral position of cricoaytenoid joint. -- • Paralysis of both recurrent
(cadaveric) Abduction and adduction. take place from this position and superior laryngeal nerves
Gentle abduction 7 mm • Quiet • Paralysis of adductors
respiration
Full abduction 9.5 mm • Deep
inspiration

„ does not move laterally on deep inspiration

n Classification of Laryngeal Paralysis l Theories to explain the median or
m Laryngeal paralysis may be unilateral or bilateral, paramedian position of the cord.
and may involve: „ Semon’s law
n Recurrent laryngeal nerve. ® states that, in all progressive organic
n Superior laryngeal nerve. lesions, abductor fibres of the nerve, which are
n Both recurrent and superior laryngeal nerves phylogenetically newer, are more susceptible
(combined or complete paralysis) and thus the first to be paralysed
n Recurrent laryngeal nerve paralysis compared to adductor fibres.
n Unilateral „ Wagner and Grossman hypothesis
l Unilateral injury to recurrent laryngeal nerve ® states that cricothyroid muscle which
results in ipsilateral paralysis of all the intrinsic receives innervation from superior laryngeal
muscles except the cricothyroid. nerve keeps the cord in paramedian
l The vocal cord position due to its adductor function.
„ assumes a median or paramedian
position (MCQ)
166
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 m Bronchogenic carcinoma is an important cause of
left recurrent paralysis.(MCQ)
q Unilateral recurrent laryngeal paralysis
m may pass undetected as about one-third of the
patients are asymptomatic.
m Others have some change in voice
m but no problems of aspiration or airways
obstruction.
m The voice in unilateral paralysis gradually improves
due to compensation by the healthy cord which crosses
the midline to meet the paralysed one.
m Generally no treatment is required.

Case of recurrent laryngeal nerve paralysis (lower wagal trunk or recurrent laryngeal nerve)
Right Left Both
• Neck trauma I . Neck
• Benign or malignant thyroid disease • Accidental trauma
• Thyroid surgery • Thyroid disease (benign or malignant) Thyroid surgery
• Carcinoma cervical oesophagus • Thyroid Surgery Carcinoma thyroid

• Cervical lymphadenopathy
• Aneurysm of subclavian artery
• Carcinoma apex right lung
• Tuberculosis of cervical pleura
• Idiopathic
ENT
• Carcinoma cervical oesophagus Cancer cervical oesophagus
• Cervical lymphadenopathy Cervical lymphadenopathy
II. Mediastinum
• Bronchogenic cancer
• Carcinoma thoracic oesophagus
• Aortic aneurysm
• Mediastinal lymphadenopathy
• Enlarged left auricle
• Intrasthoracic surgery

VOCAL CORD PARALYSIS

• Idopathic

n Bilateral (Bilateral Abductor Paralysis) „ permanent tracheostomy with a speaking

m Neuritis or surgical trauma (thyroidectomy) valve
are the most important causes. The condition is often ® relieves stridor, preserves good voice
acute. ® has the disadvantage of a tracheostomy
m Position of Cords hole in the neck.
n As all the intrinsic muscles of larynx are paralysed „ a surgical procedure to lateralise the cord.
n the vocal cords lie in median or paramedian ® relieves airway obstruction but at the
position due to unopposed action of cricothyroid expense of a good voice
muscles ® however there is no tracheostomy hole
m Clinical Features (MCQ) in the neck.
n As both the cords lie in median or paramedian n Lateralisation of the cord
position, the airway is inadequate causing l Aim is to move and fix the cord in a lateral
dyspnoea and stridor but the voice is good. position to improve the airway. The various
(MCQ) procedures are:
l Dyspnoea and stridor become worse on „ Arytenoidectomy.
exertion or during an attack of acute „ Vocal cord lateralisation through endoscope.
laryngitis (MCQ) „ Thyroplasty type II.
m Treatment „ Cordectomy. (MCQ)
n Tracheostomy ® CO2 laser has been used to excise the
l require tracheostomy as an emergency procedure cord through the endoscope.
or when they develop upper respiratory tract infection. „ Nerve muscle implant.
l In long-standing cases, the choice is between ® Sternohyoid muscle with its nerve
supply is transplanted into the paralysed
167
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 „ It is a reversible procedure.
posterior cricoarytenoid to bring some
n Combined (complete) paralysis (recurrent and
movement to the cord.
superior laryngeal nerve paralysis)
n Paralysis of superior laryngeal nerve
m Unilateral combined paralysis
m Unilateral superior laryngeal nerve paralysis
n This causes paralysis of all the muscles of
n Isolated lesions of this nerve are rare; usually, it is
larynx on one side except the interarytenoid which
a part of combined paralysis.
also receives innervation from the opposite side.
n Paralysis of superior laryngeal nerve causes
n Thyroid surgery is the most common cause when
l paralysis of cricothyroid muscle
both recurrent and external laryngeal
l ipsilateral anaesthesia of the larynx above the vocal
nerves of one side may be involved.
cord.
n Clinical Features
n Paralysis of cricothyroid can also occur when
l As all the muscles of larynx on one side are
external laryngeal nerve is involved in thyroid
paralysed, vocal cord will lie in the
surgery, tumours, neuritis or diphtheria.
cadaveric position, i.e. 3.5 mm from the midline
n Clinical Features
l The healthy cord is unable to approximate the
l Voice is weak and pitch cannot be raised.
paralysed cord, thus causing glottic
l Anaesthesia of the larynx on one side may
incompetence.
pass unnoticed or cause occasional aspiration.
l This results in hoarseness of voice and
l Laryngeal findings include:
aspiration of liquids through the glottis.
„ A skew position of glottis as anterior
ENT

l Cough is ineffective due to air waste.

commissure is rotated to the healthy side.
n Treatment
„ Shortening of cord with loss of tension.
l Speech therapy.
„ The paralysed cord appears wavy due to
l Procedures to medialise the cord.
lack of tension.
„ Injection of teflon paste lateral to the
„ Flapping of the paralysed cord.
paralysed cord (MCQ)
® As tension of the cord is lost, it sags down
„ Thyroplasty type I.
during inspiration and bulges up during
„ Muscle or cartilage implant.
expiration.
VOCAL CORD PARALYSIS

® Laryngofissure is done and a bipedicled

m Bilateral superior laryngeal nerve paralysis
muscle graft or piece of cartilage is inserted
n This is an uncommon condition.
between thyroid cartilage and its inner
n Both the cricothyroid muscles are paralysed
perichondrium lateral to vocal cord, thus
along with anaesthesia of upper larynx.
pushing the cord medially.
n Aetiology
„ Arthrodesis of cricoarytenoid joint.
l Important causes include surgical or accidental
m Bilateral combined paralysis
trauma, neuritis (mostly diphtheritic),
n both cords lie in cadaveric position
pressure by cervical nodes or involvement in a neoplastic
n There is also total anaesthesia of the larynx.
process.
n Clinical Features
n Clinical Features
l Aphonia. As cords do not meet at all.
l Presence of both paralysis and bilateral
l Aspiration.
anaesthesia causes inhalation of food and
l Bronchopneumonia.
pharyngeal secretions
n Treatment
l gives rise to cough and choking fits.
l Tracheostomy
l Voice is weak and husky.
l Epiglottopexy
n Treatment
l Vocal cord plication.
l It depends on cause
l Total laryngectomy.
l Cases due to neuritis may recover
l Diversion procedures.
spontaneously.(MCQ)
n Congenital vocal cord paralysis
l Patients with repeated aspiration may require
m Unilateral paralysis is more common.
tracheostomy with a cuffed tube and an
n cause may be
oesophageal feeding tube.
l birth trauma
l Epiglottopexy is an operation to close the
l congenital anomaly of a great vessel or heart.
laryngeal inlet to protect the lungs from
m Bilateral paralysis may be due to
repeated aspiration.
n Hydrocephalus
168
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 n Arnold-Chiari malformation TOPIC 13 - CSF RHINORRHEA
n intracerebral haemorrhage during birth
n meningocoele, CSF RHINORRHEA
n cerebral or nucleus ambiguus agenesis. n CSF rhinorrhea presents as flow of clear fluid from

n Phonosurgery the nose.

n Thyroplasty – isshiki classification (MCQ) n Aetiology

m Type I. m Traumatic

n It is medial displacement of vocal cord n Head injuries

n achieved in teflon paste injection. n surgery of frontal, ethmoid or sphenoid sinus

m Type II. n hypophysectomy.

n It is lateral displacement of vocal cord n It may follow as a complication of

n used to improve the airway. endoscopic sinus surgery.

m Type III. m Tumours:

n It is used to shorten (relax) the vocal cord. n Large osteomas of frontoethmoid region

n Relaxation of vocal cord lowers the pitch. n tumours of the pituitary or the olfactory bulb.

n This procedure is done in m Congenital defects in skull associated with

l mutational falsetto encephalocele.

l in those who have undergone gender m Spontaneous type.

transformation from female to male. n Sites of leakage

m CSF from anterior cranial fossa reaches the nose

ENT
m Type IV.
n This procedure is used to lengthen (tighten) by way of cribriform plate, ethmoid air cells or frontal sinus.
the vocal cord m CSF from middle cranial fossa reaches the nose

n It elevates the pitch. via sphenoid sinus.

n It converts male character of voice to female m injuries of temporal bone result in leakage of

n used in gender transformation. CSF into the middle ear and thence via the eustachian
n It is also used when vocal cord is lax and tube into the nose (otorhinorrhoea).
bowing due to aging process or trauma. n Olfactory slit g Cribriform plate (MCQ)
n Middle meatus g Frontal or ethmoid sinuses

CSF RHINORRHEA
n Sphenoethmoidal recessgSphenoid sinus

n Inferior meatus near the eustachian tube g

Temporal bone

169
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 Differences between CSF and nasal secretions (MCQ)

Differences between CSF and nasal secretions

Features CSF fluid Nasal secretions
History Nasal or sinus surgery, head injury or Sneezing, nasal stuffiness, itching in
intracranial tumour the nose or lacrimation
Flow of discharge A few drops or a stream of fluid gushes down Continuous, No effect of bending
when bending forward or straining; forward or straining.
cannot be sniffed back Can be sniffed back
Character of Thin, watery and clear Slimy (mucus) or clear (tears)
discharge
Taste Sweet Salty
Sugar content Morethan 30 mg/dl (Compare with sugar in Lessthan 10 mg/dl
CSF after lumbar puncture as sugar is less in
CSF in meningitis)
Presence of β2 Always present, it is specific for CSF Always absent
transferrin
ENT

n CSF rhinorrhea versus nasal discharge of allergic m Double ring sign

or vasomotor rhinitis. nIn traumatic CSF leak, when CSF and blood
m Discharge in CSF rhinorrhea are mixed, double ring sign (or target sign) is
n clear and watery helpful.
n appears suddenly in a gush of drops when n In this sign, discharge collected on a piece of
bending forward or straining filter paper shows a central spot of blood while CSF
n is uncontrollable and cannot be sniffed back. spreads out like a halo around it.
n There is no associated sneezing, nasal congestion Treatment (MCQ)
CSF RHINORRHEA

n
or lacrimation. m Early cases of post-traumatic CSF rhinorrhea
n When collected into a test-tube and allowed n managed conservatively by
to stand, it remains clear in contradistinction to nasal l placing the patient in the semi-sitting position
discharge that leaves a sediment because of mucus l avoiding blowing of nose, sneezing and
and other proteins. straining
m a nasal discharge stiffens the handkerchief. l Prophylactic antibiotics are also administered
m CSF contains glucose which can be demonstrated to prevent meningitis.
by oxidase-peroxidase paper strip or biochemical tests. m Persistent cases of CSF rhinorrhea
m β2 transferrin is specific for CSF. (MCQ). n treated surgically
n It is absent in nasal secretions or tears. n by nasal endoscopic or intracranial approach.
n Its presence confirms the diagnosis of CSF
leak.
n Localisation of CSF leak
m It is done by intrathecal injection of a dye
(fluorescein 5%, 1 ml)
m if this fails to localise the defect, a CT
cisternogram is advised.
m a noninvasive, non-ionising technique of MRI
with T2-weighted images or MRI cisternography is more
useful.
m In suspected cases of otorhinorrhoea, always
examine the ear for the presence of fluid and
conductive hearing loss.
170
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 TOPIC 14 - EPISTAXIS n Kiesselbach plexus(MCQ)
l source of the majority of nose bleeds
n Blood supply of nose
l form a plexus of vessels in the anteroinferior
m The nasal blood supply comes from both internal
nasal septum.
and external carotid artery systems
l an anastomosis with branches from both the
n External carotid
internal and external carotid artery
l facial artery
systems.
„ superior labial artery, supplies the septum and
„ Anterior ethmoidal artery (from the
nasal alae.
ophthalmic artery)
l internal maxillary artery (IMA).
„ Sphenopalatine artery (terminal branch
„ Sphenopalatine
of the maxillary artery)
® the septum and middle and inferior
„ Greater palatine artery (from the maxillary
turbinate area
artery)
„ pharyngeal
„ Septal branch of the superior labial artery
® inferior aspect of the lateral nasal wall,
(from the facial artery).
„ greater palatine
m Causes of epistaxis
® anterior aspect of the septum.
n Most common site of epistaxis in children -
n Internal carotid artery
Kisselbach ‘s plexus (littles area)(MCQ)
l ophthalmic artery
n Most common cause of epistaxis in elderly -
„ septum and lateral nasal walls

ENT
hypertension (MCQ)
l anterior ethmoid artery
n Most common cause of epistaxis in a 15 yr
l posterior ethmoid artery
old female-Hematopoetic disorder (MCQ)
m Of note, 2 anastomotic areas within the nose
n Most common cause of epistaxis in children -
often provide a source of epistaxis.
Habitual nose pricking (Trauma) (MCQ)
n Woodruff area
m Sites of epistaxis
l located on the inferior aspect of the lateral
n Little’s area.
nasal wall, posterior to the inferior turbinate.
l In 90% cases of epistaxis, bleeding occurs
l It is formed from the anastomoses of the
from this site.(MCQ)
„ Sphenopalatine arteries.
n Above the level of middle turbinate.
„ Pharyngeal arteries.
l Bleeding is often from the anterior and
l The posterior location makes it a common

EPISTAXIS
posterior ethmoidal vessels (internal carotid
source for severe, nontraumatic bleeds.
system).
n Below the level of middle turbinate.
l bleeding is from the branches of
sphenopalatine artery.
n Diffuse.
l Both from septum and lateral nasal wall.
l This is often seen in general systemic
disorders and blood dyscrasias.
m Classification of epistaxis

• Differences between anterior and posterior epistaxis

Anterior epistaxis Posterior epistaxis
Incidence More common Less common
Site Mostly from Little’s area or anterior part of Mostly from posterosuperior part of nasal cavity;
lateral wall often difficult to localise the bleeding point
Age Mostly occurs in children or young adults After 40 years of age
Cause Mostly trauma Spontaneous; often due to hypertension or
arteriosclerosis
Bleeding Usually mild, can be easily controlled by Bleeding is severe, requires hospitalisation;
local pressure or anterior pack postnasal pack often required

171
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 m Management
n First Aid
l Most of the time, bleeding occurs from the
Little’s area and can be easily controlled by
pinching the nose with thumb and index finger for
about 5 minutes. This compresses the vessels
of the Little’s area.
l Trotter’s method
l patient is made to sit, leaning a little forward
over a basin to spit any blood, and breathe
quietly from the mouth.
l Cold compresses should be applied to the
nose to cause reflex vasoconstriction.
n Cauterisation
l This is useful in anterior epistaxis when
bleeding point has been located.
l The area is first anaesthetised and the bleeding
point cauterised with a bead of silver
EPISTAXIS
nitrate or coagulated with electrocautery.
n Anterior Nasal Packing
n Posterior Nasal Packing
n Endoscopic Cautery
l Posterior bleeding point can sometimes be
better located with an endoscope.
n Elevation of Mucoperichondrial Flap and SMR
Operation
l In case of persistent or recurrent bleeds
from the septum, just elevation of mucoperichondrial
TONSILLITIS TONSILLECTOMY
flap and then repositioning it back helps to cause
fibrosis and constrict blood vessels.
l SMR operation is done for septal spur which
is sometimes the cause of epistaxis.
n Ligation of Vessels
l External carotid.
l Maxillary artery.
® done in uncontrollable posterior
epistaxis.
® Approach is via Caldwell-Luc
operation.
® Endoscopic ligation of the maxillary
artery can also be done through nose.
l Ethmoidal arteries.
„ In anterosuperior bleeding above the
middle turbinate, not controlled by
packing, anterior and posterior ethmoidal
arteries which supply this area, can be
ligated.(MCQ)
172
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TOPIC 15 -
TONSILLITIS TONSILLECTOMY
Acute and Chronic Tonsillitis
n Applied anatomy of palatine (faucial) tonsils
m Medial surface
n covered by non-keratinising stratified
squamous epithelium
n dips into the substance of tonsil in the form of
crypts.
n Openings of 12-15 crypts can be seen
n Crypta magna or intratonsillar cleft
l One of the crypts, situated near the upper
part of tonsil is very large and deep
l It represents the ventral part of second
pharyngeal pouch.
m Lateral surface
n presents a well-defined fibrous capsule.
n Between the capsule and the bed of tonsil is the
loose areolar tissue which makes it easy to
dissect the tonsil in the plane during tonsillectomy.
n It is also the site for collection of pus in
peritonsillar abscess.
n Some fibres of palatoglossus and
palatopharyngeus muscles are attached to the
capsule of the tonsil.
m Upper pole
n Its medial surface is covered by a semilunar
fold,enclosing a potential space called
supratonsillar fossa.
m Lower pole
n attached to the tongue.
n A triangular fold of mucous membrane
encloses a space called anterior tonsillar space.
n The tonsil is separated from the tongue by a
sulcus called tonsillolingual sulcus which may be
the seat of carcinoma.
m Bed of the tonsil
n It is formed by the superior constrictor and
styloglossus muscles.
n The glossopharyngeal nerve and styloid
process, if enlarged, may lie in relation to the
lower part of tonsillar fossa.
n Both these structures can be surgically approached
through the tonsil bed after tonsillectomy.
m Blood Supply
n The tonsil is supplied by five arteries
l Tonsillar branch of facial artery. This is the
main artery.(MCQ)
l Ascending pharyngeal artery from external
carotid.
l Ascending palatine, a branch of facial artery.
l Dorsal linguae branches of lingual artery.
 l Descending palatine branch of maxillary
artery.
m Venous Drainage
n Veins from the tonsils drain into paratonsillar
vein which joins the common facial vein and
pharyngeal venous plexus.
m Lymphatic Drainage
n Lymphatics from the tonsil pierce the superior
constrictor and drain into upper deep cervical
nodes particularly the jugulodigastric
(tonsillar) node situated below the angle of
mandible.
m Nerve Supply
n Lesser palatine branches of sphenopalatine
ganglion (CN V) and glossopharyngeal
nerve provide sensory nerve supply.
n Acute tonsillitis
m often affects school-going children,
m Haemolytic streptococcus is the most
commonly infecting organism.
m Constitutional symptoms are usually more marked
than seen in simple pharyngitis
m There may be abdominal pain due to
mesenteric lymphadenitis simulating a clinical
picture of acute appendicitis.
m acute follicular tonsillitis
n Tonsils are red and swollen with yellowish
spots of purulent material presenting at the
opening of crypts
m acute membranous tonsillitis
n there may be a whitish membrane on the
medial surface of tonsil which can be easily
wiped away with a swab
m acute parenchymatous tonsillitis
n The tonsils may be enlarged and congested
so much so that they almost meet in the midline
along with some oedema of the uvula and soft
palate
m The jugulodigastric lymph nodes are enlarged and
tender.
m Most of the infections are due to streptococcus,
and penicillin is the drug of choice.
m Patients allergic to penicillin can be treated with
erythromycin.
m Complications
n Chronic tonsillitis with recurrent acute attacks
n Peritonsillar abscess.
n Parapharyngeal abscess.
n Cervical abscess due to suppuration of
jugulodigastric lymph nodes.
n Acute otitis media
n Rheumatic fever.
n Acute glomerulonephritis.
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n Subacute bacterial endocarditis.
n Differential Diagnosis of Membrane Over the
Tonsil
m Diphtheria.
n Unlike acute tonsillitis which is abrupt in onset,
diphtheria is slower in onset with less local
discomfort
n the membrane in diphtheria (MCQ)
l extends beyond the tonsils, on to the soft palate
l dirty grey in colour.
l adherent and its removal leaves a bleeding surface.
m Vincent’s angina.
n Caused by fusiform bacilli and spirochaetes.
n It is insidious in onset with less fever and less
discomfort in throat.
n Membrane
l usually forms over one tonsil
l can be easily removed revealing an irregular
ulcer on the tonsil.
ENT
m Infectious mononucleosis.
n This often affects young adults.
n Both tonsils are very much enlarged,
congested and covered with membrane.
n Local discomfort is marked.
n Lymph nodes are enlarged in the posterior
triangle of neck along with splenomegaly.
n failure of the antibiotic treatment.
TONSILLITIS TONSILLECTOMY
n Blood smear
l show more than 50% lymphocytes
l about 10% are atypical.
n White cell count - normal in the first week but
rises in the second week.
n Paul-Bunnell test (mono test) will show high
titre of heterophil antibody.
n Tonsillectomy (High yield MCQ Topic )
m Indications
n Absolute
l Recurrent infections of throat.
„ This is the most common indication.
„ Recurrent infections are further defined as:
® Seven or more episodes in one year, or
® Five episodes per year for 2 years, or
® Three episodes per year for 3 years, or
® Two weeks or more of lost school or work
in one year.
l Peritonsillar abscess.
„ In children, tonsillectomy is done 4-6
weeks after abscess has been treated. In
adults, second attack of peritonsillar
abscess forms the absolute indication.
„ Tonsillitis causing febrile seizures.
l Hypertrophy of tonsils causing
„ airway obstruction (sleep apnoea)
173
 „ difficulty in deglutition
„ interference with speech.
l Suspicion of malignancy.
„ A unilaterally enlarged tonsil may be a
lymphoma in children and an
epidermoid carcinoma in adults.
„ An excisional biopsy is done.
n Relative
l Diphtheria carriers, who do not respond to
antibiotics.
l Streptococcal carriers, who may be the source
of infection to others.
l Chronic tonsillitis with bad taste or halitosis
which is unresponsive to medical treatment.
l Recurrent streptococcal tonsillitis in a patient with
valvular heart disease.
n As a Part of Another Operation
l Palatopharyngoplasty which is done for sleep
apnoea syndrome.
l Glossopharyngeal neurectomy. Tonsil is removed
ENT
first and then IX nerve is severed in the bed
of tonsil.
l Removal of styloid process.
m Contraindications to Tonsillectomy
n Haemoglobin level less than 10 g%.
n Presence of acute infection in upper respiratory tract,
even acute tonsillitis.
l Bleeding is more in the presence of acute
TONSILLITIS TONSILLECTOMY
infection.
n Children under 3 years of age.
l They are poor surgical risks.
n Overt or submucous cleft palate.
n Bleeding disorders, e.g. leukaemia, purpura,
aplastic anaemia, haemophilia.
n At the time of epidemic of polio.
n Uncontrolled systemic disease, e.g. diabetes, cardiac
disease, hypertension or asthma.
n Tonsillectomy is avoided during the period of
menses.
m Position of Tonsillectomy
n Rose’s position, i.e. patient lies supine with head
extended by placing a pillow under the shoulders.
n Hyperextension should always be avoided.
n Complications of Tonsillectomy
n Immediate
l Primary haemorrhage.
„ Occurs at the time of operation.
„ It can be controlled by pressure, ligation
or electrocoagulation of the bleeding
vessels.
l Reactionary haemorrhage.
„ Occurs within a period of 24 hours
174
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„ can be controlled by simple measures such
as removal of the clot, application of pressure or
vasoconstrictor.
„ Presence of a clot prevents the clipping
action of the superior constrictor muscle
on the vessels which pass through it
„ If above measures fail, ligation or
electrocoagulation of the bleeding vessels can be
done under general anaesthesia.
l Injury to tonsillar pillars, uvula, soft palate,
tongue or superior constrictor muscle due
to bad surgical technique.
l Injury to teeth.
l Aspiration of blood.
l Facial oedema. particularly of the eyelids.
l Surgical emphysema.
„ Rarely occurs due to injury to superior
constrictor muscle.
n Delayed
l Secondary haemorrhage.
„ Usually seen between the 5th to 10th post-
operative day.
„ It is the result of sepsis and premature
separation of the membrane. Usually, it
is heralded by bloodstained sputum but may be
profuse.
„ Simple measures like removal of clot,
topical application of dilute adrenaline
or hydrogen peroxide with pressure
usually suffice.
„ For profuse bleeding, general anaesthesia is
given and bleeding vessel is
electrocoagulated or ligated.
„ Sometimes, external carotid ligation may also
be required.
l Infection.
„ may lead to parapharyngeal abscess or otitis
media.
l Lung complications.
„ Aspiration of blood, mucus or tissue
fragments may cause atelectasis or lung
abscess.
l Scarring in soft palate and pillars.
l Tonsillar remnants.
l Hypertrophy of lingual tonsil.
„ This is a late complication
„ compensatory to loss of palatine tonsils.
„ Sometimes, lymphoid tissue is left in the
plica triangularis near the lower pole of
tonsil, which later gets hypertrophied.
„ Plica triangularis should, therefore be
removed during tonsillectomy
 TOPIC 16 - SINUS CARCINOMA
n Carcinoma of Maxillary Sinus
n Tracheostomy is making an opening in the anterior wall
m Most common histology - squamous cell carcinoma
(MCQ)
m Nodal metastases are uncommon and occur only
n Functions of Tracheostomy
in the late stages of disease.
m CT scan. is the best non-invasive method to
find the extent of disease.
m Caldwell-Luc operation. Direct visualisation of
the site of tumour in the sinus also helps in
staging of the tumour.
m Ohngren’s classification.
n An imaginary plane is drawn, extending between
medial canthus of eye and the angle of
mandible
n Growths situated above this plane (suprastructural)
have a poorer prognosis than those below it
(intrastructural).
m For squamous cell carcinoma, a combination of
radiotherapy and surgery gives better results than
either alone.
n Radiotherapy can be given before or after
surgery.
n Very often, a full course of pre-operative
telecobalt therapy is given, followed 4-6 weeks
later by surgical excision of the growth by total
or extended maxillectomy (MCQ)
n Ethmoid Sinus Malignancy
m Ethmoid sinuses are often involved from extension
of the primary growths of the maxillary sinus.
m Adenocarcinoma of ethmoid sinus occur’s
commonly in Wood workers (MCQ)
m Nickle workers have a high incidence of
carcinoma of Ethmoid sinuses (MCQ)
m Treatment
n Tracheostomy has also been divided into high, mid
n In early cases, treatment is pre-operative radiation,
followed by lateral rhinotomy and total ethmoidectomy.
n If cribriform plate is involved, anterior cranial
fossa is exposed by a neurosurgeon and total
exenteration of the growth in one piece is
accomplished by what is called craniofacial
resection.
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TOPIC 17 - TRACHEOSTOMY
of trachea and converting it into a stoma on the skin
surface.
m Alternative pathway for breathing
m Improves alveolar ventilation
m In cases of respiratory insufficiency, alveolar
ventilation is improved by:
n Decreasing the dead space by 30-50%
(normal dead space is 150 ml).
n Reducing the resistance to airflow.
m Protects the airways (MCQ)
n By using cuffed tube , tracheobronchial tree is
protected against aspiration of:
n Pharyngeal secretions, as in case of bulbar
SINUS CARCINOMA
paralysis or coma.
n Blood, as in haemorrhage from pharynx, larynx
or maxillofacial injuries.
n With tracheostomy, pharynx and larynx can
also be packed to control bleeding.
m Permits removal of tracheobronchial secretions
n When patient is unable to cough as in coma, head
injuries, respiratory paralysis; or when cough
is painful, as in chest injuries or upper
abdominal operations, the tracheobronchial
airway can be kept clean of secretions by repeated
suction through the tracheostomy
TRACHEOSTOMY
m Intermittent positive pressure respiration
(IPPR) If IPPR is required beyond 72 hours,
tracheostomy is superior to intubation.
m To administer anaesthesia In cases where endotracheal
intubation is difficult or impossible as in
laryngopharyngeal growths or trismus.
or low.
m A high tracheostomy
n always avoided
n done above the level of thyroid isthmus (isthmus
lies against II, III and IV tracheal rings).
n It violates the 1st ring of trachea.
n Tracheostomy at this site can cause
perichondritis of the cricoid cartilage and
subglottic stenosis
n Only indication for high tracheostomy is
carcinoma of larynx because in such cases,
total larynx anyway would ultimately be removed and
a fresh tracheostome made in a clean area lower
down.
m A mid tracheostomy
n preferred one
n done through the II or III rings
175
 n would entail division of the thyroid isthmus or its
retraction upwards or downwards to expose this part
of trachea.
m A low tracheostomy
n done below the level of isthmus.
n Difficulties
l Trachea is deep at this level and close to
several large vessels
l with tracheostomy tube which impinges on
suprasternal notch.
n Indications of Tracheostomy (MCQ)
m There are three main indications
n Respiratory obstruction.
n Retained secretions.
n Respiratory insufficiency
m Respiratory obstruction
n Infections
l Acute laryngo-tracheo-bronchitis, acute
epiglottitis, diphtheria
l Ludwig’s angina, peritonsillar, retropharyngeal
ENT
or parapharyngeal abscess, tongue abscess
n Trauma
l External injury of larynx and trachea
l Trauma due to endoscopies, especially in
infants and children
l Fractures of mandible or maxillofacial injuries
n Neoplasms
l Benign and malignant neoplasms of larynx,
TRACHEOSTOMY
pharynx, upper trachea, tongue and thyroid
n Foreign body larynx
n Oedema larynx due to steam, irritant fumes
or gases, allergy (angioneurotic or drug
sensitivity), radiation
n Bilateral abductor paralysis
n Congenital anomalies
l Laryngeal web, cysts, tracheo-oesophageal
fistula
n Bilateral choanal atresia
m Retained secretions
n Inability to cough
n Coma of any cause, e.g. head injuries,
cerebrovascular accidents, narcotic overdose
n Paralysis of respiratory muscles, e.g. spinal
injuries, polio, Guillain-Barre syndrome,
myasthenia gravis
n Spasm of respiratory muscles, tetanus,
eclampsia, strychnine poisoning
n Painful cough
n Chest injuries, multiple rib fractures,
pneumonia
n Aspiration of pharyngeal secretions
n Bulbar polio, polyneuritis, bilateral
laryngeal paralysis
176
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m Respiratory insufficiency
n Chronic lung conditions, viz. emphysema,
chronic bronchitis, bronchiectasis, atelectasis
n Steps of Operation
m A vertical incision
n made in the midline of neck
n extends from cricoid cartilage to just above
the sternal notch.
n This is the most favoured incision
n can be used in emergency and elective procedures.
n It gives rapid access with minimum of bleeding and
tissue dissection.
m A transverse incision
n 5 cm long,
n made 2 fingers’ breadth above the sternal notch
n used in elective procedures.
n It has the advantage of a cosmetically better
scar
m Trachea is fixed with a hook and opened with a
vertical incision in the region of 3rd and 4th or 3rd
and 2nd rings.
m This is then converted into a circular opening.
m The first tracheal ring is never divided as
perichondritis of cricoid cartilage with stenosis can
result
n Tracheostomy in Infants and Children
m Common indications of tracheostomy in infants
and children
n Infants below 1 year (mostly congenital
lesions)
l Subglottic haemangioma
l Subglottic stenosis
l Laryngeal cyst
l Glottic web
l Bilateral vocal cord paralysis
n Children (mostly inflammatory or traumatic
lesions)
l Acute laryngo-tracheo-bronchitis
l Epiglottitis (MCQ)
l Diphtheria
l Laryngeal oedema (chemical/thermal injury)
l External laryngeal trauma
l Prolonged intubation
l Juvenile laryngeal papillomatosis
m Precautions during tracheostomy in infants
and children
n Trachea of infants and children
l soft and compressible
l identification may become difficult
l surgeon may easily displace it and go deep or
lateral to it injuring recurrent laryngeal nerve
or even the carotid.
 l It is always useful to have an endotracheal tube n Inner cannula should be removed and cleaned
or a bronchoscope inserted into trachea before as and when indicated for the first 3 days.
operation. n Outer tube, unless blocked or displaced, should

n Tracheostomy in infants and children is not be removed for 3-4 days to allow a track to be
preferably done under general anaesthesia. formed when tube placement will become easy.
n During positioning n After 3-4 days, outer tube can be removed and

l do not extend the neck too much as this pulls cleaned every day.
structures from chest into the neck n If cuffed tube is used, it should be periodically

l injury may occur to pleura, innominate vessels and deflated to prevent pressure necrosis or dilatation
thymus or the tracheostomy opening may be of trachea.
made too low near suprasternal notch. n Decannulation
n Before incising trachea, silk sutures are placed m To decannulate a patient, tracheostomy tube is plugged

in the trachea, on either side of midline. and the patient closely observed.
n Tracheal lumen is small, do not insert knife too m If the patient can tolerate it for 24 hours, tube

deep; it will injure posterior tracheal wall or can be safely removed

even oesophagus causing tracheo-oesophageal m Causes of unsuccessful decannulation

fistula. n Persistence of the condition for which

n Trachea is simply incised, without excising a tracheostomy was done.

circular piece of tracheal wall. n Obstructing granulations around the stoma or

n Avoid infolding of anterior tracheal wall below it where tip of the tracheostomy tube

ENT
when inserting the tracheostomy tube. had been impinging.
n Selection of tube is important. n Tracheal oedema or subglottic stenosis.

l A long tube impinges on the carina or right n Incurving of tracheal wall at the site of

bronchus. tracheostome.
l With high curvature, lower end of tube n Tracheomalacia.

impinges on anterior tracheal wall while upper n Psychological dependence on tracheostomy and

part compresses the tracheal rings or cricoid ( inability to tolerate the resistance of the upper
l Use soft silastic or portex tube. airways.

TRACHEOSTOMY
l Metallic tubes cause more trauma. n Complications of tracheostomy (MCQ)
n Post-operative Care m Immediate (at the time of operation):

m Constant supervision.(MCQ) n Haemorrhage.

n After tracheostomy, constant supervision of the n Apnoea.

patient for bleeding, displacement or l This follows opening of trachea in a patient who

blocking of tube and removal of secretions had prolonged respiratory obstruction.

is essential. l This is due to sudden washing out of CO2

m Suction. which was acting as a respiratory stimulus.

n Suction injuries to tracheal mucosa should be l Treatment is to administer 5% CO2 in oxygen or

avoided. assisted ventilation.

n This is done by applying suction to the catheter only n Pneumothorax due to injury to apical pleura.

when withdrawing it n Injury to recurrent laryngeal nerves.

m Prevention of crusting and tracheitis. n Aspiration of blood.

n This is achieved by: n Injury to oesophagus.

l Proper humidification, by use of humidifier, l This can occur with tip of knife while incising the

steam tent, ultrasonic nebulizer or keeping a trachea

boiling kettle in the room. l may result in tracheo-oesophageal fistula.

l If crusting occurs, a few drops of normal or m Intermediate (during first few hours or days):

hypotonic saline or Ringer’s lactate are instilled into n Bleeding, reactionary or secondary.

the trachea every 2-3 hours to loosen crusts. n Displacement of tube.

l A mucolytic agent such as acetylcysteine solution, n Blocking of tube.

can be instilled to liquify tenacious secretions n Subcutaneous emphysema.

or to loosen the crusts. n Tracheitis and tracheobronchitis with crusting

m Care of tracheostomy tube. (MCQ) in trachea.

n Atelectasis and lung abscess.
177
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 n Local wound infection and granulations.
m Late (with prolonged use of tube for weeks and
months):
n Haemorrhage, due to erosion of major vessel.
n Laryngeal stenosis, due to perichondritis of
cricoid cartilage.
n Tracheal stenosis, due to tracheal ulceration
and infection.
n Tracheo-oesophageal fistula, due to
prolonged use of cuffed tube or erosion of
trachea by the tip of tracheostomy tube.
n Problems of decannulation.
l Seen commonly in infants and children.
n Persistent tracheocutaneous fistula.
n Problems of tracheostomy scar. Keloid or
unsightly scar.
n Corrosion of tracheostomy tube and
aspiration of its fragments into the
tracheobronchial tree.
ENT
TOPIC 18 - DNS
Nasal Septum and Its Diseases
n Nasal Septum proper
m Its principal constituents are
n the perpendicular plate of ethmoid
n the vomer
n a large septal (quadrilateral) cartilage
wedged between the above two bones
anteriorly.
n Fractures of Nasal Septum
DNS
m Septal injuries with mucosal tears cause profuse
epistaxis
m Septal injuries with intact mucosa result in septal n Septal cartilage may be dislocated into one of the
haematoma
m if hematoma is not drained early, will cause
absorption of the septal cartilage and saddle nose
deformity.
m “Jarjaway” fracture of nasal septum (MCQ)
n results from blows from the front
n it starts just above the anterior nasal spine
n runs horizontally backwards just above the
junction of septal cartilage with the vomer
m “Chevallet” fracture of septal cartilage (MCQ)
n results from blows from below
n it runs vertically from the anterior nasal spine
upwards to the junction of bony and
cartilaginous dorsum of nose
m Treatment
n Haematomas should be drained (MCQ)
n Dislocated or fractured septal fragments
should be repositioned
n DEVIATED NASAL SEPTUM (DNS)
178
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m This is an important cause of nasal obstruction.
m Aetiology (MCQ)
n Trauma
l A lateral blow on the nose may cause
displacement of septal cartilage from the
vomerine groove and maxillary crest
l a crushing blow from the front may cause
buckling, twisting, fractures and duplication
of nasal septum with telescoping of its
fragments.
l Trauma may also be inflicted at birth during
difficult labour when nose is pressed during its
passage through the birth canal.
l Birth injuries should be immediately
attended to as they result in septal deviation later
in life.
n Developmental error
l Unequal growth between the palate and
the base of skull may cause buckling of the
nasal septum.
l In mouth breathers, as in adenoid
hypertrophy, the palate is often highly arched
and the septum is deviated
l DNS may be seen in cases of cleft lip and
palate and in those with dental
abnormalities.
n Racial factors
l Caucasians are affected more than Negroes.
n Hereditary factors
l Several members of the same family may
have deviated nasal septum.
Types of DNS
n
m Anterior dislocation
nasal chambers.
n This is better appreciated by looking at the
base of nose when patient’s head is tilted
backward
m C-shaped deformity (MCQ)
n Septum is deviated in a simple curve to one side.
n Nasal chamber on the concave side of the
nasal septum will be wider and may show
compensatory hypertrophy of turbinates.(MCQ)
m S-shaped deformity
n Septum may show a S-shaped curve either in
vertical or anteroposterior plane.
n Such a deformity may cause bilateral nasal
obstruction.
m Spurs (MCQ)
n A spur is a shelf-like projection often found
at the junction of bone and cartilage.
n A spur may press on the lateral wall and gives
rise to headache.
 n It may also predispose to repeated epistaxis
from the vessels stretched on its convex surface.
m Thickening
n It may be due to organised haematoma or
over-riding of dislocated septal fragments.
n Clinical Features (MCQ)
m Males are affected more than females.
m Nasal obstruction
n Respiratory currents pass through upper part
of nasal cavity, therefore, high septal deviation
cause nasal obstruction more than lower ones.(MCQ)
m Cottle test.
n It is used in nasal obstruction due to
abnormality of the nasal valve.
n In this test, cheek is drawn laterally while the patient
breathes quietly.
n If the nasal airway improves on the test side, the test
is positive
n indicates abnormality of the vestibular
component of nasal valve
m Headache
n Deviated septum, especially a spur, may
press on the lateral wall of nose giving rise to
pressure headache.
m Sinusitis (MCQ)
n Deviated septum may obstruct sinus ostia
resulting in poor ventilation of the sinuses.
n Therefore, it forms an important cause to
predispose or perpetuate sinus infections.
m Epistaxis (MCQ)
n Mucosa over the deviated part of septum is
exposed to the drying effects of air currents
n leads to formation of crusts which when
removed, cause bleeding.
n Bleeding may also occur from vessels over a
septal spur.
m Anosmia
n Failure of the inspired air to reach the
olfactory region may result in total or partial
loss of sense of smell.
m External deformity
n Septal d0eformities may be associated with
deviation of the cartilaginous or both the bony and
cartilaginous dorsum of nose, deformities of the nasal
tip or columella.
m Middle ear infection
n DNS also predisposes to middle ear infection.
m Treatment
n Septoplasty done in children, adoloscents and
young female.
n Submucous resection Is indicated in adults
n Septoplasty
l It is a conservative approach to septal surgery.
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l In this operation, much of the septal
framework is retained.
l Only the most deviated parts are removed.
l Septoplasty has now almost replaced SMR
operation
l Septal surgery is usually done after the age
of 17 so as not to interfere with the growth of nasal
skeleton.
l However, if a child has severe septal
deviation causing marked nasal
obstruction, conservative septal surger y
(septoplasty) can be performed to provide a
good airway.
l Indications
„ Symptomatic deviated septum.
„ As a part of septorhinoplasty for
cosmetic reasons.
„ As an approach to hypophysectomy.
„ Recurrent epistaxis due to septal spur.
l Contraindications
ENT
„ Acute nasal or sinus infection.
„ Untreated diabetes.
„ Hypertension.
„ Bleeding diathesis.
n Submucous resection (SMR) operation
l It is generally done in adults under local
anaesthesia.
l It consists of elevating the
mucoperichondrial and mucoperiosteal
f laps on either side of the septal
framework by a single incision made on one
DNS
side of the septum, removing the deflected parts
of the bony and cartilaginous septum, and
then repositioning the flaps
l Indications
„ Deviated nasal septum (DNS) causing
symptoms of nasal obstruction and
recurrent headaches.
„ DNS causing obstruction to ventilation of
paranasal sinuses and middle ear, resulting
in recurrent sinusitis and otitis media.
„ Recurrent epistaxis from septal spur.
„ As a part of septorhinoplasty for
cosmetic correction of external nasal
deformities.
„ As a preliminary step in hypophysectomy
(trans-septal trans-sphenoidal approach) or
vidian neurectomy (trans-septal
approach).
l Contraindications
„ Patients below 17 years of age.
® In such cases, a conservative surgery
(septoplasty) should be done.
179
 „ Acute episode of respiratory infection. TOPIC 19 - EPIGLOTTITIS
„ Bleeding diathesis.
n Acute epiglottitis (Syn. Supraglottic Laryngitis)
„ Untreated diabetes or hypertension.
m It is an acute inflammatory condition confined to
l Complications
supraglottic structures, i.e. epiglottis,
„ Bleeding. It may require repacking, if
aryepiglottic folds and arytenoids.
severe.
m There is marked oedema of these structures which
„ Septal haematoma.
may obstruct the airway
® Evacuate the haematoma and given
m affects children of 2-7 years of age
intranasal packing on both sides of
m H. influenzae B is the most common organism
septum for equal pressure.
responsible for this condition in children (MCQ)
„ Septal abscess. This can follow infection
m Laryngoscopy
of septal haematoma.
n show oedema and congestion of supraglottic
„ Perforation. When tears occur on opposing
structure.
side of mucous membrane.
n avoided for fear of precipitating complete
„ Depression of bridge.
obstruction.
® Usually occurs in supratip area due to too
m Lateral soft tissue X-ray of neck may show
much removal of cartilage along the
swollen epiglottis (thumb sign).(MCQ)
dorsal border.
m Treatment
„ Retraction of columella.
n Hospitalisation
® Often seen when caudal strip of cartilage
ENT

n Essential because of the danger of respiratory

is not preserved.
obstruction.
„ Persistence of deviation.
n Ampicillin or third generation
® It usually occurs due to inadequate surgery
cephalosporin are effective
and may require revision operation.
n Hydrocortisone or dexamethasone
„ Flapping of nasal septum. Rarely seen,
n Adequate hydration
when too much of septal framework has
n Humidification and oxygen. Patient may
been removed.
require mist tent or a croupette.
„ Toxic shock syndrome.
n Intubation or tracheostomy may be required
for respiratory obstruction (MCQ)
EPIGLOTTITIS

n Acute laryngo-tracheo-bronchitis
m It is an inflammatory condition of the larynx,
trachea and bronchi
m more common than acute epiglottitis.
m parainfluenza type I and II
m affect children between 6 months to 3 years of age.
m Male children are more often affected.
m Steeple sign on AP View of neck

180
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 Acute epiglottitis Acute laryngo-tracheo-bronchitis (or group)
• Causative organism Haemophilus influenzae type B Parainfluenza virus type I and II
• Age 2-7 years 3 months to 3 years
• Pathology Supraglottic larynx Subglottic area
• Prodromal symptoms Absent Present
• Onset Sudden Slow
• Fever High Low grade or no fever
• Patient’s look Toxic Non-toxic
• Cough Usually absent Present, (Barking seal-like)
• Stridor Present and may be marked Present
• Odynophagia Present, with drooling of secretions Usually absent
• Radiology *Thumb sign on lateral view Steeple sign on anteroposterior view of neck
• Treatment Humidified oxygen, third generation Humidified O2 tent, steriods
cephalosporin (ceftriaxone) or amoxicillin

n Metastatic lymph node enlargement can also

occur.(MCQ)
TOPIC 20 - GLOMUS TUMOR n Clinical Features
n It is the most common benign neoplasm of middle n Earliest symptoms are hearing loss and tinnitus.

ear n Hearing loss is conductive and slowly

n originates from the glomus bodies. (MCQ) progressive.

n Glomus bodies n Tinnitus (MCQ)

ENT
n resemble carotid body in structure n pulsatile and of swishing character,

n found in the synchronous with pulse

l dome of jugular bulb n can be temporarily stopped by carotid

l on the promontory along the course of pressure.

tympanic branch of IXth cranial nerve n Otoscopy (MCQ)

(Jacobson’s nerve). l red reflex through intact tympanic membrane.

n The tumour consists of paraganglionic cells l “Rising sun” appearance is seen when

derived from the neural crest. tumour arises from the floor of middle ear.
l Sometimes, tympanic membrane appears

GLOMUS TUMOR
n Aetiology and Pathology
n The tumour is often seen in the middle age bluish and may be bulging. (MCQ)
(40-50 years). l “Pulsation sign” (Brown’s sign) is positive

n Females are affected five times more.(MCQ) „ when ear canal pressure is raised with

n It is a benign, non-encapsulated Siegle’s speculum, tumour pulsates

n extremely vascular neoplasm. vigorously and then blanches; reverse
n Its rate of growth is very slow happens with release of pressure.(MCQ)
n Tumour is locally invasive. n When tumour presents as a polyp

n There is abundance of thin-walled blood l In addition to hearing loss and tinnitus, there

sinusoids with no contractile muscle coat, is history of profuse bleeding from the
accounting for profuse bleeding from the ear either spontaneously or on attempts to
tumours. clean it.
n Glomus jugulare l Dizziness or vertigo and glomus bodies

n They arise from the dome of jugular bulb may appear.

n invade the hypotympanum and jugular l Earache is less common than in carcinoma of the

foramen external and middle ear, and helps to

n cause neurological signs of IXth to XIIth differentiate it.
cranial nerve involvement. n Cranial nerve palsies

n They may compress jugular vein or invade its l IXth to XIIth cranial nerves may be

lumen. paralysed.
n Glomus tympanicum n Audible bruit

n They arise from the promontory of the l At all stages, auscultation with stethoscope over

middle ear the mastoid may reveal systolic bruit.

n cause aural symptoms, sometimes with facial n Some glomus tumours secrete
paralysis. catecholamines 181
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 n Rule of 10s TOPIC 21 - LARYNGITIS PACHYDERMA
l Remember that 10% of the tumours are
Polypoid degeneration of vocal cords (reinke’s oedema)
familial, 10% multicentric and up to 10% n It is bilateral symmetrical swelling of the whole of
functional, i.e. they secrete membranous part of the vocal cords
catecholamines.(MCQ) n most often seen in middle-aged men and women.
n Investigations n This is due to oedema of the subepithelial space
n Phelp’s sign
(Reinke’s space) of the vocal cords.
l The absence of the normal crest of bone between
n Aetiological factors
the carotid canal and jugular fossa on m Chronic irritation of vocal cords due to
lateral tomography is virtually diagnostic of n misuse of voice
a glomus jugulare tumor. n heavy smoking
n CT head and MRI combined together
n chronic sinusitis
provide an excellent preoperative guidance in the n laryngopharyngeal reflex
LARYNGITIS PACHYDERMA

differential diagnosis of petrous apex lesions. m myxoedema.

n Four-vessel angiography
n Clinical Features
l It is necessary when CT head shows involvement
m Hoarseness is the common symptom.
of jugular bulb, carotid artery or intradural extension m Patient uses false cords for voice production
n Brain perfusion and flow studies
and this gives him a low-pitched and rough voice.
l They are necessary when tumour is pressing
m On indirect laryngoscopy, vocal cords appear as
on internal carotid artery. fusiform swellings with pale translucent look
n Embolization
n Treatment
l In large tumours, embolization of feeding
m Decortication of the vocal cords
vessels 1-2 days before operation helps to m Voice rest.
reduce blood loss. m Speech therapy for proper voice production.
n Biopsy
n Pachydermia laryngis
l Preoperative biopsy of the tumour for
m It is a form of chronic hypertrophic laryngitis
diagnosis is never done. m affect posterior part of larynx in the region of
n Treatment (MCQ) interarytenoid and posterior part of the vocal cords.
GLOMUS TUMOR

m Surgical removal.
m Clinically, patient presents with
m Radiation.
n hoarseness or husky voice
m Embolisation.
n irritation in the throat.
m Indirect laryngoscopy reveals
n heaping up of red or grey granulation tissue in the
interarytenoid region and posterior thirds
of vocal cords (MCQ)
n posterior thirds of vocal cords show
ulceration due to constant hammering of vocal
processes as in talking, forming what is called
the ‘contact ulcer’. The condition is bilateral
and symmetrical.
n It does not undergo malignant change.
n However, biopsy of the lesion is essential
to differentiate the lesion from carcinoma and
tuberculosis.
m Aetiology
n seen in men who indulge in excessive alcohol
and smoking
n excessive forceful talking
n gastro-oesophageal reflux disease where
posterior part of larynx is being constantly bathed with
acid juices from the stomach.
m Treatment is removal of granulation tissue

182 under operating microscope

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 TOPIC 22 - LARYNGOMALACIA TOPIC 24 - MYRINGOTOMY
n Laryngomalacia (congenital laryngeal stridor) MASTOIDECTOMY ADENOIDECTOMY
m most common congenital abnormality of the n It is incision of the tympanic membrane
larynx n the purpose is
m It is characterised by excessive flaccidity of m drain suppurative or nonsuppurative effusion
supraglottic larynx (MCQ) of the middle ear
m supraglottic larynx is sucked in during inspiration m provide aeration in case of malfunctioning
m produces stridor and sometimes cyanosis. eustachian tube.
m Stridor n Ventilation tube (grommet) may also be required
n increased on crying in the latter case.
n subsides on placing the child in prone position n Indications
(MCQ) m Acute suppurative otitis media
m cry is normal. n Severe earache with bulging tympanic membrane.
m The condition manifests at birth or soon n Incomplete resolution with opaque drum and
after(MCQ) persistent conductive deafness.
m usually disappears by 2 years of age. (MCQ) m Complications of acute otitis media,
m Direct laryngoscopy n facial paralysis
n shows elongated epiglottis,curled upon itself n labyrinthitis
(omega-shaped Ω) (MCQ) n meningitis with bulging tympanic membrane.

ENT
n floppy aryepiglottic folds and prominent m Serous otitis media.
arytenoids m Aero-otitis media
m Flexible laryngoscope is very useful to make n to drain fluid and “unlock” the eustachian tube
the diagnosis. m Atelectatic ear
m Mostly, treatment is conservative. n grommet is often inserted for long-term aeration
m Tracheostomy may be required for some cases of n Contraindications
severe respiratory obstruction m Suspected intratympanic glomus tumour.
n Myringotomy in these cases can cause profuse
TOPIC 23 - MALIGNANT OTITIS EXTERNA bleeding.

TOPICS : 22, 23, 24

n Malignant (necrotising) otitis externa n Tympanotomy is preferred.

m caused by pseudomonas infection (MCQ) n Technique

m usually in the elderly diabetics, or in those on m Incision

immunosuppressive drugs.(MCQ) n In acute suppurative otitis media,

m there is excruciating pain and appearance of l a circumferential incision

granulations in the meatus. l made in the posteroinferior quadrant of

m Facial paralysis is common. tympanic membrane

m Infection may spread to the skull base and jugular l midway between handle of malleus and

foramen causing multiple cranial nerve palsies. tympanic annulus

m Treatment l avoid injury to incudostapedial joint

n high doses of i.v. antibiotics directed against n In serous otitis media

pseudomonas (tobramycin, ticarcillin or third l a small radial incision

generation cephalosporins). l given in the posteroinferior or anteroinferior quadrant

n Complications
m Injury to incudostapedial joint or stapes.
m Injury to jugular bulb with profuse bleeding, if
jugular bulb is high and floor of the middle ear
dehiscent.
m Middle ear infection.
n Myringoplasty
m Closure of perforation of pars tensa of the
tympanic membrane is called myringoplasty.
n It has the advantage of : (MCQ)

183
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 l restoring the hearing loss and in some cases
the tinnitus.
l preventing re-infection from external auditory
canal and eustachian tube (nasopharyngeal
infection ascends easily via eustachian tube in
the presence of perforation than otherwise).
l prveenting aeroallergens reaching the exposed
middle ear mucosa, leading to persistent ear
discharge.
l Myringoplasty can be combined with ossicular
reconstruction when it is called tympanoplasty.
m Contraindications
n Active discharge from the middle ear.
n Nasal allergy. It should be brought under
control before surgery.
n Otitis externa.
n Ingrowth of squamous epithelium into the
middle ear
n In such cases, excision of squamous epithelium from
the middle ear or a tympanomastoidectomy may
ENT
be required.
n When the other ear is dead or not suitable for
hearing aid rehabilitation.
n Children below 3 years
n Cortical mastoidectomy,
m known as simple or complete mastoidectomy
or Schwartz operation,
m is complete exenteration of all accessible mastoid air cells
MYRINGOTOMY MASTOIDECTOMY
and converting them into a single cavity.
m Posterior meatal wall is left intact
m Middle ear structures are not disturbed.
m Indications
ADENOIDECTOMY
n Acute coalescent mastoiditis.
n Incompletely resolved acute otitis media with
reservoir sign.
n Masked mastoiditis.
m As an initial step to perform:
n endolymphatic sac surgery
n decompression of facial nerve
n translabyrinthine or retro-labyrinthine
procedures for acoustic neuroma.
m Complications
n Injury to facial nerve.
n Dislocation of incus.
n Injury to horizontal semicircular canal.
n Patient will have post-operative giddiness and
nystagmus.
n Injury to sigmoid sinus with profuse
bleeding.
n Injury to dura of middle cranial fossa.
n Post-operative wound infection and wound
break-down.
n Radical Mastoidectomy
184
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m a procedure to eradicate disease from the middle
ear and mastoid without any attempt to reconstruct
hearing.
m Posterior meatal wall is removed and the entire
area of middle ear, attic, antrum and mastoid is
converted into a single cavity.
m All remnants of tympanic membrane, ossicles
(except stapes footplate) and mucoperiosteal
lining are removed
m Eustachian tube is obliterated by a piece of muscle
or cartilage.
m Aim of the operation is to permanently
exteriorise the diseased area for inspection and
cleaning.
m Indications
n When all cholesteatoma cannot be safely
removed,
l that invading eustachian tube, round window niche,
perilabyrinthine or hypotympanic cells.
n If previous attempts to eradicate chronic
inflammatory disease or cholesteatoma have
failed.
n As an approach to petrous apex.
n Removal of glomus tumour.
n Carcinoma middle ear.
l Radical mastoidectomy followed by radiotherapy is an
alternative to en bloc removal of temporal
bone in carcinoma middle ear.
m Complications
n Facial paralysis.
n Perichondritis of pinna.
n Injury to dura or sigmoid sinus.
n Labyrinthitis, if stapes gets dislocated.
n Severe conductive deafness of 50 dB or
more.
l This is due to removal of all ossicles and
tympanic membrane.
n Cavity problems.
l Twenty five percent of the cavities do not
heal and continue to discharge, requiring regular
after-care.
n Modified Radical Mastoidectomy
m as much of the hearing mechanism as possible
is preserved.
m antrum is removed
m disease process is often localised to the attic
m whole area is fully exteriorised into the meatus
m removal of the posterior meatal and lateral attic
wall is done
m Indications
n Cholesteatoma confined to the attic and
antrum.
n Localised chronic otitis media.
 n Irreversibly damaged tissues are removed l It is necessary to check for submucous cleft
n preserves the rest to conserve or reconstruct hearing palate by inspection and palpation before removal
mechanism. of adenoids.
n Adenoidectomy n Nasopharyngeal stenosis due to scarring.
n Adenoidectomy may be indicated alone or n Recurrence.
in combination with tonsillectomy. l This is due to regrowth of adenoid tissue left
n In the latter event, adenoids are removed first and behind.
the nasophar ynx packed before starting
tonsillectomy TOPIC 25 - PAPILLOMA
n Indications
n Squamous Papillomas
l Adenoid hypertrophy causing snoring,
m They can be divided into
mouth breathing, sleep apnoea syndrome or
n juvenile
speech abnormalities, i.e. (rhinolalia clausa).
n adult-onset types.
l Recurrent rhinosinusitis.
m Juvenile papillomas
l Chronic secretory otitis media associated
n They are viral in origin and multiple (MCQ)
with adenoid hyperplasia.
n often involve infants and young children
l Recurrent ear discharge in benign CSOM
n present with hoarseness and stridor.
associated with adenoiditis/adenoid
n They are mostly seen on the true and false
hyperplasia.
cords and the epiglottis,
l Dental malocclusion.
n Clinically, they appear as glistening white

ENT
„ Adenoidectomy does not correct dental
irregular growths, pedunculated or sessile,
abnormalities
friable and bleeding easily
„ Adenoidectomy will prevent its
n They are known for recurrence after removal
recurrence after orthodontic treatment.
and therefore multiple laryngoscopies may be
n Contraindications
required.
n Cleft palate or submucous palate.
n They tend to disappear spontaneously after
l Removal of adenoids causes velopharyngeal
puberty. (MCQ)
insufficiency in such cases.
n They have been treated by endoscopic
n Haemorrhagic diathesis.
removal with cup forceps, cr yotherapy and
n Acute infection of upper respiratory tract.
microelectrocautery. (MCQ)
Complications

PAPILLOMA
n
n CO2 laser is preferred because of the
n Haemorrhage,
precision in removal and less bleeding.
l usually seen in immediate post-operative
n Interferon therapy is being tried to prevent
period
recurrence and has been found successful.
l Rising pulse rate is important indicator.
m Adult-onset papilloma
l Postnasal pack under general anaesthesia is
n Usually, it is single, smaller in size, less
often required.
aggressive
n Injury to eustachian tube opening.
n does not recur after surgical removal.
n Injury to pharyngeal musculature and
n It is common in males (2:1)
vertebrae.
n Occurs in the age group of 30-50
l This is due to hyperextension of neck and
n usually arises from the anterior half of vocal
undue pressure of curette.
cord or anterior commissure.
l Care should be taken when operating patients
of Down’s syndrome as 10-20% of them
have atlanto-axial instability.
n Griesel syndrome.
l Patient complains of neck pain and develops
torticollis.
l Mostly it is due to spasm of paraspinal
muscles
l It can be due to atlanto-axial dislocation
requiring cervical collar and even traction.
n Velopharyngeal insufficiency.
185
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 TOPIC 25 - VOCAL NODULE m Some cases are due to gastric reflux.
m Chief complaints are
n Vocal Nodules (Singer’s or Screamer’s Nodes)
n hoarse voice
m They appear symmetrically on the free edge of
n a constant desire to clear the throat
vocal cord, at the junction of anterior one-third,
n pain in the throat which is worse on phonation.
with the posterior two-thirds, as this is the area
n Intubation Granuloma
of maximum vibration of the cord and thus subject to
m results from injury to vocal processes of
maximum trauma (MCQ)
arytenoids
m They are the result of vocal trauma when person
m occur due to rough intubation, use of large tube or
speaks in unnatural low tones for prolonged
prolonged presence of tube between the cords.
periods or at high intensities.
m Usually, they are bilateral involving posterior
m They mostly affect teachers, actors, vendors or
thirds of true cords.
pop singers.
m Treatment is voice rest and endoscopic removal
m They are also seen in school going children who
of the granuloma.
are too assertive and talkative.
n Leukoplakia or Keratosis
m Patients complain of hoarseness.
m This is also a localised form of epithelial
m Vocal fatigue and pain in the neck on
hyperplasia
prolonged phonation, are other common
m involve upper surface of one or both vocal cords.
symptoms.
m It appears as a white plaque or warty growth on
m Early cases are treated conservatively by educating
the cord without affecting its mobility.
ENT

the patient in proper use of voice.

m It is regarded as a precancerous condition
m Surgery is required for large nodules or nodules
because “carcinoma in situ” frequently supervenes.
of long-standing in adults.
m Hoarseness is the common presenting symptom.
n Vocal Polyp
m Treatment is stripping of vocal cords and
m Risk factors
subjecting the tissues to histology for any malignant
n vocal abuse or misuse.
change.
n Allergy
n smoking.
m Mostly, it affects men in the age group of 30-
VOCAL NODULE

50.
m Typically, unilateral
m arise from the same position as vocal nodule.
m Some patients complain of diplophonia (double
voice) due to different vibratory frequencies of the two
vocal cords.
m caused by sudden shouting resulting in
haemorrhage in the vocal cord.
m Treatment
n surgical excision under operating microscope
followed by speech therapy.
n Reinke’s Oedema (Bilateral Diffuse Polyposis)
m due to collection of oedema fluid in the
subepithelial space of Reinke.
m Usual cause is vocal abuse and smoking.
m Both vocal cords show diffuse symmetrical
swellings.
m Treatment is vocal cord stripping, preserving
enough mucosa for epithelialisation.
n Contact Ulcer (MCQ)
m due to faulty voice production
m vocal processes of arytenoids hammer against each other
resulting in ulceration and granuloma
formation.
186
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 TOPIC 27 - ANTROCHOANAL AND „ In this case, antrum is opened by
ETHMOIDAL POLYPI Caldwell-Luc approach and the ethmoid
air cell approached through the medial wall
n Bilateral Ethmoidal Polypi of the antrum.
m Diseases associated with the formation of nasal l Endoscopic sinus surgery. (MCQ)
polypi are: „ These days, ethmoidal polypi are removed
n Chronic rhinosinusitis.
by endoscopic sinus surgery more
n Non-allergic rhinitis with eosinophilia
popularly called FESS (functional
syndrome (NARES) endoscopic sinus surgery).
n Asthma.
n Treatment Summary
n Aspirin intolerance.
l One or two peduncalated polyps -
l Sampter’s triad consists of (MCQ)
Polypectomy
„ nasal polypi,
l Multiple and sessile polyp - Intranasal
„ asthma
ethmoidectomy
„ aspirin intolerance.
l Recurrence of polyp after intranasal procedures
n Cystic fibrosis.
- Extranasal ethmoidectomy
n Allergic fungal sinusitis
l Infection and polypoidal changes also seen in
n Kartagener’s syndrome.
maxillary antrum- Transantral
l consists of bronchiectasis sinusitis, situs inversus and
ethmoidectomy
ciliary dyskinesis. n Antrochoanal Polyp

ENT
n Young’s syndrome
m This polyp arises from the mucosa of maxillary
l consists of sinopulmonary disease and azoospermia.
antrum near its accessory ostium, comes out of it
n Churg-Strauss syndrome.
and grows in the choana and nasal cavity.
l Consists of asthma, fever, eosinophilia, vasculitis
m Nasal allergy coupled with sinus infection
and granuloma. m seen in children and young adults.
n Nasal mastocytosis.
m Usually they are single and unilateral (MCQ)
l It is a form of chronic rhinitis in which
m Symptoms
nasal mucosa is infiltrated with mast cells but few

ANTROCHOANAL AND ETHMOIDAL POLYPI

n Unilateral nasal obstruction is the presenting
eosinophils. symptom.
l Skin tests for allergy and IgE levels are n Voice may become thick and dull due to
normal. hyponasality.
m Treatment (MCQ) n Nasal discharge, mostly mucoid
n Conservative m Signs
l Early polypoidal changes with oedematous n As the antrochoanal polyp grows posteriorly,
mucosa it may be missed on anterior rhinoscopy.
„ Antihistaminics n Posterior rhinoscopy may reveal a globular
„ control of allergy. mass filling the choana or the nasopharynx.
„ short course of steroids
n Surgical
l Polypectomy.
l Intranasal ethmoidectomy.
„ Indication - polypi are multiple and sessile
„ they require uncapping of the ethmoidal
air cells by intranasal route
l Extranasal ethmoidectomy.
„ This is indicated when polypi recur after
intranasal procedures and surgical
landmarks are ill-defined due to previous
surgery.
l Transantral ethmoidectomy.
„ This is indicated when infection and
polypoidal changes are also seen in the
maxillary antrum.
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 Differences between antrochoanal and ethmoidal polypi
Antrochoanal polypi
Age Common in children
Aetiology Infection
Number Solitary
Laterality Unilateral
Orgin Max, sinus near the ostium
Growth Grows backwards to the choana;
may hang down behind the soft palate
Size & Trilobed with antral, nasal and choanal parts.
Shape Choanal part may protrude through the choana
& fill the nasopharynx obstructing both sides
Recurrence Uncommon, if removed completely
Treatment Polypectomy; endoscopic removal
or caldwell-Luc operation if recurrent
ENT
Investigations
n X-rays of paranasal sinuses
m show opacity of the involved antrum.
n X-ray, (lateral view) soft tissue nasopharynx
m reveals a globular swelling in the postnasal space.
m It is differentiated from angiofibroma by the
ANTROCHOANAL AND ETHMOIDAL POLYPI
presence of a column of air behind the polyp.
Treatment
n An antrochoanal polyp is easily removed by
avulsion either through the nasal or oral route.
n Recurrence is uncommon after complete removal.
n In cases which do recur,
m Caldwell-Luc operation is avoided
m endoscopic sinus surgery has superceded other
modes of polyp removal.
Important Points about Nasal Polypi
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Ethmoidal polypi
Common in adults
Allergy or multifactorial
Multiple
Bilateral
Ethmoidal sinuses, uncinate process,
middle turbinate and middle meatus
Mostly grow anteriorly and
may present at the nares
Usually small and grape-like masses
Common
Polypectomy
Endoscopic surgery or ethmoidectomy (which
may be intranasal, extranasal or transantral)
n If a polypus is red and fleshy, friable and has
granular surface, especially in older patients, think of
malignancy.
n Simple nasal polyp may masquerade a malignancy
underneath.
m Hence all polypi should be subjected to
histology.
n A simple polyp in a child may be a glioma, an
encephalocele or a meningoencephalocele.
m It should always be aspirated and fluid examined for
CSF.
m Careless removal of such polyp would result in
CSF rhinorrhea and meningitis.
n Multiple nasal polypi in children may be associated
with mucoviscidosis.
n Epistaxis and orbital symptoms associated with
a polyp should always arouse the suspicion of malignancy.
 TOPIC 28 - TUBERCULOSIS OF LARYNX TOPIC 29 - SINUSITIS
n TUBERCULOSIS OF LARYNX n Acute Sinusitis
m It is almost always secondary to pulmonary m The sinus most commonly involved is the maxillary

tuberculosis m Sinusitis may be ‘open’ or ‘closed’ type

m Disease affects posterior part of larynx more than m Open type - inflammatory products of sinus

anterior. cavity can drain freely into the nasal cavity

m Parts affected are: through the natural ostia
n interarytenoid fold (most common ) MCQ m A ‘closed’ sinusitis causes more severe symptoms

n ventricular bands, and is also likely to cause complications.

n vocal cords m Aetiology of sinusitis in general

n epiglottis n Exciting Causes

m Weakness of voice is the earliest symptom followed l Nasal infections.

„ Most common cause of acute sinusitis is

TUBERCULOSIS OF LARYNX
by hoarseness. (MCQ)
m Laryngeal Examination viral rhinitis followed by bacterial
n Hyperaemia of the vocal cord in its whole extent invasion.
or confined to posterior part with impairment l Swimming and diving

of adduction is the first sign. .(MCQ) l Trauma.

n Swelling in the interarytenoid region giving a l Dental infections.

mamillated appearance.(MCQ) „ This applies to maxillary sinus.

n Ulceration of vocal cord giving mouse-nibbled „ Infection from the molar or premolar

appearance. .(MCQ) teeth or their extraction may be followed

n Superficial ragged ulceration on the arytenoids by acute sinusitis.
and interarytenoid region. n Predisposing Causes

n Granulation tissue in interarytenoid region or l Obstruction to sinus ventilation and

vocal process of arytenoid. drainage.

n Pseudoedema of the epiglottis “turban „ Nasal packing

epiglottis”..(MCQ) „ Deviated septum

n Swelling of ventricular bands and aryepiglottic „ Hypertrophic turbinates

folds. „ Oedema of sinus ostia due to allergy or

vasomotor rhinitis

SINUSITIS
n Marked pallor of surrounding mucosa
n LUPUS OF THE LARYNX „ Nasal polypi

m It is an indolent tubercular infection „ Structural abnormality of ethmoidal air cells

m associated with lupus of nose and pharynx. „ Benign or malignant neoplasm.

m Unlike tuberculosis of larynx which mostly l Stasis of secretions in the nasal cavity.

affects posterior parts, lupus involves the „ Normal secretions of nose may not drain

anterior part of larynx. (MCQ) into the nasopharynx because of their

m Epiglottis is involved first and may be completely ® viscosity (cystic fibrosis)

destroyed by the disease. (MCQ) ® obstruction (enlarged adenoids,

m The lesion spreads to aryepiglottic folds and choanal atresia), and get infected.
sometimes to ventricular bands. l Previous attacks of sinusitis where local

m Lupus of larynx is a painless and often an defences of sinus mucosa are already
asymptomatic condition and may be discovered damaged.
on routine laryngeal examination in cases of lupus l Sinusitis is common in cold and wet climate

of nose. l Atmospheric pollution, smoke, dust and

m There is no pulmonary tuberculosis. overcrowding also predispose to sinus

m Treatment is antitubercular drugs. infection.
m Prognosis is good. l Recent attack of exanthematous fever
(measles, chickenpox, whooping cough)
l nutritional deficiencies,
l systemic disorders (diabetes, immune deficiency
syndromes).
n Acute maxillary sinusitis
189
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 m Most commonly, it is viral rhinitis which spreads
to involve the sinus mucosa.
m Dental infections are important source of
maxillary sinusitis.
m Headache.
m Usually, this is confined to forehead
m confused with frontal sinusitis.
m Pain.
n Typically, it is situated over the upper jaw, but
may be referred to the gums or teeth. For this
reason patient may primarily consult a dentist
n Pain is aggravated by stooping, coughing or
chewing
n Occasionally, pain is referred to the ipsilateral
supraorbital region and thus may simulate
frontal sinus infection
m Tenderness. Pressure or tapping over the anterior wall
of antrum produces pain.
m Redness and oedema of cheek
n Commonly seen in children
ENT
m The lower eyelid may become puffy.
m Nasal discharge.
n Anterior rhinoscopy
l shows pus or mucopus in the middle
meatus.
l Mucosa of the middle meatus and
turbinate may appear red and swollen.
n Postural test.
l If no pus seen in the middle meatus, it is
decongested with a pledget of cotton soaked with a
SINUSITIS
vasoconstrictor and the patient is made to sit with n Acute frontal sinusitis
the affected sinus turned up.
l Examination after 10-15 minutes may show
discharge in the middle meatus.
n Post nasal discharge.
l Pus may be seen on the upper soft palate
on posterior rhinoscopy.
m Diagnosis
n Transillumination test - Affected sinus will
be found opaque.
n X-rays.
l Waters’ view will show either an opacity or
a fluid level in the involved sinus.
n CT scan is the preferred imaging modality to
investigate the sinuses.
m Treatment
n Ampicillin and amoxicillin are quite effective
n Er ythromycin or doxycycline or
cotrimoxazole are equally effective and can be
given to those who are sensitive to penicillin
n β-lactamase-producing strains of H. influenzae
and M. catarrhalis may necessitate the use of
amoxicillin/clavulanic acid or cefuroxime
190
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axetil. Sparfloxacin is also effective, and has
the advantage of single daily dose.
n Nasal decongestant drops.
l 1% ephedrine or 0.1% xylo- or
oxymetazoline are used as nasal drops or
sprays to decongest sinus ostium and
encourage drainage.
n Steam inhalation.
l Steam alone or medicated with menthol or
Tr. Benzoin Co. provides symptomatic relief
and encourages sinus drainage.
l Inhalation should be given 15 to 20 minutes
after nasal decongestion for better
penetration.
n Analgesics- Paracetamol
n Hot fomentation. Local heat to the affected
sinus is often soothing and helps in the resolution
of inflammation.
n Antral lavage
l It is done only when medical treatment
has failed and that too only under cover of
antibiotics.
n Complications
m Acute maxillary sinusitis may change to subacute
or chronic sinusitis.
m Frontal sinusitis.
n Frontonasal duct which opens in middle meatus is
obstructed due to inflammatory oedema.
m Osteitis or osteomyelitis of the maxilla.
m Orbital cellulitis or abscess.
m Frontal headache.
n Usually severe and localised over the affected
sinus.
n It shows characteristic periodicity,
n comes up on waking, gradually increases
and reaches its peak by about mid day and
then starts subsiding.
n It is also called “office headache” because of
its presence only during the office hours.
m Tenderness.
n Pressure upwards on the floor of frontal sinus,
just above the medial canthus, causes
exquisite pain.
n It can also be elicited by tapping over the
anterior wall of frontal sinus in the medial part
of supraorbital region.
n Oedema of upper eyelid with suffused
conjunctiva and photophobia.
m Nasal discharge.
n A vertical streak of mucopus is seen high up in the
anterior part of the middle meatus.
 n Nasal mucosa is inflamed in the middle
meatus.
m X-rays.
n Opacity of the affected sinus or fluid level
can be seen
n Both Waters’ and lateral views should be
taken.
m CT scan is the preferred modality.
m Treatment
n Placing a pledget of cotton soaked in a
vasoconstrictor in the middle meatus, once or
twice daily, helps to relieve ostial oedema and
promotes sinus drainage and ventilation.
m Surgical
n Trephination of frontal sinus.- frontal sinus
is drained externally
l Indications
„ If there is persistence or exacerbation
of pain or pyrexia in spite of medical
treatment for 48 hours
„ if the lid swelling is increasing
„ threatening orbital cellulitis
l A 2 cm long horizontal incision is made in
the superomedial aspect of the orbit below
the eyebrow
m Complications
n Orbital cellulitis.
n Osteomyelitis of frontal bone and fistula
formation.
n Meningitis, extradural abscess or frontal
lobe abscess, if infection breaks through the
posterior wall of the sinus.
n Chronic frontal sinusitis, if the acute infection
is neglected or improperly treated.
n ACUTE ETHMOID SINUSITIS
m Acute ethmoiditis is often associated with
infection of other sinuses.
m Ethmoid sinuses are more often involved in infants
and young children.
m Clinical Features
n Pain
l It is localised over the bridge of the nose,
medial and deep to the eye
l It is aggravated by movements of the eye
ball.
n Oedema of lids.
l Both eyelids become puffy and swollen.
l There is increased lacrimation
l Orbital cellulitis is an early complication in
such cases.
n Nasal discharge.
l On anterior rhinoscopy, pus may be seen in
middle or superior meatus depending on
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the involvement of anterior or posterior
group of ethmoid sinuses.
l Swelling of the middle turbinate.
m Treatment
n Visual deterioration and exophthalmos
l indicate abscess in the posterior orbit
l require drainage of the ethmoid sinuses
into the nose through an external
ethmoidectomy incision.
m Complications
n Orbital cellulitis and abscess.
n Visual deterioration and blindness due to
involvement of optic nerve.
n Cavernous sinus thrombosis.
n Extradural abscess, meningitis or brain abscess.
n Acute sphenoid sinusitis
m Headache. Usually localised to the occiput or
vertex
m Pain may also be referred to the mastoid region.
m Postnasal discharge
ENT
n It can only be seen on posterior rhinoscopy.
n A streak of pus may be seen on the roof and
posterior wall of nasopharynx or above the
posterior end of middle turbinate.
m X-rays.
n Opacity or fluid level may be seen in the
sphenoid sinus.
n Lateral view of the sphenoid sinus is taken
in supine or prone position and is helpful to
demonstrate the fluid level.
SINUSITIS
m Mucocele of the sphenoid sinus or its
neoplasms may clinically simulate features of acute
infection of sphenoid sinus and should always be
excluded in any case of isolated sphenoid sinus involvement.
191
 TOPIC 30 - LARYNGOMALACIA l no fungal invasion. .(MCQ)
n Treatment
n Laryngomalacia (congenital laryngeal stridor)
l endoscopic surgical clearance of the
m It is the most common congenital abnormality
sinuses with provision of drainage and
of the larynx. .(MCQ)
ventilation.
m It is characterised by excessive flaccidity of
l This is combined with pre- and post-
supraglottic larynx
operative systemic steroids. .(MCQ)
m supraglottic lar ynx is sucked in during
m Chronic invasive sinusitis.
inspiration producing stridor and sometimes cyanosis.
n Here the fungus invades into the sinus mucosa.
m Stridor is increased on crying but subsides on
n There is bone erosion by fungus.
placing the child in prone position
n Patient presents with chronic rhinosinusitis.
m Cry is normal. (MCQ)
n CT scan shows thickened mucosa with
m The condition manifests at birth or soon after
opacification of sinus and bone erosion.
m usually disappears by 2 years of age. (MCQ)
n Patient may have intracranial or intraorbital
m Direct laryngoscopy shows
invasion.
n elongated epiglottis, curled upon itself (omega-
n Treatment
shapedΩ) (MCQ)
l surgical removal of the involved mucosa,
LARYNGOMALACIA

n floppy aryepiglottic folds

bone and soft tissues
n prominent arytenoids.
l followed by antifungal therapy with i.v.
m Flexible laryngoscope is very useful to make
amphotericin
the diagnosis.
l followed by itraconazole therapy for 12
m Mostly, treatment is conservative.
months or more monitored by serial CT or
m Tracheostomy may be required for some cases of
MRI scans.
severe respiratory obstruction
m Fulminant fungal sinusitis.
n It is an acute presentation
TOPIC 31 - ALLERGIC FUNGAL SINUSITIS
n mostly seen in immunocompromised or
n Fungal Sinusitis diabetic individuals.
ALLERGIC FUNGAL SINUSITIS

m Common species of fungi found to involve the
paranasal sinuses Aspergillus, Alternaria, Mucor
or Rhizopus.
m Fungal ball.
n It is due to implantation of fungus into an
otherwise healthy sinus
n on CT ,it shows a hyperdense area with no
evidence of bone erosion or expansion.
n Maxillary sinus is the most commonly
(MCQ)
n Treatment
l surgical removal of the fungal ball and
adequate drainage of the sinus.
l No antifungal therapy is required. (MCQ)
m Allergic fungal sinusitis.
n It is an allergic reaction to the causative
fungus
n presents with sinu-nasal polyposis and mucin.
n Mucin contains eosinophils, Charcot-Leyden
crystals and fungal hyphae. There is no
invasion of the sinus mucosa with fungus.
(MCQ)
n CT scan shows
l mucosal thickening with hyperdense areas.
l expansion of the sinus or bone erosion due
to pressure
192
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n Common fungal species are Mucor or
Aspergillus.
n Rhinocerebral Mucormycosis
l causes rhinocerebral disease.
l Due to invasion of the blood vessels, mucor
fungus causes ischaemic necrosis presenting
as a black eschar, involving inferior
turbinate, palate or the sinus. .(MCQ)
l It spreads to the face, eye, skull base and
the brain.
l Treatment is surgical debridement of
necrotic tissue and i.v. amphotericin
B.(MCQ)
n Aspergillus infection
l cause acute fulminant sinusitis with tissue
invasion.
l Such patients present with acute sinusitis and
develop sepsis and other sinus complications.
l Unlike Mucor infection, there is no black
eschar.
l Treatment is antifungal therapy and
surgery
 TOPIC 32 - ALLERGIC RHINITIS m Diagnosis can be made by indirect laryngoscopy,
and soft tissue A.P. and lateral views of neck
n Allergic rhinitis
with Valsalva.
m a type 1 hypersensitivity reaction.
m CT scan helps to find the extent of lesion.
m It occur in two phases :
m Treatment
n Early phase or acute and occur immediately
l surgical excision through an external
within 5-30 min. of exposure to allergen.
neck incision.
n Late reaction that occur 2-8 hours after
l Marsupialisation of an inter nal
exposure to allergen.
laryngocele can be done by laryngoscopy
m Early mediators
but there are chances of recurrence.
n Histamine, PAF, Leukotrienes(C4,D4,E4),
m A laryngocele in an adult may be associated
n Neutral proteases that activate complement and
with carcinoma.
kinins and PGD2.
m Surgical t/t of allergic rhinitis -
TOPIC 34 - ATROPHIC RHINITIS
n Surgery should be used in a case of allergic rhinitis
when other methods have failed. n Atrophic rhinitis (Ozaena)
n It should never be used as first line of t/t. m It is a chronic inflammation of nose
n Surgery is done in a case of allergic rhinitis for m characterised by atrophy of nasal mucosa and
following two purposes turbinate bones.
l Relieve nasal obstruction m The nasal cavities are roomy and full of foul-
„ To relieve obstruction turbinate resection smelling crusts.

ENT
is done m Atrophic rhinitis is of two types: primary and
l Relieve rhinorrhea secondary
„ Vidian neurectomy is done to relieve n Rhinitis sicca
rhinorrhea (MCQ) l It is also a crust-forming disease seen in
patients who work in hot, dry and dusty
TOPIC 33 - LARYNGOCELE surroundings, e.g. bakers, iron- and
goldsmiths.
n Laryngocele
l Condition is confined to the anterior third

TOPICS ; 32, 33, 34

m It is an air-filled cystic swelling
of nose particularly of the nasal septum.
m Occur due to dilatation of the saccule
l Here, the ciliated columnar epithelium
m A laryngocele may be:
undergoes squamous metaplasia with
n Internal
atrophy of seromucinous glands.
l it is confined within the larynx
l Crusts
l presents as distension of false cord and aryepiglottic
„ form on the anterior part of septum
fold.
„ their removal causes ulceration and epistaxis,
n External
and may lead to septal perforation.
l distended saccule herniates through the
n Treatment
thyroid membrane
l correction of the occupational surroundings
l it presents in neck
l application of bland ointment or one with
n Combined or mixed
an antibiotic and steroid, to the affected
l both internal and external components are
part.
seen.
l Nose pricking and forcible removal of
m A laryngocele is supposed to arise from raised
crusts should be avoided.
transglottic air pressure
l Nasal douche, like the one used in cases of
m Occur in trumpet players, glass-blowers or
atrophic rhinitis, is useful
weight lifters.
m Rhinitis caseosa
m A laryngocele presents with hoarseness, cough and if
n usually unilateral
large, obstruction to the airway.
n mostly affects males.
m An external laryngocele presents as a reducible
n Nose is filled with offensive purulent
swelling in the neck which increases in size on
discharge and cheesy material.
coughing or performing Valsalva
n Sinus mucosa becomes granulomatous.
n Bony walls of sinus may be destroyed, requiring
differentiation from malignancy. 193
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 n Treatment
„ removal of debris and granulation tissue
„ free drainage of the affected sinus.
Prognosis is good
LABORATORY TESTS OF VESTIBULAR FUNCTION
inspissated plugs of mucus or even small
foreign bodies.
m It can also be easily passed through endotracheal
tube or the tracheostomy opening.

n
m it has limited utility in children because of the
TOPIC 35 - BRONCHOSCOPY problems of ventilation

n Rigid bronchoscopy TOPIC 36 - LABORATORY TESTS OF

m Indications
VESTIBULAR FUNCTION
n Diagnostic
l To find out the cause for wheezing, Laboratory Tests of Vestibular Function
haemoptysis, or unexplained cough n Caloric Test

persisting for more than 4 weeks. m Princple of this test

l When X-ray chest shows: n induce nystagmus by thermal stimulation

„ Atelectasis of a segment, lobe or entire of the vestibular system.

lung m If vertigo induced by the caloric test is qualitatively

„ Opacity localised to a segment or lobe of similar to the type experienced by patient during
lung the episode of vertigo. it proves labyrinthine
„ Obstructive emphysema-to exclude origin of vertigo.
foreign body n Modified Kobrak test

l Hilar or mediastinal shadows m Patient is seated with head tilted 60° backwards

l Vocal cord palsy. m It places horizontal canal in vertical position

l Collection of bronchial secretions for culture m Ear is irrigated with ice water for 60 seconds,

and sensitivity tests, acid fast bacilli, fungus, malignant first with 5 ml and if there is no response, 10 ml,
cells. 20 ml and 40 ml.
n Therapeutic m Normally, nystagmus beating towards the

l Removal of foreign bodies. opposite ear, will be seen with 5 ml of ice water.
l Removal of retained secretions or mucus plug m If response is seen with increased quantities of
BRONCHOSCOPY

in cases of head injuries, chest trauma, thoracic water between 5 and 40 ml, labyrinth is
or abdominal surgery, or comatosed patients. considered hypoactive.
m Complications m No response to 40 ml water indicates dead

n Injury to teeth and lips. labyrinth.

n Haemorrhage from the biopsy site. n Fitzgerald-Hallpike test (bithermal caloric test)

n Hypoxia and cardiac arrest. m In this test, patient lies supine with head tilted

n Laryngeal oedema. 30° forward

n Flexible fibre optic bronchoscopy m It places horizontal canal is vertical

m flexible fibre optic bronchoscopy has replaced m Ears are irrigated for 40 seconds alternately with

rigid bronchoscopy for diagnostic procedures water at 30°C and at 44°C (i.e. 7° below and above
particularly in adults. normal body temperature) and eyes observed
m It provides magnification and better for appearance of nystagmus till its end point.
illumination m Time taken from the start of irrigation to the end

m Due to smaller size of scope, it permits point of nystagmus is recorded and charted on a
examination of subsegmental bronchi. calorigram
m It is also easy to use in patients with neck or jaw m If no nystagmus is elicited from any ear, test is

abnormalities where rigid bronchoscopy may repeated with water at 20°C for 4 minutes before
almost be impossible technically. labelling the labyrinth dead.
m procedure can be performed under topical n COWS: Cold-Opposite, Warm-Same

anaesthesia m Cold water induces nystagmus to opposite side

m very useful for bedside examination of the m Warm water induces nystagmus to the same

critically ill patients. side

m The suction/biopsy channel provided in the n 2 types of abnormal responses to the caloric test

fibrescope helps to remove secretions, m canal paresis or dead labyrinth

194
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 m directional preponderance, i.e. nystagmus is
more in one particular direction than in the other
n Canal paresis
m It indicates that response (measured as duration
of nystagmus) elicited from a particular canal
(labyrinth), right or left, after stimulation with cold
and warm water is less than that from the
opposite side.
m It can also be expressed as percentage of the
total response from both ears
m L30 is the response from left side with water at
30°C
m L44 is response from left ear after stimulation
with warm water at 44°C.
m Canal paresis
n is indicative of depressed function of the
ipsilateral labyrinth, vestibular nerve or
vestibular nuclei
n seen in Meniere’s disease, acoustic
neuroma, post-labyrinthectomy or
vestibular nerve section.
n Directional preponderance
m directional preponderance occurs
n towards the side of a central lesion
n away from the side in a peripheral lesion
m directional preponderance does not help to localise
the lesion in central vestibular pathways.
m Canal paresis on one side with directional
preponderance to the opposite side is seen in
unilateral Meniere’s disease .(MCQ)
m Canal paresis with directional preponderance
to ipsilateral side is seen in acoustic neuroma.(MCQ)
n Cold-air caloric test
m This test is done when there is perforation of
tympanic membrane because irrigation with
water in such a case with perforation is
contraindicated.
m The test employs Dundas Grant tube which is a
coiled copper tube wrapped in cloth. (MCQ)
m The air in the tube is cooled by pouring ethyl
chloride, and then blown into the ear.
m It is only a rough qualitative test.
n Electronystagmography
m The test depends on the presence of
corneoretinal potentials which are recorded by
placing electrodes at suitable places round the eyes.
m detect nystagmus which is not seen with the
naked eye
m permits to keep a per manent record of
nystagmus.
n Optokinetic Test
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m Procedure : Patient is asked to follow a series of
vertical stripes on a drum moving first from
right to left and then from left to right.
m Normally it produces nystagmus with
n slow component in the direction of moving
stripes
n fast component in the opposite direction.
m Optokinetic abnormalities are seen in brainstem
and cerebral hemisphere lesions.
n Rotation Test
m Patient is seated in Barany’s revolving chair with
his head tilted 30° forward and then rotated 10
turns in 20 seconds.
m The chair is stopped abruptly and nystagmus
observed.
m Normally there is nystagmus for 25-40 seconds.
m Advantage : it can be performed in cases of
congenital abnormalities where ear canal has failed
to develop and it is not possible to perform the
caloric test.
ENT
m Disadvantage of the test is that both the
labyrinths are simultaneously stimulated
during the rotation process and cannot be tested
individually.
n Galvanic Test
m It is the only vestibular test which helps in
differentiating an end organ lesion from that
of vestibular nerve
DYSPHONIA PLICA VENTRICULARIS
m Patient stands with his feet together, eyes closed
and arms outstretched and then a current of 1
mA is passed to one ear.
m Normally, person sways towards the side of anodal
current
TOPIC 37 -
DYSPHONIA PLICA VENTRICULARIS
n Dysphonia Plica Ventricularis (Ventricular Dysphonia)
m Here voice is produced by ventricular folds
(false cords) which have taken over the function
of true cords.
m Voice is rough, low-pitched and unpleasant.
m Ventricular voice may be secondary to impaired
function of the true cord such as paralysis, fixation,
surgical excision, or tumours.
m Functional type of ventricular dysphonia
n occurs in normal larynx
n cause is psychogenic
n voice begins normally but soon becomes
rough when false cords usurp the function of
true cords.
m Diagnosis is made on indirect laryngoscopy
195
 n the false cords are seen to approximate partially
or completely and obscure the view of true
cords on phonation.
m Ventricular dysphonia secondary to laryngeal
disorders is difficult to treat
m Ventricular dysphonia secondary to functional
type can be helped through voice therapy and
psychological counselling.
TOPIC 38 - FUNCTIONAL APHONIA
n Functional Aphonia (Hysterical Aphonia)
m It is a functional disorder
m mostly seen in emotionally labile females in the
age group of 15-30. Aphonia is usually sudden
and unaccompanied by other laryngeal symptoms.
Patient communicates with whisper
m On examination, vocal cords are seen in abducted
position and fail to adduct on phonation;
however adduction of vocal cords can be seen
ENT
TOPIC 40 - RHINOLALIA CLAUSA AND
RHINOLALIA APERTA
n Hyponasality (Rhinolalia Clausa)
m It is lack of nasal resonance for words which
are resonated in the nasal cavity, e.g. m, n, ng.
m It is due to blockage of the nose or
nasopharynx
n Hypernasality (Rhinolalia Aperta)
m It is seen when certain words which have little
nasal resonance are resonated through nose.
m The defect is in failure of the nasopharynx to
cut off from oropharynx or abnormal communication
between the oral and nasal cavities
Causes of hyponasality and hypernasality
Hyponasality Hypernasality
Common cold Velopharyngeal insufficiency
Nasal allergy Congenitally short soft palate
Nasal polypi Submucous palate

on coughing, indicating normal adductor Nasal growth Large nasopharynx

function. Adenoids Cleft of soft palate
m Even though patient is aphonic, sound of cough
Nasopharyngeal mass Paralysis of soft palate
is good. Familial speech pattern Post-adenoidectomy
Habitual Oronasal fistula
m Treatment given is to reassure the patient of
Familianl speech pattern
normal laryngeal function and psychotherapy Habitual speech pattern

TOPIC 39 - PUBERPHONIA TOPIC 41 - NASAL SYPHILIS

TOPICS : 38, 39, 40,41

n Puberphonia (Mutational Falsetto Voice) n Nasal syphilis is of two types: acquired and
m Normally, childhood voice has a higher pitch congenital.
m When the larynx matures at puberty, vocal cords n Acquired
lengthen, and the voice changes to one of lower pitch m Primary. It manifests as primary chancre of the
m This is a feature exclusive to males vestibule of nose
m Failure of this change leads to persistence of m Secondary.
childhood high-pitched voice and is called n It manifests as simple rhinitis with crusting
puberphonia. and fissuring in the nasal vestibule.
m It is seen in boys who are emotionally immature, n Diagnosis is suggested by the presence of
feel insecure and show excessive fixation to mucous patches in the pharynx, skin rash,
their mother fever and generalised lymphadenitis.
m Psychologically, they shun to assume male m Tertiary.
responsibilities though their physical and sexual n This is the stage in which nose is commonly
development is normal. involved
m Treatment n Typical manifestation is the formation of a
n Gutzmann’s pressure test gumma on the nasal septum.
l Pressing the thyroid prominence in a n Later, the septum is destroyed both in its
backward and downward direction relaxes the bony and cartilaginous parts.
overstretched cords and low tone voice n Perforation may also appear in the hard
can be produced palate.
n The patient pressing on his larynx learns to n There is offensive nasal discharge with crusts
produce low tone voice and then trains himself n Bony or cartilaginous sequestra may be seen
to produce syllables, words and numbers n Bridge of the nose collapses causing a saddle
m Prognosis is good. nose deformity
196
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n Congenital TOPIC 43 - RHINOSCLEROMA
m Early form
n It is seen in the first 3 months of life
n It is a chronic granulomatous disease
n manifests as “snuffles”.
n caused by Gram-negative bacillus called
n Soon the nasal discharge becomes purulent.
Klebsiella rhinoscleromatis or Frisch bacillus.
n This is associated with fissuring and
n The disease runs through the following stages:
m Atrophic stage.
excoriation of the nasal vestibule and of
n It resembles atrophic rhinitis
the upper lip.
n is characterised by foul smelling purulent nasal
m Late form.
n Usually manifests around puberty.
discharge and crusting.
m Granulomatous stage
n Other stigmata of syphilis such as corneal
n Granulomatous nodules form in nasal mucosa.
opacities, deafness and Hutchinson’s teeth
n There is also subdermal infiltration of lower
are also present.
n Diagnosis
part of external nose and upper lip giving a
n It is made on serological tests (VDRL) and
‘woody’ feel
n Nodules are painless and non-ulcerative.
biopsy of the tissue with special stains to
m Cicatricial stage.
demonstrate Trep. pallidum.
n There may be subglottic stenosis with
m Treatment
n Penicillin is the drug of choice: benzathine
respiratory distress.
penicillin 2.4 million units i.m. every week for 3 weeks n Diagnosis

ENT
m Biopsy shows infiltration of submucosa with
with a total dose of 7.2 million units.
n Nasal crusts are removed by irrigation with
plasma cells, lymphocytes, eosinophils, Mikulicz
alkaline solution. cells and Russell bodies.
m Mikulicz cells and Russell bodies. are diagnostic
n Bony and cartilaginous sequestra should
also be removed. features of the disease.
m Mikulicz cells
m Complications
n large foam cells with a central nucleus and
n Syphilis can lead to vestibular stenosis, perforations
of nasal septum and hard palate, secondary atrophic vacuolated cytoplasm containing causative
rhinitis and saddle nose deformity. bacilli.

TOPICS : 42, 43
m Russell bodies
n homogenous eosinophilic inclusion bodies
TOPIC 42 - RHINOPHYMA
found in the plasma cells.
n They occur due to accumulation of
n Rhinophyma or potato tumour
immunoglobulins secreted by the plasma cells.
m a slow-growing benign tumour
n Treatment
m occurs due to hypertrophy of the sebaceous glands of
m Both streptomycin and tetracycline are given
the tip of nose
together for a minimum period of 4-6 weeks and repeated,
m often seen in cases of long-standing acne
if necessary, after 1 month
rosacea.
m Steroids can be combined to reduce fibrosis.
m It presents as a pink, lobulated mass over the
m Surgical treatment may be required to establish
nose with superficial vascular dilation
the airway and correct nasal deformity.
m mostly affects men past middle age
m Treatment consists of
n paring down the bulk of tumour with sharp
knife or carbon dioxide laser and the area
allowed to re-epithelialise.
n tumour is completely excised and the raw area
skin-grafted.

197
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 TOPIC 44 - RHINOSPORIODIOSIS TOPIC 46 - WATER/STENVER AND
RADIOLOGIC VIEWS OF PNS
n Rhinosporidiosis
m It is a fungal granuloma caused by n Waters’ view (Occipitomental view or nose-chin
Rhinosporidium seeberi. position)
m The disease is acquired through contaminated m It is taken in such a way that nose and chin of

water of ponds also frequented by animals. the patient touch the film while X-ray beam is
m In the nose, the disease presents as a leafy, projected from behind.
polypoidal mass, pink to purple in colour and m Waters’ view with open mouth is preferred as

attached to nasal septum or lateral wall it also shows sphenoid sinus.

m The mass is very vascular and bleeds easily on n Maxillary sinuses are seen best.(MCQ)

touch. n Sphenoid sinus (if the film is taken with open

m Its surface is studded with white dots mouth).

representing the sporangia of fungus. n Caldwell view (Occipitofrontal view or nose-
m In early stages, the patient may complain of nasal forehead position)
discharge which is often blood-tinged, or m The view is taken with nose and forehead

nasal stuffiness touching the film and X-ray beam is projected

m Sometimes, frank epistaxis is the only presenting 15-20° caudally.
complaint. m Frontal sinuses are seen best ( MCQ)

m Diagnosis is made on biopsy. n Lateral view

ENT

m Treatment m Structures seen are:

n complete excision of the mass with n Anterior and posterior extent of sphenoid,

diathermy knife and cauterisation of its base. frontal and maxillary sinuses.
n Recurrence may occur after surgical excision. n Sella turcica.

n Dapsone has been tried with some success n Ethmoid sinuses.

n Submentovertical (Basal) view
TOPIC 45 - MUCORMYCOSIS m Sphenoid, posterior ethmoid and maxillary

n It is fungal infection of nose and paranasal sinuses sinuses are seen best in that order)
proves rapidly fatal. Right and left oblique views
TOPICS : 44, 45, 46

n n

n It is seen in uncontrolled diabetics or in those taking m They are taken to see the posterior ethmoid

immunosuppressive drugs. .(MCQ) sinuses and the optic foramen of the

n From the nose and sinuses, infection can spread to corresponding side.
orbit, cribriform plate, meninges and brain
n The rapid destruction associated with the disease is
due to affinity of the fungus to invade the
arteries and cause endothelial damage and
thrombosis
n Typical finding is the presence of a black necrotic
mass filling the nasal cavity and eroding the
septum and hard palate. .(MCQ)
n Treatment is by amphotericin-B and surgical
debridement of the affected tissues and control of
underlying predisposing cause.(MCQ)

198
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