KEMU

ENT GENERAL GUIDELINES FOR PTOF VIVA

BY NOOR UL AIN Abdul Hannan……. BATCH 14-19
HELLO EVERYONE ….THIS IS PROBABLY YOUR LAST VIVA in fourth year
FINAL YEAR is just about the corner ..and its just a matter of few days before u
can say

So about ENT viva ,

FIRST AND FOREMOST… WHATEVER UNIT U GOT RELAXXX…..
Its really easy ….m certainly not talking about dhingra here ..its just that there
is pretty much a defined pattern for these 90 marks compared to others
30 marks for long case (very few specific cases you have to prepare )
30 for table viva (you can be asked about surgeries ,instruments,sometimes
radiographs and pretty much anything but I’ve put answers for frequently
asked questions and summaries of important topics in case you are among 80
percent students who really dont wanna go through dhingra all over again :p)
30 for short case (I’ll get back to that )
There are a lot of myths regarding vivas but based on seniors experiences
and our own here is a general pattern ,few imp points,summaries of imp
topics and and lastly instruments and radiographs to help u get through this
final giant, so stay put :p
Wish you luck !I suggest you do the topics mentioned here and there’s a 90
percent chance that all of the ans to your viva questions will remain within the
confines of these topics….wish we had known this at our time ;)
1. Surgeries (indications and complications/contraindications thoroughly
… rough idea about procedure)*for all but specially for tonsillectomy
and adenoidectomy (each and everything…procedure too …BOYLE’s
mouth gag and adenoid curette are v. v. v. frequently asked ) along with
indications of calwell luc ,SMR and septoplasty,ethmoidectomy(more or
less they are like indications of functional endoscopic sinus surgery
which is the latest procedure for sinus surgeries ) ….. difference in types
of mastoidectomy ….
2. All instruments with use but specially (instruments of tonsillectomy and
adenoidectomy) plus RADIOGRAPHS *only those few u already saw in
your ward ..nothing new just for an overview I’ll discuss most imp ones
here (1.Water’s view …we can view paranasal sinuses in this view
*frontal,ethmoid,maxillary,sphenoid…..if examiner asks you …you have
to comment on the type of view and any pathology seen like haziness in
left maxillary and frontal sinus 2.FB in hypopharynx and in larynx
…remember esophagus starts at C6 so above that would be hypopharynx
not esophagus….3. Nasal bone fracture ….4.prevertebral shadow
 widening ….i have put a picture below for this one ….criteria is if
prevertebral shadow width is more than 2/3 rd of the diameter of
corresponding vertebrae ,we say its widening ..causes include abscess
or caries of spine …can be due to radiolucent FB too )5.FB esophagus
which looks like a coin in PA view but has double outline (it’s a battery
actually)…you have to say that we cant comment on the location of FB in
this view …lateral view is needed 6…some CT scans are there mostly
pathology is is in sinuses ..again you have to comment on the view like
axial coronal or saggital ..and pathology plus they can ask you loction of
certain structure though rarely but its safe if you prepare that too ..most
asked are a.nasopharynx..b.sphenoid sinus…cribriform plate….crista
galli….lamina papyracea )
3. Watch all videos of methods of ENT exam by kemunited on youtube
4. Do anatomy of every region (you really need to focus on this one ) and
just go through imp topics (if u have time do the details otherwise just
overview of these)like
 Nose (polyps plus there are two tables for d\d of nasal
obstruction in this chapter do them too , allergic rhinitis , ch
26 complete,epistaxis ,chronic sinusitis )
 Pharynx( adenoids WITH DETAIL ,diphtheria , chronic
tonsillitis WITH DETAIL,angiofibroma and appearance of
retropharyngeal abscess on radiographs )
 Ear (otitis externa WITH DETAIL ,otitis media *this one is
super imp ….cant emphasize enough ,hearing loss k chapter
men say go through audiograms and tympanograms and if
you have time then do rest of chapter too,menniere’s disease
,Facial Nerve course ,landmarks and treatment for bell’s
palsy ,causes of otalgia and tinnitis and how will you assess
hearing of a child there s table in ch 19 )
 Larynx and Oesophagus (TRACHEOSTOMY,causes of stridor
,causes of hoarseness,causes of laryngeal paralysis , vocal
nodules,do ch 68 complete specially staging and treatment
options ,FB larynx and esophagus ,causes of dysphagia
,achlasia cardia ,plummer winson syndrome, oesophageal
strictures )
 VIVA DAY

BEDS are allotted to you based on roll no . and mostly 2 students are assigned
one bed but they do assign 1 student on 1 bed …still no worries .. everyone
around is there to help u ..(PG s will come to you so no need to panic and you
can ask your fellows too…there’s PLENTY of time almost 2 hours or so …)
In unit 2 there are few topics u must know n there s a high chance tht all your
viva will revolve around these topics (TONSILLECTOMY ,ADENOIDECTOMY
,OTITIS MEDIA ,POLYPS, MYRINGOPLASTY AND MYRINGOTOMY
,TRACHEOSTOMY , TYMPANOMETRY ,SMR AND SEPTOPLASTY )….
Obviously they are imp for unit 1 too
 HISTORY (pretty simple even if u have never taken it before in ENT
ward… you are supposed to take a THOROUGH HISTORY and by
thorough I mean exact address,phone number and detail of everything
…like if it’s a kid how many siblings he/she has and which no. is his/her
…e.g “2 siblings and she is the youngest”
 Plus dnt forget ODPARA rule
 Just know the outlines of general symptoms about imp cases like nasal
obstruction { polyps ,Inverted papilloma .DNS,otitis media AND EXTERNA
,adenoids and tonsillitis and work your way through them )
Like you get chronic tonsillitis *(you will know once u ask about presenting
complaint) now in HOPI you have to ask Onset ,Duration ,Progression,
Associated features, Relieving and Aggravating factors and fit the general
symptoms of chronic tonsillitis in them.
And obviousy like any other history ask about past medical an surgical
history…………………. Till socioeconomical status
 DO GPE ….. *sigh *(just do the vitals and v quickly check for clubbing
,cyanosis, pallor,tremors etc .note any significant finding if u noted )
 Do ENT related exam (carrying on with the previous example of
chronic tonsillitis … the relevant exam here would be of oral cavity
 ..follow the standard procedure as shown in ENT videos of
kemunited…and you have to mention findings of chronic tonsillitis
on your answer sheet Red, swollen tonsils.
 White or yellow coating or patches on the tonsils.(note no. of pus spots if
present /if there is memb. Mention its extent) and mention grade of
tonsillar enlargement)
 Sore throat.
 Difficult or painful swallowing.
 Fever.
 Enlarged, tender glands (lymph nodes) in the neck.
 A scratchy, muffled or throaty voice and Bad breath
 Table viva starts meanwhile and you have to attend to that too
Depending on the examiner s mood he can ask you to pick up an
instrument by your choice
But mostly if he names it , its an adenoid curette or some tonsillectomy
instrument *but not necessarily so do the instruments well
Then viva mostly surrounds tht instrument and its relevant surgery
\procedure…. And one or two additional questions as listed below
bonchoscopes and oesophagoscopes are favourite in unit 2,they will ask
you to hold them … so make sure u do that properly.You can be asked
about radiographs or you can be asked about general topics )
For table viva you will go rol no. wise and will come back and continue
your long case
 After some time you will be called for short case
 If its unit 2 …

Good thing is u will be given headlight instead so things

are a lot easier now
Dr.Nukhbat with some 2 -3 more teachers will take it so
should be well aware of topics like myringoplasty
,myinogotomy,tympanoplasty ,FESS in addition to general
ones
 If yours is unit 1 …. You have to focus the light properly on the area u
need to examine ..mosty they command do ant rhinoscopy ,examine oral
cavity and the moment you hold your instrument right (dnt forget the intro
part) they ask you to go

Now there are few things to keep in mind

a. Greet the pt and take consent
b.Proper positioning … (
c. INSPECTION AND PALPATION too if its nose
d.Hold the instrument right (e.g nasal speculum always in
left hand and dnt fogret to change your ear speculum
after examining one ear )
e. Do relevant lymphnode exam (try to do this right not
just by tukka , sir nukhbat can ask you their location,
levels and no. like jugulodigastric (tonsillar) nodes… how
many are they …well it’s a one large node on either
side…. )
f. Do relevant cranial nerve exam (e.g check for facial
nerve and vestibulocochlear if the command was to
examine the left ear )
 SHORT CASE is more of method oriented and mostly
examiner stops you once you have done all the
prerequisites uptill holding instrument…after that you
are mostly free if its unit 1 while unit 2 examiner
simply asks what you will see (in a case like nasal
polyp..some v simple questions related to it) … and
what you will do next (AGAIN…. DNT FORGET LN AND
CN)
MAKE SURE YOUR LIGHT IS FOCUSSED ON THE EXAMINING AREA
THROUGHOUT YOUR EXAMINATION

FEW V FREQUENTLY ASKED QUESTIONS ….

INSTEAD OF LISTING THOSE frequently QUESTIONS …I’VE GIVEN
THEIR STANDARD ANS …..BUT FOR LONG AND SIMPLE ONES ….GO
OPEN DHINGRA :p

 Tympanic memb is 9-10 mm tall ,8-7 mm wide and 0.1mm thick

 EOM is 24 mm in length .Bony part extends till TM
 DNS is a problem only when its symptomatic… sir maroof often asks this
question
 We use tympanometry to assess middle ear pressure
 Causes of red TM *bullous ,fungal ,eczematous myringitis etc
 Vocal polyps or nodules are removed by DIREC LARYNGOSCOPY

 For otitis media with effusion ,do 1.otoscopy when pt is performing

valsalva ….you will see bubbles on middle ear
2.tympanometry …u will get type 2 tympanogram
 What are curves of Tympanometry

 Water s view is 45 degree caudal to orbitomeatal line for viewing sinuses

 Law s view is lateral oblique view for temporal bone and mastoid
 FESS procedure *its just functional endoscopic sinus surgery …. …duh
 Marginal ulcers of oral cavity
 Nasal pack complications can be infection and nasopharyngeal reflex
 How post nasal pack is used , site of bleeding in ant and post epistaxis *
described in epistaxis ch
 Malignancy in tonsil (in children its lymphoma …in adults epidermoid CA)
 How would you differentiate between the turbinates of VMR and DNS
…Mucosa is congested in vasomotor rhinitis while its pale in DNS
 Widening of prevertebral shadow is mostly due to retropharayngeal
abscess
if acute then supect trauma ,chronic ? TB
 FINDINGS on X rays are describs in terms of being radiopaque or
radiolucent while on CT u would say hyperdense or hypodense
 If you encounter an enlarged prevertebral shadow and cannot assess its
boundaries its probably an abscess*see
arrow

 .A foreign body has pretty much defined outlines

 Pt had traceostomy then having dypnea …..most probably due to

immediate complications of tracheostomy e.g bleeding ,pneumothorax
etc
 Most common cancer of bone and sinus is squamous cell carcinoma
  We did traceostomy in a child and now there are hissing sounds why ?
pneumothorax…… it occurs bcz there is a difference in position of lung
apices in kid and adult ….for management of this complication
If pneumothorax is present, closed intercostal chest tube drainage is
usually necessary.

 Causes and effects of unilateral and bilateral laryngeal nerve paralysis

……
 How wax and syringing can cause syncope (due to vagal nerve
stimulation)
 Ear piercings can transmit hep b ,c aids
 Traumatic TM takes 3 months to self heal ….pt comes to you with sudden
TM perforation ….wait for this much time before advising surgery
….during this time period ,care should be taken ro avoid water entry into
the ear ….do not advise ear drops in his case

IMPORTANT TOPICS AND THEIR OUTLINES

DISCLAIMER: ALL OF THE FOLLOWING STUFF IS COLLECTED AND
COMPILED BY A CHAIN OF SENIORS …SO ALL THANKS TO THEM :P
SPECIAL THANKS TO HIRA ASGHAR and RIDA SOHAIL for sharing this stuff
If you cant motivate yourself to open dhingra make sure u go through this
section.. .. it pretty much covers all imp topics for your potential long case
except for surgeries though :P

OTITIS EXTERNA
HerPes Zoster

 ▪Disease:Herpes Zoster Oticus (Ramsay Hunt Syndrome)

 ▪Pathology:Inflammation of Geniculate Ganglion of Facial Nerve
 ▪Triad of Symptoms:
Ear Ache
Rash in the distribution of facial never
Lower motor neuron type facial paralysis
 ▪Management:
1. Antiviral (Acylclovir , if within 24 48 hours)
2. Steroids (Anti imflammatory) Early recovery to prevent spread
3. Multivitamins (for facial nerve)
4. Eye drops to prevent exposure keratitis (sunglasses in day gauze at
night)
5. Physiotherapy of face
6. Desi treatment ( kabootar khoon ) "laqwa"
 BACTERIAL OTITIS EXTERNA
 ○Disease:Ball Tor (Boil Ear)
 ○Cause :Cotton stick,Finger nail,Common pin,Ball point tip
 Pathology:Whenever scratch there maybe breach and folliculitis of hair
follicles
 ○ Organsim:Staph Aureus infection of hair follicles
 As Hair is confined to external ear so boils are limited to external ear
 ○ Clinical Presentation:
Ear Ache
Edema causing decreased hearing
Ear Blockage
Movement of Pinna is very tender In chewing talking, smiling , when we
pull the pinna patient will experience pain
Patient presents with Recurrent Boil Nose or Boil Ear what will you do?
 Diabetes Mellitus must be excluded
 ○Treatment:
Belladona plaster
Icthamol Glycerin (hygroscopic action > relieves edema and pain within
ears)3-4 percent 3-4 drops 3-4 times a day
Amoxicillin + Clavulanic Acid (Augmentin)
Incision and drainage is rare because it is folliculitis, no pus.

OTITIS EXTERNA

 ○Definition:Inflammation of the external ear

 ○Classifcation

▪Etiology based
Fungal,Viral,Bacterial
▪ Area of external area:
Localized (small part of ear),Diffuse (full ear)
▪Specific:
 Malignant Otitis Externa (not a malignancy. Said due to behavior of the
disease. It is an inflammation)
▪Environmental Factors:
▪Skin conditions:
Frost bite
Psoriasis
▪Acute or Chronic
 ○Malignant Otitis Externa:
 ▪" Primarliy an opportunistic infection. In immuno compromised patients
.Specific type of inflammation of external ear. Potentially fatal and life
threatening 70% mortality) and causative organism is Pseudomonas
Aeuroginosa.
 ▪ Clinical Presentation:•Uncontrolled Diabetes Mellitus (most common
cause of immuno compromise in our society)
 •Whenever a patient with DB presents with ear ache and Bells Palsy
 Ear Ache > more at night, excruciating pain, refractory to analgesics.
 • Starts from junction of Cartilage and Bone of external Auditory meatus.
▪Spread:Behaves like a localized tumor that can spread anywhere and
invade the structures around ear (extra cranially and intra cranially)
Ant > Tempormandibular
Post > Mastoid Antrum
Sup > Middle Cranial Fossa
Med > Middle Ear, Petrous temporal bone (facial nerve endangerment)
Infer >Infratemporal fossa (last 4 cranial nerves)
Skull based ostitis
 ▪Underlying Pathology (Why So Aggresive?)
Necrotizing Vasculitis ft. of Pseudomonas.
▪Diagnosis:CT scan of petro temporal region to see extent of disease
▪Management:
 3 principles:
1. Control of Diabetes
2. Admissions and IV antibiotics (not oral) for atleast 6 weeks
3. Debridement of the Necroric Tissue
 Mastoid > Mastoidectomy
 Parotid > Parotidectomy
 Brain Abcess > Drain it
 Antibiotics: ciprofolaxacinin , gemi , moxi
 ◇ Important Questions :Spread,Causative Organism,Management

DNS Symptomatic Deviation is DNS (not on basis of X Ray)

 SEPTUM IS MADE OF SEPTUM proper
Membranous Septum Membranous
Junction= MucO cutaneous junction
 CLASSIFICATION:
●Deviation/Deflection:a. C shaped b. S shaped
●Dislocation:
a. Inferior Dislocation: below ancillary crest
b. Anterior Dislocation: Caudal dislocation
●SPUR:Acute anglulation touching lateral wall
How it forms? Usually as a result of repair formation after trauma at the
junction of bone and cartilage.
 PRESENTATION:
•Nasal obstruction (uni or bilateral)
•Bilateral > C shaped (convex) on one (affected) side and compensated
hypertrophy of inferior turbinate (on opposite side)
 HISTORY OF:
•Post Nasal drip
•Nasal discharge
•Headcahe due to Sinusitis
•Neuralgic type pain by touching of Spur
•Single most symptom for DNS is Nasal Obst.
 INVESTIGATION:
•X ray PMS at 45°
•We cannot label a patient DNS on basis of X Ray
OPD examination of ear

Nasal Bone Fracture

○HISTORY

 •History of trauma to face

 •Exclude head injury
 History of unconsciousness, nausea vomiting and watery nasal discharge
to exclude CSF Rhinorrhea . This is most imp because to rule out head
injury
 •Exclude out history of bilateral complete nasal obstruction_septal
hematoma > septal perforation
 ○CLINICAL EXAMINATION:
 ▪Local Exam of Nose:
 •Palpate for swelling of Nasal bridge
 •Examine for Crepitus of Nasal bone
 •Anterior Rhinoscopy to exclude septal hematoma
 ▪Face
 •Eyes , extra ocular movt and vision acuity
 •Tempormandibular joint
 •Palpate frontal bone, maxilla, mandible
 •Check status of teeth
○TREATMENT:
▪Conservative treatment:
•Give antibiotics
•Wait for 7 to 10 days to let swelling go
•Check for External Deformity of nose (after trauma)
•Reduction of deformity under GA
•Ideal time of Reduction : By Digital Manipulation before there is edema
i.e Immediately. Before 21 days > formation of Callus
 Hoarseness of Voice
 GERD: At Trachopharynx level
 Smoking
 Sore Throat infections

REHABILITAGIN AFTER LARYNGECTOMY

 Intra Thoracic pressure
 Artificial electric larynx
 Tracheesophageal fistula (esophageal speech by directing air from eso to
tracheal
 One way valve to prevent secretions into Trachea.

Nasal Angiofibroma*
 Precaution: blood
 Characteristic: Red,Round ,Pulsatile
Epistaxis
Treatment: Surgery
Trans palatal
Trans nasal
Maxillary swing
Lateral Rhinotomy
Instrument names
 Threadiculum Nasal Speculum
 Peter's ear speculum (left ear left hand)
What is the immediate treatment for traumatic rupture ?

 ❌Not immediate myringoplasty (grafting of tympanic membrane)

 ✔It is > Let it heal itself.
 Conservative treatment:-
 prevent infections by antiobiotics
 Avoid water
 Avoid nose blowing (pressure build up)
 •No infection > Perforation will get healed
 •Infection > Go for Maringoplasty
 •Ear drops contraindicated?Yes. Will travel in canal, increased chances of
infection.

Chronic Suppurative Otitis Media

○ TuboTympanic and ○ Aticoantral
 Intracranial complication :Meningitis after erosion of bone
Pus formation > Sub Dural Abcess > Brain Abcess
○Aticoantral:
Granulation tissue,Blood discharge,Smell ,Marginal Perfoartion ,Hearing
loss
○Tumbotympanic
Perforation of membrane (central perf),Conductive Hearing Loss (15 to 20
decibel gap between air and Bone conduction)
 Investigation :X ray Mastoid (haziness of air cells),CT (bone erosion)
 Treatment:
1. Make ear safe and dry (Mastoidectomy)
2. Maringoplasty
■ Aticoantral :
 Mastoidectomy (make the ear safe and dry from complications. Removing
Granulation Tissue .Hearing won't be restored..can be restored later by
Tympanoplasty ) :
 Types of Mastoidectomy :
-Modified
-Cortical (intact bridge)
-Modified Radical (lowering of bridge)

Lesions of Vocal cords

●Lesion of Superior Laryngeal Nerve > Cricothyroid…Unilateral paralysis
> pitch reduce
Sensory suppy of larynx
Above the vocal cords: Superior Laryngeal
Below: Recurrent Laryngeal
●Lesion of Recurrent Laryngeal Nerve:
Unilateral paralysis > hoarseness
Bilateral paralysis > sphincteric func.loss, loss of cough reflex, aspiration
●Inflammatory Lesion:
 ▪Non Infectious: Rubbing and Fibrosis leads to > Nodule (Ant 1/3 and Post
2/3)
 If nodule has a neck it's called Polyp (v imp)…Smooth Surface
 ▪Infectious:Miller TB ,Diphtheria ,GERD
●Congenital Lesions:Vocal chords are made by recanalization,Failure to
recanalize ( Laryngeal web),Laryngeal cyst
●Cancerous Lesions:
▪Benign:8 and 14 Papilloma
 Squamous Cell carcinoma of Larynx
 There are no lympathics in this area so lymphatic spread wont happen.
Local will but no Metastatsis
○Grading:
1. One chord
2. One chord and Anterior Commissure
3. Spread to supra Glottis, a little Thyroid
4. Full Larynx
Laryngeal Tumors
□ BENIGN:
 Papiloma (most common)
》Recurrent Respiratory Papilamatosis(Juvenile): •Recurrent, Involving
Respiratory, Multiple •Palpilomas, anterior 1/3rd of the vocal chords
•Etilogy: Papiloma virus type 6 and 11
•Clinical features: change of cry (vocal chords can't meet) ,6 months to 2
yr. ,Life threatening stridor
•Diagnosis:
Pediatric Flexible Laryngoscopy:Multiple papilanotis structure in anterior
part of Glottic one anterior 1 3rd
•Treatment:
Surgical removal (recurrence chance higher)
CO2 Laser Removal (better)
Why Laser Better? Deep penetration till basement membrane, so chances
of Recurrence are less.
Follow up by flexible laryngoscopy for 2 years to look for recurrence.
•Tracheostomy good or bad?
If severe Papiloma are present then necessary.
Other wise no. Disturb mucosal blanket of trachea and virus maybe
implanted at trachesotomy site.
Trachesotomy can be a potential cause of these papilloma
 》Adults Papiloma (singular)
•Single •Posterior Compartment at Arytenoid•No repsitairy obstruction•No
change of Voice
•Etilogy : Endotracheal Intubation Trauma to Larynx ,Trauma >
Granulation Tissue > Papiloma
•Diagnosis:Indirect or Flexible
•Treatment:Simple surgical removal
□Malignant Tumors
1. Squamous Cell Carcinoma
2. Varicose Carcinoma
3. Spindle Cell Carcinoma
4. Adenocarcinoma
 》Squamous Cell Carcinoma:
Males,40 50 years,The only TUMOR in female is Post Cricoid Carcinoma
(Due to Plumor Willson, blood loss, iron def)
•Divisison of Larynx:
 A. Supra Glottic
 epiglottis
 Aryepiglottic fold
 False Vocal Chords
 Arytenoids
 Ventricles
B. Infra Glottic
•Etiology:Exact Unknown
 Predisposing factors are :-
Smoking,Alcohol ,Radiation Invasion,Asbestos ,Genetic
•Clinical Presentation:
 Depends upon region involved (supra or infra)
A.Supra Glottic:-
 Lateral: Piriform Fossa (hypopharynx)
 Posterior : Post Cricoid Region(hypopharynx)
 Anterior : Thyroid Gland
 Dysphagia
 Respiratory distress
 Hoarseness of Voice
B. Infraglottic:-
will present with voice change
 Can present with simple neck swelling
 May metastasize to neck lymphatics
 Can we differentiate swelling b/w direct and Lymphatic Spread?
 -Intermittent Voice Change is chronic infection of Larynx. (Teachers,
singers, Politicians)
 -Tumor is Continous not Intermittent
 •Examination:
 *Always examine neck* part and parcel of examination of Larynx from
back of patient :Levels of Neck Lymph Nodes:
 Direct Spread Vs Lymphatic Spread:
Direct: Swelling Will move with Larynx,Metastatic: Won't move on
examination
•INVESTIGATION:
1. CT Scan base of skull to diaphram to see :
extent of disease
Erosion of Cartilage (determines stage)
Lymph node spread of non palpabale (retro, paralaryngeal etc)
Occult Metastasis
Lymph Node will be large in size
Peripheral enhancement (on IV contrast)
Central Necrosis (on IV contrast)
2. Biopsy:
 General Anesthesia
Direct Laryngoscopy
Check mobility of Vocal Chord (if fixed:stage3)
Muscle Relaxant effect temporarily removed
3. TNM staging:
 To decide treatment
 Stages of Glottic Tumor:
1. Stage 1 :
 T (small) > limited to Glottic . One or both vocal chords with a normal
vocal chords mobility
 N0(no lymph node
 M0 (No Metastasis)
 2.Stage 2 :
 T2: Involving adjacent site (normal VC mobility)
 N0: Ipsilalteral lymph node less than 3 cm in size
 M0:
 3. Stage 3:
 T1 but M No1> small but metastazie
 T3 n0 m0
 T3: Vocal Chord fixed
 N3: 3 - 6 cm
 4. Stage 4.
 T2 M1 N1
 T4 M1 N0
 T: Extra Laryngeal Spread (tongue, skin, thyroid)
 N4: > 6 cm.
.Grading: To determine prognosis
 •Treatment:
Stage 1 : Radiotherapy
Stage 2: Radiotherapy
Stage 3: Surgery (total laryngectomy with or without neck dissection, post
op radio therapy and follow up for 5 years)
Stage 4: Paliative Treatment
• Complication (someone may or may not) (secondary hemorrhage after
tonsillectomy)
 Recurrence of disease
 Tracheesophageal fistula
 Morbidity (Will be to everyone, throat pain
 Loss of speech

Nasal Polyps
 ○Ethmoidal Polyp:
1.Bilateral
 2.Ethmoidal
3.Can't see on anterior Rhinoscopy
4.Steroid > Shrink > Remove by FESS
5.Treat: FESS: Functional Endoscopy Sinus Surgery
(Functional because we try to restore normal functions)
6.External Etmoidectomy with medial Lunch Hour incision
 ETIOLOGY:
 Allergies
 Fungal infections
 Recurrent Rhinitis
○Antroconal:

 1.Unilateral
 2.Maxillary sinus
Start from Maxillary Antrum
Ciliary movement start from osteum of Antrum upwards and backwards
towards inferior conchae so Antro - Conal
 3.Opaque on PNS X ray
 4. Treatment:
 Polypectomy
 Cardwell luc Operation: if it happens twice
 Hole in Canine fossa and remove polyp
 ETIOLOGY:
 Allergy
 (Secretions stop so> inflammation > leads to polyp > complaint of Nasal
blockage )
 Polyp can go to eye and cranium
 FOLLOW UP:
 1 7 ___15___15____15____6months_____1year
 60-70% super infective fungal infection
 FESS can be used for both
 Cardwell Luc is mostly for Antroconal
 Medial Lynch Incision is for Ethmoidal

Fungal Otitis Externa

 ○Fungus:
 Most common is Aspregillus
 ○Presenting Symptom:Ear Itch ,Ear Ache,Ear discharge ,Ear Fullness
 Humid Seasons (barsaat)
○Examination:
 Blackish spores
○Treatment:
 Antifungal ( Clotrimazole ) ear drops
 ○Precautions:
 Avoid water in ear (bath, swimming)
 Continue for atleast 4 weeks (fungal spores don't end before 4 weeks)
 Avoid Itching (secondary infection by scratching , folliculitis)

INSTRUMENTS
RADIOGRAPHS
BEST OF LUCK !!!