Questions

Topic: Anatomy and physiology of larynx

Q1. Vertibral level of cricoid cartilage?

C5 and C6

Q2. What 3 parts make up the anatomy of pharynx?

Nasopharynx-> Oropharynx->Hypopharynx or laryngopharynx

Q3. What are some muscles of the pharynx that initiate swallowing process?

- Orbicularis oris, buccinatior, masseter, digastric a & p, Tongue, mylohyoid, superior pharyngeal constrictor,
styloglossus, stylopharyngeus, hypoglossus, inferior pharyngeal constrictor, cricopharyngeus, esophagus

Q4. What are 2 of the clinically important content of the pharynx?

Palatine tonsils

Weylingers ring- made up of tubal tonsils, palatine tonsils->pharyngeal tonsils->glossal tonsils

Waldeyer’s ring is made up of pharyngeal tonsil-> tubal tonsil->palatine tonsils->lingual tonsils

Q5. What is the anatomical location of the larynx?

It is at the level of C3-C6. It rests on the pharynx. It is anterior to the oesophagus. It is the mucosal opening to
the larynx, bronchus and lung. Situated in the midline of the neck over the hypopharynx. Consists of cartilage
framework.

Q6. There are two groups of cartilage of the larynx. What are they, what are their functions and what are some
of the examples.

i) Thyroid cartilage Unpaired – functions to protect airway/larynx

ii) CricoidPaired – performs laryngeal functions

Q7. Cartilage, write their discriptions

i) Thyroid
- It is two ala cartilage. It is hard and thick It is the largest cartilage of the pharynx. It protects the
larynx or laryngeal opening. It forms the Adams apple or the V shaped notch called thyroid
notch. This is 90 degrees in men and 120 in women. The thyroid gland rests on it. The thyroid
and trachea as well as esophagus are surrounded by pretracheal or middle fascia organ fascia
(?). It gives the shape of the upper larynx. Falls under unpaired cartilage and functions to
protect airway/larynx
ii) Cricoid
- Is the hardest and thickest of the cartilages of the larynxcorrection- it is thicker and stronger
than thyroid cartilage. It is the only laryngeal cartilage wich forms a full ring and looks like a
 signet ring. It protects the larynx. It is at the level of C8 (?). It give the structural shape of the
airway. It falls under unpaired cartilage.
iii) Epiglottis
- It starts at the base of the tongue. It protects the opening of the larynx by closing during
swallowing. It is thin and leaf-like.
iv) Arytenoid, corniclate, cuneiform
- They have functions in phonation. They make up the lower side of the ring of the epiglottis.
They function respectively for that purpose. For phonation(?).

Q8. Give brief description of muscles of the pharynx;

i) Intrinsic muscles, e.g.

- Soft palate, Abductors of the vocal cord, adductor of the vocal cord
- Between laryngeal cartilage
- Abductors of vocal cord-open larynx
- Adductors of vocal cord-closes larynx
- Tensors of vocal cord
ii) Extrinsic , e.g
- Between larynx and neighbouring structures
- Strap muscles
- Pharyngeal muscles
- Muscles of facial expression(buccinators, tongue, mentalis, labilli anguli oris, hyoid, omohyoid,
digastric a&p,
-

Q9. I) Nerve supply to larynx, 2 divisions.

Ophthalmic-

- Maxillary-
- From vagus nerve (10th) – Superior laryngel
 Reccurent (inferior) laryngeal
iii) Artery
- Carotid- external carotid- superior and inferior palatine artery
- SVC trunk- subclavian (R)- Inferior thyroid artery
 Common carotid- carotid sinus-internal carotid-superior thyroid artery
iv) Veins
- IJV-
v) Lymphatic
- Submental, submandibular, cervical, Supraglottic, glottis and subglottic

Q10. Physiology of the larynx. What are its function (5)?

i) Protection of lower airway, how does it do that (4 functions)?

- Closure of laryngeal inlet
- Closure of glottis
- Cessation of respiration
 - Cough reflex
- It is the mucosal opening into the larynx, bronchus and lung
- It forms the protective ring for the airway
-
ii) Phonation
- Develops later, voice is produced by vibration of the vocal cords
- Has 2 components;
i) Pitch- vibration of vocal cords cut air columns into puffs
ii) Volume- intensity of sound depends on air pressure generated in the lungs
- The arytenoid, cuneiform and corniculate cartilages helps in production of sound. The vocal
cords assist in production of sound. The lips and teeth make appropriate words. The mouth
helps also in phonation and production of vibration, which is the beginning of phonation but not
the actual sound.
iii) Respiration
- Assist in moevemnt of air in and out through between the lungs and the atmosphere.
- The larynx plays a passive part by reflex adjustment
iv) Chest fixation
- Assists to build negative pressure in the chest cavity the helps during, digging or lifting heavy
load.
- When larynx is closed muscles of the chest become fixed
- This is important in- climbing or digging
 Straining efforts
v) Voice production
vi) – Air is used for speech production
a. Tidal air
- It the minimal amount of air needed in order to produce sound or words.
- Minimal amount of air we inhale for speaking
b. Complementary air
- This is the minimal amount of air taken in during breathing and phonation.
- Additional air we inhale for breathing

Q11. What are the 4 stages of voice production?

i) Respiration/compression
Is when air is taken in and compressed by diaphragm into lung before exhalation.
Air we inhale in compressed for exhalation by diaphragm
ii) Vibration
- The ignition stage of voice
- Occurs in the vocal cords as air is pushed up. Initial sound in produced here but that is not the
actual sound.
iii) Amplification/resonate
- Modification are made in the mouth by the lips and teeth and the mouth
- It depends on the volume of the voice that is projected.
- Initial sound is made loud and amplified into our true voice by air chambers called respnators.
o Vestibule
 o Pharynx
o Nasal cavity (PNS)
o Mouth

iv) Modification/articulation
- Modification and articulation of the sound to intelligible words.
- Sound made loud by resonators I made into intelligible sounds by lips and teeth

Topic: Anatomy and physiology of nose and paranasal sinus (PNS)

Q1. What are the external features of the nose?

-root, bridge, dorsum nasi, naso- facial angle, 2 ala nasi, alar nasal sulcus, 2 alar nasal sulcus , anterior naris
(nostril), nasal septum, Philtrum ellipticus, naris, 2 ala, apex. Nasal sulcus, cannullum collumnella

Q2. What are the

i) bonny and
- nasal bone bones, nasal part frontal process of maxillary bone, and nasal part of the frontal
bone ethmoid , below is plates of hyaline cartilage
ii) cartilaginous features of the nose?
- 2 greater alar cartilage, 2 lesser alar cartilage, fibrous sides of nose, Lateral cartilage, septal
cartilage, dense connective tissue

Q3. The external nose

i) What are the blood supply of the external nose?

- Maxillary and ophthalmic supply the skin
- Mandibular
- Skin of ala and the lower part of the septum supplied by branches of facial artery
ii) What are the nerve supply
- Facial
- Trigeminal
- Infratrochlear and external nasal braches of the ophthalmic nerve (CNV) and the infraorbital
branch of the maxillary nerve (CNV) = both Trigeminal branches

Q4. What are the features of the nasal cavity?

- Floor, base , roof, lateal wall medial wall or septal wall,

Q5. What is the floor of the nasal cavity made up of?

-mucosa and below is anterior part of maxilla

- Palatine process maxilla

-Horizontal plate palatine bone

Q6. What is the medial wall of the nasal cavity?

-Superior concha, middle concha, inferior concha. In between the concha is the meatus. Also the opening of the
Eustachian tube.

Q7. Roof of nasal cavity is made up of?

- Anterior by nasal and frontal bones, middle by cribiform plate of ethmoid (beneath anterior
cranial fossa), posteriorly and sloping body of sphenoid

Q8. What is the lateral medial wall of the nasal cavity made up of?

The nasal mucosa

Nasal septum. Has osseous and cartilaginous parts. It consists of perpendicular plate of the ethmoid bone
(superior), the vomer (inferior), and septal cortilage (anterior).

Q8. What are the meatal opening of the lateral wall of nasal cavity and what pass into them?

Marked by 3 projections.

Superior concha, middle concha, inferior concha. The space between each concha is called a meatus.

Superior meatus- Posterior ethmoid

Middle meatus- Maxillary sinus, frontal sinus and the anterior ethmoid sinus

Inferior meatus- lacrimal system

Sphenoethmoidal recess- sphenoid sinus

Q9. What are the blood supply of the nasal cavity?

- Superior and inferior palatine sphenopalatine artery

- Maxillary from branches of the maxillary artery which arise from external carotid artery.
- Sphenopalatine artery + septal branch of superior labial of facial artery in the region of vestibule
- Submucosal venous plexus drained by veins that accompany the arteries.
- Nasal artery and vein
- Mandibular
- Ophthalmic
- Septal artery
- Others; 1.sphenopalatine,2.greater palatine, 3.superior labial, 4. Anterior ethmoidal, 5.
Posterior ethmoidal

Q10. Which blood supply form the Kiesselbach’s plexus over Little’s area on Anterior septum?

-1,2,3,4

Septal artery, maxillary artery, mandibular artery

Q11. What is the venous drainage of the nasal cavity?

- Septal vein
- Facial vein
- Ethmoidal –Ophthalmic, and cavernous sinus
- Sphenopalatine- Pterygoid plexus, maxillary vein
- Woodruff’s venous plexus-
- Retro-collumnellar vein

Q12. What are the nerve supply to nasal cavity?

-facial nerve, trigeminal (maxillary branch),

- divided into 2 parts

1. Autonomic

-deep petrosal nerve (sympathetic) + superficial petrosal nerve (para-sympathetic->vidian nerve-> pterygo-
palatine ganglion-> nasal glands

Sympathetic stimulation-> vasoconstriction + decreased nasal secretion

Para-sympathetic stimulation-> vasodilation + increased nasal secretion

Q13. What are the lymph drainage of the nasal cavity?

Cervical,
Lymph vessels draining the vestibule end in the submandibular nodes
other drain to upper deep cervical node

Q14. I) What are the paranasal sinuses?

iii) They are categorized as

1) Anterior group
- frontal, anterior ethmoidal, maxillary
2) posterior group. What are the paranasal sinuses in them.
- frontal, ethmoid a&p, maxillary, sphenoid
-Posterior ethmoidal
-sphenoid

Q15. What are the functions of the paranasal sinuses?

-they reduce the skull weight

-linned by mucus membrane that produce mucus and protects airway

-resonators of voice

-help warm and moisten inhaled air

-Act as shock absorbers in trauma

Q16. What is the mucus consisting of?

- It consists of gel layer, which traps the foreign body or pathogen

- The layer below it is solution layer below it is the cilia.

TOPIC: COMMON DISEASES OF THE LARYNX

Q1. Larynx anatomy

Q2. Differentiate between larynx and pharynx?

The larynx is the opening into the airway or bronchus and lung. The pharynx is the mucosal cavity from
the base of the skull (below ethmoid and sphenoid bones) to the larynx and consists of the three parts;
the nasopharynx, oropharynx to hypopharynx.

Q3. What are the presenting complaints of the Airway?

- Stridor, SOB, cough, aphonia, hoarse voice, dysphonia, loss of voice

Q4. What are the 3 types of stridor and what do they indicate?
i) Inspiratory stridor- Upper airway obstruction above the vocal cords
ii) Expiratory stridor- Lower airway obstruction
iii) Biphasic- obstruction just below the vocal chords. Both inspiratory and expiratory stridor.
Glottis and subglottic obstruction
- Subglottic/epiglottic stridor
Q5. In emergency and non-emergency, observe what 7 factors?
Breathing rate, Blood pressure, pulse rate, Oxygen saturation, glucose level (do electrolyte screen), use
of accessory muscles, Cyanosis
Breathing rate, onset, use of accessory muscle, cyanosis, sweating, level of consciousness, restless.
Q6. Give some Causes of hoarseness
i) Neoplastic

a. Benign
- Thyroid (goiter)
- Cyst
- Polyps, scarring, haemorrhage
b. Malignant
c. Carcinoma, nodules, Reinke’s oedema
- Thyroid tumour
- Oral cancer
- Tongue cancer
- Palatine cancer
- Mouth cancer
- Mouth tumour
ii) Inflammatory
 a. Infective
b. Bacterial, fungal, viral
- Tonsillitis
- Glossitis
- Pharyngitis
- Laryngitis
- URTI
- Ludwig’s angina
-
c. Non-infective
- Allergy, reflux, stenosis, autoimmune
iii) Neuromuscular
a. Hypofunctional
- Myesthenia gravis, Parkinson’s. Bulbar palsy
b. Hyperfunctional
- Chorea, spasmodic dysphonia
iv) Muscle tension
- Overuse
- Vocal Strain, anxiety, stress, psychogenic
-

Q7. Congenital abnormality of larynx

- Atresia
-
i) What is the main symptoms
- Wheezing inspiratory stridor
ii) What is Laryhgomalacia
- Congenital laryngeal stridor
- Due to flaccid supraglottic framework, collapses on inspiration. Epiglottis is thin and weak so
covers laryngeal opening during inspiration and makes it hard for expiration and inspiration
again
a. What is the management
b. Conservative, positioning, tracheostomy
- Secure airway
- Strengthen epiglottic muscel by exercise and/or surgery
iii) What is Congenital Web
- Refers to a malformation where the is flap of tissue at the meeting end of the vocal cords.
- Developmental problem, fibrous tissue stroma with epithelium around anterior glottis
iv) What is Laryngeal haemangioma?
- Abnormal congenital vascular growth growth of blood vessel at the laryngeal area.

Q8. What are some examples of trauma to the larynx?

- Usually extra-laryngeal
- Traumatic During delivery
 - Direct hit with blunt or sharp object during pregnancy
- Umbilical cord strangulation

Q9. Give some brief description on laryngeal papilloma?

- It is usually acquired during birth from infected mother. HPV1 causes warts to grow along the
larynx mainly the vocal cords.
- It resolves at teen
- Causes hoarseness of voice

Q10. What are some infections that may cause obstruction. Give brief discussion in them.

Epiglottitis, pharyngitis, acute laryngitis

Admission to ward with high dose Ab and steroids

May require tracheostomy

Q11. Give some brief discussion on foreign body in airway?

- Foreign body can be lodge anywhere along trachea, carina, or the R/L bronchus. Mainly it
lodges in the leftright main bronchus because it is more horizontal.
- Management, we can do Heimlich manoeuvre Hamlachs maneuver to apply force on the
diaphragm to help in forceful expiration of the foreign. If the foreign body is in the carina, pull it
towards the right bronchus before removing.
- Tracheostomy if trapped in the upper airway
- Bronchoscopy and removal if trapped below glottis
- If trapped in main bronchus, push to right main bronchus before attemps at removal

Q12. Give brief discussion on;

i) Laryngeal palsy
- Injury to recurrent laryngeal nerve
- Motor neuron disease, trauma, tumour (laryngeal and extra-laryngeal)
- Caused by damage to the facial nerve by trauma, disease or congenital
- It causes dysphonia or difficulty in production of inteligible words or sounds.
ii) Laryngeal TB
May cause swelling of the site
rare
iii) Other conditions
a. Trauma
b. Laryngeal sceroma
- Needs chemotherapy, main priority is secure airway, genta or tetracyclin, steroid, endoscopic
removal of granulomatous tissue, dilation of mild stenosis, tracheostomy if sever subglottic
stenosis
c. Laryngeal polyp- may cause airway obstruction or biphasic wheezes
d. Singer’s nodule- nodules that develop in singers vocal cords due to excessive singing

Q13. What are the causes of subglottic stenosis

 - Chronic intubation and not removing intubation tube on time post prolonged intubation
- Chronic inflammation of the vocal cords post infection

Q14. What are the three categorise of laryngeal cancers?

Supraglottic

Glottis

subglottic

Q15. I) what are some examples of extra-laryngeal cancers?

- Laryngeal sarcoma
- Lymphoma, thyroid cancers, bone and muscle tumours, etc…
iii) How do we manage them
i) First priority, airway must be secured

treat or manage underlying cause

Surgery- tracheostomy, biopsy, I&D, Laryngectomy (partial or total)

ii) Medical- Ab and steroids

iii) Treatment
- Chemotherapy
- Radiation
iv) Surgery
- I&D
- Exition and biopsy
-
TOPIC: ANATOMY AND PHYSIOLOGY OF EAR

Q1. What does OTORHINOLARYNGOLOGY mean?

Oto- is ear
Rhino- nose
Laryng- throat, =(pharynx, larynx)
Ology- study
Q2. What is the rule of 3 for the ear?
The ear has 3 parts; External Outer, Middle, Inner ear.
Outer ear= Pinna/auricle-> External ear canal (EAC)Auditory cannal-> TM (ear drum)
Middle ear= Tmpanic cavity, ossicles (malleus, incus, stapes), Eustation tube
Inner ear= Vestibule, cochlear, vestibulochocler nerve (8 th cranial nerve)
Q3. What is the function of the inner ear?
Vestibule- balance or equilibrium
Conchlear- hearing
 Q4. Which organ in the inner ear is responsible for balance in the vestibule and hearing in the
cochler
i) Vestibule
- In semicircular canal = Criste- cupule (like tectorial membrane of cochlear), hair bundles, hair
cells and nerve fibres.
- In Macule= Otoconia (Na crystals on top), Otolithic membrane (= tectorial membrane of
cochlear), Kinocilium, sterreocilia, type 1 and 2 hair cells, supporting cells and nerve fibres.
ii) Cochlear
- Organ of corti – Basilar membrane, nerve fibres, inner/outer hair, tectorial membrane.

Q4. What is the function of the

i) External- Collect sound waves
ii) Middle- Sound amplification (Impedence matching) , Overload protection (acoustic reflex)
iii) Inner ear- balance and hearing (conversion of sound waves to perceivable sounds). Sound
wave conversion to nerve signal to brain.

Q5. What is;

i) Impedence matching- refers to sound amplification by the middle ear ossicle (malleus, incus and
stapes). This is in order to generate enough mechanical energy to set the perilymph moving.
ii) Overload protection- refers to tensing of the stapedius muscle in response to loud noise so as to
reduce the impact of the sound on the cochlear of the middle ear.

TOPIC: ENT EXAMINATION

Q1. What are the 10ENT instruments and their respective functions?

Stethoscope- routine examination

Otoscope or Auroscope- to check the ear cavity and TM

Laryngoscope- to check the oral cavity and larynx and pharynx

Spatula- to help depress tongue in order to visualize the pharynx

foreign body forcepts remover of the nose

foreign body forcept remover of and throat

Tunning fork 512 Hz- to check hearing and to find out about conductive or sensorineural hearing loss. Air and
bone conduction

Head Light

ENT examination Microscope – ear procedures

Nasal speculum- opens the naris for examination

Laryngeal mirror- helps to look at pharynx and the structures at the back

- Indirect laryngoscopy

Suction machine and tip- removal or secretion or mucus or excessive saliva. Ear and nasal clearance

Q2. What is done in ear examination

- Visual inspection and examination

- Check ear and pinna, auditory tube –check the shape, skin infections, swelling or pain
- Check for perforation esp. marginal. ‘
- Check for otitis media signs like retracted tm, then bulging TM, erythema at ear drum,
cartwheel signs, hearing loss using tuning fork,
- Mechanical obstruction with was or foreign body, we remove using ear foreign body remover.
- for patients who are sensitive to foreign body forcepte touching ear, we anesthetize their ear
- Otoscopy- canal skin, walls, remove wx or debri, TM (shiny, cone of light reflex)
- Audiology- Hearing tests with tuning fork (512Hz) and audiometer.

Q3. How to do a nasal examination?

- Good light, patient sitting on chair, use nasal speculum or lift nasal tip, look for normality or
abnormality
- Use the nasal opener nasal speculum. check for nasal crust and remove if any. I nose visibly
obstructed full, ask patient to blow nose before examination.
- For foul smelling, we ask patient to do irrigation. If not we do the irrigation with normal saline.
- Check for any swelling , meatal swelling or obstruction

Conditions of the nose- Rihnitis, Tumour, deviated nasal septum

Q4. How to do an Oral examination?

- Use spatula to open patient’s mouth, check the buccal lingual sulcus, buccal gingival sulcus
- Depress tongue and check pharynx area
-
- check for any ulcers or growth or discoloration due to leukoplakia. Or candidiasis. Check for
tonsillitis, or other lymph mode emlargement in the oral mucosa.
- Check for dental caries or bad tooth that may ulcerate the tongue- cancer.
- Need goodl light, rotating chair, patient sitting well, spatula, gloves.
- Inspection- Oral cavity, teeth and tonsile
- Palpation of any lesion and or lymph nodes.
- If carcinoma- may do surgery.

Condition of the oral cavity- ulcers, cancers, leukoplakia, candidae, lip ulcers, lymphadenopathy

Larynx examination- indirect laryngeal mirror

Direct with flexible laryngoscopy, ask patient to say “eeee”

TOPIC: TRIANGLES, FASCIAS AND SPACES OF THE NECK

Q1. What are the two major triangles and what are their boundaries?

Posterior triangle- anterior- sternocleidomastoid, posterior- trapezius, inferiorly- clavicle

Anterior Triangle- medially- midline of the neck, Laterally- sternocleidomastoid, superior- mandible base.

iii) What are the sub-triangels under each?

a. Anterior
i. Submental
- Nodes
ii. Submandibular
- Salivary glands and nodes
iii. Muscular
- Thyroid
iv. Carotid
- Vessels, carotid, IJV, Vagus
b. Posterior
i) Occipital
- Occipital nodes and accessory nerve
ii) Subclavian
- Brachial plexus

Q2. What is the function of fascia

- Covers the organs and the muscle of the neck

- Internal connective tissue which forms sheath that surround and support muscles, vessels, and
nerves
- They also compartmentalize

Q3. What are the sub-division of cervical fascia

i) Superficial
- Platysma- covers all anterior necks structures
ii) Deep
a. What are the 4 types
- Superficial- covers the muscle or covers all the structure of the neck. Covers platysma
- Deep
o Superficial- or investing layer- covers muscle and glands
o middle or pre-tracheal- covers the trachea and the esophagus with thyroid
- deep or prevertebral – Covers the vertebrae and the muscles
- carotid sheet – covers the vasculature with are carotid, IJV and the vagus

Q4. What are the 4 neck spaces

 - Cervical
- Correction: Parapharyngeal space, submandibular space, pretracheal space, visceral space

Q5. What is the significance of neck spaceS

- Compartmentalize on infection or tumour spread

- Correction: they are important for understanding spread of ENT infections via lymph nodes.

Q6. What are the different category of neck node

- Supraglottic
- Glottis
- Subglottic
- Correction: Level 1a-submental triangle, 1b-submandibular, Level 2 and 3- carotid triangle, level
4-subclavian triangle, level 5-occipital triangle, level 6- muscular triangle.

TOPIC: HEAD AND NECK DEVELOPMENT (EMBRYOLOGY)

Q1. What are the mesenchyme derivatives

I) Paraxial mesoderm- Skull and skin of skull. Wall and floor of brain case, all voluntary muscles, skin
II) Lateral plate mesoderm- tracheal structures bones
III) Neural crest-midfacial and pharyngeal structures Pharingeal arches and nerves

Q2. Briefly discuss pharyngeal arches, clefts and pouches.

- Formed at 6th week. They form the aero digestive tract and the external head and neck
structures. Week 4, 4 well defined pairs of pharyngeal arches. 5 th and 6th week arches are small
and cannot be seen on the surface of the embryo.
- Ectoderm- pharyngeal arches are separated by pharyngeal clefts
- Endoderm- arches are separated by pouches.
- 6 pharyngeal arches, 5 pharyngeal clefts, 5 pouches.

Q3. What structures do the

i) First pouch- TM middle ear and inner ear. And Eustachian tube , tympanic cavity
ii) Second pouch- palatine tonsil
iii) Third pouch- thyroid gland, parathyroid, inferior parathyroid and thymus
iv) Fourth-sixth pouch become dougles pouch, which makes the thyroid cells. Superior parathyroid,
ultimobrachial body.

Note: first cleft- external auditory meatus, Second, third and fourth cleft- incorporated into the cervical sinus.

Q4. What are the derivatives of the pharyngeal arch? Refer to slide.

i) 1- auditory ossicle (except stapes), TM , mandibular arch(Maxillary and mandibular processes),.

Nerves is trigeminal- maxillary and mandibular divisions, Muscles- mastication(temporal, masseter,
medial, lateral pterygoids); mylohyoid, anterior belly of digastric, tensor palatine, tensor tympani.
 Skeleton- premaxilla, maxilla, zygomatic, part of temporal, meckel’s cartilage, mandible malleus,
incus, anterior ligament of malleus, sphenomandibular ligament.
ii) 2- Maxillary arch, Hyoid. Nerve is facial, muscles- facial expression (buccinators, auricularis,
frontalis, platysma, orbicular oris, orbicularis oculi), digastric posterior belly, stylohyoid and
stapedius -– stapes Skeleton- stapes, styloid process, stylohyoid ligament, lesser horn and upper
portion of body of hyoid
iii) 3- pharyngeal arch- Nerve: glossopharyngeal, muscles- stylpharyngeus, skeleton- greater horn and
lower portion of body of hyoid bone

4-6- trachea and laryngeal cartilage Nerve- Vagus- superior laryngeal and recurrent laryngeal. Muscles-
cricothyroid, levator palatine, constrictors of pharynx, intrinsic muscles of larynx. Skeleton- laryngeal cartilages
(thyroid cricoid, arytenoud, conrniculate, cuneiform)

Q5. What is the fate of the pharyngeal pouches?

First pouch- ventral- tongue, dorsal- Tympanic cavity-middle ear and Eustachian tube

Second pouch- ventral- tongue, dorsal- palatine tonsils

Third pouch- ventral- Thymus gland thyroid, dorsal- inferior parathyroid

Fourth pouch- ventral- unknown, dorsal- superior parathyroid

Fifth pouch- ventral- ultimo-branchial body-> parafollicular cells in thyroid

Q5. How does the thyroid develop?

- It began in the foramen cecum at the base of the tongue then migrates down to the front of the
thyroid cartilage at 6 weeks. Developing gland is attached to site of origin by thyroglossal duct
which then normally degenerates. Then it is joined by the parafollicular cells

Q6. What are the artey supply to the 6 arteries of the arches.

- I- Maxillary arch- maxillary artery

- II- Hyoid- Stapedial (embryonic), Corticotympanic (adult) Mandibular, palatine (lesser and
greater),
- III- common carotidOphthalmic artery
- IV &VI – IV- rt subclavian, VI- pulmonary Trigeminal artery

Correction: first arch- maxillary, second arch- hyoid and stapedial, third arch- common carotid and internal
carotid, fourth arch- aortic and subclavian, sixth- ductus arteriosus, pulmonary artery.

TOPIC: HEARING LOSS (DEAFNESS)

Q1. What are the two types of deafness, explain them

I) Conductive- deafness caused by obstruction (mechanical or by effusion) along the auditory tube, or
middle ear that impedes hearing at the inner ear. Problems in outer and middle ear.
 II) Sensorineural (perceptive)- hearing lose due to damage to the hearing centre at the brainstem or
the inner ear. Problems in inner ear, 8th nerve and brain
III) Both

Q2. Conductive deafness can be

i) Congenital
ii) Acquired, what are some examples
- Wax, foreign body, inflammation such as otitis media, malignancy of the ear, malignancy of
neighbouring structures that compress the ear cannal. Eustachian tube. Perforation, chronic ear
infection
- Trauma, drug toxicity, infection (meningitis), chronic exposure to loud noises, tumours, etc…

Q3. How to evaluate deafness.

Good Hx, Physical exam, Audiology tests, Tx, check clinic book or chart

i) What are some findings on physical examination?

- Swollen TM(infection-discharge from ear), burst/perforated TM, wax builup, congenital
deformity,
ii) What are some audiological tests
- Tunning fork, impedence test, Audiometry pure tone test
iii) Explain the two types of Tunning fork test?
Weber- It where the tunning fork is placed in the centre of the frontal bone. It measures bone
condcuction on both ear.
Rinne- The vibrating tuning fork is placed on the mastoid bone and then at the side of the ear to
measure bone and then air conduction. This compares air conduction to bone conduction. Normally
air conduction> bone conduction . It measures first on one side then the other.
iv) What are the 3 ways that sound is conducted through bone?
- One from bone to vestibulocochlear nerve. The other is from bone to ossicle to cochlear. Third
is from air to auditory tube to TM-Ossicles-stapes-oval window- conchlea and cochlear nerve.
- Via the skull bone, via the ossicular chain, via the external auditory canal.

Q4. What is impedence audiometry?

- Normally, sound that travel to the TM are absorbed but some are deflected. This can be
measure to measure the amount of vibration deflected.
-

Q5. What is pure tone audiometry?

- Practically used in children. Consists of tympanometry, and acoustic reflex measurements.

It is to test the minimal sound that can be detected by the ear.

- Determine the lowest level a person can detect the sound at each test frequency

Q6. What are the clinical use of impedence test?

 - To find imperters malingerers, to detect cochlear pathology, to detect 8 nerve lesion, detect
lesion of the facial nerve, to detect lesion, to confirm lesion of the brainstem
- Confirm if there is tumour
- To check if there is otitis media
- To check the function of the Stepidius or the stapedial nerve innervating it.

TOPIC: OTITIS MEDIA

Q1. Definition of otitis media- inflammation in the middle ear. May also involve inflammation of mastoid,
petrou apex, and peri-labyrinthine air cells

Q2. What are the three classifications of otitis media?

i) Acute- <3weeks rapid onset of signs and symptoms.

ii) Sub-acute- 3weeks -3 months 6 weeks
iii) Chronic- > 3months 6weeks

Q3. I) What is the etiology around 5?

- Associated with age. Common among children due to shorter and more horizontal Eustachian
tube.
- Can result from; Adenoiditis, tonsillitis, rhinitis, sinusitis, pharyngitis and infections secondary to
cleft palate. Trauma to the TM. Head Injury. Barotrauma
- Viral, fungal, bacterial, blocked Eustachian tube, allergy

Q4. What are the stages of otitis media, briefly explain them, around 5 stages?

i) Catarrhal stage: Cattharal/ stage of Eustachian tube blockage and congestion of middle ear.
ii) Stage of inflammation or stage of exudation- exudate collects in middle ear and ear drum is pushed
laterally, Initially the exudate is mucoid, later is becomes purulent.
iii) Stage of suppuration- pus in the middle ear collects under tension, stretches the drum and
perforates it by pressure and necrosis and the exudate starts escaping into external auditory cannal
iv) Stage of healing- resolution of infection
v) Stage of complication- infection may spread to mastoid antrum- catarrhal mastoiditis- coalescent
mastoiditis- empyema of the mastoid.

Q5. What are the clinical features of ASOM

i) Catarrhal stage (stage of congestion)- when eustachian tube is blocked. Increased fluid in tympanic
cavity and decreased air, retraction of TM
- Fullness or heaviness in the ear, severe ear pain at night, deafness, Tinnitus, autophony, TM
retracted, cart wheel appearance of ear drum, absence of light reflex.
ii) Stage of exudation- initial stage of inflammation-> clear fluid production and a bit of bulging of the
TM. All symptoms become severe
iii) Stage of suppuration- the exudative fluid of inflammation attracts WBC like neutrophils, lymphocyte
with engulf pathogen and die –pus formation. Increase in symptoms from stage 2. Perforation of
 ear drum. Otorrhoea with mucoid purulent discharge. Palsatile discharge (ear discharge with ear
arterial dilation) or lighthouse sign
iv) Stage of healing- TM bulges-> necrosis-> perfodation. Leaking of suppuratives fluid and sibsiding of
the symptoms. TM already raptured and healing starts in this stage. Ear drum looks dull and
sometimes wet.
v) Stage of complication
- If stage 4 does not resolve- infection spread to neighboring structure like mastoid bone through
mastoid antrum. Or mastoiditif, sinusitis, cholesteotoma.
a. How do we diagnose it
- Tuning fork test and audiometry, radiography, bacteriological examination of the ear discharge,
Pneumatic otoscopy is gold standard.
- X-ray, examination of ear using otoscope, US /

Q6. What are the features of the eardrum?

- Incus heas, malleus head, posterior malleolar fold, pars flaccida, anterior malleolar fold, malleus
handle, umbo, pars tensa, annulus tympanicus, cone of light.

Q7. What are the treatment of the AOM

i) Systemic
- Antibiotics- Tetracycline, erythromycin, clindamycin, ampicillin or Penicillin “O” for 6 days all
oral
- Systemic docongestnts: phynylephrine HCL
ii) Local
- Glycerine carbolic ear drops or warm olive oil-redcue pain.
- Antibiotic ED , steroids cmp, spirits boric drops is used after perforation of TM
iii) Surgery
a. Myringotomy- artificial incision of Middle ear cavity. puncture of TM
b. Myringo-puncture- puncturing the ear drum with a long thick injection needle and aspirating
the middle ear contents.
c. Gommet (M&G)- insertion of drainage tub e

Q8. Chronic otitis media

i) Definition- it is the chronic infection of the middle ear cleft mucosa

ii) Types
a. CSOM- associated with continuos or intermittent otorrhoea suppuration
b. CnSOM- not associated with otorrhoea suppuration
c. Chronic specific OM- It is cause by specific conditions like TB OM or Syphilitic OM

Q9. CSOM description

i) What are the two types

a. Benign or tubo-tympanic type with central perforation of the eardrum
- The perforation is in the central part of TM and is regarded as safe because it will not cause
cholestoetoma
- The disease is limited to the TM and the Eustachian tube, no complication occur as a rule.
 b. Dangerous or Attico-antral type with attic and marginal perforation
- This are perforations at the atic and margins of the TM. It is categorised as dangerous because it
can lead to cholesteotoma which the skin of the middle ear grows into neiboring structures,
especially the mastoid bone,
- Characterised by presence of destructive cholesteatoma, which may spread beyond the ear
cleft causing life threatening complications.

Q10 i) Etiology of CSOM

- Intreated Acute otitis media or AOM which fails to heal, acute necrotic OM, Traumatic large
perforation, congenital cholesteatoma.
ii) Pathology of CSOM
- Benign or tubotympanic type- etiological factors-necrosis of ear drum portions which has poor
blood supply- necrosis of ossicular chain-sclerosis of mastoid bone-polyp formation
iii) Dangerous/aticco-antral typeeatoma formation- polyps and granulation- perforation and retraction
of ear drum- partial or complete damage of Ossicles

Q11. What is cholesteatoma

Skin of the middle ear that grow into neighboring structures, esp. mastoid. It blocks the mastoid and may lead
to inflammation and ulceration of the site siste

Q12. What are the clinical staged

i) Benign perforation
a. Active stage: discharge is actively flowing
b. Quiescent stage: Ear remains dry for up to 6 months
c. Inactive stage: Ear remains dry for >6months
- Central perforation
ii) Dangerous performation
- Active
- Inactive
- Attic perforation or marginal perforation that puts the person at risk for developing
cholesteotoma

Q13. How to diagnose or the examination?

- Auroscope
- Examination of nose and pharynx to find any septic focus or an obstruction around the
Eustachian tube
- Hearing test (voice test, tuning fork test, audiometry); Conductive deafness up to 60 db hearing
loss.
- Radiology of the mastoid.
- Diagnosis- testing the patency of Eustachian tube: i) Using ear drops ii) Using Valsalva maneuver
- - Otomicroscopy: perforation, cholesteatoma, polyps

Q14. Management of benign perforation

 - Ear irrigation, swab for culture sensitivity. Ab according to results, usually ‘O’ penicillin
- Adenoidectomy, tonsillectomy; treatment of sinusitis and DNS to remove the septic focci
- Antibiotic ear drops
- Chemical cautery using 50% trichloro acetic acid
- TT injection
- Tympanoplasty: reconstruction of middle ear and ossicular chain after removing the active
disease
- Myringoplasty: repair of defect in TM

Q15. What is the management of dangerous perforation.

- Suction and cleaning of cholestatoma

- Excision of polyps and granulomas
- Mastoidectomy
- Atticotomy and atticoantrostomy
- Tympanoplasty

Myringotomy, tympanoplasty

Q16. Explain on the complications of OM

- Was group presentations

- Mastoiditis, facial nerve palsy, sensorineural hearing loss,
- Mastoid infection- Mastoiditis, mastoid abscess
- Extracranial complications- petrositis, facial nerve palsy, labyrinthitis
- Intracranial complications- extradural abcess, subdural abscess, meningitis, sigmoid sinus
thrombophlebitis, brain abcess, otitis hygrocephalus

Q17. What is the treatment of CSOM

- Antibiotic, tetracycline
- Ear irrigation
- Tympanoplasty

TOPIC: SALIVARY GLANDS

Q1. What are the 3 main paired salivary glands?

i) Discuss about parotid glands

- It is behind the ear. In front of the ear (bilaterally). Drains into upper buccal area opposite second molar
tooth via the parotid duct (Stensen duct). Produce mainly serous (watery) saliva
- Produce 50% of saliva volume
- When it is infected, it is called mumbs.
ii) Discuss about submandibular glands
- It is under below the mandible. Produce mainly seromucinous(both serous fluid and mucus) saliva.
Drains into floor of mouth next to frenulum via Wharton’s duct) Duct are seratonnus
 iii) Discuss about sublingual glands
- Under the anterior tongue floor.
- Opens into serroptinous duct
- Produce mostly mucus saliva
- Has many small ducts that opne into floor of mouth

- . Q2. What are the functions (around 6) of saliva

- Lubricates food
- Facilitates mastication and deglutition
- Essential for taste
- Maintains oral hygiene
- Assists in swallowing
- Deglutition
- First line defence contains IgA
- Assists in digestion of carbohydrates or commencement of digestion
-

Q3. What are some examples of infection of the salivary glands

- Parotitis, Mumps or Sialoadenitis, Abscess, Sialolithiasis (salivary gland stone or calculi), cysts (esp
sublingial-common now)
- Tumours, Tonsilitis

Q4. What are some of the tumours of the salivary glands?

I) Benign tumour
- Benign pleomorphic adenoma, Monomorphic adenoma
Cyst , polyps
II) Mixed tumours
III) Mucoepidermoid tumour, acinic cell tumour
IV) Malignant tumours
- Adenoid cyst Carcinoma, Malignant pleomorphic adenoma, adenocarcinoma, Squamous cell carcinoma,
Non-Hodgkin’s lymphoma

Q5. How to manage this causes

i) Infection
- Treat cause
- Antobiotics, tetracyclines, ampicillin, penicillin
ii) Surgery
- Exition or biopsy ,
- I&D, cyst/adenoma excition, cancer surgery
-
-
iii) Malignancy
- Chemotherapy
- Radiotherapy
 - Surgery

TOPIC: ORAL CAVITY PATHOLOGY

Q1. What are some Pathologies of the hard palate?

- Torus Palatine
- Malignancy

Q2. What are some complications of dental caries?

- Tongue Ulcer -> cancer

- Ludwig’s angina
- Tartar
- Gingivitis
- Periodontal abcess
- Sepsis
-

Q3. Briefly describe Ludwig’s Angina?

- Refers to abcess formation from a dental caries that leaks into submandibular space and may build up
and lead to airway obstruction.

Q4. What are some Tongue pathologies?

- Ulcer
- Carcinoma
- Leukoplakia
- Candida

Q5. What are the pathologies of the buccal mucosa?

- Cancer, ulcer, polyps

- Leukoplakia, carcinoma

Q6. What are some pathologies of the lips

i) Lip sore/ulceration
- Caused by sun or viral
- Rx: Apply GV paint
ii) Cancer
- Tongue or lip
a. Management of cancers
i. Mx: Wide excision with neck node clearance
ii. What is TNM staging
- T- refers to tomour that is localized. Tumour size and local invation; T0= carcinoma in situ (no local
invasion), followed by T1-T4.
 - N- regional lymph node involvement; NO= no nodes, following by N1-N3 in increasing number of nodes
means it has metastisized to lymph nodes
- M- distant metastases; M0= no metastasis, follow by M1 for metastasis means it has metastisied to
other areas as well
iii. What are the 3 modalities of cancer treatment?
- Surgery
- Radiology Radiotherapy
- Chemotherapy

TOPIC: THYROID ANOMALY

Q1. Give brief description on embryology of Thyroid gland.

i) What week of gestation is it developed?

Between 4-7 week 3-4 weeks
ii) What is the name of its origin site?
- Foramen cecum
iii) What month does it function?
3 months
iv) What is the thyroglossal duct?
- It is the duct that connects the thyroid to the foramen cecum during its migration to the anterior
thyroid cartilage. It then degenerates in adult life. but then degenerates

Q2. What are some embryology anomaly of the thyroid?

1. Thyroglossal cyst and fistula?

- Can be found anywhere along the migratory path of the thyroid gland can block the path were the
thyroid glands migrates through
2. Aberrant thyroid
- May also be found along the path of decent Small left overs of the thyroid
3. Thyroid agenesis
- The thyroid is not growing or not developed. Without thyroid- cretinism or other developmental
dysfunction.

Q3. Describe the anatomy of the thyroid glands.

- The thyroid has two lobules , lobus dexter (R) and lobus sinister (L) and connected by isthmus.

Q4. Describe the Histology of the thyroid.

- It contains many spherical hallow structures called follicle-functional unit of thyroid

- Between follicles are parafollicular (C cells)- secrete calcitonin. Each follicle is filled with a sticky
substance called colloid
- It has thyrofolicular cells that produce colloid. C cells produce calcitriol. Colloid where T3 and T4 are
stored are composed of thyroglobuline.

Q5. Describe the physiology and the thyroid?

 - When there is increased metabolic demand and low T3, the low T3 travels to hypothalamus and + it to
produce CTRH- it stimulates the anterior pituitary gland to produce TSH which travels to the thyroid and
+ it is produce T3 and T4. T4 is then lysed to T3. The high levels of T3 and T4 then give negative feedback
to brain to hypothalamus and pituitary to stop production of CTRH and TSH respectively.

Q6. Describe the synthesis, storage and secretion of thyroid hormone.

- Tyrosine and iodine are essential for synthesis of thyroid hormones. Both are taken up by the blood.
Tyrosine is synthesised by the body (in the thyroglobulin).
- The thyrofollicular cells of the thyroid take tyrosine and iodine from the diet and produce T3 and T4. T4
is later lysed to T3. Hormone synthesis occurs on the thyroglobulin within the follicles of the thyroid
gland and the hormones are stored there. They are stored in the colloid of the parafollicular cells and
released when the body needs it.

Q7. Describe how thyroid hormone is regulated.

- When there is increased metabolic demand and low T3, the low T3 travels to hypothalamus and + it to
produce CTRH- it stimulates the anterior pituitary gland to produce TSH which travels to the thyroid and
+ it is produce T3 and T4. T4 is then lysed to T3. The high levels of T3 and T4 then give negative feedback
to brain to hypothalamus and pituitary to stop production of CTRH and TSH respectively.

Q8. Describe the physiological effects of thyroid hormone.

Increase metabolism, growth and development, especially of the brain. It acts on every cells of the body.
increases the activity of catecholamines