ENT by Rajiv Dhawan Workbook 2022

ENT by Rajiv Dhawan FMGE 2022
LARYNX
https://t.me/rajivdhawan @ENTBYRAJIVDHAWAN https://youtube.com/c/DRRAJIVDHAWAN

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CARTILAGES OF LARYNX
 LARYNX is made of six cartilages
(A) 3 unpaired cartilages
* 1. Thyroid
* 2. Cricoid
* 3. Epiglottis
Epiglottis
 It is attached to midpoint of thyroid cartilage
 It covers vocal cord = GLOTTIS

 It is elastic cartilage
 It does not ossify with Age.
Thyroid Angle
It is the Angle between two laminae of thyroid cartilage
Prominence of thyroid cartilage in males is called ...
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THREE PAIRED CARTILAGES
(i) Corniculate - rudimentary cartilage

(ii) Cuneiform - rudimentary cartilage
(iii) Arytenoids - make posterior 1/3 of vocal cord
VOICE IN ADULT
● Males low low pitch voice (dull)

● Females have high pitch voice (sharp)
DISORDERS
PUBERPHONIA
● High pitch voice in adult male (Feminine voice)

* Treatment Speech Therapy
Pull thyroid cartilage downwards and Push it Backwards

and speak (for 6 months)
If it fails then we do
= Surgical shortening or loosening of vocal cord.
ANDROPHONIA
● Low pitch voice in female (masculine)

* Treatment
= Surgical lengthening or tightening of vocal cord
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MEMBRANES OF LARYNX
1. Thyrohyoid membrane: It is pierced by

(i) Internal branch of SLN (Superior laryngeal Nerve)
(ii) Superior laryngeal vessels
(iii) Laryngocele
2. Cricothyroid Membrane: It is site of surgery called
This airway surgery is rarely

done inAcute airway obstruction
MUCOSA OF LARYNX
Larynx is lined by ciliated columnar epithelium except vocal

cords which are lined by
..
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KERATOSIS LARYNX
In some smokers, vocal cord epithelium starts shedding

faster. This leads to a disease called Keratosis Larynx .
It is a ............................. ……………disease
CHIEF COMPLAINTS---
* Treatment Surgery
.
= Decortication of vocal cord + Quit smoking
Three divisions of larynx

* Supraglottis
* Subglottis
* Glottis

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SUPRAGLOTTIS
It has 5 parts
(i) Epiglottis
(ii) Aryepiglotic folds
(iii) False Vocal Cords =
(Rudimentary)
(iv) Ventricle – Space between False vocal cords and
true vocal cords
(v) Saccule – small mucosal Out pouching
from ventricle
I t is Rich in mucus glands So called as
Supraglottic diseases
Dysphonia Plica Ventricularis

If a patient produces sound from ........................................... ,
Then it is a disease called as Dysphonia Plica Ventricularis.
Laryngocele
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● It is Abnormally
● It is a Disease More Common in People who Play
● It Pierces Thyrohyoid Membrane and Appears as an Air
Filled Neck Swelling.
* Examination-
(The Sound of Air Leak heard when Laryngocele is Pressed)

* Investigation - X-ray Soft Tissue Neck With Valsalva.
* Treatment- Surgical Excision
SUBGLOTTIS
This is the empty space in cricoid ring
GLOTTIS
Glottis is True vocal cord
length of vocal cord
● male – 18-23 mm
● female – 16 - 17 mm
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Both TA and IA are adductor muscles if they are weak it

is a disease called
Phonaesthenia
Examination shows MCQ
due to gap between vocal cords
Vocal cords do not have ...
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VOCAL CORD DISORDERS
REINKE'S EDEMA
Reinke's space is the ..................................................... ………………..in

vocal cord
Edema of this space called Reinke's edema
This is Bilateral diffuse swelling of vocal cord

* Cause - 1. Smoking (most common)
2. Vocal abuse
* Treatment ..
VOCAL NODULES
= SINGER’S NODULES /Screamer’s Nodules
= Teacher's Nodules
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* Cause 1.vocal abuse 2. Laryngopharyngeal reflux of gastric acid ( LPR)

* N o d u l e s a r e a l w a y s Bilateral
Site of Nodule = .......

Chief Complaint Hoarse voice
* Treatment ...
OR
... MCQ
VOCAL POLYP
Cause
site
Chief Complaints
Treatment Surgery MLS

(micro laryngeal surgery)
This is Surgery of vocal cord under microscope
Focal
Focal length
lengthof ENTmicroscope
of ENT microscope MCQ
EAR = 200 mm E–2

NOSE = 300 mm N–3
LARYNX = 400 mm T–4
(MLS)

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INTUBATION GRANULOMA
- Cause: Faulty Intubation (eg.after surgery under general

anesthesia)
It Is Iatrogenic disease
- t h e y a r e Bilateral
- Site = ......
* Treatment MLS (micro laryngeal surgery)
JUVENILE PAPILLOMA OF LARYNX

It is a disease of Young children (3 - 6 yrs)
Cause
(from mother at birth)
Exam--- Viral HPV warts in larynx
They can spread to Trachea

Clinical Presentation 3 - 6 yr Child
Chronic Hoarseness of voice
± Respiratory difficulty
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* Treatment Surgery MLS with

Recurrence is very common
**CO2 is most commonly used laser in laryngeal surgery.
Its Wavelength is
Difference between Pediatrics and adult larynx
Pediatrics adult
Position C2 – C3 High C3 – C6 (low)
Narrowest part Glottis
Method of Larynx Examination:
A. Indirect laryngoscopy OPD procedure
Indirect laryngoscopy mirror is a Straight mirror .
The mirror surface is warmed before using

I/L does Not show MCQ
(i) Anterior commisure of VC.

(ii) Laryngeal surface of epiglottis = under surface
(iii) Ventricle
(iv) Saccule
(v) Undersurface of vocal cords
B. Direct Laryngoscopy OT procedure
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STRIDOR
Stridor is Noisy Breathing. Its cause is Airway obstruction
3 Types of stridor
Type level of obstruction

Inspiratory ......
Biphasic Glottis, Sub glottis, Cervical trachea
Expiratory Thoracic Trachea, Bronchi
Function of Larynx
(A) Primary function – Protection of lower airway (lungs)
(B) Phonation which means Sound Production
Sound is produced from True vocal cords inAdduction
in Expiratory phase of respiration
MUSCLES OF LARYNX
1 Abductor 4 Adductors 2 Tensors
Posterior Thyroarytenoid Cricothyroid

Cricoarytenoid (main)
Interarytenoid Vocalis muscle
Lateral  Tensors give us

Cricoarytenoid quality of voice
Cricothyroid
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All muscles lie inside larynx except

MCQ
Motor supply of Larynx
All muscle of larynx are supplied by Recurrent laryngeal Nerve
( RLN) except cricothyroid which is supplied by external Branch
of Superior laryngeal nerve ( SLN).
Sensory supply of Larynx

SUPRAGLOTTIS = Int. Branch of SLN
SUBGLOTTIS = RLN
Glottis = Both these Nerves
RLN
Vagus
SLN
VOCAL CORD PALSY

Left side vocal cord palsy is 4
times more common than right
side
This is because of longer
course of Left RLN
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Most Common Cause of
Unilateral VC palsy or
Idiopathic > Ca. Bronchus
Vocal cord palsy
Bilateral VC palsy
Thyroid surgery
ORTNER SYNDROME
( CARDIOVOCAL
SYNDROME)
Left Atriomegaly causing
left vocal cord palsy

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UNILATERAL VOCAL CORD PALSY
BILATERAL VOCAL CORD PALSY --2 TYPES
A. Bilateral Abductor palsy

Cause B/l RLN Injury in Thyroid surgery
only cricothyroid left (Adductor)

Vocal cord come in median/Paramedian position
Patient Can't Breathe properly

but can speak Normally
MCQ
Symptoms: [Respiratory difficulty with Normal voice]
Immediate Treatment = Tracheostomy
After Wait for 6 months

* Definitive Treatment
= lateralization of vocal cord
* Other treatment = CO2 laser Cordectomy
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B. Bilateral Adductor Palsy
Cause = Bilateral Vagus Palsy = RLN + SLN

(Complete Palsy)
Vocal cord lie in Cadaveric Position = Intermediate Position (OPEN)
* Chief Complaints  Aphonia – loss of voice

 Aspiration – pneumonia
* Treatment .....
=
Medialisation of Vocal cord
* Other Treatment TEFLON or FAT Injection in Vocal Cord.
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IF SLN is Injured in Thyroid surgery
Cricothyroid muscle is Paralysed
(main Tensor)
C/C Poor Quality of voice

Examination shows . MCQ
LARYNGOMALACIA
MC Congenital anomaly of larynx.
It is also called congenitallaryngeal stridor.
It is the most common cause of
It is the Weakness of
 C/F Stridor
 …………………………………………. Stridor
 Stridor Starts in Ist week of life
 Stridor increases on Crying
 Stridor decreases in Prone Position
CRY Sound is Normal because Vocal cords are Normal
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Examination Finding FMGE 2022
Treatment of Laryngomalacia
– Reassure mother that it is self limiting condition
Congenital Laryngeal web
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PAEDIATRIC LARYNGEAL INFECTIONS
(A) Acute Epiglottitis

It is bacterial Infection of supraglottis
It is caused by Streptococcus pneumoniae > Hemophillus
Influenza B
Age = 2 - 7 yrs MCQ
Clinical Presentation:
● Respiratory difficulty
● …………………………….. stridor
● High fever
● Drooling of Saliva
● Hot Potato voice
● Child Sits Bending Forward
X-Ray Soft Tissue Neck ( AP View)

= Swollen epiglottis.
* Treatment
● First Treatment =

● Steroids
● Antibiotic

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B) Acute Laryngotracheal bronchitis ( ALTB) ---CROUP
It is viral Infection of complete Airway But ………………………..is

the most affected Part
It is caused by Para influenza virus
Age = 3 month - 3years
* Clinical Presentation:
● Respiratory difficulty
● Biphasic stridor
● Low Fever
● Barking cough
* X-Ray Soft Tissue Neck AP View
= Narrowing of subglottis
* Treatment:
● Humidified oxygen
● Bronchodilator ( Racemose Adrenaline nebulisation)
● Steroids
● Antibiotics to prevent Secondary
Infection
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Tuberculosis of LARYNX
* Signs (i) Mouse Nibbled appearance of V·C MCQ
(ii) Turban Epiglottis
A person while having lunch suddenly get choking & aphonia

MCQ
This is due to food particle stuck as laryngeal foreign Body
Immediate Treatment
Pressure is given on epigastrium in upward and backward

direction
if it fails Cricothyroidotomy
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VOICE DISORDERS
FMGE 2022
RHINOLALIA APERTA ( HYPERNASALITY)
Causes
 Cleft Palate
 Sub mucus Cleft palate
 Palatal Palsy
 Palatal Perforation
 Palatal weakness = Velopharnygeal Insufficiency
RHINOLALIA CLAUSA ( HYPONASALITY)
Causes
 Nasal polyp
 Adenoid Hypertrophy
 Angiofibroma
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Functional Aphonia / Hysterical Aphonia
Patient is pretending the symptoms of loss of voice
(actuallythe voice is normal)

More common in (20 yr old)
How to prove diagnosis =
MCQ
* Treatment Psychotherapy
OR
Psychiatrist Consultation
CANCER LARYNX
 Risk factor smoking, alcohol
 MORE COMMON IN MALES
 This cancer has three types
(A) GLOTTIS CANCER
It is the cancer of true vocal cord

It is the Most common site of laryngeal cancer
* Chief Complaints . MCQ
There are NO Neck Node Metastasis in glottic cancer
good prognosis 25
B) SupraGlottic Cancer
Most common site is epiglottis
* C/F (i) Throat pain Refereed to Ear
(ii) Feeling of lump in throat
(iii) Dysphagia
(iv) ………………………………………………………. voice
C) Subglottic Cancer
* Rare
* C/F Stridor MCQ
Tumor Staging of Laryngeal Cancer

T1 one structure Involved
T2 more than one structure Involved
T3 VC is fixed (= immobile) MCQ
T4 Invasion of thyroid cartilage
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Treatment of cancer larynx

T1
T2
T3
Total laryngectomy followed
T4 By Radiotherapy
After total laryngectomy patient has Permanent tracheotomy
Now a days, treatment of choice for T1 No Mo glottic cancer is

Laser Surgery > RT

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Voice production after laryngectomy

(1) Esophageal voice = Poor Method
(2) Electro larynx/artificial larynx = It is battery operated
(3) Tracheoesophageal Puncture Device(TEP)
example
TEP Is Unidirectional valve.
It is Internal device
Surgically fitted between trachea & Esophagus
LEVEL OF NECK NODES
Level I- IA- Submental Neck Nodes

IB - Submandibular Neck Nodes
Level II - Upper Deep Cervical
Level III - Middle Deep Cervical
Level IV - Lower Deep Cervical
Level V- Posterior Triangular
MCQ
Level VI- Anterior Compartment (Pretracheal).
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Level VII- Mediastinal Lymph Nodes
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RADICAL NECK DISSECTION

It is a surgery done in Metastasic (Secondary) Neck Nodes.
List of Structures Removed in RND
1. Level I To Level V Neck Nodes.

2.
3. Internal Jugular Vein
4. Accessory Spinal Nerve.
5. MCQ
6. Tail of Parotid Gland.

7. Submandibular salivary Gland.
TRACHEOSTOMY
It is mostly done to secure the airway
MC site of Tracheostomy is 2nd & 3rd tracheal Ring
This is called Mid Tracheotomy

we leave First Ring to prevent damage to larynx.
What is High Tracheostomy?
MCQ
 Tracheostomy reduces dead space by
 Tracheostomy is temporary procedure except after

total laryngectomy
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Tracheostomy can lead to Apneoa due to
Tracheostomy can lead to surgical emphysema
Tracheostomy Tubes
(A) PVC Tracheostomy Tube
uncuffed cuffed
● Cuff decreases aspiration
B) Metallic Tracheostomy Tube

eg - Chevalier Jackson Tracheostomy Tube.
It has an outer and Inner Tube.
Innertube is longer
If Tracheostomy tube is blocked due to improper suction
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Pharynx
ENT
BY
Dr. Rajiv Dhawan
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ANATOMY OF PHARYNX
Pharynx is a Fibromuscular Tube from Skull Base to C6 vertebrae
It has 3 constrictor muscles.

1. Superior constrictor muscle (SC)
2. Middle constrictor muscle (MC)
3. Inferior constrictor (IC) muscle — it has 2 parts
A. Oblique fibers- Thyropharyngeus (TP)
B. Circular fibers- Cricopharyngeus (CP)
MCQ
KILLIAN’S DEHISCENCE
It is a triangular area in Inferior constrictor muscle between
fibres of .............................................................................. This area lacks
muscular support. Therefore it is a weak area of pharynx. Therefore
1. It is the site of the formation of ........................................
...........................................................
2. It is a possible site of perforation during rigid endoscopy.
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SINUS OF MORGAGNI (SOM)
It is the space between the skull base and upper border of

superior constrictor muscle.
● Eustachian tube & Tensor veli palatini muscle
passes through sinus of morgagni.
PHARYNX It has 3 parts
(1) Nasopharynx
(2) Oropharynx
(3) Laryngopharynx
LARYNGOPHARYNX (HYPOPHARYNX)
It has 3 Parts:
(i) Pyriform Sinus (Right & left) (PS)
(ii) Post Cricoid Area (PCA)
(iii) Post Pharyngeal Wall (PPW)
● MOST COMMON site of Hypo pharyngeal Malignancy

i s -Pyriform sinus

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Internal Branch of SLN (Internal laryngeal Nerve)
gives sensory supply to
Supra glottis Pyriform sinus

A patient presents in emergency with throat pain due
to accidental swallowing of fish bone. Surgeon removed
the foreign body but while removing foreign body, the
surgeon injured the internal laryngeal nerve. Where was
the foreign body stuck?
a. Base of tongue
b. tonsillar area
c. Pyriform sinus
d. Esophagus
Laryngeal crepitus
Clicking sensation felt when larynx is moved over cervical

vertebrae
This is absent in ........................................................................

Absence of laryngeal crepitus is called ...................................... .
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NASOPHARYNX
● To put it simply, the empty space behind the nose is
Nasopharynx.
● It has 2 important landmarks.
1. Eustachian tube opening (ET)
2. Adenoid tissue (more prominent in children).
● Eustachian tube connects the middle ear to nasopharynx;

therefore nasopharyngeal diseases can lead to middle
ear diseases for example GLUE EAR (serous otitis media)
which leads to conductive hearing loss (CHL)
THREE TOPICS IN NASOPHARYNX-
1. ADENOID
2. ANGIOFIBROMA
3. NASOPHARYNGEAL CARCINOMA.
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ADENOID
Also called nasopharyngeal Tonsil
- Adenoid is a Collection of Lymphoid tissue in NPX
- Adenoid has No capsule, No crypts and it has No definite Blood
supply.
- it is Present at Birth
- increases in size upto 6 yr of Age
- start decreasing in size at puberty
and disappear by 20 years of age
Adenoid Hypertrophy
It is a disease of ..............................................................
– It is more than physiological enlargement of adenoid
– It is Due to Recurrent upper respiratory infection
* Clinical Picture (1) Mouth breathing child
(2) Adenoid face
(a) ........................................
(b) ........................................
(c) ........................................
(d) ........................................
(3) Rhinolalia Clausa
(4) ± glue ear (. .............................................. )
(5) Failure to thrive
(6) Obstructive sleep apnoea ( OSA)
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Treatment Surgery called Adenoidectomy
Position of patient during surgery
................................ Neck extension

Same position is used for
Tonsillectomy.
Over Neck extension can lead to atlanto-axial subluxation (C1–C2)
Method of surgery = Curettage

Name of Instrument = St. Clair Thomson adenoid curette
ANGIOFIBROMA
( Juvenile Nasopharyngeal Angiofibroma)
● Most common benign tumor of Nasopharynx
● Site of origin is sphenopalatine foramen
● It is a highly vascular tumor
● It is seen in .............................................
The tumor can extend into
(1) Nose
(2) Cheek
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Pharynx ▶ 55
(3) Orbit Proptosis .............................................. MCQ
(4) Brain
* Clinical Picture 12-16 yr old Boy with Nasal mass with
profuse epistaxis MCQ
* Investigations (1) Biopsy is contraindicated

(2) CECT shows Hollmann Miller Sign
MCQ
Ant. Bowing of Post. wall of Maxilla (Antrum = maxilla)
(3)Angiography
* Treatment Surgery
NASOPHARYNGEAL CARCINOMA
● More common in china
● Etiology = .................................... MCQ
● Site of origin = Fossa of Rossenmuller
This fossa lies just above ET
unilateral ET Blockage
unilateral .....................= Serous otitis media

MCQ
Conductive hearing loss

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56 ENT for FMG : Workbook – Dr. Rajiv Dhawan
 NPC is a Hidden cancer = Occult primary . so

 Most common manifestation of nasopharyngeal
carcinoma is
.......................................................................................................
MCQ
(itparalysis
This tumor also causes is a Hidden
of cancer
cranial =nerves
Occult primary)
Trotter's Triad in NPC MCQ
 Neuralgia In Temporoparietal area due to 5th nerve

 Palatal palsy due to 10th nerve
 CHL
* Treatment Chemo Radiation > Radiotherapy MCQ
OROPHARYNX
It has following parts:
(1) Soft palate

(2) Uvula
(3) Anterior and posterior Tonsillar Pillars
(4) Tonsil = Palatine Tonsil
(5) Posterior 1/3 = Base of Tongue
(6) Lingual Tonsil
(7) Posterior pharyngeal wall
(8) ........................................ MCQ
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Bed of Tonsil
It is made By Superior constrictor muscle

Styloid Process & Glossopharyngeal nerve lie in Bed of Tonsil
Eagle Syndrome
Styloid Process
long styloid process touching IX CN
This will lead to Throat Pain Referred to EAR
This is called ............................................... = Styalgia
TONSIL
Tonsil has capsule, crypts, and it has definite

blood supply
Deepest crypt is called as Crypta Magna
● Main source of blood supply of tonsil – ....................................
........................................................ . MCQ
● Venous drainage of tonsil – Paratonsillar vein
This vein is the main source of bleeding during Tonsillectomy
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Haemorrhage in Tonsillectomy (3 Types)
(i) Primary – during surgery

(ii) Reactionary – within 24 hrs of surgery
It is due to slippage of ligature
it is an emergency
Treatment .............................................
MCQ
(iii)Secondary –after 24 hours ( mostly after 5th day of surgery)

Cause infection of Tonsillar fossa
(mild bleeding)
MCQ
Treatment .............................................
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Pharynx ▶ 59
QUINSY (PERITONSILLAR ABSCESS)

● Collection of pus between Tonsil and its Bed.
● More common in adults
● Mostly unilateral
● Examination
1. Tonsil is pushed medially
2. Uvula is pushed to other side MCQ

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* Chief Complaints (i) TRISMUS difficulty in mouth opening

due to spasm of ............................ MCQ
(ii) HOT POTATO VOICE (plummy voice)

* Treatment Per oral I & D and Remove Tonsil after 6 weeks
It is called ...................................................................
– No outer neck swelling in quinsy
*Some surgeons remove tonsil at time of abscess drainage

HOT = ABSCESS TONSILLECTOMY MCQ
If same history and examination finding as of quinsy are

given in question + outer neck swelling close to angle of
mandible MCQ
Answer will be PARA PHARYNGEAL ABSCESS
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Quiencke's Disease idiopathic edema of uvula.
RETROPHARYNGEAL SPACE
Space is divided into 2 halves by mid line band
Band. These 2 Halves are called
These spaces have Retro pharyngeal Lymph Nodes also called

MCQ
as .................................................................. MCQ
Infection of these Lymph Nodes will lead to
Acute Retropharyngeal abscess
* Clinical Presentation 2 yr Child Presenting with

- Inspiratory stridor
- Respiratory distress
- drooling of saliva,
- Hot Potato voice
X- Ray Neck show – widening
of Pre-vertebral shadow MCQ
* Treatment 1. Airway management

2. Incision & drainage.
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LUDWING'S ANGINA
It is Infection of floor of mouth =
● Floor of mouth is made by ................................................

● Source of Infection ..................................................
● Bacteria = ....................................................................
* Chief Complaints After dental infection patient
develops
1. Chin swelling
2. Trismus
3. +\- Respiratory Distress
* Treatment External I & D
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ENT by Rajiv Dhawan Miscellaneous FMGE 2022
● Pre - Malignant lesions of oral cavity

- leukoplakia
- erythroplakia
- oral submucous fibrosis
● Fordyce Spot – ectopic sebaceous gland in mucosa
● Reverse smoking Risk factor for Hard palate cancer
● MC Site of oral cavity cancer lateral Border of tongue
● MC Head and Neck cancer in India
● MC site of oral cavity cancer in India
● Commando operation oral cavity cancer (Combined oro

mandibular resection with reconstruction)
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Nose and
Paranasal
Sinuses
ENT by
Dr. Rajiv Dhawan

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DESIGN OF EXTERNAL NOSE

The External nose is made of 4 paired structures
(1) Nasal Bones
(2) upper lateral cartilages
(3) lower lateral cartilages = ...............
they form external nasal opening

(4) LESSER ALAR/ Sesamaid cartilages
these are Small cartilage between upper lateral and lower
lateral cartilages
NASAL VALVE
It is Junction of upper lateral and lower lateral cartilage
 Cottle's Test ..............................................................................

..........
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SADDLE NOSE: DEPRESSED NOSE

* Causes Trauma (MC Cause)
Leprosy
Syphilis (Tertiary)
Septal surgery
* Treatment Augmentation Rhinoplasty By using Iliac

crest graft.
RHINOPHYMA (POTATO NOSE)

Hypertrophy of ......................................... of skin
of external Nose
It is more common in Males
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Most common malignancy of skin of external Nose is

MCQ
Basal cell carcinoma = Rodent Ulcer
RHINOLITH
* It is formation of stone in nasal cavity
* Chief Complaint
❖ Nasal pain, ❖ Headache, ❖ Nasal
Blockage, ❖ Foul small from Nose
Epistaxis.
* Treatment
Endoscopic Removal
FOREIGN BODY IN NOSE
More common in School age Children

* Clinical Picture
7 yr old Child presenting with unilateral foul smelling Nasal
discharge and epistaxis Foreign Body in Nose MCQ
* Treatment Endoscopic Removal
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If there is Disc Battery in Nose, Ear, Esophagus

* Treatment ........................................................................
Because battery will Release alkali
which can cause Necrosis
NASAL MYIASIS
It is Presence of maggots in Nose

Maggot are larvae of Housefly (CHRYSOMIA) MCQ
Foul smelling condition lead to myiasis

* Treatment Maggot oil [. ...................................................... ]
MCQ
& use mosquito Net.
NASAL BONE FRACTURE

It is most commonly fractured Bone of face.
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* Treatment Immediate closed Reduction Before

edema starts Using Forceps MCQ
If Edema is already there, then wait for 7 days and then

reduce fracture
NASAL SEPTUM FRACTURE

It is of two types
(i) if force is from (ii)if force is from
HORIZONTAL FRACTURE VERTICAL FRACTURE

OR OR
JARJAWAY FRACTURE CHEVALLET # MCQ
* Treatment Fracture Reduction using ................................

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ZYGOMATIC FRACTURE/TRIPOD FRACTURE
2nd most commonly Fractured Bone of Face
Injury to Infra-orbital nerve is seen in
Zygomatic # .......................................
Maxilla # due to injury to
Carcinoma of Maxillary Sinus Infra-orbital Nerve
MCQ
MC fractured Part of mandible
= Condyle of mandible ( = Subcondylar fracture)
MID FACE FRACTURE ( Le Fort Fractures)

It is FRACTURE OF MAXILLA.
There are of 3 types of Le Fort fractures:
1. LE FORT I - Transverse fracture :

It passes along the palate.
This leads to a. floating palate.
B. Ecchymosis on palate
this is called ...................................... .
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* 2. LE FORT II - also called PYRAMIDAL fracture.
* 3. LE FORT III - also called CRANIOFACIAL

DISJUNCTION.
LE FORT II & III passing through the base of the skull so

there is a possibility of ......................................... .
This is called traumatic CSF leak which is blood mixed
CSF
LATERAL WALL OF NOSE

 TURBINATE: It is a projection on lateral wall of Nose.
There are Three Turbinates
1. Inferior Turbinate (IT)
2. Middle Turbinate (MT)
3. Superior Turbinate (ST)
 CONCHA: is the Bony part of Turbinate
There are three concha.
1. Inferior Concha ..............................................................
MCQ
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2. Middle Concha
Part of ethmoid Bone
3. Superior Concha
 MEATUS: Space Below Turbinate

There three Meatus:
1. Inferior Meatus (IM)
2. Middle Meatus (MM)
3. Superior Meatus (SM)
 SPHENO ETHMOIDAL RECESS (SER)

It is the area above Superior Turbinate.
 CHOANA: Posterior opening of Nasal cavity
Choanal Atresia
It is a congenital disease due to persistence of bucconasal
membrane. Bilateral complete choanal atresia is a neonatal
airway emergency.
Why?
.................................................................................................................
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Pediatrician is unable to pass

suction catheter through nose
C/P; blue baby turns pink on crying
Immediate treatment -
Put wide bore nipple in child's mouth
PARA NASAL SINUSES

- Mucosa lined Air Filled Hollow Cavities in Skull Bones
- They are ventilated during expiration MCQ
- They secrete mucus which is drained into Nose.
There are 4 Pair of sinuses.
* (1) Maxillary sinus

also called .............................................................. .
- Largest sinus, volume – ................................. .
* (2) Frontal Sinus
* (3) Spheroid Sinus
* (4) Ethmoid Sinus = Ethmoid air cells
61
Ethmoid air cells (has 2 groups)
Anterior Posterior
Number 2–8 1–8
Two Anterior ethmoid air cells are constant they are named
as following:
BULLA ETHMOIDALIS AGGER NASI

largest anterior most
ant. ethmoid cell ant. ethmoid cell
62
In some people ethmoid air cells can grow at 3 unusual areas

MCQ
in orbital Floor Close to optic Nerve Inside middle Turbinate
........................ ........................ ..................................
STRUCTURE DRAINING IN NASAL CAVITY

1. Nasolacrimal Duct IM
2. Maxillary Sinus
3. Frontal Sinus MM
4. Anterior Ethmoidal cells
5. Posterior " " SM

6. Sphenoid Sinus SER
in chronic Dacryocystitis Surgery done called DCR (Dacryocystorhinostomy)
DCR opening is made in MM MCQ
Middle Meatus
It is the most Imp area of Sinus drainge
It has (1) Bulla ethmoidalis (BE)
(2) Uncinate process (UP)
it is sickle shaped Bone which covers BE

(3) Ethmoidal Infundifulum
Space between BE & UP

63
 3 sinuses drain into ethmoidal infundibulum

(area of middle meatus)
This whole unit is called ..............................................................
if OMC is Block due to mucosal edema
Blockage of Sinus drainage
Sinusitis
if > 3 months
CHRONIC RHINOSINUSITIS
Chief Complaints
 Nasal blockage
 Purulent Nasal discharge
 Post Nasal drip
 Decreased sense of Smell
 ................................................ – Frontal Sinusitis
MCQ
64
Investigations
(1) Nasal endoscopy (Best Investigation)

It has 3 passes
1st pass along IT
2nd pass above MT
3rd pass inside MM
(2) X-Ray Best xray view for
sinuses ...................................... It
shows all sinuses except
Best X-Ray view for Sinus

Maxillary Water's view
Frontal
Caldwell's view
Etmoidal
Spheroid X-Ray Skull lateral view
65
(3) CT Scan Best Radiological Investigation for sinuses.
Treatment Antibiotics + Decongestant ] × 3 weeks
if it fails
Surgery FESS
Functional endoscopic sinus surgery
Complicatiions of sinusitis
(i) ORBITAL INFECTION MC with ....................................

.. MCQ
(ii) MUCOCELE FORMATION Sinus expansion due

to mucus collection
MC in ........................................
.
(iii) Osteomyelitis of frontal bone itleadtosubperiosteal
frontal abscess, It
is called as.
..............................................
......
MCQ
66
DEVELOPMENT OF SINUSES
 Radiologically Sinuses appear in sequence
First to develop M
E
S
last to develop F MCQ
● M, E are present at Birth

● E Most developed at birth.
● S appear at .................................
● F appear at .................................
General Points
most common Benign tumor of sinuses Osteoma MCQ
Osteomas are most common in Frontal Sinus
MC Fungus to cause sinusitis ASPERGILLUS FUMIGATUS
most common site of

aspergilloma
Maxillary Sinus
67
NASAL POLYP
It is prolapsed pedunculated edematous mucosa of sinuses.
Etiology Chronic Infection or allergy
Chronic Inflammation
Edema
Polyp
Polyp
(A) ANTROCHOANAL (B) ETHMOIDAL POLYP =

= KILLIAN'S POLYP NASAL POLYP
 Arise from maxillary  Arise from ethmoid
sinuses & grows posteriorly air cell
toward Choana
 Can Be seen on Posterior
Rhinoscopy  More common in adult
 More common in Children allergy is the cause

due to chronic Infection  Multiple
 single, unilateral  Bilateral
Treatment Surgery FESS >
Endoscopic polypetomy Treatment T. O. C Topical
Corticosteroid Nasal spray
eg FLUTICASONE
68
* SAMPTER'S TRIAD
● .......................................................................................................
● .......................................................................................................
● .......................................................................................................
SINUS MALIGNANCY
 Most common sinus involved = Maxillary sinus
Risk Factor :Occupational Exposure to
(i) Nickel sq. cell carcinoma
(ii) Wood dust adenocarcinoma. (. ................................... )
Ohngren's Line
It is from ..............................................................................................
It is used for prognosis assesment of cancer of maxillary sinus
Tumor above this line has poor prognosis due to early orbital Involvement.
Treatment Total maxillectomy

followed By Radio therapy MCQ

69
RINGERTZ TUMOR
● It is also called Inverted papilloma of Nose.
● Site of origin = lateral wall of Nose MCQ
● more common in males

● The tumour grows Inward So called
Inverted.
● It is locally invasive tumor
* Treatment - Surgery.
MUCORMYCOSIS
It is seen in
● HIV patient
● young diabetic patient
● COVID 19 patients
It is caused by Mucor fungi
Mucor is Angio Invasive fungus, hence
grows from nose into orbit and brain
Clinical picture
Blackish Nasal mass

Blackish discoloration around eye
D.O.C...........................................................................................
(Debridement is done first)
70
VASOMOTOR RHINITIS
Parasympathetic overactivity in Nasal mucosa
* Clinical Presentation on Change of Temperature, patient
gets excessive Watery Rhinorrhea and itching in nose
* Treatment of VMR Surgery Vidian Neurectomy
Vidian Nerve = Nerve of Pterygoid
canal.
This Nerve Gives ................................................................................
RHINITIS MEDICAMENTOSA
Prolonged use of Decongestant nasal drops
eg Xylometazoline or Oxymetazoline
...............................................................
Treatment
Stop these drops
Start steroid nasal spray
OLFACTION
(Sense of smell)
Olfactory epithelium lines upper 1/3rd of Nasal cavity.
71
Olfactory Neurons Pass through ....................................................

* Anosmia Total loss of smell
* Hyposmia decreased sense of smell
* Causes
A Obstructive eg. Nasal polyp
B Neurological cause eg.
- Head injury
- COVID 19
- Parkinsonism
- Alzhimer's disease
Kallman Syndrome =
.............................................................
A patient of anosmia can still sense

It is Not a Smell. it is an Irritant. it is sense through
...............................................
NASAL SEPTUM & ITS DISORDERS
72
Nasal septum made of 7 parts (3 Major, 4 Minor)
(1) Septal = quadrangular cartilage

(2) Perpendicular plate of ethmoid 3 major parts
(3) Vomer
(4) Spine of maxilla 4 minor parts

(5) Spine of Frontal Bone
(6) Rostrum of sphenoid
(7) Crests of palatine & Maxillary Bone
Deviated Nasal Septum (DNS)

(i) Can lead to nasal Blockage on deviated side
(ii) Crust formation on patent side
Crust = dried mucus due to increased airflow
(iii) Compensatory IT hypertrophy on patent
side (ITH)
ITH gives ........................................ of Nasal mucosa
(iv) Hyposmia
(v) Sinusitis
(vi) Epistaxis
(vii) Ext. Nasal deformity
(viii) Headache = ...................................................
= Ant. ethmoidal neuralgia MCQ
It is due to contact between DNS & Middle

turbinate
73
 Treatment: of DNS is surgery called Septoplasty
MC long term Complication of FESS/Septoplasty ..................
Treatment–local application of
...................................................
Reduces Synechaie formation
Septal Haemotoma
Due to Trauma
Bilateral
* Chief Complaints Nasal swelling and Bilateral Nasal

Blockage
* Treatment ............................... MCQ
Other wise it will convert to septal abscess septal

perforation

74
Septal Perforation
Causes (i) Trauma

(ii) Septal surgery
(iii) Cocaine snorting Vaso constrictor
(iv) TB
Lupus Perforation of cartilaginous Part.
Leprosy
(v) ............................ Perforation of Bony Part
MCQ
* Chief Complaints Whistling sound

* Treatment Surgical Closure of perforation using septal
Buttons
ATROPHIC RHINITIS (OZEANA)

It is Atrophy of turbinates (mucosa, submucosa & underlying
bones) . It is more common in females
75
* Cause:
● Autoimmunity
● Vit D deficiency
● Estrogen deficiency
● Infection By ................................................. MCQ
Exam Shrunken Turbinates
Roomy Nasal Cavities
Crust formation in nose which leads to 2 complaints
1. Nasal Blockage
2. Bad smell From patient
But
Pt. has anosmia
MCQ
This is called …………………………………………………….
* Treatment
alkaline Nasal douching
Powder 1. ........................................
2. .....................................
3. .....................................
* Surgery: (1) Young's operation MCQ
(2) ...................................................................
Permanent partial closure of both nostrils
(3) Lautenslager operation
76
RHINOSCLEROMA (WOODY NOSE)

Chronic granulomatous infection of Nose By Klebsella
Rhinosclesomatis (= Frisch Bacillus)
More common in (UP, Rajasthan)
It has 3 stages
(1) Atrophic - like atrophic Rhinitis

(2) Granulomatus lead to Hard external Nose.
(3) Fibrosis stage
* Biopsy ................................................................... MCQ
* Treatment D. O. C ........................ + ............................ MCQ
RHINOSPORIDIOSIS
Infection of Nose by Rhinosporidium seeberi
This is an Aquatic Protozoan found in Ponds
Infection is acquired by bathing in ponds
It is more common in ...................................................
Sites Involved
Nose (MC)
Oral Cavity
Conjuctiva
Genital mucosa
C/P ........................................................ with epistaxis
77
* Treatment Surgery Excision of mass with

electrocautery of Base Followed By
..................... to prevent Recurrence MCQ
CSF RHINORRHEA
Leakage of CSF from Nose
* Most common site of leak ..................................................
* Causes
1. Surgery FESS
2. Head injury Traumatic CSF leak (Blood mixed CSF).
on Filter paper it gives

........................................ MCQ
Tests/points to differentiate CSF from nasal discharge
1. CSF is non stcky (Handkerchief test)

2. Patient can not sniff back CSF
3. Biochemical analysis
4. Most confirmatory Test for CSF leak is =
....................................
Tests to find the site of leak
1. Nasal endoscopy
With Flourescien dye intrathecal injection
78
2. CT Cisternography
3. MRI (T2) images
4. Best Radiological Investigation to find the site of leak =
.................... ....................................................................................
Treatment = Conservative treatment for 7-10 dayswith
bed rest and antibiotics
BLOOD SUPPLY OF NOSE
Blood Supply of Nose
UPTO MT Above MT
ECA
ICA
Maxillary Facial Opthalmic Artery
Anterior Post
Sphenopalatine Greater Superior ethmoidal ethmoidal
(SP) Palatine labial Artery Artery
(GP) (SL) (AE) (PE)
Artery of Epistaxis = ....................................................
EPISTAXIS
Little's area
It is most common area of epistaxis
This area is on Anteroinferior part of septum
79
Little’s area has .................................................... of 4

arteries[SP + GP + SL + AE] MCQ
Posterior ethmoidal artery is not a part of Keisselbach's plexus
Causes of Epistaxis
1. Most common cause of epistaxis = Finger Nail Trauma

(Nose Picking)
2. Hypertension (causes posterior epistaxis)
3. Accidental Trauma
4. Bleeding disorder eg. Haemophilia
5. Anticoagulant drugs eg. Aspirin, Warfarin
6. Haemorrhagic fever eg DENGUE
Treatment
* Pinch the Nose (2-3 min)
* Chemical Cauterization of Little's area with .........................

...................

80
* Anterior nasal packing
* Posterior Nasal packing
If posterior and anterior nasal packing fails to

control bleeding
ESPAL (Endoscopic Sphenopalatine artery

ligation )
if fails
Maxillary artery ligation
if fails
ECA ligation
if fails
................................................ MCQ
81
82
EAR
ENT
By
Dr. Rajiv Dhawan
83

84
EMBRYOLOGICAL DEVELOPMENT OF EAR

DEVELOPMENT OF PINNA
● Tragus of pinna develops from 1st branchial arch

● Rest of pinna develops from 2nd branchial arch.
● …………………………………….. is the junction of 1st arch and 2nd arch.
● There is no cartilage in incisura terminalis.
HILLOCKS OF HIS
 During embryological development of pinna, 6 elevations

form on the head and neck are of embryo from 1st and 2nd
arches which eventually fuse to form pinna.
 These 6 elevations are called ............................................. .
MCQ
 Pinna development completes by the 20th week of

embryological life
85
CONGENITAL DISORDERS OF PINNA
 PREAURICULAR SINUS
 If the union of 1st and 2nd arch is
incomplete, it will lead to a congenital
disorder called preauricular sinus
 If asymptomatic, it needs no treatment
 If recurrent infection is there in pre-
auricular sinus, surgical resection of
tract is done
Development Defects Of Pinna
ANOTIA MICROTIA
It is total absence of pinna It is small pinna.
86
What is Bat Ear ?
● Normal pinna has 2 curvatures called

HELIX (C) and ANTIHELIX(c).
● If anti helix is absent, it is called
................. .
● Cosmetic surgery of pinna called
Otoplasty.
● It is done at ................... of age. (ideal age) as pinna attains
adult size by this time MCQ
Development Of Other Structures
STRUCTURE DERIVED FROM

TYMPANIC MEMBRANE From all 3 layers : ectoderm,
endoderm, mesoderm
Development Of Ossicles
 Malleus and Incus develop from the ........................... .
 Stapes- ............................. . MCQ
87
 Cochlea
 Cochlea is derived from OTIC CAPSULE (Neuroectoderm)
 Cochlea development completes by ............................ .
Q. Which Ear structures are of adult size at birth? MCQ
Ans: Middle ear

Ossicles
Cochlea.
 Clinical anatomy
 Mastoid tip is absent at birth.
 It develops at ............................ of age. MCQ
MIDDELE EAR OSSICLES

 Names:
- Malleus (hammer)(M)
- Incus (anvil) (I)
- Stapes (stirrup) (S)
- Size- Malleus >Incus >Stapes

- Stapes is the smallest bone in the body (S for stapes,
S is small)
88
 Malleus:
 It has a hammer like shape.
 Parts:
1. Head of malleus,
2. Lateral process,
(outward), close to TM
3. Handle of malleus
4. Umbo (Tip of handle)
 Incus:
 Parts:
1. Body
2. Short process of Incus
3. long process of Incus
4. Lenticular process
(end of long process)
 Stapes:
 Parts:
1. Headorsuperstructure
of stapes,
2. Footplate of stapes.-
it is attached at oval
window of cochlea
 Stapes acts like a .................. If stapes is fixed, it will
lead to disease called ........................... .
89
MIDDE EAR MECHANICS
● Tympanic membrane and ossicles work as one unit.

● This assembly conducts sound energy to the inner ear.
● Middle ear also amplifies sound energy This amplification

factor is called Middle ear Transformer ratio
● MIDDLE EAR TRANSFORMER RATIO = ...................
● Main function of the middle ear is IMPEDANCE MATCHING
MECHANISM

90
PINNA
● Pinna is made of YELLOW ELASTIC

CARTILAGE covered by skin.
● Skin is closely attached to cartilage
on the lateral surface (front side)
● Skin is loose on the medial surface.
(back side towards skull)
NERVE SUPPLY OF PINNA
.....................................................................................................
- It is the main nerve supply of pinna;

- It also supplies lobules of pinna.
DISORDERS OF PINNA
 1. PINNA HAEMATOMA:
 It is due to trauma
 It is a sub-perichondrial hemorrhage.
 Treatment is aspiration or
drainage + pressure bandage.
◀ BOXER EAR
 Otherwise it will lead to necrosis
of cartilage, which leads to post
traumatic pinna deformity called
as ........................................................
........... . MCQ
 2. KELOID PINNA:
 Pinna can be a site of keloid
 It is most commonly found on helix. ◀ KELOID PINNA
91
 DARWIN'S TUBERCLE:
 It is anatomical variation. It is
not a disease.
 It is conical elevation on ............................ .
◀ DARWIN'S TUBERCLE
EXTERNAL AUDITORY CANAL (EXTERNAL AUDITORY

MEATUS)
(EAC / EAM)
● EAC is 24mm in length, outer 8mm is cartilaginous and

inner 16mm is BONY.
● The bony EAC is made by a tympanic part of the temporal
bone.
92
● EAC is lined by skin. Outer

part skin has hair follicles and
CERUMINOUS = WAX glands
which are modified APOCRINE
GLANDS.
● Some people produce more
wax which leads to EAC
occlusion by wax collection.
This will lead to conductive ◀ WAX in EAC
hearing loss (30 dB approx.)

● Treatment is SYRINGING- direction of water is ................
................. MCQ
● Use water at room temperature. In syringing avoid cold

water because it can lead to ...................... .
● Syringing can lead to .....................................................................
................. ...........................................................................
93
Direction of EAC
● In adults, direction is TORTUOUS. It is inward, downward

and forward. Therefore during ear examination/Otoscopy,
pinna is pulled ................................................................................
in adults
Fissure of Santorini MCQ
● These are natural defects the cartilaginous part of EAC.
Live Insect in the EAC
* Treatment
Put oil in the EAC to kill it and then remove it.

94
SENSORY NERVE SUPPLY OF EAC
There are three nerves

NERVE SUPPLY TO
Auriculotemporal nerve Anterior wall and roof of
EAC
Auricular branch of the Posterior wall and floor of
vagus EAC
It is also called Stimulation of this nerve
.. .. ... ... .. ... .. ... .. ... .. ... .. o r leads to ............................... .
ALDERMANN'S NERVE. MCQ
Sensory division of the facial Posterosuperior part of

nerve also called the nerve EAC.
of WRISBERG
DISEASES OF EAC
 1. DIFFUSE OTITIS EXTERNA:
 It includes infection of the

complete skin of EAC and/
or pinna.
 Treatment is topical
antibiotics ear drops.
 Diffuse otitis externa is

also called SWIMMER
EAR/ TROPICAL EAR.
95
 2. LOCALISED OTITIS EXTERNA/

FURUNCULOSIS (BOIL):
 It is a staphylococcal infection
of hair follicle
 It is seen in the outer part of

EAC,
 Treatment is IG packing
( ..................................................... )
(It reduces pain & edema)
 3. MALIGNANT OTITIS EXTERNA:
 It is infection of the underlying bone of EAC.
 It is also called as skull base osteomyelitis.
 It is a life threatening infection, therefore called
malignant otitis externa.
 It is seen in............................................................... (60-70
years.).
 It is caused by ........................................ . MCQ
* Clinical Picture:
 Severe ear ache.
 Blood stained ear discharge.
 +/- facial nerve palsy (it is the most commonly involved
nerve).
Active space
 +/- 9, 10, 11, 12 nerve palsy. (due to skull base

infection)
96
* Examination by otoscopy:
 GRANULATIONS in EAC, this leads to blood
stainedear discharge.
* Treatment:
 DOC- ......................................................................
 4. OTOMYCOSIS- (= SINGAPORE EAR)
 It is the fungal infection of EAC.
 The most common fungus to
cause this is ...........................
.......,
 Second most common is candida.
 It is more commonly seen in
the rainy season.
 c/c- itching in the ear.
 Examination - .............................................................. . MCQ
* Treatment-
 Aural toilet- by suction or dry mopping with a
cottontip probe.
 Antifungal ear drops. Eg- Clotrimazole, Nystatin
 5. EXOSTEOSIS
 It is also called SURFER'S EAR.
 It is hyperplasia of bony EAC.
 It is more common in water sports persons so,it is called
............................................ .
97
TYMPANIC MEMBRANE (TM)
 It is also called MYRING.
 It is …………………………….. IN
COLOUR, oval in shaped.
 Diameter of tympanic
membrane is ..........................
.......... .
 Surface area is .................... .
 Effective area is 45 sqmm, this is because the peripheral
part of the tympanic membrane is more mobile than the
central part.
 TM is lying at an angle of ’55°
with the horizontal.
 TM shows movement on
Seigelization.
Seigelization means putting air
pressure on a tympanic membrane.
It is done with the help of Siegel
speculum.
TM Has 4 landmarks
a) Handle of Malleus.
b) Lateral process of Malleus.
c) UMBO.
d) Cone of light.
98
Cone of Light
It is formed by reflection of light from handle of the Malleus.

(light of otoscope) Cone of light position
● Right ear it is .....................................
● Left ear it is .......................................
Tympanic membrane has 2 parts -
1. PARS TENSA (PT) see image below

- It has three layers.
A. outer- skin.
B. inner - mucosa.
C. middle - fibrous layer.
Pars Tensa makes the majority of tympanic membrane
2. PARS FLACCIDA ( PF) see image

It is also called SHRAPNELL'S MEMBRANE. Middle
fibrous layer is almost absent in pars flaccida. It forms
the small upper part of the tympanic membrane MCQ

99
Next Concept
● Main function of the Eustachian tube is middle ear

ventilation.
● If ET gets blocked it will lead to negative pressure in the
middle ear, this lead to retracted TM.
Features of retracted tympanic membrane
It is dull in appearance
◀ RETRACTED TM
RETRACTION POCKET
◀ RETRACTION POCKETS
100
 If there is too much retraction it will lead to formation of

retraction pockets
 The retraction pocket is most commonly seen in .................
..................
 Retraction pocket is lined by skin and filled by keratin.
 If the retraction pocket is allowed to progress there will
be small perforation at the tip of the Fundus of retraction
pocket.
 Through this perforation, skin starts growing into the
middle ear.
 Presence of skin in the middle ear is called ..........................
............... .
(It is pearly white in colour).
◀ CHOLESTEATOMA
101
EUSTACHIAN TUBE
 It connects the middle ear to the nasopharynx.

 Its nasopharyngeal opening lies 1.25cm behind the posterior
end of inferior turbinate.
 It is ........... in length, outer 12mm is bony inner 24mm is
cartilaginous
 At birth, it is nearly horizontal, but in adults it has
.............................. with the horizontal.
 Main function of the Eustachian tube is ................................
................. .
 ………………………………………………………………. muscle opens the tube
during swallowing. MCQ

102
GLUE EAR
 Glue ear is also called SEROUS OTITIS MEDIA or

SECRETORY OTITIS MEDIA. (SOM) also called Otitis
Media with Effusion (OME) MCQ
 It is collection of sterile thick glue like fluid in middle ear.

 Basic aetiology of glue ear is ET blockage
 Most common age is .....................................................................
Causes of ET blockage
 Most common cause is adenoid hypertrophy causing ET

blockage (mostly .........................) seen in ............................
.................. .
 Rare cause- NASOPHARYNGEAL CARCINOMA causing
ET blockage (mostly .........................), seen in .........................
. MCQ
103
Clinical Picture
School age child complaining of
- Heaviness in the ear (it is not painful disease).

- Conductive hearing loss (CHL).
(Poor school performance.
- +/- Adenoid face ( see image)

Examination
a) Glue like fluid behind TM.

b) Air bubbles trapped within glue.
Treatment
- Surgery – Myringotomy in (..............................................) +

Grommet insertion (also called as middle ear ventilation
tube) +/- adenoidectomy MCQ
◀ Myringotomy ◀ Grommet
MIDDLE EAR
 It is also called TYMPANUM.

 Middle ear is a hollow cavity in the temporal bone.
104
 It has three parts--

MESOTYMPANUM It is covered by TM. It is the middle
(M) part of middle ear
EPITYMPANUM (E) Also called as ATTIC, it is covered
by bone called ............................. .
HYPOTY MPANU M It is covered by bone (unnamed
(H) bone).
● Depth of middle
ear
* E - 6mm
* M - 2mm
* H - 4mm
Sensory supply of the middle ear
It is by tympanic branch of Glossophrayngeal nerve

(JACOBSON'S NERVE).
REFERRED OTALGIA
Tonsillectomy, tonsillitis, lead to earache via ........

stylalgia .........................
Supraglottic cancer, pyriform lead to earache via
sinus cancer ............... ................
105
SIX WALLS OF MIDDLE EAR
ROOF Above it lies the dura matter of temporal

lobe of the brain.
FLOOR Below the floor lies JUGULAR BULB.
ANTERIOR This wall has 2 openings,
WALL * Lower opening- for Eustachian tube
* Upper opening for Tensor tympani
muscle which is attached to Malleus).
This muscle supplied by Mandibular
division of Trigeminal nerve.
POSTERIOR It has a projection called .......................... .
WALL From pyramid, Stapedius muscle tendon
comes and attached to stapes, this
muscle is supplied by the facial nerve.
LATERAL It is made by Tympanic membrane
WALL
MEDIAL Behind this wall lies the inner ear
WALL A. Medial wall has Two projections of
inner ear
a) ...............................- projection of
basal turn of cochlea.
b) Lateral semicircular canal
projection called lateral SCC bulge.
B. Medial wall has 2 windows for inner ear
a) Oval window- which is covered by
a footplate of stapes.
b) Round window- it is covered by
round window membrane. Also
called as ............................ .
106
* Concept
Above the ear
Below the ear
Behind the ear
MIDDLE EAR CLEFT
 Middle ear cleft is a combination of all hollow cavities in

temporal bone.
It has 5 parts
a) Eustachian tube.
b) Middle ear.
c) Aditus.
d) Antrum.
e) Rest of air cells.
 Antrum- it is the largest and most constant mastoid
air cell. Antrum is connected to the middle ear through
...................... .
 All these hollow spaces are mucosa lined and are
interconnected
107
Spread of Disease
NPx to middle ear OTITIS MEDIA

ME to mastoid Mastoiditis
ME to petrous apex Petrositis
DISEASES OF MIDDLE EAR CLEFT
ASOM – ACUTE SUPPURATIVE OTITIS MEDIA
● It is an infection of the
middle ear mucosa by pyogenic
organisms.
● Most common organism to cause
this is .............................................. .
Infection reaches nasopharynx
to the middle ear via the
eustachian tube.
● C/C- earache.
● Examination- red tympanic membrane with dilated
capillaries
This is called ................................................... .
● Treatment- medical management. MCQ
Q. ASOM patient with red bulging tympanic membrane.

What is the treatment?
Ans. Treatment is Myringotomy (in ............................................... )
 If no management is done in a patient of ASOM
with red bulging TM, it will lead to perforation of
tympanicmembrane

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 If no treatment is taken for next 3months- it will

lead to permanent perforation. This disease is called
safe CSOM.
SAFE CSOM
 It is also called TUBOTYMPANIC CSOM.

 It is characterized by the presence of permanent central
perforation in Pars Tensa of TM.
109
Chief complaint
a) Ear discharge- Discharge is not foul smelling and not blood

stained.
b) Hearing loss ( Conductive)

 Ossicle Erosion
 In long standing cases there can be ossicular erosion.
 First ossicle to be eroded is ...................... .
 WHY INCUS? - Incus has no muscle
attached to it , so it has ....................
.................................. .
 Ossicle erosion will increase CHL.
 Treatment is surgery
SURGICAL OPTIONS :
 1. MYRINGOPLASTY
 It is the repair of tympanic membrane perforation using
a graft.
Most commonly used graft is ............................................. .
110
We use MOLLISON'S self retaining mastoid retractor

to expose the area. It's a microscopic ear surgery.
◀ MOLLISON
RETRACTOR
 2. Type III TYMPANOPLASTY-

 This is done when disease has eroded Malleus and Incus
M(-) I(-) S(+) situation
 TM graft is placed in contact with stapes.
 This surgery is also called COLUMELLA
TYMPANOPLASTY
MASTOIDITIS
 It is an infection of the mastoid air cells. It is a

complication of ASOM and CSOM.
111
Chief Complaint
a) pain behind the pinna,

b) profuse ear discharge
On Examination
 Mastoid surface is found to be smooth, red and shiny.

This is called the ......................................................................
. It is the first sign of Mastoiditis.

112
Mastoid tenderness is positive -
WHAT IS RESERVOIR SIGN & LIGHT HOUSE SIGN ?
 This patient complains of profuse ear discharge. On

cleaning the discharge fills immediately again this is
called .................................................................... MCQ
 The pus is continuously flowing from mastoid to middle

ear. This gives ................................................ . (can also be
seen in suppurative stage of ASOM)
Investigation -
X ray mastoid ....................................... .
Treatment -
- Surgery is CORTICAL
MASTOIDECTOMY it is also
called as ........................................
.......... . MCQ
- First cell to be located during

mastoid surgery is....................................................... since
it is the most constant and largest cell of mastoid.
113
How to find Mastoid antrum ?
- Landmark for mastoid antrum is McEwen's Triangle

also called as Suprameatal triangle.
KORNER SEPTUM
 It’s an embryological error (anatomical variation).

 It is due to persistence of ...................................................
.........
 It leads to difficulty in finding antrum for surgery.
ABSCESS FORMATION
◀ Post Auricular ◀ Bezold's Abscess.
114
* CAUSE - untreated Mastoiditis can lead to abscess

formation at 3 sites
 These Sites are
a) Most common site is mastoid abscess, which is post
auricular abscess.
b) Along Sternocleidomastoid is ......................................... .
c) Along Digastric muscle is called .................................... .
PETROSITIS – GRADINEGO SYNDROME
● It is an infection of Petrous apex air cells.

● It's a complication of ASOM or CSOM.
● Petrous apex has relation with ........................... cranial nerves
MCQ
It has 3 features – (Mnemonic GERD)
Gradinego syndrome (G)

a) Ear discharge.(E)
b) Retro orbital pain due to 5th nerve involvement.(R)
c) Diplopia due to 6th nerve involvement.(D)
* Treatment- Surgical Exploration.
115
UNSAFE CSOM – ATTICOANTRAL CSOM
 Hallmark of this disease is the presence of .......................... .
WHAT IS CHOLESTEATOMA ?
Cholesteatoma is the ectopic presence of skin in the middle

ear cleft. It is ..................................... in colour
Most common site of cholesteatoma
................................. in Epitympanum. It is the space between

the pars flaccida (Sharpnell’s Membrane) and the neck of
Malleus.
Origin of cholesteatoma (Three Types)
* 1. primary acquired cholesteatoma
Most commonly Cholesteatoma originates from

Retraction Pockets This is called primary acquired
cholesteatoma
116
Retraction Pockets are most common in Pars Flaccida.

If the retraction pocket is allowed to progress there
will be small perforation at the tip of the Fundus of
retraction pocket. Through this perforation, skin
starts growing into the middle ear. Presence of skin in
the middle ear is called cholesteatoma.
* 2. Secondary Acquired Cholesteatoma
Origin From marginal perforation
This is called Secondary Acquired Cholesteatoma.
* 3. Congenital cholesteatoma
It presents as PEARLY WHITE MASS behind .............

...................................................... . MCQ
Why is cholesteatoma unsafe ?
Answer -It is due to bone erosion.

 Mechanism of bone erosion
1. Inflammatory osteitis.
2. Secretes bone destroying enzymes.
It leads to Complications, so it is called unsafe CSOM.
Chief complaints
 Ear discharge- .................................................................

 Hearing loss is mostly conductive
117
* Treatment
Surgeryis calledMRM (ModifiedRadicalMastoidectomy)
also called as Tympanomastoid Exploration.
Main aim of MRM is to ............................................. . MCQ
COMPLICATIONS OF UNSAFE CSOM
LABYRINTHINE FISTULA
This is the Erosion of bony cover of ............................................

.......... bulge which lies on the medial wall of middle ear. It is
due to bone eroding properties of cholesteatoma.
 Chief complaint- vertigo.
* Examination- Positive fistula sign.
Fistula sign is best seen with ..................................
(putting air pressure on TM with Seigel speculum) .This
stimulates inner ear and patient experiences vertigo
and nystagmus).
FALSE POSITIVE FALSE NEGATIVE FISTULA
FISTULA SIGN SIGN
(.............................................)
* Congenital syphilis. * Fistula in a dead labyrinth.
* Fistula covered by
cholesteatoma.

118
BRAIN ABSCESS due to unsafe CSOM
 Most common site of otogenic brain abscess is the

...........................and the second site is cerebellum.
 Chief Complaint ........................................................................
..................
 Investigation- CECT brain.
* Treatment is Neurosurgery.
SIGMOID SINUS THROMBOSIS / LATERAL SINUS THROMBOSIS
 It is an intracranial complication of unsafe CSOM.

* Clinical Picture
A) Headache.
B) Spiky fever. This fever is called .....................................
............. .
C) Pitting edema on a mastoid. This is called ....................
.............................................. . MCQ
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D) There is No change in CSF pressure on pressing IJV.

it can be seen in two ways:
i) On lumbar puncture- it is called TOBEY AYER
TEST
ii) On Fundus (retina) examination- it is called CROWE
BECK TEST MCQ
◀ SIGMOID SINUS THROMBOSIS
ONE LINERS TO MEMORISE
● Most common complication of unsafe CSOM is Mastoiditis.

● Most common intracranial complication of unsafe CSOM is
Meningitis.
120
INNER EAR (LABYRINTH)

ANATOMY
 It is also called LABYRINTH.

 It has two parts-
- Membranous labyrinth- it is
the true inner ear.
- Bony labyrinth is the bony

cover of inner ear
PARTS OF INNER FUNCTION SENSORY END

EAR ORGAN
Cochlea Hearing ..................................
Utricle & Saccule Linear balance. ..................................
Semicircular canals Angular balance .................................
FLUIDS OF INNER EAR
 Inner ear is filled with endolymph and surrounded by

perilymph.
 A. ENDOLYMPH- It is produced by stria vascularis
of cochlea and it is absorbed by the endolymphatic sac.
- If the endolymphatic sac does not absorb it properly it

leads to MENIERE'S DISEASE.
- In Meniere’s disease - There will be gradual cochlear

damage due to high endolymph pressure.(Meniere’s is
glaucoma of ear)
121
 B.PERILYMPH- it is nothing but CSF.

 Perilymph is found in inner ear
 CSF is found in subarachnoid space
- CSF and Perilymph are connected by .............................
.................................................. MCQ
- This is the pathway that can lead to post meningitis

deafness.
Endolymph high K+, low Na+.

Perilymph high Na+, low K+.
COCHLEA
 It has 2 ¾ turns.
 Cochlea
BASAL TURN Senses ................... freq

sounds.
APEX TURN/ senses ................... freq
HELICOTREMA sounds
CUT SECTION OF COCHLEA
● Cochlea is a rolled tube. It’s a fleshy tube in a bony tube.

● Scala vestibuli and Scala Media are separated by ..........
............................................ .
122
● Organ of Corti is lying on the ......................................... and

covered by the ...................................... .
● SOUND ENERGY- it moves basilar membrane which

stimulates the organ of Corti.
● Organ of corti has outerhair cells and inner hair cells
● Cochlea is connected to saccule through a channel called as
............................................ . MCQ
UTRICLE AND SACCULE (VESTIBULE)
 Utricle and Saccule are also called VESTIBULE or

otolithic organs. MCQ
 Function .................................................. .
 MACULA is the sensory end organ of utricle and saccule.
It is covered by a gelatinous layer. This layer has calcium
carbonate crystals called .................................................. .

123
If Otoconia turn free and reach semicircular canals, it

leads to a disease called BPPV
BPPV (BENIGN PAROXYSMAL POSITIONAL VERTIGO)
● BPPV is the most common cause of peripheral vertigo.

● Cause--Otoconia gets displaced and reaches the
semicircular canal (the most commonly involved canal is .....
.................................................).
● Chief complaint- vertigo for few seconds on changing head
position.
● Diagnostic test of BPPV- .........................................................
MCQ
● Treatment of BPPV- ................................................ MCQ
124
DIX HALLPIKE MANEUVER. EPLEYS MANEUVER

VISUAL QUESTION
SEMICIRCULAR CANAL (SCC)
 There are three SCC.

1. LATERAL SCC/ HORIZONTAL.
2. POSTERIOR SCC.
3. SUPERIOR SCC.
 Function of canal- ANGULAR BALANCE.
125
 CRISTA- is the sensory end organ of a semicircular

canal, it lies in the dilated end of a Reverse semicircular
canal which is called ........................
 Crista is covered by a gelatinous layer called
....................... . MCQ
BITHERMAL CALORIC TEST
 This is a Test for ................................

 Steps-
1. Patient is lying supine with head lifted
30°
2. EAC is irrigated with Warm (44°C) and
Cold (30°C) water.
3. This will produce nystagmus
4. With cold water stimulation, eyes move towards the
.........................,
5. With warm water stimulation, eyes move towards the
..........................
(COWS). MCQ
VESTIBULOCOCHLEAR NERVE – (8th NERVE)
 It has 3 divisions-
1. Cochlear division.
2. Superior vestibular division. (SV)
3. Inferior vestibular division. (IV)

126
INTERNAL AUDITORY CANAL
7th & 8th nerves enter the ear via the Internal Auditory Canal
also called internal auditory meatus.
◀ Internal Auditory Canal
CUT SECTION OF INTERNAL AUDITORY CANAL -
 .................................- it is vertical bony septum in the upper

part of the internal auditory canal. MCQ
● SV -SUPERIOR VESTIBULAR DIVISION OF 8TH

NERVE
● IV- INFERIOR VESTIBULAR DIVISION OF 8TH
NERVE
127
AUDITORY PATHWAY
 It mainly lies in the brainstem area.

1. E- Eighth nerve.
2. C- Cochlear nucleus.
3. O- olivary complex (superior)
4. L- Lateral lemniscus
5. I - Inferior colliculus
6. M- Medial geniculate body
7. A - Auditory cortex.
(Mnemonic - ECOLI-MA)
AUDIOLOGY
Hearing loss is of 2 types
1. Conductive hearing loss(CHL)

2. Sensorineural hearing loss (SNHL).
128
Conductive hearing loss Sensorineural hearing loss

problems in the external ear A problem in cochlea e.g.
and middle ear cause CHL. Meniere's disease.
Causes A problem with the 8th
nerve.
wax, glue ear, CSOM, Eg- Acoustic neuroma.
otosclerosis, Ossicular
dislocation.
Sound can be heard in 2 ways
1) Air conduction (AC)- its natural way of hearing, It is

complete test of hearing.
2) Bone conduction (BC)- it is a test,
Bone conduction directly reaches cochlea. Therefore
bone conduction is a test of cochlea and 8th nerve only.
If bone conduction is poor, patient has SNHL.
TUNING FORK TEST
 Most commonly used tuning fork 512Hz

Teminology in tuning fork test-
Poor ear means Ear with hearing loss.
Better ear means Ear with normal hearing.
129
 1. RINNE TEST:
It is a comparison of air conduction and bone conduction.
In normal people AC>BC [RINNE (+)
In CHL BC>AC [RINNE (-)
In SNHL AC> BC [RINNE(+)
 2. WEBER TEST:
Place the tuning fork center of the head and ask the patient
where sound is heard.
Normal people center of forehead
CHL sound is HEARD in POOR ear.
SNHL sound is HEARD in BETTER ear.
 3. ABSOLUTE BONE CONDUCTION-

This test is done with occluded EAC.
In normal people is equal to examiner.
In CHL is equal to examiner
In SNHL it is decreased.
130
POINTS TO REMEMBER FOR TUNING FORK TEST
* RINNE (-) means conductive hearing loss.

* WEBER heard in poor ear means CHL.
* Bone conduction poor means SNHL (ABC).
SUMMARY OF TUNING FORK TESTS
NORMAL CHL SNHL

RINNE
AC> BC ( +) BC> AC (-) AC>BC ( +)
WEBER
HEARD IN HEARD IN HEARD IN
CENTER OF POOR EAR BETTER EAR
FOREHEAD
ABC EQUAL TO EQUAL TO DECREASED

EXAMINER EXAMINER
GELLES TEST
 It's a special tuning fork test used to diagnose ........................

. MCQ
PURE TONE AUDIOMETRY (PTA) AUDIOGRAM
1. It is a subjective test of hearing in air conduction and

bone conduction.
2. Frequencies tested are- 250 TO 8000
250 500 1000 2000 4000 6000 8000
low low High High high
131
3. Hearing level up to 25dB is normal hearing.
SYMBOLS USED IN AUDIOGRAM
Interpretation of Audiogram:
1. Normal- both AC & BC are within 25dB range.

2. CHL - AC is poor, BC is normal. AB gap (+)
3. SNHL - both AC, BC poor.

132
◀ NORMAL AUDIOGRAM ◀ CHL AUDIOGRM
◀ SNHL AUDIOGRAM
TWO SPECIAL DIPS IN AUDIOGRAM
133
OTOSCLEROSIS NOICE INDUCED HEARING

LOSS
CHL SNHL
.................................................... ....................................................
..... .....
DIP AT 2000 HZ IN BC DIP AT 4000 HZ IN AC
AND BC
TWO SPECIAL AUDIOGRAMS
MENIERE'S DISEASE PRESBYCUSIS

(Age related hearing loss)
. .
* Low frequency SNHL * High frequency SNHL
Therefore it shows .......... Therefore, it shows ........
............................................. ................................................
134
BRAINSTEM EVOKED RESPONSE AUDIOMETRY (BERA)
 BERA is an objective test of hearing.

 Principle- We stimulate the ear with sound and record
electrical activity from the auditory pathway (it lies mainly
in brainstem area).
 BERA has 7 waves. ( I to VII)
 The most important wave of BERA is ...........................which is
produced by ....................................... .
* Uses of BERA-
1. Pediatric patients.
2. Malingerers (MLC)
135
OTOACOUSTIC EMISSIONS (OAE)
 Emission means ECHOES.

 Principal- We give sound to ear and then we record
echoes from ......................................... of cochlea.
 These echoes are called OTOACOUSTIC EMISSIONS.
 If echoes are recorded it means cochlea is working
normally.
Ideal hearing screening investigation in MCQ
a. NEONATAL HEARING SCREENING - OAE.

b. Meningitis baby or NICU baby (high risk baby) - BERA.
Tympanometry
136
This test records freedom of movement of TM & Ossicles.
Type A Normal
Type B Flat curve seen in ......................... . MCQ
Type C Seen in ET Dysfunction

Type As seen in ......................... MCQ
Type Ad seen in Ossicular dislocation.
Stapedial reflex
Principle-On hearing loud sound, Stapedial muscle contracts

to pull the stapes out of oval window so as to protect
Afferent of this reflex ............................

Efferent of this reflex ……………………………………….
This reflex is absent in

1. Deaf patients (8th nerve is gone).
2. Bell's palsy (7th nerve problem).
3. Otosclerosis.

137
TEMPORAL BONE FEACTURES
 Cause – trauma
BATTLE SIGN - it is ecchymosis in the mastoid region. It

is seen in skull base fractures (temporal bone fractures).
Facial Palsy in Temporal bone fracture is two types:

Delayed Onset facial Palsy Immediate Onset Facial
Palsy
* It is due to edema of * It is due to direct injury
nerve. to nerve by fracture line.
* Treatment is * Treatment is
.............................. MCQ ............................... MCQ
OSSICULAR DISLOCATION & CHL
 There can be 2 possibilities in ossicular dislocation leading

to conductive hearing loss---
(A) Ossicular dislocation with normal tympanic
membrane- ...................
(B) Ossicular dislocation with Perforated tympanic
membrane - ......................................................... MCQ
138
General points to remember
CHL due to Wax - 30dB CHL.

CHL in Glue ear - 10 to 40 dB CHL.
NOISE INDUCED HEARING LOSS
 Permissible level of noise in industry is 85dB, 8 hours a

day, 5days a week. (. ...................................................................... )
 Acoustic dip, is seen in audiogram in noise induced hearing
loss. It is seen in both AC & BC at ............................ .
OTOTOXICITY
 It is Drug induced hearing loss. The list of ototoxic drugs:
1. Aminoglycoside- eg- Amikacin, Streptomycin,
Gentamicin.
2. Loop diuretics- eg- Furosemide
3. Antimalarials- eg- Chloroquine, Quinine.
4. NSAIDs- eg- Aspirin, Ibuprofen, Indomethacin.
139
5. Anticancer drugs- eg- Cisplatin, Carboplatin.

6. Desferroxamine.
7. Vancomycin.
8. Erythromycin.
● Ototoxicity shows High frequency SNHL in early

stages, therefore High frequency audiometry is a
special test used to diagnose Ototoxicity.
OTOSCLEROSIS / OTOSPONGIOSIS
 It is a fixation of the footplate of stapes. (piston like
movement is stopped)
Disease Profile
 It is more common in young females (2-3rd decade)

 Mostly Bilateral.
 Genetic disease- Autosomal dominant.
 It is gradually progressive disease, but .............................
....... aggravates it. MCQ
140
 Most common site of origin is FISSULA ANTE

FENESTRAM. It is a point anterior to the oval window.
Initial stage of disease is ............... in color.
It graduallyturns ..(otosclerosis).
 In the next few years the disease will surround
the footplate from all-around.
Clinical Picture
A young female with bilateral gradually progressive CHL
Patients hear better in noisy areas, this is called ...........

................................................. . MCQ
Examination
 90% of patients show normal Tympanic Membrane.

 10% of patients show ............................................ .
Schwartz sign is seen in................................ It is Flamingo
pink appearance behind tympanic membrane. MCQ

141
TREATMENT
 Treatment of choice is surgery called Stapedotomy

Or STAPEDECTOMY
In this surgery, fixed stapes is replaced with artificial
stapes piston prosthesis
Other treatment
1. Hearing aid- is given for patients unwilling for surgery.

2. Sodium fluoride (NaF) oral therapy.
It is treatment of choice for Schwartz sign (+) patient.
(early stage of disease). NaF leads to stablisation of
disease.
 VANDER HOEVE SYNDROME

● OSTEOGENESIS IMPERFECTA.
● OTOSCLEROSIS.
● BLUE SCLERA.
142
ACOUSTIC NEUROMA / VESTIBULAR SCHWANNOMA
● It's a benign slow growing tumor of the 8th nerve.

● Most common site of origin is inferior vestibular division
of 8th nerve.
● It is mostly unilateral except in ...............................................
......... .
● It's a brain tumor.
● It is the most common type of Cerebellopontine angle
tumour.
● Ear examination …………………………………..
● Clinical Picture
1. Unilateral, Gradually Progressive SNHL

2. Tinnitus.
3. Imbalance.
ROLL OVER PHENOMENON
This Patient has poor understanding of words and the

understanding capability decreases further when the other
person raises the intensity of sound. This is called
...............................
143
Cranial nerve involvement
It occurs in this sequence

1. 8th nerve
2. TRIGEMINAL NERVE (5th nerve) - ................................. .
MCQ
3. SENSORY DIVISION OF FACIAL NERVE --This will

lead to ...................................................
(it is loss of sensation in posterosuperior PART of EAC.) MCQ
Best radiological investigation is Gadolinium enhanced MRI.
* Treatment- Surgery
GLOMUS JUGULARE
 It is benign locally invasive highly vasculartumour.
 It is more common in ............................. .
144
 Site of origin- it arises from glomus cells lying around the

jugular bulb.
 The red vascular tumor erodes the floor of the middle ear
and grows into hypotympanum. This is called the .................
....................... . MCQ
 The tumor now erodes the tympanic membrane and grows

into external auditory canal leading to bleeding ear mass
CHIEF COMPLAINT
1. Female patient with ...................................................... MCQ
2. Bleeding red ear mass.

145
* Examination –
1. RISING SUN SIGN.
2. Red ear mass blanches on seigelisation. This is called
..............................
........... . MCQ
* Investigations
1. Biopsy is contraindicated.
2. CT scan will show PHELP SIGN.
3. Angiography
* Treatment- Rx Of choice is surgery.
Glomus Tympanicum
............................................................................................................
............................................................................................................
Promontory is the projection of basal turn of cochlea on the
medial wall of middle ear...
MENIERE’ DISEASE
 Endolymph is produced by stria vascularis of cochlea and it
is absorbed by the endolymphatic sac
 In Meniere’s disease, there is a rise in endolymph volume
due to poor absorption by endolymphatic sac. It is also
called Endolymphatic Hydrops.
 It is mostly ................................................. .
 Slightly more common in males.
 Etiology is unknown.
 It is an episodic disease.
146
During Episode
● Episode has 3 features
1. ............................................... .
2. ............................................... .
3. ............................................... . MCQ
● Episode finishes within 24hrs.

● During episodes some people fall down without turning
unconscious, this is called .................................................. .
In Between Episodes
1. Patient hears loud sounds as more loud. This is called ...

................................................................... . MCQ
2. Patients can get vertigo on hearing loud sounds.Thisiscalled

.................................................................... . MCQ
3. Patients have a dislike for noisy areas.

4. Patients hear the same sound in 2 frequencies.Thisiscalled
............................................ . MCQ
Few Years Later
Cochlear damage starts due to high endolymphatic pressure

(glaucoma of ear). This leads to hearing loss in between
episodes also. This will lead to fluctuating hearing loss. It
leads to low frequency SNHL in early stages
147
* Investigations MCQ
1. PTA
2. ............................................................. is a special
investigation used to diagnose Meniere’s disease
Treatment
A. During episode- anti vertigo medications

B. In between episode-Acetazolamide (diuretic)
If episodes of vertigo become more frequent and disabling
* Further treatment options

1. ENDOLYMPHATIC SAC DECOMPRESSION SURGERY
....................................... is surgical landmark for
Endolymphatic sac.
2. TRANSTYMPANIC GENTAMICIN INJECTION
This injection will lead to Chemical labyrinthectomy.
148
3. MENIETT DEVICE
It is intermittent pulse therapy for innerear.
FACIAL NERVE
 It enters the temporal bone via internal auditory canal
(internal auditory meatus) and it comes out through
stylomastoid foramen, then it goes to parotid gland.
 In the ear it travels through a bony canal called ..................
................. also called facial nerve canal.
Facial nerve canal has got following 3 segments
1. LABYRINTHINE SEGMENT-
It is the narrowest segment; therefore it is also called
...............................................................................
2. TYMPANIC SEGMENT or HORIZONTAL SEGMENT
3. MASTOID OR VERTICAL SEGMENT

149
THREE BRANCHES OF FACIAL NERVE in ear
 1. Greater superficial Petrosal nerve

● It arises from the 1st genu.
● this gives supply to the lacrimal gland
● Test for this nerve is ........................................... .
 2. Nerve to Stapedius-
● It arises from 2nd genu.
 3. Chorda tympani Nerve-
● It arises from the vertical segment of the facial nerve.
● It supplies Taste sensation to anterior —23rd of tongue.
Active space
BELL'S PALSY
● It is idiopathic sudden onset lower motor neuron facial
palsy.
150
● It is mostly unilateral.
● There is edema in the .......................................... of the
facial nerve canal of this edema leads to compression
of nerve.
● Recent studies show some role of Herpes simplex virus
(HSV1).( Not proven)
* Clinical features:
1. Forehead muscles ............................. paralysed in Bell’s
palsy. This is because it is LMN facial palsy.( Forehead
muscles are not paralysed in UMN palsies)
2. Angle of mouth is deviated to the ............................. .
3. This patient complains of ............................. . This is
due to loss of stapedial reflex. MCQ
4. This patient can develop exposure keratitis
Treatment - Drug of choice is ............................. for 3 weeks.
Other Treatment
1. Acyclovir (if patient comes ............................... of onset)
MCQ
151
2. Artificial tear drops.

3. Physiotherapy.
● The recovery in Bell's palsy is seen in ............................... .
MCQ
● If there is no recovery after 3 weeks of

steroid therapy, then next management is to do
ELECTROPHYSIOLOGICAL NERVE TESTING to
check for extent for nerve degeneration. MCQ
IATROGENIC INJURY TO FACIAL NERVE
● Most common cause is Parotid surgery.

● The 2nd most common cause is mastoid surgery.
RAMSAY HUNT SYNDROME
 Also known as Herpes zoster oticus.

 It is due to reactivation of varicella zoster virus.
* Clinical features
a. ............................................... .
b. 7th nerve- Lower motor
neuron facial palsy (ipsilateral)
* Treatment-
 Acyclovir and steroid therapy.
 Facial Recovery is seen in ............................................... .
152
MELKERSSON ROSENTHAL SYNDROME
A. Recurrent facial palsy.

B. Fissured tongue.
C. Swelling of lips.
EAR DEVICES AND IMPLANTS
CLASSIFICATION OF HEARING LOSS
Mild 26 to 40dB
Moderate 41 to 55dB
Moderately severe 56 to 70dB
Severe 71 to 90dB
Profound more than 90dB
1. HEARING AID
It is a sound Amplifier.
Active space
153
 Hearing aid is not of much use in profound hearing loss.

 For them we have cochlear implant surgery
2. COCHLEAR IMPLANT
 Cochlear Implant does direct electrical stimulation of
cochlear nerve endings (8th nerve).
 Prerequisite of CI surgeryis ......................................... . MCQ
Indication
 Bilateral profound SNHL (>90dB) MCQ
 Ideal age of surgery in a child deaf since birth

(PRELINGUAL DEAF CHILD) is ...........................
COCHLEAR IMPLANTS has two components-
 A. External component (behind the pinna) -It has 4
parts
154
1. Microphone.
2. ................................ (circular part which transmit current
to internal component)
3. Speech processor.
4. Battery.
 B. Internal component- it has
only one part
Called Electrode
The surgery involves insertion
of Electrode into ..................
............... of cochlea through
........................ . MCQ
3. AUDITORY BRAINSTEM IMPLANT
 Indication:
Neurofibroma type
2- bilateral vestibular
schwannoma (bilateral 8th
nerve diseased )
 ABI Electrode is placed
in .......................................
.............................................. .

155
4.BONE ANCHORED HEARING AID
 It is a specialized surgery in which titanium screw is fixed

to the skull bone and then an external sound processor
is attached to the screw through an attachment called
abutment.
 BAHA stimulates cochlea directly through BC.
Indications of BAHA
a. ANOTIA with hearing loss

b. EAC ATRESIA with hearing loss
c. EAC STENOSIS.
d. CHRONIC DISCHARGE IN EAR (WET EAR).
e. UNILATERAL SEVERE SNHL.
156
SUPERIOR SEMICIRCULAR CANAL DEHISCENCE SYNDROME
Cause -
2. Congenital.
3. Traumatic or head injury.
Clinical picture
 This patient will have conductive hearing loss due to leakage

of sound energy from this dehiscence. This is called THIRD
WINDOW PHENOMENON.
 This patient will complain of vertigo on hearing loud sounds.

This phenomenon is called TULLIO’S PHENOMENON.
 Patient gets vertigo with BLOWING OF NOSE
 Investigations
HRCT temporal bone
PTA.
 Treatment- surgical closure
157
158
159

160
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ENT by Rajiv Dhawan FMGE 2022

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(A) 3 unpaired cartilages

 It covers vocal cord = GLOTTIS

 It does not ossify with Age.

It is the Angle between two laminae of thyroid cartilage

Prominence of thyroid cartilage in males is called ...

THREE PAIRED CARTILAGES

(i) Corniculate - rudimentary cartilage

● Males low low pitch voice (dull)

● High pitch voice in adult male (Feminine voice)

Pull thyroid cartilage downwards and Push it Backwards

= Surgical shortening or loosening of vocal cord.

● Low pitch voice in female (masculine)

1. Thyrohyoid membrane: It is pierced by

2. Cricothyroid Membrane: It is site of surgery called

This airway surgery is rarely

Larynx is lined by ciliated columnar epithelium except vocal

In some smokers, vocal cord epithelium starts shedding

Three divisions of larynx

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Dysphonia Plica Ventricularis

(The Sound of Air Leak heard when Laryngocele is Pressed)

This is the empty space in cricoid ring

Both TA and IA are adductor muscles if they are weak it

Examination shows MCQ

due to gap between vocal cords

Vocal cords do not have ...

VOCAL CORD DISORDERS

Reinke's space is the ..................................................... ………………..in

Edema of this space called Reinke's edema

This is Bilateral diffuse swelling of vocal cord

* Cause 1.vocal abuse 2. Laryngopharyngeal reflux of gastric acid ( LPR)

Site of Nodule = .......

Treatment Surgery MLS

EAR = 200 mm E–2

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- Cause: Faulty Intubation (eg.after surgery under general

* Treatment MLS (micro laryngeal surgery)

JUVENILE PAPILLOMA OF LARYNX

They can spread to Trachea

* Treatment Surgery MLS with

Difference between Pediatrics and adult larynx

Narrowest part Glottis

Method of Larynx Examination:

A. Indirect laryngoscopy OPD procedure

Indirect laryngoscopy mirror is a Straight mirror .

The mirror surface is warmed before using

(i) Anterior commisure of VC.

Type level of obstruction

Posterior Thyroarytenoid Cricothyroid

Interarytenoid Vocalis muscle

Lateral  Tensors give us

All muscles lie inside larynx except

Motor supply of Larynx

All muscle of larynx are supplied by Recurrent laryngeal Nerve

( RLN) except cricothyroid which is supplied by external Branch

of Superior laryngeal nerve ( SLN).

Sensory supply of Larynx

VOCAL CORD PALSY

Most Common Cause of

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UNILATERAL VOCAL CORD PALSY

BILATERAL VOCAL CORD PALSY --2 TYPES