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C R S "Ear Nose and Throat": Ext Eneration
C R S "Ear Nose and Throat": Ext Eneration
Next GeNeratioN
HEAD OFFICE
Delhi Academy of Medical Sciences (P.) Ltd.
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Email: info@damsdelhi.com
ISBN : 978-93-89309-30-0
CONCEPTS
 Concept 1.1 Clinical Anatomy of External Ear
Time Needed
1st reading 15 mins
2 look
nd
5 mins
reater auricular ervical plexus , edial surface and posterior part of lateral
surface of pinna
uriculo temporal andibular division of trigeminal ragus, crus of the helix and ad acent helix
nerve
Protruding Ear uriculocephalic angle , caused from loss of formation of the antihelical fold
or overgrowth or protrusion of the conchal cartilage
6 | Ear Nose and Throat
Collaural Fistula:
Formation: Is a 1st branchial cleft anomaly, arises from failure of fusion of the ventral part of the st cleft.
Opening pper part opens in the oor of the external auditory canal.
Lower part: etween the angle of the mandible and the sternocleidomastoid muscle.
Anatomy of Ear | 7
Concept 1.2: Middle Ear and Mastoid Anatomy
Learning Objective: To Learn the Clinical Applied Anatomy of Middle Ear and Mastoid
Time Needed
1st reading mins
2 look
nd
mins
poster anteri
ior or
Middle ear: With Eustachian tube, aditus, antrum and mastoid air cells is called
middle ear cleft.
Middle ear is sometimes divided into
• Mesotympanum: opposite the pars tensa. (Narrowest part)
• Epitympanum: (attic) above the pars tensa.( Widest part)
• Hypotympanum: below the pars tensa.
• Protympanum: portion of middle ear around the tympanic orifice of the eustachian
tube.
Anatomy of Ear | 9
Tympanic Plexus
• Is found over the promontory.
• It is formed by the tympanic branch of the glossopharyngeal nerve, carotico tympanic
nerves which supplies the sympathetic component. The tympanic plexus provide the
following branches:
Antrum:
• Roof → a thin bony plate → tegmen tympani, which separates them from → middle
cranial.
• Medial wall separates it from: - lateral SCC- Endolymphatic Sac - Dura of posterior
cranial Fossa
• Lat. Wall: 1.5 cm thick of squamous bone
• Posteriorly: Sigmoid Sinus
• Floor: Jugular bulb
Anatomy of Ear | 13
Concept 1.3: Clinical Anatomy of Inner Ear
Learning Objective: To Learn the Clinical Applied Anatomy of Inner Ear
Time Needed
1st reading mins
2 look
nd
mins
Cochlea
Anterior part , turns around modiolus
comps S ,S and S endolymph mm long
Modiolus
Spongy bone entral axis in the cochlea
ase directed toward , transmits n. and
vessels to cochlea
14 | Ear Nose and Throat
Sensory Organs
Organ of Corti
Hair Cells
• Strategically positioned on the basilar membrane of the organ of Corti are three
rows of outer hair cells (OHCs) and one row of inner hair cells (IHCs).
• Separating these hair cells are supporting cells: Deiters cells, also called
phalangeal cells, which separate and support both the OHCs and the IHCs.
16 | Ear Nose and Throat
Basilar Membrane
• The basilar membrane is a stiff structural element within the cochlea of the
inner ear which separates two liquid-filled tubes that run along the coil of the cochlea,
the scala media and the scala tympani.
Otolith
Saccule and Utricle.
• The receptors, called maculae (meaning “spot”), are patches of hair cells topped by
small, calcium carbonate crystals called otoconia.
• The saccule and utricle lie at 90 degrees to each other.
The ampulla is a localized dilatation at one end of the semicircular duct.
A patch of innervated hair cells is found at the base of the ampulla in a structure
termed a crista (meaning crest).
The crista contains hair cells with stereocilia oriented in a consistent direction.
The cupula, a thin vane, sits atop this crest.
Anatomy of Ear | 17
18 | Ear Nose and Throat
WORKSHEET
MCQ OF “ANATOMY OF EAR” FROM DQB
Anatomy of Ear | 19
IMPORTANT TABLES (ACTIVE RECALL)
Anotia
Cleft pinna
Coloboma lobuli
Macrotia
Microtia
Melotia
Bat Ear
Wildermuth Ear
Mozart’s Ear
Protruding Ear
20 | Ear Nose and Throat
CONCEPTS
 Concept 2.1 Basics of Sound Transmission
Time Needed
1st reading mins
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Sound can be transmitted from the ear canal to the cochlea by two mechanisms
• Ossicular and Acoustic coupling
1.3: 1 LEVER ACTION
21: 1 14:1
17:1
90 mm3 55 mm3
Frequency: It is no. of cycles per second. Unit of frequency is Hertz.
Pure Tone: A single frequency sound is called a pure tone eg a sound of 250, 500 or
1000 Hz.
In PTA we measure threshold of hearing in decibels for various pure tones from 125 to
8000 Hz.
Intensity: It is the strength of sound which determines its loudness. At a distance of
one meter intensity of
• Whisper – 30 dB
• Normal conversation – 60 dB
• Shout – 90 dB
• Discomfort of the ear – 120 dB Complex Sound: Sound with more than one
frequency eg: Human voice
Masking - It is a phenomenon to produce inaudibility of one sound by the presentation
of another sound.
Masking of non test ear is essential in all bone conduction tests but for air conduction
tests, it is required only when interaural difference of hearing exceeds 40 dB.
Speech Test:
6 meters is taken as normal for both conversational and whisper.
Normally a person hears conversation at 12 metres (40 feet).
Spondee words (football, day dream) or number with letters (X3B, 5CD).
Degree of hearing loss Hearing loss range (dB HL)
Normal to
Mild to
Moderate to
Severe to
rofound
Audiometry | 23
Concept 2.2: Pure Tone Audiometry
Learning Objective: To Learn the Concepts of Pure Tone Audiometry
Time Needed
1st reading mins
2 look
nd
5 mins
Time Needed
1st reading mins
2 look
nd
5 mins
Extra Edge:
Pseudohypacusis
• STENGER’S Test.
• Lee’s Speech Delay Test.
• Lombard Test.
Time Needed
1st reading mins
2 look
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5 mins
Speech Audiometry:
• There are two basic components of the speech audiometry test battery: Speech
Reception.
• Threshold and Speech Discrimination. “Speech Discrimination” is often also referred
to as “Speech Understanding” or “Word Understanding.”
Extra Edge:
Average Hearing Loss Seen in Different Lesions of Conductive apparatus
1. Complete obstruction of ear canal: 30 dB.
2. Perforation of tympanic membrane: 10 – 40 dB (It varies and is directly proportional to
the size of perforation).
3. Ossicular interruption with intact drum: 54 dB.
4. Ossicular interruption with perforation: 38 dB.
5. Closure of oval window: 60 dB.
28 | Ear Nose and Throat
Concept 2.5: Impedance Audiometry
Learning Objective: To Learn the Concepts of Impedance Audiometry
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Impedance Audiometry
• To differentiate ossicular fixation from ossicular dislocation in cases of conductive
deafness.
• To find fluid in middle ear in serous otitis media.
• To assess function of eustachian tube.
• By eliciting stapedial reflex, it can be used to.
Localise lesions of facial nerve and find prognosis of facial paralysis.
Find recruitment.
Detect malingerers.
The following tests have been included under the battery of impedence
audiometry:
Tympanometry ustachian tube function coustic re ex threshold
coustic re ex decay ests to identify perilymph fistula
Audiometry | 29
Fig.: Tympanometry
Stapedial/Acoustic Reflex:
A tone of 70 – 100 dB HL will cause stapedial muscle to contract.
30 | Ear Nose and Throat
Concept 2.6: Electrocochleography & Bera
Learning Objective: To Learn the Basics of Electrocochleography and Bera
Time Needed
1st reading 15 mins
2 look
nd
mins
EcoG is useful
(i) To find threshold of hearing in young infants and children within 5–10 dB and
(ii) To differentiate lesions of cochlea from those of the VIIIth nerve.
▫ Normally the ratio between the amplitude of summating potential to the action
potential is less than 30%. An increase in this ratio is indicative of Ménière’s
disease
Fig.: Electrocochleography
Extra Edge:
• Recruitment: Recruitment is typically seen in lesions of cochlea (Meinere’s disease,
presbycusis).
• Short Increment Sensitivity Index (SISI) test:
• Patients with cochlear lesions distinguish smaller changes in intensity better than
those with normal hearing conductive or retrocochlear pathology.
• This test helps in determining the site of lesion in the auditory system by determining
whether a disorder is cochlear or noncochlear.
• The diagnostic accuracy of this test depends upon the amount of hearing loss a
patient may have.
• Tone decay test - Is a measure of nerve fatigue and is used to detect retrocochlear
lesions. Normally a person can hear a tone continuously for 60 seconds.
Otoacoustic Emissions
• Otoacoustic emissions (OAE) are sounds produced by motile elements of cochlear
outer hair cells.
32 | Ear Nose and Throat
WORKSHEET
MCQ OF “AUDIOMETRY” FROM DQB
Audiometry | 33
IMPORTANT TABLES (ACTIVE RECALL)
The following tests have been included under the battery of impedence
audiometry:
TYMPANOGRAMS
Ad
As
C
34 | Ear Nose and Throat
III
IV
VI–VII
3 Disorders of Ear
CONCEPTS
 Concept 3.1 Diseases of External Ear
Time Needed
1st reading mins
2 look
nd
5 mins
Treatment:
• Antibiotics (3rd Generation cephalosporins: cefoperazone).
• Debridement if no response to medical treatment.
• Radionuclide gallium and technetium scan are helpful in the management.
Tuberculosis
• Otologic: painless, odorless, watery otorrhea, multiple TM perforations.
Keratosis Obturans
• Collection of pearly white mass of desquamated epithelial cells in deep meatus.
• Keratolytic agent - 2% salicylic acid in alcohol prevent recurrence.
Myringitis Bullosa
• Virus or Mycoplasma pneumonia or Influenza.
38 | Ear Nose and Throat
Concept 3.2: Diseases of Middle Ear
Learning Objective: To Learn the Concepts of Middle Ear Infections and Management
Time Needed
1st reading mins
2 look
nd
15 mins
Atticoantral Disease
Posterior epitympanum (Prussack’s space): commonest site of origin of
cholesteatoma
• Wittmaack’s theory: Retarction pocket.
• Habermann’s theory: Epithelial Invasion.
Disorders of Ear | 41
• Ruedi’s theory: Basal cell hyperplasia.
• Sade’s theory: Metaplasia.
Sade classification of retraction of pars tensa:
• Grade 1: Mild retraction.
• Grade 2: Severe retraction–retracted TM touching incus or stapes.
• Grade 3: Atelectatic TM–TM touching promontory but moves on seigelisation.
• Grade 4: Adhesive TM–TM touching promontory, does not move on seigelisation
classification of pars flaccida.
Tos classification of pars flaccida:
• Stage I: Pars flaccid is dimpled and is more retracted than normal. It is not
adherent to the malleus.
• Stage II: In this stage the retraction pocket is adherent to the handle of malleus.
The full extent of the retraction pocket can be clearly seen.
• Stage III: In this stage part of the retraction pocket may be hidden. There may
also be associated erosion of the outer attic wall (scutum).
• Stage IV: In this stage there is definite severe erosion of the outer attic wall.
The extent of the retraction pocket cannot be clearly seen as most of it is hidden from
the view.
Mastoidectomy:
Canal wall down (CWD) procedures:
• Modified radical mastoidectomy
• Radical mastoidectomy
• Atticotomy
Canal wall up (CWU) procedures:
• Cortical mastoidectomy (Schwartz operation)
• Combined approach tympanoplasty
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Labyrinthitis
Three types of labyrinthitis:
• Circumscribed labyrinthitis
• Diffuse serous labyrinthitis
• Diffuse suppurative labyrinthitis
Time Needed
1st reading mins
2 look
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5 mins
Otosclerosis (Otospongiosis)
Irregularly laid spongy bone replace dense enchondral layer of bony otic capsule.
Age of onset - 20 -30 years Paracusis Willisii Speech - Soft speech
Deafness sually , painless, progressive
eafness increases during pregnancy, menopause, after trauma or operation
ay be associated with osteogenesis imperfecta h o multiple fractures
Vander Hoeve Syndrome riad of O.I., blue sclera and deafness
1. Stapedial Otosclerosis
Anterior focus: Most common.
Posterior focus - Behind the oval window.
Circumferential - Around Stapes footplate margins.
Biscuit type - In the footplate but annular ligament free.
Obliterative type – Completely obliterates the oval window.
2. Cochlear Otosclerosis - Involves region of round window or other areas in the otic
capsule.
3. Histologic Otosclerosis – Asymptomatic.
Tinnitus - More commonly in cochlear otosclerosis and in active lesions.
Vertigo – Uncommon.
Signs:
Schwat e Sign ormal function
is normal but is reduced in cochlear otosclerosis oss of air conduction more for lower frequencies
Medical Management:
• Sodium Fluoride
• Bisphosphonates
Disorders of Ear | 47
Concept 3.5: Meniere’s Disease
Learning Objective: To Learn the Clinical Concepts of Meniere’s Disease.
Time Needed
1st reading mins
2 look
nd
mins
ales emales
• Diplacusis: A tone of one frequency appears normal in one ear and of higher pitch
in other ear.
• Recruitment - Patients of M.D. cannot tolerate amplification of sound.
• They are poor candidates for hearing aids.
• SISI and Tone decay test show the cochlear nature of disease (Differentiates it from
Acoustic neuroma).
• Electrocochleography: Best objective test.
Tumarkin’s otolithic catastrophes rop attacks without associated autonomic or neurologic symptoms
in patients with severe vestibular disease, usually due to eniere s
disease.
Time Needed
1 reading
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mins
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Clinical features:
Progressive SNHL Tinnitus
th nerve is the earliest nerve to be involved th nerve Sensory fibers are affected first
Glomus Tumor
enign, non encapsulated xtremely vascular Most common benign
rises from glomus bodies Seen in years emales affected times more
Locally invasive
50 | Ear Nose and Throat
Clinical features:
• Earliest symptoms are deafness and tinnitus (Pulsatile) (Synchronous with pulse).
• Conductive deafness.
• “Rising Sun” appearance - Red reflex through intact TM. Seen when tumor arises from
floor of middle ear.
• BROWN’S SIGN (blanching of the TM with positive pressure).
• Pulsation Sign is +ve.
• Vertigo and facial paralysis may appear.
• Audible bruit.
Investigations:
• Serum levels of catecholamines or their breakdown products in urine.
• Skull and mastoid Xray.
• CT Scan with enhancement.
• MRI.
• Angiography.
Treatment:
Surgical Radiation mbolisation
ost cases have long standing ear discharge Seen in Radium ial painters
Clinical features
• Chronic foul smelling discharge especially blood stained.
• Pain usually severe (at night).
• Facial palsy.
• Granulations / polyps.
• Increase in deafness / vertigo.
Diagnosis is made only on biopsy.
Treatment: Combination of Surgery and Radiotherapy.
Disorders of Ear | 53
IMPORTANT TABLES (ACTIVE RECALL)
Chronic Suppurative Otitis Media
Feature Tubotympanic Atticoantral
. ischarge
. erforation
. olyps
. holesteatoma
. omplication
Features of Otosclerosis
Schwat e Sign
Rinnie
PTA\
ABC
function
Weber
54 | Ear Nose and Throat
Features of Meniere’s Disease
ermoye Syndrome
Secondary . .
IOC
reatment of choice
CONCEPTS
 Concept 4.1 Assessment Of Vestibular Functions
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Lab Tests
Vestibular function:
Fistula Test:
• Fistula test is positive in labyrinthine fistula. It is best seen using seigel speculum.
• It is false negative in fistula covered by cholesteatoma, fistula in a dead labyrinth
and an improper test.
• It is false positive in congenital syphilis and some cases of Meniere’s disease, superior
SCC dehiscence syndrome (Heinnebert sign).
• It is truly negative in a normal ear.
High Yielding Topics of Ear | 57
Caloric test (Induce nystagmus by thermal stimulation)
• Each labyrinth can be tested separately
• Modified Kobrak test - Seated with head tilted 60° backwards ( H C in vertical
position). Ice water for 60 seconds (5 ml, 10 ml, 20 ml and 40 ml)
• Fitzgerald - Hallpike test (Bithermal caloric test) - Lies supine, head tilted 30°
forward
• Irrigated for 40 seconds with H2O at 30° and 44° C
• Before labelling the labyrinth dead test is repeated with water at 20° C for 4 minutes.
• 5 minutes gap between two ears.
• COWS - Cold induces nystagmus to opposite side, Warm induces nystagmus to same
side.
Misc:
• Electronystagmography - Depends on the presence of corneo - restinal potentials
• Optokinetic Test - To diagnose a central lesion
• Rotation Test: Barany’s revolving chair with head tilted 30° forward f Rotated
• Nystagmus 25 – 40 seconds
• Galvanic Test: Only test to differentiate an end organ lesion from that of vestibular
nerve.
• Posturography
Benign Paroxysmal Positional Vertigo
ertigo in certain head positions o hearing loss Posterior SCC
pleys exercises are beneficial Hallpike Test Vertigo for few Secs
Vestibular Neuronitis
sually self limiting ew days to weeks Sudden onset
irus affecting vestibular ganglion o cochlear symptoms
Perilymph Fistula
ntermittent vertigo and uctuating
SNHL innitus and sense of fullness Complications of stapedectomy
58 | Ear Nose and Throat
Concept 4.2: Concepts of Facial Nerve
Learning Objective: To Learn the Concepts of Facial Nerve
Time Needed
1st reading mins
2 look
nd
15 mins
Facial Nerve
Mixed nerve
Sensory Root erve of risberg carries secretomotor fibres to lacrimal, submandibular and sublingual
salivary gland
Facial Nerve:
Intracranial Segment:
• Segment from brainstem to internal auditory canal (IAC).
High Yielding Topics of Ear | 59
Course of Facial Nerve
Intratemporal Segments:
Meatal:
• Segment from meatal foramen of the IAC to the fundus of IAC.
Meatal segment is ensheathed within an extension of the meninges.
Bell’s Palsy
• The most common form of facial paralysis is Bell’s palsy..
Clinical Manifestations:
• The onset of Bell’s palsy is fairly abrupt, maximal weakness being attained by 48
hours as a general rule.
• Pain behind the ear may precede the paralysis for a day or two.
• Taste sensation may be lost unilaterally, and hyperacusis may be present.
62 | Ear Nose and Throat
Pathophysiology:
• Bell’s palsy is associated with the presence of Herpes simplex virus (HSV) type 1 DNA
in endoneural fluid and posterior auricular muscle, suggesting that a reactivation of
this virus in the geniculate ganglion may be responsible. However, a causal role for
HSV in Bell’s palsy is unproven.
Laboratory evaluation:
• The diagnosis of Bell’s palsy can usually be made clinically in patients with (1) a
typical presentation, (2) no risk factors or preexisting symptoms for other causes of
facial paralysis, (3) absence of cutaneous lesions of herpes zoster in the external ear
canal, and (4) a normal neurologic examination with the exception of the facial nerve.
Treatment:
• Symptomatic measures include (1) the use of paper tape to depress the upper
eyelid during sleep and prevent corneal drying, and (2) massage of the weakened
muscles.
• A course of glucocorticoids, given as prednisone 60–80 mg daily during the first 5
days and then tapered over the next 5 days, appears to shorten the recovery period
and modestly improve the functional outcome.
• A recently published randomized trial found no added benefit of acyclovir (400 mg
five times daily for 10 days) compared to prednisolone alone for treatment of acute
Bell’s palsy; the value of valacyclovir (usual dose 1000 mg daily for 5–7 days) either
alone or in combination with glucocorticoids is not known.
High Yielding Topics of Ear | 63
Concept 4.3: Hearing Rehabilitation
Learning Objective: To Learn the Importance of Hearing Rehabilitation
Time Needed
1st reading mins
2 look
nd
mins
Hearing Aids
BTE CIC
ITE BAHA
Cochlear Implants
• Are electronic devices which convert sound signals into electrical impulses, this in
turn stimulates the cochlear nerve directly by pressing the hair cells of cochlea.
Components:
• Microphone – picks up acoustic signals.
• Speech processor – converts sound signals into electrical energy.
• Electrode – Stimulates the cochlear nerve.
Electrode is placed in Scala Tympani best Candidate is post Lingually Deaf Patient Multiple Channel
Implant is better than Single Channel Implant
High Yielding Topics of Ear | 67
IMPORTANT TABLES (ACTIVE RECALL)
Assessment of Vestibular Functions
Nystagmus
Peripheral Central
ype of in ury
racture line
Bleeding ear
S rhinorrhoea
Structure in ured
Hearing loss
Vertigo
acila paralysis.
N X
RY
LA
5 Anatomy of Larynx
CONCEPTS
 Concept 5.1 Clinical Anatomy of Larynx
72 | Ear Nose and Throat
Concept 5.1: Clinical Anatomy of External Ear
Learning Objective: To Learn the Applied Anatomy of Larynx
Time Needed
1st reading mins
2 look
nd
15 mins
Laryngeal Cartilages:
The larynx is a tubular structure that has 3 paired and 3 unpaired cartilages.
Unpaired: Thyroid, Cricoid and Epiglottis Paired: Arytenoids, Cuneiform (of Wrisberg)
and Corniculate (of Santorini)
• Only complete cartilage in whole trachea- bronchial tree: Cricoid.
• Epiglottis - leaf like yellow elastic cartilage.
• Thyroid - Largest of all the cartilages: Its two alae meet anteriorly forming an angle
of 90° in males and 120° in females
VC are attached to the middle of thyroid angle.
Most of laryngeal foreign bodies are arrested above the vocal cords.
In males In females
ength mm mm
Transverse diameter mm mm
ntero posterior diameter mm mm
ircumference mm 112 mm
hyrohyoid membrane is pierced by superior laryngeal vessels and internal laryngeal nerve.
Cricovocal Membrane
Fibroelastic membrane
pper border forms the vocal ligament
nteriorly meets with its fellow to form the conus elasticus.
Quadrangular membrane
Anatomy of Larynx | 73
Paraglottic Space
Pre-Epiglottic Space
74 | Ear Nose and Throat
Lymphatic Drainage
Supraglottic larynx ymphatics which pierce the thyrohyoid membrane and go to upper deep cervical
Infraglottic larynx lymphatics which pierce the cricothyroid membrane and go to prelaryngeal and
pretracheal nodes and then to lower deep cervical and mediastinal nodes
There are NO lymphatics in VC hence carcinoma of this site rarely shows lymphatic metastases.
Reinke’s Space - Under the epithelium of VC is a potential space with scanty subepithelial
connective tissue.
Anatomy of Larynx | 75
Difference between Adult and Child’s Larynx:
Infant Adult:
• Position igh low placed
Anatomy of Larynx | 77
IMPORTANT TABLES (ACTIVE RECALL)
In males In females
ength
Transverse diameter
ircumference
Lymphatic Drainage
Supraglottic larynx
Infraglottic larynx
• arrowest part
• Submucosal loose
connective tissue
6 Disorders of Larynx
CONCEPTS
 Concept 6.1 Congenital Lesions of Larynx
Time Needed
1 reading
st
15 mins
2 look
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5 mins
Laryngomalacia
Intermittent inspiratory stridor that improves in
prone position
orse with feeding rying or when placed
on back
resents within weeks of Normal voice
birth
Congenital Webs
Disorders of Larynx | 81
Time Needed
1st reading mins
2 look
nd
5 mins
Extra Edge
Laryngo Tracheal Trauma:
• The supraglottis is less dependent on external support and contains abundant soft
tissue and redundant mucosa.
• The subglottis is supported by the only circular cartilage in the larynx, the cricoid,
which is the narrowest point of the neonatal and infant airways.
• Laryngeal fractures are common after 40 years of age (because of calcification of
laryngeal frame work).
Disorders of Larynx | 83
Concept 6.3: Acute and Chronic Inflammation of Larynx
Learning Objective: To Learn Etiology of Laryngeal Infections
Time Needed
1st reading mins
2 look
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mins
Laryngeal Diphtheria
• Children below 10 years of age.
• Laryngeal Symptoms: Hoarse voice, croupy cough, inspiratory stridor, increasing
dyspnoea with marked upper airway obstruction.
• Cervical lymphadenopathy: Characteristic “bull - neck” may be seen.
84 | Ear Nose and Throat
Tuberculosis of Larynx
C/F:
• Weakness of voice is the earliest symptom followed by hoarseness.
• Ulceration in larynx gives rise to severe pain (may radiate to ear).
• Hyperemia of VC with impairment of adduction is the first sign.
• Ulceration of VC - mouse nibbled appearance.
• Pseudoedema of epiglottis (red and swollen) - Turban epiglottis
Lupus of Larynx
• Indolent tubercular infection.
• Affects anterior part of larynx.
• Painless and often asymptomatic.
Syphilis of Larynx
• Only gumma of tertiary stage is sometimes seen.
REINKE’S EDEMA
Disorders of Larynx | 85
Concept 6.4: Vocal Cord Paralysis
Learning Objective: To Learn The Concept Of Vocal Cord Paralysis And It’s Management
Time Needed
1st reading mins
2 look
nd
15 mins
Laryngeal Innervation
• Right recurrent laryngeal nerve arises from the vagus at the level of subclavian artery.
• Left recurrent laryngeal nerve arises at the level of arch of aorta.
• Left recurrent laryngeal nerve is more prone to paralysis.
• Superior laryngeal nerve: Arises from inferior ganglion of the vagus.Divides into
external and internal branches at the level of greater cornua of hyoid bone.
Lateralisation • Arytenoidectomy
• Lateralisation via endoscope
• hyroplasty ype
• Cordectomy
• Nerve Muscle Implant (Sternohyoid)
Medialisation • n ection of e on
• hyroplasty ype
• uscle or cartilage implant
• rthrodesis of cricoarytenoid oint
Thyroplasty:
Type I:
• Indicated for membranous vocal fold defects resulting in breathy dysphonia or
aspiration.
• Medializes vocal fold by inward lateral compression with an implant (silastic, gortex,
hydroxyapatite) placed via a window in the thyroid cartilage.
Type II:
• Lateral expansion (thyroid cartilage split with graft placed to widen anteriorly by
lateralizing the vocal folds).
Type III:
• Indicated to lower vocal pitch or address adductor spasmodic dysphonia by shortening
and relaxing vocal folds.
Type IV:
• Indicated to increase vocal pitch by lengthening and tensing vocal folds.
Reinnervation Procedures
Indications: UNILATERAL permanent vocal fold paralysis.
Advantages: Maintains muscle tone, no foreign body reaction, best preservation of
mucosal wave, most physiologic.
Disadvantage: Does not result in active ADduction and ABduction, long operative time,
delayed results (up to 6 months), high technical skill, may require a Gelfoam injection
until reinnervation becomes effective.
Disorders of Larynx | 87
ANSA CERVICALIS nerve has similar fiber composition (myelinated versus
unmyelinated) to the RLN making it compatible for RLN grafting.
Voice Abnormalities
1. Dysphonia plica ventricularis (Ventricular dysphonia): Voice is produced by
false cord (Ventricular folds).
2. Functional aphonia (Hysterical aphonia): Females emotionally labile, 15 – 30
years.
3. Puberphonia (Mutational falsetto voice): Gutzmann’s pressure test - Pressing the
thyroid prominence in backward and downward direction relaxes the overstretched
cords and low tone voice can be produced.
4. Phonasthenia: Weakness of voice due to fatigue of phonatory muscle.
I/L shows three characteristic findings:
• Elliptical space between the cords (weakness of thyroarytenoid).
• Triangular gap near posterior commissure (weakness of inter arytenoid).
• Key hole appearance of glottis (when both are involved).
88 | Ear Nose and Throat
WORKSHEET
MCQ OF “DISORDERS OF LARYNX” FROM DQB
Disorders of Larynx | 89
IMPORTANT TABLES (ACTIVE RECALL)
Description of Upper Airway Sound by Site of Obstruction
Nasopharyngeal
Oropharynx
Supraglottic
Glottic
Subglottic
Tracheobronchial
Age
Location
Onset
Cough
Posture
Drooling
Fever
Radiographs
Treatment
90 | Ear Nose and Throat
Paramedian
Intermediate
Gentle abduction
Full abduction
BRLNP
USLNP
BSLNP
UCP
BCP
7 Tumors of Larynx and
Their Management
CONCEPTS
 Concept 7.1 Benign Lesions
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Non-neoplastic Neoplastic
Solid Squamous papilloma
▫ ocal nodules ▫ uvenile type
▫ Vocal polyp ▫ dult onset type
▫ Reinke s oedema hondroma
▫ ontact ulcer granuloma Haemangioma
▫ ntubation granuloma ranular cell tumours
▫ eukoplakia landular tumours, e.g.
▫ myloid tumours ▫ leomorphic adenoma
Cystic ▫ Oncocytoma
▫ uctal cysts eurilemmoma
▫ Saccular cysts eurilemmoma
▫ Laryngocele Rhabdomyoma
Lipoma
Cystic Lesions
They are of 3 types:
• Ductal cysts: Most often they are retention cysts (seromucinous duct).
Asymptomatic if small.
If large, causes hoarseness, cough, throat pain and dyspnea.
• Saccular cyst: Obstruction to the orifice of saccule.
Presents as cyst in ventricle.
• Laryngocele:
An air filled cystic swelling due to dilatation of saccule.
Lined by columnar ciliated epithelium whereas simple laryngeal cysts are lined by
squamous epithelium.
Internal laryngocele is confined within the larynx
External laryngocele (30%)-saccule herniates through thyrohyoid membrane
External laryngocele presents as a reducible swelling which increases in size on
coughing or performing Valsalva.
Trumpet players, glass blowers, weight lifters (#transglottic pressure).
Hoarseness, cough, stridor, dysphagia, sore throat, pain snoring.
• Treatment: Surgical excision.
A laryngocele in an adult may be associated with carcinoma or papilloma larynx.
Papillomatosis
94 | Ear Nose and Throat
Juvenile Senile
ultiple sites of involvement Single site
Recurrent, may resolve spontaneously Recurrence less common
Chondromas
• More common in men.
• Most commonly arise from internal posterior cricoid cartilage (hyaline cartilage),
may also arise from thyroid, arytenoid,epiglottic cartilage (fibroelastic).
• Insidious hoarseness from vocal fold restriction, dyspnea for subglottic lesions,
dysphagia for posterior cricoid lesions, globus sensation.
• Diagnosis: endoscopic wedge biopsy,
• CT of neck (calcification).
• Treatment: complete excision via an endoscopic or external approach (depending
on the size of lesion).
Hemangioma
• Most Common Head and Neck neoplasm in children.
• Typically presents by 6 months old, then involutes by 2 years of age.
• Most common laryngeal site: Left posterior lateral quadrant of subglottis
(although may appear anywhere in upper respiratory tract).
• 50% of subglottic hemangiomas are associated with cutaneous involvement.
Sarcoidosis
• Laryngeal features: Supraglottic submucosal mass (epiglottis most common),
dysphonia, globus sensation, dyspnea.
• Treatment: Endoscopic removal for symptomatic lesions (hoarseness or airway
obstruction), may consider corticosteroids for significant exacerbations.
Tumors of Larynx and Their Management | 95
Wegener’s Granulomatosis
• Most commonly involves the subglottis.
• Laryngeal features: Subglottic mass, dyspnea, biphasic stridor.
• Treatment: Endoscopic removal for symptomatic lesions, medical management.
Amyloidosis
• Laryngeal features: Anterior subglottic mass (polypoidal covered with smooth
mucosa).
• Treatment: Endoscopic removal for symptomatic lesions (hoarseness or airway
obstruction).
96 | Ear Nose and Throat
Concept 7.2: Carcinoma Larynx
Learning Objective: To learn different types of Carcinoma Larynx and their Management
Time Needed
1st reading mins
2 look
nd
mins
TNM Classification
1TX Primary tumor cannot be assessed.
o evidence of primary tumor.
Tis arcinoma in situ.
Supraglottis
T1 umor limited to one subsite of supraglottis with normal vocal cord mobility.
T2 umor invades mucosa of more than one ad acent subsite of supraglottis or glottis or region outside
the supraglottis e.g. mucosa of base of tongue, vallecula, medial wall of pyriform sinus without
fixation of the larynx.
umor limited to larynx with vocal cord fixation and or invades any of the following postcricoid
area, pre epiglottic space, paraglottic space, and or inner cortex of thyroid cartilage.
a oderately advanced local disease.
umor invades through the thyroid cartilage and or invades tissues beyond the larynx e.g., trachea,
soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or
esophagus .
b ery advanced local disease.
umor invades prevertebral space, encases carotid artery, or invades mediastinal structures
Tumors of Larynx and Their Management | 97
Glottis
T1 umor limited to the vocal cord s may involve anterior or posterior commissure with normal
mobility.
T1a umor limited to one vocal cord.
T1b umor involves both vocal cords.
T2 umor extends to supraglottis and or subglottis and or with impaired vocal cord mobility.
umor limited to the larynx with vocal cord fixation and or invasion of paraglottic space and or
inner cortex of the thyroid cartilage.
a oderately advanced local disease.
umor invades through the outer cortex of the thyroid cartilage and or invades tissues beyond
the larynx e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap
muscles, thyroid, or esophagus .
b ery advanced local disease.
umor invades prevertebral space, encases carotid artery or invades mediastinal structures.
Subglottis
T1 umor limited to the subglottis.
T2 umor extends to vocal cord s with normal or impaired mobility.
umor limited to larynx with vocal cord fixation.
a oderately advanced local disease.
umor invades cricoid or thyroid cartilage and or invades tissues beyond the larynx e.g., trachea,
soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or
esophagus .
b ery advanced local disease.
umor invades prevertebral space, encases carotid artery or invades mediastinal structures.
Treatment
• Radiotherapy
• Surgery
(a) Conservation laryngeal surgery
(b) Total laryngectomy
• Combined therapy.
• Endoscopic CO2 laser excision
Radiotherapy.
• Cancer of the vocal cord.
• Superficial exophytic lesions, especially of the tip of epiglottis, and aryepiglottic folds.
Total laryngectomy is indicated in the following conditions:
• T3 lesions (i.e. with cord fixed)
• All T4 lesions
98 | Ear Nose and Throat
• Invasion of thyroid or cricoid cartilage
• Bilateral arytenoid cartilage involvement
• Lesions of posterior commissure
• Failure after radiotherapy or conservation surgery
• Transglottic cancers, i.e. tumours involving supraglottis and glottis across the
ventricle, causing fixation of the vocal cord.
102 | Ear Nose and Throat
IMPORTANT TABLES (ACTIVE RECALL)
Papillomatosis
Juvenile Senile
TNM Classification
1TX Primary tumor cannot be assessed.
Tis
Supraglottis
T1
T2
a
Tumors of Larynx and Their Management | 103
Glottis
T1
T1a
T1b
T2
b
104 | Ear Nose and Throat
Subglottis
T1
T2
b
G Y
L O
NO
H I
R
8 Applied Clinical Anatomy
in Rhinology
CONCEPTS
 Concept 8.1 Clinical Anatomy of Nose
Time Needed
1st reading mins
2 look
nd
mins
Nasal Valves:
External Nasal Valve (Nasal vestibule):
• Anterior nostril (nasal alar cartilage, columella, and nasal sill).
• Internal Nasal Valve (Limen nasi):
• Bordered by septum, anterior edge of the inferior turbinate and caudal edge of upper
lateral cartilage.
• Narrowest segment (50% of total nasal resistance).
Applied Clinical Anatomy in Rhinology | 111
Concept 8.2: Clinical Anatomy of Paranasal Sinuses
Learning Objective: To Learn the Clinical Applied Anatomy of Paranasal Sinuses
Time Needed
1st reading mins
2 look
nd
mins
Uncinate process he uncinate process is a wing or boomerang shaped piece of bone. t forms
the first layer or lamella of the middle meatus. t attaches anteriorly to the
posterior edge of the lacrimal bone, and inferiorly to the superior edge
of the inferior turbinate. Superior attachment of the uncinate process is
highly variable, may be attached to the lamina papyracea, or the roof of the
ethmoidal sinus, or sometimes to the middle turbinate
Bulla ethmoidalis he ethmoid bulla, also known as bulla ethmoidalis, is the largest and most
consistent air cell of the anterior ethmoid air cells.
Hiatus semilunaris he ethmoid bulla, also known as bulla ethmoidalis, is the largest and most
consistent air cell of the anterior ethmoid air cells.
Ethmoidal infundibulum structure in deep part of hiatus semilunaris, frontal sinus, maxillary and
the anterior ethmoids drain into it.
Haller cell s a variation of anterior ethmoid air cells and they lie in relation to orbital
oor.
Onodi cell s a variation of posterior ethmoid and lies in relation to optic nerve. hen
present they can increase the chance of complications.
Aggar nasi nterior most anterior ethmoidal air cell.
Concha Bullosa neumati ed middle turbinate.
112 | Ear Nose and Throat
114 | Ear Nose and Throat
IMPORTANT TABLES (ACTIVE RECALL)
Opening In Lateral Wall
nferior meatus
iddle meatus
Superior eatus
Sphenoethmoidal recess
Uncinate process
Bulla ethmoidalis
Hiatus semilunaris
Ethmoidal infundibulum
Haller cell
Onodi cell
Aggar nasi
Concha Bullosa
9 Clinical Disorders in Rhinology
CONCEPTS
 Concept 9.1 Infection of Nose and Paranasal
Sinuses
Time Needed
1st reading 15 mins
2 look
nd
mins
Sinusitis
Acute sinusitis:
Sinuses involved in order of frequency: Maxillary > Frontal > Ethmoid > Sphenoid
Major Factor Minor Factor
acial pain or pressure eadache
acial congestion or fullness ever in chronic sinusitis
asal obstruction or blockage Halitosis
asal discharge, purulence, or discolored postnasal drainage atigue
Hyposmia or anosmia Dental pain
urulence in nasal cavity ough
ever in acute rhinosinustis only ar ain, pressure or fullness
Frontal sinusitis:
• Frontal headache, oedema of upper eyelid.
Maxillary sinusitis:
• Pain referred to gums, odema of lower eye lid.
Sphenoid sinusitis:
• Headache, usually localised to the occiput or vertex.
• Postnasal discharge.
Ethmoid sinusitis:
• Pain over bridge of the nose, oedema of both the lids.
Complication of Sinusitis:
Most common organism known to produce complication of sinusitis: Staphylococcus
aureus.
1. Orbital.
2. Osteomyelitis.
3. Intracranial.
Orbital Complication:
Chandler classification:
• Group I – Preseptal cellulitis.
Clinical Disorders in Rhinology | 117
• Group II – Orbital cellulitis.
• Group III – Subperiosteal abscess.
• Group IV – Orbital abscess.
• Group V – Cavernous sinus thrombosis.
Superior orbital FISSURE syndrome:
• Cranial Nerves VI, III and IV paralysis (in that order).
Orbital Apex Syndrome: Optic nerve paralysis.
Pott’s Puffy Tumour:
• Subperiosteal abcess subsequent to frontal sinustis.
• Organisms: Staphylococcus, Streptococcus, Anaerobes
Chronic Complications:
• Mucocele / Pyoceles.
118 | Ear Nose and Throat
Concept 9.2: Granulomatous disease of the Nose
Learning Objective: To learn Granulomatous disease of the Nose and their Management
Time Needed
1st reading mins
2 look
nd
mins
Tuberculosis of Nose:
• Cartilaginous portion of the nasal septum and the anterior end of the inferior turbinate.
Lupus Vulgaris:
• Sites affected: Most common site is the mucocutaneous junction of the nasal septum.
Rhinoscleroma:
Organism: Klebsiella rhinoscleromatis
In India, Northern parts are more affected.
• Atrophic Stage.
• Granulomatous Stage.
• Cicatrical Stage.
Mikulicz Cells:
Large foam cells with a central nucleus and vacuolated cytoplasm (contain the bacilli).
Russell Bodies:
Eccentric nucleus and a pink- staining cytoplasm- Look like plasma cells.
Treatment:
• Streptomycin (2 gm/day).
• Tetracycline (2 gm/day). minimum: 4-6 wks (till 2 consecutive samples negative).
• Rifampicin: 450 mg daily 6 wks.
Leprosy:
• Anterior part of the nasal septum and the anterior end of the inferior turbinate.
• Perforation of the nasal septum.
Clinical Disorders in Rhinology | 119
Fungal Infections:
Rhinosporidiosis:
Organism: Rhinosporidium seeberi. Distribution: India (Southern parts), Sri lanka.
Sites of Affection:
Most commonly: Nose and Nasopharynx Mulberry shaped polypoidal mass studded
with white dots or sporangia on its under surface.
Site: Vestibule (septal area).
Treatment:
Complete excision of the mass with a cutting diathermy and cauterization of its base.
Medical management: Local injection of corticosteroids and courses of dapsone and
amphotericin.
Aspergillosis Mucormycosis (Rhinocerebral Phycomycosis)
Aspergillosis: is the commonest fungal • Remarkable a nity for blood vessels arteries.
infection of the nose and sinuses. • .R. . detects early vascular and intracranial invasion.
Frequency: A. fumigatus A. Treatment:
niger and A. flavus. ocal debridement and systemic amphotericin .
Wegener’s Granulomatosis:
• Systemic disorder, with upper and lower airway involvement and skin and kidney
involvement.
• Treatment: steroids, cytotoxics.
Non-healing Midline Granuloma – A Type of Lymphoma:
• Destructive disease of nose and midface.
• No lung/kidney involvement.
• Is a malignant lymphoma.
• Diagnosis: many repeated biopsies may be needed to diagnose.
• Treatment: radiotherapy, followed by debridement and nasal prosthesis.
• Steroids and cytotoxics contraindicated since they reduce the immune response.
120 | Ear Nose and Throat
Concept 9.3: Rhinosinustis
Learning Objective: To learn Concepts of Rhinosinusitis
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Chronic Rhinosinustis
When symptoms of sinusitis persist for more than 12 weeks, chronic state develops.
Commonest cause is incomplete resolution of acute episode.
• Organism: Mixed aerobic and anerobic.
• Treatment: Medical.
Vasomotor Rhinitis
• Non allergic
• Snee ing is less
• sually persists throughout the year
Complications: ong standing cases develop nasal polyp, hypertrophic rhinitis and sinusitis.
Treatment:
• Medical - voidance of physical factors, antihistaminics, oral nasal decongestants, topical and systemic
steroids.
• Surgical - asal obstruction reduce si e of nasal turbinates olyp, S.
• Excessive rhinorrhoea - idian neurectomy.
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Nasal Polyps:
Definition:
• Non-neoplastic hypertrophied, edema- tous, prolapsed mucosa.
• Insensitive to pain and do not shrink with the use of vasoconstrictors.
P.S - Polyps seen before 2 years of age: Suspect meningococele or encephalocele, hence
CT scan should be done.
If seen between 2-10 yrs of age: Suspect cystic fibrosis .
Respiratory diseases which predispose the patient to nasal polyps are:
1. Kartagener’s syndrome: Primary ciliary dyskinesia.
2. Young Syndrome: Hyperviscidosis (bronchiectasis, sinusitis and azoospermia).
Antrochoanal polyp:
Antrochoanal polyp
Ethmoidal polyps:
Treatment:
• Medical treatment: lntranasal corticosteroids for 4-6 weeks (steroid drops/ sprays):
effective in 50% of the cases
• Surgical: FESS (Functional Endoscopic sinus surgery).
Antrochoanal Polyp (Killian’s Polyp):
Parts: dumbbell shaped
a. Antral.
b. Nasal.
c. Choanal.
Treatment:
• No medical treatment.
• Surgical Management:
FESS is treatment of choice.
Aulsion/ Intranasal polypectomy.
Caldwell-Luc operation is done for recurrent AC polyp.
FESS:
Indications:
1. Chronic bacterial sinusitis unresponsive to adequate medical treatment.
2. Recurrent acute bacterial sinusitis.
3. Polypoid rhinosinusitis (diffuse nasal polyposis).
4. Fungal sinusitis with fungal ball or nasal polypi.
5. Antrochnanal polyp.
6. Mucocele of frontoethmoid or sphenoid sinus.
7. Control of epistaxis is by endoscopic cautery.
8. Removal of foreign body from the nose or sinus.
9. Endoscopic septoplasty.
Advanced Nasal Endoscopic Techniques:
1. Removal of benign tumours e.g. inverted papillomas or angiofibromas.
2. Orbital abscess or cellulitis management.
3. Dacryocystorhinostomy.
124 | Ear Nose and Throat
4. Repair of CSF leak.
5. Pituitary surgery.
6. Optic nerve decompression.
7. Orbital decompression for Graves disease.
8. Control of posterior epistaxis (endoscopic clipping of sphenopalatine artery).
9. Choanal atresia.
Synechia Most common complication of endoscopic sinus surgery
Nasal Septum
• DNS.
• Crooked nose.
• Saddle nose.
• Hump nose.
• Perforation.
Small and medium sized perforation (< 2 cm in diameter): Closure surgically.
Large perforation (> 2 cm in diameter): Obturators or silastic septal buttons.
Clinical Disorders in Rhinology | 125
Concept 9.5: Epistaxis and It’s Management
Learning Objective: To Learn Clinical Importance of Epistaxis and their Management
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Epistaxis:
Anatomy:
• Epistaxis is normally classified into anterior or posterior, but it can also be classified
as superior or inferior depending on the carotid supply.
• Broadly, the internal carotid (via the ethmoidal arteries) supplies the region above
the middle turbinate while the remaining areas are supplied by branches of the
external carotid artery. This includes the sphenopalatine artery, which supplies most
of the septum and turbinates on the lateral wall. The interface between the two
carotid systems varies in position according to the pressure in each one. There
is also crossover between the right and left arterial systems, which can result in
persistent nasal bleeding despite unilateral arterial ligation.
• Anterior bleeds are responsible for about 80% of epistaxis. They occur at an
anastomosis called Kiesselbach’s plexus on the lower part of the anterior septum
known as Little’s area. Posterior bleeding is derived primarily from the posterior
septal nasal artery (a branch of the sphenopalatine artery), which forms part of the
Woodruff plexus.
Aetiology:
• The aetiology of epistaxis can be divided into local and general causes, however most
(80%–90%) are actually idiopathic.
Local:
• Idiopathic
• Trauma
Nose picking
Facial injury
Foreign body
• Inflammation
Infection
Allergic rhinosinusitis
Nasal polyps
• Neoplasia
Benign (for example, juvenile angiofibroma)
Malignant (for example, squamous cell carcinoma)
126 | Ear Nose and Throat
• Vascular
Congenital (for example, hereditary haemorrhagic telangiectasia)
Acquired (for example, Wegener’s granulomatosis)
• Iatrogenic
Surgery (for example, ENT/ maxillofacial/ophthalmic)
Nasal apparatus (for example, nasogastric tube)
• Structural
Septal spurs or deviation
Septal perforations
• Drugs
Nasal sprays (for example, topical decongestants)
Abuse (for example, cocaine)
General
• Haematological
Coagulopathies (for example, haemophilia)
Thrombocytopenia (for example, leukaemia)
Platelet dysfunction (for example, Von Willebrand’s disease)
• Environmental
Temperature
Humidity
Altitude
• Drugs
Anticoagulants (for example, heparin, warfarin)
Antiplatelet (for example, aspirin, clopidogrel)
• Organ failure
Uraemia
Liver (for example, cirrhosis)
• Other
Atherosclerosis/hypertension
Alcohol
Clinical Disorders in Rhinology | 127
Management of Epistaxis
128 | Ear Nose and Throat
Concept 9.6: Fractures of the Facial Skeleton
Learning Objective: To Learn Concepts of the Facial Fractures and their Management
Time Needed
1 reading
st
mins
2 look
nd
mins
Nose:
Fracture of the Nose:
(Classification):
1. Class 1 Fracture [Chevallet]:
Depressed nasal fracture.
Force required 25-75 lb/inch.
Fracture line runs parallel to the dorsum and the nasomaxillary suture line.
NASAL SEPTUM is NOT involved in this injury (In a severe variant it is involved).
Features: DO NOT cause gross lateral displacement.
Treatment: Fracture reduction done either immediately or after 5-7 days once
oedema settles.
2. Class 2 Fracture [Jarajavay]:
Involves the nasal bone, the frontal process of the maxilla and the SEPTAL
STRUCTURES.
Ethmoidal labyrinth and the orbit are spared.
Here the quadrilateral cartilage gets dislocated from the maxillary crest.
Treatment: Closed reduction of the nasal bone fracture with open reduction of
the septum.
3. Class 3 Fracture:
Caused by high velocity trauma.
Naso-orbitio-ethmoid fracture.
Treatment:
• Open reduction and internal fixation.
• Distal part of the nasal bone is half the thickness of the proximal part. Therefore
more susceptible to injury.
• Untreated nasal bone fractures lasting for more than 21 days require Open Reduction.
• Caudal dislocation is a type of class 2 fracture or at times class 1 fracture.
• Any CSF leak persisting for more than 2 weeks have to be considered for repair.
Mandible:
• Most common site of fracture: Subcondylar region.
• Fracture sites: Condyle > angle > body > symphysis
Clinical Disorders in Rhinology | 129
Le Fort Type Fractures
History asal or sinus surgery, head in ury or Snee ing, nasal stu ness, itching in
intracranial tumour the nose or lacrimation.
haracter of discharge hin, watery and clear Slimy mucus or clear tears
taste sweet salty
Double Ring Sign is Helpful in Traumatic CSF Leak (Blood Surrounded by CSF).
Management: Wait and watch, I.V. Antibiotics.
130 | Ear Nose and Throat
Extra Edge:
Choanal Atresia:
• Obliteration of the posterior choana is the result of a failure of the nasobuccal membrane
to rupture during the fourth week of embryonic life.
• Unilateral.
• Occurs on the right side.
• Unilateral nasal obstruction often presents later in infancy or childhood as rhinorrhea and
congestion.
• Diagnosis is made by the inability to pass catheters through the nose or by nasal endoscopy
(flexible or rigid).
• CT scan is always obtained to confirm the physical findings.
• Bilateral atresia must be addressed during first weeks of life.
• McGovern’s nipple may be required for feeding initially for bilateral choanal atresia. If
possible, surgical repair is delayed until the child is older than 2 years.
Clinical Disorders in Rhinology | 131
WORKSHEET
132 | Ear Nose and Throat
IMPORTANT TABLES (ACTIVE RECALL)
Sinusitis
Sinuses involved in order of frequency:
Major Factor Minor Factor
low of
discharge
haracter of
discharge taste
Sugar content
Presence of β2
transferrin
10 Malignancy in Rhinology
CONCEPTS
 Concept 10.1 Tumors of Nasal Cavity
Time Needed
1st reading 15 mins
2 look
nd
mins
Inverted Papilloma
• Pathophysiology: arise from proliferation of reserve cells in squamous mucosa
(associated with human papilloma virus):More common in males
• Often misdiagnosed as a nasal polyp (polyps are more translucent, bilateral, and
bleed less)
• unilateral obstruction, sinusitis, epistaxis, rhinorrhea, diplopia, typically
presents on the lateral nasal wall (rarely on the nasal septum), may be associated
with a benign nasal polyp
• Complications: 10% malignant degeneration from lateral wall lesions (rare from
nasal septum), extension into sinuses, orbit (blindness, diplopia, proptosis), or
intracranial and skull base
• Adequate en bloc excision typically requires a medial maxillectomy, may require
an ethmoidectomy or craniofacial resection, endoscopic excision may be considered
for select lesions
• (recurrence rate up to 20%)
Malignancy
• Most common tumour: squamous cell carcinoma
• Most common site of squamous cell carcinoma: Lateral wall
• Most common site of malignant melanoma:
1st Anterior part of septum.
2nd Middle turbinate.
3rd Inferior turbinate
Radiotherapy and chemotherapy has to be avoided
Malignancy in Rhinology | 137
Concept 10.2: Malignancy of Paranasal Sinuses
Learning Objective: To Learn Malignancy of Paranasal Sinuses and Management
Time Needed
1st reading 15 mins
2 look
nd
mins
Lederman’s Classification
• Ethmoid, sphenoid, frontal sinuses and olfactory area of nose.
• Maxillary and respiratory part of nose.
• Alveolar process
Lederman’s Classification
140 | Ear Nose and Throat
IMPORTANT TABLES (ACTIVE RECALL)
Malignancy of Nose
• Most common benign tumor:
Malignancy of PNS
• Most common benign tumor:
CONCEPTS
 Concept 11.1 Clinical Anatomy Of Pharynx
144 | Ear Nose and Throat
Concept 11.1: Clinical Anatomy of Pharynx
Learning Objective: To Learn the Clinical Applied Anatomy of Pharynx
Time Needed
1st reading mins
2 look
nd
mins
Pharynx
Mucosa:
• Nasopharynx: Pseudostratified columnar epithelium.
• Orpharynx and Hypopharynx: Non-keratinizing stratified squamous epithelium.
Pharynx
Nerves:
• The Constrictors and salpingopharyngeus are supplied by branches from
the pharyngeal plexus, the Constrictor inferior by additional branches from
the external laryngeal and recurrent nerves, and the Stylopharyngeus by the
glossopharyngeal nerve.
Anatomy of Pharynx | 145
Sinus of Morgagni:
• Killian’s dehiscence: Lies between the oblique (thyropharyngeus) and transverse
(cricopharyngeus) parts of the inferior constrictor muscle. Syn. Gateway of Tears.
• Laimer- Hackeman’s area (in the upper posterior part of the oesophagus, just
below the cricopharynx where the longitudnal fibres do not cover the circular fibres).
• Tornwaldt’s disease is an inflammation or abscess of the embryonic remnant cyst
of the pharyngeal bursa appearing at the posterior median wall of the nasopharynx.
All muscles of Supplied By Which is supplied by
Tongue ypoglossal. th
alatoglossus. haryngeal plexus ,
and sympathetic
Between the middle and inferior constrictor Below the inferior constrictor
• Internal laryngeal nerves • Recurrent laryngeal nerves
• Superior laryngeal vessels • Inferior laryngeal artery
148 | Ear Nose and Throat
IMPORTANT TABLES (ACTIVE RECALL)
All muscles of Supplied By Which is supplied by
Pharynx
Palate
Tongue
Facial expression,
Buccinator
Mastication
Between the middle and inferior constrictor Below the inferior constrictor
12 Clinical Disorders of Pharynx
CONCEPTS
 Concept 12.1 Infection of Pharynx
Time Needed
1st reading mins
2 look
nd
mins
Acute Tonsillitis
Types:
Acute catarrhal or superficial tonsillitis
• Acute follicular tonsillitis – Purulent material seen in crypts as yellowish spots.
• Acute parenchymatous – Tonsillar substance is affected causing uniform
enlargement and redness.
• Acute membrane tonsillitis – Exudation coalesce to form a membrane.
Complications
hronic tonsillitis cute otitis media
Peritonsillar abscess Rheumatic fever
arapharyngeal abscess cute glomerulonephritis
Subacute bacterial endocarditis
Indication:
Absolute Relative As part of an operative
procedure
arge tonsils causing sleep apnea iphtheria carriers not responding s part of uvulopalato
to antibiotics. pharyngoplasty done for
S .
Recurrent tonsillitis docu Rheumatic fever where s an approach to nerve and
mented attacks of acute tonsillitis antistreptococcal prophylaxis styloid process.
for a period of years . cannot be maintained.
enlarged tonsil suspicion of malignancy .
Contraindications:
• Hb<10g%.
• Age< 3 yrs.
• Acute infection.
Clinical Disorders of Pharynx | 153
• In epidemics of polio.
• Bleeding disorders (laser tonsillectomy).
• Uncontrollable systemic disease (diabetes, hypertension).
Laser Tonsillectomy:
Is performed with KTP-532, decreased blood loss.
Complications of Tonsillectomy:
• Peroperative bleeding: Primary haemorrhage.
• Reactionary haemorrhage (venous bleed).
• Secondary haemorrhage (bleeding after 24 hours postoperatively (not as severe as
primary haemorrhage).
• Occurs at: 6-8 days
Extra Edge:
Thornwaidt’s Cyst (Pharyngeal Bursitis)
Interior of the pharyngeal bursa (A median recess representing attachment of notochord to
endoderm of the primitive pharynx).
Features Treatment
s a cystic nasopharyngeal swelling. ntibiotics nfection.
ersistent post nasal discharge. arsupiali ation.
asal obstruction.
154 | Ear Nose and Throat
Concept 12.2: Abscess of Head and Neck
Learning Objective: To Learn Abscess of Head and Neck and their Management
Time Needed
1st reading mins
2 look
nd
mins
Clinical features:
ever with chills and rigors eneral body ache arache.
Treatment:
• Incision and drainage (Peroral).
• I.V. fluids, antibiotics, analgesics. (Abscess requires drainage, but peritonsillitis may
respond to conservative measures).
• Interval tonsillectomy - Patient to undergo tonsillectomy at 6 weeks if recurrent
quinsy.
• Hot Tonsillectomy / Abscess Tonsillectomy
• Tonsillectomy performed in the acute stage of quinsy: not advocated.
158 | Ear Nose and Throat
IMPORTANT TABLES (ACTIVE RECALL)
Differential Diagnosis of Membrane over the Tonsils
DIPHTHERIA:
Indication:
Absolute Relative As part of an operative
procedure
13 Malignancy of Pharynx
CONCEPTS
 Concept 13.1 Tumors of Pharynx
160 | Ear Nose and Throat
Concept 13.1: Malignancy of Pharynx
Learning Objective: To Learn Malignancy of Pharynx and their Management
Time Needed
1 reading
st
mins
Nasopharyngeal Carcinoma
Commonest site of origin: Fossa of Rosenmuller.
Site: Above and behind the medial end of the eustachian tube.
nvironmental actors
Viral pstein arr irus raised antibody, viral genome in tumor cells .
eurological symptoms . ll cranial nerves except , and , can be involved. ost commonly
, , ,
Malignancy of Pharynx | 161
Trotter’s Triad
• U/L middle ear effusion and so conductive hearing loss.
• Pain in that ear.
• Paralysis of the soft palate (X nerve).
ateral rhinotomy with maxillectomy umor in the nasal fossa spilling over to the
pterygopalatine fossa
Tumors of Hypopharynx:
• Most common type of tumor: Squamous cell type
• Most common site of hypopharyngeal malignancy: Pyriform sinus
Post-cricoid Carcinoma:
• Plummer Vinson syndrome is a premalignant condition for post cricoid carcinoma.
Extra Edge
Keratosis Pharyngis
Features:
1. Benign condition.
2. Horny excrescences on the tonsillar surface, pharyngeal wall of lingual tonsils; appear
as white/ yellow dots and cannot be wiped off.
3. No constitutional symptoms.
Malignancy of Pharynx | 163
WORKSHEET
MCQ OF “MALIGNANCY OF PHARYNX” FROM DQB
164 | Ear Nose and Throat
IMPORTANT TABLES (ACTIVE RECALL)
Epidemiology of Nasopharyngeal Carcinoma
Geographical Distribution
nvironmental actors
Genetic
Viral
CONCEPTS
 Concept 14.1 Clinical Anatomy of Oral Cavity
Time Needed
1st reading mins
2 look
nd
mins
• Mouth / oral cavity extends from the lip to the oropharyngeal isthmus i.e. anterior
pillar of tonsillar fossa, posterior margin of hard palate and junction of anterior 2/3rd
and posterior 1/3rd of tongue.
• Parotid ducts open through a small papilla opposite the upper 2nd molar tooth.
• Submandibular and sublingual ducts open into the floor of the mouth beneath
the tongue.
• Myelohyoid is the main muscle which makes the floor of the mouth.
• Oral stage of deglutition is voluntary.
• Pharyngeal and oesophageal stages are involuntary.
Nerves of Taste:
• IXth CN - Posterior 1/3rd of tongue (bitter).
• Chorda tympani (VII) - Ant 2/3rd of tongue (Sweet, sour and salt).
Lymphatic Drainage:
1. Lips:
Lower lip: Medial portion drains into submental lymph nodes. Lateral portion
drains into submandibular lymph nodes.
Upper lip - Preauricular, infraparotid and submandibular nodes
2. Lymphatics from anterior portion of floor of mouth drain into submandibular nodes
and also cross the midline.
3. Tongue:
Tip - Submental and jugulo omohyoid nodes
Lateral portion - Ipsilateral submandibular and deep cervical nodes
Central portion and base – Deep cervical nodes of both sides
Applied Anatomy of Oral Cavity & Misc Topics | 169
Concept 14.2: Submucous Fibrosis
Learning Objective: To Learn the Concepts of Submucous Fibrosis
Time Needed
1st reading 15 mins
2 look
nd
mins
Submucous Fibrosis
Etiology
• Prolonged Local Irritation: Due to mechanical and chemical irritation caused by
chewing betel nut.
• Dietary deficiency : VA; VB complex
• Localized collagen disease
• Racial : Mainly affects Indians
Pathology
Epithelial atrophy & sub mucosal fibro elastic transformation.
↓
Progressive trismus and difficulty to protrude the tongue.
Clinical Features
• Age → 20 – 40 years
• Sex → F > M
• Is PREMALIGNANT
Treatment
Medical
Steroids – Topical injection of steroids combined with hyalase
170 | Ear Nose and Throat
Concept 14.3: Tumors of Oral Cavity
Learning Objective: To Learn the Tumors of Oral Cavity and Management
Time Needed
1st reading mins
2 look
nd
15 mins
Sex
Caldwell-Luc procedure:
• Intraoral approach to anterior maxillary wall from canine fossa above gum line, the
diseased mucosa is removed from the maxillary sinus, also allows for a middle meatal
antrostomy, and ethmoidectomy (transantral ethmoidectomy).
• The incision is made in the gingivobuccal sulcus, above the canine fossa.
172 | Ear Nose and Throat
Indications: Sinus disease not obtainable by endoscopic sinus surgery, inspissated
secretions, neo-ossification, cystic fibrosis.
Caldwell-Luc procedure
Time Needed
1st reading mins
2 look
nd
mins
Time Needed
1st reading mins
2 look
nd
mins
LASERS
CO2 Laser:
• 10,600 nm wavelength.
• Highest power continuous-wave laser.
No current optical fiber to carry beam.
Uses:
Laryngology:
• Laryngology is one of the speciality areas in which lasers are most often used. The
CO2 laser is by far the laser of choice. Because of the precise cutting and superficial
well delineated effect of the CO2 laser, it is widely used in laryngology for delicate
phonatory surgery, precise excision of carcinoma in situ or early (T1) tumors, and
vaporization of bulky obstructing carcinoma of the upper airway.
Rhinology:
• Most of the lasers now available to the otolaryngologist have applications in nasal
surgery.
• The CO2 laser, which mainly cuts and ablates tissue, is used most often for vaporization
of hypertrophied turbinates and occasionally for coagulation of small blood vessels in
the milder forms of hereditary hemorrhagic telangiectasia (Kluger et al, 1987).
• In the noncontact mode, the Nd: YAG laser is a good coagulator. It has been used
successfully for coagulation of vascular lesions of the nose, such as low-flow venous
malformations and hereditary hemorrhagic telangiectasia.
Otology:
• The argon, CO2, and KTP/532 lasers have been useful for ossicular surgery and
particularly stapedotomy.
• The CO2 laser is especially easy to use because of its articulating arm delivery system
that can be connected to the operating microscope and because of its small spot size
(0.2 to 0.3 mm at a focal length of 250 mm).
• The surgeon can operate using a no- touch technique, with good visualization and
precise ablation of the ossicles.
Oral Cavity:
• In the oral cavity, the laser is mainly used as a hemostatic cutting knife, and for this
purpose the CO2 is the laser of choice.
• It is used with a handpiece or with a micromanipulator to delineate and resect small
tumors of the tongue, the floor of the mouth, and the mucosa of the cheek.
176 | Ear Nose and Throat
• The KTP/532 laser, with its flexible fiberoptic delivery system, may also be used for
the excision of benign and malignant lesions of the oral cavity; however, its soft tissue
interaction is not as precise as that of the CO2 laser.
KTP Laser:
• 532 nm wavelength (potassium-titanyl-phosphate).
• Frequency doubling.
• Nd: YAG laser passes through a KTP crystal – emission is ½ its wavelength.
• Oxyhemoglobin is primary chromophore.
• Applications:
Granuloma excision of the respiratory tract.
Subglottic/tracheal stenosis.
Subglottic/supraglottic cyst excision.
Inferior turbinate reduction.
Nasal papilloma excision.
Nasopharyngeal stenosis.
Supraglottoplasty.
Laryngeal papilloma excision.
Middle ear surgery (Cholesteatoma excision, stapes surgery).
Argon Laser:
• 488 - 514 nm wavelength (Ion laser):
Oxyhemoglobin is target chromophore.
Small spot size (0.1 – 1 mm) – variable in size and intensity.
Flexible delivery system.
Applications:
• Retina or middle ear surgery.
• Facial spider veins.
• Junctional nevi.
• Cherry hemangioma.
• Vascular birthmarks.
• Limitations:
Also absorbed by epidermal and dermal tissues due to melanin.
Continuous mode of operation.
Higher prevalence of postoperative pigmentary alteration and fibrosis.
Nd: YAG Laser:
• 1064 nm wavelength (neodymium-doped yttrium aluminum garnet).
Aiming helium-neon (HeNe) beam.
• Applications:
Deeper penetration (up to 4 mm) for ablative therapy and hemostasis.
Preferentially absorbed by pigmented tissues.
Vascular malformations amenable to treatment.
Applied Anatomy of Oral Cavity & Misc Topics | 177
Used in a multitude of pulmonary, urology and gastroenterology procedures.
Minimally invasive percutaneous laser disk decompression.
• Limitations:
Greater scatter than CO2
Deep thermal injury
Risk for transmural injury
Cryosurgery (also called cryotherapy) is the use of extreme cold produced by liquid
nitrogen (or argon gas) to destroy abnormal tissue. Cryosurgery is used to treat external
tumors, such as those on the skin. For external tumors, liquid nitrogen is applied directly
to the cancer cells with a cotton swab or spraying device.
Cryosurgery is also used to treat tumors inside the body (internal tumors and tumors
in the bone). For internal tumors, liquid nitrogen or argon gas is circulated through a
hollow instrument called a cryoprobe, which is placed in contact with the tumor.
Cryosurgery is used to treat several types of cancers, and some precancerous or
noncancerous conditions. In addition to prostate and liver tumors, cryosurgery can be
an effective treatment for the following:
• Retinoblastoma (a childhood cancer that affects the retina of the eye).
• Early-stage skin cancers (both basal cell and squamous cell carcinomas).
• Precancerous skin growths known as actinic keratosis.
• Precancerous conditions of the cervix known as cervical intraepithelial neoplasia
(abnormal cell changes in the cervix that can develop into cervical cancer).
• Cryosurgery is also used to treat some types of low-grade cancerous and noncancerous
tumors of the bone. It may reduce the risk of joint damage when compared with
more extensive surgery, and help lessen the need for amputation. The treatment is
also used to treat AIDS-related Kaposi sarcoma when the skin lesions are small and
localized.
• Cryosurgery can be used to treat men who have early-stage prostate cancer that is
confined to the prostate gland. It is less well established than standard prostatectomy
and various types of radiation therapy.
• Cryosurgery offers advantages over other methods of cancer treatment. It is less
invasive than surgery, involving only a small incision or insertion of the cryoprobe
through the skin. Consequently, pain, bleeding, and other complications of surgery
are minimized. Cryosurgery is less expensive than other treatments and requires
shorter recovery time and a shorter hospital stay, or no hospital stay at all. Sometimes
cryosurgery can be done using only local anaesthesia.
• The major disadvantage of cryosurgery is the uncertainty surrounding its long- term
effectiveness. While cryosurgery may be effective in treating tumors the physician
can see by using imaging tests (tests that produce pictures of areas inside the body),
it can miss microscopic cancer spread. Furthermore, because the effectiveness of the
technique is still being assessed, insurance coverage issues may arise.
178 | Ear Nose and Throat
WORKSHEET
MCQ OF “ORAL CAVITY & MISC TOPICS” FROM DQB
Applied Anatomy of Oral Cavity & Misc Topics | 179
IMPORTANT TABLES (ACTIVE RECALL)
Carcinoma Lip– Most common cancer of oral cavity.
Sex
Age
Site
Pathology
Treatment
Sex
Site
LN
Treatment