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CLINICAL
DISCUSSION
MADE EASY
OTORHINOLARYNGOLOGY

1st EDITION-2019
DR. AVS HANUMANTHA RAO
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Preface

The main aim of this book is to help the post graduates with the major
long cases. The book has dealt with mock clinical case presentation of
long cases for practical purpose. Each clinical case deals with the history
taking aspects, importance of positive history and elaboration of each
positive symptom and role of negative history to rule out differential
diagnosis and arriving at the provisional diagnosis. It covers discussion
relating to the case scenario and the probable Viva. The important
information has been compiled up at the end of each case scenario.
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Foreword

Dr. AVS Hanumantha Rao, the author of book has always dedicated his life for the
students. He admires teaching profession. His efforts were always directed
towards making student’s life facile. His creativity has revolutionised the art of
learning. He has always inspired students to reach a mile extra. He gave wings to
the knowledge of students. The idea behind launching this book was to ease the
difficulties faced by students during case taking and discussion.

EDITORS
[Link] Bhushan
[Link]
[Link]
[Link]
Any queries kindly mail to drphani21@[Link]
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Contents
1. CSOM CASE……………………………………………6-59

2. CARCINOMA MAXILLA…………………………..60-89

3. NASOPHARYNGEAL CARCINOMA………….90-112

4. CARCINOMA LARYNX……………………………113-172

5. CARCINOMA HYPOPHARYNX………………..173-190
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CASE PRESENTATION 1
Name : ABC

Age : 34yrs

Sex : Female

Occupation : Farmer

Residence : Hyderabad

Chief complaints :

1. Right ear discharge since 6 months

2. Dizziness since 6 months

History of Present Illness :

Patient was apparently asymptomatic 6 months back .

Then she developed right ear discharge which was

- Insidous in Onset
- Gradually progressive since 6 months
- Continuous
- Yellow in colour ( Purulent )
- Foul smelling
- Scanty in amount
- Occasionally blood stained
- No diurnal / Seasonal variation
- Relieved by medication

Assosiated with hard of Hearing

-Right ear for whispered sounds,

-insidious in onset ,

- non fluctuant,

-No change in hearing during discharge or absence of discharge.

-Able to understand speech.

H/O Dizziness : Since 6 months

- Insidous in onset
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- No h/o Aura
- Having sensation of rotatory movement of surroundings
- No positional variation
-
- H/o fall towards one side (Right side)

No h/o Itching/ringing sensation/pain/Fullness in ear

No h/o headache , projectile vomiting , fever

No h/o nasal obstruction / nasal discharge

No h/o difficulty in swallowing/sob/change of voice

No h/o deviation of mouth

Past history :

Similar complaint of right ear discharge during her childhood

Relieved by taking medication

Right ear hard of hearing since childhood

No other significant past medical / surgical history

No h/o Exanthematous fever in childhood

No h/o DM/HTN/CAD/Bronchial Asthma/Epilepsy/Bleeding Disorder /Dental caries /Trauma

No allergic drug history

Personal History :

Diet – Mixed

Appetite – Normal

Bowel and Bladder Movements – Normal

Sleep – normal

Family History :

Not Contributory .No deafness history .No h/o TB in family

General Examination :

Patient is conscious , coherent ,well oriented to Time , Place and Person , cooperative
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Patient is moderately built , moderately nourished

Pallor0 Icterus0 Clubbing0 Koilonychia0 Cyanosis0Generalised Lymphadenopathy0 Pedal Edema0

Vitals :-

Temp :- Afebrile

Bp : 120/80 , Right arm , Supine position

PR : 84 / min , Right upper limb , Radial artery , regular , normal rhythm , Volume normal

Respiratory rate : 18/min

Systemic Examination :

CVS : S1+ S2+ M0

RS : Bilateral Air Entry present , No adventitious sounds

P/A : Soft

CNS : Intact , NAD

ENT Examination : Examined under Proper Light and Exposure

Ear :-
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Right Ear

Right Left
Pinna Normal Normal
Preauricular area Normal Normal
Postauricular area Normal Normal
EAC Purulent Discharge + Normal

Cholesteatoma flakes +

TM Pars flaccida :- Attic perforation Normal

+
Purulent discharge with
cholesteatoma flakes +
Margins congested
Aural polyp seen protruding
through perforation
Pars tensa :- Grade 1 retraction
, pearly white colour
COL absent
Scutum – Not eroded

Middle ear mucosa Cholesteatoma flakes + (ATTIC) -

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Funtional tests :-

Tuning fork tests :-

TFT’s Right Left

Rinne’s 256 Hz Negative Positive
512 Hz Negative Positive
1024 Hz Positive Positive
Weber’s Lateralised to Right
Absolute bone conduction Same as examiner Same as examiner

Balancing tests :-

Rhomberg’s test Negative

Gait Normal

Nystagmus Absent

Fistula test : Nystagmus towards right ear

No Past pointing

No dysdiadochokinesia

Facial Nerve Examination : Normal

NOSE Right Sided DNS

Paranasal Sinuses Normal

Posterior Rhinoscopy Normal

Oral Cavity Normal

Oropharynx Normal

IDL Normal

Neck

Trachea - Central

B/l Carotid pulsations felt

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No cervical lymphadenopathy

Cranial nerve examination : Normal

PROVISIONAL DIAGNOSIS :

RIGHT CHRONIC SUPPURATIVE OTITIS MEDIA WITH ACTIVE SQUAMOSAL DISEASE WITH MODERATE
CONDUCTIVE HEARING LOSS WITH LABYRYNTHINE FISTULA WITH RIGHT SIDED DEVIATED NASAL
SEPTUM

Investigations :

Pus for C/S

Examination under Microscope

Routine Haemotological Investigations

Diagnostic Nasal Endoscopy ( TM is Retracted)

Xray Both Mastoids

Pure tone audiometry

HRCT Both Temporal bones

Biopsy of polyp if necessary

Treatment : RIGHT MODIFIED RADICAL MASTOIDECTOMY WITH CLOSURE OF FISTULA WITH

TYMPANOPLASTY UNDER GENERAL ANAESTHESIA

Clinical Discussion :-

Q1. Summarise positive history ?

1. Right ear discharge since 6 months

2. Hard of Hearing Right ear
3. Dizziness since 6 months
4. History of fall towards right
5. History of double vision

Q2. Points in favor of Active squamosal COM diagnosis ?

• History :- Continuous, Scanty, Purulent, Occasional blood stained discharge

• Examination :- Attic perforation with active cholesteatoma flakes and purulent discharge

Q3. Points in favor of labyrinthine fistula ?

• History :- Dizziness since 6 months, not associated with fever, nausea, vomiting, pain
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• Examination :- Fistula sign positive i.e; nystagmus beating towards right

Q4. Purulent ear discharge seen in ?

• Furunculosis
• Mastoiditis
• Malignant otitis externa
• CSOM – Attico antral disease

Q5. Mucoid ear discharge seen in ?

• Safe type of Otitis Media

Q6. Mucopurulent ear discharge seen in ?

• Secondary infection in safe type of CSOM

Q7. Serous ear discharge is seen in ?

• CSF Otorrhea
• Eczematous cause in Otitis externa
• Viral Myringitis

Q8. Smell of cholesteatoma ?

• Rotten fish

Q9. Foul smelling discharge implies ?

• Infection with saprophytic bacteria ( [Link] , Klebsiella , Proteus )

• Bone erosion.

Q10. What will be colour in different type of discharges ?

• Yellow – Purulent
• Whitish Yellow – Mucopurulent
• Whitish – Mucoid

Q11. Frank Blood ear discharge is seen in ?

• Otitis Externa Haemorrhagica

• Malignancy
• Trauma
• Glomus tumours

Q12. Blood stained ear discharge is seen in ?

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• Polyps
• Malignancy

[Link] of HOH in CSOM?

. Tympanic Membrane Perforation

. Ossicular chain erosion

. Tympanosclerosis

. Diffusion of Bacterial Toxins through Round Window in Cochlea and damaging Hair cells

. Polyp / Granulations blocking EAC

Q14. Pain in CSOM indicates ?

• Masoiditis
• Otitis Externa
• Chronic irritation of middle ear mucosa due to air current

Q15. Circumduction sign or tragus sign ?

• In OE moving pinna will cause pain

Q16. Referred otalgia to ear is from which pathologies ?

• Caries / Impacted molar tooth ( Via 5th nerve )

• Pathology in oropharynx, ( Via 9th nerve ) hypopharynx ( Via 10th nerve )
• TMJ dysfunction ( Via 5th nerve )
• Elongated styloid process ( Via 9th nerve )
• Herpes zoster

Q17. Balance disturbance in a patient with CSOM indicates ?

• Labyrinthine fistula
• Acute suppurative Labyrinthitis
• Serous labyrinthitis
• Intracranial extension ( Cerebellar abscess )

Q18. How do you differentiate acute suppurative labyrinthitis, serous labyrinthitis and labytinthine
fistula ?
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• Acute suppurative labyrinthitis :- Fever, Nausea, Vomiting, Dizziness, Headache, Irreversible

Profound SNHL, Nystagmus towards opposite ear
• Serous labyrinthitis :- Nausea, Vomting, Dizziness, Reversible SNHL, Nystagmus to same ear
• Labyrinthine fistula :- Dizziness, No SNHL, Nystagmus to same ear, fistula sign positive

Q19. Which SCC is most commonly affected in Labyrinthine fistula ?

• Ampullary portion of horizontal SCC

Q20. Signs and symptoms of Intracranial complications ?

• Headache
• Fever
• Vomiting
• Neck stiffness
• Drowsiness

Q21. What is the importance of Asking about H/O Exanthematous fevers in childhood ?

. Suggests poor immunity of patient which leads to repeated upper respiratory tract infections and
thence CSOM

Q22. What is the importance of H/O Change of voice in a case of CSOM in Diabetics ?

. In Diabetics CSOM may leads to Malignant Otitis Externa , which inturn causes lower 4 cranial nerve
palsies . Involvement of Vagus causes Vocal cord palsy and Change of Voice .

Q23. Why should we ask regarding Family History of TB ?

. Diagnosis can be Tuberculous Otitis Media

. After surgery Wound Healing and Graft Uptake will not be Proper .

[Link] of Tuberculous Otitis Media ?

. Multiple Tympanic Membrane Perforations

. Pale Middle Ear Mucosa

. Painless discharge

.Hearing loss will beprofound & disproportionate between Clinical Findings and PTA findings

. Not relieved by Medication .

Q25. Which ear should we examine first ?

• Normal ear
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Q26. Why normal ear should be examined first ?

• First to see normal anatomy

• There should not be any transfer of infections from diseased to non diseased ear
• To gain confidence of patients

Q 27. Importance of Nose Examination in CSOM case ?

. Any pathology in nose causing nasal obstruction will cause Eustachian Tubal Dysfunction and then
causes Ear Pathology .

Q28. Importance of Throat Examination in CSOM case ?

. To see any Inflammatory pathology in Waldeyers Ring , enlargement / congestion of lingual or

palatine tonsils suggests some pathology in Tubal tonsils too , which causes Tubal obstruction by edema
and hence Ear pathology .

Q29. How to say Pinna Size is normal ?

. Normal sized pinna extends from the level of Supraorbital margin till Level of Ala of Nose

Q30. Position of pinna in post aural abscess ?

• Auricle is displaced laterally and inferiorly.

Q31. Pulsatile Discharge ?

• Heavily infected middle ear with pin hole perforation

Q32. Differential diagnosis of mass in EAC ?

• Neglected FB
• Furunculosis
• Exoxtosis
• Glomus tympanicum
• Malignancy
• Polyp from Middle Ear

Q33. Why cone of light is seen only in Antero inferior quadrant ?

• Light rays will directly focus on Umbo and that part of tympanic membrane around umbo lies
right angles to beam of light facing antero inferiorly .

Q34. Structures seen behind normal tympanic membrane ?

• Long process of incus

• Incudostapedial joint
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• Round window shadow

[Link] are the uses of Siegelisation ?

. Testing Mobility of Tympanic Membrane

. For Fistula Test

.Medication

.Magnification

[Link] to describe a TM?

. Colour

.Position

.Moblility

.Cone Of Light

. Texture

Q37. Features of retracted TM ?

• Dull and Lustreless

• Absent COL
• Prominent Anterior and posterior malleolar folds
• Foreshortened Handle of Malleus
• Prominent lateral process of malleus
• Restricted Mobility

Q38. Grading of Retractions ?

Pars Flacida – Tos classification

I- Pars flacida is minimally retracted but not adhered to Malleus
II- Retraction is adhered to neck of mallleus
III- Partial erosion of scutum
IV- Complete erosion of scutum

Pars Tensa – Sade’s Classification

I- Mildly Retracted tympanic membrane; not in contact with any middle ear structure
II- Retracted Tympanic Membrane in contact with Long Process of incus
III- Middle ear atelectasis, Retracted tympanic membrane in contact with promontory but moves
on siegelisation (Hypermobile)
IV- Adhesive otitis media, TM Plastered to promontory , No movement
V- Retracted Tympanic Membrane with perforation at that part which is adherent to promontory
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Q39. How to differentiate between Cholesteatoma debris and Fungal debris ?

• In Cholesteatoma there will be sac , cant be easily sucked out .

• Debris can be easily removed in fungal infections

Q40. Types of Perforations ?

• Central
• Attic
• Marginal

Q41. Definition of Central perforation ?

• Deficiency in the pars tensa part of the tympanic membrane which is surrounded by normal
tympanic membrane

Q42. Define subtotal and marginal perforation ?

1. MARGINAL PERFORATION-Involving Pars Tensa ,One Margin of Tympanic Sulcus Is Destroyed.

2. SUB TOTAL PERFORATION-Involving more than 2 quadrants of Pars Tensa,surrounded By
Fibrous Annulus.

Q43. Define a retraction pocket ?

• Invagination of a part of tympanic membrane into middle ear cavity without retention of keratin
debris but has potential to retain debris and become infected.

Q44. Tuning fork invented by ?

• John Shore

Q45. Tuning forks used ?

• Hartmann /Gardiner

Q46. Tuning fork tests discovered by ?

• Friedrich bezold

Q47. Which frequency of tuning fork is ideal for testing ?

• 512 Hz as it has optimal tone decay, less over tones, mid speech frequency and auditory >
Vibratory
• 1024 hz – Rapid tone decay
• 256 hz – More vibrations

Q48. Most suitable Tuning fork used for Webers Test ?

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. 256 hz

As Frequency of tuning forks decreases , Vibratory component increases and Auditory component
decreases .As webers test needs more of vibratory component 256 hz is more suitable .

Q49. Normal speech frequency ?

20-20,000 hz

Q 50. Audible frequency Range ?

a. 500-2000 Hz .

Q51. False negative rinnes – Seen in ?

• Severe unilateral SNHL

Q52. Define Nystagmus ?

• Involuntary , Rotatory , Oscillatory movements of eye ball

Q53. Types of Nystagmus ?

• Horizontal :- Due to involvement of Lateral SCC

• Vertical :- Due to involvement of either Posterior SCC or Superior SCC
• Torsional :- Due to involvement of both Posterior SCC and Superior SCC

Q54. Direction of nystagmus in labyrinthine fistula ?

• Spontaneous nystagmus beats towards diseased ear

Q55. What is fistula test ?

• To detect presence of fistula in bony walls of labyrinth

• Air is compressed in EAC by pressing tragus or by Siegle’s speculum
• Pressure is transmitted to TM ,Middle ear and Labyrinth
• Nystagmus Is produced towards diseased side

Q56. Reverse fistula sign ?

• Slow component of nystagmus is towards diseased side due to undue mobility of stapes foot plate

Q57. Positive fistula sign ?

• Labyrinthine fistula
• Fenestration operation
• Perilymphatic fistula
• Post stapedectomy
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Q58. Negative fistula sign ?

• Normal individuals
• Dead labyrinth

Q59. What is Hennebert’s sign ?

• False positive fistula sign

Q60. False positive fistula test ?

• Congenital syphilis ( Hypermobile stapes )

• Meniere’s disease ( Fibrous band connecting utricle to macula )
• Superior SCC dehiscence

Q61. False negative fistula test ?

• Fistula covered by cholesteatoma or granulations or polyp

• Dead labyrinth

Q62. Alexanders law of nystagmus ?

• 1st degree – Nystagmus when patient looks in the direction of fast component
• 2nd degree- Above plus when patient looks straight ahead
• 3rd degree – Nystagmus towards direction of slow component

Q63. What is Ewald’s law ?

• The stimulation of SCC causes movement of eyes in plane of stimulated canal.

• In Horizontal SCC ampullopetal flow causes stimulation.
• In Posterior & Superior SCC ampullofugal flow causes stimulation.
Q64. What are the Normal volumes of ?
• Middle ear cavity – 1ml
• Cavity after MRM – 2.4 cm3
• Cavity after Attico antrostomy – 1.4 cm3
• EAC – children – 0.5-1 ml
• Adults – 0.6 – 2ml

Q65. What is Notch of rivinus ?

• The annular sulcus houses the annulus of the tympanic membrane except superiorly ,where it
is deficient ; known as NOTCH OF RIVINUS .

Q66. What are Middle Ear Spaces ?

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Mucous membrane of middle ear cavity is thrown into series of folds by intratympanic structures ,
which divide middle ear into different compartments / spaces :-

• Superior malleolar fold

• Tensor tympani fold
• Superior incudal fold
• Lateral malleolar fold
• Lateral incudal fold
• Medial incudal fold
• Posterior malleolar fold
• Interossicular fold
• Anterior malleolar fold

Epitympanum is completely separated from mesotympanum by ossicles and their folds except at 2
openings :-

• Isthmus tympani anticus

• Isthmus tympani posticus
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Attic space is divided by Superior malleolar fold into :-

• Anterior Compartment (Anterior malleolar space)

• Posterior compartment

Posterior compartment is further subdivided by Superior Incudal fold into :-

• Superior Incudal space

• Medial incudal space

Upper part of mesotympanum is divided into :-

• Inferior incudal space

• Anterior pouch of Von Troeltsch
• Posterior pouch of Von Troeltsch
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Q67. What is Prussak's space?

Just medial to pars flaccida and lateral to the head and neck of the malleus;

Boundaries :-

• Laterally – Shrapnell’s membrane

• Medially – Neck of malleus
• Superiorly – Lateral malleolar fold & Scutum
• Inferiorly – Lateral process of malleus

Importance :- First space to get obliterated in Retraction pocket

Q68. What is Sinus Tympani ?

The mesotympanum extends into a recess of varying depth that lies posterior to the oval and round
windows, and medial to the vertical facial nerve, known as the sinus tympani.

Importance :- This space may harbor occult cholesteatoma despite careful and thorough removal of
bone around the facial nerve, which forms its lateral wall.

Relations :-

• Medially – Posterior semicircular canal

• Laterally – Pyramidal eminence & Facial nerve
• Superiorly – Ponticulus
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• Inferiorly – Subiculum

Q69. Boundaries of Facial Recess ?

The facial recess is the space bounded :-

• Laterally :- Chorda tympani nerve

• Medially :- Vertical part of facial nerve
• Superiorly :- Fossa incudes

Q70. What is Antrum Threshold Angle ?

• Superiorly – Fossa incudes

• Laterally – Tympanic annulus
• Medially – Facial nerve

Q71. What is Supratubal Recess and its importance ?

1. Bony cul-de-sac located at the anterior limit of the attic above eustachian tube opening is
known as the supratubal recess.
2. The posterior opening of this recess is marked by the cochleariform process inferiorly and the
“cog” superiorly, an incomplete bony septum oriented in the coronal plane.

Importance :- The facial nerve is vulnerable at the first genu to disease or surgical dissection within the
supratubal recess, from which it may be separated by minimal or no bone.

Q72. What is Anterior Buttress ?

• The bone where posterior bony canal wall meets the tegmen

Q73. What is Posterior buttress ?

• The bone where posterior canal wall and floor of EAC meets and is lateral to facial nerve

Q74. What is Facial ridge ?

• Is defined as posterior bony canal covering the vertical segment of facial nerve

Q75. What is Facial bridge ?

• Is defined as the part of the posterior bony canal wall that overlies Fossa Incudis
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Q76. What is COG ?

• The Cog Is A Coronally Oriented Bony Septum projecting from Tegmen to the Head Of The
Malleus that Separates The Anterior Epitympanic Recess (Supra tubal Recess) From Posterior
Attic Space.
• Facial nerve lies antero medial to it just before it turns into 1st genu
• Importance :- Can hide residual cholesteatoma in canal wall up surgery. The cog should be
removed to visualize the entire supratubal recess for safe removal of disease.

Q77. What is SOLID angle ?

• Angle formed by the 3 semicircular canals

Q78. What Is Arcuate Eminence?

• The arcuate eminence is the prominence of the superior semicircular canal on the
• middle fossa floor.

Q79. What is Trautmann’s Triangle ?

Bounded by

• Superiorly - Superior petrosal sinus

• Posteriorly - Sigmoid sinus
• Anteriorly – Bony labyrinth

Importance - Progression of disease towards this triangle may result in epidural abscess
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Q80. What is Donaldson’s line ?

A. Line formed by extending the plane of horizontal semicircular canal posteriorly to bisect the
posterior semicircular canal.

Importance :- Landmark for endolymphatic sac, the superior aspect of which lies below this line.
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Q81. Key area of ear ?

Attic – Aditus - Antrum

Q82. Parts of temporal bone?

• Squamous
• Petrous
• Tympanic
• Mastoid

Q83. Different ossification centres for Temporal bone ?

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There are 21 ossification centres for temporal bone

• Squamous portion – 1
• Tympanic ring – 4
• Petrosal part – 14
• Styloid process – 2

Q84. Theories of Pneumatization ?

1. TUMARKIN THEORY :-
• Eustachian tube obstruction with resultant intratympanic vaccum leads to arrest in
pneumatisation.
• This occurs in young children as a result of infection and enlargement ofadenoids.
2. HYPOTHESIS OF WITTMAACK :-
• Mucous membrane influences the development of mastoid air cell systemand normal
mucosa results in a well developed mastoid air cell system.
• During birth meconium or vernix caseosa may enter the middle ear andproduce a
pathological type of mucosa and infantile otitis may accomplishsame effect.
• This pathological mucosa will lead to inhibition or retraction of the processof
pneumatisation ofair cells.
• The pathological types of mucosa govern development of chronicsuppurative otitis
media.
3. DIAMANT THEORY :-
• Stated that degree of pneumatisation is determined by hereditary factors.
4. STERN’S THEORY :-
• Genetic factors implicated
5. GRAHAM AND BRACKMEN :-
• The size of mastoid depends upon the final size of the skull in an individual as in
acromegaly ( Large mastoid ) and microcephaly ( Underdeveloped mastoid )

Q85. What is Korners septum ?

• Korner's septum, the embryologic junction between petrosal and squamosal portions of
the temporal bone.
• This plate is a remnant of the petrous squamous septum, and simply separates more
superficial air cells from deeper ones
• Importance of Korner’s septum :- Difficulty in locating antrum

Q86. Infant mastoid features ?

• In infants, the mastoid tip is yet to develop.

• The stylomastoid foramen is located more superficially, making the facial nerve vulnerable to
surgical trauma
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Q87. What are different cells and cell tracts in temporal bone ?

Pneumatization may be organized into regions and tracts.

The primary regions of pneumatization are as follows :

1. The mastoid (the antrum, central mastoid tract, tegmental, sinodural, sinal, facial, and tip cells)
2. Perilabyrinthine (supralabyrinthine and infralabyrinthine areas)
3. Petrous apex (peritubal area and apical area)
4. Accessory region (zygomatic, squamous, occipital, styloid)

Tracts :-

1. Posterosuperior (sinodural)
2. Posteromedial (retrofacial and retrolabyrinthine)
3. Subarcuate
4. Perilabyrinthine (supralabyrinthine and infralabyrinthine)
5. Peritubal (associated with the eustachian tube)

Q88. Types of mastoids ?

• CELLULAR (80%): Plenty of air cells

• SCLEROTIC (20%): Small antrum, air cells absent
• DIPLOEIC (<1%): Bone marrow within few air cells

Q89. What is temporal line ?

• The temporal line is located about 5 mm inferior to the lowest level of the middle fossa floor.
• Used as a surface landmark that estimates the location of the middle fossa floor.

Q90. Mac - ewan’s triangle ?

• The mastoid antrum is located deep to the depressed cribriform area located posterior to the
spine of Henle, known as Mac ewan's triangle (Fossa Mastoidea).
• It is defined by :-
a. Temporal line or supramastoid crest - superiorly
b. Postero superior margin of EAC - anteriorly
c. A tangent joining these two - posteriorly
• Antrum lies 15mm deep to triangle
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Q91. Mastoid foramen transmits ?

• Mastoid emissary vein , connecting sigmoid sinus to occipital or posterior auricular vein
• Branch of occipital artery
• Posterior meningeal artery

Q92. Facial nerve connections ?

1. Special visceral efferents - muscles of facial expression, the stapedius muscle, the stylohoid
muscle, and the posterior belly of the digastric muscle.
2. General visceral efferent - nervus intermedius, which innervates
a. the lacrimal gland and seromucinous glands of the nasal cavity via the greater
superficial petrosal nerve and pterygopalatine ganglion, and
b. the submandibular and sublingual glands via the chorda tympani and the
submandibular ganglion.
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3. Special sensory fibers for taste innervate the anterior two thirds of the tongue via the chorda
tympani, and the tonsillar fossae and palate via the greater superficial petrosal nerve. The
geniculate ganglion contains the cell bodies of these sensory neurons.
4. Somatic sensory fibers provide sensation to touch of the EAC and conchal skin of the auricle,
and proprioceptive information from the facial muscles.
5. Visceral afferent fibers supply the mucosa of the nose, pharynx, and palate.

Q93. Facial nerve course ?

Motor nucleus (lateral portion of anterior pons )

Hooks around 6th nerve nucleus

Exits brainstem at pontomedullary junction

Crosses CPA with 8th CN & nerve of wrisberg (nervus intermedius)

Passes through IAC (10mm - length)

Labyrinthine segment (0.68mm diameter,4mm length) – narrowest & shortest

First genu

Tympanic (horizontal) segment – 11mm length

Second genu

Vertical/Mastoid segment – 13mm length

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Stylomastoid foramen

Parotid gland (pes anserinus)

Temporofacial and cervicofacial trunks

Q94. Narrowest portion of Fallopian canal ?

• The labyrinthine segment is the first, shortest, and narrowest segment of the fallopian canal
• NOTE :-
1. The tympanic segment is the most common site of congenital dehiscence of the bony canal,
especially above the oval window.
2. Bony dehiscence by cholesteatoma is also common proximal to the second genu, where the
adjacent aditus ad antrum acts as a bottleneck through which disease must pass en route to the
antrum, eroding structures in the posterior attic along the way.

Q95. Why tympanic segment is most prone for congenital dehiscence ?

• 2 ossification centres – The labyrinthine segment develops from otic capsule whereas tympanic
segment develops from 2nd branchial arch.
• So fusion of these two segments is responsible for congenital dehiscence.

Q96. Middle ear landmarks of the facial nerve ?

• The cochleariform process, the oval window, and the pyramidal eminence.
1. Cochleariform process, which serves as a consistent landmark for the midportion of the
tympanic segment of the facial nerve :- Lies anterior to facial nerve canal, the proximal end of
tympanic segment passes above and medial to cochleariform process.
2. Oval window :- The tympanic segment lies above it & posterior to it the nerve turns inferiorly to
take a vertical course, this is 2nd genu.
3. Pyramidal eminence – Nerve lies lateral and posterior to it

Q97. Cause of Facial nerve paralysis in otitis media ?

Facial nerve paralysis can result from

1. AOM :- In young children, facial paralysis that is caused by AOM is frequently incomplete and
probably occurs only in infants with congenital dehiscence of the fallopian canal in the middle
ear adjacent to the stapes.
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2. COM without cholesteatoma :- Facial nerve paralysis caused by COM without cholesteatoma
also usually affects the horizontal portion of the facial nerve near the stapes
3. Cholesteatoma :- Facial nerve paralysis caused by cholesteatoma can produce extensive erosion
of the horizontal segment of the fallopian canal
• Bacteria reach the nerve because of congenital dehiscences of the bony fallopian canal or via
erosion with granulation tissue or cholesteatoma.
• Facial nerve function is lost with inflammatory pressure or suppurative neurapraxia.
• If the edema persists, axonotmesis can ensue.

Q98. Causes of Facial nerve palsy in safe type of CSOM ?

• Dehiscent Fallopian canal

• Secondary cholesteatoma

Q99. What is House Brackmann staging ?

Q100. Grafts for Facial nerve repair ?

• Greater auricular nerve

• Sural nerve

Q101. How to locate Greater Auricular Nerve ?

• Located by drawing a line perpendicular to a line drawn between the mastoid tip and angle of
mandible.
• Lies immediately beneath platysma muscle over sternocleidomastoid.
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Q102. What is Vestibulo Ocular reflex ?

• It is the 3 arc neuron reflex between vestibule ( semicircular canals ) and eyes for maintaining
balance.
• The vestibular labyrinth is very sensitive and reacts to non sustained accelerations, such as
turning the head and redirects the eyes to maintain fixation on object of interest.

Q103. What is baffle’s effect ?

• Sound waves striking the tympanic membrane do not reach the oval and round windows
simultaneously.
• There is a preferential pathway to the oval window because of the ossicular chain.
• Thus, when oval window is receiving wave of compression, the round window is at the phase of
rarefaction.
• If the sound waves were to strike both the windows simultaneously, they would cancel each
other’s effect with no movement of the perilymph and no hearing.
• This acoustic separation of windows is baffle’s effect.
Q104. Definition of CSOM ?
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• Is an Inflammatory Process In the middle Ear cleft that Results In Long-term, Or More Often
Permanent Changes In The Tympanic Membrane Including Perforation, Atelectasis,
Tympanosclerosis, Retraction Pocket Development Or Cholesteatoma.
• Duration > 3months

Q105. Classify suppurative otitis media based on duration ?

• ASOM - Acute inflammation of middle ear space - < 6weeks duration

• Subacute SOM – 6 – 12 weeks
• CSOM - > 12 weeks

Q106. Types of COM ?

• Active – inflamed middle ear with pus

• Inactive – dry ear (no inflammation), have propensity to become active
• Quiescent -
• Healed – permanent changes of com with no propensity to become active
• Squamous – retraction of pars flaccida or pars tensa (postero superior) with or without
squamous epithelial debris
• Mucosal – Pars tensa defect with or without inflamed middle ear mucosa

Q107. Etiology of CSOM ?

• Repeted ASOM
• Eustachian tube dysfuntion
• GERD
• Craniofacial abnormalities
• Immunocompromised
• Poor mastoid Pneumatisation

Q108. Aerobic /Anaerobic bacteria in CSOM ?

Aerobic Gram positive :-

Staphylococcus aureus
Streptococci pneumoniae
Streptococci haemolyticus
Gram negative :
Proteus Mirabilis
E. Coli
Klebsiella
Pseudomonas
H. Influenza
Anaerobic Peptostreptococcus,
Bacteriodes fragilis
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Q109. MC organism cultured in CSOM ?

• Haemophilus influenza
• Streptococcus pneumonia
• Moraxella catarhalis

Q110. MC organism cultured in CSOM with cholesteatoma ?

1. Cholesteatomas contain keratin debris enclosed in a tissue space, they are subject to recurrent
infection.
2. The bacteria found in infected cholesteatomas differ from bacteria found in AOM or OME.
3. Significant anaerobic bacteria are present.

The most common aerobic bacterium is :-

• Pseudomonas aeruginosa
• Proteus
• Klebsiella
• [Link] (Gram Negative)

The most common anaerobic microorganism is Bacteroides

Q111. Pathological changes in COM ?

• Perforation
• Middle ear mucosal edema
• Submucosal fibrosis
• Hypervascularity
• Lymphocytic infiltration
• Granulation tissue
• Polyps
• Erosion of long process of incus , crura of stapes , body of incus , HOM
• Cholesterol granuloma
• Retraction pocket
• Cholesteatoma

Q112. What is the Pathology involved behind temporary perforations becoming permanent ?

• Endarteritis over the edges of perforation

[Link] long process of incus is frequently involved ?

• Delicate structure
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• Osteoclastic activity > osteoblastic activity

• Possesses a single nutrient vessel and lacks collateral circulation.

Q114. What is Cholesterol Granuloma ?

• It is a mass of granulation tissue , consisting of cholesterol crystals surrounded by foreign body

giant cells .
• It occurs where there is stasis of secretion and it is regarded as breakdown product of
haemorrhage.

Q115. What is a Polyp ?

• Hyperplastic and oedematous, prolapsed middle ear mucosa

Q116. Ear polyp attachments ?

• Promontory
• Fallopian canal
• Attic
• Ossicles
• Eustachian tube

Q117. What is Granulation tissue ?

• Vascularised fibrous tissue over underlying osteitis

Q118. Granulations on pars tensa what differential diagnosis can be suspected ?

• CSOM ( Painless, On seigelization TM will not move )

• Granular myringitis ( Painful, On seigelization TM mobile )
• Otitis externa haemorrhagica
• Bullous myringitis

Q119. Forceps for removing granulations ?

• Heathe’s granulation forceps

Q120. Define Tympanosclerosis ?

• Hyalinization of collagen & heterotopic calcification within fibrous layer of tympanic membrane
, submucosal layers of middle ear, ossicles
• Areas involved – Tympanic Membrane , tympanomastoid cavity , Stapes crura , footplate

Q121. How TS Patch over TM will effect ?

• It will involve the ossicles and leads to ossicular fixation affecting its mobility and causing
conductive hearing loss.
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Q122. End Stage pathology ?

End-stage pathology characterized by :-

1. Fibrocystic sclerosis :- Fibrosis and cyst formation that obliterates large portions of the middle
ear cleft. The cystic spaces become lined by mucosal epithelium that has been overrun by
proliferation of connective tissue.
2. Fibro-osseous sclerosis :- There is often deposition of new bone in the mastoid antrum and
surrounding mastoid cell tracts eventually resulting in a sclerotic mastoid
Q123. Define Cholesteatoma ?

• It is defined as presence of desquamated keratinized squamous epithelium in middle ear.

• It is a 3 dimensional connective tissue structure in the form of a sac conforming to the spaces of
architecture of middle ear cleft consisting of matrix made of Keratinizing squamous epithelium
with central white mass consisting of keratin debris
• This structure has capacity for progressive and independent growth at the expense of
underlyimg bone and has a tendency to recur after removal term cholesteatoma, coined by the
German physiologist Muller in 1838

Q124. What is Congenital cholesteatoma ?

• Squamous epithelium retained in middle ear space during embryologic migration of squamous
cells
• Tympanic membrane is normal and intact.

Q125. Criteria for diagnosis of congenital cholesteatoma ?

Levenson’s criteria :-

1) Pearly white mass medial to normal tympanic membrane

2) Pars tensa and pars flaccida normal

3) No history of prior ear infections

4)No h/o prior ear surgery

Q126. What are the sites of Congenital cholesteatoma ?

• Petrous apex
• CP Angle
• Mesotympanum
• Tympanic membrane

Q127. Staging of congenital cholesteatoma ?

• Stage I :- limited to one quadrant;

• Stage II :- involving multiple quadrants without ossicular involvement;
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• Stage III :- ossicular involvement without mastoid extension;

• Stage IV :- mastoid involvement.

Q128. Theories of Cholesteatoma ?

There are four basic theories of the pathogenesis of acquired aural cholesteatoma:

(1) Wittmaack’s theory :- Invagination of the tympanic membrane (retraction pocket cholesteatoma),

(2) Ruedi’s theory :- Basal cell hyperplasia,

(3) Haberman’s theory :- Epithelial ingrowth through a perforation (the migration theory), and

(4) Sade’s theory :- Squamous metaplasia of middle ear epithelium

Q129. Occult cholesteatoma ?

[Link] cholesteatoma is dangerous ?

• Because of bone eroding capacity it can lead to complications.

Q131. Causes of bone erosion in cholesteatoma ?

PRESSURE EROSION—Expanding Cholesteatoma Sac

BIOCHEMICAL EROSION - Bacterial Products, inflammatory Reactions, granulation Tissue.

CELLULAR MEDIATED EROSION—Osteoclastic Bone Resorption By Cyokines(TNF Alpha, interleukin

6,nitric Oxide)

Q132. Route of spread of cholesteatoma ?

Attic retraction cholesteatomas are directed posteriorly from Prussak's space through an opening into
the posterior epitympanum

From here, there is extension into the antrum through the aditus ad antrum

Or inferiorly into the posterior mesotympanum through isthmus tympani posticus , or both.

In advanced cases, disease may extend medial to the ossicles and to the anterior attic.

Note :- In cholesteatoma surgery, removal of the incus and the head of the malleus is required to
identify and address the anterior extension of disease.
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Q134. What are the sequelae of CSOM ?

Expected outcome of the disease is termed as sequelae.

• Ossicular chain necrosis

• Polyp
• Tympanosclerosis
• SNHL
• Secondary acquired cholesteatoma
• Permanent perforation
• Fibro- osseous sclerosis
• Fibrocystic sclerosis

Q135. Routes of spread of disease in CSOM ?

• Natural communications (Natural barriers like round window, oval window,cochlear acqueduct ,
vestibular aqueduct disrupted due to bacterial toxins )
• Direct erosion of bone ( Most common route )
• Preformed pathways ( Congenital dehiscence, Patent sutures, Surgical defect, Perilymphatic
fistula, Fracture temporal bone )
• Retrograde thrombophlebitis ( Lateral sinus Thrombophlenitis – Cerebellar Abcess , Superior
Petrosal Sinus – Temporal lobe abcess )
• Perivascular space of Virchow

Q136. What are the Complicatons of COM ?

Extracranial Intracranial
Mastoiditis Meningitis
Labyrinthitis Extra / Subdural abscess
Labyrinthine fistula Cerebellar abscess
FN paralysis Temporal lobe abscess,
Petrositis Lateral sinus thrombophlebitis
Otitic hydrocephalus

[Link] intracranial and Intratemporal complication ?

• Intracranial – Brain abscess ( Temporal lobe abscess )

• Intratemporal – Post aural abscess

Q138. What is Coalescent Mastoiditis ?

• The osteoclastic activity in the inflamed periosteum softens and decalcifies the bony partitions,
causing the small air cells to coalesce into a larger cavity.

Q139. What is masked mastoiditis ?

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• Chronic otitis with granulation tissue formation and bone erosion can occur without otorrhea.
• It can persist despite a normal or near-normal tympanic membrane.
• This condition has been referred to as masked mastoiditis

Q140. Abscesses seen in relation to mastoiditis ?

1. Post aural abscess :- Abscess beneath the periosteum of mastoid

2. Bezold’s abscess :- Formed due to perforation of tip of mastoid and seen in relation to SCM
3. Zygomatic abscess :- Abscess formed due to suppuration of air cells of zygomatic root of
temporal bone
4. Citelli’s abscess :- Behind the posterior part of mastoid in occipital region.
5. Luc’s abscess :- Abscess in deep external auditory canal due to breakdown of bony wall.

Q141. Differences between acute mastoiditis and furunculosis ?

Acute mastoiditis Furunculosis

Clinical features :- Persistent discharge, Pain, Clinical features :- Severe pain, Purulent
Hearing loss discharge
Examination :- Examination :-
Post aural region :- Smooth ironed out mastoid Post aural region :- Obliteration of retroaural
and hyperaccentuation of retroauricular groove groove
EAC :- Purulent discharge, Sagging of posterior EAC :- Furuncle +
meatal wall ( due to osteitis and periosteitis ), TM :- Intact
Reservoir sign positive Tragal tenderness +
TM :- Perforation + Three finger’s test :- Tenderness at anterior
Three finger’s test :- Tenderness at mastoid tip, border of mastoid if furuncle arising on posterior
posterior border/root of mastoid, cymba concha wall of EAC
Tuning fork tests :- Conductive hearing loss Infra auricular nodes enlarged
Tuning fork tests :- Normal hearing
Q142. Gradenigo Syndrome ?

• Deep Orbital pain

• Lateral rectus palsy
• Continous Ear discharge
1. Seen in acute petrositis
2. On the superior aspect of the petrous tip lies the trigeminal or gasserian ganglion.
Damage or irritation to the ganglion may explain the deep orbital pain that patients with apicitis
experience.
3. Extending from the tip of the petrous apex to the clinoid is the petroclinoid ligament.
The abducens nerve travels below the petroclinoid ligament (Gruber’s Ligament) in a small
canal called Dorello's canal.
Entrapment or inflammation in the ear of Dorello's canal is thought to account for the presence
of abducens paralysis in patients with petrous apicitis.
4. Undetected and poorly drained infected air cell of the petrous apex must trail through small air
cell tracts into the middle ear and mastoid causing continous ear discharge
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Q143. Symptoms in Temporal lobe abscess ?

• Nominal aphasia
• Quadrantic homonymous hemianopia
• Motor paralysis
• Jacksonian fits
• Auditory hallucination

[Link] in Cerebellar Abcess ?

. Dysdiadochokinesia

. Past Pointing

.Dysarthria

. Positive Rhomberg’s Sign

Q145. How to diagnose of Meningitis ?

• Lumbar puncture and culture of CSF

[Link] is Griesinger’s sign ?

• Oedema over mastoid bone due to thrombosis of mastoid emissary vein

Q147. What is Tobey ayer test or Queckensteadt test ?

• Spinal needle is inserted into the subarachnoid space.

• A manometer is attached and resting CSF pressure is recorded and compression of IJV is done, in
normal persons CSF pressure rises whereas on thrombosed side there will be no change in CSF
pressure.

Q148. Interpretation of Tobey ayer test ?

• Positive – Evidence of blockage of sigmoid sinus

• False positive – Sigmoid sinus smaller than opposite side
• False negative – Good collateral circulation around obstructed sinus by mastoid emissary vein or
inferior petrosal sinus.

Q149. What is Crowe – Beck’s test ?

• Pressure on normal side IJV produces engorgement of retinal veins & supraorbital veins which
subside on release of pressure.
• These changes absent on thrombosed side.

Q150. Delta sign is seen in ?

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• Empty triangle at sigmoid sinus consisting of clot surrounded by a high intensity rim of contrast
enhanced dura when thrombosis present

• Seen in Lateral sinus thrombophlebitis

Q151. What is Keratosis obturans ?

Characterised by accumulation of large keratin plugs in the osseous EAC resulting in obstruction

• Acute pain , hearing loss

• Underlying epithelium is hyperplastic with an increased rate of desquamation and loss of normal
migration
• EAC become Significantly widened
• T/t – Local debridement
• In recurrent cases – Canalplasty with skin grafting

Q152. What is External auditiory canal cholesteatoma ?

Characterised by presence of keratin debris within the canal

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• Elderly patients
• Unilateral
• Otorhea,dull pain , hearing loss
• Etiology – secondary to trauma,surgery,stenosisor chronic inflammation or spontaneous
• There will be focal erosion of bony canal (usually inferoposterorly)
• T/t – Debridement of bone , canalplasty skin grafting

Q153. What we see in EUM ?

• EAC – discharge , debris , wax

• TM – perforation , perforation edges , Squamous ingrowth
• Cholesteatoma debris
• Middle ear – Mucosa , Polyps , granulations

Q154. What is the role of Pure tone audiometry in case of CSOM ?

• Type of hearing loss

• Degree of hearing loss
• For documentation purpose
• Comparison of hearing pre op & post op
• Hearing aid prescription

Q155. What is Carhart’s notch ?

• It is seen at 2kHz at audiogram in BC curve

• Cochlear stimulation at that frequency is maximum by ossicular vibrations.
• As ossicles are fixed in Otosclerosis dip is seen at that frequency

Q156. What is Interaural attenuation ?

• Reduction is intensity of sound at opposite ear when acoustic stimulus is presented at tested
ear.
• For AC the interaural attenuation is 40 dB
• For BC the interaural attenuation is 5 dB
• Importance :- For AC the phenomena of masking is applied if difference is > 40 dB in both ears
to prevent participation of non test ear
• For BC the masking should be done in all cases

Q157. Factors influencing degree of hearing loss in CSOM ?

• Size of CP
• Position of CP
• Ossicular chain status
• Middle ear pathology ( TS patch, granulations, polyp, mucoid discharge )
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Q158. Patulous Eustachian tube is seen in ?

• Weight loss emaciated patients

• Atrophic rhinitis
• Pharyngitis

Q159. In CSOM which type of frequencies are affected ?

• Low frequencies

Q160. Cause ofSNHL in CSOM ?

• Ototoxic substances may traverse the bony wall of the cochlea directly

Q161. What are different Ototoxic drugs ?

• Aminoglycosides ( Streptomycin, Gentamicin, Netilmicin – Vestibulotoxic )

( Kanamycin, Amikacin, Neomycin – Cochleotoxic )
• Diuretics
• Quinines
• Cytotoxic drugs ( Cisplatin, Carboplatin )

Q162. Audiometric correlation with Ossicular chain disruption?

Complete obstruction of ear canal 30 dB

Perforation of tympanic membrane (It 10–40 dB

varies and is directly proportional to the
size of perforation)
Complete ossicular discontinuity with intact drum 55 - 60 dB

Ossicular discontinuity with perforation of TM 45 – 50 dB

( improvement is due to loss of barrier )
Malleus fixation 10 – 25 dB
Closure of oval window 60 dB
Q163. Who is Cholesteatoma hearer ?

• Cholesteatoma leads to ossicular erosion but still the person can hear due to cholesteatoma
bridging the gap between ossicles.

Q164. What is Patch test ?

• Cigarette foil is kept over Perforation and hearing improvement is observed

Q165. X - Ray views for temporal bone ?

• Laws view
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• Schullers view
• Owen’s view
• Chause View
• Towne’s view

Q166. What we see in X ray mastoids Lateral oblique view ( Law’s view ) ?

• Degree of development
• Trabecular pattern
• Cellular pattern (pneumatisation )
• Degree of involvement of air cells
• Anatomical landmarks - Tegmen plate , Sigmoid sinus
• Cholesteatoma (cotton wool appearance)
• Bone destruction: presence & extent
• Mastoid cavity

Q167. X ray mastoid findings in Chronic mastoiditis ?

• Non homogenous clouding of mastoid antrum and air cells

• Thickened trabeculae
• Sclerosis

Q168. Causes of large cavity in mastoid ?

• CHOLESTEATOMA EROSION
• MASTOIDECTOMY CAVITY
• TUBERCULAR MASTOIDITIS
• COALESCENT MASTOIDITIS
• MALIGNANCY
• EOSINOPHILIC GRANULOMA
• MEGA-ANTRUM
• LARGE EMISSARY VEIN

Q169. How to differentiate whether cavity is due to cholesteatoma or post mastoidectomy ?

• In cholesteatoma it will be irregular whereas edges in post mastoidectomy cavity will be smooth
& sclerotic.

Q170. Indications of CT SCAN in CSOM ?

• Suspected Complicated CSOM

• Revision mastoid surgery
Q171. Role of CT in CSOM ?
• Normal Anatomy
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• Extent of disease
• Bony erosions
• Ossicular chain status
• Facial nerve dehiscence

[Link] cuts are ideal for CT temporal bones ?

• HRCT 0.6- 1mm cuts

Q173. In CT temporal bones Ice cone appearance and snake eye appearance indicates ?

• Ice cone appearance – Head of malleus & Body of incus

• Snake eye appearance – Superior semicircular canal
Q174. Role of MRI in CSOM ?
• For intracranial extension of disease
• Assessment of lesions near Petrous apex

Q175. Objectives of Ear Surgery ?

• Primary – Safe and dry

• Secondary – Restore hearing
• Epithelised self cleansing ear

Q176. 1st cortical mastoidectomy was performed by ?

• Schwartz

Q177. 1st Tympanoplastywas performed by?

• Wullstein

Q178. 1st Myringoplastywas performed by?

• Berth hold

Q179. What is Myringoplasty ?

• The procedure in which the reconstructive process is limited to repair of tympanic membrane
perforation.
• Tympanoplasty without ossicular reconstruction

Q180. Advantages of Myringoplasty ?

• Control of recurrent otitis media if recurrent infections are from EAC through perforation
• Prevention of cochlear degeneration
• Prevention of tympanosclerosis
• Improvement of hearing
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• Can use hearing aids

• Prevention of vertigo
• Necessity in certain occupations

Q181. What is Tympanoplasty ?

• Tympanoplasty is a surgical procedure to eradicate disease in the middle ear and to reconstruct
hearing mechanism with or without tympanic membrane grafting.

Q182. Wullstein classification &Zollner’s classification of Tympanoplasty ?

Type Pathology Graft placed on

I Ear drum perforation only Malleus handle

II Malleus handle eroded Incus

III Malleus + Incus eroded Stapes head

IV Only footplate remains: Stapes Footplate

mobile

V Only stapes remains: fixed Lateral SCC opening

VI Only footplate remains: Round window

mobile
( Footplate exposed )

Q183. Austin’s Classification ?

• Type A :- M+ S+
• Type B :- M+ S-
• Type C :- M- S+
• Type D :- M- S-
• Type E :- Ossicle head fixation
• Type F :- Stapes fixation
• Type O :- M+ I+ S+
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[Link] is Sono Inversion?

• It is Type 6 tympanoplasty
• Graft is placed over Round window and footplate is exposed.

Q185. Prerequisites for Tympanoplasty ?

• Dry ear for atleast 6 weeks

• Functioning Eustachian tube
• Functioning ossicular chain & labyrinthine windows
• Normal mucosa in middle ear cavity
• Adequate Cochlear Reserve

Q186. Can we do tympanoplasty in both ears at same time ?Why?

• No as there is 1% chance of delayed Sensory neural hearing loss within 6 months.

• So wait for 6 months

Q187. When is Tympanoplasty in children indicated ?

• Unless there is cholesteatoma or b/l tympanic membrane perforations with significant hearing
loss tympanoplasty in children can be delayed until age of 10 years

Q188. Contraindications for tympanoplasty ?

Absolute Relative
Poor general health Only better hearing Ear to avoid risk of
Malignant tumours irreversible SNHL
Uncontrolled cholesteatoma Acute exacerbation of COM
Malignant otitis externa
Meningitis , Brain abscess

Q189. Where is infiltration given for tympanomastoid surgeries in post aural approach ?

• Post aural crease

• All 4 quadrants in EAC
• Incisura

Q190. Approaches in tympanoplasty ?

Three main approaches are used in tympanoplasty:

• Transcanal – Small posterior perforations

• Endaural
• Postauricular – Anterior perforations
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Q191. What are the different incisions ?

1. Rosen’s incision :-
For endomeatal approach.
It consists of two parts:
a) a small vertical incision at 12 o’clock position near the annulus and
b) a curvilinear incision starting at 6 o’clock position to meet the first incision in the
posterosuperior region of the canals, 5–7 mm away from the annulus

2. Lempert’s incision :-
• For Endaural approach
• Lempert I: It is semicircular incision, made from 12 o’clock to 6 o’clock position in
the posterior meatal wall at the bony–cartilaginous junction.
• Lempert II : Starts from the first incision at 12 o’clock and then passes upwards in a
curvilinear fashion between tragus and the crus of helix. It passes through the
incisura terminalis and thus does not cut the cartilage.

3. William Wilde’s incision:-

• Postaural approach
• It starts at the highest attachment of the pinna, follows the curve of retroauricular
groove, lying 8mm behind it, and ends at the mastoid tip.
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Q 192 Advantages of Post aural incision ?

. Good Exposure

. Better Access to mastoid Tip

.No chance of Perichondritis

Q193. Types of placement of graft ?

• Underlay
• Overlay

Q194. What is underlay technique ?

• In this technique the graft is placed medial to TM remnant, annulus and manubrium of malleus.

Q195. What are disadvantages of underlay technique ?

• Middle ear becomes narrow

• Graft may get adhered to promontory
• Anteriorly graft may lose contact from remnant TM leading to anterior perforation.

Q196. What is overlay technique ?

• Overlay technique, the graft is placed lateral to the fibrous layer of the tympanic membrane
remnant, but medial to the malleus handle.
• This technique requires complete removal of the squamous epithelium from the lateral surface
of the tympanic membrane remnant to avoid iatrogenic cholesteatoma formation.

Q197. Disadvantages of overlay technique ?

• Blunting of anterior sulcus, graft lateralization

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• Formation of epithelial pearl due to failure of complete removal of squamous epithelium of TM

remnant.
• Delayed healing due to areas devoid of epithelium in ear canal

Q198. What are the causes for failure of tympanoplasty ?

• Infection
• Poor Eustachian tube function
• Inadequate visualization of anterior sulcus , improper tucking
• Extensive tympanosclerosis of tympanic membrane remnant
• Inadequate anterior support of graft
• Patients not following instructions
• Recurrent/residual cholesteatoma

Q199. Types of Grafts ?

• Autografts :- Graft harvested from same individual

• Allografts :- Grafts harvested fromanother individual of same species
• Xenografts :- Graft harvested from animals i.e; another species

Q200. Different materials used as grafts ?

• Temporalis fascia
• Areolar tissue above temporal fascia
• Perichondrium
• Cartilage ( Conchal,Tragal )
• Periosteum
• Venous (Dorsal venous arch , saphenous )
• Dura
• Fat
• Cadaveric tympanic membrane
• Tensor fascia lata
• Synthetic – Stainless steel , Silastic , Teflon
• Heerman first used Temporalis Fascia graft
• Shea first used Vein graft

Q201. What is the fate of Tympanic membrane graft after placement in Tympano-mastoid surgeries ?

• Graft itself becomes the middle or connective tissue portion of reconstructed drum.
• Epithelialization of graft gets completed within 8-12 weeks of duration.

Q202. Why temporalis fascia is more suitable for grafting ?

• Easy to harvest in same incision

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• Same thickness
• Almost Zero metabolic rate , Avascular neovascular genesis is not required
• Fascia is tough
• Good survival

Q203. What is composite graft ? Indications ?

Cartilage shield graft from cymba concha with perichondrium

Indications :-

• Total perforation
• Atelectasis
• Revision cases
• Cholesteatoma

Q204. Graft materials for Ossiculoplasty ?

1. Autografts :- Incus or head of malleus, Cortical bone grafts, Cartilage

2. Homografts :- Taken from another individual of same species
3. Synthetic :- Polymers, Ceramics, and Metals ( Gold, Titanium ) as TORP or PORP
a. Polymers :-
• Polyethylene, Polytetrafluoroethylene (Teflon)
• Silicone rubber (Silastic)
• Polycel and Plasti-Pore .
b. Ceramics :-
• Glass ceramics and the calcium phosphate ceramic hydroxyapatite.
• Hydroxyapatite

PORP is used when Stapes is present and mobile

TORP is used when only mobile stapes footplate is present .

Q205. Disadvantageof Cartilage graft , Remodelled incus ?

• They develop chondromalacia with loss of stiffness and a tendency to become resorbed over
time . These disadvantages are less with metals .
• With Incus Patients may have recurrence because of microinvasion of Epithelium into incus of
diseased ear .

Q206. Disadvantage of homograft ?

• Risk of transmission of prion disease

Q207. What is Combined approach tympanoplasty ?

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It is a Surgical technique where in access to entire middle ear cavity will be gained without lowering down
the posterior canal wall .
Advantages :
• Cavity problems are eliminated
• Reconstruction of sound transducer mechanism which closes A-B gap

Disadvantages :

• Recurrent cholesteatoma
• Contraindicated in Children

Includes –
Cortical mastoidectomy
Atticotomy – for Epitympanum
Poterior Tympanotomy – for Meso and Hypo tympanum

Q208. Structures seen through posterior tympanotomy ?

• The promontory
• Round window niche
• Stapes
• Long process of the incus
• Cochleariform process
• Medial side of the tympanic membrane and malleus handle
• Eustachian tube

Q209. Lateral limit of dissection in extended facial recess approach ?

• Tympanic annulus

Q210. What is Cortical mastoidectomy / Simple mastoidectomy / Schwartz operation ?

• It is the procedure of complete exenteration of all accessible mastoid air cells converting them
into single cavity with posterior meatal wall left intact.

Q211. Main principles of Cortical Mastoidectomy ?

• Exploration of antrum
• Exenteration of Air cells
• Eradication of Disease

Q212. Indications for Cortical mastoidectomy?

• Suppurative mastoiditis
• Exposure of mastoid segment of facial nerve
54 | P a g e

• Combined approach tympanoplasty

• Endolymphatic sac decompression
• Internal Auditory meatus Access
• Cochlear implantation

Q213. Define Atticotomy, AtticoAntrostomy, MRM, Radical mastoidectomy ?

1. Atticotomy / Epitympanotomy /Bondy procedure :- Procedure in which disease limited to the

epitympanum is simply exteriorized by removing portions of the adjacent superior or posterior
canal wall.
2. Atticoantrostomy :- It is the procedure which is extension of atticotomy in a posterior direction
through transmeatal route which entails removal of lateral attic and aditus walls to enter antrum.
3. MRM :- It is an operation to eradicate disease from attic and mastoid which are exteriorized into
external auditory canal by removal of posterior meatal wall and lateral attic wall.

TM remnant, functioning ossicles and function of ET are preserved.

4. Radical mastoidectomy :- It is an operation to eradicate disease from attic and mastoid which are
exteriorized into external auditory canal by removal of posterior meatal wall and lateral attic wall.
All remnants of TM, malleus, incus, chorda tympani and mucoperiosteal lining removed and ET
opening closed by cartilage or muscle plug.

[Link] are the disadvantages of Canal wall down procedures ?

A)
1) Dependance (Regular Follow up )
2)Discharge
3)Deafness ( Cavity causes conduction loss)
4)Deformity

Q215. What is meatoplasty ? Types of meatoplasty ?

Is An Operative Technique To Widen The Lateral Cartilaginous Part Of The External Auditory Canal

Types :-

 KORNER’S FLAP

 SURDILLE’S FLAP

 SIEBERMAN’S FLAP

 STACKE’S MEATOPLASTY

 FISCH’S TECHNIQUE

Q216. What is Ideal Meatoplasty ?

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. Larger Speculum can be inserted through the canal

.Deepest part of mastoid is to be seen

. 2/3rd of the cavity is to be seen through the speculum

Q217. What are different types of burrs used ?

• Cutting burrs – for rapid bone removal (7mm initially)

• Diamond burrs – near vital structures where fine dissection is necessary(disadvantage is more
heat is produced –thermal injury)
• Polishing burr

Burrs should not touch Ossicles while drilling , which may transmit acoustic energy sufficient to cause
serious damage to cochlear function

Q218. Why should we do irrigation while drilling ?

• To avoid bone dusting ( hides vital structures , causes neo-osteogenesis and Conductive hearing
loss)
• Wet bone remains translucent, any anatomic structure ( nerve, vein ) can be seen through wet
bone
• To avoid heat generated by drilling which can affect facial nerve function

Q219. What is barber pole fashion of drilling ?

A. Egg shelling of facial canal is performed in a barber pole fashion, in order to avoid injury to
surrounding vital structures. Over the vertical segment, bone is thinned on the posterior aspect
and avoided laterally because of presence of chorda tympani nerve.
B. At the 2nd genu, bone is removed on the anterior and lateral surface. The horizontal semicircular
canal is damaged if bone is removed on the posterior side.
C. Horizontal segment of nerve is unroofed along inferior/anterior border upto the level of
cochleariform process. If drilling is done posteriorly or superiorly, may damage the ampullary
end of horizontal and superior semicircular canal.
D. Labyrinthine segment is traced from the geniculate ganglion by removing supralabyrinthine air
cells.

Q220. What are the cells which are difficult to exenterate ?

• Retrofacial cells
• Tip cells
• Sino dural cells

Q221. How to describe post op Mastoid cavity status ?

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• All walls are to be described

• Epithelisation status
• Clearance status of Secretions Adequate meatoplasty done or not

Q222. What are the Characteristics of an Ideal Cavity ?

. Sloping Edges

. Saucerization

. Adequate lowering of Facial Ridge

Q223. Complications of mastoid surgery ?

• Damage to the dura, facial nerve, labyrinth, and sigmoid sinus and jugular bulb.

Q224. What are the Problems of cavity ?

• Chronic Discharge From The Cavity

• Dizziness Due To Stimulation Of Semicircular Canals Either Due To Water Or Air Exposure
• Difficulty In Placing The Hearing Aid
• Unsightly Appearance

Q225. Causes of draining cavity after canal wall down procedure ?

• Recurrent or residual cholesteatoma

• High facial ridge
• Sump in cavity below floor of EAC
• Inadequate Meatoplasty
• Incomplete exenteration of infected cells
• Granulation tissue
• Normal migration of squamous epithelium of TM & EAC is lost

Q226. Management of problem cavity ?

1. Free grafts – temporalis fascia , Fascia lata

2. Muscle grafts
3. Periosteal grafts
4. Abdominal fat
5. Thin free skin grafts
6. Pedicle grafts – Temporalis Muscle, Sternomastoid, Occipitalis, Temporalis fascia pedicled grafts

Q227. Materials used for obliteration of mastoid cavity ?

• Autogenous bone and cartilage, Bone dust - osteogenic

• Free or vascularized soft tissue that is removed during meatoplasty
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• Bioactive or biocompatible alloplastic materials.

• Hongkong flap – Superiorly based Temporalis muscle flap

[Link] is Cholesteatoma Pearl ?

• When a part of cholesteatoma matrix is left within a closed Middle ear cleft , then that matrix
will develop into a Squamous epithelial retention cyst / Cholesteatoma pearl.
• It differs from acquired cholesteatoma in that it has no external opening and there is less
inflammation.

Q229. Management of Accidental defects occurred on posterior meatal wall while doing
tympanomastoid surgery ?

• Defect should be closed with Bone pate , cartilaginous graft , fascia .

• If not repaired again retraction pocket will form which leads to recurrent cholesteatoma

Q230. Treatment for Tympanosclerosis ?

Mobility of the ossicular chain is reduced by tympanosclerosis in the attic or in the oval window.
When only incus and head of malleus are fixed :-
• Corrected by removing the incus and head of malleus and reconstructing the ossicular chain
between handle of malleus or tympanic membrane and stapes.
• Or the outer attic wall can be removed and the malleus and incus mobilized.
This is often effective in the short term, but there is a tendency for refixation of the ossicles by
fibrous tissue or bone.
When the stapes is involved, surgery involves mobilizationof the stapes or stapedectomy.

Q231. Treatment of labyrinthitis ?

• Bed rest
• IV Antibiotics
• Labyrinthine Sedatives – Prochlorperazine
• Observe for meningitis symptoms
• Mastoid exploration electively

Q232. Treatment of Labyrinthine Fistula with active COM ?

• Early mastoid exploration

• Sealing of fistula with fascia

Q233. Management of Iatrogenic FN palsy ?

Intraoperative :-
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• Minimal injury – Decompression of canal proximal and distal to nerve

• Complete – Primary anastomosis

Postoperative recognition :-

• Reassess after 4 hrs for anaesthetic to wear off

• Severe paresis – exploration and repair

Q234. Advantages of endoscopic ear surgery ?

• Can view into depths of operative field

• Wide field of view
• Surgical morbidity , operating time can be reduced
• Examination of undersurfaces of ossicles , tympanic membrane and deep recess of mastoid
cavity can reduce cholesteatoma residual rates

Q235. Disadvantages of endoscopic ear surgery ?

• One hand only used

• Light induced heat may cause caloric effect and may induce nystagmus

Q236. Approaches for Petrous Apex ?

A. Eagleton’s approach :- A wide exposure of the dura of the middle foosa is made by removal of
the tegmen, the base of the zygoma and part of the squamous temporal bone. The dura of the
middle fossa is gently elevated towards the petrous apex.
B. Almoor’s operation :- The petrous apex is approached through a triangle bounded by the
tegmen tympani above, the carotid artery anteriorly and cochlea posteriorly.
C. Ramadier’s approach :- The tympanic plate of the external auditory canal, posterior to the base
of the glenoid fossa suture line, is removed. The carotid artery is lifted forward by a guaze sling.
The petrous apex may then be explored through the posterior wall of the bony carotid canal.
D. Frenckner’s approach :- Through the arch of the superior semicircular canal.
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Any queries kindly mail to drphani21@[Link]

CASE PRESENTATION 2
Patient Name :- XYZ

Age :- 58 years

Sex :- Male

Occupation :- Farmer

Residence :- Sangareddy

Came to the hospital with the chief complaints of

1) Left nasal discharge since 4 months

2) Bilateral nasal obstruction since 3 months
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3) Left cheek swelling since 2 ½ months

4) Protrusion of left eye since 2 ½ months
5) Decreased vision from left eye since 2 ½ months

History of present illness :-

Patient was apparently asymptomatic 4 months back then he developed left nasal discharge, insidious in
onset, for the duration of 4 months, continuous in nature, no aggravating and relieving factors. Nasal
discharge is mucoid, non foul smelling, occasionally blood stained which is spontaneous.

H/O bilateral nasal obstruction present which is insidious in onset, gradually progressive for the duration
of 3 months, initially developed on left side then later has progressed to right side within 2 months of
duration, which is continuous throughout the [Link] nasal obstruction is complete whereas right nasal
obstruction is partial.

No diurnal and positional variation.

No aggravating and relieving factors.

H/O left cheek swelling present which was observed 2 ½ months back, insidious in onset, gradually
progressive. Initially it was groundnut size and gradually progressed to lemon size, which is associated
with pain which is pricking in nature, present throughout the day, aggravated on chewing, relieved
partially on taking medication, radiating to left pre-auricular region.

H/O protrusion of left eye present which is insidious in onset, gradually progressive for the duration of 2
months associated with pain which is dull aching in character, constant throughout the day, no
aggravated factors, relieved partially on taking medication.

H/O decreased vision from left eye since 2 months insidious in onset, gradually progressed to complete
loss of vision.

H/O loss of smell sensation present since 2 months.

H/O hyponasal speech present.

H/O mouth breathing and snoring present.

H/O headache in left frontal region present.

H/O watering from left eye present.

H/O decreased hearing from left ear present.

H/O Pain in left ear present.

No H/O frank nasal bleeding, sneezing, post nasal discharge.

No H/O cheek numbness

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No H/O difficulty in mouth opening, loosening of teeth, loss of teeth

No H/O double vision

No H/O swelling in the neck

No H/O nausea, vomiting, personality change

No H/O ear discharge, ringing sensation, dizziness

No H/O drooping of eyelid

No H/O nasal regurgitation, difficulty in swallowing, change in voice

No H/O fever, cough, weight loss, loss of appetite

Past History :-

No H/O Similar complaints in the past

Not a K/C/O DM/HTN/CAD/CVA/Epilepsy /TB/Bronchial Asthma/ Bleeding Disorder/ Chronic sinusitis /

Chronic liver & kidney disease/ radiation exposure

No H/O surgeries in the past

No H/O blood transfusion in past

No allergic drug history

Personal History :

Diet – Mixed

Appetite – Decreased

Bowel and Bladder Movements – Regular

Sleep – Disturbed

Addictions :-

Beedi Smoker – 10/day since 10 years

Alcoholic – 60ml / week since past 10 yrs ( whisky )

No H/O sniffing / Gutka chewing

Family History :-

Not contributory ( enquire about Tuberculosis/ Malignancy in family )

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General Examination :

Patient is conscious , coherent , cooperative

Patient is moderately built , moderately nourished

Pallor0 Icterus0 Clubbing0 Koilonychia0 Cyanosis0Generalised Lymphadenopathy0 Pedal Edema0

Systemic Examination :

CNS : Intact , NAD

CVS : S1+ S2+ M0

RS : Bilateral Air Entry present , No adventitious sounds

P/A : Soft

ENT EXAMINATION :

NOSE :-

Facial asymmetry present

Fullness in left medial canthus present

Increased intercanthal distance

Skin over nose :- Normal

On tip raising Columella Normal

Right Left
Vestibule Normal Mucoid discharge present in
left vestibular region
External nares Normal Mucoid discharge present on
left

Anterior Rhinoscopy Right Left

Septum Anterior cartilaginous deviation to right present
Floor Normal Single pink exophytic mass
Lateral wall Normal with irregular surface covered
with discharge and slough
seen filling entire left nasal
cavity extending anteriorly
upto left nasal vestibule.
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On probing it is insensitive,
firm in consistency, scanty
bleeding, not friable, able to
pass probe all around except
laterally.

Posterior rhinoscopy :-

Single pink irregular exophytic mass seen in left choana.

Eustachian tube opening not visualised on left side.

Right choana normal and eustachian tube opening on right normal.

Paranasal sinuses :-

Paranasal sinus Right Left

Frontal Non tender Non tender
Anterior Ethmoidal Non tender Tenderness present
Maxillary Non tender Tenderness present

Functional tests:-

Smell :- Absent sensation

R L

Cold spatula :- Decreased misting Absent misting

Cotton wool :- Decreased movement of fibre Absent movement of fibre

Examination of eye :-

Right Left
Size Normal Proptosis present
Appearance Normal Chemosis present
Prolapse of inferior palpebral
conjunctiva present

Ocular movements Normal No movement

Vision Normal No perception of light
Infraorbital margin Normal Blunting present

Examination of face :-
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Fullness of left cheek present

Sensation over face :- Right – Intact, Left- Decreased sensation

Oral cavity :-

Angle of mouth – Normal

Lips – Normal

Mouth opening – full and adequate

Gingivo Labial sulcus –Normal

Gingivo Buccal Sulcus – Normal

Gums- Nicotine stained, widening of left alveolar ridge

Teeth – Normal , No loose tooth seen

Anterior 2/3rd of Tongue – Normal

Floor of mouth - Normal

Buccal Mucosa – Normal

Hard Palate – Fullness in left half of hard palate, mucosa intact

B/L Retro Molar Trigone – Normal

Oropharynx :- Normal

IDL :- Normal

Neck :- No cervical lymphadenopathy

Ears :-

Right ear :- Normal

Left ear :-

Tympanic membrane :-

Grade 1 pars tensa retraction

COL absent

Decreased mobility on seigelization

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Functional tests :-

TFT’s Right Left

Rinne’s Positive Negative
Weber’s Lateralised to left
Absolute bone conduction Same as examiner Same as examiner

Cranial nerve examination :-

Left 1st, 2nd , 3rd, 4th, 5th, 6th not intact.

Provisional Diagnosis :-

Left sinonasal malignancy with Left NSOM with Mild CHL with left Intraorbital extension

Clinical Staging :- T4b N0 MX Stage IVb

Differential Diagnosis :-

Invasive fungal sinusitis

Tuberculosis of Maxilla

Investigations :-

Routine investigations

Specific :-

X- Ray PNS

CECT PNS & ORBITS

DNE and Biopsy

MRI BRAIN

USG abdomen

CXR

PTA, IA

Clinical Discussion :-

Q1. What are the positive findings which support your diagnosis ?
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History :- 58 yrs old male patient came with complaints of Left nasal discharge, Left nasal obstruction,
Left cheek swelling, Left eye swelling, Decreased vision from left eye, shorter duration, rapid progression
of symptoms with history of addictions

Examination :- Exophytic Mass in left nasal cavity, irregular surface, being firm in consistency with
scanty bleeding on probing extending upto left choana, fullness in left medial canthus, increased
intercanthal distance, left cheek fullness and blunting of left infraorbital margin, proptosis of left eye,
with absent movements of left eye and loss of vision of left eye, widening of left alveolar ridge and
fullness in left half of palate with involvement of left 1st, 2nd,3rd, 4th, 5th, 6th cranial nerves

Q2. Importance of Age in Nose case ?

• JNA :- 10-25 yrs of age

• NPC :- Bimodal age with an early peak of 10 to 20 years and a second peak between 40 and 60
years
• Olfactory neuroblastoma :- Bimodal with peaks at 20 and 50 years of age
• Inverted Papilloma :- 4th – 5th decade
• Sinonasal malignancy :- 6th – 7th decade

Q3. Importance of Gender in Nose case ?

• JNA :- Exclusively in males

• Inverted papilloma :- Highest incidence in males
• Olfactory neuroblastoma, Malignant melanoma :- Highest incidence in females

Q4. Importance of occupation in nose case ?

• Furniture industry :- Sinonasal malignancy

• Rice field :- Rhinosporidiosis

Q5. Importance of residence in Nose case ?

• Coastal areas :- Rhinosporidiosis

Q6. Importance of character of nasal discharge in pointing towards diagnosis ?

• Watery :- CSF Rhinorrhea, Vasomotor Rhinitis, Allergic Rhinitis

• Purulent nasal discharge :- Acute sinusitis, Atrophic rhinitis, Neglected Foreign body, Malignancy
with secondary infection
• Mucoidal :- Allergic fungal sinusitis
• Blood stained :- Rhinosporidiosis, Granulomatous conditions, Inverted papilloma, Malignancy

Q7. If a child is complaining of unilateral foul smelling blood stained nasal discharge what do you
suspect ?

Foreign Body
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Q8. If elderly patient is complaining of unilateral foul smelling blood stained nasal discharge what do
you suspect?

Malignancy

Q9. Bilateral nasal obstruction in elderly suspect ?

Malignant mass pushing the septum to opposite side (DNS to opposite side)

Q10. Importance of nasal obstruction during expiration or inspiration ?

More nasal obstruction during expiration in AC polyp more during inspiration in ethmoidal polyps.

Q11. Causes of anosmia in present case ?

• Intracranial extension
• Malignant lesion pushing the septum to opposite side leading to mechanical obstruction of air
flow to olfactory area

Q12. When the patient is complaining of headache what do you suspect ?

• Mass obstructing the sinuses leading to tension headache

• Intracranial extension of tumor

Q13. How to rule out intracranial extension on history ?

• Enquire about nausea, vomiting and personality change

Q14. Site of headache importance ?

• Temporal headache :- Organic causes, Vascular (Temporal arteritis), TMJ dysfunction

• Frontal :- Nonspecific, Sinusitis, Visual problems, Migraine
• Occipital :- Hypertension, Isolated Sphenoid involvement

Q15. Headache increasing on bending forwards suggests ?

• Sinusitis or Raised ICT

Q16. Causes of unilateral facial pain ?

• Temporal arteritis
• Acute Sinusitis
• TMJ arthralgia
• Dental caries
• Trigeminal neuralgia
• Migraine

Q17. Differential diagnosis of cheek swelling ?

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Skin Furuncle
Folliculitis
Basal cell carcinoma
Infected acne
Subcutaneous Fibroma
Lipoma
Neurofibroma (Infraorbital nerve)
Haemangioma
Lymphangioma
Lymph node swelling
Sebaceous cyst
Subcutaneous Phycomycosis
Bone Fibrous dysplasia
Osteoma
Adamantinoma
Dental cyst
Dentigerous cyst
Aneurysmal bone cyst
Osteosarcoma
Osteoclastoma
Sinus Granulomatous conditions
Malignancy

Q18. Cheek swellings associated with trauma ?

• Aneurysmal bone cyst

• Haematoma

Q19. Features of Fibrous dysplasia ?

• Common in females, 2nd decade

• CT scan confirmatory :- Ground glass appearance

Q20. Plan of surgery for fibrous dysplasia ?

• Paring down of excess tissue by lateral rhinotomy approach

Q21. Causes of painful swelling?

• Inflammatory swelling
• Secondary infection
• Benign to malignant transformation
• Haemorrhage and cystic degeneration of malignant swelling

Q22. Cause of decreased hearing from ear ?

• Eustachian tube obstruction leading to serous otitis media

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Q23. Why should cheek numbness be enquired ?

• To rule out Invasion of infraorbital nerve

Q24. Causes of Trismus ?

Abnormalities of teeth or mandible Unerupted tooth, Stomatitis, Osteomyelitis of

the jaw, TMJ arthritis and osteoarthritis
Acute inflammation in TMJ region Peritonsillitis and abscess, Sialadenitis, Otitis
externa, Malignant otitis externa,
Parapharyngeal space abscess
Trauma TMJ fracture, Fracture of zygoma, mandibular
fracture, TMJ dislocation
Muscle spasm Spasm due to CNS causes
Tumors Tumors of TMJ
Q25. When will the patient complaint of nasal regurgitation ?

• Neurological causes
• Structural causes :- Cleft palate, Posterior pharyngeal wall mass, Soft palate mass

Q26. Why drooping of eyelid is important in this case ?

• Horner’s syndrome ( Retropharyngeal nodes compressing over cervical sympathetic chain)

Q27. Importance of chronic rhinosinusitis in past history ?

• Because it is a predisposing factor for sinonasal malignancy

Q28. Importance of asthma in past history ?

• Nose pack can trigger bronchospasm in asthma patients

• Use of Beta blockers during intra operative period for hypotensive anaesthesia can precipitate
asthma in asthmatic patients

Q29. Importance of blood transfusion ?

• Blood transfusion patients at high risk for acquiring HIV infection which may present as
lymphoma (Nasal mass)

Q30. Importance of general examination in nose case ?

• Skin nodules and conjunctival involvement in Rhinosporidiosis

• Anaemia may suggest possibility of distant metastasis to bone marrow
• Ascites may suggest possibility of distant metastasis to abdomen and liver

Q31. Importance of blood pressure in nose case ?

• Prolonged nasal obstruction can lead to hypoxia and predisposes patient to

• Hypertension, Pulmonary Hypertension
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Q32. Importance of palpation of inguinal and axillary lymph nodes ?

• To rule out lymphoma

Q33. Importance of systemic examination in nose case ?

• Per abdomen organomegaly, ascites suggests metastasis

• Crepts on auscultation of Respiratory system suggests metastasis

Q34. Fullness in medial canthus suggests ?

• Breach of lamina papyracea

• Mass in anterior ethmoids

Q35. Causes of increased intercanthal distance ?

• Ethmoidal polyps
• Extensive fungal infection
• Mucocele
• Fibrous dysplasia

Q36. What is the reason for variable consistency of tumor ?

• Cystic suggests degeneration and hard suggests infiltration of bone

Q37. On probing if mass bleeds profusely what can be suspected ?

• Angiosarcoma
• Haemangioma
• Haemangiopericytoma
• Angiofibroma

Q38. Conditions where probe cannot be passed between floor and mass ?

• Rhinolith

Q39. Conditions where probe cannot be passed between roof and mass ?

• Olfactory neuroblastoma
• Plasmacytoma
• Meningocoel

Q40. Causes of sinus tenderness in case of nasal mass?

• Malignancy
• Mass obstructing the sinus ostia and leading to acute sinusitis

Q41. Causes of enophthalmos in CA maxilla ?

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• Retropharyngeal lymph nodes compressing on Cervical Sympathetic Chain (Horner’s Syndrome)

and Infraorbital rim involvement

Q42. Blunting of infraorbital rim suggests ?

• Intraorbital spread of tumor via roof of maxillary sinus

Q43. If the patient is blind how to check ocular movements ?

Q44. If there is a sinus or fistula over skin of cheek what are the possibilities ?

• Tuberculosis
• Chronic osteomyelitis
• Malignancy
• Actinomycosis
• Fungal

Q45. Cause of loss of sensation over palate ?

• Invasion of greater palatine nerve (Branch of maxillary nerve )

Q46. Grades of trismus ?

• Grade 1 – 2.5-4cms
• Grade 2 – 1-2.5cms
• Grade 3 - <1cm
• Grade 4 – Complete closure

Q47. Importance of examination of Oropharynx in this case ?

• Restriction of movements of soft palate

• Lowering of soft palate due to mass
• Mass hanging in oral cavity

Q48. Importance of IDL examination in present case ?

• Synchronous lesion, as patient is having ear pain to rule out lesion in larynx, pharynx

Q49. Which nodes should be examined in case of sinonasal malignancy ?

• Submandibular and Upper deep cervical lymph nodes

Q50. Differential Diagnosis for unilateral nasal mass ?

Congenital Meningoencephalocele
Inflammatory Antrochoanal Polyp
Fungal Invasive :- Chronic granulomatous invasive
fungal sinusitis
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Granulomatous Bacterial :- Rhinoscleroma, Tuberculosis,

Leprosy, Syphilis
Fungal :- Rhinosporidiosis, Aspergillosis,
Mucormycosis
Unspecified :- Wegener’s granulomatosis,
Midline granuloma
Benign tumours Inverted Papilloma, Squamous papilloma,
Haemangioma, NPAF
Malignant tumours Sinonasal malignancy :-
Squamous carcinoma
Adenocarcinoma, Adenoid cystic carcinoma
Malignant melanoma
Olfactory neuroblastoma
Lymphoma
Plasmacytoma
Miscellaneous Blob of mucus
Hypertrophied Inferior turbinate
Rhinolith

Q51. According to history & examination pertaining to present case what differential diagnosis can be
suspected ?

• Inverted Papilloma
• Chronic Invasive Fungal Sinusitis
• Tuberculosis
• Rhinosporidiosis

Q52. Negative points against Rhinosporidiosis ?

• Patient not from coastal area, There will be no cheek swelling, No dead eye, Mass not studded
with white fungal spores

Q53. Sites of origin of Rhinosporidiosis ?

• Turbinates
• Nasopharynx

Q54. How to differentiate from hypertrophied inferior turbinate ?

• Pink in colour, Mulberry appearance in case of allergic rhinitis, irregular, sensitive, immobile,
firm to Hard on probing

Q55. Final confirmation for Hypertrophied Inferior Turbinate ?

• On instillation of vasoconstrictor the turbinate shrinks significantly

Q56. Characteristic appearance of inverted papilloma ?

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• Polypoidal greyish pink lesion, firm in consistency

Q57. Sites of origin of inverted papilloma ?

• Osteomeatal complex
• Posterior fontanelle
• Maxillary sinus
• Turbinates
• Lamina papyracea

Q58. Causes of bleeding in inverted papilloma?

• Coexistent malignancy in inverted papilloma

• Inverted papilloma eroding sphenopalatine area
• Invasion of skull base and anterior ethmoidal artery

Q59. How to confirm inverted papilloma ?

• Deeper biopsy. Multiple bits should be sent for Histopathological examination as some areas
may have malignant transformation

Q60. Percentage of malignant transformation in inverted papilloma ?

• 10%

Q61. Percentage of co-existing malignancy in inverted papilloma?

• 56%

Q62. Can AC polyp present with bleeding ?

• Yes

Q63. Reason for bleeding in AC polyp?

• Angiomatous polyp

Q64. What is the reason for angiomatous polyp ?

• Squamous metaplasia due to air current.

Q65. Reasons for AC polyp growing posteriorly ?

• Gravity
• Inspiratory current directed posteriorly
• Cilia beats posteriorly
• Nasopharynx roomy
• Accessory ostium directed posteriorly

Q66. Can AC polyp present anteriorly ?

74 | P a g e

• Yes

Q67. Features of tuberculosis affecting nose and sinuses ?

• Nodular type :- reddish firm nodules (Apple Jelly nodules )

• Ulcerative type :- Involves anterior end of septum, inferior turbinate, Ulcer has undermined
edges
• Sinus granuloma :- Soft tissue swelling with discharging sinuses

Q68. How to diagnose tuberculosis ?

• Mantoux test, PCR, AMTD (Amplified Mycobacterium Tuberculosis Detection ), Bacteriological

examination demonstrating AFB, Biopsy and HPE.

Q69. Features of Wegener’s Granulomatosis ?

• Triad of involvement of airway passages, lungs and kidneys.

• Purulent blood stained discharge, crusting and granulations.
• Characterized by necrotizing granulomas.

Diagnosis includes:-

Serological :- cANCA test positive

Radiological :- CXR nodular lesions in lungs

Urine Examination :- Microhaematuria

Biopsy and HPE

Q70. Features of midline granuloma ?

• Classical destruction of mid face i.e; septum, palate and throat.

• Diagnosis is by biopsy.

Q71. Midline granuloma also known as ?

• T/NK cell lymphoma and Stewart’s Granuloma

Q72. How to differentiate nasoalveolar cyst from CA maxilla ?

• Bulge of lateral wall of the nose especially inferior turbinate

which is cystic in consistency

Q73. X – Ray PNS findings in sinonasal malignancy?

• Opacification
• Sinus expansion
• Destruction
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Q74. Role of CT scan ?

• Extent of involvement, Bone erosion, Homogenous or heterogenous density

• Helpful for evaluation of tumor involvement of the retroorbital and orbital apex region, where
there should be a “central low density region of fat surrounding the optic nerve with a radial
arrangement of the extraocular muscles.
• Loss of this plane suggests advanced disease.
• CT is also valuable in assessing infiltration of the nasopharynx, where normal anatomy consists
of a very thin layer of mucosa over the medial pterygoid plate.
• Thickening in this region implies tumor infiltration.

Q75. Role of contrast?

• Vascularity, Delineation of heterogeneousity , Fungal or non fungal

Q76. Need for MRI in present case ?

• In this case as the patient is complaining of headache and loss of vision MRI is needed to rule
out intracranial extension and optic nerve involvement.

Q77. Role of MRI in sinonasal malignancy ?

• Role of MRI comes into play if CECT shows Lamina breach and intracranial extension.
• It can also predict with excellent accuracy the difference between tumor and retained secretions
in the sinuses & mucosal thickening.

Q78. For optic nerve evaluation which cuts are useful ?

• Axial cuts

Q79. Importance of USG abdomen and CXR ?

• To rule out Wegener’s Granulomatosis

• To rule out distant metastasis
• To rule out RCC & Bronchogenic Carcinoma

Q80. Which tumors can present as metastasis to maxilla ?

• RCC and Bronchogenic carcinoma

Q81. Role of DNE in this case ?

• When one nostril is completely blocked other nostril can be examined with angled scopes to
examine nasopharynx

Q82. Surgical anatomy of maxillary sinus ?

• Superiorly : Orbit and the ethmoid sinus

• Posteriorly : The pterygoid plates, the pterygoid space, and the infratemporal fossa
76 | P a g e

• Anteriorly : The canine fossa

• Inferiorly : The alveolus

• Medially : The nasal cavity

Q83. Surgical anatomy of ethmoid sinuses ?

• Inferiorly : The maxillary antrum

• Medially : The nasal cavity

• Superiorly : The fovea ethmoidalis and the cribriform plate

• Laterally : The thin bone of the lamina papyracea

Q84. Surgical anatomy of Frontal sinus ?

• Anteriorly : The soft tissues of the scalp

• Inferiorly : The dense frontal beak of the frontal bone, the ethmoidal cells, and the orbit

• Posteriorly : The anterior cranial fossa.

Q85. Surgical anatomy of Sphenoid sinus?

• Superiorly : The optic nerve and the pituitary gland

• Laterally : The internal carotid artery and the cavernous sinus

• Anteriorly : Posterior ethmoidal cells

• Inferiorly : The vidian nerve, the clivus, and the nasopharynx

Q86. Commonest site of origin of sinonasal malignancy ?

• Fronto-ethmoid junction

Q87. Commonest sinus involved in sinonasal malignancy ?

• Maxillary sinus

Q88. Rarest sinus involved in sinonasal malignancy ?

• Frontal and sphenoid sinus (1%)

Q89. Premalignant condition for Carcinoma Maxilla ?

• Inverted Papilloma

[Link] of sinonasal malignancy ?

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• Woodworkers, Leather/shoe Manufacturers, Chrome pigment Manufacturers, Isopropyl alcohol

manufacturers

Q91. Hard wood predisposes to ?

• Adenocarcinoma

Q92. Soft wood predisposes to ?

• Squamous cell carcinoma

Q93. What is Thorotrast ?

• Thorium dioxide used in paints in watch dials & radiopaque dye used as contrast agent for
antrum

Q94. Furniture industry predisposes to ?

• Adenocarcinoma of ethmoid

Q95. Mode of carcinogenesis ?

• Inhalation

Q96. Mechanism of carcinogenesis ?

• Biologically active compounds in wood dust impair mucociliary clearance & predispose to
carcinogenesis

Q97. Most common Histopathology ?

• Squamous cell carcinoma

Q98. Most common sinus involved in SCC ?

• Maxillary carcinoma

Q99. Most common histology in SCC ?

• Well differentiated & keratinizing tumours

Q100. Most common sites of origin in SCC ?

• Lateral wall of nasal cavity especially turbinates

• Nasal septum ( mucocutaneous junction )
• Columella

Q101. Sites which are responsible for poor prognosis ?

• Nasal septum & columella tumours

Q102. Reason for poor prognosis ?

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• Due to the possibility of bilateral metastatic spread to cervical nodes

Q103. Most common Histopathology in Ethmoid sinus ?

• Adenocarcinoma

Q104. Order of frequency ?

• Squamous cell carcinoma > Undifferentiated carcinoma > Adenoid cystic carcinoma >
Adenocarcinoma > Melanoma > Olfactory neuroblastoma > Fibrosarcoma > Papillary carcinoma
> Transitional cell carcinoma > Plasmacytoma >Haemangiopericytoma> Lymphoma >
Chondrosarcoma > Neuroendocrine

Q105. Characteristic of adenoid cystic carcinoma ?

• Perineural invasion and blood borne metastasis

Q106. Most common site for distant metastasis in adenoid cystic carcinoma ?

• Lungs

Q107. Most common site of origin of adenoid cystic carcinoma ?

• Maxillary sinus

Q108. Characteristic of malignant melanoma ?

• Satellite lesions

Q109. Most common sites for malignant melanoma ?

• The nasal cavity and the septum

Q110. Why does malignant melanoma poses difficulty in diagnosis ?

• Due to amelanotic melanoma

Q111. Tumor associated with paraneoplastic syndrome ?

• Olfactory neuroblastoma

Q112. Origin of Olfactory neuroblastoma ?

• Basal cells of olfactory neuroepithelium

Q113. Imaging characteristics of Olfactory neuroblastoma ?

• Homogenous mass and localised to cribriform plate

Q114. Staging for Olfactory neuroblastoma ?

• Kadish Staging
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Q115. Most common Lymphoma affecting sinuses ?

• NHL – 95 % of which B cell lymphoma is most common

Q116. Lymphoma associated with EBV exposure ?

• Nasal T/NK lymphoma and Burkitt’s Lymphoma

Q117. Common sites of Chondrosarcoma origin ?

• Nasal cavity, often from the septum or maxillary alveolus

Q118. Predisposing factors for haemangiopericytoma ?

• They have been associated with steroid therapy, coincidental trauma, hypertension and
pregnancy

Q119. Characteristics of haemangiopericytoma ?

• Arises from pericytes of outer capillary wall. Rare tumor. Radioresistant. Rarely metastasises.

Q120. Lymphatic drainage of nasal cavity and maxillary sinuses ?

• The lymphatics of the anteroinferior part of the nasal cavity and skin of the nasal vestibule drain
via the anterior pathway to the facial, parotid and submandibular lymph nodes – the first
eschelon nodes.

• These nodes then drain into the upper deep cervical chain

• The remainder of the nose and the paranasal sinuses drain through the posterior pathway which
runs anterior to the Eustachian tube to first eschelon nodes – the retropharyngeal lymph nodes

• From where they drain to the upper deep cervical chain.

Q121. Percentage of lymph node metastasis in Ca Maxilla ?

• Lymphatic spread to regional nodes becomes apparent in 25–35 percent of patients at some
time during the course of their disease, though only 10 percent have nodal disease at the time
of presentation.
Q122. What are the temporary barriers for spread of tumor ?

• Periosteum

• Perichondrium

• Dura

Q123. How they resist tumor expansion ?

• Fibroelastic connective tissue component

Q124. Least resistant areas for tumor spread ?

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• The bone of the antronasal wall

• Canine fossa

• Orbital floor

Q125. Boundaries of canine fossa ?

• A. Medially – Canine eminence

• Laterally – Maxillary tuberosity
• Inferiorly – Alveolar arch
• Superiorly – Infraorbital foramen

Q126. Distant metatsasis is common in ?

• Melanoma

• Olfactory neuroblastoma

• Adenoid cystic carcinoma

• Sarcomas

Q127. Distant metastasis indicates ?

• Local recurrence and poor prognosis

Q128. Cause of Trismus in Ca Maxilla ?

• Spread to Infratemporal fossa and involvement of Pterygoid muscles

Q129. Inferior spread of tumor may present as ?

• Loosening of teeth
• Palatal mass
• Oroantral fistula

Q130. Cause of visual disturbances in Ca Maxilla ?

• Tumor mass compressing the orbit

• Intraorbital extension
• Optic nerve involvement at orbital apex

Q131. Cause of epiphora in Ca Maxilla ?

Caused by obstruction or infiltration of the lacrimal duct situated in the anteromedial aspect of the
maxilla

Q132. What does hearing loss suggests ?

• Nasopharyngeal extension of the tumor that obstructs the eustachian tube.

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• This finding is important because nasopharyngeal extension of disease usually precludes a clear
resection margin in this area.

Q133. Common cranial nerves affected ?

• II, III, IV, V1, V2, and VI

Q134. Involvement of V1 occurs ?

• Due to invasion of Superior Orbital Fissure.

Q135. Signs of SOF invasion ?

• Pain and numbness of scalp and anterior part of nose.

Q136. Intracranial spread occurs via ?

• Cribriform plate, Foramen lacerum

Q137. Involvement of V2 occurs ?

• Due to infraorbital invasion

Q138. Involvement of 3rd, 4th and 6th cranial nerve occurs ?

• Due to extension to cavernous sinus

Q139. How is Cavernous sinus involved ?

• Via Sphenoid sinus lateral wall

• Superior orbital fissure

Q140. Staging of Ca Maxilla ?

• TNM Staging
• Lederman’s Classification
• Ohngren’s Classification

Q141. What is Broder’s Classification ?

• Grade 1 – 0-25% undifferentiated

• Grade 2 – 25-50% undifferentiated cells
• Grade 3 – 50-75% undifferentiated cells
• Grade 4 – 75-100% undifferentiated cells

Q142. Importance of Broder’s Classification ?

• Prognosis purpose

Q143. Plan of treatment for the present case ?

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• Radical Maxillectomy with orbital exenteration and post operative chemoradiation

Q144. Does Brachytherapy has role in this case ?

• No as it is a large bulky tumor

Q145. How to manage Stage 3 ?

• Pre operative chemoradiation and Surgery

Q146. What is Salvage treatment for Ca Maxilla ?

• Pre operative radiotherapy, Surgery and Post operative radiotherapy.

Q147. Surgical approaches ?

• Wide excision

• Endoscopic removal

• Lateral rhinotomy

• Trans oral trans palatal

• Weber’s fergusson approach

• Mid facial degloving ( bilateral )

• Craniofacial resection ( standard approach )

Q148. Types of maxillectomy ?

• Partial maxillectomy :-

• This entails partial removal of the upper jaw skeleton.

• Further subtypes :-

• Medial maxillectomy :-

• Medial maxillectomy involves the clearance of the lateral wall of the nose including the ethmoid
sinuses.
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• Inferior maxillectomy :-

• Palatal resection along with the adjacent alveolus is used for tumours of the oral cavity that
involve the hard palate.

• Inferior medial maxillectomy :-

• Inferior medial maxillectomy is designed for resection of the medial wall of the antrum and the
inferior turbinate
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• Sub total maxillectomy :-

• Maxillectomy in which atleast two walls (including the palatal wall) are removed.

• Total maxillectomy :-

• This entails the total removal of the upper jaw.

• Extended maxillectomy :-

• An extended maxillectomy is required when the tumour extends beyond the upper jaw.

• If this involves the skull base, the term craniofacial resection is used.

• Anterofacial resection or removal of anterior wall of skin.

• Radical maxillectomy :-

• Complete radical maxillectomy involves removal of the maxilla along with the nasal bone, the
ethmoid sinus, and, in some instances, the pterygoid plates.

• Along with removal of orbital contents.

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Q149. Different incisions used for resection of paranasal tumors ?

1. Lateral Rhinotomy Moure’s incision

2. Weber Ferguson’s incision

3. Weber Ferguson’s with Lynch extension

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4. Weber Ferguson’s with subciliary extension

5. Weber Ferguson’s with subciliary and supraciliary extension

Q150. Incision for total maxillectomy along with orbital exenteration ?

• Weber dieffenbach’s incision

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Q151. What is Moffett’s solution ?

• 2ml of 10% cocaine + 2ml 1:1000 adrenaline + 1ml of 0.9% Sodium bicarbonate

Q152. What is modified Moffett’s solution?

• 3.5cc of 4% of xylocaine + 0.5cc 1: 1000 adrenaline

Q153. Describe Weber’s Ferguson’s incision ?

• The transverse limb should be placed close to the lid margin to prevent postoperative oedema
of the lower lid.

• In the medial canthal region where the potential for skin loss as a result of radiotherapy is
greatest, it is helpful to curve the incision forward over the nasal bones for additional support
postoperatively.

• An incision along the crest of the philtrum and stepped on the lip is more acceptable than a
midline incision.
88 | P a g e

• The mucosal incision along the midline of the hard palate turns laterally at the junction with the
soft palate passing behind the maxillary tuberosity and then round the alveolus anteriorly.

Q154. Osteotomies placed in Total Maxillectomy ?

• Zygoma – Beneath the infraorbital rim

• Across the frontal process of maxilla
• Pyriform fossa
• Central upper alveolus, hard palate
• Maxillary tuberosity and pterygoid plates

Q155. In Subtotal maxillectomy which wall should be preserved ?

• Floor of orbit

Q156. Prosthesis used for rehabilitation after Total Maxillectomy ?

• Gutta percha palatal prosthesis

Q157. Define Moure’s incision ?

• The upper end should start just above the level of the medial canthus and passes along the
lateral border of the nose to the upper edge of the alar margin.

Q158. What is Whitehead’s Varnish pack ?

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• Compound iodoform paint: iodoform, benzoin prepared storax, tolu balsam and solvent
ether

Q159. Indications of Orbital Exenteration ?

• INVOLVEMENT OF ORBITAL APEX

• INVOLVEMENT OF EXTRAOCULAR MUSCLE

• BULBAR CONJUNCTIVA OR SCLERA

• RETROBULBAR FAT INVOLVEMENT

• EXTENSIVE EYELID INVOLVEMENT

Q160. What are the reasons for unresectability of tumor ?

Involvement of

• CAVERNOUS SINUS

• FRONTAL LOBES

• PREVERTEBRAL FASCIA

• WIDE SKULL BASE EROSION

• BILATERAL OPTIC NERVE INVOLVEMENT

Q161. Role of post operative radiotherapy ?

Advocated in slow growing tumors :-

• ADENOID CYSTIC CARCINOMA

• CHONDROSARCOMA

Q162. Indications of post operative chemotherapy ?

• OLFACTORY NEUROBLASTOMA

• RHABDOMYOSARCOMA

• LYMPHOMA

• SINONASAL UNDIFFERENTIATED CARCINOMA

• TOPICAL 5-FLUOROURACIL INDICATED IN ADENOCARCINOMA OF ETHMOID SINUS

Any queries kindly mail to drphani21@[Link]

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CASE PRESENTATION 3
Patient Name :- XYZ

Age :- 50 years

Sex :- Male

Occupation :- Farmer

Residence :- Nandyalam

Came to the hospital with the chief complaints of

1. Swelling in upper part of left side of neck since 5 months

2. Swelling in lower part of left side of neck since 3 months
3. Swelling in upper part of right side of neck since 3 months

History of present illness :-

Patient was apparently asymptomatic 5 months back then he noticed swelling in upper part of left side
of neck below the left mandible, insidious in onset, gradually progressive for the duration of 5 months.
Initially it was groundnut size and gradually progressed to lemon size. Not associated with pain and
trauma.
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H/O swelling in lower part of left side of neck above the left clavicle insidious in onset, gradually
progressive for the duration of 3 months. Initially it was pea sized gradually progressed to almond size.
Not associated with pain and trauma.

H/O swelling in upper part of right side of neck above the right mandible insidious in onset, gradually
progressive for the duration of 3 monthsInitially it was pea sized gradually progressed to almond size.
Not associated with pain and trauma.

H/O of bilateral nasal obstruction present ( Left > Right ) insidious in onset, gradually progressive for the
duration of 2 months, initially developed on left side then later has progressed to right side within within
duration of 1 month, which is continuous throughout the day, partial in nature.

No diurnal and positional variation.

No aggravating and relieving factors.

H/O post nasal drip present.

H/O hyponasal speech present.

H/O mouth breathing and snoring present.

No H/O nasal discharge, nasal bleeding, sneezing, smell disturbances.

No H/O facial pain, cheek numbness, difficulty in mouth opening, loosening of teeth, loss of teeth.

No H/O ear pain, ear discharge, decreased hearing, ringing sensation, dizziness.

No H/O throat pain, difficulty in swallowing, pain during swallowing, change in voice, nasal regurgitation,
halitosis, difficulty in breathing.

No H/O fever, weight loss, loss of appetite, cough, blood in sputum.

No H/O visual disturbances, double vision, protrusion of eye, drooping of eyelid, watering of eyes.

Past History :-

No H/O Similar complaints in the past

Not a K/C/O DM/HTN/CAD/CVA/Epilepsy /TB/Bronchial Asthma/ Bleeding Disorder/ Chronic sinusitis /

Chronic liver & kidney disease/ Radiation exposure

No H/O surgeries in the past

No H/O blood transfusion in past

No allergic drug history

Personal History :
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Diet – Mixed

Appetite – Normal

Bowel and Bladder Movements – Regular

Sleep – Normal

No addictions

Family history :- Not significant

General Examination :

Patient is conscious , coherent , cooperative

Patient is moderately built , moderately nourished

Bilateral cervical lymphadenopathy present. Right level 2 and left level 2 & level 5 lymphadenopathy
noted. Axillary and inguinal nodes not palpable.

Pallor0 Icterus0 Clubbing0 Koilonychia0 Cyanosis0 Pedal Edema0

Vitals :-

Temperature :- Afebrile

Pulse rate :- 76 / bpm, Good in volume, Normal in rhythm

Respiratory rate :- 14/minute

Blood pressure :- 120/80 mm of Hg, Right arm supine position

Systemic Examination :

CNS : Intact , NAD

CVS : S1+ S2+ M0

RS : Bilateral Air Entry present , No adventitious sounds

P/A : Soft , No organomegaly, No ascites

Cranial nerve examination :-

Normal

ENT EXAMINATION :

NOSE :-
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Intercanthal distance :- Normal

Nasolabial fold and nasofacial fold :- normal

Skin and external osseocartilaginous framework Normal

On tip raising Columella Normal

Right Left
Vestibule Normal Normal
External nares Normal Normal

Anterior Rhinoscopy Right Left

Septum Anterior cartilaginous deviation to right present
Floor Normal Normal
Lateral wall Normal ITH +

Posterior rhinoscopy :-

Proliferative mass completely covered with slough present in nasopharynx.

Eustachian tubal opening and choanae not visualised.

Post nasal drip present

Paranasal sinuses :-

Paranasal sinus Right Left

Frontal Non tender Non tender
Anterior Ethmoidal Non tender Non tender
Maxillary Non tender Non tender

Functional tests:-

Smell :- Normal

R L

Cold spatula :- Decreased misting Decreased misting

Cotton wool :- Decreased movement of fibre Decreased movement of fibre

Examination of eye :-

Right Left
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Size Normal Normal

Appearance Normal Normal
Ocular movements Normal Normal
Vision Normal Normal
Infraorbital margin Normal Normal

Examination of neck :-

Left level 2 lymphadenopathy present. A single, oval swelling approximately 5*3 cms with normal
surface, firm in consistency, mobile in horizontal direction, smooth, skin over the swelling is pinchable,
not fixed to underlying structures. On contracting left SCM becoming less prominent.

Left level 5 lymphadenopathy present. A single, oval swelling approximately 3*2 cms with normal
surface, firm in consistency, mobile in both directions, smooth, skin over the swelling is pinchable, not
fixed to underlying structures.

Right level 2 lymphadenopathy present. A single, oval swelling approximately 3*2 cms with normal
surface, firm in consistency, mobile in horizontal directions, smooth, skin over the swelling is pinchable,
not fixed to underlying structures. On contracting right SCM becoming less prominent.

No obvious thyroid swelling.

Trachea midline.

Laryngeal crepitus present.

Bilateral carotid pulsations present.

Ears :- R L

Tympanic membrane :- Pars tensa Grade 1 retraction Pars tensa Grade 1 retraction

COL absent COL absent

Decreased mobility on seigelization Decreased mobility on seigelization

Rest :- Normal

Functional tests :-

TFT’s Right Left

Rinne’s Positive Positive
Weber’s Centralised
Absolute bone conduction Same as examiner Same as examiner

Oral cavity :- Normal

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Oropharynx :- PPW congested

IDL :- Normal

Provisional Diagnosis :-

Nasopharyngeal malignancy with bilateral secondaries in neck

Clinical Staging :- T1 N3b MX Stage IVb

Investigations :-

Routine

Specific :-

FNAC of lymph nodes

DNE & Biopsy

CECT & MRI PNS, nasopharynx, neck

USG abdomen

CXR

Treatment :- Radiation therapy to both nasopharynx and neck nodes

Clinical discussion :-

Q1. Summarise positive history ?

1. Swelling in upper part of left side of neck since 5 months

2. Swelling in lower part of left side of neck since 3 months
3. Swelling in upper part of right side of neck since 3 months
4. H/O of bilateral nasal obstruction present ( Left > Right ) since 2 months
5. H/O post nasal drip present.
6. H/O hyponasal speech present.
7. H/O mouth breathing and snoring present.

Q2. Points to support your diagnosis :-

1. History :- Elderly male

2. Swelling in upper part of left side of neck since 5 months
3. Swelling in lower part of left side of neck since 3 months
4. Swelling in upper part of right side of neck since 3 months
5. H/O of bilateral nasal obstruction present ( Left > Right ) since 2 months
6. H/O post nasal drip present.
7. H/O hyponasal speech present.
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8. H/O mouth breathing and snoring present

9. Shorter duration rapid progression

Examination :- On posterior rhinoscopy Proliferative mass completely covered with slough present in
nasopharynx.

Left level 2 lymphadenopathy, left level 5 lymphadenopathy, right level 2 lymphadenopathy

Q3. Causes of halitosis ?

• Amoebiasis
• LPR
• Bronchiectasis
• Inflammatory conditions
• Secondary infection in malignancy

Q4. Differential diagnosis of Nasopharyngeal mass ?

I. Epithelial tumours
a Benign b. Malignant
1 Papilloma 1 Nasopharyngeal carcinoma
2 Pleomorphic adenoma 2 Adenocarcinoma
3 Oncocytoma 3 Papillary adenocarcinoma
4 Basal cell adenoma 4 Mucoepidermoid carcinoma
5 Ectopic pituitary adenoma 5 Adenoid cystic carcinoma
6 Polymorphous low-grade adenocarcinoma
II Soft tissue tumours

a Benign b Malignant
1 Angiofibroma 1 Fibrosarcoma
2 Haemangioma 2 Rhabdomyosarcoma
3 Haemangiopericytoma 3 Angiosarcoma
4 Neurilemmoma 4 Kaposi’s sarcoma
5 Neurofibroma 5 Malignant haemangiopericytoma
6 Paraganglioma 6 Malignant nerve sheath tumour
7 Synovial sarcoma
III Tumours of bone and cartilage

IV Malignant lymphomas
1 Non-Hodgkin’s lymphoma
2 Extramedullary plasmacytoma
3 Midline malignant reticulosis
4 Histocytic lymphoma
5 Hodgkin’s disease
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V Miscellaneous tumours

a Benign b Malignant
1 Meningioma 1 Malignant melanoma
2 Craniopharyngioma 2 Chordoma
3 Teratoma 3 Malignant germ cell tumours

VI Secondary tumours
VII Unclassified tumours

VIII Tumour-like lesions

1 Cysts
2 Meningocoele/meningoencephalocoele
3 Granulomas
4 Amyloid deposits
5 Others

Q5. When is the lymph node palpable ?

• 1-1.5 cms

Q6. Reasons for pain in lymph node ?

• Infection
• Haemorrhage
• Secondary infection of malignant node

Q7. Bilateral neck swelling is seen in which cancers ?

Midline structures like :-

• Tongue
• Floor of mouth
• Hard palate
• Soft palate
• Epiglottis
• Post cricoid
• Nasopharynx

Q8. Upper deep cervical nodes ( Level 2) are enlarged in ?

• Nasopharynx
• Supraglottis
• Pyriform fossa
• Tonsil
• RMT
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• Posterior Pharyngeal Wall

• Maxillary Sinus

Q9. When upper deep cervical lymph node is enlarged rule out ?

• Whether it is infective or secondary, specific or non specific, acute or chronic

Q10. Features of Infective lymphadenopathy ?

• Shorter duration
• Soft in Consistency
• Localised tenderness present

Q11. Features of secondaries in neck ?

• Longer duration
• Hard in consistency
• Non tender
• Irregular
• Immobile

Q12. How to check whether swelling is superficial or deeper ?

• On contracting the SCM of that side by asking the patient to turn the head to opposite side, if
swelling becomes more prominent it is superficial to
• SCM if it becomes less prominent it is deep to SCM
• Deeper swellings are more difficult to dissect as they lie close to vital structures.

Q13. If patient presents with unknown primary which sites should be examined ?

• Pyriform fossa
• Tonsil
• Nasopharynx

Q14. If level 1 nodes are enlarged where to suspect primary ?

• Lip
• Anterior tongue
• Buccal mucosa
• Anterior floor of mouth

Q15. If level 2/3 are enlarged where to suspect primary ?

• Larynx and hypopharynx

Q16. Isolated level 5 lymph node enlarged check for primary in ?

• Nasopharynx
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Q17. Isolated level 6 lymph node enlarged check for primary in ?

• Thyroid
• Subglottic carcinoma

Q18. In subglottic and transglottic carcinoma which nodes are involved ?

• Level 4

Q19. When Posterior triangle lymph nodes enlarged suspect ?

• Primary at Nasopharynx
• Scalp infections
• Ear infection
• Parotid malignancies

Q20. If patient presents with swelling in anterior triangle of neck how to differentiate whether it is
lymph node or pharyngeal growth ?

• On inspection ask the patient to swallow if it moves on deglutition it is growth

Q21. Multiple lymph nodes in neck ?

• HIV
• Secondaries
• TB
• Lymphoma

Q22. Features of tuberculous lymphadenopathy ?

• Multiple, matted, hard to fluctuant with draining sinuses.

Q23. Jones and Campbell classification of TB lymphadenopathy ?

• Stage 1 :- enlarged, firm, mobile, discrete nodes showing non-specific reactive hyperplasia;
• Stage 2 :- large rubbery nodes fixed to surrounding tissue owing to periadenitis;
• Stage 3 :- central softening due to abscess formation;
• Stage 4 :- collar-stud abscess formation; and
• Stage 5 :- sinus tract formation

Q24. Features of lymphoma ?

• Discrete, firm, and rubbery

Q25. Mediastinal secondaries are seen in ?

• Malignancies of Thyroid
• Cervical trachea
• Cervical oesophagus
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• Subglottis
• Post cricoid

Q26. Well defined neck swelling which moves horizontally ?

• Schwannoma
• Neurofibroma

Q27. What is the importance of neck node ?

• Staging
• Management
• Prognosis drops by 50%
• Occult metastasis

Q28. Predictors of neck metastasis ?

• T stage
• Tumor site
• Lymphovascular invasion
• Perineural invasion
• Tumor thickness
• Histologic grade
• Tumor angiogenesis
• DNA ploidy

Q29. Prognostic markers of nodal metastasis ?

• Extracapsular spread
• Multiple nodes
• Level 4/5 involvement suggests bad prognosis

Q30. Investigation of choice for neck node ?

• FNAC. Never do biopsy until and unless its Lymphoma. In Lymphoma opt for trucut biopsy
rather than open as it may lead to spread of tumor and poor prognosis

Q31. Criteria of CT scan for metastatic lymph node ?

• Size :- >1.5 cms in 1a & 1b and >1cm in rest levels of lymph nodes is significant
• Short axis diameter larger than 1cm
• Central necrosis
• Capsular invasion

Q32. Ultrasound features of metastatic lymph node ?

• Increase in short axis length

• Hypoechoic
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• Increased vascularity

Q33. CXR role in NPC ?

• Hilar lymphadenopathy
• Secondaries
• 2nd primary
• Tuberculosis

Q34. Which scan is best for NPC ?

• Gadolinium MRI

Q35. Role of CECT in NPC ?

• Stage and extent

• Bony erosion of skull base
• Can demonstrate even submucosal disease

Q36. Role of MRI in NPC ?

• More sensitive for marrow infiltration

• Better soft tissue resolution
• Can differentiate entrapped mucus in paranasal sinus from tumor involvement
• Information of perineural spread
• Can give information about parapharyngeal space spread
• Can assess clivus and retropharyngeal nodes.

Q37. Role of PET CT ?

• It is never the 1st modality.

• It can detect occult nodal disease, secondaries.
• It is done when lower deep cervical nodes are involved as there is high chance of chest
metastasis.
• In NPC there is high risk of bone metastasis.
• To differentiate from post operative edema or Residual or recurrent disease.

Q38. What is Guangdong tumour ?

• Nasopharyngeal carcinoma

Q39. In which area NPC is endemic ?

• South China
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Q40. Boundaries of Nasopharynx ?

• Anterior :- Posterior choanae and posterior part of nasal septum

• Posterior :- C1 and C2 vertebrae along with prevertebral fascia and muscles
• Roof :- Basisphenoid and basiocciput
• Inferior :- Anteriorly Soft palate and part of hard palate
Posteriorly it communicates with oropharynx through nasopharyngeal isthmus
• Lateral :- Pharyngeal end of eustachian tube

Q41. Location of Pharyngeal end of Eustachian tube opening ?

• 1.25 cms posterior to the posterior end of inferior turbinate.

Q42. Lining epithelium of nasopharynx ?

There are three types of epithelium in the nasopharynx:

• Pseudostratified, ciliated ‘respiratory-type’ epithelium :- choanae,
on the roof and upper portion of the posterior wall.
• Nonkeratinizing, stratified squamous epithelium :- lower half of the lateral and posterior walls.
• Columnar lies between these two zones
Q43. Commonest site of origin of NPC ?
• Fossa of rosenmuller
Q44. Location of Fossa of rosenmuller ?
• Behind the posterior margin of torus tubarius and posterior pharyngeal wall
Q45. Boundaries of Fossa of rosenmuller ?
• Anteriorly :- Eustachian tube and Levator palatini
• Posteriorly :- Pharyngeal wall mucosa overlying the Pharyngobasilar fascia and retropharyngeal
space
• Medially :- Nasopharyngeal cavity
• Laterally :- Tensor veli palatini and Parapharyngeal space
• Anterolaterally :- Tensor veli palatini
• Superiorly :- Base of skull with foramen lacerum medially, foramen ovale and spinosum
anterolaterally, the petrous apex and carotid canal posteriorly.
• Inferiorly :- Upper edge of the superior constrictor muscle
Q46. What is Sinus of Morgagni ?
• Space between upper edge of superior constrictor muscle and skull base
Q47. Structures passing through Sinus of Morgagni ?
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• Levator palatini
• Tensor veli palatini
• Ascending pharyngeal artery
• Eustachian tube
Q48. Retropharyngeal group of lymph nodes ?
• Nodes of Rouvier and Henley
Q49. Etiology of NPC ?
• Genetic factors
• Epstein Barr Virus exposure
• Environmental carcinogens.
Q50. HLA locus for NPC ?
• HLA A, B and DR locus situated on short arm of chromosome 6.
Q51. HLA alleles associated with NPC ?
• HLA A2, A33, B46, B58, CW1 and DR3.
Q52. HLA haplotypes associated with poor survival in NPC ?
• A33, CW3, B58, DR3
Q53. Tumor suppressor gene locus for NPC ?
• Short arm of chromosome 3 and 9.
Q54. Characteristics of EBV ?
• Human herpes virus 4. Double stranded DNA virus.
• It is lymphotrophic and its action is restricted to B- Cells.
Q55. Association between EBV and NPC was 1st proposed by ?

• Liang

Q56. EBV receptors on human pharyngeal epithelia were demonstrated by ?

• Young et al

Q57. Environmental carcinogens involved in NPC ?

• Wood dust, Household smoke, Industrial fumes, Tobacco smoke, Exposure to formaldehyde,
Incense and joss stick smoke, Salted fish ( Volatile alkylating nitrosamines )

Q58. Virus lies dormant in ?

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• B lymphocytes in bone marrow and peripheral blood

Q59. The association of EBV virus with NPC is supported by ?

• Demonstration of humoral response in patients of NPC against EBV antigens ( VCA, EA, EBNA)
• Presence of viral markers like EB viral DNA and nuclear antigen in the tumor cells of NPC

Q60. Serological markers of NPC ?

• IgA & IgG VCA

• IgA and IgG to EA
• Antibody to nuclear antigen
• Antibody dependant cellular cytotoxicity antibodies

Q61. Prognostic markers of NPC ?

• Inversely proportional to titres of VCA and EA antibodies

• Good prognosis is suggested by high Antibody dependant cellular cytotoxicity antibodies

Q62. Which immunity is impaired in NPC ?

• Cell mediated immunity and degree of impairment suggest poor prognosis

Q63. Clinical types of NPC ?

• Lobulated mass with well defined borders – more common – presents as cervical
lymphadenopathy
• Infiltrative with indistinct border – Less common – Presents as advanced disease with skull base
erosion without cervical lymphadenopathy

Q64. Histological classification of NPC ?

WHO classification :-

• Grade 1 – Keratinizing Carcinoma

• Grade 2 – 2A – Non keratinizing SCC, 2B – Undifferentiated Carcinoma

Q65. Which type is associated with EBV ?

• Grade 2
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Q66. Histologically which carcinoma is common ?

• Grade 2

Q67. Which type of NPC has good prognosis ?

• Grade 2 as it is radiosensitive.

Q68. What is the most common presentation of NPC ?

• Neck nodes in 50 % of patients

Q69. 1st echelon node in NPC ?

• Retropharyngeal lymph nodes

Q70. 2nd echelon node in NPC ?

• Upper deep cervical lymph nodes

Q71. Causes of Eustachian Tube dysfunction ?

• Mechanical effect of tumor

• Infiltration of ET musculature

Q72. Causes of headache in NPC ?

• Referred pain due to involvement of distal branches of 5th nerve

• Skull base erosion

Q73. Causes of trismus ?

• Direct infiltration of Pterygoid muscles

Q74. Cranial nerve involvement ?

• Via foramina of base of skull

• Parapharyngeal space involvement
• Cavernous sinus involvement

Q75. Cranial nerve syndromes ?

• 9,10,11 in jugular foramen :- Vernet syndrome

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• 10,11 :- Schmidt’s syndrome

• 10,11,12 :- Hughling’s Jackson syndrome
• 9,10,11,12 :- Collet Siccard syndrome
• 9,10,11,12 and horner’s syndrome :- Villaret’s syndrome
• Petro sphenoid syndrome:- Involvement of 2,3,4,5,6 Cranial nerve
• Triad of ipsilateral ophthalmoplegia, amaurosis fugax, trigeminal neuralgia
• Syndrome of foix :- Involvement of lateral wall of cavernous sinus ( 3,4,5,6 Cranial nerve )
• Avelli’s syndrome :- Involvement of 10th cranial nerve

Q76. Most common cranial nerve involved in NPC ?

• 5th and 6th cranial nerve

Q77. How is 6th cranial nerve involved ?

• Via Foramen Lacerum

Q78. Least common Cranial nerve involved in NPC ?

• 7th cranial nerve

Q79. Routes of spread of NPC to orbit ?

• From Pterygopalatine fossa to inferior orbital fissure to orbit

Q80. Routes of spread of NPC ?

• Anteriorly – Nasal cavity, Paranasal sinuses, Pterygopalatine fossa, Orbital apex

• Posteriorly – Retropharyngeal space and nodes of rouviere
• Laterally – Parapharyngeal space involvement
• Prestyloid :- Mandibular nerve, Pterygoid muscles, Deep lobe of parotid
• Poststyloid :- Vascular compression of carotid sheath, Involvement of 9-12 cranial nerves and
cervical sympathetic chain
• Superiorly – Body of sphenoid, Parasellar structures, Optic nerve, Petrous apex, Foramen
lacerum, Cavernous sinus ( 3rd, 4th, 5th, 6th cranial nerves )
• Inferiorly – Oral cavity, Oropharynx

Q81. What is Modified Ho’s Classification ?

Primary tumour (T)

T1 Nasopharynx only
T2n Nasal fossa
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T2o Oropharynx
T2p Parapharyngeal region
T3a Bony involvement of below the skull base including floor of
sphenoid
T3b Bony involvement of the skull base
T3c Cranial nerve(s) palsy
T3d Orbit, laryngopharynx (hypopharynx) or infratemporal fossa
T3p Parapharyngeal region
Regional lymph node (N)
N0 No nodes
N1 Node(s) above the skin crease at laryngeal cartilage
N2 Node(s) below the above skin crease but above the
supraclavicular fossa
N3 Supraclavicular fossa node(s)
Metastasis (M)
M0 No distant metastasis
M1 Distant metastasis

Q82. What is AJCC classification ?

Primary tumour (T)

TX Primary tumour cannot be assessed
T0 No evidence of primary tumour, but EBV positive cervical nodes present
T1 Tumour confined to the nasopharynx or extension to oropharynx or nasal cavity withour
parapharyngeal extension
T2 Tumour extends to parapharyngeal space or soft tissues like medial pterygoid, lateral pterygoid,
prevertebral muscles
T3 Tumour involves bony structures as skull base, cervical vertebrae, pterygoid structures, paranasal
sinuses
T4 Tumour with intracranial extension and/or
involvement of cranial nerves, hypopharynx, orbit, parotid, extensive soft tissue beyond lateral surface
of lateral pterygoid
Regional lymph node (N)
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NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis
N1 Unilateral metastasis in lymph node(s) or unilateral/bilateral metastasis in retropharyngeal nodes, 6
cm or less in the greatest dimension, above the caudal border of cricoid cartilage
N2 Bilateral metastasis in lymph node(s), 6 cm or less inthe greatest dimension, above the caudal border
of cricoid cartilage
N3 Unilateral or bilateral metastasis in cervical lymph nodes, larger than 6cms in greatest dimension,
and extension below caudal border of cricoid cartilage
Metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis

Q83. Stage wise management of NPC ?

• Stage I – II :- Radiotherapy
• Stage III – IV b :- Radiotherapy & Adjunct chemotherapy

Q84. Indications of surgery in NPC ?

• Salvage for local failure

Q85. Contraindication for surgery ?

Absolute contraindication :-

• Involvement of skull base, cranial nerves, vertebral bodies and carotid sheath.

Relative contraindication :-

• Concurrent failures in nasopharynx and neck.

Q86. Radiation for nasopharynx ?

• External radiotherapy is given via two lateral opposing and one anterior field.
• Whole of nasopharynx and neck is irradiated.
• Dose is 65 Gray each fraction is 2 Gy, 5-6 sessions per week for 6 weeks.
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Q87. Forms of radiation for NPC ?

• External beam radiation

• Brachytherapy
• 3D - Conformal radiotherapy
• Image guided radiation therapy
• Stereotactic radiotherapy

Q88. Forms of Brachytherapy for NPC ?

• Transpalatal insertion of radioactive gold grains

• Intracavitary afterloading radiotherapy

Q89. Indications of Stereotactic radiotherapy ?

• When tumor is too bulky or situated close to critical structures such as optic nerve

Q90. Complications of Radiotherapy ?

• Acute toxicity :- Nausea, vomiting, dryness of mouth, loss of taste, mucositis, contact bleeding
• Late toxicity :- Osteoradionecrosis of mandible, maxilla, loss of teeth, trismus, larynx necrosis,
cartilage necrosis, spinal cord damage, optic nerve damage, retinal damage, cataract, deafness,
hypothyroidism.

Q91. Reason of dry mouth post radiation ?

• Radiation damage to plasma membrane of secretory granules.

Q92. How to prevent osteoradionecrosis of maxilla ?

• Caries teeth should be extracted.

Q93. What are radiosensitising agent ?

It is a drug which make tumor cells more sensitive to radiation therapy.

• Hyperbaric Oxygen
• Nitroimidazole ( Misonidazole, Etanidazole )
• Nimorazole
• Tiparamazine
• Nicotinamide.

Q94. Role of chemotherapy in NPC ?

• Grade 1 i.e; well differentiated SCC.

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• It acts as a radiosensitiser.
• Helps to reduce chance of distance metastasis.

Q95. Choice of chemotherapeutic drugs for NPC?

• Cisplatin and 5- FU

Q96. What is neo adjuvant chemotherapy ?

• Used prior to definitive therapy.

• It aids in debulking of tumor.

Q97. What is adjuvant chemotherapy ?

• Chemotherapy given after surgical excision for any residual disease.

Q98. Follow up for NPC ?

• 2 monthly – 1st year

• 3 monthly – 2nd and 3rd year
• 6 monthly – lifelong follow up
• Nasoendoscopy, Post irradiation biopsy and imaging is done.

Q99. Various surgical approaches for nasopharynx ?

1. Endoscopic approach
2. Anterior :- Lateral rhinotomy
Transpalataltransmaxillary approach
Midfacial degloving approach
Le fort 1 osteotomy
Maxillary swing approach
3. Inferior approach :
Wilson’s transpalatal approach
Mandibular swing approach
4. Lateral approach :-
Infratemporal approach

Q100. How to manage neck node ?

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• If primary modality is surgery for Primary then node also should be managed surgically
• If Primary modality is radiation then node also should be irradiated.

Q101. Surgical management of N0 Neck in Nasopharynx ?

• Selective Neck Dissection :- Level 2 to 5

Q102. Surgical management N+ Neck in Nasopharynx ?

• MNRD / RND

Q103. When to address the contralateral Lymph node ?

• Clinically neck node metastasis positive

• Tumor reaches or crosses midline

Q104. Indication of post op radiation or chemoradiation ?

• Perineural invasion
• Lymphovascular invasion
• Multiple positive lymph nodes

Q105. Indications of concurrent CTRT post op ?

A. Extracapsular spread
B. Microscopic positive resection margin

Q106. Types of neck dissection ?

Radical neck dissection :- Removal of

a)Lymph nodes in levels I–V

b)Accessory nerve

c)Internal jugular vein(IJV) and

d)Sternomastoid muscle

Modified radical neck dissection -

 It is removal of lymph nodal levels I–V, but preserves one or more of SAN / SCM / IJV.

 It is of 3 types

MRND Type I : Preserves SAN

MRND Type II : Preserves SAN ,SCM

MRND Type III : Preserves SAN , SCM , IJV (functional neck dissection )
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Selective neck dissection :

One or more of the lymph node groups are preserved in addition to the non-lymphatic structures.

Extended radical neck dissection :

Removal of one or more additional lymphatic and/or non-lymphatic structures relative to a radical neck
dissection, e.g. level VII, retropharyngeal lymph nodes,hypoglossal nerve, carotid artery, skin of neck,
etc.

Q107. Complication of removal of both IJV ?

• Cerebral edema

Q108. Complication of removal of Spinal accessory nerve ?

• Destabilization of scapula

Q109. Management of metastasis of unknown origin ?

• MNRD & post op CTRT

Q110. EBV related conditions?

• NPC
• Burkitt’s lymphoma
• Nasal/TK Lymphoma
• Hairy leukoplakia
• Infectious mononucleosis
• Plasmacytoma

Q111. What is Trotter’s triad ?

• Ipsilateral conductive deafness due to Serous Otitis Media

• Ipsilateral Temporo – Parietal Neuralgia due to involvement of 5th nerve
• Ipsilateral Palatal Paralysis due to 10th nerve involvement
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CASE PRESENTATION 4
Name :- abc

Age :- 68 years

Gender :- Male

Occupation :- Chef

Residence :- Lalapet

Came to the hospital with the chief complaints of

1. CHANGE OF VOICE since 2 months

2. DIFFICULTY IN BREATHINGsince 20 days

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 2 months back , then he developed Change of voice which is
hoarse in nature , insidious in onset , progressive in nature , constant through out the day . No
aggravating or relieving factors

H/o Pain during speech present

H/o Cough with sputum , initially it is blood tinged , now it became mucoid .

No H/o fever,No H/o night sweats , No H/o Weakness of voice

No history of vocal abuse , No h/o neck trauma / neck surgeries /Surgeries under GA/Radiotherapy

H/o Difficulty in breathing since 20 days insidious in onset , initially mild with noisy breathing , gradually
progressive , present through out day and night , present even at rest.

no variation with position (Sitting , Supine , Standing, Walking )

No H/o Chest Pain

H/o Pain in throat since 10 days , not radiating , more during speech and no variation during swallowing

No h/o difficulty during swallowing

No h/o of choking episodes

No h/o loss of appetite , loss of weight

No h/o Ear ache/Ear discharge

No h/o Nasal Obstruction/nasal discharge

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No h/o any Neck mass

PAST HISTORY :

No h/o Similar complaints in the past

H/o Pulmonary Tuberculosis 10 years back , took 6 months complete course of treatment and relieved .

No other significant past Medical/Surgical History

No h/o DM/HTN/CAD/Bronchial Asthma/Epilepsy/Bleeding Disorder /Dental caries

No allergic drug history

Personal History :

Diet – Mixed

Appetite – Normal

Bowel and Bladder Movements – Normal

Sleep – Disturbed due to difficulty of breathing since 20 days

Beedi Smoker – 6/day since 40 years

Cigarette smoker – 20/day since past 40 yrs

Alcoholic – 360ml / day since past 30 yrs

Family History :

Not Contributory

General Examination :

Patient is conscious , coherent , cooperative

Patient is moderately built , moderately nourished

Patient is in stridor , which is inspiratory

No Cyanosis

No usage of Accessory muscles

No indrawing of Skin at Supraclavicular and Suprasternal Space

Pallor0 Icterus0 Clubbing0 Koilonychia0 Cyanosis0Generalised Lymphadenopathy0 Pedal Edema0

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Vitals :-

Temp :- Afebrile

PR :- 76/bpm, Normal in rhythm, good in volume

BP :- 120/80 mm hg, Rt arm supine position

RR :- 16/min

Systemic Examination :

CVS : S1+ S2+ M0

RS : Bilateral Air Entry present , No adventitious sounds

P/A : Soft

CNS : Intact , NAD

Cranial nerve examination :- Normal

ENT EXAMINATION :

ORAL CAVITY :

Mouth opening – full and adequate

Angle of mouth – Normal

Lips – Normal

Gingivo Labial sulcus –Normal

Gingivo Buccal Sulcus – Normal

Gums- Nicotine stained

Teeth – Normal , No loose tooth seen

Anterior 2/3rd of Tongue – Normal

Buccal Mucosa – Normal

Hard Palate – Normal.

Retro Molar Trigones – Normal

OROPHARYNX : Normal
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IDL : A single pinkish Exophytic growth seen over middle 1/3rd of Right vocal cord , Surface is irregular ,
growth is sessile , vocal cords are mobile , Growth is moving along with vocal cords side to side. No
movement with respiration and phonation. Glottic chink is inadequate.

Neck :

Trachea – central in position

Laryngeal Framework – Normal

Laryngeal Crepitus – Present

No Laryngeal Tenderness

Neck Nodes – Not Palpable

Carotids – Palpable

NOSE :

Anterior Rhinoscopy ; Normal

Posterior Rhinoscopy : Normal

Ear : Normal

PROVISIONAL DIAGNOSIS :

Malignancy of glottis ( Glottic malignancy )

Clinical staging :- T1A N0Mx Stage I

Differential Diagnosis :

TB Larynx

Wegeners Granulomatosis

Histoplasmosis

Squamous Papilloma

Scleroma

Amyloidosis

Lipoma

Schwannoma
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Investigations :

Routine Blood Investigations

Emergency Tracheostomy

Sputum for AFB , C/S , Gram Stain

Video Laryngoscopy

Stroboscopy

Xray Chest

DLScopy Biopsy

CT Neck

MRI Neck

FibreopticNasolaryngoscopy

TREATMENT :- Radiotherapy

CLINICAL DISCUSSION :-

Q1 ) Summarise your Positive History ?

• CHANGE OF VOICE since 2 months , hoarse in nature

• DIFFICULTY IN BREATHING since 20 days
• H/o Pain during speech present
• H/o Cough with sputum , initially it is blood tinged , now it became mucoid
• H/o Pain in throat since 10 days ,
• H/o Pulmonary Tuberculosis 10 years back

Q2 ) What are the positive findings supporting to your diagnosis ?

• Elderly male
• Smoker , Alcoholic
• Exophytic Growth
• Blood stained sputum

Q3) Types of Voice ?

• Husky ( Due to paralysis of SLN- Cricothyroid muscle )

• Hoarse ( Due to disturbance of normal wave pattern of vocal cord )
• Hot Potato ( Due to involvement of Supraglottis and base of tongue )
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Q4) What are different causes for Change of Voice ?

Inflammatory disorders Infective :-

Chronic laryngitis( Most common cause)
Non infective :-
Arytenoid granuloma

Structural disorders Vocal fold polyp

Vocal nodule
Reinke’s edema
Cyst, Sulci, Mucosal bridges, Vergeture
Benign and malignant tumors
Neuromuscular causes Abductor and adductor dysphonia secondary
to Parkinson’s disease, Multiple sclerosis,
Myasthenia gravis, motor neuron disease
Muscle tension dysphonia Imbalance of synergist and antagonists
muscles of larynx
Paralytic Vocal cord paralysis

Q5) What are different causes for Diurnal variations in change of voice ?

• Worse in the morning – Chronic Laryngitis

• Evening – Malignancy , Vocal cord palsy
• Worsening as day passes – Vocal nodule / polyp
• Improves as day passes – Reinke Edema

Q6) Causes for the Pain during speech ?

• TB Larynx
• Acute Laryngitis

Q7) What might be cause of Difficulty in breathing in this case?

Lesion in the Glottic chink obstructing the airway

Other causes to be kept in mind

• Lung Metastasis
• Aspiration Pneumonia
• Tuberculosis
• COPD

Q8) What are different grades of Shortness of breath ?

• Grade I :- Breathlessness on strenuous activity ( Exercise, Running )

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• Grade II :- Breathlessness on doing more than accustomed work (Climbing stairs or hurrying on
level )
• Grade III :- Breathlessness on doing less than accustomed work ( Normal pace walking )
• Grade IV :- Breathlessness at rest

Q9) Why you have enquired about Chest pain ?

• To rule out Cardiac Causes , GERD

Q10) Causes of blood tinged sputum ?

• Tuberculosis
• Malignancy

Q11) Features against TB laryngitis ?

• Exophytic growth limited to anterior part of glottis

Q12) Characteristic features of TB Laryngitis

1. Weakness of voice earliest symptom, Odynophagia

2. Hyperaemia of the vocal cord is the first sign.
3. Interarytenoid region - mamillated appearance
4. Mouse-nibbled appearance of vocal cord
5. Granulation tissue in interarytenoid region or vocal process of arytenoid.
6. Pseudoedema of the epiglottis “turban epiglottis”
7. Marked pallor of surrounding mucosa.

Q13) Why posterior part of larynx is most commonly involved in Tuberculosis of larynx ?

• Posterior part of larynx is most affected as while coughing Sputum from lungs will be coughed
out along the posterior wall and there will be stasis of sputum over arytenoids ,interaytenoid
region etc .

Q14)Indications of steroid in Tuberculosis ?

• TB Laryngitis
• TB meningitis

Q15) Treatment of TB Laryngitis ?

• Non – specific :- IV Steroids

• Specific :- Antitubercular drugs for 6 months

Q16) Why history of any surgeries under General Anaesthesiataken ?

• To rule out Intubation granuloma

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Q17) Why history of Dental caries important in this case?

• In case if Radiotherapy is adviced for the patient , Osteoradionecrosis of Mandible & Maxilla
may occur if caries tooth are present .
• If surgery is planned it may act as septic foci so treatment of dental caries is essential before
primary treatment of larynx.

Q18) What is Pack year ?

• It is calculated by multiplying the number of packs of cigarettes smoked per day by the number
of years the person has smoked.
• For example, 1 pack-year is equal to smoking 20 cigarettes (1 pack) per day for 1 year

Q19) How smoking and alcohol causes Laryngeal pathology ? What are the different Carcinogens
present in Cigarette and Alcohol ?

Tobacco causes Global hypomethylation, Hyperacetylation of DNA

Cigarettes

Tobacco carcinogens are grouped into

1. Polycyclic aromatic hydrocarbons ([Link]),

2. Heterocyclic aromatic amines,
3. Aromatic amines, aldehydes, asz-arenes
4. N-nitrosamines (N-nitrosodiethylamine), as well as other agents.

Once absorbed, most tobacco carcinogens require activation by cellular enzymes (i.e. cytochromeP450
group) to promote tumorigenesis and their effects can be offset by detoxifying enzymes (i.e. GSTM1).
Dysfunction of these enzymatic pathways has been associated with increased risk for HNSCC.

There is a synergistic interaction with alcohol due to the increased mucosal absorption of

these carcinogens as a result of the increased solubility of the carcinogens in alcohol compared

with aqueous saliva.

Alcohol

Alcoholic beverages have different carcinogenic content.

1. Beer - carcinogen nitrosodimethylamine

2. Wines -tannin.
3. Dark liquors (whisky, rum) have greater content of organic compounds (esters,
acetaldehyde) than light liquors (vodka, gin)

The non-alcohol constituents of various alcoholic beverages may have carcinogenic activities.
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Chronic alcohol use may upregulate enzymes of the cytochrome P450 system which may result in the
activation of procarcinogens into carcinogens.

Mechanism of carcinogenesis by alcohol :-

1. The immediate metabolite of ethanol is acetaldehyde.

a. Acetaldehyde is then inactivated by conversion to acetate by acetaldehyde
dehydrogenase(ALDH).
b. Acetaldehyde exerts its carcinogenic effect primarily by direct binding to DNA, but also
alters methyl transfer,resulting in genetic hypomethylation, which in turn affects the
transcription of multiple genes. In addition, reactive oxygen species are generated
during alcohol metabolism,which also have mutagenic effects.
2. Alcohol can also decrease the activity of DNA repair enzymes resulting in increased chromosomal
damage.

The interplay between the cumulative exposure to carcinogens and host susceptibility factors drives
cancer pathogenesis through induction of somatic genomic mutations.

• Tobacco and alcohol are the main risk factors for laryngeal cancer
• Smoking is main risk factor for Glottic Cancers
• Alcohol is main risk factor for Supraglottic Tumours
• Their effects are synergistic

Q20) What you want to enquire in family history ?

• History of Tuberculosis, History of malignancy

Q21) Define Generalised Lymphadenopathy?

• 3 or more contiguous enlarged lymphnodes

Q22) Define Stridor . What are different types ?

Stridor is noisy respiration produced by turbulent airflow through the narrowed air [Link] may be
heard during inspiration,expiration or both

• Inspiratory stridor produced in obstructive lesions of supraglottis or pharynx,

• Expiratory stridor is produced in lesions of thoracic trachea, primary and secondary
bronchi
• Biphasic stridor is seen in lesions of glottis,subglottis and cervical trachea

Q23) What is Stertor ?

• It is noisy breathing due to cause limited to nose, nasopharynx, oropharynx.

Q24) Illustrate procedure of doing IDL ?

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Explain the whole procedure of IDL to patient to gain his confidence and to make patient non
apprehensive

Patient sitting in front of Examiner at the same level

IDL mirror is prepared to avoid fogging

Methods to avoid fogging :-

1. Heat backside of mirror with candle light

2. Put IDL mirror In Hot Water
3. Dip mirror in Savlon( Cetrimide& Chlorhexidine Gluconate )
4. Rub IDL mirror against Patients Cheek ( Saliva contains natural defogging agent )

After preparing the mirror , check the temperature of mirror by placing back of mirror against dorsum of
hand

Anaesthetise the oropharynx with 10% Xylocaine Spray

Ask the patient to open his mouth , hold his tongue with Tongue and Middle finger and make rotative
movement outside(don’t pull the tongue).With Index finger push the upper lip upwards .

Hold the mirror like a pen and Introduce IDL mirror through one angle of mouth with mirror facing
downwards .
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Place the mirror in oropharynx , pushing uvula upwards and backwards .

Ask the patient to take deep breath , Say Aaaaa … , Eeeeee …

Q25) Draw the Diagram of IDL ?

Q26) Hidden Areas of Larynx in IDL ?

• Ventricles
• Anterior Commissure
• Subglottis
• Post cricoid region
• Laryngeal surface of Inferior Epiglottis

Q27) Fallacies in IDL ?

1. Oval picture.

[Link]-posterior reversal.
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3. 1/3 foreshortening of vertical Axis.

4. Cords look shorter by 1/3.

5. Faulty depth perception, distance between mirror and vocal cords will be decreased .

6. Gives false impression of lateral border to the vocal cord.

7. Lesions appear slightly posterior than its actual position.

[Link] epiglottis.

[Link] areas

Q28) Restricted movement of true cord is due to?

• Infiltration of vocalismuscle
• Mass effect of growth

Q29) What are different causes of Fixity of Larynx ?

• Infiltration of Nerve ( RLN in TO groove )

• Infiltration of Muscle ( Thyroarytenoid&Vocalis )
• Paraglottic space involvement
• Dysfunction of Cricoarytenoid joint

Q30) Differences between Paralytic and fixed cord ?

Paralysed cordFixed cord

Position of cord will be lower Normal

Arytenoids subluxation Normal position but fixed

Flickering movement of the cord Absent

It looks wavy and thickened Normal

Q31) Tenderness of larynx can be due to ?

• Tumour invasion of inner perichondrium and cartilage

• Perichondritis

Q32) What is Laryngeal Crepitus ? Where it is absent ?

• It is grating sound produced by movement of Cricoid lamina over vertebral bodies

• Absent in Post cricoid tumours , retropharyngeal abcess, Cervical esophageal lesions (Bocca’s
Sign )
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• Physiological absence of Laryngeal Crepitus :- Neonates & Children due to unossified cartilages
unable to elicit crepitus.

Q33) Differential diagnosis and Substantiate each ?

• Tuberculosis – features of tb larynx are absent in this case

• WegenersGranulomatosis
• Histoplasmosis
• Syphilis – gumma of tertiary stage , smooth swelling , laryngeal stenosis
• Leprosy – associated with skin lesions , diffuse nodular infiltration of epiglottis , AE folds ,
Arytenoids
• Squamous papilloma – young , warty like
• Scleroma – Subglottis is common, Lesion is fibrotic and irregular
• Amyloidosis
• Lipoma
• Schwannoma – commonly supraglottis
• Laryngeal Mycosis
• Vocal polyp - smooth surface
• Keratosis
• Leukoplakia
• Fibroma
• Granuloma due to GERD
• Glandular tumours – Pleomorphic adenoma
Q34) Embryology & Lymphatic supply of larynx ?

1) The larynx develops from the respiratory and upper digestive tracts.
2) The supraglottic region is derived from arches II and IV (buccopharyngeal anlage) and the glottic
and subglottic regions from the VIth arch (respiratory).

Lymphatic drainage :-

• Above vocal folds – Drained by vessels that accompany Superior Laryngeal Vein – Pierce the
Thryohyoid membrane emptying into upper deep jugular nodes.
• Anterior glottis &Subglottis – Through Cricothyroid ligament anteriorly to level 6 and laterally to
level 4.
• Posterior glottis and subglottis – through Crticotracheal membrane to paratracheal nodes in
level 6 and laterally to level 4.
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Q35) What are the different Subsites of Larynx ?

The supraglottis :-

1) Suprahyoid and infrahyoid epiglottis (both the lingual and the laryngeal surfaces)
2) Aryepiglottic folds (laryngeal surfaces only)
3) Arytenoids
4) Ventricular bands (false vocal cords)

The inferior limit of the supraglottis is a horizontal plane through the lateral
margin of the ventricle at its junction with the superior surface of the true vocal cord.

The glottis :-

1) True vocal cords (both the superior and inferior surfaces)

2) Anterior
3) Posterior commissures

The inferior boundary of the glottis is a horizontal

plane 1 cm inferior to the inferior limit of the supraglottis (defined as
the lateral margin of the ventricle at its junction with the superior surface of the vocal cord).

The subglottis :-

Mucosa 1cm below the apex of ventricle upto lower border of cricoid.

Q36)Intrinsic muscles of larynx ?

Acting on vocal cords

ABDUCTORS ADDUCTORS TENSORS

Posterior Cricoarytenoid Lateral Cricoarytenoid Cricothyroid
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Interarytenoid (Transverse Vocalis (Internal part of

Arytenoid) Thyroarytenoid)
Oblique arytenoids
Thyroarytenoid (External part)

Acting on laryngeal inlet

OPENERS OF LARYNGEAL INLET CLOSERS OF LARYNGEAL INLET

Thyroepiglottic (Part of Thyroarytenoid) Interarytenoid (Oblique part)

Aryepiglottic (Posterior oblique part of

Interarytenoids)

Q37) What is Pre – epiglottic space ?

A. Wedge shaped space with the point of wedge inferiorly

Also known as BOAYER’S space

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Boundaries :-

• Anteriorly :- Thyrohyoid membrane, Thyrohyoid ligament, Hyoid bone, Upper 1/3rd of thyroid
cartilage
• Posteriorly :- Anterior surface of Epiglottis
• Postero – inferiorly :- Thyroepiglottic ligament
• Superiorly :- Hyoepiglottic ligament
• Laterally, the Pre – epiglottic space is continuous with each of the two Paragottic space.

Contents :-

Fat and areolar tissue

Importance :- Invaded by tumors

because the cartilage of the epiglottis has multiple small fenestrations
through which cancers arising from the infrahyoid epiglottis may pass.
Superiorly, the hyoepiglottic ligament provides a barrier to spread of tumor to the tongue base

Q38) What is ParaglotticSpace ?

Paraglotticspace :- Also known as TUCKER’S SPACE.

The PGS lies lateral to the true and false vocal folds and extends
laterally to the thyroid cartilage

Boundaries :-

Medially (from superior to inferior) :-

The quadrangular membrane, laryngeal ventricle, and conus elasticus

Laterally :-
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The ala of thyroid cartilage

Posteriorly :-

Anterior refection of Pyriform fossa mucosa

Inferolaterally :- The cricothyroid membrane.

Anteriorly, each PGS is continuous with the PES, and tumors may spread along this pathway

Q39) What is Reinke’s space ?

• Reinke's space is a potential space between the vocal ligament and the overlying mucosa
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Q40) What is anterior macula flava ?

• At the anterior end of vocal fold there is mass of elastic fibres continuous with the intermediate
layer of lamina propria which is called as anterior macula flava.
• Importance : Protect the ends of vocal folds from the mechanical damage caused by vocal fold
vibration.

Q41)What is the position of Anterior Commissure ? What is its importance ?

• In general, the anterior commissure is located at or above the midpoint of the anterior
midline of the thyroid cartilage in women, and it is located below the mid-point in men.
• Importance :- For cuts during supraglottic laryngectomy.

Q42) What is Broyle’sLigament ?

1. The anterior commissure tendon ( Broyle’s ligament ) is a band of fibrous tissue 1

mm wide and 10 mm in length extending from the
vocal ligaments to the midline of the inner surface of the thyroid cartilage.
2. At this insertion, the thyroid cartilage is devoid of perichondrium.
3. In this area the true vocal cords are therefore in close
approximation to the thyroid cartilage.

Importance :-

• Spread of tumor to Broyle’s ligament leads to early involvement of thyroid cartilage as there is
lack of perichondrium at its insertion which leads to thyroid cartilage erosion.
• Spread of tumor occurs to opposite cord also.

Q43) Epithelium in Larynx ?

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The mucosal lining of the larynx differs in the three regions.

• Supraglottis :- Pseudostratified
columnar type, except at the edges of the aryepiglottic folds and the
lateral borders of the epiglottis, which are stratified squamous non keratinised epithelium.
• True vocal cord :- Stratified squamous non keratinised epithelium
• Subglottis :- Pseudostratified columnar epithelium

Q44) What are different layers of Vocal cord ?

The vocal folds extend from the middle of the angle of the thyroid cartilage to the vocal process of the
arytenoid cartilages and underlying them is the upper border of the conus elasticus.

Each fold is a layered structure consisting of a

1) Superficial layer of nonkeratinizing, stratified squamous epithelium, beneath which is the lamina
propria. This has three distinct layers.

2) The superficial layer (Reinke’s space) contains a fibrous substance with similar characteristics to
gelatin.

3)The intermediate layer contains elastic fibres and

4) The deep layer collagen fibres.

The intermediate and deep layers make up the vocal ligament.

5)The vocalis muscle, which forms the main body of the vocal fold, lies lateral and deep.
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Q45)What is the basic functional unit of larynx ?

• The cricoarytenoid unit is the basic functional unit of the larynx.

• The cricoarytenoid unit consists of an arytenoid cartilage, the cricoid cartilage, the associated
musculature and the nerve supply from the superior and recurrent laryngeal nerves for that
unit.
• It is the cricoarytenoid unit, not the vocal folds, that allows for physiologic speech and
swallowing without the need for a tracheostome.
• Therefore,preservation of at least one functional unit allows organ preservation laryngeal
surgery.

Q46)What is Marginal zone?

• Aryepiglottic Fold
• Lingual Surface of Epiglottis

Q47) How to differentiate a Marginal Tumour based on history?

Tumours in marginal zone can be differentiated based on history

• 1stDyspahgia ,next Change of voice – Ca Hypopharynx

• 1st Change of Voice , then dysphagia – Ca Larynx

Q48) Course of Superior laryngeal nerve and Superior Laryngeal Block ?

It arises from inferior ganglion of the vagus,

Descends behind internal carotid artery and

At the level of greater cornua of hyoid bone

Divides into external and internal branches

Innervation :-

• The external branch supplies cricothyroid muscle

• Theinternal branch pierces the thyrohyoid membrane and supplies sensory innervation to the
larynx and hypopharynx
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Superior laryngeal block :-

• Extension of head and neck

• Identification of hyoid and thyroid
• Greater horn is identified
• 2ml of 2% lignocaine is injected 1cm anterior to the midline of line from greater cornu of hyoid
to superior cornu of thyroid
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Q49) Course of Recurrent Laryngeal Nerve?

Right recurrent laryngeal nerve

Arises from the vagus at the level of subclavian artery, hooks around it and

Then ascends between the trachea and oesophagus.

The left recurrent laryngeal nerve arises

From the vagus in the mediastinum at the level of arch of aorta, loops around it

And then ascends into the neck in the tracheo-oesophageal groove.

RLN passes deep to the lower border of inferior constrictor muscle and enters larynx behind cricothyroid
joint.

Innervation :- All intrinsic muscles of larynx and sensory supply to laryngeal mucosa below the vocal
cords.
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Q50) Explanation for Right RLN hooking around subclavian artery and Left RLN hooking around Arch of
aorta ?

• During embryological development, the RLN are pulled caudad in the neck and chest around the
6th arches of aorta.
• The left 6th aortic arch remains as ductus arteriosus and later the ligamentum arteriosum.
• The right 6th arch normally resorbs allowing the Right RLN to pass inferior to Right 4th aortic arch
which becomes the subclavian artery.

Q51) What is non recurrent laryngeal nerve ?

1. On right side in less than 1% of cases, the Right RLN branches directly from the vagus to larynx
at approximately the level of Cricoid cartilage ( Non Recurrent Laryngeal Nerve ) .
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2. Crosses posterior to Common Carotid Artery and enters the larynx Posterior to Cricothyroid
joint.
3. It is due to abnormal embryological development.
4. Right 4th arch also resorbs during embryonic development in rare cases.
5. Consequence is that the right SCA arises from descending aortic arch and Right RLN nerve tracks
from the Vagus directly to larynx without looping around the vascular structure.

Q52) What is Delphian Lymphnode/Poirier’s Lymphnode?

• ‘Delphian’ node (also known as the midline anterior metastatic node or Poirier’s prelaryngeal
ganglia node) is very rare, situated anterior to cricothyroid membrane.
• It is thought to be associated with T3 or T4 tumours with significant subglottic extension

Q53) What is laryngo – cardial reflex ?

• Pressure over larynx causing bradycardia or cardiac arrest is defined as laryngo – cardial reflex.

Q54) Incidence of neck node metastasis in different subsites of Carcinoma Larynx ?

• Supraglottis – 60%
• Glottis – 10%
• Subglottis –

Q55) Significant Lymph nodes in Neck ?

• Any palpable LN in Neck (>1cm)

• In Submandibular and Submental levels - 1.5cm

Q56) If Glottic carcinoma shows nodal metastasis which node is most commonly involved ?

• Delphian node

Q57) What is the importance of Delphian node ?

• Involvement suggests poor prognosis

Q58) Different Levels of Lymph nodes ?

Level Clinical location Surgical Boundaries

la S, Symphysis of mandible
I, Hyoid bone
A (M), Left anterior belly of
digastric
Submental Triangle P (L), Right anterior belly of
digastric
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lb Submandibular triangle S, Body of mandible

I, Posterior belly of digastric
A (M), Anterior belly of
digastric
P (L), Stylohyoid muscle
lla Upper jugular S, Lower level of bony margin
of jugular fossa
I, Level of lower body of hyoid
bone
A (M), Stylohyoid muscle
P (L), Vertical plane defined by
accessory nerve
llb Upper jugular S, Lower level of bony margin
of jugular fossa
I, Level of lower body of hyoid
bone
A (M), Vertical plane defined
by accessory
nerve
P (L), Posterior border of
sternomastoid muscle
lll Middle jugular S, Level of lower body of hyoid
bone
I, Horizontal plane along
inferior border of
anterior cricoid arch
A (M), Lateral border of
sternohyoid muscle
P (L), Posterior border of
sternocleidomastoid
muscle or sensory branches of
the cervical
plexus
lV Lower Jugular S, Horizontal plane along
inferior border of
anterior cricoid arch
I, Clavicle
A (M), Lateral border of
sternohyoid muscle
P (L), Posterior border of
sternocleidomastoid
muscle or sensory branches of
the cervical
plexus
Va Posterior triangle S, Convergence of SCM and
trapezius muscles
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I, Horizontal plane along

inferior border of
anterior cricoid arch
A (M), Posterior border of
sternocleidomastoid
muscle or sensory branches of
the cervical
plexus
P (L), Anterior border of
trapezius muscle
Vb Supraclavicular S, Horizontal plane along
inferior border of
anterior cricoid arch
I, Clavicle
A (M), Posterior border of
sternocleidomastoid
muscle or sensory branches of
the cervical
plexus
P (L), Anterior border of
trapezius muscle
Vl Anterior compartment S, Hyoid bone
I, Sternal notch
A (M), Common carotid artery
P (L), Common carotid artery
Vll Superior Mediastinum S, Sternal notch
I, Innominate artery
A (M), Common carotid artery
P (L), Common carotid artery
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Q59) Incidence of malignancy at different subsites of Larynx ?

1. Glottis -60 per cent

2. Supraglottis -35 per cent
3. Subglottis - 5 per cent

Q60) How the patient will present in Ca Supraglottis , Ca Glottis , Ca Subglottis ?

GLOTTIC CANCER

• Presents early
• Even the earliest glottic cancer alters the voice by affecting wave pattern forms over the vocal
cord
• Even carcinoma in situ may produce significant voice change
• With increasing lesion size breathiness may be superimposed, with variable degrees of
aspiration
• Advanced lesions may lead to airway obstruction causing progressive dyspnoea and stridor
• Haemoptysis is usually associated with larger tumours
• Referred otalgia (via the vagal complex) is a sinister sign suggesting deep invasion
• Dysphagia and odynophagia are rare in uncomplicated glottic cancer
• Neck nodes are rarely the presenting complaint; if present, they signify deep invasion
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SUPRAGLOTTIC CANCER

• Presents Late
• Hot potato voice
• Foreign body sensation
• If exophytic, they may cause haemoptysis.
• If tumours extend to the cords, then hoarseness
• Further extension laterally may cause referred otalgia, odynophagia and true dysphagia
• Lesions may be asymptomatic until quite large and, as a result, first presentation with a neck
lump due to cervical nodal metastasis is common

SUBGLOTTIC CANCER

• Again, early symptoms can be vague, with a feeling of ‘globus’ or foreign body sensation in the
throat.
• Any involvement of the glottis or recurrent laryngeal nerves results in hoarseness
• Circumferential progression leads to progressive dyspnoea and stridor

Q61)What are the Natural Barriers for Spread of Larynx ?

• The laryngeal cartilages

• Hyoepiglottic ligament
• Thyrohyoid membrane
• Quadrangular membrane
• Conus elasticus
• Anterior commissure
• Cricothyroid membrane

Within the larynx, the pre-

epiglottic space (PES) and the paraglottic space (PGS) provide pathways for spread of laryngeal t
umors

Q62) Routes of spread of tumour in Malignancy of Glottis , Supraglottis , Subglottis ?

Spread Laryngeal squamous cell cancer has characteristic patterns of spread depending on the site of
origin.

Local spread is along tissue planes

Glottis
• Via the anterior commissure to the opposite cord,
• Anteriorly through broyles ligament to thyroid cartilage
• Or may extend posteriorly to invade the arytenoid cartilage.
• Glottic tumours may be confined to Reinke’s space by the above embryological -boundary
• Superiorly and the conus elasticus inferiorly.
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• In order to reach the paraglottic space and thence gain an easy passage cranially and caudally,
tumours need to transgress both the vocal ligament and vocalis muscle.
• External extension directly through the cartilages is regularly seen.
Supraglottis
Supraglottic cancers tend to remain locally confined (even with pre-epiglottic or nodal spread) to their
subsite until relatively late.
• Inferiorly - approximately 50 percent of supraglottic cancers spread to the glottic region.
Anteriorly - through foramina within the epiglottis
• Superior - invasion of the hyoid is rare (2–4 percent)
‘Suprahyoid supraglottic’ carcinomas tend to invade the paraglottic spaces and the deep muscles of the
tongue and spread mucosally into the piriform fossae rather than anteriorly into the pre-epiglottic
space.
Subglottis
Subglottic carcinoma tends to extend caudally and circumferentially.
• Fifty percent invade the cricoid
• 75 percent have already extended outside the larynx by the time of diagnosis.
Transglottic tumours
Transglottic cancer is defined by spread, both superficially and into the paraglottic space to span all
three laryngeal subsites.
True primary transglottic cancer is said to originate in the laryngeal ventricle.

Lymphatic spread
Glottis
• Lymphatic spread of glottic cancer is less common than at other subsites.
• It has been suggested that the lack of submucosal lymphatics in this area is responsible.
• Spread, when it occurs, is to levels II, III, IV and VI.
• ‘Delphian’ node (also known as the midline anterior metastatic node or Poirier’s prelaryngeal
ganglia node) is very rare, but is thought to be associated with T3 or T4 tumours with significant
subglottic extension.
Supraglottis
• Supraglottic tumours also have a propensity for bilateral nodal metastasis Level I,II,IV .
• In reports of advanced disease, supraglottic carcinoma has a positive nodal rate of over 60
percent
Subglottis
• Clinically detectable nodal metastasis is uncommon, although a microscopic incidence of one in
three puts this disease into the category of requiring elective nodal dissection.
• Due to the propensity for inferior extension, nodal dissection for subglottic cancer should
include the paratracheal/mediastinal nodes

Q63) How malignancy spreads into Pre Epiglottic Spacefrom Supraglottis?

• Through the fenestrations present in Epiglottis

Q64) What is the characteristic feature of tumour that has spread to Pre epiglottic space ?

• PreEpiglottic space containing Fat is replaced by tumour

• This Space has least blood supply
• Avascular Necrosis will occur
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• Radiotherapy is of no use and Contraindicated .

Q65) Metastasis to larynx is from ?

The primary tumors responsible

for these metastases to the larynx were (in descending order of incidence)

• Cutaneous malignant melanoma (34%),

• Renal cell carcinoma (16%), and
• Cancer of the breast, lung, prostate, colon, stomach, and ovary (each <10% of the total)

Q66) Most common site for distant metastasis for Carcinoma larynx ?

• Lungs

Q67) Mediastinal secondaries are seen in ?

1. Malignancies of Thyroid
2. Cervical trachea
3. Cervical oesophagus
4. Subglottis
5. Post cricoid

Q68) What is TransglotticTumour ?

1. Tumour that involve glottis as well as supraglottis and cause fixity of true vocal cord are defined
as transglottic tumours
2. Fixation is because of Infiltration of vocalis muscle and paraglottic space
3. Transglottic tumors extend across the laryngeal ventricle to involve the
supraglottic, glottic, and often the subglottic portions of the larynx
Tumors can become transglottic in four ways:
• by crossing the ventricle directly;
• by crossing at the anterior commissure;
• by spreading through the paraglottic space; and
• by spreading along the arytenoid cartilage posterior to the ventricle
4. Transglottic cancer is defined by spread, both superficially and into the paraglottic space to span
all three laryngeal subsites. True primary transglottic cancer is said to originate in the laryngeal
ventricle.
5. It is, by definition, at least T3 at presentation and subsequent consideration will therefore be
alongside advanced cancers.

Q69) T Classification of Carcinoma Larynx ?

Supraglottis
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T1 Tumour limited to one subsite of the supraglottis with normal vocal cord mobility

T2 Tumour invades mucosa of more than one adjacent subsite of supraglottis, glottis or region
outside supraglottis without fixation of the larynx

T3 Tumour limited to larynx with vocal cord fixation and/or invades any of the following:
postcricoid area, pre-epiglottic tissues, paraglottic space or inner cortex of thyroid cartilage

T4a Moderately advanced disease Tumourinvades through outer cortex of thyroid cartilage,
and/or invades tissue beyond the larynx; soft tissues of the neck, deep/extrinsic muscles of the
tongue, strap muscles, thyroid gland or oesophagus

T4b Very advanced disease Tumour invades prevertebral fascia, mediastinal structures or
encases internal carotid artery

Larynx – glottis

T1 Tumour limited to the vocal cord(s), including involvement of anterior or posterior

commisure with normal mobility

T1a – Tumour limited to one vocal cord

T1b – Tumour involves both vocal cords

T2 Tumour extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility

T3 Tumour limited to larynx with vocal cord fixation and/or invades paraglottic space and/or
inner cortex of thyroid cartilage

T4a Moderately advanced disease

Tumourinvades through outer cortex of thyroid cartilage, and/or invades tissue beyond the
larynx; soft tissues of the neck, deep/extrinsic muscles of the tongue, strap muscles, thyroid
gland or oesophagus

T4b Very advanced disease Tumour invades prevertebral fascia, mediastinal structures or
encases internal carotid artery

Larynx – subglottis

T1 Tumour limited to subglottis.

T2 Tumour extends to vocal cord(s) with normal or impaired vocal cord mobility

T3 Tumour limited to larynx with vocal cord fixation or invasion of paraglottic space or inner
cortex of thyroid cartilage

T4a Moderately advanced disease

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Tumour extends through cricoid or thyroid cartilage, and/or invades tissue beyond the larynx;
soft tissues of the neck, deep/extrinsic muscles of the tongue, strap muscles, thyroid gland or
oesophagus

T4b Very advanced disease

Tumour invades prevertebral fascia, mediastinal structures or encases internal carotid artery

Q70) Premalignant conditions of Larynx ?

The World Health Organization (WHO) classifies premalignant laryngeal lesions as Hyperplasia;

• Keratosis;
• Mild, moderate, or severe dysplasia; and
• Carcinoma in situ (CIS)
(
Very early lesions may demonstrate hyperkeratosis or parakeratosis without cellular aty
pia or dysplasia )
• Leukoplakia
• Erythroplakia

Q71) What is the order of doing Imaging and Examination under Anaesthesia?

• Ideally, scanning should be performed before examination under anaesthesia as the

manipulation of the tumour and the larynx by direct laryngoscopy may result in inflammatory
changes around the tumour, with the possibility of upstaging of the tumour.

Q72)What you will do in Direct Laryngoscopy ?

1. Once a laryngeal lesion is identified, a full examination of the larynx and surrounding sites is
necessary for staging.
2. This is usually undertaken under general anaesthesia to allow close examination of the tumour,
its depth, its relations, and to obtain a histological biopsy.
3. When examining a laryngeal tumour, assessment of the surrounding structures should be
undertaken.
4. This is especially important for the pyriform fossae and postcricoid region.
5. Tumour can extend through the aryepiglottic folds into these sites, resulting in an upstaging of
the tumour and a change of the management plan.
6. Assessment of the extension into the base of tongue and vallecula should also be made.
7. Biopsy has to be taken from the specimen at an area which should have a minimal effecton the
voice.
8. The biopsies are taken from the most abnormal area(s) which may have been highlighted by its
friability on contact bleeding

Q73)Features of malignant Lymphnode in CT Scan ?

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• Size . 1.5cm
• Central Necrosis
• Consecutive >3 lymphnodal enlargements
• Capsular Erosion

Q74)What information we will get from Histopathology ?

• Confirmation of Diagnosis
• Staging
• Differentiation
• HLA Typing

Q75) Histopathological features of Squamous cell carcinoma ?

• Macroscopically, squamous cell cancer (SCC) of the larynx may be exophytic or endophytic.
However, attempts to correlate such appearance to behaviour have been unconvincing.
• Microscopically, it is characterized by the presence of ‘prickle’ cells and keratin whorls.

Q76) Broder’s Classification

Broder suggested the division into four groups according to the degree of differentiation shown by the

cells of the tumour

• Grade I: Highly differentiated adult type cell.

• Grade II: Intermediate type.

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• Grade III Intermediate type but less differentiated cells.

• Grade IV: Undifferentiated anaplastic type.

Grade Percentage of cells undifferentiated

I 0-25

II 25-50

III 50-75

IV 75-100

Q77) Pathological features of malignant cells ?

1. Malignant squamous cells display some or all of the following features:

2. Irregular shape and orientation;
3. Increased and abnormal mitoses;
4. Nuclear hyperchromatism;
5. Coarse and clumped chromatin;
6. Nuclear pleomorphism;
7. Elevated nucleus–cytoplasmic ratio;
8. Prominent nucleoli and macronucleoli;
9. Premature keratinization (dyskeratosis) or loss of keratin production;
10. Disordered cell polarity;
11. Disorganized growth

Q78) Different Histopathologies for Carcinoma Larynx ?

A.

Epithelial Squamous cell carcinoma

Verrucous Carcinoma ( low grade SCC )
Lymphoepithelial carcinoma
Malignant melanoma
Adenocarcinoma
Acinic cell carcinoma
Mucoepidermoid carcinoma
Adenosquamous carcinoma
Neuroendocrine
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Sarcomatoid carcinoma
Mesenchymal Leiomyosarcoma
Chondrosarcoma
Osteosarcoma
Malignant histiocytoma
Fibrosarcoma
Liposarcoma
Angiosarcoma
Rhabdomyosarcoma
Synovial sarcoma
Haemopoietic Non hodgkin’s lymphoma
Multiple myeloma

Q79) Supra Vital Staining?

• It is useful in selection of the site of biopsy in leukoplakic lesion.

• Toluidine blue is applied to the laryngeal lesion and then washed with saline and examined
under the operating microscope.
• Carcinoma in situ and superficial carcinomas take up the dye while leukoplakia does not.
• Thus, it helps to select the area for biopsy in a leukoplakic patch.

Other stains used :-

1. New methylene blue
2. Brilliant cresyl blue
3. Crystal violet
4. Methyl violet
5. Nile blue
Q80) What is Field Cancerization ?

• It is defined as “ a clinical concept describing a mucosal surface in the region near an invasive
tumor with premalignant changes and the propensity for second primary tumor development in
adjacent mucosa.
• It is due to exposure of aero – digestive tract to similar carcinogens.

Q81) What is second primary ?

• It is defined as second denovo malignant neoplasm with known cancer.

• It can be synchronous or metachronous.

Warren and Gates criteria for diagnosis is :-

• Each of tumors must be malignant, each confirmed by histology

• Each must be geographically separate and distinct.
• Probability of one being metastasis of the other must be excluded

Q82) What is Synchronous and Metachronous cancers?

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Second primary tumors may be

• Synchronous (different histopathology) (identified within 6 months of the index tumor at

two distinct anatomical sites ) or
• Metachronous (Same Histopathology)
(diagnosed more than 6 months after the index tumor)

Q83) Position for Direct Laryngoscopy ?

• Boyce’s position ( Flexion of neck and extension of atlanto- occipital joint )

Q84)What is tripleScopy&Pan Endoscopy ?

• Bronchoscopy , Direct Laryngoscopy,Hypopharyngoscopy

• Above 3 + Oesophagoscopy and Nasopharyngoscopy

Q85) Difference between Direct Laryngoscopy and IDL?

Indirect Laryngoscopy Direct Laryngoscopy

1. It is simple, 2D image 1. It is 3D image
2. Inverted image 2. Real
3. Difficult to visualize anterior commissure, 3. Can be visualized
Ventricles, Subglottis
4. Not useful for therapeutic purpose 4. Useful for both diagnostic and
therapeutic purpose
Q86) Role of CXR ?

• Pulmonary status
• Aspiration pneumonia
• 2nd primary
• Pulmonary tuberculosis
• Mediastinal widening

Q87) Chest X ray findings in aspiration ?

• Diffuse bilateral lung infiltrates may be seen in massive aspiration

• Or infiltrates may be seen in dependent lung segments, such as the posterior segments of the
upper lobes and superior segments of the lower lobes in patients lying in the supine position.

Q88)Role of Barium swallow ?

• To rule out second primary

Q89) Role of PET CT ?

1. Evaluating patients with pathological cervical nodes and an unknown primary

2. Evaluating regional lymph node metastases
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3. Excluding distant metastases and synchronous primary tumours

4. Monitor tumour recurrence in the postoperative neck
5. Excluding residual disease after Chemoradiotherapy

Q90)USG features of Metastatic node ?

• Absent hilar echoes and increase in short axis length are generally considered to be
features of metastatic neck nodes.
• Normal cervical lymph nodes are elliptical in shape , outer hypoechoic cortex and a central
echogenic (bright) hilus which is continuous with the surrounding fatty tissue. Normal and
reactive cervical lymph nodes may show hilar vascularity or appear avascular.
• Malignant infiltration results in enlarged, more rounded nodes with disruption of the normal
sonographic structure. Loss of the usual sharp outline of an involved node suggests
extracapsular spread and correlates with advanced malignancy. Nodal calcification can be seen
in metastatic nodes

Q91)What is Stroboscopy ? What are its Uses ?

1. Stroboscopy is a special method of examination of a vibrating vocal folds.

2. SynchronisedFlashging (lasting a fraction of 10micro secs) is passed through flexible telescope
3. These flashes of light are synchronized to vocal cord vibration
4. This flash 'freezes' the movement of the vibrating vocal folds

Uses :

• Determine changes to vocal folds that can’t be detected by naked eye

• Vibratory pattern can be seen
• Wavy movements of vocal cords
• Minute abnormalities can be detected in vibration of vocal cords
• Early glottic cancer can be detected
• Pre & post treatment comparison

Q92) What is talbot’slaw ?

• It is the law on whichPrinciple of videostroboscopy is based.

• When an image is presented to eye it persists for 0.2 seconds ( 5 cycles/sec ).
• Rapidly vibrating object cannot be seen if vibrations are >5/sec ( vocal fold vibrations being 100
cycles per second.
• If flashes of light are exactly equal to and in phase with vocal fold vibratory cycles the folds will
appear motionless.
• The perceived stroboscopic motion of vocal fold is an optical illusion created by fusing multiple
points of several successive vibratory cycles using above principle.

Q93) Gold Standard Investigation for Malignancy of Larynx ?

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• Direct Laryngoscopy and Biopsy

Q94) Choice of anaesthesia for Direct laryngoscopy ?

General anaesthesia

Advantages :-

• Examination of tumor, site, size & extent of lesion

• Obtain a histological biopsy as cords are immobile
• Avoid laryngospasm
• To check for pyriform fossa and post cricoid region
• To palpate the neck for nodes
• Vocal cord mobility can be examined immediately after extubation.
• Panendoscopy can also be carried out in same setting for 2nd primary

Q95 ) If biopsy is planned under general anaesthesia what should be advised to anaesthesist ?

• Use armoured long tube

• Undersize tube

Q96) If biopsy is planned under local anaesthesia how to prepare patient ?

• Atropine pre - medication :- To prevent bradycardia & cardiac arrest

• SLN block

Q97) Disadvantages of local anaesthesia ?

• Aspiration
• Precipitating laryngospasm

Q98) Intra – operative factors which may precipitate laryngospasm?

• Too much trauma 0r meddling of tissues

• Bleeding

Q99 ) Risk factors for laryngospasm ?

• Obesity
• Smoking
• COPD

Q100) How to prevent laryngospasm ?

• Minimal instrumentation
• IV steroids
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• Spray 4% lignocaine
• Anaesthesist should not extubate immediately
• Oxygenation should be given in immediate post operative period

Q101) How to treat laryngospasm ?

• Muscle relaxants
• 100% Oxygenation
• Reintubate
• Immediate tracheostomy

Q102) Complications of laryngospasm?

• Hypoxia
• Cor pulmonale
• Death
• Pulmonary edema

Q103) Role of CT Scan in this case? How much mm Cuts are ideal ?

• Tumour volume & Extent

• Ventricular complex involvement
• Submucosal infiltration
• Subglottic involvement
• Anterior and posterior commissure involvement
• Laryngeal cartilage involvement( Erosion, lysis, sclerosis )
• Spread beyond the larynx
• Paraglottic and Preepiglottic space involvement
• Carotid and prevertebral involvement
• Nodal Status

1mm cuts are to be taken

Q104)Role of MRI in this case ?

• It is additive to CT scan.
• Can detect involvement of paraglottic&preepiglottic space.

Q105) Father of MLS ?

• Kleinsasser

Q106) Different types of Laryngoscopes?

• Dedo
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• Jako
• Pilling
• AnterorComissure
• Kleinsasser’s

Q107) Focal length of microscope used for laryngeal surgeries ?

• 400mm
• Ear surgeries – 250mm
• Nose surgeries – 200mm

Q108) Length of EndolaryngealInstruments ?

• 27cm

Q109)Treatment for Premalignant lesions ?

1. Avoid chronic laryngeal irritants.

2. Avoid smoking and alcohol consumption
3. Avoid radiotherapy
4. Chemoprevention :- Antioxidants and Vitamin A, C , E
5. Stripping of cords
6. Laser excision
7. Vigilant follow up

Q110) Stage wise management of Carcinoma Larynx ?

Glottic Carcinoma Supraglottic Carcinoma Subglottic Carcinoma

T1 :- Radiotherapy T1, T2 :- Radiotherapy T1, T2 :- Total Laryngectomy
Other options :- Other options :- T3, T4 :- Total Laryngectomy
Endoscopic laser Endoscopic laser +
Excision, Frontal & Excision, SCPL- CHP PORT
Frontolateral T3, T4 :- Total Laryngectomy N+ :- MNRD
laryngectomy +
T2 :- Radiotherapy PORT
Other options :- Other options :-
Endoscopic laser Supraglottic Partial
Excision,VPL, Laryngectomy
SCPL- CHP N+ :- MNRD

T3, T4 :- Total Laryngectomy

+
PORT
N+ :- MNRD
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Q111) What is Wide Field Laryngectomy ? What is Narrow Field Laryngectomy ?

• Wide filed laryngectomy :- This procedure encompasses the entire larynx with its attached
prelaryngeal strap muscles and the lymph nodes in the jugular chain (levels II, III, and IV) on
the ipsilateral side as well as the lymph nodes in the tracheo-esophageal groove on the
same side.
• Narrow field laryngectomy :- A narrow field laryngectomy is less extensive than a total
laryngectomy for the treatment of laryngeal cancer as it preserves the hyoid bone, the strap
muscles and as much pharyngeal mucosa as possible. Level 2, 3, 4 nodes are not cleared.
Q112)How to prepare a patient for total laryngectomy ?

• Assessment of preoperative pulmonary function. This assessment is particularly important for

persons who have a history of chronic obstructive pulmonary disease and are being considered
for total laryngectomy &conservation surgery.
• Preoperative counselingregarding postoperative pulmonary care and breathing exercises is
vitally important.
• Consultation and counseling from a speech therapist.
• A preoperative visit reduces the patient’s anxiety and apprehension regarding loss of speech
and results in improved understanding of voice rehabilitation after surgery.
• Preparation of the patient for total laryngectomy is important and should involve the speech
and language therapists at an early stage.
• Advising on the self care of the tracheo-oesophageal voice prosthesis.
• Part of this process is offering the patient the opportunity to meet a patient who has had a
laryngectomy to allow an insight and an opportunity to ask questions.

Q113) What are different incisions for Laryngectomy ?

• Gluck Sorensen’s or Apron flap :- ‘U’ shaped, and running into the proposed tracheostome.
• Vertical limb is just medial to anterior border of SCM
• Highest limit is mastoid process on both sides
• Horizontal limb encircles the trachestome.
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• Mac fee incision :- Skin flap is preserved. It is opted to prevent dehiscence if PORT is required.

Q114)Who has done 1stLaryngectomy ?

• Billroth in 1873

Q115) First Near total laryngectomy was performed by ?

• BrucePearson in 1981

Q116) 1st neck dissection?

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• Crile in 1906

Q117)Steps of Total Laryngectomy ?

Incision :-

• The horizontal skin incision is made in the midcervical region at around the level of the cricoid
cartilage, extended over the anterior border of sternocleidomastoid bilaterally and curved
gently superolaterally.
• It should be positioned so that the tracheostome can be placed in the inferior flap with a
sufficient bridge of skin between the superior edge of thetracheostome and the incision, this
being of the order of 2 cm.
• The upper and lower skin laps are elevated to get exposure from the hyoid to the suprasternal
notch

Mobilization :-

• The paralaryngeal, parapharyngeal space is identified and entered by sharp dissection, with
division of omohyoid with this space being opened posteriorly down to the level of the
prevertebral muscles.
• The superior vascular pedicle is divided.
• Inferiorly, the strap muscles, sterno-hyoid and sternothyroid muscles are divided as inferiorly as
possible and reflected by sharp dissection from the anterior surface of the capsule of the thyroid
gland until the hemi-thyroid has been exposed completely.
• Inferior thyroid artery is now divided and ligated
• The thyroid gland is transfixed and divided in the midline.
• The hemi-thyroid is elevated from the trachea by sharp dissection
Resection :-
• Trachea is entered by sharp dissection between 2nd and 3rd tracheal ring.
• Suprahyoid muscles are divided in the midline.
• The pharynx is entered by dissection being continued in the midline dividing the genioglossus
and vallecula.
• Divide the constrictors from the thyroid cartilage, approximately 1 cm anterior to the posterior
edge of the thyroid cartilage.
• Mucosal incisions are given and larynx resected.
• The larynx is divided from the trachea at the level of tracheostomy
Stoma creation done.
Cricopharyngeal myotomy performed.
Closure of pharyngeal mucosa done

Q118) Steps taken to prevent stomal recurrence ?

• High tracheostomy to be performed.
• Tracheostomy with cuff of skin is excised along with specimen
• Level 6 nodes are cleared

Q119)What are conditions where Total thyroidectomy is adviced in Malignancy of Larynx ?

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• Subglottic Extension >1cm

• Cricoid cartilage invasion
• Peri thyroidal soft tissue involvement
• Extensive tumour around Anterior commissure

Q120) What is the Post operative care after total laryngectomy ?

• Post operative hydration

• Prevention of laryngeal reflux by maintaining head up position
• Absolute voice rest
• Avoid exposure to pollution

Q121) What is Conservation Laryngectomy ?

• Conservation laryngectomy :- It is a procedure designed to preserve the laryngeal function of

speech.

Q122) What are the Various Conservation surgery options?

Vertical partial laryngectomy :-

This procedure may be a lateral or an anterolateral vertical partial laryngectomy. The technique involves
vertical cuts through the laryngeal cartilage. The majority of the ipsilateral thyroid cartilage, true vocal
cord, portions of the subglottic mucosa and false cord are removed

Types :-

1. Hemilaryngectomy :- For cord lesion without involvement of the anterior commissure or the
arytenoid
2. Frontal laryngectomy :- For anterior commissure lesion
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3. FrontolateralLaryngectomy :- For cord lesion extending across the anterior commissure

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4. Extended hemilaryngectomy :- For cord lesions involving the arytenoid.

Indications :-

• T2 Glottic cancer
• T1 glottic cancer where radiotherapy cannot be used
• T3 where arytenoid is mobile
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Contraindications :-

• Subglottic extension more than 10 mm anteriorly or more than 5 mm posteriorly

• Paraglottic disease extending superiorly above the level of ventricle or inferiorly upto thyro-
cricoid level
• More than 1/3rd contralateral cord involvement
• Cord fixity associated with arytenoid fixity
• Post radiation

Horizontal supraglottic partial laryngectomy :-

In this procedure, the epiglottis, hyoid bone, pre-epiglottic space, thyrohyoid membrane, upper half of
the thyroid cartilage and the supraglottic mucosa are removed . The vallecula is transected superiorly,
the ventricles inferiorly and the aryepiglottic folds laterally. Closure is by approximating the base of
tongue to the lower half of the thyroid cartilage and closing the posterior false cord mucosa

Indications :-

Infrahyoid supraglottis cancers & Suprahyoid supraglottis cancers with mobile cords.

Contraindications :-

• Poor pulmonary reserve

• Impaired cord mobility
• Erosion of thyroid cartilage
• Involvement of pyriform sinus upto apex
• Involvement of interarytenoid or post cricoid region
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Supracricoid partial laryngectomy with cricohyoidoepiglottopexy :-

Supracricoid partial laryngectomy with cricohyoido-epiglottopexy (CHEP) operation involves resection of

both true cords, both false cords, the entire thyroid cartilage, paraglottic spaces bilaterally and a
maximum of one arytenoids .

Supracricoid partial laryngectomy with cricohyoidopexy :-

Resection of both true cords, both false cords, the entire thyroid cartilage, both paraglottic spaces
bilaterally, and a maximum of one arytenoid, thyrohyoid membrane and epiglottis
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Q123)Prerequisites for partial laryngectomy ?

• No medical Problems
• Adequate pulmonary reserve
• The patient should play an active role in speech and swallowing rehabilitation.
• All patients should have a speech and swallowing assessment preoperatively and both the
patient and family should participate in the work required for rehabilitation.

Q124) Importance of cricopharyngeal myotomy?

• This is important to avoid hypertonicity and spasm of these muscles during attempted
phonation and to allow expansion of the upper oesophagus providing an air ‘reservoir’ below
the PE segment.
• Hypertonicity or spasm will interrupt the flow of air to a varying degree, restricting or
completely stopping voice production.
• To prevent aspiration post surgery

Q125)What is Near total Laryngectomy ?

• Removal of one half of the larynx and 2/3 of the opposite leaving functional cricoarytenoid unit
on unaffected side.

Q126) What is Neoglottis reconstruction ?

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1. After laryngectomy restoring only phonation without eliminating permanent tracheostoma is

achieved by means of a small tracheopharyngeal fistula through which the flow of air from the
lungs is directed toward the upper vocal resonators (pharynx, oral cavity, etc) whenever the
tracheostoma is manually closed.
2. This produces a voice of good quality with a natural sounding timbre.
3. This phonatory fistula is called neoglottis.
Indications:-
1. The indications for this procedure are the same as for total laryngectomy, with or without neck
dissection.
2. In fact neoglottis is merely a surgical step applied after the removal of the larynx.
Contraindications:-
1. Hypoglottic cancers, since they make it necessary to remove some tracheal rings.
2. Posteriorly developing cancers, since large extents of pharyngoesophageal mucosa must be
included in the removal.
3. Marginal cancers extending to the medial side of the pyriform sinus, for the same reason as in
point 2.
4. Previous radiotherapy
5. Cancers arising in lesions of Plummer-Vinson syndrome
SURGICAL TECHNIQUE :-
When a phonatory fistula is planned, the total laryngectomy, should be performed paying attention to
some details.
• Tracheotomy should be made at the fourth or fifth ring
• The transection of the trachea should be carried out according to an oblique plane ,ie, starting
anteriorly from the cricotracheal membrane, extending on both sides with a slanting cut in the
first tracheal ring and ending posteriorly just below the same ring.
• This slope of the tracheal contour, to which the esophageal mucosa will be fastened, reduces
the risk of aspiration of foods into the trachea through the fistula.
• The pharyngeal mucosa must be left as wide as possible, especially at the level of the pyriform
sinuses and glossoepiglotticvalleculae
• The construction of the phonatory fistula starts as soon as the larynx has been removed.
The procedure may be divided into five steps.

1) The esophageal adventitia is anchored to the most cranial tracheal ring with two separate
stitches at both posterior ends of the cartilage. Then, the fistula is created on the medial line by
means of a vertical incision (8-10 mm in length) which ends 2-3 mm above the upper margin of
the trachea .The different layers of the visceral wall (muscular, submucosal, mucosal) should be
separately transected.
2) Through the incision, the esophageal mucosa is pulled to the outside and sutured to the
adventitia with a few separate stitches .
3) A heavy silk thread is passed through the nasal cavity, the fistula and the tracheostoma .
4) The pharyngoesophageal flap is now sutured to the tracheal opening; In the end, the fistula
should be located approximately in the center of the tracheal lumen
5) The surgical pharyngostoma is finally closed horizontally
Q127) Complications of Total Laryngectomy ?

Early :-
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• Pharyngo Cutaneous Fistula

• Haemorrhage
• Wound Dehiscence
• Aspiration

Late :-

• Stomal Recurrence
• Stomal Stenosis
• Hypothyroidism
• Hypoparathyroidism

Q128)Voice rehabilitation after laryngectomy ?

• Electrolarynx
• Oesophageal speech
• Valved prosthesis e.g. BlomSinger , Groningen ,Provox
• Laryngeal transplantation
Blom singers voice prosthesis is a uni directional [Link] can be passed only in one direction .
Air is inhaled through the valve and is exhaled through oesophagus and produces speech.

Q129)Types of Voice prosthesis ?

Two basic types of valve are available

• The ‘standard’ valves, including the original ‘duckbill’ valve (NON INDWELLING) and
• The modified ‘low-pressure’ or ‘low-profile’ valves (INDWELLING)

Q130) Treatment of Pharyngocutaneous fistula?

• Continuation of Ryle’s tube feeding for few more weeks.

• Antiseptic Dressings.
• Minimal Debridement.
• Deltopectoral flap.
• PMMC Flap.
• Radial forearm flap.
• Gastric pull up.
• Feeding Gastrostomy/jejunostomy.

Q131) 5 Year survival rate for Ca Larynx ?

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Stage Supraglottis (5-year Glottis (5-year Subglottis (5-

relative survival rate) relative survival year relative
rate) survival rate)

I 59% 90% 65%

II 59% 74% 56%

III 53% 56% 47%

IV 34% 44% 32%

Q132) Which subsite of Carcinoma larynx has good prognosis?

Glottic carcinoma

Reasons :-

• Early presentation due to hoarseness of voice

• Biologically slow growing tumor
• Less lymphatics

Q133)When is PORT indicated ?

• T3,T4 lesions
• Multiple Neck Nodes
• Extracapsular Spread
• Close or Positive Margins
• Perineural Invasion

Q134) Advantages of Radiotherapy over other modalities of treatment ?

• It is potentially achievable in patients with poor reserve.

• Have better voice outcomes. This hypothesis is based on the principle that the laryngeal
structures are being ‘preserved’.
• The flaw to this is that at the time of presentation the laryngeal structures will already
have been destroyed to a certain extent by the malignant process.
• In addition, radiotherapy is in itself a radical treatment so it will have a deleterious effect
on the structures

Q135)Types of Radiotherapy ?
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1. External beam radiotherapy/ Teletherapy :- Radiation beam is directed from a machine placed
outside the patient to a treatment volume located within.
a. Advanced forms of EBRT :- Stereotactic radiosurgery which is highly conformal
technique allows for the delivery of relatively large doses in a single or a few fractions,
in inaccessible areas such as the skull base. Multiple low-dose radiation beams are
delivered in a pattern that allows them to overlap at the target lesion.
b. Image guided Radiotherapy : Form of EBRT where Radiation dose is conformed more
precisely to the 3D shape of the tumor by modulating or controlling the intensity of the
radiation beam in multiple small volumes.

2. Brachytherapy :- Radioactive material introduced directly to within a tumour or tumour bearing

area.

Q136) Fractions of radiotherapy ?

a. Conventional Fractionation :- 1.8 – 2 Gy fraction given daily for 5 days / week. Curative doses 66
– 70 Gy delivered in 33 – 35 fractions over 6.5 – 7 weeks.
b. Hypofractionation :- Fewer fractions and larger dose per fraction > 2Gy
c. Hyperfractionation :- More number of fractions and lesser dose per fraction < 1.8 Gy
Reduces risk of late damage for a given total dose.
d. Accelerated fractions :- Overall treatment time is reduced . treating patient 2-3 times each day
1.5 Gy per fraction continuously for 12 days to a total dose of 54 Gy
Reduces risk of normal tissue damage with benefits of completing treatment in shorter time.

Q137) Phases of radiotherapy ?

• Phase 1 :- Larger volume encompassing the primary tumor, lymph nodes, and microscopic nodal
spread.
• Phase 2 :- Smaller volume including primary tumor and involved lymph nodes alone treated.

Q138)Dosage of Radiotherapy for Ca larynx ?

• 66–70Gy in 2Gy per fraction, treating daily, five fractions a week, 7 weeks
• Phase I: 50 Gy/25#/5 weeks; Phase II: 20 Gy/10#/2 weeks.

Q139)What is CyberKnife ?

• It employs 6 Mev LINAC and image guided technology to deliver targeted high dose of radiation
to tumors in inaccesible site avoiding damage to surrounding normal tissues.

Q140)What is Cell Cycle ?

Go Phase Resting phase

Interphase (90%)

Gap1 ( G1 )
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Biosynthesis of proteins, enzymes required

for S phase needed for DNA replication
Synthetic phase ( S ) DNA replication, sister chromatids are
formed
Gap 2 ( G2) Cell grows in size
Mitosis ( M ) Active division phase

Q141)Chemetherapeutic drugs used in Carcinoma Larynx and their Dosage ?

• Cisplatin 100 milligrams/m2 BSA once in 3 weeks ( D1, D22, D43 )IV infusion over 3-4 hrs
• 5 – Flurouracil 2nd line drug 750 – 1000 mg/ day for 3-5 days
• Carboplatin – 450mg/m2 BSA
• Taxanes( Paclitaxel – 175 mg/m2 BSA )

Q142)Contraindications of Radiotherapy in Carcinoma larynx ?

• Fixed cord
• Fixed hemilarynx
• Pre – epiglottic space involvement
• Para – glottic space involvement
• Involvement of more than one site
• Ventricular involvement
• Deep ulceration
• Large volume tumor

Q143)Types of Neck Dissections ? Incisions for Neck dissections ?

• Radical neck dissection -Removal of levels I–V, accessory nerve, internal jugular vein
and sternomastoid muscle
• Modifed radical neck dissection (MRND) -Removal of levels I–V dissected; preservation of one
or
• More of the accessory nerve, internal jugular vein, sternomastoid muscle
(types I, II and III, respectively)

Structures preserved

Type I Levels I–V SAN

Type II Levels I–V SAN, SCM

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Type III(Functional) Levels I–V SAN, SCM, IJV

• Selective neck dissection- Preservation of one or more levels of lymph nodes

Types of selective neck dissection.
a. Levels I–III (supraomohyoid);
b. levels I–IV (extended supraomohyoid);
c. levels II–IV (lateral);
d. levels II–V (posterolateral);
e. level VI–VII (anterior/paratracheal).
• Extended radical neck dissection (ERND) Removal of one or more additional lymphatic and/or
non-lymphatic structures(s) relative to a radical neck dissection, e.g. level VII, retropharyngeal
lymph nodes, hypoglossal nerve
Incisions :-
• Schobinger
• Horizontal-T (Hetter)
• McFee
• Lateral utility
• Utility
• H-incision
• Visor
• Extended
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Q144)Complications of Neck Dissection ?

GENERAL:

[Link] – DVT

[Link] - Pneumonia, Pneumothorax ,Hemothorax

[Link] - Refeeding syndrome.

SPECIFIC:

[Link] – hypovolemic , cardiogenic , septic.

[Link] base imbalance

[Link] imbalance

[Link]
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[Link] injury

[Link] artery rupture

[Link] leak

[Link]

[Link] syndrome – most troublesome and crippling complication,denervation (SAN )

[Link] – nerve injury (neuropraxia, axonotmesis , neurotmesis).

[Link] – tracheostomy

[Link] healing

[Link] fistula.

Q145)What is Tracheostomy ? Types of Tracheostomy ?

A tracheotomy is a surgical opening in the trachea, while a tracheostomy is the creation of a stoma at
the skin surface which leads into the tracheal lumen.

Indications for tracheostomy are the following:

(a) Upper airway obstruction;

(b) Removal of secretions;
(c) Prolonged ventilation;
(d) Part of another procedure.

Types :

a)Permanent: Elective procedure wherein permanent stoma is created as in laryngectomy or as

diversion procedure for aspiration

b)Temporary:- It is temporary procedure where still connection between pharynx and lower airway
persists via larynx

a)Elective

b)Emergency

a)High :- It is done above the level of isthmus ( 2, 3, 4 tracheal ring )

b)Mid :- Between 2nd& 3rd tracheal ring

c)Low :- Below the level of isthmus

a)Percutaneous :- Minimally invasive alternative to open surgical technique

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b)Open surgical

Q146)Different tracheostomy tubes ?

• Uncuffed and cuffed tubes.

• Double cuff tube. Each cuff can be inflated alternately to prevent pressure necrosis at one site.
• Fenestrated tube. Single or multiple holes are situated at the upper curvature.
• Adjustable flange long tube.
• Single lumen tube. There is no inner cannula
• Double lumen tube. They have an inner cannula inside an outer cannula
• Suction-aid tracheostomy tubes.
• Tracheostomy with speaking valve.

Classification of tubes according to the material they are made of. A tracheostomy tube may be made
of:

1. Silver. e.g. Fuller, Negus or Jackson’s tube.

2. PVC (polyvinyl chloride). Shiley

3. Silicone. Bivona

4. Siliconized PVC.

5. Silastic. Moore

6. Polyurathane – Portex ,Tracoe

Q147)Complications of Tracheostomy ?

Immediate Intermediate Late

Anaesthetic complications Displacement of the tube; Tracheocutaneousfistula
Haemorrhage:thyroid
Surgical emphysema; Trachealstenosis
veins;jugular veins;arteries.
Air embolism; Pneumothorax/pneumomediastinum; Suprastomal collapse,
Apnoea; Infection: perichondritis; Disfigured scar
Cardiac arrest; Tube obstruction by secretions or
Local damage: Thyroid crusts;
cartilage;cricoid Tracheal necrosis;
cartilage;recurrent laryngeal nerve Tracheoarterial fistula;
Tracheo-oesophageal fistula;
Dysphagia
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Q148)Process of Decannulation ?

• Decannulation should take place in an ordered sequence and local protocol should be followed.
• The tube should be blocked during the day and unblocked at night for the 1st 24 hours.
• If the patient tolerates this, then the tube can be occluded for a full 24-hour period and if this is
tolerated then the tube can then be removed.
• If the patient is unable to tolerate this occlusion of the tube, then it may be necessary to
downsize the tube to give more room around the tube.

Q149) Physiological Changes after Tracheostomy ?

• Laryngeal bypass – loss of cough and phonation;

• Reduction in respiratory dead space;
• Loss of nasal mucosa filtration and humidification;
• Increased risk of infection;
• Tube acts as foreign body leading to local inflammation;
• Sump above tracheostome and below larynx, where mucus collects.

Any queries kindly mail to drphani21@[Link]

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CASE PRESENTATION 5
Name :- dfg

Age :- 55 years

Gender :- Male

Occupation :- Farmer

Residence :- Adilabad

Came to the hospital with the chief complaints of

3. DIFFICULTY IN SWALLOWING since 1 month

4. SWELLING IN UPPER PART OF LEFT SIDE OF NECK since 20 days
5. CHANGE OF VOICE since 15 days

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 1 month back , then he developed difficulty in swallowing
insidious in onset, gradually progressive for solids and liquids for the duration of 2 months. Patient is
taking very little quantity of liquid diet. There is h/o pain during swallowing.

H/O Swelling in upper part of left side of neck insidious in onset gradually progressive for the duration of
20 days. Initially it was groundnut size and gradually it has progressed to lemon size. No H/O of pain and
trauma.

H/O of Change of voice present which is hoarse in nature , insidious in onset , progressive in nature , for
the duration of 15 days, constant through out the day . No aggravating or relieving factors

H/O of pain in left ear present.

H/O weight loss present ( approx. 5 kgs in 1 month ), H/O loss of appetite

No H/O difficulty in breathing, noisy breathing, choking episodes, halitosis, throat pain

No H/o fever, No H/o night sweats , No h/o of cough, No H/o Weakness of voice

No history of vocal abuse , No h/o neck trauma / neck surgeries /Surgeries under GA/Radiotherapy

No h/o Decreased hearing /Ear discharge

No h/o Nasal Obstruction/nasal discharge

No h/o Nasal regurgitation/ retrosternal pain

PAST HISTORY :
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No h/o Similar complaints in the past

No other significant past Medical/Surgical History

No h/o DM/HTN/CAD/Bronchial Asthma/Epilepsy/Bleeding Disorder /Dental caries

No allergic drug history

Personal History :

Diet – Mixed

Appetite – Reduced

Bowel and Bladder Movements – Normal

Sleep – Sound

Beedi Smoker – 15/day since 20 years

Alcoholic – 600ml / day since past 30 yrs

Family History :

Not Contributory

General Examination :

Patient is conscious , coherent , cooperative

Patient is thin built , thinly nourished

Left level 2 lymphadenopathy present

Pallor0 Icterus0 Clubbing0 Koilonychia0 Cyanosis0 Pedal Edema0

Vitals :-

Temp :- Afebrile

PR :- 66/bpm, Normal in rhythm, good in volume

BP :- 130/90 mm hg, Rt arm supine position

RR :- 16/min

Systemic Examination :

CVS : S1+ S2+ M0

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RS : Bilateral Air Entry present , No adventitious sounds

P/A : Soft

CNS : Intact , NAD

Cranial nerve examination :- Normal

ENT EXAMINATION :

ORAL CAVITY :

Mouth opening – full and adequate

Angle of mouth – Normal

Lips – Normal

Gingivo Labial sulcus –Normal

Gingivo Buccal Sulcus – Normal

Gums- Nicotine stained

Teeth – Normal , No loose tooth seen

Anterior 2/3rd of Tongue – Normal

Buccal Mucosa – Hyperpigmentation +

Hard Palate – Normal.

Retro Molar Trigones – Normal

OROPHARYNX : Normal

IDL : Ulcero - Proliferative growth with irregular surface seen involving left aryepiglottic fold and left
pyriform fossa. Pooling of saliva present. Right Pyriform fossa Normal

Base of tongue Normal

Epiglottis Normal

Vallecula Normal

Vocal cords normal in mobility. Glottic chink adequate.

Neck :
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Left level 2 lymphadenopathy :-

A Single, Irregular, 5*3 cms with normal surface, hard in consistency, immobile, fixed to underlying
structures, skin over the swelling is pinchable. On contracting left SCM becoming less prominent.

Trachea – central in position

Laryngeal Framework – Normal

Laryngeal Crepitus – Present

No Laryngeal Tenderness

Carotids – Palpable

NOSE :

Anterior Rhinoscopy ; Normal

Posterior Rhinoscopy : Normal

Ear : Normal

PROVISIONAL DIAGNOSIS :

Malignancy hypopharynx with secondaries in neck ( Left Pyriform fossa malignancy )

Clinical staging :- T2 N2a Mx Stage IV A

Differential Diagnosis :

TB

Wegener’s Granulomatosis

Leiomyoma

Fibrolipoma

Papilloma

Investigations :

Routine Blood Investigations

FNAC of lymph node

Video Laryngoscopy

Stroboscopy
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X ray Chest

DLScopy Biopsy

CECT Neck

MRI Neck

FibreopticNasolaryngoscopy

TREATMENT :-

TOTAL PHARYNGOLARYNGECTOMY WITH RECONSTRUCTION WITH B/L MNRD WITH PORT

CLINICAL DISCUSSION :-

Q1) Summarise positive history ?

1. DIFFICULTY IN SWALLOWING since 1 month

2. SWELLING IN UPPER PART OF LEFT SIDE OF NECK since 20 days
3. CHANGE OF VOICE since 15 days
4. H/O of pain in left ear present.
5. H/O weight loss present ( approx. 5 kgs in 1 month ), H/O loss of appetite

Q2) Points in favor of your diagnosis ?

History :-

1. 55 years Male, Shorter duration, Rapid progression

2. DIFFICULTY IN SWALLOWING since 1 month
3. SWELLING IN UPPER PART OF LEFT SIDE OF NECK since 20 days
4. CHANGE OF VOICE since 15 days
5. H/O of pain in left ear present.
6. H/O weight loss present ( approx. 5 kgs in 1 month ), H/O loss of appetite
7. Addictions :- Beedi Smoker – 15/day since 20 years, Alcoholic – 600ml / day since past 30 yrs

Examination :-

1. IDL : Ulcero - Proliferative growth with irregular surface seen involving left aryepiglottic fold and
left pyriform fossa. Pooling of saliva present.
2. Left level 2 lymphadenopathy :-
A Single, Irregular, 5*3 cms with normal surface, hard in consistency, immobile, fixed to
underlying structures, skin over the swelling is pinchable. On contracting left SCM becoming less
prominent.

Q3) Points to exclude Ca larynx ?

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History :-

• As patient 1st had dysphagia and then change in voice so it suggests that the growth was in
Hypopharynx then it has spread to aryepiglottic fold to cause change in voice.

Q4) What are the growths which present with dysphagia ?

• Base of tongue
• Posterior pharyngeal wall
• Supraglottis
• Post Cricoid
• Pyriform fossa

Q5) Of these growths which growths present with change in voice ?

• Base of tongue Due to problem with

• Posterior pharyngeal wall articulation and resonance
• Supraglottis ( Muffled speech )
• Post cricoid Due to Cricoarytenoid fixation
• Pyriform fossa Due to paraglottic space, Invasion of CricoArytenoid Joint
(Medial wall presents Invasion of Posterior CricoArytenoid Muscle
With change in voice) Invovement of Recurrent Laryngeal Nerve

Q6) Of these growths which growths present with swelling in neck ?

• Pyriform fossa ( Lateral wall presents with neck node )

• Base of tongue

Q7) Dysphagia for Liquids > Solids is seen in which condition?

• Achalasia Cardia

Q8) What are the symptoms in oropharyngeal dysphagia ?

• Difficulty in initiating the swallowing

• Nasal regurgitation

Q9) What are the symptoms in Oesophageal Dysphagia ?

• Food sticking in lower throat

• Pain in retrosternal region

Q10) Physiology of Swallowing ?

• Swallowing is a process involving passage of food from oral cavity to stomach .

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• It is divided into 3 phases

• 1) Oral phase (Preparatory phase + Oral Phase Proper) – 1 to 2 secs
• Preparatory phase : Food is prepared for swallowing by reducing and mixing it with saliva by the
muscles of jaw and oral cavity.
• Oral phase proper : Tongue is moved by the action of intrinsic muscles together with
genioglossus which elevates the tongue tip and blade of tongue directing food towards hard
palate.
• 2) Pharyngeal Phase – 2secs
• As the food bolus enters the pharynx sequence of events are initiated, hyoid is drawn forwards,
larynx elevated, laryngeal inlet closes, constrictor muscles contract and food bolus directed
towards oesophagus.
• 3) Oesophageal phase – 10 to 15 secs
• Cricopharyngeal sphincter relaxes, bolus passes through sphincter and moves along the
oesophagus by peristalsis.

Q11) Different causes of Dysphagia ?

• Trauma
• Infections ( Pharyngitis , Candidiasis , Retro and parapharyngeal Abscess)
• Inflammatory – GERD , Plummer Vinson syndrome , CREST syndrome
• Motility disorders – Achalasia , Diffuse esophageal spasm
• Neoplastic – Benign , Malignant tumours
• Neurologic – CVA , Parkinsons , Multiple sclerosis , Motor Neuron Disease, isolated RLN palsy
• Ageing – Prebydysphagia
• Congenital – Tracheooesophageal fistula , Esophageal atresia, Vascular rings, Cleft lip palate
• Miscellaneous – Fb pharynx and esophagus , Pharyngeal pouch , Stricture

Q12) Growths which present with secondaries to upper deep cervical nodes ?

• Oral cavity
• Nasal cavity and paranasal sinuses
• Nasopharynx
• Oropharynx
• Hypopharynx
• Supraglottic larynx
• Parotid gland

Q13) Growths which present with enlarged supraclavicular nodes ?

• Post cricoid
• Subglottis
• Cervical trachea
• Posterior pharyngeal wall of hypopharynx
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• Pyriform fossa
• Thyroid
• Cervical esophagus

Q14)What are the subsites of Hypopharynx ?

Hypopharynx is divided into 3 subsites

1) Piriform Sinus
• Extent : Pharyngoepiglottic fold to upper end of esophagus
• Divisions :- Superior membranous part
Inferior cartilaginous part
• Boundaries :-
• Laterally :- Superior aspect :- Thyrohyoid membrane
Inferior aspect : Ala Of Thyroid cartilage
• Medially :- Hypopharyngeal surface of Aryepiglottic fold
Posterolateral surface of Arytenoid &Cricoid cartilage
2) Posterior Pharyngeal wall
• Extent :Superior border of hyoid bone or floor of valleculae to lower border of cricoid cartilage

Horizontally from one apex of piriform sinus to other.

Formed by constrictor muscles and mucous membrane.

3) Post Cricoid Area

• Extent : The level of arytenoids till inferior border of cricoid cartilage (Anterior wall of
Hypopharynx)
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Q15)What are the muscles of Mastication ?

• Medial Pterygoid : Elevates mandible, Closing the mouth

• Lateral Pterygoid : Side to side movement of jaw, Protract the mandible, Pushes the jaw
forwards
• Temporalis : Elevates mandible, Closing the mouth, Retracts the mandible posteriorly
• Masseter : Elevates the mandible, Closing the mouth
• Buccinator : Compresses lips against cheek

Q16)What are the muscles of soft palate ?

• Tensor Palatini : Opens Eustachian tube assisted by Levator Palatini, Depresses soft palate
• Levator Palatini : Raises the soft palate up & back closing nasopharyngeal isthmus, Opens ET
• Palatoglossus : Closes oropharyngeal isthmus by approximating palatoglossal arch & elevating
tongue against hard palate
• Palatopharyngeus : Approximates palatopharyngeus arches towards midline, Pulls walls of
pharynx upwards, forwards & medially to shorten pharynx & elevate larynx during swallowing
• Uvular muscle : Shortens uvula
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Q17 ) What is the nerve supply of muscles of palate ?

All muscles of soft palate are supplied by pharyngeal plexus except Tensor veli palatini which is supplied
by Trigeminal ( V3 ) via nerve to medial pterygoid.

Q18)What is pharyngeal plexus ?

Formed by :-

• Pharyngeal Branches of Glossopharyngeal nerve

• Vagus nerve
• Sympathetic fibres from superior cervical ganglion .

Location – On the surface of Middle Constrictor muscle

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Q19)What is the lining of Hypopharynx ?

• Non Keratinizing Stratified squamous epithelium

Q20)What are different layers of Pharyngeal wall from Inside out ?

1) Mucous Membrane
2) Pharyngobasillar fascia
3) Muscular layer with Inner longitudinal and outer circular layers
Inner longitudinal layer is formed by :
Stylopharyngeus
Palatopharyngeus
Salpingopharyngeus
Outer Circular layer is formed by :
Superior , Middle and Inferior Constrictors
Inferior constrictor has 2 parts – Thyropharyngeus and Cricopharyngeus ( Posteriorly gap
between them is Killians Dehiscence)
4) Buccopharyngeal fascia

Q21)Nerve supply to muscles of Pharynx ?

• All by Pharyngeal plexus except Stylopharyngeus which is supplied by Glossopharyngeal nerve .

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Q22)What is Sinus of Morgagni ?

1) Space between Superior Constrictor and Base of Skull

2) Structures passing through it are –
• Eustachian tube
• Tensor Palatini muscle
• Levatorveli palatini muscle
• Ascending pharyngeal artery

Q23)Structures piercing Thyrohyoid membrane ?

• Superior Laryngeal vessels and Internal laryngeal nerve

• Sensory innervations of this area synapses with the Jugular ganglion along with sensory
innervations of External Auditory canal accounting for referred otalgia .

Q24)Where is retropharyngeal space located ?

• It is located between Buccopharyngeal fascia and Prevertebral fascia

• From skull base till superior mediastinum , on each side by carotid sheath .
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Q25) Incidence of cancer in various subsites of Hypopharynx ?

• Piriform fossa – 75%

• Posterior Pharyngeal Wall – 10%
• Post Cricoid region – 15%
• Carcinoma PCR is more common in Females

Q26) What are the risk factors for Hypopharyngeal cancer ?

• Alcohol
• Smoking
• Plummer Vinson syndrome
• Previous irradiation

Q27) What is Patterson Brown Kelly Syndrome ?

Plummer Vinson Syndrome :

• Smooth pale facial skin

• Cheilitis
• Angular Stomatitis
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• Koilonychia
• Iron Deficiency
• Upper esophageal web

Q28) How much percentage of patients with Patterson Brown Kelly Syndrome will land up in Post
cricoid cancer ?

• 30%

Q29) Occurrence of Carcinoma in pharyngeal pouch ?

• Rare (0.4%)

Q30) What are the symptoms with which a patient of Hypopharyngeal cancer can present ?

• Dysphagia
• Hoarseness of voice
• Otalgia
• Neck Mass
• Unilateral Sore throat
• Globus pharyngeus (Lump in Throat )

Q31) Why a patient of Hypopharyngeal cancer can present with Otalgia ?

• Vagus nerve supplies mucosa of supraglottis, Piriform fossa, Postcricoid .

• Pain in these regions is referred to ear through a small branch of vagus nerve – Arnolds Nerve ,
Which supplies External auditory canal .
• When tumour extended till base of tongue , then pain is referred to ear via Branch of
Glossopharyngeal nerve – Jacobson’s nerve which supplies middle ear mucosa .
• This is a poor prognostic sign .

Q32) What is Trotter’s Sign ?

• Loss of laryngeal crepitus .

Q33) What is Gag Reflex ?

• A reflex contraction of Posterior pharyngeal wall evoked by touching it .

• Reflex arc consists of – Glossopharyngeal nerve (Afferent) and Vagus nerve (Efferent)

Q34) How does the Hypopharyngeal cancer spread ?

1. LOCOREGIONAL SPREAD :
• Medially :- Aryepiglottic fold, Arytenoids, Infiltrate deep into larynx to involve
Cricoarytenoid joint
• Laterally :- Ala of Thyroid Cartilage (near superior cornu) & Lobe of thyroid gland
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• Superiorly :- Base of Tongue and Lateral Oropharyngeal Wall

• Inferiorly :- Cervical Oesophagus
• Vocal cord fixation and Thyroid gland involvement are usually seen . (Particularly post cricoids
lesions)
• Submucosal Spread is common in Hypopharyngeal cancer .(Post cricoids lesions)
• Posterior pharyngeal wall lesions involve Retropharyngeal space and prevertebral muscles and
laterally spreads to pyriform sinus.
• Apex of PS terminates into post cricoid.
2. LYMPHATIC SPREAD :
• Level II , III ,IV
• Upper Deep Cervical Nodes (70%)
• Middle and Lower Deep Cervical Nodes
• In Posterior pharyngeal wall lesion 1st echelon node is Retropharyngeal nodes
• Inferior Pyriform sinus, Postcricoid and upper esophagus – Paratracheal nodes
• Chance of occult nodal disease is more in node negative patients .
3. DISTANT METASTASIS :
• 3% of cases to lungs, liver, bones, brain

Q35) Causes of Vocal Cord fixation in Hypopharyngeal Cancer ?

• Invasion of CricoArytenoid Joint

• Invasion of Posterior CricoArytenoid Muscle
• Invovement of Recurrent Laryngeal Nerve
• Paraglottic space extension

Q36) What is the significance of Submucosal Spread ?

• There will be formation of SKIP LESIONS

• Hypopharyngeal cancer patients are at risk of having synchronous or metachronous lesions

Q37) Classification of Hypopharyngeal cancer ?

• T1 : Tumour limited to one subsite of hypophaynx and 2 cm or less in greatest dimension

• T2 : Tumour invades more than one subsite of hypopharynx or an adjacent site, or measures
2-4 cm in greatest dimension, without fixation of hemilarynx
• T3 : Tumour measures more than 4cm in greatest dimension, or with fixation of hemilarynx
• T4a : Tumour invades any of the following: thyroid/cricoid cartilage, hyoid bone, thyroid
gland, trachea, oesophagus, strap muscles, soft tissues of neck
• T4b : Tumour invades prevertebral fascia, encases carotid artery or invades mediastinal
structures

Q38)What is FEES ?
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• Fibreoptic Endoscopic Evaluation of Swallowing

• Uses :-
• Diagnostic and Therapeutic Investigation in acute stages of Dysphagia
• Anatomy and Muscular movements while swallowing
• Any pooling up of secretions
• Airway protection
• Pharyngeal and laryngeal sensitivity

Q39) What is Videoflouroscopy ?

• Dynamic flouroscopic imaging procedure to evaluate all stages of swallowing .

Q40)What is barium swallow ?What is the liquid used ?

• In this patient is given a cup of liquid barium to swallow and the liquid is followed
fluoroscopically to stomach and films are taken.

Contraindicated in :-

• Oesophageal perforation
• Aspiration

In these cases Low molecular weight , Non Ionic , Water soluble contrast medium is used .

Barium Swallow Appearances of various conditions –

- A large pouch with distal narrowing of oesophageal lumen – PHARYNGEAL POUCH

- Anterior post cricoids web in lateral view – Plummer Vinson syndrome
- Bird Beak Appearance – Achalasia Cardia
- Rat tail appearance –Oesophageal Carcinoma
- Shaggy mucosa with irregular filling defects – Oesophageal Candidiasis

Q41) Among Laryngeal cancer and Hypopharyngeal cancer which one is having better prognosis ?

• Laryngeal Cancer
• Hypopharyngeal cancer patients is having less than half the survival rate of laryngeal cancer
patients
• 5 year survival rate is less than 30%

Q42) Reasons for poor prognosis for Cancer hypopharynx ?

• Late Presentation
• Submucosal Spread
• Neck nodes

Q43) Stage wise treatment of Hypopharyngeal Cancer ?

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Piriform Fossa :

• T1 , T2 – Radiotherapy
• T3 ( Not involving Midline) – Laryngectomy + Partial Pharyngectomy+ Reconstruction with flap
• T3(Involving Midline) – Total Laryngectomy + Total Pharyngectomy + Reconstruction +RT
• T4 - Total LaryngoPharyngoOesophagectomy +RT

Post Cricoid Region :

• Total Pharyngolaryngectomy
• Involvement of Cervical Oesophagus – Total Pharyngolaryngectomy

Posterior Pharyngeal Wall :

• Total Pharyngo Laryngectomy

Medial wall of Piriform sinus without involvement of Apex :

• Partial pharyngectomy + Partial Laryngectomy + repair

Involvement of Apex of piriform sinus /Partial involvement of post cricoid mucosa/Invasion of thyroid
cartilage/Presence of paralysedhemilarynx :

• Total Laryngectomy + Partial Pharyngectomy+Repair

Circumferential extent of tumour / tumour in Post Cricoid Area :

• Total pharyngolaryngectomy

Q44) What is the Treatment of Neck in hypopharyngeal cancer ?

• If Nodes are not palpable – Selective Neck Dissection (II,III,IV)

• If nodes are palpable – MRND
• >20% involves both sides hence Bilateral neck dissection is advised.

Q45) How will you do reconstruction after pharyngeal resection ?

SIMPLE PARTIAL DEFECTS PMMA flap

Latissimus Dorsi Flap
Deltopectoral flap
Antero lateral thigh flap

COMPLEX PARTIAL DEFECTS Forearm or thigh flap

Free jejunal flap
Primary closure with musculoperichondrial flap

CIRCUMFERENTIAL DEFECTS Tubed Radial forearm flap

Tubed Anterolateral Thigh flap
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Gastric Transposition
Gastro omental flap

Q46) How much surgical margin should be left in case of hypopharyngeal cancer surgery ?

Surgical resection margins should be :-

- 3cm inferiorly
- 2cm superiorly and laterally

Q47) 5yr survival rate ?

• Stage I – 46%
• Stage II – 25 – 40%
• Stage III/IV – 15%

Any queries kindly mail to drphani21@[Link]

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