IGMC&RI | Batch 2k17 | ENT

ENT Probable Viva Questions

➔ Hello there!!

➔ Here is a compilation of most of the questions, that we were asked in

the class and in the Viva

➔ With the collective efforts of all of our batchmates, we were able to

compile this.

➔ This pdf will mostly help you with case viva.

➔ I hope that this compilation will help my batchmates and if possible

to my juniors.

➔ I thank the Dept. of ENT, all my batchmates especially Anirudh.R,

Darshini.L.D, Gayathri Swaminath, Kaushik.M and myself
Karthigeyan V.

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EAR Questions.
1. CSOM duration/ Stages,
a. Active stage: last discharge seen within 3 months
b. Quiescent stage: no discharge for 3 to 6 months
c. Inactive stage: no discharge for more than 6 months

2. Length of EAC: 8mm (1/3 - cartilaginous part) & 16mm (2/3 bony part)

3. Difference between CSOM & ASOM

4. How facial nerve symptoms occur in CSOM

a. Tubotympanic: congenital dehiscence & enzyme cause FN edema
⇒compression⇒ultimately symptoms appear.
b. Atticoantral: compression or erosion of fallopian canal by cholesteatoma.

5. Stages in ASOM – Tubal occlusion, pre suppuration, suppuration, resolution,

complication.

6. Gradenigo Syndrome – due to petrositis - a complication of OM (Csom with

diplopia- Gradenigo syndrome)
a. Ear discharge (suppurative OM)
b. Diplopia (CN VI paralysis)
c. Retro-orbital pain (CN v involvement)
A. Why persistent otorrhoea?
Ans. Petrous can have a lot of air cells thus a lot of discharge.
B. Why diplopia?
Ans. Due to abducens nerve involvement. The abducens nerve exits dorello's
canal and is closely related to petrous apex, where it sharply turns and enters
cavernous sinus.
C. Why retro orbital pain?
Ans. Involvement of ophthalmic division on CN5. This is due to irritation of 5th N
ganglion at the meckel's canal.

7. Why is there diplopia in petrositis?

Due to 6th nerve involvement

8. Eagle Syndrome –
Elongation of styloid process.

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9. 512 Hz Tuning fork

a. Mid speech frequency
b. Less overtones and tone decay

10. Why is PTA done?

To find and document type, degree and configuration of hearing loss, for prescription
of hearing aid, for speech threshold prediction, for medico-legal record in handicap.

11. Pure Tone Audiometry - 2k dip in BC- Carhart's Notch in Otosclerosis

- 4k dip in AC & BC - Boilers’ Notch - Noise Trauma (NIHL)

12. Why does the carhart notch occur?

a. Loss of inertial component of bone conduction by stapes fixation.
b. Fixation of stapes disrupts normal ossicular resonance happening at 2000 Hz
c. Relative perilymph mobility due to stapes fixation.

13. Utricle - Horizontal movement; Saccule - Vertical movement

14. Auditory Pathway (ECOLIMA)

E- Eighth Nerve
C- Cochlear Nucleus
O- Superior Olivary Nucleus
L- Lateral Lemniscus
I - Inferior Colliculus
M- Medial Geniculate Body
A - Auditory cortex

15. Abramson’s definition of Cholesteatoma

Abramson et al accurately defined cholesteatoma as “A three dimensional epidermal
and connective tissue structure, usually in the form of a sac, and frequently
conforming to the architecture of various spaces of the middle ear, attic and mastoid.
This structure has the capacity for progressive and independent growth at the
expense of underlying bone and has the tendency to recur after removal

16. Why incision is done in anteroinferior part of tm in serous otitis media.

Suitable for grommet insertion.

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17. Role of tympanic membrane in conduction of sound.

a. Hydraulic action of TM:
1. The area of TM >stapes footplate, the average ratio is 21:[Link] the effective
vibratory area of TM is only 2/3rd, the effective areal ratio is 14:1. The product
of areal ratio and lever action of ossicles is 18:1.
2. According to (Wever and Lawrence), out of a total of 90 mm2 area of human
TM, only 55 mm2 is functional and given the area of stapes footplate (3.2
mm2), the areal ratio is 17:1 and total transformer ratio (17× 1.3) is 22.1.

b. Curved membrane effect: Movements of TM are more at the periphery than at

the centre where malleus handle is attached. This too provides some leverage.

18. Causes of blood tinged ear discharge??

AA CSOM, TRAUMA, GLOMUS TUMOR, MALIGNANT OTITIS MEDIA

19. Grafts in myringoplasty?

a. Temporalis fascia- preferred because easy to harvest as present in same
surgical field, thickness is similar to tympanic membrane, low basal metabolic
rate so less nutrients required. .
b. Other grafts tragal perichondrium
c. Subcutaneous tissue
d. Fatty tissue from globules
e. Vein from dorsum of hand
f. Cartilage graft: conchal cartilage

20. Types of mastoid pneumatization: cellular, diploic and acellular.

21. Subperiosteal abscess names :

● Postauricular abscess
● Zygomatic abscess
● Bezold's abscess
● Metal abscess (Luc's abscess)
● Citelli's abscess
● Parapharyngeal/retro.

22. Cholesteatoma hearer?

Occasionally, the cholesteatoma bridges the gap caused by the destroyed ossicles
and hearing loss is not apparent (cholesteatoma hearer).

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23. Round window shielding effect and paradoxical effect of hearing loss in safe
csom? Why does hearing improve with discharge?
Round window shielding effect produced by discharge helps maintain phase
differential. Whereas in dry ear with perforation, sound waves strike both oval and
round window simultaneously, thus getting cancelled. But in presence of discharge
the phase difference is maintained.

24. Smell of ear discharge?

a. Pseudomonas: fruity odour
b. Proteus: fishy odour
c. Staph aureus: dirty sneakers

25. Bacteriology of csom?

Aerobic – Pseudomonas aerugniosa , proteus, [Link], Staphylococcus aureus.
Anaerobic – Bacteroides fragilis

26. How do you say the quantity of discharge is profuse, moderate, and scanty?
Profuse – drips down from EAC, wets pillow. 5-6 times /day wipe the ear
Moderate – present in EAC, does not flow out. 3-4 times /day wipe the ear
Scanty – seen only in otoscope, very less in deep EAC. 1-2times/day wipe the ear.

27. Referred ear pain?

Glossopharyngeal nerve supplies sensory to tonsils. Tympanic branch of
glossopharyngeal nerve i.e. Jacobson nerve (via tympanic plexus) supplies the
medial surface of tm, tympanic cavity, mastoid air cells. So, during tonsillitis there is
referred otalgia.

28. Tinnitus in Csom (due to labyrinthitis and labyrinthine fistula)

29. Types of perforations and their definitions?

a. Small – involving only 1 quadrant.
b. Medium – more than 1 but less than 2 quadrants.
c. Large – involving 3 quadrants.
d. Subtotal – all 4 quadrants except annulus.

30. How do you assess mobility of a tympanic membrane?

a. Valsalva maneuver-ask patient to close their nose and mouth and breathe out
the tm would bulge if the Eustachian tube is patent.
b. Toynbees maneuver-ask patient to close nose and swallow the tympanic
membrane would retract if the Eustachian tube is patent.

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31. Where you will see tragal tenderness? -

Applying pressure on the tragus.

32. Ossicles in CSOM?

Ossicles affected with csom in order of high to low.(lenticular process of incus - long
process of incus- superstructure of stapes)
Most resistant ossicle to damage in csom - malleus

33. History pertaining to complications of csom.

34. Surgeries for csom?

Tubotympanic – Tympanoplasty 1
Atticoantral – MRM with Tympanoplasty

35. Mastoidectomy types and their indications, definitions, complications.(455 to

461 in Dhingra; 607 to 612 in Bansal)

36. Define Myringotomy.(70 in Bansal; 607 to 609 in Bansal )

37. Define Tympanoplasty and types.(31 to 33 in Dhingra; 612 to 615 in Bansal)
38. Fistula test- procedure, interpretation? (43 in Dhingra; 253 in Bansal)
39. Treatment of Meniere’s disease.(114 to 116 in Dhingra; 265 to 267 in Bansal)

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40. Tm retraction classification?

41. How will you grade hearing loss by tuning fork?

42. Why blood stain occur in AAD?

a. Due to granulation tissue.
b. Bone erosion causing Osteitis.

43. Which X-ray will temporal bone apex be seen?

Stenvers view, Townes view, Transorbital view.

44. Investigations for complicated csom:- HR-CT temporal bone, MRI, PTA

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45. Clinical difference between Aad and ttd?

46. Theory for lateralization?

47. Why nystagmus?

Due to vestibulo ocular reflex.

48. Where u will see fluctuating hearing loss, paracusis willisii, diplacusis?
Fluctuating hearing loss, diplacusis – meniere's disease
Paracusis welsii - otosclerosis

49. How will you differentiate CHL and SNHL from history?
a. SNHL: patient hears better in quiet environment, speech comprehension is less
so, and he asks to repeat what is said.
b. CHL: the patient hears what he speaks louder than normal therefore he speaks
softly (auto phony).

50. Why despite so much treatment, prognosis is poor in MOE? What is the cause
of death?

51. Why is there vertigo in otosclerosis?

Vertigo develops when otosclerosis has moved into the inner ear, affecting the
otolith organs and/or semicircular canals.

52. Cookie bite audiogram-

seen in Otosclerosis.

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53. Hearing loss based on Size of perforation?

54. Hearing loss based on site?

55. Hitzelberger sign - anaesthesia over posterior wall of auditory canal in acoustic
neuroma.

56. Why is temporary lateral tarsorrhaphy done in bell's palsy?

So that vision is not totally compromised yet exposure keratitis is greatly prevented.

57. Why is physiotherapy given in facial palsy?

Physiotherapy leads to generation of action potential, which is a necessary stimulus
for nerves to grow. Thus, enhances healing. It also provides psychological support to
patient.

58. Prednisolone is given as a single dose in morning at 6am because maximum

secretion of steroid occurs in morning and symptoms are manifested in the morning.

59. Triad of Meniere’s disease? Vertigo, hearing loss, tinnitus.

60. Why is there tragal tenderness in otitis externa?

In the external ear the skin is very close to cartilage... So in otitis externa there may
be perichondritis and the whole thing being one piece of cartilage from pinna to
inside... Pressure on tragus leads to pain.

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61. Swelling of meatal wall:

a. Edema in otitis externa,
b. Luc's abscess,
c. Furuncle,
d. Anatomical variation

62. Investigations for AA CSOM?

a. Examination under microscope
b. PTA
c. CT temporal bone

63. How much pressure required for bone erosion by pressure necrosis

64. Causes of erosion in cholesteatoma?

Acid phosphatase, collagenase, protease, pressure necrosis.

65. Type of epithelium in Tubotympanic and Atticoantral?

a. TT- Pseudostratified ciliated columnar epithelium
b. AA – Columnar

66. Why more secretions in TT than AA?

TT epithelium is pseudostratified columnar and has more goblet cells, and AA
epithelium has less mucous glands

67. .Causes of fluctuating hearing loss.

68. Why is x-ray mastoid done in csom?

To know the pneumatization of mastoid, bone erosions, surgical landmarks
before surgery(tegmen plate, sinus plate)

69. Why does temporal bone fracture lead to facial nerve paralysis?
Due to intramural hematoma, compression by bony spicule, transaction of nerve.

70. Which temporal bone fracture involves the facial nerve commonly?
Transverse fractures.

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71. What is cookie bite hearing loss?

Cookie-bite hearing loss is when your audiogram results are shaped like a bell or the
letter “U” and indicates mid-range frequency hearing loss. Special type of SNHL.

72. Tulio’s phenomenon?

Nystagmus on exposure to loud sound. Seen in meniere's disease, due to the
stapes striking over the distended endolymphatic system

73. Rx for inactive TT CSOM. -Myringoplasty

74. Myringoplasty - prerequisite condition and grafts used.

Prerequisite –
a. Dry ear for 3 months
b. Healthy middle ear mucosa
c. Patent Eustachian tube.
d. No focus of infection in nose, pns, nasopharynx.
e. Good cochlear reserve.
Grafts –
f. Temporalis fascia- preferred because easy to harvest as present in the same surgical
field, thickness is similar to tympanic membrane, low basal metabolic rate so less
nutrients required. .
g. Tragal perichondrium, conchal cartilage
h. Fascia lata.
i. Subcutaneous tissue.
j. Fatty tissue from globules.
k. Vein from dorsum of hand.

75. Risk factors for csom?

Recurrent URI, allergy, pre existing OME, Cleft palate, immunodeficiency, poor
nutrition, poor socio economic status.

76. Abscess due to csom in neck

a. Postauricular abscess
b. Zygomatic abscess
c. Bezold's abscess
d. Metal abscess (Luc's abscess)
e. Citelli's abscess

77. Decibel levels of various sounds?

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78. Bezold's abscess and how will you manage it?

Occurs following acute coalescent mastoiditis when pus breaks through the thin
medial side of the tip of the mastoid and presents as a swelling in the upper part of
neck.
Rx – Cortical Mastoidectomy
a. I & D of abscess.
b. I.V antibiotics.

79. Difference between Round and oval window.

Separates middle ear from Separates middle ear from

scala vestibuli scala tympani.
Closed by stapes footplate Closed by fibrous secondary
TM

80. Difference between Tubotympanic and Atticoantral type.

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81. Patch test.

A piece of cigarette paper or gelfilm coated with ointment may be placed over the
perforation with assessment of hearing before and after placing the patch. Hearing
improved indicates ossicular integrity. If hearing is same or worse ossicular
discontinuity or disruption is present

82. Tuberculous otitis media.

a. Otitis media secondary to pulmonary tuberculosis.
b. Foul smelling painless ear discharge, multiple perforations in pars tensa,
conductive hearing loss.

83. Anti-tubercular drugs.

Rifampicin,isoniazid,pyrazinamide , ethambutol, streptomycin

84. Indication of cortical Mastoidectomy.

a. Acute mastoiditis.
b. Masked mastoiditis
c. Incompletely resolved AOM with reservoir sign.
d. Initial step in -endolymphatic sac surgery, decompression of facial nerve, trans
labyrinthine procedures

85. Complications of cortical Mastoidectomy.

a. Postoperative wound infection and wound breakdown.
b. Injury to facial nerve
c. Dislocation of incus
d. Injury to horizontal semicircular canal. Patient will have postoperative giddiness and
nystagmus
e. Injury to Dura of Middle Cranial Fossa

86. Types of central perforation

a. Small – involving only 1 quadrant.
b. Medium – more than 1 but less than 2 quadrants.
c. Large – involving 3 quadrants.
d. Subtotal – all 4 quadrants except annulus.

87. Difference between pars flaccida and pars tensa.

PARS TENSA PARS FLACCIDA
3 layers – Epithelial, fibrous and 2 layers – Epithelial and mucosal
mucosal
Below lateral process of malleus Above lateral process of malleus
Grey-white Pinkish hue
Thick Fragile

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88. Complications of csom

89. Tympanoplasty types

90. Petrositis – features and why diplopia

a. Ear discharge (suppurative OM)
b. Diplopia (CN VI paralysis)
c. Retro-orbital pain (CN v involvement)
d. Diplopia due to abducens nerve involvement. The abducens nerve exits dorello's canal
and is closely related to petrous apex, where it sharply turns and enters cavernous
sinus.

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91. Types of perforation.

a. Central (pars tensa) – Perforation of pars tensa surrounded by pars tensa.
b. Marginal (pars tensa) - A marginal perforation is a perforation that has an area
with no tympanic membrane between the perforation and the bony canal.
c. Attic perforation (pars flaccida) - perforation in the attic

92. Delta sign

The empty delta sign is a CT sign of Dural venous sinus thrombosis of the superior
sagittal sinus, where contrast outlines a triangular filling defect, which represents
thrombus

93. Medical management of TT type

a. Aural toilet – dry mopping with absorbent cotton buds
b. Ear drops – Ciplofloxacin 500 mg BD 5 days.
c. Systemic antibiotics – Amoxicillin 25 – 50 mg/kg tds 5 days.
94. Round window shielding effect.
Round window shielding effect produced by discharge helps maintain phase
differential. Whereas in dry ear with perforation, sound waves strike both oval and
round window simultaneously, thus getting cancelled. But in presence of discharge
the phase difference is maintained.

95. Three finger test-mastoid tenderness

Three point tenderness is elicited by using the
a. Index finger to apply pressure over the well of the concha – tenderness over
Antrum.
b. Middle finger is applied over the posterior border of mastoid process –
tenderness over the tip of the mastoid process indicates inflammation and
thrombosis of mastoid emissary vein.
c. Ring finger is used over the mastoid tip – tenderness indicates mastoiditis.

96. Cortical Mastoidectomy incision

a. Post aural (Wilde) – 1 cm behind and parallel to retro auricular sulcus, starting at
highest attachment of pinna to mastoid tip.
b. Endaural (Lempert) – A – Semicircular incision from 12 o'clock to 6 o'clock in
post. Meatal wall at bony cartilage junction. B – From 12 o clock of first incision
and extends till incisura terminalis.
c. Endomeatal (Rosen) - It consists of two parts: (i) a small vertical incision at 12
o’clock position near the annulus and (ii) 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

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97. Characteristics of chl & snhl.

CHL -

SNHL –

98. Investigation of TT type csom.

a. Examination under microscope – to look at edges of perforation, middle ear
epithelium and granulations.
b. Pure tone audiogram- to document the type and degree of hearing loss.
c. Culture and sensitivity of ear discharge
d. Mastoid x ray – law’s view – to see pneumatization of mastoid
e. CT – temporal bone – to check for complications.

99. Relation between voice change and CSOM

100. Mid speech frequency

Frequencies of 500, 1000 and 2000 Hz are called speech frequencies as most
human voices fall within this range. PTA (pure tone average) is the average
threshold of hearing in these three speech frequencies. It roughly corresponds to the
speech reception threshold.

101. Underlying structure in cymba concha. Mastoid antrum

102. Tympanometry finding of SOM - As type curve.

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103. how to treat iatrogenic facial nerve injury

104. Tympanoplasty without Mastoidectomy (Tympanum=middle ear)

It is an operation to eradicate disease in the middle ear and to reconstruct the
hearing mechanism without mastoid surgery, with or without tympanic membrane
grafting. This means ossicular reconstruction only or ossicular reconstruction with
myringoplasty.

105. Tympanoplasty with Mastoidectomy

It is an operation to eradicate disease in both the mastoid and middle ear cavity, and
to reconstruct the hearing mechanism with or without tympanic membrane grafting.

106. In bilateral csom, weber's lateralized to side with smaller perforation

indicates? Sensorineural component in the side with big perforation, ossicles
affected more on the side with smaller perforation

107. Other causes of referred otalgia

108. what is the material used in Stapedectomy to replace the stapes - teflon

109. Irregular tympanic membrane perforation seen in - traumatic perforation.

110. What is the preferred graft for a small perforation?

Fat from lobule.

111. Latest term used for Tubotympanic CSOM - mucosal CSOM

112. Bionic ear - Ear with a Cochlear implant.

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113. Indications and uses of mastoid retractors.

Used in mastoidectomy to retract soft tissues after incision and elevation of flaps.
The pressure on the edges of the incision provides hemostasis.
a. Mastoid retractors (Jansen’s or Mollison’s) in case of postaural incision
b. Lempert’s endaural retractor is used in cases of endaural approach

114. Why does the X Ray mastoid be taken on a surgical point of view.?
If the mastoid is sclerotic , the surgeon can have control over the drill. If pneumatic ,
mastoid will be soft and may hurt the underlying structures.
Also to know the surgical landmarks.

115. What is the significance of checking pneumatization of mastoid air cells in

xray??
One with well pneumatized mastoid air cells will have lower incidence of csom and if
csom occurs , one will have a higher rate of csom complications.

116. Type 6 Tympanoplasty ( sono inversion) -

Sound travels in reverse direction from Round window to oval window.

117. Name of the incision & drainage procedure for pinna abscess
Helical incision - Incision given along the helix in a bivalve fashion.

118. Causes for mastoid cavity.

a. Cholesteatoma cavity
b. postmastoidectomy
c. large antral cell
d. Multiple myeloma
e. Tuberculous granulation
f. Eosinophilic granuloma

119. Cause for sclerosed mastoid - recurrent middle ear infection

120. Why is malignant otitis externa called malignant?

It's a misnomer. It's not a malignancy but is called so since it's associated with high
mortality. Malignant otitis externa is called malignant because it is rapidly invasive.
How MOE spreads intracranially? - Through fissures of santorini

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NOSE QUESTIONS
01. Antrochoanal polyp another name? Killian's polyp

02. Allergic rhinitis features- allergic shiners, Allergic salute, Dennie Morgan line
(crease in lower eyelid)

03. oral steroids indication in polyps - in case of medical polypectomy to shrink

polyps

04. antihistamine nasal spray - azelastine, levocabastine

05. Theories of Antrochoanal polyp - Proetz, Jakson, Mills, Ewings, Bernoulli's and
vasomotor disturbances

06. Why antrochoanal polyp moves towards choanae(6points)

07. Trilobed polyp - (antral, choanal, nasal part in AC polyp)

08. Diff. NARES from allergic rhinitis - no itching will be there, as there is no
histamine release .20%eosinophilic increase.
09. Boundaries of canine fossa -
a. Inferior: alveolar ridge
b. Medial: pyriform aperture
c. Superior: infraorbital foramen
d. Lateral: Canine eminence or Zygomatic buttress (Sathish sir)

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10. How to differentiate a congested and hypertrophied turbinate?

Congestion would be red and disappears greatly on using decongestants but
hypertrophy wont.

11. Type of hypertrophy in DNS - compensatory

12. Why speculum is not used to examine vestibule - as it obscures skin and won't
be visible

13. Causes for blood-tinged discharge and nasal bleed?

Epistaxis: JNA, trauma, septal spur, upon removal of crusts(atrophic rhinitis,
rhinitis sicca, septal perforation), Ca npx, rhinosporidiosis, rhinolith, nasal
myiasis, hemangioma, high altitude.
Blood tinged discharge: Ca maxillary sinus, ethmoid sinus malignancy,
Rhinosporidiosis, nasal myiasis, foreign body, Wegener's granulomatosis

14. Posterior rhinoscopy procedure, mirrors name and structures seen in PR

Procedure - Patient sits facing the examiner, opens his mouth and breathes
quietly from the mouth. The examiner depresses the tongue with a tongue
depressor and introduces a posterior rhinoscopic mirror, which has been
warmed and tested on the back of hand. The mirror is held like a pen and
carried behind the soft palate. Without touching it on the posterior third of
tongue to avoid gag reflex, light from the head mirror is focussed on the
rhinoscopic mirror which further illuminates the part to be examined. Patient’s
relaxation is important so that the soft palate does not contract.
Mirror - St. Clair Thompson Posterior Rhinoscopy Mirror
Structures seen -

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15. Rhinophyma - potato tumour of nose (hypertrophy of sebaceous gland)

16. olfactory pathway?? - (pg.159 in Dhingra)

17. Nasal cycle - spontaneous congestion and decongestion of nasal mucosa

during day

18. Samster’s triad - Triad of bronchial asthma, ethmoidal polyps & aspirin
intolerance

19. Sluder’s neuralgia - neurovascular headache. . It is characterized by neuralgic

pain in the lower half of the face with nasal congestion, rhinorrhoea and
increased lacrimation. It is due to neuralgia of sphenopalatine ganglion.

20. “Jarjaway” fracture of nasal septum results from blows from the front; it starts
just above the anterior nasal spine and runs horizontally backwards just above
the junction of septal cartilage with the vomer.

“Chevallet” fracture of septal cartilage results from blows from below; it runs
vertically from the anterior nasal spine upwards to the junction of bony and
cartilaginous dorsum of nose .

21. How to differentiate ca nasopharynx and antrochoanal polyp?

CA Nasopharynx Antrochoanal polyp

Usually presents with blood stained Mucoid nasal discharge, no neck

nasal discharge, epistaxis, orbital swelling and orbit is not involved.
complications and neck swelling.

Mass would be red, friable, with a Mass is grey, glistening, smooth.

granular surface.

Bleeds readily on touch. Insensitive to touch and doesn't bleed

Origin can be found to be from Origin from the middle meatus of the
nasopharynx nose.

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22. Why Cottle’s cold spatula and smell test is done in polyp
Cold spatula - to check the patency
Smell test - normally only 15 - 20 % of air reaches the olfactory epithelium
which is further reduced in case of a polyp.

23. How to do probe test??

Jobson-Horne probe. It is done under topical anesthesia. A probe is passed on
all surfaces of mass and helps in ascertaining the site of attachment,
consistency, mobility, vascular nature and sensitivity of the growth. Ulcers
should be probed to know the exposed underlying bone. Probing of an ulcer in
the floor of nose can exclude or confirm its oral cavity communication.
Rhinolith gives a grating sensation on probing.

24. How to differentiate SMR and septoplasty?

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25. In nose,
a. Unilateral mass in elderly with history of smoking & with small blood
discharge - SCC of maxillary sinus
b. Unilateral mass with recurrent epistaxis – Rhinosporidiosis

26.

27. Ostiomeatal complex

28. Why are we asking about snoring with nasal obstruction?

Because nasal mass is growing and causing obstruction in posterior nares-
[Link] polyp
29. Unilateral constant nasal obstruction which is not showing diurnal or
Seasonal variation causes:
a. DNS
b. spur
c. antrochoanal polyp
d. nasal mass/neoplasm/carcinoma which is progressing growing
e. hypertrophied inferior turbinate/ middle turbinate concha bullosa

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30. Indications of septoplasty

31. Rhinitis medicamentosa

Topical decongestant nasal drops are notorious to cause rebound phenomenon.
Their excessive use causes rhinitis. It is treated by withdrawal of nasal drops,
short course of systemic steroid therapy and in some cases, surgical reduction
of turbinates, if they have become hypertrophied.

32. Anterior deviation - septoplasty

Posterior deviation - SMR
But for theoretical purpose we do septoplasty for both
33. Killian’s incision and Freer’s incision
Killian’s - Unilateral slightly curvilinear incision, 2 -3 mm above the caudal
margin of septum just passes the mucocutaneous junction on the concave side.
Freer’s - The septocolumellar incision is made between the caudal margin of
septum and columella. Done in septoplasty. Hemitransfixion -on 1 side ;
Transfixation - on both sides.

34. Investigation for DNS

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a. diagnostic nasal endoscopy - extension of deviation/meatus/polyp/ mass

b. CT PNS to see the patency of the Ostiomeatal complex.
c. X Ray PNS/nose waters view

35. DD for unilateral obstruction of short duration - antrochoanal polyp/ trauma

causing DNS/ if sneezing present bilateral ethmoidal polyp with one side has
only few ethmoidal changes, always mention about allergy

36. Cottle's test inference - positive / negative- positive means abnormality of the
vestibular component of nasal valve - breathing improves.
37. Once allergic symptoms controlled but nasal obstruction not controlled like
snoring then surgery septoplasty with turbinate reduction
38. MUST KNOW STEPS FOR diagnostic nasal endoscopy for VIVA (475 in
Dhingra; 617 in Bansal)

39. Boundaries of nasal valve/limen nasi?

Lateral boundary: lower border of upper lateral cartilage, fibrofatty tissue and
anterior end of inf. Turbinate.
Medial boundary: cartilaginous nasal septum.
Below/caudally: floor of pyriform aperture.

40. Causes of Unilateral and Bilateral Nasal Obstruction

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41. 5 things named after Cottle: Cottle's test, Cottle's principle of septoplasty,
Cottle's speculum, Cottle's area, Cottle's line, Cottle's elevator.

42. Syndromes associated with bilateral ethmoidal polyp - Kartagener syndrome,

Young syndrome, Churg–Strauss syndrome.

43. Intranasal steroids: Fluticasone, Budesonide learn some commercial names

too Like flomist.
44. Pott’s Puffy tumor - It occurs as a complication of sinusitis where there is
subperiosteal abscess outside, extradural abscess intracranially and osteomyelitis of
frontal bone in between.
45.

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46. What are the reasons for headaches in DNS?

a. DNS can lead to obstruction of sinus ostia leading to sinusitis, headaches &
tonsillitis.
b. Pressure on the Anterior Ethmoidal nerve due to impaction of septum on the
middle turbinate leading to headache.

47. How will you differentiate btw an Antrachoanal polyp and a mass arising from the
roof of the nasopharynx?
X-ray lateral view of Nasopharynx will show a curvilinear or crescentic air shadow
between the mass and roof of nasopharynx in AC polyp

48. Nasal Voice Changes

a. Rhinolalia clausa\ Hyponasality - due to lack of resonance of words due to
blockage of the nose or nasopharynx
b. Rhinolalia Aperta\ Hypernasality – defect is in failure of the nasopharynx
to cut off from oropharynx or abnormal communication between the oral
and nasal cavities

49. Why do you do DNE in DNS?

To know the posterior extent of the deviation.
In Anterior Rhinoscopy only Anterior portion of Septum is seen.

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50. Middle meatal antrostomy (2nd step in FESS)

Maxillary ostium lies above the inferior turbinate and posterior to lower
third of the uncinate process. Once localized, it is enlarged anteriorly with a
backbiting forceps or posteriorly with a through cut-straight forceps.

51. Complication of sinusitis. (pg 223 chapter 38 in Dhingra )

52. Most dreaded complication of sinusitis Ani??checking.. Ok

Intracranial complications - especially brain abscess

53. What do you suspect if recurrent maxillary sinusitis is occuring?

54. Steps in FESS

a. Uncinectomy with Blakesley forceps
b. Middle meatal antrostomy
c. Bullectomy
d. Penetration of basal lamella and removal of posterior ethmoid cells
e. Clearance of frontal recess and frontal sinusotomy
f. Sphenoidotomy
g. Nasal packs

55. Complications of FESS

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56. why ct scan is performed before FESS

a. the extent of sinus opacification
b. opacification of sinus drainage pathways
c. anatomical variants
d. critical variants
e. and condition of surrounding soft tissues of the neck, brain and orbits

57. Why rhinoplasty is not needed in anterior septal deviation?

58. Facial features in allergy

a. Nasal signs - Dennie Morgan Line (allergic salute) a black line across
the middle of dorsum of nose due to constant upward rubbing of nose
pale and oedematous nasal mucosa which may appear bluish.
Turbinates are swollen. Thin, watery or mucoid discharge is usually
present. •
b. Ocular signs include oedema of lids, congestion and cobble-stone
appearance of the conjunctiva, and dark circles under the eyes (allergic
shiners). •
c. Otologic signs include retracted tympanic membrane or serous otitis
media as a result of eustachian tube blockage.

59. Don't mention FESS as rx for polyps mention as endoscopic

polypectomy

60. Etiology of atrophic rhinitis.

a. Primary - Hereditary, endocrinal , racial,autoimmune,
infectious-Klebsiella ozaenae
b. Secondary -
DNS, Granulomatous conditions of nose, Chronic sinusitis.

61. Principle of septoplasty

( principle of preserving or reconstructing cartilaginous and bony structures as
much as possible)

62. To correct external framework of nose and septum- septorhinoplasty

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63. Antrochoanal polyp case

a. causes of osa

b. if we can't do endoscopic polypectomy, which surgery can be done -

caldwell luc.

c. incision for caldwell luc- gingivobuccal sulcus

d. Principal of functional endoscopic sinus surgery. endoscopic mediated

sinus surgery where the ventilation and drainage of sinuses is established
preserving the nasal and sinus mucosa and its function of nasociliary
clearance.

e. Dosage of fluticasone propionate and prednisolone for Medical

polypectomy - Fluticasone spray- 50 mcg bd, Oral Prednisolone - 1mg/kg/d

f. DD for AC polyp -
i. Hypertrophic turbinate,
ii. Glioma,meningocele,
iii. inverted papilloma,
iv. JNA.

g. Air column in Ac polyp? Concavity facing anteriorly in X-Ray

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64. Bilateral ethmoidal polyposis with allergic rhinitis

a. Type of obstruction in ethmoidal polyposis - continuous or intermittent? -
intermittent

b. DD for ethmoidal polyp - Congenital- meningocele,glioma;

Polyps- antrochoanal polyp,sphenochoanal polyp ;
Granulomatous - Rhinosporidiosis, Rhinoscleroma ;
Neo- Iv, JNA, neuroblastoma

c. Treatment steps of ethmoidal polyp - in order from avoiding common

allergens till FESS

d. Elaborate medical polypectomy -

Topical steroid in combination with systemic steroids are [Link] objectives of
medical management of nasal polyposis are
1) to eliminate nasal polyps and rhinitis symptoms,
2) to reestablish nasal breathing and olfaction, and
3) to prevent recurrence of nasal polyps. Has high risk of adverse effects.

e. Why don't some polyps respond to medical polypectomy?

i. Underlying cause of nasal polyp like cystic fibrosis or ciliary dyskinesia is
unresponsive to polyp.
ii. Nasal congestion caused by nasal polyp can cause unequal intranasal
distribution of the spray

f. If unresponsive, how to manage? - Endoscopic sinus surgery

g. Colour of nasal mucosa in allergic rhinitis? - Pale blue

h. Findings in Allergic rhinitis - allergic shiners, salute,..,..

i. Treatment for ethmoidal polyp. ( medical polypectomy, FESS)

j. DDs for ethmoid polyp (s shaped nasal deviation is the first expected
answer)
k. For diagnosis write allergic rhinitis followed by b/l ethmoidal polyps as
allergy precedes polyp

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65. Superior orbital fissure syndrome..

66. Merciful anosmia..

67. Most common site for JNA, presentation of JNA, which age group is affected
most by JNA

68. Complications of SMR - bleeding,septal hematoma,septal abscess, septal

perforation,saddle nose deformity,columellar retraction,csf
rhinorrhea,persistence of deviation, flapping of septum.

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69. Kiesselbach's plexus/ Little’ area

a. situated in the anterior inferior part of nasal septum, just above the vestibule
b. Four arteries - anterior ethmoidal, septal branch of superior labial, septal branch
of sphenopalatine and the greater palatine, anastomose to form a vascular
plexus called “Kiesselbach’s plexus.”
c. usual site for epistaxis in children and young adults

70. Woodruff's plexus is involved in which systemic disease ?

a. plexus of veins situated inferior to posterior end of inferior turbinate
b. posterior epistaxis seen in HTN, atherosclerosis & von Willebrand disease

71. Causes of mucoid discharge in the nose?

Chronic rhinosinusitis, antrochoanal polyp, vasomotor rhinitis, unilateral
choanal atresia, allergic rhinitis, [common cold n gustatory rhinitis]

72. Artery of epistaxis ? - nasopalatine and posterior medial nasal branches of

sphenopalatine.

73. Commonest cause of CSF Rhinorrhea

Accidental or surgical trauma. Surgical trauma includes endoscopic sinus
surgery, trans-sphenoidal hypophysectomy, nasal polypectomy or skull base
surgery
74. Signs seen in CSF Rhinorrhea
a. Reservoir sign-fluid which had collected in the sinuses, particularly
sphenoid, empties into the nose
b. Double target sign - if mixed with blood, when collected on a piece of filter
paper. It shows central red spot (blood) and peripheral lighter halo

75. Symptoms of Chronic Sinusitis

Symptoms. The cardinal symptoms of CRS with polyps are:
a. nasal obstruction,
b. nasal or post nasal purulent discharge,
c. facial pain and pressure,
d. disturbance of smell (hyposmia or anosmia).

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76. Signs of Chronic Sinusitis

Endoscopic examination of nose may reveal:
a. oedema of nasal mucosa in the anterior or posterior ostiomeatal complex
with purulent discharge.
b. Nasal endoscopy should be done first without and then with a nasal
decongestant
77. NOTE: Rhinosinusitis Task Force (2007) gave the clinical classification as:
a. Acute RS: Symptoms lasting for ≺4 wks with complete resolution.
b. Subacute RS: Duration 4-12 weeks.
c. Chronic RS: Duration ≥12 weeks.
d. Recurrent RS: Four or more episodes of RS per year; each lasting for 7-10
days or more with complete resolution in between the episodes.

78. Mucopurulent discharge in Chronic Sinusitis changes to Mucoid due to

incomplete treatment

79. Complications in Septoplasty- bleeding,septal hematoma,septal abscess,

septal perforation,saddle nose deformity,columellar retraction,csf rhinorrhea.

80. Areas to elicit sinus tenderness?

a. Maxillary sinus - Canine fossa
b. Ethmoidal sinus - medial to medial canthus
c. Frontal sinus - supraorbital foramen

81. Patient coming to casualty with nasal fracture. He wants to know if it can be
reduced tomorrow morning. What will you say?
It will be difficult to reduce the next day as edema will develop. So, it can be
done immediately before edema develops or 1 week later when edema settles.

82. Septal perforation graft used for surgery- Sialastic buttons

83. Surgery for crooked nose and dns - Septorhinoplasty

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84. Coconut appearance is seen in - Allergic maxillary sinusitis in X-Ray PNS

85. Indications of septoplasty other than DNS?

a. To graft cartilage for other procedures.
b. As a part of trans septal transsphenoidal approach for pituitary surgeries.
c. CSF rhinorrhea.
d. As a part of dacryocystorhinostomy

86. A syndrome associated with obstructive sleep apnea named after Charles
Dickens novel character : Pickwickian syndrome

87. Causes of sudden unilateral and bilateral nasal obstruction?

U/L is foreign body. B/L is septal hematoma

88. Why do we check for tenderness at a specific point for the sinuses despite
their large size?
Weakest and thinnest bone is at that site for each sinus and it is easily
accessible.

89. What happens if compensatory hypertrophy doesn't occur in dns?

The nasal cavity will be roomy so it forms a crust leading to recurrent epistaxis
and can also result in atrophic rhinitis.

90. Surgery for Atrophic rhinitis - Young's operation.

91. Causes of cacosmia?

Recovery phase of post influenzal anosmia and the probable explanation is
misdirected regeneration of nerve fibres. Intracranial tumour can also cause it

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THROAT QUESTIONS
01. Causes of deviation of uvula- at least know quinsy, palatal paralysis(9th
nerve), parapharyngeal abscess.
02. IDL mirror is straight , the posterior rhinoscopy mirror is angulated.

03. Surface landmark for JG Node?

1.5 cm below and behind the angle of mandible.

04. What is interval tonsillectomy? Why is it done so?

Ans. Interval tonsillectomy is done about 4 weeks after acute attack.
Reason: in 4 weeks inflammation would have subsided greatly thus,
reduced bleeding during operation.

05. Indications and C\I of tonsillectomy (487 to 490 in Dhingra; 621 in Bansal)

06. What is grisel syndrome?

Ans. Pathological atlantoaxial subluxation(can occur in down's syndrome if
laid in Rose position).

07. Adenoid facies - craniofacial growth abnormalities are caused due to

chronic nasal obstruction and mouth breathing.

08. Inattentiveness in adenoid hypertrophy is due to decreased hearing

which may be due to adhesive otitis media or glue ear.

09. Complications of tonsillectomy?

Immediate:- Delayed:-

1. Primary haemorrhage 1) Secondary haemorrhage

Reactionary haemorrhage 2) Infection
2. Injury to: 3) Lung complications
a. Tonsillar pillars, uvula, soft palate 4) Scarring
b. Tongue 5) Tonsillar remnants
c. Superior constrictor muscle 6) Hypertrophy of lingual tonsil
d. Teeth
3. Aspiration of blood
Facial oedema
Surgical emphysema

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10. Causes of reactionary hemorrhage ?

11. Grading of tonsil enlargement?

Ans. Brodski grading

Alternatively, based on what percentage of the oropharynx space it has

occluded:
Grade 1- upto 25%. Grade 3- 50 to 75%
Grade 2- 25 to 50%. Grade 4- >75% kissing tonsils.
12. Recurrent tonsillitis grading?
Ans. Paradise criteria:

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13. Complications of tonsillitis?

Acute Chronic

14. Incision for quinsy?

At point of maximum bulge or at the point of junction of anterior pillar
with line drawn through the base of uvula.

15. indirect laryngoscopy- structures seen, procedure,indications &

contraindication (437 in Dhingra; 504 in Bansal)

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16. Boundary of oral cavity ?

17. Waldeyer's ring?

18. Boundary of nasopharynx and oropharynx?

19. Other names for adenoids are LUSCHKA TONSIL, NASOPHARYNGEAL OR

PHARYNGEAL TONSIL.

20. Another name for tubal tonsil is GERLACH'S TONSIL.

21. Plummer Vilson syndrome:- Characterized by the classic triad of

dysphagia, iron-deficiency anemia and esophageal web.

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22. Causes of uvula deviation to opposite side

a. Quinsy
b. Palatal paralysis
c. Jugular foramen syndrome(It is caused by a tumor, which compresses
contents that are passing through the jugular foramen. It consists of
paralysis of CN IX, X and XI, which pass through the jugular foramen
along with the internal jugular vein. It can be seen in patients of
malignancy nasopharynx, glomus jugular, large acoustic neuroma or
thrombophlebitis of jugular bulb. )
d. Carcinoma of tonsil and tonsillar fossa(?)

23. Causes of uvula deviation to same side

24. when is uvula pulled & when is uvula pushed?

a. Pushed uvula: quinsy, parapharyngeal abscess, ca tonsil and tonsillar
fossa
b. Pulled:Palatal paralysis, jugular foramen syndrome.

25. Features of Chronic tonsillitis?

a. Irwin Moore sign
b. Enlarged and non tender jugulodigastric nodes
c. Anterior pillar flushing.
26. Difference between recurrent and chronic tonsillitis?
The time between the acute episode, the patient is completely normal in
recurrent tonsillitis. Whereas in chronic, persistent symptoms like halitosis,
voice change, dysphagia would be present.
27. hoarseness of voice- definition
Hoarseness is defined as roughness of voice resulting from variations of
periodicity and/or intensity of consecutive sound waves.
For production of normal voice, vocal cords should:
a. Be able to approximate properly with each other.
b. Have a proper size and stiffness.
c. Have an ability to vibrate regularly in response to air columns.
Any condition that interferes with the above functions causes
hoarseness.
d. Loss of approximation may be seen in vocal cord paralysis or fixation
or a tumour coming in between the vocal cords.
e. Size of the cord may increase in oedema of the cord or a tumour;
there is a decrease in partial surgical excision or fibrosis.
f. Stiffness may decrease in paralysis, increase in spastic dysphonia or
fibrosis.

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28. Causes of unilateral tonsillar enlargement

a. Peritonsillar abscess
b. Lymphoma of tonsils
c. Fibroma,papilloma, [Link]
tonsils
29. interval tonsillectomy

This pic explains both the

difference and definition.

30. Treatment of peritonsillar abscess

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31. Features in case on quinsy?

a. Uvula opposite side deviation
b. Unable to open mouth
c. Unilateral enlarged on one side
d. Torticollis
e. Fullness of peritonsillar space and congestion.

32. Contradiction of TONSILLECTOMY

a. Cleft palate
b. Age less than 3.
c. Down syndrome due to subluxation of atlantoaxial joint even in spinal
cord compression glial syndrome
d. During epidemic of polio as can spread through nerve
e. Pregnancy
f. Bleeding disorders
g. Acute infection
h. Relative contraindications
i. Uncontrolled systemic infection

33. Adenoid reaches max size by 6 years age and disappears completely by
age 20.

34. Differences between adenoids and tonsils:

Adenoid Tonsil
Single, central Bilateral.
No capsule Has capsule
Ridges of lymphoid tissue Ovoid mass of lymphoid tissue
separated by clefts. No crypts Has crypts
Lined by 3 types of 3pithelium - Medial surfaces and crypts are
ciliated pseudostratified lined by stratified squamous non
columnar, stratified columnar, keratinizing epithelium lateral
transitional. surfaces lined by capsule.
Disappears completely by 20 y Does Not disappear
35. Snares in ENT

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36. Other name of paratonsillar vein is Dennis brown vein

37. Criteria’s in relation to adenoids (Dr. Sophia)

The adenoid size is described in relation to the

degree of nasopharyngeal volume it occupies.
The degree of choanal obstruction is based on
the relation of the adenoid to the posterior end
of the septum and the vomer. Tubal obstruction
is graded as present or absent. The final grade
would be represented as A-C-E-.

38. Prevertebral soft tissue widening criteria

IN ADULTS:Less than 6 mm at C2, Less than 22 mm at C6
IN PEDS:1/2 to 2/3 vertebral body distance anteroposteriorly

39. Causes of post nasal drip

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40. Signs of tympanic membrane in Serous Otitis Media

a. Treatment

41. Findings in Serous Otitis Media and why Serous Otitis Media in
adenoid hypertrophy
a. Due to the blockage of Eustachian tube by the adenoids
b. Myringotomy with grommet insertion will be done along with
adenotonsillectomy or as a separate procedure
c. The grommet insertion is done when the hearing loss is even
persistent after the surgery.

42. Positive signs to identify presence of adenoid?

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43. Incision in grommet insertion

[Link] can technique

45. Types of tonsillectomy

46. Other diagnosis for inattentiveness in class.

a. ADHD
b. Seizure
c. Adenotonsillitis

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47. Tonsil blood supply

48. Duration of primary reactionary and secondary hemorrhage.

a. Primary haemorrhage. Occurs at the time of operation.
b. Reactionary haemorrhage. Occurs within a period of 24 h

49. Tonsillectomy...procedure ... complication (487 to 490 in Dhingra)

50. Dd for white membrane over tonsil?

Membranous tonsillitis, vincent angina, diphtheria, aphthous
ulcer,infectious mononucleosis,leukemia,agranulocytosis.

51. Organism causing vincent angina?

Bacillus fusiformis and Borrelia vincentii.

52. Stages of chronic tonsillitis

a. Chronic follicular tonsillitis
b. Chronic parenchymatous tonsillitis
c. Chronic fibroid tonsillitis

53. Why is tonsillectomy contraindicated in Down syndrome?

Due to atlanto-axial joint instability.

54. How will you elicit an irvin moore sign?

On pressing the anterior pillar with tongue depressor, pus comes out of
the tonsil. It's positive in chronic tonsillitis.

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55. 3yr old child is contraindicated for tonsillectomy surgery - why?

Tonsils provide local immunity and surveillance, so removing tonsils in 3yr
old child may predispose to other infection

56. Various consistency of lymph nodes

Firm in infections
Hard in malignancy

57. Vincent angina

a. What anaesthesia is given - General
b. How it is given - through tracheostomy tube, inhalational
c. Complications if intubation is done- rupture of abscess

58. What are all the causes of secondary hemorrhage in tonsillectomy

Secondary infection

59. I&D site & route for acute retropharyngeal abscess?

Transoral route.
At the point of maximum bulge

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MISCELLANEOUS
1. DD of Unilateral LMN Palsy
a. Bell's Palsy
b. CSOM - unsafe type
c. Acoustic Neuroma
d. Temporal Bone Fracture
e. Ramsey Hunt Syndrome
f. Malignant Otitis Externa
g. Mastoid/Parotid Surgery
h. Tumours in Cerebro-Pontine Angle
i. Systemic conditions like Type II DM, Sarcoidosis, Lymes Disease

2.

3. Occupational ENT Conditions

1. NIHL - Industrial workers
2. Rhinosporidiosis - Farmers
3. Fungal sinusitis
4. Vocal polyp or nodule - Singers
5. Squamous cell carcinoma of nose in hardwood workers
6. CA maxillary sinusitis - Carpenters
7. CA larynx - Asbestos industry workers

4. Position for Esophagoscopy - Magician sword swallowing position.

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5. Levels of Neck Nodes

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