ENT

INDEX

NASAL & PARANASAL SINUSES: EXTERNAL NOSE

1. NASAL VALVE COLLAPSE 1
2. SADDLE NOSE 1
3. BASAL CELL CARCINOMA (RODENT ULCER) 1
4. RHINOPHYMA (POTATO NOSE) 1
5. RHINOLITH 1
6. FOREIGN BODY NOSE 2
7. MYIASIS 2
8. NASAL BONE FRACTURE 2
9. NASAL SEPTUM FRACTURE 3
10. ZYGOMATIC FRACTURE 3
11. BLOW OUT FRACTURE OF “ORBITAL FLOOR” 3
12. MID FACE FRACTURE (MAXILLA FRACTURE) 3
13. CSF RHINORRHEA 3
14. LATERAL WALL OF NOSE 4
15. PARANASAL SINUSES 5
16. ETHMOID AIR CELLS 5
17. MIDDLE MEATUS 6
18. SINUSITIS 6

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 19. NOSE & PARANASAL SINUSES : PARANASAL SINUSES 7
MISCELLANEOUS QUESTION
20. GENARAL QUESTION ABOUT SINUSES 8
21. TUMORS OF PARANASAL SINUSES AND NOSE 8
22. INVERTED PAPILLOMA OF NOSE (RINGERTZ TUMOR) 9
23. NASAL POLYP 9
24. TYPES OF POLYPS 9
25. MUCORMYCOSIS 10
26. RHINITIS MEDICAMENTOSA 10
27. VIDIAN NERVE (NERVE OF PTERYGOID CANAL) 10
28. OLFACTION (SENSE OF SMELL) 10
29. NASAL SEPTUM 11
30. DEVIATED NASAL SEPTUM (DNS) 11
31. SEPTAL HEMATOMA 12
32. SEPTAL PERFORATION 12
33. ATROPHIC RHINITIS (OZAENA) 13
34. RHINOSCLEROMA (WOODY NOSE) 13
35. RHINOSPORIDIOSIS 14
36. BLOOD SUPPLY OF NOSE 14
37. EPISTAXIS 15
PHARYNX
38. LARYNGOPHARYNX (HYPOPHARYNX) 17
39. NASOPHARYNX (NPX) 17
40. ADENOID (NASOPHARYNGEAL TONSIL) 18
41. ANGIOFIBROMA 19
42. NASOPHARYNGEAL CARCINOMA (NPC) 19
43. OROPHARYNX 20
44. QUINSY (PERITONSILLAR ABSCESS) 22
45. QUINCKE’S DISEASE 23
46. LUDWIG'S ANGINA 23
LARYNX
47. NORMAL VOICE IN ADULTS 27
VOCAL CORD DISORDERS
48. PUBERPHONIA 27
49. ANDROPHONIA 27

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 50. DIVISION OF LARYNX 27
51. LARYNGOCELE 28
VOCAL CORD DISORDERS
52. VOCAL NODULES 29
53. VOCAL POLYP 29
54. INTUBATION GRANULOMA 29
55. JUVENILE PAPILLOMA OF LARYNX 30
56. REINKE’S OEDEMA 30
57. INDIRECT LARYNGOSCOPY (I/L) 31
58. STRIDOR (NOISY BREATHING) 31
VOICE DISORDERS
59. MOGIOPHONIA 31
60. RHINOLALIA APERTA (HYPERNASALITY OF VOICE) 31
61. RHINOLALIA CLAUSE (HYPONASALITY OF VOICE) 32
62. FUNCTIONAL APHONIA (HYSTERICAL APHONIA) 32
63. LARYNGOMALACIA 32
64. GLOTTIC WEB 32
65. PEDIATRIC LARYNGEAL INFECTION 33
66. ACUTE APIGLOTTITIS 33
67. ACUTE LARYNGOTRACHEOBRONCHITIS (ALTB) (CROOUP) 33
CANCER LARYNX
68. GLOTTIC CANCER 34
69. SUPRAGLOTTIC CANCER 34
70. SUBGLOTTIC CANCER 34
71. LEVELS OF NECK NODES Level 1 – level 7 35
72. TRACHEOSTOMY (TR’) 36
73. FUNCTION OF LARYNX 36
74. MUSCLES OF LARYNX 37
75. SENSORY SUPPLY OF LARYNX 37
76. VOCAL CORD PARALYSIS 37
77. BILATERAL ABDUCTOR PALSY 38
78. BILATERAL ADDUCTOR PALSY 38
EAR
79. EMBRYOLOGY 39
80. DARWIN’S TUBERCLE 40
81. OSSICLES 40

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 82. PINNA 41
83. PINNA HEMATOMA 41
84. KELOID PINNA 41
85. EXTERNAL AUDITORY CANAL (EAC) 41
86. INSECT IN EAC 42
87. DIRECTION OF EAC 42
DISEASES OF EAC
88. DIFFUSE OTITIS EXTERNA 42
89. LOCALIZED OTITIS EXTERNA (FRUNCULOSIS) 42
90. MALIGNANT OTITIS EXTERNA 43
91. OTOMYCOSIS 43
92. EXOXTEOSIS (SURFER’S EAR) 43
93. TYMPANIC MEMBRANE (TM) (MARING) 43
94. TRAUMATIC PERFORATION OF TM 44
95. EUSTACHIAN TUBE (ET) 44
96. GLUE EAR (SEROUS OTITIS MEDIA 45
97. MIDDLE EAR (TYMPANUM) 46
98. DEPTH OF MIDDLE EAR 46
99. 6 WALLS OF MIDDLE EAR 46
100. MIDDLE EAR CLEFT 48
INFECTION OF MIDDLE EAR CLEFT
101. Acute suppurative otitis media (AOSM) 48
102. SAFE CSOM 48
103. ACUTE MASTOIDITIS 49
104. PETROSITIS (GRADINEGO SYNDROME) 50
105. ABSCESS FORMATION 50
106. UNSAFE CSOM (ATTICO ANTRAL CSOM) 51
107. COMPLICATION OF UNSAFE CSOM 51
108. LABYRINTHINE FISTULA 51
109. SIGMOID SINUS THROMBOSIS (LATERAL SINUS THROMBOSIS) 52
INNER EAR (LABINTH)
110. COCHLEA 53
111. UTRICLE & SACCULE 54
(VESTIBULE) (OTOLITHIC ORGAN)
112. BENIGN PAROXYSMAL POSITIONAL VERTIGO 54
113. SEMICIRCULAECANAL (SCC) 55
114. BITHERMAL CALORIC TEST (CALORIC TEST) 55

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 115. 8TH NERVE (VESTIBULOCOCHLEAR NERVE) 55
116. AUDITORY PATHWAY 56
AUDIOLOGY
TEST OF AUDIOLOGY
117. TUNING FORK TEST 57
118. PURE TONE AUDIOMETRY (PTA) (AUDIOGRAM) 58
119. BERA (BRAIN STEM EVOKED RESPONSE AUDIOMETRY) 60
120. ATOACOUSTIC EMISSIONS (OAE) 60
121. STAPEDIAL REFLEX 60
122. TYMPANOMETRY (IMPEDANCE 60
AUDIOMETRY)
123. CONDUCTIVE HEARING LOSS IN DIFFERENT SITUATION 61
124. DRUG INDUCED HEARING LOSS (OTOTOXICITY) 61
125. FACIAL NERVE 61
126. BELL’S PALSY 62
127. RAMSAY HUNT SYNDROME 63
128. MELKERSSON ROSENTHAL SYNDROME 63
129. OTOSCLEROSIS (OTOSPONGIOSIS) 64
130. ACOUSTIC NEUROMA (VESTIBULAR SCHWANNOMA) 65
131. GLOMUS JUGULARE 65
132. MENIER’S DISEASE (ENDOLYMPHATIC HYDROPS) 66
133. EAR IMPLSNTS & DEVICES 67
134. HEARING AID 67
135. COCHLEAR IMPLANT 67
136. AUDITORY BRAINSTEM IMPLANT (ABI) 67
137. ENT INSTRUMENTS 68
138. RADIOLOGICAL FINDIGING 74
IN ENT DISEASES

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 ENT BY DR. RAJIV DHAWAN
SADDLE NOSE
NASAL & PARANASAL SINUSES:
EXTERNAL NOSE

1. Nasal bone
2. Upper lateral cartilage
3. Lower lateral cartilage
(Alar cartilage)
Cause:
1. Trauma (m/c)
2. Septal surgery
3. Tertiary syphilis
4. Tuberculosis
5. Leprosy
• They form external opening
of nose.
Tx: Sx
4. Lesser alar (sesamoid cartilage)
Augmentation rhinoplasty
• Small cartilage
Graft use: iliac crest graft
• Lying between 2 & 3
2=ULC
BASAL CELL CARCINOMA
3=LLC
(RODENT ULCER)

• Most common malignancy of

external nose.
• Rolled out edges
Nasal valve: junction of upper
lateral & lower lateral cartilage. RHINOPHYMA (POTATO NOSE) Q
• Hypertrophy of sebaceous
NASAL VALVE COLLAPSE glands of skin of external nose.

Cottle’s test: is done to check the RHINOLITH

blockage of nasal valve. • Formation of stone in nasal
cavity.
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 FOREIGN BODY NOSE Q FACIAL TRAUMA
• More common in school age
children. NASAL BONE FRACTURE

MCQ: 7 years old child presenting • Most commonly fracture of face.

with UNILATERAL Foul Smelling 1. Nasal deformity
nasal discharge & epistaxis. 2. Capitus
ANS: foreign body in nose

Rx: endoscopic removal

MCQ: disk battery as foreign body

in Nose, ear, esophagus, bronchus.

Rx: urgent removal

• Because they can release alkali &
it can cause tissue necrosis. Dx: x-ray
Rx: immediate closed reduction before
MYIASIS edema Start. (Q)
• Maggots in nose/ear • Using “walsham forceps”
• Larvae of house fly
(CHRYSOMIA)
• Foul smelling conditions lead to
myiasis

Rx : maggot oil –contain—

chloroform Q + turpentine oil

Q: if edema is alredy present

Rx: wait for 7 days for edema to
disappear & then do fracture reduction.

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 NASAL SEPTUM FRACTURE (guerin sign)
2 Type: Type: 2 – pyramidal fracture
1. If force is from front – horizontal Type: 3 – craniofacial dysjunction
fracture (jarja way fracture) • Type 2 & 3 leads to CSF rhinorrhea (CSF
2. If force is from below- vertical leak from nose)

fracture (chevallet fracture) MCQ: most common fracture part of

mandible
ANS: condule fracture (sub condular
Rx: reduction using “asch forceps”
fracture)
ZYGOMATIC FRACTURE Q
• 2nd most commonly fracture of face. “roof of the nose is base of the skull”
• Cheek anesthesia -infraorbital nerve
injury.
CSF RHINORRHEA
Cause:
1. Zygomatic fracture
2. Maxilla fracture
3. Carcinoma of maxillary sinus

BLOW OUT FRACTURE OF

“ORBITAL FLOOR”
• Large blunt object striking the globe.
• On CT SCAN “tear drop sign”: eye Cause:
contain fall down in maxillary sinus as 1. Nasal surgery
a drop. 2. Trauma -leads to – skull base fracture -
leads to – traumatic CSF leak – blood
MID FACE FRACTURE (MAXILLA mixed CSF- on filter paper – dry it –
FRACTURE) we can see – “target sign” (halo sign)
3 Type: (double halo sign)
1. Le fort 1 • This sign Are not seen in every CSF
2. Le fort 2 Rhinorrhea. seen in only traumatic.
3. Le fort 3

• Most common site of CSF rhinorrhea

is CRIBRIFORM PLATE. (it’s a part of
ethmoid bone)
Type: 1 – transverse fracture
Passes at level of palate
a. Floting palate
b. Echymosis on palate
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 Q :HOW TO CONFIRM THAT IT IS • It has 3 projection calles
CSF & NOT NASAL DISCHARGE ? TURBINATES.
Tests: 1. INFERIOR TURBINATE
1. CSF is not sticky. 2. MIDDLE TURBINATE
(Handkerchief test) 3. SUPRERIOR TURBINATE.
2. Patient Can Not sniff back CSF
3. Biochemical analysis MEATUS: space below turbinate
4. Most confirmatory test: 1. Inferior meatus
B2 transferrin estimation 2. Middle meatus
3. Superior meatus
Q: HOW TO FIND SITE OF LEAK ?
1. Nasal endoscopy sphenoethmoidal recess: it is area
2. Fluorescein dye test -give above ST (SUPERIOR TURBINATE)
through lumber puncture (it
will give green color to CSF)
3. CT cisternography
4. MRI (T2 IMAGES)
5. Best radiological investigation:
HRCT scull base

Rx: TOC: Conservative Tx Q

Bed rest & Antibiotics For 7-10 days

LATERAL WALL OF NOSE

• Every turbinate has bone called

“concha”

1. Inferior concha
Its indepedent bone
2. Middle concha
3. Superior bone

• Middle and superior concha is

part of ethmoid bone.
• “these red 3 part is turbinate”
• Choana: posterior opening of
nasal cavity.
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 PARANASAL SINUSES ETHMOID AIR CELLS Q
2 groups:
1. Anterior
2. Posterior

1. Anterior
Numbers: 2-8
2 is Constant cell ( everybody
has) Q
• Mucosa lined air filled hollow I. Bulla ethmoidalis
cavities in skull bones . II. Agger nasi
• Sinuses produce mucus.
• Mucus drain in to nose. i. Bulla ethmoidalis
• Most constant & largest
Þ There are 4 pairs of sinuses. anterior ethmoid air cell
ii. Agger nasi
1. Maxillary sinus (antrum of • Anterior most anterior
highmore) ethmoid air cell
• Largest sinus
• Below the orbit 2. Posterior
• Volume: 15ml Number: 1-8
2. Frontal sinus
• Just above eyebrows. • In some people ethmoid air cell
• Obove the orbit can grow in 3 unusual sites
3. Sphenoid sinus
4. Ethmoid sinus (ethmoid air cells) 1. Orbital floor
2. Close to optic nerve
• Between 2 orbit
3. Inside middle turbinate
• Big hollow cavity is called sinus
and small hollow cavity called as
“air cells” • If grow in orbital floor
called “haller cell”
• If grow close to optic
nerve called “onodi cell”
• If grow inside middle
turbinate called “concha
bullosa

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 STRUCTURE DRAINING IN TO NASAL Q: 3 sinuses drain in to middle
CAVITY Q meatus but more specific in middle
• Nasolacrimal duct drain in to – meatus is – ethmoidal infundibulum
inferior meatus. area of middle meatus.
• Maxillary sinus, frontal sinus &
anterior ethmoid air cell drain in Osteomeatal complex (OMC):
to- middle meatus. whole complex (BE,UP,
• Posterior ethmoid air cell drain in ETHMOIDAL INFUNDIBULUM, 3
to -superior meatus. SINUSES OPENING )
• Sphenoid sinus drain in to -
sphenoethmoidal recess.
SINUSITIS
Q: direction of Nasolacrimal duct
ANS: downward backward laterally • If OMC is blocked due to mucosal
edema it will lead to blockage of
Q: surgical opening of DCR sinus drainage. It ll lead to
(dacryocystorhinostomy) sinusitis .
ANS: middle meatus
• If this process of infection stay >3
months called “chronic
MIDDLE MEATUS rhinosinusitis” (CRS)
• Most important are of sinus Dx:
drainage. 1. Nasal endoscopy- 1st
It has 3 landmarks: investigation to do.
1. Bulla ethmoidalis (BE)
2. Uncinate process (UP)
• It is Sickle shaped bone which
covers BE.
3. Ethmoidal infundibulum
• It is space between BE & UP.

• It has 3 passes

i. 1st pass- along inferior

turbinate (IT)
ii. 2nd pass- above middle
turbintate (MT)
iii. 3rd pass – inside middle
meatus
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 2. X-ray paranasal sinuses (water’s 2. Mucocele formation
view) Q with open mouth • Big sinus

• Most commonly seen in frontal

sinus.

3. Pott’s puffy tumor

• This x-ray view shows all sinuses
except POSTERIOR ETHMOID
AIR CELLS.

3. CT SCAN: best radiological

investigation for sinuses.

Rx:
1. Antibiotics Frontal sinusitis – lead to –
2. Decongestant for 3week frontal osteomyelitis – leads to –
• If no improvement then go for Sx subperiosteal frontal abscess
(functional endoscopic sinus formation (pott’s puffy tumor).
surgery) (FESS) Q
• Main aim of FESS to re-establish NOSE & PARANASAL SINUSES :
the sinus drainage. PARANASAL SINUSES
MISCELLANEOUS QUESTION
COMPLICATION OF SINUSITIS
1. Orbital infection Most common long term
complication of FESS or any other
nasal surgery: nasal synechiae
(adhesion) formation.

• Orbital infection most seen in

ethmoid sinusitis.

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 • To prevent the nasal synechiae: DEVELOPMENT OF SINUSES
Topical (local) application of • Radiologically sinuse appear in
Mitomycin-c Q reduces synechiae this sequence. - M-E-S-F
formation. Maxillary sinus
Ethmoid sinus
Sphenoid sinus
GENARAL QUESTION ABOUT
Frontal sinus
SINUSES
• S -appear at 4 year of age
• Office headache (periodic • F -appear at 6 year of age
headache) seen in – frontal
sinusitis. TUMORS OF PARANASAL SINUSES
• Occiput headache (vertex AND NOSE
headache) - sphenoid sinusitis.
• Cheek pain, cheek swelling seen Maxillary > ethmoid
in – maxillary sinusitis.
• Pain at bridge of nose or medial Risk factor:
canthus seen in – ethmoid 1. Nickel – squamous cell carcinoma
sinusitis. 2. Wood dust – adeno carcinoma of
• Most common benign tumor of ethmoid (wood worker
sinuses - osteoma carcinoma).
• Osteomas are most common in
frontal sinus. • If the cancer is on maxillary sinus
then it can easily spread to eye
cause maxillary sinus is just
below the eye. To check cancer
goes to eye or not we use line
called: ohngren’s line Q
• Ohngren’s line: medial canthus to
angle of mandible.

• Most common to cause sinusitis

– aspergillus fumigatus
• Most common sinus to form
aspergillomas (fungal balls) –
maxillary sinus.
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 • If the cancer above this line then • It can cause chronic
it will easily goes to eye. It will inflammation – leads – to
have poor prognosis. oedema – polyp

Tx: Sx (total maxillectomy) THERE ARE 2 TYPES OF POLYPS:

by weber fergusson approach. 1. Antrochoanal polyp
Followed by radio therapy. • It aries from maxillary sinus and
goes posteriorly towords
INVERTED PAPILLOMA OF NOSE choana.
(RINGERTZ TUMOR) Q • Therefore its batter seen on
posterior rhinoscopy.
• With the help of posterior
rhinoscopy mirror.

• More common in Male

• 40-60 year
• Lateral wall of nose
• It grows inwards therefore called • This polyp is also called as
“inverted” killian’s polyp
• It is more common in children
NASAL POLYP • It is due to chronic infection
• It is Single polyp
• It is unilateral polyp

Tx: Sx – endoscopic polypectomy or

FEES.

2. Ethmoidal polyp (nasal polyp)

• Most common (90%)
• It is prolapsed pedunculated • Aries from ethmoid air cell
oedematous mucosa of sinuses. • It is more common in adult
• It is due to chronic allergy
Etiology: • It is multiple
• Chronic infection / allergy for last • It is bilateral
few year.
9

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 Tx: topical corticosteroid nasal • it leads to rebound congestion.
spray. Eg. Fluticasone

Sampter’s triad Q
1. Nasal polyp
2. Asthma
3. Allergy to NSAIDs (aspirin)

MUCORMYCOSIS

Tx:
• stop this drops.
• Start steroid nasal spray. Q

VIDIAN NERVE (NERVE OF

PTERYGOID CANAL)

• it is fungal infection of nose by • Function of this canal

mucor group of fungi. • This nerve gives autonomic nerve
• It is seen in young, diabatic, supply to the nose.
HIV positive patient. • Parasympathetics over
(immuno compromise pts) dominance in nose leads to
disease called vasomotor rhinitis
Clinical feature: (VMR)
Mucor is angioinvasive fungus – it
enter to orbit and brain – Tx: Sx (vidian neurectomy) Q
1. Blackish mass in nose
2. blackish discoloration around eye OLFACTION (SENSE OF SMELL)
BLACK • olfactory epithelium it lies upper
Rx: DOC : amphotericin-B Q 1/3 of nasal cavity.
• Olfactory neurons pass through
RHINITIS MEDICAMENTOSA cribriform plate

• It is due to prolonged use of

decongestant nasal drops.
Example:
1. xylometazoline
2. oxymetazoline
10

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 Anosmia: loss of sense of smell. • It forms median wall of nasal
Hyposmia: its decrease sense of cavity.
smell. It is made of 7 structures. Q
Causes: a. 3 major
1. Nasal blockage (e.g: nasal 1. Septal (quadrangular)
polyp) cartilage.
2. Covid 19 Q 2. Perpendicular plate of
3. Head injury (head injury can ethmoid.
cut the neuron) 3. Vomer
4. Parkinsonism
5. Alzhiemer’s disease
6. Kallman’s syndrome
(it is anosmia + hypogonadism
which leads to infertility)

Q: A patient of anosmia can still

sense AMONIA(NH3) – cause
ammonia is not a smell it is an
irritant. Its sense via TRIGEMINAL b. 4 minor structures
NERVE. 1. Spine of maxilla
2. Spine of frontal bone
3. Rostrum of sphenoid
4. Crests of palatine & maxillary
bone
NASAL SEPTUM
DEVIATED NASAL SEPTUM (DNS)

DNS can lead to

1. Nasal blockage on deviated side.

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 2. Crust formation on the patent SEPTAL HEMATOMA
(wide side) side.
(Crust= dried mucus due to
increase air flow.)
3. Compensatory inferior turbinate
hypertrophy (ITH) on the patent
side.

Cause: trauma
• Bilateral

C/F: after trauma –

• nasal swelling
• ITH gives MULBERRY appearance • Bilateral Nasal blockage
of nasal mucosa Rx: aspiration Q - if not do aspiration -
then it will leads to septal abscess – septal
perforation

SEPTAL PERFORATION

4. Sinusitis
5. Epistaxis
6. External nasal deformity
7. Hyposmia
8. Headache (due to contact
between DNS & middle
turbinate) sometime its start
touching the middle turbinate – this Causes:
headache is called as SLUDDER,S 1. Trauma (M/C)
(anterior ethmoidal neuralgia) 2. Septal surgery
3. Cocaine (it is vasoconstrictor)
Rx: Sx : septoplasty 4. Tuberculosis
5. Leprosy
6. Lupus of nose
7. Tertiary syphilis
12

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 • Tuberculosis, Leprosy, Lupus • Patient has ANOSMIA (loss of
of nose can cause cartilage sense of smell) this is called
part perforation. MERCIFUL ANOSMIA Q
• Tertiary syphilis causes bony
part Q Rx: alkaline nasal douching
Rx: Sx – closer of perforation (washing) Q
using SEPTAL BUTTONS We use powder contain :
1. sodium bi carbonate
2. Sodium bibornate
3. Nacl

Surgical Rx :
a. Young’s operation
b. Modified young’s operation
• Partial closer of both nosetrils
ATROPHIC RHINITIS (OZAENA)
• It is atrophy of turbinate which
leads to roomy nasal cavity –
crust.
• Its more common in female
Etiology:
1. Autoimmunity
2. Infection (k. Ozeane) Q
Examination: c. Lautenslager operation
1. Atrophied turbinate
2. Roomy nasal cavities RHINOSCLEROMA (WOODY NOSE)
3. Leads to - they are filled with
crust

Crust will cause problem:

1. Nasal blockage • It is infection of nose by k.
2. Bad smell from patient rhinoscleromatis (Frisch bacillus)
13

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 • More common in north india (UP • Examination shows mulberry or
& RAJASTHAN) strawberry like NASAL MASS Q +
This disease has 3 stages: EPISTAXIS
1. Atrophic stage
Just like atrophic rhinitis: Rx: Sx – excision of mass with
Roomy nasal cavity & crust electrocautery of base (burn the
2. Granulomatous stage base) followed by DAPSON (DOC)
That leads to hard external
nose (woody nose) • This disease is more common in
3. Stage of fibrosis south india (tamilnadu)

Diagnosis: biopsy
It shows Russell bodies & BLOOD SUPPLY OF NOSE
Mikulicz cells Q
It is from 2 systems
1. 80% from ECA (external
carotid artery) – up to middle
turbinate.
2. 20% from ICA (internal carotid
artery) – above middle
Rx: tetracycline + streptomycin turbinate.

RHINOSPORIDIOSIS

• It is infection of nose by
rhinosporidium seeberi – it is
aquatic (village pond water)
protozoa.
• Bathing in ponds – whenever the
water will touch to nose (M/C), From ECA 2 BRANCHES
oral cavity, conjunctiva and A. MAXILLARY ARTERY
genital mucosa. B. FACIAL ARTERY
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 Causes:
From maxillary artery 2 branches: 1. Most common cause finger
a. Sphenopalatine artery (SP) nail trauma (nose picking)
b. Greater palatine artery(GP) 2. Accidental trauma
3. Hypertension (causes
From facial artery posterior epistaxis) Q
a. Superior labiol artery (SL) 4. Bleeding disorders
5. Anticoagulant drugs
ICA gives ophthalmic artery – gives 6. Hemorrhagic fever
2 branches 7. Tumors of the nose
1. Anterior ethmoidal artery (AE)
2. Posterior ethmoidal artery(PE) MCQ: ARTERY OF EPISTAXIS:
Ans: Sphenopalatine artery (SP)

EPISTAXIS Rx:
1. Pinch the nose for 3-5 minute
(then)
2. Chemical cauterization of little’s
area with AgNo3. (then)
• AgNo3 is cauterization agent it will
burn that area and bleeding will
stop.
3. Anterior nasal packing (on both
• Most common area – little’s are side) (if this failed)
(it lies at anteroinferior part of
nasal septum.
• It has keisselbach’s plexus of 4
arteries (we have total 5 arteries
SP, GP, SL, AE, PE,).
• PE is not a part of keisselbach’s
4. Posterior + anterior nasal
plexus. Q packing.

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 If the nasal packing failed then we • Between TP & CP – there is
will go for. triangular area which has no
5. Endoscopic ligation of muscle – this triangular are is
Sphenopalatine artery (SP) Q called KILLIAN’S DEHISCENCE
(1st artery to ligation) (KD)
• If SP failed then we will go for • It is a week area – it is site of
maxillary artery ligation – if its formation of ZENKER’S
failed – external carotid artery DIVERTICULUM (pharyngeal
ligation - if its failed – ethmoidal pouch)
artery ligation. • Between skull base & superior
constrictor there is space called:
Q: how to differentiate ECA FROM SINUS OF MORGAGNI (SOM)
ICA. • Eustachian tube passes through
Ans: ECA has many branch on neck SOM.
but ICA don’t have any branch on
neck. skullbase
SOM
ET
SC

PHARYNX MC

• It is a fibromuscular tube
TP
• From skull base to c6 vertebrae
• It has 3 muscles
KD
1. Superior constrictor muscle
CP
(SC)
C6
2. Middle constrictor muscle
TP +CP=IC
(MC)
3. Inferior constrictor muscle
(IC)
OESOPHAGUS
a. Oblique fibers –
thyropharyngeus (TP)
Pharynx has 3 part:
b. Circular fibers –
I. Nasopharynx
cricopharyngeus (CP)
• Behind the nose
IC = TP+CP
II. Oropharynx
• Behind the oral cavity

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 III. Laryngopharynx • Sensory supply of pyriform sinus
• Behind the larynx From – internal branch of
superior laryngeal nerve (internal
1. LARYNGOPHARYNX laryngeal nerve) Q
(HYPOPHARYNX)
• Has 3 part: Q : Most common site of
a. Pyriform sinus (PS) (right & left) hypopharyngeal malignancy ?
b. Post cricoid area (PCA) Ans: pyriform sinus
c. Posterior pharyngeal wall (PPW)
• Laryngeal crepitus: it is clicking
sensation felt when larynx is
moved over cervical vertebra. – it
is present in normal people.
• It is absent in post cricoid
carcinoma
• The absent laryngeal crepitus is
called: moure’s sign

2. NASOPHARYNX (NPX)

Larynx is pressing laryngopharynx • 2 important landmarks

1. Adenoid
2. ET opening

• Eustachian tube is start from

middle ear and end opening at
nasopharynx.
• Middle ear is always produce
mucus which drain in to ET tube

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 • Nasopharyngeal disease can lead
to middle ear disease for
example glue ear- which will lead
to -conductive hearing loss.
• If in any situation adenoid
hypertrophy and ET tube block
the it will lead to – mucus will
start collecting in to middle ear -
called glue ear.
ADENOID HYPERTROPHY
IN NASOPHARYNX 3 TOPIC: • It is a disease of school age
1. Adenoid children.
2. Angiofibroma Cause: recurrent infection – leads to
3. Nasopharyngeal carcinoma more then physiological
enlargement of adenoids.
1. ADENOID (NASOPHARYNGEAL C/F:
TONSIL) • school age child
• H/O mouth breathing Q
• Collection of lymphoid tissue in
nasopharynx.
• Adenoid has no capsule
• no crypts
• no definite blood supply
• it is irregular feel on palpation
which is called “bag of worms”
feel.
• It is present at birth.
• It increase in size up to 6 yaer of
age. • Adenoid face
• It start decrease in size at a. Open mouth
puberty. b. Pinched nose
• Disappear by 20 year of age. c. high palate
d. malocclusion of teeth
(teeth are not touching)
Rx: Sx – adenoidectomy
Method of Sx is called: curettage
Instrument: st. clair Thomson
adenoid curette

Normal adenoid tissue at 6 y/o

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 C/F: 12-15 year old boy with
Nasal mass + Perfuse epistaxis Q

Invastigation: biopsy is CI
1. CECT (contrast enhanced CT)
This shows hollman miller sign
• Position of pts during sx : rose or antral sign.
position ( neck extension ) – 2. Angiography
same position use for
tonsillectomy also. Rx: Sx

NASOPHARYNGEAL CARCINOMA
(NPC) QQ
More common in china.
Hidden cancer (occult primary)
Etiology: EB virus

Site of origin: fossa of

ROSENMULLER – it lies just above
• If to much neck extension will ET opening.
lead to ATLANTOAXIAL
SUBLUXATION (C1-C2) this is
called “Grisel syndrome) Q

ANGIOFIBROMA
• It is most common benign tumor
of nasopharynx.
• Site of origin: sphenopalatine
foramen. • The tumor star from fossa of
• Only seen is adolescent boys (12- ROSENMULLER and it will reach
14) year. to ET then unilateral ET will block
• It is highly vascular tumor. and – it will lead to unilateral glue
• It can extend in to nose, cheek, ear – unilateral conductive
orbit (proptosis) – frog face hearing loss. Q
deformity Q, brain.

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 • It’s a hidden cancer (occult
primary) – most common
presentation: secondary neck
node (metastatic cervical
lymphadenopathy) QQ

Oropharynx
Parts of oropharynx:
1. Soft palate
2. Uvula
3. Anterior & posterior tonsillar
pillars
4. Tonsil (palatine tonsil)
5. Base of tongue (posterior 1/3rd
• NPC involves cranial nerves – of tongue)
leads to TROTTER’S TRIED: 6. Lingual tonsil
1. Neuralgic pain in 7. Posterior pharyngeal wall
temporoparietal area due to 8. Vallecula Q – it is space
5th nerve involvement. between base of tongue &
2. Palatal palsy due to 10th nerve epiglottis
involvement.
3. Conductive hearing loss
(unilateral)

Rx: chemoradiation > radiotherapy

3. OROPHARYNX

• Up to the teeth is oral cavity

behind that is oropharynx.
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 BAD OF TONSIL • Tonsil has definite blood supply.
• Is made by superior constrictor • Most important source of blood
muscle. supply – tonsillar branch of facial
• In the bad of tonsil lies: artery.
1. Styloid process (long and sharp
bone). • Venous drainage of tonsil:
2. Glossopharyngeal nerve 9th nerve paratonsillar vein – it is main
• Long styloid process pressing 9th source of bleeding during
nerve – it will lead to throat pain tonsillectomy.
refer to ear – this is called eagle
syndrome (styalgia). HEMORRHAGE IN TONSILLECTOMY
• Has 3 type:
TONSIL 1. Primary – during Sx
2. Reactionary – post op.
It is within 24 hr of Sx
Cause: slippage of ligature.
It is an emergency
Rx: immediate re-exploration.Q
3. Secondary – post op.
After 5th day of Sx.
Cause: infection
Mild bleeding only
• Has a capsule Rx: IV antibiotics Q
• Has crypts – deepest crypt called
– crypta magna CAUSES OF WHITISH MEMBRANE
ON TONSIL

1. Most common cause – acute

membranous tonsilitis -mc
cause of this is strept.
Pyogenes.
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 2. Infectious mononucleosis – QUINSY
caused by – EB virus (PERITONSILLAR ABSCESS)QQ
3. Diphtheria – membrane • It is collection of pus between
extends beyond tonsil to tonsil and it’s bed.
palate VQ • It’s more common in adult
• Unilateral
• Examination: uvula & tonsil push
to other side. VQ

4. Candidiasis
5. Vincent angina
6. Malignancy of tonsil
7. Leukemia

WALDEYER'S RING
C/F:
1. Throat pain
2. Dysphagia (Difficulty
swallowing)
3. Trismus (difficulty in mouth
opening)
o It is due to spasm of medial
pterygoid muscle) Q
4. Hot potato (plummy voice) Q

• it is a ring of lymphoid tissue in Rx:

pharynx • per oral incision & drainage (give
it has: the cut and let the pus out) –
1. Adenoid after 6 weeks do tonsillectomy –
2. Tubal tonsil (around ET) this is called interval
3. Tonsil (palatine tonsil) tonsillectomy.
4. Lingual tonsil • Some surgeons do tonsillectomy
at the time of abscess drainage –
this is called abscess
tonsillectomy.
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 QUINCKE’S DISEASE LUDWIG'S ANGINA
• It is • It is infection of floor of mouth
idiopathic (submandibular space)
edema of • Floor of mouth is made by:
uvula. MYLOHYOID MUSCLE

Cause:
1. Dental infection
C/F:
After dental infection patient
RETROPHARYNGEAL SPACE (RPS)
develops:
• It’s divided in to 2 halfes by a a. Chin swelling
midline band. b. Trismus
• This 2 half are called: spaces of Bacteria: streptococci + anaerobes
GILETTE Q (mixed)
• This spaces have retropharyngeal Rx: external incision & drainage.
lymph nodes also called as:
lymph nodes of ROUVERIER. QUESTIONS:
• Infection of this lymph nodes will • Fordyce spot: it is ectopic
lead to acute retropharyngeal presence of sebaceous glands in
abscess. mucosa (normally this glands is
• It’s more common in children part of skin).
C/F:
1. Respiratory • Pre malignant lesions of oral
difficulty cavity
2. Dysphagia 1. Leukoplakia
3. Very sick child 2. Erythroplakia
4. x-ray neck will 3. Oral submucous fibrosis
show:
widening of • Most common
prevertebral site of oral
shadow. cavity cancer:
Rx: LATERAL
1. airway management BORDER OF
2. per oral incision & drainage TONGUE.
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 • Most common site of oral cavity • Larynx is made from 6 cartilages
cancer in india: BUCCAL MUCOSA o 3 are unpaired
(GINGIVA BUCCAL SULCUS). o 3 are paired

• Name of surgery done in oral

cavity cancer: COMMANDO’S
OPERATION.

• 3 unpaired cartilages
LARYNX

1. Thyroid
2. Cricoid
3. Epiglottis

• Thyroid & cricoid is palpable from

outside.

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 Thyroid cartilage • It’s attached to midpoint of
• It’s open book like cartilage thyroid cartilage.
• It’s 2 laminae • At the same midpoint:
• Angle between 2 laminae of 2 vocal cords are also attached.
thyroid cartilage called: thyroid • Epiglottis covers the vocal cords.
angle • Vocal cords (glottis)
• In male: 90o (more sharp)
• In femal:120o (flat)

• Prominence of thyroid cartilage

in male it’s called: ADAM’S APPLE

Cricoid cartilage
• It’s a ring like cartilage Q
• This ring is fits over tracheal ring

• 3 paired cartilages
1. Arytenoids
2. Corniculate
3. Cuneiform

Epiglottis cartilage
• Leaf like cartilage.
• Elastic cartilage.
• It does not ossify with age.

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 • Arytenoid is pebble like.
corniculate & cuneiform are rice
grain like cartilages.
• corniculate & cuneiform are
rudimentary (no practical or
functional value).

Mucosa of larynx
• Arytenoid cartilages • Larynx is lined by ciliated
• They make posterior 1/3rd of vocal columnar (pink)except vocal
cord. cord.

• Vocal cord is lined by stratified

squamous epithelium (white).
• Vocal cord epithelium in some
smokers starts shedding faster –
this will lead to disease called:
2 membranes on outer surface of KERATOSIS LARYNX.
larynx
1. Thyrohyoid membrane
• Pierced by internal branch of
superior laryngeal nerve (SLN)
2. Cricothyroid membrane
• It’s site of cricothyroidotomy – it
is done in acute airway o This is seen in smokers.
obstruction. o Premalignant disease.
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 C/F: hoarse voice DIVISION OF LARYNX
Rx: stripping of vocal cord mucosa 3 division
(decortication) + quit smoking a. Supraglottis
b. Glottis
c. Sub glottis

SUPRAGLOTTIS
Has 5 parts
1. Epiglottis
2. Aryepiglottic folds (AEF) (2)
3. False vocal cord (FVC)
(ventricular bands) – useless
• If a patient producing sound
using false vocal cord it’s a
NORMAL VOICE IN ADULTS
disease called: DYSPHONIA
• Males: low pitch voice (dull)
PLICA VENTRICULARIS Q
• Female: high pitch voice (sharp)

Diseases:

PUBERPHONIA
• Adult male with high pitch voice
(feminine).
Rx: speech therapy – gutzmann’s
manoeuvre (push thyroid cartilage 4. Ventricle – space between false
back and speak for 3-6 month) vocal cord & true vocal cord.
• If it’s failed – Sx ( type 3 5. Saccule – mucosal outpouching
thyroplasty) it is surgical from ventricle
shortening (loosing of vocal It’s reach in mucus gland – also
cord) called: OIL CAN OF LARYNX Q

ANDROPHONIA
• Low pitch voice in adult female
Rx: Sx ( type 4 thyroplasty) it is
surgical tightening or lengthening
of vocal cord)

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 LARYNGOCELE GLOTTIS (TRUE VOCAL CORD)
• A disease
• It is abnormally dilated saccule Q
• It is seen in people who play
wind based instruments.
• Laryngocele pierces thyrohyoid
membrane to appear as air filled
neck swelling.

Length
• Male: 18-23 mm
• Female: 16-17 mm

• On pressing, air leak sound is

produced this called: BRYCE’S
SIGN.
Investigation: x-ray neck with
Valsalva.

• Interarytenoid muscle is a
unpaired midline muscle. Q
Rx: surgical excision • TA & IA are adductor muscle
SUB GLOTTIS (they close the vocal cord).
• It is empty space inside cricoid o If they are weak the disease is
ring called: PHONAESTHENIA – it will
lead to gap between vocal cord
during adduction. – it called: KEY
Subglottis HOLE GLOTTIS.

Cricoid cartilage

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 VOCAL CORD DISORDERS Rx: Sx (micro laryngeal surgery)
(MLS)
1. VOCAL NODULES o it is surgery of vocal cord under
microscope (size of vocal cord is
very small (in mm).

Q: focal length of ENT microscope?

Ans: Ear – 200 mm
Nose – 300 mm
Larynx – 400 mm

• Also called as:

singer’s nodule
Screamer’s nodule
Teacher’s nodule 3. INTUBATION GRANULOMA
Cause: vocal abuse
Bilateral
Site: junction of anterior 1/3rd &
posterior 2/3rd of vocal cord.
C/F: hoarse voice
Rx: voice rest (speech therapy) QQ

2. VOCAL POLYP

Cause: faulty intubation

o e.g: during general anesthesia
bilateral
site: junction of anterior 2/3rd &
posterior 1/3rd of vocal cord.
Rx: Sx (MLS)

Cause: vocal abuse

Unilateral
Site: junction of anterior 1/3rd &
posterior 2/3rd of vocal cord.
C/F: hoarse voice

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 4. JUVENILE PAPILLOMA OF 5. REINKE’S OEDEMA
LARYNX REINKE’S SPACE: it is sub epithelial
• It’s a disease of young children loose connective tissue layer in
(4-6 year). vocal cord.
• It is cause by HPV 6 & 11. • Also called “smoker polyps of
larynx”

Examination:
• Edema of this space called
• Viral warts in larynx – they can
reinke’s edema.
spread to trachea and bronchi.

C/F: 4-6year old child with chronic

hoarseness of voice +/- respiratory
difficulty.
Rx: Sx (MLS with co2 laser) – co2
laser is most commonly used laser
in larynx surgery.
o It is invisible laser & wave length
is 10,600 nm
• Bilateral diffuse selling of vocal
Type I: medialization of VC. – cord.
Done in adductor palsy. Causes:
Type II: lateralization of VC. – 1. Smoking (M/C)
C/F: hoarse voice
done in abductor palsy.
Rx: stripping of vocal cord mucosa
Type III: shortening or relaxation of
VC. – done in puberphonia.
Type IV: lenghthening / tightening
of VC. – done in androphonia.

Vocal cords do not have lymphatics

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 INDIRECT LARYNGOSCOPY (I/L) STRIDOR (NOISY BREATHING)
• It’s an OPD method of Causes:
examination of larynx. • Airway obstruction
• It is done with the help of
indirect laryngoscopy mirror. TYPES OF STIDOR LEVEL OF
OBSTRUCTION
Inspiratory stridor Pharynx &
supraglottis
Biphasic stridor Glottis, subglottis,
cervical trachea
• It is a straight mirror.
• The surface of mirror warm Expiratory stridor Thoracic trachea,
before using. bronchi

Q: structure not seen in ILR?

1. Anterior commissure of vocal
cord VOICE DISORDERS
2. Laryngeal (under surface)
surface of epiglottis 1. MOGIOPHONIA
3. Under surface of vocal cord • It’s a speech problem in public
4. Upper part of subglottis appearance only.
5. Ventricle
6. Saccule 2. RHINOLALIA APERTA
7. Apex of pyriform sinus (HYPERNASALITY OF VOICE)
DIFFERENCES BETWEEN PEDIATRIC
Causes:
& ADULT LARYNX
a. Cleft palate
b. Submucous cleft palate
PEDIATRIC
c. Palatal palsy
• Position: c3-c6 (high) d. Palatal weakness
• Narrowest part: subglottis QQ (velopharyngeal insufficiency)
e. Palatal perforation
ADULT f. Bifid uvula
• Position: c3-c6 (low)
• Narrowest part: glottis QQ

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 3. RHINOLALIA CLAUSE 4. its decreases on prone position.
(HYPONASALITY OF VOICE) • Cry sound of baby is normal
Causes: because vocal cord is normal. QQ
1. Nasal poly
2. Sinusitis Examination: omega shaped
3. Adenoid hypertrophy epiglottis.
4. Angiofibroma

4. FUNCTIONAL APHONIA
(HYSTERICAL APHONIA) QQ
• Aphonia: loss of voice
• Hysteria: acting
• Patient is pretending the Rx: conservative treatment (no
symptoms of loss of voice treatment required. reassurance to
(actually voice is normal). parents that it’s self limiting
• This disease is more common in condition.
young female (20year old).
GLOTTIC WEB
How to prove diagnosis?
Ans: cough sound is normal & this
proves diagnosis. (that the
everything is fine.)
Rx: psychotherapy

Q: 20year old female sudden loss of

voice: FUNCTIONAL APHONIA

LARYNGOMALACIAQQQ
• It’s a most common congenital
disease of larynx.
• Malacia means weakness. • It’s congenital disease
• It is weakness of supraglottis. • It is the most common site of
C/F: congenital laryngeal web.
1. stridor (inspiratory stridor) • Cry sound of baby is hoarse.
2. in 1st week after birth
3. its increases on crying Rx: co2 laser excision
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 PEDIATRIC LARYNGEAL INFECTION 2. ACUTE
• Because edema of larynx – they LARYNGOTRACHEOBRONCHITIS
lead to airway obstruction (an (ALTB) (CROOUP)
emergency) • It’s infection of complete airway
• 2 diseases but subglottis is most affected
part.
1. ACUTE APIGLOTTITIS Causes: parainfluenza virus
• Infection of supraglottis • Age: 3 month – 3yaer
Cause: C/F:
• Streptococcus pneumoniae > 1. Biphasic stridor
Haemophilus influenzae B 2. Respiratory distress
• Age: 2-7 year 3. Low fever (viral infection give
C/F: low fever)
1. inspiratory stridor 4. Barking cough
2. respiratory distress
3. high fever x-ray neck shows: steeple sign – it is
4. drooling of saliva narrowing of subglottis.
5. hot potato (plumy voice)
6. child sits bending forwards
(tripod sign)

• x-ray neck will show thumb sign

(swollen epiglottis)

Rx:
1. Airway management
2. Bronchodilator
3. Steroids
Rx: 4. Antibiotics (all viral infection
1. 1st treatment is secure airway cause secondary bacterial
by intubation. infection)
2. Antibiotics
QQ
3. Steroids TB larynx has 2 signs:
1. Turban epiglottis
• Do not repeated laryngoscopy it 2. Mouse nibbled appearance of
will increase edema. vocal cord
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 CANCER LARYNX Rx:
• It is more common in male in 40- T1 & T2: radiotherapy
60year of age. T3 & T4: total laryngectomy
Risk factors: followed by radiotherapy
1. Smoking
2. Alcohol • Now days TOC of T1 Glottic
3 types: cancer – laser Sx > radiotherapy

A. GLOTTIC CANCER After total laryngectomy patient

• It is a cancer of true vocal cord has permanent tracheostomy
• It is a most common type
laryngeal cancer.

C/F: hoarse voice Q

• There is no neck node metastasis

(cause vocal cord do not have
lymphatics.) – good prognosis
Vocal rehabilitation after
laryngectomy: 3 methods
B. SUPRAGLOTTIC CANCER
1. Esophageal voice
• Most common site is epiglottis 2. Electrolarynx (artificial larynx)
C/F:
1. Throat pain
2. Feeling of lump in throat
3. Dysphagia
4. Hot potato voice (plummy
voice)

C. SUBGLOTTIC CANCER
• very rare • It is hand held mechanical
vibrator.
C/F: Stridor • It is external device.

TUMOR STAGING
T1 – only 1 structure involved
T2 – More than 1 structure involved
T3 – vocal cord is fixed (immobile)QQ
T4 – Invasion of thyroid cartilage
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 3. TEP device Sx: Radical neck dissection (RND)
(tracheoesophageal puncture • This surgery is done for
device) metastatic cervical
lymphadenopathy (secondary
neck nodes).
• In this surgery structure removed
are:
1. Level 1 to level 5 lymph nodes
• Internal valve like device 2. sternocleidomastoid muscle
e.g: blom singer prosthesis 3. internal jugular vein
4. accessory spinal nerve (11th)
5. omohyoid muscle
LEVELS OF NECK NODES 6. submandibular gland
Level 1 – level 7 7. tail of parotid gland

1. 1a. submental neck nodes Q: A PERSON WHILE HAVING

1b. submandibular neck nodes LUNCH DEVELOPS SUDDEN
2. Upper deep cervical lymph nodes CHOKING & APHONIA.
3. Middle deep cervical lymph Þ It is due to food particle stuck as
nodes laryngeal foreign body.
4. Lower deep cervical lymph nodes Þ Immediate treatment of this
5. Posterior tringle (supraclavicular patient is:
lymph nodes Q HEIMLICH’S MANEOEVURE –
6. Pretracheal (anterior (press epigastrium backward &
compartment upward)
7. Mediastinal lymph nodes

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 TRACHEOSTOMY (TR’)

• Cuff can cause tracheomalacia –

best cuff will be high volume &
• Most common site of TR’ is: 2nd & Low pressure cuff.
3rd tracheal rings and this is called • TR’ decreases dead space by 50%
mid TR’. • TR’ can lead to:
1. Hemorrhage (M/C)
2. Air beneath the skin (surgical
emphysema) Q
3. Apnea – it’s due to co2
washout.
Q: IF TR’ TUBE GETS BLOCKED QQ
Ans: It’s a Life Threatening situation.
Immediate treatment: remove TR’
• High TR’: it is done at 1st & 2nd tube immediately.
tracheal ring – this is done in • TR’ is temporary procedure
cancer larynx. except after total laryngectomy.
• Most commonly used TR’ tube:
PORTEX PVC CUFFED TUBE.
FUNCTION OF LARYNX Q
1. Primary function
• Protection of lower airway
(lungs).
2. Phonation (sound production)
• Sound is produces from true
vocal cord in adducted position.
• In expiration
• Cuff help to decrease the • we speak with close vocal cord
aspiration. & breath with open vocal cord.

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 MUSCLES OF LARYNX VOCAL CORD PARALYSIS
a. Abductor (1) QQ • Left : right (4:1)
1. Posterior cricoarytenoid • This is because of left RLN
muscle.
b. Adductors (4)
1. Thyroarytenoid
2. Interarytenoid
3. Lateral cricoarytenoid
4. Cricothyroid
c. Tensors (2)
1. Cricothyroid (main tensor)
2. Vocalis muscle
Function: quality of voice

Þ All these muscles lie inside larynx

except CRICOTHYROID MUSCLEQ In neck relation
– all these muscles are supplied
by RECURRENT LARYNGEAL
NERVE (RLN) except
CRICOTHYROID which is supplied
by EXTERNAL BRANCH OF
SUPERIOR LARYNGEAL NERVE.

Whole larynx supplied by superior

and recurrent laryngeal nerve they
both are part of VAGUS NERVE.

ORTNER SYNDROME: It is left

SENSORY SUPPLY OF LARYNX Atriomegaly.
• Above vocal cord (supraglottis): • Cause left RLN palsy – which is
internal branch of SLN lead to left vocal cord palsy.
• Below vocal cord (subglottis):
RLN MOST COMMON CAUSE OF
• Vocal cord (glottis): both 1. Unilateral vocal cord palsy (vocal
cord palsy): idiopathic >
carcinoma bronchus (malignancy)
2. Bilateral vocal cord palsy:
thyroid surgery
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 BILATERAL ABDUCTOR PALSY BILATERAL ADDUCTOR PALSY

• Abduction is absent • Adduction is absent

• Both vocal cords are in closed • Vocal cords are in open position.
position. (permanently) Cause: bilateral vagal palsy
PALSY = MOVEMENT (SLN+RLN palsy) No muscle left
Causes: working. – vocal cord come to lie in
• Bilateral RLN injury in thyroid cadaveric (open) position.
surgery. (permanently)
• Only cricothyroid is working & C/F:
it’s adductor muscle. – both 1. Aphonia
vocal cords will come in midline 2. Aspiration – pneumonia
position (close position) Definitive Tx: type 1 thyroplasty
[permanently]. (medialization of vocal cord)
C/F: respiratory distress + stridor Other Tx: TEFLON INJ. In to vocal
but normal voice. QQ cord.

• It is an emergency – immediate Q: if SLN is injured in thyroid Sx –

treatment is TRACHESTOMY. cricothyroid function is loss & it’s a
main tensor.
• Definitive treatment: type 2 Examination: BOWED DOWN
thyroplasty (lateralization of VOCAL CORD
vocal cord). C/F: poor quality of voice.

Revision:
RLN RLN gone : B/L abductor palsy
RLN+SLN RLN+SLN gone: B/L
adductor palsy
SLN SLN gone: bowed down vocal
Other treatment: CO2 laser cord
cordectomy. (remove 1 side of vocal
cord).
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 EAR

EMBRYOLOGY
1. PINNA

Þ ANOTIA: absence of pinna

Þ MICROTIA: small pinna

• Develops from 1st & second

branchial arches.
• Tragus is develop from 1st arch.
• Reast of pinna develop from 2nd
arch.
Incisura terminalis is junction of 1st • Normal pinna has 2 curvature.
& 2nd arch. 1. Helix C
• It has no cartilage. 2. Antihelix c
• If this union is incomplete it will
lead to congenital disease called:
• If antihelix is absent it is called:
PREAURICULAR SINUS.
BAT EAR

• Pinna develop completed by 20th

week of pregnancy. • Plastic reconstruction pinna is
• 1st of all 6 elevation( HILLOCKS done at 6 year of age. Because
OF HIS) form and then it will pinna gain max size by this time.
fuse to form pinna.
39

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 DARWIN’S TUBERCLE
• It is a
anatomical
variation it’s
not a disease.
• It is conical
elevation on
helix.
TYMPANIC
MEMBRANE (TM)
Develops from 3 layers:
1. Ectoderm
2. Endoderm
• Footplate is attached at oval
3. mesoderm
window of cochlea.
COCHLEA
• Stapes is act like piston.
• develop from neuroectoderm.
• If stapes is fixed –
• Develop by 20th week of
it will lead to
pregnancy.
disease called:
MASTOID TIP
OTOSCLEROSIS
• Is absent at birth.
• Develop at 2 years of age. Tympanic membrane & ossicles
work as 1 unit.
OSSICLES 1. Conduct sound energy to
• malleus & incus develop from 1st inner ear.
arch. 2. They amplify sound energy.
• stapes develop from 2nd arch • Middle ear transformer
(reichert’s cartilage). ratio is 18:1.
• Size: malleus >incus >stapes • Main function of middle ear
is impedance matching
mechanism. Q

40

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 PINNA EXTERNAL AUDITORY CANAL (EAC)
• Pinna is made of yellow elastic • 24mm in length.
cartilage covered by skin. o Outer 8mm is cartilaginous.
• Main nerve supply of pinna: o Inner 16mm is bony.
GREATER AURICULAR NERVE. § Bony EAC is made by
• The same nerve supply lobule of tympanic part of temporal
pinna also. bone.

PINNA HEMATOMA

Mastoid is part of ear.

EAC skin in outer part has
1. hair follicles
2. ceruminous (wax) gland
• Cause: trauma
Tx: aspiration Q IF WAX BLOCK THE EAC.
• Otherwise it will lead to necrosis
of cartilage. – and that will lead
to post traumatic deformity of
pinna – this is called: BOXER EAR
or COLIFLOWER EAR.

KELOID PINNA

Rx: syringing
• Direction of water is syringing is:
POSTEROSUPERIOR.QQ
• Do not used cold water it can
lead to vertigo.

• It follows trauma or piercing.

41

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 INSECT IN EAC DISEASES OF EAC
If live: put 1. DIFFUSE OTITIS EXTERNA
oil in EAC
• It is infection of complete skin
to kill it
of EAC also called:
and
(SWIMMER EAR)
remove it.
(TROPICAL EAR)
(SINGAPORE EAR)
DIRECTION OF EAC (TELEPHONE EAR)
• It is inward downward &
forwards.QQ 2. LOCALIZED OTITIS EXTERNA
(FRUNCULOSIS)

• During ear examination with

otoscopy the pinna is hold
upward outward & backward.

Fissure of Santorini Q
• It is staph. Infection of hair
It is a natural defect in cartilaginous
follicle.
part of EAC.
• It’s seen in outer part of EAC.
Examination: tragal tenderness
Nerve supply of EAC QQ
(tragal sign)
3 nerves:
1. Auriculotemporal nerve – it’s
Rx: IG packing (icthammamol
supply anterior wall and roof of
glycerine)
EAC.
2. Auricular branch of vagus
(arnold’s or aldermann’s nerve) QQ –
posterior wall and floor.
• Stimulation of this nerve
cause cough.
3. Sensory division of facial nerve –
it’s supply posterosuperior part
of EAC.
42

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 3. MALIGNANT OTITIS EXTERNA QQ 5. EXOXTEOSIS (SURFER’S EAR)
• Life threatening infection (not a • It is hyperplasia of
cancer.) bony EAC (extra
• It’s a infection of underlying bone formation)
bone of EAC. • It is mostly seen in
water sports
• It is also call as skull base person.
osteomyelitis – a life threatening
disease.
• This disease is seen in old TYMPANIC MEMBRANE (TM)
diabatic pts (60-70 yaer) (MARING)

Cause: pseudomonas
C/F:
• old diabatic pts
• Complaining of sever ear ache
(pain) with granulations in EAC.
• Facial nerve is most commonly
involved nerve (+/-) 9th, 10th, 11th,
Features: pearly grey in color
12th – because its skull base
• Oval shape
infection.
Rx: 3rd gen cephalosporins QQ • 9-10mm diameter
• Area: 90mm2
4. OTOMYCOSIS • Peripheral part is more mobile
than central part.
• It is fungi infection of EAC.
• It lies at angle of 55o horizontal.
• Most common fungus is:
• It shows movement
ASPERGILLUS NIGER.
SEIGELISATION – putting air
pressure on TM using
SEIGEL SPECULUM.

Examination: wet newspaper

appearance.

43

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 TM shows 4 landmarks TRAUMATIC PERFORATION OF TM
• TM is semitransparent.
1. Handle of malleus
2. Lateral process of malleus
3. Umbo (most reliable)
4. Cone of light

e.g:
• earbuds
• ear pins
Rx: no treatment (conservative)QQ
• Cone of light: (Keep ear dry)
o right ear: 5 o’clock position.
o left ear: 7 o’clock position. EUSTACHIAN TUBE (ET)
• ET connect middle ear to
TM has 2 parts: nasopharynx.
1. pars tensa (PT) • ET opens 1.25cm behind posterior
• It is lower major part of TM. end of inferior turbinate in to
• It is up to level of lateral process nasopharynx.
of malleus. • ET is nearly horizontal at birth.
Þ It is made of 3 layers: • In adult, it has 45o angle with
• Outer: skin horizontal.
• Middle: mucosa
• Inner: fibrous layer

2. Pars flaccida (PF)

• It is also called as sharpnell’s
membrane.
• Minor upper part of TM.
• Above the level of lateral process
of malleus.
Þ It has only 2 layer • Length of ET tube: 36mm
• Middle fibrous layer is almost • Outer bony part is 12mm
absent – it is weak • Inner cartilaginous part: 24mm
44

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 Q: ET opens during swallowing. • If retraction pocket allows to
with the action of which muscle? progress it will rupture &
Ans: tensor palati muscle (tensor through that perforation skin will
veli palati muscle) grow in to middle ear. – skin in
middle ear is called:
• Main function of ET: middle ear CHOLESTEATOMA. (pearly white
ventilation. in color).

• If ET is blocked – negative
pressure (vaccum) in middle ear
– it will lead to RETRACTED TM.

GLUE EAR (SEROUS OTITIS

MEDIA)QQQ
• Also called as secretory otitis
media.
• It is collection of thick STERILE
• (dull in appearance) – too much
glue like fluid in middle ear.
retraction will form RETRACTION
POCKET.

Causes:
Adenoid Nasopharyngeal
hypertrophy carcinoma
Seen I school Seen in adult.
• Most common site of retraction
age children.
pocket is: pars flaccida.
This cause B/L This cause U/L
• Retraction pocket is lined by skin
ET blockage. ET blockage.
it is filled by KERATIN.
This cause B/L This cause U/L
glue ear. glue ear.
The most Rare cause
common cause
45

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 C/F: DEPTH OF MIDDLE EAR
1. school Age child • Epitymanum: 6mm
2. heaviness in ear • Mesotympanum: 2mm
3. Conductive hearing loss (CHL) • Hypotympanum: 4mm
4. Poor school performance
Its not painfull • Sensory supply of middle ear is
Rx: Sx: myringotomy in by tympanic branch of 9th nerve
anteroinferior quadrant + grommet (jacobson’s nerve).
insertion (middle ear ventilation • This nerve is cause of REFERRED
tube) +/- adenoidectomy. OTALGIA in tonsillectomy &
tonsillitis. QQ

6 WALLS OF MIDDLE EAR

Glue needs grommet

MIDDLE EAR (TYMPANUM)

3 parts:
1. Mesotympanum
• It is covered by TM
1. Roof: above the roof lies dura of
2. Epitymanum
temporal lobe of brain.
• It’s upper most part of middle
ear.
2. Floor: below the floor lies jugular
• It is covered by bone called:
bulb (JB).
SCUTUM
3. Hypotympanum
• Lowest part of middle ear.
• It is covered by bone.

46

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 3. Anterior wall
• Has 2 opening
a. Lower is for ET
b. Upper is for TT (tensor
tympani muscle) – it attach to
malleus & it’s supplied by
mandibular division of
trigeminal nerve.

4. Posterior wall
Medial wall also has 2 windows
• It has a projection
1. Oval window (OW)
called:PYRAMIDQ
• Oval window is covered by
• From pyramid stapedius muscle
footplate stapes.
come out & its supplied by facial
2. Round window (RW)
nerveQ
• Round window is covered by
round window membrane
(secondary tympanic membrane)
QQ

5. Lateral wall – TM

6. Medial wall
• Behind the medial wall inner lies
inner ear.
• This wall has 2 projections of
inner ear.

1. Promontory Q
• It’s projection of cochlea.
2. Lateral semicircular canal bluge
(LSC)Q
47

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 MIDDLE EAR CLEFT • Examination: red tympanic
• It is a collection of all hollow membrane with dilated
spaces (air filled spaces) of capillaries.
temporal bone. • (normal color – purly grey)
• It will show cart wheel sign.

Tx:
MCQ: ASOM pts with red bulging
TM.
Ans: maryngotomy (postero inferior
quaderant).
Antrum Otherwise there will be perforation
• It is most constant and largest TM.
mastoid air cell. • If no treatment taken for 3
• It’s connected middle ear via months – it will lead to
aditus. permanent perforation. This
Middle ear cleft has 5 parts: disease is called: SAFE CSOM
1. ET
2. Middle ear
3. Aditus
4. Antrum
5. Rest of air cells

INFECTION OF MIDDLE EAR CLEFT

1. Acute suppurative otitis media 2. SAFE CSOM

(AOSM) C= chronic
• It is infection of middle ear It’s presence of permanent central
mucosa. perforation in pars tensa (lower
• Most common organism is part) of TM.
strept. Pneumoniae.
• Infection goes to nasopharynx to
middle ear via ET.

C/F:
• ear ache

48

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 C/F: 3. ACUTE MASTOIDITIS
1. Ear discharge It is infection mastoid air cells.
• It id not folu smelling. It is a complication of ASOM or
• Not blood stained. CSOM.
2. Conductive hearing loss.
• There can be ossicle erosion also
in this disease.
o Disease can eat away ossicle
also.
o Most common ossicle to
erotted is incus.QQ
o Because incus has no muscle
attached to it – incus has least
blood supply.QQ
C/F: pain behind pinna.
Examination: mastoid surface skin is
Tx: Sx:
red smooth and shiny.
1. maryngoplasty – it is repair of
• This is called as
TM perforation using a graft.
ironing of
• Most commonly used graft is
mastoid
TEMOPRALIS FASCIA GRAFT
surface. (it is a
1st sign of
mastoiditis)

• Patient has profuse (too much)

ear discharge.

• After cleaning pus

2. Type 3 typanoplasty (columella fills immediately
tympanoplasty)
again this called:
• This is done in ossicle erosion due RESERVOIR SIGN.
to CSOM.
• There is erosion of incus and • Pus column keep
malleus also (m- i- s+) – only moving this is
stapes is present. called: LIGHT HOUSE SIGN.
• In this case TM graft Is placed in (when pus movie otoscope’s
contact with stapes. light shadow is also move.
• This surgery is also called as
maringostapediopexy.
49

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 Investigation: 4. PETROSITIS (GRADINEGO
x-ray mastoid – schuller’s view SYNDROME) QQQ
towne’s view • It is infection of petrous apex air
cell.
• Complication os ASOM/CSOM.
It has 3 features: QQQ
1. Ear discharge
2. Retroorbital pain due to 5th nerve
involvement.
3. Diplopia dur to 6th nerve
involvement.
Rx: cortical mastoidectomy
(schwarts operation) • CT scan will show abscess of
• The 1st step of mastoid surgery – petrous apex.
finding antrum QQ
Q: How to find it? 5. ABSCESS FORMATION
Ans: Surgical landmark for antrum is • Due to mastoiditis
MACEVEN’S TRINGLE or a. Postauricular (mastoid
SUPRAMEATAL TRINGLE QQ abscess)
b. Along sternolidomastoid
muscle (bezoid abscess) QQ
c. Along digastric muscle (citelli’s
abscess)

Korner septum
• It is seen in some people
• It is anatomical variation of
mastoid
• It is remnant of petrosquamous
suture. QQ
• It lead to difficulty in finding
antrum during mastoid surgery.
Light house sign is seen in: QQ
1. Mastoiditis
2. In some cases of ASOM in
stage of suppuration.
50

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 6. UNSAFE CSOM (ATTICO ANTRAL • Bone erosion means temporal
CSOM) bone erosion.
• It is a presence of cholesteatoma
(skin in middle ear). C/F:
• It is pearly white in appearance. 1. Ear discharge scanty (less)
o Foul smelling
o Blood stained
2. Conductive hearing loss

Rx: Sx: MRM (modified radical

mastoidectomy) (mastoid
• Most common site of
exploration).
cholesteatoma: PRUSSAK’S
SPACE in epitympanum (attics)
• Main aim of MRM is to make the
3 origins (types) cholesteatoma
ear safe.
A. Congenital cholesteatoma
• Pearly white mass behind intact
COMPLICATION OF UNSAFE CSOM
TM.
B. Primary aquired • Most common complication is
cholesteatoma MASTOIDITIS.
C. Secondary aquired • Most common intracranial
cholesteatoma complication is MENINGITIS
• Most common site of otogenic
Primary aquired Secondary brain abscess is TEMPORAL LOBE
aquired ABSCESS.
Due to Due to marginal • Treatment in this case is
retraction perforation. NEUROSURGERY QQ
pocket. (M/C)
LABYRINTHINE FISTULA
UNSAFE: this is due to bone erosion • Inner ear erosion
caused by cholesteatoma. • It is complication of unsafe
CSOM.
Mechanism of bone erosion: • It is erosion of lateral semi
It causes: circular canal bulge.
1. Inflammatory osteitis
2. It secrets bone destruction C/F: vertigo
enzymes lead to – Examination: positive fistula sign
Bone erosion – lead to complication It is seen with seigelisation (put air
– UNSAFE. in ear)
51

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 Q: false positive fistula sign INNER EAR (LABINTH)
Ans: hennebert sign – seen in
congenital syphilis.

Q: false negative fistula sign

Causes:
1. Fistula in dead labyrinth
2. Fistula covered by
cholesteatoma

SIGMOID SINUS THROMBOSIS It has 2 parts:

(LATERAL SINUS THROMBOSIS) 1. Membranous labyrinth
• It is intracranial complication of • Actual inner ear (real inner ear)
unsafe CSOM. 2. Bony labyrinth
• It is bony cover.

C/F:
1. Headache
2. Spiky fever (picket fence
fever) QQ
3. Pitting edema on mastoid
(griessenger sign) QQQ
4. No Change in CSF pressure on
pressing IJV.
(in normal people if pressing
IJV in few minute rise in CSF
pressure.)
This can be seen in 2 ways:
a. Thru lumber puncture
(tobey ayer test)
b. Thru fundus examination
(chrwe beck test).
• CT brain will show delta sign. Q
Rx: MRM + clear the thrombus

52

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 COCHLEA: 1. COCHLEA
• Organ of corti for hearing.
UTRICLE &SACULE:
• Macula for liner balance
SEMI. CANALS:
• Crista for angular balance
Þ Highlighted part is sensory organ

Fluids of inner ear

1. Endolymph
2. Perilymph

1. Endolymph • 2 ¾ turn
• Inner ear is filled with • Apex for low frequency
endolymph. • Base for high frequency
• Produce by stria vascularis of • Apex is also called:
cochlea.Q HELICOTREMA
• It is absorbed by endolymphatic • Saccule is connected to cochlea
sac. Q thru DUCTUS REUENIENS Q
• If this sac does not absorb • Function of cochlea: hearing.
properly it will lead to disease • Sensory end organ is organ of
called: MENIERE’S DISEASE. – corti.
gradual damage of cochlea due • Organ of corti has 2 cells:
to high endolymphatic pressure. • Outer hair cells & Inner hair cells.
• Meniere’s is glaucoma of ear.
• High K+ low Na+ Cut section of cochle

2. Perilymph
Inner ear is surrounded by
perilymph.
High Na+ low K+
Perilymph = CSF
• Perilymph in the inner ear & CSF
is in the subarachnoid space. the
channel between this 2things
called: AQUED UCT OF COCHLEAQ
o This is the cause of post
meningitis deafness. Q
53

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 Total 3 parts BENIGN PAROXYSMAL POSITIONAL
1. Scala vestibuli VERTIGO QQQ
2. Scala media Causes: displaced otoconia
3. Scala tympani Most commonly involved semi
• Membrane between scala circular canal (posterior semi
vestibuli & scala media is called: circular canal).
REISSNER’S MEMBRANE QQ
• Membrane between scala media C/F: vertigo for few second on
& scala tympani called: TECTORIL changing head position.
MEMBRANE. QQ
• Above scala typani there is is a
structure called: ORGAN OF
CORTI.
• Organ of corti is covered by
TECTORIL MEMBRANE.

2. UTRICLE & SACCULE

Diagnosis: Dix hallpike’s maneuver
(VESTIBULE) (OTOLITHIC
ORGAN)
• Function: liner balance
• Sensory end organ: macula
• Macula is surrounded by
gelatinous layer which has
CACO3 crystals called: Rx: epley’s maneuver (particle
OTOCONIA (OTOLITH)QQ reposition maneuver

If otoconia turn free – reach semi

circular canal it will lead to disease
called: BPPV QQQ
Sit-lay-turn head- turn whole body -sit
54

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 3. SEMICIRCULAE CANAL (SCC) Steps:
• There are 3 SCC. 1. Lying supine position with
1. Lateral (horizontal) head elevated by 30o
semicircular canal 2. EAC is irrigated with
2. Posterior semicircular canal warm(44oC) and cold water
3. Superior semicircular canal (30oC) – this will produce
nystagmus (seen in normal
people).
o With cold water ice move
toward oposite side.
o With warm water same
side

Function: angular balance 8TH NERVE (VESTIBULOCOCHLEAR

• Sensory end organ is crista NERVE)
• Every canal has 1 dilated end • This nerve has 3 division:
called: AMPULLA. 1. Cochlear division
• Ampulla contain crista. 2. Superior vestibular division
• Crista is covered by gelatinous (SV)
layer which is called: cupula 3. Inferior vestibular division (IV)
• Ampulla is house of crista
• Cupula is cover of crista 7th & 8th nerve enter ear through
internal auditory canal (IAC)
(internal auditory meatus)

BITHERMAL CALORIC TEST

(CALORIC TEST)
• It is a test of lateral SCC. QQ

Internal auditory canal (IAC)

55

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 Cut section of IAC E: Eight nerve
C: cochlear nucleus
O: olivary complex (superior)
L: lateral lemniscus
I: inferior colliculus
M: medial geniculate body
A: auditory cortex
[ECOLI MA]

Auditory cortex
• Lies in the superior temporal
gyrus of brain.
AUDITORY PATHWAY
• 7up: facial
• Cock: cochlea
• Bill’s bar (BB) QQ
• It is a vertical bony septum in
upper part of IAC.

EAR IS A JURNEY FROM EXTERNAL AUDITORY CANAL (EAC) TO INTERNAL

AUDITORY CANAL (IAC) VIA TEMPORAL BONE.

56

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 AUDIOLOGY We can hear sound in 2 ways:
1. Air conduction (AC)
Ear is train with 4 compartments. • It is natural way of hearing
• External ear – middle ear – inner
ear – 8th nerve. 2. Bone conduction (BC)
• It’s a test.
• Directly reaches cochlea.
• BC is a test of cochlea.
• BC is poor in sensorineural
hearing loss.QQ

Hearing loss 2 types:

a. CHL = conductive hearing loss
TEST OF AUDIOLOGY
(if problem in external ear &
middle ear)
b. SNHL = sensorineural hearing 1. TUNING FORK TEST
loss • Most commonly used tuning fork
(if problem in inner ear & 8th is 512Hz.
nerve).
E.g:
CHL SNHL
Glue ear Meniere’s
disease
CSOM Acoustic
neuroma (8th
We do 3 tests:
nerve tumor)
1. Rinne’s test QQ
otosclerosis Drug induce
2. Weber test
hearing loss
3. Absolute bone conduction
(ototoxicity)
test (ABC test)
Age induced
hearing loss
(presbyacusis)

57

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 1. Rinne’s test • We plot of these recordings in a
• Is a comparison of AC & BC. graf called: AUDIOGRAM.

• In normal people AC > BC this is

called: RINNE POSITIVE.
• In CHL BC > AC this is called:
RINNR NEGATIVE. QQ

2. PURE TONE AUDIOMETRY (PTA)

We use symbols for AC & BC.
(AUDIOGRAM)
• For AC:

• For BC: < > [ ]

• “O” is used for right AC.

• It is a subjective test of hearing.

• We check hearing level of AC &
BC for both ear at different
frequency. (250, 500, 1000, 2000,
4000, 6000, 8000.)
• 250 to 1000: low frequency
sound.
• 2000 to 8000: high frequency
sound.
• Up to 25db hearing: normal
hearing.
Normal audiogram
58

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 In (CHL) conductive hearing loss 2 special audiograms
PTA findings
• BC is normal PRESBYACUSIS MENIERE’S
• AC is poor DISEASE
• AB gap is positive QQ SNHL SNHL
B/L U/L
In SNSL PTA finding This cause high This cause Low
• both BC & AC are poor.QQ frequency SNHL frequency SNHL
Sloping Rising
audiogram audiogram

2 special dips(bad hearing) in

audiogram QQ
1. Dip at 2000Hz in BC.
• Seen in otosclerosis
• Called CARHART’S NOTCH.

2. Dip at 4000Hz AC & BC.

• Noice induce hearing loss
• ACOUSTIC DIPQQ

59

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 3. BERA (BRAIN STEM EVOKED MCQ: best hearing screening
RESPONSE AUDIOMETRY) investigation.
• It is done in children. Ans: In neonates: OAE
• Because it is objective test of In NICU baby, meningitis baby, high
hearing. risk baby: BERA

5. STAPEDIAL REFLEX
• On hearing loud sound (8th
nerve) – stapedius muscle
contracts (7th nerve) – to protect
inner ear QQ
• We give sound to the ear and we This reflex is absent in
records electrical activity from 1. deaf patient (8th nerve gone)
auditory pathway (ECOLI MA) 2. bell’s palsy (7th nerve gone)
which lies in brainstem area. 3. otosclerosis (stapes prob.)
• BERA has 7 waves.
• Most important wave is wave 5 6. TYMPANOMETRY (IMPEDANCE
and it is produce by LATERAL AUDIOMETRY)
LAMNISCUS. • this test check freedom of
movement In TM + ossicles.

It shows 5 types of curves.

1. Type A is seen in normal people
2. Type B is seen in glue ear
(flat curve)QQ
3. Type C is seen ET dysfunction
4. Type As seen in otosclerosisQQ
4. ATOACOUSTIC EMISSIONS 5. Type Ad is seen in ossicular
(OAE) dislocation

• When we give sound to healthy

cochlea it produces echoes from
outer hair cellsQ these echos are
called OAE.
60

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 CONDUCTIVE HEARING LOSS IN FACIAL NERVE
DIFFERENT SITUATION
• Wax cause 30db
• Glue ear 10 to 40db
• Ossicular dislocation with normal
TM cause 54db.
• Ossicular dislocation with
perforation TM cause 38db
(voice goes direct to middle ear
through perforation.)
MCQ: permissible noise level in
industry -- 90db 8hours a day for • It enter ear through internal
5days a week. auditory canal (IAC)
• It comes out the ear through
DRUG INDUCED HEARING LOSS
stylomastoid foramen (SMF)
(OTOTOXICITY)
List of drugs: • In the ear passes through
1. Aminoglycosides fallopian canal (facial nerve
o amikacin canal) – this canal has 3
o streptomycin segments:
o gentamicin 1. Labyrinthine segment
2. Loop diuretics o It is narrowest segment – it is
o furosemide
also called as BOTTELNECK OF
o ethacrynic acid
3. Antimalarials FACIAL NERVE.Q
o Quinine 2. Tympanic segment (horizontal
o chloroquine segment).
4. NSAIDs 3. Mastoid segment (vertical
o Aspirin segment).
o Ibuprofen
o indomethacin
5. Anticancer
o Cisplatin
o Carboplatin
6. Miscellaneous
o Vancomycin
o erythromycin
o desferroxamine

• Drugs cause high frequency hearing

loss – high frequency audiometry is
use to diagnose ototoxicity.
61

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 BRANCHES • it is idiopathic sudden onset
1. Greater superficial petrosal lower motor neurons (LMN)
nerve. facial palsy.
• From 1st genu – it supplies • Mostly unilateral
lacrimal gland • There is edema on Labyrinthine
2. Nerve to stapedius segment (narrowest) of facial
• 2nd genu – that give stapedial nerve – this edema leads to
reflex. compression of nerve.
3. Chorda tympani nerve • Cause not edema: cause not
• vertical segment – this gives test known. (? probably HSV
sensation of anterior 2/3rd of infection).
tongue. • Angle of mouth is deviated to
normal side.
• Eye closure = normal side
• Forehead muscle are also
paralysed cause it is LMN pasy.
• Patient complain of hyperacusis
it is due to – loss of STAPEDIAL
REFLUX.

Tx:
1. DOC: oral steroids for 3 weeks
(For edema).
2. Acyclovir (if patient present
within 3 days).
3. Artificial tear drops – to
Facial nerve disorders prevent exposure keratitis.

1. BELL’S PALSY QQQQ • Facial recovery seen in 85% cases

In patient do not show recovery
with oral steroid therapy – next
management –
ELCTROPHYSIOLOGICAL NERVE
TESTING.
o To look for nerve
degeneration.

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 RAMSAY HUNT SYNDROME MELKERSSON ROSENTHAL
SYNDROME

1. Recurrent facial palsy

2. Fissured tongue
• It is caused by varicella zoster
3. Swelling of lips
virus.
• It is also called as herpes zoster
• Head injury – can lead to
oticus.
temporal bone fracture – in this
situation we see BATTLE SIGN
C/F:
(ecchymosis on mastoid tip area)
1. painful vasicles in external ear.
2. Lowe motor neuron facial
palsy.
3. +/- 5th & 8th nerve involved.

Rx: DOC: acyclovir + steroid

Facial recovery 50% cases only.
• Temporal bone fracture can lead
to facial paralysis. These can be
to types:
1. Immediate onset Q
2. Delayed onset Q

1. Immediate onset
• It is due to direct injury to
nerve by fracture line.
Rx: Therefore immediate surgery.

2. Delayed onset (after 2 to 3 days)

• It is due to edema if nerve.
Rx: oral steroid.
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 1. OTOSCLEROSIS o its seen in early stage in disease.
(OTOSPONGIOSIS)Q

• It is fixation of stapes. • PTA shows dip at 2000Hz in BC =

carhart’s notch. QQ
• It is more common in young
female. (2ND TO 3RD decades) • Tympanometry shows As curve.
• It is genetic disease
Rx: TOC: Sx (stapedotomy =
• Autosomal dominant
stapedectomy)
• Bilateral
• In this surgery we replace fixed
• It is gradually progressive disease
stapes with artificial STAPES
• But pregnancy aggravate it Q PISTON PROSTHESIS
• The disease focus most
commonly starts from ANTERIOR
TO OVAL WINDOW – it gradually
surrounds footplate from all
around.
• The color of focus of disease pink
in early stages – it gradually turns
white.
stapes piston prosthesis
C/F: young female with bilateral
gradually progressive conductive other treatment option:
hearing loss. QQ 1. Hearing aid – it is given to
• This patient hears batter in nosy patient unwilling for Sx.
area this is called: PARACUSIS 2. Sodium flouride – it is TOC of
WILLISI QQ schwart’s sign positive patient

Examination: 90% patient show Van der hoeve syndrome

normal tympanic membrane. Tried:
• 10% patient shows SCHWARTZ • Osteogenesis imperfecta
SIGN (flamingo pink appearance • Otosclerosis
behind tympanic membrane) • Blue sclera
64

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 2. ACOUSTIC NEUROMA 4. Patient has poor
(VESTIBULAR SCHWANNOMA) understanding of words & on
increasing sound intensity
understanding false further
this is called: ROLL OVER
PHENOMENON QQ

Cranial nerve involvement by

this tumor
• 8th nerve – 5th nerve & this will
lead to absent corneal reflex Q
• 7th nerve (sensory division) – lead
to – loss of sensation in
posterosuperior part of EAC –
• It is benign tumor of 8th nerve. Q
• Most common site of origin: this is called HITZELBERGER SIGN
inferior vestibular division of 8th
nerve. Investigation:
• It is a brain tumor. Best radiological investigation is
gadolinium enhanced MRI
• It is most common type of
cerebellopontine angle brain
Rx: Sx
tumor.
• Mostly unilateral except
neurofibroma type 2. 3. GLOMUS JUGULARE
• Benign locally invasive tumor.
• Highly vascular tumor. Q
• Female
• Site of origin: glomus cells lying
around jugular bulb (JB).

C/F:
1. Unilateral gradually
progressive SNHL
2. Tinnitus (ringing sensation in
ear)
3. Imbalance • Tumor goes floor of middle ear
hypotympanum.Q
65

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 • Rising sun sign • it is glaucoma of ear
• Then tumor grows in to the • there is high endolymphatic
external auditory canal as RED pressure in inner ear due to poor
BLEEDING MASS – this red mass absorbtion of endolymph by
blanches on seigelisation this is endolymphatic sac.
called: BROWN SIGN. Q • Male>female
• The CT scan will show PHELP • Unilateral Q
SIGN. • 3rd to 4th decades

Investigation: C/F: episodic disease

1. CT TRIED:
2. Angiography 1. Tinnitus
2. Vertigo (N/vomiting)
3. Hearing loss
• Episodes finishes within 24
hours.
• Some patients fall down during
episode without turning
unconscious this is called:
TUMARKIN’S CRISIS. Q

In between episodes:
3. Biopsy is contraindicated. 1. Patient hears loud sound as more
loud this is called: RECRUITMENT
C/F: female patient with pulsatile PHENOMENON. Q
tinnitus QQ (+/-) bleeding ear mass 2. Patient gets vertigo on hearing
Rx: surgery loud sound this is called:
TULLIO’S PHENOMENON. Q
4. MENIER’S DISEASE 3. Patient dislikes noisy areas.
(ENDOLYMPHATIC HYDROPS) 4. Patient hears same sound in 2
frequencies this is called:
DIPLACUSIS. Q

& FEW YEARS LATER…

• Cochlear damage starts – due to
high endolymphatic pressure –
this will lead to hearing loss in
between episodes also – it will
lead to fluctuating hearing loss.
66

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 Investigation: electrocochleography a. External components
is a special investigation used to Has 4 parts-
diagnose menier’s disease.

Rx: medical management

If fails then:
a. Endolymphatic sac
decompression surgery –
donaldson’s line is a surgical
landmark for endolymphatic sac. Internal components (1 part)
b. Transtympanic njection of
gentamicin to kill (one) inner ear
– this is called chemical ablation
of inner ear.

EAR IMPLSNTS & DEVICES

1. HEARING AID Reciver – it is surgically implanted in

to scala tympani of cochlea through
round window.QQ

3.AUDITORY BRAINSTEM IMPLANT

(ABI)
Indication: neurofibroma type-2
• It is a sound amplifier • B/L acoustic neuroma – both 8th
• It is not in much use in profound nerve abnormal – cochlear
(>90db) hearing loss – so we do implant has no use – in this
cochlear implant surgery. patient we put ABI.
2. COCHLEAR IMPLANT
• It does electrical stimulation of
cochlear nerve endings. (8th
nerve) – pre-condition of surgery
is normal 8th nerve.

Indication:
• Bilateral profound SNHL (>90db).
Cochlear implants has 2 • ABI electrode is place in lateral
components. recess of 4th ventricle.
67

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 ENT INSTRUMENTS OTOSCOPE

BULL’S LAMP

LACK’S TONGUE DEPRESSOR

HEAD MIRROR

ENT MIRRORS
INDIRECT LARYNGOSCOPY
MIRROR

SEIGEL SPECULUM

POSTERIOR RHINOSCOPY MIRROR

PULITZER BAG

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 EUSTACHIAN TUBE CATHETER
LAMPERT’S ENDAURAL SPECULUM

THUDICHUM NASAL SPECULUM

MASTOID GOUGE

MYRINGOTOME LEMPERT’S MASTOID CURETTE

MOLLISON’S SELF RETAINING

MASTOID RETRACTOR MACEWEN’S CURRETTE & CELL
SEAKER

69

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 FARABEUF’S PERISOTEAL KAAUSE’S NASAL SNARE
ELEVATOR

KILLIAN’S LONG BLASDED SELF

RETAINING NASAL SPECULUM

MASTOID SURGERY BURRS

DRESSING FORCEPS

TILLY’S DRESSING FORCEPS

LICHWITZ TROCAR CANULA

LUC’S FORCEPS HARTMANN’S DRESSING FORCEPS

70

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 WIDE’S DRESSING FORCEPS WALSHAN FORCEPS

ASCH FORCEPS

BALLENGER SWIVEL KNIFE

TONSIL & ADENOID SURGERY

INSTRUMENTS
KILLIAN’S NASAL GOUGE

BOYEL DAVIS MOUTH GAG

FREER’S ELEVATOR

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 DENNIS BROWNE’S TONSIL
HOLDING FORCEPS EVE’S TONSILLAR SNARE

NEGUS ARTERY FORCEPS

LUC’S FORCEPS

WAUGH’S TONSIL DISSECTION

FORCEPS WITH TEETH
NEGUS KNOW TIRE

ST CLAIR THOMSON ADENOID

CURETTE
TONSIL DISSECTOR & PILLAR
RETRACTOR

72

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 QUINSY FORCEPS FULLER’S TRACHEOSTOMY TUBE

CRICOID HOOK
PORTEX PVC CUFFED
TRACHEOSTOMY TUBE

TRACHEAL DIALATOR

RIGID OESOPHAGOSCOPE

TRACHESTOMY TUBE

CHEVALIER JACKSON
TRACHESTOMY TUBE

RIGID BRONCHOSCOPE

73

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 RADIOLOGICAL FINDIGING CALDWELL’S VIW
IN ENT DISEASES

THUMB SIGN

CONCHA BULLOSA

STEEPLE SIGN

Haller cell

BEST X RAY VIW FOR PARANASAL

SINUSES
XRAY NASAL BONE

74

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 WIDENING OF PREVERTEBRAL HOLLMAN MILLER SIGN (ANTRAL
SHADOW SIGN

TEAR DROP SIGN

FOREIGN BOSY ESOPHAGUS

ALLERGIC FUNGAL SINUSITIS

FOREIGN BODY ON BRONCUS

75

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