= NASAL VALVE COLLAPSE a > Cottles test- it is done to check the blockage of the nasal valve. Put ‘two fingers on the cheek and lift the cheek upwards, if ft makes breathing better than itis nasal valve collapse EXTRA POINTS DEFECTS IN THE SHAPE OF EXTERNAL NOSE 1, SADDLE NOSE > Means depression in the nose > Concavity > Causes- 1. Septal surgery < 2, Trauma 3. Leprosy 4, Syphilis 5, Tuberculosis > Treatment - surgery called AUGMENTATION RHINOPLASTY by using iliac crest graft. Kg romrenceHUMP Nose- > Convexity > Cause - = Trauma due to birth > Opposite to saddle nose. > Treatment- surgery called REDUCTION RHINOPLASTY. > If midline gets deformed 2 deformities: > Rx: rhinoplasty GROOKED NOSE DEVIATED NOSE + Dorsum is deviated but tip is in| Dorsum and tip are straight but both deviated to one side. DEvareD ) VT Nose Deeswny Te At Does Duusunig Te ME Dewaren ov" STANGHT 6¥F GOTH TIP isn Due, DEMATED To ove SDEClinical Scenario Question- Q. A young child with cystic swelling in or around the nose . > What is the investigation of choice and why? > answer: CT SCAN. > There can be three possibilities: 1. Nasal dermoid. 2. Nasal encephalocele, 3. Nasal glioma. 1, NASAL DERMOTD- > A simple nasal dermoid is cystic swelling in midline over the dorsum of nose. > There can be Nasal dermoid with sinus opening in the dorsum of nose. > This sinus can have intracranial communication, that's why we do CT scan ‘to see communications before excision > Treatment - surgical excision of dermoid with sinus tract2. NASAL ENCEPHALOCELE- ~ Most serious ~ Tt is herniation of the brain/meninges into the roof of the nose. = Brain or meninges or both can herniate. = This swelling can be pulsatile, reducible and increases in size on coughing or crying. This is called FURSTENBERG TEST POSITIVE. | NASAL GLIOMA- > It is encephalocele only whose connection with the brain has disappeared on CT scan. > In nasal glioma, FURSTENBERG TEST IS NEGATIVE, BHINOPHYMA > It is also called potato nose. > It is hypertrophy of sebaceous glands of ‘the skin of external nose. > It is more commonly seen in males. > It is a type of acne rosacea. > It is not related to alcohol consumption. > Treatment- LASER EXCISION + grofting. EXTRA POINTS> It is also called as RODENT ULCER > It is the mest common malignancy of the skin of ‘the external nose, > Presents as ulcerative, telangiectasia with rolled out lesion > It's a slow growing cancer. Lymph Node metastasis is rare in basal cell carcinoma. > Treatment - wide surgical excretion. LATERAL WALL OF NOSE/ NASAL CAVITY 1 TURBINATES- > These are projections on the lateral wall of nose. There ore three turbinates: 4. INFERIOR TURBINATE (IT) - longest turbinate. b. MIDDLE TURBINATE (MT) ¢. SUPERIOR TURBINATE (ST) see a st = a LA xr2 ears. poo] > It isa space below the turbinate. There ore 3 meatus. a. INFERIOR MEATUS (IM) b, MIDDLE MEATUS (MM) . SUPERIOR MEATUS (SM) 3. SPHENOETHMOIDAL RECE: > This is the area above the superior turbinate. (SER) > Every turbinate has space below the turbinate but superior ‘turbinate has space above it also I ery pact of tre, rer sicomke. ‘a. INFERIOR CONCHA = it is on independent bone (MCG) Beene cone €. SUPERIOR CONCHA ciperier‘and middle concha are pat of tha the bona 5.CHOANJ > Choana is the posterior opening of the nasal cavity. > Behind the choana lies the nasopharynx.cHOANAL aTBestA- = > It is @ congenital disorder. > Chona is not patient > It is due to persistence of the bucconasal membrane after birth. It can be unilateral or bilateral. > It can be bony or membranous. > Tt can be complete or incomplete. BILATERAL COMPLETE CHOANAL ATRESTA- > Tt is @ neonatal airway emergency, because neonates are obligatory nasal breathers. (mouth breathing is an acquired reflex) > Baby is cyanosed immediately after birth but turns pink on erying (BLUE BABY TURNS PINK ON CRYING) > Immediate management is putting wide bore nipple in baby's mouth to kkeep it open > It is called McGOVERNS TECHNIQUE. > Then do TRACHEOSTOMY. > At one year of age, plan to do recanalization surgery ‘ANATOMICAL VARIATION: > Some people have extra turbinate above superior turbinate it is called ‘SUPREME TURBINATE. : AgreesPARANASAL SINUSES PNEUMATIC bones > These are mucosa lined air > They are ventilated during EXPIRATION > The nose and paranasal sinuses are lined with respiratory mucosa composed of pseudo stratified ciliated columnar epithelium. > Mucosa of Paranasal sins secretes mucus. > Due to ciliary motility, the mucus is drained into the nose through the ‘opening of sinus called OSTIUM > Nesal cilia move backwards at the speed of 10- 20 beats/sec “o push mucus towards choana, to nasopharynx, to oropharynx, which is then ‘swallowed Nasal mucociliary clearance time (time taken for mucus to reach from ‘anterior end of the nose to the posterior end of choana) is 10-20 minutes > Ciliary defect can lead to sinusitis : eowe {LLARY. FRONTAL ano sereNoID sinuses Pet Here are 4 pairs of sinuses: MAXILLARY SINUS - > This i also called ANTRUM (maxilary sins) OF HIGHMORE > This is the LARGEST SINUS, > Volume is 15m > Air filled, mucosa lined colonies > It is PYRAMIDAL IN SHAPE. Boundaries: > Base of maxillary sinus is towards the lateral wall of the nose. > Apex of maxillary sinus is towards zygomatic crea. > Floor of maxillary sinus is related to 2™ premolar and first melar OROANTRAL FISTULA- > (ORO = mouth, ANTRUM = maxillary sinus). > There is possibility of oroantral fistula as a complication of dental extraction > Maxillary sinus drains into the middle meatus > There is accessory ostium seen in 30% cases.FRONTAL SINUS- > Above the orbit is frontal sinus: below the orbit is maxillary sinus > Frontal sinus is the most asymmetric pair of sinuses. (ANATOMY 2) (right ond left con vary @ lot) > Frontal sinus ostium opens into frontal recess which drains into middle meatus eins Bea «> (axel int NW) y aa CORONAL SECTION 3.SPHENOID SINUS: > Sphenoid sinus lies in the body of a sphenoid bone which lies behnd the orbit. (image of sphencid bone) ‘Sphenoid bone is pneumatic > Paired sinus It is alzo an asymmetric pair of sinuses. (After frontal sinus.) ‘Psphenoid sinus closely related to cavernous sinus, therefore sphencid 's con lead to CAVERNOUS SINUS THROMBOSIS (intracranial complication). (CLINECAL NEG) (BrowsrerrcoenEIEN CIE > Lateral wall of sphenoid sinus is related to optic nerve ond internal carotid artery. ~ Therefore optic nerve injury lof sphenoid sinus surgery. > Roof of the sphenoid sinus is related to pituitary gland in sella turciea LICA injury can be seen as a complication (Cella turcica is @ depression in the sphenoid bone, containing the pituitary gland.). = Therefore, best surgicel approach for pituitary adenoma removal is Endoscopic transnasal transsphenoidal approachEXTRA POINTS:ETHMOTD SINUS/ ETHMOTD AIR CELLS > Ethmoid sinus is not @ single cavity; itis @ collection of multiple ir cells > Ethmoid bone is the single bone between 2 orbits which contains ethmoid air cell > ETHMOID AIR CELLS - they are divided into 2 groups by a bony plate called ground lamella or besal lamella, > 4” air sinus ~ Ethmoid sinus/ ethmoid oir cells > Big hollow covity in skull - sinus > Small hollow cavities - alr calls > All sinus draining in nose, on intercommunicating cavities > Olfactory neurons pass through cribriform plate > Gribriform plate is part of ethmoid bone & Perpendicular plate of ethmoid - formation of nasal septum > Quadrancular cartilage of nasal septum ~ join with perpendicular plate of ‘ethmoid - nasal septum [SUMMARY + Below orbit ~ maxillary sinus + Avove enbit ~ frontal sinus + Between the orbit - ethmoi + Behind orbit ~ ephenoid sinus “ Aig varsnorccee» Inferior concha - independent bone > Superior and middle concha, middle and superior meatus, middle ‘urbinate, superior turbinate, lamina paperacia, cribriform plate - Fart of ethmoid bone PERPEDICULAR PLATE OF ETHMOZD - part of nasel septum } Ethmoid air cells are divided into 2 groups by a bony plate called GROUND LAMELLA or BASAL LAMELLA: = Anterior ethmoid air cells Posterior ethmoid air cells. ANTERIOR POSTERIOR i Gi Gs ia 2 - constant cells Hace Nr cet ‘Anterior ethmoid cir cells > Ist - BULLA ETHMOIDALIS, MOST CONSTANT AND LARGEST ANTERIOR ETHMOID AIR CELL > 2ND - AGGER NASI - Anterior most anterior ethmoid air cell 15 (fg rorsnorc0n:VARIATION > In some people, ethmoid air cells can grow in 3 unusual locations > NC VARIATION - CONCHA BULLOSA > Concha bullosa ~ can cause sinusitis JAL inside middle emia > HALLER cell - part of anterior ethmoidal air cells > ONODE - posterior ethmoid air cells eens Poe = Haller cell = Agger rasi = Bulla ethmoidalis + Onodi cell = Concha bullosa \ (growersSTRUCTURES DRAINING IN THE NASAL CAVITY rages DRAINAGE OF SINUSES INTO NOSE Nasolacrimal duct Inferior meatus. Maxillary sinus, 4 ‘Middle meatus Frontal sinus ‘Middle meatus Anterior ethmoidal air cells ‘Middle meatus Posterior ethmoidal air cells ‘Superior meatus. ‘Sphenoid sinus ‘Ser{ sphenoethmoidal recess area) > Most of the sinuses open into the middle meatus: 1 Kf woresnexr000MIDDLE MEATUS > It is the most important area for sinus drainage. (moxillary, frontal and. AE) it is the space between the uncinate process and bulla cethmoidalis. it is the imaginary two dimensional entry door of | cethmoidal aa, OSTEOMEATAL COMPLEX > Maxillary sinus, frontal sinus, anterior ethmaidal air cells drain into the ‘ethmoidal infundibulum area of the middle meatus. This whole complex is colled OSTEOMEATAL COMPLEX (WCQ)! = Osteomeatal complex (OMC)-BE~ UPs EI + 3 sinus openings (GE- bulla ethmoidalis, UP-Uncinate process, EI- Ethmoidal infundibulum). - It is alzo called Piccadil’s circle© Key pathology area in sinusitis is Osteomeatal complex (OMC)-BE+ UP + EI + 3 sinus openings. (BE- bulla ethmoidalis, UP-Uncinate process, EI- Ethmoidal infundibulum), > If Osteomeatal complex is blocked due to mucosal edema. TF PERSISTS > 3 MONTHS > Clinical picture of CHRONIC RHINOSINUSITIS = Nasal obstruction. - Purulent nasal discharge. ~ Post nasal drip. - HALITOSIS- bad smell from mouth. = Facial (CHEEK) pain (in maxillary sinusitis) ~ HYPOSMIA- decrease sense of smell. - Headache. ~ 11 seresnecrs‘SINUSITIS - INVEESTIGATIONS AND TREATMENT | > Investigations in a suspected case of sinusitis 1) Diagnostic nasal endoscopy(DNE) > 30 or O degree nasal endoscope is used in DNE a eras) » A voresnoxr2) X roy paranasal sinuses (WATERS VIEW) with open mouth = > This is the best x ray view for sinuses. > Open mouth is to include sphenoid sinus in x-ray » Tt is OCCIPLTOMENTAL VIEW. > This x-ray view with open mouth is referred as Pierre's view as wel. Waters view shows all the sinuses except posterior Ethmoid air cells. PZskea CERES Best x-ray view for di sinuses Is as follows: aa f sims WATER'S VIEW/ OCCIPITO MENTAL VIEW Frontal and ethmoid | CALDWELL'S VIEW/ OCCIPITO FRONTAL VIEW XRAY SKULL LATERAL VIEW. | 3) CT SCAN OF PARANASAL SINUSES > It is best radiological investigation for sinusesOo > For fungal sinusitis, MRI is better investigation to rule out the irvasion into surrounding tissues. > chronic rhino sinusitis > Antibiotic + decongestant for 3 weeks. > If it fails to give relief, we do surgery called FESS. FESS - FUNCTIONAL ENDOSCOPIC SINUS SURGERY ‘Main aim of FESS is to re-establish the sinus drainage. > Ethmoidal Infundibulum is the opening where they drain (has 2 walls - bulla ethmoidalis and uncinate) > Steps of FESS- - Ist step -UNCINECTOMY. 2nd step- REMOVING BULLA ETHMOIDALIS. > Complication of FESS- 1) Haemorrhage- bleeding is commonly from anterior ethmoidal artery. This artery can retract back into orbit, which can lead to orbital hematoma. 2“ (prevenORBITAL HEI Caer 2) Injury to orbital contents- Va ag - Orbital fat prolapse which leads to ENOPHTHALMOS. = Injury to medial rectus muscle~ this will lead to DIPLOPIA. 3) Injury to cribriform plate- which will lead to CSF Rhinorshea. (leaking of CSF from stall) 4) Optic nerve and Internal carotid artery injury.(it can get injured in ‘sphenoid sinus surgery) '5) MC Long term complication most common long term ‘complication of FESS or any nasal ‘surgery is synechiae formation ‘application of MITOMYCIN ie > This drug has onti fibroblastic action.COMPLICATION OF SINUSITIS 1) ORBITAL INFECTION- it is most commonly seen in ethmoid sinusitis. = Double chance as ethmoid bone is present between 2 orbits 2) MUCOCELE FORMATION > It is expansion of the bony wall of sinus due to retained mucus > Mucoceles are most commonly seen in frontal and second commen in Ethmoid sinus ide. > MUCOCELE OF FRONTAL SINUS - - Tt is Non tender and cystic swelling has E66 SHELL CRACKLING FEEL. ~ Eyeball is pushed forward, downward and laterally. > MUCOCELE OF ETHMOID SINUS- ~ It is Expansion of medial wall of orbit. = This will Displaces eyeball forward and laterally 3) OSTEOMYELITIS- > When infection spreads in the bones Maxillary osteomyelitis- more common in children,> Frontal sinusitis will lead to frontal ‘esteomyelitis which will lead to sub periosteal frontal abscess, This is called as POTT'S PUFFY TUMOUR > POTT'S PUFFY TUMOR. not a tumour. It is given a pseudonym. It presents as Red, painful, Forehead swelling. > INTRACRANIAL COMPLICATIONS- @, MENINGITIS. b. CAVERNOUS SINUS THROMBOSIS. FUNGAL SINUSITIS > Most common fungus to cause fungal sinusitis is ASPERGILLUS. FUMIGATUS. > TYPES - = Allergic fungal rhino/ sinusitis.(AFRS/AFS) - MOST COMMON TYPE = Chronic non-invasive fungal sinusitis ~ Chronic invasive sinusitis ~ Fungal ball, it is also called as ASPERGILLOMAS. (woven ball of hyphae) It is most commonly seen in maxillary sinus. - Acute fulminant fungal sinusitis. (seen in HIV patients)E.9.~ MUCORMYCOSIS EXTRA POINTSal \LLERGIC FUNGAL SINUSITIS/ RHINOSINUSITIS (AFS=AFRS) > Allergy of fungal element present > Tr is seen in IMMUNOCOMPETENT PATIENT. (very common) > It is a combination of type T and type IIT hypersensitivity reactions. > Clinical pieture- 1) Allergic nasal mucin, its features are: ~ Tt is Very thick. = Peanut butter appearance ~ Fungal hyphae. ‘ALLERGIC FUNGAL, ~ It has Eosinophils. SINUSITIS/ = It has Chareot leyden erystals RHINOSINUSITIS (AFS=AFRS) 2) NASAL POLYP > On CT scan the difference is as follows Fungal polyp ( AFRS) Normal polyp (AC LY) ® Heterogeneous with double ye > density appearance > This appearance is due to fungal debris in the polyp. Homogeneous in appeararce> Treatment - FESS followed by ORAL STEROIDS. ~ Antifungal agents are only given if there is any invasion of surrounding tissues MUCORMYCOSIS » It is acute fulminant fungal sinusitis. > It is more commonly seen in HIV positive patients or young diabetic patients & in COVED=19 patients. > It is an infection of Nose and sinuses by _-RUCOR (RHIZOPUS) FUNGT. _ ® It is Angio-invasive fungus.(it invades blood vessels) > It can grow into orbit and brain. Tt is the ‘threatening disease. > Ir causes Ischemic necrosis of tissues. Hence, ‘there is BLACKISH discoloration of tissues. > Clinical picture - = Blackish nasal mass. = Blackish discoloration around the eye > Treatment ~ 1. Debridement 2, DOC is Amphotericin -MUCORMYCOSISDeere G0C ettcytne sentence fr bret, tere is @ 2nd line drug for Rhinoscleroma ATROPHIG RHINITIS also called OZAENA. > It is progressive atrophy of mucosa, sub mucosa and underlying bones of nasal cavity, (particulerly turbinate bone) > It is more commen in females > Etiology - Autoimmunity. Vitamin D deficiency = ESTROGEN deficiency. (as more common in females) > > Crusts will lead to following symptoms ~ Nasal obstruction ~ Bod smell from patients, but patients have Anosmia (loss of sense of ‘smell). This is also called MERCIFUL ANOSMIA as patient can't sense their own bad smell zi amesDer Gea > Anosmia is due to 1. There are atrophic changes in olfactory epithelium. 2. There is decreased airflow due to crusts. > Treatment Rx of choice Alkaline nasal douching (washing). It & done bby ponder dissolved in AL of water fill in syringe which contains- ~ Sodium bicarbonate - part ~ Sodium biborate - tpart = Sodium chloride - 2parts > Other treatment- 1. 25% glucose (bactericidal) in Glycerine (hygroscopic~ retains moisture) nasal drops. 2. Topical application of a. oestrogen (because of estrogen deficiency) b. Placental extract, 3. KEMICETINE ANTI OZEANA NASAL DROPS, It contains: Vitamin D, Estradiol and chloramphenicol. (WCQ) 2 artes% see > Sagal trecmant- 8 diferent series can be done Yo ret tepid ii, NASAL POLYP. > Tt is defined as prolopsed pedunculated oedematous mucosa of sinuses. (Sometimes from nasal mucosa also). ® Etiology- Chronic infection or chronic allergy leads to chronic inflammation that will couse edema, this edematous mucosa will ‘eventually prolapse to from poylp. Nasal polyp is of 2 types- ‘@) Antrochoanal polyp = It is also called KILLIAN'S polyp. > It arises from maxillary sinus and grows posteriorly towards CHOANA. Therefore it is better seen on a posterior rhinoscopy. This is done using posterior rhinoscopy mirror. 2 19g roses 0008CN Tor SCAN NASAL POLYP POLYP TWO DIFFERENT TYPES OF MIRRORS ARE USED IN IN ENT OPD: 4) Indirect laryngoscopy mirror - straight mirror 2) Posterior rhinoscopy mirror - angulated mirror '3) For anterior rhinoscopy we use THUDICHUM NASAL SPECULUM FoR ANTEROR Ruwaccory POSTERSA RRINOSCOrS Mineor, THUD icHumis wasnt SPEC uLUrH|> Cause - chronic infection (sinusitis) > Iris single in number, unilateral in origin and more common in children. > C/¢ - It presents with nasal blockage and dull voice (itis called RHINOLALTA CLAUSE) > Treatment- Surgery + FESS or endoscopic polypectomy. Recurrence is less common in ‘Antrochoanal polyp. » Antrochoanal polyp has 3 parts- ~ ANTRAL - arises from maxillary sinus ~ NASAL ~ CHOANAL - big mass in there > ET scan - homogenous mass Q. If a 12 year old male child has polypoldal mass In Nose, > There are two diagnostic possibilities,b: ETHMOTDAL POLYP- is de cled NASAL POLY a = 1 Area fom ettsial co > Cases chron ley > It is multiple in numbers, bilateral in origin and more common in edults, Chronic ellergy Malipte Bilateral [adults KILLTAN'S POLYP NASAL POLYP arises from maxillary sinus ‘Arise from ethmoidal air cells Cause- chronic allergy. Cause - chronic infection (sinusitis) single in number ‘multiple in numbers, unilateral in origin bilateral in origin more common in children. ‘common in adults. > Treatment of choice- Topical corticesteroid nasal spray. E.9, fluticasone, mometasone, budesonide etc. + If they fail, then we give oral steroids. = If oral steroids fail, FESS is done (recurrence is very common) aT onan erg er leo) Peay thr i, Bronchial asthma (very common). Cystic fibrosis (most important for exam).‘SAMPTER'S TRIAD (allergic) = Nesal polyp ( ethmeidal) + Bronchial asthma. Allergy to NSAIDS (like aspirin). Fungal origin polyp of Allergic fungal rhinosinasitis (ARS) Heterogeneous ‘appearance (double density) EXTRA POINTS a (@ rorer0rr0008‘ess through cribriform plate. (It is part ‘of ethnocide bone). » Cribriform plate te olfactory bulb Olfactory Pathway - Eee) Clearance neni) > Anosmia~ loss of sense of smell > Hyposmia- decreased sense of smell Causes of anosmia/_ hyposmi > Obstructive couses e.g - nasol polyp, deviated nasal septum (DNS), inferior turbinate hypertrophy (ITH). > Neurological causes- e.g. head injury, diabetes, parkinsonism, ond Alzheimer's disease, COVID-19 infection eoDEVIATED NASAL SEPTUM (DNS) > It can lead to different clinical outcomes i. Tt con be ASYMPTOMATIC sometimes. 11 can cause nasal obstruction on the deviated side 11 can cause crust (dried micaus) formation on the patent side due 10 Therefore there is compensatory inferior turbinate hypertrophy on patent side. Inferior turbinate hypertrophy(ITH) gives MULBERRY APPEARANCE OF NASAL MUCOSAI(MCG) iv. DNS con cause sinusitis ¥. Th ean case HYPOSMIA i. Tr-can lead to SPUR formation. (VIVA) SPUR isa sharp anglation on pasal seprum, SPUR may lead to epistaxis. External nasal deformity. Headache- it is due to contact between DNS and middle turbinate. Due to constant sensation, it can lead to neuralgic headache (MOG)! This i= called SLUDDERS or anterior ethmoidal neuralgia. > Treatment- surgery called Septoplasty. It is a conservative surgery in which only deviated parts of cartilage and bone are removes. * Kg enoneeed Staal lee of ervey = = Septal buttons (obturators) which are made of silastic. = Local flap rotation Ecacecaae) RHINITIS SICCA > People who are engaged in work at higher temperatures. E.g. - bakers, blacksmith > It involves the anterior part of the septum. There will be excessive crust formation on septum. > Treatment- glycerol nasal drops. Glycerol is a hygrescopic agent which keeps the nasal cavity hydrated. 8 Kocoav hoe TUMORS OF NOSE AND PARANASAL SINUSES = NEOPLASM OF SINUSES AND NOSE BENIGN TUMOUR- OSTEOMA > MC benign tumor of sinuses is OSTEOMA. > Osteomas are most commonly seen in frontal sinus followed by ‘ethmoidal sinus. > Most of the time, Incidental finding in frontal sims on Xray paranasal sinuses > They need treatment only if they are symptomatic .¢.9. Causing sinusitis due to mechanical blockage to drainage of sinuses. CT SCAN FRONTAL SINUS OSTEOMA » geeav hoe TUMORS OF NOSE AND PARANASAL SINUSES = NEOPLASM OF SINUSES AND NOSE BENIGN TUMOUR- OSTEOMA > MC benign tumor of sinuses is OSTEOMA. > Osteomas are most commonly seen in frontal sinus followed by ‘ethmoidal sinus. > Most of the time, Incidental finding in frontal sims on Xray paranasal sinuses > They need treatment only if they are symptomatic .¢.9. Causing sinusitis due to mechanical blockage to drainage of sinuses. CT SCAN FRONTAL SINUS OSTEOMA » gee4 ees of uper teeth | 5. Proptosis and diplopia, due to orbital extension. OHNGREN'S LINE & CLASSTFCATION- © >T ‘an imaginary line from medial canthus to angle of mandible. > It divides the maxilla into superstructure and infrastructure. > Malignancy above this line has poor prognosis due to early orbital invasion. ONGRENS LINE LEDERMAN'S CLASSIFICATION- > This classification uses 2 lines called lines of sebileau > The 1st line is at the base of orbit and the 2nd line is at the base of the maxillary > It divides an area into three areas: ~ superstructure, - mesostructure, ~ infrastructure.— > Treatment- total vvvyyv v = maxillectomy by WEBER FERGUSSON approach ++/- orbital exenteration followed by Rodiotherapy. INVERTED PAPILLOMA OF NOSE It is also called RINGERTZ TUMOR or SCHNEIDERIAN PAPILLOMA It is more common in males. It is more common in 40 - 60 years of age. Fleshy polypoid mass is there in nose. In Inverted papilloma there is some role of HPV. It's Site of origin is the lateral wall of the nose. ‘On histopathology examination- popilloma is growing inwards (therefore it's called INVERTED PAPILLOMA, Hence it is locally INVASIVE and it can show malignant ‘change in 10% cases.) ® greenestheated [nec iraraN > Cle - Firm reddish nasal mass + epistaxis. > Treatment- surgery is MEDIAL MAXILLECTOMY (locally aggressive) by LATERAL RHINOTOMY approach using MOURE'S INCISION. peo Le ooo) ie MALIGNANT MELANOMA OF NOSE > It is seen in 50-60 years of age. > Site of origin is the nasal septum, particularly anterior part of septum. > Examination shows SLATY GREY OR BLUISH BLACK nasal mass. > Treatment- wide surgical excision, avoid chemotherapy and radiotherapy ‘as immunological defence of the patient ae pavient Bladen tayo | plays an important role. > 5 years survival rate of this patient is REG NEAGS 130%. — 1 =PACTAL TRAUMA & NASAL BONE FRACTURE- + This is the most commonly fractured bone in the face .There is history of trauma. + Findings- Nasal deformity, Crepitus, Swelling may or may not a TT es > Treatment- immediate closed reduction before edema starts. > Using WaALSHaM FORCEPS MIE crea prcen Th wal soc Tare coat subside and then reduce the fracture. > Nasal bone is a cosmetic bone that needs absolute pase eeM ett cdovm nai] mice JARIAVAY fracture 2) If force is from below- vertical fracture or CHEVALLET fracture. > Treatment - septal reduction using ASCH forceps. = 1 reesein_mind while MANAGEMENT OF FACIAL TRAUMA- + Airway management. + Bleeding + Other injuries. Tt may be a polytrauma case.— F 7 lone CSF RHINORRHOEA P] » It is leakage of CSF from nose, drop by drop clear fluid leaking from the nose. as 1. Most common cause- iatrogenic > ~ during FESS. Thi CSF leak is mostly due to injury to CRIBRIFORM PLATE. 2. Head injury - skull base fracture > e.g, - NASOETHMOIDAL FRACTURE, LE FORT IE & IIT fracture. This is called a traumatic CSF leak, this leak is blood mixed CSF, and therefore on filter paper it gives a > Mest common site of traumatic leak is FOVEA ETHMOIDALIS (roof of Ethmoid). 3. Brain tumours. 4. Spontaneous (raised ICP) CSF leak. > Site- OVER ALL most common site of CSF rhinorrhoea is cribriform plate. > Mest common site of traumatic CSF leak is FOVEA ETHMOIDALIS.eter ad oe far 5, Posterior nasal packing 4. Zt is placed in conjunction with anterior pack. b. It isa Major procedure, placed under general anaesthesia, | 6. It has three threads, two treads tied at the nostril and a single thread hhangs in the throat for pack removal. din place of the posterior nasal pack sometimes Foley's (urinary) catheter can be used. It is not that efficient but sometimes it is used in place of conventional nasal packs. ete eo eer Sacer} hawas IN ThROAT > 13 FoR CA Removal,d distalMYTASIS | > This is presence of maggets in nose or ear. Maggots are larvae _ of housefly (Chrysomia). Foul smelling conditions lead to myiasis. > Treatment maggot cil installation in the nose. + use mosquito net. > Maggot oil contains chloroform © ‘turpentine oil a ‘Angles of nose > Naso frontal angle- normal is 115° - 135) » Naso - labial angle normal is 90° - 110° VASOMOTOR RHINITIS » Vidian nerve- It is autonomic nerve supply to nose. It is also called the nerve of the pterygoid canal > Vidian nerve is made by combination of two Nerves ~ Greater superficial petrosal nerve. (Parasympathetic) - Deep petrosal nerve. (Sympathetic) > Parasympathetic over dominance can lead to disease called vasomotor rhini > Clinical Picture- on change of temperature, pavient ‘experience be sessNOSE &PARANASAL SINUSES Qusl: Target sign on filter paper is a feature of ©. Spontaneous CSF leak Traumatic CSF leak Fracture mastoid 4 Meningeercephalocele Qus2: A resident of Tomilradu has presented to ENT OPD with recurrent nasal bleeding and nasal obstruction. The anterior rhinoscopy picture is given in the image. Which of the following is not on applicable statement in this condition? og @. Caused by aquatic protozoan© CT scan of sinuses shows homegereous opacities ‘4. Nosal polyp wad Qusil: A patient of suspected sinusitis has undergone CT scan of paramsal sinuses coronal cuts Sm. The CT scan shows an unusual cell marked with arrow. What is ‘the name of this cel ‘0. Bulla Ethmoidalis. Agger Nesi € Concha Bullasa_d. Onodi cell Qusl2: Septodermoplasty isa treatment option in which of the felawing conditions? ‘a, Atrophic Rhinitis b. Deviated nasal septum Rendu Osler weber syndrome 4. Rhinoscleroma Qust3: Which of the following is not a true statement regarding the Epistaxis? 2. Hypertension leads to posterior epistaxis,‘QUSIE.Which of the following sinus is rot visible on X-ray PNS ( Water's View) Pa @. Maxillery| . Sphenoid «Frontal 4. Posterior Ethmoid ‘QusI7: One day old child presented with respiratory distress and cyanosis which Improves on crying. An endoscopy of nase is done ard follewirg the CT scan is ‘obtained ( see images) Choose the most inappropriate statement: A. Occurs due to persistence of bucconasal membrane B. Bilateral, usually presents with respiratory difficulties . Failure to pass catheter from nose to pharynx D. Recaralisation surgery is done at birth{Qius18: A 23 year old person suffering from acute frontal sinusitis has developed o poinful read forehead swelling (see the imoge) ‘Which of the following is the possible diagnosis ? 2, Orbital cellulitis b.Ringert2 rumour Port's puffy tumeur 4, Osteoma of frontal sinus {QusI9: A 43 year old mole patient presents with roomy nasal cavity filled , nasal crusts with disfigured hard external rose. Biopsy from external rose is shown in ‘the image. Whet is the diagrosis? ‘a Rhirolith h Rhinosporidiosis © Rhinoscleroma dD. Rhinophyma», Agger Nasi € Onedi cell 4. Haller Cell Qus25: What is the significance of given line in the image? A Total Maxillectomy in carcinoma of maxillary sinus 5s Partial Maxillectomy in carciroma of maxillary sirus Pragrestic evaluation of carcinoma of maxillary sinus »p Total laryrgectemy in carcinoma of larynx (Qus26: The given two nasal features are seen in which stage of Syphilis 0. Congenital Syphilis| S.EPIGLOTTIS >» Epiglottis is leaf like cartilage. inside the larynx. ‘attached. > Single cartilage, cant be palpable Basic function - Epiglottis covers vocal cards. (Gfi = above, glottis = vooal cards) |. Anytenoids - pob cartilage sitting | on top of cricoid cartilage hence making | ericoarytenoid joint. |2. Comniculate (rudimentary cartilages) - rice | grain like cartilage |. Cuneiform - (rudimentary cartilages) - rice grain like cartilages Corniculate & cuneiform are rudimentary | cartilages. | 6 » Attached to the midpoint of thyroid cartilage » To the same midpoint, vocal cords are also PAIRED CARTILAGES OF LARYNX eas Canton a) Kf noresnexr00084, ARYTENOIDS Arytencids make posterior 1/3rd of vocal cords. (ANT 2/3"° VC membranous) It has a body. vocal ond muscular process VOCAL ! PRocess muscles cf "MUSCULAR as SUMMARY ~ » 4 cartilages - thyroid cricoid outside, epiglottis and arytencid inside Thyroid and cricoid form outer framework of larynx > Epiglottis covers the VC Arytenoids make posterior 1/3™ of VC | JOINTS IN LARYNX- 1. Cricothyreid joint 2. Cricoorytenoid joint- it shows | rotatory and gliding movement > Both are synovial joints (a soresses 6a avn ‘Two membranes inside lary ‘3. QUADRANGULAR MEMBRANE > Tt forms : eee fas cal eade sige end mueve sport he lym > From the epiglottis to the arytenoids > 2 membranes Certite 4. CRICOVOCAL MEMBRANE- + mucese > Iris also called as conus elasticus. % The free edge of this membrane makes the true vocal cord when covered by the mucosa > Cricoid to the Ve in MUCOSA OF LARYNX % Larynx is lined by ciliated columnar epithelium, except vocal cards which are | lined by stratified squamous epithelium. > In some smokers vocal cords epithelium sheds faster this condition is call i larynx. LARYNGEAL MUCOSA| KERATOSIS LARYNX > This disease is seen in smokers > Increase in the shedding of stratifies squamous epithelium of VC > Tt is @ premalignant condition. > Cle- hoarse voice ( e/e= chief complaint) > Treatment- stripping of vocal cord mucosa = decortication + quit smoking. > Other treatment- co2 laser cordectomy “ Kg rorornePITCH DISORDER OF VOICE features in adults. low pitch voice ee > High pitch voice in males (feminine). midesintof shrreid cantieee > It is seen in emotionally labile young males. > Tx - 1. Speech therapy (for 3 - 6 months) + Gutzmann's manceuvre- patient is asked to pull thyroid cartilage downwards and press it backwards (so that VC loosens) and then speak (speech therapy). This is done for 3 to 6 months Psychotherapy is also needed. > If speech therapy fails, then we do | Summary questions - surgery called type III _thyroplasty EGpen stoctennc/ Dl orarna Vor semall er oe cords). a 1) What is puberphonia ‘ANDROPHONIA 3) What is type TIX thyroplasty > Low pitch voice in females. (masculine) > Surgery- Type IV Thyroplasty ( surgical lengthening= tightening of vocal cards) 5) What is Type IV Thyroplasy |4) What is Andrephoni_ > Tt isa leaf like structure |= Tt extends beyond the level of hyoid bone. = Hence it has 2 parts: suprahyoid ond infrahyoid epiglottis. Supraglottis projects into the throat . therefore problems in suprahyoid resembles of that of pharyngeal symptoms - throat pain, dysphagia 2. Aryepiglottic folds (AEF) (made by quadrangular membrane) 8, False vocal cards = ventricular bands (made by quadrangular membrane) = They are rudimentary structures. If a patient produces sound using a false vocal card, it is a disease called dysphonia plica ventricularis. [FALSE VOCAL CORDS Fvc) A TRUEVOCALCORDS(TVC]| _ARYEPIGLOTTIC FOLDS 7 RRVTENOID (8) ARYEPIGLOTTICFOLD (AEF)LARYNGOECELE Xray soft tissue neck with Valsalva | Air filled neck swelling showing laryngocoele SUBGLOTTIS SuagvoTTis > It is the empty space inside the cricoid ring. k CRicow RING GLoTTIs true vocal cords= vocal cords 18-23mm 16- 17mm of thyroid cartilage > Start at the thyroid and end at the arytenoid > Posterior commissure is also called as INTER ARYTENOID AREA > Which muscle of larynx is a single/ unpaired muscle - IA muscle (MEQ) B KG ronseTRUE VOCALCORDS ANTeRioR Commissne | 7 Tnterarsnod much (TA) > Thyroarytenoid and interarytenoid are adductor muscles. If they are weak, closure will be incomplete; it will lead to a disease called PHONASTHENIA. It will lead to gap between vocal cards even after adduction. This appearance of gap is called keyhole glottis: > The key hole has 2 components A. Elliptical gap is due to TA. B. Triangular gap is due to IA > Tx- speech therapy. _ KEY HOLE GLOTTIS ARIE riGueTTC| a Fd 1 Krossathe TAYRNX REINKE'S EDEMA » It is edema of reinke's space. It is bilateral diffuse swelling of vocal cords. > It is also called smoker's polyp of larynx > Couses 1. Smoking(most common cause) 2. Laryngepharyngeal reflux (lpr) 3. Hypothyroidism 4. Vocal abuse. > Cle ~ hoarse voice > Treatment surgery in the form of stripping of vocal cord mucosa (ecortication) - fluid will leave and mucosa will regenerate. Done on one vocal cord at a time If we remove both VC together then there will be fusion of VC, as there might be healing taking place REINKE’S EDEMA fa Kf roresnerae|Laryngopharyngeal reflux ( Ipr) Causes: Vocal abuse (m/c/e) Laryngopharyngeal reflux (pr) Site junction of anterior 1/3 and ‘posterior 2/3™ ( this is because of ‘the reason that this is the most vibrating part of the vocal cords) Site- junction of anterior 1/3 and Posterior 2/3" ( this is because of the reason that this is the most vibrating part of the vocal cords) C/e- hoarse voice C/e- hoarse voice This patient may additionaly complain of double voice ( diplophonia) They are always bilateral Tt is unilateral x= speech theropy which includes ‘voice rest (+/- proton pump inhibitors ‘eg. Omeprazole). ‘Microleryngeal surgery is only indicated if disease does not respond VOCAL NODULES Rx- MLS (microlaryngeal surgery) followed by speech therapy VOCAL POLYP nau, EAR= 200MM NOSE= 300mm YNIX= 400MM, LS} 18 Kf woresnesvent JUVENILE PAPILLOMA OF LARYNX ( recurrent respiratory popillomatosis) > Etiology- it is causes by HPV- 6, 11 > This disease is more common in children in 4-6 years of age. > Source of infection is mother with genital HPV warts at the time of delivery > Examination viral warts on vocal cords > These warts can also spread to trachea and bronchi. > This is a pre malignant disease > Cle - 4-6 years of age child 6. Chronic hoarseness of voice. 7. /- respiratory difficulty. (if they block the laryngeal inlet) » Treatment - MLS (micro-laryngeal surgery) with CO2 laser excision. Unfortunately recurrence is very common > Agents used to decrease recurrence of ipl. 1. Intralesional cidofovir. 2. Indole 3 carbinol. 3. Interferon alpha. 4, Bevacizumab 5. Cis-retinoic acid CO2 laser is invisible lazer ond it has wave length of 10,600nm. It is most ‘commonly used laser in ent sungery. JUVENILE PAPILLOMA OFTreatment- PPE (proton pump Treatment- PPI (proton pump inhibitors). PSEUDOSULCUS VOCALIS FAC HME LARYNGIS 0 Kf norsnoneavRN YNGEAL_ INFECTIONS, > These ore airway emergencies because of abundant subcutaneous loose comective tissue that can lead to laryngeal edema . 1, ACUTE EPLGLOTTITIS- This is infection of supraglottis. Cause is streptococcus pneumoniae (most common) and H. Influnzae B (2nd most common.) ‘Seen in age group of 2-7 years. C/p (clinical picture) - - High fever. = Respiratory distress. = Inspiratory stridor. = Very sick child ~ Drooling of saliva (due to pain patient wont be able to swallow the saliva) = Very sick child = Plummy voice (as if the child is holding a plum in the throat) - Airway obstruction, to decrease the problem, the child will be sitting on the emergency bed with his hands out stretched and placed on ‘the bed ond the child will bend forwards. By doing this, epiglottis falls away from the vocal cord and the airway is atleast partially ‘open. When viewed from the side, it is called as tripod signavant > Treatment is conservative (no cyonosis/ hypoxia). Reassurance, that it is self-limiting condition, > More than 90% patients improve by 12- 18 months of age > Tf no improvement with age then we do surgery called cupraglottoplasty or EPIGLOTTOPEXY. LARYNGOMALACIA ital disease of layrnx ~ weakness of supreglottis = supraglottic collapse during inspiration = Omega shaped epiglotis = 6/6 Inspiratory stridor = strider appears by 1st week of life = strider decreases in prone pesition ~ stridor ineneases in erying = normal ery of baby = Rx: conservative, self limiting by 1. CONGENITAL GLOTTEC WEB > Incomplete canalisation of glottic area, web is left ® This is the most common site of laryngeal web > Cle - hoarse ery. (VC is affected, sound problem) wes > Treatment is CO2 laser excision, > Raw area of both side can get connected again > Followed by placement of MC NAUGHT SILASTIC KEEL for few days in between VC for re-epithelization and to prevent reformation of web. > Rig rersrerose> It is capillary hemangioma. In the subglottic area > It is sometimes associated with facial ‘A. Respiratory difficulty B. Strider. C. Cry is mostly normal. > Immediate Treatment ~ The child may need tracheostomy ot birth if significant airway compromise is there. Then wait and watch because hemangioma can spontaneous regress with age. If no improvement then co2 laser excision (GroverCONGENITAL SUBGLOTTIC STENOSIS: = diameter Image of the laryne with the help of the mirror > Hold tongue with gauze > Check the warmness of mirror and back of shaft or F = [ ‘METHODS OF LARYNGEAL EXAMINATION i 1. Anterior commissure of vocal cords 2. Laryngeal surface of epiglottis (undersurface) 3. Under surface of vocal cords 4. Adjoining area of subglottis. 5. Ventricle and saccule. 6, Apex of pyriform sinus.PPAR ROC RYN ( 3BILATERAL ADDUCTOR Palsy ‘Adduction absent > Causes- bilateral vagal palsy > In BILATERAL vagal palsy, ‘no muscle is left working (RLN + SLN palsy= complete palsy) > Vocal cord come in cadaveric position/ intermediate position (open vocal cord) > C/e- ophonia, aspiration (leads to recurrent pneumon respiratory distress. ~ Not an emergency Tf no recovery seen after 6 months, then definitive treatment option wil be as follows: A. Treatment of choice is surgery called TYPE T THYROMASTY/ Iedialization of vocal cord. Make a window in thyroid cartilage and put ‘the implant through a window that pushes vocal cord medially. 2, Teflon injection in the vocal cord ~ will swell up permanently the VC ond it will lead to medial Ve |. There is no TYPE | THYROPLASTY=MEDILAISATION OF VOCAL CORDTNM STAGING OF CANCER LARYNX Supragiottis Tuo inte 6 one suit of sopraTath with normal vocal cord i Tenet vas mcon of more than one adjacent abate of spragathor lots or region outside the supragiotts (9, mucosa of base of tongue, vallecla, media wal or yrorm snus without firation ofthe yr Lorie to lane with veal cred fation or invades any of he ing: postriold area, pre epiglotc tissues, paraglotte space, oF trina held earageereson (egy ner crts) ‘Tumor invades through the thyroid cartilage or Invades tues beyond the larynx (eg. tracha, soft tesues of neck Including deep extrinsic mule of the tongue, strap muscles, thyroid, or e1ophagus) ‘Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures ‘Tumor limited to the vocal cordis) (may involve anterior or posterior commissure) with normal mobility, ‘Tumor limited to one vocal cord, Tumor involves both vocal cords Tumor extends to supraglottis or subglottis, or with impaired vocal cord moby Tumor lined tothe larynx wit vocal cord fixation or invades paraglotic Space, or minor thyroid cartilage erosion (eg, Inner cores) ‘Tumor invades through the thyroid cartilage or invades tues beyond the Tar (te. trachea, soft thsues of neck Inching deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) “Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures tis Tumor imited to the subgiottis ‘Tumor extends to the vocal cord(s) with normal or impaired mobility ‘Tumor limited to larynx with voaal cord fixation ‘Tumor invades cricoid or thyroid cartilage or invades tissues beyond the larynx (eg, trachea, soft tisues of neck Including deep extrinsic musdes of the tongue strap muses thro or ephagus) ‘Tumor invades prevertebral space, encases carotid artery, or invadesTreatment > T1- radiotherapy. - Now-a-days, for T1 glottic cancer > T2- radiotherapy » 2nd best option is partial laryngectomy if lungs are normal. > Partial laryngectomy is of 2 types 1. Horizontal (hpl) is done for T2 supraglottic cancer = Growth involving epiglottis or aryepiglottic fold = Both Vocal cords are normal = Cut just above Ve = Save both VC and lower part of layrnx 2. Vertical (vpl) is done for +2 glottic cancer = Growth involving 1 VCide jation if paCRICOID HOOK ‘Stobalise the cricoid with the cricoid hook ‘and can inscise trachea easily ‘STYPES OF TRACHEOSTOMY. DEPENDING ON SITE OF TRACHEOSTOMY 1. Mid tracheostomy. > Mest common site of tracheostomy. » It is done at the level of 2nd and 3rd tracheal ring. > We avoid first tracheal ring to prevent damage to larynx. (eg: subglottic. stenosis) 2. High tracheostomy > It is done at first and second ring. Petree in/eancersferyre.| (IN > This is done so that adequate length of trachea is available after total laryngectomy to be sutured to the skin of the neck to make permanent ‘tracheostome. 3. Low tracheostomy, > It is done at 3rd and 4th or 4th and 5th tracheal ring. > Indication is tracheal stenosis in upper part. m greenePHARYNX ANATOMY AND PARTS OF PHARYNX > Pharynx is a fibromuscular tube from skull base to C6 vertebrae strictor . Superior constrictor muscle ( SC) . Middle constrictor muscle (MC) |. Inferior constrictor (IC )muscle - it has 2 ports a ‘Thyropharyngeus KILLIAN'S DEHTS: > It is a triangular area in Inferior constrictor muscle between fibres of thyropharyngeus and cricopharyngeus. » This area lacks muscular support. Therefore it is a weak area of pharynx. Tito praneneus 1. It is the site of the a chwcorRARNGens pouch ). 2. It is a possible site of ‘perforate on during rigidRavn (PHAYRNC ‘SINUS OF MORGAGNI (SOM) > Tt is the space between the skull base and upper border of superior constrictor muscle. > Eustachian tube & tensor veli palatini muscle (tensor polati muscle) asses through sinus of morgagni. (WCQ) LARYNGOPHARYNX > It is also called HYPOPHARYNX. > Hypopharynx has Sparts 41. Pyriform sinus( PS). - due to pressure of larynx divided into right and Een > Internal branch of the superior laryngeal nerve, also called the internal laryngeal nerve, gives sensory supply to Supraglottis and pyriform sinus. va KgroererosNASOPHARYNX > Behind the nose is Nasopharynx. > It has 2 important landmarks. 1. Eustachian tube opening 2, Adenoid tissue (especially in children) > Eustachian tubes connect the middle ear to nasopharynx: therefore nasopharyngeal diseases can lead to middle ear diseases for example GLUE EAR (serous otitis media) which leads to conductive hearing loss. ‘TOPICS IN NASOPHARYNX- 1, ADENOID 2. ANGIOFTBROMA 3. NASOPHARYNGEAL CARCINOMA. ADENOID, > It is also called NASOPHARYNGEAL TONSIL. (tonsil - collection od Iymphoid tissue in phayrnx) > Site- lying at junction of roof and posterior wall of nasopharynx. > It is ill defined lymphoid tissue in nasopharynx because it has - No CAPSULE. - NO CRYPTS.¢. ‘Pave, ~ NO DEFINITE BLOOD SUPPLY. > It feels irregular on palpation. This is called "BAG OF WORMS FEEL". > Adenoid is present at birth: it increases in size up to 6 years of age. It starts decreasing in size at puberty and it disappears by 20 years of ose. CHULDREN ADULTS ADENOID HYPERTROPHY. > Adenoid hypertrophy is a disease of school age children, > It is more than physiological enlargement of adenoid, > It is due to recurrent upper respiratory infection > Clinical picture - The child is mouth breather with history of recurrent upper respiratory infection (URI). > Patient has a typical facial appearance called ‘Adenoid face. It has following features: 1, Open mouth. (mouth breather) ue 2. Pinched nose. 3. High arched palate. N | 4. Malocclusion of teeth. > This patient can have- 1. RHINOLALIA CLAUSA( hyponasality of voice) va (green2, Glue ear features - conductive hearing loss ( mostly bilateral) > Investigations- X ray soft tissue Nasopharynx lateral view > Treatment = Surgery: Adenoidectomy under General anaesthesia ® Always palpate adenoid before removal. To confirm the diognosis and to rule out any artery passing over it Position of patient- ROSE POSITION. 1. Extension of neck on chest 2. Extension of head on neck. > Over extension of neck can lead to atlanto-axial subluxotion ( C1-C2). This is called GRISEL SYNDROME > Same position is used for tonsillectomy elo. METHODS OF 1, CONVENTIONAL METHOD Senna > Curettage. By using ST.CLAIR THOMSON ADENOID CURETTE. ' 2. NEW METHODS OF SURGERY 1.COBLATION- controlled ablation, I 2. SUCTION DIATHERMY.. 3. MICRODEBRIDER. These 3 are ENDOSCOPIC guided methods hence there are less chances of ‘The curette is held in Dagger bleeding and other complications holding fashionANGIOFIBROMA > Angiofibroma is the most common benign tumor of nasopharynx. > Site of origin is the superior margin of sphenopalatine foramen > This is a tumor seen in young, adolescent boys ( 12- 14 years) > This tumor is highly vascular, The blood vessels of this tumor do not have muscular layers. Therefore if once cut, they do not contract or retract. So, it alwayspresents with profuse epistaxis and biopsy is contraindicated for this tumor. >It is a hormone sensitive tumor, therefore preoperative ‘estrogen/flutamide shrinks the tumor. > Angiofibroma is a locally invasive tumor. Tt can extend into a. Nose, sinuses b. Cheek . Orbit - orbital involvement will lead to protosis, which is called FROG FACE DEFORMITY. d. Brain (middle cranial fossa, anterior cranial fossa) Cheek extension (reAXcePACATINE Fash FROG FACE DEFORMITY. Hollman Miller sign. - Cheek extensi > Tumour grows into pterygopalatine fossa behind the maxilla and it and pushes the anterior wall of maxilla forwards.This finding when seen on (T scan is called Hollman Miller sign. The tumor then enters into infratemporal fossa from here with further extension. 1 (9 rmeorom> Clinical picture ~ 12-14 year old boy with nasal mass and profuse epistaxis. +/- = Nasal obstruction, ~ Hyponasality of voice. ~ Glue year causing Conductive hearing loss. > Investigation- 1. CECT(contrast enhanced CT) will show HOLLMAN MILLER SIGN (it is also called ANTRAL SIGN). it is anterior bowing of the postenor wall of maxilla. 2.2. Angiography - maxillary artery is the most common blood supply of ‘this tumor. Preoperative embolization will reduce blood less during surgery. Embolization is done 24- 48 hrs before surgery, if surgery is delayed after embolisation, the collaterals will develop. Pecan Tumour St /stems for Angiofibroma 1, FISCH STAGING 2, RADKOWSKI STAGING ve [greeceANGIOFIBROMA STAGING ( FISCH) FISCH STAGING CLASSIFICATION ‘Done for prognosi: ind therapeutic approaches: ‘Stage I: Tumor limited to the nasal cavity ‘Stage IL: Tumor extension into t maxillary, sphenoid or ethmoid ‘Stage Ila: Tumor extension into the orbit or infratemporall fossa without intracranial involvement, © Stage IITb: Stage [la with extradural (parasellar) intracranial involvement Stage IVa: Intradural without cavernous sinus, pituitary, of optic chiasm involvement Stage IVb: Involvement of the cavernous sinus, pituitary, of optic chiasm ANGIOFIBROMA STAGING( RADKOWSKI) Radkowski Staging -1996 ‘+ Ia-Limited to the nose and nasopharyngeal area ‘= Tb-Extension into one or more sinuses ‘+ 2a-Minimal extension into pterygopalatine fossa ‘> 2b-Occupation of the pterygopalatine fossa without orbital ‘erosion ‘= 2c-Infratemporal fossa extension without check or pterygoid plate involvement ‘+ 3a-Erosion ofthe skal base (middle cranial fossa or pterygoids) ‘+ 3b-Erosion of the skull base with intracranial extension with or ‘without cavernous sinus involvement> Nasopharyngeal carcinoma is hidden cancer (occult primary). Therefore ‘the most common presentation is secondary neck nodes (-metastatic cervical lymphadenopathy) MCQI ROSSENMULLER cd > First lymph node to be involved- retropharyngeal lymph nodes, and then it reaches cervical lymph nodes. > Nasopharyngeal carcinoma is a skull base cancer, it enters the cranial cavity through foramen lacerum, > Therefore cranial nerve palsy is the feature of this tumor. Most common nerve to be involved is the 6th cranial nerve. Tt can also involve jugular foramen, hypoglossal canal , hence causing 9th 10th, 11th, 12th cranial nerve paralysis. ll cranial nerves can be involved except 7 and 8" nerves. 1” MG rcrercoceTROTTERS TRIAD OF NPC © N+ Neuralgia in temporo-parietal area due to 5th nerve involvement. © P- Palatal palsy due to 10th nerve involvement. © C- Conductive hearing loss which is unilateral. (All are ipsilateral) > Diagnosis- nasopharyngoscopy + biopsy. > Treatment- CHEMORADIATION (Cisplatin/5- FU ~ radiotherapy) TRORN WALDT DISEASE Tnfechon qf euesh of IVASOP KARIN POS FULED CYSTIC SHELLING BeHvD wose MARSUALSATION ® OROPHARYNX > Tmagine two lines 1. at the junction of anterior 2/3rd and posterior 1/3rd of tongue below 2. at the junction of soft palate and hard palate above. > Anterior to these two imaginary lines is oral cavity > Posterior to these two imaginary lines is oropharyrecSTRuCTURE MADE BY ANTE oR Tow siLLAR PILLAR > PALATOCassus MuseLé POSTE ROR TOSILLAR {Lie PALATHPHARIEUs MUSCLE ED OF TOWSIL ———-> SWEMon COUITRICTIR MisKLE > Tonsil is lined by non keratinizing stratified squamous epithelium 1. Tt has a capsule 2. It has crypts. The largest or deepest crypt is called Crypta Magna. Prone Ward or are MANGA TONSILLOLITH > The collection of keratin debris in ‘tonsillar crypt which present as whitish hard mass called tonsillolith,Ruan TONSILLITIS TONSILLECTOMY > Most common and conventional method of tonsillectomy is dissection and snare method. > After dissecting the tonsil from its fossa, EVE'S TONSILLAR SNARE is used to crush and cut the lower pole of pedunculated tonsil TMs HOt Pacers INSTRUMENTS FOR TONSILECTOMY. 14 KremerCOBLATION Enya HOT METHODS Dissection and snare Electrocaautery Intrecapsular with debrider Loser tonsillectomy Harmonic scalpel Coblaation Cryosurgical technique Radiofrequency ra WHITISH MEMBRANE OVER TONSIL CAUSES 1, Acute membranous tonsilliis coused by streptococcus pyogenes. . Infectious mononucleosis caused by Ebstien barr virus, Diphtheria.- diphtheria membrane it extends beyond tonsil to palate. Candida Vincent angina. . Malignancy of tonsil Leukemia and agranulocytosis. PraHE WALDEYER RING. Tt is a ring of lymphoid tissue in pharynx.it has 6 ports= ‘Adenoid. Tubal tonsil around the Eustachian tube, Palatine tonsil Lingual tonsil on the base of tongue |. Lateral pharyngeal bands. . Lymphoid follicle in posterior pharyngeal wall. Lymphoid follicles on posterior pharyngeal wall can show hypertrophy, ‘this is called cobblestone appearance of the mucosa youswnny WALDEYER RING ABSCESSES QUINSY/ PERITONSTLLAR ABSCESS » It is a collection of pus between tonsil and its bed (supericr constrictor muscle). > Quinsy is more common in adults, but also seen in children > Tt is mostly unilateral. > Tt mostly follows an episode of acute tonsllitis 137 [groteQUINCKE'S DISEASE- it is angioneurotic edema of uvula. OW Neer DEN caw et 5 Bucephaageat ft > Prevatebreh e gree» Retropharyngeal space is divided into two halves by a midline band, ‘these 2 spaces are called spaces of GILLETTE. > These spaces have retropharyngeal lymph nodes also called lymph nodes of RANVIER > Infection of this lymph node will lead to acute retropharyngeal abscess. » Acute retropharyngeal abscess is More common in children. > Clinical Picture + Avery sick baby. + Approximately 2 years of age. + With respiratory difficulty. + With inspiratory stridor. + With a hot potato voice.( Phummy) > Differential diagnosis- acute epiglottitis. gt > Examination shows unilateral bulge on. _posterion pharyngeal wall. > X ray soft tissue of neck lateral view shows “widening of prevertebral shadow with normal “cervical spine. > In acute epiglottitis X ray shows thumb sign. > Treatment 1. Airway management 2. Per oral incision and drainage.PREVERTEBRAL ABSCESS BS GS] noe Buxtphamaet due to TB of cervical spine > Examination- shows midline diffuse bulge on posterior pharyngeal wall in prevertebral abscess Hor Porat Voce CAUSES 4. Qunsy 2 Reale Engst 5 frosle Pebaphargnguk seem 4H Supregistte concer S- Bose Tongue concer” > X ray neck findings 1. Widening of prevertebral shadow. 2. Erosion of vertebral bodies (Pott spine features) > Treatment- Incision and drainage + ATT. (Groen 1aEAR EMBRYOLOGICAL DEVELOPMENT OF EAR DEVELOPMENT OF PINNA ‘Tragus of pinna develops from 1st branchial arch, Rest of pinna develops from 2nd branchial arch. The line called incisura terminalis is the junction of 1st arch and 2nd ‘arch > There is no cartilage in incisura terminalis. Therefore, LEMPERT'S ENDAURAL INCISION passes throuch incisura ‘terminalis and enters the external auditory canal. LEMPERT ENDAURAL INCISION The other incisions in ear surgery are- ‘s groves> Wildes postaural incision, it lies behind pinna 6 mm lateral to retroauricular groove. > Rosen's endomeatal incision is given inside External auditory canal, ‘6mm away from the tympanic membrane. It is used for surgery for CONGENITAL DISORDERS OF PINNA 41, PREAURICULAR SINUS > If the union of 1" and 2“ arch is incomplete, it will lead to a congenital disorder called preauricular sinus > If asymptomatic, it needs no treatment zi fpsa Oa eR) > If recurrent infection is there in prearicular sinus, surgical resection of ‘tract is done > PINNA development completes by 20" week of TUL HILLO&KS OF HIS > During embryological development of pinna, 6 elevations form on the head and neck are of embryo which eventually fuse to form pinna. > These 6 elevations are called HILLOCKS OF HIS. (MEG) > Pinna development completes by the 20th week of embryological life a gress> Normal pinna has 2 curvatures called HELIX (C) and ANTIHELIX(). 4. BAT EAR > Tf anti helix is absent, it is called BAT EAR. > Cosmetic surgery of pina called otoplasty. » It is done at 6 years of age. (ideal age) 5. Other abnormalities in shope of pinna a, WILDERMUTH EAR- It is absence of curvature of helix, in this condition there is flat/ unfolded helix/ outer border of pinna. = corrected at 6 years b MOZART EAR- it is a fusion of HELIX and ANTIHELIX, = cosmetic surgeryLDERMTH'S EAR EXTERNAL AUDITORY CANAL (EAC) MOZART’S EAR Ast branchial cleft. EUSTACHTAN TUBE, MIDDLE EAR Ast branchial pouch. CTO jENco: ist ist BRANCHTAL Y-~ PRANCHTAL CLEFT TaN, POUCH rac ME, SKIN 2 PHAYRNX Devel > Malleus and Incus develop from the 1st arch. > Stapes- it has two sources of embryological development. ‘a, Head of stapes develop from 2nd arch. b. Footplates of stapes develop from OTIC CAPSULE (neuroectoderm). - Footplate of stapes is attached at the oval window of cochlea. > eochlea is also derived from otic capsule > Cochlea development completes by 20th week o growersDEVELOPMENT OF INNER EAR > OTIC CAPSULE- has 2 divi + PARS SUPERIOR. gives origin ‘to semicircular canal and utricle. = PARS INFERTOR- gives origin to cochlea and saccule, 'Q) Which Ear structures are of adult size at birth? (VIVA/MEQ), ‘Ans: - Middle ear + Ossicles ~ Cochlea Q) Which muscle attach to the mastoid dip? ‘Ans: Sternocleidomastoid Clinical anatomy > Mastoid tip is obsent at birth. > It develops at 2 years of age. (WCQ) > Stylomastoid foramen is the exit for facial nerve 8 (grower> Therefore in children below 2 years of age the facial nerve lies very ‘superficial. So, during ear surgery in patients of this age group, the conventional post aural incision should be avoided ~ In its place, Horizontal or oblique incision should be given. ‘MIDDLE EAR OSSICLES > Names: Malleus(hommer)(M) , Incus (anvil) (Z), Stopes (stirrup).(S) > Size- Malleus >Incus >Stapes > Stopes is the smallest bone in the body ($ for stapes, small) MALLEUS- > Tt has @ hammer like shape. > Parts- = Head of malleus, ~ Lateral process, (outward), close toT™ Handle of malleus Umbo (Tip of handle) INCUS- Lath > Ports - Body, = Short process of Incus = long process of Incus = Lenticular process (end of long process)» Stopes is the smallest bone of Say ‘the body ead » Parts: vis = Head or superstructure of fos ‘stapes, ~ Footplate of stapes.- it is ‘attached at oval window of cochlea > Stopes acts like a piston. If stapes is fixed, it will lead to disease called Otoscleros Otosclorosis hearing loss JOINTS OF MIDDLE EAR > Incudomallea! joint- Saddle joint > Incudostapedial joint- Ball and socket joint > All joints of ENT are synovial jointsDISORERS OF PINNA 1. BINA HAEMATOMA > It is due to trauma » It is a sub-perichondrial hemorrhage. > Treatment is aspiration or drainage + pressure bandage. » Otherwise it will lead to necrosis of cartilage, which leads to post traumatic pinna deformity called as BOXER EAR or CAULIFLOWER EAR 2. KELOID PENNA- Pinna can be a site of keloid It is most commonly found on helix y ib 3. BASAL CELL CARCINOMA > Uleerating lesion non-healing type BCC can also be on nose and pinna Basal cell carcinoma4, GOUTY TOPHE OF PINNA > Most commonly seen on helix. 5. DARWIN'S TUBERCLE- > It is anatomical variation, It is not a disease > Tt is Conical elevation on helix.URE OF SANTORINI] L FISSURE OF HUSCHKE > Isthmus of EAC, ~ it is the narrowest part of EAC. ~ It lies 6mm lateral to the tympanic membrane. ~ Any foreign body beyond isthmus can get impacted - then have to operate under anesthesia and cant be performed in the OPD FOREIGN BODY > Insect in the EAC- treatment is to put oil in the EAC to kill it and then remove it o (geenCOLLAURA L FISTULA 3. LOCALTSED OTITIS EXTERNA/ FURUNCULOSIS(BOIL} > Iris a staphylococcal infection of hair follicle, > It is seen in the outer part of EAC, > In this patient TRAGAL SIGN is positive. (if we touch tragus, pain is seen, tragus tenderness) > Treatment is T&D followed by I6 packing (ICHTHAMMOL - antiseptic, GLYCERINE - reduces edema) 4, MALIGNANT OTITIS EXTERNA- > Tt is an infection of the underlying bone of EAC > It is also called as skull bose osteomyelitis. > It is a life threatening infection, therefore called malignant etitis externa. > It is seen and elderly diabetic patients (60-70 years.). > It is caused by pseudomonas. > clp- ~ Severe ear ache ~ Blood stained ear discharge. - +/- facial nerve palsy (it is the most commonly involved nerve). @ (Groen= +/- 9,10,11,12 nerve palsy. (due to skull base infection) > Examination by otoscopy ~ GRANULATION in EAC, this leads to blood stai > Investigation = CT scan. (for extent of disease) ~ Technetium (technetium) bone scan.- for diagnosis > Treatment- DOC- 3rd gen cephalosporin +/~ ciprofloxacin. > How to assess the response to treatment ~ ~ Gallium bone sean, - ESR ear discharge. ~ C- reactive protein, ~ Clinical examination, LOCALISED OTITIS EXTERNA } 5. OTOMYCOSTS= |» It is the fungal infection of EAC. > The most common fungus to cause this is aspergillus niger, Pert cornea | ematal > Tt is seen in the rainy season. > fe itching in the ear. io (grt© Examination - it looks like @ WET NEWSPAPER like appearance. » Treatment = Aural toilet- by suction or dry mopping with @ cotton tip probe ~ Antifungal ear drops. Eg- clotrimazole, nystatin Trt is also called SURFER'S EAR Tt is hyperplasia of bony EAC. EAR, it is more common in water sports persons so,it is called SURFER'S ‘T. OSTEOMA OF EAC 6. EXOSTOSIS OF EAC Tt is single mass, This is multiple, unilateral Bilateral SessileBiv Right Eardrum Left Eardrum > Tympanic membrane hes 2 part: 1) PARS TENSA- It hos three layers. A. outer- skin, B. inner ~ mucosa C. middle - fibrous layer. > Pars tensa makes the majority of tympanic membranes ve Kgrowe.> Main function of the eustachian tube is middle ear ventilation > If ET gets blocked it will lead to negative pressure in the middle ear, there will be @ vacuum, this lead to retracted TM . > Features of retracted tympanic membrane- = This dull ~ Handle of the malleus is medialized. = Cone of light is distorted. ~ Lateral process of malleus is more prominent. = On segelixation (air pressure), it shows less or no movement, > If there is too mich retraction it will ead to formation of retraction pockets. RETRACTION POCKET: > This retraction pocket is most commonly seen in pars flaccida end secondly seen in posterosuperior part of pars tensa. > Retraction pocket is lined by skin and filled by keratin. > If the retraction pocket is allowed to progress there will be smell perforation at the tip of the fundus of retraction pocket. wt (G rosrerconea Baan > Through this perforation, skin starts growing into the middle ear. > Presence of skin in the middle ear is called cholesteatoma. (It is pearly white in colour) MYRINGITIS BULLOSA > This is Viral infection of tympanic membrane, > There are multiple clear fluid filled vesicles. > It is a poinful disease and self limiting disease. MYRINGOSCLEROSI: > It is a hyaline degeneration of the middle fibrous layer of tympanic membrane. > It can be a sequel of pre-existing infection.TRAUMATIC PERFORATION OF TYMPANIC ‘MEMBRANE- » Treatment - conservative, keep the ear dry. > No ear drops for 3 months by cleaning car after bath > TOC - conservative EUSTACHTAN TUBE(ET) > It connects the middle ear to the nasopharynx > Tt is nasopharyngeal opening that lies 1.25cm behind the posterior end of inferior turbinate. It is 36mm in length, outer 12mm is bony(towards ‘middle ear), immer 24mm is cortilaginous(towards nasopharyn). > At birth, it is nearly horizontal, but in adults it is 45° angle with the horizontal > Main function of the eustachian tube is middle ear ventilation. > Tensor veli palatini or tensor palati muscle opens the tube during swallowing. 166 [GG rersservoeePETS > ET function tests are (whether the air is going or not) ~ Valsalva (crude method)- it is @ forceful expiration with closed nose and closed mouth. Eustachian tube catheterization ~ Eustachian tube politzerization- itis done with the help of plitzer bag, Politzer bag has an olive shaped tip, Kept in the nostril, Olive shaped tip kept in the nose and balloon in the doctors hand, TM moves if T patent w (erent~ Tympanometry- this is the best test. GLUE EAR > Glue ear is also called SEROUS OTITIS MEDIA or SECRETORY OTITIS ‘MEDIA. (SOM) > New name is OME (OTITIS MEDIA WITH EFFUSION). > C/P- collection of sterile thick glue like fluid in middle ear. > Causes of ET blockage- = Mest common cause is adenoid hypertrophy causing ET blockage (mostly bilateral) seen in school age children. Rare cause- NASOPHARYNGEAL CARCINOMA causing ET blockage (mostly unilateral), seen in adults ‘Most common age is school age children che- ~ Heaviness in the ear-(it is not painful) - Conductive hearing loss(CHL). ~ Poor school performance. - +/~ adenoid face. Ss eS y a (enter> Investigation- ~ PTA- pure tone audiometry (10-40d8 in CHL) = _Tympanometry ~ type 8 (flat curve) q as To = ey > Examination ~ Glue like fluid behind TM. - Air bubbles trapped within glue = Retracted tympanic membrane. - Very rarely bluish tympanic membranes > Treatment- = Medical management - DECONGESTANT THERAPY. Surgery MYRINGOTOMY (anteroinferior quadrant) + GROMMET INSERTION ‘middle ear ventilation tube) dumbbell shaped,rice grain size ‘tomy @. EY 0 iy cw +/- ader Ly NS eA ae ae Ciao 1 Psen‘MODEL OF MIDDLE EARMIDDLE EAR CLEFT > Middle ear cleft is a combination of all hollow cavities in temporal bone. > Tt has 5 parts = Eustachian tube. penne, - Middle ear, ren + Aditus. am = Antrum. = Rest of air cells Sel m (fg rereDISEASES OF MIDDLE EAR CLEFT ASOM. ACUTE SUPPURATIVE OTITIS MEDIA > It is an infection of the middle ear mucosa by a pyogenic organism. > Most commen organism to cause this is streptococcus pneumoniae, Infection reaches nasopharynx to the middle ear via the eustachian ‘tube. > Stoges- ~ Stage of tubal acclusion. = Stage of pre suppuration + Stage of suppuration ~ Stage of resolution(with treatment) or 4. Stage of complication. Polen eos > C/C- earache. > Examination- red tympanic membrane.(CART WHEEL SIGN) with dilated copillaries | > Treatment- medical management. > Antibiatics like Co- amoxiclav. | > decongestant (first nasal decongestant ‘and then systemic decongestant) | > naigeses. a er> a Dhow » Meq- ASOM patient with severe earache and red bulging tympanic ‘membrane > Tf no management, will lead to perforation of tympanic membrene(pus will come out of ear). > Treatment is myringotomy (in posteroinferior quadrant) > Otherwise this situation will lead to perforation of tympanic ‘membrane(pus will come out of ear). > If treatment is taken- this perforation has spontaneous healing within ‘the next few weeks in most of the cases, Healed membrane is thin and weak and lacks fibrous layer, so called DIMERIC MEMBRANE. > Tf no treatment is taken for next 3months- it will lead to permanent perforation. This disease is called safe CSOM. PERMANENT PERFORATION So Oe Tae ve greeSAFE CSOM > Tt is also called TUBOTYMPANIC CSOM. » It is characterized by the presence of permanent central perforation in pors tensa of TM. OG (CENTRAL PERFORATION > Permanent means margins of perforation are epithelized and there is no possibility of spontaneous healing, > CENTRAL PERFORATION MEANS INTACT TM MARGIN ALL AROUND ‘THE PERFORATION >» cle- - Ear discharge- it is mucopurulent, not foul smelling and not blood stained. Amount of discharge increases wh ory infection. = Hearing loss (no pain ear) fe In long stonding cases there canbe ossicular erosion. First osscl to be eroded mostly is incus. - WHYXINCUS? - Incus has no muscle attached to it , so no blood supply. The first part of incus to be eroded is lenticul : followed by long Kgrowen> Most commonly used approach is the postaural approach, it is done by ™ WILD'S post aural incision. ~ This incision is given 6mm lateral to retroauricular groove. We use MOLLISON'S self retaining mastoid retractor to expose the area. It's a microscopic ear surgery. Cree > Other approach- PERMEATAL APPROACH. > Most commonly used technique for putting the graft is UNDERLAY TECHNIQUE. In this technique we put the graft below the margins of TM after elevating the TYMPANOMEATAL FLAP > Another technique of putting graft is OVERLAY TECHNIQUE. In which graft is placed between the skin and other layer of TM . EwMASTOIDITIS > Tris an infection of the mastoid including air cells. Tt is a complication of ASOM and CSOM. > C/C~ pain behind the pinna, > On examination ~ Mastoid surface is found to be smooth, red and shiny. This is called ‘the ironing of the mastoid surface, It is the first sign of mastoiditis. ‘Mastoid tenderness is positive- tenderness is checked at Over the antrum.(in cymba conchae area). . Over posterior border. 3. Over the tip of the mastoid. > This patient complains of profuse ear discharge. > On cleaning the discharge fills immediately again this is called RESERVOIR SIGN. > The pus is continuously flowing from mastoid to middle ear. This is called PULSATILE OTORRHEA and also called LIGHT HOUSE SIGN. (can also be seen in ASOM) > In EAC there is sagging of skin in the posterosuperior area. Nes 182 G rotesnosr 0008eo Coa PETROS! GRADINEGO SYNI > It is an infection of petrous apex air cells. » It's a complication of ASOM or CSOM. > CT scan of temporal bone will show abscess at petrous apex. > It has 3 features- ~ Ear discharge. (E) = Retro orbital pain due to Sth nerve involvement. (R) = Diplopia due to 6th nerve involvement. (6) ‘4 [GrocerGUZEN ~ arama > From marginal perforation, absent of one margin. EAC skin cen enter to ‘the middle ear through absent margin. This origin is called HABERMANN'S THEORY. This type of cholesteatoma is also called SECONDARY ACQUIRED CHOLESTEATOM M.. [Yona arn Nes aan eA) CENTRAL PERFORATIOI [MARGINAL PERFORATION, —| > Congenital cholesteatoma- we use LEVENSON'S CRITERIA to diagnose this condition. PEARLY WHITE MASS behind INTACT TM . > Tertiary acquired cholesteatoma, it is due to accidental implantation of ‘skin in middle ear during surgery or trauma. Safe CSOM > Why is cholesteatoma unsafe? ‘Ans-It is due to bone erosion.> TUNNEL OF CORTE - between the pillar cells > It has got 2 types of cells> If @ patient of BPPV does not respond to this treatment for months, ‘then the patient gets chronic BPPV, this leads to Recurrent disabling vertigo. Then this patients go for surgery called SING NEURECTOMY (singular nerve supplies posterior SCC). > In BPPV- VERTIGO only for a few seconds and no hearing loss. SEMICIRGULAR CANAL(SCC) > There are three ] Tnor Ear sce. 1, LATERAL SCC/ HORIZONTAL. 2, POSTERIOR SCC. 3. SUPERIOR SCC. > These 3 canals have Five ‘epenings, because one limb Function of canal- ANGULAR BALANCE. Synergistic canals- 3 pairs 1. Right - lateral semicircular canal & left- lateral lar canal. (R LSCC & L LSCC) (growersNe 0 \ > ELECTRONYSTAGMOGRAPHY(EMG) is electrical recording of nystagmus. BUTTERFLY CHART is used to plot the findings of ENG CALORIC TEST. ~ This plot the cumulative frequency of nystagmus. ~ No nystagmus, problem - dead inner ear = More nystagmus - hypersensitive ear ® aXe cxonl f > ERENZEL GLASSES- are with +20 D lens, it doesn't allow the patient to gaze. Hence this is used for gaze suppression of nystagmus. > VIDEONYSTAGMOGRAPHY(VMG)- nystagmus has beth slow component end fast component. - Slow component is by virchow of disease and fast component is the central corrective response. ~ By rule the direction of nystagmus is always taken by fast components. - The basic reflex behind nystagmus is vestibulo ocular reflex(VOR).FRENZEL GLASSES VIDEONYSTAGMOGRAPHY(VM6) Peripheral causes of vertigo Central causes of vertigo. BPPY Meniere's disease Labyintitis Ototoxicity Superior canal dehiscence syndrome ‘Migraine headache. Multiple sclerasis. ‘Mal de débarquement syndrome Cerebellar hemorrhage and infaret Vertebrobasilar insufficiency Vertebral artery dissection Brain neoplasm Peripheral vertigo Central vertigo = Mostly sudden onset “= Mostly gradual onset. = Intermittent with severe + Constant with milder symptoms. symptoms. + Affected by head position and | = Unaffected by head position and movement. movement. + Nausea and vomiting are more | - Nausea and vomiting: are less frequent and severe. predictable. = Motor function, gait and coordination typically intact. + Motor function, gait instability. ‘and loss of coordination frequent.VESTIBULOCOCHLEAR NERVE-(8TH NERV! > It has 3 divisions 1. Cochlear division. 2. Superior vestibular division. (SV) 3. Inferior vestibular division. ZV) > 2/3% ear is for balance and 1/3” for hearing > 7th & 8th nerves enter the ear via the Internal Auditory Canal also called internal auditory meatus. A BILL'S BAR- it is vertical bony septum in ‘the upper part of the internal auditory ‘canal.AUDITORY PATHWAY Wi sacdccsse (geen:LeTEMPORAL BONE FRACTURE BATTLE SIGN - it is ecchymosis in the | mastoid region. It is seen in skull base | fractures (temporal bone fracture). ‘Temporal bone fracture are two types: Longitudinal fracture Transverse fracture + This is due to falling on the + due to Fall on front or the side. back. + 80% of total fractures. + 20% of total fractures. + Less dangerous. + More dangerous. + Ossicular dislocation. + Damage cochlea. + CHL + SNHL + Vertigo is uncommon. + Vertigo is common. + EAC bleeding and CSF EAC bleeding and CSF otorrhoea cotorrhoea are more common. are less common. (L for leaking, L for longitudinal) + Facial palsy is more common and + Facial palsy is less common and | immediate in onset it is due to delayed in onset it is due to direct injury to nerve. | edema. + So treatment is immediate + So treatment is oral steroids. surgery. 26 Ki rorsTEMPORAL OSSICULAR DISLOCATION > TEMPORAL bone fracture can lead to ossicular dislocation, most common ‘ossicle dislocation is TS joint. (as incus hes not muscular support) > There can be 2 possibilities in ossicular dislocation 4. Ossicular dislocation with normal tympanic 54d8 CHL. . Ossicular dislocation with Perforated tympanic membrane - 3848 CHL. (through the hole, some sound will also be able to directly ener in the ear) N_SNHL is defined as sudden hearing loss of minimum 3048, it should be visible at least 3 contionous frequencies in PTA, in 3 days. > It's unilateral » Unknown etiology. > Hypothesis 1. Inflammatory cochleitis.. > Definition- m genesSCHWARTZ > Treatment - Rx © C is surgery called stapedotomy (stapedectemy older surgery) > Steps of stapedotomy- A 1. Rosen's endomeatal incision. 4 2. Expose middle ear | 3. Disengage Incudostapedial joint 4. Remove the head of the stapes. I 5. Moke a hole in the footplate of stapes. 6. Place stapes piston prosthesis(looks like question mark.). It is made up of titanium or teflon. m Kf worsrexro0e