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EXTERNAL CAR AND MIDDLE CAR |

• EAC arises from(1st ec+odermal cleft

• Middle ear cleft Mastoid antrum +Middle ear cavity +Eustachian tube) develop from the first
ectodermal pouch+2 nd endodermal pouch (small part)
• The ear ossides(MalLeus +lncus+ Stapes Suprastructure ) arise from the mesoderm of 1st
and 2nd pharyngeal arch .
• The TM develops from 3 sources:-Ectoderm ,Endoderm,Hesoderm
• Foot plate of stapes arise from Bony labyrinth / Otic capsule.
The pinna arises from mesodermal thickening of 1st and 2nd arch called Hillocks of Itis.
•
COLLAURAL FISTULA

• ItAbnormality of 1st brachial cleft

• has 2 openings EAC (middle ear )
Neck (below &behind the angle of mouth)

INNER EAR (LABYRINTH)!

MEMBRANOUS LABYRINTH BONY LABYRINTH

Arises from Otic placode(Surface Ectoderm) Otic capsule ( Mesenchyme around membranous
labyrinth)
(Utricle+ saccule+3 semicircular ( 3 Semicircular canals+vestibuLe+Scala vestibule
Consists of canals+Scala media+ Organ of + Scala media)
Corti)

CONGENITAL ANOMALIES

• Michel aplasia - Total non development of inner ear

• Alexander aphasia - Dysplasia of basal turn of cochlea
• Mondidni aplasia( ) - Cochlea has only 1.5 turns
• Schiebe aplasia MC - Anomaly of saccule & Cochlea

% notespaedia 1
0 Previous Year Questions NEETPG 2020

From which of the following structure does the saccule develop?

A ) Saculus anterior
B) Saculus posterior
C) Pars superior
tyfPars inferior

% notespaedia 2
PINNA

LANDMARK FOR MASTOID ANTRUM ( Ntfj )

BONY LANDMARK Mac evens triangle

O'
at
CARTILAGINOUS Cymba Concha
LANDMARK

\
bo««

BOUNDARIES OF MACEVENS TRIANGLE

Supramastoid
crest
Superiority - Temporal Line

-
I Anteriorly- Posterosuperior segment of external
Macewen's
triangle l ::A acoustic meatus

Posteriorly- Line drawn tangent to EAC

•External
ear canal
process
Styloid
process

% notespaedia 3
ANATOMY OF EXTERNAL AUDITORY CANAL
External auditory canal

CART 1LAGENE 0US PART BONY PART

Length (8mm) (16mm)

Lined by skin with hair & ceruminous glands stratified squamous epithelium without skin
appendages
Directed upwards &backwards downwards and forwards

Significance Site of furuncle Narrowest part of EAC(isthmus)

<
Foramen of Huschke
• Deficiencies in EAC Fissures of santorini

< ANTERIOR Auriculotemporal Nerve

•Nerve Supply : WALL
POSTERIOR Arnolds nerve( Branch of Vagus N )
WALL Facial Nerve

% notespaedia 4
0 Previous Year Questions NEETPG 2020

Cough on scratching the external acoustic canal is due to?

A) Auriculotemporal nerve
Auricular branch of vagus
C) Great auricular nerve
D) Facial nerve

ANATOMY OF TYMPANIC MEMBRANE

• ItJunction between external ear and middle ear

• is tilted forward making an angle of 55 degree
and the posterior border is tilted more towards
the EAC making it more accessible .
• Colour:Pearly white / Grey
• 2 parts: |— > Parstensa
L Pars flaccidalSharpnells membrane )
*
Nerve supply of TH : Identification of side based on :
o Cone of light
MEDIAL SURFACE Jacobsons nerve(Branch of CN IX ) Anterior tilt of tympanic membrane
°
LATERAL SURFACE Arnolds nerve.Auriculotemporal nerve

Predicted Question i r< Predicted Question i

Q.A 25yr old woman presents to the OP with Q.Identify the side of ear based on TM
do of pain and decreased hearing in the ( R) picture?
ear for 1 week.No h/o ear Ans: Left
discharge,bleeding,fever.OH : impacted wax
in the ( R) ear.She was instructed to use wax
solvents and after 1 week.Upon review
syringing using water was done.She started
coughing continuously during the
procedure.What caused this?

Ans:Stimulation ofCNX
f

% notespaedia 5
^ Predicted Question
Q.A patient presented with h/o persistent discharge from ( L ) ear for the past one month
which is not foul smelling or bloody.O/E, TM perforation seen in the anteriorinferior
quadrant.Xray mastoid showed clouding ofaircells.She was diagnosed with CSOM and
posted for surgery.The surgeon found it difficult to access the mastoid antrum because of
the persistence of a certain suture in the mastoid.Identify the condition.

Ans.Korners septum due to persistence of petrosquamous suture.

% notespaedia 6
 /I r^W w i 4 H U t I

Walls of middle ear and the structures related to them

Posterior 6 Medial
Lateral 7
9

Anterior
3 5
13
Vi 10
8 -4 O 1
2

1.Canals for Tensor Tympani.

V12

<T7?\
2.0 pening of Eustachian tube. 3.0val Window A.Round Window.
5.Processus cochleariformis. 6.Horizontal Canal. 7. Facial Nerve. 8.Pyramid
9.Aditus. 10.Chorda Tympani. 7 7.Carotid artery. 12.JugularBulb. 13. Promontory

•Has 6 walls
1 . MEDIAL WALL
• Lateral SCC
• Oval window covered by stapes footplate( opens into vestibule of inner ear )
• Round window lined by secondary tympanic membrane (opens into Scab tympani of inner ear )
• Promontery (impression of basal turn of cochlea )
• Process cochleariformis (Bony projection which acts as a landmark for 1st Genu of facial
nerve .tensor tympani takes a turn here )
• Horizontal segment of facial nerve

2.POSTERIOR WALL
• Aditus topening into mastoid antrum
• Fossa incudis: impression of short process of incus
• Vertical segment of facial nerve
• Sinus tympani: HC site of residual cholesteatoma
• Facial recess:Site of approach to middle ear through mastoid
• Pyramid :Site of origin of stapedius muscle
Chorda tympani: enters the middle ear and exits through anterior wall
•

% notespaedia 7
3. ANTERIOR WALL
• Exit of Chorda +ympani(Canal of Huguier )
• Opening of Eustachian tube
• Origin of tensor tympani

4. FLOOR
• Related to Jugular bulb
• CN IX XXI
• Entry of tympanic branch of CN IX (Jacobson' s Nerve)
5 ROOF
• Formed by tegmen tympani

CAVITY OF MIDDLE EAR

Lateral attic wall

Epitympanum

Pars flaccida —

Mesotympanum

Hypotympanum

Divisions of middle ear into epi-tmeso- and hypo- tympanum.

Epitympanum
• Divided into 3 parts

• Si e:6 ml
2
E Mesotympanum
Hypotympanum

• Protympanum:Area of Middle ear around the Eustachian tube

• Prussack s Space:Most common site for T Cholesteastoma
'

NERVE SUPPLY OF MIDDLE EAR

• Sensory supply is by Tympanic plexus
• Formed by :Jacobson s Nerve '

Superior and Inferior Caroticotympanic Nerves

% notespaedia 8
INTRATYMPANIC MUSCLES
TENSORTYMPANI STAPEDIUS

Attached to Neck of malleus The stapes

Function Tenses the TM Stabilises the ossicular chain

Supplied by CN V 3 CN VII

Malleus Incus

Body
Head
Short process
Neck

Anterior process Long process

Lenticular process
Lateral process

Handle Stapes

Head
Anterior crus
Posterior crus

Footplate
Ear ossicles and their parts.

Previous Year Questions ( AIIMS 2017 )

The given image is of a patient in whom mastoidectomy is done. Identify the lateral semicircular canal:

A) A
MB
C) C
D) D

% notespaedia 9
A ) MEMBRANEOUS LABYRINTH

Ductus reunions
Fnciolymphiiltc duel Erutulymphatic MC

Elliptical recess
( for utricle )

Spherical recess
( for saccule )

Scale vest )Puli

Osseous spiral
lamina
Scala tympam Opening for
Opening of endolymphatic duct
c cochlear aqueduct
(A) Lett Pony labyrinth (B) Left membranous labyrinth. (C) Cut section of Pony labyrinth

PARTS OF MEMBRANEOUS LABYRINTH

3 semicircular canals Utricle Sacule Scala media

FilLed with endolymph

10
SEMICIRCULAR CANALS

Semicircular canals

[ I
Superior Posterior Lateral

• They open into utricle through 5 openings

• (Superior APosterior SCC has a common opening crus communae
• Endolymphatic duct drains endolymph from utricle & saccule to endolymphatic sac.
• SCC.Utricle & Saccule acts as the sensory end organ of balance.
UTRICLE AND SACCULE see

Contains Macula Cristae

Detects linear acceleration rotational acceleration

• Macula contain Calcium carbonate crystals (otolith)

• BPPV is due to dislodgement of otolith from macula to SCC(MC Posterior )

0 Previous Year Questions AIIMS 2019

Which of the following features is not associated with

superior semicircular canal dehiscence syndrome?
A ) Gaze dependent nystagmus
B ) Positive Fistula test
Sensorineural hearing loss
D ) Positive Tulio phenomenon

% notespaedia 11
ANATOMY OF ORGAN OF CORTI

% notespaedia 12
ORGAN OF CORT 1

• Sensory organ of hearing

• Hair cells are involved in transduction of vibratory signals to electrical signals.
• 2 types of hair cells
INNER HAIR CELLS OUTER HAIR CELLS

Less in number More in number

Less prone to damage More prone to damage

Produce OAE

Affected more by ototoxic damage.

B )B 0NY LABYRINTH

• FilLed with perilymph

• Bony covering of membraneous labyrinth
PARTS

3 Semicircular canals
Vestibule(Covers utricle& saccule )
Cochlea ( forms Scala vestibule & Scala tympani around Scala media )

Predicted Question

A child of age 5 yrs was admitted following development of fever,stiff neck & vomiting.He was
started on treatment and was stabilised . His mother do the child looking dull and not responding
to conversations.On evaluation he was found to have SNHLWhat caused it?

to inner ear via cochlea Ul

% notespaedia 13
AUDITORY PATHWAY

Organ of corti
Auditory
4
cortex Cochlear nerve
( Area 41)
Auditory 4
radiations
Medial SuperiorOlivary complex
geniculate
body 4
Ventral and dorsal Lateral lemniscus
cochlear nuclei Inferior
colliculus 4
VIII Nerve Nucleus of
Inferior colliculus
r /
(W\) lateral lemniscus
4
Lateral lemniscus
w Medial geniculate body
Superior olivary 4
complex
Cochlea Auditory cortex
Trapezoid body
Auditory pathways from the right cochlea. Note bilateral
.
route through brainstem and bilateral cortical representation

• Superior olivary complex is the centre for stapedius reflex

o Previous Year Questions AIIMS / INICET 2020

Identify the correct sequence of the auditory pathways:

A. SuperiorOlivary nucleus
B. Cochlear Nucleus
C. Inferior Colliculi
D. Lateral lemniscus
E. Medial geniculate ganglion

AJABCDE
&BADCE
C) BACDE
D ) BAEDC

% notespaedia 14
VESTIBULAR PHYSIOLOGY

• Sensory organ of balance:Cris+ae &Macula

• Defect in them causes nystagmus.imbalance
• Based on the direction of nystagmus(fast component)
• Direction of nystagmus is always towards the active side or hyperactive ear
Eg:lf (R ) sided nystagmus is present

Destructive /hypoactive lesion of (L) side Irritable /hyperactive lesion of (R) side

0 Previous Year Questions AIIMS 2018

A patient complains that he feels like the room is spinning when he gets
up from lying down or turning his head. He has no history of loss of
consciousness. Which of the following could be the probable diagnosis?
Benign paroxysmal positional vertigo
B ) Meniere's disease
C) Labyrinthitis
D ) Syncope

o Previous Year Questions AIIMS/ INICET 2020

A patient complaining of vertigo without hearing loss has consulted an ENT surgeon.
The surgeon performs a diagnostic maneuver and cautiously performs a therapeutic
maneuver. What is the diagnostic maneuver?
A) Hampton's maneuver
tyDix-Hallpike maneuver
C) Epley's maneuver
D) Simon's maneuver

% notespaedia 15
 .
BENIGN PAROXYSMAL POSITIONAL VERT 1G O ( BPPV ) //M52078j
^
• It is a common condition affecting middle aged population
• There is dislodgement of Otolith of macula into SCC leading to dizziness on movement of
head.
• Diagnosed by Dix Hallpike Haneoveur
• It is managed by using Epleys maneoveur
Dix- Hallpike Maneuver
Tests for canalithiasis of the posterior micircular canal, which is the most
common cau of benign paroxysmal positional vertigo (BPPV )

1 .
With the patient sitting up turn the head 45 degrees to one side

2 Lie the patient down with head overhanging the edge of the bed
and look for nystagmus

3 Repeat on the contralateral side

THE EPLEY
Redistributed
particles

Particles n
semicircular
canal

'F
The head may be rap dty turned The clinician rotates the patient s
even further to almost* face the floor head toward the affected ear. then
The patient ts relumed to the lowers the pat » enr backward to the
upnght position, and the head «s supine position with the head
rotated back to normal
^ —— _ hanging over the table s edge

1
The head is turned further, so that The head is turned to the other side.
the ear » s parallel to the floor

% notespaedia 16
CALORIC TEST

• Used to access the inner ear functioning.(lateral SCC)

PROCEDURE

+ + + kept in lateral supine position with head tilted up by 30 degree

Posi ioning:Pa ien

Warm water ( 44 degree) is poured on the right ear

4
Warm water is poured on the left ear

4
Cold water (30 degree) is poured on the right ear

4
Cold water is poured on the left ear

4
Normal response
Cold water Nystagmus on the opposite side
Warm water- Nystagmus on the same side
*

o Previous Year Questions AIIMS 2018

While performing a caloric test, what type of nystagmus

would you expect on cold water irrigation?
A ) Horizontal nystagmus towards the same side
B ) Vertical nystagmus towards the same side
$ Horizontal nystagmus towards the opposite side
D ) Vertical nystagmus towards the opposite side

% notespaedia 17
HEARING LOSS

Hearing Loss

i
Organic Nonorganic
i

i
Conductive
i
Sensorineural

Sensory
i i
Neural
(cochlear)

Peripheral Central
i
( VIIIth nerve) (Central auditory
pathways)

CONDUCTIVE HEARING LOSS

Due to any defects in the conductive pathway of sound in the middle ear.

CONGENITAL CAUSES ACQUIRED CAUSES

External ear Hiddle ear
•Heatal atresia •obstruction in •Perforation in the TM:traumatic or
•Fixation of stapes footplate the ear canal. infective.
•Fixation of malLeus head Eg: wax ,foreign •Fluid in the middle ear:
•Ossicular discontinuity body , furuncle, SOH.Hemotympanum
•Congenital cholestatoma acute •Hass in the middle ear :benign or
inflammatory malignant tumour
swelling. •Disruption of ossides:trauma to
ossicular chain.CSOM,Cholesteatoma
•Fixation of ossicles: otosclerosis,
tympanosclerosis.adhesive otitis media
»Eustatian tube blockage:retracted
TH.SOH

% notespaedia 18
SENSORINEURAL HEARING LOSS

• Results from lesions in the inner ear or neural pathway of hearing.

Causes of sensory neural hearing loss:

CONGENITAL ACQUIRED

• Anomalies in inner ear • Labyrinthitis

• NIHL
• Ototoxicity
• Trauma
• Presbyacusis
• Meniere s disease
'

SUDDEN SENSORY NEURAL HEARING LOSS

•Defines db
as 30
period of days less.
a 3
of
or more
or
at least contiguous frequencies occurring within
SNHL over 3

•Management
Common ethologies infections
: Ototoxicity etc
,Trauma, ,

• Steroid therapy.Carbogen inhalation Vasodilator drugs.Oxygen therapy

: ,

PROGNOSTIC FACTORS IN SUDDEN SNHL

GOOD PROGNOSIS BAD PROGNOSIS

Mild. Loss Severe loss

Low & medium frequency loss High frequency loss

Recovery starting in 2 weeks Recovery does not start in 2 weeks

No history of vertigo History of vertigo +

Younger patients Older patients

Early treatment Late treatment.

% notespaedia 19
NOISE INDUCED HEARING LOSS

Chronic exposure to Loud sounds can damage the organ of corti

# If affects the higher frequencies first
9 Especially in workers at factories,traffic policemen
• Adequate protection must be given(ear plugs,mufFlers )in these cases.

0 Previous Year Questions AIIMS 2017

A metal factory worker suffers from noise - induced hearing

loss. Which of the following structures will be affected?
A ) Crista ampullaris
B) Macula
C) Cupola
PfOuter hair cells

PRESBYACUSIS

SNHL Associated with normal aging process

• High frequencies are affected first

OTOTOXICITY

• Damage to the inner ear by various drugs or chemicals.

• Host common implicated drugs are aminoglycosides or diuretics(loop diuretics)
• Other drugs include salicylates anti malarial drugs.anti cancer drugs
,

• Streptomycin Gentamicin Tobramycin. Vestibulotoxic

, ,

• Kanamycin.amikacin Neomycin.
, Cochleotoxic

% notespaedia 20
WHO CLASSIFICATION OF HEARING LOSS

DEGREE OF HEARING LOSS

1.MILD 26-HOdB
2.MODERATE m-55dB
56- OdB
3.MODERATELY SEVERE ^
•i.SEVERE T1- 91dB
5.PROFOUND More than V dB
6.TOTAL

•Those with hearing loss of > 90 db in the better ear or total loss of hearing in both ears are
considered deaf

% notespaedia 21
1) TUN1NG FORK TESTS

IRinnes test
2.Webers test
3.Absolute bone conduction test
k. Schwabach test
S.GelLes test

1 )R !NNES TEST
•To assess & compare air conduction & bone conduction of both ears
Positive Rinnes - AC >BC Negative Rinnes - BC >AC
I
SNHL Normal Ear CHL
*
Severe SNHL
(False negative Rinnes)

2) WEBERS TEST
• To differentiate between conductive and SNHL
CHL Lateralised to affected ear
Severe SNHL Lateralised to normal ear
• Lateralisation implies a conducive loss of 25 db in affected ear.

3 ) ABS01UTE BONE CONDUCTION

•Compares bone conduction of patient with examiner to check for SNHL

I ABCl

Same:normal/ C HL Shortened:SNHL

4 )SCHWABACH TEST

•Tests both CHL & SNHL SCHWABACH TEST

I
Shortened: SNHL
Same as examiner
Normal
11 Lengthened : CHL j

% notespaedia 22
5)GELLES TEST
•Test for assessing ossicular -fixation
• Pressure in EAC is altered using Siegel speculum

| GELIES TEST |
I
I
I Positive | I Negative|
(Hearing varies with pressure) (No change in hearing with pressure )
Normal Ossicular fixation

0 Previous Year Questions AIIMS 2018

In which of the following conditions is Gelles test negative?

A ) CSOM with Cholesteatoma
B) Senile deafness
C) Meniere ' s disease
Otosclerosis

11) PURE TONE AUDIOMETRY

Ear
• Subjective test
Modality
• Differentiate
Assess degree of hearing loss Right Left
• Normal threshold
CHI & SNHL
AC unmasked O
• is 0 25 db of hearing
-
X
AC masked A
BC unmasked
BC masked C
No response P

% notespaedia 23
NORMAL PTA
Frequency in Hertz ( Hz)
125 250 500 1.000 2.000 4.000 8.000
750 1.500 3.000 6.000 12.000
-10 -10
0 0
10 10
o
I 20
30
* 20
30
7
I 40 40
50 » 50
s 60 - 60

3 70 70

r * 80
1 90 90
100 100
110 110
120 120
AM Conduction Right left
Threshold Ear Ear
Unmatked O X

CHI
x
- 10
0
10
X
X x
$
*
!“
I: 3C
IOC
110
IX
IX
125 RC W 1000 2000 4000 8 X0
frequency ( HJC)

AB Gap >15 db

MEN1ERES DISEASE
-10
o
10
20
30

“ 40

> 50
s
o 60
c
c
s
I
80
90

100
110
120
125 250 500 1000 2000 4000 8000
Frequency (Hz)

Low frequency SNHL: Meniers disease

% notespaedia 24
 OTOSCLEROSIS
frequency in Her+z
VDO 5*00 COO 2000 4000

0
10
20
-
ft 3
4 30
c

*140
Z0

f*
|
®
70

* 00
90
oo

o Previous Year Questions

m H era ( He )
AIIMS 2017

Q. A 25 -year-old woman presented with hearing loss that

developed shortly after her first pregnancy. Her audiometry
.
,r

10 k
.
~ “
HLH ^
>000

0
7000

to

report is given below. What is the diagnosis? i TO

5 "
I«
A ) Ototoxicity 9 *>
B ) Meniere disease
s
00
^
—
70

$ Otosclerosis J
Z HO
+
D ) Noise induced hearing loss
I
no IIO

% notespaedia 25
HIGH FREQUENCY SNHl
Frequency n Hertz
125 250 500 1000 2000 4000 8000

•acousticPresbyacusis.ototoxicity
Seen in . o
10
trauma
neuroma,noise
20

• dip at -Boilers notch 1-J

In NIHL kK
30
40
50
T 50
§ 70
80
90
100
1IQ

MILD FREQUENCY SNHL

AC BC B7 *
125 250 500 Ik 2k 4k

-
• Cookie bite /U shaped audiogram
10

10
o
c
20
« A
N

30 0- 0
OX 5
? 40
AX
© o
x
- O
X — <
X - X>
/
X

2
I 50 S
5
60

1 70
80
90 I
100
110
I
120
750 1 5k 3k 6k

BARONY ’S NOISE BOX

•Barony 's noise box is used to mask the non test

ear while testing bone conduction.

% notespaedia 26
 Predicted Question

What is the transformer ration of middle ear ?

AnsiTransformer Ratio = Areal ratio X lever ratio
= 17: 1 x 1.3: 1

=22

Predicted Question

A patient with h/o decreased hearing was subjected to tuning fork tests.Rinnes test negative in
R ear ,Webers test lateralised t ear interpretation?
Ans: ( R) severe SNHL

111) IMPEDANCE AUDIOMETRY

% notespaedia 27
TYPES OF TYMPANOGRAM

• AAs - Normal
• Ad - Reduced compliance at the ambient pressure (Otosclerosis)
•B Increased compliance at ambient pressure (ossicular discontinuity)
• - Flat or done shaped(Huid in the middle ear)
•C - Maximum compliance at the pressure more than -200mm water

% notespaedia 28
STAPEDIAL REFLEX ( ACOUSTIC REFLEX )

• Loud sounds cause contraction of the stapedius muscle to stabilise the ossicular chain
that inner is not damaged.
• Can decrease the amplitude of sound waves upto ^Odb
• It is an objective test & is used to identify malingering.
• Afferent:CN VIII
• EfferentrCN VII

BERA

Recruitment
TESTS FOR ACCESSING SNHL

j Electrocochlcography j
Roll over
phenomenon

| CERA |

0 Previous Year Questions AIIMS / INICET 2020

Which of the following are the objective tests for the hearing?
1. BERA ( Brainstem evoked response audiometry )
2. OAE (Otoacoustic emission )
3. PTA (Pure tone audiometry )
4. Tympanometry
tf 1, 2, and 4
B ) 1,2, and 3
C) 2,3, and 4
D ) 1,2,3, and 4

% notespaedia 29
 A ) OTO ACOUSTIC EMISSIONS

* Outer hair celLs of normal cochlea produce low intensity sounds.

* Absent OAE- Cochlear pathology (Noise induced damage to hair cells )
* Used in :
Monitoring ototoxicity
Asssess for NIHL
Screening hearing in neonates

B )BRA 1NSTEM EVOKED RESPONSE AUDIOMETRY

• It is used to assess the entire neural Auditory cortex

pathway of hearing body(VI VI)

*

* Best investigation for:

> -

— Testing malingering
_ Testing for retrocochlear hearing loss
j
nucM (V|
(acoustic neuroma )
\
— Screening for neonates in ICU itno

To differentiate befween cochlear and

Auditory pathway
retrocochlear hearing loss
HIM
i
"tmvip i)

075 INTENSITY 80 dBnHL

0.50

0.25

0
AMPLITUDE
(MV)
- 0 25

- 0.50

1 2 3 4 5 6 7 8 9 10
TIME (ms)

% notespaedia 30
 WAVES IN BERA

• Wave V (lateral lemniscus)is the largest

• In case of cochlear defect:Wave 1 appears late
• Acoustic neuroma:Increased gap between Wave 1 & 2
C )RECRU1TMENT
Rt. Lt. Rt . Lt.
• Seen in Meniere ' s disease. 90
^ 90 90 - 90
8i 80 80 80
• Patient hears better when the 7 70 70
'
amplitude of sound is increased. 6i 60
• Tested by SISI. 5i 50 50
40
't
— Normal ear can distinguish 30 30
^20
30

smaH increase in amplitude ~ 1

20 20
-
db
10 10 - 10
A B
° *

Alternate binaural loudness balance test.

Patient with Henieres can ( A) Nonrecruiting ear. The initial difference of 20 dB between the right
and left ear is maintained at all intensity levels.
identify t0-100% of small (B) Recruiting ear right side. At 80 dB loudness perceived by nght
ear is as good as left ear though there was difference of 30 dB
increments initially.

D )ELECTROCOCHLEOGRAPHY J

• Best test to assess cochlear pathology

• Studies electrical activity in the organ of corti
I— Summation potential:sum of inner & outer hair cell activity
l-Action potential of cochlear nerve
Normal SP / AP<30%
•SP / AP ><i5% or 0 5 - Meniere ' s disease
^
E )R 0LL0 VER PHENOMENON

• Seen in retrocochlear patholgyCneural deafness )

• Fatigue of nerves on repeated testing.

F )CERA ( CORTICAL EVOKED RESPONSE AUDIOMETRY )

• Objective hearing test done in adults

• Records signals from auditory cortex.
• Patient must be still throughout.

% notespaedia 31
 c4"l
HEMATOMA OF EAR

• Cauliflower ear
• Commonly seen in cases of trauma
Hanagementraspiration with high pressure dressing
l& D if stilL not resolved

MALIGNANT OTITIS EXTERNA

Seen in elderly.immunocopromised people

Arises from pseudomonas infection of EAC
C /F:severe pain.granulation tissue.necrosis of EAC.Cranial involvement (CN VII ,IX , X , Xl )
Infection can spread to skull base leading to osteomyelitis
• Management:antibiotic therapy(Ciprofloxacin,3rd Gen cephalosporins )

DIFFUSE OTITIS EXTERNA

• Occurs due to change in PH of EAC leading to pseudomonas infection

Seen in immunocompromised

PRESENTS WITH

Diffuse edema of external ear

Discharge
Severe pain

Management:Antibiotics.ear toileting

FURUNCLE OF EXTERNAL EAR

Infection of hair follicle presents in cartilageneous part of EAC( Outer 1/3 rd)
• Presents with pain on movement of jaw & pinna,tenderness of tragus
Usually caused by staphylococcus
Hanagement:Antibiotics

% notespaedia 32
OTOMYCOSIS
Fungal infection of external ear
Clinical features:Pain,itching,ear discharge

O /E :EAC SHOWS

Cotton wool discharge: Candida

Wet newspaper appearance :AspergilLus niger

MANAGEMENT

b Ear Toileting
Anti fungal ear drops

BULLOUS MYRINGITIS (OTITIS EXTERNA HEMORRHAGICA )

• Commonly by streptococcus pneumonia

Results in development of bulLae in TM and EAC which leads to bloody
discharge
• Management:Ear itching- local & systemic antibiotics

IMPACTED EAR WAX

Ceruminous glands are modified apocrine sweat glands present in EAC.

EARWAX

l consist of

ceruminous secretions+desquamated epithelium

Excess production

leads to impaction & pain in ear

Management: loosening of wax using solvents & syringing with water

% notespaedia 33
 Predicted Question

A 20 year old male presents with discomfort in (L ) ear which stared last night during his
sleep.He complaints pain &itching .On otoscopic examination an insect was found deep in his
( L ) EACHow will you manage this?

Ans:Kill the insect first using oil syringing afterwards

Predicted Question

A 4 year old child present to the OPD with deformity of his external ear( pinna ).His parents ask
for cosmetic surgery for this defect.When is surgery done in such cases.?

Ans:After 6years of age{ Completing development of pinna )

4 Predicted Question
k
A patient with h/o recurrent otitis media presented to the ENT OPD for routine evaluation
and te following finding was seen. Identify
Ans:
Tympanosclerosis
( Myringosclerosis if only confined to TM )

% notespaedia 34
 ACUTE OTITIS MEDIA

• Acute infection of middle ear

• Mostly occur secondary to URTI
Routes of infection
i 1
Via external ear (perforated TM) Via Eustachian tube (MC)

• HC organism :Streptococcus pneumonia

A ) STAGE OF TUBAL OCCLUSION

• Blockage of ET due to edema of infection

• Patient c /o earache.deafness
• Retraction of TM
B ) STAGE OF PRE SUPPURATION

Pyogenic infection of middle ear

* C / O severe pain
#
O /E: red,congested TM.
STAGES OF AOM Hyperaemia of TM(Cartwheel appearance )
A ) Stage of tubal occlusion
B)Stage of pre suppuration C ) STAGE OF SUPPURATION
C)Stage of suppuration • Collection of exudates / pus in the middle ear
D) Stage of resolution • TM shows bulging to the point of rupture
E)Stage of complication • c / o severe pain which gets relieved on rupture of TM
• Perforation usually occurs in anterior inferior quadrant
• Pus comes out due to pressure (pulsatilla otorrhea)

D ) STAGE OF RESOLUTION

• Infection subsides after release of pus

E ) STAGE OF COMPLICATION

• Spread of infection seen in case of high virulent

organism.

% notespaedia 35
SIGNS OF RETRACTED TM

• Prominent lateral process of malleus

• Shortened handle of malleus
• Sickling of mdleolar folds
• Loss of cone of light

MANAGEMENT

• Antibiotics
• Nasal decongestants
• Analgesics.antipyretics
• Ear toilet
• Myringotomy : If done early during bulging TM,Perforation can be avoided

ACUTE NECROTISING OTITIS MEDIA

• Variant of ASOM
• Caused by
l— beta haemolytic streptococci
• Widespread destruction of Tympanic membrane
Annulus
Ossicular chain
Mastoid air
• Management:
L— r Antimicrobial therapy

% notespaedia 36
 SEROUS OTITIS MEDIA 9

Aka glue ear

^
There is collection of sterile fluid in middle ear

CAUSES
Occurs because of obstruction of ET Adenoid hypertrophy
•
Nasopharyngeal cancer
Otitic barotrauma
Increased production(aHergy)
As a complication of ASOH

CLINICAL FEATURES

• Presents with bilateral painless -fluctuating conductive hearing loss .

• O /E rTH is dull and retracted
LFluid level & air bubbles seen through it

AUDIOMETRY
• Rinnes (-)
• Webers lateral!sed to affected ear
• PTA-CHL
• Tympanometry B curve

MANAGEMENT OF SOM

MEDICAL SURGICAL

• Nasal decongestants • Hyringotomy &aspiration of fluid

• Antihistamines • Grommet insertion
• Antibiotics Surgical treatment of underlying patholgy.

COMPLICATIONS

• Tympanosclerosis
• Ossicular necrosis
• Cholestatomar
• Cholesterol granuloma

% notespaedia 37
 Predicted Question

In which quadrant is,Myringotomy done for a patient with SOM ?

Ans:Anterior inferior quadarant

CHRONIC SUPPURATIVE OTITIS MEDIA

• Chronic infection of middle ear & mastoid

• Major pathology involved is the formation of permanent perforation in TM and
formation of cholestatoma.

TYPES OF CSOM

Features TUBOTYMPANIC / ATTICOANTRAl/

SAFE TYPE UNSAFE TYPE

Discharge Profuse.mucoid,odourless Scanty.purple , foul smelling

Perforation Central Attic /marginal

Granulations Uncommon Common

Polyp Pale Red/fl.eshy

Cholesteatoma Absent Present

Complications Rare Common

Audiogram Mild to moderate conductive Conductive or mixed deafness

deafness

Location Anteroinferior part of middle Involves posterosuperior

ear deft part (attic antrum.aditus)
of middle ear cleft

% notespaedia 38
TUB 0TYMPAN1C TYPE

• Confined to the mucosa &considered safe

• Presents with discharge.hearing loss.perforations.polyps in middle ear
INVESTIGATIONS

• Examination under microscope to r /o cholesteatoma

• Audiometry. - CHL
• X Ray mastoid,CT Scan
• Culture & sensitivity

MANAGEMENT

• Aural toilet
• Systemic antibiotics
• Antibiotic ear drops
• Surgical excision of polyp
• Once ear is dry: reconstructive surgery

6 Q (v
Central perforation
(anterior)
)
Central perforation
( medium sized)
Subtotal perforation

Total perforation with

destruction of even
the fibrous annulus
<3 0
Attic perforation Posterosuperior marginal
perforation

Figure 11.7 Types of perforations in the tympanic membrane seen in CSOM.

% notespaedia 39
TYMPANOPLASTY
• Myringoplasty (repair of TM ) + Ossiculoplasty ( repair of ossicles )
• Myringoplasty

OVERLAY TECHNIQUE UNDERLAY TECHNIQUE

Outer epithelial layer of TM is raised & Graft is placed under the

graft is placed under the malleus.over the malleus,under the annulus
annulus.

0 Previous Year Questions

The following instrument is used for:

NEET 2018

A) Septoplasty
B) Myringoplasty
$ Myringotomy
DJAdenoidectomy

WULLSTE1N CLASSIFICATION OF TYMPANOPLASTY

• Type 1:graft is placed over malieus.only tm repair is done(Myringoplasty )

• Type 2 :graft is placed over the incus
• Type 3:graft is placed over the stapes head(myringostapediopexy )
Type Ground window is covered by graft and oval window is kept open to maintain phase
difference

OSSICLE RECONSTRUCTION

PORP TORP

• Partial Ossicular reconstruction prosthesis • Total ossicular reconstruction prosthesis

• Prostheis is placed over head of stapes • Stapes head should be absent
• Graft is placed over stapes • Graft is placed over the foot plate of stapes

% notespaedia 40
 O Predicted Question

Graft material used for tympanoplasty?

Temporalis fascia( MI ),Conchal cartilage,perichondrium of tragus

o Previous Year Questions AIIMS/ INICET 2020

Which of the following is not seen in a case of otitis media?

A ) Bezold abscess
B ) Griesinger' s sign
$ Battle sign
D) Delta sign

CHOLESTEATOMA

• Cholesteatoma is composed of keratinising squamous epithelium with keratin debris.

• It has bone eroding properties

THEORIES OF ORIGIN OF CHOLESTEATOMA

Wittmacks theory formation of retraction pockets in pars flxiccida

Habermans theory Epithelial invasion from EAC to the middle ear via pre existing
perforation
Ruedi theory Basal cell hyperplasia of mucosa of middle ear during infection

Sade theory Metaphysis of middle ear mucosa

% notespaedia 41
 Eustatian tube obstruction

I
Persistent negative pressure in the middle ear

I
Attic or posterosuperior retraction pocket

I
Metaplasia of Primary Acquired cholesteatoma Proliferation of basal layer

r
middle ear mucosa

T Subclinical infections of middle ear

Repeated infection through perforation Acute necrotising otitis media

J
Large central or marginal perforation

I
Metaplasia of middle ear mucosa Epithelial migration through perforation

+ Secondary Aquired cholesteatoma #

CLINICAL FEATURES OF CHOLESTEATOMA

• Due to widespread ossicular necrosis.cholesterol granuloma.osteitis

• Foul smelling ear discharge,bleeding through ear
• Hearing loss(conductive, sensory if affects the inner ear )
o
• >/n
-+ Perforation )
^
Retraction pockets of TM (+ )
White Hakes of cholesteatoma (+ )

% notespaedia 42
STAGES OF RETRACTION

1 mild retraction

2. touches the incus

3 TM lies on the promontary( middle ear atelectasis)

TH is thin & covers the promontory & ossicles.

MANAGEMENT OF CSOM
• Mainly surgical
* Aim of surgery is to remove the disease process (cholesteatoma ) initially & do
reconstruction afterwards
TYPES OF MASTOIDECTOMY

Intact canal wad mastoicectomy Canal wall down mastoidectomy

INTACT CANAL WALL MASTOIDECTOMY

• The mastoid air celLs are exenterated and the mastoid antrum is cleared ofF the disease
• The middle ear is accessed via the facial recess( posterior tympanotomy )
Disease of middle ear is also removed via the endaural approach

CANAL WALL DOWN MASTOIDECTOMY

• Middle ear and mastoid antrum are converted to a single cavity by bringing down the
posterior wad of middle ear
• Meatoplasty is done to increase the si 2e of the cavity
AIL ear ossicles are removed and ET is closed in Radical Mastoidectomy
• In Modified Radical Mastoidectomy,the healthy ossicles are preserved and reconstruction is
done along with Tympanic Membrane reconstruction

% notespaedia 43
0Identify the
Previous Year Questions AIIMS / INICET 2020
given retractor :

A ) Joll's retractor
B ) Perkins retractor
Mastoid retractor
D ) Langenbeck retractor

o Previous Year Questions NEETPG 2020

What is the surgery done to widen the cartilaginous part

of the external auditory canal called?
Meatoplasty
B ) Tympanoplasty
C) Myringoplasty
D) Otoplasty

CANAL WALL UP PROCEDURE CANAL WALL DOWN PROCEDURE

MEATUS Normal appearance Widely open meatus communicating

with mastoid

DEPENDENCE Does not require routine Dependent on doctor for cleaning

cleaning mastoid cavity once or twice a year
RECURRENCE OF
RESIDUAL High rate of reccurence Low rate of reccurence
DISEASE

SECOND LOOK Requires surgery in 6 months Not required

SURGERY
to r /o cholesteatoma

PATIENT No limitation Swimming can lead to infection of

LIMITATIONS Patient alLowed swimming mastoid cavity

AUDITORY Easy to wear hearing aid Problems in fitting hearing aid due to
REHABILITATION large mastoid cavity

% notespaedia 44
COMPLICATIONS OF CSOM

INTRATEMPORAL INTRACRANIAL

• Mastoiditis • Extradural abscess

• Petrositiis • Subdural abscess
)
Facial Nerve paralysis
• Labyrinthitis • Meningitis(MC Intracranial
• Brain abscess
• Lateral sinus thrombophlebitis
• Otitic hydrocephalus

FEATURES INDICATING COMPLICATIONS IN CSOM

• Pain:uncommon in uncomplicated CSOM

• Indicate Extradural.perisinus or brain abscess
, Sometimes due to otitic externa
• Vertigo: indicate erosion of lateral semicircular canal
• Can progress to Labyrinthitis or meningitis
• Fistula test should be done
• Persistent headache: suggest intracranial complication
• Facial weakness Indicate erosion of facial canal

• A listless child refusing to feed

o Previous Year Questions INICET 2021

Patient was operated for safe CSOM in right ear. He then presented with complaints of vertigo,
tinnitus & ear fullness. He experienced relief on turning his head to the opposite side. Identify
his condition.
( A) Paget's disease
0
( Perilymphatic fistula
(C) Labyrinthitis
( D) Schwannoma

% notespaedia 45
A )MAST 01DIT 1S

. MC Intracranial complication
• HC Organism: beta haemoLy+ic streptococci
• Infection of mucosa of mastoid along with accumulation of pus occurs
• Pus can erode the bony margins and collect in areas around the ear
• Presents with fever.tenderness behind the ear

Mastoid tenderness(+ )
-* Pulsatile ear discharge (+)- light house sign
Reservoir sign (+)
^ Sagging of posterosuperior meatal wall
• X ray & CT shows dosing of mastoid

" IMANAGCMCNTI
-» Surgical drainage of pus(cortical mastoidectomy done)
- Antibiotics

% notespaedia 46
C )PETR 0S1T 1S

• Spread of infection to petrositis part of temporal bone

CHARACTERISED BY
Persistent ear discharge
CN VII palsy
, Gradenigos syndrome

Retro orbital pain(CN V )

^
D ) BRA 1N ABSCESS

• MC involved lobe is temporal lobe

• Presents with:

b Nominal aphasia
Homonymous supraquadrantanopia

0 Previous Year Questions NEETPG 2021

A patient with a history of chronic ear infection presents with fever, headache, vomiting, irritability,
and confusion. His CTbrain is shown in the image below. What is the possible diagnosis?

^ Temporal lobe abscess

B ) Cerebellar abscess
C) Subdural abscess
D ) Meningitis

E )LATERAL SINUS THROMBOPHLEBITIS ( SIGMOID SINUS THROMBOPHLEBITIS )

• Infection causing thrombosis of sigmoid sinus

• Presents with
— Picket fence fever /Hectic fever . The thrombus is released into blood
— Gresingers sign:non tender edema of mastoid due to obstruction of mastoid emissary vein
— Otic hydrocephalus : Rise in ICT due to obstruction of IJV
— Seen as papilledema(Crowe beck sign)
_ Raised CSF pressure during LP ( Queckenstedt test)
• CECT/ HRI - thrombus does not take up contrast & appears empty
(Delta sign/Empty triangle sign)

% notespaedia 47
0 Previous Year Questions NEETPG 2019

Which of the following is not a feature of tubercular otitis media?

$Far ache
B ) Multiple perforations
C) Pale granulation
D) Foul smelling ear discharge

o Previous Year Questions NEETPG 2019

Which among the following statements is true about keratosis obturans?

A ) Failure of migration of desquamated epithelium along posterior meatal wall
B ) Widening of meatus and facial nerve palsy might be seen
C) Associated bronchiectasis and sinusitis
tyfAll of the above

% notespaedia 48
 • Replacement of normal enchondral bone by imma+ure / wavy spongy bone.
• HC site :Fissula ante fenestrum
• Histologically composed of osteodasts,osteoblasts,new blood vessels
• Appears basophilic on H& E stain
• Seen in 20- 30 years age group especially females
Exacerbated during pregnancy or menopause
• Inherited as AD disorder( Family history-!- )

CLINICAL FEATURES m

• Bilateral progressive conductive hearing loss Sensorineural hearing loss in cochlear

otosclerosis
• Hears better in loud surroundings(Paracussis Willisi phenomenon)
. Normal pearly white TM in majority
• 10% cases have active otosclerosis leading to flamingo pink appearance of TH
(Schwartz sign)

INVESTIGATIONS

• Tuning Fork Tests:

Rinnes negative
— Weber lateralised to affected ear
— ABC - Same as examiner
— Schwabach- lengthened
Gelles-negative
• PTA i— Dip in BC curve at 2000hz (Carharts no\ch ) - NEET
L A- B Gap of 15 db or more
• Tympanometry :As type of curve
• Stapedius reflux absent in case of fixed footplate

MANAGEMENT

MEDICAL

• Sodium fluoride(NEET)
used in active cases
hastens the maturation of focus
• Bisphosphonates

% notespaedia 49
SURGERY

• (only in case of mature inactive focus)

• Mobilisation of foot plate of stapes
• Done only when threshold of hearing is 30 db or more & AB gap 25 db or more
• Done first on worst ear

SURGERIES FOR OTOSCLEROSIS

STAPEDECTOMY STAPEDOTOMY

• Removal of entire stapes • More conservative

• Replaced by prosthesis attached to • Only suprastructure of stapes is removed

incus
v Fixed foot plate is left
• Footplate is replaced by a
facial graft covering the oval • Opening/ fenestra made on foot plate &
window one end of prosthesis is placed on it

CONTRAINDICATIONS OF SURGERY

• Only hearing ear

• Associated meniers disease
• Young children.
I—
I— Recurrent ET dysfunction is common in children.can displace the
prosthesis or cause acute otitis media
I Growth of otosclerosis focus is faster in children leading to re closure of oval
window
* Those working in noisy surroundings: after Stapedectomy prone to NIHL
* Professional athletes.high construction workers,divers and frequent air travellers
* Otitis externa.TM perforation and exostosis are relative Cl

% notespaedia 50
% notespaedia 51
 flcwt tc\Vf> \< * X it\
PARTS OF FACIAL NERVE

Intracranial part Intratemporal part Extracranial part

(Origin to internal acoustic ( lAH to Stylomastoid (Stylomastoid foramen
meatus) foramen) till end branches )

Intracranial part Intratemporal part

1
2

Motor N. of / £3 3

CN VII
Nucleus of
/
CNVIv 4
2
^
)
Extracranial part

Temporofacial div.
— Temporal \
— Zygomatic

Cervicofacial div.
— Buccal
— Mandibular /
— Cervical

A )Course of Facial Nerve

Intratemporal part consists of 4 segments: l )Meatal, 2 )Labyrinthine, 3 )Tympanic,4 )Mastoid.
B )Branches of facial nerve on face.

% notespaedia 52
INTRATEMPORAL COURSE AND ITS BRANCHES

• Lie in a bony canal (Fallopian canal)

Intratemporal segments

I
Labyrinthine Tympanic/horizontal Mastoid segment/
Meatal segment
segment segment vertical segments

MEATAL SEGMENT

• 8-10 mm
• Lies in the anterior superior part. Separated from the superior vestibular nerve by belLs bar

LABYRINTHINE SEGMENT
• 3 - *i mm
• Shortest and narrowest segment
• Host prone to compression during infection
• Ends at first genu on entry into middle ear

% notespaedia 53
TYMPANIC /HORIZONTAL SEGMENT

•11Liesmmin the medial wall of middle ear

• Makes the first on into middle ear
• genu entry
• Geniculate ganglion lies at the first genu and is anterosuperior to processus
cochleariformis
•The horizontal
(
segment passes between the lateral SCC prominence & oval
)
window MC site of dehiscence of fallopian canal

MASTOID SEGMENT /VERTICAL SEGMENT

•13Runsmmvertically down on the

• Lies lateral and posterior walL
• posterior to pyramid and medial &inferior to fossa incudis
• 2 nd genu is present at the junction of medial wall & posterior wall (MC site of surgical injury ]

BRANCHES OF FACIAL NERVE IN TEMPORAL BONE

1. Greater superficial petrosal nerve
2. Nerve to stapedius
3.Chorda tympani nerve
k.Sensory auricular branch

GREATER SUPERFICIAL PETROSAL NERVE

• Arises from geniculate ganglion

• Gives secretomotor fibres to lacrimal,nasal & palatine glands.
• Injury leads to dry eye(tested by Schirmer test)
NERVE TO STAPEDIUS

• Supplies
Arises from mastoid segment near the pyramid
• stapedius muscle
• Injury leads to loss of stapedius refl.ex(hyperaccusis)

% notespaedia 54
 CHORDA TYMPAN1

• Arises from mastoid segment before exiting the Stylomastoid foramen

• Gives taste to anterior 2/3 rd of tongue and parasympathetic
secretomotor supply to sublingual & submandibular salivary gland
• Injury leads to loss of taste sensation

SENSORY AURICULAR BRANCH —

• Sensory supply to pinna & EAC

CORNEAL REFLUX

• Afferent: Opthalmic division of CN V

• Efferent: CN VIII
TOPODIAGNISTIC TESTS

• Schirmer test
• Stapedial reflux
• Taste sensation assessment- Electrogustometry
• Salivary flow studies

SUPRANUCLEAR PALSY

• UHN palsy of facial nerve Thalamus

# There is hemiparalysis or
hcmiparesis of muscles Lesion
of lower half of opposite
side of the face with Motor cortex
sparing of forehead. Nucleus of CN VII
(B/L Innervation)

Forehead receives bilateral innervation and is thus saved in

supranuclear paralysis .Emotional movements controlled by
thalamo- nuclear fibres are also preserved .

% notespaedia 55
INFRANUCLEAR PALSY

• LHN lesion
• There is complete paralysis of the facial muscles on the same side (ipsilateral) ,

no sparing of forehead.

ASSESSMENT OF FACIAL NERVE INJURIES

• Electroneuronography :3rd day to 3 weeks of injury

• Electromyography :injuries>3 weeks duration

BELL ’S PALSY -

• He idiopathic cause of facial nerve palsy

• Acute onset
• Unilateral
• Rapidly progressing facial palsy
• Host likely cause :HSV 11nfection
CLINICAL FEATURES

Patient is unable to close his eyes

.
On attempting to dose his eyes eye ball turns up and out(Bell' s phenomenon )
Saliva dribbles in the angle of mouth
— Tears fl.ow from the eye (Epiphora)
Pain in the ear (may precede or accompany the nerve paralysis)
Noise intolerance(Stape-dial paralysis)
p Loss of taste (involvement of Chorda
tympani)
Paralysis may be complete or incomplete
MANAGEMENT

Steroids(Prednisolone is the DOC )

Antivirals (if presenting within 3 days )
— p Eyecare:

• Lubricants
;Physiotherapy
Closure of eye using pad

% notespaedia 56
CAUSES OF FACIAL PARALYSIS
• Central
• Brain abscess
• Pontine gliomas
• Poliomyelitis
• Multiple sclerosis
• Intracranial part (cerebellopontine angle)
• Acoustic neuroma
• Meningioma .
Congenital cholesteatoma
• Metastatic carcinoma
• Meningitis
• Intratemporal part
• Idiopathic
— Bell palsy
— Melkersson syndrome
• Infections
— Acute suppurative otitis media
— Chronic suppurative otitis media
— Herpes zoster oticus
— Malignant otitis externa
• Trauma
—
— ^
Surgical: Mastoyn ctomy and stapedectomy
Accidental: Fraa/ures of temporal oone
• Neoplasms ¥ \
— Malignancies or external and middle ear
— Glomus jugulare tumour
— Facial nerve neuroma
— Metastasis to temporal bone (frorri cancer of breast,
bronchus, prostate) /
• Extracranial part \ /
• Malignancy of parond /
• Surgery of parotid \ /
• Accidental injury in parotid region I
• Neonatal facial injury ( bstetrical fo/ceps)
^^
• Systemic diseases
Diabetes mellitus
Hypothyroidism
Uraemia
Polyarteritis nodosa
\.
— ^
/

Wegener ’s granulomatosis
Sarcoidosis (Heerfordt ’s syndrome)
Leprosy
Leukaemia
Demyelinating disease

% notespaedia 57
MELRERSON ROSENTHAL SYNDROME

• Recurrent alternating facialSwelling

palsy along with
of lips and
Fissuring of tongue
• Rx: Steroids
RAMSAY HUNT SYNDROME

• Herpes zoster of external ear with facial palsy

• Due to reactivation of latent varicelLa zoster virus ( VZV) in geniculate ganglion.
" C/F: Pinna Vesicles in the ear canal

E associated with pain

Involvement of CN VIII can cause hearing loss

Predicted Question

Which temporal bone If is commonly a/ w CN I/11 palsy ?

retroub

FREYS SYNDROME

• Abnormal regeneration of auriculotemporal nerve following injury during parotid surgery.

• C /F:Sweating during eating
• Rx
Botox injection

E Implantation of graft below skin

Tympanic neurectomy

CROCODILE TEARS

• Tearing during salivation

due to the aberrant regeneration of facial nerve following injury before the origin of
• Occurs
greater superficial petrosal nerve in the labyrinthine segment
• RxrBotox injection
% notespaedia 58
 • Aka Endolymphatic hydrops
• Occurs because of the distension of the membranous labyrinth due to increased
.
endolymph ( increased production decreased absorption)
CLINICAL FEATURES

- Vertigo(1st symptom)
TRIAD OF Due to sudden gush of endolymph into perilymphatic
MENIERE’S compartment following rupture of reissner ' s membrane.
DISEASE
-
Fluctuating hearing loss(low frequencies affected first)
—
Tinnitus
, Tumarleins Drops Crisis( sudden falls without loss of consciousness),because of the distortion of
macula .
.
• TulLio' s phenomenon ( Vertigo on loud sounds) due to distortion of utricle and sacule.
LERMOYEZ ’S SYNDROME

#
Rare variant
# Hearing loss before vertigo

INVESTIGATIONS

AUDIOMETRY
Tuning fork tests
• Rinne' s Test : Positive
0 Weber' s Test: Lateralised to better ear
• ABC: shortened
• Schwabach' s shortened
PTA :
•Upsloping audiogram(low frequencies affected).
• No A-B gap.
Stapedial reffex:threshold decreases.
Recruitment present.
Electrocochleography :SP / AP > 0.k 5%

• MRI with Gadolinium contrast demonstrate mixing of endolymph and perilymph.

% notespaedia 59
 MANAGEMENT

GENERAL MEASURES

• Low salt diet

• Smoking cessation
. Reassurance

MEDICAL

• Labyrinthine sedatives
Promethazine
Cinnarizine
Prochlorperazine
• Vasodilators :Betahistine

SURGICAL

• Selective Vestibular destruction if hearing is present

*
Chemical(using Gentamycin ) Vestibular Neurectomy

• Total labyrinthectomy if no hearing left

• Endoscopic sac decompression
• Sacculotomy (Fick' s Operation)
• IPPV using Heniett device therapy

0 Previous Year Questions AIIMS 2018

What is the definitive treatment of intractable vertigo due

to Meniere's disease?
A ) Acetazolamide
Labyrinthectomy
C) Vestibular neurectomy
D ) Intratympanic gentamicin

% notespaedia 60
Predicted Question

30 year old male presenting to the OPD with a h/ o recurrent episodes of

vertigo decreased hearing of low frequency sounds,tinnitus and feeling of fullness in
the ear.Possible diagnosis?
Ans: Meniere's disease

% notespaedia 61
 i

# 4- Hi44t^ i/
TUMOURS OF EXTERNAL EAR

A ) PRE AURICULAR SINUS

H -
• Occurs due to the defect in the fusion of hillocks of 1st and 2nd brachial arches.
I

• Presents as small opening in the crus of helix.

• Can get infected.
• Rx:Surgery only if symptomatic.

B ) 0STE 0MA G )EXOSTOSIS ( SURFER ’S EAR )

• Seen in EAC EAC

# Presentation Single, smooth , B /L.multiple,

Pedunculated, Sessile ,
Bony .hard tumor. Bony swellings in the deep part of EAC

#
Treatment Surgical removal. Surgical removal if symptomatic.

TUMOURS OF MIDDLE EAR

GLOMUS TUMOR

• Arises from paraganglion cells(paraganglioma)

• 2 types based on origin
Glomus Tympanicum(M /c) Glomus Jugulare
(Arises from tympanic plexus)
A ( Arises from Jugular bulb )

• Me benign tumor of the middle ear.

• Benign.non-encapsulated
• Locally invasive
% notespaedia 62
CLINICAL FEATURES

PRESENTS WITH

Conductive hearing loss

Pulsatile tinnitus(Transmitted from ICA)

o/e
Red Refl.ex /Rising sun appearence through intact TH.
Pulsation Sign(Brown Sign)Positive when pressure is raised in ear canal using
Siegel' s speculum.
Audible bruit over mastoid.

INVESTIGATIONS

Always check urinary VHA levels to r /o functional Glomus fumours

• CECT: Absence of crest of bone between Jugular bulb and ICA

• Biopsy is never done as it can cause profuse bleeding.

MANAGEMENT

• Mostly conservative as tumor grows slowly and is benign

In symptomatic cases:
•
—
Ip Excision of tumor if > 3 cm si2e
Gamma knife therapy if < 3cm si2e
L Embolisation.
*

% notespaedia 63
• Aka Vestibular Schwanomma .
• Benign.invasive
unencapsulated .slow growing tumor.
• Locally .
• HC arises from inferior vestibular nerve in Internal acoustic meatus
• HC tumor of cerebellopontine angle.
• UsualLy seen in elderly but can be seen in young patients with NF-2 & NF -1
• It can involve other cranial nerves by compression.

Bills’ bar
CN VII
Superior vestibular nerve
(to utricle, superior and
lateral canals)
Transverse
crest Inferior vestibular
nerve (to saccule)
Cochlear Foramen singulare
nerve (for posterior vestibular
nerve to posterior canal)
Inner aspect of lateral end of internal auditory canal with structures passing through

different areas.

% notespaedia 64
 CLINICAL FEATURES

• Cochleovestibular symptoms are earliest because of involvement of CN VIII.

•
c Progressive U/L SNHL often companies by tinnitus
Imbalance or Unsteadiness
Compression of CN V:

c Reduced corneal sensation

Paraesthesia of face
• Compression of CN VII:
Hypoaesthesia of Posterior meatal wall(Hit2elberger sign)

•
E Loss of taste
Reduced lacrimation
Compression of CN IX & CN X:

•
c Dysphagia
Hoarseness of voice
Due to Brainstem involvement:
Ataxia

E Numbness
Weakness with exaggerated tendon reflexes.
• Cerebellar symptoms
• Raised ICT

INVESTIGATIONS

AUDIOLOGICAl TESTS

• Tuning fork tests

Rinne' s Test: Positive
Weber ' s Test: lateralised to better ear
ABC Shortened
Schwabach: Shortened

• PTA SNHLr No A -B gap

• Stapedial reflex:decay +
• BERA
c Increased latency between waves I & V
Increased latency difference of wave V > 0.2 ms

% notespaedia 65
GADOLINIUM ENHANCED MRI
• Shows ice cream on a cone appearnce (Best test)

8hi \

m,I# i IT
%

* m 4 r >I
*
•v

*
*
v A- ,

Ii

to
¥
i ->

MANAGEMENT I

# Usually conservative as tumor is slowly growing

# Surgical excision
# Gamma knife surgery if si2e < 3 cm.

< Predicted Question

60 year old female presents to ENT OPD With do U/ L SNHLJoss of taste,dry eyes.
0/ E:there is decreased sensation in the posterior side of arterial auditory
meatus.ldentify the sign elicited.
Ans: Hitzelberger sign

% notespaedia 66
0 Previous Year Questions INICET 2021

A young man presented with hearing loss and tinnitus. Histology image is shown below.
What is the diagnosis?
r \ t •
v

Neurofibroma 4
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C) Leiomyoma
r
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% notespaedia 67
 A )COCHLEAR IMPLANT

• Replacement of organ of cor+i.

• Ac+s by stimulating cochlear nerve

INDICATIONS

• B /L severe SNHL
• No benefit from hearing aids(at least 3 months of use needed)

PRINCIPLE OF COCHLEAR IMPLANT

Speech processor
and transmitter
1. External speech processor captures sound
and converts it to digital signals
2. Processor sends digital signals
to internal implant
3. Internal implant turns signals
into electrical energy, sending
it to an array inside the cochlea
4. Electrodes stimulate hearing
nerve, bypassing damaged hair
cells, and the brain perceives
signals; you hear sound

Array of electrodes

\
% notespaedia 68
0 Previous Year Questions NEET PG 2018

Where is the electrode placed in cochlear implant procedures?

A) Round window
B ) Oval window
C) Scala vestibuli
QfSeaIa tympani

B ) AUDITORY BRAINSTEM IMPLANT

• Replaces the cochlear nerve.

• Acts by stimulating the cochlear Nucleus directly.
• Used in cases of B /L Acoustic neuroma.
• The electrode lies in the lateral recess of the Mth Venricle.

% notespaedia 69
C )BONE ANCHORED HEARING AID (BAHA )

INDICATIONS

1. When air conduction ( AC ) hearing

aid cannot be used:
Canal atresia .congenital or
acquired not amenable to treatment.
Chronic ear discharge.not
amenable to treatment.
Excessive Feedback and
discomfort from the air conduction
hearing aid.
2. Conductive or mixed hearing loss
Eg:Otosclerosis and Titanium
fixture
Tympanosclerosis where surgery is
contraindicated. Bone-anchored hearing air ( BAHA )
3. Single- sided hearing loss.

o Previous Year Questions NEETPG 2020

A person who met with an accident, and suffered from a skull fracture presents with the
following finding. Identify this clinical finding.

$ Battle sign
B) Bezold abscess
C) Mastoiditis
D) Griesinger sign

% notespaedia 70
0 Previous Year Questions INICET 2021

Identify the hearing aid used for bilateral canal atresia

(B)

( C) (D)

C)

% notespaedia 71
 Bone (upper 1/ 3rd)
• External nose : Osterocartilagi nous framework
Cartilage ( lower 2/3rd)

BONY PART

- 2 nasal bones
Consists of -_ Frontal process of maxilla on each side
Nasal process of frontal bone (unpaired)

CARTILAGINOUS PART

— Upper lateral cartilage

Consists of — Lower lateral cartilage(Alar Cartilage) Paired
Lesser alar cartilage
Septal Cartilage Unpaired

% notespaedia 72
% notespaedia 73
 /butt^wj e|U&etyMt.
into 2 by nasal septum
• Divided
• Anterior opening is called nares/nostrils
• Posterior opening is called choana
• Skin lined portion is called vestibule(site of hair follicles sebaceous glands)
,

• Lining epithelium — Upper 1/3rd by olfactory epithelium

, i

I— Rest of nose by Pseudostratified ciliates epithelium.

• Ventilation of sinuses occur only during expiration

NASAL VALVE
Septum
L
Upper Lateral
Oartil
• Narrowest portion of nasal passage. SZ
Lower Lateral
Cartilage
BOUNDARIES
Medially by the septum.
— > Superiorly and laterally by the caudal Inferior
Mucosa

margin of the upper lateral cartilage Turbinate

and the anterior end of the inferior

turbinate.
Interiorly by the floor of the pyriform
aperture. Nasal spine
\ Pyriform
aperture

0 Previous Year Questions AIIMS /INICET 2020

Given below is the endoscopic view of the right nasal cavity. Identify the marked structure?

Inferior Turbinate
B) Middle turbinate
C) Superior Turbinate
D) Uncinate process

% notespaedia 74
 4 uwi W'ttt 4
• 3 bonybelow
projections called turbinates /concha.
• Space turbinates called meatus.

Sup. turbinate and meatus

Agger nasi

Atrium
Middle turbinate
and meatus

Vestibule Inf. turbinate

and meatus

Structures on lateral wall of nose.

• Inferior turbinate is a separate bone.
• Superior and middle turbinates are part of ethmoid.

OPENINGS IN THE LATERAL WALL OF NOSE

Sphenoethmoidal recess-Sphenoid sinus

• Superior
• Middle meatus
meatus -Posterior ethmoid all sinuses
• p Ant & Hiddle ethmoid all sinuses
L Maxillary sinuses
L Frontal sinus
0 Inferior meatus-NLD opening(NLD moves downward,backwards.laterdly)
Bound by valve of Hasner
• Eustachian tube opens 1.25 cm posterior to the inferior turbinate.
Spenopalatine foramen opens 1cm posterior to the middle turbinate.
• Site of Entry of spenopalatine artery
Origin of angiofibroma.

% notespaedia 75
OSTEOMEATAL COMPLEX

•OpeningBulla
of all 3 sinuses in the middle meatus.
• ethmoidalis is the largest anterior ethmoidal air cell.
• Concha Bullosa :Pneumatised middle meatus.

Middle
turbinate Hiatus
semilunaris

Bulla
ethmoidalis

Infundibulum
Uncinate
process

% notespaedia 76
0 Previous Year Questions INICET 2021

Identify the marked structure in the given NCCTscan

Jfl( f)Pneumatised Superior Turbinate

B Onodi cells
(C) Haller cells
( D ) Concha bullosa

% notespaedia 77
 CoLumeliar septum
Nasal spine of
Membranous septum frontal bone %

Crest of nasal Perp. plate of

Septum proper bone ethmoid
Membranous
septum Septal cart. Vomer Rostrum of
Ethmoid sphenoid
Columellar
— Vomer septum

— Sphenoid Ant. nasal spine

of maxilla Crest of maxilla
— Maxilla
Crest of palatine bone
— Palatine bone
Anatomy of nasal septum
Septal cartilage.

STRUCTURES SEEN ON POSTERIOR RH!NOSCOPY .( AIIMS 2020)

% notespaedia 78
0 Previous Year Questions AIIMS / INICET 2020

A senior resident in the hospital is performing the following clinical examination as shown in
the image below. Which of the following structures will not be visible to him?
A ) Adenoids
$ Arytenoids
C) Torus tubarius
D) Upper surface of soft palate

% notespaedia 79
 UJ \V\ <

• *1 paired sinuses
“ HaxilLary
— Ethmoid
Frontal
_ Sphenoid
• Develop as lateral outpouching from the lateral wall of nose
• Lined by Pseudostratified columnar epithelium.
• Order of development:
HaxilLary Ethmoid •Sphenoid Frontal

1)MAX 1LLARY SINUS

• Largest sinus
• Opens into infundibulum of middle meatus.
• He sinus to get infected in adults.
• Related to the 2nd premolar and first molar .
(Teeth extraction can lead to Oro- natural fistula )

Cribriform
plate
Roof of ethmoid

Orbit
Olfactory
sulcus
Uncinate Middle
process turbinate

Inferior
Maxillary turbinate
sinus
Floor of maxillary
sinus

i
Coronal section showing relationship of maxillary and ethmoid all sinuses to the orbit and the
nasal cavity.Floor of the maxillary sinus is about 1cm below the floor of nose.

% notespaedia 80
11)ETHM0»D SINUS

• Composed of multiple group of air cells.

• Divided into anterior and posterior groups by basal lamella of middle turbinate.
t Anterior group opens into the middle meatus.
,

Posterior group opens into the superior meatus.

• Most common infected sinus in infants and children.
• Important celLs of ethmoid sinus are:
Agger nasi cell : anterior most air cell

E Onodi cell:
Haller cell.
Posterior most air cell.

% notespaedia 81
0 Previous Year Questions AIIMS/INICET 2020

Anterior most air cells of anterior ethmoidal sinus are known as?
A ) Bulla ethmoidalis
B ) Onodi cell
$ Agger nasi
D ) Haller cell

% notespaedia 82
HALLER CELL

111)FR 0NTAL SINUS i

• Last to develop(absent at birth)

• Drains into middle meatus via frontonasal duct.
• Frontal sinusitis presents with early morning headache which subsides by evening
Referred to as Office headache or Periodic headache.

% notespaedia 83
IV ) SPHEN01D SINUS

• Present in the body of sphenoid.

• Drains into spcnocthmoidal recess.
• Closely associated with:
Cavernous sinus
Pituitary gland
Optic nerve
ICA
C N I I I .I V . V & VI
• Least common sinus to get infected.
• Headache of spenoid sinus referred to occipital region

% notespaedia 84
% notespaedia 85
0 Previous Year Questions NEETPG 2018

Water's view is used to best visualize

which of the following sinuses?
Maxillary sinus
B) Ethmoidal sinus
C) Frontal sinus
D) Sphenoid sinus

o Previous Year Questions NEET PG 2020

What is occipitomental view with open mouth also known as?

Jef Water's view
B) Towne's view
C) Law's view
D) Stenver's view

% notespaedia 86
0 Previous Year Questions AIIMS/INICET 2020

The radiograph shown below is done for better assessment of the frontal sinus. What is the
common name of this view?
A) Water' s view
Caldwell view
C) Pierre's view
D) Towne's view

C )HIRTZ VIEW ( SUBMENTO VERTICAL VIEW )

% notespaedia 87
% notespaedia 88
G )IATERAL VIEW

• To view Frontal.Ethmoid.MaxilLary Sphenoid sinuses .

: ,

% notespaedia 89
 • Major artery:Sphenopalatine artery
• Me site of bleed :Li++ie' s area/Kiesselbach' s plexus.
ARTERIES FORMING RIESSELBACH’S PLEXUS

• Anterior Ethomoidal Artery.

• Sphenopalatine Artery.
• Greater Palatine Artery.
0 Previous Year Questions AIIMS 2017

Which of the following is not a branch of the external

• Superior labial Artery.
carotid artery in Kiesselbach 's plexus?
$ Anterior and posterior ethmoidal
B) Sphenopalatine artery
C) Greater palatine artery
D ) Septal branch of superior labial

BLOOD SUPPLY OF NASAL SEPTUM

% notespaedia 90
0 Previous Year Questions AIIMS 2019

Which of the following marked structures is a branch of

the internal carotid artery?

#1
B) 2
C) 3
D) 4

o Previous Year Questions AIIMS/ INICET 2020

Which of the following is not a branch of the external

carotid artery in Kiesselbach's plexus?
Anterior and posterior ethmoidal
B ) Sphenopalatine artery
C) Greater palatine artery
D) Septal branch of superior labial

VENOUS DRAINAGE

• Deep facial vein carries blood from fhe dangerous

area of face to fhe pterygoid plexus of veins which
drains into cavernous sinus.
• Hence infections in this area can lead to cavernous
sinus thrombosis.

% notespaedia 91
VENOUS DRAINAGE OF FACE

Supraorbital vein + Supra trochlear vein

Superior ophthalmic vein

Cavernous sinus
Angular vein
i
Facial vein
I Emissary vein

Pterygoid venous plexus

Deep facial vein
Drained by

MaxilLary vein.
+
Anterior division Superficial temporal vein.

Common facial vein

Retromandibular vein

Posterior division + Posterior auricular vein

I
External Jugular vein

% notespaedia 92
 EXTERNAL NOSE

Ophthalmic
• Ophthalmic division of CN V nerve
• Maxillary division of CN V (VI )

Maxillary
nerve
(V2 )

Mandibular
- nerve
(V3)

INTERNAL NOSE

OLFACTORY SENSATION

• Olfactory nerve
• Supporting cells of olfactory nerve are destroyed in COVID infection.

COMMON SENSATION

• Ophthalmic N ( V1) via Ant &Post Ethmoidal nerves.

• Maxillary division ( V2)

AUTONOMIC SUPPLY

Together form Vidian Nerve /

• Parasympathetic :Greater Superficial Petrosal Nerve. Nerve of
• Sympathetic : Deep petrosal Neve.
pterygoid canal.

% notespaedia 93
 FUNCTIONS OF NOSE

Olfaction

Humidification Nasal resonance

Respiration Protection of airway

Temperature regulation

DEFECTS IN OLFACTION
• Anosmia : Total loss of smell
• Hyposmia : Decreased sense of smell.
• Paraosmia : Altered sense of smell.
• Presbyopia : Age related decline of sense of smell.

RHINOLALIA CLAUSA RHINOLALIA APERTA

Causes. Obstruction in Nose or Pharynx. Velopharyngeal insufficiency
(Cleft palate,Bifid uvula)

Voice Hyponasal voice Hypernasal voice

KALLMANN SYNDROME

• Congenital anosmia+ Hypogonadotrophic hypogonadism

• X linked disorder
• Common in females.

% notespaedia 94
• Diseases of external nose are managed by rhinoplasty.
SADDLE NOSE

% notespaedia 95
 4 s<f
| DNS
• Host common cause is trauma (especially birth trauma).
TYPES
• Anterior dislocation
• C - shaped defection
• S - shaped defection
• Nasal spur impinging on turbinate
• Thickening of nasal septum

Anterior dislocation C-shaped deflection S- shaped deflection

Nasal spur impinging Thickening of nasal

on turbinate septum

CLINICAL FEATURES
•Nasal obstruction: Septal deviation leads to the hypertrophic of the turbinates of the
opposite side leading to nasal obstruction.
• Headache
• Sinusitis
• Epistaxis
• Middle ear infections
• Anosmia
•External nose defects

% notespaedia 96
COTTLES ’S TEST
• Done in patients with DNS.
• On pulling the check cheek away from the midline ,the nasal valve opens,increasing air flow
from that side of nasal cavity.

MANAGEMENT
• Septal surgery is usually done after
the age of 1T so as not to interfere
with the growth of nasal skeleton.
• However .if a child has severe septal
deviation causing marked nasal
obstruction.conservative surgery Killian incision
( septoplasty ) can be performed to
Hemitransfixion
provide a good airway.
• 2 types of septal surgeries:
• Submucus resection of septum (SMR )
• Septoplasty
SUBMUCUS RESECTION OF SEPTUM ( SMR ) SEPTOPLASTY
•Killian incision •Freer ' s incision
•Mucoperichondrial &mucoperiosteal iaps •Mucoperichondrial iap is
raised on both sides. raised only on one side.
• Only a thin strip of oral Scaudal cartilage •Only deviated parts of septum
maintained.rest of septum removed. removed.
•Higher incidence of saddling & perforation. •Lower incidence of perforation.

% notespaedia 97
OTHER DISEASES OF NASAL SEPTUM | >
SEPTAL HEMATOMA
• Collection of blood under perichondrium on both sides due to trauma.
• B /L nasal obstruction.
• Immediate drainage(or it can lead to necrosis & abscess formation of septum).

SEPTAL ABSCESS
• Infection of septal hematoma or formation of furuncle can lead to septal abscess.
• B /l nasal obstruction.
• Has to be drained immediately.

SEPTAL PERFORATION
• Causes
• Trauma(HC)
• Granulomatous diseases
• Syphilis : Bony perforation
• Tb.leprosy.Lupus : Cartilaginous perforation
• Wegners : Bony + Cartilaginous perforation
• Management
Small perforations closed with a fl.ap.
Large perforations closed with statistic button.

% notespaedia 98
ATROPHIC RHINITIS
• ETIOLOGY
• Females > Hales
• Deficiency of Vitamin A, Vitamin D, Fe
• Autoimmune
• Oestrogen Deficiency
• Infection with K. Ozaenae, Proteus vulgaris, E. Coli.
• PATHOLOGY
• Ciliated columnar epithelium converted to Stratified squamous epithelium.
• Bones of turbinates undergo resorption.
• Crushing occurs due to proteolytic enzymes, wide nasal chambers.
• CLINICAL FEATURES
•Foul smelLing from the nose which is not evident to the patient (MERCIFUL ANOSMIA ).
•Nasal obstruction due to crusting ( greenish or greyish dark ).
•Bleeds on removal of crust.
• TREATMENT
• Medical
• Nasal Irrigation and removal of crusts using alkaline solution.
( Soda bicarbonate 1 part. Sodium chloride 2 parts in 280 ml of water )
• Painting with 25% glucose in glycerine after crust removal.
• Local antibiotics solution.
(Kemicetine TM Antoozaena solution contains Chloromycetin, oestradiol and Vitamin D2)
• Oestrodiol spray.
• Surgical
" YOUNG S OPERATION

0 Previous Year Questions NEET PG 2020

Surgery where one nostril is partially or completely

occluded is done for which condition?
A ) Vasomotor rhinitis
Atrophic rhinitis
C) Invasive aspergillosis
D ) Allergic rhinitis

% notespaedia 99
0 Previous Year Questions NEETPG 2021

A female patient presents with nasal obstruction, nasal discharge, and loss of smell. On
examination, foul smelling discharge and yellowish -green crusts are present in the nasal cavity. She
is found to have merciful anosmia. Which of the following finding can also be seen during the
examination of her nose?
Roomy nasal cavity
B) Nasal polyps
C) Inferior turbinate hypertrophy
D) Foreign body

RHINITIS SICCA
• 1+ is also a crust- forming disease seen in patien+s who work in hot, dry and dusty surroundings.
• E. g. bakers, iron- and gold- smiths.
• Condition is confined to the anterior third of nose.
• Here, the ciliated columnar epithelium undergoes squamous metaplasia.
• Crusts form on the anterior part of septum and their removal causes ulceration and epistaxis,
and may lead to septal perforation.

RHINITIS CASCOSA
• It is usually unilateral and mostly
affecting males.
•Nose is filed with offensive purulent discharge and cheesy material.
•The disease possibly arises from chronic sinusitis with collection of inspissated cheesy material.

RHINITIS MEDICAMENTOSA
•Due to prolonged use of nasal decongestants.
•Patient experiences nasal obstruction despite increasing frequency and dosage of medications
(REBOUND CONGESTION).
• Management : Withdrawal of drug, local and systemic steroids.

HYPERTROPHIC RHINITIS
• Chronic rhinitis that is not managed properly results in fibrosis and hypertrophy of turbinates.
• MULBERRY APPEARANCE.
•Host common : Inferior Turbinate
• Rx : Turbinectomy

% notespaedia 100
ALLERGIC RHINITIS
• Mediated by IgE (Type I Hypersensitivity Reaction).
•Family history present.
• INVESTIGATIONS
• Skin prick test
• Absolute Eosinophil count
• Radio Allergosorbent Test (RAST)
• MANAGEMENT
• Avoid possible alLergens
• Antihistamines
• Intranasal steroids
• Mast cell stabilisers
• Systemic Steroids
• Immunotherapy
VASOMOTOR RHINITIS
•Due to parasympathetic overactivity leading to vasodilation and congestion.
•No history of allergies present.
•MANAGEMENT
• Medical : Decongestants (Oral, Nasal), Nasal Steroids
• Surgical : VIDIAN NEURECTOMY

% notespaedia 101
• Host Common cause : Viral Infection
• Host Common Bacterial Sinusitis : Streptococcus pneumoniae
• Can be acute ( <3 months duration) or chronic ( >3 months duration).
CLINICAL FEATURES
•Nasal obstruction and discharge
•Headache
•Post nasal drip
• Anosmia
•Pain on pressure
INVESTIGATIONS
• Anterior Rhinoscopy : Reveals congested mucosa
• X Ray of PNS
• Nasal Endocscopy (First Investigation in Chronic sinusitis)
Pathognomic Sign : Presence of mucopus of chronic sinusitis
• NCCT of PNS (Best Investigation)
MANAGEMENT
• Medical
• Antibiotics
•Decongestants
•Steroid Spray
• Surgical
• FESS (Functional Endoscopic Sinus Surgery )

MUCORMYCOSIS
• Caused by mucor /rhi2opus.
•Fungus has angioinvasive property because of which it invades blood vessels and spreads to
orbit and intracranialLy.
• Life threatening infection especially seen as Post COVID sequelae.
• On examination, black necrotic turbinates and debris is seen due to necrosis.
• Rx : Surgical debridement + Amphotericin B

% notespaedia 102
0 Previous Year Questions INICET 2021

The given image is of a person with a history of minor trauma with a piece of wood, 20 days
back. His face is affected on the leftside with facial swelling and orbital edema. Gscan
revealed clear sinuses and the presence of subcutaneous nodules. Microscopy of the tissue
sections was PAS-positive and stained positive with Grocott 's methenamine silver stain.
What is the most likely diagnosis?

$fPhycomycosis
B ) Midline lethal granuloma
C) Foreign body granuloma
D ) lgG4 granuloma

FUNGAL SINUSITIS
• Most Common Cause : AspergilLus fumigatus.
• 1+ can be invasive or non - invasive.
NON - INVASIVE FUNGAL SINUSITS INVASIVE FUNGAL SINUSITIS
• Occurs in immunocompetent. • Occurs in immunocompromised.
• Presents as • Presents as :
•Fungal Ball • Invasive aspergillus
• Allergic fungal sinusitis • Mucormycosis
• Management • Management
• Removal of fungal ball • Antifungals (Oral or iv)
• FESS • FESS
• Steroids

• Diagnostic Criteria of Allergic Fungal Sinusitis

• Raised IgE
• Positive fungal stain
• Nasal polyps
• Heterogenous opacities on CT.
• Fungal elements, mucin and eosinophils on biopsy.

% notespaedia 103
0 Previous Year Questions INICET 2021

All of the following are major diagnostic criteria for allergic fungal sinusitis except?
A ) Presence of nasal polyps
B ) Eosinophilic muon without invasion
C) Characteristic CT findings
Qjf Positive fungal culture

MUCOCELE /MUCOPYOCOELE
• Commonly affects frontal sinus.
• Occurs because of chronic obstruction of ostia of sinus /cystic dilatation of sinus mucous glands.
• Presents as a firm, non - tender swelling in the supromedial quadrant of orbit pushing the
eyeball downwards, forwards and laterally.
• In case of ethmoid sinus, mucocoele eyebalL is pushed forwards and laterally.
• When mucocoele gets infected, it is called PYOCELE/MUCOPYOCOELE.

POTT ’S PUFFY TUMOUR

• Subperiosteal abscess of frontal bone presenting externally as a soft doughy swelling.
• CN VI is the first nerve involved in cavernous sinus thrombosis, hence lateral ga2e palsy is seen.

DIFFERENCES BETWEEN ORBITAL CELLULITIS AND CAVERNOUS SINUS THROMBOSIS

ORBITAL CELLULITIS CAVERNOUS SINUS THROMBOSIS
Source Commonly ethmoid sinuses. Nose, sinuses, orbit ear or pharynx .
,

Onset Slow; starts with Abrupt with high fever and chills with
edema of eyelids near signs of toxaemia.
the inner canthus - chemosis - proptosis Oedema of eyelids, chemosis and
proptosis.

Cranial nerve Involved concurrently with complete Involved individually and sequentially.
Involvement ophthalmoplegia.

Laterality Often involves one eye Involves both eyes.

% notespaedia 104
COMPLICATIONS OF SINUSITIS
• LOCAL
• Mucocele / Mucopyocele
• Mucous retention cyst
• Osteomyelitis
•Frontal bone (more common )
• Maxilla
• ORBITAL
• Preseptal inflammatory edema of lids
• Subperiosteal abscess
• Orbital cellulitis
• Orbital abscess
• Superior orbital fissure syndrome
• Orbital apex syndrome
• INTRACRANIAL
•Meningitis (Most Common)
•Extradural abscess
•Subdural abscess
•Brain abscess (Most common site : Frontal Lobe)
• Cavernous sinus thrombosis
• DESCENDING INFECTIONS
•Otitis media
•Pharyngitis
•Tonsilitis
•Laryngotracheobronchitis
• FOCAL INFECTIONS

% notespaedia 105
 iWvtl fa
•Mainly of +v/o fypcs : Ethmoidal, Antrochoanal
ETHMOIDAL ANTROCHOANAL
•B/L, multiple. •U/L, single.
•Allergy is the main etiology. •Infection is the main etiology.
•Arise from multiple ethmoidal air cells. •Arise from maxillary antrum.
•Recurrence is common. •Recurrence is common.
•Best investigation is NCCT of nose and PNS.
•Management
•Medical : Anti - histamines, Steroid sprays
•Surgical : FESS
DIFFERENTIAL DIAGNOSIS
• ENCEPHALOCELE/MENINGOCEPHALOCELE
• Soft
• Compressible
• Brilliantly transilluminant
• Expands when child cries (FURSTENBERG TEST )
• CONCHA BULLOSA
•Pneumatised middle turbinate
•Probe test is done to differentiate from polyps.
•Polyps don't bleed nor does it hurt on probing.
•Probe can be passed around the polyp.

% notespaedia 106
 DISEASE ORGANISM CLINICAL FEATURES , TREATMENT
DIAGNOSIS
BACTERIAL
Rhinoscleroma KlebsielLa • Presents as atrophic rhinitis. MEDICAL
Rhinosderomatis • Excessive granuloma formation. •Streptomycin
(Frisch Bacillus) • WOODY NOSE /HEBRA NOSE . •Tetracycline
•Extensive fibrosis leading to •Rifampicin
deformity / stenosis. •Ciprofloxacin
•Steroids
•Biopsy is diagnostic SURGICAL
Granuloma with plasma • Lasers
cells and macrophages.
•Mikulicz cells
•Russel Bodies

Syphilis Treponema Pallidum •Congenital Syphilis •Inj Benzathine penicillin

•Snuffles 2.k mu im weekly X 3
•Gummas weeks.
•Acquired Syphilis
•1‘: Chancre
•2' : Extenive Ulcers
• 3’ : Gummas, perforation of
both bony and
cartilaginous nasal septa.

Tuberculosis Mycobacterium •Involves anterior part of nasal •ATT

Tuberculosis septum.
•Causes perforation in
cartilaginous part of septum.
•Apple jelly nodules.
•Biopsy : AFB Stain
Lupus Vulgaris

Leprosy Mycobacterium •Same as Tuberculosis •Rifampicin

Leprae •Dapsone

% notespaedia 107
 DISEASE ORGANISM CLINICAL FEATURES , TREATMENT
DIAGNOSIS
PROTOZOAN
Rhinosporidiosis Rhinosporidium • H/o bath in contaminated • Wide excision with
(AIIMS 201T) seeberi ponds. cauterisation of
• Patients are base.
immunocompetent • Dapsone
• Presents with blood tinged
nasal discharge.
• Nasal obstruction.
• O/E : Red polypoidal mass
like MULBERRY /
STRAWBERRY with white
dots.

SYSTEMIC

Wegner ' s • Blood tinged nasal discharge. • Steroids

Granulomatosis • Septal perforation. • Immunomodulators
(Bone + Cartilage)
• C - ANCA positive.

Sarcoidosis • Nasal crusting, obstruction. •Steroids

• Thickening
and discolouration of skin of
nose (LUPUS PERNIO ).
• Septal perforation
(Cartilage).
• O/E : Red nodules within
nasal mucosa ( Strawberry
Appearance).

• Biopsy, ACE levels, ESR,

Chest X Ray.

% notespaedia 108
0 Previous Year Questions AIIMS 2017

Rhinosporidium seeberi is now classified as a/an

Aquatic protistan protozoa
B) Fungus
C) Virus
D) Bacteria

% notespaedia 109
 • Bleeding from nose.
USUAL CAUSES
•Host common cause in children : Trauma (Nose picking)
• Child presenting with unilateral epistaxis : Rule out foreign body
• Young male presentin with profuse and recurrent epistaxis : Rule out angiofibroma
• Host common cause in elderly : Hypertension
• Host Common Site : KIESSELBACH’S PLEXUS/LITTLE ’S AREA
• In elderly, epistaxis is usualLy posterior , from Woodruff ' s plexus
( WOODRUFF ' S PLEXUS : Anastomosis of Sphenopalatine Artery and Posterior
Pharyngeal Artery.)
MANAGEMENT
• First step : TROTTER ’S METHOD (Pinch nose for 5 minutes, sit and lean forward, spit
blood and lean through mouth)
• Bleeding site is cauterised (chemically or electrically ).
• Nasal packing is done if bleeding still persists.
• Last resort is ligation of arteries involved ( TESPAL - Trans nasal endoscopic
sphenopalatine artery ligation, Haxillay artery , External carotid artery , Anterior
Ethmoidal Artery ).

0 Previous Year Questions AIIMS 2017

Which of the following is not ligated for the control of epistaxis :

Jtf Internal carotid artery
B) Anterior ethmoidal artery
C) Maxillary artery
D ) External carotid artery

o Previous Year Questions NEET PG 2021

A patient presents to the emergency with epistaxis. There was no relief on pinching the nostrils.
Nasal packing was done but the patient still continues to bleed. What would be the next appropriate
step in the management of this patient?
A ) Ligation of external carotid artery
B) Ligation of internal carotid artery
$( Ligation of sphenopalatine artery
D) Ligation of maxillary artery

% notespaedia 110
NASAL FRACTURES |
Fvutttyc
^4P
• Most common fracture of face.
• Always rule out presence of septal hematoma (drained immediately).
CHEVALLET FRACTURE (CLASS 1)
• Vertical fracture line involving septm of nose (parallel to dorsum of nose).
•No septal deviation.
•Due to blow from below.

.
*

>

JARJAWAY FRACTURE ( CLASS 11)

•Horizontal or C - shaped fracture.
•Septal deviation present.
•Blow from front.

•
•••
%•

» •

.*

% notespaedia 111
0 Previous Year Questions NEETPG 2018

The vertical and horizontal fracture of nasal septum is

4fChevallet and Jarjaway fracture
B ) Citelli fracture
C) Tripod fracture
D ) None of the above

NASO - ORB1TO - ETHMOID FRACTURE (CLASS 111)

•High velocity trauma.
•Depression of dorsum of nose and pulling of tip of nose upwards because of crushing of
perpendicular plate of ethmoid (PIG NOSE DEFORMITY ).
•C5F leakage can be present.
MANAGEMENT
•Class I and Class II fractures are managed by closed reduction only after oedema subsides( ~ 1
week) .
•Closed reduction is done using WALSHAM FORCEPS AND ASCH ’S FORCEPS.
•In case deformity is still not correctd or if patient presents after 3 weeks of injury, they are
taken up for RHINOPLASTY OR SEPTORHINOPLASTY . (Only if patient is above 1T years of age)
•Class III fractures are treated immediately by open surgey and internal fixation.
.
Walsham 's forceps. I sed for disimpacting and reducing fractures of nasal bone

Asch's septum forceps. Used for reducing fractures of nasal septum.

% notespaedia 112
FRACTURE OF ZYGOMATIC BONE | >
• Zygomatic bone articulates via :
• Zygomaticofrontal suture.
• Zygomaticotemporal suture.
• Zygomatico maxillary suture.
• Fracture of all 3 : TRIPOD FRACTURE.
• Presents with step deformity, enophthalmous, restricted EOM movement, anaesthesia of area
supplied by infra - orbital nerve.

Zygomaticofrontal fracture Zygomaticotemporal fracture

Infraorbital fracture

Fracture Zygoma Left

ORBITAL FLOOR FRACTURE

• Called BLOW OUT FRACTURE .

• Because of blow on orbit with blunt object.
• X - R a y shows TEAR DROP APPEARANCE.
• Presents with enophthalmous, diplopia (due to entrapment of inferior rectus and inferior oblique ),
anaesthesia of cheek in infraorbital nerve supply.

% notespaedia 113
FRACTURES OF MAXILLA

• LE FORT fracture.
LE FORT 1
•Seperates palate from face.
(Hanging palate / Guerin fracture )
c
LE FORT II B
•Pyramidal fracture (Hanging Maxilla). A
•Involves infraorbital nerve.
• Associated with CSF rhinorrhea.

LE FORT III
•Cranio - facial dysjunction. Fractures of Maxilla
• Associated with CSF rhinorrhea. A : Le Fort I
B : Le Fort II
C : Le Fort III

|FRACTURES OF MANDIBLE
•Fractures of mandible : DINGMAN 'S CLASSIFICATION.
• Condylar fractures are the most common, folLowed by those of the angle, body
and symphysis of mandible.

Coronoid
Condylar process
process
Alveolar process

Ramus I

5%

Angle 20% Symphysis

15%

Body

% notespaedia 114
 j csr »
•Host common cause is trauma.
• It can occur via 3 routes :
• Via cribriform plate damage (Host common in trauma).
• Via damage to sinuses (Ethmoidal, Frontal, Sphenoid).
• Via Eustachian tube (because of middle ear fracture ).
• Can result in meningitis.
DIAGNOSIS
• Clinical Examination
• SNIFF TEST
• HAND KERCHIEF TEST
• HALO/TARGET SIGN of filter paper
•RESERVOIR SIGN
• Biochemical Examination
• Glucose estimation
• P2 transferin
• Radiological Examination
• HRCT (Best)
• CT Cisternography
• Intrathecal dye administration (Fluorescein Dye )
• HRI
MANAGEMENT
• Conservative management initially for 2 weeks.
(Bed rest, diuretics, antibiotics, propped up position)
• Surgical repair (preferable endoscopic) if not controlled.

% notespaedia 115
 4IW vA <

| BENIGN TUMOURS
INVERTED PAPILLOMA / TRANSITIONAL CELL PAPILLOMA / R 1GERTZ TUMOUR
•Most Common benign tumour of nasal cavi+y.
• Associated with HPV, more common in men.
•Locally invasive, presents with unilateral nasal obstruction and epistaxis.
•Rx : Surgical Excision.

0 Previous Year Questions INICET 2021

A 76yr old female patient presented to the ENT OPD complaining of chronic nasal discharge with
occasional epistaxis. Her CTscan showed the following findings. What could be the possible
diagnosis?
(A ) Nasopharyngeal angiofibroma
Inverted papilloma
(C) Esthesioneuroblastoma
( D ) Maxillary carcinoma

OSTEOMAS
•Most common benign tumour of paranasal sinuses.
•Mostly seen in frontal sinus.
•Leads to chronic sinusitis, headache, diplopia, facial deformity.
•Rx : Surgical excision.

FIBROUS DYSPLASIA
• MedulLary bone is replaced by fibro - osseus tissue.
• Most commonly seen in maxilla.
• Ground glass appearance on CT.

% notespaedia 116
MALIGNANT TUMOURS | I
BASAL CELL CARCINOMA
•Most common malignancy of skin of external nose .
•Sunlight (UV Radiation) is an important etiological factor.
•Locally invasive, rarely show distant metastasis.
•Present as ulcers called RODENT ULCERS.
•Rx : Wide local excision by MOH ’S MICROGRAPHIC SURGERY .

SQUAMOUS CELL CARCINOMA

•Most common malignancy of nasal cavity and paranasal sinuses.
• In the nasal cavity, it arises from lateral wall of nose or from nasal septum.
(NOSE PICKER ’S CARCINOMA )
• PNS Ca is most commonly seen in maxillary sinus.
•Presents with blood tinged nasal discharge , nasal obstruction.
•Usually lymph nodes are not involved initially as maxilla drains into retropharyngeal
lymph nodes which are inaccessible.
•Palpable neck nodes is a sign of advanced disease.

• In people working in wood furniture industries, Most common carcinoma of PNS is adenocarcinoma
of Ethmoid sinus.

o Previous Year Questions AIIMS 2019

Which of the following is notan etiological factor for head

and neck malignancies?
A ) EBV infection
B ) HPV infection
C) Betel nut
Qj Vitamin A deficiency

% notespaedia 117
CLASSIFICATION OF PNS CA | >
• OHNGREN'S LINE extends from medial canthus of eye fo the angle of mandible.
• Growths anteroinferior to this plane (infra- structural) have a better prognosis than those
posterosuperior to it ( suprastructural).

Suprastructure
Ohngren's
line

Infrastructure

o Previous Year Questions

Identify the following line shown in the below picture:

AIIMS 2017

A ) Frankfurt line
B) Donaldson line
C) Kassum line
tyfOhngren line

% notespaedia 118
 Suprastructure

Meso-
structure

Infrastructure

Lederman's Classification

MANAGEMENT OF CA MAXILLA
• Surgical resection followed by radiotherapy for all stages.
•Partial or total maxillectomy.
• Incision used : WEBER -FERGUSSON 'S INCISION.

Weber-Fergusson 's incision used in maxillectomy

% notespaedia 119
TNM CLASSIFICATION AND STAGING SYSTEM OF CANCER OF MAXILLARY SINUS

MAXILLARY SINUS
T1: Tumour Limited to maxilLary sinus mucosa with no erosion or destruction of bone.
T2 : Tumour causing bone erosion or destruction including extension into the hard palate and/or
middle nasal meatus, except extension to posterior wall of maxillary sinus and pterygoid
plates.
T3 : Tumour invades any of the following: bone of the posterior wall of maxillary sinus,
subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa and ethmoid sinuses.
Tka : Tumour invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal
fossa, cribriform plate, sphenoid or frontal sinuses.
Tkb : Tumour invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial
nerves other than maxillary division of trigeminal nerve ( V2), nasopharynx or clivus.

REGIONAL LYMPH NODES (N)

Nx : Regional lymph nodes cannot be assessed.
No : No regional lymph node metastasis.
N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension.
N2 : Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in
greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest
dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest
dimension.
N2a : Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in
greatest dimension.
N2b : Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest
dimension.
N2c : Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest
dimension.
N3 : Metastasis in a lymph node, more than 6 cm in greatest dimension.

DISTANT METASTASIS (M)

Mx : Distant metastasis cannot be assessed.
Mo : No distant metastasis.
Mi : Distant metastasis.

% notespaedia 120
| ANATOMY OF ORAL CAVITY AND PHARYNX

Hard palate
Buccal mucosa

Retromolar Oral tongue

trigone ( anterior 2/3)

Floor of
Gingiva mouth

Vestibule ^
i Area between lip and gingiva )

Contents of Oral Cavity

Base of Skull

Nasopharynx Narrower portion of pharynx :

Hard ,
Soft
Cricopharyngeo - oesophageal junction
Palate
Oropharynx
• Hyoid
Bone

Laryngopharynx
( Hypopharynx )

Lower border of
cricoid

Pharynx extends from base of skull

to the lower border of cricoid cartilage

% notespaedia 121
NASOPHARYNX
• Roof contains lymphoid tissue ( adenoids ).
• Lateral wall contains
• Eustachian tube opening
• Bulge around opening : TORUS TUBARIS
•FOSSA OF ROSENMUU.ER
• Recess / Fossa behind the torrus tubalis.
• Host common site of origin of Nasopharyngeal Carcinoma.
• Sphenopalatine foramen
• Host common site for origin of angiofibroma.
• Sphenopalatine Fossa
• Contains HaxilLary artery and sphenopalatine ganglion,
• Opens laterally into infratemporal fossa through the pterygomailLary fissure.
• Sensory Supply : HaxilLary Nerve

OROPHARYNX
• Lateral wall contains palatine /faucial tonsils.
• They are between the anterior pillars (Palatoglossus muscle ) and posterior pillars
(Palatopharyngeus muscle).
• Fibres of superior constrictor and palatopharyngeus together form the PASSAVANT ’S RIDGE .
• Soft palate moves upward against the Passavant ridge to prevent regurgitation of food.
• Sensory Supply : Glossopharyngeal nerve.

LARYNGOPHARYNX /HYPOPHARYNX
• Post cricoid area is present anteriorly (Site of carcinoma in Plummer Vinson Syndrome ).
• Pyriform fossa is present anterolaterally on both sides serving as passage for food while
swallowing.
• Sensory Supply : Superior Laryngeal Nerve, Recurrent Laryngeal Nerve
• Hotor Supply
•Hainly by vagus nerve.
•Exceptions : Stylopharynx - CN IX. Tensor Palati : Handibular Nerve

% notespaedia 122
 Pharyngeal Borders
ha
• Choana
• Soft palate
a
Root of tongue • Soft palate
& lingual tonsil
• Palatoglossal arch (anteriorly)
Pharyngo- ._ • Pharyngo- epiglottic fold & Epiglottis
epiglottic fold

Piriform Laryngopharynx
recess • Pharyngo- epiglottic fold &
Thyrord Epiglottis
cartilage • Inferior border of cricoid
Cricoid
cartilage Esophagus
Esophagus

LAYERS OF PHARYNX .
• Mucosal Layer
• Pharyngo - basilar fascia
• Muscle layer
• Bucco - pharyngeal fascia

MUCOSAL LINING OF PHARYNX

• Entire pharynx is lined by stratified squamous epithelium (including tonsilitis) except for
nasopharynx which is lined by ciliated columnar epithelium.
•Pharyngobasilar fascia is present behind the epithelium and in front of the nnuscle layer , it
forms the capsule of tonsils.

WALDEYER ’S RING
Adenoids
Lateral
Tubal tonsil
pharyngeal band

Nodules on posterior Palatine tonsil

pharyngeal wall
Lingual tonsil
Figure 47.2 Waldeyer ’s ring.

% notespaedia 123
WALDEYER 'S RING COMPONENTS ALSO CALLED AS LOCATION

Adenoids Lushka s or nasopharyngeal Nasopharynx (in the

tonsil. midline at the junction
of the roof and
posterior walL).

Tubal tonsils Gerlach' s tonsils Nasopharynx (on the

lateral walL behind the
Eustachian tube
opening).

Palatine Faucial tonsils Oropharynx (in

between the anterior
and posterior pillars ).

Lingual tonsils Posterior 1/3rdi.e. base

of tongue.

Lateral pharyngeal band Posterior pharyngeal

and nodules wall.

MUSCLE LAYER OF PHARYNX

• 2 layers
• Inner Longitudinal : 3 pharyngeal muscles (Salpingopharyngeus, Stylopharyngeus.
Palatopharyngeus )
• Outer Circular : 3 constrictors (Superior , Middle and Inferior )
• SINUS OF MORGAGNI
•Space between base of skull and upper border of superior constrictor.
•Filled by just pharyngobasilar fascia.
• Structures passing through :
• Tensor Veli Palatini
• Ascending Palatine Artery
• Levator Veli Palatini
• Auditory Tube

?• notespaedia 124
 A B
on as+ac of
* Rwyngaal (nets

ft

4 .
( t

/
m *
Superior congvtcio
*
\
YA
Mn3dte conjtrcio#

ClOf^«0U9

Structures passing between superior constrictor and middle constrictor

•Glossopharyngeal Nerve
•Stylopharyngeus Muscle

Structures passing between middle constrictor and inferior constrictor

•Internal Laryngel nerve ( Superior Laryngeal Nerve )
•Superior Laryngeal Vessels

Structures passing betweem inferior constrictor and oesophagus

• Recurrent Laryngeal nerve ( Inferior branch of vagus)
• Inferior Laryngeal vessels
INFERIOR CONSTRICTOR
•Inferior Constrictor of 2 parts
•Oblique Thyropharyngeus
•Transverse Cricopharyngeus
•Space between them is calLed Killian' s dehiscence through which Zenker' s diverticulum can arise.
(FALSE DIVERTICULUM).
•It lies posteriorly (mostly on left side).
•Presents with dysphagia, halitosis, regurgitation.
•On palpation of swelling, gurgling sound is produced (BOYCE SIGN).
•Barium swatLow is used for diagnosis.
• Management
• Surgical excision of pouch follwed by cricopharyngeal myotomy.
• Endoscopic stapling or by using laser (Dohlman' s procedure) is also used nowdays.

% notespaedia 125
 Thyropharyngeus
Muscle
Kilian's dehiscence

Cricopharyngeus
Muscle

Posterior view
Pharyngeal diverticulum
through Kilian's
dehiscence .ateral view

BUCCOPHARYNGEAL FASCIA
• Lies behind the constrictor muscles.

0 Previous Year Questions AIIMS 2018

A patient presents with oral cavity findings are seen in the image below. He is a
smoker. What would you choose as your next step in the management of this patient?
A ) Give corticosteroids
$ Cessation of smoking and do biopsy
C) Lifestyle modifications
D ) Injection vitamin B12

% notespaedia 126
RETROPHARYNGEAL SPACE
•Space between buccopharyngeal space and alar fascia.
•Extends from base of skull till Tk vertebra.
•Divided by midline fibrous raphe into two lateral spaces (SPACES OF GILLETTE ).
•Contents : LYMPH NODES OF ROUVIER
•Infection here presents a unilateral paramedian bulge of the posterior pharyngeal walls on one side.
• ACUTE RETROPHARYNGEAL ABSCESS
•Common in children.
•Suppuration of lymph nodes.
•In adults, it is usually due to trauma (fish bone).
•Rx : I & D.
• CHRONIC RETROPHARYNGEAL ABSCESS
Common in adults.
Most common cause : TB of lymph nodes.
Rx : ATT

% notespaedia 127
DANGER SPACE
•Space between alar fascia and prever+ebral fascia.
•Extends from base of skull through post mediastinum till the level of diaphragm.
•Infection here can spread to mediastinum leading to mediastinitis, pericarditis, pleuritis, etc.

PREVERTEBRAL SPACE
• Space between prevertebral fascia and vertebral bodies.
• Extends from base of skull till coccyx.
• Infection here presents as a diffuse midline bulge.
PARAPHARYNGEAL SPACE
• Aka pterygomaxillary /pharyngomaxillary space.
•Most common infected space in pharynx.
•Present between mandible and lateral pharyngeal wall.
•Divided into 2 compartments by the styloid process : Anterior and Posterior.

Prevertebral space
Prevertebral
CN IX , X , XI fascia
Alar fascia
Parotid gland Danger space

Buccopharyngeal
fascia
Parapharyngeal space
Retropharyngeal space
•Anterior compartment
•Posterior compartment
Peritonsillar space
Medial pterygoid muscle

Spaces in relation to pharynx where abscesses can form.

% notespaedia 128
ANTERIOR COMPARTMENT
• Pre - Styloid.
• Infection here can involve the medial pterygoid causing trismus.
• Abscess/ swelling here can push the tonsil medially (D/d : Quinsy ).
• Bulge in the neck at the angle of jaw present : Differentiates from quinsy.

POSTERIOR COMPARTMENT
• Post - Styloid.
• Contains Internal Carotid Artery, Internal Jugular Vein, CN IX , X, XI, XII, Sympathetic Trunk.
• Abscess / Infection here can involve the mentioned structures.

MANAGEMENT OF ABSCESS
• I & D by horizontal incision below the lower border of mandible + Antibiotics

Space Extent Location Source of infection

Parotid space Within two layers of superficial Parotid area Infection of oral cavity via
layer of deep cervical fascia Stenson's duct
Submandibular space • Sublingual space. Oral mucosa Below the tongue • Sublingual sialadenitis,
(submaxillary plus to mytohyoid muscle tooth infection
sublingual) • Submandibular space. Mylohyoid Submental and submandibular triangles • Submandibular gland
muscle to superficial layer of sialadenitis
deep cervical fascia extending • Molar tooth infection
from mandible to hyoid bone
Peritonsillar space Between superior constnctor and Lateral to tonsil Infection of tonsillar crypt
fibrous capsule on the lateral
aspect of tonsil
Retropharyngeal space Base of skull to tracheal Between alar fascia and the buc- • Extension of infection from
bifurcation (T4) copharyngeal fascia covering con- parapharyngeal space,
strictor muscles parotid or masticator space
• Oesophageal perforation
• Suppuration of retropharyn-
geal nodes
Danger space Base of skull to diaphragm Between prevertebral fascia and alar Infected by rupture of ret-
fascia ropharyngeal abscess
Prevertebral space Base of skull to coccyx Between vertebrae on one side and • Tuberculosis of spine
prevertebral muscles and the prever- • Penetrating trauma
tebral fascia on the other
Parapharyngeal space Base of skull to hyoid bone and Buccopharyngeal fascia covering lateral • Pentonsillar abscess
{Lateral pharyngeal submandibular gland aspect of pharynx medially, and fascia • Parotid abscess
space or pharyngo- covering pterygoid muscles, mandible • Submandibular gland
maxillary space) and parotid gland laterally infection
• Masticator space abscess
Masticator space Base of skull to lower border of Between superficial layer of deep cervical Infection of third molar
mandible fascia and the muscles of mastication-
masseter, medial and lateral pterygoids
insertion of temporalis muscle and the
mandible

129
0 Previous Year Questions AIIMS 2018

Which of the following features will not be manifested in an infection

of the post-styloid compartment of the parapharyngeal space?
Trismus
B ) Vocal cord palsy
C) Parotid swelling
D) Horner's syndrome

% notespaedia 130
 • Usually adenoids increase in si2e till 6 years of age and starts atrophy by puberty
disappearing at 20 years of age.
CLINICAL FEATURES
•NASAL SYMPTOMS
•Nasal Obstruction, Mouth breathing. _
•Pinched up nose, Absent nasolabial crease. ADENOID FACIES
•High arched palate, crowding of teeth.
•EUSTACHIAN TUBE OBSTRUCTION
•B /l serous otitis media.
•Conductive hearing loss (dull look of child during conversations).
•RHINOLALIA CLAUSA (Hyponasal voice )
• SLEEP APNEA

• Diagnosed by endoscopy , lateral X - Ray of nose and nasopharynx.

MANAGEMENT
• Initially for acute adenoiditis : Antibiotics, Anti histamines and decongestants.
• Indications for adenoidectomy
• Adenoid hypertrophy causing snoring, mouth breath- ing, sleep apnoca syndrome or speech
abnormalities, i.e. (RHINOLALIA CLAUSA ).
• Recurrent rhinosinusitis.
• Chronic otitis media with effusion associated with adenoid hyperplasia.
• Recurrent ear discharge in benign CSOM associated with adenoiditis/ adenoid hyperplasia.
• Dental malocclusion.
• Contraindications for adenoidectomy
• Cleft palate or submucous palate. Removal of adenoids causes velopharyngeal insufficiency
in such cases.
• Haemorrhagic diathesis.
• Acute infection of upper respiratory tract.

THORNWALST ’S BURSITIS
• Infection of Thornwald bursa (remnant of notochord) situated at the junction
of roof and posterior wall of nasopharynx .
• Presents with persistent post nasal drip, occipital headache, sore throat.
• Management : Antibiotics, Marsupial! sation. Cyst excision.

% notespaedia 131
0 Previous Year Questions INICET 2021

Identify the condition shown in the image.

$ Adenoid facies
B) Goldenhar syndrome
C) Horse facies
D) Frog facies

% notespaedia 132
 • Juvenile Nasopharyngeal Angiofibroma.
• Seen in males, especially near puberty.
• Most common benign tumour of nasopharynx.
• Arises from sphenopalatine foramen.
• LocalLy invasive.
CLINICAL FEATURES
• Red fleshy mass on anterior rhinoscopy .
•Recurrent episodes of epistaxis.
•Unilateral nasal obstruction.
•Unilateral serous otitis media because of Eustachian tube obstruction.
•Pressure effects
•Proptosis
•Swelling of cheeks - FROG FACE DEFORMITY
•Brodening of nasal bridge.

% notespaedia 133
STAGING OF JUVENILE NASOPHARYNGEAL ANIOFIBROMA (Modified sessions, etal)
• IA: Limited to nose and/or nasopharyngeal vault
• IB: Extension into > 1 sinus
•II A: Minimal extension into PMF
• MB: Full occupation of PMF with or without erosion of orbital bones
•II C: IF with or without cheek or posterior to pterygoid plates
• IIIA: Erosion of skull base-minimal intracranial
•I B: Erosion of skull base-extensive intracranial with or without cavernous sinus

0 Previous Year Questions AIIMS 2018

A teenager has a mass in his nasopharynx that has minimally spread into
the sphenoid sinus with no lateral extension.
Which stage of nasopharyngeal angiofibroma could this be?
A ) Stage IA
jrfStage IB
C) Stage IIA
D ) Stage IIB

MANAGEMENT
• Surgical Excision
•Preoperative embolisation can also be done to reduce bleeding.
• Radiotherapy is also used especially in case of unresectable tumours.

% notespaedia 134
• 1+ is a squamous cell carcinoma that arises commonly from THE FOSSA OF ROSENMULLER .
• If is the most common malignancy of nasopharynx .
• 3 main etiological factors :
•Genetic : More common in Chinese people ( GUANGDONG CANCER )
• Environmental : Exposure to nitrosamines, polycyclic hydrocarbons, smoking.
• Viral
• EBV Infection [2 antigens : Early Antigen (EA ) and Capsid Antigen ( VCA ) ]
• Antibodies against EA and VCA are used in diagnosis.
CLINICAL FEATURES
• Nasal symptoms : Obstruction, Discharge, Epistaxis, Rhinolalia Clausa
• Otologic : U/L SOM because of ET obstruction; U/L CHL
• Involvement of Cranial Nerves
• Diplopia (CN III, IV, Vl )
• Jugular Foramen Syndrome (CN *t, 10, 11)
• CN XII involvement
• Horner ’ s Syndrome (Cervical sympathetic chain involvement)
• Loss of Corneal refl.ex (CN V )
• Blindness (CN ll)
• TROTTER ’S TRIAD : CHL + l /L Temprorparietal Neuralgia (CN V ) + Palatal Paralysis (CN X )
• Majority (75%) of patients present with painless cervical lymphadenopathy ( nodal metastasis )
as first symptom.

Ophthalmic symptoms
and taaal pam (CN III , IV, V, VI)

Foramen lacerum and

ovale
Cranai nerve
(IX X. XI Ml. tube Serous OM
’
syndrome)

Nose and orbit Nasal obstruction

Ptoygod Epistaxis
musdes Proptosis
(trismus)
Retropharyngeal
nodes Secondaries
Neck pan Distant metastases
lung, liver.
andsaffness
bone
Cervical nodes

Upper-jugular and
posterior triangle nodes enlargement

Routes of spread (green areal and cfcracal features (blue area) of nasopharyngeal cancer.

% notespaedia 135
 PRESENT WHO TERMINOLOGY
Type I ( 25%) Keratinizing carcinoma
Type II (12% ) Nonkeratinizing differentiated carcinoma
Type III (63% ) Nonkeratinizing undifferentiated carcinoma
(Poor Prognosis)

Tl Tumor confined to the nasopharynx .

T2 Tumor extends to soft tissue of nasopharynx and/or nasal fossa.
T2a: without parapharyngeal extension.
T2b, with paraphuryngeal extention.
T3 Tumor invades bony structures and/ or paranasal sinuses.
Tk Tumor with intracranial extension and/or involvement of cranial nerves,
infratemporal fossa, hypopharynx or orbit.
NO No regional lymph node metastasis.
Nl Unilateral metastasis lymph node( s) measuring < = 6 cm in greatest
dimension above the supraclavicular fossa.
N2 Bilaleral metastases in lymph node ( s) measuring < * 6 cm in greatest
dimension above the supraclavicular fossa.
N3 Metastasis in a lymph node( s ):
( a) > 6 cm in greatest dimension;
(b) extention to the supraclavicular fossa.
MO No distant metastases.
Ml Distant metastases.
Stage I T1 NO MO
Stage IIA T2a NO MO
Stage MB T1 N1 MO
T2a N1 MO
T2b NO-1 MO
Stage III T1 N2 MO
T2 N2 MO
T3 NO- 2 MO
Sage IVA Tk NO- 2 MO
Stage IVB Any T N3 MO
Siage IVC Any T Any N Ml

% notespaedia 136
MANAGEMENT
•Mainly by radiotherapy as surgical margins of resection are difficult to acheive.
•Concurrent chemoradiation is preferred on advance stages. (Stage III, Stage IV)

% notespaedia 137
EMBRYOLOGY AND ANATOMY I t
• Arises from 2nd pharyngeal pouch.
• Lined by non - keratinized stratified squamous epithelium.
• CRYPT A MAGNA is a remnant of the ventral portion of 2nd pharyngeal pouch.
• Capsule of the tonsil is formed by pharyngobasilar fascia.
• Bed of tonsil is formed by superior constrictor and styloglossus muscle.

Secondary crypts

Crypta magna

Primary crypt

Primary and secondary crypts of tonsils.

Relations of tonsil. Tonsil is related laterally to its cap-

sule (1), loose areolar tissue containing paratonsillar vein (2), superior
constrictor muscle (3), styloglossus (4), glossopharyngeal nerve (5),
facial artery (6), medial pterygoid muscle (7), angle of mandible (8) and
submandibular salivary gland (9), pharyngobasilar fascia (10), bucco-
pharyngeal fascia (11).

% notespaedia 138
BLOOD SUPPLY OF TONSIL

Maxillary artery

Descending
palatine artery

Tonsillar branches
J of ascending
c
<
pharyngeal artery
Ascending
pharyngeal
artery Ascending
palantine artery

Facial artery Tonsillar artery > Main Artery

Lingual artery Dorsal linguae
branches
External carotid
artery
Arterial supply of tonsil.

• Venous drainage is done by the external palatine vein/paratonsillar vein which lies in the
peritonsillar space.
• Most common cause of haemorrhage causing tonsillectomy : Injury to paratonsillar vein.

• Lymphatic Drainage
• Upper deep cervical Lymph Nodes : JUGUL 0D1GASTR 1C NODES ( TONSILLAR NODES )
• Nerve Supply
• Glossopharyngeal Nerve
ACUTE T 0NSIL1TIS

•Most Common Cause : Viral Infection

•Most Common Bacterial Cause : Beta - Hemolytic Streptococci
•Presents with : Fever , Sore throat. Dysphagia, Ear Ache, Head Ache, Malaise
ON EXAMINATION
• Congested Uvula, Soft palate
• Inffammed tonsils with yellow spots of purulent material : FOLLICULAR T0NS1LITIS
• Whitish membrane on the surface of tonsils which can be easily
wiped off : MEMBRANOUS TONSILITIS
• Uniformly enlarged tonsils that almost meet in midline : PARENCHYMATOUS TONSILITIS

% notespaedia 139
 • Management : Analgesics, Antimicrobials
• Complications : Chronic tonsilitis, Peritonsilar abscess, Parapharyngeal abscess, Acute Otitis
media. Acute Glomerulonephritis.

0 Previous Year Questions NEETPG 2018

Which of the following nerves is responsible for referred

otalgia from tonsillitis?
Glossopharyngeal nerve
B ) Facial nerve
C) Trigeminal nerve
D) Vagus nerve

CHRONIC TONSILITIS
• Because of recurrent acute attacks of tonsilitis.
CARDINAL SIGNS
•Flushing of anterior pillars compared to rest of the pharynx.
• Enlargement of jugulodigastric nodes.
• IRWIN - MOORE SIGN : Expression of cheesy material from tonsil on applying
pressure to anterior pillar .

TONSILLECTOMY

• Positioning : ROSE ’S POSITION (Extension at neck and Extension at head)

INDICATIONS
•ABSOLUTE
•Recurrent Episodes of Acute Tonsiltis
•
3 episodes / year for 3 consecutive years
5 episodes / year for 2 consecutive years
- T episodes in a single year
•Chronic Tonsiltis
•Peritonsillar abscess (after 2 episodes in adults, 1 in children).
•Febrile seizures due to hypertrophied tonsils.
•OSA and dysphagia due to hypertrophied tonsils.
•Unilateral enlargement of tonsils with suspected malignancy.
•RELATIVE
•Streptococcal and Diphtherial carrier

% notespaedia 140
 It is also done as an approach to other surgeries.
•Eagle's syndrome (Styalgia )
•Glossopharyngeal Neuralgia
•Uvulopalatopharyngoplasty

CONTRAINDICATIONS
• Hb < 10 g%
• Acute upper respiratory tract infection
• Bleeding disorders
• Children < 3 years
• At the time of polio epidemic
• Submucous cleft palate

COMPLICATIONS
•IMMEDIATE
• PRIMARY HEMORRHAGE : Bleeding at the time of surgery .
• REACTIONARY HEMORRHAGE : Bleeding within 24 hours of surgery.
• Aspiration of blood.
• Injury to surrounding structures.
•DELAYED
• SECONDARY HEMORRHAGE : Bleeding between 5th - tth day post surgery because of sepsis.
• Infection.
• Lung Complications.

0 Previous Year Questions NEETPG 2021

A patient post-tonsillectomy in the recovery room starts bleeding from the operative site. On
examination, blood clots are seen. What will be your immediate management?
Shift to OT, remove the clots, and cauterize/ ligate the vessel
B ) Shift to OT, start IV antibiotics, and pack the tonsillar fossa
C) Give anticoagulants, repeated gargling, and wait for 24 hours
D) Do blood transfusion and wait and watch

% notespaedia 141
LUDWIG S ANGINA
• CelLulitis of the submandibular space.
• Host common cause is dental caries.
• It is a mixed aerobic and anaerobic infection.
• Clinically presents with difficulty in eating speaking, raised floor of mouth.
• O /E : Tense swelling with woody feel of skin of neck below chin and mandible.
• Management : l &D to relieve pressure.

PERITONSILLAR ABSCESS / QUINSY

• Collection of pus in the peritonsilLar space (Space between capsule of tonsil and superior
constrictor muscle).
• Patient presents with Odynophagia, Muffled speeh (Hot potato voice), Trismus, Ear ache.
•O/E : Tonsils are pushed medially, pushing uvula to opposite side.
• Management
• l & D.
• Antibiotics.
• Interval tonsillectomy.

0 Previous Year Questions NEETPG 2020

A 9-year-old boy comes with complaints of right ear pain, difficulty in opening the mouth,
painful swallowing, and fever. The oral cavity examination reveals the following. The
external facial examination is unremarkable. Which of the following is likely?
A ) Pharyngitis
B ) Parotid abscess
C) BezoId 's Abscess
{ Quinsy

% notespaedia 142
RANULA
• Mucous retention cysts arising from the sublingual salivary glands.
• It commonly presents as a translucent bluish soft cystic -fluctuant swelLing below the tongue.
• If there is a deficiency in the mylohyoid, ranula can extend through it resulting in a swelling in
the neck.
• This is termed as plunging ranula.
• Treatment : Marsupialisation of cyst/Surgical excision of sublingual salivary gland.
PLUMMER - VINSON SYNDROME
• Aka Paterson - Brown - Kelly Syndrome.
• Seen in women over kO years of age.
• CHARACTERISTIC TRIAD
•Post - cricoid dysphagia : Initially to solids, later to liquids.
• Iron - deficiency anaemia : Weakness, fatigue, dyspnoea, Glossitis, Koilonychia, Achlorhydria.
•Upper oesophageal webbing.
• It is associated with development of post - cricoid carcinoma.

% notespaedia 143
EMBRYOLOGY & ANANTOMY

•Larynx develops from 4th and 6th pharyngeal arches.

•Supraglottis, epiglottis arise from the 4th arch and are supplied by superior laryngeal nerve.
• Glottis, subglottis arise from 6th arch, supplied by recurrent laryngeal nerve.
Opening for
superior laryngeal Epiglottis
vessels and internal
branch of superior
laryngeal nerve (x
/
Hyoid bone
Superior - 0 — — Thyrohyoid
membrane
cornua of
thyroid ;/x
Thyroid cartilage

Inferior Cricothyroid
cornua of membrane
thyroid
Cricoid cartilage
Cricotracheal
membrane

Laryngeal Framework

Hyoepiglottic
ligament

Hyoid bone
Fat in pre-epiglottic
space
Thyrohyoid membrane
Corniculate Thyroid cartilage
cartilage
Thyroepiglottic
Arytenoid ligament
cartilage Quadrangular
membrane
Cricovocal
membrane

Sagittal section of larynx showing cricovocal and quadrangular

membranes and boundaries of the
pre-epiglottic space.

% notespaedia 144
 •Larynx is composed of 3 paired and 3 unpaired cartilages.
• Paired : Aretynoid, Corniculate, Cuneiform
•Unpaired : Epiglottis, Thyroid, Cricoid
• Aretynoid, Thyroid, Cricoid : Hyaline Cartilage
• Corniculate, Cuneiform, Epiglottis : Elastic Cartilage
• It extends from C3 - C6 vertebra.
• It has extrinsic and intrinsic membranes.
• Extrinsic Membranes
• THYROHYOID : Pierced by internal laryngeal nerve and superior laryngeal vessels.
• CR 1COTRACHEAL
• HYOEPIGLOTTIC
• Intrinsic Membranes
" QUADRANGULAR
~Upper border : Ary - epiglottic fold.
Lower border : False vocal cord.
• CONUS ELAST1CUS ( CRICOVOCAl MEMBRANE )
- Upper border : True vocal cord.
- Lower border : Attached to cricoid.
• Cricothyroid membrane is the anterior thickening of cricovocal membrane.
MUSCLES OF LARYNX >
INTRINSIC
• Acting on vocal cord
• ADDUCTORS : Lateral cricoarytenoid, Interarytenoid, Thyroarytenoid
• ABDUCTORS : Posterior Cricoarytenoid
• TENSORS : Cricothyroid, Vocalis (Part of Thyroarytenoid)
• Acting on Laryngeal Inlet
• OPENERS : Thyroepiglottic
• CLOSERS : Interarytenoids

EXTRINSIC
•Elevators
•PRIMARY : Stylopharyngeus, Salpingopharyngeus , Palatopharyngeus, Thyrohyoid
•SECONDARY : Mylohyoid, Digastric, Stylohyoid, Geniohyoid.
•Depressors
•STERNOHYOID, OMOHYOID , STERNOTHYROID

% notespaedia 145
 Aryepiglottic
Thyroepiglottic
Transverse and
oblique arytenoid
Thyroarytenoid

Posterior Cricovocal
cricoarytenoid membrane

Lateral
cricoarytenoid

Intrinsic muscles of larynx as seen on lateral view.

Cartilago
Laryngeal triticea
inlet
Thyrohyoid
membrane
Oblique
arytenoid m.

Transverse
arytenoid m.

Posterior
cricoarytenoid m.

Laryngeal inlet and intrinsic muscles of larynx as seen

from behind
CAVITY OF LARYNX
• Laryngeal inlet
• Vestibule : Part between inlet and vestibular folds.
• Ventricle (Sinus of Larynx ) : Space between vestibular folds and vocal folds.

% notespaedia 146
 Epiglottis
Hyoid bone -
Supraglottis

Vestibular folds

Thyroid cartilage Glottis

Vocal folds
Subglottis
Cricoid cartilage

Trachea

SACCULE
• Saccule is a diverticulum of mucous membrane which s+ar+s from the anterior part of ventricular
cavity and extends upwards between vestibular folds and lamina of thyroid cartilage.
• VESTIBULAR FOLDS : False vocal cords.
• VOCAL FOLDS : True vocal cords
• Anterior 2/ 3rd formed by upper free border of cricovocal membrane (membraneous).
• Posterior 1/3rd fromed by the vocal process of arytenoids (cartilaginous ).
• RIMA VEST 1BUL 1 : Space between the false vocal cords.
• GL 0TTIS/R 1MA GL 0TTID1S : Space between true vocal cords.
• Larynx is lined mainly by ciliated columnar epithelium except the vocal cords and vestibule
which are lined by stratified squamous epithelium.

LYMPHATIC DRAINAGE
• SUPRAGLOTTIS : Upper deep cervical lymph nodes
• INFRAGLOTTIS : Pretracheal and prelaryngeal lymph nodes - Lower deep cervical lymphnodes.
• Glottis has no lymphatic at all.

% notespaedia 147
PRE-EP1GL 0TT1C SPACE
41
• SPACE OF BOYER .
•Lies in between the thyroid and thyrohyoid mebrane anteriorly and epiglottis posteriorly.

PARAGLOTTIC SPACE
• SPACE OF TUCKER
• Bounded laterally by thyroid cartilage.
• Bounded medially by quadrangular membrane, ventricle, conus elasticus.
• Bounded posteriorly by pyriform fossa of hypopharynx.

REINKE ’S SPACE
• Sub - epithelial space in the medial free border of the membranous true vocal cords.

LARYNGOSCOPY
•Indirect laryngoscopy
Done using straight laryngeal mirror.

Base of tongue

Ventricular
fold Vallecula

Vocal [ Epiglottis
cord - Ventricular space
Cuneiform
cartilage

Pyriform Corniculate
fossa cartilage
Interarytenoid area

Structures seen on indirect laryngoscopy

•Direct laryngoscopy is done during intubation.

% notespaedia 148
 | rfectie*% 4 L
ACUTE EPIG10 TT 1TS
• Host common cause : H. Infl.uenzae Type B
• Clinical Features
• Sick looking child with fever and inspiratory stridor.
• Tripod positioning.
•Drooling of saliva. Odynophagia.
•Normal voice.
• O /E : Congested swollen epiglottis
• Lateral X - Ray soft tissue of neck shows characteritic " THUMB SIGN *.
• Management : Antibiotics, Steroids, Humidification, Oxygenation, Hydration,
Intubation in severe airway obstruction.

LARYNGOTRACHEOBRONCHITIS
•Most Common Cause : Parainfluenza Virus
• Presents as :
• URTI with hoarseness and croupy cough
• Inspiratory Stridor
• Respiratory difficulty
• STEEPLE SIGN on AP view X - Ray neck.
• Management : Adrenaline, Humidification, Steroids, 02, Antibiotics, IV Fluids.
Intubati on /Tracheostomy

REINkE ’S OEDEMA
• Bilateral symmetrical swelling of membranous part of VC because of oedema in Reinke ' s space.
• Occurs because of voice abuse, smoking, laryngopharyngeal reiex .
• Presents with hoarseness, low pitched and rough noise.
• O /E : VC appear as fusiform swellings with pale translucent look.
• Management
• Voice rest
• Decorrication of VCs
• Speech Therapy

% notespaedia 149
 ACUTE EPIGLOTTITIS ACUTE LARYNGO- TRACHEO-
BRQNCHITIS ( OR GROUP )
Causative organism Haemophilus influenza type B Parainfluenza virus type I and ll
Age 2- T years 3 months to 3 years
Pathology Supraglottic larynx Subglottic area
Prodromal symptoms Absent Present
Onset Sudden Slow
Fever High Low grade or no fever
Patient s look Toxic Nontoxic
Cough UsualLy absent Present (barking seal-like)
Stridor Present and may be marked Present
Odynophagia Present, with drooling of secretions UsualLy absent
Radiology Thumb sign on lateral view Steeple sign on anteroposterior
view of neck
Treatment Humidified oxygen, third generation Humidified 02 tent, steroids
cephalosporin (ceftriaxone) or
amoxicilLin

PACHYDERMA LARYNGl
•Also known as CONTACT ULCER /kISSING ULCER .
•Chronic hyoertrophic laryngitis affecting posterior part of larynx due to prolonged voice abuse.
•There is forceful rubbing of vocal processes of arytenoid resulting in heaping of epithelium at the
posterior commissure area.
•This rubs against the opposite VC creating an ulcer.
•Management
•Removal of granulation tissue under operating microscope. Speech Therapy .
TUBERCULOSIS OF LARYNX
• Occurs secondary to pulmonary TB.
• Affects posterior part of larynx : Interarytenoid fold, Ventricular bands. Vocal cords. Epiglottis.
• Clinical Features
•Weakness of voice (Earliest Symptom)
•Hoarseness
•Odynophagia
• 0 /E :
~ Hyperemia of Vocal cords

- MamilLated appearance of arytenoids

Mouse nibbled appearance of vocal cord.
•

Pseudoedema of epiglottis (Turban epiglottis )

• Management : ATT

% notespaedia 150
 CW*jorttat 4t
STRIDOR
• Inspiratory : Lesion in supraglottis /pharynx.
•Expiratory : Lesion in thoracic trachea, primary or secondary bronchi.
• Biphasic : Lesions of glottis. Subglottis and cervial trachea.

Pharynx &
supraglottis Inspiratory stridor

Glottis, subglottis & cervical Biphasic

trachea

Thoracic trachea Expiratory stridor

& bronchi

Types of stridor and their site of origin

LARYNGOMALACIA
• Host common congenital anomaly of larynx.
• Host common stridor in infants.
• Clinically presents with inspiratory stridor
that worsens in supine positon and disappears
in prone position.
• O /E :
• Bulky supraglottis is seen.
• Omega shaped epiglottis.
• Floppy aryepiglottic folds.
• Prominent arytenoids.
• Hanagement
Laryngomalacia
• Conservative (Symptoms disappear by 2
Note : epiglottis is folded longitudinally
years of age).
forming an omega .
• Provide Reassurance
• Supraglottoplasty is done in severe cases.

% notespaedia 151
LARYNGOCELE
• Dilatation of laryngeal saccule due +o chronic increase in transglottic pressure.
• In glass blowers, trumpet players.
• It can be intrinsic, extrinsic or combined.
Compression of the external swelling leads to a hissing sound (BRYCE SIGN).
• Management
• EXC1S10N/MARSUP1AUSATI0N

Laryngocele left side as seen on Valsalva ( arrow )

Thyrohyod Laryngocele:
membrane External
component
Internal
component

Laryngocele mixed type with internal and

external components

SUBGLOTTIC STENOSIS
• It can be congenital or acquired.
•Most common cause of acquired subglottic stenosis : Prolonged intubation.
•Diagnosis of congenital subglottic stenosis
Subglottic diameter : < *imm in full term neonate
< 3mm in premature neonate
• Management
• Conservative in most cases.
• In symptomatic patients
• Emergency tracheostomy
• Cricotracheal resection followed by end to end anastomosis.
• Laryngotracheal reconstruction.

% notespaedia 152
0 Previous Year Questions
NEETPG 2021

The image of a drug is given below. It is used in which of the following conditions?

$Subglottic stenosis
B ) Rhinocerebral mucormycosis
C) Adenoidectomy
D) Tympanoplasty
' tonyanC 10 mg
***> para soluci6n i
*

LARYNGEAL WEB
• Due to incomplete canalisation of larynx.
• Presents with airway obstruction, weak cry or aphoria.
• Rx : C02 laser excision/excision using knife.

% notespaedia 153
 \)eico <\xX [)i
VOCAL NODULES
• SINGER ’S /SCREAMERS NODULE.
•Mostly affects people with professions involving prolonged voice abuse like teachers, vendors,
singers, etc.
•This leads to trauma causing sub - mucosal hemorrhage resulting in development of bilaterally
symmetrical sessile nodules at the site of maximum vibration (Junction of anterior M3rd and
posterior 213rd ).
•Presents with hoarseness and voice fatigue.
•Rx : Voice rest, speech therapy.
Excision by microlaryngeal surgery if not resolving.

VOCAL POLYPS
• Due to sudden vocal abuse /misuse by unprepared larynx.
• Presents as unilateral pedunculated swelling at the junction of anterior M3rd and posterior
213rd.
• Because of difference in vibratory frequency, there is double voice : DIPLOPHON1A .
• Rx : Excision by MLS followed by speech therapy. No role for conservative management.
DYSPHON1A PLICA VENTRICULARIS
• Abnormal production of voice by false vocal cords because of non - functioning true
vocal cords.
• Voice is rough, low pitched.
• Rx : Treat underlying organic / non - organic cause.

SPASMODIC DYSPH0N1A /LARYNGEAL DYSTONIA

•Due to involuntary spasm of phonatory muscles leading to dysphonia.
•Associated with other dysphonias.
•Can be ADDUCTOR SPASM : Scratchy crealy voice.
•Can be ABDUCTOR SPASM : Whispery or breathy voice.
•Rx : Botulinum injection.

% notespaedia 154
FUNCTIONAL APHONIA
•HYSTERICAL APHONIA .
•Seen in emotionally labile females in the 15 - 30 year age group.
•Quality of voice doesn't remain constant.
•Can present with history of sudden complete loss of voice.
•On exmination, vocal cords are abducted during phonation but on coughing adduction is present
indicating absence of palsy.
•Rx : Psychotherapy and Reassurance.
PUBERPH0N1A
• MUTATIONAL FALSETTO VOICE.
• Failure of change in voice from high pitch to low pitch in boys at puberty.
• Seen in boys who are emotionally insecure, immature.
• Rx : Voice training.
• GUTZMANN ’S PRESSURE TEST : Applying pressure (backwards and downwards) on thyroid
cartilage releases vocal cords and produce low tone voice.
PHONASTHESIA
• Weakness of voice due to fatigue of phonatory muscles.
• Mainly 2 groups of muscles are involved
• THYROARYTENOID : Proper adduction is not possible resulting in an elliptical gap.
•INTERARYTENOID : Triangular gap is formed in post commissural area.
• If both muscles are involved, key hole appearance is formed.
• Rx : Voice Rest

% notespaedia 155
 Iiec4 Cetyl
NERVE SUPPLY OF LARYNX

SENSORY SUPPLY
• INTERNAL LARYNGEAL NERVE (Branch of Superior Laryngeal Nerve) : Larynx and
hypopharynx above the level of true vocal cord.
• RECURRENT LARYNGEAL NERVE : Larynx and hypopharynx below the level of true
vocal cords.

MOTOR SUPPLY
• EXTERNAL LARYNGEAL NERVE : Cricothyroid
•RECURRENT LARYNGEAL NERVE : All other phonatory muscles.
•Left recurrent laryngeal nerve is more prone to injury because of its longer course.
• Most common cause of unilateral and bilateral recurrent laryngeal nerve and external laryngeal
nerve palsy is injury during thyroid surgery.

Situation in

Position of the cord Location of the cord from midline Health Disease

Median Midline Phonation RLN paralysis

Paramedian 1.5 mm Strong whisper RLN paralysis
Intermediate (cadaveric) 3.5 mm. This is neutral position of Paralysis of both recurrent
cricoarytenoid joint. Abduction and and supenor laryngeal
adduction take place from this position nerves
Gentle abduction 7 mm Quiet respiration Paralysis of adductors
Full abduction 9.5 mm Deep inspiration

Position of the vocal cord in health and disease

Position of vocal cords

— Median

Paramedian

Intermediate ( cadaveric)

Slight abduction
Fufl abduction

% notespaedia 156
TYPE OF PALSY POSITION OF VC SPEECH ASPIRATION RESPIRATION
U/L RLN Hostly median, Normal, None Normal
sometimes paramedian. Sometimes
mild hoarseness
initially.

B /l RLN Hostly median. Largely normal None Stridor and

Sometimes mild dyspnoea
hoarseness. on exertion
(therefore the
most life
threatening palsy).

U/L SLN Normally moving Weak Voice and Occasional Normal

curved VC. voice fatigue.

B/L SLN Normally moving VC Husky voice Present Normal

but Both are curved.

U/L complete Cadaveric Initial dysphonia Sometimes Normal

oraphonia
subsequently
hoarseness.

B /L complete Both VC in Aphonia Severe Normal

cadaveric position. aspiration
episodes.

0 Previous Year Questions AIIMS 2019

A patient undergoes surgery of the lateral part of the base

of the skull. Postoperatively, the patient presents with
aspiration but does not have a change in voice. Which of
the following is the reason?
&fSLN injury
B ) Glossopharyngeal nerve injury
C) RLN injury
D ) High vagal injury

% notespaedia 157
THYROPIASTY
• types
( l ) Medialisation of VC.
( ll ) Lateralisation of VC.
( ill ) Shortening of VC : Done in puberphonia.
( IV) Lengthening of VC : Done in androphonia.

0 Previous Year Questions NEETPG 2021

Following total thyroidectomy, a patient started having difficulty in breathing, and repeated
attempts to extubate were unsuccessful. The most probable cause is
A) Superior laryngeal nerve injury
B) Unilateral recurrent laryngeal nerve injury
$ Bilateral recurrent laryngeal nerve injury
D ) Hematoma

% notespaedia 158
LARYNGEAL PAPILLOMATOSIS
4l
• Host common benign tumour of Larynx.
• Has a bimodal age distribution.
JUVENILE LARYNGEAL PAPILLOMATOSIS
• Most common benign tumour of Larynx in children.
• Caused by HP V 6 and 11. rarely undergo malignant transformation.
• Transmission occurs during vaginal delivery through contact with mother ' s birth canal.
• Presents with hoarseness and abnormal cry , with stridor in advanced cases.
• O /E : Multiple papillomas seen.
• Rx : Excision by MLS using C02 laser , microdebrider or cryosurgery.
• Tracheostomy is not done as it can increase spread to distal airways.
ADULT LARYNGEAL PAPILLOMA
• Compared to juvenile papillomatosis, here papilloma is single, less aggressive and
less recurrence.

o Previous Year Questions AIIMS 2017

A 5 year old with gradually progressive hoarseness of voice over three months and respiratory distress
for 2 weeks. Diagnosis is
A ) Croup
jf Respiratory papillomatosis
^C) Vocal nodule
D ) Acute epiglottitis

CARCINOMA LARYNX

• Most commonly squamous cell carcinoma.

• Most common site : Glottis
• Risk Factors : Smoking, Alcohol consumption, HPV 11, 16 and 18 infection.
SUPRAGLOTTIC CANCER
• Presents very late as patient remains asymptomatic.
• Diffuse spread because of rich lymphatics.
• Presents with
• Dysphagia
• Throat Pain
• Referred Pain to ear .
•Neck nodes (Upper and Middle deep cervical)
• Hoarseness

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GLOTTIC CANCER
•Host common site of Ca larynx.
• Presents early with hoarseness because of involvement of VC.
• There is least metastasis as lymphatics are absent in this region.
• Best prognosis.

SUB GLOTTIC CANCER

• Presents with stridor.
• Hetstasises to lower deep cervical lymph nodes, pretracheal and mediastinal lymph nodes.
• Worst prognosis.

• Diagnosis is done by biopsy, radiological investigatins (CT.HRl).

MANAGEMENT
• Conservation of larynx is given priority, hence radiotherapy is preferred over surgery.
•For early stage I small glottic carcinoma, endoscopic C02 laser cordectomy by MLS can be done.

TN CLASSIFICATION OF CANCER LARYNX ( American Joint Committee on Cancer, 2002)

SUPRAGLOTTIS
•T1 : Tumor limited to one subsite of supraglottis with normal vocal cord mobility.
•T 2 : Tumour invades mucosa of more than one adjacent subsites of supraglottis or glottis or
region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, medial wall of
pyriform sinus) without fixation of the larynx.
•T3 : Tumour limited to larynx with vocal cord fixation and/or invades any of the following:
postcricoid area, pre-epiglottic tissues, paraglottic space and/or minor thyroid cartilage
invasion.
•T 4a : Tumour invades through the thyroid cartilage and/ or invades tissues beyond the larynx
(e.g., trachea, soft tissues of neck including deep extrinsic muscle of tongue, strap muscles,
thyroid or oesophagus).
•T4b : Tumour invades prevertebral space, encases carotid artery or invades mediastinal structures.

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GLOTTIS
• T 1 : Tumour Limited to vocal cord( s) (may involve anterior or posterior commissures) with
normal mobility.
• T1a : Tumour limited to one vocal cord.
• T1b : Tumour involves both vocal cords.
• T2 : Tumour extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility.
• T3 : Tumour limited to the larynx with vocal cord fixation and/ or invades paraglottic space and/
or minor thyroid cartilage erosion.
• T 4a : Tumour invades through thyroid cartilage and/ or invades tissues beyond the larynx (e.g.,
trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap
muscles, thyroid, or oesophagus).
• T4b : Tumor invades prevertebral space, encases carotid artery or invades mediastinal
structures.

SUBGLOTTIS
• T1: Tumour limited to the subglottis.
• T2 : Tumour extends to vocal cord( s) with normal or impaired mobility.
• T3 : Tumour limited to larynx with vocal cord fixation.
• Tka : Tumour invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g.,
trachea, soft tissues of neck including deep extrinsic muscle of tongue, strap muscles,
thyroid or oesophagus).
• Tkb : Tumor invades prevertebral space, encases carotid artery or invades mediastinal structures.
REGIONAL LYMPH NODES (N )
•Nx : Regional lymph nodes cannot be assessed.
•No : No regional lymph node metstasis.
•N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension.
•N2 : Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in
greatest dimension, or multiple ipsilateral lymph nodes, none more than 6 cm in greatest
dimension, or bilateral or contralateral lymph nodes, none more than 6 cm in greatest
dimension.
•N2a : Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in
greatest dimension.
•N2b : Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension.
•N2c : Metastasis in bilateral or contralateral lymoh nodes, none more than 6 cm in greatest
dimension.
•N3 : Metastasis in a lymph node more than 6 cm in greatest dimensin.

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DISTANT METASTAIS (M) HISTOPATHOLOGIC GRADE (G)
•Hx : Distant metastasis cannot be assessed. • Grade 1 : WelL-differentiated
•Mo : No distant metastasis. • Grade 2 : Moderately differentiated
•M1 : Distant metastasis. • Grade 3 : Poorly differentiated

STAGE GROUPING
0 T No Mo STAGE TREATMENT
I T1 No Mo I & II External beam radiotherapy.
II T2 No Mo
III T3 No Mo III & IV a without If radiotherapy fails then
T1 N1 Mo thyroid cartilage conservation surgery.
T2 N1 Mo invasion.
IVA T3 N1 Mo
T4a No Mo IV a with thyroid Concurrent chemoradiation.
T4 a N1 Mo cartilage invasion.
T1 N2 Mo
T2 N2 Mo IVb & c Total laryngectomy along with
T3 N2 Mo adjuvant radiotherapy.
T4 a N2 Mo Palliative radiotherapy.
IVB T4 b Any N Mo
Any T N3 Mo
I VC Any T Any N M1

CONSERVATION SURGERIES
• Done for stage I and II where radiation therapy is not effective.
" HEMILARYNGECTOMY /VERTICAL LARYNGECTOMY
• Done for tumour involving one vertical half of the larynx with subglottic extension not more
than 1 cm.
" SUPRAGLOTTIC LARYNGECTOMY
• Done for supraglottic tumours not involving glottis. T3 carcinomas of supraglottis.

INDICATIONS FOR TOTAL LARYNGECTOMY

• Stage IVa patients and thyroid cartilage invasion.
• Patients with stage III and IV who cannot tolerate chemoradiation.
• Patients with recurrences after radiotherapy now presenting with Stage III or Stage IV a.

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SPEECH REHABILITATION AFTER TOTAL LARYNGECTOMY
• OESOPHAGEAL SPEECH
• Production of speech by vibration of pharyngo - oesophageal segment by swallowing
small volumes of air during speaking.
• ARTIFICIAL LARYNX
• Electrolarynx : Battery operated portable device.
• Transoral pneumatic device.
" TRACHEOESOPHAGEAL SPEECH
• Carry air from trachea to oesophagus or hypopharynx by the creation of skin-lined fistula
•

or by placement of an artificial prosthesis.

• The vibrating column of air entering the pharynx is then modulated into speech.
• Use BLOM SINGER or PANJE PROSTHESIS.

0 Previous Year Questions AIIMS / INICET 2020

A patient underwent total laryngectomy for laryngeal cancer. Identify the modality of voice
production in this patient shown in the image given below.
A ) Electro- larvnx
B ) Chicago implant
Tracheoesophageal prosthesis
D ) Esophageal speech

o Previous Year Questions

Post total laryngectomy rehabilitation, which of the following is not used.

INICET 2021

( A) Polite yawning
JJtfSupraglottic prosthesis
(C) Oesophageal speech
( D) Tracheo-oesophageal prosthesis

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 T| uj V

•Position : ROSE S POSITION (Same as adenoidectomy and Tonsillectomy ).

’

•Types of Tracheostomy
• High Tracheostomy
• Hid Tracheostomy
• Lou Tracheostomy
HIGH TRACHEOSTOMY
• Done above the level of thyroid isthmus ( isthmus lies against II, III and IV tracheal rings).
• It violates the first ring of trachea.
• Tracheostomy at this site can cause perichondritis of the cricoid cartilage and sub- glottic
stenosis and is always avoided.
• Only indication for high tracheostomy is carcinoma of larynx.

o Previous Year Questions NEETPG 2018

Which of the following is an indication of high tracheostomy ?

A ) Vocal cord palsy
B ) Tracheomalacia
C) Foreign body obstruction
stffSuspicion of Laryngeal carcinoma planned for surgery later

MID TRACHEOSTOMY
• Host preferred.
• Done through 2nd and 3rd tracheal ring (at the level of thyroid isthumus).

LOW TRACHEOSTOMY
• Done below the level of isthumus.

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INDICATIONS FOR TRACHEOSTOMY |
RESPIRATORY OBSTRUCTION
• INFECTIONS
- Acute laryngo- tracheo-bronchitis, acute epiglottitis, diphtheria
- Ludwig s angina, peritonsillar , retropharyngeal or parapharyngeal abscess, tongue abscess.
• TRAUMA
- External injury of larynx and trachea
- Trauma due to endoscopies, especially in infants and children
- Fractures of mandible or maxillofacial injuries
•NEOPLASMS
- Benign and malignant neoplasms of larynx , pharynx , upper trachea, tongue and thyroid.
" FOREIGN BODY LARYNX
• OEDEMA LARYNX due to steam, irritant fumes or gases , alLergy (angioneurotic or drug
sensitivity ), radiation.
• BILATERAL ABDUCTOR PARALYSIS
" CONGENITAL ANOMALIES
- Laryngeal web , cysts, tracheo- oesophageal fistula
- Bilateral choanal atresia

RETAINED SECRETIONS
•INABILITY TO COUGH
- Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic overdose.
- Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain- Barre syndrome,
myasthenia gravis.
- Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning.
•PAINFUL COUGH
- Chest injuries, multiple rib fractures, pneumonia
•ASPIRATION of pharyngeal secretions
- Bulbar polio, polyneuritis, bilateral laryngeal paralysis

RESPIRATORY INSUFFICIENCY
•Chronic lung conditions, Vi 2. emphysema, chronic bronchitis, bronchiectasis, atelectasis.
•Conditions listed in Respiratory Obstructions and Retained secretions.

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COMPLICATIONS
IMMEDIATE COMPLICATIONS INTERMEDIATE COMPLICATIONS —
•Hemorrhage •Bleeding (Reactionary or Secondary)
•Apnoea (due to sudden washout of C02) •Displacement, Blockage of tube.
•Pneumothorax • S/L Emphysema
•RLN injury •Tracheitis, Tracheobronchitis
•Aspiration of blood. • Atelectasis, Lung Abscess
•Oesophagus Injury
LATE COMPLICATIONS
•Bleeding
•Laryngeal Stenosis, Trachela Stenosis
•Tracheoesophageal fistula.

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