Contents

Ear : Part 1  1

Ear : Part 2  11

Ear : Part 3 16

Ear : Part 4  22

Ear : Part 5  28

Ear : Part 6  33

Ear : Part 7 38

Ear : Part 8 43

Nose : Part 1 51

Nose : Part 2 60

Nose : Part 3 69

Nose : Part 4 76

Pharynx : Part 1 81

Pharynx : Part 2 89

Larynx : Part 1  99
Larynx : Part 2  108
 Ear : Part 1 1

EAR : PART 1 ----- Active space -----

Embryology & Anomalies 00:00:52

EMBRYOLOGY
Structure Origin
Tragus, anterior helix 1 pharyngeal arch
st
Via Hillocks of HIS
Rest of the pinna 2nd pharyngeal arch
External Auditory Canal (EAC) 1st pharyngeal cleft
External Auditory Meatus (EAM) 1st pharyngeal arch
Middle ear cleft : Middle ear cavity,
1st pharyngeal pouch/Tubotympanic recess
mastoid antrum, eustachian tube
Malleus, incus 1st pharyngeal arch
Stapes suprastructure 2nd pharyngeal arch
Stapes footplate Otic capsule (Bony labyrinth)
Tympanic membrane : All 3 germ layers :
1. Outer layer (Epithelial) 1. Ectoderm
2. Middle layer (Fibrous) 2. Mesoderm
3. Inner layer (Mucosal) 3. Endoderm
Mastoid : Temporal bone :
• Superficial • Squamous part
• Deep • Petrous part
Semicircular canals, utricle, utriculosaccular
Pars superior
duct, endolymphatic sac Otic capsule
Saccule & cochlea Pars inferior
Note : M/c congenital anomaly of middle ear Fixation of stapes footplate.

ANOMALIES
Pinna :
1. Preauricular sinus :
• Fusion defect of the auricular tubercle.
• M/c site : Root of helix.
Preauricular sinus
2. Microtia : Malformed/underdeveloped pinna.
3. Anotia : Absent pinna.

Microtia

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----- Active space ----- Management of Microtia/Anotia :

1. Pinna reconstruction :
• AKA Otoplasty/Pinnaplasty.
• Graft : Autologous costal
(Rib) cartilage.
• Age : >6 yrs (Costal cartilage Pinna reconstruction Pinna cartilage
is developed). framework

2. Bone Anchored Hearing Aids (BAHA) :

Indication : External ear deformities +
Unable to afford Sx.

EAC :
1. Meatal atresia : Incomplete development of EAC.
• Rx : Meatoplasty (Widening of cartilaginous part of EAC).
2. Collaural fistula : Persistent ventral part of 1st pharyngeal cleft.
• Internal opening : Floor of EAC.
• External opening : B/w angle of mandible &
sternocleidomastoid.
• Significance : Relation to facial nerve.
• Mx in repeated infection : Excision of tract.

Collaural fistula

Mastoid & Inner Ear 00:08:14

Mastoid :
Structure Significance
• Persistent petrosquamosal suture.
Korner’s septum
• Incomplete clearance of disease.
• Largest air cell
• Present at deep-petrous part.
Mastoid antrum
• Fully developed at birth.(Other mastoid air cells
grow until 18 years).
• Develops at 2 yrs of age.
• Exposed facial nerve.
Tip of mastoid
• Postauricular incision <2 yrs :
Superior & horizontal to prevent facial nerve injury.

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Comparison of fetal and adult skull : ----- Active space -----

Absent mastoid tip

Mastoid tip
Stylomastoid foramen
(Exit of facial nerve)
Bony external
Tympanic membrane seen directly auditory canal is seen
(After removal of cartilaginous part of pinna)
Inner Ear :
Parts : Membranous, bony labyrinth.

Anomalies :
Defect Features
• Cochleosaccular dysplasia.
Scheibe aplasia
• M/c congenital abnormality of inner ear.
Mondini aplasia Cochlea has only 1.5 turns.
• Defect in basal turn of cochlea.
Alexander aplasia
• High frequency hearing loss.
• Complete absence of bony and membranous labyrinth.
Michel aplasia
• Absolute C/I for cochlear transplant.

Note : Development of parts of ear

Parts completely developed at birth Parts not developed at birth
• Middle ear
• Inner ear : Organ of corti developed by 20-25 wks of
• Mastoid tip : 2 yrs
gestation.
• Bony EAC
• Mastoid antrum
• Outer cartilagenous part of EAC

Pinna 00:17:54

Anatomical Landmark :
Ascending helix
Cymba conchae :
Cartilaginous landmark
Incisura terminalis :
for mastoid antrum.
• Devoid of cartilage
• Site of incision in endaural
Tragus
approach : Lempert’s incision

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----- Active space ----- Diseases :

Cause : Skin (Lateral side of pinna) tightly adherent to perichondrium.
Presentation Mx
• Aspiration/drainage.
Hematoma Swelling lateral
• Contour dressing.
(Organised hematoma side of ear,
• For cauliflower/boxer’s/wrestler’s/
AKA cauliflower ear) h/o trauma +
pugilist’s ear : Plastic Sx.
Perichondritis Red hot painful pinna, • Does not resolve spontaneously.
(M/c d/t Pseudomonas) sparing lobule. • Antibiotics : Ciprofloxacin.
Keloid H/o trauma, • Intralesional steroids : 1st line of Mx.
(Fibrous tissue firm rubbery nodule • Excision f/b post-op intralesional
formation) on pinna. steroids/radiation to prevent recurrence.

Hematoma Cauliflower ear Perichondritis Keloid

Upper 1/3rd

Lower 2/3rd

Darwin’s tubercle
(Atavistic feature)

Anatomy of External Auditory Canal (EAC) 00:24:05

Total length of EAC : 24 mm.

Parts :
Cartilaginous (Outer 1/3rd : 8 mm) Bony (Inner 2/3rd : 16 mm)
Upwards, backwards, medially
Direction Downwards, forwards, medially
(Pulled to visualize TM)
Lining epithelium Stratified squamous epithelium
Skin Thick skin Thin skin
Skin Contains sweat, sebaceous, ceruminous
Absent
appendages (Modified apocrine) gland.
Fissures of Santorini Fissures of Huschke
Deficiency (Present throughout birth) : (Close by 4 yrs of age) :
Spread to parotid gland Spread to base of skull
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Isthmus ----- Active space -----

5-6 mm lateral to TM; Narrowest part of EAC Foreign body

impacted medial to isthmus Difficult to remove

Condition of EAC 00:27:49

Conditions of EAC Features Mx

Impacted wax
Aural syringing :
• Temperature of water
• Feeling of ear block Body temperature
• Pain + • Direction : Postero superiorly
• C/I : TM perforation, removal of
battery from ear

Keratosis obturans • Keratin collection (Laminar onion skin

arrangement)
• C/f : Severe otalgia; H/o chronic sinusitis,
Removal by instrumentation under
bronchiectasis
anaesthesia
• O/E : White mass + wax in deep meatus;
Ulceration/granulation; EAC widening
Facial palsy.
Furuncle
• O/E : Localized swelling
in cartilaginous part
of EAC Antibiotics : Amoxiclav
• M/c cause :
• Etiology :
Staphylococcus
M/c : Bacterial
(Pseudomonas) >
Diffuse otitis externa Fungal > Viral.
• C/f : Pain
• O/E : Diffuse swelling
±
• Itching Abrasion
Purulent discharge
• AKA Swimmer’s/ Antibiotics : Ciprofloxacin
±
tropical ear
Blocked ear
• Cause : Pseudomonas

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----- Active space -----

Conditions of EAC Features Mx

Malignant otitis externa
• Seen in immunocompromised 1. Antibiotics:
• M/c : Pseudomonas • Oral : Ciprofloxacin
• C/f : Severe otalgia • IV : Ceftazidime,
• O/E : Necrosis, granulations cefoperazone,
Complications : newer penicillins
• 7th nerve palsy (M/c) 2. Correct immunosuppression
AKA Skull base osteomyelitis • 9, 10, 1199CN : Affected late 3. Gallium-67, Indium-111,
(D/t infection spread via • Ix : Tc bone scan ↑Uptake serial ESR to check resolution
fissure of Santorini)
Otomycosis
• Aspergillus niger (M/c cause) > Candida

• O/E : Wet newspaper Cotton ball Antifungal ear drops

appearance appearance
• C/f : Pain ± Discharge ± Blocked ear

Herpes zoster oticus • C/f : Pain ± Discharge ± Blocked ear

• O/E : Vesicles in EAC
• A/w facial nerve palsy Called Ramsay Hunt
syndrome (D/t herpes zoster reactivation in Antivirals + steroids
geniculate ganglion)
• Other CN involved : 5th, 8th, 9th, 10th
• Poor prognosis

Note :
Mucopurulent discharge : Disorder of middle ear.

Anatomy of Tympanic Membrane (TM) 00:38:43

Pars flaccida/Shrapnell’s membrane

• Most mobile
Umbo
Lateral process (Handle of malleus)
Cone of light
(Anteroinferior Pars tensa :
quadrant) • Fixed to umbo & annulus
• Mobile part : Paramedian/periphery
Right TM

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Characteristics : ----- Active space -----

• Colour : Pearly grey & translucent.
• Angle : 55° with horizontal.
• Effective vibratory area : 55 mm2.
• Middle ear structures seen through tympanic membrane :
- Incus.
- Incudostapedial joint.
- Shadow of round window.
(1)
- Eustachian tube area (Anteriorly) : Very rarely.

Anterior
Side Identification :
1. Upper end of malleus (If point to right, (2)
indicates right sided TM).
2. Cone of light : Antero-inferior quadrant.
Left TM

TM Perforation 00:43:00

Traumatic Perforation :
C/f : Pain, ↓hearing, ear bleed.

Mx
Blood dot

Small perforation Large perforation Perforation

Spontaneous healing by Thin/cigarette

2 layers paper patch
(Absent 3rd/fibrous layer)

Tympanosclerosis :
• Chronic inflammation of ME (CSOM, SOM). Calcification
• TM perforation.
Hyalinization

Tympanosclerosis

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----- Active space ----- Anatomy of Middle Ear 00:44:50

Walls :
Structures Significance
• Tympanic membrane :
Lateral

- Pars tensa
-
- Pars flaccida
• Scutum
Tympanic/Horizontal segment of facial nerve M/c dehiscent segment of facial nerve
• Landmark for 1st genu of facial nerve
Processus cochleariformis • Tensor tympani takes lateral turn to attach to upper end of
malleus handle
Oval window Foot process of stapes present here
Medial

• M/c semicircular canal eroded d/t infection/by cholesteatoma

Lateral semicircular canal bulge
• Stimulated by caloric test
Round window Electrodes of cochlear implant & drug delivery
• Formed by basal turn of cochlea
• Tympanic plexus lie over promontory :
Promontory
Formed by Jacobson’s nerve (Branch of 9th CN) & sympathetic
plexus around ICA
Aditus Superior most (Connecting middle ear to mastoid)
Chorda tympani Enters posterior wall Exits from anterior wall
Vertical/Mastoid segment of facial nerve M/c site of facial nerve injury during mastoid Sx
Fossa Incudis Short process of incus present on fossa
Posterior

• Boundaries :
Laterally Chorda tympani; Medially Vertical part of
Facial recess/Supra-pyramidal recess
facial nerve; Superiorly Fossa Incudis
• Intact canal wall mastoid Sx & cochlear implant
• Hidden area (B/w ponticulus superiorly & subiculum inferiorly)
Sinus tympani/Infra-pyramidal recess
• M/c site for residual/recurrent cholesteatoma
Pyramid Stapedius arises (Attaches to neck of stapes)
Tensor tympani Originates here Attaches Upper end of malleus handle
Anterior/Carotid

Chorda tympani Exits through this wall Called canal of Huguier

Eustachian tube Opening +
Close relation to internal carotid artery
(Separated from anterior wall by thin bony plate If ICA aneurysm/Anterior wall sx ↑Risk of injury)

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Identification of structures : ----- Active space -----

1. Pars flaccida. 9. Oval window.
10 1
2. Lateral process of malleus. 10. Tympanic/Horizontal
3. Handle of malleus. segment of facial nerve 2
11 7
4. Eustachian tube. (M/c dehiscent).
5. Promontory. 11. Lateral SCC. 12 8
3
9
6. Round window. 12. Pyramid.
7. Incus. 5 4
8. Incudostapedial joint. 6

Right TM
Malleus Icecream
cone Short process Fossa incudis
Incus
appearance of incus Facial recess
Round
window Round window
Fossa
incudis
CN VII
Facial recess
Facial recess

Floor & Roof :

Structures related Significance
Jugular bulb Glomus jugulare (Project as red mass from floor)
Forms tympanic plexus Sensory supply to
Floor From floor : 9th Nerve branch Jacobson’s nerve
whole middle ear
Cranial nerves : 9, 10, 11 -
Tegmen tympani : Separates middle ear from Chronic middle ear infections Temporal lobe
Roof/ middle cranial fossa (Temporal lobe) abscess
Tegmen
tympani • Present above processus cochleariformis
Cog (Bone hanging anteriorly)
• Landmark for 1st genu of facial nerve

Eustachian Tube (ET) :

• Opens at nasopharyngeal opening (1 cm behind & below inferior turbinate).
• Surrounded by Ostmann pad of fat (Loss of fat Autophony d/t patulous ET).
• Parts Bone : Lateral 1/3 (12 mm)
rd
At junction : Isthmus (Narrowest)
Cartilage : Medial 2/3rd (24 mm)
• Length Adult : 36 mm (At 45° angle with horizontal)
Children : 13-18 mm (Shorter, wider, horizontal, flaccid ↑Infection)
• Tensor palati (Opens ET) : Cleft palate/palatoplasty Improper ET function
Recurrent infections.
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----- Active space ----- Middle Ear Cavity 01:06:51

Parts :
Tegmen tympani
Head of malleus
Scutum (The bone
above pars flaccida) Epitympanum (Widest : 6 mm)
Forms
Prussak’s space Chorda tympani
epitympanum
Pars flaccida Footplate of stapes
Forms lateral Pars tensa Mesotympanum (Narrowest : 2 mm)
wall of
mesotympanum
Hypotympanum (Smallest)

Parts
Sinus tympani is a part of retrotympanum.
Prussak’s Sac :
Boundaries :
Laterally : Pars flaccida (Shrapnell’s membrane).
Medially : Neck of malleus.
Inferiorly : Lateral process of malleus.

Significance : M/c site for retraction pocket 1° cholesteatoma.

Ear Ossicles 01:10:32

Head Incus
Malleus Short process
(Largest) (Posterior wall)
Neck Body
Lateral process Long process
(Towards TM)
Head
Anterior process
Posterior crus
Handle
Footplate
Umbo Stapes
Lenticular process (Smallest)
Anterior crus
Neck
Ossicles

Joint Type of synovial joint Clinical significance :

Incudo malleolar Saddle Lenticular process > Long process of incus :
Incudo stapedial Ball & socket M/c site of necrosis d/t otitis media.

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EAR : PART 2 ----- Active space -----

Anatomy of Inner Ear 00:01:05

Membranous Labyrinth :
• 3 semicircular canals 5 openings Utricle (Crus commune : Common opening for
SSCC & PSCC).

Superior SCC : Into utricle

Utricle
Posterior SCC : Towards mastoid Saccule
Lateral SCC : Towards middle ear Cochlear duct
• M/c eroded (D/t cholesteatoma)
• M/c stimulated by caloric test Endolymphatic duct

Endolymph
• Utriculosaccular duct Endolymphatic duct Endolymphatic sac.
absorption
• Scala media/Cochlear duct : 2 1/2 around modiolus (Coiled).

Location Organ Function

SCC Cristae Rotational acceleration
U&S Maculae Linear & gravitational acceleration & head tilt
Basal : High frequency
Scala media Organ of Corti Hearing Travelling wave
Apical : Low frequency theory
Bony Labyrinth :
• Bony semicircular canals (Around SCC).
• Vestibule :
- Around utricle : Elliptical recess.
- Around saccule : Spherical recess.
• Cochlea (Around scala media) :
- Above : Oval window Scala vestibuli Helicotrema (Apex)
- Below : Round window Scala tympani

Connections from inner ear : Basal turns :

Forms promontory
• Round window : Covered by secondary tympanic membrane. (Near oval window)
• Oval window : Related to footplate of stapes. To middle ear.
• Vestibular aqueduct : Around endolymphatic sac (Intradural).
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----- Active space ----- • Cochlear aqueduct :

- Connect CSF & S. tympani. To brain (Infections
- Forms perilymph. transmitted via
• Internal acoustic meatus (IAM) : these routes).
Facial nerve, vestibulocochlear nerve

Organ of Corti 00:11:14

Features Endolymph Perilymph

Scala vestibuli,
Present in Scala media
scala tympani
Electrolyte High K+ High Na+
concentration (Similar to ICF) (Similar to ECF) Basilar
Secretion Stria vascularis From CSF membrane
Organ of Corti
Hair Cells :
Inner hair cells : Outer hair cells :
• Single row, less number. • 3-4 rows, more in number.
• Flask shape. • Cylindrical.
• Less prone to damage. • More prone to damage.
• Afferent (90-95%). • Efferent (80%).
• Releases glutamate • Lips are in touch
(Excitatory : Auditory stimulus). with tectorial membrane.
Supporting Cells :
Dieters, Claudius, Hensens.

Auditory Pathway 00:20:54

Mnemonic : SLIM.
Cochlear nerve (Spiral ganglion)

Cochlear Superior Lateral Inferior Medial Auditory cortex

nuclei olivary lemniscus colliculus geniculate (Area 41)
complex body (Superior temporal gyrus)
IAM
• Cross over : Through trapezoid body.
• Stapedial reflex (Facial nerve connection).
• 1st area of localization.

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Internal Acoustic Meatus 00:23:45 ----- Active space -----

Location : Posterior slant of petrous temporal bone.

Structures passing through :

Anterior Posterior
Bill’s bar (Vertical crest)

7th nerve
Superior vestibular nerve

Transverse crest
8 nerve
th

Inferior vestibular nerve :

M/c origin of acoustic neuroma
Singular nerve : Supplies PSCC Note :
Structures in IAM • M/c beingn tumor of CP
Labyrinthine artery
angle : Acoustic neuroma.
(Branch of anterior
Structures in upper part • Posterior SCC : M/c cause of
inferior cerebellar artery)
Structures in lower part BPPV.

Mastoid Anatomy 00:27:14

Mastoid antrum : Deep part. Bony landmark : MacEwen’s triangle, spine of Henle.
(Largest mastoid air cell) Cartliaginous landmark : Cymba concha.
MacEwen’s Triangle/Suprameatal Triangle :
• Drilled to reach mastoid antrum (Around 1.5cm).
• Beyond this can cause injuries.
Citelli’s angle : Sinodural angle.

Superiorly :
Temporal line.
(Middle cranial
fossa) late
dural p
Anteriorly :
sinu

Spine
Inferiorly : Posterosuperior of Henle
s pl

Tangent b/w border of bony EAC.

ate

Sinodural angle
other 2 lines. (Facial nerve)
(Sigmoid sinus)
MacEwens triangle Sinodural angle spine of Henle

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----- Active space ----- Note :

Komers’s septum : Persistent petrosquamous suture (Inadequate drilling : 0.5 cm)

Posterior Cranial Fossa 00:30:06

Identification of structures :
A
I S
External acoustic meatus
Malleus head P
Short process of incus

Facial recess

Lateral SCC
Superior SCC
Posterior SCC

Chorda tympani Facial nerve

Note :
Posterior tympanotomy : Approach middle ear through facial recess.

Donaldson’s line :
Through lateral SCC, bisecting posterior SCC

Inferior to it : Superior to it :
Approach to Trautmann’s triangle : Approach to
Endolymphatic sac posterior cranial fossa.
• Superior : Superior petrosal sinus
• Posterior : Sigmoid sinus
• Anterior : Bony labyrinth

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HRCT : Temporal Bone 00:35:34 ----- Active space -----

IOC for ear conditions. Petrous apex

Inner ear

Middle ear

External auditory canal

Mastoid

Sigmoid sinus

Nerve Supply of Ear 00:36:50

Nerve Supply of Pinna :

Mnemonic : GOAA-F.
Auriculotemporal N (V3) Lesser occipital N (C2)
Auriculotemporal N

CN VII, X Greater auricular N

Great auricular N (C2,3)

Sites of referred otalgia
Referred Otalgia :
Areas supplied
Nerve Referred otalgia
Auricular Extra auricular
• Anterior & superior EAC
Anterior 2/3rd • Costen’s syndrome : TMJ dysfunction
Auriculotemporal • Anterior & superior TM
of the tongue • Dental, parotid infections & tumors
• Pinna, tragus
• Cervical degenerative conditions
Angle of mandible,
Greater Auricular • Pinna • Shaving area numbness
Temporomandibular
(C2-C3) • Lobule • Parotid infections/tumors (Investing layer
joint
of deep cervical fascia stretch)
Hitzelberger sign : Hyperesthesia/anesthesia
Facial Parts of EAC -
in posterior EAC, seen in acoustic neuroma
Arnold/Alderman's • Concha • Larynx
• Larynx, hypopharynx, thyroid Ca
nerve (Auricular • Floor & posterior wall of EAC • Thyroid
• Cough while cleaning ear
branch of X) • Lateral wall of TM • Hypopharynx
• Oropharynx
• Acute tonsillitis
Jacobson's nerve/ • Soft palate
Medial wall of TM • Peritonsillar abscess
Tympanic plexus • Tonsillar fossa
• Ca base of tongue/tonsils
• Base of tongue
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----- Active space ----- EAR : PART 3

Acute Otitis Media vs. Bullous Myringitis 00:00:57

Acute Otitis Media (AOM) Bullous Myringitis

AKA Acute serous otitis media Myringitis bullosa/Otitis Externa Hemorrhagica
• M/c : Pneumococcus
• M/c organism : Pneumococcus
Etiology • Others : Influenza virus, Mycoplasma
• M/c route : Eustachian tube (ET)
pneumoniae
• C/f : Acute otalgia, H/o URTI
• Stages :
• C/f : Acute otalgia, H/o URTI
- Tubal obstruction
• O/E : TM red, congested with bullae
- Hyperemia/pre-suppuration
If
Features
Rupture
Cartwheel appearance of TM
- Suppuration Light house sign
Serosanguinous/hemorrhagic discharge
(Pulsatile otorrhea) ;
Maximum pain.
• Medical Mx : Antibiotics (1st line)
Mx Medical mx : Antibiotics
• Sx : Myringotomy

Myringotomy :
• J-shaped curvilinear incision :
- Made in posteroinferior quadrant of TM.
- C/I in posterosuperior quadrant of TM
(↑Risk of injury to 7th CN + related structures).
• Indications :
- Bulging TM.
- Facial palsy, labyrinthitis. Cartwheel appearance of TM

Bullous myringitis

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Chronic Otitis Media 00:17:16 ----- Active space -----

AKA Chronic Suppurative Otitis Media (CSOM).

TYPES
Mucosal CSOM Squamous CSOM
AKA Tubotympanic/Safe CSOM Atticoantral/Unsafe CSOM
• Marginal perforation/
• Central perforation Retraction pocket
TM abnormality • Pars tensa involved,
(Permanent) annulus spared • Annulus eroded
• Non-healing in nature Mucosal CSOM
Cholesteatoma formation
Trauma, ASOM >3 months :
Etiology
Repeated infections
-
Eroded
• Scanty, purulent, foul- annulus
• Profuse, mucoid/
smelling, blood-tinged ear
mucopurulent, painless,
discharge + bony erosion
Clinical features non-foul smelling ear
• O/E : Granulations
discharge (Active) Retraction
appearing as red, fleshy
• Hearing loss (Inactive) pocket
polyp (Never to be avulsed)
• Active disease : Medical mx
Mx • Inactive disease : Sx Only surgical
(Mainstay) Cholesteatoma :
Squamous CSOM
MANAGEMENT OF MUCOSAL CSOM
Treatment Protocol :
Myringoplasty.
Medical Mx : Antibiotics Dry ear >6 weeks Surgical Mx
Tympanoplasty.
(To make the ear dry)
Pre-operative Assessment of Ossicular Status & Further Mx :
• Pure tone audiometry.
• Patch test : Perforation closed with patch.
Assess hearing loss

Improves worsens

TM perforation only Ossicular discontinuity + TM perforation

Myringoplasty Ossiculoplasty Myringoplasty

+
Graft placed (M/c :
Overlay technique (Over Temporalis fascia) Underlay technique
Tympanoplasty.
fibrous layer of TM). (Under TM)

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----- Active space -----

Note : M/c ossicle to undergo necrosis Long/lenticular process of incus.
Tympanoplasty : Incisions & instruments used in tympanoplasty.

Wilde’s postaural incision : Lempert’s endaural Rosen transcanal Self retaining haemostatic mastoid
(M/c) incision incision retractor
Wullstein Classification of tympanoplasty :
Type I Type II Type III

Myringoplasty : Malleus Myringoincudopexy : Incus Columella tympanoplasty/myringostapedopexy : Stapes

Type IV Type V
Key :
• : Graft placement.
• PORP : Partial Ossicular Replacement
Prosthesis.
• TORP : Total Ossicular Replacement
Prosthesis.

Cavum minor/round window shielding : Fenestration (Obsolete) : Fenestra over LSC

Round window (Fistula test + )

In Type IV : Oval window exposed to maintain phase difference.

Austin’s classification of ossicular abnormality :

Based on the presence of malleus handle (m) and stapes suprastructure (s) :
Type Ossicular status
A M +, S +
B M +, S -
C M -, S +
D M -, S -
Kartush modification :
O : Intact ossicular chain, E : Ossicular head fixation, F : Stapes fixation.

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Cholesteatoma 00:26:44 ----- Active space -----

TYPES
Theory/criteria Migration M/c site
Anterosuperior quadrant of
Congenital Levenson’s criteria Congenital cell rests
middle ear
Wittmaack’s
1˚ acquired invagination theory Through retraction pocket Pars flaccida/Prussak’s space
(M/c route)
• Through marginal perforation
Habermann’s theory • M/c cause : Acute Posterosuperior marginal of
2˚ acquired
(M/c route) necrotizing otitis media Pars tensa
(β-hemolytic streptococci)

MANAGEMENT Aims : Safe, dry & hearing ear.

Surgical Mx (Mastoid Sx)
Pre-op Ix : PTA, HRCT temporal bone
(Assess bone erosion).

Types of Mastoid Sx :
• Intact Canal Wall (ICW) Sx/Posterior tympanotomy/Combined approach
tympanoplasty.
Radical mastoidectomy.
• Canal Wall Down (CWD) Sx
Modified Radical Mastoidectomy.

Intact canal wall Sx Canal wall down Sx

Disease in mastoid Limited Extensive
Procedure Opening through facial recess Complete common wall removed
Visualization during Sx Limited Good
Chorda tympani Preserved Sacrificed
Healing Fast Slow
Tolerance of water entry Better Worse (Avoid water entry)
Collection of wax, debris
Cavity problems -
Requires periodic cleaning
Hearing aid Well tolerated Problematic
Recurrence ↑↑ (Site : Sinus tympani) ↓

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----- Active space ----- Types of canal wall down Sx :

Radical mastoidectomy Modified radical mastoidectomy
Mastoid air cells Removed
Posterior bony EAC wall Removed
Extent of removal of Middle Only stapes footplate Healthy mucosa, TM,
Ear (ME) structures preserved ossicles preserved
Eustachian tube Closed Not closed
Reconstruction of ME
Not done Done
(Tympanoplasty)
Squamous OM with/without
Indication When disease left behind
complications
Meatoplasty (EAC widening) Done

Complications of Otitis Media 00:37:22

M/c following squamous CSOM > ASOM, mucosal CSOM.

Intratemporal/Extracranial Complications :
Complication Presentation Mx Images
• C/f : Fever, ear discharge, post-
auricular oedema + tender.
• O/E :
- Post auricular : Ironed out
mastoid.
- EAC : Reservoir sign, sagging of Medical Mx (IV Antibiotics)
posterosuperior meatal wall. No response
• Abscess following mastoiditis : in 48 hours
Mastoiditis Mastoiditis
- Postauricular (M/c) Surgical Mx (Simple/
- Bezold abscess (Relation to Cortical/Schwartze
sternocleidomastoid) Mastoidectomy)
- Citelli abscess (Relation to
posterior belly of digastric/
occipital region)
- Luc’s abscess (Relation to
posterior wall of EAC) Mastoidectomy

IV Antibiotics + Modified
Gradenigo triad : Retro-orbital pain (5th
Petrositis Radical Mastoidectomy
CN) + Diplopia (6th CN) + Ear discharge
(MRM)

HRCT : Petrositis

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----- Active space -----

Complication Presentation Mx Images

• Features of otitis media +

• In ASOM : Myringotomy
facial deviation to normal side
Facial nerve + IV antibiotics
• Route in :
palsy • In CSOM : MRM +
- ASOM : Dehiscence
facial decompression
- CSOM : Erosion of fallopian canal

Others : Labyrinthitis (Presents as vertigo)

Intracranial Complications :
Complication Presentation Mx Images

Temporal lobe • CT/MRI : Ring enhancing

abscess Features of OM + headache, lesion
(M/c brain nominal aphasia/homonymous supra • IV antibiotics
abscess quadrantanopia/seizures/ • Abscess drainage
following otitis C/L hemiparesis Patient stabilizes
media) MRM.

• Features of OM + picket fence/hectic

fever
• Griesinger’s sign (Tenderness + edema
over mastoid) : Mastoid emissary vein • CT/MRI
Sigmoid sinus/ thrombosis
lateral sinus • Internal jugular vein (IJV) thrombosis : Delta/empty triangle sign
thrombosis
On compressing N IJV ↑ICT • IV antibiotics + MRM
- Tobey Ayer/Queckenstedt’s test + Papilledema
- Crow beck sign + (Crowbeck sign)

Other complications : Meningitis (M/c intracranial complication), extradural abscess, subdural abscess,
cerebellar abscess

Tubercular Otitis Media 00:49:20

Clinical features Mx
• Symptoms :
- Painless, foul-smelling
ear discharge. • Biopsy.
- Hearing loss (Out of • Antitubercular Rx.
proportion to symptoms) • Sx debridement (If needed) :
• O/E : Removal of sequestrum.
- Multiple TM perforations. • Middle ear reconstruction.
- Pale granulation tissue. (Only once TB free)
• Complication : Facial nerve
palsy. Tubercular otitis media
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----- Active space ----- EAR : PART 4

Auditory Localisation & Functions Of Middle Ear 00:01:50

Localisation :
Pathway Structures Defect
Conductive pathway Pinna Footplate of stapes Conductive Hearing Loss
Sensorineural/ Organ Auditory cortex Sensory (Cochlea) hearing loss or
Cochlear pathway of Corti (Superior temporal gyrus) Neural/Retrocochlear hearing loss

Functions Of Middle Ear :

1. Transformer action/Impedance matching :
a. Areal/Hydraulic ratio : Vibratory area of TM (55 mm2)
= 17 : 1 Total transformer
Area of foot plate ratio : 17 x 1.3 = 22
b. Lever ratio : 1.3 : 1

2. Curved membrane effect/Catenary lever :

• Peripheral TM : More mobile
2x amplification of sound.
• Central TM : Less mobile

3. Phase difference :
• Function : Prevents sound cancellation & hearing loss.
• Significance :
Exposure of both windows Loss of phase difference Maximum CHL.

Tuning Fork Tests 00:07:16

Frequencies used : 512 Hz > 256 Hz, 1024 Hz

Note :
• Hearing range : 20-20,000 Hz.
• Speech frequencies : 500, 1000, 2000 Hz.

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Rinne’s Test : ----- Active space -----

Inference Interpretation Conditions

• Normal
Rinne’s true + AC > BC
• SNHL
Rinne’s true - BC > AC CHL
Severe SNHL
Rinne’s false - BC > AC
(>70 dB loss)

Significance : Helps determine degree of CHL.

Rinne’s test at different frequencies Degree of
256 Hz 512 Hz 1024 Hz CHL
- + + 20-30 dB
- - + 30-45 dB
- - - 45-60 dB

Minimum CHL for negative Rinne’s : 15-20 dB.

Maximum CHL : 60 dB.

Weber’s Test :
Significance : Differentiate b/w CHL & severe SNHL.
Lateralization : Weber lateralizes when minimum 5 dB difference b/w both ears + .
Mnemonic : SOCS
• SNHL Lateralizes to better ear (Opposite side of disease).
• CHL Lateralizes to diseased ear (Same side of disease).

Absolute Bone Conduction Test (ABC) :

Assesses only bone conduction (Sensorineural pathway) by occluding tragus.

Inference :

Same as examiner : ↓/Shortened :

• Normal • SNHL
• CHL
Schwabach Test :
Assesses both conductive & sensorineural pathway (Tragus not occluded).

↑/Lengthened CHL
Inference
↓/Shortened SNHL

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----- Active space ----- Gelle’s Test :

Significance : Assesses change in hearing with change in EAC pressure.
Gelle’s +ve : Normal/SNHL.
Inference
Gelle’s -ve (No change) : Otosclerosis.

Bing’s Test :
Significance : Assesses change in hearing on pressing & releasing tragus.
Bing’s +ve : Normal/SNHL.
Inference
Bing’s -ve : CHL.

Pure Tone Audiometry 00:31:45

Subjective test.

Uses :
• Confirmatory test of CHL/SNHL.
• Determines degree of hearing loss.

AUDIOGRAM
Symbols :
Right ear Left ear
Colour Red Blue
AC unmasked ×
AC masked ∆
BC unmasked < >

BC masked [ ]

No response

Interpretation :

Right ear BC
25 dB Right ear AC Right ear AC
(Normal :
Upto 25 dB.)

1. Normal PTA : Right ear

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----- Active space -----

Right ear BC normal

Right ear
Air-bone gap + AC defective
Right ear
Right ear AC BC defective
(Defective
conductive
hearing)
2. Right CHL 3. Right SNHL (No AB gap)

Left ear Right ear BC

BC abnormal
Right ear AC
A-B gap >15 dB
Left ear BC
Left ear
AC abnormal Left ear AC

4. Mixed hearing loss 5. High frequency SNHL

Downsloping audiogram :
1. Noise induced hearing loss.
2. Ototoxicity 3. Presbycusis

Normal AC in
right ear
Right & left (No CHL/SNHL)
acoustic dip
Low frequency
hearing loss in
left ear

6. Noise induced HL 7. Left low frequency SNHL

Acoustic dip : Dip in AC & BC Upsloping audiogram :
at 4000Hz (Earliest feature) Seen in Meniere’s disease.

Normal left ear BC Normal hearing at

Carhart’s notch high & low frequency.
Defective left ear AC U shaped/Cookie
8. Left CHL with Carhart’s notch : bite audiogram.
• Carhart’s notch : Dip in BC 9. Mid (Congenital SNHL)
curve at 2000 Hz. frequency HL
• Seen in Otosclerosis.

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----- Active space ----- Classification Of Hearing Loss 00:48:37

a. WHO Classification : b. ASHA Classification :

Degree of Pure tone Pure tone average range in dB Degree of hearing loss
hearing loss average (dB) -10 to 25 Normal hearing sensitivity
0 None ≤25 26 to 40 Mild
1 Slight 26-40 41 to 55 Moderate
2 Moderate 41-60 56 to 70 Moderately severe
3 Severe 61-80 71 to 90 Severe Indication for
Profound, including >91 Profound cochlear implant
4 ≥81
deafness

WHO Grading Of Disability :

Grade of impairment Audiometric iso value Disability
0 : None 25 dB or better Able to hear whispers
1 : Slight 26-40 dB Able to hear words spoken in normal voice at 1 metre
2 : Moderate 41-60 dB Able to hear words using raised voice at 1 metre
3 : Severe 61-80 dB Able to hear words when shouted
4 : Profound ≥81 dB Unable to hear words even when shouted
Note : Threshold frequencies
• 30 dB : Whisper. • 90 dB : Shout.
• 60 dB : Normal conversation.
Degree Of HL In Different Conditions :
Condition Degree of HL
Complete obstruction of EAC
40 dB
Protection provided by earplug/headphones
TM perforation 10-40 dB
TM perforation with ossicular discontinuity 40 dB
Ossicular discontinuity with intact TM 55 dB
Complete fixation of stapes footplate 60 dB

Impedance Audiometry 00:51:38

Objective test of hearing done using 226, 220

Hz frequencies.
Indication : Defect is middle ear (CHL + Intact
TM). Impedance audiometry devices
Tympanometry
Component
Stapedial reflex
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TYMPANOMETRY ----- Active space -----

Best investigation to assess ET function.

Compliance
Compliance ∝ Ease of mobility of TM

-400 -200 -100 0 +100 +200

Middle ear pressure (In mm H2O)

Types Of Tympanogram Curves :

Type of curve Middle ear pressure Compliance Diagnosis

A Normal Normal Normal middle ear
AS (Sclerosis) Normal ↓ Otosclerosis, tympanosclerosis

AD (Discontinuity) Normal ↑ Ossicular discontinuity

B (Dome curve) ↓ ↓ SOM
C ↓ Normal Early eustachion tube obstruction
Flat - - Perforation of TM, later stages of SOM
STAPEDIAL REFLEX
Protective mechanism of inner ear against noise trauma.
Pathway :
• Afferent : I/L 8th nerve.
• Centre : Superior olivary complex.
• Efferent : B/L 7th nerve (B/L reflex).
Significance :
Stapedial reflex Significance
Completely normal hearing pathway
Normal
Hence, can be used to detect malingering.
• Conductive hearing loss (Otosclerosis, SOM).
Absent B/L
• Ipsilateral VIIIth nerve palsy.
Absent U/L Ipsilateral VIIth nerve palsy.
Sensory/Cochlear hearing loss
↓Threshold (Present at <70 dB) (↓Threshold d/t loss of fine tuning of loudness
Abnormal ↑ of loud sounds : Recruitment).
Decay (Present only briefly) Neural/neurocochlear hearing loss.

Note : Best test for malingering BERA.

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----- Active space ----- EAR : PART 5

Brainstem Evoked Response Audiometry (BERA) 00:00:55

AKA Auditory brainstem response.

Objective test.

Latency Response :
Duration Response Assessed by
Sound stimulus 10 ms Short latency BERA
12 ms 50 ms Middle latency -
50 ms 500 ms Late latency CERA
BERA
Interpretation :
Corresponding part of auditory
Waveform
pathway being tested
Distal part of VIII nerve
Wave I
(Towards inner ear)
Proximal part of VIII nerve
wave II
(Towards brainstem)
Wave III Cochlear nuclei
Wave IV Superior olivary complex
Lateral lemniscus (Largest wave/most
Wave V
prominent/most consistent wave) Waves in BERA
Significance :
Adults : Best audiometric test for
1. Retrocochlear hearing loss (Eg : Acoustic neuroma).
2. Differentiating b/w cochlear & retrocochlear hearing loss.
3. Detecting malingering.
Note : Best Ix for acoustic neuroma Gadolinium enhanced MRI.
Neonates : Best audiometric test to
1. Confirm hearing loss in neonates & infants.
2. Screen hearing loss in neonates in ICU.
3. Determine hearing threshold.

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Otoacoustic Emissions (OAE)/Kemp Echoes 00:10:20 ----- Active space -----

Objective test.

Pathway :
EAC Tympanic Middle ear Inner ear Basilar membrane Outer Hair Cells
(Sound from probe) membrane (OHC)

Picked up by the probe

Types :
Spontaneous
OAE
Transient evoked : Screening.
Evoked
Distortion product evoked : Frequency specific test.
Inference :
OAE present : OHC, cochlea, middle ear are all normal.
OAE absent (>30 dB hearing loss) : Referred for tympanometry & BERA.
Significance :
Adults :
• Differentiates b/w cochlear & retrocochlear pathology.
• Distortion product evoked OAE : Detects NIHL & ototoxicity.

Noeonates :
Transient evoked OAE : Best to screen for hearing loss in neonates (Except in ICU).

Electrocochleography & Recruitment 00:21:20

ELECTROCOCHLEOGRAPHY
• Objective test to measure electrical activity of cochlea.
• Best test for Meniere’s disease.

Waves :
1. Cochlear microphonic : Movement of outer hair cells.
2. Summating Potential (SP) : Sum of activity of inner & outer hair cells.
3. Action Potential (AP) : Activity in the nerve (Secondary to neurotransmitter
release).
SP
Inference : >45% Indicative of cochlear lesion (Meniere’s disease).
AP

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----- Active space ----- RECRUITMENT

Feature of cochlear pathology (Meniere’s disease).

Tests :
Short Increment Sensitivity Index
Alternate Binaural Loudness Balance (ABLB) Stapedial reflex
(SISI)
Increments of dB

Not able to Able to identify

Stapedial reflex
identify
Recruitment + threshold ↓
• Compare loudness perception b/w both Normal
SISI score : 70-100% Recruitment +
ears
• Hearing in defective ear imporves with
Cochlear pathology
intensity of sound.
(Meniere’s disease)

Decoy Tests & Speech Audiometry 00:26:16

Tone Decay :
• Subjective test.
• Test for retrocochlear/neural hearing loss.

Speech Audiometry :

Discrimination Score (DS) : Speech Reception Threshold (SRT) :

• Ability to discriminate between words. • Assess hearing threshold by
• Indicative of nerve function. manipulating speech intensities.
N • Usually matches PTA threshold.

Condition Change in DS with loudness

CHL Improves with loudness
Improves & plateaus
Cochlear deafness
(Never 100 %)
Retrocochlear
Improves & then falls : Roll over phenomenon
deafness

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Protocol for Neonatal Hearing Screening 00:31:00 ----- Active space -----

Transient Evoked Oto Acoustic Emission (TE OAE)

(Within 48 hrs of birth ; max. 1 month)

Present Absent

Pass Clean the EAC

Repeat TE OAE after 7-10 days

No risk factors Risk factors +

Screening Regular screening Present Absent

not required
Pass Refer for tympanometry

Middle ear defect Normal (Middle ear is normal,

defect is in inner ear)
Correctable Not correctable
Refer for BERA
Correct the defect Hearing aid at the earliest (Max. within 3 months)

Cochlear defect Auditory nerve defect

(Defect in organ of Corti)
1-3-6 rule Auditory brainstem implant (ABI) :
• By 1 month : Screening tests for hearing. Hearing aid at the Directly stimulates cochlear nuclei
• By 3 months : Referral tests. earliest (Max. 6 months) (1.5-2 years of age)
• By 6 months : Rehabilitation by hearing aids.
No benefit

Cochlear implant (At 1 yr of age)

Auditory Neuropathy Spectrum Disorder 00:36:26

Pathophysiology :
• Damaged inner hair cells.
• Demyelination of nerves. Dyssynchrony • Hearing : Normal.
• Loss of axon. • Speech intelligibility : Absent.
(Late presentation : School
going age).

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----- Active space ----- Investigations :

Test Result
PTA Normal/mild to moderate SNHL
Speech audiometry Disproportionately poorer than degree of HL
OAE Normal (OHC : Normal)
BERA
Middle latency response Abnormal
Cortical response

Management : Hearing aids, cochlear implantation.

Behavioural Observation Audiometry (BOA) & ASSR 00:40:00

BOA
• Done for children b/w 6 months - 5 yrs.
• Similar to PTA.
• Behavioural change in response to sound is observed.

Tests :
5-24 months :

Free field audiometry Visual reinforcement audiometry

2-5 years :

Note :
>5 yrs : PTA.

Play audiometry
ASSR (AUDITORY STEADY STATE RESPONSE)
Estimates threshold at different frequencies.
Uses : Helps assess
- >80 dB hearing loss.
- Frequency specific hearing loss.
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EAR : PART 6 ----- Active space -----

Serous Otitis Media (SOM) 00:00:49

AKA otitis media with effusion/glue ear : Collection of serous or sterile fluid in
middle ear.

Causes of clinical features :

Children Adults
M/c cause Adenoid hypertrophy Nasopharyngeal Ca
B/L fluctuating painless hearing loss
(HL), speech delay, h/o snoring + ;
C/F U/L progressive HL
A/w high arched palate, open mouth
(Adenoid facies)
O/E : Air bubbles in
middle ear
Tympanic membrane (Tm) : Bluish, Intact but retracted
+ air bubbles/fluid level. Dull,
retracted TM

Myringotomy
Investigations :
incision
Tuning fork test : TM in som
• Rinne’s test : - .
• Weber’s test : Lateralized to affected ear CHL.
Pure Tone Audiometry (PTA) : A-B gap +
Confirmatory Ix : Tympanometry
• Type B curve.
• 1st Ix in children.
Management : Tympanogram : Type B curve
1st line mx : Medical Mx (3 months).
Not recovering/chronic
(Monthly tympanometry : Type B curve)
Sx : Myringotomy + grommet/ventilation tube + Myringotome
adenoidectomy.
Myringotomy :
• Radial incision Grommet insertion (Antero-inferior quadrant of TM).
• Short term grommet : Self extruded in <6 months (Preferred).
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----- Active space ----- Sequelae :

No Rx Retraction pocket 1° cholesteatoma.

Tympanic Membrane Retractions 00:10:38

TM retractions Pars flaccida (PF) : Tos classification.

Pars tensa (PT) : Sade classification.
SADE CLASSIFICATION

Stage 1 : Retracted Tm, Stage 2 : Touches incus, Stage 3 : Atelectasis Stage 4 : Adhesive otitis
not touching incus incudostapedial joint (Touches promontory) media (Adherent to
promontory mucosa)

Note : Stage 3 & 4 can be differentiated by siegalisation/

pneumatic otoscopy.

Features : Siegel's pneumatic speculum

• Cone of light : Distorted/ - .
• Tm appearance : Dull.
• Handle of malleus : Foreshortened. As stage Features : More
• Lateral process of malleus : Prominent. progresses prominent.
• Anterior + Posterior malleolar folds : Sickled.

TOS CLASSIFICATION :
Stage 1 PF retracted, not touching malleus
Stage 2 Retraction touching neck of malleus.
Part of retraction pocket may be hidden, may be
Stage 3
a/w erosion of scutum
Stage 4 Part of retraction hidden and definitive erosion of scutum

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Otosclerosis 00:23:08 ----- Active space -----

Bone remodelling disease, AKA otospongiosis.

Site of origin :
Fissula ante fenestram Overgrowth on oval window
(Enchondral layer of otic capsule) (Fixes stapes foot plate).
Presentation :
• B/L progressive CHL. • Aggravating factors :
• Age group : 20-30 yrs. Measles, pregnancy.
• F >> M. • Family H/o +
• Paracusis willisii : Hearing better in (Autosomal dominant inheritence).
noisy surroundings.
Tests
• Rinne's : B/L -
• Weber's : Lateralized to worst ear/centralised
• Gelle's test : - (No change)
• PTA : AB gap, Carhart's notch
• Impedance audiometry (Best Ix)
• Tympanometry : ‘As' curve
• Stapedial reflex : Absent
O/E :
TM appears : Pearly white >> Flamingo pink (Active d/t ↑vascularization).
HPE findings : Blue mantle of manasse in enchondral layer.

Flamingo pink TM Carhart's notch : Dip at 2000 As curve

(Schwartz sign) Hz in bone conduction curve
Cochlear otosclerosis :
• Overgrowth towards inner ear : Cochlea involved.
• Present as : Mixed hearing loss
(CHL + sensorineural HL).
• Ix : HRCT  Halo/double ring sign
(Ring of lucency around cochlea). Halo/double ring sign

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----- Active space ----- Management :

Active cases (Schwartz sign + ) : NaF (Sodium fluoride). Crimped around long
process of incus
Mature/non-active cases :
Stapedectomy + teflon piston (Worse ear treated first).
Attached to opening
C/I for Sx : on footplate
Only one hearing ear Mx with hearing aid/
cochlear implant. Piston
Note :
Van der Hoeve disease : Osteogenesis imperfecta + blue sclera + otosclerosis.

NIHL, Ototoxicity & Presbycusis 00:39:14

Conditions of Adult B/L Sensorineural HL :

Features Ix Prevention/Mx
• Safe limit : 85 dB, 8 hr/day • Early diagnosis : Distortion
• Prevention :
• H/o noise exposure above safe product Otoacoustic
Noise • Ear muffs (40 dB) >
limit Emission (OAE)
induced Ear plugs (30 dB)
• BL high frequency hearing • PTA :
hearing loss • Rx in Permanent HL :
loss, tinnitus - Early : Acoustic dip at
(NIHL) - Hearing aid
• Early damage : Outer hair cells 4000 Hz
- Cochlear implant
affected - Late : Down sloping curve
• H/o exposure to drugs :
Mnemonic A3 VCD
- Aminoglycosides • Early identification of
- Antimalarials • Early diagnosis : Distortion
hearing loss : ↓/stop/
- Analgesics product OAE (Outer hair
change ototoxic drugs
Ototoxicity - Vancomycin cells affected)
• Permanent HL :
- Cytotoxic drugs : Cisplatin • PTA : Down sloping curve
Hearing aid, cochlear
- Diuretics (Na K 2CL (High frequency HL)
implant
channels of stria vascularis)
- Erythro/azithromycin
: Irreversible HL
• Age >50 years/elderly
• Slowly progressive + PTA : Down slopping curve • Hearing aid
Presbycusis
B/L symmetrical HL (High frequency HL) • Cochlear implant
• M/c : Neural type

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----- Active space -----

Aminoglycosides :
• Cochleotoxic :
Neomycin > K anamycin,
AmiKacin
• Vestibulotoxic :
Streptomycin, Gentamycin

Down sloping audiogram Acoustic dip at 4000 Hz

Idiopathic sudden SNHL :

• Otologic emergency (Sudden U/L HL).
• >30 dB SNHL, 3 continuous frequencies, over 3 days.
• Severe SNHL - Rinne's test.
(>70 dB) Weber’s test lateralize to opposite ear.
• MRI : To rule out acoustic neuroma (In elderly SNHL).
• Mx :
- Steroids Oral.
Transtympanic (Microwick Round window).
- Carbogen (5% CO2 + 95% oxygen).
- Hyperbaric 02.
Not C/L routing of signal (CROS) hearing aid.
- Hearing loss
recovering Bone anchored hearing aid (BAHA).

PTA : Severe SNHL

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----- Active space ----- EAR : PART 7

Only vertigo : Vertigo + hearing loss

• BPPV.
• Vestibular neuritis. Vertigo + SNHL : Vertigo + CHL :
• Meniere’s disease. SCC dehiscence.
• Labyrinthitis.
• Perilymphatic fistula.

BPPV, Nystagmus & Vestibular Neuritis 00:01:18

BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)

M/c canal involved : Posterior SCC > Horizontal SCC > Anterior SCC.
Examination & Management :
Maneuver SCC tested Positive result Management
• Vertigo (Episodic & positional)
• Epley’s maneuver
• Nystagmus :
Dix-Hallpike maneuver Posterior • Semont maneuver
- Vertical
• Brandt-Daroff exercise
- Towards hyperactive side (I/L)
• Vertigo (Episodic & positional)
• Nystagmus : • Gufoni maneuver
Supine roll Horizontal
- Horizontal • Barbecue roll maneuver
- Towards hyperactive side (I/L)

Dix-Hallpike maneuver

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NYSTAGMUS ----- Active space -----

Peripheral nystagmus Central nystagmus

Latency + -
Duration Limited Not limited
Fatigability + -
Direction of fast component Fixed Changing
Optic fixation Nystagmus disappears Nystagmus persists
Vertical/horizontal nystagmus Pure horizontal/pure vertical
Torsional component
with torsion /pure torsional

Direction & Types of Peripheral Nystagmus :

Structure involved Type of nystagmus Conditions
Vertical canal Vertical nystagmus • BPPV Hyperactive labyrinth I/L nystagmus
(Posterior & superior SCC) with torsion • Superior SCC dehiscence
Horizontal SCC Horizontal nystagmus Horizontal SCC BPPV
• Vestibular neuritis
Complete involvement of Horizontal nystagmus • Purulent labyrinthitis Hypoactive labyrinth
labyrinth with torsion • Meniere’s disease
C/L nystagmus

VESTIBULAR NEURITIS
C/f :
• Vertigo : Sudden onset, continuous, lasts 5-7 days.
• Spontaneous nystagmus.

Management :
• Labyrinthine sedatives.
• Vestibular rehabilitation exercises.

Head Impulse & Caloric Test 00:16:00

Head Impulse Test :

• Test for vestibulo ocular reflex (VOR).
• Abnormality of labyrinth Lag + saccades + .
Significance :
• Office procedure.
• Normal physiological stimuli (Head movements).
• Each SCC can be tested separately.

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----- Active space ----- Caloric Test :

• Test for lateral SCC.
• Position : Supine with 30° head elevation.

Inference : Mnemonic : COWS. Dundas grant tube

Temperature Labyrinth Direction of nystagmus (Use : Cold air caloric test)
Cold : 30˚C Hypoactive Opposite
Warm : 44˚C Hyperactive Same

Meniere’s Disease 00:24:27

Unilateral. Note :
M = F. Lermoyez/reverse Meniere’s syndrome :
Age : 20 - 50 years. Hearing loss Vertigo Normal hearing.
Clinical Features :
• Vertigo :
- Episodic (20 mins - 24 hours).
- A/w aura & vagal symptoms.
- Tullio’s phenomenon & Hennebert sign.
• Hearing loss :
- Fluctuating.
- Low frequency affected first.
- Diplacusis (U/L).
- Recruitment (Intolerence to loud sound).
• Fullness in the ears, tinnitus.
• Tumarkin crisis (Drop attacks).

Tests :
Investigations Result
Tuning fork tests SNHL
Pure tone audiometry Low frequency SNHL (U/L)
SISI 70-100 % (D/t recruitment)
Electrocochleography SP/AP = >0.45
Glycerol test Vertigo improves

PTA : Upsloping audiogram

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Management : ----- Active space -----

Microwick soaked in gentamicin
Medical Mx :
• Salt & caffeine restriction
• Labyrinthine sedatives
• Diuretics Round window
• Vasodilators : Betahistine (M/c)
No improvement
Transtympanic administration of steroids
Intractable vertigo

Hearing intact Hearing lost

• Transtympanic steroids. Total labyrinthectomy.

• Chemical labyrinthectomy :
Gentamicin (Vestibulotoxic).
• Endolymphatic sac decompression
(Below Donaldson’s line).
• Vestibular neurectomy
(Salvage precedure).

Perilymphatic Fistula, SCCD, VEMP 00:36:56

PERILYMPHATIC FISTULA
Causes :
• Cholesteatoma.
• Barotrauma.
• Surgeries (Stapedotomy, cholesteatoma sx).
C/f : Management :
• Vertigo : On coughing/straining, • Conservative : Avoid straining/lifting
Tullio’s phenomenon + . weights.
• Hearing loss : SNHL/Mixed HL. • Definitive : Surgical repair.
Fistula test : Positive.

Note : Fistula test.

False +ve/Hennebert sign False negative

• Meniere’s disease • Cholesteatoma covering fistula
• Congenital syphilis (Hypermobile footplate) • Dead labyrinth

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----- Active space ----- SUPERIOR SEMICIRCULAR CANAL DEHISCENCE SYNDROME (SCCD)
AKA third window.
C/f :
• Vertigo : • ↑ BC sounds :
- Tullio’s phenomenon + . - Autophony.
- Hennebert sign + . - Pulsatile tinnitus.
• Conductive hearing loss.

Tests :
Investigations Findings
Tuning fork tests BC > AC (Rinne’s - )
PTA AB gap +
Tympanometry Normal middle ear
VEMP Reduced threshold
IOC : HRCT.
Management : Conservative/Surgical repair.

VESTIBULAR EVOKED MYOGENIC POTENTIAL (VEMP)

Normal response :
• Cervical VEMP : Loud sound Saccule Inferior vestibular nerve

I/L SCM relaxation +

• Ocular VEMP Superior vestibular nerve Vestibular nuclei VOR

C/L
eye movement
Abnormal response :

Response D/d
• Fistula
• Hypermobile footplate (Congenital syphilis)
Hyperactive
• SSCD
• Meniere’s disease
• Vestibular neuritis
Hypoactive
• Acoustic neuroma

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EAR : PART 8 ----- Active space -----

Tumours of EAC 00:00:50

Exostosis (Surfer’s Ear) : Osteoma :

• D/t entry of cold water in the ear. • Single.
• M/c benign tumour of EAC. • Bony outgrowth in lateral bony EAC.
• Multiple, sessile.
• B/L bony outgrowth in deep EAC.

Exostosis

TM

Glomus Tumours/Paraganglioma 00:02:00

• M/c benign tumour of middle ear, locally invasive.

• Non-chromaffin tumour, 10% multicentric.
• Capsulated.
Origin :
Paraganglionic cells Jugular bulb (CN 9, 10) : Glomus jugulare.
(Neural crest cells) Tympanic plexus (CN 9) : Glomus tympanicum (M/c).

Clinical Features :
• Pulsatile tinnitus + conductive hearing loss.
• Aquino sign (Glomus jugulare) : Tinnitus disappears
on carotid compression.
• Brown’s sign/pulsation sign : On siegalisation.
• Multiple cranial nerve palsies ( CN 9, 10, 11, 12).
O/E : Red polypoidal mass in EAC.
Rising sun/red reflex/setting sun sign

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----- Active space ----- Investigations :

CECT : Best.
• Glomus tympanicum : Vascular area in middle ear cavity adhering to
promontory.
• Glomus jugulare : Phleps sign (Crest of bone separating carotid canal & jugular
foramen is absent).
Note :
Ear polyp : Avulsion is C/I.
MRI :

Carotid canal
Crest of bone
Jugular foramen

MRI : Salt & pepper Base of skull CT : Glomus jugulare

appearance

Staging : Management :
Fisch classification : CECT based. Preoperative Ix : Urinary Vanillyl mandelic
Type Involvement acid (VMA).
A Middle ear Slow growing tumour/in elderly : Wait &
B Mastoid watch (Close follow up).
C (Labyrin- C1 Vertical Limited Fit for Sx :
thine &Infra- C2 carotid canal Extensive <3 cm : Stereotactic radio Sx/gamma
labyrinthine) C3 Horizontal carotid canal knife Sx.
D (Intra- D1 <2 cm intracranial >3 cm : Surgical excision with pre-op
cranial) embolisation.
D2 >2 cm intracranial

Acoustic Neuroma 00:13:48

Tumour features :
• M/c benign CP angle tumour.
• Origin : Vestibular nerve at Internal Acoustic Meatus (IAM).
• Locally invasive, slow growing.
• No capsule.
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Clinical Features : ----- Active space -----

Younger patients : NF-2 to be ruled out.
Nerves involved Features
Cochlear nerve (8th) : Earliest Tinnitus + U/L SNHL (in elderly)
Vestibular nerve (8th) Vertigo absent : Slow growing
Facial nerve Hitzelberger’s sign
D/t upper pole of tumor :
• Earliest nerve involved intracranially
5th nerve
• Loss of corneal reflex
6th nerve Diplopia
D/t lower pole of tumor :
9th, 10th, 11th nerve -
Cerebellar compression Imbalance, nystagmus, coma
Note :
D/d Presbycusis : B/L SNHL.
Investigation :
Tuning fork test : SNHL.
Audiometry findings :
• Puretone audiometry : U/L or asymmetric SNHL.
• Speech audiometry : Poor discrimination score.
• Roll over phenomenon (Retrocochlear disease).
• BERA : Best audiometric test.
- ↑Distance b/w wave I and wave II.
Ice cream cone appearance
- Difference of >0.2 ms b/w both ears (If only wave V present).
Gadolinium enhanced MRI : Best investigation.

Compact arrangement

• Loosely placed
• Cystic spaces
• Bad prognosis
• Mx : Excision

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----- Active space ----- Treatment :

< 1.5 cm/slow growing/elderly : Wait and watch.
1.5-3 cm : Stereotactic radiosurgery/gamma knife.
>3 cm/cystic tumor : Sx excision.
Post-op Mx :
• Auditory brainstem implant.
• Rehabilitation of hearing in NF-2.
• Placed in lateral recess of 4th ventricle.

Facial Nerve : Branches & Investigations 00:26:17

Motor (Major).
Mixed nerve
Sensory : Nervus intermedius/Nerve of Wrisberg.
Temporal Part :
Meatal segment : Internal acoustic meatus.
Labyrinthine segment : Shortest + narrowest part.
Horizontal/tympanic segment :  M/c part dehiscent (M/c congenital
anomaly of temporal bone).
Vertical/mastoid segment : M/c injured in mastoid Sx.

Branches :
Nerve supply Injury Topodiagnostic test
Greater superficial Lacrimation, nasal &
Dry eye Schirmer’s test
petrosal nerve palatine secretion
Hyperacusis: Abnormally Stapedial reflex
Nerve to stapedius Stapedius muscle high perception of normal (Impedance
sounds audiometry)
• Taste sensation over
ant. 2/3rd of tongue
• Salivation from Loss of taste, loss of
Chorda tympani Electrogustometry
sublingual & salivary flow
submandibular
glands
Hitzelberger sign :
Sensory supply to
Hypoaesthesia in this
Posterior auricular posterosuperior part of
region d/t facial nerve -
nerve EAM & adjacent part
compression by acoustic
of canal
neuroma

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Investigation : ----- Active space -----

Electroneuronography : Not done before 3 days
Electrophysiological test False +ve results d/t Wallerian degeneration.
(Determines prognosis)
Electromyography (EMG) : Useful >3 weeks of injury.
• Action potential : Good prognosis.
• Fibrillation potentials : Bad prognosis.

Facial Nerve Palsy 00:33:30

CAUSES
Idiopathic :
Bell’s palsy :
M/c cause of acute idiopathic LMN facial nerve palsy.

Facial nerve palsy

Features Presentation Management
• U/L Complete • High dose steroids immediately : 1 mg/kg body
• Idiopathic > Viral (HSV-1 in 60 %)
facial deviation weight
• M/c site of involvement : Labyrinthine
• U/L sweating • Acyclovir : If presented within 3 days
segment
• Hyperacusis • Supportive care : Physiotherapy, nerve
• Can recur
• Loss of taste stimulation, eye care, Vitamin B12 nerve
• ↑Susceptibility in DM, Pregnancy, AIDS
• Dry eye nourishers

Non-iatrogenic :
Temporal bone fracture : M/c cause.
Types :

Longitudinal fracture Transverse fracture

Relation to long axis of petrous
Parallel Perpendicular
part of temporal bone
Incidence More common Less common
Direction of blow Lateral Posterior (Occipital)
TM perforation Yes No
Hearing loss CHL SNHL
CSF otorrhoea Present (Leak of CSF through perforation) Absent
CSF rhinorrhoea Absent Present (Leak of CSF through ET)
Vertigo Absent Present
Facial nerve injury Less common More common
Severity Less More

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----- Active space ----- Clinical findings :

Ecchymosis behind ear

Battle sign Hemotympanum

Iatrogenic :
Cause : Parotid Sx > Mastoid (Vertical segment) Sx.

Facial nerve palsy post Sx : Grafts for facial nerve repair :

Sudden onset Late onset • Greater auricular nerve (M/c).
Cause Nerve transection Edema • Sural nerve.
Mx Re-exploration and repair Steroid • Lateral cutaneous nerve of thigh.

COMPLICATIONS
D/t aberrant regeneration of facial nerve.
1. Synkinesis : Contraction of two separate groups of muscles.
• Eg : Movement of lips on closing the eyes & vice versa.
2. Crocodile tears : Tearing of eyes during salivation.
• D/t aberrant connections b/w chorda tympani fibers & greater superficial
petrosal nerve.
3. Frey syndrome : Gustatory sweating over parotid region.
• Aberrant regeneration of auriculotemporal nerve after parotid Sx.
Temporary : Botox.
• Management
Permanent :
• Sternocleidomastoid flap implantation.
• Tympanic neurectomy.
Note :
Parotid gland nerve supply :
• Sensory : Auriculotemporal nerve (ATN).
• Parasympathetic :
Otic ganglion
9 nerve
th
Tympanic plexus Lesser superficial petrosal nerve ATN.
Foramen ovale
via Greater auricular nerve
• Stretching of parotid fascia Pain.

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Bone Anchored Hearing Aid (BAHA) 00:48:52 ----- Active space -----

Prerequisite :
Age >5 years : 3 mm skull thickness required for osseo-integration.
Indications :
• Cannot use normal hearing aid.
- Congenital deformities of external ear (Eg : Atresia).
- Discharging ears. Speech processor
- Following MRM Big mastoid cavity. Abutment
• U/L deaf ear.
Implant/fixture

Mechanism : Components of BAHA

Sound Speech processor implanted on the bone Fixture vibrates Stimulates inner ear.
Other Prosthesis/Aids :

Partial ossicular Stapes piston Cochlear implant

replacement prosthesis (External component)

Cochlear Implant 00:52:20

Invented by : William F. House (Father of neuro-otology).

Indication : B/L severe to profound HL Not benefitting with hearing aids.
Done : Earliest at 14 years of age.

Components :
Microphone

Transmitter Magnet
coil Receiver
stimulator
Ground
Speech electrode
processor Electrodes
External component Internal component Cochlear implant

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----- Active space ----- Electrodes :

• Insertion : Mastoid Facial recess Middle ear Round window
Scala tympani (Inner ear).
• Replaces : Organ of Corti Stimulation of cochlear nerve.
• Reference/ground electrode (Placed in temporalis muscle) : Regulates power
consumption + stimulation intensity.

C/I : Michel aplasia, cochlear nerve lesions, central auditory lesions.

Age of implant placement :

• Earliest : Pre-lingual deafness (Deaf at birth).
• Any age : Post-lingual deafness (Acquired).

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NOSE : PART 1 ----- Active space -----

Anatomy of Nose 00:00:46

Anatomy of External Nose :

External nose Upper 1/3rd : Bony.
Lower 2/3rd : Cartilaginous.
Nasal process of frontal bone
Nasion
Nasal bones
Frontal process of maxilla Rhinion : 3 paired cartilages

Upper lateral cartilage

(ULC) Septal cartilage (Unpaired)
Sesamoid cartilage
Alar cartilage/lower
lateral cartilage (LLC) Limen nasi
(Lat. wall of nasal valve)
Lining Epithelium :
Sinus
Ciliated columnar pseudostratified epithelium.
Nose
Vestibule : Stratified squamous keratinized epithelium.
Upper 1/3rd : Olfactory epithelium.
- Dangerous area of nose.
- Receives only 10-15% of inhaled air, ↑by sniffing.

Anatomy of Lateral Wall of Nose :

Part of Ethmoid bone

(MT)

(IT)

• Largest.
• Anterior & inferior most.
• Independent bone, articulates with :
- Ethmoid (Superiorly)
- Maxillary (Laterally)

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----- Active space -----

Meatuses & SER :
Superior Sphenoethmoidal
Inferior meatus Middle meatus
meatus recess (SER)
• Most congested
meatus
Significance Largest - -
• M/c meatus
approached for FESS
Nasolacrimal duct : Anterior group of sinuses : Sphenoid sinus
• Site : Junction of anterior 1/3rd & • Frontal
posterior 2/3rd of IT (Highest point) • Anterior ethmoid
• Valve : • Maxillary
Posterior
Valve of Hasner
Openings drains ethmoid
• Orientation (Direction of massage if
into sinus
blocked) : Downwards Backwards
Osteomeatal complex
(Middle meatus) SER
Lateral

Osteomeatal Complex :
Frontal recess/frontonasal
Frontal recess/frontonasal duct duct

(bulge producedbyby
(Bulge produced thethe
mostmost
prominent
anterior
prominent ethmoidal
anterior cell)
ethmoidal cell)
Hiatus semilunaris is theHiatus
spacesemilunaris
between
bulla ethmoidalis and uncinate process
(sickle-shaped part
of ethmoid bone)

Infundibulum (mouthofofmaxillary
Infundibulum (Opening maxillarysinus)sinus)

Note :
• M/c sinusitis : Maxillary > Ethmoid.
• First step for FESS/Infundibulotomy : Uncinectomy.

Nasal Endoscopy :
Parts examined
First pass Inferior meatus, nasopharynx
Second pass Superior turbinate, superior meatus, sphenoethmoidal recess
Third pass Middle meatus

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Septum ----- Active space -----

Middle turbinate
Inferior turbinate

Floor
Rt. Nostril

1
1 Uncinate process
2
2 Bulla ethmoidalis
3 3 Hiatus semilunaris

Lt. Nostril

Identification of Structures :

Fovea ethmoidalis : Cribriform plate

• Orbital plate extension Orbit
of frontal bone Bulla ethmoidalis
• Forms roof of ethmoid sinus
Hiatus semilunaris
Septum
Infundibulum
Middle turbinate (MT)
Inferior meatus Uncinate process
Inferior turbinate (IT) Maxillary sinus

CT

Concha bullosa :
• Pneumatized turbinate
• M/c site : MT
• On endoscopy :
Resembles polyp
Hypertrophic turbinate :
• M/c site : IT

Rhinoscopy CT

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----- Active space ----- Sinuses 00:20:40

Ventilation of sinuses :
Expiration Resistance at nasal valve area Eddy currents Ventilation.
formed
Maxillary sinus (MS)/
Ethmoid sinus Sphenoid sinus Frontal sinus (FS)
Antrum of Highmore
• Largest (Capacity : 15 ml). • Max. pneumatized at • L/c sinusitis. • Superior most.
• Earliest to develop. birth. • M/c pneumatization. • Last to develop.
• Present at birth. • M/c sinusitis in children. type/best for • Absent at birth.
• M/c sinusitis in adults. • M/c sinusitis leading to transsphenoidal • Last to be seen on
• Sinusitis risk factors : Orbital complications hypophysectomy : X-ray : At 6 yrs.
- Extraction of (D/t common venous Sellar. • Drainage : Via frontal
2nd premolar/1st molar drainage & lamina • Relations : recess.
papyracea). - Optic nerve.
Risk of oroantral fistula. - Internal carotid
- Dental infection. artery (ICA).
- Pituitary gland.

C
C A A D
B
B A

Maxillary sinus
A : Ethmoid sinuses A : Sphenoid sinus
B : Bulla ethmoidalis B : ICA + Cavernous sinus
C : Lamina papyracea C : Optic nerve
D : Pituitary

Transverse view

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Named Ethmoidal Cells : ----- Active space -----

Anterior group
Bulla ethmoidalis Most prominent
Haller cell
Location :
Near floor of orbit/Roof of maxillary sinus

Narrows opening of maxillary sinus

Recurrent maxillary sinusitis

Supraorbital cell -
Agger nasi (a)
• Present in 90% of population
• Anterior most
FS • May block frontal recess

MS Recurrent frontal sinusitis

• Visualized in coronal cut with small
maxillary sinuses
CT : Sagittal view CT : Coronal view
Posterior group
Onodi cell
• Location : Near sphenoid sinus
C D • Relations :
B - Internal carotid artery (ICA)
A - Optic nerve

Risk of injury during FESS

A : Sphenoid Sinus C : Optic Nerve (Most dreaded complication of FESS)
B : ICA + Cavernous Sinus D : Onodi Cell

Note :

Pneumatized superior turbinate

Large maxillary sinus

(Agger nasi not visualized)

CT : Coronal cut
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----- Active space ----- X-ray Views :

F F

AE
AE
M
M
S

Waters’/Occipitomental View : Pierre’s View/Waters View with Open Mouth :

• Position : Nose-chin Sinuses seen : Frontal (F), Anterior Ethmoidal
• Mandible : Appears inverted ‘U’ shape (AE), Maxillary (M), Sphenoid (S)

AE PE S
F Sella

Lateral View : Caldwell View/Occipitofrontal :

• All sinuses seen, including • Position : Nose-forehead
posterior ethmoid (PE) • Mandible : Appears straight
• Superiormost sinus : Frontal • Sinus best seen : Frontal

Rhinosinusitis 00:42:17

Clinical Features :
Nasal obstruction + nasal discharge + facial pain + hyposmia.
Facial pain characteristics Seen in
Pain/tenderness over root of nose, medial and deep to eye
Ethmoid sinusitis
Pain increases with eye movements
Pain/tenderness over frontal area
Frontal sinusitis
Early morning pain/periodic/office headache
Pain/tenderness over cheek and upper jaw Maxillary sinusitis
Occipital headache Sphenoid sinusitis

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----- Active space -----

Mucopurulent discharge/
pus in middle meatus

Endoscopy

CHARACTERISTICS

Acute Rhinosinusitis Chronic Rhinosinusitis

Duration < 12 weeks > 12 weeks
• Anterior rhinoscopy
Investigation NCCT (IOC)
• Nasal endoscopy

• Viral Disordered interaction b/w immune system

• Bacterial : & local microbes
Etiology/
- Strep pneumoniae
Pathophysiology
- H. influenzae Chronic inflammation & obstruction of
- M. catarrhalis osteomeatal complex

1. Medical (1 month)
• Symptomatic : - Steroid nasal spray (TOC)
- Nasal decongestants - Saline irrigation
Management
- Pain killers - Antibiotics in acute exacerbation
• Antibiotics 2. Surgical (FESS) : If refractory to medical
management

Functional endoscopic sinus surgery (FESS)

MT
Uncinectomy : Pack infused with
First step of mitomycin C inserted
FESS
Reduces synechiae
formation

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----- Active space ----- COMPLICATIONS

Acute Complications :
1) Orbital :
Chandler’s staging Clinical features

• Involves only
eyelid
A) Preseptal • Globe : normal
cellulitis Edema of eyelid

• Chemosis
• Proptosis
• Restricted ocular
B) Orbital cellulitis movements
• Decreased vision

Subperiosteal abscess
C) Subperiosteal Sinusitis
abscess Orbit pushed out
(Non axial proptosis)

D) Orbital abscess -

• B/L involvement
• Spread :
E) Cavernous sinus - Direct : nose & PNS
thrombosis - U/L B/L
(Cavernous sinus
communication)

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Note : Orbital cellulitis vs. cavernous sinus thrombosis ----- Active space -----

Orbital cellulitis Cavernous sinus thrombosis

Onset Gradual Abrupt
Nerve involvement 3, 4 & 6 concurrently 6th 3rd 4th sequentially
Trigeminal paresthesia Absent Present
Progresses
U/L or B/L U/L U/L B/L

Other orbital complications

Superior orbital fissure syndrome Ophthalmic branch of CN III, IV, V, VI
Orbital apex syndrome Superior orbital fissure syndrome + CN II involvement
2) Osteomyelitis of frontal bone :
• M/c bone affected : Frontal (Adults), maxillary (Children).
• Clinical features :

Soft doughy swelling

(Subperiosteal abscess)
Eye displaced
downwards, laterally &
forwards (Proptosis)

Potts puffy tumor

3) Intracranial complications :
• Subdural abscess (m/c) > Brain abscess > Extradural abscess, meningitis,
cavernous sinus thrombosis.
• Brain abscess :
M/c frontal lobe abscess (Follows frontal sinusitis) Personality changes.
Note : M/c brain abscess following otitis media Temporal lobe abscess.
Chronic Complications :
1) Mucocele :
• Collection of secretions in sinus (D/t blocked drainage)

Cystic swelling.
• Causes :
- Frontal sinusitis (M/c).
- Trauma (RTA, post FESS).

2) Pyocele : Infection of mucocele.

Non axial proptosis Mucocele
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----- Active space ----- NOSE : PART 2

Fungal Sinusitis 00:00:39

Non-invasive Acute invasive

Fungal ball Allergic Fungal Sinusitis (AFS) fungal sinusitis
• Mucormycosis : Rhizopus
Dematiaceous fungi :
Causative and Mucor
M/c : Aspergillus Bipolaris, Curvularia,
Organism • Invasive Aspergillosis :
Alternaria
Aspergillus fumigatus
Immunocompetent + Atopic Immunocompromised
Immune Status Immunocompetent
(Type 1 Hypersensitivity) (DM, steroid use)
Sinus Involved M/c : Maxillary sinus M/c : Ethmoid sinus -
• Angioinvasive + neural
Chronic rhinosinusitis + spread : Rapidly to orbit,
Presentation Chronic sinusitis
Nasal polyps palate, brain
• Acute sinusitis
• Nasal discharge :
Endoscopy Cheesy/clay-like Mucinous, peanut butter/ Black necrotic areas/
Findings debris in middle meatus axle-grease anaesthetic areas
• Nasal polyps
Double density sign :
Double density sign + sinus
CT Findings Heterogeneous -
expansion Bone erosion
appearance
Nasal smear/biopsy (IOC) :
Diagnosis - Bent and Kuhn criteria Infarcts, angioinvasion,
perineural invasion
• FESS F/b Steroids Local debridement + Rx of
(Local/short course : immunosuppression +
Functional Endoscopic ↓Edema) IV antifungal :
Mx
Sinus Surgery (FESS) • Refractory cases : • Liposomal amphotericin B
Post-op antifungal Rx (Mucormycosis)
(Itraconazole) • Voriconazole (Aspergillosis)

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----- Active space -----

Fungal ball Allergic fungal sinusitis

Cheesy debris CT : Double density sign Nasal polyps Double density sign
(Entrapment of metals)

Invasive fungal sinusitis

Mucormycosis : Aspergillosis : Black necrotic areas

• Septate hyphae. • Ribbon-like aseptate hyphae.
• Branching at acute angles. • Branching at right angles.

Bent and Kuhn Diagnostic Criteria :

For allergic fungal rhinosinusitis.
Major criteria Minor criteria
• U/L predominance
• Nasal polyps
• Asthma
• Eosinophilic mucin
• Serum eosinophilia
• Type I hypersensitivity (↑IgE levels)
• Charcot leyden crystals
• CT : Hazy sinuses + Heterogenous opacities
• Bony erosion
• Fungal smear : +
• Fungal culture : +

Types of mucormycosis (Phycomycosis) :

Rhino-ocular or Pulmonary Cutaneous Gastrointestinal Disseminated

Rhino-oculo-cerebral
(M/c) • Occurs in immunocompetent.
• Percutaneous implantation : Injury with vegetative matter.
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Nasal Polyps 00:20:21

----- Active space -----

Mechanism of formation : Bernoulli’s principle.
C/f : Chronic sinusitis Nasal obstruction, nasal discharge.
Best Ix : NCCT.
B/L Nasal Polyps :
Conditions Features
B/L nasal polyps in adults
• Watery nasal discharge
Allergy (M/c) • H/o sneezing/itching, family h/o allergy
• ↑IgE levels
• Non-allergic, non-IgE mediated hypersensitivity reaction
Aspirin Exacerbated
• Abnormal arachidonic acid metabolism : COX 1 > COX 2 inhibitors
Respiratory Disease (AERD,
• C/f : Nasal polyposis, asthma, aspirin hypersensitivity
AKA Samter's triad)
• Mx : Desensitization with aspirin, symptomatic Rx with Montelukast
Eosinophilic Granulomatosis with
• Chronic rhinosinusitis + Adult onset asthma
Polyangiitis (EGPA)/
• Eosinophilia >10%
Churg-Strauss Syndrome
Triad : Chronic sinusitis + Bronchiectasis + Infertility
Young’s syndrome (Rare)
(Obstructive azoospermia)
B/L nasal polyps in children
• Recurrent pulmonary airway infections, bronchiectasis, intestinal
Cystic Fibrosis/
obstruction, pancreatic insufficiency, and malabsorption
Mucoviscidosis
• Multiple polyps

Kartagener’s Syndrome/
Primary Ciliary Dyskinesia Triad :
(PCD)
Situs inversus/ Chronic sinusitis Bronchiectasis
Dextrocardia

Tests for Mucociliary Function :

Normal : Mucus blanket movement 5-10 mm/min Cleared into pharynx every
(Ciliary action) 10-20 mins.
• Used in diagnosis of PCD & cystic fibrosis.

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1. In vivo testing :
----- Active space -----
Saccharine test Nuclear testing/scintigraphy
• Saccharine placed on inferior
turbinate Time taken for sweet Radiolabelled Tc99 albumin colloid
taste assessed. particles placed on inferior turbinate
• Saccharine mixed with color
(Methylene blue, indigo blue, Migration checked by gamma camera.
charcoal) : Objective test.
N Mucociliary Clearance Time (MCT) : N : Radioactivity disappears from nasal
< 30 mins cavity in 30 mins.

2. In-vitro testing :
Electron microscopy : Ciliary ultrastructure abnormal in PCD.

Management of Nasal Polyps :

Medical Mx :
Surgical Mx :
• Nasal steroid spray :↓Size of polyp. If not effective FESS + Nasal polyp
• Saline nasal spray.
excision.
• Mx of underlying condition.

Mx remains the same if recurrent (Medical Sx).

U/L Nasal Polyps :

Conditions Management
Adults
Allergic fungal sinusitis FESS F/b Local Steroids (Post-operatively)
Bacterial rhino sinusitis Medical Mx (1 month) No benefit FESS
Children/Young

Antrochoanal polyp
(Growth : Maxillary FESS
antrum Choana)
CT : Transverse view

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----- Active space ----- Differential Diagnosis :

Features Imaging
Concha bullosa
(Pneumatized turbinate) Probe test (On probing) :
• Polyp : Bleeding & pain - ,
able to pass probe around
• Concha : Bleeding & pain + ,
unable to pass probe around
Middle turbinate

• Compressible
Meningocele or
• Transillumination +
Meningoencephalocele
• Furstenberg test +
(Polypoidal mass in infants)
(Cry/cough ↑Mass size) Meningoencephalocele

Malignancy
IOC : Biopsy -
(Polypoidal mass in elderly)

Nasal Septum and DNS 00:38:38

Anatomy of Nasal Septum :

Crista galli
Frontal bone
Sphenoid sinus
Frontal sinus • Quadrangular/
Nasal septum : quadrate shaped.
Nasal bone 3 • Supports lower 2/3rd
Perpendicular plate of 1
ethmoid bone of nose.
4 • Removal Saddling
Vomer bone Septal cartilage
2 b) a) of nose
Sphenoid bone
Palatine process of
Horizontal plate maxilla 6
of palatine bone 5
Sagittal section
Nasal septum : 3 parts
a) Columellar septum
b) Membranous septum
c) Septum proper :
• Bony : 1 , 2 , 3 , 4 , 5 , 6
• Cartilaginous

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DEVIATED NASAL SEPTUM (DNS) ----- Active space -----

M/c nasal septal abnormality.
External trauma.
Causes
Birth trauma/Developmental abnormalities (M/c).
Clinical Features :
• C/o paradoxical nasal obstruction (D/t turbinate hypertrophy).
• Recurrent sinusitis.
• Recurrent otitis media.
• Epistaxis, hyposmia.
O/E :
DNS
• Septal deviation.
• Compensatory turbinate hypertrophy of opposite side
- M/c : Inferior turbinate (IT). IT
Investigations : Septum
1. Nasal endoscopy : Confirmatory Ix.
Nasal endoscopy
2. Cottle’s test : To check nasal valve patency.

Cheek pulled upward + laterally

Upper lateral Valve angle
If obstruction ↓ cartilage (10-150)
(LOwer border)
DNS at nasal valve area. Septum
Cottle’s test
Nasal valve area
Surgical Mx :
Only if symptomatic.

Septal surgery
Septoplasty (TOC) Submucosal resection (SMR)
Freer’s/Hemitransfixion incision : Killian’s incision : 1 cm above lower/
Over lower/caudal septal border caudal septal border Sx incisions
Mucoperichondral flaps raised on Mucoperichondrial flaps raised on
one side both sides
Only deviated part removed. Most of cartilage removed.
↓Complication rate ↑Complication rate : ↑Chances of
(Surgery of choice). septal perforation, saddling of nose
Septoplasty not done in <17 years of age. Septal perforation
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----- Active space ----- Fractures of Face 00:47:28

NASAL BONE FRACTURE

M/c facial #, h/o trauma + .
C/f : C/o nasal obstruction, edema over external nose & crepitus +

Nasal bone #
Types of nasal bone #
Class 1/Chevallet Class 2/Jarjaway Class 3/Naso-orbito ethmoid #

Horizontal/C-shaped #
Vertical septum fracture
septum (Gross deformity + • Pig nose deformity :
(No or mild deformity) # nasal dorsum +
Septal deviation)
Perpendicular plate of
ethmoid + Cribriform plate +
Lamina papyracea
• CSF rhinorrhea +

Management of class 1/2 # :

1. Early presentation (<3 weeks) :
Wait for edema to ↓(5-7 days)
Management :
- Deformity + Follow ABCD of trauma

Symptomatic Rx Closed reduction Immediate Sx

(Using forceps + Splint) (open reduction and internal
2. Late presentation (>3 weeks) + Deformity : fixation)
Open rhinoplasty or septo-rhinoplasty
(Not done in <17 yrs of age)

Asch’s forceps Walsham forceps V-shaped incision Septal hematoma

(For septal reduction) (For nasal bone reduction) (Rhinoplasty)

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Septal Hematoma : ----- Active space -----

H/o trauma.
C/f : B/L boggy swelling on both sides of septum.
Rx : I & D within 72 hours Not done Septal necrosis, perforation, saddling,
or abscess formation.
FRACTURE OF ZYGOMATIC BONE
AKA Tripod # (# at 3 suture sites).

Clinical Features :
Zygomatico-frontal suture
• Flattening of malar eminence.
+
• Anaesthesia over cheek Zygomatico-temporal suture
(Infraorbital nerve injury). +
Zygomatico-maxillary suture
Orbital/eye findings :
Tripod # of zygomatic bone
• Periorbital emphysema.
• Step deformity of infra-orbital margin.
• Restricted ocular movements
(Inferior oblique, inferior rectus entrapment).
• Enophthalmos.

Zygomatico-frontal suture involved : Step deformity of lateral orbital margin.

Zygomatico-temporal suture involved : Trismus (TM joint involved).

Blow out # :
• # of inferior wall of orbit
(D/t severe blow on orbit).
• Infra-orbital nerve injured :
Anaesthesia over cheek.
• CT finding : Tear drop sign
(Orbital fat protrusion into maxillary sinus) Blow out #

FRACTURES OF MAXILLA
AKA Le Fort #.

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----- Active space ----- Le Fort I/Guerin's Le Fort II Le Fort III

Runs parallel to Runs through maxillary
palate (Floor of nose sinus, infra-orbital margin, Craniofacial
# line + lacrimal bone up till root of dysjunction
maxillary sinuses) nose (Pyramidal #)
Floating palate/
X-ray/CT Hanging maxilla -
Floating teeth
CSF rhinorrhea - + +

Infraorbital
- + -
nerve injury

CSF Rhinorrhea 01:01:18

M/c cause : Trauma.

Frontal bone
Anterior cranial fossa
Lateral lamella
Site of # (Cribriform plate : Lateral lamella)
Medial lamella
Middle cranial fossa
(Sphenoid, transverse temporal bone)
C/f : Cribriform plate
• H/o trauma.
• U/L watery nasal discharge (↑es on leaning forward).
CSF
• Not able to sniff back.
Handkerchief test : No stiffening seen. Blood
Reservoir sign : + .
Investigations : Halo sign/double ring
Biochemical IOC : β2 transferrin, β trace protein + . sign/target sign
Radiological IOC : HRCT (Look for exact site of #).
MRI/CT cisternography.
Active leak assessment
Intrathecal fluorescein
(Locate site of leak).
Management :
HRCT
Conservative Mx :
• Propped up position. Surgical Mx :
• Avoid straining. No resolution in 2 weeks Endoscopic > Open
• Stool softeners. repair
• Prophylactic antibiotics

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NOSE : PART 3 ----- Active space -----

Nerve Supply of Nose 00:00:55

OLFACTORY SUPPLY
Olfactory Pathway :
Olfactory mucosa Olfactory nerves Olfactory 1° & 2°olfactory
(Lines upper 1/3rd of (12-20 in number) bulb cortex.
nasal cavity)
Disorders of Smell :
Disorders Meaning Causes
Hyposmia ↓ sensation of smell Partial nasal obstruction
• Viral infections
• Fractures of cribriform plate
(Transects nerve)
Anosmia Complete loss of smell • Olfactory bulb tumors
(E.g. Frontal lobe meningiomas)
• Atrophic rhinitis
Perversion of smell
Parosmia/Cacosmia/
(Patients c/o rotten eggs/ Aberrant regeneration of nerves
Dysosmia
burnt rubber smell)
Phantosmia Delusion of smell Temporal lobe seizures
Neurodegenerative diseases :
• Alzheimer’s
Presbyosmia Age related loss of smell
• Parkinson
• Multiple sclerosis
Hypogonadotrophic hypogonadism :
Congenital anosmia Inability to smell from birth
Kallman syndrome

Tests :
1. Smell Identification test (SIT) :
a) University of Pennsylvania smell identification test (UPSIT) :
40 scratch & sniff questions.
b) Cross-cultural/brief smell identification test :
Uses odors well known in most cultures.

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----- Active space ----- 2. Smell Diskettes 3. Sniffin sticks :

Tells degree of loss of smell.

SENSORY SUPPLY
Trigeminal nerve

Ophthalmic branch Maxillary nerve

(Exits via foramen rotundum)
Nasociliary

Anterior Posterior Infratrochlear :

ethmoidal ethmoidal Sensation to upper
part of external nose
Pierces lamina papyracea &
enters external nose via infra-orbital via sphenopalatine
foramen foramen

External nasal : Internal nasal : Infra-orbital nerve : Sphenopalatine/

Supplies lower part Supplies lateral wall Supplies cheek & ala nasopalatine nerves :
of external nose of nose. of nose. Major supply of nasal
(Tip). cavity.

Nerve Blocks :

External nasal nerve Infratrochlear nerve Nasociliary nerve

Medial to medial end of • 1 cm above medial canthus
eyebrow • 1.5 cm deep Anterior ethmoidal
• 2.5 cm deep Posterior ethmoidal

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Infraorbital nerve block : ----- Active space -----

External approach Sublabial approach

Sphenopalatine ganglion block : Anaesthesia of internal nose.

Via nose Via greater palatine foramen (Medial to 3rd molar)

Note : Foramina
Lesser wing Superior orbital fissure

Optic foramen Greater wing

Foramen rotundum
Sphenoid sinus Pterygoid canal
(AKA Vidian canal)

Infra-orbital foramen Foramen rotundum

Sphenopalatine foramen
(1 cm behind middle turbinate)

Sphenopalatine foramen
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----- Active space ----- AUTONOMIC SUPPLY

Vidian Nerve :

Branch of facial nerve GSPN Fusion

Vidian nerve
Sympathetic plexus around ICA DPN

Parasympathetic fibres Sympathetic fibres

GSPN : Greater superficial petrosal nerve. Via Pterygoid canal
DPN : Deep petrosal nerve. Relays in SPCT No relay in SPCT
SPG : Sphenopalatine ganglion.
Functions : Function :
• Lacrimation. Vasoconstriction.
• Vasodilatation.
• Nasal secretions.
• Palatine secretions.
Note :
Nasal cycle :
• Simultaneous vasodilatation of one nostril & vasoconstriction of other.
• Duration of one cycle : 2.5-4 hrs.
Rhinitis : Allergic, Vasomotor, Medicamentosa 00:20:37

Allergic vs. Vasomotor Rhinitis :

Allergic rhinitis Vasomotor rhinitis
Etiology Allergen Idiopathic
Nasal obstruction, nasal discharge/PND, itching, sneezing.
• Allergic salute
C/F Facial signs • Allergic shiners -
• Dennie Morgan lines
Family h/o allergy + -

Anterior Congested mucosa

Pale/boggy
rhinoscopy

IgE levels (RAST) ↑↑ Normal

Skin prick test + -
• Anti-allergics • Intranasal steroids
• Nasal steroid spray No improvement
• Leukotriene inhibitors (Montelukast) Vidian neurectomy
Rx
• Nasal decongestants (<7 days)
• Partial/total turbinectomy : If hypertrophy of
No improvement inferior turninate (Mulberry appearance) present.
Immunotherapy
RAST : Radioallergosorbent test. PND : Post nasal drip.
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Note : Otto Veraguth folds are seen in depression. ----- Active space -----

Dennie Morgan lines

(Crease in lower lid)

Allergic salute Allergic shiners (Dark discoloration

& puffiness below eyes)
Rhinitis Medicamentosa :
Pathophysiology :
Prolonged use of nasal decongestants Prolonged vasoconstriction Ischemic changes in nose.
Prevention : Avoid nasal decongestant use for >7 days
Rx :
• Stop decongestant use.
• Short course of steroids : Local (Nasal spray) > Systemic.

Atrophic Rhinitis 00:28:45

F > M (Starts during puberty).

Types :

Primary : Secondary :
Causes : Causes :
• Unknown (M/C). • Granulomatous conditions.
• Klebsiella ozaenae. • Tissue destructive Sx
Empty nose syndrome.
Atrophic rhinitis
Clinical Features :
• B/L excessive nasal crusts Nasal obstruction & infection.
• B/L roomy nasal cavity.
• Foul smelling nasal discharge (Merciful anosmia : Patient is unaware).
Treatment :
1. Removal of crusts : Alkaline nasal douche.
Contents : Sodium chloride, Sodium bicarbonate, Sodium biborate
(2 : 1 : 1 in distilled water)
2. Treat infection :
- 25% glucose in glycerine spray.
- Kemicetine solution contents : C hloramphenicol, Oestradiol, Propylene glycol
& Vitamin D (Mnemonic : COPD).
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----- Active space -----

3. Surgery :
- Young’s operation : Complete closure of nasal cavity.
- Modified Young’s operation : Nasal cavity closure with 3mm opening in center.

Granulomatous Conditions of Nose 00:34:05

Rhinoscleroma :
Etiology : Klebsiella rhinoscleromatis (Frisch bacillus) Endemic to Asia & Africa.
Stages 1. Atrophic stage 2. Granulomatous stage 3. Cicatricial stage
C/f Crusting, nasal obstruction Hard, woody nose Nasal deformities + (Eg : Hebra/Tapir nose)
Biopsy :

Russel bodies :
Plasma cells
Mikulicz cells : with eosinophilic
Macrophages inclusion bodies.
containing
phagocytosed bacilli.

Treatment :
• Antibiotics : Ciprofloxacin (DOC), Streptomycin, Rifampicin, Tetracycline.
• Steroids : ↓fibrosis.
Common Clinical Features :
• Nasal obstruction.
• ↑Crusting Removal Blood tinged nasal discharge.
• Septal perforation :
- Cartilaginous part : All granulomatous conditions.
- Bony part : Syphilis, granulomatosis with polyangiitis (Wegener’s
granulomatosis).
• Saddling (Later stages).

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----- Active space -----

Specific Characteristics :

Condition Clinical features Investigations

• c-ANCA +
Granulomatosis
• Biopsy :
with
Necrotizing granulomatous
polyangiitis
vasculitis
Serous otitis media Strawberry gingiva
• Septal perforation (Bony > Cartilaginous)
Syphilis -
• Congenital : Snuffles (Rhinitis)
Biopsy : Caseating granulomas +
TB Saddling + perforation in cartilaginous septum
acid fast bacilli
Non-blanching brownish nodules (Apple jelly nodules)

Lupus vulgaris -

Skin patches, sensory loss,

Leprosy -
paresthesia/numbness in extremities
• Strawberry nasal mucosa
• Heerfordt’s syndrome/Uveoparotid fever (Triad) :
- B/L parotid enlargement
- Facial nerve paralysis
- Anterior uveitis
Biopsy :
Sarcoidosis Non-caseating
granulomas

Lupus pernio : Anterior uveitis

Violaceous affection of nose

T-cell Lymphoma 00:45:36

AKA Midline lethal granuloma/Stewart’s lymphoma/NK lymphoma.

A/w EBV.
Clinical features : Destruction of midline structures (Septum, palate).
Investigations : Biopsy.
Treatment : Radiotherapy ± Chemotherapy F/b Reconstruction of defect.
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----- Active space ----- NOSE : PART 4

ARTERIAL SUPPLY
Internal carotid artery < External carotid artery

Ophthalmic A.

Post. Ant. Maxillary A. Facial A.

ethmoidal A. ethmoidal A.
1. Sphenopalatine A. Septal branch of
(Main arterial supply). superior labial A.
2. Greater palatine A.
(Supplies palate & nose).
: Supplies lateral wall & septum.
Anterior ethmoidal artery Sphenopalatine artery
Pierces lamina Enters Nose : Anterior ethmoidal
Features Runs through sphenopalatine foramen.
papyracea notch/Nipple sign.
Injury during FESS Orbital hematoma. • Main artery of epistaxis + Little’s area/
(Emergency) kiesselbach’s plexus.
Significance Mx : Lynch Howarth Ligation of anterior • Ligated in sphenopalatine foramen (1 cm
incision ethmoidal artery. behind posterior end of middle turbinate.)

Kiesselbach’s Plexus :
• Anastomoses in Little’s area (Antero-inferior part of the septum).

Anterior ethmoidal A
Posterior ethmoidal A.
Sphenopalatine A.

Greater palatine A.
Superior labial artery
(Septal branches) Nipple sign on CT Lynch Howarth incision

: Arteries forming Kiesselbach’s plexus

• Posterior ethmoidal A. : Not a part of Kiesselback’s plexus.

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EPISTAXIS ----- Active space -----

M/c site :
• Children & young : Little’s area.
• Adults : Posterior epistaxis. Woodruff’s plexus :
Venous plexus behind inferior turbinate.
M/c cause :
• Children : Trauma (Nose picking).
• Adults/elderly : Idiopathic.

M/c artery involved : Sphenopalatine artery (Anterior + posterior epistaxis).

Recurrent epistaxis : In young male Rule out angiofibroma.

Note : Foreign body in children U/L foul smelling nasal discharge > Epistaxis.

Management : Small volume bleeds Large volume bleeds :

• Airway, breathing, circulation.
• IV access :
1. Hippocratic/Trotter’s method : - Blood parameters, grouping.
Pinch nose tightly + sit leaning forwards - Fluid resuscitation.
• History + Rx underlying cause.
Bleeding continues
2. Endoscopic cauterization :
• Silver nitrate used.
• Bipolar cautery.
Bleeding continues
3. Anterior nasal packing :
Trotter’s Cauterization Merocel sponge
• Ribbon gauze.
method
• Merocel packs/sponge.
Bleeding continues
Foley’s bulb
4. Posterior nasal packing :
Using foley’s catheter
Bleeding continues
Admit the patient + prophylactic Anterior nasal Posterior nasal
antibiotic coverage packing packing
Bleeding continues Maxillary artery ligation
5. Ligation (Order & site) : Site : Sphenopalatine/pterygopalatine fossa.
• TESPAL (Sphenopalatine foramen)
TESPAL : Transnasal Bleeding continues Approach :
Endoscopic Sphenopalatine • Maxillary artery ligation 1. Endoscopic.
Artery Ligation. Bleeding continues 2. Caldwell Luc procedure :
• ECA ligation (Neck)
Bleeding continues Sublabial incision
• Anterior ethmoidal artery ligation
(Anterior ethmoidal canal)

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----- Active space ----- Rhinosporiodiosis 00:15:14

Etiopathogenesis :
• Causative organism : Rhinosporidium seeberi (Aquatic protozoa).
• Cattle breeders, farmers (Commonly).
• Endemic to South India (M/c : Tamil Nadu)
Features :
H/o bathing in ponds frequented by animals.
Symptoms : Epistaxis, nasal obstruction, blood tinged nasal discharge.
O/E : Subcutaneous nodules on skin + , Strawberry/mulberry mass (Polypoidal, vascular)
Management :
Ix : Biopsy (IOC).

Sporangium filled
with sporangiospores

Mass with white dots

(Sporangia of protozoa)
HPE of Rhinosporidiosis Strawberry mass
Rx : wide excision of base + cauterization F/b Dapsone (Post operatively,
↓recurrence rate)

Tumours Of Nose 00:19:08

Inverted Papilloma :
• AKA Ringertz tumour/Schneiderian papilloma/Transitional cell papilloma.
• M/c benign tumour of nasal cavity.
Features
Cause : Human Papilloma virus (HPV).
• Locally invasive.
C/f :
• Premalignant
• M > F (40-70 years).
• Recurrent
• U/L nasal obstruction + blood tinged nasal discharge.
Investigations :
a. Endoscopy : b. Biopsy : c. CT scan :

Papillary
appearance Epithelium growing
towards stroma
U/L polypoidal mass
(Arises : Middle meatal area)
Cerebriform appearance
Mx : Wide excision (Endoscopic > External approach).
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Carcinoma Of Nose : ----- Active space -----

Basal Cell Carcinoma (BCC) Squamous Cell Carcinoma (SCC)

AKA Rodent ulcer AKA Nose picker’s carcinoma
M/c carcinoma of external nose M/c carcinoma inside nasal cavity

BCC : Basophilic cell bundles + palisading nuclei (HPE). BCC/ Rodent ulcer

Tumours Of Paranasal Sinuses 00:22:19

Sinus affected (M/c L/c)

Benign tumours Frontal > Ethmoid > Maxillary > Sphenoid
Carcinoma Maxillary > Ethmoid > Frontal > Sphenoid

BENIGN
Osteoma : M/c benign tumour of PNS (M/c : Frontal sinus).
Fibrous dysplasia :
• Normal bone replaced by fibrous tissue.
• Seen in young; M/c : Maxillary sinus.
• X-ray/CT : Ill-defined ground glass appearance.
MALIGNANT
SCC : M/c carcinoma PNS (M/c sinus : Maxillary).
Adenocarcinoma : M/c in hard wood furniture industries/
Carpenter (M/c : Ethmoid sinus).
Esthesioneuroblastoma/Olfactory neuroblastoma :
• Neuroendocrine hormone secreting
tumour from olfactory mucosa.
• Highly vascular, cherry-red,
polypoidal mass.

CT : Esthesioneuroblastoma
Maxillary Sinus Carcinoma :
Ohngren’s classification : Investigations :
a. CT scan :

Root of Nose
Bony erosion
Suprastructure :
Infrastructure : • Bad prognosis.
• Better prognosis. • Late stage tumours.
• Early stage Maxillary sinus carcinoma
Angle of mandible
tumours. Ohngren’s line
b. Biopsy : Carcinoma features.
(Mitotic figures)
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----- Active space ----- TNM classification :

T1 Antral mucosa involved.
Involvement of :
Bony erosion :
• Pterygoid plate.
T2 • Medial maxillary wall.
• Infratemporal fossa.
• Floor of maxilla (Hard palate).
T4 • Orbital contents.
Bony erosion of : • Cribriform plate.
• Floor of medial wall of orbit. • Frontal Sinus.
T3
• Posterior wall of maxillary sinus. • Sphenoid sinus.
• Pterygopalatine fossa invasion.
Management :
• T1, T2 : Sx (Partial/Total maxillectomy).
• T3, T4 : Sx + Radiotherapy.
Sx approach

Denker’s operation :
• Endoscopic approach.
• Anteromedial maxillectomy.

Lateral Rhinotomy Weber Ferguson Midfacial degloving

(Moure’s incision) incision (Sublabial incision;
Cosmetically better.)

Note :
Juvenile nasopharyngeal angiofibroma Rhinophyma/Nasal Elephantiasis
• Arises from sphenopalatine foramen. • Seen in middle aged males.
• Holman miller sign : • H/o long standing acne rosacea. Potato
Pushing posterior wall of antrum (Sebaceous gland hypertrophy). nose
anteriorly (On CT). • Sx : Wide skin excision.
(For large deformity).

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PHARYNX : PART 1 ----- Active space -----

Nerve Supply of Tongue 00:00:49

Ant. Post.

Circumvallate papilla
Sulcus terminalis
2/3 1/3 Base of tongue

Sensory Supply :
Sensory Taste Referred pain to ear
Lingual nerve Chorda tympani Lingual nerve
Anterior 2/3rd
(Branch of mandibular) (Branch of facial) (Branch of mandibular)
Posterior 1/3rd Jacobson’s branch of
(Base of tongue) glossopharyngeal nerve
Glossopharyngeal nerve
Circumvallate papillae
-
(In ant. 2/3rd)
Arnold’s branch of vagus
Posterior most Vagus nerve
nerve

Motor Supply :
• Muscles : derived from occipital myotomes.
• Hypoglossal nerve. Exception : Palatoglossus by pharyngeal plexus.

Clinical significance :
U/L hypoglossal nerve palsy D eviation of tongue to weaker side
D/t genioglossus of normal side.
Action of genioglossus :
• Protrusion
• Deviation to opposite side.

Note : Nerves passing through jugular foramen CN IX, X, XI. Deviation of tongue

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----- Active space ----- Anatomy of Pharynx 00:05:03

Parts of Pharynx :
• Fibromuscular tube.
• Extension : Base of skull Lower border of cricoid.

Ciliated columnar Base of skull

Nasopharynx/
pseudostratified
Epipharynx Hard palate
epithelium
Oropharynx
Stratified squamous
non-keratinized
epithelium Laryngopharynx/ Hyoid
Hypopharynx Lower border
of cricoid

Waldeyer’s Ring/Mucosal Associated Lymphoid Tissue (MALT) :

Present in nasopharynx & oropharynx.
Adenoids/Lushka’s/
Nasopharyngeal tonsil
Tubal tonsil/Gerlach’s tonsil

Lateral pharyngeal
band
Palatine tonsil/Faucial tonsil
Nodules on posterior
pharyngeal wall
Lingual tonsil

Muscles :
Muscles of pharynx : Pushes food into esophagus

Longitudinal : Dilators Circular : Constrictors

• Stylopharyngeus At level of nasopharynx,
• Superior constrictor (SC )
• Salpingopharyngeus bed of tonsil.
• Middle constrictor (MC)
• Palatopharyngeus • Inferior constrictor (IC)
Fascia :
Pharyngobasilar fascia : Anterior fascia
Thickened part lateral to palatine tonsil Capsule.
Buccopharyngeal fascia : Posterior fascia outside circular muscles.

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Constrictors & Relevant Anatomy 00:11:42 ----- Active space -----

Sinus of Morgagni 1

SC

MC
2
3
IC

Lateral view

Structures Passing Between Each Constrictor :

Landmark Structures
• Tensor veli palatini
• Ascending palatine artery
1. Sinus of Morgagni : Superior constrictor
• Ascending pharyngeal artery
B/w base of skull &
• Levator veli palatini
superior constrictor
• Auditory tube (Eustachian tube)
Mnemonic : TAALA Middle constrictor
2. B/w superior & middle • Glossopharyngeal (IX) nerve
constrictor • Stylopharyngeus muscle
3. B/w middle & inferior Internal branch of superior Inferior constrictor
constrictor laryngeal nerve (Branch of CN X)
4. B/w inferior constrictor Recurrent laryngeal nerve Circular Muscles
& esophagus (Branch of CN X)

Killian’s Dehiscence/Zenker’s Diverticulum/Gateway of Tears :

• Outpouching of mucosa in pharyngobasilar fascia. Superior pharyngeal
• Most common in elderly, left side. Constrictor
• Posterolateral extension. Middle pharyngeal
• Pulsion diverticulum. constrictor
Thyropharyngeus (IC)
• False diverticulum.
Killian’s dehiscence
Cricopharyngeus (IC)
Posterior View

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----- Active space ----- C/f : Cough, hoarseness, halitosis.

• Dysphagia, regurgitation Recurrent laryngitis.
(D/t food collection) Lung complications.
• O/E : Boyce sign Gurgling sound on
neck palpation. Zenker’s diverticulum
Investigation :

Rising tide appearance :

Rising of pouch filled with
food, fluids.

Esophageal lumen

1. Barium Swallow 2. Endoscopy

(Lateral view) : Best Ix.
Management :
• Dohlman’s procedure : Laser-based procedure. • Open excision : For large
• Endoscopic stapling diverticulectomy. diverticula.

Endoscopic diverticulectomy Removal of common wall

Spaces of Pharynx 00:21:02

Prevertebral space
Prevertebral fascia Fascia behind
Post styloid Alar fascia pharyngeal wall
Space of Gillette
compartment Retropharyngeal space
(Formed by fibrous
Styloid process in septa) Buccopharyngeal fascia Mnemonic : BAP
parapharyngeal space Buccopharyngeal space • Buccopharyngeal fascia
Pharyngobasilar fascia Circular • Alar fascia
Longitudinal muscle layer
forming capsule of tonsil • Prevertebral fascia
Medial pterygold Pharyngobasilar fascia Forms capsule
(Mucosa
Tonsil associated lymphoid
(MALT)
Mandible tissue (MALT): waldeyer’s ring)
Masseter Epithelial/Mucosa*
Tonsil Transverse Section of pharyngeal wall
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Extension : ----- Active space -----

Lower limit Upper limit
Retropharyngeal space T4
Base of
Danger space Diaphragm
skull
Prevertebral Space T4

On Examination :
Retropharyngeal space/Space of Gillette Prevertebral space
Posterior wall bulge U/L swelling (D/t fibrous septa) Diffuse midline swelling

Applied Anatomy :
Danger space : Infection Spreads Mediastinum Mediastinitis, pericarditis, pleuritis.

Acute Retropharyngeal Abscess 00:25:00

Content : Nodes of Rouviere (Lymph nodes).

Etiology :
• Children (M/c) : Acute suppurative lymphadenitis (D/t nasopharyngeal/ oropharyngeal infection).
• Adults : Penetrating injury (Eg : Fish bone).

Clinical Features :
• Fever. • Stridor.
• Dysphagia, odynophagia. • Torticollis (D/t spasm of prevertebral muscles).
Investigation :

Loss of cervical lordosis

↑Prevertebral shadow
• >7 mm at C2
• >14 mm in children
At C6
• >22 mm in adults
Air fluid level in the abscess

X-ray
Note : CT To differentiate between retropharyngeal & prevertebral abscess.

Management :
• Airway, fluid management.
• Intra-oral incision & drainage of abscess.
• IV antibiotics.
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----- Active space ----- Peritonsillar Abscess/Quinsy 00:28:20

Peritonsillar space location : B/w capsule of palatine tonsil & superior constrictor.

Spread :
Crypta magna (Largest tonsillar crypt) : M/c in adults d/t tonsillar atrophy.
Anterior pillar
Clinical Features :
• Fever.
• Sore throat. Base of uvula
• Odynophagia, dysphagia.
• O/E : Medially pushed tonsil.
• Hot potato voice.

Site of Incision : Lateral to point of

intersection b/w line drawn along
Management: anterior pillar & base of uvula
• IV antibiotics.
• Aspiration of abscess Not treated Incision & drainage.
• Interval tonsillectomy : 6 weeks after 1st episode : Children
2 episode : Adults

Parapharyngeal Space 00:31:35

AKA Lateral pharyngeal/Pharyngomaxillary space.

Boundaries :
Medial : Lateral pharyngeal wall,
buccopharyngeal fascia.
Lateral : Mandible, medial
e

(P)

pterygoid, masseter.
(R)
ia ia
rane

cia
Prevertebral fasc
fas D)

Base : Base of skull.

(
Alar fasc
Verteb

Apex : Hyoid bone.

pharyngeal

R : Retropharyngeal space
Bucco

D : Danger space
P : Prevertebral space
Parapharyngeal Space

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Compartments : ----- Active space -----

Divided by styloid process.

Anterior/Pre-styloid Posterior/Post-styloid
compartment compartment
• Internal carotid artery
• Loose areolar tissue
• Internal jugular vein
Compartments • Maxillary artery branches
• CN : IX, X, XI, XII
• Mandibular nerve branches
• Cervical sympathetic trunk
Bulge behind posterior pillar
O/E Tonsil pushed medially
of tonsil
• Abscess
Clinical • Neurogenic tumor
• Trismus (D/t mastication
significance • Horner’s syndrome
muscles involvement)

Parotid bulge
(Bulge at angle
of mandible)

Note : Absent in peritonsillar abscess

Management :
• Incision & drainage : 2-3 cm below angle of mandible. To prevent marginal
mandibular nerve injury.
• IV antibiotics.

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----- Active space ----- Submandibular Space 00:40:31

Anatomy :

Sublingual compartment
Floor of mouth
Mylohyoid muscle
Submandibular space
Submaxillary compartment

Ludwig’s Angina :
Cellulitis of submandibular space.
Spread : Dental caries C/f
Raised floor of mouth, difficulty in speaking,
Premolar Sublingual
breathing & swallowing
Molar Submaxillary Brawny edema (B/L woody feel)

Management :
• Airway management : Tracheostomy.
• Fluid management.
• IV antibiotics.
• Incision & drainage : Incision b/w both
angles of mandible.
• Caries Mx. Brawny Edema

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PHARYNX : PART 2 ----- Active space -----

Nasopharynx 00:00:26

• Located behind nasal cavity.

• Extension : Base of skull Adenoid

Hard palate.

Torus tubarius
Opening of auditory
(Eustachian) tube
Hard palate Soft palate Uvula
Structures in Nasopharynx :
Structures Features
Posterior wall :
Adenoids • At the junction of roof & posterior wall.
Lateral wall :
• 1.25 cm behind inferior turbinate.
1. Eustachian tube
• Bounded postero-superiorly by torus tubarius.
• Behind torus tubarius.
2. Fossa of Rosenmuller
• M/c site of nasopharyngeal carcinoma.
Note : Sphenopalatine foramen.
• 1 cm behind posterior end of middle turbinate (Nasal cavity).
• Contents : Branches of maxillary artery & nerves.
Sensory supply (Main) : Maxillary nerve.
Arterial supply (Main) : Maxillary artery branches.
Visualization :
Posterior pharyngeal wall

Fossa of Rosenmuller

Eustachian tube

Torus tubarius

Nasal endoscopy : 1st pass Posterior rhinoscopy

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----- Active space ----- Clinical features of mass in nasopharynx :

• Nasal obstruction.
• ET obstruction Serous Otitis Media (SOM).
• Voice change : Rhinolalia clausa (Hyponasality).

Passavant Ridge :
Formed by : Superior constrictor & palatopharyngeus.
Action : Closure of nasopharyngeal isthmus by joining soft palate.
Clinical significance :
Incomplete closure Rhinolalia aperta.
(D/t paralysis of palate, cleft palate) (Hypernasality)

Adenoid Hypertrophy 00:07:22

• Component of Waldeyer’s ring.

• Present at birth Provides immunity.
Growth : ↑till 6-7 years, plateaus - 7-12 years,
Atrophies - >12 years.
Features : No capsule, vertical ridges Makes it appear
multiple.
Clinical Features :
Adenoid facies
• Nasal obstruction :
Chronic nasal obstruction Pinched nose (D/t nasal atrophy), absent
nasolabial folds.
• Rhinolalia clausa.
• ET obstruction Serous otitis media.
• Adenoid facies : Mouth breathing Open mouth, high arched palate, crowding
of teeth.
• Recurrent infection : D/t failure of passage of secretions.
Failure to thrive.
• Sleep apnea (In large adenoids).

Investigation :
Endoscopy : X-ray lateral view : Done in young children.

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Management : ----- Active space -----

Medical : Surgical :
• Steroid nasal sprays. Adenoidectomy + grommet
• Antibiotics : If infection + . insertion (If SOM + ).
Adenoidectomy :
Indications C/I
• Sleep apnea • Bleeding diathesis
• Chronic serous otitis media • Acute infection
• Recurrent infections (Sinusitis, • Velopharyngeal insufficiency (Cleft palate)
AOM) Post sx
Rhinolalia aperta, nasal regurgitation of food

Instruments : Position : Rose position

Cold methods : Hot methods :

Curettage Coblation

Extension at atlanto occipital

& cervicothoracic joints..
Blind curettage
Complication :
• Hemorrhage (M/c).
• Unmasking of velopharyngeal insufficiency.
• Grisel syndrome : Non- traumatic inflammatory
atlanto-axial subluxation.
- Neck stiffness.
- Torticollis. Paraspinal spasm
- Severe neck pain. d/t inflammation. Torticollis

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----- Active space ----- Angiofibroma 00:14:40

• M/c benign tumour of nasopharynx.

• Locally invasive.
Site of origin : Sphenopalatine foramen (Posterior nasal cavity).
Etiology :
Androgen stimulation
D/t incomplete regression of 1st arch artery Proliferation.
Pubertal male
Characteristics :
• No muscular coat.
• Well circumscribed.
• No capsule.

Clinical Features :
• U/L nasal obstruction.
• Recurrent epistaxis.
• Rhinolalia clausa.
• SOM d/t ET obstruction.
• Frog facies : Broadening of nose, swelling of cheek,
proptosis.
Frog facies
Spread :
• Sphenopalatine fossa.
Laterally Swelling of cheek.
• Infratemporal fossa.
• Proptosis : Superior spread.

Investigation :
• Endoscopy : Red fleshy mass.
• CECT : IOC.
• Biopsy & digital examination : C/I.
Nasal endoscopy

Nasal cavity
Holman Miller/antral sign (Anterior bowing
of posterior wall of maxillary sinus)
Maxillary sinus
Angiofibroma
Sphenopalatine foramen
CECT

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Staging : ----- Active space -----

a. Radkowski staging :
Ia : Limited to nose & nasopharynx.
I : Medial spread
Ib : Extension into one or more sinuses.
IIa : Minimal extension to sphenopalatine fossa (SPF).
II : Lateral spread IIb : Complete filling of SPF & spread to orbit.
IIc : Extension to infratemporal fossa (ITF).
IIIa : Minimal.
III : Intracranial spread
IIIb : Extensive.
b. Fisch classification.

Management :
• Surgical excision.
• Pre-op : Embolisation of maxillary artery (Main supply of angiofibroma).
• Radiotherapy : Unresectable (3b) tumour.
Recurrence : ↑↑

Nasopharyngeal Carcinoma 00:22:48

• M/c carcinoma of nasopharynx. Fossa of

• Type : Squamous cell. Rosenmuller
• Radiosensitive tumour.
Site of origin : Fossa of Rosenmuller
Etiology :
• Genetic : Southern China (AKA Guandong/Mongolians Ca).
• Virus : EBV.
• Exposure to :
- Nitrosamines : Preservatives in salted fish.
- Hydrocarbons : Wood & incense burning.

Clinical features :
• Painless cervical lymphadenopathy (70% cases).
- Retropharyngeal LN Upper deep cervical LN
(Level II) Posterior group LN (Level V).
• Nasal obstruction.
• U/L ET obstruction U/L SOM.
• Rhinolalia clausa. Cervical lymphadenopathy

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----- Active space ----- Spread :

Base of skull Sinus of Morgagni Parapharyngeal space

(Posterior compartment)
Trotter’s triad :
Cervical sympathetic
1. Mandibular neuralgia. chain
2. Palatal palsy.
Horner’s syndrome.
3. Conductive hearing loss d/t SOM.
Investigation :
Screening : EBV IgA viral capsid antigen (VCA), Early Antigen (EA).
Confirmatory : Nasal endoscopy + biopsy.
Treatment :
• Early stages : Radiotherapy.
• Late stages : Concurrent chemoradiation.
WHO Classification :
• Type I : Keratinizing SCC.
• Type II : Non keratinizing SCC.
- IIa : Differentiated.
- IIb : Undifferentiated (M/c in endemic areas, most aggressive,
most radiosensitive).
• Basaloid.

Oropharynx 00:28:10

Structures comprising oropharynx :

• Superiorly : Soft palate.
• Laterally : Tonsils.
• Inferiorly : Base of tongue, vallecula.
• Posteriorly : Posterior pharyngeal wall.
Sensory nerve supply : Glossopharyngeal nerve. Oropharynx

TONSILS : Stratified squamous

Embryology : non- keratinised epithelium
• Development : 2nd pharyngeal pouch.
- Crypta magna (Largest) : Remnant 1
Capsule
of 2nd pouch. 2
• Present at birth. 3
• Max size by 12 yrs.
Bed of tonsil
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Bed of Tonsil : ----- Active space -----

1. Peritonsillar space : Abscess Quinsy.
2. External palatine/paratonsillar vein : M/c site of hemorrhage following
tonsillectomy.
3. Superior constrictor muscle.
4. Parapharyngeal space : Divided by styloid process into 2 compartments.
• Styloglossus muscle.
Arterial Supply : Maxillary artery
Branches of external carotid artery (ECA).
Lingual Dorsal lingual branches. Descending palatine artery
Facial Tonsillar branch (Main). Tonsillar branches of
ECA Ascending palatine. ascending pharyngeal artery
Ascending pharyngeal Tonsillar branch. Ascending palatine artery
Tonsillar branch
Maxillary Descending palatine. Facial artery

Clinical significance : Lingual artery

Ligation
Lower pole (Main supply) ↓hemorrhage risk.
Lymphatic drainage :
Upper deep cervical (Tonsillar node).

Acute Tonsillitis 00:32:11

Etiology :
• Bacterial : Group A b- hemolytic streptococcus (M/c).
• Viral.
Types :

Pseudomembranous/
Acute catarrhal Follicular Parenchymatous
membranous

Appearance

• Invade parenchymal
Diffuse involvement of Pus/exudates Formed by fusion of
Features spaces.
tonsils & pharynx. in crypts. exudates.
• C/F : Sleep apnea.

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----- Active space ----- Management :

Tonsillectomy.
Membrane over Tonsils : D/D
Mnemonic : AL VITAMIN D.
• Agranulocytosis.
• Leukemia.
• Vincent’s angina/trench mouth.
- Acute necrotizing gingivitis.
- Causative organism : B. vincenti/F. fusiformis (Anaerobe).
• Infectious mononucleosis :
- Causative organism : EBV.
- C/F : Multiple B/L lymphadenopathy.
- Dx : Heterophile antibodies in Paul Bunnel/Monospot test, atypical
lymphocytosis.
• Trauma.
• Aphthous ulcer.
• Moniliasis (Candidiasis).
• Infection of throat.
• Neoplasia.
• Diphtheria.

Diphtheria 00:34:59

No h/o immunization.
C/F of membrane :
• Dirty grey membrane.
• Extends beyond tonsil.
• Tightly adherent Bleeds on removal.
Ix : Throat-swab microscopy C lub shaped gram
positive rods.
Membrane over tonsil
Rx :
• Antitoxin against diphtheria exotoxin (After sensitivity).
• Antibiotics : Beta-lactam, macrolides.
Complication :
• Respiratory obstruction, d/t membrane dislodgment.
• Myocarditis, arrhythmia.
• Peripheral neuritis Palatal palsy. Bull neck
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Tonsillectomy 00:36:15 ----- Active space -----

Position : Rose position.

Indication :
Indication Criteria
• >3/year for 3 consecutive years
Recurrent infections • >5/year for 2 consecutive years
• >7 in a single year
Non-infectious Obstructive symptoms (Sleep apnea)

Methods :
Cold method : Hot method :
• Dissection & snare (M/c). • Coblation.
• Microdebrider. • Laser.
• Cautery.

Microdebrider Coblation wand

Type of Tonsillectomy :
• Extracapsular (Tonsil & capsule removed) Infectious.
Indication
• Intracapsular (Part of tonsil removed) Obstructive.

Complication :
Hemorrhage (M/c) : Paratonsillar vein/external palatine vein.
Hemorrhage Characteristics Mx
10 During Sx 1. Removal of clots
2. Pressure with
• After Sx upto 24 hours gauze/cotton/pack
Reactionary • Due to slippage of ligature/ 3. Cauterize bleeders
dislodgement of clots 4. Ligate the vessel
• 24 hrs - 10 days
2 0
• D/t infection IV antibiotics
(M/c : 5-6 days)
Paratonsillar vein

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----- Active space ----- Instruments :

Tonsillar Anterior pillar

dissector retractor
Boyle Davis mouth gag Eves tonsillar snare :
To crush & cut the
lower tonsillar pole

Hypopharynx/Laryngopharynx 00:43:04

Components :

Pyriform fossa
Post cricoid
Posterior pharyngeal
wall

• M/c site of foreign body lodgement.

Pyriform fossa • M/c site of carcinoma of hypopharynx.
- Presents with cervical lymphadenopathy.
Post cricoid M/c site of carcinoma in Plummer-Vinson syndrome.

Nerve Supply :
Upper part : Internal laryngeal nerve.
• Runs in pyriform fossa.
• Referred pain to the ear.
Lower part : Recurrent laryngeal nerve.
Lymphatics :
• Pyriform fossa : Upper (II), middle deep cervical (III) LN.
• Hypopharynx : Level II, III, IV (Lower deep cervical LN).
Visualisation :
1. Indirect laryngoscopy.
2. Endoscopy.

Indirect laryngoscopy
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LARYNX : PART 1 ----- Active space -----

Anatomy of Larynx 00:00:40

DEVELOPMENT
Upper larynx Lower larynx
Develops from 4 arch : Hypobranchial eminence
th
6th arch
Nerve supply Superior Laryngeal Nerve (SLN) Recurrent Laryngeal Nerve (RLN)
Same arch derivatives Thyroid, epiglottis Cricoid

CARTILAGES

Paired (3) : Unpaired (3) :

• Arytenoid (Pyramidal)
• Corniculate (Santorini)
Epiglottis : Thyroid : Cricoid :
• Cuneiform (Wrisberg)
• Do not calcify • Largest • M/c site of stenosis
• Leaf shaped • Ala angle : • Signet ring shape
- Females : 120˚ (Only complete ring cartilage)
- Males : 90˚
Key : (Laryngeal prominence/
: Elastic cartilages. Adam’s apple)
: Hyaline cartilages (Mnemonic ACTh)
• Calcify later in life. Epiglottis
- Visible on X-ray.
- Can fracture on trauma.
Cuneiform
Arytenoid cartilage :
Corniculate
• Pyramidal : Apex and base.
Arytenoid
• 2 processes :
- Anterior process (Vocal process) : Thyroid
Attached to true vocal cords.
Cricoid
- Muscular process : D/t muscle
attachments.

Note : Nerve of Wrisberg Sensory part of facial nerve.

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----- Active space ----- Membranes 00:04:36

Intrinsic : Connect laryngeal cartilages with each other.

Extrinsic : Connect laryngeal cartilages to other structures.
Cartilage Structures Connected
Extrinsic
Hyoepiglottic Hyoid & epiglottis
Thyrohyoid Thyroid & hyoid
Cricotracheal Cricoid & trachea
Intrinsic
• Upper border : Aryepiglottic fold
Quadrangular (Arytenoid Epiglottis)
• Lower border : False vocal cords
Conus elasticus/Cricovocal • Cricoid & true vocal cords (Conical)
• Cricoid & thyroid
Cricothyroid membrane
(Anterior thickening of conus elasticus)

Parts of Larynx 00:07:00

Supraglottis Glottis Subglottis

Level Above true vocal cords True vocal cords Below true vocal cords
• Epiglottis, arytenoids
Anterior and
• Aryepiglottic folds
Structures posterior
• False vocal cords
commissure
• Ventricle
No lymphatics
• Upper deep cervical LN (II) Lower deep cervical LN
Lymphatic drainage (No lymphatic
• Middle deep cervical LN (III) (IV)
metastasis)
Stratified squamous
Lining epithelium Ciliated columnar Ciliated columnar
non-keratinized
Narrowest part in Narrowest part in
Features
adult children

Epiglottis
Anterior commissure
False vocal cord
True vocal cord
Ventricle
Posterior commissure Aryepiglottic fold

Endoscopy : Larynx
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Cavity : ----- Active space -----

Inlet/Epilarynx : Epiglottis, aryepiglottic fold and arytenoids.

Ventricle : Space b/w true and false Vocal Cords (VC) Quadrangular
membrane
Goes laterally to form saccule. Ventricle
Saccule
Cricovocal
Clinical significance : membrane
Laryngocele (Enlargement of saccule)
Pierces thyrohyoid
membrane

Extrinsic laryngocele
(External neck swelling)
• ↑Size on valsalva manoeuvre.
• Hissing sound on compression : Bryce sign.
External laryngocele

Spaces :
Pre-Epiglottic space/Space of Boyer : Space in front of epiglottis.
• Superior : Hyoepiglottic ligament.
• Anterior : Thyroid, thyrohyoid membrane.
• Posterior : Laryngeal surface of epiglottis.

Paraglottic space : Lateral glottis.

• Lateral : Thyroid alae.
• Medial : Quadrangular membrane, ventricle & conus elasticus.
• Posterior : Pyriform fossa mucosa (Separates from hypopharynx).

Reinke’s space : Submucosal space of true VC.

Pathologies :
• Edema : Reinke edema.
• Polyp
• Nodules

Note :
Above hyoepiglottic ligament Lingual surface.
Epiglottis
Below hyoepiglottic ligament Laryngeal surface.

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----- Active space ----- Muscles 00:15:17

Acting on inlet Act on true VC Tensors

Adduct : All except
• ↑Tension/pitch/length : Cricothyroid
• To open : Thyroepiglottis
• To close : Aryepiglottis Abduct : Posterior cricoarytenoid • ↓Tension/pitch/length : Vocalis
(Safety muscle) (Innermost part of thyroarytenoid)

c
• Only unpaired muscle : Interarytenoid.
• Only intrinsic muscle lying outside :
Cricothyroid.

Lateral

Note : Larynx in child vs. adults Muscles of larynx

Child Adult
• Children, higher up C2-C3. • Lies opposite to C3-C6 in adults.
• Epiglottis can meet soft palate when swallowing. • Epiglottis moves down Closes inlet.
• Can either swallow/breathe.
Milk goes into Air from nasopharynx
pyriform fossa goes to larynx
• They can suckle & breathe at same time.

Infections 00:22:04

Symptom Structure affected

Stridor :
1. Inspiratory 1. Supraglottis
2. Inspiratory/biphasic. 2. Glottis
3. Biphasic 3. Subglottis (Till cervical trachea)
4. Expiratory 4. Intrathoracic trachea till secondary bronchi
Wheeze Trachea below secondary bronchi
Speech affected Glottis (True VC)
Odynophagia/Drooling of saliva Epiglottis
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----- Active space -----

Laryngotracheobronchitis/
Epiglottis/Supraglottic laryngitis TB Larynx
Croup
Parainfluenza virus
Etiology Streptococcus : M/c Note : Starts in posterior part
(Mainly involves subglottis)
• Acute onset
• Fever, toxic look • Gradual onset
• Low grade fever
• Inspiratory stridor • Prodromal symptoms +
• Cough
Symptoms - ↑ : Supine • Hoarseness
• Weight loss
- ↓ : Leaning forward/Tripod • Barking cough
• Severe odynophagia
• Odynophagia, drooling of saliva • Inspiratory/biphasic stridor
• Normal cry
Thumb sign Steeple sign • Hyperemia & edema of VC &
posterior commissure
• Mammilated arytenoids
• Mouse nibbled VC
(Multiple ulcers)
• Turban epiglottis
(Pseudoedema)
Ix

X-Ray lateral view X-ray AP view

C/I investigation :
Indirect laryngoscopy
(Laryngeal spasm)
• Secure airway :
Intubation (1st choice)
• Steroids
• IV antibiotics
Mx • Adrenaline nebulisation ATT
• IV fluids
• IV fluids
• Steroids
• Adrenaline nebulisation

Congenital Conditions 00:31:44

M/c : Laryngomalacia > Vocal cord palsy > Subglottic stenosis.

Laryngomalacia/Congenital Laryngeal Stridor :

Symptoms :
• Inspiratory stridor at/shortly after birth Supine : ↑; Prone : Disappears.
• No signs of distress or cyanosis.
• Cry : Normal.

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----- Active space ----- Examination :

• Elongated, large omega shaped epiglottis.
• Short, floppy aryepiglottic folds.
• Prominent arytenoids.
• Excessive redundant tissue in supraglottis.

Management :
Omega shaped epiglottis
Reassurance (Disappears by 2 years).

Subglottic Stenosis :
Types : Examination :
1. Congenital : Subglottic diameter Rigid endoscopy : Stenosis +
- Full term : <4 mm.
- Preterm : <3 mm.
2. Acquired : Prolonged intubation.
(Cuff Pressure necrosis of glottis)

Symptoms :
Biphasic stridor.

Myer-Cotton grading of subglottic stenosis :

Endoscopic
Classification From To Mx
appearance

Grade I None required

No obstruction 50% Obstruction
Early Late

Grade II Balloon Cricoid splitting + Graft placement

dilatation (Anterior & posterior) f/b stenting.
51% 70%

• Early : Same as for grade II

Grade III • Late : Same as for grade II
• Severe : Same as for grade IV
71% 99%
• Cricotracheal resection + End to end
anastomosis.
Grade IV No detectable lumen
• Adjuvant : Mitomycin C (↓Fibrosis).
• Montgomery T-tube insertion (Stenting).

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----- Active space -----

Montgomery T-tube

Juvenile Laryngeal/Recurrent Respiratory Papillomatosis :

Etiology :
• Low malignant potential HPV : 6 and 11 (More virulent).
• Via birth canal (H/o vaginal delivery)
• Starts at squamo-columnar junction (True vocal cords).
↑Papilloma size
Symptoms : Hoarseness Stridor.
(Months later)
Management :
• Microlaryngeal excision : Microdebrider (TOC) > CO2 laser.
Laryngeal Papillomatosis
• To ↓ recurrence :
- α interferon (Immunomodulator) - Cidofovir (Intralesional)
- Bevacizumab
• Tracheotomy is C/I (Intubation preferred).

Structural Disorders of Glottis 00:42:30

Muscle tension disorder

Note : Disorders of glottis
Psychogenic

Vocal cord nodules Reinke’s edema/

Vocal cord polyp Pseudosulcus
(Teacher’s/Singer’s nodules) Smoker’s larynx
Lesion :
Lesion :
• Bilateral • H/o laryngopharyngeal
• Solitary • Bilateral
Features • <3 mm efflux
• Pedunculated • Symmetrical edema
• Sessile • Infraglottic edema
• Large size
• Symmetrical
Site Junction of anterior 1/3rd & posterior 2/3rd Whole length of VC Vocal cords
• Smoking cessation
Excised by MLS
• Voice rest • Voice therapy
Mx (Microlaryngeal -
• Speech therapy • Reduction
surgery)
glottoplasty

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Vocal cord nodules

Reinke’s edema/
(Teacher’s/ Vocal cord polyp Pseudosulcus
Smoker’s larynx
Singer’s nodules)

Imaging

Procedures in Larynx : Instruments & Position 00:45:20

Instruments :

Indirect laryngoscope Flexible Rigid Stroboscope

endoscope endoscope • Visualization of mucosal
wave of VC in slow motion.
• Detects small lesions of VC.
Boyce Position :
• AKA Chevalier Jackson/Barking dog/Sniffing morning air position.
• Flexion at cervical spine & extension at atlanto-occipital joint.
• Used in MLS & direct laryngoscopy (Intubation).

Note :
Pillow placed
Boyce position Rose position (Extension at cervico-thoracic joint).
below shoulders

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Functional Disorders of Glottis 00:48:20 ----- Active space -----

Hysterical/ Puberphonia/ Dysphonia plica

Functional aphonia Mutational falsetto ventricularis
• Female
• Adult male • Low pitch
Presentation • Following stressful episode
• High pitch voice • Rough voice
• Only whispers
Gutzmann’s pressure test :
Press larynx
• Speech : No adduction of VC Voice produced
O/E
• Cough : Normal adduction of VC ↓VC function by false VC

Low pitch voice

Mx Psychotherapy & reassurance Type III thyroplasty

Note :
Spasmodic dysphonia :
• Neuromuscular disorder.
• Spasm of vocal muscles during speech with focal dysphonia.
• Mx : Botulinum toxin injection.
Mx :
Voice
Botulinum toxin injection to
Adductor spasm (M/c) Strained Thyroarytenoid
Abductor spasm Breathy, whispery Posterior cricoarytenoid

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----- Active space ----- LARYNX : PART 2

Nerve Supply of Larynx 00:00:19

Vagus

At base of skull
1. Superior laryngeal nerve (SLN) 2. Recurrent laryngeal nerve (RLN)

At greater cornu of hyoid

Right Left
Internal branch (ILN) External branch (ELN) (Winds around (Winds around
Rt. subclavian A.) arch of aorta)
Pierces thyrohyoid Motor supply : Cricothyroid
membrane • Tensor & adductor
Enters larynx • Intrinsic muscle Enters tracheoesophageal groove
Sensory supply above
Enters larynx behind cricothyroid joints
vocal cord (VC)
(Supraglottis)
Sensory supply : Motor supply :
Superior ganglion of vagus Below true VC All muscles except
Jugular foramen (Glottis, subglottis) cricothyroid.

Inferior ganglion of vagus

Applied aspect :
Vagus nerve
Biopsy above VC :
Superior laryngeal nerve
Anesthetize at
Internal branch thyrohyoid membrane.
External branch
Vagus nerve
Inferior thyroid artery
Right recurrent laryngeal nerve
ILN anesthesia
Subclavian artery
Left recurrent laryngeal nerve
Arch of aorta

Nerve supply to larynx

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NERVE INJURY : ----- Active space -----

M/C RLN affected : Left RLN (Longer course).
M/C cause of b/L RLN palsy : Surgical trauma (M/c : Total thyroidectomy).

SLN Injury :
Symptoms
ILN Aspiration
ELN Inability to ↑pitch

Vocal Cord Palsy :

Vocal cord palsy

Complete/adductor palsy Incomplete/abductor

(SLN + RLN palsy) (RLN palsy)

Cricothyroid (Adductor) : Intact

Cadaveric/intermediate position Median/paramedian position

(3.5 mm from midline) (1.5 mm from midline)

C/F :
U/L incomplete palsy B/L incomplete palsy U/L complete palsy B/L complete palsy
Speech Normal/hoarseness Normal Aphonia
Respiration Normal Stridor Normal
Aspiration - - Occasional Chronic
Cough Normal Ineffective -
Aphonia + chronic
Aphonia + aspiration
Overall
Asymptomatic Stridor Occasional
presentation
aspiration Recurrent chest
infections
• Tracheostomy :
Immediate
• Type 1
• Lateralisation of VC
thyroplasty
- Woodman’s :
• Medialization
Management - cordectomy + -
of VC : Injection
arytenoidectomy
of teflon, fat,
- Kashima : Posterior
hydroxyapatite
cordectomy
Type 11 thyroplasty

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----- Active space ----- Surgical Trauma :

Site of injury Nerve injured
Base of skull Complete vagus/SLN
Carotid triangle ILN/ELN/SLN
Upper pole of thyroid ELN (M/c injuried in thyroid Sx)
Lower pole of thyroid RLN (2nd m/c injured in thyroid Sx, Rt > Lt)
Left RLN
Mediastinal (Note : Also involved in Ortner’s/cardiovocal
syndrome)
: Carotid triangle
Treatment of VC Palsy :
Mnemonic : Plasty.
Isshiki’s thyroplasty

Thyroid cartilage Thyroid cartilage

pushed medially pulled laterally

Type I : Medialisation (Proximalisation) Type II : Lateralisation

Indication : U/L complete/adductor palsy Indication : B/L RLN palsy

Part of thyroid
cartilage cut
Rest of thyroid Vocal cord : Shortens
ala is sutured Type IV : Tightening (Tensing)
Relaxes
Indication : Androphonia
Pitch of voice ↓
Type III : Shortening
Indications : Puberphonia

Note :
Laryngeal inlet : Epiglottis + arytenoid.
• Component : ILN (Injury Absence of cough reflex).

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Carcinoma Larynx 00:23:15 ----- Active space -----

Squamous cell Ca.

M/c in males, smokers.
Clinical Features :
Glottic Ca : M/c Site Supraglottic Ca
Referred pain to the ear (via vagus nerve).
Presentation
Hoarseness : Earliest Dysphagia
Lymphatic • Maximum (Upper, middle deep cervical)
Least
metastasis • B/L : Epiglottic Ca
Prognosis Best -
Investigation :
• MRI : IOC for cartilage erosion.
• CT.
TNM Staging :
Stage Extent Management
• Limited to one site (Glottis/subglottis) or one
subsite of supraglottis
T1 • VC : N
T1a One VC involved TLM
T1b Both VC involved TLM/RT
2 adjacent sites/Subsites involved
T2 T2a Both VC mobile TLM/RT
T2b Impaired mobility of VC
• Fixed VC
Concurrent
T3 • Involvement of pre epiglottic space/para glottic chemoradiation
space/post cricoid/inner cortex of thyroid.
Local invasion :
Anteriorly : T hyroid cartilage/thyroid
gland/strap muscles Total laryngectomy
T4 T4a Superiorly : Tongue muscle + adjuvant RT
Inferiorly : Trachea
Posteriorly : Esophagus
Unresectable Palliative
T4b
(Pre vertebral space/carotid sheath/Mediastinum) management
RT : Radiotherapy, TLM : Transoral laser microsurgery
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Thyroid catilage
----- Active space -----

Lumen of larynx

Arytenoid

CT : T4a stage

Rehabilitation Following Laryngectomy :

1. Permanent tracheostome :
• Trachea is pulled to an external opening.
• Done following total laryngectomy.

2. Speech Rehabilitation :
a. Oesophageal speech :
Regurgitation of swallowed air Vibration of
pharyngoesophageal segment. Permanent tracheostome

b. Tracheo-oesophageal speech : Best.

Blomsinger valve placed on trachea
b/w trachea & pharynx.

Closure of trachestome opening Produces sound.

Electrolarynx
c. Electrolarynx : External vibration Speech.
3. Heat & moisture exchanger :
Temperature regulation
Placed at the opening.
Humidification of air

Heat & moisture exchanger

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4.Olfactory rehabilitation : Polite yawning. ----- Active space -----

• Nasal airflow-inducing manoeuvre.

Note :
Super-supraglottic swallowing :
• Method for swallowing.
• Indication : Dysphagia + aspiration.

Standard tracheostomy

Newer Techniques in Laryngeal Endoscopy 00:33:56

Contact Endoscopy :
• Lesion stained with Lugol’s iodine/methylene blue
(Supravital stain)

Visualized with Hopkin’s endoscope

(Magnification : 60-120 times).
• First 3 layers of epithelium visualized : Contact endoscopy
- Cytological features.
Determines benign/malignant.
- Microvasculature.

Autofluorescence :
• Helps to identify benign/malignant :
Normal mucosa : Green fluorescence (Specific wavelength absorbed).
Light
Neoplastic mucosa : Red-violet fluorescence.

Narrow Band Imaging :

Filtered light Visualization of neo-angiogenic features.

Longitudinal
vessels : Benign

Pin- shaped :
Longitudinal vessels Malignancy +
Reinke edema

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----- Active space ----- Tracheostomy 00:40:20

Indications :
Mnemonic : Occupy Most Seats in Medical Association.
• Obstruction : Above T2-T4.
• Mechanical Ventilation : M/c indication for elective tracheostomy.
• Secretion removal/pulmonary toilet (In coma, or chest injury).
• Maxillofacial, head and neck surgeries.
• Prevent aspiration (B/L complete VC palsy).
Position :
Rose’s position : Extension at cervico-thoracic and atlanto-occipital joint.
Incision :
Thyroid cartilage
Emergency Elective Thyroid gland
Types of incisions
Vertical incision : From Horizontal incision/Skin
Trachea
lower border of cricoid crease incision : 2.5 cm
to suprasternal notch above suprasternal notch Types of skin incisions

Tracheal incision : 2, 3, 4 tracheal rings.

High tracheostomy : Incision at T1.
• Complication : Laryngeal stenosis.
• Indication : Ca larynx. Incision in trachea
Trachea
Retractor
Bjork flap Thyroid isthmus
Tracheostomy Tube :
• High volume, low pressure.
• For air tight seal.
Tube block :
• C/f of complete block : Stridor.
• Prevention : Saline/sodium bicarbonate suction.
• Management : Change tracheostomy tube.
Portex cuffed tube

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Foreign Body 00:45:14 ----- Active space -----

Age : 1-4 (M/c).

M/c foreign body : Nuts & peanuts.
Symptoms :
• Sudden onset paroxysmal coughing/ • Hoarseness, stridor.
choking/gagging : Earliest. • Hemoptysis.
Management :
First aid :

1. No respiratory distress, speaks 2. Conscious + universal choking sign :

Inability to speak, breathe, cough
• Encourage coughing
• Back blows Heimlich manoeuvre : Sudden
thrust just below sternum
↑intrathoracic pressure

Back blows
Heimlich manoeuvre

Contraindication of Heimlich maneuver :

• Age <1 yr.
• Unconscious.
• Pregnancy & obese Chest thrust.
3. Visible foreign body : Finger sweep method. Cricothyroid
Definitive : membrane
First aid fails Cricothyrotomy (Cricothyroid
membrane)/coniotomy/Inferior laryngotomy/ Cricothyrotomy
minitracheostomy Rigid bronchoscopy (Foreign
body removal).

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----- Active space ----- Investigation :

AP view Lateral view

Rim
Laryngeal
foreign body Round

Airway

Esophageal Rim
foreign body Round
Airway

M/c site of foreign body in esophagus : At or just below cricopharyngeal sphincter.

Button battery :

Double density/
halo appearance Bi- levelled +
Step- off at the
edge
AP view Lateral view

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