1, h{ISTCIRY AND EXAMINATION

HISTORY
Name, age, sex, religion, occupation, address.
Chief cornplaints :
o Discharoe
/, from the ear / Otorrhoea
o Decrease in hearing / Deafness
o Pain in the ear / Otalgia
o Giddiness / Vertigo -
o Noise in the ear / Tinnitus
o lnability to close the eyes, mouth deviation etc. / Facial palsy.
: lt is preferable to present only two of the above complaints as chief complaints followed by their
. (Notei.e.,
ODP Onset, Duration, Progress and then details of the rest of the complaints.)

ODP (Onset, Duration, Progress)

COMPLAINT ODP (Onset, Duration, Progress)

Otorrhoea ,/ o Unilateral / bilateral / state the side

o Type - serous, serosanguinous, mucoid, mucopurulent, purulent, watery, blood
c Foul smelling / not
o Copious / moderate / scanty
o Continuous / interrnittent
o Associated with pain / decrease in hearing / respiratory tract infection
o Any aggravating / relieving factors - medications / ear drops,.'ear drops reiachilglfre throat or ndt,
Deafness :r o Unilateral / bilateral
o D_,e-gree of hearing loss - cannot hear whispers / spoken speech / doorbell / loud sounds
o .Onset - sudden / gradual
o Duration
o Progress . rapid / slow
o J|Up_!qq!'! / constant
o Associated with discharge / pain / tinnilus / fullness
o _Affecting routine work / not.
Otalgia Unilateral / bilateral
c Typg 9f pain-dull aching / throbbing
t lntensity-rnild / moderate / severe
o Affecting routine work / sleep
Necessitates medication
with upper respiratory tract infection
Asgqqia't.-e-d

[5r]!eving / aggravating factors

- Relieved with discharge
- netlevEO witf' ear Orops / medication
Vertigo o Onset-sudden/gradual
a Type-rotatory / swaying / tilting
 ClinicalENT

ODP (Onset, Duration, progress)

Positional element present or not
Gait disturbances present or not
Fluctuant / constant
Associated symptoms
- Vomiting
- Sweating
- Hearing loss (Meniere's disease)
- Tinnitus
- Blackouts
- Tullio's phenomenon (Meniere's disease)
- Nystagmus.
lmbalance while walking
- Precipitatingfactors
- Sneezing
-
Change in position of head
Tinnitus o Unilateral / bilateral
. Onset
o Duration
. Type
- Continuous / intermittent
- Low pitched / high pitched
- Fluctuant / constant
- Rhythmic / pounding / roaring t dull I humming
Trigerring factors : mental or physical stress
- Pr,eslangLl.ltengllqqliol
- Alcoh-olism
- _Expos1.1qg -to e-xcessive nois-e t
- f,?y.ry"
- Associated with ear discharge / fullness in ear. I
Facial Palsy . Change in facial contour
o lnability to close eye t
o Dribbling of saliva from one side
o Difficulty in blowing cheeks and chewing food. I
o lnability to whisfle.
o -Decreaseg.l o!'fg9.u-Piol- ',i'{:'i.unu i.Ft,rrr"',, li*.L',r,r" ilr.lr;,; \
o $e!1es9 / itching { wgtering of eyes I
o Characteristic of tne paisy * -- "

I
- Slow fsudden onset I
- lncomplete / complete palsy a
- Hlo concurrent or preceeding upper iespiratory tract infection with the parsy. t
- Hlo pain or numbness around the ear
- H/o surgical intervention / trauma to the nerve. I
4
t
Positive / Negative history
o H/o post-aural swelling associated with fever or headache (mastoid abscess). e
o H/o fever, vomiting, unconsciousness, headache, visual disturbances, speech problems (intra-cranial
complications). t-
te
z
I

a
lr
r^ Section I Case Presentation - Ear

rr
rr,'r.t

T.
"7 ).16,
-
',-t"Hlo trauma, exposure to excessive noise, use of ototoxic drugs etc.
o H/o nasal blockage / recurrent attacks of rhinitis. }-rri i " 'i"',i:'' \
o H/o odynophagia, fever / recurrent upper respiratory tract infections
o H/o any other nose / throat complaints.

E o
o
,.r
H/o tuberculosis / tuberculous contact, blood pressure, diabetes.
Hio asthma, allergy or sexually transmitted diseases.
r-'.* 'l'f i | ' . , r / i .i , ". ' t

F
H!9 otological / any major surgery / !l!n"qs (mql1!ng,!!is) !1 !!.re pagt. Q .':.
", '
Past history
o H/o any similar complaints in the past.
o

tr
H/o any major surgery or illness in the past.
Personal history

H
o Bowel / bladder habits

rn
o T.B. lB.P. lD.M. /,,ffi,
o Socio-economic status.
Family history

n
o Similiar complaints in the family
o

rr
Hearing loss
o Ear operations
o T.B. / B,p. / D.M.

rn
GENERAL EXAMINATION
o Patient is conscious, co-operative and well oriented in time, space and person.
o General condition : - Built and nourishment
-

r
Afebrile or not
o Pallor
o Oedema

rr
o Cyanclsis

]' o Clubbing
o Jugular venous pressure
o Lymphadenopathy

rr
:

- Cervical
- Axillary
- lnguinal

r Respiratory System
o Air entry : - Bilaterally equal / not
Rales / rhonchi / foreign sounds.

F
Central Nervous System
o Consciousness, orientation in time, space and person.

rr o Craniallervgq I !o_XII
o Muscle pgwer
o Reflexes.

n r Cardiovascular Systgm
o Heart sounds - firsta and second
o Apex beat

r-
 t
ClinicalENT
|6\
\
Gastrointestinal System fr
o Hepatosplenomegaly
o Ascites h
LOCAL EXAMINATION h
o Pre auricular region
o Pinna
\
.F

r Post auricular region l.

o External auditory canal
o Tympanic membrane E
o Mastoid region
a
Tuning fork tests
o Rinne's test with 256, 512 and 1024 Hz tuning fork t
o Weber's test ir
o Absolute bone conduction test
p Nystagmus t

\ Fistula sign t
l
J Facial nerve t
I
{ Tests for eustachian tube patency
t
Seigalization
Tests for balance I
o Rhomberg's test - \ . .. ro,t .

o Urtenburger's test t r "'r' ' t

Exariination of the eYes t
o lnspection
o Nystagmus
t
r.-r'Corneal reflex t
NOSE t
External examination
External deviation, bridge of the nose, scars, sinuses etc.
t

Anterior rhinoscopy t
o Septum : Deviation, spurs, perforation
o Mucosa : Congestion, atrophy, secretions. \
o Turbinates : HypertroPhY, atroPhY i
t

PosteriorrhinoscoPY !i ,. a qt^.t..
ct\L\r'':-' t
o Secretions
o Adenoids
o Eustachian tube area
ari:o Tenderness over paranasal sinuses. lr

THROAT t
o Oral cavity : Teeth, tongue, buccal mucosa.
I
t
r^
Section I
-
Case Presentation - Ear

r o
o
Oropharynx : Tonsil, tonsillar pillars, posterior
lndirect laryngoscopy. tqi l.'r'.'
!' ! ;1"1.i-.
pharyngeal wall'

I DIAGNOSIS
t: Right / left, inactive / active, chronic suppulalive.,gtitis. 130|1,
/ mixed / sensorineural hearing loss with / without intracranial
with mild / moderate / severe conductive
complications with nose / throat
t: complaints, if any (e.g. with deviated n"""r ="ft,.
to the left and mild granular pharyngitis)'

r:
r: INITIAL PARTICULARS
rr PARTICULARS

NAME (Full name

IMPORTANCE

Gives identitY to a Person. lt

COMMENTS COMMENTS

the
with middle name and may helP in identifYing
r. surname)
AGE
unknown religion.
Certain diseases are related Children Elderly

r" to certain age groups. o

r
Bilateral ear diseases 9-'Carcinomas
o Bone conduction

r:
Glue ear
r Tonsilloadenitis decreases after the age of
50 Years
T" !, Sensorineural hearing loss

I: o
o
is prbsent in elderlY
Diabetes
Hvpertension .. ;i;,,'
T"
I: JEX Certain diseases are common Males
in a particular sex. r" Meneire's disease.
Females
o' Otosclerosis

n e-'Carcinomas o Goitre
o Postcricoid
o Plummer Vinson sYndrome
r ! - TemPoral arteritis
r: During menstruation
o lncrease.iri d-eafnes-s can
r occur

I- I

o
o Tinnitus may occur.
PregnancY
Deafness maY occur
r_
I
I

n
I following the PregnancY

Certain diseases are common

I:
RELIGION

rI_
in cnmo rqcoq / relioion
Noise Hay / garden Pollen can lead
OCCUPATICN Occupational hazards
Noise induced hearing loss / to:
occupational deafness- is seen o Allergic rhinitis
in: o Nasal PolYPosis

n
o Smoke / air Pollution can
r makers
Boiler
o Black smiths cause :

n I Rivglgs. o Asthma
-Pathological effect is due to : o Carcinoma nasoPharYnx

l-
n
 ClinicalENT

PARTICULARS IMPORTANCE

o Constant vibrations Farmers can get :

o Loud and continuous noise r Rhinosporidiosis.

Changes in air pressure :
e Divers
o Mountaineers.
o Full postal address is Goitre is seen in :
necessary. "
Sahyadri range
o Essential for follow-up tnagiri district
o Certain diseases are
common in certain areas

OTTORHOEA
It means discharge from the ear.

TYPES CHARACTERISTIC CONDITIONS COMMENTS

Serous Like serum Seborrhoeic otitis externa.
Serosanguinous Serum + blood tinged Seborrhoeic otitis externa.
Mucoid Mucin threads seen on Secretory otitis media (with Mucoid discharge. is, always
sucking the discharge through perforation). from the middle ear as middle
a suction cannula. Otitis media ear lining consists of goblet
o Acute cells, which secrete mucin.
o Chronic
Mucopurulent Mucoid discharge + pus Otitis media
o Acute
. Chronic
Purulent Pus-like.fipus cell is a dead Otitis media S Purulent non mucoid
lymphocytej lt is yellow in o Acute discharge is characte-ristic of
colour and may have a foul o Chronic:- Safe chronic osteitis without
smell. - Unsafe cholesteatoma
Watery Clear like water. . CSF otorrhoea is seen in Confirmatory tests for CSF
:
:

- Trauma * 'l Glucose estlqrg_tiqir >30

- Temporal bone fractures ru4qr in lfe lluio Y
- lntraoperative damage 1; 2. lmmunoelectrophor:esis of
. Eczematous otitis externa the fluid : B_2 tr_an-s-f*errin
band is present ., . , .,.
i
S lglg r,_g.!_: Halo around .
dried CSF on kerchief.
Blood Actual blood. t Trauma
o polyp
- External ear I

Middle ear
I
I Acute otitis media t
o Foreign body
a
t
t
I

I
?^
91, $:g'"** *,. i'HH,nff
Section I Case Presentation - Ear
-
CHARACTERISTIC CONDITIONS COMMENTS

o Tuberculosis
o Granular mvringitis
.. Malignant otitis externa.
r Vascular anomalies i '''
Other characteristics
o Foul smell Fishy odour., Chronic suppurative otitis Organisms responsible for the
media-unsafe variety odour :

o Anaerobes -
o Peptostreptococci
o Bacteroidesfusiformis
o .Bacteroidesfragilis
o Bacteroides melanogenicus

n
rn
o Saprophyticorganisms.
o Copious quantity RESERVOIR SIGN : Reservoir sion is oositive in
,-€-s :

Discharge filling the concha Coalescent mastoiditis.

and reappearing on wiping it Ooerated radical mastoid

rt: o Scanty discharge

cgyjjljllj! :econdary
infection.
Chronic suppurative otitis
media - unsafe variety

rI:
l- causes of otorrhoea
Causes ororrnoea :

IA
EXTERNAL EAR MIDDLE EAR INNER EAR MISCELLANEOUS

.) Localised otitis externa (furunculosis) r Acute otitis hds

media c/ Suppur?tive I Parotid absoess rupturing into

rI:
'!
o Generalised otitis externa r Chronic otitis media labvrinthitis
,".l"+
ear
o Seborrhoeic otitis externa o- Tumours .,'in o Temporomaqdibular
'/ joint
o Eczematous otitis externa abscess ru$ture

rI-
'o Bacterial / viral otitis externa 1

o Otomycosis
o Foreign body with secondary infection

r- DEAFNESS
1- Defrnr.on
lt is the term commonly used to indicate a change in hearing acuity.
l-
I ^ Deafness : Total loss of hearing function
Hearing loss: Partial loss / partial hypoacusis
f
TvDes:
I- t. ConAuctive deafness : Defect in the conducting mechanism of the external and/or middle ear.
2. Sensorineural deafness : Due to lesions in the labyrinth, eight nerve and the cochlea.
l-

r:
I

1--
3. Mixed deafness : Both conductive and sensorineural components are present.

t-
r"
 Clinical ENT
a
\
Difference between conductive and sensorineural deafness : (also on pg 10)
tt
DEAFNESS CONDUCTIVE SENSORINEURAL

External ear and middle ear lnner ear, eight nerve and central connections lta
Site of lesion
2. Rinne tesl Bone conduction better than air Air conduction better than bone conduction
conduction
;
3 Weber test Lateralised to the worse ear. Lateralised to the better ear. h
4. Audiological tests Bone conduction better than air Air conduction similar to bone conduction
conduction t
5. Hearing loss Not more than 60d8. May be more than 60d8.
6. Speech Speaks in. a low voice. _S_peakS_ tqudly. h
Speech discrimination Good fQor.
8.) Recruitment Absent Present in cochlear deafness
:
9 Paracusis willisi Present in otosclerosis Absent
a

Causes of deafness L
A. Conductive deafness
a
l External ear :
- t,.
o Wax" o Myringitis t
o Otomycosis o , Stenosis.
I
o Oiitis externa o Atresia t
o Foreign body o Tumours.
I
2. Middle ear :

r Cqnggnital defects of the eardrum and ossicles. I

o fJlammatory :
- Otitis media : acute / chronic - Tuberculous otitis media
t
- $ecretory otitis media - Syphilitic otitis media t-
- Adhesive otitis media
o Traumatic t-
- 9arotrauma - Ossicular discontinuitY
t
I

- Rupture of eardrum - Fracture of skull base

a
- Haemotympanum i
o Others I
- Eustachian catarrh t
- Eustachian tube dYsfunction. \ A

B. Sensorineural deafness a
I
o Causes of sensorineural deafness :

le
ASYMMETRICAL t
1. Trauma 1 [eapon firing / exPlosion
- 2. t{ead injurY ,- t
_Head injurY u'
- ta
_ Blast injury L
- Surgical damage r-
2. Vestibular schwannom :
3. Mumps
t

t
I
n Section I
-
Case Presentation - Ear

C. Mixed hearing loss

I

>-'Chronic suppurative otitis media (toxins)

'o--Otosclerosis (abnormal mechanics of sound transmission)

D. Fluctuant hearing loss

Causes of fluctuant hearing loss
CONDI,ICTIVE SENSORINEURAL
1. Upper respiratory tract infection ,1<- Syphilitic labyrinthitis
2. Eustachian tube dysfunction 2' Meneire's disease
3. Otitis media with effusion &: Lermoyez's disease
4. Perilymph fistula
Change in hearing loss associated with background noise is seen in patients on :
. 4m!_oglycosides
o Loop diuretics
o Quinine
E. Sudden deafness
Causes of sudden deafness :
'c-]{ascutT dlsease o _.\{e4rlgitis
'o--Viral disease I Mumps o Acoustic neuroma
.r' Perilymph fistula
F. Sudden and fluctuant deafness
Causes of sudden and fluctuant deafness :

RETROCOCHLEAR (Vil) N AND CNS

lnflammatory Vascular r _-M91!!silq
o fu1ute otitis media o Hypertension o Multiple sclerosis
' TYPhoid o -Hypercoagulability c :\coqq!!c neuroma
o SYPhilis Haematological . Alzeihmer's disease
Viral o Polycythaemia
o l\4umps o . Sickle cell disease
. Measles o Thalassaemia
o Rubeola Autoimmune disease
o Infectious mononucleosis o Systemic lupus erythematosus
O HIV o _Wegener's granulomatosis
Traumatic Metabolic disease
o Electricity o Renal failure /
latrogenic o Diabetes mellitus .
o Radiotherapy o Hypothyroidism
o Post operative L,-L,,. --t.. -t /

Common medical illnesses causing hearing loss

L. :

{ o Meningitis
I Cerebral malaria
o MUmpS
o Measles
 10 Clinical ENT

Difference between conductive and sensorineural deafness :

CONDUCTIVE SENSORINEURAL
Site of pathology External and middle ear lnner ear. and Vlll nerve
Tuning fork tests
1. Rinne test y Normal --------------\ n Reduced / nil ---'- -:*--.--
2. Weber test Lateralised to worse ear Lateralised to better ear \
3. Absolute bone conduc\ Negative Positive (not heard in severe cases)
tion test
Audiological tests
1. Pure tone audiometry Air-bone gap present No air-bone gap
Both air and bone conduction are reduced
2. lmpedance audiometry

3. Bekesy audiometry Type I

I-v q e 1,.: 9 _o"_cl'1g.q r.p.e" q!1
-e.s.q
Type tll./ fV ; Neupl deafness
4. Recruitment Absent Present in cochlear deafness
Absent in nerve deafness
5. StSt Low score 0-20% High score 0-60% in cochlear deafness
0-20% score in nerve deafness.

lmportant points :
+ r Conversation in a quiet environment is conducted at 40dB
+ . Tqlgplplic, convers_qlJon is at 40-70dB in the frequency range'of 200- 1Z00Hz.
o Following decibels indicate the noise levels created by I
Automobiles-trains /

B5-115d8 for oatient

140d8 in EAC
Fire crackers

o Servicaeble hearing :

Definition: An average loss of 40dB or better over the speech frequencies 500, 1000 and 2000H2.
Hearing reaches a serviceable level in
B0% - Type I and Type II ossicular reconstruction
40% - Type III
15% - Type IV f!' '.

rt o Paracusis willisii The phenomenon in which a person with a conductive hearing loss hears better in a
noisy environment is termed as Paracusis willisii. lt is seen in Otosclerosis. ln
sensorineural hearing loss, there is decreased discrimination of speech in
background noise and it is not helped if the speaker raises the intensity of voice
Reasons for this phenomenon :
1. Reduction of masking effect of the background noise
2. lncrease in intensity of voice of the speaker
 Sectionl-CasePresentatiOn-Ear ,.,! rr \.i{. .i,i: . ,.. j, 11

a Recruitment of loudness is a characteristic of cochlear hearing loss

a Poor-speech discrimination without recruitment sugEests auditory nerve lesion
a Diplag_uslsis an apparent difference in the pitch of a tone between the two ears and is associated with
9o1d1t1ons causllg endo!ymphatlc hy$1op5
r Autophony . lt is abnormal perception of one's own breadth and voice sounds and is associated with a
permanently open or patulous eustachian tube
o Social noise trauma includes
- Pop music
- Rifle shooting
- Motor racing

CONGENITAL DEAFNESS
Congenital deafness suggests deafness due to hereditary or genetic causes.

Classification :
Classifrcation of genetic deafness / herediiary deafness
l. According to causes : ll. According to type
1. Genetic 1,. Conductive
a. Syndromic 2. Sensorineural
b. Non-syndromic 3. tVixed
c. Mitochondrial disorders 4. Non-organic
d. Chromosomal disorders
2. Non-genetic
CONDUCTIVE DEAFNESS
-Causes of congenital conductive deafness :

APPEARING IN PREDISPOSITION TO OTITIS

AT BIRTH MISCELLANEOUS
CHILDHOOD MEDIA WITH EFFUSION

a{
o Down's syndrome Osteogenesis imper-fecta ,r-- Cy9!9 f!"Qrcts!s_ lsolated malformations
o Crouzon's syndrome Otosclerosis '9. lmmotile cilia syndrome Congenital cholesteatoma
i Marfan's syndrome r-. Cleft palate Rhabdomyosarcoma
o Treaclier Collin's o lmmune deficiency states Fibrous dysplasia
syndrome

lsolated malformations : Mqrquet's classification into two types / Cremmer's, Oudenhoven and Marres into
three types
TYPE I : Failure of canalization of external auditory canal
Small external auditory canal, atreiic laterally
Normal I near normal auricle
Small tympanic membrane
TYPE II : Largest group of ear deformities
Rudimentary tag instead of an auricle
Rudimentary tympanic membrane / partially / totally aplastic external auditory canal
_! v'f1xed malleus and incus
i.''Abnormal course of VII nerve
 12
ClinicalENT i
\{
TYPE IIA : Type 11 + partial bony stenosis of ear canal
TYPE IIB : Type Il + complete bony stenosis of ear canal !
Congenital Cholesteatoma : I
Three criteria are set by Dedacki and Clemis
o Development behind an intact tympanrc membrane t
o No history of ear infections ' 'rsr'11'3r''1 {''"1 h
o The lesion must arise from inclusion of squamous epithelium during embryonic development
Types t
1. External auditorY canal
i
. -2. Middle ear
. 3. Mastoid a
. 4. Petrous apex
a
...5. Cerebelllo pontine angle
It behaves in the same way as an acquired cholesteatoma' t

SENSORINEURAL DEAFNESS t
pathological abnormalities of the cochlea seen in these cases are of four patterns :

at
1. ,Nlichel dysPlasia
o Most severe
t
. r"t"1ffiiflof labYrinth
o
FailurEoiotic capsule to separate from neural ridge t
2. Mondini deformitY i ! I| ii '
,, O Affects cochlea and semicircular canal '- \
i,,,, o Cochlear duct reduced to basal turn only t
" i . . Absent / reduced organ of corti
3. Bing - Siebenmann dYsPlasia t
o Normal bony labYrinth
t
o Decrease development of membranous part
4. Scheibe (cochleosaccular) dysplasia t
o Stria vascularis has alternate areas of aplasia and hyperplasia
i
o Rudimentary organ of corti t
o Sparse / absent hair cells
\l
o Collapsed saccule
I
Genetic disorders with deafness present at birth t
Syndrome :
I
'l . Turner's syndrome
')' 2. Usher's syndrome I
3. Pendred's sYndrqme
t
Genetic disorders with deafness developing after birth
t-
Syndrome : t

(li'k 1. Alport's sYndrome

2. _Renal tubular acidosis t
3. fiefsum's disease
I
4. Cogan's syndrome
I
n Section I Case Presentation - Ear
'13

Y^ -

T Non genetic deafness

I:
rt:
Causes of non-genetic deafness
1. lntra-uterine disease
a. Rubella
b. CytomeEalovirus
c. Syphilis

F d. ToxoplaEmosis
2. lrradiation

1: 3. Ultrasound
r.- !-lypoplasia of l/rC,

t-
+. Uqlqf1e! diabetgs -
lr Fetal alcohol sYPdrome

t:
I:
5. Ototoxic drugs
a. AminoglYcosides : lntrauterine cochlear damage
w" Erythronrycin, tobramYcin
. Cisplatin
t-
agents :
. .,b QhelotheraPeutic
..,p -LooP diuretics

n
t:
Perinatal causes of SNHL
r-e-- Hypoxia : Decrease in cell no : of cochlear nucleii

"r Hyperbilirubinaemia

t- o low birth weight / Fre{erm child

It has immature metabolic function, more likely to suffer hypoxia.
They may suffer from life threatening

1: infections for which ototoxic drugs may have to be given

t-
t:
.r--Mumps : Unilateral SNHL
rr- Measies : Degeneration of organ of corti, spira!
o lmmunization : T-etanus injection : peripheral neuropathy
ganglion, vestibtllar sensory cells

t-
t-
o Sq-to immune SNHL
r.r Meningitis : Bacterial labyrinthitis
. TEvIa :Rupture of RW, OW
o Neoplastic disease : - Acoustic neuroma

l-
r-
- Leukaemia of ternPoral bone
o ldiopathic : Vascular thrombosis, embolism

F
f-
MIXED DEAFNESS
Causes of mixed deafness :
,Ju Earpits deafness syndrome
2
[ ?r ' r i; r rr ' I

f-
Osteopetrositis

rr
.3: Ljlngerhans cell histiocytosis !';' '" 'r;"'
4. f4ucopolysaccharidoses

ASSESSMENT OF A CONGENITALLY HEARING IMFAIRED CHILD

rr Aims
o To determine if a hearing loss is present
o To decide the type and severity of hearing loss

f-
n
14
ClinicalENT

o To determine the age of onset of the hearing loss

(Prelingual hearing loss has more serious implications on the child)
o To look for other relevant handicaps

Assessment
1. History :
The parents are asked to state :

- Their main worry about the child

- About the child's hearing
- H/o of delivery / postnatal life
- ENT symptoms / family history
- Child failing to develop speech / screening tests
2. Audiological assessment :

1.. Test for behavioural reflexes

First few weeks of life o Loud sounds : startle reflex

o -M,s!o's-rgflc-x:change in heart rate and pattern of respiration and a backward
head jerk and body movement on sound
lnfant under 4 months of age a Respond by stiiling and listening
a Smiles in a communicative way
4-6 months of age o Turning the head towards the auditory stimulus
7-9 months of age o Localizes sound accurately
a Turns readily towards the sound source and searches for it
a May also begin to copy sounds
10-12 months of age a Localizes sound
a Verbal comprehension of sound occurs
13-24 months of age o Localizes sound, searches for sound starl, therfore distraction may be
necessary
r Vocabulary increases, picks up toys on request
9ver 2 years of age . May carry out PTj, also

z.
-EeEyig_9gr-egg!9q9!ry' I
Behavioural responses seen on giving auditory stimulus
Pre requisites are :

- Appropriate test is chosen accor:ding to the developmental age of the child

- Auditory stimulus is given either live or through loud speakers in a sound free field l

1 . _Dislra sigr'-
Jes!_e e-a{! 9,;
-f_.".b
/
It is for a child aged 9_llojlllp_-qlg aQ-qvg \
Distraction is needed as such a child wanders or searches for sound. a
2. I
Vi s u a l _re il {.ojg_el! _e11_t311{og e_t ry .

Similar to the above test but the response of the child is reinforced by a visual stimulus (flashing of
light). This method is said to reduce the habituation to sound seen in children > 1yr. of age I
I
3. csa-{(iglr'ng a
eggio11g_tly i
The child is told to carry out a simple task (eg : putting a brick in a box) in response to sound
t
I

I
a
\
{
n
r^
rr
Section I Case Presentation - Ear 15
-
Difficult children are :

- _v'rsq_ally lgpe[gq cnlql_gtt

- Mqnt4liy- Le-!er{9-d-9ni-g,Fl-
- QpreQs! p,gl-s-v,chllgtqn

E - tl yp_q
tg c-!1v*9j_trj19 te_!
Children which are difficult to handle and those below 3-4 months of age, in whom behavioural
testing is not posible, objective methods of testing are used :

E
r
3. Objective audiometry
Electric response audiometry
- AUdLlgty Q1a!1 stgm re-sponse

n
h
-
-
-ElcEtfppo ch I

Period evoked potential

$gogs_tlg stapedial reflex
e o g ra p h y

rn a) Auditory brain stem response

Brainstem responses measured in response to a click stimuli recorded in the 1-lOms.interval.The
hearing threshold is determined by the lowest stimulus intensity at which the auditory evoked

rn
potential is detectable visually.
Principle i

When sound leacheg lhe qochlea, it ig converted into an electrical response which passes finally to
!19 auditory cortex. eassage of the impulse through !l!g paihwalq"eates an electrical activity which

n
can-!e nanllAtqd by placing a surface electrode on the scalp. Graphic recoiding of this electrical
altLViW jq dq-ne !,r.r qryaye-fotn, *ttt*".ILis siuOieO toi any abnormality in the pathwa=y.
b) Electrocochleography

r H The S.chLgal!qLYg qqt!oJ potential is an exogenous transient response recorded in the first
l0ms.interval, from a number of sites around the ear.
c) Period evoked potential
It is a new technique, based on frequency following response, the frequency reflects auditory units

F
in the brainstem

r
4. lmpedance audiometry
The otoimpedance to the sound presented to the tested ear is measured. lt qyes an idea about middle ear
tppeQance .q1qlching mechanism, the elastic_ity / compliance of the middle ear system

Results

F
rr o
INCREASED COMPLIANCE
Ossicular chain discontinuity o
o
o
DECREASED COMPLIANCE
Otosclerosis
Adhesive / Secretory otitis media
Middle ear tumours like glomus tumours
o
NORMAL COMPLIANCE
Eustachian tube obstruction
4

r Tynrpanosclerosis

f- New related techniques

H
rr
a) TM displacement measurement
Principle
Changes in hydrostatic pressure on the cochlear perilymph produces a minor variation in the movements of
ossicles and tympanic membrane. The resuiting tympanic membrane displacement is measured over time.

n r
l:.
 16 ClinicalENT

b) Acoustic reflectornetry
!t ts a test performed as an impedance audiometry but instead, with the help of an acoustic otoscope
Advantages :
- Can be done on a crying child
- Does not require an air tight seal
- Useful in assessment of a difficult child
g)-Otoacoustic emissions
Tlq g[Lssfq]9*gl-9- que to release of acoustic elergy_orlginating from outer irair cells of the cochlea. They
are recordeo rn the-exfernal audrtory canil and ur" u of a normally functioning coctrtea.
gl|Speech audiometry "irlo"ncL
- Speeg! detection
- S-peechdiscrimination
. lpgecl-l pe.ryqp-tion
This is done by, presentation of phonetically balanced words to the child with instructions to repeat the
word heard.
Management of the hearing impaired child :
o Early detection :

- By screening tests of hearing

- High level of parental suspicion
- Screening / testing children with undeveloped / poor speech
o Parental counselling
- For future pregnancies ,f
- For rehabilitation and schooling of the deaf child
o Complete audiological assessment
o Other investigations
INVESTIGATION REASON
Serological o TORCH _s-Elq- ntng
. -Eq b.9!Le
-
s.p,g_qlf-ip lg*c, l gM

jvgl'ji.i g$i!g-9js-'
'
o Thyroxine levels
Urine a Cytomegalov_i1us
a *Benal disea-se
X'ray skull c lntracranLal c_alificatjon in Toxoplasmosis
C.T. Scan / HRCT . 9tfqclU1q! abnormalities of middle e-ar, inner ear
o For cochlear.implantation
Ophthalmic checkup o Bub-e"Lla retinopathy
Paediatric / neurology opinior o -Head and n-eg!. gpnSlrua.lity
o Qyqdrgqes-
o _Mental retardation

MANAGEMENT
1. Appropriate hearing aid selection Hearing aid
Cochlear implant
 Section I Case Presentation - Ear
r^ -
2. Surgical correction of congenital malformations
l^ a
J. Promotion of development of language I speech

t: 4. Rehabilitation : education, schooling

r \ r. Hearing aids
Thehearingaidamplifiesthepresentedsoundstimulatingtheresidualhairceilslsensoryorgan.
I: lndications
a)llriqrellryIh lltf
t:
L

b) Qqlselllalg Qr,9rnrli!y.,9j-Pr19l! al unl

t:
rr
Types
.Jz Personal hearing aids t"
gody worn hearing aids
|-
$" Behind the ear aids
{--ln the ear / conchal aids
n g'- pone conduction / bone anchored aids
.6r Aicls not entirely worn by the listener .ls
r: r r-- *^-+ ^hirrrran
Therangeofaidsissuchthatasuitableaidcanbefoundformostchildren.Thebehindtheearatc
r

n aretoobigformostchildren.Theconchalhearingaidismostexpensiveandisreservedforchildrenwith
deformities of the pirrna. Bone conduction hearing
aids are for chircrren with deformed ears or severe
aid is di'ectly
n anchored to the mastoicl bone with the nlip
of Lar morrds.The bone anchored hearing
recurrent ear infections which prohibit insertion
of screws without any intervening. soft tissue and
gives good
with severe conductive losses' lt is not suitable
for

r: results. lt is used for uni / bilateral *u,. .rifortations

chirdren whose skulr bones are not sufficientry
thick to accept the osseointegrated screw.Tr-rg
g1e-q!est--

n l' ibeir speech sounds and

inab-itit-y-to--diEting'uish between
dSe-d-v-atleg-e--9-t-a-oilyA1lLql1l-hp.zuing u'd
by the following means (in school)':
glyA$eq !q"-fg1b-u[q *'s-e._fr||i is puiiry ot'ot"ome
n Aids not entirely worn by the listener

r: a)-S_peech trainen
ln this, the microphone part of the lrearing aid
is kept close to the speaker ( teacher's) rnouth

r: hearing aids
-b)r Q.iouP-

n s"""rur'"niiorun aie conne"ted to eachother and the

d Radio hearinE aids
teacher by amplifiers

I:
1:
The teacher / parent wears a microphone transrnitter
radio sYstems are used
d) lnfra red hearlng aid sYstem
and the child a receiver' FM (frequency modulation)

I: The infrared signals pass from the teacher's transmitter

to the child's receiver

I:
.e} L__o*oPsYstem
directly u|?yld an electromagnetic loop installed
lnput from the teacher,s microphone is transmitted either

n
I-
I
ontheclassroomwalls,orbymeansofaloopwornaroundthechild,sneck,
C_ochlear lmPlants
Prerequisites

I.
1-Prcifoundsensorineuralhearinglosswithnocr:nductivecomponent
2. Proper developmental / mental / psychologiical age

n
l:
3. No medical illness
4. Pre oP. C.T.Scan
5. Good parental understanding / cooperation
*

l-
n
r
 1B
ClinicalENT

Types
1. lntracochlear
Simultaneous electrodes are implanted within the lumen of the cochlea in the scala
tympani and which are
typically multichannel
2. Extracochlear:.
A single channel in which an active electrode is implanted in the region of the round window.
2. Surgical management I

Congenital aural atresia

o Fenestration of the lateral canal
Disadvantages : - Creation of labyrinthine fistula
- Wide exenteration of mastoid is required
r Type lll tympanoplasty
Direct contact between stapes and drum head
- Disadvantages : An open mastoid cavity with a constant risk of otorrhoea
o Canalplastytechnique
- lt is done in more severe cases with repair of microtia. ln least severe cases, removal of atretic plate
of the ear canal is carried out.
o Plastic reconstruction of the pinna
- lt is carried out with surgery for hearing reconstruction
Auricular prosthesis can also be used
3. Rehabilitation i Education of the deaf
o Teachers for the deaf
o Parental counselling : - Care of the hearing aid
To talk normally to the child etc.
b. School children Sent to : - Ordinary classrooms using hearing aid
- Specialised teachers are appointed
- Speech and language units / hearing units
- School for profoundly deaf

4. Communication methods
g)-Auralism
- To use only speech and lip reading as a means of communication
- Signing is prevented
'.PfFinger speiling
c) Cued speech
-Uses B different hand shapes in 4 different positions to enable the child to discriminate lip movement
r!)€igning systems
- Signed English a
\
- British sign language
e)-Tota I com mu nication t
- Use of all modes of communication eg. speech, gestures, writing etc. .a
\
t

I
)
I
 Section I Case Fresentation - Ear
- 19

OTALGIA
Otalgia : lt means pain in the ear
Causes of otalgia

EXTERNAL EAR MIDDLE EAR INNER EAR

. Wax o Acute otitis media c Noise
o Foreign body . CSOM with intracranial c Tinnitus - loutl tinnitus is perceived as otalgia
o Otomycosis complications t- Meniere's disease
o Otitis externa . Acute mastoiditis ,l Vestibular schwannom a - 30o/o of patients get
o Trauma \* .o-' Secretory otitis media pain in the ear
o Herpes zoster \. .r." Traumatic perforation H l':: {: l. t ir ?., ;l.r ?.- I'.r' '
o. Exostosis \ t- Otitic barotraurna i 'r,,, .....r. .i'; ,I ,; ':- :
o Keratosis obturans i', 6
r,.i ,

o Haemotympanum
. Hypersensitivity to local eardrops . Tumours / carcinoma

Character of pain

ACUTE OTITIS MEDIA ACUTE OTITIS AUDITORY TUBE

COALESCENT MASTOIDITIS
EXTERNA DYSFIJNCTION
o Acut€ Pain is behind the ear in o Diffuse pain generally Pain occurs within
o Deep seated coalescent mastoiditis and r Severity of pain depends sometime on
o Violbnt / severe behind the eye in Petrous ap€x upon amount of oedema lying down
Associated with rnastoiditis o Pain is aggravated by
continuous / paroxysmal biting. chewing and pinna
pulsations
movements
' lncreases in severity Very severe pain is seen in
at night furunculosis

Conditions associated with severe pain :

Herpes sirnplex oticus

Herpes zoster oticus
b- Bullous myringitis

lmportant points :
o As the skin is very closely applied to the meatal and auricu[ar perichondrium, severe pain is associated with
otitis externa
o Pain is not a feature of chronic otitis media unless associated with otitis externa or dural inflammation
 20 GliniealENT

q rc
lnnervation of the ear2,] , t
Cranial nerves V, VII, IX, X and C2, C3
ANATOMIC PARTS
a Greaier auricular nerve C2, C3
a Lesser occipital nerve C3
o Auricular branch of vagus
a Auriculotemporal nerve
a Facial nerve
Tympanic membrane o Tympanic branch of Glossopharyngeal nerve
c Auricular branch of vagus nerve
o Branches from facial nerve
o Glossopharyngeal nerve via tympanic plexus
o Meningeal branch of Trigerninal nerve

Referred pain
Pain is referred to the ear via the V, Vll, IX, X, upper cervical and sympathetic nerves.

"+1 CAUSE OF REFERRED PAIN NERVE CAUSING REFERRED PAIN IN EAR

Tonsil lo_n-s!ttltiq Via Glossopharyngeal nerve
P_eritons il I a r abscess
P_-osttonsillectomy
fletropharyngeal abscess
Parotid Parotitis Via Facial nerve
Mumps Via Triqeminal nerve
Thyroid Acule thyroiditis Via Vagus nerye
Subacute thyroiditis
Hashimoio's thvroiditis
Larynx Tuberculosis Via Vagus nerve
Carcinoma
Styloid process Eagle's syndrome Via Glossopharyngeal nerve
Oral cavity Dental caries, Alveolar abscess Via Trigeminal nerye
Oral ulcers, lmpacted molars
TM Joinl lrauma Via-lrigeminal nerve
lnfection
Arthritis
Nervous origin flerpes,__499te1 Via Trigeminal nerve
G*lossoph4 rynqe*ql zoster Via Glossopharyngeal nerve
Spine Cervica! spine degelel?lig! { tumours Via Cervical nerves

Neoplasms (carcinoma) causing referred pain Common causes of referred pain

o Pyriform fossa o Caries teeth
o Glottis / supraglottis o Impacted molars
o Post cricoid carcinoma o Posterior tongue lesions
o Posterior pharyngeal wall c Pharynx / tonsiilar lesions
o Posterior lzr of tongue
o Parotid gland
o Nasopharynx
 Section I Case Presentation - Ear
- 21

VERTIGO
DEFINITIONS
1. lt is defined as an illusion of movement.
2. The disagreeablelseisatlorffiIinslE6ifity or disordered orientation in space
3. lt is definqd gq g. f.alLucination of movement.

ETIOLOGY

OTOLOGICAL NEUROLOGICAL VISUAL

l. CJrqliq middle ear disease ',rCqleQel]opontine angie lesion o Ocular pqlhology
f. Meniere's disease \c' C_erebellar lesions o fetro-orbilal lesiqn
-o B_enlgn paroxysmal positional vertigo o l[tqrnal capsule / thalamic lesions TOXINS
.. Acoustic neuroma 'c Epilepsy e- Ethanol
.. Cholesteatoma r Parkinsonism o" Qarbon monglldg
o Otosclerosis 'r- M_ultiple sclerosis ENDOCRINE
.

o Temporal bone leslons o I.lydrocephalus o l!ypothyroidism

o I ibyrinthine. contusion f -Meningitis e-
-Hypoglycaemia
o SYPhilis I Neurosyphilis SKELETAL
.. Viral labyrinthitis o Subdural / extradural lraenratoma o Ogteoarthritis
o Tuberculosis o Whiplash injury o Paget's disease
PSYCHOGENIC

CLASSIFICATION OF VERTIGO
I. a) Rotational
1. Episodic
2. Prolonged
b) t"lnsteadiness
1. Episodic
2. Prolonged
Il. a) Central
bJ i_glipheral
Difference between central and peripheral vertigo

CENTRAL VERTIGO PERIPHERAL VERTIGO

Gradual
-Nql-aq i4eitag ye-(Eq
lncrease disturbance of gait occurs instead
\qtrygch.qllgctefl py po._ellignal qt'ranges I Lq f e_a_s,Q s- qlr ! e a q _ry q y,9 1n e n !s- 1 pp si t i o n a I gha rr ge s
SwayIS l lit!!g-mq_re_.q! q1e side [otatory_irlcharacter _
D_!lq !q lg9!o1 i1 tle bialn or its central conneciions Due {q lesion in tle inner ear (l"abyrinth)

INVESTIGATIONS
o Complete blood count
r Blood sugar
o Cholesterol / Triglycerides
 Clinical ENT

o Renal function test / Liver function test

o Blood pressure measurement
o X'ray cervicalspine, internalauditory meatus, mastoid
o ECG
o CT scan / MRI

Subjective tests :

o Fistula test
o_$f roJnqgrg_s_"le_-s!
o_U(q! b_e1ge r s_ t s-q!_
l

o
-Qal_qrj_q!,eq_tlng
. _Ll_qlgKg mangjgyre
Objective tests :
o Pure tone audiometry / lmpedence audiometry I BERA
o ENG, Craniocorpography' Posturography
o Acoustic reflex

MANAGEMENT
Medical treatment
L VegtibUlel,s,,elgliy_e_9": These act by augmenting the "Cerebellar clamp"
- Cinnarazine
- Cyclizine
- Prochlorperazine
- Diazepam : labyrinthine sedative + anxiolytic properties
Disadvantages
- These drugs delay central compensation and can also make it incomplete
- ln vestibular inadequacy, these labyrinthine sedatives increase the unsteadiness
2. Mild trqnquillizers
- For suppression of emotional reaction
3 aewll-orne Clgrcgy--exg*lgl5gs*can accelerate the process of compensation.
Surgicaltreatment :

lndications :
1. Lack of response to adequate medical treaiment
2. When symptoms are incapacitating, interfering with daily activity
3. ln uncompensated vestibular disease
Surgical treatment for vertigo is grouped as :

t.owingchronicsupprativeotitismedia(unsafetype),
z. Qsrsrge!. m-q!g,geq-e r !-ql \4-q!t-19l'-9 ls-{sg-ag e
3. $g g-e-ry_lo r aco-u sti c n e ulglrla
+. 9_y t g qry.l,o *-9 lig lp utg ry s m ?!_p e 9 i!191 q ! y e (! s o
5. Management o[ p,e1i!y_pph llstqlq
 Case Presentation - Ear

1. Treatment of labyrinthine fistula following CSOM

A canal wall down mastoidectomy must be done, with the middle ear cleft disease
to be cleared first and site
of fistula last. Pluggllg !b-e- fillqlg Wtl!f-n--ollg-pg"!,e-l'9rlg!,iq dqlre
2. Surgical management of Meniere's disease
i) Ueqtng-c--o!9e1-v4iy.- p,!-q,ced UJg-s :

lndications
1 lryhqtr-r99l{selbesrusis-s9od "

2 .l_q!e-nl !'ygg!_9"
3 _!lrse_ase is !_tlglglel
Lh9I9 po:pl.b-!!i1y ql9.it"-q:",ogJg!gp-,1g, !n the 9!h9r ear'
!.! ?
-4
i Procedures
- a ) q11_c9$yl p {!1u!"qlqlY
Rationale : - To correct the microcircg!a!9.ry,J9y!t !n slqia vascularis
\/
"r Resection is done from C, to To levels'
b) Endolymphatic sac decompression
di-
Rationale Decompression and drainage of endolymphatic fluid so that increased Pressure
rects itself away from the inner ear.
patients with positive SlSl scores and positive Glycerol test, are said to benefit better with this surgery'
I

c ) 4.ilrc!l*e-cl9[y : -
S€l eally_e y-eglibgl
input.
Abnormal vestibular input is worse for vestibular compensation than absent
Approaches i) Mrddle cr-gniqlfogsa approach
ii) Se(g labY11th11e aPProach'
iii) Rqtro sigmoid / Posterior cranial fossa approach'.
ii ) tlgflltg" $,e"
gtru gliye p-1og"qQ u-r-qs :

1.Labyrinthgclomy - Removal of all nueroepithelial elements

2 C,&g.ryrLpgl taQy-f|l!.1e9!-g1y.bl tal,llY-mpanic injection of streptomvcin -,-l
neurectomy' J
Best result for Meniere's disease is that following labyrinthectomy with vestibular
3. Surgery for acoustic neuroma
Approaches :

a ) l\{r d qg_lo-9_s_a.-qrplo--qg-ft

b ) IG Ls,]e-9"yl$[! rc*epplqe-c h
c ) P9 9 !-e_q! g_l_o_tg3 9-P P_l_o_u
"
h

Essentials of surgerY are :

1. Adequate exposure
2. Facial nerve is to be identified and preserved
3. Ability to control bleeding in posterior fossa with minimum trauma to brain stem and cerebellum
of BPPV
[+ Surgical treatment
- Singular neurectomY
- Porterior semicircular canal occlusion wiih bone dust
- QO, laser neurectomY. I
Surgical management of perilymph fistula
P,luggllg gl flstulq ryi!!!g!,qlo coveling with fascia'
24 ClinicalENT

TINNITUS
Definition :

The conscious expgrience of a sound that originates in an involuntary manner in a person, or may appear to
him to do so.

Types :

I q u !iqq!__v_e_/"
-_o!j--e_
qiiye .
2 i"llAnllte!!
Qen!rue"s-s_/
3. Low pitched / high pitched
4. Physiological I pathophysiological / pathological / pseudotinnitus.
5 "!!gc!qant / constant
Source of Tinnitus :

o lQochlea. -_
o Cer_ebral.gotqx_
o l.leurql pa-tbyv.gygi
Etiology
1. Local
'r'_Wqx
u- Otitis media
-.Middle ear catarrh
2. General
v' Hyp,e1t9!-1s!o.L

"r" _Anaemia
- Renal disease
-
Cardiac disease
-
lntracranial tymogr9.
3. Trauma
r= Noise induced hearing loss
'* Ossicular discontinuity
- Rupture oval / round window
v- Post-operative
4. Drugs
l- Salicyclates
'- Streptomycin
* Quinine
5. Neoplasrns
i-. Acoustic neuroma
v- Glomus jugulare
6. ldiopathic
7. Psychogenic
I
8. Miscelladeous
u,- Palatal myoclonus
''' Aneurysms
 Section | Case Presentation - Ear 25
-
Triggering factors for tinnitus :

1. Stress - Mental / Physical

2. Noise
3. Ototoxic drugs
4. Trauma
5. Pregnancy
Characteristics of tinnitus :
1. Dull / continuous - Conductive hearing loss
Y(f ry_trrrn,_-cJpgrNLlg_-ryj$_P-q19-q;*p*!-oi1qe-tunQqrs
r-3r Fluctuant tinnitus - Meniere's dlq.ease
Treatment of tinnitus :

o Reassurance
o Anlidgpressants
t-d $-c-da!!V,eg - Tab Diazepam 5-10 mg Hs 3'lrr',
I
r Vasodilators
o Angesthelj.q Q[qSs
r _lqe.!1o1, lidq-q?Ltg HCt
- Blocks multisynaPtic channels
- Shor"t-term effect on tinnitus
-f o Tinnitus maskers
-./Electronic gadgets worn behind the ear to mask the patient's tinnitus.
r Psychotherapy
o Surgical treatment :

- ..Qlellele,ga1g!o-n b!9-9k
- "9 e ryic"el "-sy-Tp-?ltt -e,!_9_c-tPpy
- Ty.mp d_q"Lg q gi_e- ql-g_1| y
- *9f plg alyrygLq !-9 t]
te- 9!9Ty
lsbygJ!te-c:!gmY

MANIFESTATIONS OF SYSTEMIC DISEASES IN E.N.T.

1. Syphilis
THROAT / NECK

o _Profound unilateral deafness o Syphilitic gummas o Crervical lymphadenopathY

(obliterative endarteritis) o Septal perforations o Syphilitic laryngitis
o Vertigo, tinnitus o Condylomatag
o Fusion of ossicles o Syphilitic ulcers in oral cavitY
Osteitis of temporal bone
o EndolymphatichydroPs
 1

\
ClinicalENT
\a
2. Tuberculosis
THROAT / NECK
I
o ,Tubelculous otitis media
o .Lupus vulgaris
. Iqqglg,{gus larynsitis I
o Sensorineural hearing loss o Nasal tuberculosis o Cervical lymphadenopathy / sinus / fistula
o Septal perforationg o Qold abscess !
o Tuberculous ulcers in oral cavity
t
Diabetes mellitus
j
THROAT / NECK
I
Sensorineural hearing loss o Oral thrush
o Diabetic neuropathy N'ocal cord palsy. I

;
4. Hypertension
EAR NOSE

o Sensorineural hearing loss o Epistaxis

. lltcrease bleeding at surgeries
 2" GENERAL EXAMINATION

GENERAL EXAMINATION

COMMENTS CONDITIONS IN ENT

Paleness of skin and Sites to look for pallor : Conditions in ENT with pallor :
mucous membrane due to . Lower palpebral !l--Cases of dysphagia
decreased red blood cells conjunctiva Throat carcinomas
blood supply. o Tongue '^r-* Nasopharyngeal angiofibroma.
I Soft palate 'r- Plummer-Vinson syndrome
o Palms and nails 'grAtrophic rhinitis.
Collection of fluid in Oedema occurs when Conditions in ENT with oedema :
interstitial spaces or serous 5-6 litres of water l9- Myxoedema
cavities collects in the spaces.
't!.. Angioneurotic oedema
Pitting on pressure r.-- Cachexia. in malignancy
occurs when circumfer- \t" Liver metastatic carcinoma.
nce of the limb is 'c"" Metastatic lymph nodes
increased by 10%. pressing on lymphatics.
Bluish discoloration of Types Conditions in ENT with cyanosis :
appendanges due to 1. Central : Decreased o Chronic obstructive lung
ipcreased amount of aderial oxygen saturation disease
Ieduced haemoglobin in the Seen on skin and mucous o l91e!01lody bronchus with
gapillary blood (More than 5 membranes (tongue, lips,
lung collapse
cheek)
2. Peripheral : Decreased
blood flow to the part.
Seen on skin only.
o Bulbous enlargernent of Grades Conditions in ENT with clubbing :
soft parts of terminal 1. Softening of nail bed rr,t€ronchogen ic ca rcinoma
phalanges 2. Obliteration of angle of Igpelgglosis with secondary
o lnterstitial oedema and nail bed rnlectior'1
dilatation of arterioles 3. Parrot beak / Qrum Lulg -apgcgqs
and capillaries stick appeqrance
o Curving of nails 4. Hypertrophic pulmonary
_osteo-arthropathy
Jugular venous The normal JVP consist of Elevated
pressure three positive pulse *uu", o Right ventricular failure
a, c and v and two negative o Hyper kinetic circulatory
.pulse waves x and y. state
Nq11,ql,_Q 4 qms. . lncreased blood volume
o Pulmonary diseases
- Asthma
- Emphysema

27
 ClinicalENT

DEFINITION COMMENTS CONDITIONS IN ENT

Decreased
e S!Loq!1__
o
_Dehydration
Temperature It reflects the temperature of Types o Bacterial, viral, fungal infections
Fever is increase in the viscera and tissues of Continuous : ,Raisgd o Thyrotoxico_sis
temperature by more the body temperature, fluctuation nol o !.n{gctlous mononucleosis
than 1oC or any rise _more than 1oC over 24 hrs. o Specific infections like
above maximal normal Sites :Oral Remittent : .Fluctuation - -DiPilhe-rra-
temperature. Axillary pore than 1oC gvgr
-2-4
hr9 - Tonsillitis-
Rectal lntermittent : Temperature - Vincent's angina
only for some hours in a - -ll-qlpe-p !-aFt-a!is
day. o CSOM with intracranial
complications.
]tlormq! I,B:99:f
Mild fever 99-1000F
Moderate fever 100-1030F
High fever 10_? 10qoF
Hyperpyrexia upla t00oF
Pulse Components of pulse Types Conditions in E.N.T. with
o Anacrotic wave. o Anacrotic Tachycardia
o Tidal / Percussion wave o Pulses Bisferiens o _Ame1ra*
o Dicrotic notch o Dicrotic . Il'y!0-lgxic9si:
o Dicrotic wave r Water hammer pulse o Fever
Normal rate = 60-100 / etc.
minute
Blood pressure Systolic B.P reflects : Hypertension :

o Stroke volume of tlie Hypertension is persistently c Thyrotoxicosis

heart elevated systolic or r Raised intracranial tension
. Stiffness of arterial diastolic blood pressure. Hypotension :

vessels. o Cachexia,,o!fgligiiglcy
Diastolic B.P. reflects : o Tuberculosis
o Peripheral resistance e Anaemia
Normal Blood Pressure = o f unctional
upto 120 / 80 mm of llg

\
I
!

!
q

t
\
I
Section I Case Presentation - Ear 29
-
Lymphadenopathyl Enlargement of lymph nodes, inflanimatorir cr n,:n,inflarnniatory in origin.
I
Neck nodes are examined by standing behind the patient with the patient's neck flexed. Nodes
are examined from above downwards.
Neck nodes :
o Sub mental o Cervicai
o SLlb mandibular o Posierlor auricular
c Tonsillar e Occipital.
Tuberculous iymphadenitis ; i

o Affects deeo cervicai. axillarv and nrcsenteric nodes

.'.'.--_
o Maited lynllli noii,-c dire tc lreriadenitrs
r C-entral casealion resylts in a cold ahiscess
o Burstinq of the abscess results iir qqlir<lnrc@
. C.onstitutiortal s t
Syphilitic lymphadenitis :

o Painiess. firm. ,l;screlc arci :hotLysiands.

o Epitrochiear and occi;,:lri ,-err.les are irrvclved in secondary syphilis
o Generalised lyniphadencpathy irr st:i;ondary sy,philis.
Lymph-sarcoma:--
o Affects cervical giands which are eniargecj, firrn and fixed
o Highly malignant turnotir
c Overlying skin niay shr:w dilateci biue veins urrcler it"
Secondary carcinomra :
o Stony hard iymphrrodes
c Eniarged, irreguleir and fixed nodes
o Primary growth may lre there
r Constitutic;nai syn']ptom-l are preseni.
Hodgkin's lymphoma :

o Affects young maiL.s

o Cervical giands are afferied first
o Lymph nodes :
- Elastic - Discrete
- Fiubbery - Mcl;ile
c General sigris :

- Pel Ebstein fever

- Hepatosplenornegaly
- Anaemia
- Weight loss by more than 10%
o Diagnosis :

- Lymph node biopsy-

- Reed Sternberg's cell
- Peripheral smear-
- Lymphocytosis
- Eosinophilia
Non-Hodgkin's lymphorna :

. Waldeyer's ring and Suprairor:hiear nodes are affected.

. Less sympioinatic than Hodgkirr's lyrnphoma.
c Histologicatr e;xamination of tlie bone rtarrow confirms the diagnosis.
 ClinicalENT

Cranial Nerves

CRANIAL NERVE SENSATION TESTS INTERPRETATION

Olfactory Smell To smell non irritant substances Anosmia : Abolition of

iike tea, coffee, clove oil, sense of smell
etc. Smelling irritating Hyposmia : Decrease sense
substances (eg. ammonia) leads of smell
to additional stimulation of Parosmia : Perversion of
Trigeminal nerve. Common sense of smell eg. offensive
bedside substances used are substance having a pleasant
999P,-:c9!!'-ltgi! "CIg. The patient odour
can smell from smell bottles,
Ul9]]-sef{:.(a s_,c"flpl 91 the
€Id_tgg_qg, !o_ eruption _o_f,
s-mell)
or an olfactometer
Optic( /r' . r\ri
r
Visual acuity Bed side test - Finger counting
,Lr\ini- -t at 1 meter.
,{l(" I
-' | ' ,.'( 'r' t Visual field Distant vision test-Snellen's chart
. ."-i
, r 'l t /- \!ear vLsion Jqegger's -q!1g(
Oculomotor.-zl Eye movements Test eye movements by Squint
confrontation method.
Trochlear Eye movements It supplies the superior oblique
muscle
Abducens Eye movements Lateral rectus palsy in Vl
It supplies the lateral rectus
muscle nerve damage
Trigeminal Ophthalmic : The tactile sensibility includes A lesion of the whole nerve
(Ophthalmic, Supplies the conjunctiva, lower light touch and pressure, tactile leads to loss of sensation in
Maxillary Mandibular) lid, lacrimal gland, nose tip localisation and discrimination. the skin and mucous memb-
and skin, upper lids, forehead, Test sensations with cotton wisP rane of the face and
scalp till the vertex / tip of index finger / pin. Test nasopharynx. The salivary,
Maxillary : Cheek, front of a bno rrn a I sidg,-JLr*s-!, buccal and lacrimal
temple, side of nose, upper liP, Corneal reflex : Twist a light secretions may be diminished
upper teeth, roof of mouth, wisp of cotton into a fine hair and trophic ulcers maY
part of soft palate, tonsils and lightly touch the lateral edge develop in the mouth, nose
Mandibular : Lower part of of the cornea at its conjunctival and cornea. Weakness of
face, lower lip, ear, tongue and margin with the wisp, having muscles of nrastication is also
lower teeth. Parasyrnpathetic asked the patient to gaze into a feature.
fibres to the salivary gland" the distance or at the ceiling.
The motoq root innervates the The two sides should be
muscles of mastication. compared. The cornea should
Reflexes : not be wiped with cotton and the
e Corneal central part should not be touched
o Conjunctival in view of risk of corneal
o Jaw jerk ulceration in cases of cofneal
anaesthesia. ln a positive reflex,
the patient blinks.
Facial The facial nerve is almost Ask the patient to close his eYes ln facial paralysis, the
entirely a motor nerve. lt as tightly as he can. Affected eYe affected side of face loses
Section I Case Presentation - Ear
-
INTERPRETATION
CRANIAL NERVE
supplies all the muscles of is barely closed or not closed at its expression. The nasolabial
face and scalP, excePt the all: Test taste sensation on fold is less pronounced, the
levator palPebrae suPeriorts anterior % of tongue" furrows of the brow are
The chordatymPani carries To test the sense of taste, use smoothened out. the eYe is

taste sensation from the At qi-9,,r"ger-e.ry1- more widely oPen than on the
anterior % of the tongue. "u"noto
qg.p-po r.r. s-a.l !,. q n-d w.9 9 k-
-s-g.t"t
ttig n normal side, and when the
There is a small area of of citric acid and q{nine, as patient smiles, the mouth is

cutaneous sensation in the tapjp-s- sf swe-e-!' aalL-99ur-a!r-d- drawn towards the normal
auricle. lLtlgl _le_:p_e,,ctiv_e1 y_ Th ey are side. The patient is unable
ideally applied with the helP of whistle and food is bound to
wooden rod on the surface of collect between teeth and
the protruded tongue The Patient gums. Any fluid maY escape
is asked to indicate the from the angle of the mouth.
perseverance of taste before
withdrawing the tongue. After
each sensation is tested, the
mouth is rinsed. Th,e qgldlq tegi
lggpgte_q ! €!--e :_ $ _
e_f f e*c! _ip

Vestibulocochlear The nerve consists of two All sub.lective and objective tests
of fibres. One suPPlies the of hearing
cochlea and subserves
hearing, the other suPPlies the
labyrinth and semicircular
canals and maintains
equilibrium, balance and
bodily displacement.
Glossopharyngeal Afferent arm carries Te$las!e-eel_:g!9!l ltgll P9919-

sensations from Posterior Part tioJ p?rt 91 Lqjg.g_e,

of tongue and oroPharynx. lt Pslatal leflqa ;. -T--i_c-(!q -Ue*.pe,qf o
innervates the middle pharyll alq note the_reflex
pharyngeal sPhincter and the
stylopharyngeus muscle. lt
contains taste fibres from
posterior part of tongue.
Vagus is motor to soft Palate Ask the patient if he notices Palatal reflex.: The Palate
Vagus , , l,
'^ -{ LL (except tensor Palati), Pharynx regurgitation of fluids through his get elevated and there will be
$-'r ./u and larynx. lt is sensorY and nose on swallowing seen in total
generalised movement of the
,1 / motor for respiratory Passages, paralysis of the soft Palate Also oro and hypoPharynx
the heart and most of the patient may be unable to Efferent - Vagus
abdominal viscera. pronollnce words requiring
complete closure of
n a so ph
a rynx. U!!49la|pafq!ys-i9

dgggnll 3u9q tltgse sYmPtqms.

For direct examination of the
palate, ask the Patient to saY
 ENT

CRANIAL NERVE SET,JSATION TESTS INTERPRETATIO$.I

with an open mouth antl

l'ah'
depressed tongue. Watch for a
motionless palate, bilateral
paralysis, unilaieral paralysis
pulling the median raphe to tlre
il
healthy side or a normat palate.
'l-lre
f supcrior laryrrgeal blanclr Unilateral cSrrrage to sr-,perror
lct the vagris cdrrics seirsaiion Iaryngeal nerve does noi produce
the vocal corrls ancj also
any syrnptoms while biiater;rl
lolroo*
motor fiirres thai damage leads to vocal cord
ic;arries
the cricol.hyroid. Ttrr reiaxatiorl resulling in a hoarse
li,rnervate
I recurrent laryngeal nerve and deep voice irr v,,hich higii
t
se'lsaliofi lo the notes are difiicult to pioncunce.
lstrpplies
i-'clow the vocal c.rrri and in recunrent laryngeal rrerve
ilatyltx
alt inrrsclcs of larynx except affectron, appearances r:f the
Itr:
llire cricothyroi,J v<lr;al cot,1 ln iarynqosc()p'/ gi'/c
an idea of the affection. 'j'he
speech is characteristically
il blurred and the paiient cannot
cough ciearlyr'. lndirect
laryngoscopy can heip test vocal
Ir trord rnovements.
Spinal accessory It is pureiy a mgi.g.i 1e1ve Each sternocleidomastoid js
nerve innervating the pharynx, larynx :hecked by turrring the face i
ancl supplies ;hin to the opposite side and
Sternocleidonraslcid and rpplying rcsisiance to it.
Trapc;zlur; muscle 3oth strernocleidornastoiCs-,are
:hecked by bending the face
iownr,vards and applying resistance.
lo, qheck the trapezir.rs, the
zstiqqt i9 qs\eg to ghqu.g !i!,s
;houlders whiie pressing the
;houlders ciown"
Hypoglossai Motor supply tc all muscles :xamination r:f the tongue on itsl Uniiateral hVpogls55sl
of the tongue excep{ rrotruslon and rnovements
laffectiorr : On tongue protrus-
Palatoglossus deviation of tongue occurs
lion
affected side because of
Ito
action of the cont-
lunopposed
j ralateral eenioglossus Atrophy.
tasciculations, fibrilldt,Jns
I

loccur on thc aflected muscles.

lTo fasciculatron. keep
".rcru
Ith" tonou" relaxed in the
lmcutn not protrLrded
IAilateral hypoglossat affection
't'
l, Dyspnoea. Dysarthria for
'd phonemes occur
land
 3. KCGAL ffiXAruTf,ruATIffiN

it is ideai to begin examination with the normal ear as it decreases the chances of transferring infected debri
from the,pratlgiogicat ear to the nornial ear

PAR]'ICULARS I RIGHT AND L.EFT EAR - LOOK FOR

Preauricular region I Cysts, stnuses, scars;, lyrnphadenitis
P''*t- i
arGlnituf derormities, anola. microtia
lesicns . gnLly tophi. calcinoma. perrclr_ontiritrs
IAcquircrl
l1ut"urg"l9l.9.E,'.n__ LlqT{nli?l / non, sur-sical, Ig!'0, qry!rya, tencierness, ahisi:ess
External auditory canall t)ongestion ,cedenra, fungus, polyp, stenosis, osteoma, excstosib
lnspeci pr:stero-supericr region for erosion due to choleseatoma or a rlastoid cavity.
Tympanic rnembrane | 1. Normal appearance
rGlrstenin_9, jigll-s.Jgy"jl-991_o-U_(n_?19--tS_n-:.g)
, Qgllp-o (leis-.{ia,pgq,?)
o $oqe of iiqnlir lhe aqlgpjnfe1g1qgg[raqt
2. Retraction / fiecretory otitis rnedia
e Dull drum
a Loss / distortion of ligirt reflex
r&v, bruls;.f, tnicbeled druni
"o Ag_,bg[Qjes / air fLid level seen
o Fore-shortened handle--of malleus
e Decrea.se^dlnobiiity on seigalisation rn aChesive oiiiis nredia
3. Fe#oration
^ s $tze
e/c Iype
qil$|l-M"etgjr,ql rotai i Ailic
{ -s-Vllqill 1
o Site
- All / v;hich quadrant
- Pars tensa / flaccida
o Rirn of perforation
- l-hirr / thigk
- R9d / pink / white
- Congested i fibrosed
- Oedematous / no.t
- Tympanosclerotic plaques +l
o fuliddle ear mucosa seen through the per{oration
- Pale. pink / pink / red / angry re,1
- Congested i not
- Granuiar i polypoidal / not
- Secretions / discharge, if any-seror-is. / rnricoid I puruleni
o Ossicles seen througylr tlre perloration
- N4alleus
- lncudostapedialjoint

't2
 ClinicalENT
34

PARTICULARS RIGHT AND LEFT EAR - LOOK FOR

'a Eustachian tube oPening seen / not
- Discharge at that site
- lnflamed mucosa +/-
Round and oval window seen / not
Attic
- Congestion / debri / flakes
Retraction pocket
- Site - quadrant
- Position - o'clock
- Fundus seen / not
- Flakes present within / not
- Neck wide / not
- Self emptying / not
Mastoid region Erythema, induration, oedema, tenderness, abscess

TUNING FORK TESTS

Simple and reliable tests
Tests are performed with 256, 512 and 1024 Hzfrequency tuning forks.

RINNE'S TEST
It is a tuning fork test in which air and bone conduciion of the test ear are 9o1!1m90

METHODS
prongs are held
1. The tuning fork is struck gently on the elbow, knee cap or a rubber pad and then the vibrating
at distance of about 1 inch. This step tests the air conduction
against thl ear in line with the external canal a
fork then placed over the mastoid to test the bone conduction' The
of the ear. The footpiece of the vibrating is
of the two sounds. Thus the test compares air conduction of sound to
patient is asked to indicate the louder
than that over the
bone conduction. ln normal / Rinne positive cases, the ear canal sound is better heard
mastoid.i.e. air conduction is better than bone conduction
2. The foot of the vibrating fork is kept over the mastoid bone or the non-hair bearing
skin posterosuperior to the
external audrtory meatus. When it is no more heard it is held infront of the ear'
:
lf it is still heard Rinne Positive
lf it is not heard : Rinne negative
Thls i-q-ilqe1!-e-Lg9$9q-?9-1!9 rgl r'g:.!l-'e prgpgrye{:9ep-le!on 9$ yrllt not llgqr lhe qgund if the fork ie-lept
co_ltinuously over the mastoid

RINNE TEST RESULTS

INTERPRETATION CONDITION
RESULT
Air conduction better than bone conduction o Normal individuals (AC : BC = 2:1)
Rinne positive (R +)
(AC > BC) o Presbyacusis
The point Conductive deafness
Rinne negative (R -) lqlq_c-ol9_ugtion better than air conduction.
gap
at_yhrgl.Rlle !9rns neg.allrie is at an air-bone
qf !5-20 qp-(_q_dB)
 35
Section I -- Case Presentation - Ear

RE;SULT INTERPRETATION

Air and bone conduction, both are reduced but air Sensorineural deafness
Reduced rinne Positive
[R + (reduc;ed)] conduction is still better than bone conduction'(AC
> BC both reduced)
Bone conduction faisely better, with poor or Severe unilateral sensorineural deafness
False negative
(R - False) no response to air conduction- This is because the
patient is actually hearing the bone conducted sound
across the skull through the normal ear" Masking
(the normal ear) is done to avoid this false result'
(BC>AC-False)
Air conduction equals bone conduction (AC = BC) Mild conductive deafness
Rinne equivocal (R =)
Air condr.lction is only heard. (AC oniy) Severe sensorineural deafness

(R + infinite)
Rinn'e infinite negative
go* only heard, tlntested ear is masked Severe conductive deafness
"*Ou"tion
(R - infinite) (BC only)

LOSS
CORRELATION OF RINNE TEST RESULTS WITF{ DEGREE OF I'IEARING
:

DEGREE OF HEARING LOSS Rinne Test

RINNE TEST RESULTS
High specificitY
TUNTNG FORK (HZ) FREQUENCY: Low sensitivitY

NYSTAGMUS
Definition :
rhythmical oscillatory move-
1. Nystagmus is a disturbance of ocular posture characterised by a more or less
ment of the eYes.
2. lt is tlre term applied to a disturbance of ogulqr movement characterised by involuntary, conjugate and
oGn rhythm'ical osciliaiion of ihe eyes'
Types :

1. According to the cause:

o Central with other signs of intracranial disease
hearing'
o Labyrinthine / vestibular with signs of inner ear disease like vertigo, decrease
o Ocular with signs of ophthalmic disease
2. According to its origin :

o Spontaneous : nystagmus occurs on its own

stimuli'
o lnduced : nystagmus is induced by caloric, rotational, galvanic, positional or optokinetic

3. According to movement of the eyeball :

o Horizontal
o Vertical
 Clinical ENT

o Rotatory
o Pendula
4. Acccrding to its characteristic :

c Phasic
e Jerk
Classification :

NystaEmus is classified into thr-ee c!egr*e:,

1. First degree : i'jysiagrnus i:; prrcsi:r'r'i ;'':r'iii,, rqrl;i;11 1j:i,r ilert;6'ii. llcks iri tiie directiort of the quick compo-
fient
2.. Seconddegree : in addrtion, nysierlr'ilris rr;lir; irir,ri:::.)rii wl-ier-l the patient looks siraight in front.
3. Ihird degree : !N"ysiagrnus is aiso 1;r*;eent ,riri:lr iil+., 1;,'.:li*ni iuoks in il:e d!rection of the slow compo-
neni. (iri edditir;it tr thi,r abr;',* t*rJ
x,
':.1 lVlechanisrn of h{ystagmus :

Labyrinthine : I'JorrrallV ihe laby'iilt:-, r;1 q],lll cci, ti ,-: tr-, ris-r,iale e.r'es slawly to the opposite side be-
caLlse oi its torilc ilii.ilit'1. eg. . r-i';l'ri iab"'riritn deviates tlre eyes to the left and vice-versa.
-f
ire r:1i-riyi ee;r;jl$t-'dr,es li:: i::i'rnro;jri ih*,:=ffe:,:i gets ne 'rtraiised and the eyes remain in
ihe ntic!liilc"
Abnormal state : Whe;r orie iai,r,r.iiiith qeis stirnr.;iateo erthei' [-.v ciisc,ase or caloric / positional stimulus it
rilcvcrs the er/e.'!:iall liorr,rir,r tr-' the r:pi.:r:sittl ::ide-slow cornponent. The cerebral cortex
trecornes .iw*;rrs li tl-ic r.r;iu;,rt;on ;rr-rd qurckly cci-rei;t:g tlie deviaticln and brings the eyes to
the origini'il lcsriian.l-[-ri:r -rr;r'.:i; di:,;i.,rlir:n i:. the fast *crnponent of the nystagmus. The
continuous si*w anrl fasi :.ncve,rrrerli uj'irre everhall rorrstitLites the two components of
ilre nyst.:rgrnus. -lire opF{li'}ite {}{-:iiilrF ir', i-^::is,* nf hypoaciirre / dead labyrinth. The unaf-
fectei-j labyrinth beccl-ne:; $tior'lq{:r'aiid i.jr,:viate s ilrc eye to the opposite ie; to the side of
tlie affei:ted eye, lhus tlre slcvu {rofrrIijr€:ir]t {jricurs r:n the affected side and fast on the
unaffeciei si{ie.
Central ; This rlystagrnrrs (.rcii-!f:i dLjt,i iir itLlrl;t,i'tii;iliiiir,:: il-l ilre cerrtr;l! ccnnections of the vestibular
nerve.
Exarnination of nystagrnus
"i
The patient is placecl in good lighrt ann ti"ie e;an-rino:" {iices trre patierirt. he patient's head is kept steady and
he is asked to fo!low tl-ie direct;cn oi'ihe flnger ll;: r:i the exi:riincr.
The examiner's fing_er is-1!gl llepl ai a disl;,incr iro;"i:r iir;rn the irc;rl iength of liie patient, at approximately
45cms.Distancelessthanthefoc:.i iergil:',laJ:i,.,,-',:r-:-!j'n.g,-'{il :ocytrirail -lhc{rngeristhenmoved30"
laterally. Mal€llrqnt og!s!,Je !htg fie!{ lqads_tq olr}'-"rql..i!ll!;r,i ny9!agnurs caL,ised by fatigue of ocular muscles.
Nystagmus is tested by asl<ing the patienl Jy; loqir at ti:e three iinger positions - ceritre, left lateral and right
lateral. Observe the rate. anrplitude i.jnd ih_\iii-lr:r ir; silch r-lirccliorr anr:j whether or not nysl.aEmus is sustained.
The direction of the fast component is the rlir*o-:iion i:i lf-:e rrr,,st..r;JrrL:s. A,l-rolishme nt of nystagmus occurs by four
weeks in labyrinthine destructive lesicns.
Difference between lahyrinth i ne an d central ny*ta grir r"is

i_AtsYRiMri.ltNF CEf{TRAL

Unidirectional
Associafed with vertigo *itir vertigo. Vertigo, if present is like spin-
The vertigo is always rotational, eiiirer tire sun'oundinc; in the h*-'ad.
the patient appears to move.
Not very iong - lasting i I Lrl:!i-l'l[,ir':g
n
r^ Section I
-
Case Presentation - Ear 37

n
n Horizontal
LABYRINTHINE CENTRAL
/ Oblique
Horizontal / Vertical

n
n
Fine
Lesion in semicircular canals
Nvstaqmus increases on visual fixation (eye closure, frenze
glasses, darkness)
Coaqg lSlqggish I viqlgll jerk in.cerebellar.!y-pe

n
I:
lncreases in lhe ditectton of fast phase
Falling and past pointing are present with third degree
nystagmus
Does not vary on oaze I eye movements
Falling and past pointing are often present but do not fol-
low the rules of direction.

I: Positional Nystagmus

I-
t:
WITH VERTIGO

Nystagmus produced when head placed backwards and

WITHOUT VERTIGO

Nystagmus produced when head placed in any position.

n
to one side
Latent period present No latent period (sudden nystagmus)

I:
Giddiness present Giddiness absent
Fatiguable Unfatiguable

t:
n
Above test can be repeated and is positive in peripheral
disorders.
Above test can be repeated and is positive in central le-
sions.

n
Rhomberg's test
Falling test

n
n
Patient stands upright with the feet together and eye closed

RESULT INFERENCE LESION

n
LABYRINTHIhIE CENTRAL

Positive Patient falls Patient falls towards the side of lesion Patient falls away from side of lesion,
Tendency to fall Towards the side of slow component Towards the side of fast component.

TT
I:
I:
Drugs causing nystagmus
1,-4lcohol
,lr-Barbiturates

l- 3. Tranquillizers
u-

I:
4. Anticonvulsants
5. Phenytoin'--

n
F
){
grBenzodiazapenes
1, y-'1 .r'it-t"t{'!.

FISTULA TEST
n
l-
This is the test performed to detect a fistula in the vestibule of the inner ear.
Principle :

l-. Erosion of the bony part of the vestibule (usually the lateral semicircular canal) either by ear disease or trauma
exposes the membranous labyrinth to external pressure changes. lf the labyrinth is functioning, the pressure

l- changes will lead to its stimulation and cause a subjectrve feeling of vertigo, vomiting and associated nystag-

t-
 ClinicalENT

mus. ln the test, external pressure changes are achieved by various methods and erosion /fistula is.demon-
strated by a subjective feeling of vertigo.
The external pressure can be altered by :

1 . Alternativ9ty,-99!P999-[lg"3l-d-rq.lqggil_g--tlg-q-Ag]r-s-qgainst the external meatus, attering the pressure in the

ear canal and stimulating the labyrinth.
2. Using a trggL€qP_e_c-qqln lelncrease and decrease the pressure in the ear canal.
s ut,ngllgggQ"_{gl,'tUgggg_a_ggig"ng-lqltg*ggy"t-g ple,s-9urq c-haqses.
+ BJ'Tgy_lg_giglqlg"!.1_r"
1 p.ot"v".q",l lhe 9a1 Qy_.9._c9!ton_tiqped. appticaror
Fistula test results :

INTERPRETATION RESULT CONDITION

Positive Subjective feeling of giddiness, nausea, Labyrinth is functioning and erosion is present
vomiting with or without nystagmus
False positive Subjective feeling of giddiness with no fis- Seen in ponqenital syphilis {rl-e to hypermobile
tula in the labyrinth stapes foot plate. lt is called as Hennebert's sign
It is also seen after-siap_ed_ec_tamy_
False negative Negative fistula test with the presence of a Seen in a lgqg]g!_y1n-th which does not react to any
fistula in the labyrinth stimurus.ffjtuu.Q (\DeA e1 Qhol ur&Xn4

SITE OF FISTULA TYPE OF NYSTAGMUS

1. Lateral semicircular canal ryy-s*tq.gnq:_tgya_{g !tr9 ry,rpa! _gj-de (tf fistuta is anterior to
the ampulla, then nystagmus is towards the affected sid-e)
2. Posterior canal o ,.Ny.-stagmus in a vertical direction
. Rotatory horizontal nystagmus towards the abnormal ear
4. Superior semicircular canal o Bajalqlf nyglqsmus towards normal

EXAMINATION OF FACIAL NERVE

On Gross Examination :
o Facial asymmetry +/-
. One half / both halves affected
o UMN / LMN Facial Patsy
- Same / opposite half of face affected
- Fore head spared / not
On passive movements :

o lnability to close the eye

o Absence of wrinkling of forehead
o Loss of nasolabial fold
o lnability to blow cheek on one side

On active movements :
The above passive movements are tested with resistance to the particular action
Any associated movements :

e Synkinesis t
o Facialtwitching
n
r" Section I
-
Case Presentation - Ear 39

o
r_ Hemifacial spasm

n o Blepharospasm
Scars of any previous surgery

I: o Ear surgery - Postaural / Endaural scar

o Parotidectomy scar
n Tests for facial nerve function //
a
/ c't,

n 1. Schirmer's test / Lacrimation flow assessment

A smallfilter paper is piaced on both the lower
(Topognostic test done
cqJilrngliyqlhncs:lg1
at bedside)
9.n11-t' and the amount of lacrimation

I: is compared from side to side

Lre_ductton_pflaq-lqratian !o'=9_0"1-"_ gl leSS_S_-mpaledfryilh !qla! lacripqtlgr.r of
potft eyes or bilateral reduction

n
I:
to 250m. is gSl1gtders{qg![ !l
It caqj,e Used A_s_a_potejttia! fqrcXpo_qure_keratitis Bglgqliolr of lacrimation occurs when lesion is at point of
orig_in of greqteq superficial petrosal nerve.

n 2. Stapedial relfex
Contraction of ,stqpqdius mus-clg occurs on presen,ti4g !q_Ud -s*o-Unds to the ear, as a protective mechanism.

n
n
This reflex occurs only if the nerve to stapedius (branch of intact facial nerve) is functioning.
3. Electrodiagnostic tests
o qleqtroqeuronogrqphy

n
n
o electromyography.

TESTS FOR EUSTACHIAN TUBE PATENCY

n
n 1. Valsalva's
TEST METHOD

It is based on the principle of forced

COMMENT
Therapeutic uses of Valsalva's manoeuvre are for

n
:

manoeuvre expiration against a closed glottis. o Retracted ear drum

n
With the mouth tightly closed, the nose o Catarrhal otitis media
is pinched and air is blown out forc- o Aero otitis.

n
rt:
ibly. This increases the pressure in
the post-nasal space and air enters
the middle ear causing the ear drum
to bulge out, if the tube is patent and
Disadvantages of Valsalva's manoeuvre

o
respiration
:

o lt can be performed ony in expiratory phase of

Pressure built up can be very high and can cause

the drum is mobile. dq_lnege tq middte 991 /. q?r d!r-t!_r'

t:
o Patient has to learn the procedure.
o Positive subglottic pressure can lead to hypoxia

I:
(rare) due to peripheral pooling of blood.
o lt_Sa1*be_negative-in norJnal individuals.

t:
F
2. Politzerisation Politzer's bag is a rubber bag of 8 oz Bulging of the tympanic membrane is seen as the
capacity. The bag is attached to a rub- air gushes in.
ber tubing, the other end of which has

t:
a rubber / vulcanite nozzle. The tip of
the nozzle is fitted into the nasal vesti-
bule and the other nostril is pinched.
The air in the bag is pressed while

F
l-
the patient is asked to either swallow

t-'
40 Clinical ENT

TEST METHOD COMMENT

with mouth closed or say the letter 'K'
repeatedly. This manoeuvre opens up
the tubes on swallowing and air
gushes in the middle ear causing
outward movement of the tympanic
membrane. By swallowing or saying
'K'the soft plate touches the poste-
rior pharyngeal wall and air is not al-
lowed to leak into the pharynx and also
nasopharyngeal pressure is main-
tained.
3. Eustachian catheter Eustachian catheiers are malleable lnterpretation :

ization. metallic catheters of varying sizes. A 8 o

Hollow sound : Normal
oz rubber bag is used to blow air o
Wheeze : Narrow lumen stricture
through the catheter. The ear canal is o
Bubbling / Crepitations : Otitis media with middle
plugged with an auscultation tube, ear effusion.
one end of which is placed in the Uses :
examiner's ear and the other end in o To test patency of tube.
the patient's ear. The sound heard by o To diagnose partial / complete obstruction of tube.
the examiner indicates passage of air o To dilate tubal strictures with bougies.
through the eustachian tube. Alterna-
tively the movement of the tympanic
membrane can be heard through the
canal.
Procedure :

The nasal cavity is anaesthetized with

4o/o Xylocaine spray. The eustachian
catheter with its tip facing down is
passed along the floor of the
nasal cavity without touching it till it
reaches the posterior wall of the na-
sopharynx. The catheler is now
brought forwards till the tip hooks
against the posterior edge of the soft
palate. The tip of the catheter (the dire-
ction of which is indicated by the ring
at the proximal end) is rotated by 90n
laterally. A politzer's bag is then at-
tached to the proximal end and is
squeezed to allow air to enter the tube.
From this position if the catheter is
rotated by 1800 to the opposite tube,
rts patency can also be tested.

Seigalization
The Seigle's speculum consist of an aural speculum (of various sizes)with a 10 diopter lens.
n Section I Case Presentation Ear
41

r^ -
The speculum is connected to a side tube which is attached to a rubber
bulb. The rubber bulb can be pressed

r- and released to alter pressure in the ear canal. The speculum should
snugly fit into the earcanal to make the
in the earcanal and pressing the

r: system airiight. The pathology of the ear is examined by fitting the speculum
rubber bulb.

r- Functions

n The Seigle's speculum is helpful in the following ways :

1 . To g ive a ne grr il! ed v-ie-w- qllh e. lyll p g i-lic 1!
gmb ra n e

t: 2. To give a [agdled -Vtp"W ol-1]:r.q--p"gl!:Lo!-gy (eg. : perforation)

n 3. To asg-ess mg,bllity of ihe tympanic tr-rg1rh,rane

4. To e'licit fistula sign by causing alteration in.ear canal pressure

n 5. To instill rnedication or suck out discharge from the middle ear by varying pressure
in the ear canal'

n
n
Examination of the eyes :
The eyes are inspected for nystagmus (refer page 35)

Corneal reflex :

n
which would result in brisk blinking
This reflex is tested with a wisp of cotton wool applied to the cornea laterally
or ciosure cf the eyes. The afferent arm of the reflex is by the trigeminal
nerve and the efferent is by the facial

n
'rhe reflex may be absent in lesions affecting the faclal nerve.
nerve.

t:
I:
n
I:
t:
I:
t:
n
r
rr
n
r
r
tr
r
 4. INVESTIGATIONS

The following investigations may be done in a patient with chronic otitis media :

L Ear microscopy
o Confirmation of ear findings
o Finding hidden cholesteatoma / squamous epithelium
o Knowing ossicular chain status
o Collection of discharge for smear, culture and antibiotic sensitivity testing
o Suction and cleaning of ear
o Probing of retraction pockets
2. Routine investigations
o Haemogram
o Blood sugar analysis
o Urine examination
o X'ray chest and electrocardiogram if required
3. Pure tone audiometry
o To know the type and amount of hearing loss !
o To compare pre and post - operative results
For medico-legal purposes
4. X'ray mastoid - Schuller's view
o For destruction of mastoid air cell system
o To see cholesteatoma cavity
o Boundaries / anatomy of mastoid region
o To detect a low-lying dura or an anteriorly / posteriorly placed sinus plate
5. X'ray paranasal sinuses - Water and Caldwell's view to rule out sinus infection before surgery

42
n
I: 5. CHRONIG SUPPI.JRATIVE OTITIS
Ir: MED!A
r: Definition
Chronic suppurative otitis media is a chronic inflammatory
process involving the middle ear cleft and producing

r: irreversible pathological changes' lt is due to improper

and inadequate treatment of acute suppurative otitis

n media.

Predisposing factors
o Poor general condition
F: o lmproper diet / nutrition
r: o Chronic tonsilloadenitis
o Sinusitis
r" o Specific infections like
r_ - Measles
r:
r
- Scarlet fever
- DiPhtheria
- Tuberculosis
Types
r_
:

It is basicallY of two tYPes

r" 1, TubotYmPanic tYPe

n 2. AtticoantraltYPe

n
n
1, TUBOTYMPANIC TYPE
It is a benign type of chronic suppurative otitis
Types :
media confined only to the middle ear cleft

or nasopharynx and reaches the

r: 1.'.Tubal : The focus of infection lies in the nose, paranasal sinuses

miOOte ear via the eustachian tube lt is usually seen in cUgryn of low soql,q:economlc

t:
I:
2
_rympan
c:
status.

njH y[3 ;H:::jf[';tr1ilj[,#i*_""1,#ffiff*:T::JJ[:?:

of water entering
;"i g*"; iiJ" to recurrent infeciion !ryav the ear
:l#';ffifffr
(Persistent perfora-

I:
r: Pathology
ir; iv"oi"",e) lt is usually seen in6oJtF and involves gne ear only'

1. Persistent mucosal disease

tube or through a perforation in the tympanlc mem-

t:, lnfection reaches the middle ear either via the eustachian
brane. lnfection in middle ear leads to hyperplasia
of middle *r"oru. lt can also lead to polyp formation by

n
n
prolapse of oedematous mucosa. the muclsal prolrferation
2. Cholesterol granuloma
cholesterol granuloma like picture occurs when there
exudation of mucoid fluid with an inflammatory reaction.
"u|.
leads to chronicity by trapping of infection'

is defective ventilation of the middle-ear cleft'

There is release of cholesterol crystals
middle
leading to
and
ear
blood
cleft
pigments giving a biuB ting{o the tympln1c'membr3ne'
The mucous membrane of the
crystals' foreign

F
granuloma. lt-shows cholesterol
shows the typical histopathological picture oi a chotesierol
and mucin granules'

r
body giant cells, granuiation tissue, haemosiderin

43

l-'
 44 Clinical ENT

Clinical features
Types of tympanic membrane perforations :
1. Tubal type
o Central
o Profuse bilateral mucopurulent discharge o Marginal
o Running nose o Attic
o Bilateral anterior perforation in tympanic membrane o Subtotal
o Nasal examination shows either a deviated septum or o Total
signs of sinusitis
o Adenoids are usually present.
2. Tympanic type
o Scanty discharge in one external auditory canal
o Large (subtotal) central perforation seen, more often kidney shaped
o Granulations and polypi may be seen in the middle ear
o Pure tone audiometry reveals atleast moderate conductive hearing loss. These patients hear better when
the external canal is full of pus as the thick pus seals off the defect in the tympanic membrane leading to
better transmission of sound. wrnSouo th!"
PERFORATION DEFINITION PATHOLOGY

Central It it u rnd Tubotympanic disease confined to middle ear

surrounded !y tympanic rng_Gblate-aX_arclld. Sinusitis/adenotonsillitis may be present.
Marginal It is a perforation in which bone forms any Bony necrosis associated with grang@lions and
of the edqe of the perforation cholesteatoma.
Attic It is a perforation, which occurs in the pars Associated with cholesteatoma
flaccida of tympanic membrane
Subtotal t
L's g_pef g_{_qtio n, _wh ch s, s u rro u n d ed by_![e
!
i Tubotympanic disease
annulus on all sides.
- :ir Total It is a perforation in which there is corlglgte Tubotympanic disease
lqs_9 of tympanic membrane and annulus. Associated exanthematgus fever.

Stages of tubotympamic disease

1. Active o When there is active discharge from the ear
2. Quiescent o Discharge from the ear stops and becomes dry
a A small perforation may heal in about 6 months
a A big perforation remains open, needs repair
3. lnactive . No discharge
a Disease is inactive
a Ear has been dry for more than 6 months
o When the ear stays in the quiescent stage for more than 6 months, it becomes inactive
o Perforation needs to be closed by plastic repair

INVESTIGATIONS
1. Tuning fork tests 3. Smear, culture and antibiotic sensitivity test of the discharge
2. Pure tone audiometry 4. X'ray mastoid and paranasal sinuses may be needed in some cases.

TREATMENT
Aim :

'1
. To control infection 3. To make the ear dry
2. To treat underlying cause 4. To restore hearing.
 45
Section | Case Presentation - Ear
-
Medical treatment
AuralToilet
The external and middle ear is cleaned by
o Sterile drY cotton wool moPs
o Synnging
o Suction
powder insufflation in big perforations'
cleaning is followed by instillation of eardrops in small perforations and

Thepowdershouldbejustenoughtoformathinfilmandnotathicklayerasithindersdrainaggandcauses
cotton vaseInL should foilow instillation of
eardrops'
material rike
irritation. prugging *re ear with nonabsorbent the condition worsens, allergy to drops
with frequent aurar toiret, the ear shourd uu"or" iry in 2-3 weeks. rf
'ocal
or powder should be susPected'

Zinc lonization
otitis media'
It is a line of treatment for safe chronic supp-urative
germicidal and bactericidal' The inflamma-
principle : lontophoresis : ln which zinc ions are liberated which are
organisms decrease in number'
tory process subsides as soon as infecting
Pre-requisites
o Central perforation, which is large
r lnfection confined to middle ear'
o No cholesteatoma, granulations or polyp' /t
,l
Procedure /
Supine position with affected ear up'
Avu|caniteauralspeculumiskeptintheearandthecanalisfilledwith2o/ozincsulphatesolution.
to a part of any limb wrapped in a moist
positive electrode is attached to the speculum and negative electrode
upto 3-4 mA and then
croth. The current is passed through the
electrodes for*about 20 minutes, lncreasing
decreasingtozero.ltrequires3-4applicationstoobtainadryear.somepatientsmaynotimproveandanaural
have to be dealt by myrinogoplasty'
per{oration may
swab culture may be required. Persistent

Surgical treatment
o MyringoPlastY
o TympanoPlastY

Patch Test
in patients with a central perforation
o -,,lt is a test used to assess any gain in hearing following a myringoplasty
with a central perforation'
: llrp; urr"".ing whether myingoplasty will be helpful to a patient
Procedure perforation'
gelatin sponge'.lt is then placed over the
A patch is made of cigarette paper or compressed patch.
Tuning fork tests or audiological tesis are
done before und uft"|. application of the

lnterpretation
INTERPRETATION

lntact ossicular chain

Ossicular discontinuitY OssiculoPlastY is needed
Ossicular fixation StapedectomY is needed

2. ATTICO-ANTRAL TYPE
Thisisanunsafetypeofchronicsuppurativeotrtismediaandisusuallyassociatedwithcholesteatoma
of its incidence of intracranial complications'
disease b-ecause
formation, rt is a rerativery dangerous type of
46 ClinicalENT

CHOLESTEATOMA
DEFINITION
Cjqleglgatoma has been defined as a three dimensional stratified squamous epithelial sac confirming to the
analomy oithe middle ear cleft, containing keratin debri and having the capacity for progressive and independent
growth at the expense of the underlying bone.
It is a misnomer as it is not a tumour nor does it contain cholesterol crystals or fat.

HISTORY
Johannes Muller - Cholesteatoma- term
Schuknecht - Keratoma

ORIGIN OF CHOLESTEATOMA :

Toynbee It arises from hair follicles / glands of external ear ("Molluscous lllng!4
Habermann and Bezold It arises from squamous epithelium of ear canal
Von Troeltsch It arises from inspissated exudation of chronically inflqtg9Mglg
Politzer Formation of epithelial lining in downgroMh of mucosa
Habermann Role of embryonic remnant in development of attic cholesteatoma
Bezold Role of eustachian tube in formation of cholesteatoma

PATHOGENESIS OF CHOLESTEATOMA
Cholesteatoma may be classified according to its etiology into :

1. Congenital
2. Acquired
a) Primary b) Secondary

1. CONGENITAL CHOLESTEATOMA :
Definition : (Derlacki and Clemis)
Embryonic'Sst of epithelial tissue in an ear without tympanic membrane perforation in a patient without a
history of ear infection.
Criteria for definitio n !l-nt^y\a^'ry t Jn;1
o White mass medial to a normal tympanic membrane
o Normal pars flaccida and pars tensa.
o No prior history of otorrhoea or perforation.
o No prior otologic procedures.
(Canal atresia and intra membranous and giant cholesteatomas are excluded.
Prior bouts of otitis media are not grounds for exclusion).
lncidence
o Sex - M:F = 3:1
o Mean age at presentation : 4.5 years
o Antero superior quadrant is affected more than the other quadrants
Pathogenesis of con genital cholesteatoma
Asquamous cell rest- the epidermoid formation, identifiablefrom 10-33 weeks of gestation in the anterior
superior lateral wall of the tympanic cavity has been held responsible for its origin
 Case Presentation - Ear
Y^ Section |
-

t:
t:
lf the epiermoid formation failed to involute, its continued presence and
later expansion could result in its
eventual appearance medial to the tympanic membrane in the anterior superior
a congenital cholesteatomai On furiher migration, the congenital cholestedtoma
quadrant of the middle ear as
can occur in thb posterior

n
t:
middle ear space.
2. ACQUIRED CHOLESTEATOMA
1. Primary acquired cholesteatoma
ln this type, therejhas been no predisposing chronic otitis media and cholesteatoma
occurs in theattic or

l: in the posterior part of the tympanic cavity'

2. Secondary acquired cholesteatoma

I:
chronic disease with defects
ln this type, cholesteatoma develops in ears which have suffered from active

rt: THEORIES

1.
in the tymPanic membrane.

CHOLESTEATOMA

n
fmplantation into the
o Trauma Penetrating or blast injury causes implantation of squamous epiltheluim

rr
pneumatized portions of the temporal bone.
fn *t *tg".y medial displacement of epilthelium occurs during
i) burial of epilthelium under an onlay graft in tympanoplasty
ii) during insertion of ventilation tubes

n r iii) following removal

lnvasion of squamous epilthelium inwards following perforation by acute

otitis media

r
F-
3. Metaplasia
Mechanismt
(Reudi)
11_F _,-,
Stimulation of basilar layer of squamous epilthelium of pars flaccida by
papillaryingrowth+expands+accumulationofkeratindebri+cholesteatoma
inflammation +

n
r
R"r'd*i mesenchymal tissue in epitympanum (pleuripotent) undergoes metaplasia
inflammation + keratinizing epithelium capable of migration in both
directions =
due
cyst =

r
bursts externally = cholesteatoma'
Negative middle ear Eustachian tube malfunction
pressure (Whitmacks u
Fluctuating positive and negative pressure
u

F
atelectasis
Marked excursions on the tympanic membrane, loss of elasticity and subsequent

rr
1,

Attic and Posterosuperior region

i,
Retraction Pocket formation
u

r
rn
Grows inwards

later +
IJ

lnitially self cleansing

u
neck becomes narrow
I
accumulation of debris + foreign body inflammatory reaction
U

-u\
granulation tissue formation i

tr
r new areas into which squamous epilthelium would penetrate

rr
 48
CIinicalENT

PATHOLOGIC ANATOMY OF CHOLESTEATOMA

Gross :

o Pearly grey or yellow, well defined structure

o Usually situated in the upper posterior part of the middle ear cleft
o May extend through the aditus into the mastoid antrum and mastoid air cells
o Ossicles and/or the scutum may be eroded
o Layer of granulation tissue is always present between the sac and underlying bone
Histopathology
1. Perimatrix : Granulation tissue layer between the sac and the underlying bone.
2. Matrix :

a) Corneallayer
It is the pearly material of the cholesteatoma. lf consists of dead, fully differentiated, anucleate keratin
squames.
b) Thin granular layer prior to the malphigian layer
c) Malphigian layer of 5-6 rows of cells with intercellular prickles
d) Basal layer made up of small cuboidal cells
The deeper layers show downgrowths into the underlying connective tissue separating cholesteatoma into
lobules.

Causes of bone erosion by cholesteatoma

1. Pressure theory : Tumour causing pressure necrosis of the surrounding bone
2' Pyogenic osteitis : Secondary bacterial infection causes pyogenic osteitis which causes necrosis and scle-
rosis of the surrounding bone
3. Enzyme theory : ln presence of the granulation layer, enzymes are released by the osteoclasts.
The enzymes are :
o Acid phosphatase I Transforming growth factor (TGF)
o Collagenase re' Tumour necrotising factor (TNF)
o Proteolytic enzymes o lnterleukins ,-
r- Epidermalgrowth factor (EGF) o Prostaglandins -

SURGICAL ANATOMY OF CHOLESTEATOMA

A cholesteatoma can be a :

1. Posterior epitympanic cholesteatoma :

Originating in the Prussak's space and passing via

a) Superior incudal space into aditus and antrum
b) lnferior incudal space by descending through the floor of Prussak's space into posterior pouch of von
Troltsch into middle ear.
2. Posterior mesotympanic cholesteatoma :

It is formed due to retraction of posterior portion of pars tensa and spreads to involve stapes, long process
of incus, facial recess, sinus tympani or to mastoid via posterior tympanic isthmus. lt passes medial to malleus t
head and incus while passing to mastoid in contrast to posterior epitympanic cholesteatoma which passes
laterally to these structures. I
3. Anterior epitympanic cholesteatoma :

o lt is formed from epitympanic retraction anterior to head of malleus.

o lt may involve geniculate ganglion, horizontal part of Vll nerve causing facial nerve dysfunction
:
o lt reaches middle ear via anterior pouch of von Troltsch to involve the eustachian tube
t
E Section | Case Presentation - Ear
49

-
F Clinical Features
Symptoms
]: 1. Otorrhoea

n o
o
Purulent

n o
o
Foul smelling
Scanty

r: 2. Deafness
Blood-stained

I; o
o
Slow onset

n
Progressive
o Associated with tinnitus
3. onset of vertigo, vomiting, headache may signify intracranial complications'
1:
n Signs
1. Tympanic membrane defect

n
n
a) Attic perforation : The perforation is present

b)
in the pars flaccida of the tympanic membrane' lt is asso-
ciated with cholesteatoma formation. The perforation may be covered
by granulations or polypii'
posterosuperior marginal perforation : one of the edge of the perforation is formed by bone, rest by the
tympanic membrane] lt indicates bony necrosis associated with cholesteatoma
and granulation' Cho-

n
n
lesteatoma is seen as white shiny flakes present in the
2. Fistula sign maY be Positive.
postero-superior region'

E
MANAGEMENT

t:
History:
and a solution of 4ok
office management of cholesteatoma by irrigating with antral cannulas
Boric acid + Salicylic acid at room temperature

T:
t:
Stacke (1893) First radical mastoid surgery
Heath (1904) Heath's modification of the above surgery'

n
n
Bondy (1910)
Tumarkin (1948)
Modified radical mastoid surgery.

History and assesment of the patient

o Examination of the ear in detail

F
a) For character, colour, consistency of discharge
b) ln external auditory canalfor :
- Destruction of bone

rl-
T: -
-
-
PolYPs, granulations
Flakes
SecondarY otitis externa

rrr
- Bulge in Posterior canal wall
c) Suction aspiration of the discharge
o Fistula sign
o Examination under microscoPe
- Exact site of origin, posterior limit of cholesteatoma
- Status of ossicles

r
50 Clinical ENT

Status of tympanic membrane

Swab for culture sensitivity
The culture usually reveals mixed group of organisms like -
- Bacillus proteus
- Pseudomonasaeruginosa
- Pseudomonaspyocaneous
- Anaerobic bacteria, which are the cause for the secondary infection

INVESTIGATIONS
1. Pure tone audiometry
o For documentation
o lt usually reveals conductive hearing loss unless the inner ear is involved.
o For comparing the pre operative and post operative hearing status
. o For medicolegal purpose
2. X'ray mastoid (Schuller's view / Towne's / Law's view)
o Configuration of mastoid Signs of cholesteatonla on x'ray
o Anatomical landmarks ?,-Loss of normal osseous pattern of attic
- Sinus plate YWidened aditus
- Dural plate r/ Antral enlargement
- Sinoduralangle o Radiolucent bone defect in the antral area surrounded by thin osteitic bone
o Extension of disease rosion of dural / sinus plate

(seen as a lytic shadow with surrounding sclerosis)

3. C. T. scan ofTemporal bone
The following features are looked for :
o Presence of soft tissue erosion and destruction of scutum
o Widened aditus
o Lateral displacement of ossicles with destruction
o Presence of fistula
o Erosion of facial canal {

o Dehiscence of tegmen tympani

o Destruction of mastoid
o Dehiscence of sigmoid plate with or without sinus thrombosis
o Erosion and sagging of the EAC
o Atypical locations of cholesteatoma
- EAC cholesteatoma
- Petrous apex cholesteatoma

TREATMENT
Surgery is the treatment of choice for majority of the cases.
Aims and objectives of surgery :
g.-complete eradication of the disease
r""to provide the patient with a safe and dry ear
r'to improve or preserve the hearing acuity
r'"-to minimize the need for long-term care of the operated ear.
r^ Section I Case Presentation - Ear

fn -
Approachesavailable:'

rr
1. Canalwall down (open) procedures
o Atticotomy
o Classical radical mastoidectomy

rr
o Modified radical mastoidectomY
o Modern modified radical mastoidectomy (Tympanomasioidectomy)
2. Canalwall up procedures (closed)
o Combined approach tympanoplasty / Posterior tympanotomy

rr Easy to
CANAL WALL DOWN

Good access
perform v Technically difficult
Relatively poor access
CANAL WALL UP

n
External auditory canal contour lost Normal contour of external auditory canal is maintained

rr
F Shallow middle ear Normal middle ear
Cavity problems are present Absent cavity problems
o Discharge r-z
o Dizzinesslr
o r--

n
Deafness
o Disability''-"

n
o Doctor dependencet/
Lesser reccurence rate Higher rates for the same

n
rr
RECIVIDISM
Residual cholesteatoma :
It can be defined as a disease that grows back from viable squamous epithelium that was not removed
initial procedure
at the

Recurrence: .

It can be defined as a disease that grows back because of the inability of the eustachian tube to
adequately

F
and bone
aerate the middle ear, mastoid or both, resulting in retraction of the ear drum with keratin accumulation
resorption
clinically it became difficult to differentiate between a residual and a recurrent cholesteatoma, so a new concept

tr
of RECIVIDISM was introduced, encompassing both the above types of disease.

r
Causes of residual cholesteatoma Sites of residual cholesteatoma :

1. Squamous epithelium left behind as in

rH
:
Sinus tympani
a) Canalwall up surgery Anterior epitympanum and eustachian tube
b) lnaccessible areas o Medial to ossicular heads
c) On purpose inodural angle
.r-'To cover a lateral semicircular canal fistula. Mastoid tip
.J- To cover a facial nerve. o Peri labyrinthine region'--".

.o' Over stapes foot plate. o Over footplate of staPes

F 2. lmproper lowering of the facial ridge.

lmproper drainage of the cavitY

tr
+- lnadequate meatoplastY.
Management of residual cholesteatoma

r
:

1. Small residual keratin pearls are excised

r
52 Clinical ENT

2. Revision mastoidectomy :

o Canal wall up procedLlre is converted to canal wall down mastoidectorny

o Adequate lowering of facial ridge is achieved
I
o The affected sites are exposed and the matrix is removed
o Good meatoplasty is made I
3. Close follow up of the patient is essential
a
I
Difference between Safe and Unsafe ear
SAFE EAR UNSAFE EAR
t
Type of disease Tubotvmpanic Atticoantral I
Perforation Central Attic/maronial
Discharge Mucoid Purulent, cheesy \
Copious Scanty
Non foul-smelling Foul-smelling
lntermittent Continuous
Bleeding Rare Often
Rare Common
Granulation/polypi t
Squamous epithelium Not present Present
Focus of infection Present in respiratory tract. lncrease in discharge Absent t
is seen during respiratory tract infection No change in discharge during respiratory t
infection \
Ossicular chain Less destruction More destruction
Mild to moderate Moderate to severe
\
Deafness
Audiogram Conductive hearinq loss Mixed hearing loss
X'ray mastoid Cellular/sclerotic Sclerotic with a destruction cavity
Complications Rare Fatal complications can occur \
Prognosis Good Not good because of complications
t

t
n
Y^
n 6. TUBERCULOUS OTITIS MEDIA
n
n
n Tuberculous otitis media is quite common in lndia. lt is almost always secondary to pulmonary tuberculosis.

I:
n
Routes of infection
1. Eustachian tube :
:

The tubercular bacilli are coughed out in the sputum from the infected lungs. This
infected sputum reaches the eustachian tube while coughing and enters the middle

t:
I: 3.
ear via the tube.
2. Drinking unpasteurised milk of infected cows can cause the disease.
Blood borne infection in those suffering from-glbyqig.(ndliary.-t*qQerculosis)

t:
I
The infection can spread to the labyrinth through the round and oval window. lt may spread to the mastoid via
the haematogenous route.

Clinical features :

t:
1. Slow onset of disease
r"k Painles-s condition

t:
n
' &- IlIl *s g,q l ty a. n-d..-o. lptt
4. Pale yellow colour of the tympanic membrane
t l.q

5. Posierior part of tympanic membrane is bulging

p,s d i s c h a rg e

n
6. Anterior part of tympanic membrane shows dilated blood vessels.
'J<-lvlgltiple perf,o-rations of tympanic membrane. The perforations are caused by necrosis of the drum by the

t:
t:
breakdown of multiple tubercles which are formed on the tympanic membrane.
r&-The perforations may be associated with pale granu.lations, which recur after removal
9: Frequent involvement of the facje|4gty'p
g0tgg!!g lqs_s
by the disease process.
-occurs
is disproportionate to the ear findings.
ll.lntraoperatively, lot of sequestra and bony granulations are seen.

F Diagnosis :

Confirmation of disease is done by smear and culture of discharge or by biopsy of granulations.

Treatment

F
:

1. Antitubercular therapy consisting of four drug regime

t-
o lsoniazid
o RifamPicin f.\(i:;i:"

t:
t-
o Ethambutol
o Pyrazinamide
2. Surgical treatment is indicated in tuberculous mastoiditis with caries and granulations
o Removal of granulations
o Removal of bony sequestra via a mastoidectomy approach.

F
F
l--
l*.
l*
53
 7. TYMPANOSCLEROSIS

SYNONYMS
Chronic adhesive otitis media
Chronic adhesive catarrh

DEFINITION
It is an abnormal condition in wnicfr, local deposition of plaques of collagen along with calcerous deposits are
seen in the submucosa of middle ear cavity. When it is confined to the tympanic membrane, it is called a "Chalk
patch." ,'
Sites : lt affects tympanic membrane, ossicular ligaments, interosseous joints, muscle tendons and submu-
cosal spaces.
Common sites Other sites Rare sites
r Qlqpespyqlwindowarea o Long process of incus o Hypotympanum
o Sub-fallopian groove o Stapedius tendon o Eustachian tube area
o Upper promontory o Horizontal portion of fallopian canal. o Round window niche
o Epitympanum
o Malleus

TYPES:
1. Depending on the integrity of the tympanic membrane :

o Open
o Closed
2. Depending on the consistencY
o Soft
o Dense / hard
3. Depending on the histologY :

r Sclerosing mucositis
It is a superficial non-invasive form in which surrounding mucosa and perrosteum remain intact
o OsteoclasticmucoPeriostitis
It is a deeper invasive form in which underlying bone is destructed.

PATHOLOGY
The main pathology is hyalinosis ie; hyaline degeneration of the collagen in which calcium is deposited. ln the
healing process of otiiis media, the collagen in the fibrous tissue hyalinizes, looses its structure and becomes
fused into a homogenous mass. Calcification then occurs followed by ossification. These deposits form in narrow
glandular
spaces where inflimmatory exudates accumulate during infection The reduction in ciliary activity and
plaques'
secretion decreases the elimination of these exudates. They thus get organized to form tympanosclerotic

CLINICAL FEATURES
o Past history of otitis media
o Deafness
- Stationary or Progressive

54
Section I Case Presentation - Ear 55
-
- Mainly conductive, sometimes sensorineural
- Hearing loss of about 30 dB
o Tinnitus
o Signs
- Signs of past attack of otitis media
- rympqlr9-1rtql$_pne, yv!! 9l9w wh1!9_qhalky pa(qhes
- !:!aY"-b-e-m-obile
- -Plgq
Fibrosis and adhesions will be there between the drum, ossicles and promontory
- 9IqL4-p-9!9Jr9-q.ot'r-er oss-icf qs
- QS-sipqlar immobility
Fi bp gg*liqsug Ll fqqnQ g nQ.gyal w!nd gw 4 igh gs

DIAGNOSIS
. Beg-|htp!,qry 9f otllis mediq
o lgql4gss
o Qhelly-pqt,c,he-s_ oyer dry1n
o Bloc_kg$ 9!s!ag_h1pq1 !q b9_
DIFFERENTIAL DIAGNOSIS
1. Otosclerosis : lt is difficult to differentiate between the two especially. if tympanosclerosis only involves the
ogg-c-lp-q-qng-ty.n p.-elf'tj f"
ien,4lij";q*ai. pasi rristoiy ot otiiii meoii and'a negative famityhistory hetps
to differentiate the condition. !r{!pan-o_!.gmy'may Qg rreeded at times. Also the conductive deafness is usu-
ally nonprogressive and the mastoid is acellular.
2. Oho-le-s-tealqma CIags -: lt lacks the glistening appearance of a tympanosclerotic plaque and is softer to
touch.

TREATMENT
1. Prevent progress of disease
o Tonsilloadenqjdqqlgqy
o Treatment of sinusitis
o M.ylngotomy / aspiratio_n of effusion
2. No_trealmel! lor.sqal! plaqqqs wjth no hga{19 loss
3 Sgr_g1c-af tregtment (only if euglachi3q tube.--!s patgnt)
$
. Rglqelgglgi9-dlq egr aQl,rggions
. 39-n9vd _._l
pl_eqy-"_.
o Mp bllLZati=o n,o{ _o_r s_!qle.s
o Slgpe_d99_t-om1r (if th-e_ footpl_ate is fixed)
o Fenqstralign opelatlon
4 H,garing alds are used for advanced cases.
 8. OTOTOXICITY

The following drugs are ototoxic :

DRUG SYMPTOMS MECHANISM OF ACTION

h Antimalarials Decrease otoacoustic emissions ddiosyncratic reaction occurs with even small
J-
o Quinine doses of Quinine
o AFE
4e .'g-g9l9greq-P-!o9! flow to cochlea / stria
Chloroquine
o,Vasoconstriction of small vesse_ls / ischaemic
effect.
o"Degeqerative changes in s-P[elganglion.
2."/Diuretics
o Frusemide Reversible hearing loss
o Ethacrynic acid
3YAntiepileptics
o Phenytoin Vestibulotoxic
&P
o Ethosuximide
4. Antiheparinizing agents
o Hexadimethrinebromide Deafness Degeneration of orqan of corti and stria yascularis
5. Antibiotics
o./Gncomycin Deafness Ototoxic
r vdapromycin
o'.,,AmPicillin
o id hloramphenicol
6. Topical Agents
o Chlorhexidine in alcohol Deafness Absorption through round or oval window.
o Ear drops containing Neo-
mycin
o Framycetin
o Polymycin
7. Miscellaneous
o Mercury Deafness Eight nervq qeqltls
r Arsenic Deafness Herxbpute',I%91!on
o Tobacco Tgxic neuritis
o Alcohol
o B -Blockers Deafness
- c Prooanolol ?
-)+\
- \L4+-
oxvorenolol \\
- " Fractolol )

o q{glolic changes in organ of qqrti.

Nitrogen mustard

MANAGEMENT
o patient on drug therapy
Suspicion of ototoxicity if high pitched tinnitus and deafness occurs in a
o Stoppage of drug use.

56
Section I Case Presentation - Ear 57
-
o Mqltjyrtamins for nerve regenelation
o Labyrinthine sedatives for vertigo
. lg,qllng aid for deafness.

-Clwn^h^o a Jec'lne'ls -+ o{r'toxiLiry J

L1+,, {'rrci^t}
n
rr
n
n
r:
n
rn
r:
1:
r:
I:
n
n
rn tosr
r
r-
rr-
]-
r:
r:
rr
rr
r
 1. HISTORY AND EXAMINATION

History and Examination

Name, Age, Sex, Religion, Occupation, Marital Status, Postal address'
Age :

Young Nasopharyngeal angiofibroma

Rhinosporidiosis
Elderly Carcinoma maxilla
Sex :

Males Nasopharyngeal angiofibroma

Rhinosporidiosis
Carcinomas
'il':Females Atrophg*rhinitis
Address
Rhinosporidiosis Aong@ureas in tropical countries like-tnc@-Eangladesh--S-ri Lanka.-Afriea.-
Rhinoscleroma : Rural areas of lndia. S.puth A.l'ica, g

Occupation : Rhinosporidiosis :

Farmers : Rhinggroridiosis Coastal areas of lndia

Dusty environment: Vas*qntalqJh4i!g-- Bangladesh
Sri Lanka
Chief Complaints :
Af rica
o H/o Rhinorrhoea / nasal discharge
r H/o Nasal obstruction / blockage
o H/o Headache
o H/o SneEzing
o H/o Lo-ss / decrease / change in sense of smell.
r H/o Epistaxis / bleeding from the nose.
progress.
Each of the above complaint has to be described in detail with their onset, duration and

Other Complaints :
o H/o fever with redness / swelling in association with nose or paranasal sinuses.(acute vestibulitis, furuncu-
losiS, acute rhinitis / siriusitis, septat abscess, secondary infection of a nasal /
paranasal mass, nasal frac-
tures)
nasal fracture.)
,1r,Alo trauma / nose picking (cause of epistaxis, underlying
,VHto use of nasal packs (epistaxis, bleeding diasthesis, trauma, hypertension, spontaneous or induced
bleeding due to surgicai manipulation of a nasal mass, routine use of packs post-operatively in
nasal sur-
geries).
o H/o lacrimation (nasal packing, nasal mass / polypii blocking nasolacrimal duct, orbital complication of si-
nusitis).
invasion,
o H/o visual disturpances / diplo,pia (sinusitis with orbital complications, nasal masses with orbital
malignancy).
o H/o earache (eustachian tube block by acute / chronic rhinosinusitis, nasal mass.obstructing eustachian
tube, malignancY.)
58
 Section I Case Presentation - Nose 59
-
,p/Hlo recurrent upper respiratory tract infection / cough (nasal mass / polypii / severe deviated nasal septum
causing blockage of ostiomeatal complex and recurrent upper respiratory tract infection, secondary infection
of nasal mass and chronic sinusitis causing post-nasal drip and cough.)
o H/o loss of sensations over front of cheek (infraorbital anaesthesia in carcinoma maxilla).
o H/o mouth breathing, snoring, (adenoid hypertrophy, nasal / nasopharyngeal mass, upper respiratory tract
infection).
o H/o difficulty in speech / loss of nasal twang (huge nasal / nasopharyngeal mass hql1peqg Jgigg!_by its
mechqljgelQbggqction, absgnt / imprgLer palatal movements ana ng
@ch).
Past History :
o H/o evening rise of temperature, loss of weight, appetite (Kochs / Koch's contact, tuberculosis of nose -
nodular / ulcerative, lupus vulgaris).
o H/o blood pressure (Blood pressure - epistaxis, relative contraindication to surgery), Diabetes mellitus (fun-
gal in,fections of nose), Asthma (associated nasal allergy), Allergy (allergic rhinitis, vasomotor rhinitis, eth-
moidal polypii, asthma).
,, H/o sexually transmitted diseases (syphilis gumma on septum, yarys - nodules in nose).
t9 H/o similar complaints in the past (recurrent ethmoidal polypii, recurrence of carcinoma).
t H/o any rnedica[ / surgical treatment in the past.
Personal History :
o H/o smoking, alcoholism, drug / snuff addiction (septa.l perforation in addicts.)
o H/o excessive use of nasal decongestants, hypotensive drugs (rhinitis medicamentosa, chronic nasal ob-
struction)
Family History:
o H/o similar complaints in the family (Allergy, Asthma, polypii).
o H/o Bleeding disorders i hypertension / diabetes mellitus

GENERAL EXAMINATION
Pallor is seen in :
Saddle nose deformity is seen in :
o Nasopharyngeal angiofibroma
o Congenital Syphilis
. Repeated epistaxis.
o Tertiary Syphilis

LOCAL EXAMINATION o Post-traumatic

o External examination o Post-operative

o lntranasal examination o Septoplasty

o Examination of paranasal sinuses. r Nasal surgeries
o Septal;bscess / haematoma
EXTERNAL EXAMINATION : o Sarcoidosis
lnspection . For obvious deformities of nasal form. o Wegener's granulomatosis.
Nasal bridge deformities : Saddle - nose
Hump deformity
Crooked nose
Bridge deviation
Obvious scars, sinuses, cysts, ulcers, growth (Rodent ulcer, lupus vulgaris on skin of nose.)
Broadening of nose. (Large polyps, malignancy) t

Swelling, redness of skin over nose, surrounding area (Vestibulitis, furuculosis, rhinophyma)
t

I
60 ClinicalENT

Examination of the shape of the nose, columella and position of caudal septum with respect to the col-
umella can be done by asking the patient to raise the chin and looking from the front and the sides.
Simple elevation of the tip of the nose allows assessment of the membranous septum, the valve region and
the floor.
Palpation :

o Palpation of cyst, sinuses,.growth, ulcers etc.

o Palpation of the bridge for assessment of deformity, fractures, crepitus, oedema,.
o LoqK for woody feel in rhinoscleroma.
o Palpation of the bony and cartilagenous vault with special emphasis on the areas around the inner canthus
of the eye and the alar base.
o Patient can be told to take a heavy breadth and alar collapse can be looked for during inspiration.
Anterior Rhinoscopy :
It is the examination of the anterior nares and nasal cavity using a nasal speculum. Usually a Thudicum's
nasal speculum is used. The speculum is held at the junction of the two prongs by the thumb and index finger
in the left hand with the blades facing the patient. The spring action of the prongs is controlled by the ring and
middle finger. li is introduced with the blades closed which gently open up when the spring action is released
in the nasal cavity.

Structures seen on anterior rhinoscopy :

STRUCTURES SEEN LOOK FOR / COMMENTS

1. Nasal septum Normally mildly deviated or in the midline.
Look for :

Deviated nasal septum

'1
. 'C' or 'S' shaped
2. Anterior / posterior
3. Presence of spurs, if any.
Septal perforation :
o Anterior / Posterior
o Small / Medium / Large
o Edges can be probed to rule out bleeding / irregularity.
2. Nasal mucosa Normal mucosa is pinkish red in colour
o Bright red : Acute in{lammation
o Pinkish white : Anaemia
o Pale white : Allergy
Topical vasoconstrictor solution can be used to decongest a congested mucosa.
3. Nasal floor Normally seen as a concave lunnel.
Look for foreign bodies, rhinoliths etc.
4. Lateral wall The anterior ends of the inferior and middle turbinates are seen with their respective meatuses.
Causes of hypertrophied turbinates :

o on gppsslte-Elde-atnf{S-
r Allergic rhinjtis
r Vasomotol1lt!_d_Iis.

t. Vasoconstrictor drops are used to differentiate between hypedrophied turbinates and

A hvpertrophied turbinate shrinks on vasoconstriction while pglypjeqg-ngt.
.a
polypii.

Meatus :

o Purulent secretions are seen in chronic sinusitis

Section I Case Presentation - Nose 61
-
STRUCTURES SEEN LOOK FOR / COMMENTS
5. Cavity Both cavities ideally should be almost equal on both sides.
A wide cavity is one through which one can get the view of the postnasal space.
Qqqses of a roomy cavity :

Unilateral : \/\J'\-\t'
Secondary atrophic rhinitis, Deviated nasal septum
Bilateral : Primarv atroohic rhinitis
'J\t-' '
The cavity is inspected for :

o Secretions
o Foreign body / maggots
o Tumours
o Polypii
o Adhesions
6. Lesion Note :

o Surface
o Colour
o Ulceration
o Consistency
r Tenderness
o Sensitivity to touch
o Bleeding on louch
7. Secretions o Discharge from middle meatus indicates inflammation of one of the anterior group of si-
nuses ie; frontal, maxillary or anterior ethmoidal cells
8. lnferior meatus o lt is the first meatus to be identified
o Collection of mucus or pus may be seen, beneath which a foreign body may be present.
9. Middle meatus o Middle meatus isEearlshaOed and appears as a gark cleft.
o Repebted suction and decongestant drops helps to locate source of pus or polypii.
o Frontal sinusitis : Discharge, swelling, redness and oedema is seen high up and forward.
o Ethmoiditis : Generalised swelling of outer wall of middle meatus.
10. Superior meatus o / lt is difficult to see
o lt can be seen in Atrophic rhinitis and only after repeated decongestion

Posterior Rhinoscopy :
It is the visualisation of the posterior nares / choana with the help of a mirror. lle size of the mirror ranges
from B-15 mm in diameter. A 10 mm diameter mirror is adequate. The instrument has a bayonet shaped
handle and is used with the mirror facing upwards
Method :
The mirror is first warmed to prevent condensation of vapour on it by :
o Dipping the mirror in warm water.
o Warming the mirror in the flame of a spirit lamp.
o Rubbing the mirror surface on the buccal mucosa and generating minimal heat by friction.
o Dipping the mirror in commercially available demisting / defogging solutions like cetavlon.
The warmth is tested on the flexor aspect of the wrist before putting it in the mouth.
The tongue is then depressed with a tongue depressor and the mirror is passed behind the soft palate
without touching the uvula and surrounding structures to prevent gagging.
t, 62
ClinicalENT

Y^ soft
to relax the soft palate' (Smiling often relaxes the
I^ Patient must breathe through the nose and mouth
t?
n palate)

I:
n
n
r^
n
n METHOD OF PERFORMING POSTERIOR RHINOSCOPY

n
I
Structures Seen :
AnteriorlY :
o Posterior end of nasal septum. (lt is vertical and the first structure to be identified)

n
t:
o Posterior end of middle and inferior turbinate'
o Posterior part of superior and middle t"u"''
\r',* landmark)
small and the highest
o Posterior end of superior turbinate (Superior turbinate is\^'r\

n
n
o Nasal surface of the soft palate and the uvula on tilting the mirror further anteriorly'
Laterally :
tubal elevations seen behind the posterior end of
inferior

rr
o Eustachian tube openings on either side with the
turbinate.
o Fossa of Rosenmuller behind the eustachian
tube orifice (difficult to examine)'

SuperiorlY :

H
r- o Roof of nasoPharYnx
o Superior part of posterior pharyngeal wall'

f*
rr Superior and middle
turbinate Bony nasal septum
ustachian tube oPening

rn
Uvula
lnferior turbinate Fossa of Rosenmuller

STRUCTURES SEEN ON POSTERIOR RHINOSCOPY

rr Abnormalities to be looked for

o Polyps
:

rr o Cysts
o Secretions
o Foreign bodies

rr* o Ulcers
o Tumours
 ^1\

63 \
.n
Section | Case Presentation - Nose
- \
Difficulties encountered :
to lack of cooperation' \
o Difficult to perform in children and mentally retarded patients' due 4% local anaesthetic /
by proper method of examination and using
o Gag reflex : lt can, be preventedpharyngeal \
wall'
Xylocaine spray on the posterior
o Recurrent fogging of the mirror surface of the instrument' \
;\
-l
Methods for examination of Nasopharynx
:

o Posterior rhinoscoPY.
o Digital examination of the nasopharynx \
o Rigid Yankauer's nasopharyngoscope under general anaesthesia' passed through the nose into the mouth \
o Lifting of soft parate with the herp of retractors or rubber catheters
under general anaesthesia' \
. Digital palpation of nasopharynx under general anaesthesia'
o Use of 90' I 120" nasal endoscope through the nose' \
o Fibreoptic flexible nasopharyngoscope'
o Radiological examination of nasopharynx' \
- X-raY lateral view nasoPharynx i
- Xeroradiogram soft tissues nasopharynx'
- C.T. Scan / MRI nasoPharynx' \
Digital examination of nasopharynx ^^r^r r+ i^ arrrrorrc felt through the soft pal- \
space cannot be inspected. lt is ulY?yt
It is useful in chitdren when the postnasal examiner stands on the
ate and never behind it except ,n0",
g"n"iar anaesthesia. The "i'rro ir herd and the t
between the teeth' The exam-
right side. The chird is ast<ed to open
nis mou*, and the reft cheek is pressed postnasar space
iner passes his index finger of the right
h";;;i;"g the hard parate and presses it up into the \
at the edge.
t
Tests for Nasal Obstruction : through the
is compared by asking the patient to exhale
1. spatula Test : The air blast from both the nostrils depressor allows fr
spatula. 1.'" uiuu oi togging on the tongue
nostrils on the tongue depressor or a metal
obstruction'
an assessment of the degree of nasal lr
2.Cotton-woolTest:Awispofcotton-woolrsheldundereachnostrilandthedegreeofitsmovement
gives an idea about the air blast' :
ProbeTest: . ..,1L^t- site of origin and / or at- :
probe or a eustachia,n catheter to find their
Nasal masses can be probed with a touched with a
masses are preferabri to avoid breeding. A mass can gently be
tachment. vascurar ""ipi"n"d and splaying of i
probe to test its sensitivity.
potyps are r-etativelv aspue t" ;;;;,;"cause of the dearth
plane'
nerve endings rn their submucosal t

EXAMINATION OF PARANASAL SINUSES I

'"'ffiff; :
sisns or inrlammation - swellins' f"dn::'l ::1"f::^:t:",^*igiowth ::::;,:il::?:i?:;1"01#0""
encroaching the skin in cases of
,-nuy f"-'rt""ration or a fungating
lying sinusitis, osteomyelitis. There pigmentation over the sinus
maxita. Also rook to. ."urt .iir"r"r, fistura, I
sinus tumours, especialry carcinoma
area. Asymmetry of the face / sinuses'

lr
 GlinicalENT

Palpation : '

To confirm inspectory findings and elicit tenderness in sinusitis

SINUS SITE TO ELICIT TENDERNESS

1. Maxillary sinus Canine fossa or anterolateral wall of maxilla (thinnest wall)

2. Frontal sinus nOo* in" inner canthus of the eye - this area corresponds to the floor of the sinus
which is the thinnest part, the anterior wall comprising of 2 layers of bone.
3. Anterior ethmoidal cells SO" of the nose midway between inner canthus and nasion, against the orbital plate of
ethmoid.
4. Posterior ethmoidal cells Deep in the skull, not amicable to palpation
5. Sphenoid sinus Deep in the skull, not amicable to palpation. A probe can be passed over its anterior
surface and patient feels pain in occiput or temporal region'

Each sinus has to be palpated on both sides simultaneously with moderate pressure after steadying the
head.

Posture Test :

This test differentiates between frontal and maxillary sinusitis. The nose is cleared of its discharge and the
patient is made to sit. lf the discharge appears in the middle me'atus in the sitting position, it is said to be com-
ing trom the vertically draining frontat sinus. lf it does not appear, the patient is made to lie down on
the unaf-
teiteo side (for drainage of irre possibly affected maxillary sinus). lf the discharge reappears in the middle
meatus, it is said to be coming from the maxillary sinus. Thus by variation in posture, the pathological sinus is

identified.

Transillumination Test :
This test is performed in a dark room after removal of any oral cavity denture / prosthesis. Maxillary
sinus :

Light is shun with the help of a torch placed in the oral cavity facing upwards and an infraorbital
glow / cres-
with clear fluid
cent and retinal illumination is looked for. lt appears if the sinus is clear, or if there is a cyst
with pus
within which is able to transmit the light. The glow and retinal reflex do not appear in a sinus filled
or
neoplasm.
Light is also pressed against the floor of the frontal sinus. Presence of illumination indicates a normal sinus
but iti absence is not neclssarily pathological since the sinus may not have got developed.
Other Relevant Examination :
Oral cavity :
o Teeth : Tooth involvement by tumour
Loosening of teeth
Dental caries
o Palate: Bulge due to tumour
Perforation
Movements
o Tumour extension to gingivo-buccal sulcus.
Eyes :

o Unilateral / bilateral proptosis

Cranial nerves :

o lnvolvement of cranial nerves V Vl, IX, X in nasopharyngeal carcinoma / masses.

Regional lymph nodes :

lnvolved in nasopharyngeal carcinoma.
Section I Case Presentation - Nose 65
-
INVESTIGATIONS :

1. Routine and specific blood investigations :

o HbICBC
o ESR
o Peripheral smear if lymphoma is suspected.
o Blood sugar / RFT : if fungal infection is suspected
o VDRI_
o HIV

2. Bacterial / Fungal Culture of Nasal Swab

3. Radiography :
- X-ray Para nasal sinuses : - Occipito mental (Water's) view
- Occipito frontal (Caldwell's) view
- X-ray Skull : Anteroposterior and lateral views
- X-ray Nasopharynx
- Orthopantomogram
- X-ray Chest
4. High Resolution CT Scan of Nose and PNS :
o Extent of involvement by any neoplasm or any pathology can be known
o lnvasion into brain, orbit, palate can be assessed
o Good image of ostiomeatal complex
o Details of bony invasion, calcification
o lt can't differentiate between soft tissue and cystic lesions
5. MRI
o Good soft tissue differentiation
o Poor bone - soft tissue differentiation
o Superior to CT scan in assessing invasion of ossified hyaline cartilage.
o Advantageous in nasal / nasopharyngeal tumours with intracranial extension.
6. Diagnostic endoscopy
7. FNAC
o FNAC of the swelling and secondary lymphnode can be performed.
o FNAC of vascular tumours may cause a lot of bleeding
o Ultrasound / CT guided FNAC is valuable in posterior nasal space lesions.
8. Biopsy
It is necessary if malignancy is suspected.
9. Allergic test
10.Tests for olfaction
o Pure olfactory stimulants are used eg: asafoetida, clove, coffee (Ammonia is not used as it is an irritant
and it stimulates trigeminal nerve in addition). Commercial kits are also available.
o Evoked response olfactometry
MUCOCILIARY / CILIARY FUNCTION TESTS
SACCHARIN TEST : 0.5 nrm diameter crystal of saccharin is kept 0.5 mm behind the anterior end of the
inferior turbinate and the time taken to taste sweetness in pharynx is noted. Normal time taken is 20 minutes.
r. 66

clearance as seen ln
r: A time of more than 60 minutes indicates abnormal mucociliary
:

o Kartagener's sYndrome

r: o Young's sYndrome

r: o Cystic fibrosis
These conditions are associated with nasal polyps

n
n RHINORRHOEA
n It is the term used to denote discharge from the nose'

n Types

n o Watery
o Mucoid / MucoPurulent
r o Purulent

n o Blood-stained

n
EtiologY

n
n
1. Watery rgic rhinitis

n
n
Rhinitis medicamentosa
SF rhinorrhoea
thmoi(ql PolYPii

n
2. Purulent Bacterial rhinitis : acute or chronic
Sinusitis : acute or chronic

t- JubplsuLssiq

rl- Syphilis
t-ong Stunoing foreign bodY
Nasal granulo-mas
Atroph'rc rhinitis

n
Choanal atresia
Nasal mass with secondary infection
Foreign bodY

l: Rhinitis sicca

n
l:
Furuncle
Vestibulitis

rn 3. Blood-stain
pharyngeal angiofibroma
trophic rhinitis
Causes of Unilateral Nasal Discharge
.o-J,o1gig1 bo{Y
o-_Rhinolith

rr
Carcinoma with sloughing
Nasal granulomas
.- Antrochoanal Pot54P

r-- Unilateral choanal atresia

lnverted PaPilloma
'o 'Nasal tumours on one side
Nasal diPhtheria

rf-
o --$qcg1dary atrophic rhinitis (Unitateral)'
Acute / chronic rhinosinusitis
 67
Section I '- Case Presentation - Nose

NASAL OBSTRUCTION
ETIOLOGY
1. Congenital Causes of Unilateral nasal obstruction
o Choanal atresia
'o- Deviated nasal sePtum
o Congenital tumours
'o-Unilateral choanal atresia
2. lnflammatory body
o Acute/chronic rhinitis
"r-foreign
o- Hypertrophied turbinate
o Acute/chronicsinusitis 'r-- Antrochoanal PoIYP
o Allergic rhinitis 'o- Rhinosporidiosis
o Vasomotor rhinitis 'o' lnverted papilloma
o Atrophic rhinitis 'r-- Synechiae
3. Neoplastic / Swellings 'o*- Modified Young's operation on one side
'e- Nasopharyngeal angiofibroma o- Tumours in one nostril
r Rhinosporidiosis
o lnverted paPilloma
o' Carcinoma of nose/paranasal sinuses
o Nasalpolypii
o Adenoids
o TurbinatehypertroPhY
o- Haemangiomas
4. Granulomatous diseases Causes of nasal obstruction in children :
o Rhinoscleroma u-Foreign body
o Wegener's granuloma 'r-Adenoids
o Sarcoidosis o Rhinitis
o Tuberculosis b'.Choanal atresia
o Midline granulomas t- Nasaldiphtheria
r Foreign body granulomas

5. Traumatic
o Fracture nasal bone
o Facio maxillary injuries
o Septalhaematoma
o Septal abscess

6. Mechanical obstruction
o Deviated nasal sePtum
o Synechiae
o Modified Young's oPeration

7. Miscellaneous
o Foreign body
o Hypotensive drugs
o Hypothyroidism
o Smoking
o Alcoholism
o Drug addiction
o Rhinitis medicamentosa
t
ClinicalENT

t:
t: Causes of headache

t: o
PARANASAL SINUSES

o Sinusitis
1: o
Deviated nasal sePtum
Rhinitis
o Ostial block : vaccum headache

o o ComPlications of sinusitis
1: o
Atrophic rhinitis
Nasal masses / granulomas / PoIYP
- PYocoele

t: - Cavernous sinus thrombosis

rr o
o
Rhinolith
MalignancY
-
-
-
OrbitalcomPlications
lntracranial abscess
Aural comPlications

E
I. EPISTAXIS
r:
j: Epistaxis means bleeding from the nose'

t
I
F
t-
l[ tu terioalLit1"', ur""
f z. eo.t"riorl'''oooruiis P'e^"Li';eri'
lcnitor."n
and vouns nersons

--.------'-- -- -- | |
EPistaxis digitorum
o Epistaxis in children due to nose picking
ll l] .o Commonest
cl*rnon"rt cause of epistaxis children. ll
eoistaxis in children'

rr:
n oF BLEEDING
souRcE OF
SOURCE

1. Little's area (Locus valsalvae) (James

Little in 18
Z-WooOtutf's plexus (Nasal-Nasopharyngeal
nnurto*o.i, of nasopalatine, greater palatine' anterior
arteries ( Arterial bleed) - C"**""""t tit" "t
Collection of large blood vessels
Oleeding
ethmoidal

posteriorly

n l-Pt""") ! r''"*n
Situated in the lateral wall of inferioimeatus
i='^""
septum mucosa on the septum
Engorged vascular nasal mucosa
il

-------f
t- ll"--"
F Ir3.
3.turbinate

4.
Septal turbinate

Haemorrhagic nodules
l:u:::r:J:J:,:1ilil:'"""*
Can cause severe ePistaxis

ffi"fyttd
cure
Submucous resection helps to .

dil"t"tt" of un unu'uully placed muscular artery with

ll

Il

l,=
I
pertensive changes in its walls'

n lu% From retrocolumellar vein, common in Young Personr

ErtoLocY
I- ETIOLOGY
Local :

I l[. tntr"n.*"to.y :
l- l, :il:ff,
lNon-Specific il
-
l: il

rl-
ll I . atr.,nnic rhinitis il
1-
Section I Case Presentation - Nose
-
o Bacterial / viral infections
o Adenoid infection
Specific :

o Granulomatousdiseases
- Syphilis
- Tuberculosis
- Rhinoscleroma
- Sarcoidosis
- Rhinosporidiosis
o Leprosy
o Fungal infections
o Nasal Diphtheria
2. Neoplastic Benign tumours
o flgioma
o Angiofibroma
o lnverted papilloma
o flaemangloma
Malignant tumours
o Nasopharyngeal carcinoma
r Carcinoma mg1llla
o Malignancy of nose
r Squamous cell carcinoma
o Adenocarcinoma
o Adenoidcysticcalciloma
3. Traumatic lnjuries to the nose
o ,Nose picking
o Surgical / latrogenic
- ReScli_o!.a-ry haemorrhage
- Sqcqndary hqemoryhage
4. Drugs / lnhalants Topical decongestants
o -Qgcaile
o Tobacco
o Cannabis
o Heroin
o Wood dust
o Phospho.rus
5. Miscellaneous Foreign bodies
o lnanimate
- Buttons
- Batteries
- Peas
- Nuts
o Animate
- Maggots
r nninoiitn
 ClinicalENT

General :

1. Congenital . Bglqg-o9]91w9!et _gynCiqne

- Ep1glqxis
- ttr".q.!lip! g
-tnrl 99-99 |
tgle 1.s_99-!-a
sia
- Q-u!a"1goqs- !el9nge9!g,s-iq
o Meningocoele
o Von-Willebrand's disease
o' Hereditary telengectasia of Little's area
o Unilateral choanal artesia
o Glioma
2. Cardiovascular o Hypertension
o Atherosclerosis
r Congestive cardiac failure
o Mitral stenosis
o Secondary hype(ension due to nephritis
3. Haemopoetic o Blood dyscrasias
o Haemophilia
o Leukaemia
o Thrombocytopenia
o Coagulopathies
4. Endocrinal o Puberty
o Vicarious menstruation
o Pregnancy
o Granuloma gravidarum
o Hypothyroidism
5. Hepatic o cgltqqls o,f !i_et
o Portal hypertension
a Jrlepb K 9el1giency,
6. Drugs o Aspirin
o Anticoagulants
o Methotrexate
o lmmunosuppresants
o Alcohol
r Chloramphenicol
7. Exanthernatous fevers c Measles
o Chicken pox
8. Miscellaneous o High altitude
. Etl!1e_r:pgg of temperature
o Head injuries
r HIV
o Barotrauma
9. ldiopathic
Section I Case Presentation - Nose
-
Common causes of epistaxis in E.N.T.
CHILDREN I ADULTS
Nose picking I Hypertension
Trauma Angiofibroma
Acute rhinitis I Malignancy
Foreign body I Rhinosporidiosis
Exanthematous fever I Head injury
Diphtheria I ldiopathic
Blood dyscrasias
ldiopathic

Pathology : (ln elderly)

CHART
Atherosclerotic vessel under
delicate nasal mucosa
I vessel susceptible to
J
f Orying and cracking
Hypertension
I
*
Bleeding from anterior ethmoidal vessels
,4..
Vessel does not retract lnadequate clot formation

Anterior nasal / severe post-nasal bleeding

INVESTIGATIONS
1. Detail history of epistaxis
Epistaxis
o Quantity o Onset
o Frequency o Anterior / post-nasal blood
o Duration o Haemoptysis / haematemesis
o Previous episodes
o Unilateral/bilateral
o Clots / frank blood
2. History
o Trauma
o Exanthematous fevers
o Foreign body
o Bleeding disorders
o Hypertension
o Drug intake
3 Examination of nose and sinuses
 ClinicalENT

Systemic examination
o Blood pressure
o Pulse
o Temperature
Blood lnvestigations
o Bleeding time
o Clotting time
o Prothrombin time
6. Radiology
o X'ray nasal bones for trauma
o C.T. scan for nasal mass
Biopsy for non-vascular masses
Endoscopy of nose and sinuses

TREATMENT EPistaxis
u

I:
n
First aid
lt

r
n
Trotter's Manoeuvre
l,
Digitalcompression over Little's area by pinching
the nostrils between forefingers and thumb for
5-10 minutes in sitting position with mouth open

F and head bent down

n
F Bleeding stoPs
Allay anxietY
Bleeding continues

t-
l-
Cold effusions to face (vasoconstriction)
lce-packs over nose
II

t-
l: -
-
Bleeding continues
u
Quick examination of nose, nasopharynx
Measure pulse, blood pressure, respira-

I:
rt-
tion, sYstemic examination
- Exclude general causes
- Anterior / posterior rhinoscopy / endos-
copy

rr Anterior nasal Packing

{t

With ribbon gauze diPPed in

rr
- Liquid Paraffin
- BIPP
- Vaseline

r
t,
 73
Section I Case Presentation - Nose
-
(Adrenaline pack is not used in hypertension')
-ltisdoneinalayeredfashionstartingfrombelow.Thismethodofpacking
givesuniformg"ntl"pressureandpreventslooseningofpackinoropharynx.
- lt is removed bY 4B hrs'
- Now a days synthetic sponge nasaltampons are available'
- Send blood for
o Haemoglobin
r Blood counts
o Bleeding and clotting time
o Platelet count
o Prothrombin time (Extrinsic clotting system)
o Partial Prothrombin time
o Blood grouping / cross-matching if required
u
Bleeding
u

Continues
StoPs
- A 4 x 4 inch gauze rolled to 1 inch diameter, secured
RePeat ePisode of bleeding
with silk threads or umbilical cord tapes is placed in
1. Cauterization of Little's area with the post nasal sPace
- Silver nitrate, - lt is done under general anaesthesia with the help of
- Trichloroacetic acid simple rubber catheters
- DiathermY u
Bleeding continues
2. Cryosurgery Repacking or Foley's catheter placement
3. Local sclerosing injections u
(Sodium morrhuate) Catheter passed transnasally till balloon reaches
(lnduction of fibrosis) behind the uvula
4. RadiotheraPY 15 ml air rs injected into the balloon which should
snugly fit into the post-nasal space
(telangectasia)
The catheter is pulled anteriorly to place the balloon
5. Submucous resection of bony spurs
against the Posterior nares
u
lntractable cases
u
Blood transfusion
Ligation of
o External carotid artery
o lnternal carotid artery
o Maxillary artery
o Common carotid artery
AngiograPhY with embolization
t:
r
r^ 74

SURGICAL LIGATION
ARTERY METHOD
ClinicalENT

F
r
1. lnternal maxillary artery

2. External carotid artery

Sublabial incision
Posterior wall of antrum is pierced
Ligation is done in pterygopalatine fossa
Division is done close to sphenopalatine foramen
Curved incision over the neck at the upper border of thyroid cartilage rs taken.

F
f-
lncision is centred over the bifurcation of common carotid artery.
External carotid artery is identified by its branches and ligated in contrrruity with 3/0 silk

rr
or linen thread.
3. Anterior ethmoidal artery External ethmoidectomy incision
Artery is identified at junction of medial and superior walls of orbit
Posterior ethmoidal artery located 'l cm behind anterior ethmoidal artery.

l--'
n
r
F
rrr
l-
rl-
rr-
l_'
rt-
rl-*
r
 \
.A
\
i
2. DEVIATED NASAL SEPTUM \
i
condition found in adults Nasal septum
is usually never central' A
Deviated nasal septum is a very common
-
Types of deviations :
i
l. 1. Cariilagenous
2. BonY \
3. Combined
ll. 1. 'C' shaPed \
2. 'S' shaPed ,-
3. Caudal deviation'
\
influences the
: The intrauterine position of the foetus and that during tabour
T:'*?; Mourding Theory h
deviation of the sePtum
2. Trauma during birth and further on \
3. HereditarY
races !
4. Racial : Common in white
5. High arched Palate t
Pathology in deviated nasal septum i\

1- Deviations i More or loss a generalized bulge

2. Bony or cartilagenorrs deviation \l

3. 'C' or'S' siraped

the septal
at tne-tunctron of the vomer below with n
A spur is a sharp ungrl"ti* -hut occurs
cartilaqe and / or ethmoid above.
I
3. Dislocations Lowerborderofseptal""'t"s"s"Go"pr"""o-r'.,''.n''*dialpositionintooneofthe
I
occurs'
Compensatory hypertrophy of turbinates
t

Cottle's classification
The lesion is classified rnto three types
sental leston
he septal
TREATMENT
PATHOLOGY VASOCONSTRICTION
TYPES
No treatment is required
1. Simple deviation '1 Mild deviation of the sePtum
2. Does not cause obqlgglon
decongestants
1. More severe devlatlon Obstruction is relieved by shrink- Medical
2. Obstruction SurgerY may b9 re9!{99
ona n{ tho tr rrhinates
2 SeDtum touches lateral wall
occurs on vasocons SurgerY is essential
3. **"i9[- l Marked angulation of the seP- No relief
tum triction

2. Spur lies in contact with the

laleral nasal wall.

75
 Clinical ENT

Clinical features
Symptoms
1. Nasal obstruction
o Unilateral, mostly on the side of the convexity side'
o Bilateral due to compensatory hypertrophy of the turbinate, on the opposite
o Snoring maY be Present'

t: 2. Headache
Causes of headache in a case of deviated nasal
septum are :

n 1. Sinusitis
2. Obstruction of the frontonasal duct
3. pressure over anterior ethmoidal nevre by the middle
turbinate (Sluder's neuralgia) (Anterior
11
r: ethmoidal nerve sYndrome)
4. Severe deviation of the septum can cause pressure on the
lateral nasal wall causing referred trigeminal

rn Pain.
r_ 3. Anosmia
reach the olfactory nerves'
ln acute deviation, blast of air does not adequately
4. Epistaxis
ltoccursduetostretchingofvesselsoverthebonyspur.

n Paradoxical Nasal Obstruction

nasal obstruction but anterior rhinoscopy reveals
deviation of

r: It is seen in patients complaining of unilateral

the septum on the opposite side. These
patients have a long-stand.ino r11ed l1::.!:ottt'ctron
to which they

n
1-
have become accustomed to and are now unaware
associated with the nasar cycle causes intermittent
symPtom.
of it. Mucosa'swelring occurring on the opposite side
obstruction, which the patient appreciates as
the main

n
I-
Signs
1. 'C' or 'S' shaPed deviation
2. Spurs

n
t-
3. Caudal deviation maY be Present
4. Compensatory hypertrophy of turbinate occurs on the
opposite side
(Bernoulli's phenomenon)'

r
5. Mucosa around the deviation may be oedematous
'C' shaPed deviation
pyramid to one side and the whole of the cartilagenous
Displacement of the upper bony septum and

n
l:
septum and vomer to the oPPosite'

'S' shaPed deviation

Deviation of the middle third (upper cartilagenous
vault and associated septum) is in the opposite
directton

n
r
to that of the uPPer and lower third'

Treatment

rF'
1. Medical
o Decongestants
o Analgesics for Pain relief

rr
o Antibiotics for concomitant sinusitis'
2. Surgical
o Submucous resection
o SePtoPlastY

T-
 3, SEPTAL PERFORATION t

\
t
perforations are important in children
It is a condition in which a perforation is present in the nasal septum. septal
since if not treated they can hamper the growth of the nose and mid-third of the face'
!

I
ETIOLOGY
I Congenital t
ll Acquired
t
1. Trauma
to- Septal haematoma
',-r Septal abscess
'c, Nose picking

2. Surgical trauma t
r. Submucous reseclion of the septum
"-. Submucous cauterization t
'"o- Rhinoplasty

3. lnflammation
:r Syphilis'
,. Tuberculosis
.o Leprosy
o Diphtheria

4. Granulomatousdisease I
'o Sarcoidosis
o Wegener's granulomatosis I

5. Malignant tumours of the nose

6. Drugs
'. Addiction to cocaine
'. Topical corticosteroids

7. Occupational / lndustrial
'. Chromium
Arsenic
i' Mercury

8. ldiopathic

77
t:
t: PATHOLOGY

I^
l
Chart I

Loss of mucociliary clear-ance from perforation site

;: I
r: Stagnation of mucus

t:
rr
Drying of secretions

Crusts formation
t
Extrusion of crusts

T:
I
Trauma to mucosa

T. Vicious cycle
I
Epistaxis

F: Clotted blood

r:
r:
r:
r: Turbulent air flow

n
r-
n
rr Chart Il

Large pe.rforation Anterior zone Perforation

n *I
I

Moreloss of Already a1 inactlvq anterior

n mucociliary
function
ione is superimPosed bY loss
of mucous membrane

n
I-
F
F
]-

1-
l-.
 79
Section I Case Presentation - Nose
-
STAGES OF SEPTAL PERFORATION t
of a septal perforation
The following are the stages'of clevelopment
t

Redness and congestion of mucosa t

lrritation and rhinorrhoea
Blanched and anaemic mucosa I

Development of crusts over the area

t
Necrosis of the area starts
cartilage
Crusts extend into the substance of the
t
Septal Perforation

CLASSIFICATION OF SEPTAL PERFORATION

to their size into three types
Septal perforations are classified according
FrnronnrtoH btnmrren
Small U,pto.1 cm
Mediunl 1-2:!-
i Large >2 cm

CLINICAL FEATURES
Small septai perforatrons may be asymptomatic
A perforation may have the follott'ng ty*p*
SMALL
- Lnncr
PERFORATION
I ernroRATloN
Whistling sound at resPiration Dryness
Crusting
Epistaxis
Nasal obstruction
Disturbed Phonation

by ulceration'
Septal perforations are usually preceeded

DIAGNOSIS
History and examination
r CrLrsting
o Epistaxis
o Trauma
o Occupaiion

Biopsy
o When edge of perforation is raised
o In Wegener's granulomatosis
Serological tests for SYPhilis
Eryth rocyte sedimentati on rate for
Wegener's g ranulomatosis
 Clinical ENT
80

C.T. Scan / MRI

o lt is rarelY required
o The size of the per{oration can be determined
o Bone erosion can be determined
TREATMENT
PrinciPles :

no treatment
Asymptomatic perforations require
c Perforations usually do not heal spontaneously
o lt is difficult to close perforations >2cm surgically
o Avoidance of nose picking' blowing
o Clearance of occupational hazards
o Treatment of underlYing disease
Medical treatment
o Local aPPlication of
Petroleum jellY
- Glucose glYcerol
r: 25o/o

rr: o
- Cicatrin cream
Nasal douching to remove crusts

Closure of perforation by prosthesis

o Obturators made of Acrylic / silastic

r: r Prefabricated silastic buttons'

r: Advantages of using a Prosthesis

o SimPle, safe method
r: o Reliable method

n r Better insertion and retention occurs with silastic obturators

r Closure of defect can be achieved
n
r-
Disadvantages of Prosthesis
o Prosthesis do not replace lost septal mucosa
o Replacement is needed for a loose prosthesis
n o Retention of silastic buttons is poor

n o Displacement of obiurators occurs

o Acrylic obturators are rigid for insertion

n Surgical treatment

n
I-
Suroical closure can be achieved by the
urglcal clos

APPROACH

High
following approaches

PERFORATION SITE ON SEPTUM

I-
External rhinoPlastY
Alar facial crease lnclslon G* 6-lPP"r limit of ,Lr"
_R

I-
rl-'
1--
Section I Case Presentation - Nose 81
-
Closure
After selecting a proper approach, depending on the site of the perforation, the perforation is closed by either
grafts or flaps raised from the surrounding structures.

GRAFTS FLAPS

rzl Temporalis fascia o Mucosal flaps

o. Free grafts from turbinates V SePtal
v'Three layered composite graft from pinna ':/ Upper lip
r' Fascia lata '.o' Buccal mucosa
rz Labial flap
.92' Laleral nasal wall
l- Cartilage flap
o Bipedicled flap based on
- Sphenopalatine adery
- Superior labial artery
Disadvantage Disadvantage
o Amount of tissue available from turbinate grafts is limited o Limited width of buccal flap (2 cm)
o Thinness of buccal flap
r-
t: 4, ATROPHIC RHIhIITIS
I:
t: b9n.e with formation

r: by progressive atrophy of mucosa,and underlying

r
It is a chronic nasal disease characterized
from the nose'
of crusts and characteristic foul smell called o4=aena emanating

TYPES

r: t. lt is classified into primary and secondary

:
atrophic rhinitis

r: '1. PrimarY lt is usuallY bilateral

2. Secondary : lt is secondarY to
r: I Deviated nasal septum : atrophic changes
occur on the concave side
in the nasal mucosa

n * Specific infections which cause atrophic changes

- Syphilis Atrophic rhinitis

r: -- LeProsY
I
lndia
crrina

n
Tuberculosis l

v/ LuPus vulgaris
i Egvpt

n ,
\,- Atrophic stage of rhinoscleroma

n
Chronic sinusitis
l/ lrradiatton

n
I-
rr-Radical surgery of nose
r'' over correction of deviated nasal septum
-
''r
Extensiverhinoplasticprocedures

n
t-
TurbinectomY
y'RninosPorid iosis removal
V' Nasopharyngeal angiofibroma removal
y'R"touul of nasal PolYPi'

1- ll. Histopathologically, it is divided into type I and

type Il

l- ESTROGEN THERAPY

l-. Endarteritis

t:
Periarteritis
Vasodilatation of caPillaries

t:
n nasal septum cause unilateral atrophic

rr
anatomical abnormalities lrke deviated

worsens durtng me-

deficiency' It affectes females more and
2 Endocrine i hormonal dysfunction : estrogen
narche, menopause and PregnancY'

rr 9: Deficiency of fat-soluble vitamins' especially

"4- HYPoProteinaemia
.5r Malnutrition and poor general condition
vitamin A'

rr 6. Autonomic dYsfunction'

8?
Section I Case Presenlation - Nose 83
-
7. Reflex sympathetic dystrophy syndrome.
B. Bacterial infection caused by:
o Coccobacillus foetidus ozaena (Perez)
o Klebsiella ozaena
g o Diphtheroids
o Bacillus mucosus
o Coccobacillus
9. Autoimmune disorder
1 0. Heredity : racial preponderance

11. Familial : occurs in members of the same family.

l2.Environmental : common in tropical countries.
l3.Exanthematous disease in childhood predisposes to atrophic rhinitis due to altered immunity
14.11 is seen in blood groups O and B.

PATHOLOGY l,r, ' , ' t

The following pathological ihanges occur in atrophic rhinitis :

1. Atrophy of mucosa
2. Metaplasia of epithelium to stratified or cuboidal type
3. Atrophy of cilia and secretory glands
4. Drying of secreiions to form crusts
5. Secondary infection leading to foul smell (ozaena)from the nose
6. Atrophy of turbinates leading to roomy nasalcavity
7. Periarl.eritis and endarteritis of blood vessels leading to ischaemia and atrophy of mucosa.
B. Atrophy of sensory nerves and olfactory nerve endings.

CHART
Pathological changes in Atrophic rhinitis

Atrophy of turbinates ROOMY CAVITY Eddycurrents

-------------+* of air flow
Atrophy of olfactory nerves
------I-
OZAENA L--* nruOSN,ltn

t t
Foul smell from nose Blocks air flow to olfactory nerves
lschaemic effect
t
i
I
I ,,o"king of ostia <- CRUSTS ----+ Nasal
Secondary infection Obstruction
ATROPHY OF MUCOSA
I
I 1
sinusitis
+ f
ATROPHY OF CILIA ----------> Stagnation of secretions -----------D- Drying of secretion
I

+
ATROPHY OF SECRETORY -----+ Decrease secretion --> Decrease moistening effect-----+ DRY
GLANDS MUCOSA
I 84

It: CLINICAL FEATURES

Symptoms

rr Foul odour o
o
Perceived by neighbours, relatives
patient unable to perceive because of atrophy of olfactory epithelium

rn Nasal obstruction
o Called as "Merciful anosmia"
Causes of nasal obstruction
c Crusts in nasal cavitY

Causes of Purulent discharge

:

nerves giving false sense 9f obstructlon' as pa

r: Purulent discharge
c Secondary infection of the crusts

rr
r: o Sinusitis
Causes of headache :

o Associated sinusitis as crusts block the ostia

of nostrils
o Change in "eddy currents" in the nose due to widening
Causes of anosmia :

o Atrophy of olfactory nerve endings

r: o Obstruction of airflow to the nerve endings by crusts

r: Causes of dry cough

rn
:

? Drying of Pharyngeal mucosa

f Crusts extending downwards from choanae

tt s Or" to ingestion of septic material'

I- Epistaxis
Psychiatric disturbances
It is caused by removal of crusts by the patient
They are due to

I-
r
o
o
Foul-smell emanating
Social out-casting

t-
l-
Signs
Primary
o Bilateral atroPhY of nasal mucosa. o
Secondary

o
Unilateral atroPhY
Deviated nasal sePtum

l-" o Signs of the causative factor

l- Common features

t-
r
External examination
o Bridge of nose may be depressed due to atrophy of nasal bones and the septum'

rr
Anterior rhinoscoPY
o Roomy nasal cavities
o Pale, atroPhied drY mucosa

rr
o Atrophied and shrivelled turbinates
o Yellowrsh green crusts in the cavity
o Meatus maY be seen
o Posterior nares and nasopharynx may be seen

rr o Loss of anatomical landmarks

o Crusts on posterior pharyngeal wall
 85
Section I Case Presentation - Nose
-
Posterior rhinoscoPY rt shows atrophied
rt rs rerativery easy to perform as atrophy
of sensory nerves causes diminished sensations.
mucosa and crusts'
Differential Diagnosis
present like chancre' gumma etc'
o syphilis : Atrophy of mucosa and sysJemic signs of the disease are lymphadenopathy btc'
o Tuberculosis : Atrophy of mucosa, anaemia, cachexia, cough' cervical palsies are present
o Leprosy : Atrophy of mucosa and systemic signs like skin lesions' nerveare not affected'
o Al1qp1rig gtage- of rhinoscleroma : Mu-cosa is pink and the turbinatesthere is no foul smell
o Rhinitis sicca : crusting is present only in anterior part of nose and
lnvestigations
(CIinical diagnosis usually suffices)
o X'ray Paranasal sinuses :
- Sinusitis
- Walls of the sinus may be thickened
o X'ray chest : for Tuberculosis
c Nasal smear : for Leprosy, Tuberculosis
o VDRL test :for SYPhilis
o Dermatological tests for Leprosy
c Biopsy to rute out rhinoscleroma'

Complications
o Sinusitis o Middle ear infection
o Pharyngitis o External nasal deformitY
o Laryngitis o Psychiairrc Problems
o Nasal mYiasis

Treatment
Surgical treatment chart

Prrnciples

Decrease stze of
lncrease secretions
To helP regeneratlon cavity
Decrease drYness
of epithelrum / to give rest
to cavitY
I l
I I
I

t
I
I

t *
v
Y
Wittmack's oPeration Lautenslager's
Young's oPeration
Stellate ganglion block operation
Modified Young's oPeration
Raghav-sharan's oPeration Submucosal imPlants
Gadre's double breasting operation
r:-
r: 86
Clinical ENT

t: PRINCIPLE OPERATION \DIAGRAM\

t: ^v/Regeneration of Young's operation Closure of anterior nares

n epithelium (1 e67) Folds of skin are raised from within the nostril and then sutured
'r,z Rest to cavity -
The closure is maintained for 9 months 1 yr, followed by
,'f\
I: g,,,Avoidance of
turbulent air cur-
opening after healthy mucosa and absence of crusts is con-
firmed by posterior rhinoscoPY.
The nasal mucosa is given rest and helped to regenerate in
,41 N
ir',,1I\\
,'r(\
1: rents
ihe closed nostrils.
# The high CO,nostrils
/
\4/\-J
t'/ |
\

T: concentraiion in the expired air collecting in

Closed

t-
the closed helps to regenerate mucosa and goblet
cell growth.
anterior

F Patient has to breathe through the mouth leading to halito-

nares

sis, snorinq

l-
t-
Modified
operation
YOUNG'S A 3mm. opening is left during closure of anterior nares'
A 3mm. size opening is just about adequate to allow rest
and maintain minimal respiration.
Advantages of the oPening :

o Allows minimal resPiration

F
l- GADRE'S double
o Opening allows visualization of regeneration of mucosa,
if any with an endoscoPe / otoscoPe
Similar to Young's operation but two folds are raised within
Opening

t-
breasting the nostril
Double layered closure is done

t-
l-
r
o
lncrease secretton Wittmack's oPera-
Decreasedryness. tion
Transplantation of parotid duct (Stenson's duct) into maxil-
lary sirius
It moistens nasal mucosa.

t-
Disadvantage :
Profuse rhinorrhoea occurs while eating food
Stellate gan- By abolishing sympathetic supply, parasympathetic predomi-

l-
a
glion block nates causing an increase in blood supply. lt thereby makes

t-
l-
a Cervical sym-
pathectomy /
the nasal mucosa more supple, increases secretions and
also helps it to regenerate.

r
blockade
F Raghav Sharan's Transplantation of antral mucosa into nasal cavity.

rr
operation
o Decrease in size Lautenslager's Medialization of the lateral nasal wall.
of cavity operation The lateral wall is displaced by the intranasal route
Submucosal The width of the septum is increased by the following

rr
implants submucosal imPlants:
g/Bone (autogenous medullary bone graft)
-r"''Cartilage
o lnjection of

rr
'--- Teflon
'r Paraffin
- Dermofat
- Acrylic resin.

rr
'd'" Placental extracts
'd- Gold
'o'lvory
 87
Section | Case Presentation - Nose
-
MEDICAL TREATMENT
Aim:
- To reduce crusts
- To prevent foul smell
-Nasal hygiene / toilet
r---Adequate nutrition / high protein diet
'y'Administration of vitamin A and dilute hydrochloric acid to improve apetite.
o lnjection ofpl-q-q-gntal--exlmats intrarnuscularly (biogenic stimulator)
o I nj ecti on*St;qplqm -c.fn...(a
g a in st g ra m n eg a tive ozaena baci I I i
)'
o Po-tassium. i-o,$j-Q.-e--.orally to increase nasal secretions
o Mandl's paint applied to nasal mucosa increases nasal secretions
l.' Massage of turbinates to stimulate the glands'
c Nasal drops:
.i) sry::Te lu:3lgl9-p. or pul!!fee times a dav
?5% g!:9_:_g_ln !aTp-9on?
(gl!r99-se -:9-.9-*i, glvcerine - 30 9c)
Action :

- Sacchqrolytig-gfganismq bleak -up the glucose and lactic acid is Ploduced

r rr 9 I !.r jp-{g growth o_f prof eo !v-!!c .org a n s ms
i
!
i

- Gtycerine hetps to m9!_st91![e c1us.t9- a1d muQQga a-nd.preve,n-ts drying'

in Arac-h.1s 9il (1:10'000)
'jj) -E!tyleng.oegtiadig!
',t.ii) Chloramphenrcol / Sllgptomycin nasal drops
..jv) Liquid paraffin na-s3l-d1gps !o, s-gflgn the crusts'
o NasalToilet
i) Alkaline Nasal Douche
;:. Sodium bicarbonate Creates an alkaline medium, necessary to dissolve the crusts'
Sodium diborate 28.4 gms
Maintains isotonicitY

The resulting solution is used for

one teaspoonful of the above powder is added to half pint of water (280 ml).
20 cc plastic / glass / Higginson's syringe can be
nasal washing twice a day. A simple rubber catheter with a
used for nasal toilet
ii) Hydrogen Peroxide
in arachis oil/ coconut oil is
Hydrogen peroxide is used to dissolve the crusts before douching. oestrogen
school treatment)
then applied to improve vascularity of the musoca. (Edinburgh
iii) Kemicitin Antiozaena solution :

Each ml contains
Chloramphenicol 90mg
Oestradiol d iProPionate 0.64 mg
vit. D2 900Iu
Propylene glycol Base

iv) Removal of crusts after application of oestradiol in arachis oil.

o Autogenous vaccines
Rajvanshi)
a Tissue therapy with systemic human placental extracts (sinha, Sardana,
a Rifampicin 600 mg orally once a day for 12 weeks'
j:
II: 5. DIFFERENTIAL DIAGNOSIS OF
A NASAL MASS
t-
n NASAL POI-YPS
r Anasal polyp is prolapsed, pedunculated, oedematous and hypertrophied
mucosa of the nose and sinuses'

r: Antrochoanal polyps are common in children while ethmoidal

polyps are common in adults

F- TYPES

f- '1. Antrochoanal PoIYP

2. EthmoidalPolYP

r-
rn ETIOLOGY
'1. lnfection : Antrochoanal polyps are of infective origin'
2. Allergy : Ethmoidal polyps are of allergic origin'
3. Vasomotor imbalance : lmbalance of sympathetic and parasympathetic
system
in fall of air-pressure in the vicinity

rI-
4. Bernoulli,s phenomenon : Air passage through a narrow constriction results
1- of the constriction. As regards to the paranlsal sinuses,
the ostium is considered as a constriction' a fall in
pres.sure results in prolapse of mucosa around the constriction
and subsequent blockage'
polyp formation'
5. polysaccharide changes : ln the ground substance of the mucosa, predispose to
6. Mast cell reactions in the mucosa

t- 7. lmmunoglobulin changes predispose to polyp formation'

l-" PATHOLOGY

Long standing -------.1

Allerqy / lnfection / MalignancY

t-
+
|-
Perilymphangitis, PeriPhlebitis

t- Vasodilatation
l
i
lncrease in permeabilrty of tissues
Obstruction to lYmPh flow

t:
|-

r
I
v
Oedema

rr i I

lncrease in mucosal oedema

I

rr
+
Prolapse of mucosa

f
I

Pedunculation

rr +
I

Polypus formation

r 88
 89
Section I -' Case Presentation - Nose

COMPLICATIONS
o Secondary sinusitis
o Epistaxis due to inflammation / infection
o Metaplastic changes due to trauma
o Mucocoele and pyocoele formation
o Deviation of septum to opposite side
o Broadening of nasal bridge
o Hypertelorism.

DIFFERENTIAL DIAGNOSIS
c Hypertrophiedturbinates o Angiofibroma
o Rhinosporidiosis o Rhinoscleroma
o lnverted papilloma a Rhinolith
o Malignancy a Nasal granulomas

1. ANTROCHOANALPOLYP
its ostium and enters the nasal cavity' lt
It arises from the mucosa of the maxillary antrum, passes through
hanging behind the palate Some-
then passes backwards to the posterior ihoana, nasopharynx and throat
iimes it may project anteriorly into the nasal cavity'

PATHOLOGY
Gross :

It is ideally trifoliate in shape and consists of three parts

Antral : lt is the first part to form and it fills the maxillary antrum.
metaplastic changes'
Nasal : lt is the smallest part present in the nasal cavity. lt's exposed part may show
because
Choanal : lt is the part seen in the posterior nares and nasopharynx' lt grows backwards
:

- Ciliary
- r@nd creates a negative pressure which pulls the p-91yp-!ackwards.
- Bernoulli's phenomenon: when gases or fluids pass through a constricted area, a negative Pres-
sure develops in the vicinity of the constriction with resulta.nt oedema'
-Flos
- Di!'s-a!s!
- ;ffi T-qre Epo.ce- p-ostenerr[ - Clgrvi
Microscopy
Polypislinedbyc@withsubepjlhe:[e]-aede.maandplentyofroundcells,d,9tqinfective
origin.

CLINICAL FEATURES
Symptoms
c Unilateral nasal obstruction (bilateral if nasopharynx is glstlucted)'
o Nasal discharge
o Hyponasality
c Sneezing
t,loilE breathing
"
Headlhe
"
o Deafness
t: ClinicalENT
r^ 90

t_ Signs :

o Trifoliate shaped
1: o Soft, smooth mass
l- o Greyish lpearly white in colour

I: o Probe test .

- Soft, mobile and insensitive to touch.

n - Probe can be Passed all around.

- Does not bleed on probing (relatively avascular mass)

n o Posterior rhinoscoPY
- Globular smooth mass in the choana.

F
X'ray Sinuses
o Thickening of mucosa in the antrum
o Opacification in the antrum
o LFteralview naso_pharynx: cresccnlsign positive. (Soft tissue mass with radiolucent curvilll-ear-zqnc !-Qllryeen

F it and the roof of nasoPlgrynx).

1: DIFFERENTIAL DIAGNOSIS

I: o EthmoidalpolyPii o Adqroids o Hypertrophied turbinate

o a Rhinosporidiosis a Malignant tumours
Nasopharyngealfibroma

F PROGNOSIS

F prognosis is good since it rarely undergoes malignant change. Recurrence is not very common if Caldwell-Luc
,rrg-"ry is pe*ormed. Nowadays f fSS witn canine puncture is done to remove
the entire polyp'

t-
I- TREATMENT
o Surgical removal of the PolYP.

l-
l-
Nasal polypectomy with the help of a nasal snare and avulsion technique

position.
polyp
roolthe antrum.lf

Polyp if recurs, is removed by Caldwell-Luc operation'

so that the polyp is removed from its
extended to the throat, it can be removed by the oral route in tonsillectomy
has

l-
t- o
Nowadays Functional Endoscopic Sinus Surgery is performed with a
Medical treatment of the underlying infection'
pre-operative C T' scan of the sinuses'

l-' ETHMOIDAL POLYP

These are polyps arising from ethmoidal air cells'

t-
t-'
They are common in adults, rare in children'

PATHOLOGY

l-
l-.
Gross :

Theyaremultiple,bilateral,soft,greyish/pearlywhitemasses.Theyui"'.Yltip|:.!9:.?Y#"
present in mictrtte conr:nu ott"
multiple. They appears like a bunch of grapes. They arise from ethmpid
semilu4;!-ris and rarelY the roof.
cells

l- Polyps are common in the ethmoids because :

o Laxitv of tunica ProPria

l-
r
o
o
o
Narrowness of roof
Erect oosture

r
Gravity
 9'l
Section | Case Presentation - Nose
-
Microscopy :
A polyp has ciliated columnar epithelium with subepithelial oedema with plenty of eosinophils. lmmunoglobulin
lgE is high in polyps of aliergic origin.

CLINICAL FEATURES
SYMPTOMS
o Bilateral nasal obstruction
r Nasal discharge
o Frontal headache
o Anosmia
o Sneezing

SIGNS
o Big polypii cause broadening and frog-face defr:rmity
o Anterior rhinoscopy : multiple greyish white masses like bunch of grapes bilaterally.
o Soft, mobile, insensitive and do not bleed on touch.
o Posterior rhinoscopy : no abnormality
o X'ray sinuses :
- Haziness of ethmoidal air cells
o Blood examination . eosinophilia
o Cytology of nasal secretion : eosinophilia

TREATMENT
Treaiment of allergY
o Prolonged therapy with antihistaminics prevents recurrence
o Local steroid sprays pre and post-operatively prevent recurrence
- Budesonide
- Beclomethasone

SURGICAL TREATMENT
lntranasal polyPectomY with Luc' s / Citelli's forceps under local / general anaesthesia'
A piece of the underlYing bone is removed as it undergoes osteitis. lf the
polyps recur, intranasal ethmoidectomy
is performed.
post-operative C'T. scan of the sinuses'
Nowadays Functional EndoscoPic Sinus Surgery is performed with a pre-and

RHINOSPORIDIOSIS
(Rhinosporidium Kinealy)'
A chronic fungal disease of the nose caused by fungal - parasiie Rhinosporidium seeberi
has not been reported. lt is endemic in lndia and Sri Lanka'
Australia is the only continent from which this disease
followed by Madhya Pradesh' Orissa and West Bengal.
ln lndia, the incidence is highest in Tamilnadu and Kerala
males are commonly af-
Hyperendemic areas in TJmilnadu are the districts of Madurai and Ramnand. Young
fected.

Hyperendemic areas in Tamilnadu : Rhinosporidium seeberi :

o Madurai o Described by Seeber and also by Kinealy

o Ramnand o The fungus does not satisfy koch's postulates - cannot be cultured
 ClinicalENT

Endemic regions :

lndia :

o Tamilnadu
o Kerala
o Madhya Pradesh
o Orissa
o West Bengal
Sri Lanka - CeYlon
Not reported from Australia

It is acqqired bY :

r Swimming in water contaminated by cow dung'

o lnhaling dust of dried dung.

Common site : Nose

o Septum
o Lateral wall of nose

r: r lnferior turbinate

n o Middle turbinate

Sites of affection
r:
:

\, Nose

r: '4
.
NasopharYnx
Lacrimal aPParatus

r- r' o Conjunctiva

n
r
o
o
o
Palate
Genitalia
Middle ear (

n \/. Maxillary antrum

Clinicalfeatures
Symptoms:
:

o Eprstaxis - chief sYmPtom

F o Mucoid / blood stained nasal discharge

n
n
o ltching
o Sneezing

n
Signs :

o A bleeding polypus is the commonest lesion'

o Friable, red, polypoidalstrawberry like mass'
F
I-
oStuddedwithsporangia,showingasminutewhitespotsonundersurface

r1*
o Pedunculated / sessile mass
o Polypoid / nodular / granular mass
o Broad nose if the mass is big.

rr*.
Nasal secretion :

o Viscid
 93
Section I Case Presentation - Nose
-
o Spores present
a Hyperaemic nasal mucosa

Spread :

To surrounding regions by autoinnoculation by finger

nails
o
o Lymphatic widespread cutaneous and subcutaneous rhinosporidiosis
:

r Haematogenous : visceral rhinosporidiosis

HISTOPATHOLOGY
columnar epithelium
o Papillomatous hYPerPlasia of mucosa lined by ciliated
o Fibro-mYxomatus stroma
o High vascularitY in stroma
o Sporangia in various stages of development
Stains used to study rhinosporidiosis include :
o Conventional Eosin and Haematoxylin stains
spherule lightlY
oSudanblack,stainsthewallofthespheruledeeplyandthebodyofthe
o Methyl green stains tlre centre of the spherule deeply'
o Toludine blue and Bismarck brown are also used"

Sporangia :

o Mature sporangium is 300-400 pr in size'

o Has a double laYered wall.
o Outer wall is thick chitin.
o Nu.merous spores are reieased from mature sporangia through pores covered bY anis then seen
oPerculum

o Sporulation occurs and the spores spread through the lymphatics' the trophic stage
o Size of spore is that of RBC i'e ' 7 '2yt '

Diagnosis :
o Characteristicclinical appearance'
Microscopic examination of the nasal discharge for
r spores

o Histopathological examination of the biopsy specimen

o High tendencY to recur

Differential Diagnosis
o Papilloma
r Rhinoscleroma
o Malignant tumours

Treatment :
Surgery : Excision of growth with cauterization of base'
'1 bottle of blood pre-operatively'
It is mandatory to cross match and reserve at least
o Recurrences are common if inadequately excised"
o Recurrences are Prevented bY '
- Cauterization of base
- Dapsone 100 mg tds with lron and multivitamins coniunctival lesions
- Local application of 2ok acqueous solution of Antimony tartarate to the nose and
o l/VAmPhotericin
o Local injection of sieroids
t: ClinicalENT
,94 t
r"
t: RHINOSPORIDIOSIS
o Chronic fungal infection
I: o RhinosPoridiumseeberi
I: o Endentic : lndia, Sri Lanka
o Swimming in dung contaminated water
t: o lnhalation of dried dust dung
t: o Strawberry-like bleeding polypus
o Undersurface : SPorangia
r: o Affects septum, lateral nasal wall
r Surgical excision with cauterization of base
r o High tendencY to recur
r:
l'" RHINOSCLEROMA
r:
r: Synonym:Scteroma
It was first described by Hebrew
in 1B7B'
Otr\e\-\$lg- S\YtbaS(opU.
.,,. ,,,-,.-,^,r^ Dhi^^-^r6rnmari^

r: rt is a chronic granuromatous disease

or Diprobacirus of Frisch characterized
of the nose caused by Gram negative baciti,. Kreibsieta Rhinoscleromatis
by screrosis and stenosis of thL nasar cavities.
rt initiariy affects the nose

r: and then extends into the nasopharynx,

oropharynx, sub glottis' trachea and bronchi'

n
r:
ltaffectsboththeSeXes,iscontagiousandismainlyseeninpoorunhygienicconditionsassociatedwithlow
socio-economic status ti is commln in
Rhinoscleroma
Central and Northern lndia'

n
I-
Central and Northern lndia
Eastern EuroPe
Middle East
Africa

n
I-
lndonesia
South America

I: CLINICAL STAGES
PATHOLOGICAL DIAG NOSIS

I: FEATURES

e Diagnosis only by complement fixation

test

I:
I:
1. AtroPhic stage

2. Nodular stage/
AtrophY of mucosa
Crusting and painless foul smelling discharge
Pink nasal mucosa
Nodules "o Pt"dominant cells are plasma cells
Difficult to demonstrate the organtsm
stage of granula- o lndia-rubber consistencY
l-.- tions o Bluish-red

l- o Non-ulcerated

t*
External deformitY
o Hebra nose
o

t*
Typical histological Picture
Scarring occurs all over the nose

r
Cicatrisation/
of external nose
stage of sclerosis Tapir nose-coarsening
progresses posteriorly

r
Fibrosis starts anteriorly and
1 fibrosisi stenosis
Section I Case Presentation - Nose 95
-
Histology :

Granulomatous tissue infiltrates submucosa. The predominant cells are plasma cells with hyalrne bodies-Russel
bodies (fuschinophil degeneration). Other cells are fibroblasts, endothelial cells, lymphocytes and eosinophils.
The characteristic cell is the Mikulicz cell
Mikulicz cell :

o Large mononuclear cell

o 30-40um in size
o Foamy / vacuolated cytoplasm
o Nucleus is irregular, central or compressed to one side
o Cytoplasm contains clusters of capsulated Frisch bacillus.
There is a high content of mucopolysaccharides around the walls of the organism (Klebsiella), thus protecting
it from antibiotics and antibodies.

CLINICAL FEATTJRES
o Atrophic changes in nasal mucosa in the initial stages
o Slow progressively increasing nasal obstruction
o Hard, non-tender, non-ulcerated swelling
o Swelling initially anteriorly below the nostril and lips
o Stenosis of the nose
o Cough, hoarseness and stridor due to subglottic stenosis
lndirect laryngoscopy :

o Atrophy of vocal cords

o Subglottic stenosis
o Lymph node involvement is rare as fibrous tissue deposition blocks the lymphatics

DIAGNOSIS
o History
o Clinical features
o Smear examination for bacilli
o Biopsy shows typical histological picture.

DIFFERENTIAL DIAGNOSIS :

o Atrophic rhinitis
o Syphilis (tertiary stage)
o Tuberculosis
o Leprosy
o F?hinosporidiosis
 Clinical ENT

TREATMENT
TREATMENT

1. AtroPhY / Granulations Antibiotics :

o StreptomYcin
o ChloromYcetin
o Tetracycline
o Ampicillin with TrimethoPrim
Local APP|ication :

e Rifampicin
o Acriflavine 2%
(2%Acriflavineisveryeffective.5%causesvestibulitis,epistaxis,septalperforation'1%
produces no effect )

Kailash Rai regime :

Local iniection of carbolic acid

2. Cicatrization +'Laserexcisionotst"nosi'*itf'polyethylenetubeinsertionforBweeks
,+' Electrocautery
+ CryosurgerY
o Plastic reconstructive surgery
o TracheostomY for stridor
o Local steroid injection
eRadiotherapy.3000-3500CGYoverthreeweeksdestroysscleromaorganisms
o Surgical removal of stenosis and dilatation therapy

RHINOSCLEROMA
o Chronic granulomatous disease'
o Klebseilla rhinoscleromatis
o 3 stages :

- AtroPhic
- Granulomatous / nodular
- Cicatrization / fibrosis
o Features:
- Hard nodules which do not ulcerate
- Hebra nose
- TaPir nose
o Pathology :

- Mikulicz cells
- Russell bodies
o Treatment :

- Local acriflavin / rifamPicin

- Antibiotics, streptonrycin, tetracycline
- Excision of stenotic tissue
Section I Case Presentation - Nose 97
-
INVERTED PAPILLOMA
o Synonyms :

- Ringertz tumour
- Transistional cell tumour
o lt arises frorn lateral wall of nose and sinuses
o 1-4ok of all nasal neoplasms
o Males : Females = 5 ; 1, seen in old men.
o Soft, pinkish-red, friable vascular mass
o They are often single.
o Clinical features
- Nasalobstruction
- Bleeding
- Nasaldischarge
- Deformity of nose
o Histology :

- lnversion of epithelium beneath the stroma

- Basement is intact
- The surface is covered with alternating layers of squamous as well as columnar epithelium. lt is also called
transitional cell papilloma.
- Malignant change can occur
Treatment :

o Wide excision by lateral rhinotomy.

o Recurrence is common.

MIDDLE TURBINATE HYPERTROPHY

o Less common
o Could lead to chronic sinus disease
. PneullatLqgd middle turbinate - Concha bullosa.
Treatment :

o Decongestants
o Reduction with punch forceps
o Submucous diathermy
o Removal at Functional Endoscopic Sinus Surgery
o Complete excision by Lateral rhinotomy

INFERIOR TURBINATE HYPERTROPHY

o Usually due to submucosal oedema
o Bony hypertrophy is rare
o Dilatation of the submucosal venous sinusoids occurs
o Venous sinusoids are under sympathetic control
n
lt: o Agonist drugs cause vasoconstriction and mucosal decongestion
Clinical features :

rE o
o
Soft sensitive mass arising from the lateralwall'
Associated with symptoms of intrinsic rhinitis

Treatment :

o Systemic and local decongestants (No response if submucous fibrosis has occurred)
o Submucous cautery (diathermy, laser)
E o Partial or total turbinectomY
r:
r" NASOPHARYNGEAL ANGIOFI BROMA
r
r-
Synonym
o Juvenile Angiofibroma

l- o Nasopharyngealfibroma
It is a vascular swelling arising in the nasopharynx of prepubertal
and adolescent males and having a strong

r:
rn
tendency to bleed.

SITES OF ORIGIN
o Vault of nasoPharynx
o Choana

n o Sphenopalatineforamen

rn .?tteo*tEs
(t\
Ringertz
oF DEVELopMENT oF ANGIoFIBRoMA
Arose from periosteum of nasopharyngeal vault
ng skull base resulting in hypertrophy of underlYing Periosteum

I-
Som and Neffson
t? basiocci
,'-C' Bensch and Ewing Tumour arose from emOtyoni" tiOro"attilaSg between
and buccopharyngeal fascia

r
Brunner
'c)c' Osborn Hamartomatous theory:
]- o Hantartomas
o Residual erectile tissue subject to hormonal influence
Girgis and FahmY
]-' Arose from vestiges of atrophied stapedial artery

I:
Hormonal theorY
-Androgen and oestrogen imbalance

r
*

PATHOLOGY
Gross

F
o Pink, smooth mass
r Firm, hard to touch

l- o Bleeds on touch
o Broad based/small base

l*
tr
o Pedunculated
o Covered with mucous membrane
r Ulceration is rare

l*
]-'
Section I Case Presentation - Nose 99
-
a Tendency to spontaneous regression
a Can be bilobed, dumb.bell swelling with one portion in nasopharynx, other in pterygopalatine and infratempo-
ral fossa, stalk in the sphenopalatine foramen.

Microscopic
o Tumour is made up of plenty of young fibroblasts, blood vessels, and collagen.
o Tumour has no capsule, hence it has to be removed from its attachments without breaking into the growth
o Surface epithelium is columnar ciliated.
o Blood vessels are more in the centre than the periphery.
Characteristic of blood vessels
o Numerous blood vessels are present.
o Wall of the vessel is thin
o Wall is lined by flattened endothelium
o Wall is devoid of contractile muscular and elastic layers
o The vessels therefore do not contract on cutting and bleed profusely.

BLOOD SUPPLY
o Enlarged maxillary artery
r Ascending pharyngeal artery
'r-Vidian artery
r Branch of lnternal carotid artery
*--Vertebral artery
o Bleeding is caused by disruption of parenchyma of swelling or feeding vessels or it can be spontaneous
CLINICAL FEATURES
o Spontaneous, recur(ent, intractable bleeding from the nose. The bleeding may be dangerous to life.
o Nasal obstruction
o Nasal discharge
c Headache (chronic sinusitis, dural compression, invasion of sphenoid sinus).
o Rhinolalia clausa
o Anosmia, hyposmia
e Deafness due to eustachian tube obstruction.
o Otalgia
o lnterference with deglutition, respiration
r Anaemia
o Anterior rhinoscopy
- Nodular, lobulated mass
- Reddish in colour
- Mostly unilateral, at times bilateral nasal extension
- Mucopurulentsecretions
- Bowing of septum
o Posterior rhinoscopy
- Pinkish red mass filling the nasopharynx
In 100 ClinicalENT

t: Extensive disease
r Splaying of nasal bones
o Swelling of temple and cheek

F o Fullness between ascending ramus of mandible and side of maxilla

o Trismus
n o Bulging of parotid gland
o Proptosis, falling vision
F: o Classlcal frog face

r_ SPREAD OF NASOPHARYNGEAL ANGIOFIBROMA

Pterygopalatine lossa
F lncreased intracranial lM;;ffi.3]
tension a I -..i.il<;,:k-
^!?*o^

r- =._
-\ 1
Cranial caviiy
\
Lateral extension
I
\"d/
rnfratemporalfossa

f= Spread / Extension
<--lDpreaq/trxrensrorrl
r: fp."!".irl
Grows medially beneath the mucous
membrane of nasopharynx
+I f \ \ \ fissure ,/ U
inferiororbital

r-
I

+ Below \ -
Occupies postnasal space | Retromaxillary fossa
I
* autge ortott palate I "

F Anterior surface of sphenoid

sinus eroded contact with dura of
o
o
Bulging of cheek, nose
Broadening of nose

r- I

+ --+ middle fossa

I- Grows forward in
nasal fossa t
I

I-
1-
I

J
Displaces nasal septum
Displaces maxillary
nerve, optic nerve

t-'
DIAGNOSIS
'1
. History-recurrent epistaxis
2. Seen in males
]-' 3. Appearance of the mass
1- 4. X'ray lateral view nasopharynx

t- o Soft tissue mass in nasopharynx without any air shadow between it and the cervical vertebrae

I-
5. C.T. scan
o Extent of growth

I-
F
o
o
o
o
Erosion of bones
lntracranial extension
lnvasion of sphenoid sinus, pterygopalatine fossa
fossaX
_/

F-
Forward bowing of posterior antralwall (angiofibroma filling pterygopalatine
6. Carotid angiography
o

rI-
To find vascular supply : vascular blush rn postnasal space

l-l o Collaterals
 Case Presentation - Nose 101
Section |
-
a Feeding vessel embolization
o No BIOPSY is taken because of risk of severe haemorrhage

COMPLICATIONS
o Haemorrhage
o Shock
o Sepsis
o lntracranial complications

DIFFERENTIAL DIAGNOSIS
o Antrochoanalpolyp
o Chordoma
o. Tumours of postnasal space
o Large adenoids

TREATMENT
1. Hormone therapy
o Testosterone
o Oestrogen
Action
o Maturation of collagen in the tumour
o Reduction in vascularity
2. Radiotherapy is for
'r'
lnoperable intracranial extensions
t/ Recurrent tumours
3. Action
o Hardening of tumours due to reduction in vascularity
4. Surgical excision

Approaches
SURGICAL APPROACH COMMENT

Transpalatal o This approach is for tumours iust in nasopharynx

Lateral rhinotomy o Tumour in nasopharynx and in infratemporal fossa
Combined o For extensive tumours
Transnasal
Transantral achieved by Weber Ferguson incision

PRINCIPLES OF SURGERY IN COMBINED APPROACH

e To sufficiently expose the maxillary antrum
o Removal of all walls of the maxillary antrum edpecially the medial wall including the perpendicular plate of
palatine bone
o The orbital floor and upper alveolar arch can be left intact
r'/ffre nasal cavity, antrum, infratemporal fossa, pterygopalatine fossa and nasopharynx are converted into a
single large cavity
o The maxillary artery is ligated first followed by tackling the tumour in the infratemporal fossa, antrum and then
the nasopharynx. Removal of perpendicular plate of palatine bone uncaps the part of the iumour occupying
the sphenopalatine foramen
t; Clinical ENT
r^ 102

TI COMPLICATIONS
.r- Palatal fistula w-Ectropion of eyelid
t/Crusting in nose o Recurrence

F '/Anaesthesia of cheek

n NASOPHARYNG EAL CARCINOMA

1:
n It forms B0% of all head and neck cancers and 18% of all malignancies. It is commonly seen in China
It is seen more in males than females. M:F=2-3:'1
It has a bimodal age group presentation, seen in 10-20 yrs and 55-65
yrs.
Nasopharyngeal carcinoma
o China

F of age.
o
o
Far East Asia
South East Asia

F ETIOLOGY
1. Genetically determined susceptibility
o
o
Europe
lndia

I-
I:
2. Epstein-Barr virus infection. (lt is said that Epstein-Barr virus genomes get
integrated into nasopharyngeal mucosal cells and form a tumour)
-
-
Manipur
Assam

I:
3. Nasopharyngeal carcinogenicagents
'/ lngestion of salted fish v/Cigarette (tobacco) smoking
o
t- o
o
o
Smoke of incense burning
Soot from lamps
Unburnt kerosene
lndustrialchemicals
!"'Metal smelting
o Furnaces

1-
t- 'cl Preserved vegetables b.'Formaldehyde
y' \r/Wood dust
Nitrosamines and nitro-precursors
./
l-' Chinese herbal medicine

t-
l-
PATHOLOGY
It arises from the crypts and squamous/respiratory epithelium

Types of nasoPharYngeal tumours

lining the nasopharynx'

l-' Nasopharyngeal carcinoma

l- Adenocarcinoma
Adenoid cystic carcinoma

l- Mucoepidermoid carcinoma
Malignant lymPhoma

l-' Burkitt's lymPhoma

Hodgkin's lymPhoma
Plasmacytoma

F
r
Fibrosarcoma, angiosarcoma-
Rhabdomyosarcoma '

rr Gross
Melanoma, Chordoma, Craniopharyngioma

r
o Polypoidalmass
o Ulcerative mass
o lnfiltrative mass

l-*
F
 103
Section | Case Presentation - Nose
-
HistopathologY :

o Squamous cell carcinoma

o Undifferentiatedcarcinoma
o Non-keratinizingcarcinoma

CLINICAL FEATURES
o Bilateral nasal obstruction
o Cervical metasiasis Trotter's Triad :

o Epistaxis o Pain on iPsilateral side of face

o Headache
o lpsilateral Palatal PalsY

o Deafness, tinnitus, otalgia

o lpsilateral conductive deafness

o. Nerve palsies, Horner's sYndrome

o Metastasis
fossa, parapharyngeal space
- Loco regional : paranasal sinuses, orbit, parotid gland, infratemporal
-Distant:bone'lung,liver(thoracolumbarspineisthemostcommonsite)
with the primary area hidden (occult cancer) The
Nasopharyngeal cancer is known to give rise to secondaries
to other groups.
lymph nod" lroup affected rapidly increases in size and spreads
palpable clinically. The nodes thus first palpable
The first nodal station is the retropharyngeal node which is not
Epistaxis and ozaena due to tumour
are the jugulodigastric or the apical node under the sternocleidomasioid'
erodes skull base or in sphenoid sinus
necrosis is seen in advanced stages. Pain is seen when the tumour
Cranial nerves lX and X get most commonly
sepsis. Trismus is seen when the [terygoid muscles get involved.
the cavernous sinus. otitis media with effusion
involved. cranial nerves lll, lV and Vl are next to be affected within
causing tinnitus occurs gradually.
Spread of nasopharyngeal carcinoma

CHART I

Foramen lacerum
Petrous aPex
Optic nerve
Superiorly
Parasellar structures

Anteriorry
I Posteriorrv _* -r"i';il?:t":l
f.l rZ :3::"
Nasal cavity
Paranasal sinuses fN-*:eh",y"s= ,l
Apex of orbit
Pterygopalatine fossa
"*_i* lnferiorlY

Laterally
I
OralcavitY
Retrotonsillar region
i
I

Parapharyngeal sPace involvement

t:
rI: 104

Parapharyngeal space involvement can be :

ClinicalENT

1. PRESTYLOID 2. POST STYLOID COMPARTMENT

lnvolvement of vz-Vascular compression of carotid sheath

F s,- Mandibular nerve

.z']nvasion of cranial nerves IX, X, Xl, XII and Cervicalchain

n v'Pterygoid muscles
vr Deep lobe of parotid gland

r_ CHART II

n
I- (Roof of fossa of Rosenmuller)
Upper deep
cervicalglands
Deafness
Tinnitus
v

r-
Foramen Lacerum I
Eustachian Metastases to
Lymphatic
lungs

l-
Spread tube
Jugularforamen syndrome( + spine
\\\_ \ I liver

r- Mandibular # Foramen ovale <- N aso pha ryn ge al car cin9ryt--

-+ Pterygoid muscles --+Trismus

n
I:
nefve
SinusofMorsasni I
''"';:l#:lnugn' I
dura and base or
of
,/
I
II
sph"l;ail
I
\\ \ronunoidbone
\
I \\ \.\.\.

rroo.. oii',iJoru craniarrossa

I-
duriaer\:?eJse / Sphunoidal
skull / fittut" i
-\
n
F
Symypathetic chain
. r I
"/
,.drn"r'"tynorot"
rt\
^ -^-:
Cranial
J
nerves
v +
Destruction of tip
of petrous bone
Il' Ill' lv' vl' IX' x orbit
- vl [JEll vuJ

\
vvl lv

I-
rt-
+
Enophthalmos
Miosis
Ptosis
Anhydrosis
Blindness
Ophthalmoplegia
Dysphagia
orbitalmuscle paralysis
Gradenigo's
syndrome

Diplopia

l- DIAGNOSIS

l-' 1. Delay in diagnosis can occur because of :

a) Occult nature of the carcinoma c) Nasopharynx is a relatively inaccessible sPace

I-. b) Bizarre symptoms d) First metastasis is to clinically non palpable retropharyngeal node

l- 2. Posterior rhinoscopy

l-
3. Digital palpation of nasopharynx
4. Nasopharyngoscopy

l-
l-
5. X-ray lateral view / Submentovertical view of nasopharynx
6. C.T. scan / MRI
o Obliteration of paranasopharyngeal soft tissue planes
o Obliteration of fat in the paranasopharyngeal space.
t-' o Erosion of base-skull

l-
l*
o Extension of tumour through carotid artery or foramen lacerum
o Upward extension through floor of middle cranial fossa into cavernous sinus and parasellar region

f-'
Section I Case Presentation - Nose 105
-
o Asymmetry of muscle layers is seen in :

-Neuromuscular infiltration by the carcinoma

-Post radiotherapy cases.
o Ring enhancement seen in affected nodes due to central necrosis/peripheral vascularity.
7. EBV serology : High lgA titre io the viral capsid antigen (VCA), 1 :1 0 is suggestive of nasopharyngeal carci- I
noma.
B. Biopsy under general anaesthesia is taken through a visible growth or a blind biopsy is taken from fossa of t
Rosenmuller and roof of nasopharynx with angled forceps or a biopsy is taken (with postnasal biopsy forceps)
after retracting the palate forwards.
9. Pure tone and lmpedance audiometry
10.X'ray chest and radionucleide bone scan for secondaries.

DIFFERENTIAL DIAGNOSIS
1. Adenoids 2. Plasmacytoma
3. Petrositis 4. Trigeminal neuralgia

TREATMENT
Principles
o Surgery plays a minor role because of relative inaccessibility of primary growth and early bilateral spread
o Tumours are extremely radiosensitive
o Presence of cervical metastasis does not aiter the cure rate
o Distant metastasis carries a bad prognosis
o Chemotherapy does not markedly change the prognosis

Radiotherapy
o Main mode of treatment
o Use of facial shells is advocated
o Prophylactic neck radiation should be given in patients with No neck
o Treatment failure can occur if parapharyngeal space is already involved.
o Dosage is 5000-6000 rads over 5-6 weeks (200 rads/day for 5 days in a week)

Brachytherapy
o High dose is given to the tumour
o lntracavity lridium-192 is used for residual/recurrent disease.
Complications of radiotheraPY :

o Ablation of parotid gland o Osteoradionecrosis (mandible, skull base)

o Xerostomia o Radiation myelitis, encephalomyelitis
o Mucositis o Optic atrophy, retinitis
r Radiaiion otitis media with effuston o Temporal lobe necrosis
o Dental caries o Hypopituitarism

SURGERY
The nasopharynx is a relatively inaccessible area making surgical intervention difficult
Reasons
o Situation is deep in the skull
o lnternal carotid artery and carotid canal are in close proximity to lateral nasopharynx where most tumours
rCCUT
r"
o Adequate removal of tumour requires drilling of clivus
I: o Lack of adequate surgical margins
t: o Post operative trismus is a problem

I: Surgical approaches to the nasopharynx

w' Transnasal o Transmandibular-mandibular swing

I: 'o Transmaxillary
e'
o
o
lnfratemporalapproach
Transtemporal - sPhenoidal

I:
Transpalatal
o Sublabial midfacialdegloving o Transpharyngeal

I: o Transfacial-maxillary swing o Transcervical

l: o
PROCEDURE

For removing tumours in maxillo-ethmoid region

t: o
o
Denker's extension of Caldwell-Luc can be tried
Lateral rhinotomy / Weber Ferguson improves exposure but is complicated by
r: midfacial scarring

r: o Lefort I osteotomy approach can be used by down fracturing entire hard palate
and inferior maxilla

r: .
o
lt may affect facial groMh and damage non-erupted teeth
Shortest and most direct approach

r_ o
o
Allows extension to sphenoid and choana
A
,U'
incision on the palate extended to a 's' type around the tuberosity of

r maxilla is taken. The greater palatine bundle is preserved and after elevating

r: Sublabial midfacial degloving .

o
palatal mucopeliosteal flap, tumour is exposed
Allows enousi'
"xposwe
of nasal complex, nasopharynx and mid-third of face'
Gingivolabial incision is carried across from one maxillary tuberosity to the
r_ approach

r:
other
o Soft tissues are elevated
o
r- o
lnfraorbital nerves are preserved
Routine rhinoplastic incisions are taken

n o septal-vestibular incision is connected to sublabial incision for degloving

upto root of nose

rn
f-
Prognostic factors
o The necessary bones are removed and the tumour tackled
combines weber-Ferguson-Long-mire incision with splitting of hard palate and
multiple osteotomies detaching the maxilla

r: The prognosis depends on the following factors

n
r-
o
o
Nodaldisease
Degree of differentiation
5 year survival rates are :

o 7Sok in early cases

f-' o 15o/o in late cases

F-.
F-
f-'
F-
 107
Section | Case Presentation - Nose
-
Women have high survival rate than men'

ttRSOPgnnVNGEAL CARCINOMA
o Chinese race
e Occult cancer
o Early bilateral lymphatic spread
o Cervical metastasis occurs
o Neurological Palsies common
o Very invasive tumour
o Metastasis very common
o Paradoxical tumour and nodal stage relationship
o Radiotherapy is treatment of choice'

cencrNoMA (MAxrLLe) pARANASAL Srxusns

Sex .

Men are more affected than women

M:F = 10:1
Age
50 yrs of age (lesser age grouP)
<20ok of head and neck cancers

TYPE Carcinoma maxilla :

o Squamous-cell - commonest Bantu tribe of South Africa is more prone due to

o Adenocarcinoma - rare use of home-made snuff'
o Sarcoma - in children
o Burkitt's lymphoma - in children of South Africa
ETIOLOGY
Predisposing factors
'1. Chronic inflammation (not a major factor)
LeukoPlakia of Palate
-2.
p. lrradiation to nose, sinuses in
o Telangectasia
o Fibrous dYsPlasia
3{ lnhalation of snuff
-.$.- Exposure to wood dust in timber industries
6. Cutting and polishing of beach wood
-Z Working in chrome, nickeland shoe industry

Premalignant conditions
o Ringertz tumour
o Squamous cell PaPilloma
o Maxillarv sinus
o Ethmoid sinus
.: -J I 99%
o Frontal sinus
l1%
o Sphenoid sinus -"r

CLASSIFICATION
I. Ohngren's classification
the pupil
An imaginary line drawn from medial canthus to angle of mandible and a perpendicular line through
creates four zones for carcinoma maxilla bearing different prognosis.
FOUR ZONES ARE THUS FORMED PROGNOSIS

o . Antero inferior medial Good, causes earlY sYmPtoms

a Anfero inferior lateral Poor
o Postero superior lateral Poor
a Postero superior medial Worst, spreads raPidlY

II. Moffet (1952) classification

Upper group
o Arising from middle and superior meati
Lower group
o Alveolus
o Teeth
o Gums, extending into antrum
III. Ledermann's (1970) classification
o Two parallel lines are drawn across a frontal section of the skull. Upper line - passing through the orbital floor

o Lower line through the floor of the antrum.

-
These
o Two vertical lines are drawn extending down from medialorbital wall on each side of nasalfloor.
vertical lines separate ethmoids and nasalfossa
o The nasal septum separates the region into right and left sides.
o Three regions are thus formed
- Supra structure
- Mesostructure
- lnfrastructure
lV. TNM classification
T: Primary tumour
N: Regionalnodes
M: Distant metastasis
1. Primary tumour (T)
Tx Minimum requirements to assess the primary tumour cannot be met
T No evidence of primary tumour
0
Tis Carcinoma in situ
T Tumour confined to the antral mucosa of the infrastructure with no bone erosion or destruction
Tumour confined to the suprastructure without bone destiuction, or to the infrastructure with de-
1

T
struction of medial or inferior bony walls.
2

More extensive tumour invading skin of cheek, orbit, anterior ethmoid sinuses, or
pterygoid muscles
T
 109
Section I Case Presentation - Nose
-
nasopharynx, ptery-
T Massive tumourwith invasion of cribriform plate, posterior ethmoids, sphenoid,
4
goid plates or base of skull.
2. Nodal involvement (N)
Nx Minimum requirements to assess the regional nodes cannot be met.
N No clinically Positive nodes
0
N Single clinically positive homolateral node 3 cm or less in diameter'
I multiple clinically positive
N Single clinically positive homolateral node 3 cm to 6 cm in diameter or
homolateral nodes none more than 6 cm in diameter'
2

N single clinically positive homolateral node (3 cm to 6 cm) in diameter

2a
in diameter.
N Multiple clinically positive homolateral nodes, none more than 6 cm
2b (> 6cm)
N Massive homolateral node(s), bilateral nodes or contralateral node(s)
Clinically positive homolateral node (s), one more ihan 6 cm in diameter
3
N
3a
Bilateral clinically positive nodes (in this situation, each side of the neck
should be staged separately)
N
3b
:
N : Contralateral clinically positive node(s) only'
3. Distant metastasis (M)
be met
Mx : Minimum requirements to assess the presence of distant metastasis cannot
M : No (known)distant metastasis
Mo : Distant metastasis Present

V. Clinical classification
Antro - alveolar
Antro - ethmoidal
Vl.Classification according to site of origin
Primary : Arising from maxilla
palate'
Secondary : lnvolving maxilla from surrounding structures like the nose' alveolus'

CLINICAL FEATURES
Symptoms
o Absent in early stages (growth when confined to antrum)
o Discomfort over face
o Dull pain over cheek
o Anaesthesia or paraesthesia of cheek
o Swelling of nose and maxillary region.
Characteristic of Mass / Anterior rhinoscopy
o Visible mass in nostril
o Nodular, irregular mass
o Friable mass
o Ulceration is common
o Bleeds on touch
o Fast growing

SPREAD
of the posterior choana
c Lymphatics from the nose pass backwards to a plexus in the lateral wall
o jugular nodes. Retropharyngeal nodes are difficult to
The lymphatics then drain to retropharyngeal and deep
detect clinically and require C.T. scan for assessment'
110

. lf the skin is involved, the glands get affected soon

The submaxillary and internaljugular glands are affected
first followed by the mediastinal glands'
o Glandular enlargement occurs late in the disease
o Distant metastases are rare

DIAGNOSIS
o High degree of suspicion in early cases
o Visible mass on anterior rhinoscopy
o Mass over cheek
o Exophthalmos
o Palatal ulceration
o Loose teeth
o Glands in neck
o Radiologicalevidence
o Biopsy
DIFFERENTIAL DIAGNOSIS
1. Gumma
o Destructive lesion involving cartilage and bone
o VDRL positive
2. Lupus
o Apple jellY nodules on sePtum
o X'ray chest for tuberculosis

INVESTIGATIONS
Apart from routine investigations, the following specific
investigations may be required :

o Biopsy : The various methods are :

- Directly with Luc's forceps if nasal mass is seen
'rlThrough intranasal antrostomy if growth is not visible
- caldwel-Luc operation is not preferred for biopsy for fear of implanting malignant cells wall is removed at
- lntranasal antrostomy is preferred since it acts as a drainage channel. The anterolateral
surgery or even for irradiation'
- Endoscopic biopsy rs preferred nowadays
o X'ray paranasal sinuses maY show :

- Soft-tissue mass
- Bony erosion
o C.T. Scan / MRI to show
- Extent of growth
- Spread
- Erosion / destruction of walls of antrum
o Cytology from antral lavage washings

TREATMENT
o Surgery
o RadiotheraPY
o ChemotheraPY
 Section l- Case Presentation - Nose 11',|

SURGERY
Removal of tumour by :

o Palatal fenestration
o Denker's operation
o Moure's lateral rhinotomy
o Maxillectomy
- Partial
- Total
- Radical
- Extended radical
Contraindications
.c--lnvolvement of base-skull
'.r"/lnvolvement of pterygoid plates
'o-lnvolvement of cranial nerves
'9-"1 noperable g la nds'*-
/$,/'Trismus
o Presence of Horner's syndrome
r-- Distant metastasis -
o Poor general condition ---
Poor cardiac and pulmonary reserve.'*

RADIOTHERAPY
lndications
o Anaplastic carcinoma
o Sarcomas
Contraindication
";{nvolvement of malar
bone
Advantages of radiotherapy
o Reduction in size of tumour
o Reduction in vascularity of tumour
o Prevents tumour dissemination
Mode of administration
1. Preoperative radiotherapy
_
2. Postoperative radiotherapy
{l .
3. Sandwich treatment (pre and post operative)

CHEMOTHERAPY
It is mainly palliative in nature and the following agentq are used
'rr'5-fluorouracil
\c."" M"1no,r"*","
o Antimetabolites
lmmunotherapy is also palliative in nature.
t:
r.
I"
n
I-
n
I-^
1:
t:
t
F
I:
t:
F
t- [nnvilx
t-
t-
t-
l-
l-
t-
t-
t-
l-
rl-
t-
l-
r
n
I
I
IL 1. HISTORY AND EXAMINATION

Ir: HISTORY
1. Change in voice
Hoarseness of voice is one of the commonest disorder seen. Other alterations in voice are those of strength,
pitch, tone and quality. Hoarseness implies a rough, huskV voice. lt is due to lesions affectrng the vocal
r: cOds. ti is seen in patients with vocal abuse ug@IdF,tetaghgts. Hoarseness is Tq.l|lyjug.tp,!"aryngqal
inflammatron, tumo;urs, trauna or vocal cor{mobiiiif?Eorders. Hoarsenesffieherfy can be due to malig-
r: na ncy. Hysterica I fe ma le patients may have f u nctiolq!-9phqn 1a.

r: 2. Dyspnoea
Obstructive pathology in the larynx produces dyspnoea. S,triOot is nqty.9Eqg :9gqig,qbt-!!q$i9!-!9 ?il

r flow. Stertor is low-pitched sound produced by obstruction E66ve iF6lev-61:of the larynx. lt is due to vibration
fiihe -9!u-t9
l"tYnguut,

r: tracheal or bronchial obstruction.

Expiratory obstruction usually produces a wheezing sound during respiration. Respiratory obstruction is

r: characterized clinically by an increased respiratory rate, indrawing of larynx and trachea into mediastinum,
intercostal, suprasternal and subcostal retraction.
r:
rr: 'i
Differential diagnosis of Stridor
Congenital (Laryngeal / tracheal / bronchial)
r Larvnoomalacia o Cvsts

rr
'r:+'+---
o Webs
,'€ a
Y-gqglryJgia'alyeP
o Stenosis
.F-
a llgratgtqryeq

rr
o,. Tracheomalacia

, lnflamrnatory
) Larylgttis a Tube[culosis
- ! Laryngo tracheobronchitts a Diphthe_ria

rr ',r,
r Epiqlottitis

Traumatic
o

rn
Corrosive burns
o latrogenic
r-r-"Blunt injury
\"r- Penetrating injury
Neoplastic
o Papillomas "oc \iri"'r-
. C66nomas

F Foreign body

r- .
o
Lal4ngelgcheobroLrchial

f-
Oesophageal

r
f-
Miscellaneous
o
r
Allergy
Mediastinal tumours.

112

1--'
 113
Section | Case Presentation 'Larynx
-
3. Cough
Dry cough is due to laryngeal irritation. Productive cough is seen in lower respiratory tract
infections. Blood-
laryngitis, iracheitis are
stained, foul smelling rprtrr is seen in malignancies. Laryngeal foreign bodies,
common causes of cough production.
4. Dysphagia and odYnoPhagia
especially in-
Dysphagia is seen more in pharyngealdisorclers. ln laryngeal pathology, supraglottic tumours
in neoplasms with secondary infection
uotuing the aryepiglotiic folds pro-oriu dysphagia. odynophagia is seen
and in laryngeal tuberculosis.'- I
5. Foreign body sensation and blearing of throat (hawking)
It is seen in laryngitis, vocal cord polyps and early malignancy'
6. Swelling in the neck
perichondritis'
It is seen in secondaries in the neck, neoplasm spreading outside of larynx and in
7. History suggestive of etiologY :
o Tobacco intake by chewing or smoking
o Alcoholism
o Vocal abusb seen in singers, hawkers and teachers'
o Tuberculosis,sYPhilis

EXAMINATION OF LARYNX
lnspection
respiration' lt gets
The larynx is inspected for any mass, fullness, fistula and movements during deglutition and
during inspiration in laryngeal obstruction. Tracheal obstruction does not produce such changes' Laryn-
indrawn
geal framework may get distorted in certain-tumours, malignancied and inflammatory conditions'

Palpation
flexed to relax the
It is done with both hands standing behind the patient. The patients head should be slightly
The cartilages are palpated
neck muscles. The hyoid bone pnJ ft'" thyroid and cricoid c,ariilages are identified.
for thickening, tenderness and any broadening'
is examined for its
The thyroid gland lies over the thyroid cartilage from the second to fourth tracheal rings. lt
examined at deglutition and protrusion
consistency, swellings within, tumouqor any pulsations. lts movement is
of tongue.
produced when the larynx is
The larynx is examined for lary^ngealcrepitus. lt-is the,grating sensation which is -

moved laterc.tlylside lgriidp)pn the vert+ral colr 11 15 prss

nancy and retrophSflngeq!-Gsions, Oeciuse tfre'tarynx gets pushed forwards and its
movements over the
vertebral column do not occur.
A systematic examination of the neck nodes is carried out'
procedure'
lnternal examination of the laryn;< is done by indirect laryngoscopy. lt is an oulpatients

INDIRECT LARYNGOSCOPY
patient is exp,la.!ned-!he,-pto-ggdll-re. The patient and the examiner are both seated facing eachother' A head
' :-L:;-::1-
The
" '^;;;; i"'ritJJGiunot
laryngoscopy mrrror, gauze prieces to hold the tongue' spirit lamp to warm the
mirr6illth a light source, indirect
mirror are the instruments needed for the protedure. ih" ligr,t is focussed on the
patient's moulh.An indirect
or in hot water to.prevent fogging on ifs surface'
laryngoscopy n1irroiot uJ"qrut" size is warmed on a spirit lamp
patient opens his mouth and protriides the tongue which is held
It,s warmth is tested on the exaininer's hand. The
The teft index frnger retracts the upper lip'
by a gauze piece between.the left thumb and middle finger.
!i patient is asked to breathe quieily (through his mouth). The warmed mirror with the mirror facing downwards is
' the tongue surface lt is
f,"fO in the right hand like a pen and g"ntty introduced from the angle of mouth, above
slowly taken behind and finally rested against the base of the uvula.
114 ClinicalENT

By tilting the mirror and gently lifting the uvula, the following
structures are seen :

1. Base of tongue
2. Valeculla
3. Epiglottis (lingual surface)
4. Posterior aspect of arytenoids
5. Aryepiglottic folds
6. True and false vocal cords
7. Anterior and posterior cnmmissures
B. Upper tracheal rings and subglottis rnay be seen
9. Pyriform fossa qnd part of posterior pharyngeal wall METHOD OF PERFORMING INDIRECT LARYNGOSCOPY

The mobility of the vocal cords is examined during phonation by asking the patient tc say "ee". The true vocal
cords appear as ivory white ribbon-like bands and the false cords appear as dull-red bands. The tension, position
and adduction of vbcal cords is seen on phonation and deep inspiration. The vocal cords are examined for any
redness, nodules, polyps, ulceration, carcinoma eic. ln cases with overhanging epiglottis, the anterior commis-
sure may not be seen.
The epiglottis is pinkish white and the arytenotds are pink in colour.
The pyriform fossa, lying on either side of the epiglottis between the aryepiglottic fold and the lateral pharyngeal
wall are common sites for foreign bodies. They lodge in the pyriform fossa because of contraction of the
cricopharyngeus muscle. Pooli

Difficulties encountered in indirect laryngoscopy are :

1. Patient co-operation is essential

2. Gag reflex gets elicite$ if the mirror touches the posterior part of tongue or posterior pharyngeal wall
3. ln cases with overhanging epiglottis, anterior commissure is difficult to visualise.
4. lt is difficult to perform in children, unco-operative adults and obese patients with a short neck.
5. The tongue may obstruct the view of the vocal cords during phonation.
6. ln cases with overhanging epiglottis, direct laryngoscopy is indicated to see the anterior commissure.
7. Anterior commissure, ventricle and subglottic areas are not adequately visualised.
Uses :

1. For diagnosis of laryngeal pathology

2. Removal of foreign body from posterior lArd of tongue, valeculla and pyriform fossa.
3. To take biopsy from suspected lesions in larynx and hypopharynx.
4. To perform direct laryngoscopy and bronchoscopy, local anaesthesia can be given via indirect laryngoscopy.
5. Removal of small lesions or cauterisation of srnall ulcers.
Other methods of examination of larynx :

J. Direct larynqo.scopy
2. Stroboscopy
3. Microlaryngoscopy
4 F1breopt'c luyngoscopy
5. Laryngogram
.-
b. romograpny
'X?"y
,.
"""k
8. C.T. scan / M.R.l.
 Section I Case Presentation - Larynx 115
-
VOCAL NODULE
Synonyms
'1. Singer's nodule
2. Screamer's nodule
3. Chronic nodular laryngitis
It is seen in people who overuse and abuse their voice, like teachers, singers and hawkers
Pathology'Tlere is hyperp (uocal"buse).Subepi-
- thelial haemorihages occur beneath the hvperplastic epithelirrrn. "
At this stage, the no_dules_a_te_gAft-The_S_Utegr-
thelial collection qets slowlv orqanized and leads to formation of firm nodules. This occLrrs at the jrrnction-of
t
stress or work-lead,
Features of the nodule :
1. Greyish white in colour
2. Bilaleral
3. Symmetrical
Treatment
1 . Absolute voice rest for 2-3 weeks, soft nodules may regress.

2. Removal of the nodule by micro laryngoscopy

3. Speech therapy

VOCAL CORD POLYP

Vocal cord polyps are commonly seen in adults and affects males more than females. They are thought to be due
to trauma caused by overuse of voice. They are seen in hawkers, factory workers, teachers and people who
shout against background noise.

PATHOLOGY:
Trauma
I
Abrasion/haematoma over cord
J
lnflammatory reaction sets up
I
Subepithelial oedema in lamina propria (Reinke's space)
I
lncrease-in oedema
J
Bulge of overlying epithelium
1
Pedunculation
I
POLYP formation
r:
I:, 116 Clinical ENT

I:
rn HISTOLOGICAL TYPES
o
o
o
Gelatinous
Transitional
Telangiectatic
:

n FEATURES

n
1:
o Pink in colour
o Pedunculated or sessile lesion
o Usually near the anterior commissure

rn
o Moves with respiration and coughing
o Causes hoarseness of voice of gradual onset and of long duration
o A large polyp carr cause choking spells
TREATMENT
o Removal of the polyp by microlaryngoscopy with microsurgical instruments
l-
l:
r The polyp has to be properly grasped, pulled medially and trimmed off by scissors without damaging the
o
underlying cord.
Post operative speech therapy

n
t-. INTUBATION GRANULOMA

n
l-
ETIOLOGY
o
o
Prolonged intubation in general anaesthesia
Blind intubation causing trauma.

t-' o Prolonged surgery on a lightly anaesthetised patlent in whom vocal cords keep brushing against the tube.

t-
l-
PATHOLOGY

lrritant material Brushing / vibration of vocal cords

l- of tube against the iube.

l-
l- Trauma to vocal cord
I
l-
r
Resultant deepithelization of
cartilage of vocal process
l
F'
rr
Mild perichondritis

1
Granuloma formation over that site

rr
rD
 117
Section I Case Presentation - Larynx
-
SITES
o Vocal process
o Anterior commissure

FEATURES
o Past history of surgery
o Typicalsite
o Hoarseness of voice

TREATMENT
it needs to be removed to
Removal of granuloma under micro laryngoscopy. lf the underlying cartilage is infected,
help new mucosa to grow over it.

VOGAL CORD PARALYSIS

in origin'
The lesion could be central or peripheral. Central causes could be supranuclear or nuclear

VOCAL CORD POSITIONS

'1. Median
2. Para median
I
.ll 3 Cadaveric
4. Gentle abduction
i

5 Full abduction

POSITION COMMENT

Full abduction o Normal position

a Seen in forged / deep insP@!g^
Gentle abduction a t'l.qn'gl-pgsjllon
o Seen in quiet respiratioll
a A!so seen in bilatelal adductor paralysis-functional apholg
lntermediate / cadaveric o corcj lies halfwav between midline and gentle-abduction positlql-.
paralysed
-r"Position seen when all the'abductors and adductor muscles are
, e__T--_-. _
r'' Cords
-*;:+= are flaccid a&-sh-ot,va'qavlIne,
l. This position is_maintained by the elasticity of the capsule surrqu4tng 1!9

Para median o Cord lies adjacent to tlre midline

,, F

.o Complete paralysis ofrec-urrent larynqeal nerve

--:-
r T[_{!1c-o!fy.Jolq[muscle supplied by the exte-rnallarngc.al--rlgry9-!9-9peFd
t/ This position is maintained by th" tut"b
"ti"othy,oid
Abductor chink o Cords al11cgllggc[ege!-qtftqr
o Abductors are paralysed. AdductoJs atq q,g!.rve.
ytords do not completely adduct because of the tilting of the arytenoid
id posticus muscle'
,_ lartilages forwar
Median / phonatorY Position o Vocal cords close the glottis
' lry'"9" --'qgly::jiq9:{:g=9 91$3rrl :q-
 118
ClinicalENT

FEATURES
1. Superior laryn- o Direct trauma in operations of o
Rough, feeble, toneless voice Electric stimulation
geal nerve the neck o Easily fatiguable voice
palsy. . Tumours in the neck o Unaffected respiration.
o Complication of Diphtheria.
margin of cord because of
cricothyroid paralysis
o Unilateral cases : Cord shorter and I

higher than the opposite and disap_

pears under the ventricular fold on
respiration.
o Bilateral cases : Rima glottidis has
an irregular outlirre
o Analgesia of larynx can lead to
aspiration.
2. Unilateral Lesion in the vagus nerve above o Feeble voice
Aim : To bring the paralysed
superior and the level of superior laryngeal o Respiration unaffected cord to midline
recurrent nerye. o Cord in cadaveric position Teflon injection in affected
laryngeal o Cord also atonic, flaccid cord
nerve paraly-
lncomplete paralysis Clicoarytenoid arthrode-
sis o Abductor fibres succumb si5 : The joint is opened,
o Adductor action intact roughened and arthrodesis
o Cord in midline because of unoppo_ is carried
out with a Mont
sed action of adductors gomery screw.
. Tensor muscle keeps the cord taut
o Voice is nornral because of the other
cord
Complete paralysis
o Hoarse voice
o Cadaveric position of cord
o Affected side cord appears shorter
because of tilting of the afienoid car_
tilage.
Compensation
o Normal cord moves to the opposite
side. Con'rplete comp_ensation does
not occur in the posterior part.
o Harsh voice
3. Bilateral com o Lesion of cerebral cortex a Uncommon
bined paralysls o Lesion of medulla affecting bul_ o
. Tracheostomy
Voice is completely lost o CricoDharyngeal myot-
of superior and bar centre o Glottis is wide omy.
recurrent - Haemorrhage . Aspiration is common o Total laryngectomy
laryngeal - Thrombosls r Respiration is unaffected
nerves. - Embolism o Bad prognosis
- Syphilis
Section | Case Presentation - Larynx
-

- Tumours of base of skull

- Nasopharyngeal car-
cinoma
- Glomus tumours
o Lesion affecting vagus nerve in

the neck.
Minimal hoarseness of voice o No treatment in minimal
4. Unilateral re- Left side paralysis
Paramedian position of cord. voice disturbance
current laryn- o Carcinoma oesoPhagus
o Compensation occurs bY 6
geal nerve Pa- o Carcinoma bronchus
o Carcinoma thYroid months
ralysis.
o Operations o Teflon paste injection can

- ThyroidectomY be given in non-recov-

- Radical neck ered cases-

dissection
- Cardio-PulmonarY
surgeries.
o Enlarged left atrium
o Malignant tumours in thorax.
o Aortic aneurysm
o Peripheral neuritis
o Diphtheria
Right side paralYsis
o Carcinoma thYroid
o Carcinoma aPex of lung
o Thyroidectomy
o Tuberculosis
o Subclavian aneurysm
o Peripheral neuritis.
o Sudden palsy: stridor o lmmediate relief with
5. Bilateral Pa- Total thyroidectomY
o Gradual onset: adaPtation tracheostomY.
ralysis of re-
o Cords are almost in the midline bY o Permanent tracheostomy
current laryn-
the unopposed action of adductors. with a speaking valve
geal nerve (Bi-
or later, respiratory embar- can be used to retain
lateral abduc-
voice.
tor paralysis).
aneous recovery can
occur by 6 months.
o Surgical procedures Pro-
viding adequate airwaY but
not an adequate voice can
be tried on patients after 6
months, not willing to carrY
on with the tracheostomY.
Operations :

o External arytenoidectomY
o ArytenoidectomY and
cordopexy.
 ClinicalENT
120

TREATMENT
o ArytenoidoplastY and
r eordopexy.
of 4 mm. is created al
6ip
the posterior end in the
above.
Blien's king's oPeration :

Attachino the omohYoid

muscle to the arvtenoid
cartilaqe throuqh a urir]dour in
the thyroi-d cartilage. The
tulglio1 9Jlnq voqqt cord
mgy Selreglo-red
Kelly's operation : The
aMenoid is disPlaced later-
&
allv and fixed.
Wooamalt's operation :

The arytenoid is rotated lat-

erally and anchored to the

Tgrt"!d:
Endolaryngeal
arytenoidectomY
Nerve muscle imPlants:
lmplanting descendens hY-
poglossi nerve into Posterior
cricoarytenoid muscle.
Laterofixation of vocal
cords.
o H/o sudden loss of voice which was o Psychotherapy
6. Bilateral ad- Occurs in young anxious, ner-
ductor paraly- vous emotionallY unstable fe- normal till then.
sis (Func- males. (20-25 yrs) o Normal movements of vocal cords
aresis of adductor muscles is on respiration.
cal aphonia) due to derangement of cortical o Gap is Present in between the vo-
centres. cal cords on Phonation due to lack
of patient's efforts to produce voice.

CARCINOMA LARYNX
. Common in old age (50-60 Yrs.)
o Males are more affected than females
o Third most common cancer among males.
 /f$

121
\
Section I Case Presentation - Larynx
- \
ETIOLOGY \
L Smoking
2. Alcohol i
3. Abuse of voice
lrradiation for laryngeal papilloma
\
tA"
"Occupational exposure to asbestos' dust
n ,,.5.
.ileredity \
* .6:
\
PREMALIGNANT CONDITIONS
ErYlhroPlakia \
'-):
r,2 Laryngeal PaPillomatosis \
3. Vocal cord PoIYP
..,-"4{ Chro nic larYng itis -
.-5. Keratosis of larynx \
.-6:" LeukoPlakia of larynx
t
CLASSIFICATION
I UICC classification I

Laryngeal surface of ePiglottis :

AryePiglottic folds
Arytenoids I

False cords
i
Vocal cords
Anterior commissure -
Posterior commissure L
cord
St"rtt 10 tt below the free margin of vocal
Extends to inferior edge of cricoid cartilage' :
to natural barriers to cancer
ffiseregionsdoesnotaffecttheotheruntillatedue I
spread.Theseemoryologicallyseparateunitscanthusbetreatedseparately.
II. Ledermann's classification I

lnthisclassification,marginalzoneisincludedtosupraglottis,glottisandsubglottis. I
Marginal zone : - TiP of ePiglottis
AryePiglottic fold I

('!879) classification
lll. lsambert (1876) and Krishabuer's t

lnvolves Larynx ProPer

I
False cords
lrue coros
Sub glottic region
:
il;l
Extrinsic Pott"riot Pharyngeal wall P,'1i'lrt'Jf I

t
I:
t: IV. TNM classification
Tis: Carcinoma in situ
t: SUPRAGLOTTIS
I: Tx : Tumour cannot be assessed by rules'

n T0 : No evidence of Primary'

lr: T1 : Confined to one subsite with normal

Vocalcord mobility'
normal vocal cord mobility'
T2: lnvolving more than one subsite of supraglottis or glottis with of pyriform sinus' or
and/or extension to postcricoid area, medialwail
T3 : Limited to rarynx with vocalcord fixity
Pre-ePiglottic sPace' or causing de-
to involve oropharynx' soft ttssues of neck'
r4.. Massive tumour extending beyond the larynx
f.. struction of thYroid cartilage'

f- GLOTTIS

r: Tx Tumour cannot be assessed by rules'

r: TO
T,I
No evidence of Primary.
confined to vocal cord(s) with normal mobility
(includes involvement of anterior or posterior
commrs-

r: T1a
sures).
Limited to one vocal cord.

rr
r- Tlb
r2
T3
lnvolving both vocal cords'
Supraglottic and/or subglottic extension of
tumour with normal or impaired cord mobility'
Confined to larynx with fixation of vocal cord'
beyond the confines of the larynx

rr
r4 :Massivetumourwiththyroidcartilagedestructionand/orextenston
into oropharynx or soft tissues of the neck'

r
SUBGLOTTIS
Tx: Tumour cannot be assessed by rules'
T0 : No evidence of Primary'
Tl : Confined to subglottic region'

r- 12:Extendingtovocalcordswithnormalorimpairedcordmobility.
T3: Tumour confined to larynx with cord frxation'
r4.. Massive tumour with crrcoid or thyroid cartirage destruction and/or extension beyond the confines of the
]-
I- larynx.

I-
rI-
REGTONAL LYMPH NODES (N)
No : No evidence of regional lymph node involvement
N1 : Singlerpsilateral mobile lymph node (< 3cm)
(< 6cm)
N2 . lpsrlateral involvement of multiple nodes
Multiple ipsilateral mobile lymph nodes (< 6cm)
N2a :

F
F-
N2b :
N2c :
N3 :
Bilateral mobile lymph nodes (< 6cm)
Contraiateralmobile lymph nodes (<6cm)
LYmPh nodes >6cm in size

t*
l- t*

l*
F-
 123
Section I Case Presentation - Larynx
-
DISTANT METASTASES (M)
M0: No evidence of distant metastases
M1: Distant metastases Present
FIXED /MOBILE PSI LATERAL / CONTRALATERAL
N STAGE SINGE / MULTIPLE I

ilateral

lpsilateral 3-6 cm
Bilateral 3-6 cm
Contralateral 3-6 cm

Single / MultiPle Fixed / mobile

STAGING

I Tt No MO

II T2 N0 M0

ill T3 NO M0

T, -'-l
T2 I- N, M0
T3,
IV T4 NO MO

T--aNr
any Mo
l-u, Mo

anyT anYN M1

DIAGNOSIS:
1. EndoscoPY and bioPsY:
a) To visualise extent of disease, including subglottic extension'
procedure'
b) Biopsy taken at margins is important to study crtteria for conservation
2. CT Scan:
It is the best radiographic technique
post cricoid region, subglottic
..,kltoassess invasion of the ventricle, pre-epiglottic and paraglottic spaces, the
and extralarYngeal extension'
2. to assess fixation of the vocal cord'
to uneven pattern of ossification of the
3. for evaluation of cartilage invasion (it is difficult to assess due
laryngealcartilage).
4. may help to assess metastatic disease in the neck'
n-
n
n
124

CLINICAL FEATURES
ClinicalENT

FEATURE COMMENT

F
r
Change of voice
Hot potato voice
Dyspnoea-inspiratory
Glottic cancers
Supraglottic cancers '-.'.' . L
Sub glottic cancers (narrowest part)

t-
l-'
Dysphagia
Odynophagia
Cough with expectoration
Blood-stained sputum
Growth involves cricopharyngeal sphincter
Cancer involving epiglottis

F Referred ipsilateral otalgia

Choking on swallowing food \
(via Xth Cranial nerve)
Aspiration
Cancer epiglottis causing mechanical fault in closure of ,laryngeal inlet
t-."
t-
t-.'
Signs :
-
-
- Halitosis
Growth on IDL
Cervical lymphnodes
cancer pyriform fossa involving superior laryngeal nerve causing sensory loss.
Laryngeal crackle : Larynx is moved in a transverse direction over the cervical vertebrae
a nd no crackli n g sou nd i nd icates extralery4qeaLSpfeAd-of-sarcUerna.

l-
rl- -
enlarged
Loss of laryngeal
crackle.

rr FEATURES OF GROWTH

CANCER SITE

Supraglottis o
o
G ROWTH CHARACTERISTICS

Exoohvtic orowth
;l

Arises from eoiqlottis

CLINICAL SIGNS

Hqsky_ar'4
m9ff1e4__v-_9ice
TREATMENT

Cancer epiglottis
Supraglottic laryngectomY

rr
o Sllell nodule ovel ery€piglgtle.lqkls Lymph nodes in - Radical cervical lvmPhadenec-

l--- .
o
Bgg pryeltrg.'9y_glel:9-99'q.'
Growth invades the pre-epiglot-tic
neck
-
tomy if glands are palPable
Radiotheraov is not used as Pri-
sp3q9 marv mode of treatment

rr o
o
Bsgrolgryu.Ph
volyed
nq-d.--c.set in-

Rich ne!ryg1\ _o!!yqp. lati_cs is pr-esent

Cancer arveoiqlottic fold
- Qupraqlottic larynggqtornv Wrth
neck dissection
"

rr
sqregds,lg. {tg gLgttt !n !e!_" :1e9ff- Cancer false cords
. l1e!!"919!Ej91cgL lolh 9i!9;.glneck Radiotherapy
Total laryngectomy for recur-
S gts |Lv_g!,vq d.wjth meta-9lqqi
s
o Poor pl_og-!991q:qs,eql!y_ly!T.'p! !9qq rences
splqad

l-' o Fixation of cord indicates invasion of

rr Glottis o
cricoarytepoid jpin! or thyroarytenoid
muscle.
Localized congestion, ulcer or a small a Change of voice o T1 tumours

rr
mass over the vocal cord a Hoarse and aph- - Radiotherapy
o Occurs over anterior third of vocal onic voice - 95% success rate
cdrd Progressive o Tumours of small size (2.5 cm)
o Spreads along the edge anteriorly hoarseness - Laser surgery

rr more than posteriorly - Laryngofissure and cordectomY

Section I Case Presentation - Larynx 125
-
CANCER SITE GROWTH CHARACTERISTICS CLINICALSIGNS TREATMENT
o Spreads to anteriol posterior com- Vertical hemilaryngectomy
missures and opposite cord in late
stages
o Least spread occurs upwards
o Cords becoming fixed due to involve-
ment is rare because of dearth of glot-
tic Iymphatics
o , Rarely Delphian node (cricothyroid
node) may get involved.
o Excellent prognosis
- As it is localized for a long time
- Length of vocal cord is 2 cm
- Presents early
Subglottis o These rare tumours occu.r from un- Emergency presen- o Poor results
der surface of vocal cord to lower tation with dyspnoea o lncrease chances of recurrence
'^^,,--^^^^
border of cricoid and stridor o combined treatment
It occurs : - Radiation I

o Primarily in subglottic region - Total laryngectomy i

o Direct spread from glcttic region - Surgery for fixed vocal cord and I

o Metastasis from distant organs. nodal metastasis cases I

It spreads to : - Neck dissection ]

o Thyroid gland - Paratracheal glands ,r" ul"o r."-l

o Trachea moved I

r Strap muscles - High tracheostomy in emer- I

. Paratracheal glands gency cases. I

o Vocal cords may become fixed by di-

rect invasion
Transglottis Metastasis occur to paratracheal and Total laryngectomy with/withouJ
legf
mediastinal lymph nodes rather than in dissection
the neck
o' Cancer involving all three_regions of
larynx
e Aggregsivelumours
c- Metastasizes tq lhyrqidjllatdJervi-
catf1m0! muscles.
ry1t9s_31d ckap
o Fixed vocal cord occurs in invasion
of cricoarytenoid joint.
o Poor prognosis

DIAGNOSIS
1. Endoscopy / Biopsy
o Extent of disease-subglottic extension
o Biopsy from margins
o Deeper biopsy in submucosal spread ie; small lesions with decrease cord mobility
o Debulking can be carried out.at endoscopy.
n-
n 126
ClinicalENT

n 2. C.I. Scan : lt is indicated for the following :

a. To study extension to : Ventricle, pre epiglottic, paraglottic'

regions
post cricoid, subglottic and extra laryngeal

F
.

b. Fixation of vocal cord

radiotherapy or conseryative surgery as treat-
lnvasion of cartilage : Thyroid cartilage invasion excludes

F
L.

ment of choice

t- d. Metastasis in neck

t-
t--
DIFFERENTIAL DIAGNOSIS
o Tuberculous laryngitis
o
o
SyphiliticlarYngitis
Vocal nodules
o
o
o
Vocalcord PalsY
Leukoplakia
Vocal cord granuloma

t-' o Vobalcord PolYPs

t- INVESTIGATIONS

F
f-
o Complete blood count
o Biopsy

rl-
o Direct laryngoscoPY
o X'ray chest, neck
o C.T. scan

r
o VDRL test

rr TREATMENT

PRINCIPLES
Supraglottic carcinoma

rr T1 and T2
o
o
Radiation for T1 calilPmas
Supraqtottic horizontat partial
r'i--
tarvnge _dggp!y-!filfating-]-e-sign-g.-ol
I i :-!-^L.,^;i
^^,^l^+
fals,e-Esrds,-and l-nfrahyald-gplg.tot-
,

rr a'
T3 and T4
. ZJlane!-4on-eitherside)

rl-' o Post operative radiotherapy

sinus

Glottic cancer
: for all lesi

o Radiation therapy is preferred in eatlv glg-ltiq cancers (Tl ' T2)

l-. o Surgery (Total laryngectomv) is preferreO for advanc

rr
)

o Total laryngectomy is the ireatment for post radiation residual/recurrent cancers or

o Premalignant lesions of glottis are treated by complete stripping of mucosa of vocal cord by microsurgery
laser. Repeated stripping may be required for recurrences'

rr oRadiotherapyisnotveryeffectiveincarcinoma-in-situcaseS.
o Endoscooic
,2 co Laser for early glottic carcinoma equals radiotherapy cure

Advantages of Co, laser treatment

rates'

r - Precision
 Section I Case Fresentation - Larynx 127
-
- BJog!]g:r *!g"'y
- Decrease
+ oedema
\._,l,"'Recurrence in radiated patients does not follow usual patterns of spread
;r-'"Stomal recurrence occurs from residual tumour in soft tissues surrouhding trachea and partracheal nodes
T2 and early T3 lesions
V.ertica|hemila V
Radiotherapv : qualitv of voice is better

T3 Lesions
Cordal fixation : Laryngectomy
lndications of post operative radiotherapy
o Cartilaqe invasion
o Subqlottic extension
-€-
. @sgtgrsa!-nE{gin
o.@
. Tumour i!soft tisS
T4 Lesions
o Wide field laryngectomy with / without radical neck dissection
o lpsilateral thyroid lobe may also be removed

Subglottic carcinoma
o Radiation for early lesions
o Surgery for fixed vocal cord and nodal metastases
o Stomal recurrence results from residual turnour in soft tissues surrounding trachea and para tracheal nodes

SURGERIES FOR LARYNGEAL CARCINOMA

Vertical Partial Resection
o _+.
Cordectomv
o Lateral, partial laryngectomy (laryngofissure)
o Fro4olql9-f{Ll"?4t?t tgryryqqlo_mv
. E{g!999 fronto lateral partial larec!-omy
. FJ_ojJe l_pg$gl.lqryn g g_g!g ryry
H_o r j
B-es e*E! q n
-zgn!_al..l,q1!ifl
o Epiglo_ttgglgny
o S,up1.g$_o,ttic partialla!{1_g-eqtomy
.EI19!99-L'{pies-L9l!'_c_partBlqryls_ec_teny
Total Resection
o Totallaryngectomy
o Total laryngectomy with partial pharynge-cto11y or glo-ss-ectomy
. T_o$-l_lglyry o - p h a ry1111p - o e s o p h a g g_c to my yqit I r e-c_o-q g tr u ct o n
i

RADIOTHERAPY
o External beam radiotherapy
. CoO"lt OO ii the source
128 ClinicalENT

o Dose 6000-7000 rads, (200 rads/day for 5 days in a week) over 6-7 weeks
o ProteCtion of cervical spine with shields is needed.

CHEMOTHERAPY
Palliative treatment for dysphagia and pain relief

TREATMENT PROFILE
Stage I Radi.otherapy
Preservation of function of larynx
Stage ll - Surgery / Radiotheraoy
Equal results
Stage Ill Surgery with pre / post operative radiotherapy
Stage IV Palliative treatment

PALLIATIVE TREATMENT
o Nasogastric feeding
o Palliativechemotherapy
o Palliative radiotherapy
o Tracheostomy
o Antibiotics,analgesics
REHABI LITATION OF POST-LARYNGECTOMY PATIENT
o Voice rehabilitation
-
o Socio-economicrehabilitation
o Care of permanent tracheostomY
 ORmGntsrrwffimn
0noPHnBvilK

F"
n
I-
F..
r^ I,HISToRYANDEXAMINATIoN
r,
F HistorY and examination
t g::,:::::ll-:l'-":.";lt;S:,:n""nx and oesophasus
lf:nthr.urtv in swarrowing rt can resurt rrom

F Difficulty in mastication is due to inttr*|"nutory

o Onset, duration, Progress
or infective lesions of the oral cavity'

f* o To solids / liquids
o Associated with odynophagia / not
F-
f- Differential diagnosis of dysphagia
DYSPHAGIA
l.
1- Organic

I:
I-
1. ExtraoesoPhageal
a. Oral
o Stomatitis
o Ulcero membranous conditions
b. OroPharyngeal
o Tonsillitis
o QuinsY
c. Others
o Trismus
o Nasal tumours

F
l-
o DYsPePtic ulcers
o Cleft Palate
o Ludwig's angina
o Foreign bocites
o Carcinoma
r Bulbar PalsY
r Nasal Packing
o Maxillofacialtrauma

t-
l-
o Carcinoma
o PalatalPalsY
o RetroPharYngealabscess
o ParaPharyngealabscess
o Plummer-VinsonsYndrome

l-
l-
2. OesoPhageal
a. ln the lumen (Luminal) and in the wall
i) Congenital
(lntrinsic)

F
r
-
-
-
-
Web
Stricture
Tracheo-oesoPhagealfistula
Foreign bodY
ii) NeoPlastic

F -
-
-
Benign tumours like leiomYoma
Malignant neoPlasms
Malignant strictures

F iii) lnfective / lnflammatory

- OesoPhagitis
- Benign strictures

rr
l'-t- iv) Traumatic
- Corrosive poisoning leading to oesophagitis and stricture
- latrogenic trauma at neck surgeries
formation

rr v) Neurological
- MYaesthenia gravis

129
130 Clinical ENT

- Paralysis of oesoPhagus
- Spasm of cricopharyngeal sphincter
- Tetanus
- Achalasia cardia
- Diffuse spasm of oesoPhagus
b. Outside the wall (Extrinsic / Extraluminal)
External compression bY :
- Tumours of thyroid gland-benign / malignant
- Pharyngeal pouch / diverticulum
- Cervical lymph node metastasis
- Cervicalspondylosis(Cervicaldysphagia)
- Retrosternalgoitre
Dysphagia lusoria (pressure on the oesophagus by an aberrant blood vessel)
- Mediastinaltumours and lymph nodes (Hodgkin's disease, malignancy)
- Cardiomegaly
- Pericardial effusion

TI. Non-organic
o Functional / Globus hystericus
2. Odynophagia
Odynophagia means painful deglutition. lt is mainly due to inflammatory lesions of oropharynx and supraglottis
o Unilateral/bilateral
o lntermittent / continuous
o Referred to ear
Differential Diagnosis of odynophagia :

o Stomatitis o Quinsy
o Glossitis o Retropharyngeal abscess
o Tonsillitis o Parapharyngealabscess
o Pharyngitis

3. Foreign body sensation in throat

This happens due to presence of an actual foreign body, secretions or tumour causing irritation in the throat
Gauses :
tr
1. Post nasal drip Styalgia-Eagle's Syndrome
2. Granular pharyngitis 6 Malignant tumours
3. Viral/bacterial pharyngitis 7. ldiopathic
o
4. Foreign body throat Functional

4. Lumo in throat
It isjeen in
ol"4{,lalignancy
.r$out^ of cricopharyngeal sphincter
o
v$ervical spondylosis
tPhuryngual pouch
.
5. Nasal regurgitation and nasal twang
Nasal regurgitation is regurgitation of ingested material to the nose
 Section I Case Presentation - Oral Cavity And Oropharynx 131
-
It occurs due to inadequacy of velopharyngeal sphincter leading to incomplete closure of nasopharynx
from
the oropharynx.. lt occurs in palatal paralysis and in abnormal communication between oral and nasal cavi-
ties
NasalJwllg in vgrce is known as Rhinolglia aperla. lt is due to excessive escape of air into the nose during
speecrrouusuallyassoc.iatedwithnasalregurgitation
6. Rhinolalia aperta'
lt is seen in the following conditions :

-L Cleft palate
2. Short palate
€1 Palatal paralysis
-4. Palatal perforation
'€( Following adenoidectomy (in submucous cleft patients)
Pharyngeal paralysis leads to dysphagia along with aspiration into trachea.
Rhinolalia clausa is decrease in nasal component of voice.
'_
It i9 seen in the fottowing
"onJiti;;a
,
1. Nasopharyngeal tumours
2. Enlarged adenoids
7. Muffled voice t,

\4-qn!9q*u-o-!9" le9.UJ19-gue-tq rrrsChanical

-o!g!yc!!on to speech a1d _qr,ticulgtiglQalgmours within. tt is seen
in bas-tfongue--"pq;otti;;ia-h)'ribehaivngeir tumours. The speech ir 9,n"1q9t_"_iGj,.gel1;jjr"r{,!r",ar:or-'
potatq speech", (a person trying to speak with a hot potato in his mouth).

8. lncreased salivation
It is inability to swallow the saliva completely due to pain (odynophagia) or difficulty in swallowing (dysph-
agia).
The saliva may be blood-stained in cases of malignant tumours with ulceration or erosion.
9. Halitosis
Halitosis is foul smell emanating from the mouth. lt is due to poor oral hygiene.
It is seen in :
r.-.ry-Dental caries
\"e- Aphthous ulcers l

r,-!- Malignancy
l0.Trismus
lnability to open the mouth is seen in cases with submucous fibrosis and cases of carcinoma with invasion to
retromolar trigonfl
11. Paraesthesia / anaesthesia of area of chin tateral to midline. lt indicates invasion of inferior alveolar nerve
by a tumour
After noting down chief complaints, ask the following history :

H/o '6 S'

- Smoking 'i .

- Spices
- Spirit
- Syphilis
- Sharp tooth
- Speckled candidiasis
These "6 S' predispose to pathological lesions and carcinoma in the oral cavity and oropharynx.
 132
ClinicalENT

EXAMINATION OF ORAL CAVITY AND OROPHARYNX

lnspection
The clinical examination is done using a light source (Bull's lamp) and a head mirror.
The lips are first examined to see any colour changes, ulceration or tumours..The patient is asked to
open the
mouth and the oral vestibule is inspected. Halitosis may be present. Oral hygiene is noted. The corner
of the
mouth is inspected for any fissures. Small painful ulcers on the lips and chLek are usually associated
with
'dyspepsia. A tongue depressor is used to retract the cheek. The opening of the parotid duct (as a papillae at the
root of the upper second molar tooth) has to be looked, for evidence of pus. The teeth, gums and the cheeks
are
inspected for signs of caries, infection, pus, ulcer or any growth. The patient is asked L lit tnu tip
of the tongue
and the orifices of the submandibular duct and floor of mouth are seen. The duct orifices are inspected
for
redness, oedema and pus by pressing on the gland.
The tongue is inspected for any superficial glossitis and any ulcer with its size, shape, surface and relation
to the
surrounding part is noted. Movements of the tongue are inspected for paralysis or neoplastic infiltration.
The
palate is examined for its colour, clefts, ulceration or any swellings. Pallor of palate is
seen in anaemia or
tuberculosis.
The oropharynx is now examined by depressing the anterior 2/z'd of the tongue with a tongue depressor. The
tongue depressorshould not be put on the posteriort/z,d of the tongue to avoid gagging.
The faucial pillars are inspected for redness. Pressure by the tongue depressor squeezes the debris
from the
tonsillar crypts in chronic tonsillitis. Lingual tonsil, if hypertrophied appears as a second tonsil on each side
of
the base of tongue.
The whole oropharyngeal mucosa is examined for its colour, ulceration or membrane formation. Any swelling
or
neoplasm is noted for its size, shape, colour, surface, and surrounding area. Movements of the soft palate"are
observed by asking the patient to say "Ah". Post-nasal discharge may b" seen trickling behind the sofi palate
on
the posterior pharyngeal wall. lt is seen in inflammatory conditions of the nor", plrunasal sinuses and the
nasopharynx. The posterior pharyngeal wall is examined for granulations or a bulge as seen in retropharyngeal
abscess.

PALPATION
Finger palpation is required to examine inside the oral cavity.
First bidigital palpation of the submandibular salivary gland and its duct is done for any calculus and gland
hypertrophy. A submandibuJar salivary gland is bimanually palpable, a submandibular lymph node is notl
Palpation of the tongue kept within the oral cavity and floor of mouth is done for any tumour infiltration. Any
ulcer, swelling and surrounding induration is palpated for. Palpation of base tongue and tonsils is done to rule
out infiltrative growths. Digital examination of the tonsii is done to detect any calculus in the supratonsillar crypt.
An elongated styloid process may be felt on palpation through the tonsillar fossa.
An important area of palpation is the Tonsillo-lingual sulcus. This is the junction between the anterior pillar and
the tongue where malignancy is commonly hidden. lt is known as the Graveyard of oropharynx as it frequently
hides malignancy which can be missed if cautious examination of oropharynx by way oi palpation is not carried.
out.
There are certain other sites also where malignancy can be easily missed if not adequately examined. These
sites are referred to as the Surgeon's Graveyard.
Surgeon's Graveyard:
Another area of importance is the retromolar trigone. lt is an area of mucosa cover-
1. Tonsillo-lingual
ing the ascending ramus of the mandible, roughly triangular is shape. lt,s base is the sulcus
2. Valeculla
posterior surface of the last molar tooth and the apex is the tuberosity of the max-
illa. Laterally and above is the ascending ramus of the mandible joining the 3. Pyriform fossa
gingivobuccal sulcus. Medially is the mucosa of the gingivolingual sulcus and the 4. Floor of mouth
mucosa of the inner surface of the lower alveolus. 5. Nasopharynx
This area is examined by using two tongue depressors, one to retract the cheek later-ally and the other to retract
the tongue medially. This area is important as it is difficult to see this site clinically and an early cancer may be
missed.
Palpation of the neck for lymph nodes completes the examination.
E
n
2. OROANTRAL FISTULA
F
F
t-
t--
Definition
It rSgl a$*o11la!_p__o-nn.g!i-c-g!gry b-g!11ye,,e1 the gral.ca.vity and the maxillary antrum

l- +.
Etiology

F
Dental : Extraction of upper molars or premolars.
c. Traumatic : lnjury to palate, gums, teeth
. Maxillofacial injuries.

t-' ., . lnflammatory : u-- Ot,"omyelitis of antral floor

l-' r--"Osteorad ionecrosis of maxilla.

f-
r--"-"Sinusitis
,. Neoplastic : Carcinoma maxilla ,
, :
Caldwell-Lucsurgery 1'r)rt"f^''r': t'rr1e1r]!r

f.'
latrogenjc
9 Palatalfenestration surgery in the past

l-" Sites of oroantral fistula

l-
t-'
o
o
o
Sublabial
Palatal
Alveolar

t*
t-
Clinical Features
o
o
History tooth extraction, surgery etc.
Fogl 94e!l_a1d taste in mouth due to drainage of pus in oral cavity.

t-
l-
o
o
o
Change of taste
Nasal regurgitation of fluid / food particles (oro nasal fistula)
Fistulous opening seen in oral cavity. Granulation tissue may be present within the opening or surrounding
inflammation may be seen

t-
t-"
Jerobe may pass in the fistulous tract
Diagnosis
o Clinical features

t-
l-
o Fistulogram : lnstillation of radioopaque dye into the tract outlines the tract and its openings on radiography.
Treatment
o Local hygiene

t-' -
-
Antibiotic / Antiseptic gargles

l-
Systemic antibiotics

r
t-
o
o
Primary closure with sut-ures
lnferior meatal antrostomy can provide
-
-
Adequate drainage of sinus
Antibiotic washes can be given

l-
l-
A small fistula can heal by the above measures by secondary intention and granulation tissue formation

f-' 133
134 Clinical ENT

o Use of local flaps for closure

- Palatalflap
- Buccal mucosal flaP
 3. SUBMUCOUS FIBROSIS

DEFINITION
It is an insidious chronic disease of unknown etiology, characterized by gradually increasing fibrosis of submu-
cosa of oral cavity, pharynx and occasionally the oesophagus

Geographical distribution :
It is seen in lndians, lndians living abroad and also reported from Ceylon, Malaysia, Nepal, South Vietnam.

Common sites of affection :

r _9. -Buccal mucosa

rrlRetromolar trigone
'.,r"Soft palate
Tonsils
'..*;-
,_9--Faucial pillars
tips, uvula, floor of mouth
-r-Larynx is always free from the disease. Respiratory distress never occurs.

ETIOLOGY
Exact etiology is unknown but following factors have been mentioned
I. Hereditarypredisposition
II. Prolonged local lrritation
-1. Betel nut
2. Betel nut lime
a. Paan
-4. Tobacco (Desa 1957)
'-5. Chillies (Desa 1957)
ll I.Deficiency diseases
1. Vit B complex (Roy 1952)
2. Vit A (Krishnamoorthy 1970)
.,-+t'Defective ron meta bolism
l

"{4 Localised collagen disease (Rao 1962)

VI. Reaction to bacterial infections
o Klebsiella Rhinoscleromatis (Sengupta'1952)
o Streptococcaltoxin (Mukherjee and Biswas)
1. Hereditary predisposition
Found in lndians and lndians living abroad. Thus a genetic factor is suspected

135
 ClinicalENT
136

2. Prolonged local irritation

'1. Betelnut
c Acts by mechanical and chemical irritation
superficial ulceration
a. Mechanical - Nut is hard and its sharp jagged edges cut into mucosa. lt causes
which heals bY fibrosis
and also acts on
b. Chemical - Arecolins - alkaloid present in areca catechu nut. lt is a local irritant
' nerve endings in oral mucosa - Neurotrophic changes
2. Betelnut with Lime
It contains arecolins, lime and tannic acid. lt causes local irritation, damage
to mucosa, vesiculation and
ulceration. Commonly chewed is paan'
3. Kapuri Tobacco
of camphor containing
lncidence of SMF is high in Manipuri district associated with habitual consumption
tobacco.
4. Chillies
from capsicum has been
Allergic reaction to chillies is an important factor. Capsicin - an active ingredient
shown to be an irritant
3. Deficiency disease
It is characterised by repeated vesiculation and ulceration of oral cavity'
intake in advanced cases'
The deficiency could be the effect of defective nutrition due to impaired food
4. Localised collagen disorder
mediastinalfibrosis'
This localised collagen disease of the oralcavity is similarto retroperitonealand
5. Defective iron metabolism
o Hiranandani (1970) reported achlorhydria in cases of SMF
by Millard (1966)in SMF
o Microcytic hypochromic anaemia with increase serum Fe has been reported
6. Reaction to bacterial infection
stage of disease
Rise in mucopolysaccharides and mucoprotein - represent reactants in active
Desa - cultured fluid from vesicles' found it to be sterile
and suspected that this may be a
Sengupta - reported growth of Klebsiella rhinoscleromatis in cases of SMF
factor in its causation

PATHOLOGY
ln the connective tissue, there is progres-
Histopathologically, there are connective tissue and epithelial changes.
collagen and fibrosis' The epithelium
sive accumulation of fluid, constriction of blood vessels, hyalinization of
divided into very early, early' moderately
shows progressive atrophy, hyper and parakeratosis. Pafhoiogically it is
advanced and advanced cases.
 137
Section I Case Presentation - Oral Cavity And Oropharynx
-
CLINICAL FEATURES
lnsidious in onset
Clinicalstages
1. Stage of stomatitis and vesiculation
2. Stage of fibrosis
3. Stage of sequelae and complications

STAGES SYMPTOTA S SIGNS

1. Stage of stomatitis o Burning sensation of oral mucosa o Vesicles, ulcerations

and vesiculation a lnability to eat spicy foods o Granulating spots on cheek, palate, pillars
o lncrease / Decrease salivation
2. Stage of fibrosis o Difficulty in opening mouth o Vesicles on soft palate, anterior pillars, buccal
o Difficulty in protruding tongue mucosa, mucosa of liPs
o Difficulty in blowing out cheeks, whistling o Vesicles - are painful, and when rupture, leave
o Nasal twang of speech - Rhinolalia aperta superficial ulcers
(decrease palatal movements) o
Culture of fluid from vesicles is sterile
Stage of sequelae This stage is similar to stage of fibrosis. 9'''Oral mucosa - Whitish, blariched or mottled.
and complications Oral mucosa loses its natural suppleness. o Soft palate - Whitish. Decrease mobility.
Fibrous bands originate from pterygomandibular
raphe to anterior faucial Pillar
o Trismus is seen due to contraction of fibrous
tissue underneath the mucosa.
o Faucial pillars - Thick, short and hard- Tonsils
pressed between fibrosed Pillars
o Progressive narrowing and inability to open
mouth fully.

INVESTIGATIONS
o Complete haemogram Decrease Hb
- lncrease EosinoPhils
o ESR is raised in 50% of individuals
o Routine urine and stool examination
o Blood biochemistry
o Serum protein : decrease Albumin, increase Y-Globulins
o X-ray chest
o Electromyography
- Gives an exact state of contracirlity of muscles. EMG of Temporalis, Buccinator, etc is done.
of
Use - To differentiate in SMF whether pathology is contraction due to fibrosis or is sustained contraction
muscles"

o Exfoliative cytologY
- Morphological characteristics are examined
TOLUIDINE BLUE STAINING
It is metachromatic drug of thiazine group. Malignant cells which contain more DNA than
RNA have got affinity to
this dye. Dye reacts me]achromatically with malignant cells delineating the abnormal cells which can be biopsied.
PAS staining shows increase PAS +ve granules in connective tissue.
138 Clinical ENT

SMF as a Pre Cancerous Condition : -

1 F:requency of leukoplakia is 6-8 times more common in SMF
2. ln South lndia about '/zof cancer patients show SMF
3" E:xpectancy of life is not reduced unless SMF is associated with malignancy.
4. There is a chance of recurrence after relief of early symptoms, hence close follow-up is essential.
5 L ong term follow-up shows it to be turning malignant by 6-10%.

MANAGEMENT
PREVENTIVE MEASURES
a. Abstaining from ingestion of irritants Eg. Betelnut, Pan parag, Tobacco, Chillies etc.
b. Maintainance of proper orai hygiene
c. Vrtamin supplements
d Well - balanced diet

MEDICAL TREATMENT
Submucosal injections of
o Fibrinolysins
o Gold
o Vit A and D and
o Corticosteroids
1. Steroids: -
a. Cortisone given in doses of 20 mg or '100 mg daily for a total of 1500 - 2500 mg. can be given orally /
parenterally
b,. Hydrocortisone with lignocaine can be - injected in oral cavity and soft palate
It is most effective in early / moderately advanced cases

Mode of action : -
1. lmmuno suppressive action
2. Decreases inflammation
3. Decrease fibroblastic proliferation - Prevents fibrosis

2. Hyalase : - (Hyaluronidase)
o Acts on Hyaluronic acid and decreases its formation which plays an important role in formation of collagen
Regime (Kacher and Venkatachalam)
1500 u of Hyalase + 1 ml of 2% lignox - Twice weekly for first 3 weeks
followed by '1500 u of Hyalase + 4 ml of dexamethasone - Twice weekly for 7 weeks
3. Placental extract and dexamethasone can be given for 6 weeks.
Irnprovement by these injections is temporary.

4. POTABA : - (Potassium Amino Benzoic Acid)

It decreases collagen formation and inturn decreases fibrosis.
Section I Case Presentation - Oral Cavity And Oropharynx 139
-
SURGICAL TREATMENT
lndications :

1. Severe trismus
2. Dysplastic / neoplastic changes
a. Excision of fibrotic bands
Always done under general anaesthesia
It is difficult or impossible to intubate if patient has severe trismus

Means of giving anaesthesia :

1. Blind awake intubation is done through nose
2. Retrograde rail roading technique
3. Tracheostomy
Procedure
Forcefulopening of mouth with the help of jaw stretchers is done. lncision is taken on the mucosa frbm the
angle of mouth to anterior pillar, taking care not to damage the parotid duct. lncision is deepened down to the
muscle and associated fibrous tissue with muscle is incised.
Postoperatively physiotherapy is given in the form of active and passive wide opening of mouth. Wound at site
of division heals in 4-6 weeks.
b. Excision of fibrotic bands with split thickness skin grafting
Excision of fibrotic bands is done in a similar fashion followed by split thickness skin grafting of raw surface to
cover the defect. Graft is immobilised over a sponge bolus. Mouth ig.kept.open with a pair of small smooth
rubber anaesthesia props to produce an inter incisor distance of 35-40 mni.
Postoperatively, patient is fed via a Ryles tube for 7 days
- Daily mouth opening exercises are done
- Nocturnal props are used for + weeks.
c. Excision of fibrotic bands with split thickness skin grafting with bilateral temporalis myotomy or
coronoidectomy
Rationale of temporalis myotomy : - Secondary contracture formation occurs in temporalis tendon, muscle
and in the pterygomandibular raphe which is the principle cause of trismus
d. Excision of fibrotic bands with reconstruction
lndication : - Severe trismus with interincisor distance < 1 cm
An ideal tissue for reconstruction is
i. Adequate in amount
ii. Has less tendency to fibrosis and contraction
iii. Maintains its vascularity until healing is achieved.
Reconstruction is done with :
'1. Bilateral full thickness nasolabial flaps
2. Tongue flaps.
Advantages of a tongue flap :

i lt is available near the site

ii. lt is vascular
iii. Less tendency to contraction
iv. lt is the only mucosa left in the oral cavity without fibrosis
 4. ULCERS OF THE TONGUE
Dr. Rajiv Joshi

D/D:
1. DyspePtic or aPhthous ulcer
2. Traumatic or dental ulcer
3. Malignant ulcer
4. Tuberculous ulcer
5. Syphilitic ulcer
6. Simple ulcer due to glossitis
7. Post-pertussis ulcer
B. Herpetic and pseudo herpetic ulcers
9. Chronic non-sPecific ulcer

1. Dyspeptic ulcer:
o Occurs at anY age
r Seen usually at the tip but may occur at any site with or without abcess in the lip or cheek
o Single or multiPle
o Small and circular
o Edge of the ulcer has an oedematous hyperaemic zone
o Floor is white
o Thin and waterY discharge
o Pain and tenderness Present
o Generalised features of dyspepsia
lnvestigation - To Rl/O malabsorption syndromes
Rx : Ulcers respond to high doses of Vit A, C, B complex
Correction of dYsPePsia'
2. Traumatic or dental ulcer :

o Can occur at any age

o Usually at the margin of the tongue, commonly towards the back
o Single
o Any shape according to shape of traumatic agent
-,,{ ' Depth and size is moderate
. o Edge of the ulcer is oedematous
. o'-Floor is covered with slough
.. --r'"Discharge is often purulent
o .o lnduration is Present
. o Pain and tenderness is marked
, . Presence of a sharp tooth or ill-fitting denture
o Neck lymph nodes are firm and tender if, secondarily infected
/ oPG
lnvestigations : for presence of sharp tooth or ill-fitting denture-X-ray
Rx : Usually heals after removal of source of irritation

140
I.
t: Section I
-
Case Presentation - Oral Cavity And Oropharynx '141

I 3. Malignant ulcer Z
l-
rr
o Seen in elderly
o Usually seen at the margin and common in ant. %'d

o Single or multiple
o Raised, rolled out and everted edge
o Floor covered with necrotic debris and looks ditly grey
o
t-- o
Discharge is offensive

l-
t-'
o
o
Painless initially, painful later with pain referred to the ear
LN enlarged, stony hard and fixed in late stage
Excessive salivation, difficulty in articulation and speech
Rx - Surgery or RadiotheraPY.

t-" 4. Tuberculous u.lcer :

t-' r
c
o
Young adults
Multiple sites - tip, margin, dorsum

t-.' Shallow ulcer of moderate size

t:
r
o Oval or circular
1--.",6iscfrarge-apple jelly nodules

rr-H
\y'--Undermined edges
c Floor covered with pale granulation tissue
o Painful
o Lymph nodes are enlarged and matted with or wrthout cold abscess
r -.t'Associated tuberculosis of the lungs or larynx with features of TB toxaemia
RX: AKT
5. Syphilitic ulcer:

rH o Seen in tertiary stage of syphilis

o Dorsum of the tongue
o Single
o Oval or circular
o Punched out edges
F- 1-l' "Fioor deep with washed leather slough
H
rr
. o. Slightly indurated
r,."r,'" Discharg e greyish-white
o Painless
o Lymph nodes are enlarged, shotty and discrete-usually epitrochlear, occipital lymph nodes are involved

rr lnvestigations : Sr -VDRL
Rx : Antisyphilitic doses of Penicillin

rr
6. Simple ulcer due to glossitis :

r-r' Occurs in chronic superficial glossitis

known as 'Smoker's patch'
',"-.r" Usually single
o Burning pain during food intake present

rr
r
 142 Clinical ENT

7. Post-pertussis ulcer :
o Occurs in children following whooping cough
o Confined mostly to the phrenum linguae-'.,

t- {. Herpetic ulcers :
o Common in children and young adults
o Occurs due to herpetic-affection of lingual nerve.
o Acute, unilateral neuralgic pain on affected side - vesicle - ulcer
9. Chronic non-specific ulcer:
o Seen in individuals with poor oral hygiene
Rx : Correction of poor oral hygiene and high dose of vitamins
Note on lymphatic drainage of tongue :

Tip - Submentalnodes
Bilateral drainage
Post % Upper deep cervical lylnph nodes (Jugulodigastric), Bilateral drainage
Ant% Unilateral drainage to submandibular nodes and then to deep cervical chain

x-'--Ultimately all the lymph drainage from the tongue reaches the jugulo-omohyoid lymph node in the deep cervical
chain
lm portant Characteristics :

a. Lymphatics draining the ant zA'd of |he tongue and floor of the mouth traverse the periosteum of the mandible
on their way to submental and submandibular lymph nodes. Hence part of the mandible is removed during
radical dissection

rl
tl * b. Lymphatics decussate in the midline, hence contralateral lymph nodes may be involved. lt is necessary that
on both sides be dealt with in Rx of Ca tongue.
g_l.e-ndq

i c.".Lenthal Cheatle)showed that the lymphatics draining the tongue which pierce the mylohyoid and tongue
i muscles are of exceptionally large calibre. Hence in Ca tongue embolic spread is more common due to
i
squeezing of the malignant cells (by activity of the tongue musculature) through these large lymphatic
vessels without being held up in them.
d.
l

i
Because of the secluded position and consequent late diagnosis, growths of the posterior l/:'d of tongue show
the highest incidence of cervical metastasis.

i
. e. Septic infection which invaribly occurs in the malignant ulcer may cause a non-malignant enlargement of
the lymph nodes under the jaw.
l

:ig+;.,-l;.+*=4+:=!i'4,**giaidF*-:rrt..
 5. CARCINOMA OF TONGUE

Common lesion and accounts for more than 15% ot HFN malignancies and more than 50% of all intraoral
malignancies..._._, --

Aetiology: M:F3:'1 1

5th-6th decade usually

Predisposing factors :
1. Chronic irritation caused by
o Sharp tooth or illfitting dentures
\o Smoking - particularly pipe smoking
o Spirits - excessive alcohol intake
o Spices
\. Sepsis - poor oral hygiene / oral health
'-'' 2. Syphilis
' 3. Superficial glossitis - Chronic
4. Sessile papilloma
5. Syndrome Plummer - Vinson
Precancerous lesions
1. Leukoplakia
2. Erythroplakia
3. Chronic superficial glossitis
4. Syphilitic ulcer
5. Sessile papilloma
v 6l Melanoplakia (rarely)
Macroscopic features :
1. Ulcerative type - raised, irregular, rolled or everted margins, a sloughing yellow grey base and induration of
surrounding tissues.
2. Papilliferous or warty types
3. Fissured or cracked type with induration - usually follows chronic superficial glossitis or syphilis
' 4. Nodular type - a submucous nodule or plaque - oral, raised plaque with keratin flakes on the surface
r,5. Frozen tongue - indurated tongue or wooden tongue

Microscopic features :

Ant %'d - Squamous cell carcinoma

Post %'d - Lymphoepithelioma or basal cell Ca or transitional cell Ca

Ant2/t'd Post %'d

1. Epidemoid Ca e Lymphoepithelioma
2. Lymphatic spread is ipsilateral except tip o Lymphatic spread is bilateral
3. Ulcerative growth (primary presentation) o Primary (silent)
r Malignant secondaries (active lesion)
4. Different Rx portal c Always subjected to radiotherapy

143
 n

ClinicalENT
144
!

Metastases : i
t
'1
. Local spread : Through substance of tongue
o To floor of mouth (Ant %d) I
o To mandible (Junction of ant %d and post %'d)
o To tonsil, epiglottis, soft palate, larynx, cervical spine (Post %'d) i
,2.' Lymphatic spread : Occurs early by embolisation than by permeation and follows lymphatic drainage of tongue'
I
3. Hematogenousspread(rare) :MorefrompostTi'd,occursonlyin2o/oofcasestolungs'
\a
Symptoms:
Early cases are virtually symptomless or there is a painless
lump / irregularity or ulcer on the surface of the
!
tongue.
More advanced cases Present with :
;
1. Enlarging ulcer, pain in the tongue
Pain - infection and ulceration !

o Lingual nerve involvement

o pain referred to the ear (auriculotemporal nerve which is also a branch of mandibular division of trigeminal
t

nerve). :
o Post Ca-OdYnoPhagia
%'d

Pain in the back of the tongue

2. Excessive salivation-Pain promotes salivation. saliva may be blood stained I
3. Dysphagia and difficulty in mastication
ca Post
o Still, lumpy, partially fixed tongue makes swallowing difficult. More pronounced in %'d
I
4''Foetor oris : - Due to poor oral hygeine and secondary bacterial stomatitis
tl \' Necrosis-infection (offensive odour)
I
, 5. AnkYloglossia : - Frozen tongue leading to inability to protrude the tongue'
of floor of mouth l|
l
Deviation to one side is due to fixation by extensive infiltration
il
l 6. Difficulty in sPeech :
o lnability to articulate properly is due to extensive carcinomatous infiltration of the tongue and / or floor of the
mouth. t
7. Alteration in voice especially in post V{d Ca
S.Lumpintheneck(duetosecondarydepositsindraininglymphnodes)
Signs - Site and character of the lesion (macroscopic features) I

- Palpate for induration, mobility of the lesion and of the tongue

- Cervical lymPh node enlargement

D/D - Other tyPes of ulcers on tongue

- Rare tumours of tongue
-Papilloma,lymphangioma'haemangioma'neurofibroma,lingualthyroid

,., Terminal event or death occurs due to

', tL Aspiration bronchopneumonia from superadded oral sepsis
'\ "*'
2. Haemorrhage from the growth
t-e--E.rosion of lingual artery
\,-r-€rosion of carotid artery or internal jugular vein in post %'d Ca or by metastatic lymph nodes

r -. 3l-'Ma lignant cachexia I

r' 4. Starvation and exhaustion from a combination of

o Pain, dYsPhagia, odYnoPhagia

3 i.. j:.1--:-Fi-+i" j s---

 Section I Case Presentation - Oral Cavity And Oropharynx 145
-
o Compression of pharynx, oesophagus by metastatic lymph nodes
-o Anorexia resulting from infected fungating ulcer in mouth
VC Rsphyxia due to airway obstruction from enlarged and fixed carcinomatous lymph nodes or due to oedema of
glottis which is due to an extension of the lymphatic oedema around a growth at the back of the tongue

Management
lnvestigation : o Routine
o Sr. VDRL
o Laryngoscopy to see post %'d of tongue especially the region of the valeculla
o Pus swab for SCAST from ulcer
o X-ray of the mandible to rule out bone involvement
o Biology - Documentary evidence of growth
- Type of growth
o L. N. FNAC
o X-ray chest for pneumonia / secondaries in lung
o OPG
Rx-Preliminary measures :;r Oral hygiene is established
,.,3-Eental Rx of carious teeth
'.'o",*Teeth-scaling and polishin g
".",,r'- Extraction of teeth if they block radiation
' o' Frequent antiseptic mouth washes
.-/Antibiotics to prevent and control secondary infection, correction of nutri-
tional and metabolic disorders
''"Correction of anaemia, respiratory status
'.-""e
"'itprouement of general condition
'.-
Prophylactic Rx :
o Remove source of chronic irritation
o Excision of unresolving or suspsicious areas of leukoplakia
o Biopsy of suspicious lesion
Treatment in Ca tongue
1. Surgery : lndications

: :,I'ff:iffi:::,T5i:?['l,i *"0,,",*,
o Ca supervening in cases of leukoplakic patch
o Growth involving the jaw or in close proximity of bone
Modalitive of Sx Rx are :

1. Partial Glossectomy
2. Hemiglossectomy
3. Subtotal glossectomy (removal of anl2/z'd of tongue)
4. For neck - Hemiglossectomy +hemimandibulectomy + RND (radical neck dissection) Commando
Nl
operation followed by reconstruction with a pectoralis major myocutaneous flap (PMMF) or pectoralis
major osteocutaneous flap (PMOM)
For No neck one may do a glossectomy with a suprahyoid block as a staging procedure
 ClinicalENT
146

2. Radiotherapy:
,/z,d Ca(by teletherapy only because this part is anatomically difficult, both for
It is treatment of choice in post
surgery and interstitial therapy).
r-
lnterstitial
o Type of radiotherapy--l t
I Tele therapy
a
o Dosage 6000 rads I

lndications for RT :

o Post t/3td Ca
o lnoperable groMh with fixed lymph nodes
o Reccurence of growth after surgery

Cbntra indications
o lnvolvement of bone
o Growth in close ProximitY of bone
o Mobile lymph nodes

3. ChemotheraPY
a. Regional arterial Amphotericin
b. Prrnce - Hill regime
Bleomycin, Adriamycin, Vincristin.
M Other drugs used are
o Cisplatin
o Methotrexate
e Endoxan

Management of LNs :

1. For No neck - Suprahyoid block as a staging procedure

2. For N1 neck - Commando oPeration
3. For N3 neck - RT with Sos salvage block dissection of cervical nodes

For N, neck
with adjuvant RT or CT
Full block on side followed by modified neck dissection on the other side along
Palliation lndicated in large unresectable primary fixed lymph nodes'
o lrradiation
o Mouth washes to reduce local infection and foul small of necrotic lingual carcinoma
o Antibiotics
o Controlof pain and apprehension with adequate analgesia and sedation with morphine
o Tracheostomy in respiratory obstruction
o Feeding with a nasogastric tube in patients with dysphagia

Prognosis Depends on site, stage and lymph node involvement

1. Site a. Growth in ant %'d - 50% 5 yr. survival rate
b. Growth in post t/td - 1oo/o 5 yr. survival rate'
2. Stages a. Early stage - 60% 5 yr. survival rate
b. Late stage - 15% 5 yr. survival rate
3. Nodes a. lf involve d - 15% 5 yr. survival rate
b. lf not involved - 60% 5 yr. survival rate
Section I Case Presentation - Oral Cavity And Oropharynx 147
-
Radical Neck Dissection [RND] is En Bloc removal of all the cervival L.N. + Fibrofatty tissue in neck + the
structures which are :

1. Sternomastoid
2. Omohyoid / digastric
3. Accessory nerve
4. lnternaljugularvein
5. Sub mandibular gland
6. Tail of parotid gland
 6. CLEFT LIP AND PALATE \
- Dr. Uday Bhatt T

i
HISTORY
Name, Age, Sex, Religion, Occupation, Address. !

Cleft lip is more common in males and cleft palate rn females.

n
Chief Gomplaints
CLEFT LIP + ALVEOLUS (Cleft of primary palate) : ' :
H/o deformity of lip and palate.
u
H/o cosmetic problems.
H/o additional complaints.
H/o occlusal problems (cleft alveolus).
H/o difficulty in speech / articulation (bilateral cleft lip).
t

H/o sucking problems (usually no problem in cleft of primary palate).

I

CLEFT PALATE
H/o deformity of palate.
H/o cosmetic problems (maxillary hypoplasia). I

H/o difficulty in suckling because of failure to generate negative intraoral pressure.

t
H/o occlusal problems.
H/o nasal regurgitation of fluids.
H/o speech problems - hypernasality, nasal escape, unintelligibility (in associated velopharyngeal insufficiency)
\r
H/o articulation problems.
H/o recurrent middle ear infections.
u
H/o upper respiratory tract infections (occasional).
Submucous cleft *
H/o Speech and articulation problems. I
H/o Symptoms of velopharyngeal insufficiency.
H/o Nasal regurgitation. -
H/o Hypernasaltty / nasal twang in voice.
I
H/o Risk factors : (Cleft lip and palate)
Maternal : !

H/o increased maternal age during pregnancy.

t
H/o smoking, alcoholism, phenytoin therapy in mother.
H/o deficiency of vitamin A, riboflavin, folic acid etc. in mother. q

Foetal :
H/o hypoxia during embryogenesis. -
Genetic : -
H/o family history.
E
H/o consanguinous marriages.
T

148

-
 149
Section I Case Presentation - Oral Cavity And Oropharynx
-
H/o syndromes : - Treacher Collins syndrom€'
Trisomy of group D' G, E chromosomes'

Past / Personal / FamilY History

To lay special emPhasis on :

o Past H/o of middle ear infections / secretory otitis media'

o Past H/o of any medical / surgical management with their result / benefits'

c Family H/o of similar siblings / syndromes'

Clinical Examination
General Examination
As per routine format with emphasis on
o Pallbr (because of feeding problems)'
o signs of upper respiratory tract infection (because of possible regurgitation)'
Local Examination
Description of AnatomY of cleft :

o Unilateral/ bilateral
o Completg / incomPlete
o Primary / secondary / both

Cleft lip : Describe :

o ObliquitY of cuPid's bow.
o Hypoplasia of vermilion.
o lll-defined white roll.
Cleft alveous : Describe :
o Through which teeth the cleft is passing'
o Collapse if anY of alveolar arch.
r Occlusion defect.
Cleft palate : Describe :
o Clefi anatomY in detail.
o Whether vomer touching any of the shelves'
o Movement of soft palate, posterior pharyngeal wall on phonaticn'
o Passavant's ridge.
o Shortness of Palate.
o Hypoplasia of maxilla.
Also describe the tongue, tonsil and oral hygiene in each'

Submucous cleft describe :

o lntact oral and nasal mucosal layer'
o Description of middle muscle layer'
o Bifid uvula Present-
- zona pellucida seen in the midline from the oral side
if light is thrown in the
r A zone of transillumination
nostrils.
o Palpate for midline bonY defect'
 ClinicalENT
150

Examination of nose
o Flaring of nostrils.
o Hypoplastic alar cartilages.
o Oblique columella.
o Round and asYmmetric tiP
o Deviated sePtum.
o Signs of rhinitis.
Examination of ear
Bilateral affection
Signs of secretorY otitis media.
o Dull bluish ear drum.
o Retracted tYmPanic membrane'
o Air-fluid level maY be seen.
Signs of chronic suppurative otitis media :

o Bilateral safe, central perforation'

o Active mucosal disease may be present'
MANAGEMENT OF CLEFT PALATE
carried out' Presurgical orthopaedics includes
At birth, parental counselling and presurgical orthopaedics are
protrusion of the premaxilla'
means to realign the alveolar segments and to retract the
palate repair between 6 to 12 months of age' The first
Lip repair is ideaily carried out at 3 months of age and
6 and 9 months of age of the child'
phonemes, that require closure of the velophaiynx are used between
carried out by Veau's technique or
therefore repair should ideally preceed this age. ihe
palatal repair can be
Von Langenbeck's method.
Veau's method
the sides of the cleft and on the palatal
ln this method bone deep oral mucosal incisions are made on
surface to raise flaps based on the greater palatine artery'
palate musculature and the nasopharyngeal
After raising mucoperiosteal flaps, the nasal mucosa, soft
mucosa is mobilized. The mobilizaiion should be adequate
to let the flaps reach the midline with ease' The
three layers are sutured separately'
rryhich heal by secondary intention'
By mobilization of flaps, defects are created laterally
of growth of mid-face and postoperative
cleft palate repair may be complicated by haemorrhage, affection
fistula formation.

SUBMUCOUS CLEFT PALATE

It is a condition characterized by a triad of :

1. Bifid uvula
2. Palatal muscle diastisis .
3. Bony notch in the hard Palate
mucous membranes are intact and the muscle
They can be overt or occult' Usually the oral and nasal
in the Palate.
tayer is deficient giving rise to a white translucent zone
 7. CHRONIC TONSILLITIS
_
SYNONYMS:
o .'Chronic follicutar tonsillitis
o
) arenchymatous tonsill itis
o
- Hypertrophic tonsillitis
o"/ Lacunar to nsi itis I I

It is chronic inflammation and infection of faucial tonsils

It is commonly seen in children netwee(3--A-F$ of age.

ORGANISMS
o Bacteria
- Streptococcus
- Staphylococcus
- Diphtheroids
- Pneumococcus
o Virus

ETIOLOGY
'1. Recurrent acuie tonsillitis
2. Subclinical tonsillar infections aggravated by diseases like measles, scarlet fever etc
3. Excessive ingestion of carbohydrates.

PREDISPOSING FACTORS
o Overcrowding
o Contact with person with tonsillitis
o lmmunodeficiency
o lngestion of cold eatables (causes localized vasoconstriction and lowered immunity)
o Pollution
o Foreign body embedded in the tonsil
CLINICAL FEATURES
o Dysphagia / odynophagia : repeated attacks associated with fever and symptom free interval in between-
o Fever
o Cough
o Difficulty in breathing
o Affects speech.
o Poor apetite
r Halitosis

151
 d

id-djqq)
,in eYlY;--
w:= /|
t
TONSILLAR SIGNS A
o.-€nlarged tonsils project beyond the anterior pillar, meeting in the midline-kissing tonsils. These Dypg$qphied \
tonsils(@e)cangiverisetochokingattacksonfeeding,inchildren
"-
o-Congestion of bilateral anterior pillars. !
o--Tonslts may be hidden within the pillars-Fjbrgseq-Iensil9. This is seen in eJ99lly-re@e
4lopfri.c,small, rt
o Pus may extrude out from the crypts on pressure over the tonsils-L,acunar Tonsillitis (lIwin Mqore's Siql). s
o Non-tender and palpable jugulodigastric lymph nodes. @lpablqug! lgfgg-and behind the angle of mry I
dlblc)
I
CHRONIC TONSILLITIS
Cardinal signs !
o I More than 4-5 attacks of acute tonsillitis in a year
o t Hypertrophied lonsils !

o3 Congestion of anterior pillars

!
&l Pus exuding from crypts on pressure over the tonsils
o5 Enlarged, non{ender jugulo-digastric lymphadenopathy !

TREATMENT !
Medical treatment
o Antibiotics
: s\

o Anti-inflammatoryanalgesics :
o Antiseptic gargles
o Antiseptic throat paints !
- Mandl's paints
o General measures
- Good nutrition I

- Exercise
- Fresh air
I

Surgical treatment I

o Tonsillectomy is the treatment of choice

I

I
rtl
I: 8. LINGUAL TONSILLITIS
I
F
F
The linqual tonsil is an aqffegalc of lvmphoid tissue situated posteriorlv at the base of the tonque. lt is bounded
by circumvallate papillae anteriorly and epiglottis posteriorly.

l-
Hvpertrophv of linqual tonsil occurs rnore in women. Acute and chronic forms occur. lt is affected in the same
manner as the faucial tonsil. I

l-
t-
CLINICAL FEATURES
./Seuere dysphagia
o/Foreign body sensation in throat

l-' o' lndirect laryngoscopy will shcw e.nlarggd, hvledrophied tonsils a! the base of the tongue

t- TREATMENT

I: o
o
o
o
Antibiotics
Local application of throat paint
Removal of the tonsils bv Linqual tonsillotome
Cryosurgery

F
t:
r
o
Diathermy reduction of size
Laser application

l-
l-
l-
F
l-
l-
t:
t:
l--
l--
l*
l-
r!:
F-, 153
 9. ADENOIDS
r-r' P o,i I uJ c
j, ' u'*...
t{-Z --{ '
Synonym : Nasopharvnqeal tonsil ' t{vr '
.'

J
Adenoids is the lvpertrophied mass of lvmphoid tissue gtgq]ledjjllhe iunction of the-rc4{-al4EQslerior wall ol
pa'rp!ryx
The mass of lymphoid tissue is termed as 'Adenoids" only when it is hypertrophied. lt is difficult to differentiate
between physiological hypertrophy and pathological enlargement
It usually undergoes atrophy by puberty (13-14 yrs.)

ETIOLOGY
r Heroditary
e Cold climate
o Specific infection like tuberculosis.
o Physiological hypertrophy may be seen between 3-t O Vr.

FEATURES
o v'Pink, globular mass
o' Vertical ridges on its surface
o' No crypts
o Lined bv colulnrlar ciliate-d epithelium ^ ,--\
o '4\o capsule . ..n""t*I-
g.rr- s(..
SYMPTOMS
Local (Due to adenoid hypertrophy and infection) :

o Bilateral nasal obstruction Features of adenoid facies

o Snoring o Sunken eyes
o Mouth breathing o Narrow pinched nostrils
o Rhinolalia clausa o Open mouth
o Frequent -r.t
rhinorrhoea o Gothic (high-arched) palate
o Epistaxis o Crowded teeth

o Feeding problems in children

o Loss of nasolabial fold

o Adenoid facies (seen if nasal obstruction persists for a long time)

o Dull mask-like face

o o Rhinorrhoea
Conductive deafness due to eustachian tuble block
o Everted upper lip
o Enlarged cervical glands
o Protruding teeth
o Bronchitis o Drooling of saliva
o Otitis media
o Gastrointestinal disturbances Aural manifestations in Adenoids :

General Otalgia
o Anorexia Secretory otitis media
o Lethargy Acute otitis media
Atelectasis
ET block
Chronic otitis media
154
 155
Section I Case Presentation - Oral Cavity And Oropharynx
-
o Poor physical and mental development
o Bed-wetting
o Pigeon chest
o Protruberant abdomen

DIAGNOSIS
o H/o nasal obstruction, rhinorrhoea
o Pink globular mass with vertical ridges on posterior rhinoscopy
o Bilateral retracted eardrums
o X'ray postnasal space shows soft tissde mass'

Adenoids
DIFFERENTIAL DIAGNOSIS Petection of
o Thornwaldt's cYst v.?osterior rhinoscoPY

o High arched Palate -'- Digital PalPation

-Examination under GA
COMPLICATIONS ray soft tissue nasoPharynx

1. Adenoid facies
2. Otitis media with effusion
3. Recurrent acute otitis media
4. Rhinolalia clausa
5. Chronic sinusitis
'
6. Sleep apnoea sYndrome
7. Decrease mental/physical deveiopment

TREATMENT
Medical
o Adequate nutrition
r Antibiotics
o Anti inflammatorY analgesics
o Decongestant nasal droPs
Surgical
o AdenoidectomY
o Myringotomy with grommet insertion'
'tt

ffiGsE{

>A

'4

-,i
t
I
I 1. SWELLINGS IN THE NECK
t
t"
Differential Diagnosis of a Neck Swelling
1: Il- _-1
I !
!*
Midline-swellins 11",:L:l1ins (see pase 157)
1: I

t: I

Does not move with deglutition

Moves with deglutition
r: u
Submental lymph lodes
I Subling-ual dermoid cYst

r: ThYmic swelling
Swellings of su praster3e!-gpqeq gl-qglns
r:
rr I
Butterfly-shaPed
I

t
Moves on Protrr;sion
-------T
*
I

Cystic
bone
---1 I

+
Firm

rr_ Below hyoid Solid

At level of .thYroid of tongue
cartilage u 1U
ThYroglossal Subl-rycgL-qq11sitis Prqlarvngeal or,
u
structure Pt9[9,"!99.!-.!uoPn
Thvroid structure nodes
-t'- I
I

t.L
F - Discharge -
-
Cystic

r. - Previous historY of oPeration

u
Fluctuant
1l

r^ Thyroglossal fistula Thvroolossal cYst

F
E
F
f-
rl-- 156

tr
E
 rf
,t\

Section I Case Presentation - Neck 157 \

- .1
\
Lateral Swelling
r\
\
Submandibular triangle Carotid triangle Posterior triangle (pg 158) \
\
l
!
J
Bimanually palpable Not bimanually palpable Others \
Submandibular gland Submandibular lymph node {i
swelling Plunging ranula
rf
Mandibular tumours il

Slow growing
-ta
Rapid growth
Lateral sublingual
derrhoid cyst r!

No pain Painful
No fixation Fixation -
u u i
Benign swelling Malignant A
swelling !
t
E

\
a\
\
F
Carotid triangle
\
l_
q
!t i

Pulsatile Non-Pulsatile
{t
I

I
\
- Carotid artery aneurysm I

\
- Carotid body tumour I

I
\
il
I

Cystic I hrough Solid \

Junction of
I
I

+uilJ;il,l:.
u
lnternal jugular chain
lfmphlro'de
\
-/l
upper third and \
lower 2/t of '/- Cor,stitutional - Laryngoco-ele
symptoms,
sternoclei- \
domastoid - Other lymph.
muscle nodes in the E
l.t
neck

Branchial cyst
U rq
 ClinicalENT
158

Posterior triangle

Bony
u
Cervical rib

Cystic _

u
Cystic hygromqT Lymph node swelling
Haemangioma
/, - Metastatic v
Cold abscess / - Tuberculous"
- Lymphomav
- LipomqT

Sublingual dermoid cYst

It is a sequestration dermoid cyst occuring in the midline due
to sequestration of ectodermal cells at the site
epithelium and contains sebaceous and sweat
of fusion of two mandibular arches. lt is lined by squamous
glands, but no hair.
A lateral variety also exists, arising from the 2^d branchial cleft.
Features :

o Swelling in submental regton (midline variety is more common)

o Soft, cystic swelling
o Painless
o Seen in young age group
o Positive fluctuation test
oNegativetransilluminationtestasitcontainsthickcheesymaterial
Treatment :
Excision by intraoral aPProach

Pretracheal and prelaryngeal lymph nodes

Theselymphnodesgetenlargedinthefollowingconditions:
1. Laryngitis : ln acute laryngitis, the nodes are tender and soft
2. Tuberculosis
3. Carcinoma of larynx : Metastatic nodes are hard in consistency
Papillary carcinoma of thyroid,: lt spreads via lymphatics
to these nodes' The nodes would be firm to hard'
4.
Subhyoid bursitis
just below the hyoid bone in front of the thyrohyoid
The subhyoid bursa as the name suggests is located
membrane. lnflammation of this bursa results in r tender
swelling with collection of inflammatory fluid within'
It can develoP into an abscess.

Features :

o Midlrne subhYoid swelling

 159
IJ
I:I
Section I Case Presentation - Neck
-.
o Tender
o Oval swelling placed horizontally
o Soft, cystic
o Positive fluctuation test :l
o Negative transillumination test (Fluid inside is not clear)
o Swelling moves up with deglutition
Treatment :
I:1
Complete excision
Swellings in suprasternal space of Burns
:'l
1. Thymic swellings
2. Aneurysm of innominate artery
:'l
3. Aneurysm of subclavtan artery :"1
4. Sequestration dermoid cYst -^t
5. Lipoma -a:
Enlarged submandibular lymph nodes
These nodes lie deep to the deep fascia. They are not bimanually
palpable unlike the submandibular salivary i
t$
gland.
They get enlarged due to the following conditions :
-
1. Acute lymphadenitis : Due to dental caries causing soft, and tender
enlargement of the nodes' l.
caseous necrosis
2. Tuberculous lymphadenitis : The nodes are firm and matted with central
3. Metastasis from carcinoma of oral cavity mainly from the cheek and tongue'
The nodes are hard and may L
be fixed. A
'!l
4. Non-Hodgkin's lymphoma : The nodes are firm and rubbery in consistency
-

\
\

-
rrl

\
!f

\
i
::
F!
x
rf

;
r:
r:
r.
rt 2. THYROID GLAND
- Dr. Rajiv Joshi

n HISTORY
Name, age, sex, occupation, residence, religion.

t_ Residence - Endemic areas : Foot hills of Satpuda, Ratnagiri, Subhimalayan region, Dhule, Nashik

1- f-
Endemicity >10% general population
Young - primary / physiological
Endemic Areas

r- Aoe : ---l
I
r- Middle aged - secondary
o
r
o
Satpuda foothills
Ratnagiri
Dhule
r_ \-€ex - Goitre commoner, in females o

rr^
Nasik

I *
H/O - Swelling and onset of symptoms :

,'-Onset ' (simultaneous or otherwise, to differentiate between primary and secondary thyrotoxicosis.)
o SubHimalayan region

o Sudden increase in size :

- Malignancy

n -
-
Haemorrhage.
Long duration of swelling : Multinodular goitre, Colloid goitre.

r_ Symptoms :

n o Pain in the gland :' 'inflammation

'-

I:
Malignant change. eg; Follicular carcinoma in MNG
H/o :

1. Pressure symptoms :

- Trachea - lnspiratory stridor

F
r -
\..:
!.r'-
\ --.
Oesophagus
Recurrent laryngeal
Carotids
-
-
nerve -
Dyspnoea
Dysphagia
Hoarseness of voice / dysphonia
-
Transient lschemic attacks (TlA) / syncope
Carotid sheath and cervical sympathetic trunk - Horner's syndrome : in Ca thyroid

F I- Pressure symptoms due to retrosternal goitre - Superior mediastinal compression syndrome

I:
I-
2. Endocrine status of the gland

1.
SYSTEM
:

HYPERTHYROIDISM HYPOTHYROIDISM

n
Central neryous system lrritability, anxiety, insomnia / altered Lethargy, somnolence
sleep habits, restlessness Normal contraction with sustained
Later - hyperreflexia, fine tremors relaxation.
Qtadriceps Sign : feeling of give away

F
1--
2. Cardio vascular system
of knees while climbing down stairs.
Palpitations, high output cardiac failure Congestive Cardiac failure / (RVF)
(LVF) causing pericardial effusion,
oedema feet and dyspnoea.
causing effusions and dyspnoea.

l-- l. Gastrointestinai system lncreased appetite with loss of weight, (N) appetite and gain in weight,

f-
diarrhoea (lncreased Basal Metabolic rate) constipation.

n 160

r:
 Case Presentation - Neck 161
Section I
-
SYSTEM HYPERTHYROIDISM HYPOTHYROIDISM

4. Skeletal system Weakness Weak and Flabby muscles.

Wasting of muscle
Osteoporosis
5. Skin Heat intolerance Cold intolerance
Warm and moist skin (increased Skin-cold and dry, cool, pale, rough,
perspiration) doughy with periorbital oedema
ln anxiety - skin is cold and moist
6. Genito - Urinary SYstem Oligo menorrhoea Polymenorrhagia, increased frequency
Amenorrhoea of micturition
7. Ophthalmic Exophthalmos, bulging of eYes with
failure to close eyelids.
8. Respiratory system
There is dyspnoea due to
pressure of the gland and CCF.
There is cough (CCF/LVF) and
recurrent URTI.

Conditions where appetite increases with loss of weight :

o Hyperthyroidism
o Early Tuberculosis
. Diabetes mellitus
o Hypertrophic pyloric stenosis.

3. Etiology l Etiology
o Drugs : o Drugs
. INH o Endemic
- lodides . Stress

- PAS
o lrradiation

- Thiouracil
o Goitrogens

o Residence - to rule out endemic goitre o Familial

o lrradiation :

r-," Hlo irradiation of neck-in adults for carcinoma

r 7- lr children for thymoma / Hodgkin's lymphoma.

.,/' ln young for Hodgkin's disease.

a Stressful episodes in life :

- Puberty
- Pregnancy
- Bad obstetric history
- Mental stress.
Excessive ingestion of Cabbage
Cauliflower Contaminated fish
Kale Turnip
Brassica family Spinach
 ClinicalENT
162

o Excessive flourine uPtake

o Family h/o - enzyme linked disorders'

4. lnvestigations done and treatment taken

: Positive ResPonse to treatment :

lnvestigations : o lncrease in aPetite

o FNAC - may cause tenderness' o Weight gain

o X-ray neck . Decrease in sleePing Pulse rate

o Decrease T3, T4 levels'
o USG neck
o Thyrotd scan
o CT scan
o lndirect larYngoscoPY (lDL)
o Blood investigations.
Treatment :
o Drugs - antithYroid drugs
o Surgery
o lrradiation
I: 5. Malignant changes and metastatic Tmptoms
o Skeletal mets - pains '*-' ''!. - "
'1

l Bone
- Pathologicalfractures
ParaParesis 'i '
L ,.i'
i . mets - DYsPnoea
Pulmonary
t- ,,'

o Cranial mets -
- HaemoPtYsis, cough
Headache' convulsions' motor deficit
t o Liver mets - Jaundice' ascites' lump rn abdomen (hepatomegaly)

t . o Lymph node mets - Painful lymphadenopathy with ulceration

t 6.Evidenceofotherhormonaldeficitse.g.secondarySeXcharacteristics

[-
EuthYroid
t: lmpression on h/o HYPothYroid

t I Hyperthyroid

t Past History :
o Previous surgery
t: o Medical theraPY for toxicitY

Family History :
;:
oFamrlialcause:Deficiencyofe-nzymedehalogenase
r: MedullarY carcinoma thYroid
o syndrome: Goitre + congenital deafness
t: Pendred
HYPothYroidism
Absence of enzYme Peroxidase
r: '

r:
r
GENERAL EXAMINATION
o Built and nourishment (usually poor) Look
for "
Pallor
LymphadenoPathY

-
 fi!
A
163 '\
Section I Case Presentation - Neck
- \
o Temperature:
-lncreases in hYPerthYroidism \
-Decreases in hYPothYroidism
\
lt is difficult to differentiate tachycardia
o pulse rate : Tachycardia during active examination is meaningless.
due to thYrotoxicosis and anxietY \
pulse rate is taken either 4 hours after sleeP
To differentiate - sleeping pulse rate is taken' Sleeping
a full 1-3 minutes for 3 consecutive daYs at
(REM sleep) / by sedating il-,e patient with diazepam - for
)round the same time and the average is calculated'
-
over 3 daYs)
r -(Patients with ll" thyrotoxicosis have cardiac arrhythmias and hence taken for 3 minutes
"a
lmportance of sleePing Pulse rate rt
- Helps to grade severity of thyrotoxicosts
\-96-100 - mild
\ 1'00-110 - moderate
\ >110 - severe E

- Helps iudge response to treatment

\

o Respiratory rate (non specific) - increased "t HypothYroidism

Hyperthyroidism
Metastasis
q

\
o Blood Pressure : Changes seen in secondary thyrotoxicosis'
a Tremors : Fine tremors of the hand are elicited by
asking the patient to extend his upper extremities
wtth -
,^ -{rafn}rad finnorc
fingers'
Aiiece ot paper is kept over the stretched
;riT:?""";n'!"*""*ias and fingers stretcr'eo afart. E-l \
They are seen in Grave's disease Tremors : Site :
n .. Tongue tremors o Hand / fi
-\
' -"' Uvula tremors o Tongue
q
o Oedema feet : Congestive cardiac failure' pretibial myxoedema o Uvula

o Lymphadenopathy - cervical in : - Thyroiditis \

- Carcinoma
oRaisedJugularVenousPressureincongestivecardiacfailure.
't
o Examination of oral cavity for : Ltngual thyroid \
r- ExoPhthalmos
o Eyes I I
I

\
Periorbital mYxoedema
o Skin changes, if anY
\
\
LOCAL EXAMINATION cms
of the neck' which moves with deglutition' of size -*--
lnspection - Single, ovoid swelling, in the midline notch (vertical :
cms above suprasternal
x -- cms, and extending frim the hyoid bone above, to =.---
(lateral extent)'
e*tenq anO from one sternomastoid to the other \
Swelling :
t
o Number
o Size
o Shape
r Movement with deglutition hr

e Extent t

*:t' r r;-i-6i65-ir''-;,:;., i:."- -

 ClinicalENT
164

o Surface : Smooth / nodular

Surface : Goitre
r Smooth : r--r'-Adenoma
'.r Puberty goitre
'o- brave's disease
o No.dular : Multinodular goitre
o lrregular : Carcinoma thYroid

Skin over the swelling

- Scars / sinuses
- Pulsations
- Dilated veins

D/D of midline neck swellings which movewith deglutition'

oThyroidglandswelling{o.'.Prelaryngeallymphnodes(Delphianlymphnodes)
o Thyroglossal cyst r Pretracheal lymph nodes
o Laryngocoele "o Fxternal Ca of larynx
o Subhyoid bursitis

GOITRE THYROGLOSSAL CYST

o Moves with deglutition o Moves which deglutition

o Does not move with protrusion of tongue o As well as with protrusion of tongue (tested after fixing the
mandible)

- Goitre is differentiated from rest by :

o History
: o FNAC
o Thyroid scan
-
proved otherwise'l
Any midline swelling of neck which moves which deglutition is thyroid swelling unless
q

ri Situations when thyroid will not move with deglutition :

Carcinoma thyroid
-t Subacute / Riedel's thYroiditis
Post operative thYroid.
- o Post irradiation.
o Large goitre which retrosternal extension.

Platysma sign :
-l r') ln carcinoma thyroid, nodules in skin occur with puckering / dimpling on tensing the
platysma

Pemberton's sign
1. lnspection
rf 2. Percussion

jo
-\i-q r'+J J,^ r. i * a go-:-Q a i, :.r cr !p { e< ..< H ts ild--tt-5oN- zo ,2
 165
Section I Case Presentation - Neck
-
lnspection :
o Ask patient to raise his arms and look for . congestron of face
.'
i'" Engorgement of neck veins
' ResPiratory discomfort

Direct percussion :
over manubrium sterni produces a dull note in retrosternal goitre
Types of retrosternal goitre
o Substernal : Lower limit of gland can be seen on deglutition.
o lntra thoracic : Lower limit of gland can't be seen even on deglutition
o Plunging : Swelling appears on coughing and goes down again'

Clinical lmportance of Retrosternal Goitre

r,-..r-' Superior mediastinal compression syndrome (SMCS)
precipitate or exacerbate
c Anti-thyroid drugs are given wiih caution since gland may increase in size and
SMCS.
Diagnosis XraY chest
CT scan.

Surgical approaches :
o Kocher's (skin crease) incision, as vascular control has to be achieved in the neck'
o Gland can then be removed piecemeal.
r o"'A sternal split may be required for extremely large and vascular RSG'

PALPATION OF THYROID GLAND

Normally thyroid gland is not palpable'
4 methods of PalPation :
o From back of the patient with cups of hand (standard)
o Lahey's method.
o Pizillo's method
o Crile's method.
e Palpation from behind (Standard method)
Advantages :

- Concavity of hand fits into convexity of neck'

- Palpation is facilitated with pulp of fingers which are more sensitive.
- Patient is less anxious than when palpated from front'
- Gland palpation is better with neck flexed, since platysma and other muscles are relaxed
o Lahey's method :
- Thyroid is palpated from front with neck flexed'
- one lobe rs made prominent by pushing the gland on other side and then palpated'
- Similarly palpated on other side.
o Pizillo's method :

- Employed in fat females with shori neck'

- Neck extended (no hyperextension)
- Gland PalPated from front.

r +:---a
r:
r 166
CIinicalENT

rr: r Crile's method

-
-
:

For solitary thYroid nodule.

Palpation with flat of thumb.

r: On Palpation :
o Findings of inspection are confirmed.
r^
r
r
o Temperature over gland is increased in

o
Thyroiditis
Vascular tumours
Thyrotoxicosis
Tenderness is present in
:

r: - Thyroiditis
:

r: r
-
Thrill
Malignancy (due to to haemorrhage and necrosis)
:

r^ \.-'felt at superior pole of gland.

circulation and numerous A-V fistulae.
r: - present in thyrotoxicosis because of hyperdynamic
o Consistency
n
:

$ - Stony hard - Malignancy, Riedel's thyroiditis

n Rubbery - Hashimoto's thYroiditis

r
n
o
-
-
Firm - Colloid goitre
Soft - Grave's disease
Mobility : - Fixed in malignancY.
palpation of cervical lymphnodes is to be carried out to rule out hard, fixed lymph nodes seen in thyroid
carcinoma.

r_ Relation to Surrounding Structures :

r o Trachea : Pressure effect on trachea is tested by :

n
leading to an inspiratory strido: is a
.--,-'"Kocher's test - compression of the gland and hence of trachea
positive test. Scabbard Trachea :

n
rr:
''Positive test is seen in long standing benign goitres.
' N'egative test : malignancY.
Pressure atrophy of posterior wall
Benign enlargement of thyroid gland

pressure on the lateral sides of the gland causes narrowing of tracheal lumen and therefore inspiratory
stridor.
ln Malignancy - trachea flattens out and pressure on lateral sides of the swelling causes an
increase in

n
>
**
o
diameter of the tracheal lumen and therefore no stridor is seen.
Shift of trachea - Traile's sign
shjrt or trachea
I ^ o
rraire's-slg!-: li9-nl9l9g-9J -?l9il-9.I?-:].9i9.91"t|" '19.9- 9r

r Carotids -

ln a normal individual carotid pulsations are palpable against the tubercle of the transverse
vertebra (Chassagnaec tubercie). A positive berry's sign is one in which carotid pulsations are
process of C6
not palpable'

E Berry's sign :

r-
POSITIVE NEGATIVE

Malignancy Benign goitre

f-' Reidel's thyroiditis

tr
n
r l\' ,Aif{isxxg;'l {60J (,)r o N
ild-o-r'oosoNr
 Section | Case Presentation - Neck
167 \
-
\
o Sternomastoids :
against
Extent of the gland and involvement of sternomastoid is tested by contracting the sternomastoid \
resistance.
With patient srtting in front of you, put right hand to check'the patient's right sternomastoid. \
o Cervical sympathetic trunk :
lnvolved in malignancy - Horner's syndrome
\
\
PERCUSSION Horner's Syndrome :

Direct percussion over manubrium sterni o Ptosis ,\i --

Dullness - Plumberton's sign positive in retrosternal goitre o Miosis
Resonance - normal o Anhydrosis -
o Loss of ciliosPinal reflex :t
AUSCULTATION
Bruit heard over the superior pole of gland in toxic goitre \
Bruit is heard over suPerior Pole :

o Superior thyroid artery is a direct branch of external carotid artery -l\

o superior thyroid artery is more supedicial than the inferior artery ht

Examination of other sYstems :

\t
o For endocrine status
o Metastasis r\
o Complications
o Per abdomen :

- Hepatosplenomegaly in Hashimoto's thyroiditis

\
are also Present)
- Hepatomegaly due to metastasis in carcinoma thyroid (present usually if lung mets
o Cardiovascular sYstem : \
- Ejection systolic murmur in thyrotoxicosis'
- Loud S1, S2. \
- Pericardial rub in congestive cardiac failure \
e Central nervous sYstem
Cranial metastasts. \
Hyperthyroidism - hyperreflexia / i.e. brisk contraction and relaxation
Hypothyroidism - normal contraction and sustained relaxation.
\
o Musculo skeletai system : wasting of muscles - hypothyroidism \
a Respiratory system : Crepitations in congestive cardiac failure in thyrotoxicosis
o Eye signs :
\
1. Exophthalmos :
\
Causes of Exophthalmos in thyrotoxicosis :
. \
l-r lncreased intraorbital congestion.
c- Retroorbital fibrofatty and glycogen deposition'
o Paresis of extraocular muscles which support the eyeball' \
o Exophthalmos producing substances.

l$Nr{rr
Q*g9J!n9) iEree rnr^r-'@{6oJ
l'_
11 168 ClinicalENT

I_
n
Differential diagnosis of exophthalmos :

o ldiopathic

n
n
o Thyrotoxicosis.
o Cushing's syndrome
o Retroorbital tumours
- Retinoblastoma
:
?

n
r:
- Craniopharyngioma
- Antral tumours
o Cavernous sinus thrombosis

n o Haemangioma(pulsatile)
o Retinal artery aneurysm.
n
n Eye signs in thyroid
o Joffroy's sign
;

n
I:
o
o
o
o
Moebius sign
Dalrymple's sign
Nafzigger's sign

r:
Gifford's sign
o Ballet's sign
o
r: o
Anroth's sign
Jellinger's sign

r: o
o
Stellwag's sign

n
Von graeffe's sign
o Rosenbach's sign

n
o Becker's sign

r
t:
Diagnosis of exophthalmos
o
t
:

With the patient. looking straight :

- Normally : Either one limbus present aI6112 O'clock position or none is seen
-' Exophthalmos : Both are seen simultaneously.
r- o
"
.
Accurate diagnosis - Measurement by Kelly's exophthalmometer :
- Distance between limbus and outer canthus of eye : is 16-23 mm
..-' Exophthalmos : >23 mm. lt does not hold good in squints.
) .

]-
t: Signs for exophthalmos :

n o Joffroy's sign Absence of wrinkling of forehead on

downwards
tookiffiwards with face inclined

n
r
o Moebius sign Convergence of eye is difficult.
o Dalrymple's sign lncreased width of palpebral fissure.
Test : Finger brought suddenly from distance to nose.

I:
]--
o
o
o
Nafzigger's sign

Gifford's sign
Feeling of resistance
Tangential view (from patient's back) over the forehead shows
protruding eyeballs.
Difficulty in passively everting upper eyelid.
When pressure is applied to eyeballs (due to retroorbital congestion and

l-' fibrofatty deposition).

It_
a EUdiQ-Qixxss^< QQisjs-e= s^<
 -T
169
Section l- Case Presentation - Neck I

' ;ffi!";ff.] ^-^ particularlv effer'le.

The superior rectus and inferior oblique are ^arfin'lor.r
affected and
And I
'v
M "r*"i """i.'n'*"'u. I
' *::::m::il;:'"'ratientcanrotreehqPss-qe'
o lids'
oedema of the conjunctiva and
5
increased I
tncteasuu,mohatic conjunctivae by
o caused by obstruction of normal venous and lymphatic drainage of the {
retroorbital Pressure' ^ il
4. Jellinger's sign : Pigmentation of skin of eyelids'
T
' :,";il:r1Jil:',['ff::,HTTfifi"X # ",",?13il0,,: {
w*h infrequent brinking rhis sisn ,,
(smooth) muscle part of levator palpebrae superioris'
lf the uppe
overactivity of involuntary
position' patient has no lid retraction'
higher than normal and lower lid in its correct I
r Vqn graeffe's sign.:
Lagging behind of upper eyelid on looking downwards
rq downwards :I
it follows a finger moving from above downwards
(at
lf upper eyelid doesn't keep pace with eyeball as T
accomodation distance), patient's eyelid has
lid lag'
*
o Rosenbach's sign : Fine tremors of eyelid
arteries on fundoscopy' -l
o Becker,s sign : Abnorrflal pulsations of retinal

6. Epiphora
5
7. DiploPia
8. PhotoPhobia.

DIAGNOSIS
$
o A - year old, male / female patient' a case of
o Toxic / nontoxic
o Multinodular goitre / diffuse, smooth / solitary thyroid nodule
o With / without Pressure sYmPtoms
o With / without retrosternal extension
o With / without eYe signs'
INVESTIGATIONS IN A THYROID CASE
A. Hematological and biochemical :

o Haemoglobin : anaemia correction'

\y'Total/differentialWBCcount:lflowcounts,thenanti-thyroiddrugsarenotgiven,sincetheymaycause
agranulocYtosts.
\-J ESR : lncreased in thYroiditis'
thyrotoxic myopathy'
'-6. BUN / Sr. creatinine : lncreased levels in
o Serum cholesterol : - lncreased in hypothyroidism'
- Decreased in hYPerthYroidism'
;-Fastino
o Blood sugar --l I
Post-Prandial (PP)
o Serum electrolYtes.
r"
I 170

o Thyroid function tests :

ClinicalENT

r: - T3, T4 levels.
t: - TSH estimation.
- Estimation of thyroid antrbodies / thyroid immunoglobulin (LATS)
t" lncreased in: -
-
Hashimoto's thyroiditis

r" -
Grave's disease
Antimitochondrial antibodies (AMA)
r" - Thyrotropin releasing hormone (TRH) test

r: CLINICAL STATE

HyperthYroidism
F- HypothYroidism
Euthyroid
!'" T3' T4 is a must to detect subclinical
ln clinically euthyroid patient's' also estimation ofduring surgery' Also 6-10% of patients with
r_ hyperthyroidism, which may manifest as
'tf.ryt"iO storm'

r. a-normal sleeping pulse rate may have latent ThYrotoxicosis.

n B. Radiological :
o X'ray neck
r: -
-
AnteroPosterior
Lateral view
r_ - Position of trachea for intubation

r. - Calcification in thYroid

r: D
o
/ D : Calcification in thYroid :

Fine stippled calcification Psammoma bodies

:. in papillary carcinoma

r- o
o
Sparse, coarse calcification : Long standing benign
Calcification also seen in :-
goitres'
Medullary carcinoma

r_ Anaplastic carcinoma

t:
n
o X-ray chest (PA) : -
-
Tuberculosis
Retrosternal goitre

rn o USG of thYroid

Thyroid scan
:

and 1131)
(1125
-
-
-
Secondary metastasis in lung
For morPhologY
Solid / cYstic lesions.

n
"

- ActivitY (function) of gland'

- Morphology of gland : especially in solitary nodule to rule out carcinoma

n CT scan : - Neck - in carcinoma

- Thorax - in retrosternal goitre
I-
t:
C. Miscellaneous :

o Electrocardiogram : Cardiac changes

f-' HYPOTHYROIDISM HYPERTHYROIDISM

o Low voltage ECG a Sinus tachYcardia

l-- o Bradycardia a ST-T changes

t:
t:
o lnverted 'T'waves a Arrhythmias

r idipaqQ=
>l=d;dd;
rsri{
eo@@ ss s t ts 316'Po
.. ,, ,, i, i' rr
-f'Ol O S <": ru
:2
i<
o
o
 Case Presentation - Neck 171
I
)

II
Section I
-
a Sleeping pulse rate
a lndirect laryngoscopy : ln 2% of general population, there is intrinsic vocal cord palsy These cases
have to be detected, ai well as those who have recurrent laryngeal nerve damage due to carcinoma for
medicolegal purposes.
:I
I:t
Ankle tendon reflex duration bY
- Phototomography
- Electromyography
Hyperthyroid - brisk contraction and relaxation
Hypothyroid - normal contraction and sluggish relaxation
:I
Diagnosis of :
- Physiological goitre
- Colloid goitre
:I
- Carcinoma :'l
FNAC - limited role in
- MNG
:
:'l
- Follicular ca - cannot differentiate between follicular adenoma and carcinoma -'l
-
-
BMR - obsolete now
Presesently, Resting energy metabolism (REM) is estimated'
:'l
Both these are increased in case of hyperthyroidism. :'l
Kelly's exophthalmometer - exophthalmometry.
:'l
TREATMENT
Overall view
:'l
l'l
A. Diffuse, smooth, non-toxic goitre :
(ie. either physiological / endemic goitre)
tI
Hyperplasia
lJ
Colloid
u
:'l
Give T4 Give lodine
(thyroxine) (eg. iodised salt)

B. Solitary thyroid nodule : Refer pg 177

II
)

c. Primary toxic goitre

o
o
:

Medical treatment followed by medical treatment throughout.r

Medical treatment followed by surgical treatment.'
I:'l
D. Secondary toxic goitre :
o Medical treatment alwaYs. l'l
1. MEDICAL RX
:I
A. Supportive Rx
o
:

Admit patient (thyrotoxic) in a cool (A/c) quiet, cosy corner of the ward - to allay anxiety and irritability
:t
l'l
.1
-'l

fi *E*t$tsd*-$* :. **i:x;:; ;-q.as Si S I B i1;; .oo..r'--soNJ

 172
ClinicalENT

o Tepid water sponging to decrease temperature

o Oral / LV. fluids.
Correction of catabolic state :

o High protein diet.

o Vitamins
o Correction of anaemia - haematinics

B. Drugs :

o Diazepam - sedative and anxiolytic 10 mg Hs.

r Antithyroid drugs :

- Carbima zole - 40 mg / day in divided doses and to suppress TSH - thyroxine in low doses (0 1

mg)
Disadvantages of carbimazole :

o. Long duration of treatment

. Expensive
o Takes longer time to act
o Prolonged use causes : - Agranulocytosis,
Drug rash
- Sore throat
Diarrhoea
| .. Makes gland more vascular and causes enlargement of gland, hence to be given with caution in
retrosternal goitre / when pressure symptoms are present'
o Patient may slip under effect of drug and relapse again'
o Regular monitoring of CBC is required.
o propylthiouracil 100-150 mg / day in divided doses and little doses of T4 to suppress TSH.

C. Propranolol :20-40 mg TDS

Contraindication : - Bronchial asthma
- Congestive cardiac failure
- Myocardial ischaemia
- Arrhythmias and heart block
D. Lugol's iodine : given 10 days prior to surgery. Dose 5-15 drops / day discontinued 2 days before the
operation.
Response to theraPY is judged bY :

o Sleeping pulse rate

r Patient's sleeP Pattern
o Weight gain
o Confirmation by biochemical levels of T3' T4, TSH

Lugol's iodine (orallY)

o lt makes the gland firmer and hence easy to handle during surgery
o lt decreases vascularity of gland.
precaution : since it causes an increase in size of gland, it is to be given with caution in patients with
retrosternal goitre.
o lt is also indicated during a thyroid storm.

rr:
r:
{(rqt { ooor,
G)
o6, 1- or (, (b (r) -l' {cnq)r
o660
(.) r
55 N
G)
o)
-oo
(,) 600 .(.)
.s NNN ;z (tr o) o ctr- : aZ
N N
iiit;i .ll
N.}J N
{.-u
N
lr- 1l jlt il lt.: il.-
a.d!
r0 I n:1t u I
ct)
rl It tr ll: rillril ilil tr ii l ,!r' ilr ir ll ti il tl ll ll ll --11
/.' t<
ilm
 Case Presentation - Neck
173
II
I:t
Section |
-
2.SURGICALMoDALITYoFTREATMENT.SUBToTALTHYRoIDECToMY(STT)
lndications for surgerY (3F s)
o Medical Rx not fancred - for socioeconomic or other reasons like patient's incompliance
o Medical Rx fails.
:l
o Medical Rx not feasible.
eg . - Multi-nodular toxic goitre
- Diffuse goitre with pressure effects'
I:l
- Side effects of medical treatment
- Retrosternal goitre
Contraindications for surgery :
I:I
o High risk patients
r Thyrocardiac Patients
o Recurrence of thyrotoxicosis after previous surgery
Advantages of surgery :
I:I
o Radical cure of disease is obtained 'l
c Suitable for Patients < 35 Years
o Suitable when medical Rx
Fails
Not feasible II
II
Not fancied
Disadvantages of surgery :
o complications - haemorrhage, recurrent laryngeal nerve damage etc.
o Recurrence - due to inadequate removal of gland'
3. RADIOACTIVE IODINE THERAPY
The isotope used is li3'l which emits p rays which destroys the thyroid cells.
The isotope gets concentrated
II
It
in the thyroid gland.
Dosage : B-10 millicuries on empty stomach'
lndications : o
df*d':"Jnffixicosis arter previous sursery / drus treatment. (hot nodure)
:''l

Advantages :
: o Patients < 40 years of age
Contraindications
o Pregnancy
o Easy mode of"administration
II
o ldeal for high risk and thyrocardiac patients -l
Disadvantages : o Radiationthyroiditis .l
rr- May induce malignant changes
o Development of hYPothYroidism
in
I
o Requires strict follow-up and patient should be intelligent enough to void urine
a

safe place
.'']
"e- lnfertility (therefore contraindicated before 40 years of age) l''l
e Relatively small group of patients can be subjected to this mode of treatment
:.,1

:'1
.-!
rq

\
t

S6i66iR***-< S
N
il
RRRHRHsssstu
llllllllllIrlililfiil
L s:*s;$'.* .eS s B iid.co"r'--aoNr
 174 Clinical ENT

TREATMENT : (OF INDIVIDUAL CASES)

o Hot nodule :

- Antithyroid drugs
- After patient becomes euthyroid / toxicity controlled - hemithyroidectomy
- lf patient refuses surgery - radioactive l, treatment to ablate the nodule
o Warm nodule :
- Usually patient left alone and kept under observation.
- lf patient worried about cosmesis : - Hemithyroidectomy (or)
- Resection and enucleaiion
o Cold nodule :

Benign Malignant
u IJ

Hemithyroidectomy Total thyroidectomy

o Diffuse smooth non-toxic goitre :

Puberty
Endemic / physiological goitre ;- Pregnancy
I str".,
FNAC
I

Hyperplasia Colloid
u u
Give T4 Give iodised salt
(to suppress
TSH)

lndications for Sx :

- Cosmetic disfigurement
- Pressure symptoms
- Failure of conservative line of Rx
Surgical treatment - subtotal thyroidectomy (STT)
(formerly - partial thyroidectomy was done)
Multi nodular non-toxic goitre :
Rx always surgical because :-
- Doesn't respond to conservative treatment, this being an autonomous gland.
-- Compression symptoms common with multinodular goitre
"-' Cosmetic disfigurement
t-- Chances of secondary thyrotoxicosis are high.
u--Chances of developing malignancy are more.(follicular ca)
Surgical Rx - subtotal thyroidectomy (STT)
Diffuse smooth toxic goitre :

rr:
(Grave's disease / primary thyrotoxicosis)

(lt { ('r o.+ $iii-.-..=8t; -r''-f;-

o) o.600d oooo
NNN! a e
5 c-F 6
N
5
N NN.NNN
.ll tr-'n ll- ll il n Ir*'r
iz
id ;i.
 s""tio
-I
t
)
3 modalities of Rx : o Medical :l
: :::::?,,:':?:j,,lvroidec'1omv I
o Multinodular toxic goitre (Secondary thyrotoxicosis) \
- Medical treatment to control toxicity I
- Surgery - subtotal thyroidectomy after control of toxicity I
o Ca thyroid - Total thyroidectomy -l
ln toxic goitre, patient is put on medical line of treatment to control toxicity to prevent development of - I
thyrotoxic crisis on operation table'
:I
- Once toxicity is reasonably controlled,, patient
-- ^ . is" subjected
^., ^. ,.to surgery
. ^ weeks
6 ^^,..-^{+^- ^^^i-nr
after control.
- 7-10 days prior to surgery, patient is administered Lugol's iodine :I
scHEME FoR THE DrAGNosrs oF A THyRorD :tl
'*ELLTNG
After exarnination of the patient with goitre, one should be able to derive one of the following conclusions about
activity. \- I
the gland and its
rhe Grand
' l'l
o Contains one palpable nodule (solitary thyroid nodule) -l
o Contains >'1 palpable nodule (multinodular goitre) " I
o Diffusely enlarged (smooth / hyperplastic)
I\l
Activity of thegland :
Normal, hyper / hypo secretion e I
Normal - euthyroid (non{oxic)
:tl
\rv^rv/'
Hyper {hyrotoxicosis (toxic)
Hypo - myxoedema -l
I
o lf only one swelling is palpable it may be :
- The only palpable nodule of multinodular goitre. I
- Whole of one lobe is usually involved by Hashimoto's Thyroiditis I
- Benign adenoma
- Papillary I
- Follicular :tl
- Carcinomu \
- Cyst caused by haemorrhage into a necrotic nodule - |
o lf more than 1 swelling palpable
- goitre ' I
Multinodular \i
- Anaplastic carcinoma I
o lf there is diffuse homogenous enlargement of whole gland (hyperplasia)
- Grave's disease / primary thyrotoxicosis t
- Slight to moderate enlargement, diffuse, smooth, soft with a bruii :tl
- Hyperplastic colloid goitre \
- Moderate to gross enlargement, bosselated, no bruit : I
- rhyroiditis :I
:1
lt-'l

]IJNJJJJJ N

s*Fil$tE€d$$* i_
iz ;*;s;$s; ;sdes Fn F 6 E i.
OJ
El ,oo 50N
r:
r: 176 Clinical ENT

r Thyroid Swelling

rt I
I
l ..-l

r" Diffuse enlargement of whole gland Nodular

n I
enlargement (pg 177)

r_ Cold intolerance No clinical Palpitations

r- Lethargy
lncreasing weight
features of
thyroid
Heat intolerance
Restlessness
r_ Menstrual changes malfunction Eye signs

r- u
Dry hair / skin
u
(N) T,, T4' TSH
Diarrhoea
Pretibial myxoedema

r. Slow pulse {1 u
1I r.,
r- Hoarse voice
Slow reflexes U rSH
To

n Periorbital puffiness I

r:
I

u
1I rsn I
r. ll T, To
tHyperlh-rthyroial

n
l
u i I

I I

\V
n
I

Biochemical
;.F assessment
l

n
u u

rr_ Antithyroid No antibodies TSH stimulating

antibodies antibodies
I

u
!
I

u
Puberty / Moderate to gross - Mild to moderate

rr
Middle-aged pregnancy enlargement enlargement
female u No bruit
U Bosselated
- Soft thyroid
- Bruit over thyroid

r
u
u
Grave's disease
u

r. Medical suppressive

n
therapy

t-_ Any swelling of thyroid gland - goitre

T- MNG - Il thyrotoxicosis

n
F
Thyrotoxicosis --l
f-
L- oSC - thyrotoxicosis (Grave's)

r_
r_
a qtQ{QreislqE<
I\)NJJJJJ
.oo -rr
eQ:.€{qQt
33S,tjS3*3sSS3 I
3
n2
rji=
OOOoOOtOt(', ;SS$ Si S E ts ru-O@O!'(')oAoNr
 Section I Case Presentation - Neck \
-
NODULAR ENLARGEMENT OF THYROID GLAND
\
__L
I
\
i

+ \
Solitary thyroid nodule MultiPle nodules (Pg 178)
ultrasound (40ok of clinically solitary nodules are actually multiple) i
\r
I

!
Solid
u
Cystic
il
I
i
131
I Scan Aspirate and CYtologY \
I
__1 i \
t
I

"t
+-t
Malignant Benign
Hot Cold Warm
u
\
(Functioning
adenoma)
Total
Thyroidectomy
i
u FNAC
-l ++ I
\
Give radioactive I
Reaccumulates DisaPPeas
l2 I

vt1
\
I

l l
Surgical excision \
i u
Disappears
L

I HemithyroidectomY \
I

\
I
Cosmetically
I

objectionable
Resection / \
"L__
I

Enucleation
I
) Pressure )
\
L

HemithyroidectomY
symptoms
l
\
l

f
I -f \
II i

Malignant Benign \
u
t-
I
\
lnactive adenomatous nodule /
j.t collord nodule
Lymphoma Carcinoma \
_______ U
___-_
- HemithyroidectomY \r
- Total Tl-rloidectomY
\
- HemithYroidectomY
\
\
\
--

\
,1

;s;s3s
NNNNNN)
o
N
€€ie{qE<
Jjj-
aa-O666a
Sltr(d-
d'd
oJ
rr 178
Clinical ENT

Multiple Nodules

F Slow growth
Regular bosselated
Rapid growth
lnvades surrounding structures

F Non-invasive U

Suspicion of

n
u
Multinodular Goitre Anaplastic Carcinoma

n
l-
-
-
Control toxicitY
Radio-iodine ablation
u

- Surgery for :- Cosmesis

I.
n
- DYsPnoea / dYsPhagia

SOLITARY THYROID NODULE

F
n
Synonym : lsolated thyroid swelling
Definitions
o lt is a discrete, clearly defined swelling in the thyroid gland diagnosed by palpation. The surrounding tissue
may be normal or a diffuse goitre may be present'
I o A nodule is defined as an area of hyperplasia and involution following physiological / pathological changes in
the thyroid gland.
l-_
t:
t:
lncidence :3-4% of adult population.
Classification :
on basis of its appearance on the thyroid scintigram (i.e. thyroid scan)

l-
t:
1. Hot nodule : - 5% of all nodules
Causes hyperthyroidism
Predominantly observed in endemic regions in elderly'
Almost never malignant.
: -

F
2. Cold nodule Commonest
Always considered malignant unless proved otherwise'

t:
t:
3. Warm nodule (neutral nodule)
Etiology:
o 3-4oh of adult PoPulation

n
L
o F:M ratio 4:1
o 30-50 years age grouP
c External irradiation increases risk
o Positive family history increases risk

T: Clinicalfeatures
o
:

lsolated thyroid swelling

tr o Pain occurs due to :

- Subacute thYroiditis

t:
t:
-
-
Haemorrhage / necrosis within nodule
Malignancy

t ei s=-*-ffi t+=:-=:= €r i.e-:r+--=:r a: .+:.r+:Fi*

 Section I Case Presentation - Neck 179
-
o Hoarseness of voice occurs in :

- Advanced carcinoma
- Large benign nodule inrpinging on recurrent laryngeal nerve
- Malignancy
t
Solitary thyroid nodule should be treated because :

o lt could be carcinogenous \
. lt undergoes inflammatory changes
\
. lt undergoes degenerative changes
o lt bleeds in itself \
o lt produces pressure effects
o For cosmetic reasons \
o lt may be a part of a multinodular goitre
\
GOITRE
Causes of goitre
\
WITH HYPERTHYROIDISM WITHOUT HYPERTHYROIDISM
Graves disease (primary thyrotoxicosis / hyperplastic Diffuse goitre of adolescence / pregnancy (hyperplastic \
toxic goitre) non-toxic goitre / physiological goitre)
o Toxic multinodular goitre (secondary thyrotoxicosis) Endemic goitre (hyperplastic non-toxic goitre)
\
a Thyroiditis :
- Chronic lymphocytic thyroiditis
Drug induced goitre (hyperplastic non{oxic goitre) \
: Simple non{oxic qoitre
- Autoimmune tlryroiditis - Multinodular \
- Hashimoto'sthyroiditis - Colloid
- Subacute thyroiditis - Adenomatous \
- De quervains thyroiditis Thyroiditis
- Silent thyroiditis - Chronic lymphocytic thyroiditis :
\
- Autoimmunethyroiditis
- Hashimoto'sthyroiditis
\
- Subacute \
- De quervain's thyroiditis
- Riedel's thyroiditis \
- Suppurative thyroiditis
Neoplasia :
\
- Anaplastic carcinoma -]
- Lymphoma \
Dyshormonogenesis
-l
\
A. WITH HYPERTHYROIDISM
.l
\
o Grave's disease / primary thyrotoxicosis
- Diffuse, smooth toxic goitre
: -l
C/F : o Slight to moderate enlargement
o Diffuse, smooth, soft with a bruit
r Swelling and toxic symptoms appear simultaneously
o Sudden anxiety.
I:t
)

o lncreased appetite with loss of weight

:1
-1
"l
.N)-N Jd4{J._
g): n
OO
t9N
s-rsssSx-q-Qs Ig qa=e{qQ
NNNNNNNNNN
-rr
rri=n-r
rr Clinical ENT

rr:
180

)'.-. Eye signs marked

{ o Manifestations essentially of central nervous system

rn o Diagnosis is confirmed biochemically by:

- Measurement of serum T3 and T4 levels. ldeally free T3 and T4 levels should be measured
but facilities for such measurements aren't easily avatlable
- ln patients with possible mild thyrotoxicosis in whom T3 and T4 measurements are equivo-
cal, simplest way of establishing / excluding diagnosrs is a thyrotrr:pin releasing hormone

r, (TRH) test. tt is done by giving LV. TRH. li stimulates release of pituiiary TSFI (peak
response at about 20 minutes). Little / no TSH response occurs in thyrotoxicosis. This

n
r
simple test has largely replaced radioiodine uptake studies in possible thyrotoxicosis.
Toxic nodular goitre :
- Less common cause of toxicity than Grave's disease.
- Less severe, occurs mainly in older women.
l-- CtF : o Swelling appears first followed by toxic symptoms over a period of iime.
r. $o
c
Manifestations are essentially cardiovascular.

n
lt is rarely associated with extra thyroidal manifestations as exophihalmos.
Diagnosis :

n o
o
Multinodular gland

n
Biochemically confirmed toxicity

pRtMARY THYROTOXICOSIS (GRAVE',S DISEASE) SEcoNDARY THYROTOXICOSIS iTOXIC MULTI

r: NODULAR GOITRE}

n o Swelling and symptoms appear simultaneously o Swelling first

A
o CNS manifestations e CVS manifestations

r: o
o
Eye signs prominent
Manifestations are of severe intensity
o
c
Eye signs less severe or absent
Manifestations are of less severe intensity

n
r_
o
o
Younger women
Gland : diffuse, smooth
o
o
Older wome-n
Gland : multinodular

THYROIDITIS

rr
r_ 1. Chronic lymphocytic thyroiditis
It is of two types :
1. Autoimmune thyroiditis
2.Hashimoto's thyroiditis
:

r: It is most often seen in middle aged women.

CIF : . Gland is enlarged, firm and bosselated.
n o Patients are usually clinically euthyroid, though hypothyroidism may occur at any time and the
marginal thyroid function is commonly revealed by elevated TSH levels in the presence of nor-

n o
mal To levels.

n
Transient mild thyrotoxicosis / raised T4 levels occur infrequently
Etiopathology :

n
r
o Autoimmune thyroid disease, characterised by
1. Presence of circulating thyroid antibodies.
2. Lymphocytic infiltration on histology.

rr:
o Elevated thyroid antibody levels are present in 75o/o of patients with Grave's disease and lymphocytic
infiltration is also common. The spectrum of autoimmune thyroid disease includes Grave's disease together
]- with the condition / conditions best termed - Chronic lymphocytic thyroiditis as well as myxoedema.

r ifdje:re{r
AFRFSSSSS a
ol
6
.D

o (tl
6 at
(rt o) o) ;ss;i *rPi s 3 x iiEi,oo
 Section I
-
Case Presentation - Neck
181
II
o Surgery, only if changes to lymphoma.
:I
2.
o May present as a soliiary thyroid nodule when one whole lobe is involved'
chronic lymphocytic thyroiditis in subacute form (De quervain's)
CtF' : - Enlarged gland, painful and tender
II
-
-
Fever
Systemic upset with variable severity and duration
lx : 1. lnvestigation of choice:FNAC
2. Cause of mild hypothyroidism, though thyroid function is more often normal.
I
r1
of abnormal release
3. Transient hyperthyroidism when present in De Quervains thyroiditis is the result
of thYroid hormone. r'l
CHRONIC LYM PHOCYTIC THYROIDITIS SUBACUTE THYROIDITIS r'l
1.
2.
lncreased titres of thyroid autoantibodies
Normal / increased radioactive l, uptake
1.
2.
Absent / decrease antibody titre
Suppressed radio active l, uptake If'l
3. Riedel's thyroiditis :

\ o Gland stony hard. ''l

II
clF -
Diagnosis r rr lmpossible to differentiate from anaplastic carcinoma
. .,o' Adjacent tissue infiltrated by pale, hard tumour like tissue'

'r Histologically there is intense fibrous tissue deposition'

D/D o Ca thyroid. \
Rx Surgery only if pressure symptoms cause
'. r Respiraiory distress
:
-l
\
o Difficulty in swallowing -l
o Hoarseness of voice :1
4. Suppurative thYroiditis
CtF : o Gland enlarEed, painful, extremely tender' :1
, o
o
Attributable to bacterial infection usually either staph / streptococcal.
ln most cases, source of infection is from a fistulous remnant of the 4rh pharyngeal
pouch' T
Silent thyroditis : :1
I
5.
o Atypical forms are without Pain
o Systemic upsets are being increasingly recognised
Diagnosis of thYroiditis :
:''1
C/F : . Pain
o Fever
o Systemic uPsets
:l-!
o Firm, tender enlargement of thyroid \
lx : o lncreasedESR
o lncreased plasma globulin levels \
o Decrease radio l, uptake in De quervain's and silent thyroiditis. -l
o Normal / increase radio l, uptake in autoimmune thyroiditis
o Normal response to TRH. :l
is that, destructive
Rx : Essentially medical. The irnportance of thyroiditis as a cause of hyperthyroidism
conditions being self limiting' :1
treatment, in particular surgery, should not be embarked upon, these -rf
i
rq!

N-J(O J..t
J
o o.o
d6iE{qa< I ;alsles<
a dDkiRi kl 3 kt i :-+-i i * * *;
{grg)J
@-c'dd
@r
s5- N
o
o) N
5 NJ
j <o o -r'or o a o N r
rr:
Clinical ENT
182

B. WITHOUT HYPERTHYROIDISM
1. Adolescent diffuse goitre :

o in adolescent fe-
Mild diffuse thyroid enlargement in the absence of abnormal thyroid function occurs
males and less often during pregnancy.
r o Treatment - Physiologic goitre requires only reassurance'

n 2. Endemic goitre : (Mc Harrison theory of lodine depletion in the soil because of running
Etiology : Attributable to l, deficiency'
HrO)'

ft lncidence : . Found in mouniainous areas

n o lncrease incidence at foothills of Alps., sub Himalayan belt and foothills of Vindhyas
(Ratnagiri's)

n C/F:. tn young, the goitre is diffuse, but it progresses to nodule formation often with de-
generative features.

r^ An endemic area is characterised by a prevalence of goitre of

>10ok'

n 3. Drug induced goitre :

n
n
o Goitrogens which interfere which thyroid hormone synthesis, resulting in over secretion of TSH which
mediaies the thyroid enlargement, are an uncommon cause of goitre.

Drugs causing goitre :

r: o
.
Antithyroid drugs
Aminoglutethimide
Lithium carbonate
r_ o Sulfonylureas, sulfonamides i biguanides

n o
o
lodides
PAS (red rice grain like granules)

T- Flourides

I:
r
INH

4. Simple non-toxic goitre / colloid goitre

o Females : males ratio = 14'.1

rr
o NormalTSH levels
r_ o There's an initial hyperplastic phase and excessive colloid accumulation with patchy involutation and
subsequent development of nodules.
Multinodular goitre may change to follicular carcinoma or anaplastic ca

t:
Nodules are :
a. Cystic / contain colloid

n
n o
b. Solid and cellular : resembling true adenoma. Such nodules may develop autonomous function and
may be responsible for hyperthyroidism
Common features are
- Cyst formation
.

I -
Haemorrhage

t.
Necrosis
- Fibrosis

t-
1-,
o
o
- Calcification
lnvestigations : serum T' To levels
Ultrasound / thyroid scan are not required.

t-..
I:
r difdipree< 9 d6le{qa< {(,l(.)J (.)+ a o N
;jroo..r'ouaoN
o
o
FFAA FSBSSS i- :-i= s d d dd o66@ 55 N NJ
 \
Section I Case Fresentation - Neck 183 \
5. Dyshorrnonogenesis \
It comprises rare inherited defects in thyroid hormone production, probably attributable io various enzyme
\
deficiencies, that are an uncornmon cause of goitre, often associated with hypothyroidism and usually
present in childhood.
\

CLASSIFICATION
THYROID NEOPLASMS
I
i
I
-__ \
Papillary
lMaiignant Beniin \
Follicular adenoma
i
?rl mary
\
\
i
)

+ + I

Carcinoma Malignant Medullary Local Metastatic

I
lymphoma carclnoma (infiltration) (Blood borne) from
I
I \
l Ca breast
)

Malignant melanoma \
Differentiated ifferentiated
i-.lnd
Carcinoma kidney
(anaplastic) \
\
Papillary Follicular
\
CARCII'{OMA TF,IYROID i
Etiology
o Goitre : There is a positive correlation between sporadic or endemic goitre of the multinodular type and \
follicular and anaplastic carcinorna. lt is believed that increase TSH secretion may have a role to
play
o Radiation : Exposure of growing / fetal thyroid to radiation can lead to carcinoma thyroid especially, pap-
illary carcinoma.
a Genetic : Heredo-familial incidence, especially seen in medullary carcinoma.
o Autommunethyroiditis : Leads to malignant lymphoma Causes of carcinoma thyroid :

C/F : Annual incidence - 20i 1 million of population - Goitre

Sex ratio F:M = 3:1 - Radiation
Presentation - Genetic
o Solitary thyroid nodule. - Autoimmune
o Clinicaily malignant gland (hard, fixed, irreguiar gland with evidence of direct spread)
c Goitre with a long history.
c ln',rolved lymph node on the lateral side of the neck. Pain referred to the ear especially in infiltrating growths
e Recurrent laryngeal nerve palsy
o Distant nrelastasis :

- Jaundice,hepatomegaly
- Patholcgical fractures, bone pains
- Cough, haemoptysis, breathlessness
 ClinicalENT
184

Diagnosis
oEverysolitarythyroidnodule(cold)hastobetakenasmalignantunlessp'og
o Many times diagnosis is obvious on clinical observation' Thyroid scan cold nodule :

-ThyroidSCan:failuretotakeupradioactiveiodineischaracteristic c Carcinoma

ofallthyroidcarcinomasbutalsooccursindegeneratingnodulesand . Degenerating nodules

thyroiditis.
o Thyroiditis

- Thyroid antibody titre : often raised in malignancy'

. FNAC
frozen section is essential'
- lf no diagnostic test is confirmatory, exploration with

SURGICAL PATHOLOGY
1. Papillary carcinoma
o Commonest
o lt usuallY occurs rn Young adults
o Gross features : complex mass of papilliferous material lying in cystic spaces' tree'
o Microscopic : glomerulus like papillary processes often arranged like a christmas
o Many show some areas of follicular pattern'
o No signs of encaPsulation.
o spread : tumour is slow growing, but has a special tendency to spread via the lymphatics through the
and inferior ihyroid arteries, the pretracheal lymph
thyroid gland and outsideio the nodes around superior
nodes and deeP cervical nodes
in thyroid may be minute and easily overlooked
o The tumour is TSH dependent and the primary tumour
even when lymph nodes are involved' - papillary - lYmPhatic sPread
PL

r: o Fine calcific areas - psammoma bodies - are diagnostic

features of papillary carcinoma

n Psammoma bodies are seen In

o Papillary carcinoma of thYroid
:

r_ o Meningioma

r: o PheochromocYtoma

r: 2. Follicular carcinoma
o
r: o
Less common
lt is usually seen in middle-aged females

n o Gross : initially well capsulated, but local invasion and

fleshy haemorrhagic and cystic areas'
breach of capsule is always likely' cut section shows

n o Microscopic : invasive and non-invasive tumour, colloid

masses or trabeculae of cells'
follicles filled with masses of epithelial cells or solid

50% of patients present with metastases to

r^ o Spread : is essentially by blood stream (haematogenous),

n
lungs and bones.

n
n
3. Anaplastic carcinoma
o
o
Uncommon
occurs particularly in females > 60 years of age. Sometimes
there is a goitre present for years

1- oTumourgrowsrapidlyandsurvivalforlongerthan6monthsisunusual.

I:
n
r
Section I Case Presentation - Neck
- 185

a Macroscopic
: thyroid is hard and tender.
a Microscopic : there is considerable cell variation of giant cells, small round
cells or spindle cells.
o Spread : rapid and predominantly by direct infiltration
to local structures with the production of recurrent
lymph nodes, sympathetic nerve lesions, dysphagia and respiratory obstruction.

A. D. - anaplastic - direct spread

4. Medullary carcinoma
o Tumours of parafollicular / ,C, cells
o Usually occurs in 50-70 years age group and is very srow growing
o Gross : solid and circumscribed, cut surface is grey / yellow.
o Microscopic : variable amount of amyloid surrounding undifferentiated cells.
o Spread : is characteristically by lymphatic and blood stream.
o Patients with widespread medullary carcinoma have been shown to have enormously high levels of serum
calcitonin.
o ln some cases' tumour is familial and association with parathyroid adenomas, pheochromocytomas
and
rnultiple neuromas of the mucous membrane is preseni (MENi syndrome)
o Diarrhoea is a fearure in 30% of cases and this may be due to 5HT / prostaglandins produced
by tumour
cells.

TREATMENT
o Papillary carcinoma
- Because of multifocal nature of the disease - total thyroidectomy is usually advised.
- Because of the high incidence of lymph node metastases; even in the occult
tumours, the pretracheal and
paratracheal nodes should be resected (Anterior compartment clearance).
Other involved nodes (Ee16/
picking)should be removed individually. Rarely is block dissection required.
[RND on more involved side
and MND on less involved sidel. After operation, TSH production must be suppressed
by full doses of
thyroxine : 0.3,0.4 mg / day.
Recurrences are treated.by radioactive I, for which tumour cells usually have a greater
affinity once the
gland has been removed. i

Local deposits are managed by radiotherapy. lf properly treated - the prognosis is

extremely good
I
Advantages of total thyroidectomy :
o Tumour markers will be helpful to detect metastasis or recurrences.
o Radioactive I, will be selectively taken especially by metastasis
a
Follicular carcinoma
- Because multiple foci are rare, wide excision by hemithyroidectomy is a good treatment.
lt

- Lymph nodes rarely require excision and although not particularly hormone dependent,
full doses of thy- I
roxine should be given in the post-operative period.
- lsolated secondaries may be eradicated directly with external cobalt therapy but131I therapy
offers the only I
prospect of success when metastasis are multiple.
- Prognosis depends on invasive / non-invasive picture histologically. t
(Newer concept : Total Thyroidectomy for Follicular Ca).
Anaplastic carcinoma ;
- Extremely lethal tumours.
t!
- Survival for >6 months after presentation is most unusual.
- An attempt at curative resection is only justified if there is no infiltration through thyroid capsule. i

t
 ClinicalENT

-Radiotherapyisgiveninallcasesandmayprovideaworthwhileperiodofpalliation'
respiratory obstruction'
is usually done to avoid
- Tracheostomy following an isthumectomy
r Medullary carcinoma
-Thetumourisnothormonedependentanddoesnottakeupradioiodine.
-Prognosisdependsprincipallyonpresenceorabsenceoflymphnodemetastasis.
-Treatmentisbytotalthyroidectomyandresectionofinvolvednodes(RND+MND)
Malignant lYmPhoma
cell anaplastic carcinoma
Difficult to differentiate it from a small
Good Palliation maY follow
/ or chemotherapy'
Totalthyroidectomy' irradiation and

). ', .'

r:
r:
rr
r:
r:
n
rr
rr:
n
n
n
n
n
rnr
t-
 \
a
\
a
\
3. SALIVARY GLANDS \
\

PAROTID GLAND
i
. H/o swelling \
Below and behind the ear lobule
At the angle of mandible \
ln the retromandibular sulcus
Detailed history of the swelling has to be asked (onset, duration, progress) with special emphasis on :
i
o H/o unilateral/ bilateral swelling \
- Parotid tumours are usually unilateralthough Warthin's tumour may be bilateral \
.t/lHto swelling appeared in the tail / body of the parotid gland.
- Pleomorphic adenomas occur in the;lqil of the gland \r
- Tumours mimicking a pleomorphic adenoma but preseni in the body of the gland
!-' Neuromas of facial nerve
.

i
- Myxoma of masseter muscle \
/ Lipomas
o H/o slow / rapid growth of the tumour \
- Benign tumours grow slowly whereas malignant tumours grow rapidly and may have associated sudden
pain and facial nerve paralysig \
- Sudden increase in size is seen in :
\
- Malignancy
- lnfection in a cyst \
- Haemorrhage in a cyst
- lnfection of lymphoid component of tumour
\
o H/o pain associated with the swelling. \
Painless tumours Pleomorphic adenoma
Painfull enlargement with meals Stone obstructing the duct
Sudden appearance of pain Malignant transformation :''l
\
Severe pain
Bilateral painful enlargement
Abscess formation
Parotitis
-l
H/o involvement of skin and facial nerve :''1
It is seen in malignant parotid tumours, tuberculosis, sarcoidosis. Pressure from a benign tumour never -r1
causes facial paralysis. Facial paralysis may be due to previous surgery sacrificing the facial nerve. Parotid nl
abscess may have associated skin inflammation \
^l
H/o change in the size of gland
It is seen in calculus or inflammatory disease of the gland. Change in size may be seen during meals
H/o inability to open mouth or trismus
It is seen in inflammation or malignant change
I:l
Other History :
o H/o watery discharge from a sinus in the parotid region (parotid fistula) or sweating in that region on
:1
meals (Frey s syndrome) :1
11
'187
'll
 ClinicalENT
188

paralysis) or bursting of an abscess (parotid fistula)

o H/o trauma to that region (parotid fistula, facial
a H/o enlargement of all salivary glands (Mikulicz's disease)'
o H/o fever (parotitis, parotid abscess)
a H/o systemic illness
Parotomegaly is seen in the following systemic illnesses
:

'z- Diabetes Drugs -

- Tuberculosis - ContracePtive Pills
t' Myxoedema - Thiouracil
- Gout
v- Cirrhosis
- Cushing's disease
- Alcoholism
tr Bulimia
adenomas, recurrence seen after malignancy)
o H/o similar complaints in the past (Recurrent plemorphic
o past'
H/o any medical / surgical treatment taken in the

Examination :
General examination
Look for
o Signs of sYstemic illness
o Anaemia, cachexia (malignancY)

Local examination
lnspection
o Unilateral / bilateral
o Site : in front, below and behind the ear lobule'
ltobliteratestheretromandibularsulcusandshiftstheearlobule.
o Extent / size, shaPe, surface :
-Mixedparotidtumourscanbeverylarge,surfaceisnodularandbosselated.
the shape of the gland'
- tumours have an irregular surface. lnflamed gland bears
Malignant
-Ablueorpurplishhueovertheskinmightsignifyavascularswelling.
o Edge:
- Welldefined in a tumour
- Ill defined in Parotitis
o Fixity to surrounding structures :
- Fixity to masseter muscle shows no movement of the gland on clenching the teeth'
- Skin fixity / infiltration is seen in malignant tumours'
o Signs of facial ParalYsis :

gland and previous radical surgery'

They are seen in malrgnant tumours of the parotid

Palpation
o Temperature / tenderness
parotitis' parotid abscess
Rtse in temperature and tenderness is seen in acute
o Surface :

I- Smooth
nodular
: Benign swellings
Malignant swellings

n
lrregular, :

n
r
 \
I

Section I Case Presentation - Neck 189 \

- a
\
o Size, shape, edge
a
o Consistency I
Firm : Pleomorphic adenoma
Cystic : Warthin's tumour !

Mucoepidermoid tumour
I
Parotid cyst
i
Pleomorphic adenoma \
lndurated: Parotitis
rf
o Fluctuation test :
It is positive in parotid cysts, abscess
\
o Fixity :
It is tested at rest and by making the masseter taut and checking the movements of the swelling. ;r
They will be decreased if the swelling is fixed to the muscle.
o Examination of facial nerve
o Movements of Temporo-mandibular joint :
Movements are decreased in inflammatory swellings and malignant tumours.
o A sinus, fistula or an ulcer over the gland is examined and mentioned in detail. E

Examination of oral cavity and oropharynx :

\
Parotid duct ;
The parotid duct opening lying against the upper second molar tooth is inspected for any signs of inflammation. i
The duct end over the masseter muscle is palpated by rolling the finger over the taut masseter muicle. lts
terminal part can be palpated bimanually by placing the index finger in the mouth near its opening dnd the
thumb over the cheek.
On pressing the parotid gland, pus or blood-stainecl discharge may extrude from it opening. This may be seen
in suppurative parotitis and malignancy respectively.
\
Deep lobe of parotid gland :
The oropharynx is inspected to see if the ipsilateral tonsil and soft palate are pushed anteromedially by an \
enlarged deep lobe or parapharyngeal extension of a tumour. Swellings, seen both in the parotid region and the
pharynx indicate a deep lobe tumour which pushes the parotid externally and the palate and fauces medially, thus q
extending into the parapharyngeal space. Such a swelling on bimaunal examination shows the typical sign of
ballotment between the examining fingers which is absent in a pure parapharyngeal space tumour. i
Palpation of the deep lobe :
\
Palpation of the deep lobe is done by placing one finger inside the mouth in front of the tonsil and behind the third
molar and the other finger externally behind the ramus of the mandible. t
Examination of regional lymph nodes :
I
The preauricular, paroiid and submandibular group of lymph nodes get involved in parotid pathologies and are
examined as per lymph node examination.
t
Auscultation :

lr
A vascular hum on auscultation signifies a vascular swelling in the gland.

SUBMANDIBU LAR SALIVARY GLAND

Apart from routine history of a swelling, specific points are listed below :
r H/o presence of swelling in the submandibular triangle (neck / floor of mouth)
o H/o increase in size of swelling with pain during meals / intake of food. t
(Submandibular calculi)

I
;:
190 Clinical ENT
1:
I: Examination
lnspection :
:

t: On intraoral inspection the opening of the submandibular duct (Wharton's duct) may be inflamed. The orifices
are situated on either side of the frenum linguae. A stone lying in the ampulla just below the orifice may be
t: seen at times on careful inspection.
The patient may be given a sialagogue / lemon to suck to check for appearance of a swelling, confirming the
1: presence of a stone obstructing the submandibular duct. Also two dry swab sticks can be placed on the

t: orifices and each checked for salivation following some lemon juice.drops on the tongue. A swab remaining
dry suggests impaction bY a stone.

Palpation :
The gland is palpated to confirm inspectory findings.

F Pressure on the gland on palpation may lead to extrusion of pus from its orifice.

r: Bimanual palpation:
A gloved index finger placed.on the floor of the mouth medial to the alveolus below the lateral border of the
r: tongue is pressed as iar back as possible along with an another finger placed externally
infeiior margin of the mandible being pushed upwards. This method ensures palpation of
just medial to the
both the lobes of

r" the gland upd

"un
also determine the presence of a calculus
of differentiating an enlarged gland from a submandibular
in
lymph
the duct.
node
lt is
swelling.
one of the most efficient ways

r: The submandibular lymph nodes are palpated as a part of routine examination.

r:
rn o
o
o
o
SUBMANDIBULAR SALIVARY GLAN D

Single gland on each side

Bimanually palpable
Smooth surface
o
o
o
o
SUBMANDIBULAR LYMPH NODES

Multiple nodes on either side

Bimanually not palpable
Nodular surface
Primary focus of infection / malignancy present elsewhere

r: o
No other focus of infection
Enlarges on intake of lemon juice / sialagogues o No enlargement on anY tests

r^
if ductal obstruction Present

n
-

r-
I-
t:
n
n
f-"
t:
]-
1-
rt
1:
r
 Section l- Case Presentation - Neck
191
II
Scheme I Scheme of diagnosis of a parotid region swelling :t
Rule out conditions that mimic parotomegaly

-tI :I
:l
Parotid gland sweJling

OJr e / both-gLleuds-effcetqd
Differential diagnosis

,1 P_H!I' clg
Dpntalcysts
t
U
v n:Phegq! t ti s I:'l
I:1
My1sm_a_gl m9!:9!er
lnfratemporal fossa tumours
I
I l
J
Unilateral Bilateral Fibroma, lipoma in masEeter
l, Mandibular tumours

II
sglectasts- '.4 Neuroma of fqcial nerve
\z SiOOren'S sVndrOme u:'
P@sl!rlq!"'
- e6rxqnltmP-hqqP[heIa!-leqLon Branchial cvsts
- Calculus disease w: Sebaceous cYsts
- h aE e n tG-6{.Parotid-noAe s
SFiemic endocrine conditions Y' Lv6p I

Warthin's tumour
- :''l
lnvolvement of facial nerve / sktn :'']
associated with Pain
-i :'l
-!
I
a
J Present
Absent \
U
u
MalignancY
Beniqn
Evidence of malignancy in a parotid
Swelling
tumour : :.I
- Pain \
t
Diffuse enlarg*emen1
I
j
tumour - ffiiji#ffi;I
Nodular hard surlace \
U
Acute
Lump /
I
- FaaiElpals/
st<in@iueqent i
I Trismus - fixity to masseter, mandible
U I - Presence of lymph nodes \
Suppuration l " - ]
i
C.T. / M.R.t. findings :
1t-
-
I ] obliteration- of fat
-t!^L^t,
Plan-es
I ] lnfiltratron of surroudingrnnuscles :1
I Norr-homogenous mass
II -L II I consistency _
UUIl>lJtClluy Expansion
*'L::'- - of facnl_nerve )
!+
Drgll \
Coq;ienuative lncise and
treatment
.r i
I-
,
I i!

\
-uuu
Firm Soft / sPongY CYstic
\
- Vascular / Warthin's tumour
-i
lll
PleomorPhicSdgla-rc
- r-fffiatic - ereol!@!-9-!Qe1-o1a
Associated with its characteristics s*Jiinls : Ptrotid cyst
- Pres@ Yyg:t!"lmoi{lun191t
-
l
Sfffipt-om-l-s9-
MrdAl€@ad Patlelt
- No-dflar, mo6-G lumP
- Rbund, firm,fre"llieiralgated - \
rt
I
t f;
n
I: 't92 Clinical ENT

rt: Scheme II Parotid gland swelling

l- l

+
l

n
i

Diffuse enlargement of the whole gland Lump / Nodule in the gland

r: Chronic
{i
Associated systemic features

E
r- Bilateral
U
,.
-
-
i-
Xerostomia
Xerophthalmia
-
-
-1
Bilateral
Diffuse

r- Paediatric age group

Orchitis, pancreatitis
- Connective tissue
component i/-
-
-
Chorioretinitis

n
Cranial nerve
Severe pain j,
-u
Fever
involvement

n
SJOGREN'S DISEASE u
SARCOIDOSIS
VIRAL PAROTITIS / MUMPS

rn
u
-
r_ -
Symptomaticlreatment
Vaccination
- Rapid growth
- Facial nerve function affected
Pain and enlargement with meals - Seriously ill patient - lnvolvement of skin
Purulent materiql / altered salivq may - Dehydration - Trismus
come out on pressure on the gland - Poor oral hygiene - Fixed to underlying bone

F- with pain relief u u

n u
Plain X'ray / Sialggraphy
reveals =+ stone
lJ_
SUPPURATIVE PAROTITIS

- Antibiotics
l,
MALIGNANT PAROTID SWELLING

Radical parotidectomy
U

r_ and.drai.nage
lncisi-_on
lA/ fluids
Sacrificing facial,nerve-with /
without reconstruction

r:
i

PAROTIO CALCULUS
u Oral hygiene
I

Ra_dio-tlherapt +f
i
lntraoral removal of stone / excision of I

- gland.
Y
F
- Slow growth
- No faciEl-nerve involvement

I:
- Well defined
u
BENIGN LESION

n
n +
t-_-
Tumour
I
I

Lymph node
i
I

+
I

- No Biopsy takq1r

T- - F\{AC lhrqleloorc.al

r:
Diqgqqsis usual ly after

F 'u
Pleomorphic adenoma Monomerphic adenoma
O![_e_r {umours
/ RarelLamalignanllesion
is revealed

n
Commonest

I:
r
 )
Case Presentation - Neck

l
Section I
- )
lnvestigations

l
:

LABORATORY TESTS COMMENT / LOOK FOR

Endocrine tests
Blood sugar
Thyroid function test
Serum cortisol / ACTH
:

Diabetes
Myxoedema
Cushing's disease
lI
ESR Sjogren's syndrome
Protein electroPhoresis Sjogren's syndrome )
Antinuclear factor :r
\
Collection and examination of saliva
Radiological tests : \
Plain X'rays Parotid calculi - usually radioluscent
Submandibular calculi - radioopaque \
lntraoral films may be used for submandibular calculi
Parotid calculi
\
Non-neoplastic salivary
\
a Warthin's tumour - "Hot" .t
o Other tumours - "Cold"
Differentiates solid from cystic tumours \
o Parotid cysts - radioluscent
o Warthin's tumour - cystic appearance \
o Other tumours - solid masses
o Malignant tumours - low reflectivity
\
o Mixed tumours - variable reflectivity
\
Evaluation of Parotid tumours
o Relation to facial nerve \
o Extension to deeP lobe /
M.R. lrnaging o oofiteration of fat planes in the paraphayngeal space signifies malignancy, \
contrast between tumour and surrounding tissue is greater than with c'T-
scan.
\
o Lack of lonizing radiation.
\
. lt not recommended because of fear of implantation and recurrence
'r
especially of pleomorphic adenoma and carctnomas' \
o FNAC is preferred.
oobviousmalignanttumourinvolvingskinmaybe,subjectedtoincisional \
biopsy.
o Sublabial biopsy is done for Siogren-rsy:rdrome, \
\
\
\
\

I
n
n 194 Clinical ENT

t: o
z
E
0)
ei
oooE 9-;
z(D
L-
(U#
=-
1_ o o-
fO_

n
O>-L
o r===oc
o) Y o k X.c
o I E= si;;jpl c-
z

n \aq1 .:l-PL G!!

Q
E
*
t!
l!r>\c'i-",fgP
sr
"l
-
->
u
;:E': Nl
-.c)c
U*
=(sly
U.-n\U,
o c (trl- c o o n F i;i; q
.! .9 9 = ='c
Y1 c)
F 5 ^ F E - F 1 oq)'/!.c.
e=
I_
(L =iE
;l+g gE s E i E sE\ =l a-!q

€*l +
=
o 6Ea2o-oo.otrdroE aQdz.l!

E 3a
E=
p6o'O'
E:, HS
E/
€ 5 FEi:- FiE FonX
fr-
!,frtL
HsJ !
r L! Cl
€l Or
Sl el p
l:1

#l
El
p
s
E= ; dBr, -€1 3l e :l e ElE5€ sl iial pl
el sfpl ;'-l
E ngH : f,l Et 5al H$q#l : eAd dl d -q
g Ut 3er I
{l El :l ql HJEI
B
*

n
@
LrJ
il Ee br HpEl 3€3J d *r ;l.or H;l or il
> >i El d=,
t

t
'i..=r
5-pl I g
l
F
g Ht! olotq(D "i -: =r

t:
^r

rr
LrJ
lJ- $fir flElHgf,E$
$ a3:li t\;lefilfsl=
o
E,
f
o
333El pflu [;; fl*i EirAE\9Ei;E
3;'_? 6 8.'tj:'sr_d; E 6;t€; rj ir $H;15#l t\:l ' Ergr EgrEg

n
r:
=
D
F
t
qq
oJ-
'=d
oJ dt
qd
=,
El
.^
!r ,I
.n Ol *rl cd.
al

ol
rot
OI
col
N
'l
OI
,l
E
c
o

n 919l;bl9=l
IIJ (qd
o qs\ l=lv'-Ol(oal C1
= z
UI
9l
l!.=rAl
-l
Ll
d
9t
'Et
(gt
o
@ -!l
o o'1 c d)l o
C) 5i ol sld,ElFlH;l ot :(!
u)
z cr)l rl
trl ol
Lt
3l
ttLl
ql Pl 3l :Pr o'!
(Ol
L:t -o Jl
Cl
a

F
Ol
El Ol #l trl d) O!r
=\ -l
@-

t:
I:
X
UJ
a
(s:
rlOl
o
O
c
d:

u-_
5 n-\

t:
ul L'
o o
uj (!
o o

n
0)
>-. I
OI OI
<-r N

n
I-
z=
o
a
z aEItr
I.x I P dl
-=qS: E
3--
>-'5'Q
- (D'o
= =
fle^
p EFe
= c -c o =.=,X- = o =,
:3'e' E4 E3'€
"i
E
LL()OO--<tr20(U
,
F -E
>;,
gF
iP.L
E'E F ---i€
€
E

I:
F
zta 9tg
of OE
a9
.9

E9
6o
^o
CL

=o
(!E

l* c0 :) (L(!
F
=:

n
I:
 \
i
195
Section I
-
Case Presentation - Neck \
\
a .l
z(, \
o 4
o \
z
a c
a O) o
(o
G
E
o
C
E
.E
E= \
F oQ
a= =
o
a 2d
(L c) e' o
C
\
= '(!o
=3 oo
a o_a ao- (/)Fu-
i
-ov'tf!o0)
XcxX^=
LL
o o);
ocP:
A'
oQ
a
L i
U- 5sP- HE!
9L6
=Ye
ro
i!(6^a = =
c?
\
o
C)
rE83
::oe 8E=
o;.
s-=E
olt6
.o-YR Ze ..
:o'r.9oS
-V
iY ,- a. )

a
OO .2t=t=c(Eq)
oEteX.g:P od-co;Eh'' d I 465 \
qE€-e f i v-A
Or.l
ul
tf roox Ee€.EAm:a HE
a" -c. X >'
9,ekt>PY! F>'-i-!:o
>>9 ir*oO.= \r
F
=(U0) h-+kPY'58 O;EEH8C Eg.*oooOF
.9 or 6 o o I'o: * 9:h"pi.cS-.,lrir.o,atr
UJ
IL bPU
g-cDc.:
3Eo9
F9€=;3*sI
:66.qFF3e
J>:-_n
O i'6
oEoSqE
o) v X :r tr 9.bI.sPE6>
b'F.:l-c(!>,o
-cz()-co
\
YYc(o (s F ot".; E-! € trE.ii5nbe8 bP'3=3Ro.e
01e O
> O .=
C ;EE;egiie
cOFOr:.=v) qT:?-eilEE3 60)>,UtrC-oc
oflolh>o \
6.?q.tu
-!2)
6 6 i o-.= P ^ $ !+o-(!o
(n4(o> OgEaditr,*2E F'll ll ll F.c'E o:F - rao o a : E a)
\
.g
AAC \
-u
O-\-r'
ul -(U-
\
C)
zul -
o :a
(oL FU \
6 O=
o ULAC
z <oE ()o-!
rv-= \
Ff Q:

-oc
(s \
Vor
X
c)
O
c
\
:C)
UJ
a Yo
+'()l
ulc LL L! \
a
UJ
o LcO.^ :0)
^+ OE \
d)C)>t
P- -
._-O).O* b 3.r 6'=
o)!
(JO-(!Gtr)
=(gc-ooo) tla.o>\O o- i!
\
E 6o(!
z \
o -c. =o
z >\ dl
x;
@ o6 'r!
a
c,
E C
c(o -t
zt o
(!_
\
(rf
,o o
o
> oEP
:l:o9
ov-r
=
€G
-E
C^
)\ .Y o -l
[rJ>
mlF o
o

d;
oF-
(E=
>do
+
-J O)
ri
o
o
tri
tl
:'']
I
'rl
!
\
r- Clinical ENT
196
1:
I a
z
^a
roc

t:
V-
Ia ts-
0J o)

r
d)>
o IO
z _-
!-=

a = .2 d)

t:
>*
E n\EY
o F^(DL
F (UcJ
'5A.o.s
I olP!c
I" E
SaEs
rr" a <EOO
a,
cc
G
o)
c)

r: .C,

rr"
"E
o o
a o
a oc)o o
u (!
d C
f -c. E
F o- =
$
E
tU

r: TL

E
a
c)
6
^C
AE
r: 5c)

rri
()
C)
oE
OX
LL C)

r: UJ
o

n ztu
o
6
z
r_
r_
r_
r_
r:
n
n
E
z
o
z
o
r_
n zt b 38
Of
=o
=o\
a

tl.l> !u:,b
=oBaa
dtf O.lJoo
c
,1
(Eil
.:2

f-
- F
d

t:
1:
r-
 T
4. SINUS OR FISTULA II
HISTORY
H/o onset - congenital eg : preauricular sinus-acquired eg . thyroglossal
H/o previous swelling over the site
H/o abscess / cyst / lymph nodes which brust to form a sinus
fistula
l:lI
H/o progress -
-
SPreading
Healing / stationary
H/o discharge from sinus / fistula
II
o Quantity and qualitY
o Nature - serous, serosanguinous, purulent, bloody :1
o Colour and smell
:1
o Duration
H/o pain -
-
lnflammation of tract
Blockage of outer oPening
H/o weight loss eg : tuberculosis
It
H/o any treatment taken
:'1
H/o recurrence
H/o trauma or surgery - foreign body or suture material inside
II
I
GENERAL EXAMINATION
Stigmas of tuberculosis or syphilis
o Anaemia, cachexia, malnutrition
Examination of respiratory system :1
o For puimonary tuberculosis
\-l
\
LOCAL EXAMINATION
.l
lnspection
1. Site
:

- determined from the position of the opening

preauricular sinus - roof of helix or tragus and directed upwards / backwards (because of non fusion of the ear
tubercles)
tI
Branchial fistula - lower %,d of neck, infront of sternomasioid (failure
of fusion of 2"d branchial arch with the -1
fifth) dl
\
Actinomycosis - back of the neck' foot
Parotid fistula - Parotid area
.l
Tuberculosis - over lymph nodes in neck t1
2. Number
Single.parotidorlymphaticfistulafollowingtraumatothoracicduct )
Multiple - aciinomYcosis
3. Size and aPPearance
t1
Wide opening - tuberculous sinus resembling an ulcer :'1
Edge of tuberculous sunis is undermined while that of a malignant
one is irregular'
-l
197
-
!
198 ClinicalENT

Sprouting granulation tissue - underlying foreign body

4. Discharge
o Pus - osteomyelitis
o Serosanguinous - tuberculosis
o Sulphur granules - actinomycosis (the sulphur granules are the colonies of actinomyces)
5. Surrounding skin
o Loss of hair - tuberculosis, oesteomyelitis
o Dermatitis and pigmentation - actinomycosis
Palpation :
1. Temperature - increases in inflammation
2. Tenderness - inflammatory process
3. Discharge on pressure
4. Wall of sinus - thickened due to fibrosis, secondary to chronic inflammation
5. Mobility / fixity - osteomyelitic sinus is fixed to the underlying bone.
6. Surrounding tissue - enlarged matted lymph nodes - tuberculous sinus thickening and irregularity of underly-
ing bone - osteomyelitis
7. Probe examination of the sinus - The following points are noted
o Direction and depth of the sinus
o Presence of a foreign body inside
o Communication with hollow viscus
o Relation to deeper structures
o
Fresh discharge on withdrawl of probe
B. Regional lymph nodes - whether palpable or not

SINUS
A sinus is a blind tract lined by epithelium or granulation tissue from a surface epithelium into the deeper
tissues.

FISTULA
o lt is an abnormal communicating tract between two epithelial surfaces.
- External fistula - between the skin surface and an internal hollow viscus.
- lnternal fistula - fistula between two internal hollow viscera.
Both the types are lined by epithelium or granulation tissue.

INVESTIGATIONS
'1. Examination of the discharge from the fistula
o Actinomycosis - Sulphur granules
o Salivary fistula - Ptyalin
2. Biopsy - either the edge or entire tract is excised for histopathological examination for tuberculosis or malignant
change
3. X-ray chest - PA view - For tuberculosis
4. Plain X-ray of bones - Osteomyelitis / sequestrum
- Foreign body
5. Sinogram / Fistulogram - lnjection of a radiopaque fluid (lipiodol/ hypaque)willdelineare the tract
 \+l
\
Section I
-
Case Presentation - Neck 199
-l
\
CAUSES OF PERSISTENCE OF A SINUS / FISTULA
1. Epithelisation of the tract
.l
\
\^l
2. Repeated trauma to the Part
3. Chronic irritation by the discharge
4. Untreated infection - tuberculosis, actinomycosis, syphilis -l
5. Untreated malignancY \-l
6. lnadequate drainage - Smallopening \
- Non dependent drainage -l
7. Presence of foreign body or necrotic material =!
B. Unrelieved obstruction of lumen of a viscus distal to fistula
9. Dense fibrosis which prevents contraction and healing :
10. Persistent mobility of the part \
Exuberant granulation tissue / Proud flesh \
It is seen in
o Pyogenic granuloma i
o
o
Sinus
Fistula
i
It is due to the persistence of the source of infection. \
Treatment :
\
1. Excision of excessive granulation tissue
2. Use of acriflavine in the dressing \
3. Removal of source of irritation / foreign body
4. Excision of sinus / fistula tract \
SALIVARY FISTULA \
Salivary fistula more commonly arise from the parotid gland than the submandibular gland.
\
The fistula may be
o External : OPening on skin surface i
o lnternal : Opening in the oralcavity
o Ductal : Arising from the main duct system
\
o Glandular : Arising from the gland substance
\
o Congenital : Since birth, arising from aberrant salivary tissue or as a part of branchial cleft anomalies.
o Acquired : Following - partial parotidectomy, trauma and sepsis / infection. Ductal fistulas leak profusely, \
the discharge being saliva with a high amylase content. Major ductal fistulas causing skin
excoriation need operative treatment for closure' \
Treatment : \
1 . Conservative

Decrease in production of saliva can be achieved by : \

o Drugs : Probanthine bromide -r
o lrradiation
2. Operative
l'1
tl
:

o Denervation : Tympanic neurectomy, auriculotemporal neurectomy

o Excision of the fistula tract
:1
I-
-
rn 200 GlinicalENT

I" a Reconstruction of the duct : Newmann and Seabrook's operation

I" a Diversion into mouth : Conversion to internal fistula

I-
a Removal of the gland eg : - Submandibular gland.
ldeally salivary fistulae should be avoided by dividing the duct most distally and then ligating it, followed by

t:
I
tight pressure dressing post-operatively.

I.
T-
r
I
rt:
I

r.
n
]_
l'_
F
T-
I_
I:
n
n
T
l'_
]-
l-
f-.
r:
r-
r
7
1,
,a

,-

-
-
E

F,

a-

a-

a
E

ar-

-ft

-
ar-
SECTION T II
-
a
INSTRUMENTS
arlr

-
-
E
a
E

-, a
>
'a

- \
-hi a\
I
r"
F;
Ir.
n
r.
n
n
n
7^
r-.
n
n
n
r. EAR
n
n

n
n
r
I"
I:
l-'' EAR
I
rn 1. AURAL SYRINGE
rr
r^
r1!tz
r. Z \\-

r.
r^ Fig. 1.'t AURAL SYRINGE

n It is a metallic syringe with a cylinder and a well fitting piston and nozzle.

n Uses :

n
f-.
o To remove softened wax.
o To remove (non-hygroscopic) foreign body eg: buttons
o To remove contents of external auditory canal, mostly dust / debri, to rnspect the tympanic membrane'

n
n
Syringing
It is a procedure in which the contents of external auditory canal usually wax,
removed by the force of water.
foreign body etc. are syringed /

n
n
lndications :

Refer uses above.

Contraindications :
p- Hygroscopic foreign bodY.
I-^
n
n
t'- Perforation of tympanic membrane'
u- CSF otorrhoea.
u- Otitis externa
o Avoided in patients with previous ear surgery'
Procedure
J-^ It is done in a sitting position with the head turned to the opposite side of the
legs between
ear to be syringed' Children
their's and holding the childs
are to be held firmly oi ir,eir attendants by positioning the child's
I-^ crossed arms. The coiresponding arm is draped with a cloth and a kidney tray is held below ihe ear'
A 4 ounce syringe with the
F. The syringe is hetd in the right hand and its filled to its full capacity with water.
capacity of 120 ml is commonly used. The water should preferably be sterile
and at body temperature to avoid

I,. stimulatron of the labyrinth. The thumb fits in the middle ring and the
rings of the syringe. The tight fit of the nozzle is checked and the water
index and the ring finger in the other two
jet is injected directing it to the

l-
l*
postero-superior canal wail. This direction allows the water to get behind the mass.
the pinna upwards and backwards
direction. Care should be taken to avoid pointing the nozzle directly on the
lt may be required to pull
in adults and downwards and backward in children, to maintain the
eardrum to protect it from

n
l-
201

r
 ClinicalENT
202

inadvertant injury and to avoid the full force of the water jet striking the drum. The washed out
material is
il
collected in a kldney tray and inspected. Syringing may be repeated if
a swab stick to prevent otomycosis.
Complications :
required. The canal is mopped dry with

.1- Trauma to the external auditory canal and eardrum. lt may cause bleeding and lead to otitis externa'
I
.Z Vertigo can occur due to stimulation of the labyrinth'
$
O.- Otitis externa can occur due to trauma or use of unsterilized water.
V. Otomycosis can result because of persistent dampness in the external auditory canal. :t
5. Exacerbation of otitis media occurs if syringing is performed on a ruptured ear drum.
:l
rO. Vaso vagal attack.
:l
II
Essentials of syringing :
r Firm holding of the child.
o Sterile water at body temperature to be used.
o Greased syringe with a well fitting nozzle has to be directed postero-superiorly.
o Examination and mopping of external auditory canal is required after the procedure.
:I
WAX
Wax is the external secretion of the ceruminous and pilosebaceous glands of the external auditory
along with dust, debri and squamous epithelium. Ceruminous glands are-specialised
eccrine function situated deep within the skin of the outer two-third of the
glands
external
with
auditory canal.
canal
apocrine
Wax
and
is
I:'l
assisted in expulsion by the natural movements of the
Contents of wax
\t Fatty acids
:
jaw'

II
r-Amino
''.
..
acids
Lysozymes
lmmunoglobulins
II
o
o
rlr
Bactericidal agents
Squamous epithelium
Dust / debri
f:'l
Types :

. Dry :
o Wet :
Grey, granular and brittle seen in Mongoloids'
White, brown coloured seen in Caucasians, Negroes'
:1
Features of wax imPaction :
:1
o Earache
o Deafness
:'l
o ltching :"1
o Fullness in the ear.
o Tinnitus :"1
o Reflex cough (through auricular branch of vagus nerve)' l''l
o Giddiness.
o Obscuring of eardrum. l'l
o May precipitate otitis externa.
Water jet directed on hard impacted wax impacts if further. lt has to be either softened before
removal or l'l
a chink has to be made in it with a hook before removal'
:'1
-'1
''l
-

6'6: elsTi?i'*-'--::
rn Section Il
-
lnstruments - Ear 203

Treatment
I_ Removal of wax by means of :

r" {-- Hooking :

:
Wax hook / vectis passed beyond the wax.

r. &- Suction Sucking out under direct vision.

']: Syringing : Refer above.

n 4. Ceruminolytics : These are agents which dissolve the wax and assist its removal. They should ideally
not cause any chemical irritation. Some agents only soften wax, do not dissolve it.

r- +
Agents incorporated in ceruminolytics :

r AGENT
Choline salicylate Analgesic
PROPERTY
),".;
\-(.
'ir

r_ Anti-inflammatory

r. Glycerine Emoiient
Polyoxypropylene glycol Cerumen softener,

r. Olive oil, almond oil Organic solvents (can cause irritation of skin)

n
n
FOREIGN BODY IN EAR
Foreign bodies :

t: TYPES

n
r_
LIVING

lnsects, flies, maggots Hygroscopic

NON-LIVING

Non-Hygroscopic
Nuts, peas, flour, vegetable matter. Metals, stones, tubes, plastics, beads, button

n
rn
batteries, silicone material.

The foreign body enters the ear through the external auditory canal and generally lodges at the isthmus, the
narrowest part of the canal about 5 mm lateral to the tympanic membrane. lf present.for a short time, it may
not cause any problems, but longer duration foreign bodies may induce an inflammatory reaction of the

n
external auditory canal by blocking the clearance of cerumen, releasing toxins, becoming oedematous and

rr
swelling up thereby damaging squamous epithelium, if hygroscopic in nature.
A foreign body can perforate the tympanic membrane, enter the middle ear and rarely cause bacterial
labyrinthitis. Button batteries can leak an alkaline electrolyte solution and cause extensive liquefactive necrosis.

Clinical features :

o No symptoms or
t: o H/o foreign body in ear.

n
n
o H/o trauma.
o H/o pain, bleeding (because of instrumentation or scratching)
o H/o deafness
o Signs of otitis externa obscuring the foreign body.

r- Treatment :

n
r
Removal by means of
o Hook
o Forceps
a :

r Syringing - for non hygroscopic objects

I-.
r:
r
-
NltJsg+:r
sd s_a^q^q*s^{^{^a*
 \
ClinicalENT \
o Suction aspiration For vegetable matter to avoid breaking it into pieces
\
- For spherical objects as it is difficult to probe beyond these objects. \
Removal under general anaesthesia may be required for impacted foreign bodies with otitis externa along
with medical line of treatment for the infection. \
\
2. JOBSON HORNE'S PROBE AND \
RING CURETTE \
\
\
\
1
Ring Curette
I
Serrated Probe End \
Fig.2.1 JOBSON HORNE'S PROBE AND RING CURETTE
\
Uses : \
o Curette
- Removal ofwax \
TYPES OF AURAL POLYP PASSING OF PROBE ALL
- Removal of foreign body
- Removal of granulations from external auditory canal
AROUND THE POLYP \
1. External ear 1.Can pass all around
o Probe 2. Middle ear 2. Cannot pass all around \
- Probing of polyp in ear. ^t
\,,i
- For aural toilet, to clean aural discharge as a cotton swab carrier
- To trace a sinus track ^l
- :1
I
To apply medications in external auditory canal.

3. TUNING FORK :1
Parts of tuning fork II
t
o Prongs
o Shoulder
o Base
o Stem \
o Foot Piece ^l
l'l
:I
Fig.3.1 TUNING FORK
fI
-.|
''l

S-,8"S ****sx^qk= 9t9rr!9S!n-drj

rn
rn Section ll

Uses
o
o
:
-
lnstruments - Ear

To know type of hearing loss

205

F
Degree of hearing loss

rn The following frequency tuning forks are used in clinicar practice.

FREQUENCY Hz

o Neurologists use it to test vibration sense

H
n
o
.
o
To detect degree of hearing loss
May be more sensitive to detect air-bone gap

rr
Produces more overtones
o May enhance perception by vibration sense

Falls in mid speech frequency range.

rr
+ Overlones are minimal
o Mild hearing loss can be detected

rr
Sound is more auditory than vibratory.
Tone decay is optimal
o To detect degree of hearing loss
o Tone decay is very fast

Tuning fork is struck at the junction of upper t/s'dwithlowerv{dt of the prongs,

to minimize overtones. Distance

r
between tuning fork and auricle is 2.5 cms.

l-_ Audible frequency

Speech frequency
:
:
20-20,000 I1z
87-117SHz
Overtones : Frequency above fundamental frequency

tr
They are present if the vibrations of the tuning fork are felt by the examiner's
hands in the stem of the fork.

r
rr 4. POLITZER BAG

rr
n
l- {-- Bag

tr
rF' Fig.4.l POL|TZER BAG

t-
r
Tg$3.q^i.{Fts.**H* -+r
!t(,)J!PS9t-crr
 \
CIinicalENT \
\
To perform politzerisation to test eustachian tube patency. \
Politzerisation \
The nozzle of the bag is inserted in one nostril and the other nostril is blocked by pressing with fingers against the
septum. The patieniis asked to say'K'while the bag is pressed. This manoeuvre increases nasopharyngeal \
pressure and opens up the eustachain tubes and air gushes inside the middle ear.
\
\
5. SIEGLE'S PNEUMATIC SPECULUM i
\
\
\
\
\
1 \
Fig. 5.1 SIEGLE'S PNEUMATIC SPECULUM \
It consists of an aural speculum attached to a rubber bulb by a hollow rubber tubing. The aural
speculum is \
placed in the external audiiory canal and the rubber bulb is squeezed to aiter pressure in the canal. The drum is
simultaneously visualized through the speculum with the help of a head mirror and lamp.
\
Uses: \
Diagnostic
-1,-To examine external auditory canal and tympanic membrane with magnification.
-t
r/ To assess mobility of tympanic membrane \
y'To elicit fistula sign.
-t/to assess eustachian tube patency by seeing mobility of drum on Valsalva's manoeuvre. \
.r'To differentiate between healed perforation and adhesive otitits media.
\
Difference between healed perforation and adhesive otitis media on seigalization
\
Healed perforatior Adhesive otitis media
Thin drum moves Strong adhesions to middle ear prevent drum from moving \
Therapeutic \
,/ To instill medication / powder in chronic suppurative otitis media -/
l

v \
o
To suck discharge from deep recesses
To cause mobility of the drum to break adhesions between drum and middle ear mucosa-
.l
Magnification : 2X.
l'r
Power : '10 dioPter
:'1
I
-!
!r
N-tde r -&rr - - ,n
! 4+-
O ss^a^{ ln9rr!9Jgl-c)r
Section ll lnstruments - Ear 207
-

6. EUSTACHIAN TUBE CATHETER

f-Opening at tip

Fig.6.1 EUSTACHTAN TUBE CATHETER

Uses :

Diagnostic
l."Io assess patency of eustachian tube by catheterization
Therapeutic
|.- To clear eustachian tube block
r-As a suction cannula for nasal cavity
r-- For removal of nasal foreign bodies.
Methods to test Eustachian tube patency

1. Valsalva's manoeuvre # Forced expiration on"a closed glottis

2. Frenzel's manoeuvre Voluntary contraction of floor of mouth
3. Toynbee's manoeuvre # Swallowing with mouth and nose closed
4. Tympanometry }r Change in middle ear pressure on respiration.
5. Politzerisation 4 Air insufflation into the eustachian tube
6. lnstillation of agents in presence of
tympanic membrane perforation
a. Sterile sweet / sugar solution. Sweet taste in mouth if tube is patent
b. Radio-opaque substance Eustachian tube and passage of substance visualized radio-logically
c. Ligature material Studying the ease of passage of material intraoperatively and also
seeing it in the nasopharynx.

Types of eustachian tube block :

'1
. Anatomical Obstruction of lumen of tube by mass effect eg : tumour
2. Physiological Defect in mucociliary clearance leading to failure in drainage of secretions from ear to nasopharynx.
Stagnation of secretions occurs leading to a block. No mass lesion obstructing the lumen.
 208
ClinicalENT

7. EAR SPECI.JLUM
TOYNBEE'S AURAL SPECULUM

t
:
Fig.7.1 EAR SPECULUM
t
The speculum is gently inserted into the ear canal
by a rotatory motion; (after ruling cut otitis externa).
inserted only upto the cartilagenous meatus,.not lt is t
touching the bony meatus as it is very sensitive
painful' The pinna is pulled backwards, laterally and can be
and upwaids in adults and backwards, lateraly
in children to straighten the canarfor easy and downwards t
insertion of the specurum.
Uses
O Examination
EXaminatinn of
nf externar
ovfornat auditory
artAi+^-,, canar ^.- , tympanic
\
^^-^r and ,
membrane for
\
Wax : examination and removal Chronic otitis A

Foreign body
media \
Adhesive otitis media
Otomycosis Retraction pocket \
Acute oiitis media
Granular myringitis i
Grommet
\
ln operative procedures
v'- Myringotomy
:
i
v' Grommet insertion \
v' Polypectcmy
Foreign body removal under anesthesia \
Granuloma removal
\
A black (carbon coated) speculum is used to take
an endomeatal incision for Stapedectomy and
Tympanic
Black colour of the speculum prevents reflection
of light to the surgeon', fror \
;:ffi"# "yu
the operating

.,1.', \

" ;,jl
II
\:
:1
I:1
:1
rr Section ll
-
lnstruments - Ear 209

8. LEMPERT'S ENDAURAL SPECULUM

F
rt: lndications for an endaural incision
o
o
Myringoplasty
Tympanoplasty
:

rt.
o Stapedectomy
o Atticotomy
o Foreign body removal.

t_
r
Fig. 8.1 LEMPERT'S ENDAURAL SPECULUM

Use :

r To take an endaural incision.

T:
t.
rl- 9. MYRINGOTOME (DAGGET'S
MYRINGOTOME)

F
t--
t-
F
F
t: Use :
Fig. 9.1 MYRINGOTOME (DAGGET'S MYRTNGOTOME)

I-
To puncture tympanic membrane for insertion of a grommet. (Myringotomy).

Myringotomy

t-
l-
A radial incision is made on the tympanic membrane in the appropriate quadrant and a ventilating tube is inserted
if indicated.

INDICATION DURATION SITE OF PUNCTURE

F
F.
Otitis media with effusion

Acute otitis media

Short or medium term
Lonq term
Antero-inferior quadrant
Antero-superior quadrant
Postero inferior quadrant

rr
I-.'

Y:6'i ffi i e"i q€a d 6'3 e=r eQ<'- J" g,., (ra a o N
210 ClinicalENT
II
MYRINGOTOMY INCISIONS
II
II
:'l
Circular
:'l
:'l
rNcrsroN
Fig. 9.2 MYRINGOTOMY INCISIONS

RADIAL CIRCULAR
I:'l
Relation to tympanic membrane fibres Along tympanic membrane fibres Cuts across the fibres
l'l
I
Blood stroolv from annulus Does not hamper il It qets cut off.

Edge Less chance of inward edges Edges get curled inwards

Healing on grommel Takes less time to heal More time to heal
extrusion / removal May not heal leading to a small perforatlon -rl
Character More physiological / attatomical Less physiological / anatomical -l

Treatment of otitis media with effusion

:1
\j
Medical Surgical AI
o Valsalva's manoeuvre
o
o
Anti-inflammatory
Antibiotics
o Aspiration of the effusion
drugs o
o
Myringotomy
Myringotomy with uni / bilateral ventilating tube insertion
II
o
o
o
Mucolytics
Decongestants
Enzymes
o
o
Adenoidectomy combined with the above
Cortical rnastoidectomY
I:'l
:'l
MOLLISON'S SELF.RETAINING
1 O.
HAEMOSTATIC MASTOI D RETRACTOR
I:'l
\
I-l
:'l
Il'l
Fig. 10.1 MOLLISON'S SELF-RETAINING HAEMOSTATIC MASTOID RETRACTOR
:'l
-'l
-r
t
rr Section ll
-
Instruments - Ear
211

rI Uses:
o
r
To retract skin edges and deeper tissues after aural incisions.
To remove temporalis fascia graft in ear operations like
- MastoidectomY

]: - TympanoPlastY
-
E o
Facial nerve decomPression.
To retract cartilagenous or bony edges / incision edges in
-
T- -
Laryngofissure
Burr hole oPeration
- CraniotomY

F -
-
ExternalethmoidectomY
Optic nerve decomPression

r:
r
r_
Advantages
o Self-retaining, no help is required to hold the incision edges
o Haemostasis is well achieved by the pressure exerted by the teeth of the retractor on the tissues
o lt retracts away from the field of vision

n
n 11. FARABEUF'S PERIOSTEAL
F: ELEVATOR
n
n
It has a broad end and a thumb rest.

n
F:
r] Broad end

r:
n
Fig. 11'1 FARABEUF'S PERIOSTEAL ELEVATOR

n
n
Uses:
g'To elevate periosteum over mastoid bone in Mastoidectomy'
o-To elevate periosteum over the antrum in caldwell-Luc operation
o To elevate periosteum over bony sudaces in head and neck surgeries eg : Maxillectomy' External
fronto

n
I.
o
ethmoidectomY
To elevate soft tissues

n
rn
1:
la
212
ClinicalENT
:i
12. BALANCE'S AURAL SNARE
:l
I
lI
:I
Fig' 12''l BALANCE'S AURAL SNARE
II
It is the smallest of allthe snares used in ENT'

Use:
t
f'l
oForauralpolypectomy.ltisperformedviatheexternalauditorycanal.Aural'polypshouldneverbeavulsed
may be aitached to important structures like the
(pulled) as it
cause damage to these structures'

Advantage of using a snare :

faiial nerve' ossicles and labyrrnth' Avulsion can
II
o lt crushes and cuts the pedicle of an aural polyp'
T
)
13. LEMPERT'S MASTOID SCOOP t]
Contribution of LemPert :

:.I
o
o
o
Lempert's endaural sPeculum
Lempefts endural incision
Lempert's mastoid scooP'
Lempert's malleus head niPPer
I:'l
Uses :
Fig. 13.1 LEMPERT'S MASTOID SCOOP
o LemPert's Periosteal elevator'
I:'l
o ln MastoidectomY
-Removal/scoopingofboneandmastoidaircells(diseasedboneissofter) :'1
- ScooP out granulation tissue'
-r!
o ln StapedectomY \
-TocuretteposteriorsuperiormeatalwalltillpyramidalprocesslSSeen.

I
:'1
:l
:r
-
r.r
a
 Section ll lnstruments - Ear 2'13
-

14. MACEWEN'S CELL SEEKER WITH

SCOOP
Uses i
Seeker
o To seek the antrum and mastoid air cells.
o To seek aditus ad antrum.

Scoop
o To curette bony prominences
o To curette posterior superior bony wall.
o To curette anterior, posterior buttresses.
o To scoop diseased air cells.

15. MALLET

n
n Uses :
Fig. '15.1 MALLET

for its removal

Ia
To hammer bone

n
n
o
o
TO HAMMER

Bone chips / cortical bone

Spurs
Mastoidectomy
Septoplasiy
SURGERIES

I:
r:
o
o
o
Nasal bones
Antral walls
Mandible parts
Rhinoplasty
Caldwell -
Mandibulectomy
Luc operation, Maxillectomy

n
Fr:
Disadvantages
o Slow and tedious process
o
o
Difficult to assess depth of breaking
Damage to facial nerve, sigmoid sinus, lateral sinus, labyrinth, dural plate and ossicles is likely to occur at
mastoidectomy

n
].

F
n
II
la
214
ClinicalENT
II
16. CHISEL I:I
:I
Fig. 16.1 CHISEL
I:'l
:1
17. JENKIN'S MASTOID GOUGE :'l
''l
"

Rounded ____) :l\

edge

Fig. 17.'l JENKIN'S MASTOID GOUGE -t

:
Uses :

o ln MastoidectomY -
:-
- To remove bone
-
-
To explore antrum and air ceils
To lower facial bridge in radical operations (chisel)
i
o To remove bone (along with mallet / hammer) in -rl
- Caldwell- Luc oPeration -t
- Rhinoplasty -
- SeptoplastY \
- Head and neck surgeries.
o To remove exostosis, osteomas from external auditory canal'
*a
\
Curved rounded edge
-r!
a
Bone removal is done parallel to the structure exposed
A gouge is more preferred as bone removal is easier because of its edge
\

-
\
18. DRILL AND BURR \
piece. \
The drill bears a motor to which the hand piece is connected' Burrs are connected to the hand
Motor
-l
\
Types
o
: "t
\
o
Hanging type
Stand type ,l
-t
:(

T
rr Section ll lnstruments - Ear

n
215
-

r o
o
Table top - 12,000
Micro motor - 30,000
Hand piece
- 20,000 rpm
- 40,000 rpm.

F
Types :

o Straight : Ordinary burrs are used with it.

o curved / cotrangular : Gear fitting burrs are needed for this kind of handpiece
Burr
Types :

F
o Cutting
o Diamond
o Polishing
Tungsten carbide is used as the cutting edge in allthe burrs. Each variety is available in sizes 1 to 10 mm. The
shape of the burr is usually round. . ---'-------:--

F
l:
1.
2.
BURR

Cutting
Polishing
1.
2.
Cutting bone-work
Smoothening the cavity
USE

II
3. Diamond 3. Used near structures like facial nerve, dura, sinus

llt: The hand piece is held like a pen and the side of the burr is used for cutting bone. While using burrs, continuous
irrigation is essential to prevent overheating and clogging of burrs. Ringer lactate can be used as the irrigating
fluid. The burrs and hand-pieces are cleaned thoroughly after use. They are then lubricated with oil and stored.

n
They are sterilized by formalin vapour.

Advantages of using drill and burr

n g""Bone cutting is very fast

o Bone is cut smoothly and more precisely
o No irregular cavity or bone chips are left behind
tr Damage to ossicles, facial nerve, dura etc. is minimized

F v-Shaping of ossicles is easier

o
o
Depth of bone cutting can be adequately judged
Less time-consuming.

F
t: 19. SICKLE KNIFE
n
t:
F
l-'
1-'
f
Fig. 19. 1 SICKLE KNIFE

lr
 T
216 Clinical ENT \rl
Uses:
::I
$: To make a myringotomy incision
?. To freshen the edge of the perforation in myringoplasty, tympanoplasty. :'l
g; To elevate tympanomeatal flap and annulus from tympanic sulcus
"4. To tuck graft in myringoplasty, tympanoplasty, mastoidectomy and other aural surgeries "l
&- To put and remove gelfoam in aural surgeries :"!
G- To manoeuvre ossicles in ossiculoplasty
''l
tr - To dislocate incudo-stapedialjoint "
€-- To downfracture stapedial crura in stapedectomy \
9: To break middle ear adhesions (between ossicles, tympanic membrane and promontory)
{.dTo cut stapedius tendon and tensor tympanitendon
i
(l:To cut facial nerve sheath in facial nerve decompre;sion. \
12.To dissect out granulations in tympanoplasty, mastoidectomy.
13. To remove cholesteatoma matrix
i
-a
Y E
20. SIDE KNIFE
\
\
\
I

r
Fig. 20.1 SIDE KNIFE

It is a microsurgical instrument, also known as the flag knife or Plester's first incision knife.
i
\
i
\

Uses :
i
'1. To elevate tympanomeatal flap from posterior meatal wall in aural surgeries like myringoplasty, tympano-
plasty, mastoidectomy, stapedectomy etc.
i
2. To take 6 and 12 O'clock incisions before elevation of tympanomeatal flap. \
3.
4.
To elevate chordatympani nerve and the annulus
To peel off cholesteatoma matrix.
I
\
i
\
i
t!

a
Section ll lnstruments - Ear 217
-

21 . CIRCULAR KNIFE
It is a microsurgical instrument, also known as Rosen's knife. Samuel Rosen
. Stapes mobilisation
o TranstympanicstapedectomY

Fig. 21.1 CIRCULAR KNIFE

Uses :

1. Freshening the edge and undersurface of the perforation in myringoplasty and tympanoplasty.
2. Elevation of tympano-meaial flap from the posterior meatal wall and annulus from the tympanic sulcus
3. Breaking of adhesions between handle of malleus and promontory
4. To clear sinus tympani and hypotympanum of cholesteatoma

22. PICKS

il

il
Straight pick
ll \./"
Angulated picks

Fig. 22.1 PTCKS

Types :

1. Straight
2. Angulated.
Uses :

Straight
'1
. To clear cholesteatoma matrix from footplate area, sinus tympani and ossicles.
2. To put graft and manoeuvre ossicles
3. To elevate tympanomeatalflap and chordatympani nerve
4. To manoeuvre grommet and teflon piston.
 218

Angulated
ClinicalENT
I
)

'1

2.
. To remove part of footplate in stapedectomy
To dislocate incudostapedial joint. ll
)

23. ANTRUM CELL :'1

!

SEEKER IBALL.POINT ^l
-'r]
-t

l
l!{

-
-
E
\
Fig. 23.1 ANTRUM CELL SEEKER / BALL-POINT
E
It is a blunt angulated microsurgical instrument. lt is also called as a ball-point instrument by some. lt is an
atrau matic instrument. \
Uses :
\
.1,,. To seek the antrum and aditus during a mastoidectomy
{.: To probe sinus plate, sinus, dural plate and dura. i
&'" To probe retraction -pockets.
4. For dislocation or mobilization of necrosed ossicle \
5. To check for dehiscence of facial nerve
\
6. To remove cholesteatoma from eustachian tube area, over labyrinthine fistula and over dehiscent facial
nerve \
7. To check graft position and middle ear air pocket
B. To peel off granulations \
9. To peel off squamous epithelium over promontory in Grade lV atelectasis.
\
\
24. CURETTE \
Uses :
\
1. To curette posterior superior bony meatal wall in stapedectomy, ossiculoplasty, tympanoplasty
\
2. To curette anterior and posterior buttress in mastoidectomy

Methods to remove postero-superior bony overhang :

\
1. Use of hammer and chisel
\
2. Drilling
3. Curettage
-

I
r:
r: Section ll
-
lnstruments - Ear 219

rl 25. HOUSE'S MEASURING ROD

r:
Ir: *illtt
it
stitI
i

r- tEf
xj
s.5i
*)

r- ),'
r_ Eir

f Fig.25.1 HOUSE'S MEASURING ROD

n Uses:
o To measure length from footplate to undersurface of incus in stapedectomy

n There are three markings present at a distance of 3'/q,31/z and 3% mm. from the lower end of the rod.

n The length of the teflon piston to be inserted is decided by adding 0.5 mm to the length from footplate to
undersurface of incus, measured with the help of the markings.

r:
F: 26. JIG
r_
r-:
r: LJ T*J LI
r:
f-, /o \ v*i

ril
ir-rlr11r i-l-i lLi
r: *'v
,,\ rs
a
z
*|;
3t rJ-
+A
ci
"/*
f-_ I' "t

l- Fig. 26"1 JIG

f': It is an instrument like a measuring scale. lt has markings and perforations on the scale. The Teflon piston is to
be inserted in the perforation corresponding to the marking which denotes the decided length of the piston to be

l-: put. The excess length of the piston is cut.

n
f-l
l-'
F-3
b;,

I
l',:
7
j
 Clinical ENT

27. PERFORATOR

Fig.27.1 PERFORATOR

It is a slender microsurgical instrument with a guard little away from its tip to avoid excessive penetration
through the footplate.
\
Methods to perforate stapes footplate
Causse's method of stapedectomy o With a perforator
ln this method, the stapedial tendon is cut near o Use of Portmann's perforator
the stapes and it is then attached to the o With a laser beam
new prosthesis -

Use
-
l
o To perforate stapes footplate in stapedectomy

\
\
28- MICROSURGICAL SCISSORS
"rl
:'l
\
^l
II
Fig. 28.1 MICROSURGTCAL scrssoRS (BALUCHt SCTSSORS) II
Use
^1lfo cut stapedius tendon, tensor tympanitendon
?rTo cut adhesions
I
:'l
I:I
,r|,{o cut pedicle of a polyp.

:I
:I
-1
S.- _-: ,t
 Section ll lnstruments - Ear
- 221

29. GROCODILE FORCEPS

rt

Fig. 29.1 CROCODILE FORCEPS

Uses :
1 To hold graft materiar and put in the tympanic
/ mastoid cavity
t 2. To put and remove cotton pledgets and gelfoam
3. To put and remove ossicles.
4. To put teflon piston. (Some use special piston holding forceps).
5. To hold and put grommet or prosthesis
6. To achieve haemostasis by pressure with adrenarine soaked
cotton predgets.

30. POLYPECTOMY FORCEPS

Fig. 30.1 pOLypECTOMy FORCEPS

Use
1. To hold an aural polyp and cut its pedicle
2. To remove granulations
3. As an alternative to crocodile forceps.

31. MALLEUS HEAD NIPPER FORCEPS

a
Fig.31.1 MALLEUS HEAD NtppER FORCEPS

Use :

To remove head of malleus for access to area

medial to it and to rbi:nove cholesteatoma matrix, granulations
etc.
F:
F:
F-
222

32. MlcRoscoPE
ClinicalENT
tI
:t
Uses:
:t
r}^ For all ear oPerations
o
-
Nasal surgeries
Trans-sphenoid aPProaches
I:r
:l
- , HypophysectomY
gz--Microlaryngoscopy
o Head and neck surgery where minute work is required'
:I
Parts of the microscoPe
l. OpticalsYstem
o Controls distance between lens and object
o Controlsmagnification
I:I
The optical system has the following parts
Eye pieces
:

Magnification :
:1
1. Binocular assemblY
o 10x :1
o
o
12.5 x (commonlY used)
16x :'l
o ZOx
:1
2. Magnification changer Knobs on the side of the head of the
Diopter scale
o -5to+5
Magnification
o6
II
microscope (turette)
o 1O-Routine ear work
o 't 6-Finer ear work
o 2S-structure identification
II
3. Objective lens Fitted at the bottom of the head of the
microscope
o40
Surgery : Focal length
Ear : 200 mm
Nose : 300 mnt
II
II
Focal length is the distance between
the object and the lens Laryngeal : 400 mm

ll. Lighting
Source :
o lncandescent lamp|-of 6V' 30V, 50V
w-
o
Halogen lamp
Fibre oPtic light system.
IT
Thelightshouldgivegoodilluminationandnotcauseaglare.
l'l
ttl. Stand
The micr:oscope is fitted on the stand and can be moved in any direction with the
number of knobs and arms :I
present.
:I
:1
-1
-1
-"1
,1
n
n Section ll
-
lnstruments - Ear 223

r Advantages of an operating microscope

t-r Magnification
:

9lllumination
]^
n
n
o ldentification
rr.-Depth perception

n 33. MIDDLE EAR TELESCOPE

F Uses :

n To examine middle ear through a perforation or a surgically made puncture.

F. 34. OTOSCOPE
n
n
1.:
n
n
n
n Fig.34.1 OTOSCOPE

n It is an instrument used to examine the tympanic membrane and external auditory canal

n It has a fibreoptic light built in system. Various specula can be attached to the end used for otoscopy

Uses:

r: o Examination of tympanic membrane and external auditory canal

r: o To perform seigalization
Advantages

r: o Magnified (2X) view of tympanic membrane is obtained

o Better assessment and diagnosis of pathology
r: o Direct vision
o Easy to carry / portable instrument
;:: o Easy to handle
rt o Strong illumination

n o Battery operated
o
o
Various size of the specula can be attached to the otoscope
Seigle's pneumatic speculum can be attached to it to perform seigalization.

F
r:
F:
r*
rH
n
n
n
F
rH
rr
rr
rr
rn NosE
H
F
F
F
r
F
r
n
r
r
I:
E
I: NOSE
E
T:
r: 1. THUDICUMS NASAL SPECULUM
r. Named after Johann Ludurig Wilhelm Thudicum

n
n
n
n
r.
n
F:
t
Blade
T
Handle Method of holding the sPeculum

Fig. 1.1 THUDICUMS NASAL SPECULUM

l-:
n
n
It is held in the left hand. The index finger and the thumb
middle finger control the movement of the handles'
hold the junction of the two handles and the ring and

Before anterior rhinoscopy, the tip of the nose should be elevated

to examine the nasal vestibule as the blades of

n
I:
the speculum do not p"r*it visualization of the vestibule and
missed.

Uses:
an ulcer, furuncle or mild caudal deviation could be

n
I:
Diagnostic
For Anterior rhinoscopy to examine
o Little's area
:

t:
t:
o Nasal sePtum and its deviations
o Lateral wall of nose
r Anterior ends of inferior and middle turbinates
o Floor

I:
n
o Pus in middle meatus
o Rhinolith, foreign bodY, PolYPs
o Septalperforation

n o Nasal masses
Therapeutic
o Removal of foreign bodies

F
l*
o Antral puncture
o Nasal packing (insertion and removal)
o Cauterization

lr
I:
224

F
Section ll

o
-- lnstruments - Nose

Application of medications
I:l
r Nasal surgeries
-
-
-
Sub mucous resection
Septoplasty I
.-N
I:t
Polypectomy
o lnfiltration of local anaesthesia

2. ST. CLAIR THOMPSON'S LONG BLADED NASAL

SPECULUM I:t
It is used only after the patient is anaesthetized, otherwise it can cause pain and reflex sneezing

f- Long blades
I:I
:1
Fis.2.1 ST. CLAIR THOMPSON'S LONG BLADED NASAL SPECULUM
II
Uses
-'l
I:1
:

o To retract mucoperichondrial and mucoperiosteal flaps in SMR / Septoplasty. The long blades protect the
flaps against injury
o To examine deeper structures in the nasal cavity for any pathologies
o To retract lateral wall of nose away for polypectomy, probing of
nasal masses, biopsy taking
Advantages :
Contribution of St. Clair Thompson
o
o
Long bladed nasal speculum
:

I:'l
II
o Allows visualization of deeper structures
Posterior rhinoscopy mirror

o Decreases chances of septal perforation or damage to flaps

o Adenoid curette
titrrrrrS.S t\)( ioJ)

3. KILLIAN'S SEI-F-RETAINING NASAL SPECULUM

It is a long-bladed self-retaining instrument. The blades are available in different sizes. The distance between the
II
II
blades can be adjusted and fixed with the screw.

it ii' :'l
,v\
l1

sq="---.*..
'i (- Long blades
:I
:I
Fig. 3.1 KILLIAN'S SELF-RETAINING NASAL SPECULUM
:I
-I
-'l
:'l
r^
rr 226

Uses
o
:

SMR / septoplasty
ClinicalENT

F
Nasalpolypectomy
o Biopsy taking

Advantages

F
o Self retaining
o Blades can be adjusted
o Allows visualization of deeper structures Killian's contribution
o Decreases chances of mucosal damage o Killian's mucoperichondrial elevator

F
or septal
o Killian's nasal speculum
perforation
Killian's incision for SMR

H Other nasal specula

o Cottle's speculum =o
Killian's SMR
Killian's polyp (AC polyp)

l:
n
o
o
Palmer self-retaining nasal speculum
Lenox-Browne's nasal speculum
o
o
Killian's dehiscence (pharyngeal diverticulum)
Killians nasal gouge

l- 4. ST. CLAIR THOMPSON POSTERIOR RHINOSCOPY

l- MIRROR
E
r This instrument has a bayonet shaped handle (to differentiate it from indirect laryngoscopy mirror), so that
examiner's hands do not block the vision. The mirror should be of an appropriate size so as to pass behind the

t:
soft palate and also reflect enough light for the image to be seen. The size (written on the back of the mirror) is
selected seeing the intertonsillar di'stance on tongue depression. lt is available in sizes 0 to 5.

t: It has a plane mirror without any magnification.

F
t:
Bayonet shaped handle

Fig.4.1 ST. CLAIR THOMPSON POSTERIOR RHINOSCOPY MTRROR

Used for posterior rhinoscopy

F
l-
5. LUC'S FORCEPS

F
l€
IlTT Fig.5.1 LUC'S FORCEPS

7
Section ll lnstruments - Nose 227
II
-
This forceps has a screw joint and 2 fenestrated sharp ended blades which provide a secure grip on the tissue
held. The tissues bulge through the fenestra and are therefore not crushed.
Uses :
II
r- SMR / septoplasty : removal of cartilage or bone
:t
'e- Caldwell-Luc operation / nasal polypectomy : removalof polyp
g-
o
Punch biopsy from oral cavity and oropharynx
Substitute to tonsil holding forceps in tonsillectomy
I]I
Y-Turbinectomy
o Removal of adenoid tags
I:l
6. GLEGG'S NASAL SNARE
II
:'l
J"*f -_

1
Wire loop '!
L
I
!/'
,...- i'r..I
-.,.- *tl
- \\
\\
\l
;; I:.l
Fig.6.1 GLEGG'S NASAL SNARE
II
It is used for nasal polypectomy.lt removes polyp by the mechanism of avulsion. The steel wire of the snare does
not withdraw completely on closure. This prevents cutting of the polyp and instead pulls it out gently (avulsion)

Snare Gauge of wire

tI
r1

II
Aural JZ
Nasal 30
Tonsillar z6

7. KILLIAN'S MUCOPERICHONDRIAL / PERIOSTEAL

ELEVATOR
II
II
Bayonet shaped ]I
handle Finger rest
:I
Fig. 7 .1 KILLIAN'S MUCOPERICHONDRIAL / PERIOSTEAL ELEVATOR
:t
This instrument is bayonet shaped and has a finger rest. One side of the elevator is flat and the other is convex
The flat side faces the septum, and the convex side faces the mucoperiosteal flap. :I
.I
-1
t
rn 228 ClinicalENT

I: 8. FREER'S MUCOPERICHONDRIAL ELEVATOR

I:
n
t: j;€$i:.iF\.s'S"S.":S:::--:-:.S

n
i$.ri =

t:
t_ Uses
Fig. 8.1 FREER'S MUCOPERICHONDRIAL ELEVATOR

t:
l^
t/to
o
o
elevate mucoperichondriurn / osteum flaps in SMR / septoplasty operation. The plane of elevation is the
submucoperichondrial plane
Septal perforation repair
Harvesting cartilage for rhinoplasty, tympanoplasty

n
n
rr4or fracturing of turbinates
c/to Oisplace inferior turbinate in antrostomy
o To remove maxillary crest is SMR
operation

l.
la 9. BALLENGER SWIVEL KNIFE

n
n
I:
I:
s€.{;.i;.+i*::t'+.1:-:€;-!€#istt'tF$'*!'-r''"rsis€'i

I:
t:
Fig.9.1 BALLENGER SWIVEL KNIFE

This knife can rotate around for 3600. lt can cut without rotating or reintroducing the whole instrument (only the

t:
knife rotates) being advantageous in the small nasal cavity. lt is called a swivel knife since the cutting blade can
revolve around the two bars.

I:
t:
Uses
o
o
:

To remove cartilage in SMR. The movement of the instrument is backwards, downwards and forwards
To harvest cartilage
-
for

l-
Rhinoplasty
- Tympanoplasty

I,'
Advantages of a swivel knife
o Cartilage can be removed in one piece
o Left-over cartilage has smooth edges

F
l*
I:
I:
r
 \
.i
Section ll lnstruments - Nose 229 \
- ,t'
\
10. KILLIAN'S NASAL GOUGE fi'
\
\ll

t
Fig. 10.1 KILLIAN'S NASAL GOUGE
\
!t
This gouge is bayonet shaped to allow adequate visualization inside the nasal cavity. lts edge is rounded, con-
cave or'V' shaped for a better grip on the bone. lt is to be used with a mallet or a hammer.
i
Uses :

o Removal of spurs in SMR / septoplasty \

o Removal of maxillary crest
o Opening the bone of the canine fossa in antral surgeries / Caldwell-Luc operation ,
-
\

11. HENCKEL TILLEY'S PUNCH FORCEPS i

\
\
i
'\
Fig. 11.1 HENCKEL TILLEY'S PUNCH FORCEPS
\
It is a nasal forceps with markings on the upper surface to estimate the depth, the instrument has reached and
the region underneath. lt is an ethmoid punch forceps and the markings help to prevent damage to important \
surrounding structures.
Uses :
\
o lntranasal ethmoidectomy \
o Frontoethmoidectomy
o Punch biopsy from nasal cavity
r{
\
12. CITELLI'S PUNCH FORCEPS \
\
\
\
I

\
-t t

Fi1.12.1 CITELLI'S PUNCH FORCEPS \

I

-!
E
fq
rr
r.. 230

It is a stout instrument with no markings

ClinicalENT

Uses :

o To remove or punch bone in

- Caldwell-Lucoperation
- External frontoethmoidectomy
-
F
lntranasalantrostomy
- Sphenoidectomy

F
t:
13. TILLEY'S ANTRAL HARPOON
It is an instrument used to make an opening in the maxillary antrum. lt is held like a dagger in one hand and the
index finger and thumb of the other hand are used for an adequate fulcrum.

l^
t:
t:
l:
Fig. 13.1 TILLEY'S ANTRAL HARPOON

l:
n
Uses
o
:

For intranasal antrostomy

The puncture is made just below the genu of inferior turbinate, where the bone is the thinest. The opening
made is large, of the size of 2 x 1.5 cms. A large opening remains patent for a longer time

lntranasal antrostomy indications

o For additional drainage of maxillary sinus
o As an adjunct to Caldwell-Luc operation
o ln children, where Caldwell-Luc operation is contraindicated

F o Chronic sinusitis not responding to conservative measures.

F 14. MYLE'S NASO ANTRAL PERFORATOR

r*
F L-
Fig. 14.1 MYLE'S NASO ANTRAL PERFORATOR

This instrument has an antegrade and a retrograde cutting edge.

F
Uses :

o lt is used to enlarge an antrostomy opening. The opening is enlarged to the size of 2 x 1.5 cm. lt is not
enlarged posteriorly to avoid damage to sphenopalatine artery and its branches.

l*
Ir
I:
l-
 \
Section ll lnstruments - Nose \
- ,t
\
15. TILLEY'S ANTRAL BURR .i
\
\
\
Fig.15.1 TILLEY'S ANTRAL BURR
\
\
o lt is used to smoothen the edges of an antrostomy opening. i
\
16. OSTROM'S ANTRAL PUNCH FORCEPS \r
Uses : \r
r To enlarge maxillary ostium anteriorly
The ostium is widened posteriorly with Luc's forceps or Erwin Moore's forceps. -l

\
17. TILLEY LITCHWITZ ANTRAL TROCAR i
AND CANNULA \
Cannula
I \
t"r'r'f\{*-
rlglld** i
\
ffi-,_T \
Fig.17.1TlLLEY LITHCHWITZ ANTRAL TROCAR AND CANNULA \
Uses : \
o To puncture maxillary antrum for antral wash. The site of puncture is just the below the genu of inferior
turbinate in the inferior meatus as the bone is the thinnest here. \
\
18. HIGGINSON'S RUBBER SYRINGE \
Uses : \
o Antral wash following antral puncture -t
o Antral wash after antrostomy
o Nasal douching in atrophic rhinitis post - operatively.
:1
It is made up of a red rubber bulb with tubing on both the sides. One end has a one-way valve and the other a :"1
nozzle to which an antral trocar and cannula is attached. The capacity of the syringe is about 90 ml (3 oz). The \
one-way valve allows only inflow of fluid into the syringe.
.l
r!
I
I

F
 232
ClinicalENT

19. ROSE'S ANTRAL WASHING CANNULA

2\
Opening at the side

Fig.19.1 ROSE'S ANTRAL WASHING CANULA

It looks similar to the Eustachian tube

ET CATHETER ROSE'S ANTRAL WASHING CANNULA
catheier.

It has an opening at the side to prevent blockage

by antral mucosa on entering the antrum.
Uses:
o For antral wash after an antrostomy is made. It is used with a Higginson,s syringe

20, JENSON MIDDLETON'S DOUBLE.ACTION

BONE PUNCH

Fig.20.1 JENSON MTDDLETON,S DOUBLE_ACTION BONE pUNCH

This instrument is called a double action punch since it has

four joints with double lever system to allow the punch
to open and close to a limited extent. This is useful in a narrow
deep cavity. The double lever system allows
greater amount of force to be exerted at the tip of
the instrument.
Uses:
o Removal of bony spurs during septal surgery

Advantage
o lt crushes bone whire removing it, thus achieving haemostasis

I-
G
 \
.. 1

Section ll
-
lnstruments - Nose \
.l ,t
\
21. RONGEUR trl
. GLASGOWPATTERN - KERRISON
t rl
\
I
^1
\
rl I

-r!
-l
\
Fig.21.1 RONGEUR
\
Uses : For
o Maxillectomy
Osteotomies in maxillectomy
o Palatal
:
i
o Mandibulectomy o Zygomatic \
Types of mandibulectomy :
o Pterygoid process
Mandibulotomy
o Frontal process of maxilla
-
- Median
\
- Paramedian
r/ Marginal mandibulectomy \
f Segmental mandibulectomy
'r- Hemimandibulectomy \
\
22. BLAKESLEY UPWARDS CURVED FORCEPS \
*b=.=r--- .i::\ \
ilh \
€r \t'ilio,
l,t 1.\r
\
ltl \\--=
_jij "{-.\
'\-'l \
:?'-'{
\LJ \
Fiq.221 BLAKESLEY UPWARDS CURVED FORCEPS
\
\
23. COTTLE'S ALAR RETRACTOR \
\
\
\
.-%"\( -11
---@,#-" -\*J/
\r
Fig. 23.1 COTTLE'S ALAR RETRACTOR
L
E

F
 234
ClinicalENT
Uses :

o To retract nasal alae in

Rhinoplasty
- Vestibuloplasty for
- Atrophic rhinitis
- Vestibular stenosis

24. HILDYARD POST NASAL BIOPSY FORCEPS

Fig.24.1 HtLDYARD POST NASAL BtOpSy FORCEpS

Uses :

o To take biopsy from post-nasal space

Routes of nasopharyngeal biopsy
Advantages o Transnasal
o Smalltumours can also be biopsied o Transoral
o The scope is away from the biopsy site, vision through it is not obscured
by bleeding

25. HARTMANN'S FORCEPS

It is a bent instrument with a diamond or
olive shaped tip. The tip has a groove in the centre

ig. 25.1 HARTMANN,S FORCEpS

Uses :

o Removal of anterior nasal packs

o Removal of packs (medicated), cotton predgets from externar auditory
canar
o Removal of nasal foreign body

n
rT
r-
 \
-
Section ll lnstruments - Nose \
-
r Removal of bone chips, pieces of cartilage in nasal surgeries. \
o lntroduction of cotton pledgets in nose for local anaesthesia. ol:

Its olive tip may entangle packs, hence not used for nasal packing. \ I

\
26. TILLEY'S FORCEPS \
\
\
\
straisht lootn tip
\
Fig. 26.1 TILLEY'S FORCEPS i
\
This is an angled instrument with a straight smooth tip with serrations at the end.
Uses : i
o For anterior nasal packing
\
- Post operatively for haemostasis
- ln epistaxis \
- ln fracture nasal bones for fixation.
o lntroduction of cotton pledgets for local anaesthesia.
\
Its smooth tip does not entangle packs on removalof the instrument (unlike the Hartmann's dressing forceps).
It is therefore used to insert packs rather than to remove them.
\
\
27 . TURBINECTOMY SCISSORS \
\
\
\ I
Gl

:'!
\
\
\
^l
Procedures on the turbinate
o lnjection treatment
Fig. 27 .1 TURBINECTOMY SCISSORS

I:'r
- Corticosteroids
\
-n
-'l
:l

F
r^
r e
ClinicalENT

F
Fracture of turbinates

r
o Cautery treatment
- Electrocautery
- Chemical : silver nitrate
o Cryosurgery
o Laser application.

F o Partialturbinectomy
o Totalturbinectomy

F
Gomplications of turbinectomy

r
o Crusting
o Haemorrhage

rn o Atrophic rhinitis

+(

rr
28. HAJEK'S CHEEK RETRACTOR

rn
rr Uses:
To retract cheek in
o Caldwell-Lucoperation
:
Fig. 28.1 HAJEK'S CHEEK RETRACTOR

o Maxillectomy

E o Repair of oro-antral fistula

o Trans-antral ligation of maxillary artery

F
o Vidian neurectomy

r
rr 29. WALSHAM'S FORCEPS

rl^
tr Rubber tubings on blade

Fig. 29.1 WALSHAM'S FORCEPS

H
I-
r
 -{
Section ll lnstruments - Nose 237

l
- )
It has two blades, the outer blade is covered with a rubber tubing. This outer blade lies against the skin and the
rubber tubing makes it atraumatic for the skin. The other blade is introduced in the nasal cavity under the nasal
bone.
:1
Uses :

The forceps are used to refracture and disimpact fractured nasal bones. This is followed by realignment. I
:'!
30. ASCH'S FORCEPS
This instrument has two blades, which when closed have a gap in between to enable to hold the septum without
l
-1
traumatizing it.
There is a wider gap proximally to accommodate the columella and prevent damage to it. lt does not have any l'1
rubber tubing.
:r
(FWide gap l'l
-rl
\
--
Fig. 30.1 ASCH'S FORCEPS
\
Uses :

- lt is used to elevate and straighten the septum

\
WALSHAM'S FORCEPS ASCH'S FORCEPS \
Straight forceps
Rubber tubings on blade
Minimally angled forceps
No rubber tubings
i
No gap on approximation Gap on approximation of blades \
Used to refracture and disimpact nasal bones Used to elevate and straighten the septum
i
:'1
31. YANKAUER'S NASOPHARYNGEAL SPECULUM
:''1
:1
)
\

l''l
:.7
l'!
Fig. 31.1 YANKAUER'S NASOPHARYNGEAL SPECULUM
l'1
I
\
\
rr 238 ClinicalENT

Uses

E
:

rr
o To visualize the nasopharynx and obtain biopsy
Methods to visualize the nasopharynx :

o Posterior rhinoscopy

rr
o Yankauer's nasopharyngealspeculum
o Rigidnasopharyngoscopy
o Flexiblenasopharyngoscopy
o Digital palpation under local or general anaesthesia

rr o Lifting of soft palate with retractors or rubber catheters passed through the nose under anaesthesia
o Retracting the palate with the curved end of two Lack's tongue depressors

H
rr
rr
rr
r
F
r
F
rr
t:
tr
r
lr
IT
r
F
F
F
tr
n
H
rH
r
I-
r
rH THRoAT
tr
tr
rH
F
E
H
r
r
l
t
T THROAT
T
r.
t: l.DoYEN'SSELFRETAININGMoUTHGAG
t*ti,'h*,o-.',"-*:i * -i'-.
1: . .' .-

Ru bbe r tuur n g --+ {i :i'::-r. :'i:.,,. . -l'j',(,l. -'l-J

\:;"
"i'"l-*-'*'"--
r:-i I
[;.,^ ""j".,t ' t.:;.r-
E r.i -';:,
''l'-.- -

I:
",r'

r: , Fig.1.1 DOYEN'S SELF RETAINING

MOUTH GAG

r, This mouth gag has two brades

which are covered with rubber tubing.
two roots *J
withstand th" f,'"t"i"
They are set against the second
of an open mouth') and
premolars
then opened'

r- or molars (as they are teeth bearing "un

TherubbertubingprovidesatraumaticCoverageoverenamelofteethandgums.

r: It

Uses:
can be used only under general anaesthesia'

F: o To open mouth in intra-oral surgeries

:

n - Glossectomies

l.
r_
- Palatal surgeries
- Tongue-tie release
- Dentalsurgery
- Marsupialization of salivary cysts
r_ - Removalofcalculusfrom salivaryducts

n
r_
- Removal of benign tumours' submucous cysts
- Laser surgery for benign swellings
- Excision of ranula

I:
t-
o To oPen mouth in :

v/ Unconscious patients for oral toilet and to prevent airway obstruction

o/ Temporomandibular joint fibrosis i ankylosis
\,/ Forcible opening in submucous fibrosis' under anaesthesia'
E -
-
Before a rigid nasopharyngoscope
ln Poisoning cases'
is introduced'

F^
E
l-^
Advantages
o Self-retaining
c Avoids the use of a tongue depressor
o Atraumatic

F Disadvantages
o Cannot be used in edentulous patients since it fulcrums
on the teeth'

t:
t-
239

r
 \
a
240 ClinicalENT \
..'
\
2. JENING'S MOUTH GAG a
\
\
\
a
\
-
\
Fig. 2.1 JENING'S MOUTH GAG \
\
It is a mouth gag which can be used in edentulous patients. lts blades open on closing and close on opening. The
blades rest on the alveolar margin. lt is a self-retaining instrument. \
Uses: \
As for DOYEN'S MOUTH GAG.
\
\
3. BOYLE DAVIS MOUTH GAG \
\
(- Tongue depressor \
\
\
\
\
\
Fig.3.1 BOYLE DAVIS MOUTH GAG \
\
This is a self-retaining mouth gag used with Draffin's bipods. lt has Boyle's blade and Davis's gag. The tongue
depressor is inbuilt in the gag. lt is introduced in the closed position after depressing the lower jaw. The mouth gag \
is then gradually opened and the rachet lock makes it self-retaining. The whole assembly can be lifted up and
maintained in that position by using Draffin bipods.
\
Parts:
{ Jarry piece \
o Tongue plate / depressor
\
Uses:
To open jaws in : \ l

o Tonsillectomy
-

iq
il- {
 Section ll lnstruments - Throat
- 241
o Adenoidectomy
o Palatal surgery-for cleft plate, submucous cleft
o Operations on the nasopharynx, oropharynx.
o Operations in cranio-vertebral anomalies.
Disadvantages
o Swelling of lips and palate can occur
o lnjury to incisor teeth.
o Can be used under general anaesthesia only.
Advantages
o Can perform operations / tonsillectomy from head end of pafient in sitting position.
o ln-built tongue depressor, obviates the need for an assistant
o Can be used for various surgeries.

4. DINGMAN'S MOUTH GAG

This instrument has a tongue depressor, cheek retractors
and a wire spring on all sides which help to fix the palatal
flaps with stay sutures.

Uses: Other mouth gags

o Repair of cleft palate / palatoplasty o Doyen Collin
o Pharyngoplasty o Davis Meyer
o Uvulopalatopharyngoplasty o Whitehead
o Palatal fenestration
o Operations on the nasopharynx
o Nasopharyngealbiopsy
o Surgery for choanal atresia
o Transpalataloperations
- Sphenoidectomy
- Hypophysectomy
- Vidian neurectomy
o Can be used for Tonsillectomy.

5. DRAFFIN BIPODS

Fig.5.1 DRAFFTN BtpODS

 242 ,l
Clinical ENT \
R
It is a bipod metallic stand. lt comprises of 2.stands with multiple rings I
in a row to fix the Boyle Davis mouth gag.
The stand lies on either side of the patient's head with the neck extended
in supine position. ll
I
Use:
To fix Boyle-Davis mouth gag for oral or oropharyngeal surgeries. |l
It is mainly used for tonsillectomy, not for ad-
enoidectomy.

\
6. LACK'S TONGUE DEPRESSOR \
\
\
\
\
-

Fig.6.1 LACK'S TONGUE DEPRESSOR

\
It has one flat end and another slightly curve-d end. The flat end is placed
depress it. lt should not touch the posterio r,/r'o , to prevent gagging.
over the anterior 2/z,d
of thetongue to \
Uses: \
o Examination of oral cavity and oropharynx for :
- Ulceromembranous conditions of oral cavity \
- Cysts
\
- Openings of submandibular ducts
- Dental caries \
- Bifid uvula
- Tonsils \
- Posterior pharyngeal wall
\
- Submucous cleft etc.
o To retract lips and cheek \
Y To squeeze tonsils to detect pus within
!' To test gag reflex
\
Y "Spatula test" : To test for spasm of masseter muscle is
a suspected case of tetanus. \
?- ln posterior rhinoscopy along with its mirror
v" Test air blast from the nostrils I "Cold Spatula Test". The tongue depressor is held in front of both the nostrils \
and the misting / fogging area on it is seen from the exhared a]r.
r- Examine nasopharynx : The soft palate is lifted up by the curved end of two tongue depressors \
o Dental caries : Sensitivity of the tooth is tested by rubbing the depressor over the affected tooth.
o ln oralcavity procedures like \
- lnjection of steroids in the pillars Tongue depressors :
\
- Biopsy taking from oral / oropharyngeal mass. . Hartmann (fenestrated handle)
o Davis Meyer
- Excision of cysts. \
- Surgeries on submandibular ducts
=

l
<
r
Y- Section ll
-
lnstruments - Throat

Operations like tonsillectomy, when a mouth gag with no tongue blade is used. ln dissection method, the
tongue is depressed enough to make the anterior pillar taut and an incision is then taken.
243

Nasal surgeries like sMR / septoplasty in which oral suction is required.

F
r
Quinsy dra.inage
Removal of foreign body from throat
To check post operative post nasal bleeding

t:
r
t:
l-
7. YANKAUER'S OROPHARYNGEAL SUCTION

t
Curved instrument with
long length
a

l_
t:
l. Uses:
Fig. 7.1 YANKAUER'S OROPHARYNGEAL SUCTTON

l.
l:
o To suck out oropharyngeal secretions or blood in
|Y/-
!-
lonstllectomy
Adenoidectomy
\r- Palatal surgeries
!:" Laryngectomy

E -
-
Other oral surgeries
Nasal surgeries

E
Advantages:
o The rubber coating at the tip makes it atraumatic for the oropharyngeal mucosa

I: o
o
o
Curve of the instrument helps to suck without obstructing view
lts long length and the large handle help to suck from a distance. The operating field is therefore not obscured
by the hand ofthe surgeon
Multiple openings on the tip prevent blockage of the suction. (lf one opening gets blocked, others still function)

E
l;
8. BALLENGER'S GUILLOTINE

F
l{
n
I:
Fig. 8.1 BALLENGER'S GUILLOTINE

r
 ClinicalENT
t
Il'l
244
)

o For Guillotine method of tonsillectomy.

Guillotine method
o Tonsil is engaged in the Guillotine
:'l
o

o
Tonsil is cut by one slide of the fenestrated blade.

GUILLOTINE METHOD

Fast procedure o
DISSECTION METHOD

Slow procedure
I:'l
o
o
lncomplete removal of tonsils is likely
More bleeding
o
o
Complete removal of tonsils occur
Less bleeding l'l
o o
o
Damage to surrouhding structures is more
Ghastly or crude method o
Less chance of damage
This method follows the principles of surgery
:1
o Difficult to remove non-hypertrophied tonsils o Non-hypertrophied tonsils can also be removed.
:..|
Disadvantages of guillotine : Methods of tonsillectomY :'1
o More bleeding. o Dissection and snare method
o Difficult to achieve haemostasis o Guillotine method :"1
o lncomplete removalis likely. o Cryosurgery
o Only hypertrophied tonsils can be properly removed. o Electrocautery
:'1
'.l
o Damage to surrounding structures can occur
o Laser surgery
\
Tonsillar hypertrophy :

GRADES % OF OROPHARYNGEAL REGION OCCUPIED BY BOTH THE TONSILS

Tonsil in fossa
:
0
- <25Yo :"1
2 - 25-50% \
J
4
- 5o-75o/o
- >750k
-l
-r1
This grading takes into account the medial to lateral space occupied by the tonsils, not the anterior to postertor
\
space. -l
:'1
9. TONSIL KNIFE :'1
It has a no:12 'J' shaped blade attached to a Bard Parker handle l"l
Uses:
.r
o To take inverted 'J' shaped submucosal incision on the anterior pillar in tonsillectomy.

Advantage
-I
-l
o The shaped blade helps to take a superficial submucosal incision. The incision therefore does not go deep
,J,

and cause bleeding by cutting across a wrong plane or the substance of the tonsil. :''l
]l
:'l
t]
I
-1
-
rc Section ll
-
lnstruments - Throat 245

10. MOLLISON'S BLUNT TONSILLAR DISSECTOR AND

F PILLAR RETRACTOR
l
;:
n Uses:
Fig. 10.1 MOLLTSON'S BLUNT TONSTLLAR DTSSECTOR AND PILLAR RETRACTOR

F Dissector
o To separate tonsillar capsule from its bed.

r" Retractor
o To retract the anterior pillar:
- Postoperatively to look for bleeding points

F -
-
To look for tonsillar tags in the fossa
.To look for retained gauze pieces

r o To cross clamp and ligate bleeders.

n 11. DENNIS BROWN TONSIL HOLDING FORCEPS

T.
F LUC'S FORCEP

Cutting edge
Traumatic
DENNIS BROWN TONSIL HOLDING FORCEP

No cutting edge
Atraumatic

F
I:
Box joint

Uses:
No box joint

o To hold the tonsil during dissection tonsillectomy

o To hold medial tip of anterior pillar after incision for tonsillectomy.

F
This instrument is similar to a Luc's forcep but it does not have a cutting edge. Hence it is atraumatic.

t:
E
12, EVE'S TONSILLAR SNARE

t;
I
t:
l-
l€ Fig. 12.1 EVE'S TONSILLAR SNARE

n
n
r
 246

Uses:
ClinicalENT
tI
-(s
o To remove the tonsil by snaring the lower pole after dissection.
lower pole is achieved.
The lower pole is snared since tonsillar blood vessels enter and
By snaring the tonsil, cutting and crushing of the

leave from this pole. on crushing, thromboplas-

This helps in haemostasis'
=-
:l
-|
dt.....-" tin is released which causes vasoconstriction and platelet aggregation.

Blood loss in routine tonsillectomy : 50 ml

a thickness of 28 gauge' The middle and index
I:t
The snare has a stainless steel wire which is 3 inches long and
fingers are inserted into the two rings provided on the outer tube.
;,'i* ,ffiil
The thumb is inserted in the single ring provided
ararl Fbyrr rrrilhdnrvinn
Jithu'""ntrul movabte slide. The tonsil is engaged in the loop and then snared
and ring fingers together'
withdrawing -l
the wire totally inside the tube by bringing the thumb and index
:r
13. TONSILLAR HAEMOSTAT II
:I
%mmsuffi - :'l
Fig. 13.1 TONSILLAR HAEMOSTAT :'l
at a depth and to avoid catching soft tissues along with
:'1
It is a long and slender instrument used to catch bleeders
the bleeders. :'l
Uses:
o To clamp and ligate bleeders during tonsillectomy
:1
Blood supPlY of tonsil :
:1
ArterialsupPlY :1
Upper pole :
o Ascending palatine branch of facial artery :1
o
o
Tonsillar branch of dorsal lingual artery
Tonsillar branch of facial artery
:'l
Lower pole : :'l
o AscendingPharyngealartery :1
o Lesser palatine artery.
o Contributions from ::r
-
-
lnternalcarotidartery
Vertebralartery :r
=1
Venous Drainage
o Mainly to the Paratonsillar vein (Dennis Brown Vein)
:'1
-rrl

:I
-r
Et
r!
/^
Section ll lnstruments - Throat 247
.7\ -
14. NEGUS LIGATURE SLIPPER OR KNOT TIER
Uses:
To slip the ligature over the tip of the tonsillar haemostat during ligation of blood vessels following tonsillectomy.
It is a long instrument with a blunt forked end.

.^
15. VALSELLUM
Use:
o To hold tonsil and pull it medially during dissection.

16. TONSILLAR PUNCH FORCEPS

Uses:
o For biopsy of the tonsil. Biopsy in usually taken in suspected carcinoma cases.

Unilateral enlargement of tonsil

o Carcinomatous
- Squamous cell carcinoma.
- Lymphoma
o Peritonsillar abscess
o Tonsillolith
r Tonsillar cyst
o Tonsillar foreign body
o Parapharyngeal mass pushing tonsil medially
o Carotid aneurysm pushing tonsil medially.

17. THILENIUS QUINSY DRAINING FORCEPS

a
?\ Fig. 17 .1 THILENIUS QUINSY DRAINING FORCEPS

a.
Uses:
o Drainage of peritonsillar obsess.

Advantages

r
o lt has a guard at some distance from its tip, preventing more deeper penetration and avoiding complications
 \
.l
248
Clinical ENT \
\
18" ST" #$-Anffi Thssnn$ffiN ApffiNoEm GUmETTH WlTb{ I
\
WHTI{ffiUT GAGH
\
\
\
.tt]..t $T. (: LA{R Tr-iOn{1sohl ADFt"tolD cURETTE WlTl-llwlTFlotlT cAGE
Frq.

The cureite, first heid like a^pen, is introduced into the oral cavity
s
\
It is an instrumenl used to !"enrove the ;adenoi
beyoncl the soft ;ralate v,,ith the blades facing down. li is then rotatecl by 180" and positioned against the posterior \
superior part of ihe nilsr.rpharyngeal rvall in ihe niidline against the posterior end of nasal septr"tm. The grip is then
movemernt, the adenoids are curetted out'
charrgeci to that of a cJa.qger arrd with a single sweepinE \
Uses of tl'le eage
o lt pnevent siiprpirrg of
.ii-cl;ue
arrd asprrati<:n into lower respiraiory tract.
\
o lt ensur<*s cornpiete refi.iovai ci adenoirjs. \
Curette without cage
t aden*id tissue"
Ttr remove neryinant:; o{
i
c To rerncve iubal t6nsiis witliout rlar-riaging elistachian tube cpenings, since withoui caEe, the instrument be- \
comes rcl.ri,vi'lY atr"' lrla tic r

\
Rernoval of adenoids hY \
o Natural finger naii (ol-'si:iete no'"v)

o Steel nail \
o Laforce adenctcrne
c St. Clair Thontsorr atienoicl curette
\

Adenoicls hypertrop:hY
\
Grading : \
OBSTRUCTIOil{ CIF CI.'SAf\.IA
GRADE \
Upto l,!'i
ll
/.r.1
tA t/-r'1 \
ilt
ti
>)//111

Cornplete obstruction clf choana

i
\
Differential diagnosis of aderroids
c Adenoids \
-/ Thornwald's cyst
\
o Chordoma

"6 Juvenile nasopharyngeal angiofibro''na i

f Antrochoanalpolyp
c \
Craniopharyngiorna
V fuleninglon-ra \
q

:
rr Section ll
-
lnstruments - Throat 249

19. TROUSSEAU'S TRACHEAL DILATOR

F
n
n
r
r Fig. 19.1 TROUSSEAU'S TRACHEAL DTLATOR

It is an instrument used to dilate the opening made on the anterior tracheal wall at tracheostomy. On closing the
handle of the forceps, the dilator end opens, lt does not have a catch and there are no serrations at the tip.

Uses:

F
n
To dilate
r
o
trachealopening for
lntroduction of tracheostomy tube
Changing of tracheo.stomy tube.

Advantages

IT o

t:
Allows easier introduction of tracheostomy tube
o Less chances of a false passage.

l: 20" DOUBLE I.NOOK RETRACTOR

F
t: -) ////
//

t: A
(a
{(

F t€
{_g

F
II It is a blunt instrument with two hooks.

Uses:
Fig.20.1 DOUBLE HOOK RETRACTOR

o To retract pretracheal layers or strap muscles in the neck during tracheostomy. lt is used to retract skin,
subcutaneous tissue, strap muscles on both sides of the incision.

F
l-'
t:
r
1T
 \
A
250 ClinicalENT \
A
\

l
21. SINGLE HOOK RETRACTOR {
\
SHARP / CRICOID HOOK
A
\
\
a
\
A
\
L] \
Fig.21.1 SINGLE HOOK RETRACTOR
Use:
-
To retract cricoid cartilage superiorly an( to stabilize trachea prior to tracheal incision in tracheostomy.
\
\
22. BLUNT / ISTHMUS HOOK
O i
/ \
)I \
ffi
ilg \
\
)_g
Fig.22.1 BLUNT/ISTHMUS HOOK \
Use:
thyroid gland superiorly in tracheostomy.
\
To retract soft tissues / isthmus of
\
23a. TRACH EOSTOMY TU BES \
\
\
Outer tube
\
!

\
lnner tube
\
\
Pilot obturator lrr
Fig. 23a.1 CH EVALIER JACKSON'S TRACHEOSTOMY TUBE r!

fr
,an
 251
Section ll lnstruments - Throat
-
and a pilot obturator
of an outer tube' an inner tube
The chevaIer Jackson's metallic tube consists
Parts
o Outertube : Fits into tracheostomY tract
2-3 mm'
o lnnertube : Protrudes beyond the outer tube for
o Pilot obturator Blunt ended curved obturator
o Shield : ltrsattachedtotheproximalendoftheoutertube.lthasholesonitssidesthroughwhich
tube to the neck
linen thread is passeJto fix the tracheostomy
inner tube to the outer one'
i Luer lock : lt is fitted to the shield and fixes the secretion / crusts' The inner tube
is
tube is longer than the outer tube to prevent.bl:"fug" by dried for permanent tra-
The inner tu-bes are thus more suited
cleaned anorelnserted. Metaliic
removed when brocked and then cor-rghing. The pilot obturator allows
Luer lock herps in fixing the tune ana retains it during """"*iu" The outer tube
cheostomy.
a tracheat diratoi. tt is made
of German sirver which is a non-irritant'
insertion and acts as pirot is withdrawn and the
smooth in in" trachea, the
the obturator is passed through tne tracn-eosio*y op"ning on""
with
inner tube is inserted and then
locked '

23b. FULLER'S BIVALVED TUBE

opening present on the postero superior
acts as a d'ator and helps in introduction r:f tube. There is an Decannulation can
The bivarve
which helps to determinelhe air-frow ano r,ence irre time of decannuration'
wail of the inner tube
becarriedoutifnormatairnowisestablishedonblockingthetracheostomytube'

TUBE
23c. PORTEX TRACHEOSTOMY

tf- Tube

TUBE
Fis. 23c'1 PORTEX TRACHEOSTOMY

Parts
1. Single tube : lt may be cuffed or non-cuffed
2. Pilot passed which are tied around
through which rrbbon tapes are
3. Flanges : The flanges are attached to the tube
the neck for fixing the tube'
4. Cuff : - low volume high Pressure cuff
- high volume low Pressure cuff

H
-r
 ClinicalENT
II
II
252

salt is present throughout the tube for radiological

evidence of
5. Blue radio opaque line impregnated with barium
the site of the tube.

Advantages of a cuffed tube

-Prevents
w asPiration
^-l
o
o
Can use it for intermrttent positive pressure ventilation
Makes it PartlY self-retaining :t
Advantages of a Portex tube :!
.9'Less
o
irritant
Can be used for intermittent positive pressure ventilation
:I
w"'Can be used in radiotherapy patients
c Prevents asPiratron
:I
v,.Used to give general anaesthesia. Cuff prevents leakage
of anaesthetic gases
:1
:1
24.INDIRECTLARYNGoSGoPYMIRRoR :'l
I
_rl
-l
\
rrl
t \
^l
I
mirror

Fig. 24.1 lf'IDIRECT LARYNGOSCOPY MIRROR :1

without magnification'
\
It has a long straight handle with a plane mirror ^l
\
Uses:
o lt is used to perform incjirect iaryngoscopy
-l
-rl
cToremoveforeignbodiesfromoropharynx(eg:fishbone)
oSr-tperiorlaryngealnerveblockfordirectlaryngoscopyunderlocalanaesthesia. )
Ways of heating the mirror Structures not seen on IDL
o Spirit lamP
'b/Post cricoid region :'l
\
o Rubbing against the buccal mucosa'
l--Apex of PYriform fossa
t'Anterior commissure (difficult to see)
c Dipping in hot water. \
Ly'i,/entricles
lndirect larYngoscoPY bz-Laryngeat lurfaT q gqg]qg \
Advantages
o Simple Procedure
\
o Out patients Procedure
\
Eisadvantages
e Mirror image is an anterior-posterior reversal of
structures i
o Vocal cords aPPear flat.
Yt
o smaller due to angulation of the rnirror'
Size of lesions at the anterior commissure appear
o Overhanging epiglcttis may hide lesion' qt

E
 Section ll lnstruments - Throat 253
-
o Ventricle of larynx cannot be seen.
o Foreshortening of antero-posterior diameter to lzr'd .

o Vocal cords appear white.

o Difficult to see ariterior commissure
o Depth appears less than actual
o Ventricular bands appear at the level of vocal cords like flat bands.
o Patient co-operation is required.

25. TONSIL NEEDTH

It is a curved needle on a long handle.

Uses:
To suture anterior pillars togeiher for control of posltonsiliectomy bleeding"

Methods to control post-tonsillectomy bleeding :

r Pressure packing
o Cross clamping and ligation of vessels
c Haematinics, vitamin K, coagulants etc.
r Control of blood pressure, antibiotics
o Hydrogen peroxide gargles
o Dislodging of ck:t
c Tincture benzoin cauterization
r Pillar suturing
o Resuscitation, bloodtransfusion
r External carotid artery ligation

t:
rn
11
t"
n
1:
r:
rn
n
r"
r_
r:
t:
t:
rt: ScoPES
1:
r_
r^
r:
I:
n
n
n
l_
t:
I_
I--
I:
r:
r^
rI:
1: SCOPES
t:
1"
t: 1. DIRECT LARYNGOSCOPE
l" L, -.:-_-. =,.}il
\ti:
1l !k.
'Lrif-
_ \|t

E
\.:+ _ -_.<'

q-- -- --::t+S
E ;i' ll
:,t,1#

n
I: Fig. 1.1 DIRECT LARYNGOSCOPE
-.: . - ._-:l-y.l

t: The direct laryngoscope is 'U' shaped and is made up of German silver. The illumination is by
fibreoptic light
system. There is no magnification.

t:
t:
Types :

gHEVALIER JACKSON

Distal illumination
NEGUS

Proximal illumination

F Uses :

o To examine hypopharynx and larynx

o Removal of foreign body from hypopharynx and larynx
e To take biopsy from suspected lesions.

F
n
o To remove benign tumours / nodule from vocal cord
o For introduction of bronchoscope, (laryngoscope with a detachable blade is of use)

2. KLEINSASSER'S MICROLARYNGOSCOPE
E
l- Chest piece

F
l*
I:
Fig. 2.1 KLEINSASSER'S MICROLARYNGOSCoPE

254

l:
r:
 \ l
a
Section ll lnstruments - Scopes \
-
It is a stainless steel scope consisting of a wider proximal aperture and a narrower distal one. lt is made self-
\
retaining with the help of a chest piece fixed to the laryngoscope on one hand and the patient's chest on the other A

Microlaryngoscopy is performed with the help of an operating microscope with a 400 mm lens. \ I
I

-l
1. Surgical laryngoscope \
o Proximal end having wide flat plane surface which lies in apposition to the teeth
o Distal oval end. \
o The greatest diameter of the tube lies oblique to the longitudinal axis of the handle.
o \
The broad flat proximal end of the laryngoscope evenly distributes pressure and prevents dental trauma.
o The inner surface is roughened to avoid reflections during photography \
o
2.
The illumination is provided by a simple low voltage bulb affixed to a rod
Chest holder (Riecker's) i
o Easy to handle and very stable i

\
o Holds laryngoscope in place.
o Has a wide pressure plate / plastic plate covered with foam rubber to be placed under the chest holder to \
avoid pain and undesirable pressure spots.
Use :
\
For m icrolaryngoscopy. t\

Advantages
*t
o Wider proximal aperture / broad lumen: allows good visualizalion, use and manipulation of wider instruments.
o
o
Self-retaining : surgeon's hands are free for instrumentation
Can be used with operating microscope, so magnification is possible for various procedures.
i
o Flat bottom allows good stabilization of scope \
o Photography and videography of endolarynx is possible
o Biopsy can be taken -
o Therapeutic procedures like stripping of vocal cords, laser surgery can be coupled with ML scopy.
\
o ldeally the scope should be matt black to prevent glare and reflection of light from the microscope.
o Flat lower surface on the patient's teeth allows even distribution of force. i
Types :
\
- Anteriorcommissurelaryngoscopes
- Hollingers : anterior curved lips are present to visualize anterior commissure. \
- Negus
\
3. CRICOPHARYNGOSCOPE / HYPOPHARYNGOSCOPE i
/ OESOPHAGEAL SPECULUM / UPPER END \
OESOPHAGOSCOPE \
It is same as an oesophagocope but shorter in length (length = 29 cms.)
\
Uses :

o To remove foreign body from cricopharynx / hypopharynx \

o Biopsy from post-cricoid region malignancy.
\
Most common site of foreign body: Cricopharynx in upper aerodigestive tract
\
q!

t!

r!
rl" 256 ClinicalENT

t-
l_
l-
n
tt: Fig.3.1 CRICOPHARYNGOSCOPE / HYPOPHARYNGOSCOPE / OESOPHAGEAL SPECULUM i UPPER END
OESOPHAGOSCOPE

t_
I- 4. BRONCHOSCOPE

t
I"
F
t:
#-a

t'-
-{.qnc<--_-
I
Vents

t:
F (Bronchios = Wind pipe
Fig.4.1 BRONCFIOSCOPE

t" Skopos = Inspect)

r
It is a hollow metallic instrument with distal illumination. A fibreoptic Iight source is used. A ventilating broncho-
scope has vents on its distal end. They are so placed that few of them remain above the level of the carina to
ventilate the remaining lung when the scope in introduced in one of the major bronchus.

Parts
o Shaft

I_ o
o
Handle
Light source

F
n
o
o
o
Eye piece
Suction connection
Ventilation connection

t:
n
F
r
rn
t:
r-
F
F
r"
r
r
F
rt:
F
GENERAL h',sTRUMENTS
F

l*
t:
I-
l-
 GENERAL INSTRUMENTS

1. BULL'S EYE LAMP

Bulb within the chamber

Fig. 1.1 BULL'S EYE LAMP

It is the light source used for outpatient's examination. lt has a 100 watt white frosted bulb in a chamber which
is dark or black from within. A convex lens is attached to the chamber which allows dispersion of light from the
bulb. The rays of light fall on the head mirror used by the examiner.

2. HEAD MIRROR

1- Head band

Central aperture
a

.^ Fig.2.1 HEAD MIRROR

I:
257

la
 \
258 Clinical ENT \
It consists of an adjustable head band to which a concave mirror is attached \
MIRROR DIMENSIONS \
1 Focal length 1. 23.6 cm
2. Diameter 2.9cm \
3. Central circular aperture 3.2cm
\
Use :
\
For routine ear, nose, throat examination. The light from the light source / Bull's lamp is reflected on the head
mirror to the examined area. The head mirror is adjusted with the central aperture over right eye. \
Advantages of using eye lamp with head mirror
o Binocular vision is retained -
o Part under vision is brilliantly illuminated and clearly seen as the circular aperture coincides with the right \
eye pupil. The examiner's gaze is parallel to the reflected beam of light.
o Both hands are free to carry out procedures eg : aural syringing. \
\

3. SPONGE HOLDING FORCEPS i

It is a long straight instrument with round fenestrated ends, which bear transverse serrations. The adequate \
length of the instrument ensures that antiseptics can be applied to the part from a distance. The rachet lock
allows a secure grip. I
Uses:
o Preparation of the operative site.
\
o Haemostasis by pressure of a swab. \
o To dry operative field by application of a dry swab.
\
\
\
\
\
Fig. 3.1 SPONGE HOLDING FORCEPS
\
\
4. TOWEL CLIP
Doyen's towel clip - short instrument with curved ends that end in sharp points with handles joined at the \
proximal ends so that when pressed the tips open and vice-versa.
\
Mayo's towel clip - shaped like a haemostat but has tips like those of a towel clip. The ratchet catch achieves
a secure grip.
\
Uses :

o To fix the draping towels in position. \

o To fix the suction tube to the draping sheet.
_l
!l
I

- I

r!
I

lrt
l
 Section ll lnstruments - General lnstrumenb
- 259

o To hold the tongue during intra-oral operations like tongue-tie release

o To fix faciomaxillary fractures.

Doyen's towel clip

% Mayo's towel clip

Fig.4.1 TOWER CLtp

5. SCALPEL
A scalpel is a sharp cutting instrument. lt is basically a knife,
but in surgical practice, a knife refers to an
amputation or skin grafting knife, hence the term scalpel.
The combined handle and blade type are not used but instead,
Bard-parker handles with disposable blades
are used' The blades are sterilised by gamma irradiation and
are packed in aluminium foils. The handles are
sterilised by autoclaving or boiling.

ldeal scalpel :
o lt is light in weight.
o lt has a sharp cutting edge
o lt has a good grip.
o lt is easy to sterilise.
o Different types of blades should fit to the same handle.

Diagram of Blades

(No. 11)

ttr{
IF
V
(- Handle

Fig. 5.1 SCALPEL

6. DISSECTING FORCEPS
Plain or nontoothed forceps have no teeth but have transverse
serrations on the inner surface of the blades
near the tip for a secure but nontraumatic grip on the structures
herd.
Toothed forceps have 1 or 2 teeth for a secure grip on the
structures held. The joint has a spring action.
o Plain forceps are used to hold soft and friable tissues which
may be traumatised by toothed forceps.
o Tough structures like fascia and muscles are held with toothed forceps.
 ClinicalENT
II
II
260

o Small and fine forceps (Adson's) are used in microsurgery'

Toothed forcePs
.-l
Plain forceps +
Fig. 6.1 DISSECTING FORCEPS
I:l
:t
7. SCISSORS
Scissors are sharp cutting instruments; small, medium or large in size, straight or curved
at the end'
I:I
fibres and insertion of closed
curved scissors are used for dissection, by both, division of connective tissue
scissors into a tissue plane and then opening the blades'
are long, curved or flat,
:1
Straight scissors are usually used to cut sutures. Steeli's or Metzenbaum's scissors
fine scissors used for fine dissection. r'l
Uses
r
:

Temporalis fascia graft harvesting in ear operations (small scissors).

:'l
:'l
o
o
o
o
Tissue dissection e.g. : in thyroid operations.
To cut sutures and ligatures during surgery'
Suture removal (fine, sharp, pointed scissors)'
Cutting bandages.
It
o Venesection.
I:1
8. HAEMOSTAT
A haemostat is an instrument designed for haemostasis by catching bleeding vessels.
Since it is used to catch l'1
both arieries and veins, it is better to use the term 'haemostat'.

I
:''1
It may be long or short, straight or curved.
or only in their distal
Its blades have transverse serrations either throughout their entire extent (pedicle clamp)
halves (haemostat),
Mechanism of Haemostasis : :'1
The serrations permit a secure grip on the structures held and also crush it. lt
achieves haemostasis by
of the intima causes a blot clot formation which also :'1
occlusion of the lumen of the blood vessel. crushing -r!
promotes haemostasis. The ratchet catch helps to maintain a grip on the tissues held'

Uses : \
o To catch bleeding vessels for haemostasis.
o As a pedicle clamP.
-l
o To hold the cut edges of the fascia during dissection and while suturing them' -'1
o As sinus forceps to open abscess cavity'
o To hold the ends of the ligature. -rr]
o To hold ,pearruts for blunt dissection : (a'Peanut'is a small ball of gauze with cotton inside, about 3-4 mm -1
in drameter).

-
q

Hr
t:
F Section ll
-
lnstruments - General lnstruments 261

o To clamp a catheter / tubing / suction drain - it is preferable to use the portion between the hinge and

F ratchet catch as it is less traumatic.

A good haemostat does not permit one to see through the approximated blades on locking the ratchet

I-
l-
once.

l
F
Fig.8.1 HAEMOSTAT

t: 9. MOSQUITO FORCEPS
Mosquito forceps is a fine curved short haemostat. lt is known as mosquito forceps because its tip is said to

F
be so fine as to be able to catch the proboscis of a mosquito.

n
Uses :

' o To catch fine bleeding vessels.

o To hold the ends of fine sutures.
1: o For tissue dissection.

I: 10. BABCOGKS FORCEPS

F
I:
It is a nontraumatic instrument with 2 finger grips, a ratchet catch and fenestrated curved blades. They are
useful for holding soft tissues and delicate structures.

Uses :

r-
r
o To hold lymph nodes during lymph node biopsy.
o To hold cysts and lumps during dissection.

f- Ratchet catch

F
r:
n
n
Fig. 10.1 BABCOCKS FORCEPS

11. ALLIS FORCEPS

n
r_
It has 2 finger grips, a ratchet catch and tips which are flattened, curved inwards a little and with fine teeth on
the distal edges for a secure grip on the structures held. lt cannot be used to hold delicate structures, since its
teeth are traumatic.

Uses :

F o To hold fascia tissue and aponeurosis.

r To hold fibrous capsule of various structures.

1'-.
r:
r
 \l\l
262 ClinicalENT -r]
Gl
\
o To hold subcutaneous tissue just under the skin..
^l
\
.l\
I

\ I
Al
Fig. 11.1 ALLIS FORCEPS \
I
A

\
12, SINUS FORCEPS. \
Sinus forceps are long, straight with slightly expanded tips but no ratchet catch on the handles.
lJses :
i
o lncision and drainage of an abscess - to explore the abscess cavity and break all the septae within by \
Hilton's method to drain the pus inside.
o To remove foreign bodies from wounds or sinuses. \
o To place a drain in an abscess or sinus cavity.
o To pack an abscess cavity. \
o To drain a haematoma. \
\
\
\
Fi1.12.1 SINUS FORCEPS
\
\
13. NEEDLE HOLDER
A needle holder is available in different sizes - small medium and large. lt has two finger grips, ratchet catch
i
and small blades. The ratio of lengths of the handle to blades is 4:1. Thus the grip is strong.
\
The inner surface of blades have criss-cross serrations for a secure grip on the needle held. Each blade has
a longitudinal groove on its inner surface, which makes the grip on the needle stronger and stabilises it during \
USC.

Uses : \
o A needle holder is used to hold a curved needle for suturing. i\
\
It is held at the tip of the instrument, at the junction of proximal '/{d and distal %'d of the needle.
\
\
\
i
Fig. 13.1 NEEDLE HOLDER '!
.-
r{

-
r^
r Section ll
-
lnstruments - General lnstruments
263

14. SUTURE NEEDLES

F
Anatomic parts of a needle :

o Eye
o Body
o Point

H Types
1. Cutting
:

2" Round bodied

Cutting needle :
These have sharp edges, often triangular in section.
A cutting needle is triangular in cross - section, the apex of the needle directed upwards. The cutting
force is
maximum at the apex of the tract cut in the tissues, which increases the risk of the ligature cutting
thiough the
tlssues when a knot is tied.
A reverse cutting needle is also triangular in cross - section, but the apex is directed downwards. The force
of
cutting is spread over the base of the tract cut in the tissues which decreases the risk of the ligature
cutting
through when a knot is tied.
Round bodied needle :
These needles have pointed tips. They do not cut tissues but puncture them and the punctures

E
close very
-
easily afterwards. These are used for suturing delicate tissues like serosa, mucous membranes
etc.
Suture needles may be straight, curved, half circle, five-eights of a circle or of any special
shapes.

H
r

F
l-'
I:
F
 CLEFT PALATEAND
Rru NoPrAsrY I nrsrRu M ENTs
- Dr. Uday Bhatt
n
n
I^ CLEFT PALATE AND RHINOPLASTY
I_ INSTRUMENTS
r"
l: CLEFT PALATE INSTRUMENTS
n 1. Dingman's mouth gag
2. Mucoperiosteal elevator
3. Periosteal elevator
4. Howarth periosteal elevator

E 5. Mitchel periosteal elevator

6. Detachable blade for Dingman's gag with a groove to accomodate the endotracheal tube
7. Long BP handle.
F-
r.
F-
r:
n
r^ @

n
I:
n
F
F
I: RHIONOPLASTY

n
1. Nasal Aesthetics
A. 1. Nasofrontal angle

n
2. Iip columellar angle
3. Naso (columellar) labial angle
4. Soft Triangle
B. '1, Bony dlorsum
2. Cartilagenous

E 3. Supratip area
4. Light reflex
5. Tip
point

F 6. Columella
7. Ata
8. Alar-facial junction

n
I:
264

r
 )t
Instruments - cleft Palate And Rhinoplasty lnstruments
265
I
II
Section ll
-
C. 1. Soft triangle
2. Nostral sill
3. Nostril floor
4. Medial crura
5. Naris
foot Plates
:l
I
II
:I
II
:'l
NASAL AESTHETICS
I
:'1
I-l
\

:1
:'1
-tl
2. Osteocartilagenous Framework
1. Nasal bone \
2. lateral cartilage
3. Alar cartilage
-t
-1
4. Septal cartilage
:'1
:'1
\
\

\
:r
g 11
OsTEOCARIILA6ENOU5 TRAIAEW O R,K :r
-1
r!
|{
*l
 266 ClinicalENT

Rhinoplasty lnstruments
1. 2 mm osteotome
2. 2 mm Osteotome with guard
3. 10 mm Osteotome
4. 10 mm Osteotome with guard
5. Walsham's nasal forceps
6. Mallet
7. Cartilage scissor"s

[ilr!
w
lncisions and Osteotomies
1. Medial Osteotomy
2. Laleral Osteotomy
3. lntercarlilagenous incision
4. lntracartilagenous incision
5. Rim incision
6. Transfixion incision

tNClsloNS ANp osrEOIO/vllES

F
 '!
J
Section ll lnstruments - Cleft Palate And Rhinoplasty lnstruments
I
l
-
\
Rhinoplasty lnstruments
1. Aufritch retractor Jl'r
.I!
2. Kilian's ala retractor i

3. Push rasp q
4. Pull rasp
5. Joseph saw

\
!l
\

\
!

#t *
A
I

fl l("
t
q

rf

\
i

\
rf

i
I

ts

:r

t
SECTION I III
OPERATIVE SURGERY
r:
n
n 1. MYRINGOPLASTY
n
I_
t:
I:.
It is an operation performed to repair or reconstruct the tympanic membrane
ear ossicular chain).
(without disturbing the middle

n
n
INDICATION
It is indrcated in benign type of chronic suppurative otitis media ie; tubotympanic type
central perforation and no ossicular or middle ear pathology'
of disease with a dry

I^ CONTRAINDICATIONS

n
n
1. Active stage of chronic suppurative otitis media
2. Eustachian tube malfunction
3. Ossicular chain pathologY

n
4. Squamous epithelium lining the middle ear.

n
I-
PREREQUISITES
1. Ear should ideally be dry for atleast six weeks preoperatively ie; a dry central perforation
2. Patent and functioning eustachian tube
3. Tuning fork tests and pure tone audiometry showing conductive hearing loss.

L. 4. No ossicular chain pathologY

n
t:
5. No squamous epithelium lining the middle ear.
6. No focus of infection in the nose, paranasal sinuses and the nasopharynx.

t:
PREOPERATIVE
ANAESTHESIA

t:
l^
Local or General anaesthesia
Local anaesthesia is preferrable as it causes less bleeding, making of an air-pocket medial to the
easier and hearing can also be tested on table if required. General anaesthesia
erative adults.
is used in children and
graft is
uncoop-

t:
t:
POSITION

r
Supine position with affected ear up.

rNcrsroN

n
n
A postaural, endauralor an endomeatal incision can be taken. The incision is deepened upto the mastoid
mucoperiosteum.

PROCEDURE

t: Afterthe incision is deepened, its edges are retracted with self-retaining mastoid retractors.
Atemporalis fascia graft is harvested, Temporalis fascia rs the fascia covering the temporalis muscle. Via the
same incision, all the layers above the fascia are separated with an artery forcep and then held up by a retractor.

tr An incision is taken on ih" fascia according to the amount of graft material requtred. The fascia is elevated from
the underlying muscle and the graft is removed.

n
Injection of a litile amount of saline underneath the graft helps in easy separation of the graft from the

r
r^
268

.+ r io"J o i;---*- I ;{ r ra'J--r. 1.; .

 \'il
Section lll Operative Surgery - Myringoplasty 269 \
- .11

underlying muscle. The graft is spread on a glass slide and ihen covered with an another slide. \ I
F'l
A semicircular or Y shaped incision is made on the mastoid mucoperiosteum. The mucoperiosteum is \
elevated with a periosieal eievator. A meatotomy is made in the elevated flap at the level of the spine of Henle,
to enter the external auditory canal from behind. The external auditory canal is cleaned and the perforation is \
inspected.
The perforation is made raw by removing the edges with a sickle knife. A tympanosclerotic plaque abutting \
the edge needs to be removed. The undersurface of the edge is made raw with a circular knife till the edge
becomes thin.
Once the perforation is made raw, the canal skin lying on the posterior canal wall re; the tympanomeatal flap is
=
elevated from the canal wall. A 6 o'clock and 12 o'clock incision is taken on the canal skin deep down to the \
bone upto the annulus. The flap is then raised including the annulus. The middle ear is entered after raising the
flap and the ossicles are inspected.
The flap is abutted to the anterior canal wal[ and thorough cleaning and suction is carried out to prepare the
-
ear to lay out the graft. The graft-is either put wet or dry like $archment paper, \
It is spread on the canal wall and then underlaid (beneath all the layers of the tympanic membrane) with the
help of a sickle knife and suction. The eciges of the graft are tucked properly under the remnants of the tympanic -
membrane. There should be an adequate air-pocket medial to the graft. The tympanomeatal flap is replaced on
the posterior canal wall. Small pieces of gelfoam are placed over the tucked edges of the graft to secure it in \
place. The external auditory canal is fiiled with gelfoam and the wound is closed in layers.
i
Anterior tucking :

!t !s lhe procedure done when the anterior remnant of the tympanic

membrane is insufficient to hold the grafi. \
H n smatt iympanomeatal flap is raised from the anterior canal wall and the edge of the graft is tucked beneath it.
-
POSTOPERATIVE
o Oral antibiotics
o Anti inflammaiory analgesics. .\
o Decongestants
'o Local antibiotic ear drops once the external canal gelfoam gets dissolved (at around three weeks)'
\
.Valsalva's
. _o manoeuvre from second day to enable better contact between the graft and its bed if underlay \r
technique has been used.
\
\
?
\

\
!i

r.{

s3-{sstE;$s;
|\'JJJJJ
 2. CORTICAL MASTOI DECTOMY

SYNONYM : Simple mastoidectomy

Schwartz operation
Definition : lt is an-operation in which co!]p-]glx glenteration of all-accessible
@l!" posiaioioanal-w;it intuci:-"'=-'':'r:-:':''. --':'- mastoid air cells is carried out,
'*.*"'""'':- ' . -' '

Indications:
1. Coalescent mastoiditis
2. Subperiosteal mastoid abscess or fistula.
3. Masked mastoiditis
4. As an approach to :

o Labyrinthectomy"
o Endolymphatic sac decompression
o Facial nerve decompression
o Vestibulo-cochlear nerve section
o Acoustic neuroma excision
o Petrosectomy
Preoperative :

X'ray mastoid is essentialfor :\."/ Delineation of mastoid air cell system.

'-.-"'position of dura, sinus plate.
POSITION
Supine position with head turned to opposite side.

ANAESTHESIA
Generalanaesthesia : for
o Children
o Uncooperative adults
r Patients with intracranial complications.

lNclsloN ..--
Post auricular incision : A curved incision
few milimeters behind and parallel to the postauricular groove

OPERATION
1. The incision in deepened onto the mastoid periosteum
2. Exposure of mastoid cortex
The mastoid mucoperiosteum is elevated in
all directions with the herp of a Lemperts mucoperiosteal
The limits are as follows : elevator.
o Superiorly : Tothelevelofupperattachmentofpinna.
o Anteriorry / Forwards : r-aterar end of posterior bony meatar wail.
o Posteriorly / Backwards : A few millimeters.

270
 \
,t
Section lll- Operative Surgery - Cortical Mastoidectomy 271 I
a
I
Adequate haemostasis is achieved. The elevated mucoperiosteum is kept retracted with the help of Mollison's
self retaining haemostatic mastoid retractor. li
!
3. Exposure of mastoicl antrum
The mastoid antrum is first located as it is the most consistent and largest air cell i
!
MacEwen's triangle boundaries
Mastoid Antrum Landmarks :

o Superiorly : Supramastoid crest r MacEwen'sTriangle-surfacemarking i

o Anteroinferiorly : Posterior margin of external canal o Depth of 15 mm from the triangle in an adult ;
which cuts the suprameatal crest.
o Depth of few mm in an infant / child.
Posteroinferiorly: A tangent to external canal which
q
cuts the suprameatal crest.
ln the adult the antrum lies 1 .5 cm deep to the supra-meatal triangle. A first straight cut with the burr is made
fi
along the supramastoid crest starting from anterior part of MacEvens triangle, extending towards the sino-dural
angle. A second straight cut is made posterior to posterior meatal wall starting from anterior part of MacEwen's
tt
triangle extending towards mastoid tip. Cortex removal with good saucerization is necessary before, deeper
penetration into the antrum.
!i
It is better to open the antrum at a higher rather than a lower level to avoid injury to lateral semicircular canal
or facial nerve. fr

To confirm that the antrum has reached

o Pass a Dundas Grant probe / Antral cell seeker into the Antrum: ;
aditus.
o Largest mastoid arr cell
c Lateralcanaldome can be seen on its medialwall. o Aditus in its anterior wall It

o Judge the adequacy of the aditus.

o Smooth white dome of horizontal semicircular t
canal on its medial wall.
The above manoeuvres are pedormed with great caution
to avoid dislodging the short process of incus from the fossa incudis. The aditus may be enlarged with a bone t
curette if required for adequate drainage. lf pus is encountered on openrng the antrum, a swab may be collected
for culture.

Air cell exenteration t

After identifying the antrum, the air cell tracts are slowly drilled from the antrum outwards in all directions
It is important to clear the following air-cell groups :
\
o Sino-dural angle cells ri
. Root of zygoma cells in a well-pneumatized bone
o Mastoid tip cells \
o Peri labyrinthine cells
h
o Cells in relation to the vertical facial nerve
o Removal of mastoid tip if it is necrotic, in cases of Bezold's abscess. \
G

TEMPORAL AIR-CELL GROUPS /TRACTS : (ALLAM'S CLASSIFICATION) \

Middle ear: Mastoid : Perilabyrinthine Petrous : Accessory :

o Epitympanum o Mastoid antrum o Supralabyrinthine o Peritubal o Zygomatic \

o Mesotympanum o Tegmental/ Dural o lnfralabyrinthine o Apical o Occipital rlt
o Hypolympanum o Sinodural o Styloid
o
o
Protympanum o Sinal c Squamous i
Posterior tympanic o Facial
. ltp cells. \
\
rl
 272
ClinicalENT

The alr cell tracts are then removed one

and a bony cavity results. After complete removal
tracts, the surgeon shourd be abre to see the 9y..one of air-cell
foilowing oornorii". ,'

Boundaries of a cortical mastoidectomy cavity:

Superiorly : Dural plate
lnferiorly : Digastric ridge
Anteriorly : Bony meatalwall, Aditus.
Posteriorly : Sinus plate
Depth ; Lateral semicircular canal at the deepest point.

Special cases :

The followed techniques are followed

in special cases :

ALTEMTION INTECHNIQUE
1. Extradural abscess r Part of dural plate is removed
r Middle fossa dura is exposed
o Check for granulations, pus collection / extradu_
ral abscess
o lf present, the pus is evacuated and exposure
is
continued till healthy dura is reached
2. Lateral sinus thrombophlebitis a Part of sinus plate is removed
a Sinus is exposed
ibrosed / organised clot if present is not
touched
o Unorganised clot is aspirated with wide
bore
needle,

Smoothening of cavitv :

edses and is to be smoothened with the

,.,ntl";::[:rffi:T:Xi;?"",ili:ilf"beverred herp of diamond burrs. rt

Closure of wound
The mastoid mucoperiosteum is reposited'
some surgeons advocate the use of a drain,
and brought out from the mastoid tip. inserted into the antrum
ihe cavity heats byi";;;;;;-or nony granutation
of skin is acheived and a tight masioid tissue and fibrosis. ctosure
Orressing is given.

POSTOPERATIVE
1. Antibiotics, Decongestasts
2. Drain removal after discharge stops
3. Suture removal on seventh day.
 \
,{
\
Section lll- Operative Surgery - Cortical Mastoidectomy
a
\
COMPLICATIONS n'
\
Damage to structures
fri'
a. Dural plate No treatment is required or \
Bridge the edges with a graft
- Temporalis fascia q
- Temporalis muscle
r CSF leak: E
o Repair the tear with temporalis muscle / fascia graft with post-operative :

r--flssfl high Position \

- Avoid straining i coughing \
c. Lateral sinus . Massive bleeding occurs which is treated as follows :
\
- Pressure Pack the site {
- Arrest haemorrhage with surgicel \
- Bridge the gap in sinus plate with bone wax' ri
- Pack the mastoid cavity with an antibiotic soaked roller gauze which is removed
graft is put' \
Lateral r Cou"|. the fistula with bone pate' (bone dust + blood) over which a tissue
semicircular canal i
Facial nerve o Partial cut : suture
o Complete cut without a gaP : suture !
r Complete cut with a gap :

- Nerve graft
t
rt

Jlre tone audiogram : Persistent post-operative conductive hearing loss'

\
2. Dislocation of lncus
- lmpedance audiogram : Disruption of ossicular chain Ft
- Reconstruction of ossicular chain may be required'
3. Persistentotorrhoea Causes of persistent otorrhoea are :
\
o lncomplete exenteration of infected cells
r lnfection of residual cells. q
Treatment :

!i
- Reopening of mastoid and exenteration.
- Antibiotic theraPY
I

i
6,
t

I;.-. '. -*i+E# s e:+..F?..:'-i*+];#*!nr:{

r^
n
F
r
3. SEPTAL SURGERY

rr HISTORY OF SEPTAL SURGERY

n
rr
Metzenbaum (1929)
OPERATION
Devised the operation for caudal dislocation
of the septum
o He compared caudal deviation of the
septum to a swinging door, with a
hinge on one side and free edges
on the rest

r Peer (1937) Operation for caudal deviation of the septum.

o

o
ln the Metzenbaum operation, the
hinge was produced by an incision
at the level of the deviation
Devised the principle of cartilage ex

F
r o
cision followed by cartilage repla
ment

rr
Excised the deviated caudal seg-
ment and inserted it / other grafting
material as a free graft
Galloway (1946) Extended Peer's principle to the septum Removal of entire nasal cartilage a

rr
replacing the anterior septum with
the free cut cartilage
Fomon (1948) Septal removal followed by septal replace- o Use of small autografts
Rees (1986) ment
r Mobilization and repositioning of se-
ptal cartilage

F
ubin (1983) Cartilaqe morselization o Dgviated septum is crushed with a
\

rrr
morselizer
. New flattened cartilage may rem
on a permanent'basis

r
F
l*
I:
I:
274

l- '* +,--. .a1?; :i;*.j,+r:.. =r

:' a;.-=-€:. :+
 4. SUBMUCOUS RESECTION OF THE
SEPTUM (SMR)
Definition
It is an operation in which the deviated cartilage is removed submucosally. It is done for deviations posterior to
the Cottle's Line.
Cottle's Line
INDICATIONS
It is a vertical line joining nasal
'1. symptomatic deviated nasal septum (headache, nasal obstruction, epistaxis)
process offrontal bone to nasal
All septal devrations posterior to the imaginary line joining nasal process of process of maxillary bone
frontal bone to nasal spine of maxilla are treated by SMR.
2. Complications of deviated nasal septum like recurrent sinusites, headache, middle ear infections etc.
3. As an approach to the sphenoid sinus, pituitary gland and vidian nerve.
4. To obtain graft material (nasal cartilage, vomerine bone) for rhinoplasty, plastic surgery of ear etc.
-5;
'As a treatment for heriditary telangiectasia.
Here the mucoperichondrial flaps are elevated and repositioned to
cause frbrosis and prevent epistaxis.
fr
6. For closure of septal perforation
7. As an access for endoscopic sinus surgery -t
B. As an access for removing polypii
9. As an access for ethmoidectomy
1 0. As a part of septorhinoplasty
'11
. Before palatoplasty

CONTRAINDICATIONS
I Absolute lr

1. Bleeding disorders
2. Age less than 1B years as
e Ossification of vomer is not complete and \
r Developrnent of face is incomplete till then
II Relative
'1. Acute rhinitis
2. Acute sinusiiis
3. Lcwer respiratory tract infection
4. Hypertension
5. Diabetes mellrtus
6. Tuberculosis

PREOPERATIVE \
ANAESTHESIA
Locai anaesthesia is used as it is performed rn aduits mainly
Advantages of local anaesthesia : \
a) Paiient is conscious
b) Bleeding is less -a
rq
275

{ oo
(!' (,ro
o o o
N N N N
il !t ,I I lt
NN
ltil
*i€d*$*=
llllltIII t?
,o
qeiq{qe<
rJi-
OooOCDOTOO
1lllIltilltlI
;sss g;
= il

s ON
OA NJ O,OCo-f.-<nSOru-
 276
ClinicalENT

c) Air blast or relief of nasal obstruction can be checkedon table after correction of deformity.
Patient is sedated with 1ml of Fortwin with 1ml of Phenargan
diluted to '10 ml given intravenously slowly.
The nose is packed with gauze strips dipped in 4% lignocaine
witn 1:1,00,000 adrenaline for ten minutes prior
to surgery.
ln the operation theatre, the packs are removed
followed by infiltration of the submucoperichondrialplane
and nasal froor with 2ok rignocaine with 1 :1
,00,000 aorenaline sorution.
Advantages of infiltration
'1. lt creates a plane submucoperichondrially
2. Tissue planes are thus easily elevated
3. Bleeding is less
4. Provides local anaesthesia.
General anaesthesia with endotracheal intubation
and throat packing is done for uncooperative adults
indicated children. rt is usefur if rhinoprasty needs and in
to be carried out.

POSITION
Supine position with the head minimally extended.

lNclstoN
An incision is made Smm F-ehind thg anteriorfres
made on the concave sioe oitne naiaGeptum
edge of the naggllgglg(KilliglL!.,Igition). tt is preferabty
rorE-ett* uis*ffiron and more operative space.
The mucoperichondrial flap on the side of the
incision is elevated with the help of a Freer,s elevator.
of elevation is the submucoperichondrial plane. The plane
lt is a relatively white avascular plane. lf elevation
correct plane, there is minimarbreeding and erevation is made in the
is smooih.
An incision is then made on the cartilage through
its entire thickness leaving a caudal strip of the
mucoperichondrium on the opposite side ihould septum. The
nlt oe incised. Through this in-cision, the mucoperichondrialflap
on the opposite side is elevated' The mucoperiosteal
flaps over the bony septum ,nJ tn" maxillary crest
elevated on both the sides' A Killian's sellretaining are
nasal speculum is inserted on the sides of the
small nick is made on. the edge of the septal cartiiage septum. A
z-g;m berow the roof of the nose. The blade of the
Ballenger swivel knife is inserted in this niik and
the t<nite is moved backwards, downwards and forwards.
septal cartilage gets separated in one piece The
and is removed with Luc,s forceps.
. The Killian's nasalspeculum is removed and the flaps are brought Advantages of using eattengtswivel
to the midline' The incision in the mucoperichondiiar
frap is Ju- kru.fu
tured with 3-0 chromic catgut. The nasar air
brast can be checked
o Cartilage comes out in one piece
on table on a tongue depressor, o The cut edges of the cartilage are smooth
Both the nostrirs are packed with roiler gauzedipped
in riquid pur#in
POSTOPERATIVE
o Antibiotics
o Anti-inflammatoryanalgesics
o Tincture benzoin inhalation four times a day to humidify air breathed
in through the mouth
o Condy's gargles to prevent halitosis.
r Nasalpack removalafter4g hours.
o Liquid paraffin nasal drops four times a day to loosen crusts after pack
removal.
 ,nil

T
Section lll- Operative Surgery - Submucous Resection Of The Septum (SMR)
l
COMPLICATIONS

I. lmmediate
lI
a. Primary haemorrhage

b. Trauma to surrounding
stru ctu res
This occurs from maxillary crest area. lt is controlled by adrenaline packs, electro-
cautery or use of bone wax
Damage to mucosa, mucoperichondrial flaps and turbinates can occur. I
:1
c. Anaesthetic complications Cardiac arrhythmias, hypedension, sensitivity to Xylocaine.
IL Delayed
a. Reactionary haemorrhage It occurs by 48 hours of surgery.
1
Causes :
:1
o Effect of adrenaline wearing off
o Rise in blood pressure after coming out of general anaesthesia (if given).
:''l
It is treated by tight anterior nasal packing.
:''l
b. Secondaryhaemorrhage It occurs 48 hours after surgery and is caused by infection.
Treatment
-'l
o Repacking of nose
o Change of antibiotics I
c. Septal haematoma It is accumulation of blood between the two mucoperichondrial flaps. Excessive
accumulation of blood can cause pressure necrosis of the underlying cartilage as :l
-r\
it is depleted of its nutrition from the perichondnum. lt is treated by drainage of the
haematoma by making a nick in one of the mucoperichondrial flaps followed by \
insertion of a long wick in the space and anterior nasal packing.
d. Septal abscess It is collection of pus in between the flaps and is due to infection of the haematoma. -t!
It can give rise to fever, severe throbbing pain, nasal obstruction and intracranial -l
complications, if untreated
It is treated with urgent incision and drainage, putting a wick in the space and
]

i
t:
intravenous antibiotics and analgesics.
:
e. Septal perforation It occurs if both the mucoperichondrial flaps are torn at the same site
f. Flapping septum This condition occurs if excessive nasal mucosa is left behind after removal of a :
grossly deviated septum. The mucosa sags on one side on lying down and makes
a flapping sound on respiration. :'l
g. lnfection lnfection of the nose or paranasal sinuses can occur if the packs are kept longer
tl
h.

i.
than 48 hours or if drainage of the sinuses suffer.
Synechiae and adhesions These develop between the septum and lateral nasal wall resulting in nasal
obstruction. They are cut and a silastic sheet is inserted in between the raw areas.
External nasal deformity The operation can result in a saddle nose deformity, columellar retraction etc. if
II
the cartilage at the roof and the caudal strip are not preserved. -r!

.l\
l''l
:'1
l'l
:1
-']

I
n
n
t: 5. SEPTOPLASTY
n
n
H Definition :
It is an operative procedure in which the deviated part of the septum is corrected by removalof
bony and/or

r" cartilagenous septum. lt is carried out for deviations anterior to the Cottle's line'

INDICATIONS

F 1. Symptomatic deviated nasal septum

2. Complications of deviated nasal septum like recurrent sinusitis, epistaxis, headache, upper respiratory tract

I^ infection.

I- 3. As a part of septorhinoPlastY.

n
n
CONTRAINDICATIONS
I Absolute
1, Bleeding disorders

l.
n ll
2. Age less than 1B years
o
o
Relative
as
Ossification of vomer is not complete and
Development of face is incomplete till then

1: 1. Acute rhinitis

t:
I:
2. Acute sinusitis
3. Lower respiratory tract infection
4. Hypertension

n
n
5. Diabetes mellitus
6. Tuberculosis

t:
ANAESTHESIA
anaesthesia. ln uncooperative patients, in children and in cases where a rhino-
It is usually done under local

t:
plasty would be carried out, it is done under general anaesthesia'

t:
n
POSITION
Supine position with minimal head extension'

n
lNclsloN
Freer's incision : A unilat_e_ral hemitra_nsfixation incision is made at the l9we1 !-orQgr g[*t[e-geOt{,cqrlpqe_

n
r
Advantages of the incision
1.
:

Th.e incision is in a relatively avascular plane

2. Mucosal edges are thick and tough, therefore less chances of a tear
3. lt provides good access to the whole of the septum, caudal border, anterior nasal spine
crest.
and the premaxillary

tr 3[ Theincision can be extended to the opposite side producing a full transfixation incision, which can be used for
a rhinoplasty.

IT 278

I:
r^
 I
Section lll
-
Operative Surgery - Septoplasty 279
I
The incision is deepened, including the perichondrium. Elevation of the submucoperichondrial plane is done
with a Freer's elevator. lI
l
Exposure
The subperichondrial plane is elevated to expose the cartilagenous and bony septum. The mucosal flap is
elevated on one side only ie; usually the concave side. The opposite mucoperichondrialflap is maintained.

Advantages of elevation of a unilateral mucoperichondrial flap :

:
\-4<"lt ensures the viability of the cartilage
2. lt reduces the chances of :
o Septal perforation \
o
t]
-l
Septal abscess
o Septal haematoma "l-l
o Overriding of segments of cartilage. trr'!

Difficult flap elevation \

o
o
lt is encountered in cases with variation of anatomy.
lt occurs at junction of septal cartilage above, anterior nasal spine, premaxillary crest and vomer below. I
\ir-- Most iatrogenic perforations occur along the chondrovomerine suture.
i
PROCEDURE
\
After elevating the mucoperichondrial flap from the concave side, the cartilagenous and bony septaljunction is
identified and punctured with a Freer's elevator. The posterior edge of the cartilage is separated from the bony \
septum and the inferior edge is separated from the maxillary crest on the concave side. Once the cartilage is free,
the opposite side mucoperiosteum is separated from the bony septum and the deviations of the bony septum are \
removed with Luc's forceps. The deviations of the cartilage if any, are corrected by resection or cross-hatching of
the cartilage. The maxillary crest is then removed. The mucoperichondrial flap is repositioned and the rncision is
sutured with 3-0 chromic catgut sutures. Both the nostrils are packed with roller gauze dipped in liquid paraffin.
\
\
POSTOPERATIVE
o Antibiotics \
o Anti-inflammatory analgesics
o \
Tincture benzoin inhalation four times a day to humidify air breathed in through the mouth
o Condy's gargles to prevent halitosis. \
o Nasal pack removal after 48 hours.
o Liquid paraffin nasal drops four times a day to loosen dry crusts after pack removal. \
COMPLICATIONS
\
o Anaesthetic complications \
o Haemorrhage : primary, reactionary or secondary
o Trauma to surrounding structures \
o Synechiae formation
o Persistence of nasal obstructron.
\
\
\
\
I
\
q
E,
n 280

SUBMUCOUS RESECTION SEPTOPLASW

ClinicalENT

F o
o
o
Usually cartilage is removed in this operation
Flaps are elevated on both sides of the septum
Risk of septal perforation is higher
o
o
o
Usually bone is removed.
Flap is elevated on one side of the septum.
Chance of perforation is less

tr
o , Septal haematoma and abscess can occur o Chance of haematoma and abscess formation
is less.
o Cosmetic complications like supratip deformity, columellar r These cosmetic complications are less.
retraction and saddle nose deformity are more

tr
o Cannot be combined with rhinoplasty o Can be combined with septorhinoplasty.
o Revision surgery is difficult o Revision surgery is relatively less difficult.

F
n
rH
tr
F
tl

F
n
+
-
t
t:
4\

F
t:
r
 T
t\
6. ANTRAL PUNCTURE *l
I
..1

:
It is a procedure in which.lavage of the maxillary sinus is carried out with a trocar and cannula inserted through \
the inferior meatus.
:
INDICATIONS
Diagnostic
\
1.
2.
To confirm diagnosis of chronic maxillary sinusitis. i
To examine ihe returning fluid for bacterial culture, antibiotic sensitivity and malignant cells.

Therapeutic
i
.a
'1. Lavage in chronic maxillary sinusitis \
2. Acute maxillary sinusitis not responding to conservative measures
3. Atrophic rhinitis causing sinusitis. -
CONTRAINDICATIONS
i
'1. Age : lt is not indicated in children under 3 yrs. of age as the sinus is very small.
\
2. Acute maxillary sinusitis : lf performed in acute cases, it results in flaring up of inflammation, osteomyelitis and
increase bleeding. \
3. Systemic conditions like
o Hypertension \
r Diabetes mellitus
\
o Bleeding disorders
!
PREOPERATIVE
o Nil by mouth for 4 hours before the procedure \
o lnjection Atropine 0.6m9 intramuscularly % hour before the procedure to prevent vasovagal attack
!
o lnjection Tetanus toxoid 0.5 ml intramuscularly before the procedure.
c Written informed valid consent \
ANAESTHESIA r!
Local anaesthesia
I

It is given using three swab sticks dipped in 4% Lignocaine with adrenaline (1 :2,00,000) placed at the following
\
sites for ten minutes :
\
a) lnferior meaius - for anaesthesia of superior alveolar nerve
b) Middle meatus - for anaesthesia of sphenopataline ganglion and its branches \
c) Roof of nose - for anaesthesia of anterior ethmoidal nerve.
\
General anaesthesia
It may be required in children under 12 yrs. of age and in uncooperative nervous adults. The endotracheal tube \
is passed through the mouth.
\
POSITION
Supine position
i
\
281
i
 282
ClinicalENT

The Tilley-Lichwitz trocar and cannula and the Higginson's syringe

are inspected. The
trocar should be sharp
and its tip should proiect 3mm. beyond the cannulalrne trocar should
easily slide in and out of the cannula.
The patient's head is steadied and the trocar and cannula are
held in the left hand for a left antral puncture. The
site of puncture in the inferior meatus is visualised with a Thudicum's
nasal speculum. The trocar and cannula (the
cannula covering the point of the trocar) are then inserted in
the inferio, r"uir, rf ong it, lateral wall, nearer to the
roof than the floor,
The tip is pointed in the direction of the tragus of the ipsilateral
ear. with a genle boring motion and moderate
pressure after withdrawing the cannula so that the
trocar protrudes out, the t-rocar is made to pierce the medial
wall of the antrum' There is a sudden feeling of give-way
as the trocar and cannula enter the antrum. ln the adult,
the ideal point of entry is 3.Scm posterior to the laterat
eOge of the vestibule. This point lies behind the nasolacri-
duct and pierces the thinnest area of the bonywallof"the meatus
-'mal
moves in all directions and does not fall back.
(Robsmith). A properly positioned cannula

. A Higginson's syringe filled with sterile normal saline at 370c is attached to the cannuta. The patient is asked
to bend forwards, flex his neck and breathe through his
open mouth. The antralwashout is carried out by com-
pressing the syringe' The fluid from the syringe pirr"s
tl-rrough the cannula to the antrum. lt flows out from the
natural ostium into the anterior nares, from where it
is collectei in a kidney tray. The washing is continued
returning fluid is clear' Thereafter the cannula is removed till the
and the nostrir is pactieo with a cotton pledget to prevent
oozing of blood' The returning fluid is sent for bacteriological/required
examination. The same procedure is re-
peated on the opposite side if indicated.

POSTOPERATIVE
o oral antibiotics depending on the character of the returning fruid.
o Anti inflammatory analgesic drugs.
o Nasal decongestants
COMPLICATIONS
1. Anaesthetic
o Vasovagal attack
o Hypotension
o Cardiac arrest
2. Surgical
r.-r,-Haemorrhage
L-c False passage into the cheek or orbit. Bulging of cheek
or proptosis results when a false passage is
created and water/air enter in.
t-o" Air emborism if air enters a ruptured vein accidenily from the
antrum
L-r Infsgli.r.
Difficulties that may be encountered at antral puncture
:
1. lnability to pierce bone with trocar and cannula
Reasons
a) Blunt trocar
b) Thickened bony wall in
r .,,-' Chronic sinusitis
,,
'y'-Atrophic rhinitis
2. No returning fluid
Reasons
a) Blockage of cannura reads to difficurt introduction of fruid itserf.
Section lll- Operative Surgery - Antral puncture
283

b) Blockage of natural ostium of the maxillary sinus. A second

cannula can be introduced besides the first to
enable drainage from the sinus
c) Cannula may abut against the wall of the antrum preventing fluid
from entering into the antrum.
It is withdrawn a little and then fluid can flow in smoothly.
d) A false passage may have been created in the cheek or the eye.
lntroduction of water results in proptosis
or swelling of the cheek. The cannula is withdrawn in such cases. lt
is again correcfly put in required cases
or the procedure may be abandoned.

!
i

!
rr
rr 7. C ALDWELL.LUC OPE RATION

I
rl: It is an operation in which an opening is
to visualise and remove disease from tf,e
made in the anterior wall of the maxillary sinus through
sinus.
the canine fossa

t:
It was described by caldwell from Newyork and
Luc from France.

PRINCIPLES
'l
I 2'
Removal of unhearthy irreversibry damaged mucosa
of the sinus.

l^
Tofacilitate aeration and drainage of the sinus
by creating an antrostomy.

I- INDICATIONS
'1. lntractable infection

I:
in the antrum
2. Non-resolution of chronic sinusitis following intranasal
antrostomy.

t:
n
3. Antrochoanal polyp in the antrum
4. Osteonecrosis, to clear debri
5. Foreign body in antrum (especially root of molar/premolar
teeth)

t:
6. Fracture maxilla reduction
7. Removal of dental cyst involving the antrum

n
I:
. -8. Oroantral fistula excision

9. Fungalsinusitis
'10.As an approach

r:
a) To pterygomaxillary fissure and sphenopalatine
fossa for lnternal maxillary artery ligatron and vidian
tomy. neurec-

I: b) To sphenoid sinus/pituitary for hypophysectomy.

Treatment of atrophic rhinitis :

n
11 .

Raghav Sharan operation : lmplantation

of maxillary sinus mucosa into nasal cavity

n
whittmack's operation : rmprantation of stenson's
duct into nasar cavity,
12. Orbital decompression for malignant
exophthalmos

l': 13.Jenson Horgan operation : Transantral

'{4.lmplantation of radioactive needles into
ethmoidectomy

n
the antrum for carcinoma of maxilla
t t of fracture of orbital floor by intra antrat packins.
tt is usefut for reduction of btow-out
F:".Y]:::,il: :l??:"t"tion

n
n
CONTRAINDICATIONS
1. Age below 12 years
Damage to second dentition results in hypoplasia

r- 2. Acute sinusitis
of maxilla

r: a
J.
operation on inflamed sinus leads to excessive
Diabetes mellitus
Hype(ensror''
bleeding, dissemination of infection and osteomyelitis

- Sleeiling drsorders

-
r: 2U
r:
hafs 3"&r
r ..n ari
<Qtse.e9{qEr I 6.-ijlat{OIOJ
Section lll Operative Surgery - Caldwell-Luc OPeration
285
II
-
PREOPERATIVE :t
ANAESTHESIA
anaesthesia tl
:I
Generai anaesthesia/Local , i -^^^r:^^ soaked cotton nlcdoetr
nnrrnn pledgets
with adrenaline ^^-r,ari
Local anaesthesia : surface anaesthesia is given with 4Yo Xylocaine

I
inferior turbinate'
placed in both nostrils ulout and below the
arong the gingivobuccar surcus in
the region of
rnfirtration anaesthesia
.. 2%Xyrocaine with adrenarine is injected the infraorbiial nerve'
siperiorlyto include
the canine fossa. The injection is continued

Generalanaesthesia
F$"rt:1ff;:Hffil,t"J:J1or.nu'u"v
is passed rrom the unarrected side'
Aoequate
t]
:1
POSITION
Supine position with 150 head high'
:'l
rNclsloN roots of the teeth lt extends
:I
gingivobuccal sulcus well (3 mm) above the
. A transverse incision is made along the runs for around 3 5-4 cms' :"1
iricisor to the second morar. fhe incision
from the rever of the raterar border of raterar i\

paralfe,l tb thei teeth. I

{
PROgEDURE periosteum' The perios-
ie;through the mucous memb.ane and the r_
The incision is deepened down to the bone with an elevator or with a
from the canine fossa up*ards 5-mm short of ir," infraorbitar canar
teum is then erevated prevent injury to the infraorbital nerve'
chiser and gauzepiece. The erevation is made as atraumatic as possibre to
avoid damaging the irrfraorbital
\
anJ the othe; superorateiatiy are useo to
Two retractors, one praced superomedially
nerye'Gentleretractionisessential.Theanteriorwalloftheantrumisthusexposed' \
Perforation of canine fossa :
curette' whatever method is \
a gouge and_hammer, rotating burr or
The canine fossa can be fenestrated with The openrng is enlarged
pruuuniJ"iiug-u to infraorbitar n"r* oi" tooth root. \
used, a fracture has to be avoided to the openrng is avoided
f6rceps. Lateraf and inferior extension of
with a bone punch, a burr or Kerrison bone-cutting
to prevent damage to the branches of
sprrenoputJtin" ariery anct roots of the teeth
from the bone margin which can be controtied
respectivery. Bleeding may occur
by using (errison forceps. The entrre contents
of the antrum are i
inspected. \
lnsPection of the antrum : L
olrreversiblydiseasedlining:Removedwithelevators,forceps,curette
oCystsandbenigntumours:Removedwithelevatorsandforceps -{
a bony canal Bleeding
from the roof as the nerve may not have
care has to be taken while dissecting mucosa
stops once all the diseased mucosa is removed.
After inspecting and removing disease
frorn the antrum' an i
intranasal antrostomy is performed' \
lntranasal antrostomY :

An opening in the inferior meatus of the size

of 1 .5 cm is made with rilley's antral harpoon'
lt can be enlarged
of the antral floor ancj the anterior
I
of *'" opening snoutJ Je at the iever
anteriorry by Kerrison forceps. The rower "nJ
end upto the anterior eno oiinrerior turbinatJ,
Enr"igii-.'g polteriorly can cause bleeding
from greater palatine artery'
ro|ler gauze to
i
packed with an 3ntibi:t]:':l:li"^1.^1:]'"') soaked
Following the antrostomy, the antrum is
achieve haemostasis and asepsis. *,e
pacx rJurougr,t out via the antrostomy opening
and
surcus
taped
which
to the cheek' The
herps in denture
i
Gooi approximation pr"suruur the
incision in the gingivobuccar surcus is croseJ.
fitting. The antrar pr"[ i, removed arter z+-hours.
An ice pack is kept over the cheek
postoperatively
in
to
the
prevent
antrum'
i
encountered
are indicated if purulent secretions are
oedema and haematoma formatron. Antibiotics
The nose is also Packed'
I
i

t
q
J
 286
ClinicalENT

COMPLICATIONS
lmmediate
1' soft tissue swelling : oedema of cheek and upper lip. lt is avoided by gentle retraction throughout
the procedure.
2. Haemorrhage
3. Pain
4. Damage to teeth
5. Paraesthesias over cheek (damage to infraorbital nerve)
6. Damage to orbitalfloor
7. Osteomyelitis of maxillary bone.
Delayed
1. lnfraorbital neuralgia
2. Dentalneuralgia
3. Oroantralfistula
4. Devitalisation of teeth
5. Recurrent sinusitis

MODIFICATIONS OF CALDWELL.LUC OPERATION

1. Denker's operation (1906).
The incision is similar to caldwell-Luc operation except that
it extends more medially upto the frenum ie;
approximately to the midpoint of upper lip.
Elevation of soft tissues reveals the anterior bony pyramid of the
maxilla.
A triangular piece of bone from lateral wall of nose and the
front of antrum is removed with removal of nasal
and antral mucosa.
This procedure thus creates a window for inspection of the
antrum and an anteriorly-placed antrostomy,
2. Canfield's operation (1909)
ln this operation, an incision is made behind the nasal vestibule. periosteum
is elevated to expose the
canine fossa through the incision. Anterior angle of maxillary
sinus (antegmedr"rfy+"*.rrsgfiSd off to expose
the sinus contents. The same opening is continued poster.iorly
into aqlfitnusulani..iry.
3. Mcneill maxillary sinus obliteration (1966) ..-..--.."..-... -.: ."/)
ln this operation, the maxillary sinus is obliterated with
abdominalfat after its mucous membrane lining is
completely removed. The incision, antral opening and closure
is similar to Caldwell-Luc operation.

CALDWELL.LUC OPERATION
o Sublabial gingivobuccal incision
o Elevation of soft tissues including periosteum
. Exposure of anterior wall of the antrum
o An opening made in the anterior wall in the region of the canine fossa.
. lnspection of antrum
o Removal of diseased mucosa or procedure carried out as per the indication
o Creation of inferior antrcstomy
o Haemostasis
o Closure
: 'Gen19 r?traction :ncl rrrotection of infraorbital nerve is maintained throughout the procedure.

H
r
 II
8. FUNCTIONAL ENDOSCOPIC SINUS
SURGERY
I:l
ThrsprocedureisarecentadvanceinsinusSurgeryinwhichblockageoftheostio-meatalunitisclearedto
establish drainage and ventilation of the
paranasal sinuses
I:l
Principle
Messerklinger's Principle
lr ctereq that c
'^inra: lt states that chronic
cells blockrng *re natural ostia in the middle
stnus dtsease ; primarily due to disease
tt

meatus leading to impaired diainage of the

rn the ethmoidal air
sinuses; predisposing :l
them to recurrent infection' ,:t
Therefore if the ostium of the diseased sinus
normal drainage ano ventitation of the ,in*
is no need to remove all diseased mucosa
,-.. -^*^.,^r ^{ Aioacco^

L i"-"stabrished uno diruured mucosa comes

as was thought earlier'

The mucociriary transport in the paranasal sinuses

aihmoidal air cells
by removarof diseased ethmoidaraircells'
is unbrocked surgrcaily
back to normal' There

occurs rn a genetically predetermined definite

pattern, trans-
II
:I
made as in maxrllary sinus
Thus a oepenoeni openlng
porting the mucus always towards the natural ostium. the antrostomy opentng
drarnage as the secretions circumvent
inferior antrostomy, does not resurt in adequate
and get transported towards the natural ort,rr.
atus area which is the key drainage site oi in"
ethmoidal air cells is removed by removal of tne
ay wai of functional endoscopic sinus surgery'
paranarat sinuses is visuarised and
a'ir cells, and ventrlation and drainage
its
of
brockage
the
the middle me-

frontal
by diseased
and maxillary I:'l
sinusisre-establlshed'Forthesphenoidsinus,diseaseinthesphenoethmoidalrecessissimilarlyremoved.
PathologY in chronic sinusitis :
Disease in ethmoidal air cells
II
u
Blockage of middle meatus ostia

--
Staqnatiorr of secretions in sinuses
"'"" "."
II
u
Secondarylnfection
* Lott
1l
of mucociltary clearance

Further blocking
II
Mucosal oedema
:'l
Polypus forqration
:1
Aim
II
I
ostia
1. To re-establish drainage through the natural
2. To restore ventilation
3. To restore mucociliary clearance
lndications of Endoscopic sinus surgery )
1. Chronic sinusitis
2. Recurrent sinusitis
3. Chronic slnusitis with orbital cellulitis t',tasat potyposis and chronic sinusitis
not
I
:'1
line of treatment are
4. Nasal PolYPosis
5. Mild fungal sinusitis
responding to medical
classic indications for FESS
ll-1
287
\
tl
l_
r"
r Clinical ENT

6. Concha bullosa - excision

F
t:
7. Partial turbinectomy
8. lnterior turbinate - bipolar cautery

rl^
9. Synechae release
'10. Epistaxis - cauterization
1 1. Dacryocystorhinostomy

rt:l^
12. Optic nerve decompression
13.CSF rhinorrhoea
14. Mucocoele removal
15. Pyocoele removal
I 6. Meningocoele removal
lT.Osteoma removal
18. lnverted papilloma excision

t:
19. Rhinosporidiosis
20. Hypophysectomy

t-
2'l.Vidian neurectomy
22. Adenoidectomy

l- 23. Sphenopalatine ganglion block

t:
24. Nasopharyngeal biopsy
25. Endoscopic septal resection

t:
t:
26.F acial recess examination
27 .Orbilal d ecom press io n
2S.Congenital choanal atresia surgery

t:
29. Foreign body sinuses
30. Blow-out fracture repair

t:
t-
31.Biopsy of tumours (postero lateral wall of maxilla)
32.lnspection of post-operative cavities (maxillectomy, craniofacial resection)
33.Removal of small nasopharyngeal angiofibromas.

l:
Contraindications

n
1. Aggressive fungal sinusitis (Mucormycosis)
2. Sinusitis with intracranial complications

n
t:
3. Stenosed frontonasal duct
4. Osteomyelitis of sinuses
Procedure

n Pre-requisites Anatomical variations

o Concha bullosa
C.T. scan of paranasal sinuses o Enlarged ethmoidal bulla

t:
l-
o
r
o
Axial and coronal views
To study anatomical landmarks before surgery
To study anatomical variations

PREOPERATIVE
o
o
o
o
Everted uncinate process
Paradoxical middle turbinate
Agger nasi cells
Haller cells

F Anaesthesia
Local anaesthesia/General anaesthesia

n
n
n
 lll- operative surgery - Functional Endoscopic sinus surgery
289
II
I
section

Advantages of local anaesthesia :

1. Bleeding is less
2. Pain during surgery is recognized ]
Undue pain at surgery is seen when :

:I
o
o
Dura is touched

I
I]I
Orbitalperiosteum is breached
lolion.2ok
Nasal cavity is sprayed with 4ok Xylocaine and packed with ribbon gauze soaked in Xylocaine
and the uncinate process'
Xylocaine with i:2,00,000 adrenaline infiltration is carried out rnto the lateral wall of nose
SLOtaUiat infiltration is carried out if the canine fossa is to be punctured'

OPERATION:
:I
Thorough endoscopic exarnination of the nose
A thorough endoscopic examination of the nasal cavity is done with a 300 endoscope.

reaching the choana, the eustaehian tube openings;and the nasopharynx are visualised
The endoscope is first
passed between the nasal septum and the inferior turbinate examining the whole cavity upto the choana
(First pass)' The
On
endo-
pass). lt is then passed
II
scope iJtnen passed along the middle meatus to examine any pathology there (Second
between the superior turbinate and the septum upto the anterior wall of the sphenoid sinus
(Third pass)'
l'l
Uncinectomy with lnfundibulectomy
An incision is given circumferentially just anterior to the uncinate process with a sickle knife using
telescope passeJ through the nose. Mucosa rs elevated and the uncinate process is carefully
Blakesley forceps and rJmoved by a twisting movement, exposing the infundibulum' This
procedure
Hopkins O0
grasped
is
with a
known as
I
r1
infundibulotomy. Alternatively, the uncinate proc"rs can be straight away grasped with a reverse
cutting forceps \
FI
tI
part exposes the frontal recess area'
and then removed. When the whole process is completely removed, the upper
The maxi!lary sinus ostium may now be visible in the lower part
Anterior Ethmoidectomy and Middle Meatus Antrostomy
fr:rceps' Ethmoid air
The bulla ethmoidalis - the largest of the ethmoidal air cells is now removed with Blakesley
cell exenteration is carried out within the said limits :
Superiorly
Laterally
Medially
. Upto the roof where the anterior ethmoidal artery is identified'
: Lamina papyracea (medial wall of the orbit)
: Crrbriform plate"
II
from
Ground lamella-posterior bony attachment of middle turbinate, which separates the middle
Posteriorly :'1
II
:

the Posterior ethmoidal cells

Ethmoid cell exenteration has to be done within the said limits otherwise laterally the orbit
may be entered
papyracea and superiorly the cribriform plate with the dura can get damaged leading to CSF
breaching the lamina

II
leaks.
The maxillary ostium if stenosed is enlarged Stankwicz Sign
terrorly by using backbiting forceps. movements of periorbital ti
ressure on the eyeball transmits
Posterior enlargement is avoided to prevent dam- or fat to the nasal cavity if the lamina papyracea is breached'
age to branches of sphenopalatine artery.
Exploration of the Frontal Recess
The frontal recess is explored after removal of the anterior ethmodial cells, agger nasi cells
upward biting forceps.
with a 300 telescope and Il'l
After removing anterior cells the opening of the frontonasal duct is seen which is cleared by removing
rnucosa around it.
The frontal sinus is clearly visible only after removal of the cranial extension of the uncinate
process'
the diseased

ethmoidectomy
It]
Some surgeons prefer to keep the bulla intact, clear the frontal recess first followed by an anterior
t]
I
-1
 290
ClinicalENT

Posterior Ethmoidectomy and Sphenoidectomy

The posterior ethmoids can be reached after opening the ground lamella
with the tip of Blakesley,s forceps. The
course of the ground lamella is followed with the enoosiope and part it
of is removed.
The bulge of the sphenoid is evident in the infero-medial aspect of the
mosi posterior ethmoid cell and is opened.
Any pathology in the sphenoid sinus is removed under direct vision
because of the close relationship of the nerve
and internal carotid artery to its lateral wall. The sphenoid sinus can
also be approached from the posterior end of
the superior turbinate where its ostium lies.

Direct visualization of maxifiary sinus

The canine fossa is punctured with a trocar puncture and a 300
or 700 telescope is used for visualization.
The maxillary sinus can also be visualised through its widened
ostium.
The ethmoid cavities are packed with gelfoam.
The nasal cavities may be packed if required with a BIPP or
merocel pack, to be removed after 2 days.
Nasal douches are given after removar of packs to remove any
crusts.

POSTOPERATIVE
o Antibiotics
o Anti-inflammatoryanalgesicdrugs.
o Pack/merocel removal after 4g hours
r Nasal washes to remove crusts and prevent adhesions.
o lntranasal steroid sprays for indicated cases.
o Follow-up nasal endoscopy.
Nasal endoscopy is done post-operatively
1. To check healing of the ethmoid cavity
2. To remove any secretions and blood clots
3. To break any synechiae
Complications
o Haemorrhage
r Cerebrospinalfluidleak
o Blindness (damage to optic nerve)
o Diplopia
o orbital haematoma (damage to anterior ethmoidal artery and retraction into the orbit)
o Orbitalsurgicalemphysema
o Injury to internal carotid artery
o lnjury to nasolacrimal ducUEpiphora
o Synechiae
r Antrostomy closure
o Toothache
o lntracranialhaemorrhage
o Pneumoencephalous
o Brainabscess/Meningitis
DEGREES OF ENDOSCOPIC SURGERY
Ciliary activity present. Widening of ostio meatal unit
Associated Ethmoidar porypi. rntranasar Ethmoidectomy.
widening of ostia
Frontal sinus involvement also. The frontoethmoidal and
maxillary sinus are converted to one cavity.
to thu frontoethmoid and maxillary cavities
"t"d
 9. RHINOPLASTY
- Dr. Uday Bhad

Rhinoplasty : To mourd the nose in an aestheticaily preasing shape.

Septoplasty : To change to shape of the septum to achieve functional improvement.

INDICATIONS
The basic indication is the patient's desire to have an aesthetically pleasing
nose and the ability of the
surgeon to deliver the desired resuits withrn surgical and anatomical
constraints.-
commonest deformities of the nose that are treated by rhinoprasty
are :
1. Saddle nose : depressed nasal dorsum requiring augmentation
2. Humped nose.
3. Crooked nose.
4' Tipdeformities:lnadequatetipprojection/definition(roundtip),bifidtip,boxytip,flarednostrils.
5. Cleft tip nose.
6. Postraumatic / surgical deformities
I
CONTTIAINDtCAT|ONS
'1. Anatomic unsuitability. I

,1. Emc tional inadequacy.

I. Medrcally unlit.
4 Rela tive cont"aindication is a young patient (prepubertal)
A natomy
1 . Bony v;ul -Nasal bones, frontal process of maxilla.
t
2. Carti agenous vault - Upper lateral cartilages. \
3' Tip : Low:r laterarl cartilages (alar cartilages), accessory cartilages, fibrofatty tissue.
4. Septt n : t
Bony .,a,'ts
ri
a. Pe"penr,icular plate of ethmoid
b. Vo-ner E
c. Cre.st of maxilla anci palatine bones
Cartilage,rouspart : quadrangularcartilages q
Membranous septum : between caudal border of septum and medial crura of alar cartriage t
\
Sensory innervation (for local anaesthesia) :

o External nose : Anterior ethmoidal nerve, branches from nasociliary, infra orbital, \
infratrochlear
and supratrochlear nerves.
o lnternalaspects : Branches of nasociliary nerve and sphenopalatine ganglion \
PREOPERATIVE \
Clinical exarnination
'l Exierrsl : The nose has to be viewed fiom the frontal, profile, \
oblique and worm,s ey* view (from below)
2 lnt:rr'al : The septurn, vestibule, valve area, posterior choanae and the turbinate size have \
to be seen.
q
291

t
 292
ClinicalENT

3' To determine what is unattractive above the nose

eg : a hump, inadequate projection of dorsum, alar flare,
round tipetc.
The operative plan is made after clinical examination, surface
measurements and photographic analysis.

ANAESTHESIA
Most surgeons prefer hypotensive general anaesthesia.
lt can be done under local anaesthesia.

POStTtoN
Supine position with neck extension by a pillow under the
shoulder and minimal head high tilt.

OPERATION
It is divided into five components :

Component I :
Exposure
a) open approach a bilateral rim incision is taken which is connected by a transcotumeilar
' l:].li::pproach
tnctslon.
Advantages of an open approach :
a) lt gives excellent exposure to the entire nasar framework.
b) lt preserves the tip-septal angle relationship
c) lt makes it easier to operate on the tip.
lndications of an open approach :
'1. For revision rhinoplasty
cases
2. When the surgeon is relatively inexperienced.
b) closed approach the use of a rim incision, inter-cartilagenous and intracartitagenous
' ll:l:ll!
ton tnctstons.
transfix-
Rim incision : lt is useful to approach the tip.
lntercartilagenous incision ; lt gives excellent exposure for the bony and cartilagenous
dorsum
lntracartilagenous incision : lt is useful when cephalic trim of the cartilage is indicated.
Through the alar
cartilage, the portion of the cartilage cephalad to the incision
is r6moved.
Advantages ofa closed approach :
r lt avoids a transcolumellar scar

Disadvantages :

1. lt gives poor exposure

2. lt is difficult to approach the tip through this procedure
3. The transfixion incision disturbs the tip-septar angre rerationship.
Component ll :
ln tl"ris step' degloving of the skin from the bony
and cartilagenous septum is carried out. The entire skin
the dorsum has to be degloved as the loose skin of
evenly drapes"over the changed framework.
Component lll :
ln this step, modification of the bony and cartilagenous
dorsum is carried out by :
a) Reduction / augmentation
b) Narrowing of the vault
a) Reduction : ln this step, removal of the cartilagenous hump is done with
a knife / rasp. Removal of
bony hump is done with an osteotome or a rasp. Removal
by a push-rasp is safer.

H
E
Section lll
-
Operative Surgery' Rhinoplasty
293
II
b) Augmentation : Most lndian patients require an augrnentation rather than a reduction. :'l
Materials used'for augmentation are :
i) Cartilage :
:''l
Septal/ conchal.
dorsum as it is straight in :"1
Septal cartilage is in the same operative field. lt is the best material to augment the
shape and has least chances of resorption. Also the septum can be corrected in the same step'
:1
ii) Bone
a) lliac crest bone : lt can be sculptured into a desired shape and large amounts can be harvested' There :']
are chances of resorption, which may be uneven producing deformities'
b) carvariarsrafr harvestins requires speciar instru- :'l
[:il::j":;ffi?ffi._."llii3Tli,i;,lo*"u"'its :''l
iii) lmplants \
o They can be of silastic or portex material
o They are available in different shapes and sizes \
o lt requires extreme aseptic precautions for insertion'
\
o lt is ideally not to be inserted through an intranasal incision'
o lt should not be used along with major nose work like osteotomies etc' \
o There are chances of infection and extrusion.
However implants are tolerated well by lndians than caucasians. \
c) Narrowing of the vault : \
It is always necessary along with hump reduction to close the open-roof.
It is achieved bY :
\
i) Lateral osteotomY :

pyriform \
It may be external (transcutaneous) with a 2mm. osteotome or internal along the edge of the
apert:ure. The frontal process of the maxilla is broken along a line joining the ala to a
point approxi-
mately 5mm. medial to the medial canthus \
ii) Medial osteotomy and out fracture :

It is done on either side of the bony septum (perpendicular plate of ethmoid) with a B-10 mm' os-
\
teotome to separate the nasal bones from septal attachment. At the end, the osteotome is swung
laterally to break the superior attachment of the nasal bones with the frontal bone (out-fracture).
n
ln-fracture : The loose nasal bones are compressed along the line of lateral osteotomy so as to \
achieve a medial shift and narrowing of the vault.

Component lV : TiP work. -f

A drooping tip can be corrected bY :
\
a) Cephalic trim of alar cartilage
b) Hitching the alar cartilage to the septum \
c) Excision of caudal sePtum
d) lnvagination procedure-the septal angle is invaginated between the two medial crura and domes and su- \
tured.
e) Umbrella type tip graft.
\
A boxy tip can be corrected bY :

\
1. Scoring the domes
2. Dome transection \
3. Tip graft.
\
i
\
\
,d
rr:
rr^
ClinicalENT
294

An inadequately projecting tip can be corrected by :

1. Scoring or cross-hatching the domes

2. Umbrella graft or an onlay graft'

n The flaring of the ala can be corrected by alar wedge resection.

Gomponent V : Closure and sPlintage

l:" Closure is achieved by 4-0 absorbable sutures.

n Nasal packing is usually not required unless extensive septal work has been
The nasal dorsum is covered with an adhesive tape. The tip is splinted to
adhesive tape. Splintage with Plaster of Paris is indicated in cases
maintained for one week.
of
done'

onlay
the dorsum by a 'u' shaped
grafting and osteotomies' lt is to be

F Ancillary proceclures : These are procedures to improve the profile and harmony
of facial features along with a

n
I-
rhinoplasty:
i) Forehead augmetation or reduction.
ii) Malar or chin imPlants
iii) Genioplasty.

I
t:
l:
t:
t:
n
t:
F
t:
n
I:
n
t:
t:
n
tr
t:
n
r
 \
'l
\
\
10. ADENOIDECTOMY A
n
\-
is an operation in which the nasopharyngeal lymphoid tissue-adenoids is removed surgically. \
rs usually performed along with a tonsillectomy.
\
INDICATIONS
1. Persistent or recurrent enlargement of adenoids leading to
\
. Severe nasal obstruction \
o Mouth breathing
o Adenoid facies \
o Nasal discharge
o Obstructive sleep apnoea
\
o Failure to thrive \
2. Secondary infection giving rise to
o Otitis media \
o Bronchitis
\
o Cervical adenitis
\
CONTRAINDICATIONS
1. Blood dyscrasias \
i) Haemophilia
ii) Purpura \
iii) Leukaemias \
2 Submucous cleft palate. ln there cases, velopharyngeal insufficiency can develop postoperatively
as the
adenoids help to close the velopharynx \
3. Upper respiratory tract infections . t
4. Systemic disorders
o Hypertension \
r Diabetes mellitus

5.
o Tuberculosis
o Anaemia
Epidemic of polio. (rare nowadays)
II I

\
Adenoidectomy is performed only in children as the adenoid tissue undergoes atrophy
berty' lt can be done in children under 5 yrs. of age where tonsillectomy is
coritraindicated
by the age of pu-
.l
\
PREOPERATIVE -l
:'l
ANAESTHESIA
General anaesthesia with orotracheal intubation.
performed in children.
lt is always performed under general anaesthesia as it is
Il'l
:1
295
tl
:1
*1
 296
ClinicalENT

POSTTTON
Supine position with less extension than that for tonsillectomy ie; Rose's position
with less extension of neck
The reduction in extension is to prevent damage to atlanto-occipltatloint
ouiing curettage.

PROCEDURE
Palpation of nasopharynx
Under general anaesthesia, after application of a mouth-gag
an index finger is passed behind the soft palate to
ASSESS
o Width of nasopharynx
o Size of adenoids
o To feel any abnormal pulsations
o To push adenoids medially
lnsertion of curette
The broadest adenoid curette has to be selected to fit in the postnasal Methods of Adenoidectomy :
space
without encroaching on the eustachian tube orifices. After palpaiion Using adenoid curette
of adenoids,
the tongue is depressed and the adenoid curette, held like pen Using adenotome
a is passed into
the oropharynx just behind the soft palate. lt is passed Finger dissection (in the past)
with
the blade facing the
footend. once it reaches behind the uvula, it is rotated
by 1800, thus facing
superiorly, without damaging the uvula and posterior pharyngear
wail.
Curettage of adenoids
Now the grip is changed to that of a dagger and the adenoid
curette is brought in contact with the posterior
edge of the bony nasalseptum. lt is ensured that the curette
is in the midline und then the adenoids are shaved
away with a sweeping downward movement of the wrist,
maintaining a constant steady pressure. The curettage
should not be too deep as it may injure submucosal vessels
running horizontally at the junction of roof and
posterior wall of nasopharynx' The whole adenoid
mass is thus shaved off with tne otaoe of an adenoid curette
with cage' The cage prevents the adenoid tissue or its
fragments from falling into lower respiratory tract. Alterna-
tively, the central mass of the adenoid is removed with
a curette without a cage and the adenoid is delivered out
of the oropharynx with Luc's forceps. The remaining lateral
masses are removed with a smaller curette.
Haemostasis
Following removal of the adenoids, an adenoid pack made
of rolled up gauze is put in the postnasal space to
achieve haemostasis' lt is left in place for 4-5 minutes if only
adenoidectomy is to be performed, (lf adenoidec-
tomy is combined with tonsillectomy, the pack is left in the postnasal
space, till the whole procedure of tonsillec-
tomy is completed and removed thereafter).
After the adenoid pack is removed, the nasopharynx is palpated
for any adenoid tags. lf tags are present, they
are removed using a smallsized adenoid curette oia tui's
forceps or a conchotome.

COMPLICATIONS
1. Haemorrhage
a) Primary haemorrhage occurs at the time of surgery. lt is due to :

o Adenoid tags
o Deep curettage leading to damage to pharyngeal mucosa
Adenoid tags if present are removed followed by repacking for a
while. Damage to mucosa may
require repacking for a longer time or rarely a postnasal pack
which is to be removed within 4B hrs.
lntravenous antibiotics need to be given arong with the packing.
Also the soft palate can be retracted with retractors or with two
simple rubber catheters passed
through the nose and brought out through the oral cavity and any
bleeding vessel is looked for. A
bleeding vessel high in the nasopharynx ii detected by flexing the patierrt's rrJao
so that the nasophar-
ynx is no longer dependent' Bleeding points can
be cauterized with a silver nitrate stick or with electro-
cautery.
 \
.-l
Section lll
-
Operative Surgery - Adenoidectomy 297
I
b) Reactionary haemorrhage
trol.
c) Secondary haemorrhage
occurs within 12 hours of surgery and may require a postnasal pack for con-

occurs due to sepsis between 5-'10 days. lt requires intravenous antibiotics,

lI
styptics, sedation followed by postnasal packing if bleeding is not controlled. Blood transfusion is required
in rare instances.
2. Trauma to surrounding structures
a) Eustachian tube openings leading to fibrosis and secretory otitis media.
II
b) Palate
c) Uvuta :'1
d) Tongue
:'1
e) Teeth
3. lncomplete removal leading to persistence of symptoms. :'1
4. Otitis media due to spread of infection to the middle ear via the eustachian tube
5. Subluxation of atlanto-occipitaljoint due to trauma, infection, decalcification of verterbra or laxity of ante-
:'1
rior vertebral ligament.
\
6. Hypernasality due to velopharyngeal insufficiency, especially if performed in patients with a submucous
7. Aspiration pneumonia due to aspiration of blood and secretions into the respiratory tract.
cleft.
i
B. Torticollis occurs due to damage to aponeurosis of vertebrae or prevertebral muscles \
9. Secondary atrophic pharyngitis can occur if excessive pharyngeal mucosa is stripped off during adenoid \
curettage.
\
\
\
i
i
\
i
\
\
\
\
\
\
\
\
-I
\
!
b. i
 11. TONSILLECTOMY
_+--_---

Definition
It is an operation performed for removal of palatine tonsils

lndications
I. Local
II. Focal
III.Systemic
lV. General
V. As an approach
l. Local
loThese are indications which are related to the pathology in the tonsil
:----r' Hypertrophied tonsils causing obstruction to respiration or deglutition (most important indication)
w Chronic tonsillitis: recurrent attacks of acute tonsillitis (4-5 attacks I year)
\r pello*;ng an attack of quinsy (lnterval tonsillectomy performed 4-6 weeks later)
lF,V Carriers of Diphtheria -
'- ABSOLUTE INDICATIONS
w^ Tonsillolith '
\r.-i-onsillar cyst
o Hypertrophied tonsils obstructing respiration or deglutition
o Sleep apnoea syndrome
\e-Foreign body embedded in tonsil '-/
rr-Benign tumours of tonsil
f Excision biopsy in suspected malignancy of tonsrl-
.e^Part of treatment of sleep apnoea syndrome.--
II. Focal
p. Wnen recurrent tonsillitis affects regional / surrounding structures, tonsillectomy is indicated
o Persistent non-specific jugulodigastric lymphadenitis or suppurative cervical lymphadenitis r.equiring drain-
age.
o Tuberculous cervical lymphadenitis where tonsils are the source of infection
. M91 infections (secretory / chronic suppurative otitis media) due to recurrent tonsillitis.
III.Systemic
6 Recurrent tonsillitis becomes a focus of sepsis for various systems of the body

1. Respiratory system a Chronic bronchitis

a Exacerbation of asthma
2. Cardiovascular system o Rheumatic heart disease
o Subacute bacterial endocarditis
3. Renal r Acuteglomerulonephritis
4. Cutaneous o Urticaria
o Erythema multiforme
5. Qphthalmic o Phylectenular conjunctivitis
o Choroiditis
6. Bones / joints o Rheumatoid arthritis

298
 Section lll

tV. General
-
Operative Surgery - Tonsillectomy
299
I:l
I:t
lndications For Unilateral Tonsillectomy :

o Dyspepsia Excision biopsy in suspected malignancy or ulcer on tonsil

o Debility o Excision biopsy in lymphomas / tumours
o Failure to thrive/grow Tonsillolith
o
o
Secondary anaemia
Febrile convulsions
V. Approach to
o
Tonsillar cyst
Tonsillar foreign bodY
Styloidectomy
Glossopharyngeal neurectomY
I:t
I:I
3 Styloid process for Eagle's syndrome
o Glossopharyngeal nerve for glossopharyngeal neuralgia
o Distal end of branchial fistula tract in posterior faucial pillar

CONTRAINDICATIONS
Absolute
These are contraindications which impose a danger to life
L Blood dyscrasias
II
o Haemophilla
:'l
2.
o
o
Purpura
Leukaemia
Pulsatile tonsils
I:'l
3.
Aneurysm of lnternal carotid artery
Abnormal / anomalous tortuous vessel in posterior pharyngeal wall (ascending pharyngeal artery)

Relative
II
These are contraindications in which the operation can be performed after cure of disease.

o
o
Acute tonsillitis
Upper respiratory tract infection
o Risk of haemorriage Il'l
o
-
-
Coryza
Granular pharyngitis
Age below 5 yrs
.
o
o
lt may flare up after the surgery
Tonsils may act as iq!!1g!elq'ttg_oJg-q_09.
May lead to compensatory hyperlrophy of other lymphoid tissue
Il'l
c BlgeglSlgmay not be welltolerated
:1
o
o
o
Diabetes
Hypertension
Asthma, allergy
o Difficult surgery as operative space is less and risk of anaesthesia remains

II
o Epidemic of poliomyelitis Surgery can precipitate bulbar poliomyelitis
T
Il'l
o Pregnancy
o Menstruation
o Oral contraceptive use

PROCEDURE
Preoperative
:1
o Written informed valid consent l'l
o lnjection Atropine 0.6 mg intramuscularly half an hour prior to surgery
tI
t
-.1

:1
ri
n 300

r lnjection Tetanus tcxoid 0,5 ml intramuscularly one day prior to surgery

ClinicalENT

F o Systemic antibiotics if required

n
Anaesthesia
General anaesthesia with endotracheal intubation.

n The endotracheal tube is either cuffed or a tight throat pack is kept surrounding the tube to prevent aspiration
of blood and secretions into the lower respiratory tract. The tube can be passed transorally or transnasally.

n Transoral route is preferred if adenoidectomy is to be performed.

Local anaesthesia
It is used in adults. lt is used along with intravenous sedation and local infiltration of peritonsillar tissue and

F
pillars with 20k Xylocaine with 1 :'1 ,00,000 adrenaline.

Advantages of local anaesthesia

r:
:

o Rrsk of general anaesthesia is avoided

n
t^
o Faster procedure
o Less haemorrhage
Position
Supine position with flexion of neck and extension of head.

]^
r:
rn
DISSECTION METHOD TONSILLECTOMY
Mouth is kept open with a mouth gag (Doyen's / Boyle-Davis / Jenning's). Tongue is depressed with a tongue
depressor. Under local anaesthesia, the patient is instructed to keep the mouth open.

lncision : An inverted 'J' shaped incision is taken submucosally along the edge of the anterior pillar after it is
stretched by depressing the tongue. The incision is taken with a tonsillar knife (no:12 blade on a Bard-parker

r: handle)from lateral border of tongue to the base of the uvula. The medial lip of the incision is held with Dennis-
Brown tonsil holding forceps and the lateral lip is pushed laterally to expose the plane of drssection-the tonsillar
capsule. Dissection of the tonsil is then carried out in the plane between the capsule and the fossa with the help
of Molllson's tonsillar dissector and pieces of roller gauze. This blunt dissection separates the tonsil with its

F capsule from the loose areolar-tissue which binds it to its bed, and also achieves haemostasis. The tonsil is
dissected free from its fossa except at the pedicle / lower pole which contains the insertion of the palatoglossus

n muscle in addition to blood vessels.

Snaring : Eve's tonsillar snare is passed around the pedicle and the tonsil is separated by crushing and cutting
the pedicle. The tonsil is held with forceps while snaring so that it doesn't fall freely into the frypofnarynx. The

F
other tonsil is similarly removed.

Haemostasis : The tonsillar fossa is packed with roller gauze for a while to control oozing. After removal of

n
rr:
gauze, the fossa is checked for any bleeding points. Haemostasis is achieved by contraetion and retraction
blood vessels. Some bleeding potnts still remain, which are ligated by cross clamping. They are first held with
of

straight tonsillar artery forceps followed by cross clamping with curved (Negus) ai'tery forceps and then tied with
silk or linen. The ligatures are not to be removed, they slough off by 7-10 days.

POST.OPERATIVE MANAG EM ENT

'1. Position

t_ o Left-lateral position
I: o Knee and hip of upper leg flexed
o Lower arm flexed at the elbow and shoulder and placed below the head of the patient.
o This prevents the patient from aspiration in case of haemorrhage and also from rolling under the effect of
F 2.
anaesthesia

n
Monitoring of temperature, pulse and respiration every four hourly

n
r r=+::f::.ii=1i?i:j tl:.'+.-::a -=.+.--
 !

a\
Section lll- Operative Surgery - Tonsillectomy 301

^t
J. Medical treatment
a) lmmediate
o
:

lnjectableantibiotics
\
o Injectable analgesics \
o Hydrogen peroxide gargles on the day of the surgery to clear the fossa.
b) Later : \
c Antibiotic syrup for one week
r Antiinflammatory analgesic syrup
\
o Condy's gargles (1 :{Q!Q p_olg!-gi!n p_e-n-qlg-a!.qj9_ ?--4 times/day for 7-10 days) {
\
Diet:
o Nil by mouth for six hours \
o Cold liquid feeds orally after six hours eg: cold milk, ice cream.
o lt is followed by soft, cold, non-spicy diet for a week to ten days. eg:- bread and milk, mashed potatoes
\
o Avord lime juice (acidic), hot drinks (vasodilatation and bleeding)
o Hard spicy foods are avoided for 10 days.
o Each feed is followed by antibiotic gargles. \
The patient is asked to lake semisolid feedE soon as it prevents stiffness of pharyngeal muscles. Chewing
J.

chewing gum also helps for the sameand alleviates pain.

a
\
6, Patient is asked to follow up after '1 week. \
COMPLICATIONS: \
I. lntraoperative
\
Arrhythmias, Hypertension / Hypotension
Surgical \
Primary haemorrhage (Average Arterial in nature
blood loss in Tonsillectomy =*9,q!|) Controlled by ligatures \
May be more if the operation is performed on inflamed tonsils.
To anterior/posterior pillars
\
Tongue \
Teeth
Uvula \
Palate
Aspiration of : \
o Blood
o Tonsillar tags
\
o Adenoid tags
\
Diagnosis :

Cough and fever postoperatively \

Prevention :

o Cuffed endotracheal tube/pack around the tube \

o Rose's position intra-operativelly
(Head-low with extension at atlanto-occipital joint with sand bag under \
o
shoulders)
Post operative left lateral position
i
\
rr!

I!

.t
l(o{('to+P:l
666aiar?^iww qq+S JJr>>:\i <'eN
 302
ClinicalENT

II. Postoperative
1. Reactionary haemorrhage
It occurs 6-24 hrs. after surgery

Causes :

'r- clot in fossa preventing retraction of pharyngeal constrictors

p- Slipping of ligature
rr Dislodgement of clot by excessive coughing or straining
o Failure to ligate all bleeding vessels intra-operatively.
telWearing off effect of local anaesthesia with adrenaline
lr-Rise in blood pressure as patient comes out of general anaesthesia
o lncrease in venous pressure due to coughing
Clinical features
o Rattling noise during breathing.
o swallowing movements postoperativery (chird swailowing brood)
o Raised pulse, respiration
o Fall in blood pressure in severe bleeding
o Pale child in a state of shock and sweating over the forehead in severe bleeding
o Spitting out of blood by adults and older children.
Management
o Secure airway by postoperative tonsillar position.
o Assess blood loss
o Start lntravenous fluids
o TPR / B.P monitoring
o Removal of clot from fossa :
- Small clot comes out with hydrogen peroxid.e gargles
- Larger clot requires a swab for removal
o Ligature of bleeding vessel
- Undergeneralanaesthesia/sedation
o Supportive therapy :

- Vitamin C, K
- Calcium
- Styptics etc.
lf the above methods fail :

o Pillar suturing : Approximation of anterior and posterior pillars by suturing with

tighily packed gelfoam
within.
o Ligation of external carotid artery.
o Blood transfusion.
2. Secondary haemorrhage
It occurs between 5-7 days.

Causes :

o Sepsis / infection in the fossa

o Sloughing off of the walls of the ligated vessels.
 T
Section lll- Operative Surgery - Tonsillectomy
303
:!
Clinical features
o Pain in oropharynx
:1
o Rise in temperature
-'[
o Diffuse bleeding
o Tonsillar fossa covered with unhealthy granulations or slough' 1
Management :1
o Admission to hosPital \
o TPR / B.P. monitoring
o Hydrogen peroxide gargles
-l
o lntravenous high generation antibiotics :1
o lntravenous fluids :'l
o Packing the fossa with gauze. -r!
o Cauterization with trichloroacetic acid (TCA) i

o lf bleeding is more and still continues, (r t/'t0* of blood volume)fresh blood transfusion can be given. lt \

o
replaces coagu lation factors.
Pillar suturing
i
o Externalcarotid artery ligation. \
3. Oedema of uvula
4. Aspiration pneumonia
\
5. Change of voice can occur due to
o Damage to uvula
i
o Damage to anterior pillars \
o Fibrosis of anterior pillars/soft palate
\
6. Acute suppurative cervical lymphadenitis
o Due to spread of infection from septic tonsils \
o Can lead to septicaemial/pyaemia
7. Reflex otalgia
\
o lrritation of glosspharyngeal nerve endings \
8. Otitis media -
9. Dislocation of temporomandibular joint \
l0.Dislocation of aganto occipitaljoint can occur if a patient is shifted from operation table with a hyperex- \
tended joint and neck not supported
11.
1
Subacute bacterial endocarditis
Exacerbation of granular pharyngitis
2.
i
l3.Recurrent / residual tonsillitis : lnfection of tonsillar tags' \
14.Quinsy in residual tonsil/tonsillar tag.
\
\
\
 12. THYROIDECTOMY
Rajiv Joshi

INDICATIONS
I have seen a subtotal thyroidectomy (srr) being performed in a female patient aged 45 years
thyrotoxicosis. with secondary
Before taking such a patient for surgery, I would
like to confirm that the toxicity is reasonably
she has got adequate medical treatme"nt io prevent controlled and
oevetopment of thyrotoxic ciisis I ,storm, on
table. the operation

PRE-O PE RATIVE PRE PARATION

Pre-operatively :

o Carbimazole 4Omg / day

o Diazepam i0mg/day
o Propranolol 40 mg TDS
r Lugol's iodine 7 to 10 days prior to surgery
Response to therapy is judged by :
o Sleeping pulse rate.
o Daily weight gain.
o Good sleep pattern.
Fitness for anaesthesia is taken
lndirect laryngoscopy is done (rDL) to rure
out recurrent raryngear nerve pararysis.
Pre-operative :

o Shaving of neck in a male patient

o lnj. Atropine 0.6 mg intramus cular t/z hour prior to surgery.
o lnj. Ampicillin 1gm intravenous on operation table.
r Written consent.
o Blood grouping and cross_matching done.
Anaesthesia:
General anaesthesia with endotracheal
intubation.
Position ;

supine position with neck extended with a pillow

below each scapula, doughnut (ring) under the head and
sand bags by the side of the neck as to
maintain the thyroid cartilage, chin and suprasternar
straight line. notch in the same
Anti-Trendelenburg position of tabre (head
high to prevent venous congestion)
Parts painted and draped.

lncision :

Kocher's skin crease incision i'e. a curvilinear

skin crease incision 2 cms above the suprasternal
the concavity facing upwards and.extending
fror one sternomu"toio to the other. priorio taring the notch with
marked with a thick twine (thread). incision, it is
Saiine and adrenaline is infiltrated along
the line of the incision. The skin in incised with
mounted on a no' 34 Bard Parker handle)llternatively a knife (no.23 blade
a No. 15 blade mounted on a No. s Bard parker
can also be used (More cosmetic, thin handle
scar).
304
Section lll- Operative Surgery - Thyroidectomy
305
tI
I:l
Exposure :

layer and flaps are raised. The upper flap is raised

The subcutaneous tissue and platysma are incised in one self-
notch. The 2 flaps are retracted by using a pair of Joll's
till the hyoid bone and lower flap till the suprasternal
on either flap'
retaining thyroid retractors or retracted using skin stitches
using a mixter and ligated and divided' The deep fascia
Anterror jugular vein coursing vertically is undermined
rs incised verticatty avoiding theveins and the
'strap muscles''

tf the lesion is small, retraction of the strap muscles

The strap muscles are divided as high as possible because
laterally suffices. lf it is big, the strap muscles are divided'
:
I:l
o The nerve supply (ansa cervicalis) is from below'
o prevents fromation of a hypertrophied scar which is a possibility when the skin incision and
lt
division of the
:l
muscle are in the same line'
:I
Thethyroidg|andisexposedlaterallyuptothesternomastoids'

DEVASCULARISATION
First hug the middle, then kiss the superior and stay away
from inferior' I
II
mixter, ligated and divided as close to the gland as
c The middle thyroid veins are dissected, hooked up with a
:1
I:'l
possible to avoid tumour emboli to be released'
and vein are hooked up' ligated and
o Dissection is carried onto the superior pole. The superior thyroid toartery nerve'
injury
divicied as close to the superior pole as possible - to avoid
pole and inferior thyroid artery is ligated in continuity as far
Dissection is now carried out downwards to inferior

II
a leash of inferior thyroid veins are ligated indi-
from the inferior pole as possible using 1-0 chromic catgut and
vidually. Ligation in continuity serves 2 purposes :
o Recurrent laryngeal nerve division is prevented'
o gland'
Helps in maintaining blood supply to the parathyroid
laryngeal nerve, whereas in hemithyroidectomy the
ln a Subtotal thyroidectomy, do not search for recurrent
:1
nerve is preferablY identified.
The same procedure is carried out on the opposite side'

su BTOTAL THYROIDECTOMY (STT)

to each lobe and the raw surface is ligated (using
II
Drvrsion of isthmus is carried out by applying clamps close
chromic catgut) to achieve haemostasis'
clamps are applred allround the gland / multiple mosquitoes are
thrust into the capsule of the gland from all
:1
sides and the diseased tissue is cut above the clamps'
Each of the bleeders are under run with chromic catgut and
perfect haemostasis is achieved'
l'l
lobes are approximated using 2-0 chromic catgut' continuous
Alternatively the 2 edges or 2 poles of the :1
locking sutures.
ln subtotal thyroidectomy for multinodular goitre, if diagnosis
is in doubt, afrozen section is done if malignancy :1
is suspected.
ll
\
HEMITHYROIDECTOMY (HT)
removed in which case the concerned lobe is -1 I

ln a hemithyroidectomy, the diseased lobe and isthmus are

artery divided'
devascularise<l as describld earlier r'vith the inferior ihyroid
using a peanut and the isthmus is hooked up
The isthmus is separated from the trachea by blunt dissection
wrth a mixter, clamped close to the opposite lobe and divided' l'1
The raw sudace on the side of the opposite lobe is ligated
and the isthmus are then dissected off the trachea taking care to
with a 2-0 chromic catgut' The whole diseased lobe
protect the recurrent laryngeal nerve' ll
l'1
-1
r!
q
 306
ClinicalENT

Closure :
o After achieving haemostasis, either a corrugated rubber drain or preferably
a suction drain is left anterior to
in the thyroid fossa and the drain-is brought out
tnrorgr, , ,"p"rut" stab incision by the side of the
[""[""n""
t t pads are now removed and the strap muscles
are sutured with 2-0 chromic catgut using interrupted
,tff::f
o DeeP fascia is sutured vertically with 2-o chromic
catgut interrupted sutures (to allow adequate drainage
case haemostasis is not achieved) in
o Platysma is sutured with a 2-0 prain catgut - interrupted
sutures.
t |;;Sfi;r,*lted with subcuticular stitches or 4-0 silk interrupted sutures
or using skin ctips e.g. Mitchel,s
Plil
o. Thyroid dressing is given.
o During extubation' movements of the vocal cords
are checked to rure out recurrent laryngeal nerve
damage.
Post-operative orders :
o Nil by mouth for B-10 hours.
o After that, oral fluids.
r Antibiotics / analgesics
o Tincture benzoin inhalations.
o Removal of drain usually by about 48 hours (once purpose is
served).
o Suture removal by 5rh day.
o Clips removal by 4th day,
COMPLICATTONS OF THYROIDECTOMY
Complications of anaesthesia
o Damage to vocal cords and oedema.
o Difficult intubation.
Complications of surgery
o lntra-operative
- Primary haemorrhage.
- Damage to trachea.
- Damage to external laryngeal nerve.
- Damage to recurrent laryngeal nerve
- Tracheomalacia (collapse of trachea _ respiratory
distress)
- Damage to carotid arteries, internaljugular
vein.
- Thyroid crisis /,,storm',.
o lmmediate post-operative
1. Breathlessness :

Causes :

- Tracheomalacia.
- Vocalcord palsy.
- Large haematoma compressing trachea
- Tracheobronchial secretions.
- Laryngismusstridulus.
- Damage to pleura as in large / retrosternal goitre.

H
E
 \
a
Section lll- Operative Surgery - Thyroidectomy 307
a
- Laryngealoedema due to difficult intubation. rr

2. Reactionary haemorrhage a
3. Hoarseness of voice - due to :
\
- Vocal cord palsy (damage to recurrent laryngeal nerve) t
- lrritation of vocal cords due to intubation.
4. Wound complications : i
- Oedema of the flap.
- Accumulation of serum.
\
- Haematoma.
\
- lnfection (sepsis)
5. Thyroid crisis \
o Delayedpost-operative \
- Hypothyroidism
- Hypoparathyroidism. \
- Recurrence of thyrotoxicosis.
- Hypertrophied scar and keloid formatton
\
- Hoarseness of voice - due to fibrosis leading to entrapment of recurrent laryngeal nerve. i
TREATMENT OF COMPLICATIONS OF THYROID SURGERY \
o Haematoma - Compression on trachea causing respiratory problems.
Rx : open up sutures over the deep fascia and evacuate the haematoma.
\
Prevention :
\
- Good haemostasis.
- Leave a drain \
- lnterrupted sutures
- Remove extension and check for haemostasis.
\
c Recurrent laryngeal nerve darnage : \
Rx: Repaired by mrcrosurgical technique and nerve graft using greater auricular nerve
- King's operation.
:
\
- Woodword's operation. \
o Vocal cord palsy :

Hoarseness of voice.
\
Rx: \
- lnjection of Teflon paste into vocai cords.
- Arytenoidectomy (excision of cartilage) \
r Parathyroid damage :
\
Diagnosis : Recognised by the fact that the gland turns bluish black on minimal trauma and sinks when
put in a bowl of normal saline (D/D is Fat which willfloat) \
Treatment : ln cases where all 4 parathyroids have been removed, as in total thyroidectomy one of them
ts reimplanted in the forearm after slicing it into multiple pieces (to facilitate revascularisation).
Advantages: Of implanting the gland in forearm are : :"!
Easy to implant
Easily recognisable, if pathological changes occur and if removal is necessary.
:r
:'1
-1
:1
'l
 308
ClinicatENT
Reimplantation in sternomastoid muscle
is not preferred as it lies in the field
of irradiation.
o Treatment of thyroid crisis :
- Patient is shifted to an air_conditioned,
dark and silent room.
- Nasal oxygen
- Constant monitoring of vital parameters.
- Tepid sponging.
- Resotration of fluid and electrolyte
balance.
- Anti-thyroid drugs
- Steroids.
Digoxine/B_blockers
- Antihistaminics
- Propanolol
- Na iodide, Lugol,s iodine
o Treatment of tracheomalacia
- Low and permanent tracheostomy

I:
r
 \A
o1g. TRAGHEosroMY

DEFINITION
Tracheostomy is an operative procedure in which the anterior wall o-f trachea !s(connected'[o the exterior or
sutured to the skin of the anterior neck. \---l
History ?,f-\
Antoni{Br asovo to) t S+O ;
1 1_ :9!91"9 y99q9q!! I rra c_[9_9s!91y
"_s
Heister (1718) Coined the term Tracheostomy"
Caren 1"t successful Paediatric Tracheostomy.
-:/
INDICATIONS

Signs of Laryngeal obstruction :

o lnspiratory stridor
o Prominence of sternocleidomastoid muscle
o lndrawing of suprasternal, epigastrium and intercostal spaces
o Cyanosis

t
\9 INDICATIONS
I. Ob:tructlve
Il. Non-obstructive a

#
I. Obstructive I
OBSTRUCTIVE

Conqenital
'#- \
++
lntrinsic , Extrinsic a

c-I rA-.*
o
o
o
Laryngeal webs
Laryngonralacia
/
Subglottic stenosis \-/
r o -Brlateral
o
ellgp4*
Pierre
-#
choanal

Robin syndrome
I

V . l-lggmanglg-Ua !--
-r'
=*-o- Cystic
\
*,-,*^r
\.
Qt.
L) o QYs*- t
.tr'
- tptglotttc \-/
Valecullar "v I
il-J*7,,/
Cords v
t

lnflammatory t
- lntrinsic o Accidental
--==t=*
o Acute r Larvnoeal t
- Cut throat injuries
:
tI 'et----'
!
309

I
 310
ClinicatENT

_ ,.i I

'\--#'tPqldttitis
^ - Diphtheric
laryngitis in chitdren
o Chronic
*-al.t
S

oma
--*-
o ExtifnGiC
.-,-tudwig's Surgical
anqina
5_+
\--P€ relar]rrgegLa
- ThyrorOec-tomv
bsces s
- ^::E:_j surgeries
uardtac
tPet.rgllgryggeat"bscess
j
<_c:€:

Neoplastic : +
1. Benign Miscellaneous
:

- R""Jrrg$_trSpqatory papiilomatosis
-
n.F--.
sre.ma
2. Malignant

:w,v
:

- CJSnrnx
5 cwt)dications :

- clllyroio
Ca oesophaqus o
e
l_aryngeal
trauma b/
Br3plogslJ]qgrcinoma o iarynx
Ca
,4A.'
x-
\)/ )r)/
Meljastinal-masses
L@:_-
-

Cervical lymph
dary metastasis
It, Non-obstructive
1' ResPglg{ilsufficiency ;

a. Centrall--=
El..d;
i. Cor"-Ehe. to

^--'fGu-iu
*<:'
r;--ffead injuries
accidenis
fj t,qlvrfr"
or+a"/-).----- on
" -
"t,
f-Pl a bSlef=tsefoaci O o.
ii. Respiratory centre depression :
- Fracture base skull
----
- Barbituratepoisoning
- Butlgl plqrryetiris
--F<

,_-:i-
- Inldl9!.lqsq,nal cord
b. Peripheral / neuromuscular
o Guillian Barre syndrome
. Tetafriffi--
c. Rutffiry:
o Pneumothorax

rl
.....=F--
astinum

n
l':
 \
nl
Section lll- Operative Surgery - Tracheostomy
\
-l
o Fracture sites \
-=E

\-l
o Flatl chest
l'
;
2. Trachedbronchial toilet .
I

o BroDciApneumonia
^,-=--:--.
. broncntectasts \
IPPV:
--tG
Post - surgical
i
o Total larvnqectomv Y'4 \
.#*
o Totdl qlossectomv r----'7
:tF-'-
o Maf,!&Efomy \-n \
q Laryngoll$ure \_,r" \
CONTRAINDICATIONS \
There:re no contraindicationsjg ul_gr"rgency tracheostomy
The following contrgindications are for elective tiacheostomy-: \
1. Bleeding disorders \
..FE=:::=;*,
2. Diabetes mellitus
3. Hypbrtension \
+. cffiE1-i'-'enittty
* \
Types of tracheostomy
4
:

K A:g9ro,nglg-- I ndications of p_ermanel!_E$€gstomy : \

I. Pr{pg!.e
Carcinoma
s:ff>? larvnx

t-ry{4t \
' Pgggegt
NX

'
ll. Timrng_
4r/
\o_"H{atefal abductor pqlplysis of vscal cord
\
o Elective \
o Emeroencv
4A-
---a:-+-
lll. Level
\
- -)-^ 1l+
"
o Hioi \
.ffi ?) $r.rrj,t1L
*f l .| ^_ f,{D
.:)t
. gg_,ed'E-'
15.<-\ok-
Iy t-x),
I> f n
\
-
-rl
I

Functions of tracheostomy
il\ o allvqy obstruction -l
\
o
o Can be used for
P9%g -l
:
\
Anaesthesia \
To dETr m."edications I

a
t]
o :1
:'l
G
toilet by aspiraling secretions and permittinggq_s_Qiffu t=rA.-,
"ron.

11
-1
t*1
 312
ClinicalENT

PROCEDURE
. Pre-procedure orders :
W:*hl"f"rry1g9!!€I_(except n em erg e ncy) i

lnjbction Arroptne
ilueuuon Atropine u.b intra,iffiularlv- ,.!
0.6 mg intramuscularly -'-?
lry J-oi cc intramuscutarty \-/'
X-ray neck to note position of the trache a. V
o Anaestfesia :

\: No dnaesthesia is required in acute emergency. Advantages of a pre-intubated patient :

o Procedure can be done without haste.

*-€'eheral-or f-ca f a naesihesia ca n be used.
The patient may be already intubated
Local Anaesthesia :
- lnfiltration of 2"Uyt_g_gaing wittr ad19-naline
1,1.@re_q is oone rn a ,h";p_",d
b y-,!! 6
$"ie boundeo
tI e-nla i iFg o n a o ota,-i u p ri s t; ;";i ;
i
;
below and sternomastoids iaterally. lt is also "l;
injected along the line of the incision
o Positiori :
- s,rg!g_p9:!9l.--
- rVilelIglgor_gf heg{-qqQ_nesf
- Pillow is kept below shoulders
: jnd sllrast"rnat
- 9.ll,aqg[:jp.plg
notch shoutd be in one tine
(1!g extef sionis siv-en in 6;@ \__---z
o lncision : The incision on the stin--of the neck
can be :

rNctstoN ADVANTAGES DISADVANTAGES

. Increqse.0ls$.tns
'\.@tn
dgeperlissucs.
.
. Fj@e o
An ,nc,sion miO*ay
o D.t:llrqase#clns
suprasterpal notch
. .l?-ltneJA/i14iee"o. iissues
o Midline dissection :

- DeSrenUlg._qt ingislon is carrjed out tfirough

the
-
Skrn--
-
Subcutaneoug-tissueand
-
Srpg{!,-gt tayer of deefl fascia
- separation of strap muscles-Sternothyroid and sternohyoid, is done
in the midline
- tn@a-ariti wGe sepai,tion of pretracheat fascia i"
- Altur j9!ul{'!g_!!,u ptglrg_qleal fascia, the trachea may
""rrl""o.
be uiriOr".
o ldentification of trachea :
is identified by the following features :

tlS*r"l1-r19ture idea ty.

Y,o I

Wr'ilfgqlllgggnous n ngs
Rings feel firm on palpation
:
Movement with respiration is present.

n
r
 ,{ l

\
Section lll Operative Surgery - Tracheostomy 313
.i
- )
Aspiration of 1rl_gc,c_qqs with syrjnge and needle.
- lryection of Xylocaine causes-initial cough. :']
o lncision on trachea
q \
^l
:
Before !:iebeal. incision :
- After identifying the trachea an incision is tak en on -'l
"-
Jl*_-
Ychieve complete haemostasis
o -l
- Achieve compleie haemostasis before incising the
iracnea.
Take skin stav sutures.

ry ''l
- lfie%T*fml of 4% Xylocaine into tracheal lumen to
us with tube should be re -'!
a.E"itl^'eiise the mucosa
- Types of tracheal incision.
\
---=--.'.;:+-
Cruciate Flap door 'H' Shaped \
Base
I
\
-t-
I
U Superior
tt
tt
a-l
\

-
Y
n
llqElon should be between 2nd and ath tg_qfgq! 1ing.
lnferior
ll
\
\
\
- '1"'rino
F is avoided
r:
to p_lgygt 9elage_to cricoid
.:-
cartilagq
- --:
an{subsequent{subglottic
\__:_
stenosis\
. - 'j \
r An ideal opening on the trachea is :

- ofjp,ry3ls!_ze \
- No raooed edqes
- Not round, or circumferential contraction with stenosis occurs
\
Different technique should be carried'out for the following variations of trachea :
\
-
\
o Hard / calcified trachea
t
\
\
\
ln case of an emergency tracheostomy : \
o lt is to be performed faster as aloxia causes death in 4-5 min_utes
o Local anaesthetic solution is not injected into the lumen as the cough that occurs may wo.r,sen-Lbedistress. \
o Also ttrE-anaestnetic should not infiltrate paratracheal gutters to cause more respiratory distress by paralysis
of recurrent laryngeal nerves. \
Tracheostomy tube insertion : \
After making a tracheal incision, a tracheostomy tube is inserted.
o Previously selected tube \
Size., Sex
\
I
rq

i
 314
ClinicalENT
oCuff is checked fqr-leak
_1:-_-.+-
a to flanges and a dirator is inserted in
,:HT,lieo i!9 iybe
a rhe tracheostomy-tube
with the obturator within is inserted
the trachear opening
in *re opening
o obturator is immediatety removed.
o
?gP.^,
slty inLo trachea
uong111
a s".culg_ljr2,*,Ie-_!;,p-.q_
a Aspirate blood, muqqs_,_
secretions.
The following tests are used to
confirm tracheostomy tube in the trachea
o J\ir bt€_o_ve{t_re_!qbe opening :

. ltille]ory confirmation of air entry in both

r cotton-woor test : moving of cotton wick due the tungs
o X-re), n_eck / chest to demonstrate the tube. to air brast frorn the tube opening
o Catheter :

- Passage of catheter through the tube opening

into
'" the
rv rur
lungs.
- Airls[i-rbtion from the outlr Lr I

Fixation of the tracheostomy tube

".0 "i,n" "rrn"i",
:

r Cuff is inflated

Post-procedure orders :
o No sedation' no atryping and no
drugs shouid be given which depress
w'x-ray cr'ilFpn vrew to check for position the respiratory centre.
of the tube
o Proper suction :

- s@ter srrouto oe z:l."r-:-"*Grq[r_q!.9,r..-"f

t
tracheostomy tube.
C qly lSpms, al.pggk of inspiration
VPtipte eveO tuOricaru_catheteL: js preterred :
- it t?don" q d sZ:_ylc-gs
r Deflation tg!!g.1t the end olinspiration.
r1ej9ttonotc!tfshouldbe.6$-e.d{r!g%+.:F.'o'@D""@'r"*"qbyreinflation
of cuff should O, Oo* O*
^*.sY,"tion
o Froi metar tuhes'-inner tube has to oe iemoved,
creane;;irrepraced every 4 hourry.
o single moist gauze piece shoulo oe tepi ou"r',nu
rtil; u r,uriorioutionl";arn which oxygen or
f#Si:]:": rs passed ,rrouin sierri"i ;;[';iin" ,.ri; ir s-z rit,". r
-n. ,r,orrd be used to humidiry
o chest physiotherapy for iung ventirq!^on-a-nclg-4eyil!.pg]nrg!-g
infection. Humidified air can be
. €Xgu=E_!og$?, a o q&s_-an d, ikUggy ru
AU n t, provided by
I
o To keep the foilowing by the,iO.-of6i-Gni-f s- s d . :

o Morst qauze lS€

-
-
Suctgnglpelatus
lrabheostorny tray. '"W-w
o
E-rt-

Droplet infusion r\
- eett, noffiiland a slate.
a-t:: e
CPg.prercia I ni, - i.r iri
-#
Sequelae following tracheostomy
& o :
Loss of speech as air bypasses the
larvnx

r:
l-
 \
Section lll Operative Surgery ..\
- Tracheostomy
- 315 \
A
of smell as air b \
therefore increased risk of foreign body aspiration. ,t
\
n..
\
tlgeqjg$q=ryryf__g_c:a14-o-!_ps_Qg1!!_up(dif f icutt-fi4ationof
\
HOME CARE OF TRACHEOSTOMY TUBE
. Cleq!,n€_j!@r
:
\
!.u_bu
. eEirg the inner tube \
o Changilg tl,re*[qqhAestqgy tube
-+ rir:l r!l9g-l9*rllhi n three to five_{gy9*gl_p19ceglg5e \
--| Subsequent
\
. b.*$eryg %-:--
. --
FlXnq-rybe \
a Child is ftgg;_Wrt"1=4d sand
a Speech therapy for valved tube patients. \
DECANNULATION :
\
Hospital Set-up :
\
Pre-procedure :
o There should not be any aspiration during eating \
o Lateral X'ray-neck
o Xerogram / CT. scan / MRI \
o Endoscopicexamination \
o To comPare peak inspiratory air flow through mouth and through tracheostomy
tube
o Granulations or fibrotic tissue from the tract shourd be removed \

,-___-
\
PECANNULAflON) \
MEDICAL
{ SURGICAL
\
-l
,E+csg@ -rr!
Eg4!*bes -l

Rry
El prg rL :!j!_r!!!_[Orour_[ssue are u nd
Ii
-r1
the stoma_lulreedjy cutting drathqUry -l
+
I -'f
Suprastomal triangle of anlerrior tracheal
\
-l
P i
ryFu-d-q9y9t-$,o rrrg Wilh _a. steri I e gau ze p i ece

r - v -:--::-:-
Remains patent .Trachea closed with Vicrvl :'1
?-4*

Wo rn d in tay,ers,aftsl :1
"]gr_+
gg:$sl!a!!rap=mu sc l es
tI
:1
:1
t]
-I
rr
n
315
ClinicalENT

n
PAEDIATRIC TRACHEOSTOMY :

r
rt:
The following lmportant anatomicalfeakrres are p-esent in crritoren
- Distance
-) Cricoid to suprasternal notch
- Neonates - 2.5 cm
- l0yrold -6cm
:
.

rlal^
Level
--+ Cricoi'd cartilage :

- ]#J+rca
- Pubertv C6
-!r-*=--
Soft trachea \----l'
Hfiffioilnu
/r-:- n""t \*---

t:
n
l-
t:
t:
PROCEDURE
o Suitably warmed infant
o Supine position

t:
t:
o Partial / no extension of the neck
o Prevent lolling of head by a head ring
o GA + Satine + Adrenatine (tocally) (1 : 2,00,000)
o lniision : verticar incision on skin and trachea is preferred
o Keep first tracheal ring intact

F o Slit muscle from down to up

o Do not damage the post-trachealwall.
o Pass tracheostomy tube :

F
n
--| Metal- with introducer
-+ Portex - pinch with an artery forceps and insert
--+ Rail-roading over a simple rubber catheter
o Stay sutures are essential

n
n
TRACHEOSTOMY TUBES
History:
:

o lntially the tubes were made up of bone, rubber and crude metar.
l_ o The paediatric tubes were a smailer version of the adult tube.

t: o With further advancement the tubes were made of silver and the inner tube was added.
o Negus - added a valve to the tube for phonation
r Wilson - developed a silver paediatric tube with funnel shaped opening to be attached

F o A window was also present on the outer tube to allow transglottic breathing prior to to a respirator.
decannulation.
o Alder Hey tube - This was a modification of the previous tube with addition of a window

t:
t:
inner tube.
and a valve to the

r
 Section lll Operative Surgery - Tracheostomy 317
I
--l
o
-
Polyvinylchloride and silicone rubber tubes.

Id""l trb" : An ideal iracheostomy tube should fulfill the following criteria
o All parts should be snugly fitting'
:
I:t
o lnner tube should project slightly beyond the outer tube
--I
o Optimum air flow should be achieved
-
-
Shorter shaft
Greater radius of curyature
I
I
- Smooth inner surface :1
Non-toxic material with minimal tissue reactivity.
o Comfortable / easy to change / easy to clean / easy to connect to a ventilator :1
lfl :1
,/
PARTS OF A TRACHEOSTOMY TUBE
Portex r]
I:'l
Metal
o Outer tube o Tube
o *-
''
r -*<:
Flanoes
o
lnnggQle
Pilot t !lq$=.q[E!.gd obturator
F
l:'l
Fw@ )
w@
Tracheostomy tubes
)
:1
:

.z
It
Metallic tubes
\_.r' Chevalier Jac

@,shierd,rr",@[
I:1
is removed when it gets blocked, keeping the outer tube patent
-
n1ffltuO" is longer than the outer tube. lt
f

Th:*qp-t9lq-to1 / pilot helps in an atraumatic entry and tracheal dilatation

:'l
- Luer lock prevents dislodging of tube by coughing / pressure exerted during expiration :1
I:'l
' \9,,

-
-
Valve helos in phonation
BrT-an!'e acts as a tracheal d!!a!or, ea-sy introduction.
<-=:=
->J*j#ls
Disadvantages :
- t'
I:'l
,jt-
-
-
Tyb" tiq_99lJ?use
--V>.- irril-ation and is shgrg
Broken flanges can act as a foreign bo-dy'
l'l
rO Durham's tube :'l
l'l
'ffi6*J4-
T
-.|
-1
r: ClinicalENT

r: 318

r
r Colledge's tube
- Used after laryngectomY

r: o
-
Hollinger tracheostomY tube
Rotating lock, attached to shield at 750 as opposed to other tubes
r - Funnel shaped opening provides easy installation of aspiration catheters.

n o Alder Hey's tube

- Large radius of curvature

r- -
-
Silver tube
lnner tube has valve and window
l-_
n
rn
Non-Metallic
r !9Se5 '\-
- pgrteJjtands
Blue radioopaque line
,9"h rrru#**
fo(hedqT"gth-?TLTy

- -h--|PPV \,.--
-c

- Self-retainino
n
T

n
-tu
#

ryNtr{]l'Yseeiry-e-q![-
Sizes 3-10 (difference of 0.5)

t:
H lffitro"
FnoT-nilijrn"
-.'-.'.2/.-
tube
whole tube is to be replaced or taken out and cleaned when blocked.

t:
n
-
-
lrritant totissues
3=-"
Used for irradiation

I:
-4-E4''
DOW Corning :

n
Silastic tube .

Kistner plastic tube :

I.
t:
o Extends only to the intraluminal surface of the tracheal fenestra
o Tube should fit snugly. The tracheostomy opening should be smaller than the diameter of the tube'
o Made of polyvinyl plastic

n
I:
o One way valve - speech occurs without occluding the tube
o Non-irritant
r Used for patients for radiotherapy

n
lt_
Olympic tracheostomy tube :
o Same as above
o Adaptor is present for IPPV
Salpekar :

o Double cuffed tube

l-
l*
r Alternate cuff inflated by turns to prevent tracheal stenosis

t:
n
r ffd,3e"{ s'{= 6 6': q={e-Q * { o qt Jr, or
:: 6
A N
A NJ
-
Nf
--.-*::
2.
 Section lll- Operative Surgery - Tracheostomy 319
II
DIFFERENCES BETWEEN METAL AND PORTEX TUBES

METAL
:

o
PORTEX
II
:l
o Consists of two tubes, hence less chances of getting blocked More chances of getting blocked
o No cuff present r Cuff present
- Can give IPPV
- Prevents asPiration I
r Cannot be used in patients who have to undergo
- MRI
: r
- Less chances of accidental decannulation
Can be used for the same
II
r

o
- Radiotherapy
Some patients cannot tolerate this tube

Usually used in long term tracheostomies

o

o
Can be used in patients who do not tolerate
metallic tubes
Usually used in short term tracheostomies.
It
Advantages and Disadvantages of Tracheostomy :
rI
l'l
If
ADVANTAGES DISADVANTAGES

r lt can be kept for a longer time o lt is a formal surgical Procedure

o Patient can swallow o lt reduces cough efficiencY

I:'l
r lt decreases dead space bY 50% o lt takes more time than intubation
o lt decreases respiratory resistance o Greater bacterial colonization rate
o Tracheal stenosis is not very common o Permanent scar occurs
o Tracheal toilet is easier o Decannulation can be dlfficult
o No risk of main stem bronchus intubatior
l'l
Il'l
."0
V'- rrRAc H E_!)STgnav : (Mathews a!4lt gpEr n goll
M rN

Main indications :
o To remove chest secretions-
o For.treatment of respiratory failure
ttjonsist of a vertical-stab incision (cgtg!g['y) nglb:lbroughthe
[email protected]=toahighfr.equencyjetventillatorn.ltn1!1ac|9o1tomvt1!
-
isE-lso aVait6bTe.-
-crnothyr.oid membrane
under local anaes-
I:'l
PERCUTANEOUS TRACHEOSTOMY :
o Puncture trachea at the chosen level with a needle and cannula
II
.
Pais guidtwire by Seldinger's technique
Gradually dilate stoma with increasing size dilatols
Pass the tracheostomy tuOe
Scnacnhbr (Rapitrae system)
II
- Tracheotome passed oyer the-guide wire
- Dilate tract fully in one steP :'l
-1
- 6pening d-ilated to pass tt-re tracheostomy tqbe
- Creation of false passage is a likely complication . -'l
-
:'l
-'l
-'l
T
Y?a*-*lgr:g,e= ! dijp're. <'"- lgrg)a sl'd) O 5 (, N 2
 ClinicalENT

c RICoTHYROI DoToMY : ( Ljgg-QgJ

( M a i n l y*y3ecl a s_gp q_e ige.ncy p roc e-dlre
)

Three Methods :

r Using an intravenous_cgtheter +rl'

Nu Trake's cricothyroidotomy device
O

- DECIDING THE SIZE OF TUBE :

For an intubated patient, No of portex tube is same as that of the endotracheal tube.
formula
Aoe
.iur. A9"
*".
r' 3 -""
'8r--S-ias
- Metal to Portex : Metal no : - 2
4
Portex to metal : Portex no : x zr
(Portex no : x 4) + 2 = Metal No :

T:
n
r
+ -r
EYAi-{'Aisx^qS^<. a d: ,o: t*
i
J---
\\\\
or
\\
 Operative Surgery'Tracheostomy
321
II
ll
Section lll
-
c,
/*. COMPLICATIONS
FEATURES TREATMENT

II
COMPLICATIONS

ANAESTHESIA a Anaohvlaxis V4
-#'
o ca-idiac arreslV
O Hypotensioruo,rr
SURGERY
,=4:--+ r Atropine Prior to Procedure.

I. 9u Injecting 4% Xylocaine in tracheal

t
lmmediatecomPlications
r=41 vassyrygEgruh lumen. :'1
o Midline dissection
@.Pjgs+;r,o^
-- a)-Tnterior jugular vein / Ante-
-'-_
rior ffi'municating vein.
'']
-
o Retract lsthmus uPwards.
b) Thyroid isthmus /
o \
r
Avoid its transaction.
^l
Clamp, cut and ligate isthmus be- \
fore proceeding.
o Avoid blind dissection in supraster- \
c)
nal notch. -\
a Suction with cauterisation.
d) Tracheal wall
o Tight fitting tracheostomY tube. \r
e) Anomalous vessel
Thyroidia ima
\
lnnominate artery May be high in children o Midline dissection

3) Damage to surrounding struc-

\
tures :
\
1. Apical Pleura Pneumothorax results (Post-op X'ray +; o Suture tear of Ple-ura
+=:, . stffffi-"r-will get absorbed
#** o'Small \
r Large o Oxygen
.'fffii[" \
o Sedatives
o liEltio*n'ot lco I
o Tension o --Aspiration of upper anterior thorax
with 14-16 gauge needle.
\
2. Oesophagus Tracheo-oesophaqeal fistula. may \
re"-'-
-- resirlt
-8= o Small o Conservative management with \
nasogastric tube.
o Large o sJlc3l_clgsyre \
Both TraPhea and Oesgpne-S-y1 to
be s-utuied_separately, with inter po
\
sition of sofi tissue.
- us';;f prop-;;ffsical technique. \
\W>2??rt€ry ;t
3. Kcarotid o Major bleeding
4. fiecurrent laryngeal nerve o Hoarseness o Midline dissection
\
-
4-t=-:='= r Respiratory distress.
4) Failure to establish resPiration Reasons : \
-,.
--=:::,- -: - :-t_=---:
1. Vagal stimutation. o Atropine to be given
2. Central resPiratory failure o Alylrister Carbogen (90ok 02 + \
r!

:6 i 6-A,i H * dSis'is-Qj {ooJ

$i6t;oii'--o'--t
 322
ClinicalENT

COMPLICATIONS FEATURES TREATMENT

Respiratory centre 10% ca2)

u o Partial obstruction of stoma :

Used to high Co, 02 I Co2 saturation change occurs

u gradually for the respiratory centre
Tracheostomy to adopt.
u r
.ll co, + 1l g, ring,Eilrffiffin-"
lVouth to tracheostomy tube breath_

u
Drive for respiration gets lost
3. Blockage of tube o Regular suction and change of tube.
4. Creation of a false oassaoe o Reinsert the tube
,l 5. Cardiac failure Keasons :
J
o Fast rise in pH
/a o lncrease adrenaline
. lncrease in K. levels
( Air embotisn{) o Large neck veins may be o Head-low position to be given
inadvertantly opened during o Conservative management.
surgery.
7. Hypotension r Due to sudden decrease in Co, o l. V. fluids
levels. o Vasopressors
IL lntermediate complications
I
1. Displaced tube. o lmproper placement
,E# o Excessive movement of patient
l. Tying tube ftanges to skin

o l. Securing tapes with neck in flexion.

Excessive coughing
r Chest physiotherapy
, Loose fixation of tube.
:actors affectin g dislodgement
:
r Length of tube
r Thickness of neck
) Post-op emphysema, oedema,
haematomb
I Distance between skin and
anterior tracheal wall
2. Blocked tube It leads to :
- e#+- o Airuay obstruction o Regular suction
o Difficult catheter suction o Tube change
'al 3. Emphvsema
L r racneltts
A 5. Pneumothorax
6 Local skin
4 o Change of dressing
a Skin creams
4
7. Trgg.heo-adgielflstuta
III. DelayedFompl i cations
q 1. Bleedino Causes :
.-aA'+
a) Reargatary-lqeqjnS . Loss of effect of adrenaline
(affer 48 hours) o Reestablishment of normal B. p/

I:
1:
--
 \
Section lll
-
Operative Surgery -Tracheostomy \
\
COMPLICATIONS FEATURES TREATMENT

rise in B. P. \
. Repeated paroxysms of cough.
o Granuloma formation \
b) Secondary bleeding (5th - Due to infection a Antibiotics
8rh day) - Pressure necrosis of high a Coagulants \
innominate artery
\
2. Delayed tracheo-oesoph- Causes ; o Endoscopic examination
ageal fistula (Srh-7rh day) o Tube pressure o Right curvature tube \
o Overinflated cuff with RT in situ. r Conservative management.
Symptoms: o Surgical closure \
. lncrease secretions
o Skin irritation \
o lnfection
o Poor phonation
\
3. Surgical
ry#
emphysema : Causes : \
o Air ieak into o Pretracheal fascia not adeouatelv o Use of cuffed tubes
subcutane'ous tissue opened. o Release of skin and subcutaneous \
wffi'ch-lS preven"teO o a--.

Uncuffed tube. s utu res

from escaping. . affili*
s-!-r texcessive)
\ o Multiple incisions over affected area. \
o usuaty c-ontiieJ-to tne o Tigh-t sulures_of skin causing o Treatment of cough.
. neck ball-valve effect. o Reassurance.
\
o lt may present on the 1.t o targelE;h;;tomy opening with
day and is self-limiting a small tube.
\
(by 7th day). o Obstruction to egress of air. \
o Symptoms : Discomfort, pyrexia.
4. Profuse bronchorrhoea Cause : \
o lrritation due to tube
o Endotracheal aspiration of food \
5. Pneumothorax Diagnosed if dyspnoea does not
improve after the procedure.
\
==::
6. Pneumomediastinum a Positive HAMMAN's sign. o Oxygen \
-=:=-1= o Respiratory rate increases. a Antibiotics
o X-ray chest oblique lateral view : a Sedatives \
7. Tracheobronchial infection / Organisms:
air in mediastinum
i
Pfr-eumoqa o Pseudomonas o Appropriate antibiotics
*5-'-l-
o Proteus o Aspiration of secretions
\
. Aerobacter
\
o Fungi
8. Crusting o Dry weather a Wet gauze over stoma \
# o Non-humidified air going to the a Use of humidification tent
patient \
9. Atelectasis r Partial atelectasis is a Conservative management.
due to aspiration of blood and \
-*T-: secretions
o Total atelectasis is due to o Readjust the tube
\

rf
324
ClinicalENT

rmproper placement of tube o Shorter tube to be used

into one bronchus leading to a
collapse
. Seen in infants and elderly . Decannulation
o Swallowing movements occur r Change tube to different size
post tracheostomy. o RT aspiration.
o Abdominal distension, vomiting,
dyspnoea.
Late complications
1. Laryngeal stenosis Causes:
eaffi o High tracheostomy leading to
Prophytactic antibiotics, steroids.
perichondritis
Surgical management.
. lmproper curve of tube
o Chemical irritation by sterilizing
agents / component of tube.
. Damage to mucosa during
procedure.
o Movements of tracheostomy tube
because of ventilation / degluti_
tion.
. lmproper care.
- Non-deflated cuff
- Oversized / overinflated cuff.
ldeal cuff pressure : 15_25 mm of H
2. Tracheitis
3, Tra-bheal stenosis. Causes :

o Tracheal resection o Tracheal dilatation

o Tracheal infection o lnitial ulcer can be allowed to heal
o Repeated incisions secondarily or excised with primary
o Scar contracture closure.
4. Tracheomalacia
<#'" o Large part of tracheal wall excised.
o Pressure necrosis
Dlfficult decannulation
o Dependence of tube Endoscopy is done to assess
o lndication for tracheostomy is still the larynx / trachea.
present.
Rx:
o Granulations in trachea around o Decannulation as early as possible,
the stoma. r Partial increasing blockage of tube.
o Tracheal oedema. o Surgical closure.
o Inability to tolerate upper airway
resistance on decannulation
- Laryngo tracheal stenosis
- Tracheomalacia
6. Persistent tracheocutaneous
o lt heals if present for less than 16

{sor\
o600 :N -,S g:'..,1$ $--=ffi=$ffif
Section lll- Operative Surgery -Tracheostomy

r Poor phonation Surgical closure with excision of old

Seen after long-term
scar tissue.
tracheostomies
o Poor cosmesis

lII
I]I
II
I
:1
:'l
t]
:.l
T
:1
:'l
:''l
:''l
l'1
:
-1
:1
-1
.I
:l
 14. RADICAL NECK DISSECTION
- Dr. Shridhar lyer

It is enbloc removal of all lymph bearing area between the clavicle and the mandible and horizontally from
the midline to the trapezius posteriorly.
A specimen of radical neck dissection contains :

1. External jugular vein

2. lnternal jugular vein
3. Sternocleidomastoid muscle
4. Omohyoid muscle.
5. Submandibular salivary gland
6. Tail of parotid gland
7. Accessory nerve
8. Sensory branches of cervical plexus,
9. The following lymph nodes are removed :

o Lymph nodes of submandibular triangle

o Deep cervical lymph nodes
o posterior triangle nodes
o Supraclavicular nodes.
Lymph node groups not removed :

1. Superficial nodes of the preauricular, postauricular and occipital region

2. Nodes in the parotid gland
3. Retropharyngeal, lateral pharyngeal nodes
4. Prelaryngeal and paratracheal nodes.

TERMINOLOGY
1. Conservation or functional neck dissection : lt is an alternative to radical neck dissection in which any
of the following structures are preserved :

a) Accesspry nerve
b) Cervical plexus branches
c) Branches to trapezius, sternomastoid muscle
d) Part of internal jugular vein.
2' BOCCA'S operation : lt entails removal of lymph nodes and fascia as a single block with. preservation of
internal jugular vein, sternomastoid and accessory nerve.
3, Suprahyoid neck dissection
It includes removal of nodes above the level of hyoid borp.
4. Supraomohyoid neck dissection
It is an operation which involves dissection of anterior triangle of neck preserving the internal jugular
vein,
sternocleidomastoid muscle and accessory nerve.
5. Elective neck dissection
It is carried out in patients with no palpable disease in the neck but a high incidence of subclinical
disease
(20-400/").

326
H
l..
r
 Section lll Operative Surgery - Radical Neck Dissection 327
-
Occult metastases is commonly seen in the following carcinomas :

1. Nasopharynx
2. Supraglottis
3. Oral cavity (floor of mouth, tongue)
4. Pharynx
6. Block dissection :
I

It is removal of primary tumour in continuity with an enlarged mass of nodes. This procedure leaves be-
hind smaller involved nodes and is therefore not preferred.
Assessment of cervical lymph nodes :
1. History and examination :
r Presence of swelling in the neck
o Palpation of anterior and posterior triangles
Retropharyngeal and parapharyngeal nodes are not amicable to palpation
o The following structures can be mistaken for enlarged nodes :

- Transverse process of aflas

- Carotid bifurcation
- Submandibular salivary gland. I

2. Radiology
a) C. T. Scan : The three criteria on C. T. scan to denote a node as metastatic are :

i) Size of node :A likely node is suspected to be metastatic if its size is more than 1.5 cm in subman-
dibular and jugulodigastric group and >1 cm in all other groups. C. T. scan is preferred over MRI for
nodes less than 1.3 cm in size.
ii) Peripheral enhancement
iii) Central necrosis (low attenuation area)
b) M. R. l. : Enlarged nodes and nodes with central necrosis are well shown by MRl. lt differentiates nodes L
from surrounding tissues better than C. T. Scan.
c) Ultrasound : Metastatic nodes show a heterogenous appearance with a solid and cystic image.
d) Radioisotopes : lt demonstrates metastatic nodes (not until they are 2 cm in size) and not normal nodes.
\
Neck Dissection
History : The operation of systemic radical excision of regional lymphatics was described by Crile in .1906.
This was popularised by Hayes Martin and has since become a standard procedure of head and
neck surgery. Subsequently Bocca advocated that radicality should be directed against the tumour
and not the neck and in 1967 Bocca and Pignataro popularised the conservative neck dissection.
As more conservative dissection were described there was an increasing confusion on terminol-
ogy, till Suen and Goepfert and recentty Robbins, Medina et al standardised the nomenclature.
Radial Neck Dissection
INDICATIONS
'1. With resection of primary carcinoma in head and
neck when clinically positive cervical node is present
2. Nodal involvement beyond I't echelon group. \
3. clinically positive nodes when surgery is the only treatment planned
!
4. Regional metastasis after primary has been controlled by radiation and/or surgery
5. Clinically positive node after previous radiation. \
CONTRAINDICATIONS
1. Uncontrollable primary site 'ir
r!

j(D..lOo4
aoooooi
NNNA)Nt^\
o
N
o
l\)
qq+5=sss {gtoJ
o606 ili,oo-r.--aoNJ
r_
H 328

2. Distant metastasis
ClinicalENT

F
r
3. Fixed nodes
4. Life expectancy <3 months.
Fixity to carotid artery, brachial plexus, prevertebral fascia and mandible are relative contraindications

H
r
PRE.OPERATIVE
ANAESTHESIA

rr
General anaesthesia is used. Tracheostomy is needed for a bilateral neck dissection.
Shaving from angle of mouth to the nipple.
POSITION : Supine
Neck extended and head turned to the opposite side.

H
rr
Incisions for Radical Neck Dissection

Crile
lNcrstoN ADVANTAGE

o
DISADVANTAGE

The 3 point junction of the in

rn
cision may lie on the carotids
MacFee oViability of skin flap is maintained Restricted access
o Preferred in already irradiated patients
Horizontal 'T' or half - H o Good access o

rr
Vertical limb may heal with
o Protects carotid artery scar contracture
o Healing of horizontal incision is better
o Conforms to main cutaneous blood vessels of neck

rr o Other incisions
-
-
'S' shaped incision

rF
Modified Schobinger
- Unilateral apron flap
Modified Schobinger incision
The first-limb (horizontal limb) begins at the chin and descends to the hyoid bone and passes 3cm below
the angle of mandible to reach the mastoid. The vertical limb begins just posterior to the carotid pulsation (so
that three point suture doesn't lie on the carotid) perpendicular to the horizontal limb and drops to the clavicle
in a lazy 'S' to reach upto the midpoint of the clavicle,

rt:
lf the patient has been irradiated, then a double horizontal incision is taken which protects against wound
breakdown' The first horizontal incision is same as the horizontal limb. The second incision lies 2cm above the
clavicle starting at the anterior border of trapezius and ending medially at the midline.
Limits of dissection

rt. o Mandible (horizontal vamus)

o Clavicle
o Midline
o Anterior border of trapezius

t:
t-
Contents : - Fat, fascia, lymph nodes
- Sternocleidomastoid

rt:
- Omohyoid
- Cervical nerve roots, Cutaneus branches

I:
r r@ { qq
o6 .o)
SH.EFd*fr=f sT$E===- {gro-,
S* s P N
 Section lll Operative Surgery - Radical Neck Dissection 329
-
- Accessory nerve
- I JV with the sheath
- Submandibular gland and tail of the parotid gland.
Flaps are raised in the subplatysmal plane. Skin is incised down to and through the platysma. ln the pos-
terior part of the neck, the platysma is very thin and the fibres of the sternomastoid are inseried direcly on the
skin, which may cause some bleeding. Care is taken not to make the flap very thin posteriorly and io retain
some sternocleidomastoid muscle insertion on the flap.
The skin is held with skin hooks by the assistant and lifted upwards and dissection is done with adequate
countertraction.
Flaps are raised upto the mandible superiorly, clavicle inferiorly, anterior border of trapezius posteriorly and
midline anteriorly. Care is taken not to damage the spinal accessory nerve while raisrng the posterior flap which
may happen if the flap is too thick.
Care is taken not to damage the lower branches of facial nerve (rima-mandibularis) while raisrng the supe-
rior flap. This may be achieved by :

1. Ligating and dividing the facial vessels on the submandibular gland and lifting them over the mandible,
keeping the ligature long" (Hayes Martin technique).
This manoeuvre may cause damage by pressure of the suture if the course of the nerve is lower
than usual and will also cause compromise in removal of pre and post facial nodes.
2' lncising the deep fascia over the submandibular gland and elevating the flap with the deep fascia; so
that the nerve remains protected.
The flaps are held apart by stay sutures
The External jugular and anterior jugular veins are ligated and divided superiorly and tnferiorly. The
lower end of the stenomastoid muscle is divided.next, just above the clavicle using electrocautery. The
lower end of divided muscle should not be transfixed as it may cause bunching up and necrosis. The
carotid sheath is exposed and incised transversely. The internal jugular vein is identified and dissected.
The vagus nerve is identified between the carotid and internai jugular vein, this step is important to pre-
vent accidental ligation / transection of vagus. Three ligatures are used to transfix the internal jugular
vein and division is between top and 2"d stitch.
On the left side, care must be taken to prevent damage to the thoracic duct. The sternomastoid and
internal jugular vein are raised for a little distance. Middle thyroid vein may be ligated at this stage.
Supraclavicular Dissection :

The fascia and fat just above the clavicle is sharply divided and traction is applied to it.
The omohyoid muscle now visible is divided with a cautery without clamping.
The fatpad and fascia is held with Allis or Babcocks forceps and, traction is applied to it and dissection rs
continued in a plane just above the prevertebral fascia. The supraclavicular nerves are drvided. Care is taken
to protect the transverse cervical artery and vein which run in this triangle (Especially if a trapezius
myocutaneous or osteomyocutaneous flap is planned). The ascending branch of the transverse cervical runs
alongside the phrenic nerve but above the prevertebral fascia and is OiviOeO and ligated and the specimen is
freed from the supraclavicular fossa. Care is taken not to breach the prevertebral fiscia as the phrenic nerve
and brachial plexus run beneath it.
Sometimes if the ascending branch of transverse cervical is damaged and bleeds, blind plunging of hemo- \
stat to catch it may cause injury to phrenic nerve. The Phrenic nerve lies beneath the prevertebral fascia on
the scalenus anterior muscle and runs from above down from a lateral to medial direction. \
The Chassaignac's triangle (between the longus colli and scalenus anterior) is cleared where scalene nodes
are present. Care is taken on left side to prevent damage to thoracic duct. At this point, the anaesthetist is \
asked to give positive pressure ventilation, and if a leak is detected, it is ligated with figure of ,s, stitch imme-
diately. The supraclavicular dissection is done upto the anterior border of irapezius. \
The operation now is continued in an upward direction towards the posterior triangle.

t!

qE{S-{SSS
O
N N)
tl il
*nFilt**ss**s*
llrilI
Inl 6;;o,o,o,6rot
{(Jlror
- X* ;
or
X= S 3 ! $-o-o_r.--s'@Nr
r^
E 330 ClinicalENT

F
The Accessory nerve runs in the 'roof of the posterior triangle and must be identified and dissected before
dissecting in posterior triangle if it is to be protected (as in MND).

n
H
The nerve exits the sternomastoid muscle at the junction of the uppertAd and lower z/td and then has a
sinous course before reaching the lower anterior border of trapezius. The point of exit is known as Erbs point
and in the operation it is identified I cm above the point where the greater auricular nerve winds around the
sternomastoid muscle.

n
rr
This dissection is carried upto the mastoid tip.
o The dissection continues clinging the fascia from anterior border of trapezius upto the mastoid tip where the
sternomastoid and trapezius insert. The sternomastoid is divided from the mastoid tip. At this point, the tail
of the parotid is also divided taking care to secure the retromandibular vein. Firm downward traction is
applied to the sternomastoid and the digastric rnuscle (posterior belly is identified). Posterior belly of digas-
tric is retracted upwards with a langenback retractor. Here the upper end of internal jugular vein along with
the accessory are identified. The accessory nerve is divided and care is taken to identify and secuie any
tributaries of internal jugular vein,

F
rr
o

o
The internal jugular vein is ligated and divided between double ligatures.
The specimen is next released from the posterior triangle by applying a series of tissue forceps and ap-
plying traction and releasing the cutaneous branches of cervical plexus.
The internal jugular vein is dissected with the carotid sheath with manoeuvre of traction countedraction and
is dissected off the carotid and vagus.

rH ldentify and preserve the hypoglossal nerve as it traverses across the external carotid artery.
The occipital artery crosses the posterior part of the IJV and should be secured.
At this stage the specimen consisting of inferior belly of omohyoid / sternomastoid, lJV, fat, fascia and

n
nodes from supraclavicular triangle and posterior triangle are lifted off and dissected free anteriorly (from strap
muscles).

rr As the specimen is released, ansa cervicalis, superior thyroid vein and the facial venous trunk are identified
and divided.
Anteriorly the omohyoid (superior belly) is released from its attachment to hyoid and the specimen is now
pedicled to the submandibular region.

Dissection of submandibular triangle

tr
The specimen is now attached superiorly only. The submental triangle is cleared (between anterior bellies
of digastric muscle).
The fat, lymph nodes and fascia are now elevated upto the anterior end of the submandibular gland. The
anterior end of submandibular gland is identified and dissected upto the posterior border of mylohyoid. The

tr
n
posterior border of mylohyoid is retracted to reveal the submandibular duct. Here the lingual nerve ii seen to
loop down and attach to submandibular ganglion. The lingual nerve is freed by detaching it from the ganglion
and then dividing the submandibular duct, between ligatures as there may be a blood vessel atong witnit.

n
Bleeding from submental artery is encountered which is diathermised.
The facial artery and vein are ligated at the lower border of mandible and the specimen is pulled towards

r
posterior flap.
The facial artery is again encountered as it enters the submandibular gland, winding above the superior bor-
der of digastric.
The facial artery is ligated and divided and the specimen is removed.
Haemostasis is achieved
A check is made for chyle leak and bleeding

F
rl:
wound is closed in two layers (platysma and skin) after keeping suction drains.
Complications
1. Bleeding :
Sources :
:

a) IJV-internal jugular vein lower end

n
:

r q
6
:\
6\
'.1 {Jl o':t1,,
@cto-o I
$,;;E ,S
 a
Section lll Operative Surgery - Radical Neck Dissection 331
-
Treatment :
\
Pack I Pressure !r
'1. HEAD LOW (danger of air embolism)
2. Good suction, keep vascular clamps ready
3. Release and see if clamps can be applied
4. lf not, repack \
5. Excise medial end of clavicle and access the subclavian vein for vascular control. 'il
b) IJV internal jugular vein upper end :

1. Head low position

2. Pack, control the area by firm pressure with finger.
3. Retract the posterior belly of digastric well or divide it and then control the bleeding. lf the vessel can-
not be secured, pack jugular foramen with muscle and oversew. ln some cases, removal of mastoid
tip may help gaining exposure.
c) Damage to carotid arteries :

It occurs while dissecting off (adherent) tumour from the vessel wall.
Post operative bleeding is recognised as neck swelling.
Damage to common carotid artery and internal carotid artery is repaired after vascular clamps are ap-
plied and heparin is started.
2. Nerve injuries :

The marginal mandibular, vagus, phrenic, brachial plexus, facial, hypoglossal and lingual neryes are likely
to be damaged.
Nerve repair must be performed if vagus, phrenic or brachial plexus is injured.
Nerves which are deliberately divided are :

1. Accessory nerve : lt's division gives rise to shoulder syndrome which includes pain in the shoulder
joint, limitation of abduction and drooping of affected shoulder.
2. Branches of cervical plexus :

o Lesser occipital
o 'Greater auricular nerve
o Transverse cutaneous nerves of ihe neck
o Supraclavicularbranch
o Nerve to trapezius
3. The descendens hypoglossi
3. Chylous fistula :
There is no disgrace in damaging or cutting a thoracic duct whilst operating on left sjde of the neck. lndeed
it may be neccessary while doing radical surgery low in the neck or mediastinum. lt is disastrous tc fail to
recognise a leak.
Operating loop may be used to identity and secure it.
lf injury is unrecognised, it doesn't usually manifest itself until the patient is subsequently fed, and at this
time, the suction drain increases dramatically. Many small leaks (< 400 ml / day) will settle with conservative
treatment.
1. Fat free diet (Medium chain triglycerides recommended)
2. Pressure over supraclavicular fossa.
lf drainage is 500 ml / day for 2-3 days, reexploration should be done.
Chyle has specific gravity > 1.012
Fat content 1-3% ;
Protein content 3%

*-$--ilnnxss$s-g i. ***5;$;-s X il6-co:.r'ooaaNr z

 332
ClinicalENT

It produces intense inflammatory response, probably due to

alkaline pH or inflammatory vasoactive sub-
stances produced by leukocytes.
4' Raised intra cranial tension : lt is not commonly seen as bilateral radical neck dissection is almost
never
done simultaneously.
Bilateral neck dissection where internal jugular vein is present
on one side may sometimes lead to this
complication if .the vessel gets thrombosed.
As a staged procedure if, bilateral dissection is done then pre-operative
tracheostomy is a must.
Treatment :
o Head up position I Airway management (tracheostomy SOS)
o No constricting dressings
o Diuretics
o Steroids
o Mannitol
o Subarachnoid - peritoneal shunting
5. Seroma
6. lnfection
Late Complications
1. Shoulder Syndrome ;

It causes long standing pain and inability to perform certain

manoeuvres involving abduction of shoulder.
(Abduction beyond 450 becomes almost impossible) The
best way to avoid this complication is to pre-
serve the accessory nerve and branches from cervical plexus
to trapezius (c3 & c4). lf these cannot be
preserved, then it is mandatory to start post-operative
shoulder physiotheiapy-
2' carotid artery rupture : lt is due to necrosis of the arterial wall because of infection in and around the
artery. lt occurs in patient's treated with preoperative radiotherapy
and those
who develop postoperative fistula. lt is rarely seen nowaduys
and there is no
need to cover the carotid with muscle. lf the adventitia of
the carotid is dis- j
sected off due to adherent node then it may be prudent to
cover it with leva-
tor scapulae flap' lf it occurs, a warning bleed usually occurs prior
to the rup-
ture' The wound is reopened and the carotid artery ligated. Blood
transfusion
may be required^and a cuffed portex tracheostomv t,io" is introduced
to pro-
tect the ainruay. Carotid artery rupture is associate'd with a
high mortality late
and risk of hemiplegia.
3. Wound infection
The following factors affect healing of the wound :
i) Contamination of surgical field
ii) lncontinuity removal of primary tumour and neck node
specimen
iii) Flap necrosis and wound breakdown
iv) Postoperative fistula
v) Postoperative wound breakdown
 i
.'l
a
\
.T
1 5. COMPOSITE RESECTION/SEGMENTAU .l
\
H EM I MAN DI B U LECTOMY/"COMMAN DO O PERATION'' i
l

- Dr. Shridhar lyer

\
Composite resection, "En block" resection of various tissues with the lymphatics.

INDICATIONS
\
'1
. Primary tumours of oral cavity and tumours of oropharynx (eg. tonsil) which extend to involve the mandible. \
2. Tumours with extensive soft tissue involvement around the mandible requiring the need to sacrifice an interven-
\
ing segment of mandible to accomplish in confirmity resection.

rNctstoN \
Standard trifurcate incision for neck dissection beginning at the mastoid tip and curving anteriorly, remaining \
approximately 2 finger breadths below the body of the mandible upto the midline of neck at level of hyoid bone. The
incision then turns upwards dividing the skin and soft tissues of chin and lower lip in midline. The vertical limb \
begins perpendicular to the horizontal limb and posterior to the carotid bifurcation. The incision may be modified
depending on individual merits of the case. eg : angle splitting incision is taken if the primary is too close to angle \
of the mouth

PROCEDURE \
The steps of radical neck dissection/modified neck dissection/supraomohyoid dissection are first carried out.
\
As the operation proceeds cephalad to level l, no attempt is made to dissect the contents of the submandibu-
lar triangle, which remain attached, through the floor of the mouth and soft tissues medial to the mandible to the \
primary site.
The sternomastoid is divided at upper end and digastric muscle (posterior belly)is exposed. \
The tail of the partoid gland is divided and the retromandibular vein is ligated and cut.
The upper end of the internaljugular vein is divided and the stump is doubly ligated. \
The neck dissection specimen is now pedicled to the mandible at level l.
\
At this point the neck incision is extended upwards in the midline dividing the chin and the lower lip in its full
thickness
A tongue stitch is taken and the throat is packed.
i
A mucosal incision is placed in the gingivobuccalsulcus remaining close to the attached gingiva. \
The lower cheek flap is now elevated remaining right over the cortex of the mandible from lateral of the midline
to the angle of the mandible, keeping as much musculature in the cheek flap as possible depending on the \a
primary tumour. Using cautery, the masseter is detached from the mandible.
\
This manoeuvre provides exposure to the entire lateral cortex of the mandible from the mandibular notch to
the symphysis menti. \
All the muscular attachments over the coronoid process including the tendon of temporalis muscle are divided.
The mandible is divided above the entry of the inferior alveolar nerve, usually through the mandibular notch at \
its ascending ramus leaving the condyloid process but excising the coronoid process.
Care is taken that the power saw does not cut through the tissues medial to the mandible otherwise brisk \
haemorrhage will result from laceration of the pterygoid muscles.
The mandible is now divided at the appropriate place depending on the site, size, surface, extent o{ the
\
-^l I

tumour and the extent of soft tissue disease contiguous to the mandible. A straight cut is made through the
mandible (usually just distal to the mental foramen) \
The mandible, now divided at two places, permits its lateral retraction.
-l
\
With gentle traction on the mandibular segment, mucosal incision is marked around the tumour medial to the
mandible. 333 -
rl
\
{i

s=i€s*-= E=:-a:.:: i.4.;*:+ :=:.-5:t*:'

rn 334

of mucosa and soft

ClinicalENT

Using electrocautery, three dimensional resection of primary tumour with generous cuff
1_ tissue is done ('1-1 .Scm.)

I- The attachments of mylohyoid, digastric and medial pterygoid muscles are divided.

n
n
Once allthe medial attachments are removed, the specimen is detached.
Frozen sections from appropriate areas are obtained'
Haemostasis is checked.
Appropriate reconstruction is planned and primary closure of mucosa (buccal mucosa with
floor of mouth

tr
n
mucosa)using interrupted 3/0 vicrylsutures (mattress or single)is
The closure continues upto the mucosal aspect of the lip.
carried out if there is not much mucosal loss'

r The vermilion is now accurately approximated using 5/0 Ethilon. The lip musculature
Drains are placed in the neck.
is also approximated.

rn
The neck is now closed along with the chin in two layers after confirming haemostasis and
absence of chyle leak
on the left side.

Reconstruction :

Each patient's defect must be considered individually

The primary indication for bone reconstruction for lateral segmental defects is restoration
of mastication'

n
t:
a. Dentate mandible / patients wearing dentures / young patients : Bone reconstruction.
b. Edentulous patients not wearing dentures : soft tissue replacement.
Soft tissue replacement is accomplished by :
1. Pectoralis major myocutaneous flap (most commonly used)

I-
t:
2. Pectoralis major flap with deltopectoral flap (if there is skin loss > 6 cm)
3. Bipedicled pectoralis major myocutaneous flap (if skin loss < 6 cm)

t:
t:
4. Trapezius myocutaneous flaP
Bony reconstruction is by (Composite tissue transfer with microvascular
anastomosis is 'State of the art')
'1. Free fibula flap
Types of mandibulectomies
1. Segmental
o Lateral
:

2, lliac crest free flaP o Arch

F
r
Advantages of bony reconstruction :
1. Good resioration of function and cosmesis
2. HemimandibulectomY
3. Arch saving hemimandibulectomy
4. Marginal mandibulectomY

rr
2. Early radiotheraPY is Possible
3. Flap loss and failure are less as com-
pared to other methods of bone re- Other methods of bone reconstruction :

construction. o Pectoralis major osteomyocutaneous flap

o

n
Disadvantages : Trapezius osteomyocutaneousflap
o Latissimus dorsi flaP

rr
1. Complex procedure
2. Complications maY delaY radio- o Reconstruction plates
therapy o Titanium trays
While describing a case of o Corticocancellous grafts
mandibulectomy/composite resection o Cadaver mandibular bone
o Osseointegrated imPlants.

H Mention :
1. Type of mandibulectomY
2. Site of lesion in oral cavitY
All the above have significant rates of complications, hence not commonly
used.

tr
lf bone reconstruction is contemplated, microvascular free composite
(e.g. This is a description of compos-
tissue transfer is the best.
ite resection with a lateral segmental
Middle %'d or anterior segment resection results in debilitating deformity if

l:
mandibulectomy for a case of T4
not reconstructeded. Hence "Reconstruction of bone is mandatory"'
squamous carcinoma of buccal mu-

rr cosa (alveolus/floor mouth/tongue)

 \
a
Section llHPerative Surgery4omposite Resection / Segmental / Hemimandibulectomy/ "Commando Operation" 33S 'rl
i

COMPLICATIONS i
1. Orocutaneousfistula
2. Flap necrosis I
3. Mandibulardeviation q
The medial pterygoid action causes displacement of the remaining mandibular segment medially. This maloc-
clusion can be prevented by 'bite guide'fitted immediately especially after hemimandibulectomy
4. Stump tenderness/osteomyelitis
i
5. Complications of neck dissection :
i
\
i
\
i
i
\
i
\
\
\
\
\
i
\
\
\
\
\
-t
\
.l rt

'1
-l
-t
-'1

:1
 16. DIRECT LARYNGOSCOPY ")jr,*

This is a procedure in which the larynx is direcfly examined with

a laryngoscope.

INDICATIONS
Diagnostic
1. when a lesion on indirect laryngoscopy needs further evaluation.
2. Diagnosis of
r Congenitallaryngealweb
o Laryngomalacia
o Vocalcord paralysis
o Benign and malignant tumours
r Chronic laryngitis
o Laryngealkeratosis
o Laryngealforeign body
3. Overhanging epiglottis impeding view of endolarynx
tA( fo evalute the blind areas on indirect laryngoscopy
5. To examine larynx in children in whom indirect laryngoscopy may not possible
be
6. As a part of panendoscopy
7. To take diagnostic biopsy.
Therapeutic
1. Removal of foreign bodies from larynx, hypopharynx
2. Removal of thickened secretions, crusts
3. Removalof vocarcord nodures, cysts, poryps, benign tumours etc.
',{ For endotracheal intubation in general anaesthesia

'-s Direct laryngoscopy with a detachable blade is used to pass

a bronchoscope, particularly in children.
..-61 To inject Teflon paste in unilateral vocal paralysis.
cord

CONTRATNDICATIONS
Absolute
Disease of the cervical spine. ln caries spine, direct laryngoscopy
can lead to spinal cord damage and quad-
riplegia.

Relative
1. Trismus or ankylosis of temporomandibular joint
2. Short, thick neck
-.& Long incisor teeth
4. Systemic disorders
o Diabetes
o Hypertension
o Cardiac abnormalities

336

t-
E

r
 \.l
Section lll- Operative Surgery - Direct Laryngoscopy
\
PREOPERATIVE \
-t
\
ANAESTHESIA I

Local or General anaesthesia \

Local anaesthesia : The oral cavity and oropharynx are sprayed with 4% Xylocaine spray. The larynx is sprayed
with a laryngeal atomizer
\
A cotton wool soaked in 4% Xylocaine in placed in both pyriform fossa with a Krause's
laryngeal forceps for five minutes. This is to anaesthetise the internal laryngeal nerve \
running under the mucosa of the pyriform fossa. The subglottis is anaesthetized by instill-
ing Xylocaine through the glottis while the patient holds his tongue and says 'EEE' i
General anaesthesia : This is preferred as it allows detailed examination and adequate relaxation and control
\
over the airway. A smaller size endotracheal tube is preferred.

POStTTON
i
(BOYCE'S position) \
Supine position with flexion of neck and extension of atlanto-occipital joint. This particular position brings the
larynx in direct axis with the oral cavity and facilitates introduction of the scope.
i
PROCEDURE
\
The laryngoscope is held in the right hand and passed from the right side of the mouth. The upper lip and teeth \
are protecied with a thick layer of gauze to prevent injury during the scopy. The endoscope is introduced from the
righi angte of mouth to the literat siOe of tongue till the posterior part of tongue is reached. lt is then shifted to the \
midline and the base of the tongue is elevated. This brings the epiglottis into view. The tip of the laryngoscope is
passed behind the epiglotti" und th" epiglottis is lifted by lifting the handle of the laryngoscope upwards. This
brings the posterior part of the larynx into view. By proper manipulation of the scope, keeping in mind to avoid
i
prer-rrre on the lip and teeth, the whole of the larynx especially the blind areas are visualized for any pathology'
\
The following structures are visualized on drrect laryngoscopy. jg
o Valeculla o
.
lnterarytenoid region
Btind areas of larynx,
(Difficult to visualize areas of larynx) i
o Base tongue True vocal cords o Laryngeal surface of epiglottis below its tubercle
o Lingual surface of epiglottis . False vocal cords r Ventricle of larynx
\
o
o
Aryepiglottic fold
Pyriform sinus
.
o
Anterior commissure
Posterior commissure
o
o
Anterior commissure
Subglottis
i
o Post cricoid region \
The laryngoscope is then gently withdrawn. A microlaryngoscope abuts against the true vocal cords while
direct laryngor"op" is only intioduied upto the epiglottis to visualize the supraglottis and glottis' A straight blade
a
i
taryngosto[e is only ,red to examine the larynx and to pass a rigid bronchoscope. The anterior commissure
taryngoscope is used to visualize the anterior part of glottis, anterior commissure, subglottis and to fix the vocal
i
cords for therapeutic Purposes. i
COMPLICATIONS
'1. Trauma to lips, teeth, gum, tongue, palate etc i
2. Damage to cervical spine or spinal cord \
3. Laryngospasm or stridor may be precipitated.
4. Anaesthetic complication like hypertension, cardiac and respiratory arrest. \
Direct Laryngoscopy in children
It is indicated in children having stridor with feeding difficulties. lt differs from adult laryngoscopy
in that the tip \
of the laryngoscope is not placed behind the epiglottis, but anterror to the epiglottis in the valeculla. This manoeu-
vre brings the laryngeal inlet in line with the optical axis of the laryngoscope and allows a good view of the larynx. \
Also in ihi, *ry, the tip of the laryngoscope does not press on the aryepiglottic fold which would restrict cord .|l!

rq
 338
ClinicalENT

movements in a case of cord paralysis.

stridor is common in infancy and chirdhood because of

certain anatomical differences between adult and
infantile larynx.

1. Higher in the neck, therefore the air currenl 1. Lower in the neck
enters more straight into the larynx. The pharynx, larynx and
trachea meet at an acute angle.
Smaller and narrow especiatty in tn-iGglot_
3. Antero-posterior diameter of 3. The lumen of the larynx and trachea is The larynx and trachea are pro-
.glottis smaller in proporlion to the body as a whole. portionate to the body.
.-Gl6ttis 7 mm
q_!!n (4 mm is stenosis)
4. - Folded 4. - Leaf-Iked
- Funnel shaped - Not curled
- lnfantile
5. Softer and more pliable
6. Hyperexcitable

7. Loose and less fibrous

INDIRECT LARYNGOSCOPY

1. Mirror image of larynx 'l . Direct visualization

2. lnverted image obtained 2. True image is seen
3. Two-dimensional image :
3. Three-dimensional visualization
4. lnadequate visualization of anteriorcommissure, ventricle 4. Good visualization of entire larynx with its blind areas.
and subglottic region
5. Overhanging epiglottis may hamper view
5. Epiglottis is lifted up with the tip of the scope
6. Out patient's procedure
6. Operative procedure
7. No anaesthesia is usually required
7. General anaesthesia is preferable.

Types of Laryngoscopes

Endotracheal intubation
Jackson's direct laryngoscope (with a sliding Most
commonly used for direct turynorcopyLt nas distal
illumination.

Anterior commissure laryngoscope

Direct laryngoscopy. lt has a wiOu proximffi
It has a bevelled end and is use
vocal cord operations
+1

r:
E
 17. BRONCHOSCOPY

I
Diagnostic
I
o Patients with respiratory disease of long duration.
o Diagnosis of :
I
- Unexplained chronic cough, sputum production.
- Stridor. I

- Wheeze.
- Haemoptysis.
o Suspected foreign body
o Paralysis of a vocal cord.
o A mass in neck (thought to be metastatic carcinoma.)
o Suspicion of tracheal, bronchial or pulmonary disease,
I
o Sputum cytology suggestive of a malignant tumour.
o Oesophageal and thyroid diseases involving the tracheobronchial tree. t

Specific lndications for Bronchoscopy : t

o Atelectasis
r Emphysema
o Parenchymaldensities
o Foreign body
o Mediastinal masses
o Pleural effusion
t

rf
Therapeutic
o For aspiration of tracheobronchial secretions in atelectasis and bronchiectasis rl
o Removal of benign endobronchial neoplasms - such as papillomas, lipomas etc.
o Removal of foreign bodies and broncholiths. !
o Drainage of lung abscess. lf
o Dilatation of bronchial stenosis.
r Lung lavage in asthma and cystic fibrosis t
o Biopsy of a suspected tumour
i
Contraindications
Absolute \
o Aortic aneurysm.
o Bleeding tendencies. \
o Recent massive haemoptysis of any cause.
\
Relative
o Acute respiratory infections q
o Cervical spine ankylosis
o Trismus.
i
!
339
q

fr
340 ClinicalENT

PREOPERATIVE
ANAESTHESIA
General anaesthesia is preferred. Ventilation is maintained by oxygen-venturi system.

POSITlON
Supine position with head extended and the cervical spine flexed at the atlanto-occipitaljoint. The surgeons
left hand steadies and controls the upper jaw. The upper teeth are protected with a double-layered gauze from
pressure of the scope.

OPER.ATION
lnsertion of bronchoscope with the aid of the laryngoscope : The direct laryngoscope is first passed lifting
the epiglottis. The assistant holds the bronchoscope at its midpoint like a pencil and places the distal tip of the
bronchoscope in the laryngoscope. The operator takes hold of the handle and advances the bronchoscope
through the laryngoscope, supraglottis, the vocal cords and then into the trachea. Once the bronchoscope is
in the trachea, the handle of the laryngoscope is rotated to the left, its slide is removed and then the
laryngoscope is removed.
lnsertion of only bronchoscope : ln this method, the bronchoscope is inserted like an oesophagoscope. lt
is introduced through the right side of the mouth, following the tongue to the epiglottis. The epiglottis is
elevated and using the left thumb as a fulcrum for the scope, it is advanced towards the glottis. Before
entering the glottis the tip is rotated by 900 to the right. This makes the tip vertical and enables the scope to
pass thiough the vertical axis of the glottis and to visualise the left vocal cord. lt should be remembered that
while withdrawing the bronchoscope, the opposite is followed ie; the tip of the scope is rotated to left by 900.
So that the righl vocal cord and its undersurface can be visualised. With gentle twisting movements, the
bronchoscope is further advanced down the larynx into the trachea.
lnspection of trachea and carina : The scope is gently advanced visualising the tracheal walls till the sharp
outline of the carina is seen.
The carina is evaluated for its position, sharpness, and mobility on respiration and cardiac contraction.
Enlarged lymph nodes and masses may displace the carina. As a general rule, the right bronchus and its
subdivisions are examined first. As the right bronchus is entered, the head and neck are turned to the left to
allow a more direct passage of the scope. The handle of the bronchoscope is rotated to the right so that the
tip of the bevel will enter the right bronchus. After bronchoscope has entered the right bronchus, the handle is
rotated to the left so that the orifice of the upper lobe bronchus may be inspected. lt ideally requires a iateral
viewing telescope for adequate inspection.
All subsequent lobar bronchi are examined and as the bronchoscope is withdrawn, the head and neck are
shifted back to the midline and then to the right as the left bronchus is entered. Entry into the left bronchus
requires more caution as it is longer and curved at an oblique angle to the carina.

BRONCHO . PULMONARY SEGMENTS

RIGHT LUNG LEFT LUNG

Lobes Segments Lobes Segments
Upper Apical 81 Upper Superior division Apical Posterior B1'2
Posterior 82 Anterior 83
Anterior 83 lnferior division (Lingula) Superior 84
Middle Lateral 84 lnferior 85
Medial 85 Apical 86
Lower Apical (SuperioQ Bo Lower Medial basal 87
Medial basal A7 Anterior basal Bg
Anterior basal 88 Lateral basal 89
Lateral basal Bg Posterior basal 810
Posterior basal 810
 \
.l
Operative Surgery'Bronchoscopy 341
Section lll
- )
The bronchoscope is withdrawn to just below the carina. Bronchial washings are usually taken from each :'1
bronchial tree separately. Normal saline,5 to 10 ml is injected through the bronchoscope and aspirated' The
"rr'|
specimen may be sentior bacterial culture and sensitivity, acid fast smear and culture, fungus culture and
cytologic examination. A large sample of biopsy can be taken. Biopsy is carried out at the end of the
-l
\
pioceC'ure, so that the bleeding that follows does not hamper visualization. lt is required to fix the scope to the
ieeth before any therapeutic indication is carried out since the scope may move with respiratory movements. \
COMPLICATIONS
^l
-!
o Trauma to surrounding structures.
o Arytenoid dislocation \
o Laryngeal oedema
o \
t
Haemorrhage
r Bronchospasm
o Aspiration
\
Foreign Bodies of the Tracheobronchial Tree :
They are mainly seen in children. Common foreign bodies are seeds, nails, pins, beans, smooth objects
like peanuts, peas and plastic toys. Foreign body in the tracheobronchial tree produces severe spasmodic
i
cough which lasts for approximately half an hour and then subsides. Foreign bodies most frequently lodge into \
the right bronchus.
Foreign bodies are more common in the right bronchus because :
\
o Carina is slightly to the left \
o Right bronchus is larger in diameter than the left.
o Right bronchus is a more direct extension of the trachea then the left. \
o Action of trachealis muscle.
o Greater volume of air enters the right bronchus' \
As the cough abates, auscultation of the chest may show signs of bronchial obstruction. \
Types of bronchial obstruction \
o Bypass valve.
o Expiratory check / one waY valve
o lnspiratory check / stoP valve
i
\
A foreign body in the bronchus may produce a bypass valve, an expiratory check or one way valve, or an
inspiratory check or stop valve type of obstruction. The most common is the one-way valve, in which the air
may enter the bronchus distal to the foreign body during inspiration but may not escape from the lung on
i
expiration. This type of valve obstruction produces emphysema distal to the foreign body' \
Signs of obstructive emPhYsema l \
1. Respiratory system examination
o increased resonance \
o decreased breadth sounds
2. X'ray picture \
o emphysema obvious on expiratory film \
o increased rachioluscency of lung is present distal to the foreign body
o mediastinal shift to opposite side. \
o separation of ribs from eachother
\
\
\
\
r^
E 342
ClinicalENT

F Signs of stop-valve kind of obstruction :

1. Atelectasis of lung distal to the foreign body (absorption of air in
2. Shift of mediastinum to opposite side
the lung)

tr
3' compensatory emphysema of the opposite rung for adequate ventiration
4. Respiratory distress, cyanosis and cardiorespiratory fairure can occur.

H
5. Absent breadth sounds on the affected side.

n
The stop valve kind of obstruction completely occludes the bronchus.
smaller tracheal foreign bodies may move in the trachea during respiration.

rH
Radiography is not usually
helpful with tracheal foreign bodies,
Vegetable foreign bodies produce severe inflammatory reactions
which are particularly severe with peanuts
and nuts which produce arachidonic bronchitis. After a lltent period
of 24 hours, the patient develops cough
with purulent sputum and fever. Beans and peas are hygroscopic
and swell as water is absorbed. Metallic and
plastic foreign bodies that cause partial obstruction
of j bronchus may be tolerated for long periods.
General anaesthesia is used in most paediatric and adult patients
for foreign body removal. Antibiotic therapy
is required in patients with long standing foreign bodies.
The size of the ventilating bronchoscope should be appropriate

F
to the patient. lt should be small enough in
diameter to reach the level of the foreign body and yet piovide
large working lumen as possible. An over sized

r
bronchoscope can lead to subglottic o-edema post-operatively.

Causes of subglottic oedema

rr
:
o Over sized bronchoscope
o Prolonged bronchoscopy
o Extensive manipulation during scopy.
o Trauma during extraction of foreign body.

once the foreign body is seen, it is important not to displace the foreign
body. surrounding secretions
should be gently suctioned away and the foreign body should be for

F
inspected the best position of the
bronchoscope for forceps application. sharp or pointed ioreign bodies
may require disengagement from the
mucous membrane before withdrawl. The distal tip of the bronchoscope
should be as closJ ai possible to the
foreign body' There should be an adequate space around the foreign
body needed for application of the
particular forceps for that foreign body. (Forcep space)

tr
r
- Bronchial foreign bodies are removed by placing the distal end of the forceps beyond the centre of the
foreign body so that it is not propelled distaliy'as thJforceps is closed.
fragile foreign bodies such as peanuts. Foreign bodies are usually
the foreign body is too large, it must be removed as a trailing
the foreign body to the bevel of the bronchoscope, fixing iI tn"r"
foreign body are removed as one unit. The foreign body hls
Care must be taken to avoid crushing
withdrawn through d;;;il;;;#;;';,
foreign body. This is ione by genily withdrawing
and then the forceps, bronchoscope and
to be manoeuvred at the level of the glottis for its

F
passage through the narrow space. lf there is subgtottic
swelling or expansion oi roreign body, then a
tracheostomy has to performed and the foreign b6dy removed by introducing

n
the scope through the
tracheostoma.

Principles of removal :

o Selection of an adequate size bronchoscope.

o Achieving best exposure of foreign body.
o Bronchoscope positioned close to foreign body without touching
it and keeping adequate forcep space.

F
I The distal end of the forcep used should pass beyond the centre
of the foreign body
o small foreign bodres ar

rlr
oved through the scope while larger once are removed by trailing mechanism
Chances of endobronchial oedema increase if the procedure takes
more than half an hour.. After foreign
body removal a check scopy is done to inspect the tracheobronchial
tree for a second foreign body.

I-
r
Section lll Operative Surgery - Bronchoscopy 343
l\
.ni

-
o Smooth foreign body in a peripheral bronchus can be removed by passing a Fogarty balloon catheter distal \ I
I
to the foreign body, gently inflating it and withdrawing it.
o Hollow foreign bodies can be removed by placing one blade of an alligator forceps inside and one outside.
\
o Pointed foreign bodies, such as nails, hooks and pins are almost always situated with the point directed
superiorly. The point must be enclosed in the blades of the forceps to prevent perforation of the bronchus.
,\
lf the point is already embedded in the mucous membrane, the foreign body must be pushed distally with
the forceps to disengage the point. Klerf Arrowsmith safety pin closing forceps are used to close open \
safety pins and to remove them.
\
Methods of removal of an open safety pin :
r Disengagement from mucous membrane and closure of pin with closing forceps and then removal through -
the scope.
r lf th'e tip is facing upwards and not closing, the pin can be rotated so that the tip faces downwards and then \
removed through the scope. (Retroversion)
r Gastroversion can be attempted in which the safety pin is pushed into the stomach, rotated to face the tip \
down, closed and then removed. \
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
!
q
r{
r-
rF 18. MICROLARYNGOSCOPY
H
n
n
r It is a surgical procedure in which the endolarynx, especially the vocal
operating microscope.

Pre requisite
cords are examined with the aid of an

tr
lndirect laryngoscopy is needed before microlaryngoscopy.

rr
INDICATIONS
Diagnostic
To come to a diagnosis in a case of
'1
. Hoarseness of voice
2. Suspicion of laryngeal carcinoma
3. Biopsy from pathological lesions

F
rr
Therapeutic
1. Removal of vocal cord nodules, polyps, granulomas.
2. Cauterisation of vocalcord ulcers
3. Stripping of vocalcords in Reinke,s oedema.
4. Teflon injection in vocalcord palsy.

F GONTRA]NDICATIONS
1' General debility making general anaesthesia risky - myocardial infarction, embolism,
sion.
arrhythmias, hyperten-

tr
2. Patients in whom hyperextension of the cervicalspine is difficult
r Cervicalspinediseaseisurgery
o Tuberculosis
3. Small glottis

F
r ANAESTHESIA
o A high level of co-operation between the surgeon and the anaesthesiologist

rr
is required
o Generalanaesthesia with a smallsized endotrachealtube is preferred.

POStTtON

r
o supine position with no head rest and no sand bags under the shoulder.
o Protection of the teeth with rubber tubings or gauze pieces is required.

INTRODUCT]ON OF THE LARYNGOSCOPE

o The neck is placed in maximal flexion and the laryngoscope (largest possible
size) is introduced from the
cornerof the mouth.

F
o The anaesthetic tube is followed passing the uvula, lifting the epiglottis and finally positioning
the scope a few

rt:
millimeters cranial to the anterior commissure of the vocil cords.
o The scope is then fixed in place with the chest holder.
o Both the vocal cords are visualised along their entire length.
o lf the anterior commissure is difficult to visualize, larynx is pushed slightly posteriorly
with externally applied
manual pressure

t:
T
344
 .'il
Section lll
-
Operative Surgery' Microlaryngoscopy

EXAMINATION U NDER MICROSCOPE

I
:T
o The initial light source is removed.
o Zeiss surgical microscope with a 400mm objective lens attached is placed in front of the laryngoscope
:T
o
r
Working distance between the laryngoscope and the microscope is approximately 20 cm and the eyepiece is
adjusted.
After proper suctioning, the following areas are examined.
l
:.I
-
-
-
-
Vocal cords
False cords
Ventricle
IT
I
Subglottis
- Arytenoid area

Documentation of the laryngeal findings is done.

:1
POST OPERATIVE CARE
o Voice rest and speech therapy, if required
''l
^
''r
-
\
\
\
\
\
\
\
\
\
i

\
\
\
\
\
\
I
i

\
!
-i
\ l
; i

\
rl
r{
 SECTION I IV
SURGICAL PATHOLOGY
- Dr. N. K. Behl

H
E
r"
l:
t: 1. STAINING
t:
F For routine haematoxylin and eosin staining, tissue sections need to be processed as per the following
1. Fixation - by formalin
2. Dehydration - by ascending grades of ethyl alcohol
steps :

F 3. Clearing - by xylene
4. Embedding - by paraffin.
This processing can be manual ( hand processing) or automated (autotechnicon)
After tissue embedding in paraffin, blocks of paraffin are prepared and sections are cut (4-6 p thick) on
micro-

E tome. These seciions are then stained.

r" Fixation
o Purpose of fixation :

r_ a) To study cell morphology as in living state (i.e. to prevent autolysis)

r" o
b) To kill bacterta and other infectious organisms.
c) To render tissue resistant to further steps of processing and staining.
Amount of fixative used is 10 times the volume of the tissue
o Time required is 24 hours
E o Mechanism of fixation is that it causes coagulation of proteins in the cell'
r_ Types of fixatives

r:
t: 1. 10% Formalin
USED FOR

Routine processing
Most commonly used.
Advantages
REMARKS (ADVANTAGE i DISADVANTAGE)

1. Cheap
I

2. Easily available 1

F 3. Rapidly penetrates tissue

4. No overhardening occurs even if tissue is kept for a
long
5. Permits
time
wide range of staining
i

F
t:
Disadvantages.
1. lrritant to conjunctiva, skin, mucosa
2. Allergic reactions can occur
3. Formalin pigment artefact may be created in the tissue
2. Bouin's fluid For liver and testicular bioPsY
3. Zenker's fluid For muscle biopsy and CNS studies '1 . Overharde ing of tissue occurs if kept for a long time

F" Tissue is stained yellow due to the colour of fixative So

prolonged washing is required to remove the colour'

f-" 4. Alcohol lTo preserve glycogep

(which is wa-

l-- Iter soluble) Over harden's tissue

Dissblves fat

F
5. Glutaraldehyde
6. Osmium For electron microscoPY

t:
tetraoxide
/

t:
346

r_
 I

Section IV Surgical Pathology - Staining 347 \

-
!
Staining
Methods of staining : I
1. Vital staining - applied in living tissue.
2. Routine staining - eg. Haematoxylin and Eosin. lt differentiates between nucleus and cytoplasm I

Nucleus : stains blue (haematoxylin).

Cytoplasm : stains pink (eosin) !
3. Special staining - For specific structure identification and microorganisms !
Special methods :

- !
1. lrnmunological lmmunohistochemistry.
lmmu nofluorescence t
- lmmunoelectron microscoPY
2. Flowcytometry t
3. Molecular biology techniques \
!

ts

\
I

t
\
!

rf

trr

i
t

lr
 2. MICROBIOLOGY

The specimens sent for microbiology study (eg : pus swab) should be sent in a sterile container to be pro-
cessed without delay

Laboratory diagnosis of disease is :

- 1. Direct : isolation of organism by smear, culture and biochemical reaction (identification of organism)
2. lndirect : blood counts, serological and biochemicaltests.
o Purpose of smear -
' 1. Organism identification - cocci / bacill and gram +ve / gram -ve will help in selecting culture media.
2. Presence of pus cells - indicates inflammation.

STAINS
1. Gram Stain
Smear is air dried and fixed by passing 3-4 times through the flame
ll
II
-z
- Stain with Gentain violet or methyl violet for 1 lo 1t/z min (principle stain)
I'
Wash with Gram's lodine (1 min) (lt is a mordant ie. fixes dye over smear)
{,
Wash and add decolourising agent (spirit, alcohol, acetone)tillblue colourcomes out (15-25 sec.)
u
Lastly counterstain with safranin. (40 sec.)
lt
Then wash, dry and see under oil lens.
Gram +ve : due to Mg - ribonucleate protein complex in cell wall, appears blue
Gram -ve : appears pink

2. AFB stain (Zeil Nelson stain)

Smears fixed by passing in flame and covered with carbol fuschin. lt is kept warm for 8 min. Basic Fuschin is
a dye, (warm dye penetrates better). Carbol acts as a mordant.
.1,

Wash and decolourise wilh 20% H SO or 3% HCI for 2 min.

JJ, 4

Counterstain with methylene blue or malachite green for about 1 min. Dry, see under oil lens
u.

AFB look red.

'4
a,
z,

a
-

348
 ,l'I

I
3. CYTOLOGY :t
l
o
o
purpose - Rapid diagnosis of malignancy and other conditions eg. tuberculosis, Hashimoto's thyroiditis etc'
Examination of cells which are obtained by
lI
1. Exfoliativecytology
2. FNAC
:1
3. lmprint or crush smear from tissue pieces :'l
4. Brush cytology (through fibreoptic endoscopes)
r FNAC (Fine Needle aspiration cytology)
:'l
- lt is a most commonly used technique. lt is an out-patients procedure.
- Disposable syringe and needle (usually 23 no.) of variable length as per the need is taken. Negative
:'l
pressure snoutO be applied only after entering the lesion to be aspirated. The negative pressure should :'1
be released while removing needle out of the lesion.
:''l
-
-

-
usG or cT guided FNAC can be done especially for deep seated organs.
The material obtained in the needle is expressed on a glass slide, smears are prepared and rapid fixation
in ether-alcohol is done for PAP staining while other remaining air dried smears are used for Giemsa
staining. H and E staining can be done instead of PAP staining.
Complications (rare) :
t
:1
r_
Local haematoma, very rarely dissemination of malignancy via needle tract may occur
- Advantages:
^l
Rapid, easy, inexpensive and reliable if done by an experienced person. )
- Disadvantages
-
:

lnterpretation of smears needs experience

:'1
- lnherent limitations in cases where diagnosis depends mainly on tissue architecture eg. in follicular :'1
carcinoma of thyroid where diagnosis of malignancy depends on capsular and vascular invasion and
not on cytomorphologY. :1
- lt is commonly used for diagnosis of enlargement or swelling of :
\
.l
Thyroid, lymph nodes, breast and salivary glands.

It
tI
)

t]
:'l
:'l
:1
349 -.I
=1
F
t: 4. FROZEN SECTION
k $r

n
I:
\\-r\
f^ ,-"

\-
ts
-

n
t:
o lndications
1. Rapid tissue processing and staining
(Routine paraffin embedding and processing of tissue takes about 1 day)

I:
l-.^
2.
So it is useful for intraoperative diagnosis of tumours
For demonstration of
a) fat (in routine processing, it is dissolved by alcohol)

t:
n
r
b) antigen - antibody reactions
Technique
1. Freezing microtome - rarely in use now since sections are thick'

n
n
2. Cryostat - Microtome enclosed in refrigerated chamber (200C) and can be operated to give thin sec-

-
tions
Tissue is hardened by rapid freezing with CO, gas and embedded in ice.

t:
o Disadvantages -
(As compared to routine haematoxylin and eosin staining)

t:
t:
1. Morphology is less preserved
2. Sections are thicker
3. Bone and fatty tissue create problems in technique

n
I:
4. Serial sections are difficult to obtain.

F
t-
F
t:
n
F
r
l*
l-'
t:
350

r
 II
5. SPECIMENS I:t
:t
._,21. NASAL PoLYP :t
U lq vu,ounkJ fttinah
E +1"€ ll.,.tts,rw-r,os 1x\p L+e*-y Zp*"tt :t
Gross features
:I
II
tts-iq-n
A p p e a r a n ce : B g!-oolJ! 9 -4uEos-alsalr

Types of nasal PolYPs

1. An trochgqn a -u n la teral, a ri s n g f p.n-max! AILa[trum
I i i I

2. Ethmord a l-bilatera l, grape-.].t91n9:!99 from the eth mo-ld sin uses'

Sit-e . Nasglcavity, sometinres in
Size : Variable. UgqqllY-];Q-qlr
palalasalsinuses
II
Number:Srngleormultiple,maybebilateral(inbothnostrils)
Shape : Ovallo elongated'
:1
- lrregular in antro-choanal polyp'
whitish pale grey in colour with a shiny translucent
appear- :'l
External surface : smooth or finely bosselated,
ance. Surface may be ulcerated
discharge 4nd tinycysts may-be seen'
:'l
cut surface : May shpw haemorrhage, neclosis, mucoid
Consistency : Soft, tends to tecome firm with incpase
in fibro-collageoous tissue' :'l
Modalities of treatment - Steroids .'
:'l
-
-
-
PolYPectomY-
Caldwell Luc oPeration t]
-
EthmoidectomY
FESS
l']
Difference between Antrochoanal and Ethmoidal
polyp' :'1
ri
ETHMOIDAL
FEATURES ANTROCHOANAL
I

Vnrrnn adrrllq and children _-

Elderlv

t
:"1
Age
Ir/avillanr antrum Ethmoid cells
Origin
Multiole
Number Single
Trifnli:1p Bunch of qrapes
Shape
Side
Bilateral
:'1
Size Can qrow very large \
RelativelY. vascular
VascularitY Avascular
Recurrence Uncommon
\
Backward ,
Forward
Extension
Towards choanae
Towards anterior nares \
lnfection vv
EtloloqV
Polypectomy / External ttnmotoectttttty I rco'
-rrl
Treatment
trtrqq/crldwell-l rrc ooeration/Polvpectomy
Caldwell-Luc / FESS f gSS I nntif,istarninics / Topical /'oral steroids \
Prevention of recurrence

tfrr!

I
351
q

<

\
rr
n
352
ClinicalENT

n
rr dependent.
r
2. NASOPHARYNGEAL ANGIOFIBROMA
It is almost exclusively seen in males between'10 and 25 years age because
this neoplasm is androgen

Origin from distinctive erectile - like fibrovascular stroma located in the postero-lateral
-

wall of the roof of

nose. characteristic location is useful in case of a diagnostic problem.
o

rr
Gross : Polypoidal mass which bleeds severely on manipulation. lt can
f-_ free edge of the soft palate and even into the orbit and cranial cavity.
CT scan / MRI is required to see extension of mass.
extend into antrum, protrude below

o Microscopy:

t:
Blood vessels from capillary to venous size with surrbunding characteristic
fibrous tissue stroma which have
"erectile tissue" appearance. (ie. loose, oedematous

rl:
tissue with stellate fibroblasts, rnast cells and collagenised
tissue,)
D/D from capillary haemangioma is.necessary.
Fate : May regress partially after puberty; but treatment is indicated.
Surgery and radiothe rapy areavailable.
Recurrence may develop, usually within first year of treatment. chemotieiapy

n
is added for a more aggres-
sive tumour. Rarely sarcomatous transformation occurs.

t:
t: 3. NASOPHARYNGEAL CARCINOMA
lncidence - leading cause of death in south east Asia and northern Africa.

t-_ Age : Bimodal peak-at 15 to 25 years and at 60-70 years

Etiopathogenesis - Combined action of genetic predisposition, environmental
factors and Epstein Barr virus

F
(EBV)infection
Gross features - Tumour may be very difficult to detect. Random blind
biopsies from nasopharyngeal area
should be taken in suspected cases.

l-
t:
Microscopy - types :
1. Epidermoid or Squamous cell carcinoma (keratinization +)

r
l-
- older age group, less association with EBV, poor prognosis
2. Non keratinising and undifferentiated (sometimes spindle cells)
-
More frequent than epidermoid carcinoma
-

t:
Microscopically lymphocyte rich inflammatory infiltrate is common, hence
also called lymphoepithelioma
Growth pattern :

t:
t:
Carcinoma cells can be in well formed aggregates or diffuse fashion.
lymphoma.
3. Adenoid squamous carcinoma
4. Papillary adenocarcinoma f*
---i
rare

It has a strong tendency to metastasize to regional lymphnodes and

The diffuse pattern can be mistaken for

commonest clinical presentation is

cervical lymphadenopathy.

F
l-
Radiation therapy cures over half of the patients and survival is better young
ln children, the most common types of nasopharyngear marignancies
L Embryonal rhabdomyosarcoma
in
are :
individuals.

l* 2. Lymphoepithelioma

l-
I:
3. Malignant lymphoma.

;:
Section lV'- Surgical Pathology - Specimens 353
.l
o lncidence:
4. GARCINOMA OF MAXILLARY SINUS II
- Malignant tumours of nasal cavities and paranasal sinuses represent only 3% of the all upper aerodigestive
tumours (amongst these, tumours occur more frequently in maxillary sinus followed by nose and ethmoid .1
o
sinus. )

Types of malignant turnours

T
A. Primary tumours :
:1
i. Epithelial
a) From the mucosa :1
-
Squamous cell carcinoma
Melanoma
:1
b) From the mucous glands :1
-
-
Adenoid cystic carcinoma
Adeno carcinoma
l'l
ii.
c) From odontogenic epithelium - Ameloblastic carcinoma
Non-epithelial
:'l
a) From bone - osteosarcoma :'1
b) From cartilage - chondrosarcoma
c) From connective tissue - fibrosarcoma
:1
B. Metastatic tumours
o
-
:'l
c
More common in mandible than maxilla
Primary tumours in adults :'l
- Carcinoma from breast, lung, large bowel, prostate, kidney, thyroid, testis
o Primary tumours in children
:1
- Adrenal neuroblastoma, embryonal rhabdomyosarcoma
- Wilm's tumour.
:'l
:1
Squamous cell carcinoma of maxillary sinus
lncidence :

o 80% of all malignancies of maxillary sinus.

II
o More frequent in men over 40 years of age
o Usually previous long history of chronic sinusitis
Presentation
II
o
o
o
Unilateral nasal obstruction
Persistent rhinorrhoea and epistaxis usually for more than 4 weeks.
Tumours grow undetected until whole sinus is filled.
II
Dragnosis
o Anterior and posterior rhinoscopy can be useful in visualising tumour mass
II
o Radiology will be usefulto determine extent of lesion and bone erosion.
:I
o
r
o
o
FNAC by sinus puncture and aspiration of contents
Biopsy obtained by endoscopic guidance or surgical exploration"
C. T. Scan
Orthopantomogram
I:I
-r
-T
:t
 ClinicalENT

Gross : lrregular cauliflower like whitish grey necrotic tumour mass. There may be areas of haemorrhage
and
necrosis
Microscopic examination - Squamous cell carcinoma.
Classification
1. Ohngren's Classification
2. Moffets Classification
3. Ledermann's Classification
4. TNM Classification
5, Broder's Classification
Staging : Staging system can be considered as follows.
Ohngren's imaginary line from medial canthus of eye to angle of mandible divides maxilla in
a) Anteroinferior portion (lnfrastructure)
b) Posterosuperior portion (Supra structure)
Treatment :

o Total/ extended maxillectomy

r Radiotherapy and chemotherapy as adjuvant treatment.
Prognosis :

r Five year survival rate is around 30%

o Tumours of infrastructure are away from the eye and base of skull and may be resected more easily, hence
carry better prognosis.

5. CARCINOMA OF ORAL CAVITY

Leukoplakia
- lt is a clinical term for a white patch or plaque which is at least 5 mm in diameter, cannot be removed by
rubbing and cannot be classified as any other diagnosable disease
- Epidermoid carcinoma has been reported to develop in 1% to 6% of leukoplakia cases followed up for .10
years.
It is usually seen in lesions with dysplastic epithelium.
Squamous cell carcinoma
- Predisposing factors
- For lip carcinoma - sunlight, fair complexion
- For oropharyngeal carcinoma - tobacco, alcohol, syphilis, oral sepsis, candidiasis
- lncidence - Usually in males over the age of 50 years
Common sites'are -
1. Floor of the mouth (especially at exit of Wharton,s duct)
2. Anterior pillar of soft palate and retromolar area
3. Ventrolateral aspect of tongue
- Apart from typical microscopic appearance, cells may have acantholysis with pseudoglandular appear-
ance. Definite stromal invasion is the criteria for malignancy.
- Role of frozen section is for evaluation of surgical margins.
- After radiotherapy, abnormal appearing mucosa if seen, should not be biopsied till 6-8 weeks because
interpretation of biopsy may be difficult and misleading.
 ,fi
Section lV Surgical Pathology - Specimens 355 \
-
- F. N. A. C. has main role in detecting lymph node nietastases.
\
- Two morphological patterns which may create diagnostic difficulty in lymph node assessment include ri.,\
\
a) Cystic degeneration in metastatic deposits
,d'
b) Extensive foreign body giant cell reaction around clumps of keratin without viable tumour cells. \
Prognosis :

o Depends on stage, location and grade.

\
o Overall 5 year survival rate is : \
- CA of lower lip - 90%
- CA of anterior tongue - 60%
q
- CA of posterior tongue, floor, tonsil, gingiva - 40%
!i
- CA of soft palate - 20% to 30%
Other microscopic types ;
1. Verrucous carcinoma IE
2. Adenosquamous carcinoma
3. Basiloid carcinoma ri
4. Spindle cell carcinoma
5. Small cell carcinoma I

o Spread and Metastases

-
1. Direct Spread :
E
a) Carcinoma lip - adjacent skin, orbicularis muscle, buccal mucosa, adjacent mandible and mental
nerve.
b) Tumours of floor of mouth - sublingual gland, oris gingiva and mandible
\
c) Tumours of tongue - Often on lateral and undersurface and remain localised for a long time. They \
eventually invade the floor of mouth
d) Tumours of buccal mucosa - lnfiltrates in underlying muscle and skin \
e) Tumours of gingiva - Quick spread to periosteum and oral mucosa
f)Tumours of hard palate - lnfiltrate in underlying bone but extension to maxillary antrum is very rare.
\
2. Lymphatic spread : \
lmportant points -
a) The more anterior is the tumour, the lower is the position of cervical lymph nodes involved. \
GROUP OF LYMPH NODES SHOWING METASTASES PRIMARY SITE OF CANCER \
1. Upper cervical lymph nodes 1. Posterior tongue and oropharynx
2. Middle cervical lymph nodes 2. Anterior tcngue \
3. Lower cervical lymph nodes 3. Lip, gingivae, floor of rnouth, hard palate. \
b) Cervical lymphnode enlargement due to metastases can be the initial clinical presentation (due to
occult primary carcinoma) \
c) Cervical lymphnode metastases can undergo cystic degeneration and may be misdiagnosed as \
branchial cyst with malignant transformation.
d) F. N. A. C. is a useful screening procedure. \
e) Mediastinal lymphnodes may be involved
3. Haematogenous spread :
\
Rarely seen - to lung, liver, bone.
t
!l

-
rr
nr 356

Treatment
-
-
:

Surgery and radiotherapy in combination

Radical neck dissection may be curative in early stages.
ClinicalENT

F
n
,,/6.cARclNoMA oF LARYNX
*pq,wr,t NL\t Ug4n* *Lttwl looily
r
Lt4 q ruou*Q
Laryngeal carcinoma (invasive)

rH lncidence
o
o
o
Men - 2.2% of all cancers
Women - 0.4% of all cancers
960/o are males, usually in decade or beyond.

n
5'h

Predisposing factors

n
rr
1. Smoking. Ris( increases
2. Chronic laryngitis
o
with. heavy alcohol consumption.

Types : According to location - % of total cases

1. Glottic (60% to 65%)
- From true vocal cords,

t:
rt:
- Tends to remain localised due to surrounding cartilage and paucity of lymphatic vessels. prophy,
lactic lymph node dissection is not indicated
2. Supraglottic (30% to 35%)
-
-
From false cords, ventricles, epiglottis
Tends to spread to preepiglottic space but the oropharynx is protected by the thick hypoepiglottic

n
ligament.
-
Average incidence of lymph node metastases is 40%
3. Transglottic (less than 5%)
o Cancer spreading beyond laryngeal ventricle

F 4.
o Highest incidence of lymph node involvement (52%)
So lymph node dissection should be done with total laryngectomy.
lnfraglottic (Subglottic) (less than 5%)

F
l:
o
o
o
Cancer involving true cords with subglottic extension of more than 1cm. or tumours confined to subglottic
area only
Tends to involve cricoid cartilage, thyroid gland and trachea.
Management needs radical surgery with resection of trachea and clearance of paratracheal lymph nodes
o Tumours of pyriform fossa or post-cricoid areas are considered of pharyngeal origin.

F Pathology
Gross -
-
Usually 1-4 cm pink, grey ulcerated mass
Polypoid appearance in verrucous carcinomas
Microscopy (types)

F
l-
1. Squamous cell carcinoma (g0%)
o
o
o
Well differentiated
Moderately differentiated
Poorlydifferentiated

1*
I:
r
 .ft

Section lV Surgical Pathology - Specimens 357 \

- f
t
2. Verrucous carcinoma
o Diagnosis based on deeper biopsy to demonstrate invasion. \ i

3. Small cell (oat cell carcinoma) - (less than 0.5%)

d
, ^th _th
o ln 6 7
-
,
decade and heavy smokers !
o Cells exhibit neuro-endocrine differentiation
t
o Metastases common.
r Prognosis is bad i
4. Basiloid squamous carcinoma
o ln heavy smokers I

o Squamous cell carcinoma associated with small cells resembling basal cells. I
o Extremely aggressive behaviour.
5. Adenocgrcinoma - very rare F
6. Sarcomatoid carcinoma (spindle cell carcinoma)
t
o Polypoid, usually supraglottic
o High predilection for upper aerodigestive tract. L
o Cells are pleomorphic - sarcoma - like but immunohistochemistry indicates epithelial origin.
I
Prognosis
It depends on the following factors :
I
'1. Clinical stage and site
5 year survival t

o Glottic - 80%
t
o Supragloltic - 64% Stage lV <5%
o Transglottic - 50% I
o Subglottic - 40%
2. Microscopic grade - poor prognosis in high grade tumours t
3. DNA aneuploidy - worse prognosis
!
4. Host reaction - Langerhan cells in stroma carries a better prognosis
I

7. CARCINOMA OF OESOPHAGUS t

t
It is usually an epidermoid carcinoma (squamous cell)
It is seen in men over 50 yrs. of age I
It is common in China and other oriental countries
t
It is associated with :

a) Achalasia cardia \
b) Stricture / web
i
c) Oesophagitis
d) Local irradiation :
o Gross
Site in oesophagus -
a) Upper %'d - Rarest
F
b) Middle %'d - Commonest
c) Lower %'o Follows middle %'d I

T
 358
ClinicalENT

Tumour is usually circumferential, often ulcerated with

sharply demarcated margins. on cut section greyish
white tumour is seen jnvading the deeper wall. Due to rich
lymphatic suppry, lym"pnnooe metastases are fre-
quent. Metastases to liver, lung and adrenal glands
ur"
"ornrnon.
Microscopy
o lt is usually moderatery differentiated squam'us ceil carcinoma.
o ln situ carcinoma and superficial spreading variants have
been described.
o Brush cytology shourd be used arong with biopsy to improve
diagnostic yierd.
Treatment
o Surgery for lower'/r'd
r Radiotherapy for upper %'o and middle %'d.
o Prognosis iE poor.
o 5 year survival after surgery is 4%
Other microscopic types :
1. Spindle cell carcinoma
2. Verrucous carcinoma
3. Adeno carcinoma
4. Adeno squamous carcinoma
5. Basiloid carcinoma
6. Small cell carcinoma.
Other tumours and tumour like lesions :

o Commonest benign tumour of oesophagus is leiomyoma

o Malignant melanoma - predilection for lower %,0
o lnflammatory pseudotumour
o Amyloidosis

8. THYROGLOSSAL CYST
o lt is a congenital abnormality - arising due to cystic
change in a part of the persistent thyroglossal duct. The
duct runs from foramen caecum of tongue to the thyroid
isthmus. lt usually passes through the hyoid bone.
o Common in children but can present later in life.
o cystic change deverops due to secretion of the rining ceils.
The cyst may be connected to foramen caecum or to
skin or appears as a sinus. lt may get infected.
o MicroscopV _

cyst is lined by pseudostratified ciliated or squamous epithelium.

Mucous glands and thyroid follicles are
commonly seen in the adjacent stroma.
o Management -
Surgicalexcision.
It is important to include excision of middle third
of the hyoid bone to minimize recurrence.
When sinus is formed, entire tract should be excised.
o Thyroid tissue located within the cyst can undergo malignant
change - (usually papillary carcinoma).
Causes of enlargement of thyroid
1. a) Development abnormality - Thyroglossal cyst
b) Congenital - Dyshormonogenetic goitre
 \
,l
Section lV
-
Surgical Pathology - Specimens \
2. Autoimmune Grave's disease \
Hashimoto's thyroiditis
3. lnflammatory lnfectious etiology
\
Granu lomatous thyroiditis \
Riedel's thyroiditis
4. N eoplastic en largement \
6 lodine deficiency - Physiological/ colloid / simple goitre.
\
6. Thyroid stimulators / autonomous behaviour - Multinodular goitre
\

/,APPEARANcE rN THYRoTD LESToNS i

\
1. Simple goitre:
a) First stage (Due to compensatory hyperplasia of follicular cells) i
Size : Moderate, weight upto '150 gm.
Shape : Maintained, enlargement is symmetrical, diffuse
i
External and cut surface : Near normal brownish homogenous appearance. \
Consistency : Soft (Honey-comb appearance)
b) Second stage (Due to involution of the stimulated follicular cells) \
Size : Moderate -tr!
Shape : Maintained with symmetrical enlargement (diffuse)
External surface : Near normal \
Cut surface : Brownish glossy and translucent due to excessive colloid (Hence also termed as colloid
goitre)
-l
-I
Consistency: Soft
ln both these stages, enlargement of glands is diffuse, hence it is also termed as diffuse non-toxic goitre.
c) Third stage (Due to recurrent episodes of hyperplasia and involution of follicular cells)
:.I
\
It is also termed as Multi-Nodular Goitre -l
Size : Massive, weight upto 2kg
Shape : lrregular - assymetrical enlargement ^l
:''l
I:1
External surface : Multiple bosselated areas corresponding to nodules of variable sizes
Cut surface : lrregular nodules with variable amount of brownish gelatinous colloid.
Consistency : Variable (Due to regressive changes)
Regressive changes (in older lesions) : Areas of haemorrhage (reddish brown), fibrosis (whitish, firm

Extension :
irregular), calcification (chalky white, gritty) cystic change( con-
taining colloid or haemorrhages)
can compress adjacent trachea, oesophagus or may extend behind sternum or clavicles
(termed as intrathoracic or plunging goitre)
tI
Differential Diagnosis : (on gross examination)
:1
II
One nodule may be dominant (adenomaious goitre) so clinically or on gross examination may be misdi-
agnosed as a neoplasm.
2. Hashimoto's thyroiditis :

Size : Moderate
Shape : Maintained usually, enlargement is symmetrical, diffuse, rarely irregular - resembling solitary thy-
roid nodule
:1
External surface : Pale brown
-1
11
;1
 360
ClinicalENT

Cut surface : Lobular accentuation, pale grey-tan, finely nodular,

whitish streaks due to trbrosis may be seen.
Consistency : Firm
Variant : Fibrosing variant - reveals small atrophic gland with extensive
fibrosis. However gland is well demar-
cated from surrounding structures. (Differential diagnosis-Riedel's
disease - where fibrosis is more
extensive with extrathyroidal involvement.)
3. Grave's disease :

Size : Moderate, weight upto 150gm

Shape : Maintained, enlargement is symmetrical, diffuse
External surface : Smooth, brownish red appearance. Sometimes prominent
vessels are seen.
Cut surface : Soft, meaty appearance resembling muscle. (due
to its rich blood supply)
Consistency : Soft
4. Toxic nodular goitre :

It is a solitary thyroid nodule with hyper function (excessive

secretion of thyroid hormone)
Size : Variable.
Shape : Distorted if nodule is large or if the nodule is part of a
multinodular goitre.
Externalsurface : Smooth or bosselated, brownish.
Cut surface : Brownish, rarely nodule may be capsulated (termed
as follicular adenoma)
Consistency : Soft.
5. Carcinoma of thyroid
A) Papillary Carcinoma
B) FollicularCarcinoma
C) MedullaryCarcinoma
D) Anaplastic Carcinoma
E) Metastases to thyroid.

A, Papillary carcinoma
Gross types : i) Smail (occult - clinically not palapable)
ii) tntrathyroidat (ctinicaily patpable)
iii) Extrathyroidat(massive)
i) Small papillary carcinoma :
Size : Less than 1 cm. Thyroid is normal in size.
Shape: Maintained
External and cut surface :
o Near normal, except for the lesion
o Sometimes it may be associated with multinodular goitre or
Hashimoto,s thyroiditis
o sometimes it is'seen as an incidentalfinding in autopsies or in thyroidectomy
done for other causes.
Appearance of lesion : Sclerotic white to a tan nodule
Consistency : Firm
Presentation : May remain occult with cervical lymphnode
metastases at presentation.
ii) lntrathyroidal papillary carcinoma
o size : Lesion more than 1.5 cms, mird enrargement can occur.
o Shape : Usually maintained
o External surface and cut surface :

- occasionaily papiilae, sorid areas or haemorrhages are seen.

H
E
 \
e{
Section lV .* Surgical Pathology - Specimens 361
:'1
- Multicentric tumours are known. \n{
o
- Fibrosis and calcification is common but necrosis is rare.
Consistency : Variable, usually firm, if no cystic change has occured.
Variations : Gross variants are -
l
\
a) Encapsulated
b) lnvasive \
c) Diffuse
d) Cystic -
iii) Extrathyroidal papillary carcinoma. \
Size - Moderate, nodule usually more than 5cm.
Shape - lrregular
i
External surface - lnfiltration by tumour is often seen.
Cut surface - Nodule with infiltration is seen in surrounding structures
i
Consistency' Usually firm. i
B. Follicular carcinoma
Types : i) Minimally invasive -
ii) Widely invasive \
i) Minimally invasive follicular carcinoma
Size : Moderate, solitary nodule variable in size
\
Shape: Usually maintained, but may be enlarged atsite corresponding to nodule (so may be irregular) -a
External surface : Capsule of thyroid appears intact.
Cut surface : Solitary, well circumscribed and encapsulated tan to pink nodule. \
Central part is homogenous and regressive changes are not common.
Consistency : Soft.
\
o Gross appearance of follicular adenoma is srmilar. However, sometimes, follicular carcinomas may show \
thickening of capsule (response to tumour infiltration.)
ii) Widely invasive follicular carcinoma \
Size : Moderate to massive
Shape : Often irregular \
Externalsurface : Gross infiltration of tumour is.seen beyond thyroid capsule and in cervicalveins.
\
Cut surface : Solid irregular mass with infiltration.
Consistency : Soft to firm. \
Widely invasive follicular carcinomas are often non-curable by surgery and only tumour debulking is
done. \
C. Medullary carcinoma
\
Size : Mild to moderate, enlargement depends on the tumour size
Shape : May be distorted depending on the tumour. \
Appearance of the tumour -----
o Site in thyroid : lateral upper 2/zrd of gland (highest 'C' cells) \
External and cut surface - Solitary, whitish grey circumscribed nodule \
- 'Multicentricity known, especially in familial cases.
- Regressive changes like calcification, haemorrhage or necrosis are rare. i
Consistency : - Usuallyfirm.
r!

-
f

F
tq
rH
n
362 ClinicalENT

r D. Anaplastic carcinoma '

Size : Moderate to massive thyroid.

Shape : Usually distorted, irregular

tr
External surface : lnfillrated by tumour beyond thyroid capsule, extending in extrathyroidal tissue.

rr
Cut surface : Tumour seen as whitish tan, fleshy irregular mass with haemorrhage and necrosis
Consistency : Soft to firm.
Anaplastic carcinomas are often non-curable by surgery and only tumour debulking is done.

H
H
10. LYMpHADENopATHy

rn Causes of lymphadenopathy
1. lnfective -
:

r
a) Bacterial
---_l

rr
I

Acute Chronic

Non specific Specific Non specific Specific

u u u u
Suppurative Non Suppurative

rr
Associated with tonsillitis, TB

J-^ U
eg. Staphylococcal infection
u
eg. Typhoid
dentalsepsis Leprosy

b) Viral eg. lnfectious mononucleosis

c) Fungal eg. Histoplasmosis
d) Parasitic eg. Toxoplasmosis,

F
filariasis

r
2. Neoplastic -
a) Primary - lymphoma
b) Secondary - carcinoma
3. Reactive -

F
rn
4.
Follicular hyperplasia, rheumatoid arthritis
Unknown etiology
o Sarcoidosis
5. latrogenic

r
6. lmmunological
I mmuno blastic lymphadenopathy
7. Associated with connective tissue disorders
o SLE
o Rheumatoid arthritis
o Polyarteritis nodosa

F
l-'
rr
Section lV Surgical Pathology - Specimens 363
-

J 1. TU BERCU LOUS LYM PHADENITIS

o Sites -
1. Upper deep cervical. (Tonsillar infection)
2. Bronchial or hilar (Lung)
3. Mesenteric (lntestine)
4. Rarely inguinal I axillary
o Gross :

I
The appearance depends on the stages of development which are :

1. Hyperplasia
2. Periadenitis
3. Caseation
4. Fibrosis and calcification
- Enlarged, discrete but get matted with periadenitis. Firm (hyperplasia and fibrosis), soft (caseation)or
hard (calcification) in consistency
Skin is attached over the swelling and a sinus may form.
o Histopathology ;
Loss of normal architecture and caseous necrosis with epitheloid cell granuloma, Langhan giant cells, lym-
phocytes, macrophages. t

Primary Tuberculosis : t
o Primary complex consists of three components :
o Focal lesion + draining lymphatics + regional lymph nodes t

Secondary Tuberculosis :

o Reactivation or reinfection
o Hypersensitivity - manifests as caseous necrosis t

\
12. LYMPHOMA \
Lymphoma is a neoplastic proliferation or accumulation of cells native to lymphoid tissue ie. lymphocytes, histio- \
cytes and stem cells.
\
Types :

1. Nodal - in lymph node rr

2. Extranodai - other sites containing lymphoid tissue. eg. gastrointestinal tract, brain, thymus, etc.
\
Spread
1. To other lymph nodes \
2. To viscera - (usually spleen, liver, bone marrow)
3. Spill over into blood stream - leukaemia like blood picture. \
Gross rl
o Enlarged lymphnodes, usually cervical. Sometimes mesenteric and axillary, rarely inguinal
o Size depends on stage and varies from few mm to several cms. \
I Shape is round to oval. Enlargement of group of lymphnodes may occur but glands are discrete and fleshy
q
without matting or caseous necrosis as in tuberculosis. Lymphnodes may be adherent due to periadenitis
o Cut surface - homogenous fish flesh appearance, foci of necrosis may be seen. Consistency is soft to firm. E
n
H
n
n
364

Microscopy
Histological types :
1. Hodgkin's disease
ClinicalENT

tr
2. Non Hodgkin's lymphoma

rr
o Hodgkin's disease
Diagnosis is based on histologicalfeatures
- Reed stenberg cell

rH
Large cells (15-45 p), usually binucleate (mirror image appearance) with thick nuclear membrane
and large
eosinophilic inclusion like nucleolus. Variants of R-S cells have been described. (- lacunar, polypoid, pleo-
morphic)
- ln the background of R-S cell, the lymphnode usually shows loss of normal architecture with polymorphic

rn
cellular infiltrate (ie. lymphocytes, plasma cells, eosinophils, neutrophils)
- Histrologicaltypes :
1. Lymphocytic predominance
2. Mixed cellularity

rn -
3. Lymphocytic depletion
4. Nodular sclerosis
Clinicalfeatures

rr o
-
-
Presents as lymphnode enlargement, (Primary extranodal Hodgkin's disease is very rare)
Can present with constitutional symptoms like fever etc.
Non Hodgkin's lymphoma

rn
- Lymphomas other than Hodgkin,s disease
So this is a heterogenous group which includes nodal and extranodal lymphomas.
- Classification is based on
L Cell type - T cell, B cell etc.
2. Degree of differentiation

F
3. Type of cellular infiltrate
4. Pattern of growth

rr ' nodular or diffuse.

Staging of Lymphoma

r
Stage
L Single group of lymphnodes involved
2. Two or more lymphnode groups on same side of diaphragm are involved
3. Two or more lymphnode groups on both sides of diaphragm are involved
4.

F
Disseminated lesions
Each stage has subgroups -
A. Without Symptoms
B, With Symptoms. (Fever, night sweats, loss of weight)

F
r
l-'
E
r-
I:
n
n
I^
n
1:
t:
n
t:
I:
I_
n
t:
n
rt: SECTION I V
RADIOLOGY
- Late Dr. Suren Kothari
- Dr. Jigna Rathod
rr
t:
tr
l:
I:
t:
n
n
T
l^
I:
t:
n
rH 1. Axial high resolution CT Scan showing
longitudinal fracture through the right
mastoid (arrow).
2. HRCT of temporal bone showing chronic
sclerosing otitis media. Note soft tissue !n
middle ear and destruction of the bone_

t:
t:
I:
I:
t:
t:
t:
n
n
I-
I:
l-
3. Axial CT Scan of brain showing abscess in
right temporal region. A well defined,
peripherally enhancing low density lesion
with presence of air within (arrow) is seen
4. X-ray mastoid - sclerosing mastoiditis.
Sclerosis of mastoid air cells is seen.

F in the right temporal region. Temporal

bone shows acute mastoiditis. lncidentally

r:
right temporal lobe arachnoid cyst is noted
(small arrow).

r:
r^
-;:l-
$ff*-3eg6=iF.s13$: fi l. .ir=-ia6ifu -r*=.'l-: : : * ' #+5 s
 \
\
\
\
\
\
\
\
\
-.
rl

\
5. X-ray mastoid Schuller's view - sclerosing mastoiditis on right side. Note normal
mastoid on the left side. \
\
\
\
\
\
\
\
\
\
\
i
-f
6" X-ray mastoid Schuller's view - sclerosing mastoiditis on right side. Note normal mastoid
on the left side.
q!

-{
.!

-dia-d.iere€= dd=e'r' orq,

o
Fs-s-Fs-s33ss ;z
\\\jj
66do,o,
J
<
c',
{(,lor
o@@o
or
55 N
ON
6rF ild-os'--aoNJ zu
N N
Jt. IltilltllIuIllil ,o ll!r lt I il I
C'r
l ir ilil|llllllt [[ rrrt-irunlrrittrtrrr
n
n
n
n
n
rr
rr
rr
n
rr
rn 7. CT Scan showing a polyp. The left
maxillary antrum shows a homogenous
low density lesion with convex margins
(arrow).
X-ray PNS - Water's view - polyp. A well-
defined soft tissue opacity is seen in the
left maxillary sinus with convex margins

rr
(arrow).

r r
F
rr
rt-
rr 9. CT left maxillary carcinoma - contrast
enhanced CT Scan shows a fairly large, ill-
10. CT Scan showing antrochoanal polyp (p)
on left side. The left maxillary sinus is

r
defined, heterogeneously enhancing soft completely filled with low density, homog-
tissue lesion involving left maxillary sinus enous mass expanding the bone, going
with bone erosion. Extra-antral soft tissue through posterior choana into the na-

l*
mass is seen anteriorly (arrow). sopharynx. Polyps are noted in the right
maxillary antra (small arrow) and in the left

t:
I:
ethmoid sinus.

i -$:$
:i**5.iJ.3 o"<i cir'o -=t
(o{(ro-- q (D
',r ' ,, ,-- l. .-*_:::ia :--. Er::
CJ o .oq)c)o G) (.r (.) (d si !
NNNNN f Jlj\\\
r{ ts Si6-o o'
N N NN,NN
;....,....r'! z dl- lo o
o, o) or oo @@@
O.i
 11. X-ray PNS - Water,s view - Malignant 12. X-ray nasal bone - complex fracture involv_
neoplasm involving right maxillary sinus. ing nasal bone.
Note haziness in right maxillary sinus with
destruction of lateral wall of sinus (arrow).

fr

\
\
\
\

13. CT Scan axial view of maxilla - Malignant

neoplasm of right maxilla. Large ill-de-
fined, lobulated, heterogeneously enhanc-
ing mass is seen involving the right maxil- \
lary sinus, overlying soft tissue and the
nasal cavity. -

(o{ cIo+ (o{o Olor

o 6.O
N N NN
;!l: ll: Ilt
oo6
NNN
lrII
aq)o
NNN
il[I
I
t:
to
c'r d! d! o, o)
ll ll lr lt tl
or o) ot
rt rr
iaqS$", Si ru-o@(D-{.ooaoNr
!.{ ri t,'tt r',t r rr rt, ir ir tr r, ,i ,,
IEF

14' cT scan of PNS - sinusitis; mucosalthickening is noteo wKnlxln

in reft maxillay sinus with blockage
,i,::'::T:::i:ff g:,9,,"_y).: cr scan .or ;";; ;il;, th roush the sphenoid sin us
reveals mucosal thickening in t'he sphenoid
sinus ("rd;

l*
Ir
I:
N $*ail$H$r***s*s$ er!=R{qQ{ {glOr
o=abb qt <.) N
JJJ-
OooOOtOlOCt) 55 =
A' CD A X)[email protected]'OOAONT z o
il .ll[[ilIltil[Illil , o? llflltIllllt lllllt[[ o
JJ+{J
! NbJJJ
lllrilil rrttirirlIrl q2
 ,*
.ffi
flffi

#
il
t il
W: ii
*
15. X-ray chest AP view shows foreign body -
safety pin in left main bronchus (arrow)
q

\
\
\
\
\
\
\
\
\
\
i
16. Xray chest anteroposterior and left lateral view showing fracture tracheostomy tube as a i!
foreign body in the left main bronchus.
t'q

NNrrr.rr o
QQie+qE< {o6r
r. r. r rr rr ri ii r u r r l i,
FFFd$fiF*d$fi* Si S 3 ts ia;;,o-i;;;---
r{i-\\1\
OoOOO)OlOto', @@@(I'
,o
-a llll tt lt l lt | | l r,,r,,
 -
-

17' xray AP and Lateral views of neck showing presence

of foreign body - coin in cervical
oesophagus.

18. X-ray neck lateral view - Retropharyngeal

abscess. A large soft tissue swelling in
retropharyngeal and prevertebral region
(arrow) with air is seen within tne soit
tissue . Tracheostomy tube is seen in situ.

T:
F
s*$.$ $'se,*= i
.ll :,ll'..ti tt-:tf '1 r.1 i$-q'*,Str tr ol: ';
 19. Bariurn swallow : lateral view of oesopha- 20. Barium swallow shows multiple irregular
gus reveals malignant stricture in the mid strictures due to corrosive burns. Note
thoracic oesophagus with irregularity of irregularity of mucosa.
mucosa.

NNd o
o
H*Fd$fiFs*d$fi* Irz Qa=Q{qQ=
3
sjj-
666OO)O)O6 ;SSS *i s N
lA

EAR

G
r"
r:
t_ NORMAL ANATOMY
l'- Temporal bone is made up of five bony parts : squamou-s,,mastoid, petrous, tympanic and styloid portions.
External ear: The lateralone-third of the EAC is cartilagenous. The vestibule is seen as a rounded lucent area
r_
n in the bony labyrinth situated lateral and posterior to the fundUs of internal auditOry canal. The medial. two thirds
of the canal is osseous and lies within the tympanic bone. External auditory canal is covered by skin and

t:
periosteum.
Mastoid : There are three important landmarks of the mastoid - the mastoid antrum, the aditus ad antrum and

n
I_
the Koerner's septum. The aditus ad antrum connects epitympanum (attic) of middle ear cavity to the mastoid
antrum. The Koerner's septum is a part of petrosquamosal suture. lt runs posterolaterally through the mastoid
air cells and serves as a partial barrier to extension of infection from lateral mastoid air cells to medial mastoid
air cells, and it is also one of the important surgical landmarks.

n
I_,
Middle ear cavity : The middle ear is divided into the epitympanum (or attic), mesotympanum (tympanic cavity
proper) and the hypotympanum. The epitympanum on coronal HRCT is the tympanic cavity above the line
drawn between the inferior tip of the scutum and the tympanic portion of facial nerve canal. lnto the epitympa-
num, projects the malleus head and the body and short process of the tncus. On the axial CT, the head of the

n
n
malleus and body of the incus form classical "ice-cream cone" sign, where the cone is formed by the body of the
incus and ice-cream is formed by the head of malleus. Prussak's space is an important area, which can be
assessed on coronal plane - this is the area between the incus and the lateral side wall of the epitympanum. This
is the most commonest site for pars flaccida cholesteatoma. Within the mesotympanum, lies the rest of the

n ossicles (i.e. the manubrium of the malleus, long process of incus and stapes) and two muscles of the middle
ear (i.e. tensor tympani and stapedius).

t:
n,
lnner ear : MR shows fluid spaces of the membranous labyrinth whereas CT shows bony labyrinth better. Bony
labyrinth houses cochlea, vestibule, semicircular canals, and vestibular and cochlear acqueducts. Cochlea is
situated anteroinferior to the vestibule and resembles a snail shell with a two and three quarter turns.

n
t: X'RAY MASTOID ISCHULLER'S VIEW
t:
l-
X'ray Mastoid
Schuller's view - The two sides are taken separately. The patient is lying in the lateral position and the side to be
examined lies in contact with the X-ray plate. The central ray is directed at an angulation of_3_Q59p1"uent overlap

t:
t:
olthe other: mastoid bone. This angulation of-the X-ray.beam makes it different from the lateral--skull view.
Structures seen are - External canal and tympanic cavity, temporo-mandibular joint, mastoid air cells, dural
plate, srnus plate, dense bonb of labyrinth. Schuller's view can document the extent of neoplastic and inflamma-
tory lesions in the region of the ty,mpanic cavity and the qastoid. Bone destruction due to cholesteatoma, mas-

I:
n
toiditis, and middle ear effusions can be seen

Types of mastoid :
'1. Pneumatic - Air cells are seen not only covering the mastoid but also beyond the limit of the dural plate and
the sinus plate.

l-, 2. Moderate pneumatisation - The air cells are s€en filling up the mastoid cavity, however do not cross the
confinei of the dural and sinus plate.
I 3. Sclerotic - Absence of air cells is notable. The whole mastoid appears to be small in size with marked opacity.
This is a common feature in chronic otitis media but however, sometimes also seen in normal patients.

F
l--
t:
I:
365

r^ {t (,t o Jr\t
3 * ,'*'-,8
 \
^l
ClinicalENT
366
)
-'1
sclerotic mastoid'
4. Mastoid with radiolucent cavity - Here a single radiolucent shadow is seen in an otherwise
Eventhough it indrcates a disease, it may also be seen in normal patients \
Causes of a radiolucent cavity within the mastoid are :
"l
\
o Cholesteatoma o Eosinophilic granuloma
o Operated mastoidectomy . Tuberculosis
o Large antral cell o Multiple myeloma :
o Large peri-antral cell o Skull metastasis from kidney, bronchus, breasts etc \
oMalignancyoChronicmastoiditiswithgranulations
-
*aa

r!
C.T. SCAN
CT Scan is poor -
High resolution CT scan (HRCT) in axial and coronal planes is the primary imaging modality'
definition' HRCT gives good
in evaluating the otic labyrinih and internal auditory canal as it has poor soft tissue \
intravenous contrast
bony definition and is used to evaluate the air spaces and bony structures. ln most cases
isn,t needed. ln case of CNS examination and vascular pathology contrast enhanced CT
scans are required'
i
\r
MRI \
components of the
MRI has become the primary investigatron of choice for the evaluation of the non osseous
temporal bone region inciuding ihe majoi brood vessels, fluid spaces (cerebrospinal fluid, endolymph, perilymph) \
nerves, skin, fat and important structures surrounding the temporal bone'
T, and T, weighted images should be obtained using spinoecho (SE) sequences. lntravenous
administration \
of contrast agent like gadoinium (Gd)-DTPA is needed in some cases e.g. when
differentiating a haemangioma
turbo-FLASH T, weighted sequences.
\
from a glomus tumour in dynamrc
Bony resolu-
lmages in coronal, saggital, and axial planes can be obtained and there is no radiation involved. \
tion is poor in MRl.
\
\
INFLAMMATORY DISEASE OF THE TEMPORAL BONE
MASTOIDITIS
Acute mastoiditis : \
ln this condition the middle ear appears more opaque than normal, and the ossicles may
appear blurred' The
get blurred, and the alr cells may get somewhat opaque. ln addition to these
mastord antral oulines may also
of acute mastorditis may be seen. lmaging rs performed in
changes, radiological evidence of the complications
acutJmastoiditis only if there is a clinical suspicion of coalescent mastoiditis. \
This is diagnosed on CT by identification of thinning orthe erosion of the mastoid septae. \
lf this defect
The external mastoid cortex is looked at for any defect that can result in a subperiosteal abscess'
soft tissue of the neck and result in a Bezold's
occurs at the mastoid tip, the infection may extend inferiorly to the itl
the sigmoid sinus. The lateral sinus thrombosis
abscess. The inflammation can extend rnternally to the dura over
can be due to direct extension or due to retrograde thrombophlebitis. Ef
visible on the
Spread of the debris into the labyrinth is usually via the round or the oval window- This is
of the membranous labyrinth. Petrous apex infection
enhanced T, weighted images as a faint enhancement r-l
petrous apex. The patients usually present with Gradenigo's syndrome'
occurs in individuals with a pneumatized
On CT this appears as erosive changes wrth abnormal enhancement of the adjacent meninges. r{

EiAidQi^ex^eH^= Qdis'+sq< \l(,lOJ rl<

Section V Radiology - Ear 367
-
Granulation tissue in chronic otomastoiditis is probably the most common cause of middle ear debris and is
diagnosed on CT by lack of bone erosion. The granulation tissue shows intense enhancement on MR unlike a
cholesteatoma.
The CT appearance of tympanic cavity with cholesterol granuloma is similar to that of a granulation tissue. MR
is diagnostic as this displays a bright signal on all spin echo pulse sequences. A quiet cholesteatoma is a concen-
trically enlarging collection of exfoliated keratin. This arises within the Prussak's space located between the neck
of the malleus and the lateral attic wall. Cholesteatoma may result in an erosion of the tegmen tympani and the
ossicular chain. lt may also result in a labyrinthine fistula which usually occur at the level of the lateral semicircular
canal.

Chronic mastoiditis :

It occurs as a sequel of acute mastoidiiis, when the infection is not fully resolved, or if the infection is chronic by
itself. Destruction of the cell walls takes place, with a concomitant reactive bony sclerosis, which may be
extremely dense in character. Total obliteration of the air cells may result. ln addition, the radiological signs of any
of the complicatrons of the condition may be seen.

Complications:
Labrynthitis may be tympanogenic, meningogenic, haematogenic or post traumatic. There is contrast enhance-
mentof the membranous labyrinth on gadolinium enhanced TIW image. Once labrynthitis becomes a chronic
process, membranous labyrinth is replaced with fibrous tissue and becomes ossified.
Otitis externa is usually a benign, self limited process, however it may become a life threatening condition in the
elderly, diabetic or immunocompromised patients (malignant external otitis), Both CT and MRI give excellent
delineation of soft tissue invasion in the subtemporal region and the status of the stylomastoid foramen. CT is
needed for osseous erosion, involvement of the middle ear, mastoid and infratemporal facial nerve canal.
1. Abscess formation : Due to localised destruction of the cell walls, a large lucency is seen. This abscess may
be surrounded by an area of sclerosis.
2. Cholesteatoma formation : The commonest site of appearance of the cholesteatoma is the 'attic', i.e. the epi-
tympanic recess. lt is usually alairly welldefined lucency in a typical site, with little or no surrounding sclerosis.
There is invariably sclerosis of the mastoid process.

CHOLESTEATOMA
Cholesteatoma is an abnormal accumulation of the keratin producing squamous epithelium in the middle ear,
epitympanum, petrous apex and or mastoid. The pathologically accurate term is keratomas. Cholesteatoma is
a sac lined by keratinizing stratified squamous epithelium which is trapped and grows within the middle ear and
other pneumatized areas of petrous bones.

TYPES OF CHOLESTEATOMA
1. Congenital cholesteatoma (epidermoids)
2. Acquired cholesteatoma : account for 98% of all the lesions and are further subdivided into
a) Primary acquired - with no history of otitis media.
b) Secondary acquired - with a past history of otitis media.
congenital cholesteatoma (also called Epidermoid or Primary cholesteatoma) :

These account for 2ok of all cholesteatomas. They are similar to their intracranial counterparts. They are seen
at five characteristic sites in the temporal bone - petrousgp_e_x, mi{Oje-ear, mastoift, middle ea_r. cavry-and
e x t e r nal,al d tory_cana.l .
i

ln the middle ear, there is a propensity for the formation of a congenital cholesteatoma near the junction of the
eustachian tube and the anterior tympanic ring. Generally these cholesteatomas are seen anteriorly within the
epitympanum or mesotympanum and in the vicinity of the incudostapedial articulation. High resolution CT scan-
 t
368 ClinicalENT

ning is advocated in the preoperaiive evaluation of these lesions as -

o Retrotympanic location of the pathoiogy makes an exact determination of the lesion difficult only on the basis \
of clinical examination
o CT is sensitive for the evaluaiion of spread of the lesion to the mastoid, epitympanum, middle ear and for !

evaluation of the ossicles.

rf
Acquired cholesteatoma :

Primary acqutred cholesteatomas usually arise from the pars flaccida. Secondary cholesteatomas usually arise rr
from the pars tensa of the tympanic membrane. Pars flaccida type is more common in adults. Pars flaccida (attic)
cholesteatoma begins in the Prussak's space. lt displaces the ossicular chain medially. Commonly it expands in
the posterosuperior direction initially via the superior incudal space to,the attic and then further posteriorly through
the aditus to the antrum and the mastoid. Pars tensa cholesteatoma are generally due to posterosuperior retrac-
tion of the ear drunr. These Iesions begin in the posterior tympanicum and often involves posterior recesses
includrng the facial recess and sinus tympani. rr

CT Features of Cholesteatoma :
CT had three advantages over plurrdirectional tomography. These advantages are, betterdemonstration of the
soft tissue details, better spatial resolution and reduced radiation dose to the patients.
The features of cholesteatoma are :

a) Erosion and destruction of the scutum (lateral attic wall). t

b) Widening of the aditus to antrum when the lesion extends into the antrum.
E
c) Displacement and or destruction of the ossicles.
d) Erosion into the facialcanal. !t

e) Dehiscence of the tegmen tympani.

f) Destruction of the mastoid (automastoidectomy)
g) Formation of fistula between middle ear and the posterior and lateral semicircular canal and vestibule.
h) Erosion ancl sagging of the r:xternal canal roof.
i) Dehiscence of the sigmoid plaie with or without venous sinus thrombosis. E
j) ln cases of petrous apex choiesteatomas, enlarged or dilated faciai nerve canal which acts as a conduit
q
connecting middle ear and ;retrous apex can be seen.
k) External ear cholesteatornas are seen as soft tissue lesions lateral to the tympanic membrane.
fr
l) Since most of these lesions are associated with chronic mastoiditis, evidence of the same in form of opacifi-
catron of the mastoid air cells, sclerosis of the mastoid air cells etc is seen. it

BRAIN AFSCESS t

Brain abscess may develop from temporal bone inflammatory processes by several mechanisms, Petrositis t
of the apical air cells can extend into the epidural and skull base spaces. ln these instances CT Scanning will
show the bony destruction with dural enhancement adjacent to the temporal bone. This is seen in Gradenigo's q
syndrome. Cholesteatomas can erode through the tegmen tympani or tegmen antri into the middle cranial fossa,
or though the mastoid into the posterior cranial fossa. CT or MRI studies wrth contrast enhancement will show q
elevation and enhancement of the dura with extension of pus into the epidural space. Classic ring-enhancing
lesions can also be seen. Otological brain abscess can be ternporal or cerebeilar, depending on the location of
the abscess in the brain. Patients with recurrent cholesteatomas after radical mastoidectomies may develop
intracranial spread of the rnfection. This occurs when the bony barriers have been surgically removed.
-r

-r

'g j-i.iJJ
!o{uro*9:!
r - Q3 * f, i ro=n-(,l -o:- j-i-
 Section V- Radiology - Ear
369

TEMPORAL BONE TUMOURS

Paragangliomas or glomus tumours are the most
commonest tumours. These tumours are classified
ing to the location : Glomus tympanicum - only accord-
the middle ear is involved, and Glomus jugulare - only
foramen is involved, and Glomus jugulotympanicum the jugular
- both the middle ear and jugular foramen is
involved.
on cr scan' glomus tympanicum is seen as an intense enhancing globular
soft tissue mass abutting the
cochlear promontory in the middle ear cavity. Glomus jugutotymf
anicurniJseen as an intensely enhancing mass
extending from the jugular foramen into the middle
ear lavity. ih";rgrr"l- spine and ihe bony floor of
ear are eroded' MRI may be sometimes used to complement the middle
extension at the base of the skull or intracraniat extension.
cr findings, particularly to look for soft tissue
on MR gro;r" iJr"i;;;;. as a soft tissue mass
with multiple flow voids due to small vessels within
the tumor. These" small hypointese ,flow voids,
to a appearance called as ,,salt and pepper,'appearance. often give rise
Miscellaneous temporal bone tumours like haemangioma,
meningioma, adenomatous tumour and vascular
metastases can' also present with a vascular tympanic
membrane. Rhabdomyosarcoma - lt is the most common
malignant paediatric middle ear tumour. About 7%
lesions occur in middre ear region. ir-,"r" are highly
mesenchymal tumours seen in children below years malignant
5 of age. cr scan shows an enhancing soft tissue
mass with destruction of the surrounding bone. tumour

TRAUMA
ln the setting of temporal bone trauma cr and
MRI are complimentary. MRI is recommended for patients
whom an intracranialabnormality is suspected. in
cr is recomtnended for those patients with post
ing loss' vertigo, csF leak or slventh'nerve patsy;;;;'oo"ny traumatic hear-
o*tuir ro
is to
Lv us
be uurrrur
demonstrated. Temporat bone
fractures are crassified as rongitudinar, transverse
or mixed
Temporal bone fractures are described as per
their orientation to the long axis of the petrous borie
accordingly considered as longitudinal or transverse. and are
Number of fractures r,lve both a longitudinal and
verse component and are best classified as mixed. trans-
The longitudinal fracture rine, directed parallel to
of petrous bone' usually results from a blow the long axis
to the tempor6-parietal region. Tne tympanic membrane
ruptured and an associated haemotympanum is uiually
leads to secondeiry conductrve neaiing loss. ossicles
commonly involved. i too are
The transverse fracture line, directed perpendicuiarto
the long axis of the petrous pyramid, begins nearthe
jugular foramen or foramen magnum
and extends i" tn"riJlr" cianiat fossa. ihu nroricommon
transversely oriented fracture of temporal bone is site of injury in
within the labyrinth. Damage to the facial nerye occurs
the horizontal as well as in the longiiudinal both in
component or tr'," iJrporar bonJfracture and may present
neural haematoma, impingement by fracture as intra-
fragrnents oru resection.
Persistent vertigo may indicate a perilymph "orpr"te
fistula. The presence of a pneumolabyrinth is highly
suggestive in
Vascurarcomprications such icno""r,rion,lugurarvein aijsismoid
ff;i:::::_:tj$"JfiT$,fj"J::ffi ",
ln patients with sensorineural hearing loss following
trauma, MRI can help by demonstrating intralabrynthine
haemorrhage' Enhancement of labyrintti may indicate-post
traumatic taoyrinirritL. wnen tne hearing loss is con-
ductive' cr can establish a diagnosis. ossicular
to fracture. -- ""
chain can be disrupted at multiple sites. The incus
.'-'" is vulnerable

References
1' John R' Haaga, c. F. Lanzierietal :crand MRlof thewhole
Body, third edition part lll.
2. K.C. Clark. positioning in Radiography, ninth edition.
3. s' Howard Lee, Krishna c. v. G. Rao. craniar MRr and
cr, triro edition. 477_s04.
4. R. G. Grainger, D. J. Allison. Diagnostic Radiology.
5' Chakeres DW' A systematic method for evaluation
of the temporal bone by cr. Radiology 1gB3; 146:g7-106,
u

rr
and MR imaging of the normal anatomy of the temporat
bone. semin Uttasound cr MR 1989;
?,i.,%[o"T
1

NosE
-a

-t

-.t

i.

a.
 PARANASAL SINUSES
VIEWS FOR PARANASAL SINUSES
1. OCC|PTTO-MENTAL VIEW (WATER'S VIEW) :

This x-ray is ideally taken in the standing or sitting position. The patient's chin and the tip of his nose should
gently touch the film. The film is taken with the patient's mouth kept open. ln this view, the maxillary antra are
seen free of any overlap of the petrous bones, and if the mouth is kept open, then the sphenoid sinus and
nasopharynx may be seen. The frontal sinuses are also seen on this view, but a foreshortened view is
obtained. The floor of the orbit is also demonstrated.
2. OCCTPITO-FRONTAL VIEW (CALDWELL'S VIEW) :
This view is also taken in the erect position. The patient is positioned with his forehead and the tip of his
nose touching the film and the film is taken in the postero-anterior projection with the X-ray beam making
angle of 20 with the orbito-meatal line. ln this projection, the frontal sinuses, ethmoid sinuses and nasal
septum are well demonstrated. Maxillary antra are not well demonstrated as they are overlapped by the
petrous temporal bones.

A Caldwell's view can be grouped under the following headings :

a. Normal - There is individual variation in the size and the shape and asymmetry is seen in the paired
sinuses also. I'Jormally the frontal sinus shows a radiolucent shadow and individual cells are made out,
giving it a scalloping (clove like) appearane.
b. Chronic frontal sinusitis - lncreased opacity of the frontal sinuses is seen with absence of the normal
scalloping (crenated outline of the sinuses). Such an appearance is also seen in a mucocele or pyocele,
which results as a complication of chronic frontal sinusitis.
c. Osteoma - This lesion shows a marked opacity (denser than bone) in the frontal sinus. Patient is usually
asymptomatic and the finding is incidental.
d. Pneumatization - Hypoprreumatization of the frontal sinuses is common in severe erythroblastic anaemia,
whether sickle cell or Cooley's type, Hyperpneumatization is a feature of acromegaly and Sturge-weber
disease.
3. LATERALVIEW
This view is of limited value, due to superimposition of bilateral structures. The sphenoid sinus is well
visualized,

FUNCTIONAL ENDOSCOPIC SINUS SURGERY AND

MUCOCILIARY DRAINAGE
Functional Endoscopic Sinus Surgery (FESS) is now the standard care for the treatment of uncomplicated
inflammatory disease of the paranasal sinuses. Experienced otolaryngologists use it for treating complicated
sinonasal conditions like mucocele, allergic fungal infections and localized benign neoplasms.
The health of the sinus cavity depends on the normal mucociliary clearance mechanism that propels the
mucus and debris towards the drainage outlet. Maintenance of this mucociliary clearance depends upon ad-
equate spacing between mucosal surfaces allowing room for both the sole phase of mucus in which the cilia beat
and the superficial gel phase of mucus that transports the mucus and debris. Any disease process of the sinuses
alters this mechanism causing loss of the adequate spacing resulting in jamming of the ciliary movement and
inadequate drainage of the mucus. FESS treats sinusitis by reestablishing the normal mucociliary clearance.
This concept of FESS as a functional surgery is to restore the normal ventilation through the narrow convolute
drainage pathways,.allowing peripheral mucociliary clearance to resume. The sinus mucosa then can heal by
normal mechanisms. As FESS is a functional procedure it is important to recognize the functional areas of the
paranasal sinuses like the frontal recess, osteomeatal unit (OMU) and the sphenoethmoid recess (SER). The
extent of sino-nasal inflammatory disease, important anatomic landmarks and their variations can be easily

n
n
l-r
370

kqqx*xx :4*'+.itatt'::i-j
 Section V- Badiology - Nose 371

depicted on CT scans, thereby providing a reliable 'road-map'to endoscopic surgery, aimed more at functional
restoration and preservation. Advancement in the CT scan techniques like faster scan, higher spatial resolution,
helical volume acquitions etc enables the radiologists to provide invaluable information about frontal recess,
OMU and SER.
lmaging Techniques :
Plain radiographs thotlgh widely available and inexpensive do not provide sufficient details for planning sur- I
gery. MRI with its excellent soft tissue contrast shows mucosa and secretions very well. However MR is limiied in
evaluation of the cortical bone and does not depict thin osseous structures. On the other hand CT scan shows I
excellent bone detail in the sinonasal region and is very good for soft tissue evaluation as well. CT thus rentains
the best technique to evaluate the presence, type and extent of the disease before planning any surgery. I
\
Common indications of CT scan in evaluation of inflammatory paranasal sinus disease are
1. Chronic and recurrent sinusitis.
:
i
2. Sino-nasal polyposis. ;
3. Evaluation of complications of acute sinusitis like periorbital cellulitis, mucocele, and in the assessment of
intraocular and intracranial extent of the disease. I

4. Headache with sinogenic cause.

:
INFLAMMATORY DISEASE OF THE PARANASAL
t
SINUSES
t
1' Acute Sinusitis - Acute infection of the paranasal sinuses causes mucosal swelling and accumulation of fluid
within the sinus. Maxillary antra are affected most frequently, followed by the frontal sinuses. ln X-rays, the t
findings are-loss of lucency due to mucosal thickening or fluid content, opacification of the air passages with
soft tissue and the presence of fluid. (useful diagnostic feature in a sinus). A fluid ievel is seen sometimes \
which has a concavity pointing upwards. The finalconfirmation of fluid level is done by repeating the plate in
lying down position, resulting in obliteration of the fluid levei. ln allergic sinusitis the mucosa tends to show t
scalloped appearance and polypi may be seen occasionally.
There are five major patterns of occlusion of the mucosal drainage channels. Three commonest are \
infundibular, osteomeatal unit, and sphenoethmoidal recess patterns. Additional patterns are sinonasal poly-
posis pattern (also called allergic sinusitis or hyperplastic rhinosinusitis) and unclassifiable pattern. On CT \
Scan there is smooth and nodular mucosal thickening produced due to submucosal oedema and mucosal ,$
inflammation. lf

2' Chronic maxillary sinusitis - Haziness (radio-opacity) of the sinus is seen. The mucosa may show persis-
tent thickening in chronic sinusitis. Occasionally associated is some sclerosis and thickening of bony walls of \
the sinus, which may proceed to a marked reduction in the sinus volume. Chronic sinusitis is most often seen n
in the maxillary antra and then the frontalsinuses, \
On CT scan, osteitic thickening, due to long standing mucosal inflammation and reactive bony proliferation
l{
of the sinus walls is seen. Retention cysts are frequently seen in patients with sinusitis. These smooth rounded
and sharply marginated cysts are usually found in the floor of the maxillary antrum, broad based along the r{i
inferior cortical margin. Retention cysts are difficult to distinguish from polyps, unless the polyp is clearly \
pedunculated. The retention cyst can fill a sinus cavity but it never causes bony expansion.
Periosteal new bone formation, followed by sclerosis involving the posterolateral antral wall is seen follow-
\
ing Caldwell-Luc antrostomy and should not be interpreted as indicative of infection. A persistent antral fluid
level following dental extraction, particularly of a canine tooth, suggests the presence of an oro-antral fistula,
\
3' Polyp ' Opacity is seen, as compared to the rest of the maxillary sinus. Here, there is a convexity which \
points upwards and a repeat plate shows no shift in opacity. Polyps are smoothly rounded or pedunculated
soft tissue masses in the nose and sinus cavities, of relatively low density on the CT scan. They may obstruct rl
the sinonasal drainage channels if located within the OMU, frontal recess and the sphenoethmoidal recess.
lrr
x
i
n
n
n
372
ClinicalENT

n
Polyps exert a pressure effect on the adjacent bony structures with
resultant enlargement of the involved bony

r
cavity' The process is gradual and causes expansion and distortion
with relativJ preservation of the inters-
pinous septations, a finding usually seen in the ethmoid
sinuses. Antrochoanal polyps, (4-6% of the polypoidal
disease) have distinct radioiogical appearances. lt fills the maxillary

rr
antrum, then expands into the middle
meatus eventually growing through the choana into the nasopharyn*.
ft,*y are usually of low density associ-
ated with smooth bony expansion of the maxillary sinus watt. MRt
can help in differentiating polyp from a
tumour.
4' Granulomatous slnusitis 'Granulomatous diseases

rr
affecting the paranasal sinuses have both infectious
and noninfectious causes. lnfectious causes are actinomy"orir, tuberculosis,
syphilis, rhinoscleroma, and
leprosy' Noninfectious causes are Wegener's granulomatosis,
and sarcoidosis ai well as foreign body reac-
tion from beryllium, chromium salts and cocaine. Allthe granulomatous
diseases are potentially dangerous
and erode both the cartilage and the bone. on CT, they alihave
similar appearance starting with non specific

n
soft tissue nodules along the nasal septum with maiked mucosal
thickening through out the nasal cavity,

r
Perforations of the nasal septum then occurs, the hallmark of
this group of diiorders.
5' Fungal sinusitis - lt is a diverse group of disorders that are categorised into four
distinct clinical entities
based on the host immunological status : invasive fungal sinusitis,
chronic indolent sinusitis and mycetoma
in
the immunocompromised host, and allergic fungal si-nusits in-the
immunological hypercompetant or atopic
host' lnvasive fungal sinusitis owing to tr"oriycosis and hspergillosis
is an acutely fulminant disease

F
characterised by marked erosion and bony destruction. lt is commonly
seen in diabetic patients. chronic

rr
indolent sinusitis is a slowly growing disease and slowly progresses
eventually destroying the bone. Myc-
etoma is associated with repeated facial trauma. lt causes partr:al
or complete opLcification of the sinus
cavity
and may be associated with thickened mucosa. Mycetomas can
be hyperdense on cT, scan and contain
flocculent calcifications in about 25% of the cases. Allergic fungal
sinusitis typically occurs in young adults

rr-
with nasal polyposis. on cr the involved sinus contains
ieripheral rim of low attenlation, oedematous mu-
cosa and complete opacification of the central cavity by homogenous
high density material that is diagnostic
of the disease.
6' Mucocele ' A mucocele is an obstructive complication of chronic sinus

rr
inflammation, polyposis, trauma,
surgery or tumour' The frontal sinus is most commonly affected followed
by the ethmoid, *r"iitury and sphe-
noid sinuses' Radiologically smooth rounded enlargement of
a completely opacified sinus cavity of an air cell
is seen indicating the slow nature of the expansile piocess.
The bony walls are thinned out. Mucopyocele is an
infected mucocele and it causes rapid bony dehiscence. on
cr, mucoceles are of low density and do not
enhance following contrast administration thus differentiating them

t:
from polyps.
7' Malignancy ' Opacity of the sinus is seen. Destruction of the walls of the maxillary
sinus is diagnostic of
malignancy' The distance between the antero-lateral wall of the
maxilla to the process of the man-

f-
dible is measured. lncreased distance on one side suggests invorveme.i "oronoid fossa
(Handousa's sign). squamous cell carcinoma accounts for
irrrJ#ioral by a tumour
80-90% of the"imalignant tumors of the nose and
paranasal sinuses. rt arises most often from the raterar

l-- wail of the nasar cavity, 6r from the maxiilary antrum.

Most patients are Men in their sixth decade.'CT scan shows a

lr
mass, bone destruction, extension of the
tumour into the"adjacent sinuses and surrounding compartments.

rn
lntracraniur rpreuj, i;;;;il; u,' il;
pterygopalatine fossa and intraorbital spread can be
assessed. Metastatic tymphntoes may be recognized.
other malignant tumours are adenocarcinoma, adenoid cystic carcinoma,
olfactory neuroblastoma, plas-
macytoma, lymphoma and chondrosarcoma. !

Adenocarcinoma has predilection for the upper nas_al,caVjty

and_the adjacent ethmold cells. Adenoid cystic
carcinoma commonly arises in the lower part of tl.re nisai Cavity

l-
and the maxillary antrum. Hard palate is
commonly involved.

F
l-'
FRACTURE NASAL BONES
The patient sits erect with the head in the lateral position and
Any disruption seen in the nasal bone architecture would indicate
the X-rays are directed to the root of the nose.

t*
a fracture of the nasal bones.

n
n
 i
Section V Radiology - Nose 373 \
- {t
I
Reduction of this fracture is done only as an elective procedure, i.e. for cosmetic reasons. Before doing so, the
complications caused by fractured nasal bones are ruled out. They are CSF rhinorrhoea, epistaxis, septal he-
jl
I
matoma, proptosis and oedema.
!

t
NORMAL ANATOMIC VARIATIONS ON CT SCAN
I
The variations in the anatomy of the paranasal sinuses are important because some of these variants can
narrow ihe drainage channels predispoging to chronic recurrent sinusitis. Certain normal variants increase op- tf,
erative risk.
I
M I D D L_E T-U-BE] NATE VABTAilONS
1 Corfqha-bultosa - The middle n_asal tq'-birratals usually a thin bony structurewhich may show varying amount :
of pieumatization. Balloon titebr significant pneumatization of the middle turbinate is called as concha bullosa.
When large, it may constrict the middle meatus or encroach upon the infundibulum. Concha bullosa may be I

bilateral and may occasionally contain polyps, mucocele and pyocele. True concha bullosa in normal popula-
tion has a reported prevalence of 4.to 15% qnd in patients with chronic sinusitis it is as high as 33%' t

2. paradoxically curved middle turbinate - Middle nasal turbinate has a,convexity which is directed medially
towards the septum. When it is paradoxically curved towards the lateral sinus wall it is presumed that it may -
predispose to recurrent sinusitis due to narrowing of middle meatus. lt is required to know that paradoxical
curvature of the middle meatus is important"in its anterior portion and not in the posterior portion. I

I
NASAL SEPTUM VARIATION
Nasalseptum variation is the second most common variation and is seen in upto 20% of the population. The t
deviation is usually at the junction of the nasal cartilage and the vomer. The deviated nasal septum or bony spur
causes decrease in the area of the osteomeatal unit predisposing to obstruction. Synechiae formation between
the turbinates and the lateral wall or with the uncinate process can lead to failure of FESS and recurrent
sinusitis. I

ETHMOID VARIATION I

Haller cells are extensions of the middle ethmoid air cells placed laterally along the floor of the orbit' These
can result in narrowing of the infunibulum predisposing to maxillary sinusitis. I

These are more common in women. Sometimes large ethmoid bulla may contribute to sinus disease by
obstructihg middle meatus or infundibulum' t

I
U NCINATE PROCESS VARIATION
pro-
Abnormal deviations of the uncinate process may narrow the drainage channels. Occasionally uncinate I
cess is pneumatised which may narrow the maxillary infundibulum'
I
DANG EROUS NORMAL VARIANTS
Onodi cells are posterior ethmoid air cells that extend posteriorly and sometimes superior to sphenoid stnus, t
lying medially to the optic nerve. Onodi cells are in close relationship to the optic nerve and share a common wall
nerve may be
-wititfre sphenoid sinus, the sphenoethmoidal plate. ln case of posterior ethmoidectomy the optic t
at risk in these cases. Another dangerous variant is extensive pneumatization of the sphenoid sinus with aeration
of the anterior clinoid process. The optic nerve lies just medial to the anterior clinoid process and nerve can be t
damaged if dissection extends posteriorly. Complete dehiscence of the optic nerve may be seen in 3-12% of the
patients. t
The integrity of the lamina papyracea is important when the uncinate process is located laterally or abuts the
lamina. Resection of the uncinate process may be difficult and injury to the lamina may occur. occasionally the I

nasolacrimal duct is located anterior to the maxillary sinus ostium and may be injured during anteriorly directed

T
E
t:
I:
374 Clinical ENT

surgical enlargement of the ostium. Pre-operative CT should be carefully looked at for a low lying fovea ethmoidalis.
Cribriform plate, roof of posterior ethmoid air cells and superior and lateral walls of the sphenoid sinus should be

I^ looked at carefully as these can predispose to CSF leak post operatively. Bulging of the carotid artery into the

n
n
sphenoid sinus has to be noted. Rarely the carotid artery may traverse through the sphenoid sinus and injury to
this artery during surgery can be fatal.

n
t:
t:
t:
t,
l:
t:
l:
T:
t:
t:
t:
F
F
t:
F
F
r
l-
t:
r^
t:
n
I:
I_
I
l:
t:
t:
t:
I:
I:
F-
n
t:
t:
l-_
t: LARYNX, PHARYNX
tr
t:
F
I:
l:
n
F
t*
t*
I:
I-^
 TRACHEO.BRONCHIAL FOREIGN BODIES
These foreign bodies may lead to a life threatening situation due to obstruction caused in the respiratory
passages. Coins form majority of the tracheal foreign bodies. Here antero-posterior view shows
a vertical opaque
slit and lateral neck plate shows the complete coin. This is because of the'C'shaped cartilages of the
trachea,
resulting in the antero-posterior diameter greater than the transverse diameter.

Bronchialforeign bodies are divided into 3 types according to the air-flow pattern. :

a. Bypass of air - Foreign bodies like buttons, rings or beads which have an opening within itself allow passage
of air to either side. X-ray picture shows no abnormal findings other than the fore-lgn body.
b. One sided airway obstruction - Metallic and other non-organic foreign bodies lead to an unilateral obstruction
to the airway. On inspiration the bronchial diameter increases and this leads to the passage of air distal
to the
foreign body.On expiration as the bronchial diameter decreases, it leads to entrapment of air distal to the
foreign body. These changes in airway pattern lead obstructive emphysema and therefore the X-ray findings
and breathlessness.
c' Total airway obstruction - Vegetable foreign bodies like peas or groundnuts, swell up in the bronchus due to
their hygroscopic nature. This causes impaction of the foreign OoOy onto the bronchial wall. Air cannot pass
distal to the foreign body, nor can escape out. This leads to collapse of the lung segment distal to the foreign
body and compensatory emphysema of the remaining lung. Changes occur aicoioingty which are seen
on
the X-ray' The classical feature is a mediastinal shift-which being the change in position of the mediastinum
with each phase of respiration on account of the collapse caused by the foreign body.
Lateral Skull (Nasopharynx)
Normally the nasopharynx is seen as a radiolucent shadow because it is occupied by air,
o Shift of the air shadow posteriorly occurs with an antrochoanal polyp, as it arises from anteriorly. The air
shadow is reduced to a small ouilining shadow around the polyp (Grescent sign).
o Shift of the radiolucent shadow anteriorly is seen with adenoids (children) and nasopharyngeal carcinoma
(elderly), both of them arising posteriorly.

OESOPHAGEAL FOREIGN BODIES

The commonest foreign bodies lodged in the oesophagus are coins, marbles or traumatic foreign bodies like
dentures, pins and meat bone.
a' Coin - They lodge in the oesophagus occupying a classical position that is in the transverse plane. This is
due to the fact, that the transverse diameter is much greater than the longitudinal diameter. Therefore, on
an
antero-posterior view of the neck-chest, the whole coin can be seen showing a totally radio-opaque shadow
A lateral plate is also taken to confirm the exact position of the foregin UoOy and aiso to rule out a second
foreign body if overlapping the first. On a lateral plate a vertical slit likb struciure is seen.
b' Marble - These also give a radio-opaque shadow which is less dense as compared to a coin. The other
feature being that on both antero-posterior and lateral x-ray film, a circular shaped foreign body is seen. The
use of may forceps result in pushing the foreign body more distally. A folley's catheter is passed distal
to the
'foreign body and the balloon is inflated. Gradually the catheter is removed and the foreign body is taken out.
c' Traumatic foreign bodies - Sharp foreign bodies can cause a complete vertical tear in the oesophageal wall
during its removal. Traumatic foreign oboies are either pins or dentures.

OESOPHAGEAL STRICTURES
oesophageal strictures can be classified into benign and malignant types.
1. Benign strictures
375
376 Clinical ENT

2. Malignantstrictures-
Commoner causes of oesophageal strictures are listed below
I. Benign

I.BENIGN SITE FEATURES

o Peptic
:r

- Reflux oesophagitis Distal, near GOJ, above a hernia Smooth, tapering

!
- Barrett's oesophagus More proximal Deep ulcer, reticular mucosa
o Nasogastricintubation Distal Long stricture, hisiory
I
o Schatzki's ring Gojunction Syrnmetrical, 2-4 rnm long
o Caustic ingestion Single or multiple, long stricture History t
o. Radiation Related to the po(al Tapered stricture, history
o Skin disease High in the oesophagus Strictures or webs, bullous diseases I

o Drug inqestion Above left atrium History of drug ingestion (enteric KCI)
o Post infective Usually in mid paft Candida, TB
o Benign tumour Variable Submucosal lesion.
Smooth muscle tumour content
I
lI. Malignant
r carcinoma !
o leiomyosarcoma
o lymphoma i

o extrinsic carcinoma
Barium studies :

Biphasic double contrast radiography is the method routinely used for examining upper gastrointestinal tract.
High density barium, gas producing granules and hypotonic agent (glucagon)are used. Double contrast views
are best for evaluating mucosal abnormalities, where as the single contrast views are best for evaluating oesoph- t
ageal and gastroduodenal motility, and for demonstrating structural abnormalities restricting wall expansion.
Oesophageal motility is assessed by fluoroscopic observation after a single swallow of barium taken by a !
patient in the prone oblique po$ition. 3 to 5 successive single barium swallows are recommended as necessary
to demonstrate incidence of peristalsis. !

Difference between benign and malignant stricture on bariumc study !

BENIGN MALIGNANT rf
1. Multiple 1. Single
2. Sites of normal constriction !
2. Middle %'d or anywhere
3. Regular mucosa 3. lrregular mucosa t
4. Marked proximal dilatation 4. No proximal dilatation
5. Corrosive burns is the commonest cause 5. Carcinoma due to chronic irritation is the cause rt

Endoluminal ultrasonography (EUS) \

Endoluminal ultrasonography is often used in conjunction with fibre-endoscopy. For exploration of the oe-
l!
sophagealand rectalwall, a water-filled balloon covering the ultrasonic probe is used. Due to its high resolution
properties, EUS readily identifies the different layers of gut wall.
b{
By means of the high frequency EUS beam intramural tumour growth is classified, as is the existence of
spread to local lymphnodes. Thereby the evaluation of tumour resectability is facilitated. Malignant mucosal
lesions are hypoechoic and in most instances clearly defined.
t

F
 Section V Radiology - Larynx, Pharyni 377
-
R ETROPHARYNG EAL ABSCESS
The diagnosis of a retropharyngeal abscess can be made by :
'1. Marked increase in the prevertebralspace area, it being more than three-fourth
of the size of the vertebra.
2. Air-fluid level. Normally the pharynx is a collapsed structure, not containing any air.
3. Loss of normal curvature of the spine leading to straightening of the cervical spine.
The vertebrae should be carefully seen for any destruction or presence of a foreign botly (mutton bone).
Commonest cause of retropharyngeal abscess is Koch's spine and foreign body in the pharynx (adultsj,
dental and tonsillar infections in children.

i;
r
SECTION I VI
ANAESTHESIA
- Dr. Vandana Lehiri
- Dr. Prerna Shroff
 GENERAL PRINCIPLES
Cooperation between ENT surgeon and anaesthesiologist is esserrtial as both of them work in ihe same field. Other
principles to be followed are :
o Secured airway
o Deep level of anaesthesia
o Rapid recovery

PREOPERATIVE ASSESSMENT
o Generalexamination
o Systemic examination
o Medical diseases
. Drug allergy
o Previous history of anaesthesia (especially difficult intubation)
o Airway assessment : nasal passages, neck mobility, dentition, mouth opening
o lndirect laryngoscopy, if required

INVESTIGATIONS
r Complete blood count
o Bleeding time, clotting time
r X-ray chest
o Electrocardiogram*
o Blood sugar (fasting and post-prandial).
o Others depending on medical problems and surgical procedures to be performed
*For more
than 35 years of age and if history suggests the need to do in patients less than 35 years of age.

CONSENT
r Written, informed, valid consent for anaesthesia and for surgery
o Special consent for medical problems due to medical diseases and for tracheostomy, if difficult intubation or
airway pathology is suspected

PREOPERATIVE FASTING
o For solids : not less than 6 hours
o For liquids : not less than 4 hours

MONITORING
o Pulse
r Blood pressure
o ECG
o Pulse oximetry.
o End tidal COr*
o Others depending on medical problems and surgical procedures to be performed e.g., Centralvenous pressure
(CVP), input / output, blood loss, temperature, air eptry, airway patency etc.
-lf available,
makes it easy to diagnose hypoxia, vasoconstriction, circuit disconnection, oesophageal intuba-
tion, inadequate ventilation and many such events

378
Section Vl Anaesthesia
379
II
II
-.
PREMEDICATION
Aim : To allay anxiety, make the patient calm and co-operative and to prevent nausea and vomiting

DRUGS FOR PREMEDICATION

:'l
Il'l
B. ANTIEMETICS C. ANXIOLYTICS i SEDATIVES / TRANQUILIZERS

Midazolam Pentazocine
Atropine
Diazepam* Pethidine-
Glycopyrrolate
Promethazine Tramadol
Fentanyl
:'l
*Long acting, hence to be used for major / long lasting surgery

tl
GENERAL ANAESTHESIA (G.A.) :.I
The following steps are followed in an orderly manner
A. PREOXYGENATION
:

:'l
1OO% O2is given under mask for 3-5 minutes. lt is given prior to any general anaesthetic to take care of
respiratory depression or apnoeic episodes during anaesthetic induction (effect of anaesthetic drugs)
:'l
:"1
I
B. INDUCTION
l- lntravenous (Faster and pleasant induction)
2. lnhalational (Slow induction but useful in children and in patients with difficult airway)
l- lntravenous :

Any one of the following agents + any one muscle relaxant for intubation
DOSE
II
INTRAVENOUSAGENTS MUSCLE RELA(ANTS: DRUG

Pentothal - 5-7 mg/kg. Depolarizing Scoline* 1-2 mg/kg. l"l

- 1-2 mg/kg. Nondepolarizing Pancuronium** 0.08 mg/kg
Propofol
0.08 mg/kg
:..|
Ketamine - 1-2 mglkg. Vecuronium**
t1
I:1
Atracurium** 0.5 mg/kg
*Short **Long acting
acting
2. lnhalational :

Or+NrO+lnfialational agent (Halothane / lsoflurane / Sevoflurane / Ether / Trilene)

o
o
o
Muscle relaxant is not mandatory for intubation'
When patient is deeply anaesthetized, he/she can be intubated on spontaneous breathing during the
inspiraiory phase when vocal cords are most apart.
lf airway obstruction occurs while patient is being anaesthetized (despite chin lift,
jaw thrust and oropha-
t:'l
methods of intubation
ryngeaiairway), the process can be reverseci by administering
100% O, and other
:''l
can be tried, especially when difficult airway is suspected.
lf difficult intubation is anticipated, following things should be kept ready
-
:

Extra large blade laryngoscope, flexitip blade larynogscope and endotracheal tube stylet
I:1
- Endotracheal tubes of various sizes (especially small sized tubes)
-
-
Endotracheal tube guide and tube exchangers
Oesophageal bougie, light wand or lighted stylet
:'l
- Laryngealmask airwaY (LMA) :'l
-
-
lntubating LMA, if available
CricothyrotomY set
:'l
-1
- Tracheostomy set
'1
;r
rr Once intubation is done, confirm correct placement of endotracheal
Throat packing is to be done in nasal and oropharyngeal
C. MAINTENANCE
tube
surgery soon after induction

F
Any one of the foilowing methods can be used to maintain
anaesthesia :

rr
1. Intravenous agent + NzO and Oz + Muscle relaxant
2. lnhalationalagent + NzO and Oz + Muscle relaxant
3. lntravenous agent + lnhalational agent + NzO and O, + Muscle relaxant

rr
During maintenance of anaesthesia, following things
should be taken care of :
Adequate oxygenation and ventiration (removarof carbon
dioxide)
o Maintenance of adequate circulation
o
Maintenance of normothermia
r

n
l.V. Fluids: 2muKgrhour of 5% Dextrose / Ringer
Lactate / DNS and
o

rr
Replacement for insensible loss + expected or actual
urine output + blood loss
lnduced hypotension may be used for microscopic surgeries
or vascular tumours with either judicious
use of inhalational agents or propofol alone or in combiriation
with B blockers like Esmolol (short acting)
or Metoprolol (long acting)

r
D. REVERSAL AND EXTUBATION
o Shut off inhalational agent and NrO
o

I:
Continue giving 100% oxygen
o lf non-depolarizing muscle relaxant is used, reverse
it with anticholinesterase like neostigmine or prostigmine
(only after patient.shows signs of attempting
breathing). An anticholinergic drug tite airopine or glycopyrrolate
is administered along with an anticholinesterase

l-^ to counteract the muicarinii side effects like bradycardia,

t:
profuse salivation, bronchospasm and at times
arrhythmias.
o with return of airway reflexes, remove the throat pack, if inserted,
and deflate the endotracheal tube cuff
o with the return of consciousness, protective airway reflexes
and muscle power (sustained head lift for > 5

F
seconds), extubate the patient
o
Keep the patient nil by mouth for afleast 6 hours
E. POST.OPEMTIVE PAIN RELIEF
Any suitable analgesic which is not a respiratory depressant
TT ' 2-3mg I Kg'l'M' half to one hour before the end
extubation is to be given.
or a strong sedative e.g., Diclofenac sodium
ot rrrg;ry or Tramadol 1-2mg/ Kg, l.V. / l.M. prior to

F
n LOCAL ANAESTHESIA

t:
t:
A. Topical (surface).
*
B. lnfiltration*
Practiced extensively by ENT surgeons.

Commonly used nerve blocks in ENT practice, especially

C, Conduction (various nerve blocks)

for awake intubation are :

I^ BLOCK ANAESTHETISEDAREA
Superior laryngeal nerve block Anaesthetizes the
area from inferior r
DOSE

Patient in supine position with neck

F
ex_
aspect of epiglottis to the vocal cords tended
o Displace the hyoid bone laterally to the side

1* to be blocked

t:
o lnsert the needle so as to walk off the

n
 f.f

Section Vl Anaesthesia 381 \^

-
\
BLOCK ANAESTHETISEDAREA DOSE

greater cornu of the hyoid bone inferiorly

\
and advance the needle 2-3 mm \
o As the needle passes through the thyro-
hyoid membrane, a slight loss of resistance \
is felt
o The block is repeated on the other side \
Translaryngeal block : Anaesthetizes the trachea below the o Avoid in patients in whom coughing is
(Transtracheal injection) vocal cords undesirable
\
. Patrent in supine position preferably with
neck extended
i
o Locate the criciothyroid membrane in the \
midline and introduce the needle to punc-
ture it \
o Aspiration of air confirms the placement of
needle in trachea \
o lnject 3-5 ml of local anaesthetic solution
rapidly, resulting in coughing which aids in
i
spread of the solution within the trachea
\
Glossopharyngeal nerve Anaesthetizes posterior %'d of c lnject 5ml of local anaesthetic solution al
block : (lntraoral approach) tongue, plrarynx and suPerior the base of each posterior tonsillar pillar \
surface of the epiglottis
\
Surgical procedures that deserve special mention are :

1. Post tonsillectorny bleeding : \

Problems:
o Hypovolemia
i
o Hypotension \
e Fullstomach (swallowed blood)
o Airway obstruction
\
Management : \
o lntravenous fluids
o Blood transfusion
\
o Ryle's tube suction prior to induction \
o Awake intubation or inhalational technique without using muscle relaxant
o lf muscle relaxant is used for intubation then rapid sequence intubation with cricoid pressure is done \
o Extubate only after proper haemostasis and return of protective airway reflexes
\
o Observe the patient for signs of hypovolemia and anaemia
2. Endoscopies : (D.L. Direct laryngoscopy, M.L. Microlaryngoscopy, Cricopharyngoscopy' \
Nasopharyngoscopy, Bronchoscopy and Oesophagoscopy)
Aim : To give the surgeon a clear immobile view and sufficient space to work despite difficulty in maintaining \
a clear airway, adequate oxygenation and adequate ventilation
\
Anaesthetic implications :

o Airway protection \

-
r!
fr
 382 ClinicalENT

o Difficult airway
o Antisialogogues to reduce secretions
o Steroids io reduce airway oedema
o Adequate oxygenation and removal of CO,
o Deep level of anaesthesia
o Rapid awakening and return of reflexes

Methods:
o Small size endotracheal tube for all endoscopies (except bronchoscopy)
o Ventilating bronchoscope or jet ventilation (venturi principle) or insufflation technique (apnoeic oxygenation
for bronchoscopies).
o Muscle relaxant to be avoided if vocal cord movement is to be seen.

COMPLICATIONS
There can be innumerable complications following generalor local anaesthesia. However, those related to ENT
surgery that deserve mention are :

General anaesthetic :

AIRWAYOBSTRUCTION BRONCHOSPASM HYPOTENSION

o Trauma / oedema e lrritation of airway o Allergic reaction

o Airway pathology r Patients with allergy o Dysrrhythmias
r Post instrumentation o Patients with COPD / asthma r Blood loss
o Bleeding / secretions

Local anaesthetic : mostly as a result of toxicity (higher dose) or intra-vascular injection (since the area is highly
vascular and many prolonged procedures are done under local anaesthesia)

CVS CNS

o Dysrrhythmias o Tingling
o Hypotension o Circumoral numbness
. Dizziness
o Convulsion

Treatment :

o Maintain airway
o 100% oxygen under mask
o Maintain blood pressure (fluids) and heart rhythm (xylocard)
o LV. diazepam / midazolam / thiopentone sodium (pentothal)

CARDTO PU LMONARY RESUSCITATTON (CpR)

Since many ENT surgeries are done under local anaesthesia in the absence of an anaesthesiologist, the
operating surgeons must be well versed with the prompt diagnosis of a cardiac arrest and its management as
prompt recognition and treatment is the key to favourable outcome.
Pale surgical field or sudden cessation of bleeding should raise the suspicion of a cardiac arrest to the operating
surgeon. Dark coloured blood suggests airway obstruction due to the drapes or inadequate breathing due to over-
sedation, which if ignored, may ultimately lead to hypoxia and cardiac arrest.

rT
r
 \

Section Vl Anaesthesia
383 \
-
MANAGEMENT
\
To call for help but do not leave the patient \
1. PRIMARYSURVEY
A. Airway . Open airway by jaw thrust, chin lift and give head tilt
\
B. Breathing : Positive pressure ventilation - mouth to mouth 6r via resuscitation bag
\
c. circulation : closed chest compression (external cardiac massage)
D. Defibrrllation : ln pulse-less patients with ventricular tachycardia or ventricular frbrillation -
2. SECONDARYSURVEY
A. Airway : Endotrachealintubation \
B. Breathing : Assess adequacy of ventilation via endotracheal tube and continue IPPR t!
of rhythm
C. Crrculation : l.V. access for fluid + medication. Appropriate cardiovascular drugs for correction
while continLting cardiac massage rl
mea-
D. Diagnosis Differential diagnosis of cause of arrest especially reversible causes and the Remedial
-
SUTCS.

External cardiac massage : t'l

1'/z to 2 inches by the palms of both
It is given by compressing the lower sternum and xiphoid process by about
hands without flexing the elbows. External cardiac massage to IPPR ratio or chest compression
to ventilation ratio i
should be 15'.2 in case of one rescuer and 5:1 when two rescuers are present'
Defibrillation It is given in a pulse-less patient having ventricular tachycardia or ventricular
fibrillation =
Begrn wrth 2oojoules, repeat with 300 joules and 360 joules i.e. 3 shocks \
lf no response, continue CPR for 1 min.
lf no pulse, repeat shocks: 3 of 360 joules each \
lf no response, continue CPR for 1 mrn' and again repeat 3 shocks
Continue the above sequence till the rhythm comes back -
Drugs (to be combined with CPR and defibrillation in Drug-Shock-Drug-Shock" 'Pattern) q
Adrenaline* 1 mg to be pushed I.V., to be repeated every 3-5 minutes
Sodabicarb 1 mEq./Kg., only if hyperkalemia or metabolic acidosis is documented or suspected
\
Lignocaine 1-'1 .Smg/kg. 1.V., to be repeated after 3-5 min. upto maximum of 3mg/kg rl
. Defibrillation to begin within 30-60 seconds of adrenaline injection
lf asystole occurs (confirmed by more than 1 lead)--> continue cPR, No defibrillation \
Treat cause Hypoxia, hyperkalemia, hypokalemia, hypothermia, acidosis, drug over-dosage
Drugs Adrenaline '1 mg to be pushed 1.V., to be repeated every 3-5 minutes
\
Atroptne 0.6-1mg to be pushed 1.V., to be repeated upto 0 03-0.04m9/kg' \
Consider transcuta neous pacing
Continue CPR, No defibrillation
\
lf pulse-less electri calactivity
Treat cause Hypoxia, hyperkalemia, hypokalemia, hypothermia, acidosis, drug overdos \
age, nypovolemia, cardiac tamponade, tension pneurnothorax, pulmonary
embolism, acute myocardial infarction \
Drugs Adrenaline : 1mg to be pushed 1.V", to be repeated every 3-5 minutes
lf H.R. < 60/min Atropine :0.6-'1mg to be pushed l.V', to be repeated upto 0'03-0'04m9/kg' \
\
\

-
 Clinical ENT

ANAESTHETIC DRUGS
DRUGS USES DOSAGE EFFECTS

I. PREMEDICANTS o Premedication : used to Dosages : o Tachycardia

A Antisialogogues: decrease oropharyngeal Premedication : 0.01m9/ o Decreased secretions
1. Atropine : secretions kg l.M.il.V o Pupillary dilatation
- lt is an anticholinergic o During reversal of non- Reversal of muscle relax- o Bronchodilatation
drug depolarizing muscle re- ant : 0.02m9/kg. l.V. o Crosses blood brain
- Available as 0.6m9/ml laxant to antagonize the barrier
muscarinic effects of an-
ticholin estera se
2. Glycopyrrolate : o Premedication : used to Dosage : o Mild tachycardia
- lt is a synthetic anticho- decrease oropharyngeal Premedication : 4pLglkg, . Decreased secretions
linergic drug producing secretions LM./t.V o Does not cross blood
less tachycardia than o During reversal of non- Reversal of muscle relax- brain barrier
atropine depolarizing muscle ant: 8prg/kg LV.
- Available as 0.2 mg/ml. relaxant to antagonize
the muscarinic effects of
anticholin esterase
B. Anxiolytics/Sedatives/Tran- Premedication Dosages : o Anxiolytic
quilisers Conscious sedation lnduction : 0. 1 5-0.o rng/kg, o Hypnotic
1. Midazolam : lnduction of anaesthesla Sedation: o Amnesic
- Available as 1 mg/ml. Supplimentation of o l.V.: 0.03-0.05 mg/kg. o Anticonvulsant
or 5 mg/ml. anaesthesia o l.M.: 0.1-0.'15 mg/kg.
- Water soluble, less o Oral : 0.5-0.75 mg/kg.
irritant and hence no o Nasal : 0.2 -0.3 mg/kg.
pain on injection
- Action lasts for 1-4 hours
2. Promethazine o Premedication Dosages : Hypnotic
(Phenargan) o Sedative 0.5-1.0 mgi kg l.V. Antihistaminic
- Available as 25 mg/ml. . Antiemetic Antiemetic
or 50 mg/ml. Antishivering
Bronchodilator
Antanalgesic
C. Opioid analgesics o Premedication Dosages: a Sedation
(Narcotics) : o Analgesic 0.6 mg/kg I V. o Analgesia
1. Pentazocine (Fortwin) : o Sedative o Tachycardia
- lt is a synthetic o Raised B P
Benzomorphinian Na usea
opioid Vomitinq
- Available as 30 nrgl/ml.
2.P"thidi"", o Premedication Dosages : o Sedation
- lt is a synthetic opioid o Analgesic 0.5 mg/kg l.V./l.M o Analgesia
agon ist o Sedative o Tachycardia
- Available as 50 mg/ml o Olthostatic hypotension
or 100 mg/ml o Vomiting
o Dependence
 rI
t.
Section Vl Anaesthesia 385 \
-
\
DRUGS USES DOSAGE EFFECTS

3. Tramadol : a Premedication Dosages : o Sedation \

- lt is a synthetic opioid a Analgesic 0.5-2 mg/kg l.V./1.M. o Analgesia
agonist o Sedative o Tachycardia \
- Available as 50 mg/ml. o Vomiting
4. Fentanyl: Premedication Dosages : Sedation
\
- lt is a phenylpiperidine Analgeslc 0.5-2 mcg/kg l.V Analgesia \
opioid lnduction of anaesthesia Bradycardia
- lt has a rapid onset and Hypotension \
short duration of action Bradypnoea
(30-60 minutes) Muscle rigidity \
Available as 50 pg/ml. Nausea, vomiting
Pruritus =
Dosage: o Accelerates gastric
D. Antiemetics: Antiemetic \
1. Metoclopramide 10 mg l.V./1.M. either soon emptying and intestinal
- Available as 5 mg/ml. after induction or 15-30 min. transit l
\
prior to extubation o lnhibits chemorecePtor
trigger zone mediated i
vomiting
o Minimal sedation
qr
e Occasionally
extrapyramidal reaction
\
2. Ondansetron Antiemetic Dosage : c Antagonizes 5-HT" \
- Available as 2 mg/ml 4 mg (50-150 pg/kg.) slow receptors on vagal
or Syrup 4 mg/S ml. LV. (over 1-5 min.) just nerve endings and in
before/after induction or jusl chemoreceptor trigger -
prior to extubation zone \
o Transient increase in
hepatic transaminase \
levels
o Constipation
\
o Crosses placenta and \
is excreted in breast milk

II. I. V. INDUCTION AGENTS : Dosage : o Hypnosis \

1. Thiopentone Sodium 5-7 mg/kg. o Unconsciousness
(Pentothal) : c Hypotension I
\
- lt is an ultrashort acting o Antanalgesia
o Respiratory depression
\
thiobarbiturate
- lt is also an anticonvul- if given too fast
\
sa nt o Bronchospasm in

- it is available as 0.5 or susceptible PeoPle \

1.0 gm vial in powder o Laryngospasm in lighter
form plane of anaesthesia t
- lt is to be diluted with o Pain on injection if

normal saline or distilled extravasates \

water to make a 2.5oh
\
r{r!

F
 386 ClinicalENT

DRUGS USES DOSAGE EFFECTS

solution (25 mg/ml.)

Absolute contraindica-
tion : Acute intermittent
porphyria
2. Propofol: Sedation : LV. Bolus -0.5-1.0 mg/kg, o Rapid induction
- lt is a diisopropylphenol lnfusion - 20-75 prg/kg/min. o Rapid recovery
- lt is available as an o lnduction : l.V.-2.0-2.5 mg/kg slowly o Hypotension
emulsion : 10 mg/ml. o Maintenance l.V. Bolus-25-50 mg o Bradycardia
- lt is should be protected lnfusion -1 00-200 pg/kg/ o Pain on injection
from light min. o Allergic reaction in the
It should be shaken well Antiemetic: l.V.-10 mg form of anaphylaxis
before use
4 It is contraindicated in
patients allergic to eggs

r.
t:
or soyabean oil
3. Ketamine
-
:

lt is a phencyclidine
o Sedation : LV.-0.5-1.0 mgikg.
or
Dissociative anaesthes-
ia

l:
derivative 2.5-10|M mg/kg. a lncreased salivation
- lt is available as 10 mg/ o Analgesia : Oral-6-10 mg/kg. a Slightly enhanced

l:
t:
-
ml or 50 mg/ml
To reduce secretions,
antisialogogue
premedication is
o
o
lnduction:
Maintenance :
Nasal - 3-6 mg/kg
1.0-2.5 mg/kg
nfusion-1 5-80 pg/kg/min
I
laryngeal and pharyn-
geal reflexes
Hallucinations, delirium
Bronchodilatation
necessary lncrease pulse,

F - To reduce hallucinations
it is generally combined
with diazepam or
blood pressure.
lntra ocular
pressure, intra cranial

F
midazolam pressure and blood
It is contraindicated in sugar
patients with intracranial Nystagmus, convulsion
hypertension or raised

F
r
intraocular tension
III. INHALATIONAL AGENTS
1. Halothane
- lt is noninflammable
halogenated volatile
: o Hypotension
o Bradycardia
o Arrythmias
r Bronchodilatation
o Myocardial depression

E
liq uid
- Used for induction as o Respiratory depression
well as maintenance of o Sensitizes myocardium
anaesthesia to the action of
- Available in amber adrenaline
o

F
coloured 250 ml bottles. Hepatic dysfunction
-

rl-'
lt is to be used in
vaporisers meant for
Halothane e.g. Goldman
or Fluotec

t:
r /
Section Vl Anaesthesia 387
-
DRUGS USES DOSAGE EFFECTS

2. lsoflurane :

- lt is noninflammable o Hypotension
volatile liquid o Tachycardia
- Used for induction as o Arrhythmias
well as maintenance of o Peripheral
an aesthesia vasodilatation
- Available in amber o Respiratory depression
coloured 1 00m1. bottles.
- lt is to be used in
vaporizers meant for
lsoflurane
!
3. Nitrous oxide :

- lt is a noninflammable Diffuses into air-containing

anaesthetic gas, but cavities faster (34 times
supports combustion. more soluble) than
- lt is a strong analgesic, nitrogen, causing
but a weak anaesthetic. potentially dangerous I
- Used for supplementa- pressure acumulatron e.g. :

tion of anaesthesia o Diffusion hypoxia

- Supplied in blue o Middle ear abnormalities
I
coloured cylinders (serous otitis media,
(liquid + gaseous form) transient postoperative
hearing loss)
o Bowel obstruction
o Pneumothorax
o lncreased endotracheal t
cuff volume and press-
lq
ure (resulting in glottic
and subglottic trauma) q
IV. MUSCLE RELAXANTS : o Fasciculation
1. Succinyl choline (Suxa- o Hyperkalemia
methonium, Scoline) o Bradycardra (with
- A depolarising muscle second/repeated doses)
relaxant . lncreased rntraocular
- Available as 50 mg/ml. pressure t
solution or 100 mg/vial o lncreased intracranial
l!
powder pressure
- Solution is to be refrig o lncreased intragastric
erated, powder is stable pressure
at room temperature !
- Generally used for
intubation (1-2 mg/kg)
- Quick and short acting
rf
- lntubation can be done
between 60-90 seconds
Eq

rr

;
 388
ClinicalENT

Action lasts for 3-5 minutes

Can be used for main
tenance in short surgical
procedures e.g. scopies
Does not require reversal
2. Pancuronium (pavulon) :
o lncreased heart rate
- A non-depolarising
o lncreased blood pressure
muscle relaxant
o No fasciculation
- Available as 2 mg/ml.
r Histamine release-
- Can be used for
rarely
intubation (0.08 mg/kg)
- Takes time to act-intuba-
tion can be done betw-
een 150-180 seconds
- Long acting, action
for 45-60 minutes
- Generally used for
maintenance in surgical
procedures, lasting
more than 40 minutes
- Maintenance dose :-
0.01-0.05 mg/kg
- Requires reversal at
end of surgery
3. Vecuronium (Norcuron) : o Can be used for Maintenance dose No change in heart rate
- A non-depolarising intubation (0.08 mgikg) 0.01- 0.05 mg/kg or blood pressure
muscle relaxant o Takes time to aclintuba-
No fasciculation
- Available as 4 mg/vial in tion can be done between
powder form 120-150 seconds
- Requires reversal at the r Long acting, action lasts
end of surgery for 25-30 minutes
o Generally used for
maintenance in surgical
procedures lasting
more than 30 minutes
4, Atracurium (Tracrium) : o Can be used for Maintenance dose :- 0.1-0. o Hypotension
- A non-depolarising intubation (0.5 mg/kg) mg/kg. o lncreased heart rate
muscle relaxant o Takes time to act- (>0.5 mg/kg. doses)
- Available as 10 mg/m|., intubation can be done o No fasciculation
to be refrigerated between '1 50-180 o Histamine release
- Requires reversal at the seconds (>0.5 mg/kg. doses)
end of surgery o Long acting, action lasts
- Metabolised by Holfman for 10-20 minutes
degradation and ester o Generally used for
maintenance in surgical

n
r I
 Section Vl Anaesthesia
-
DRUGS USES DOSAGE EFFECTS
in patients with renal and procedures lasting more
hepatic disease than 20 minutes
V. LOCALANAESTHETIC Maximum safe dosages :

AGENTS: c Without adrenaline 4 mg

'l . Xylocaine (Lignocaine) I
: kg.
- lt is an amide group of o With adrenaline
local anaesthetic (1:200,000) (5 mcg per
- lt is available as: 0.5, 1.0, kgl) (1 ml of adrenaline ir
1.5 and 2.0% solutions 200 ml solution) 7 mg/kg
without/with adrenaline Duration:
(1:50,000, 1:100,000, 45 min. to one hour
1 :200,000) 4.0% solution One to one and haif hour
and 10ok spray for use in Route of administration :

ENT surgery o Topical

- lt has antianhythmic effects o lnfiltration
- 1.0-1.5pg/kg l.Vandthen . Superior laryngeal nerve
15-50 mgikgimin. l.V block I
- lt attenuates the pressor Transtracheal
d
response (tachycardia and I

hypertensiorr) to intubation I

- 1.5-2.0 mg/kg I V. given

I
I

to
2-3 min. prior I

taryngoscopy I

2. Bupivacaine (l\Iarcaine) Maximum safe dosage :

- It is an amino amide c Without adrenaline : 2
local anaesthetic mglkg (<150 mg for t
- lt is available as :0.25 and infiltration/nerve block)
0.5 % solutions c With adrenaline : 3 mg/kg q
without/with adrenaline (<225 mg) - lt improves
(1:200,000) lr
quality of analgesia and
- lf the dose exceeds the not duration
maximum safe level, can o
\
it Do not exceed rate of
cause refractory cardiac injection to more than \
arrest anci death '10 mg/min of the drug
Duration:2to6hours \
VI,OTHER DRUGS:
1. A,drenaline E
Therapeutic doses
- An ionotropic agent that Effect on B-receptors
activates both o and B- o
\
lncreased myocardial
adrenergic receptors contractility r!
- Available as 1 mg/ml. c lncreased heart rate
(1 :1 000) o lncreased blood \
- Used with local pressure
anaesthetics to reduce o Relaxation of bronchial \
their absorption and smooth muscles
\
r!

{(rod {0O-iri, dJ
I:
rl: 390 Clinical ENT

l:
DRUGS USES DOSAGE EFFECTS

thereby lessening the o Dilatation of skeletal

potential for systemic muscle vasculature
toxicity and to prolong Higher doses

F
:

their duration of action Effect on o-receptors

o lncreased total periph-

n
and to reduce blood loss

rt:
The concentration eral resistance
should not exceed r Decreased renal blood
5-10 pg/mlor 0.5-1.0 flow
mg/100 ml (1:2,00,000 Decreased urinary out-
- 1 :1 ,00000) put

l:
l-
The dose should not
exceed 100 prg (10 ml
of1:1,00,000)overa10
o Ventricular arrhythmias
a Angina

t:
min. period or 300 ;rg
(30 ml. of 1:'1,00,000)

I:
over any 60 min. period
in adults.

t:
t:
lf used along with
inhalational agents like
halothane; can give rise

rt: -
-
to arrhythmias
2. Neostigminei
Prostigmine
An anti-cholinesterase
Available as 0.5 mgiml
o lncreased secretions
oral and bronchial
o Bronchospasm
o Respiratory depression
-

F
or 2.5 mg/ml o Bradycardia
- Used for reversal of . Hyp0tension
o

l:
nondepolarising muscle Arrhythmias
relaxants (0.05 mg/kg,
max. of 5 mg)

F- - lt is used along with

atropineig lycopynolate to

r
F- avoid muscarinic actions

ANAESTHETIC INSTRUMENTS

F
1. MASK
r lt is an integral part of any anaesthetic breathing system or circuit during the induction phase (beginning) of
anaesthesia or any resuscitation procedure
o Allowsadministrationofgasesfromthebreathingsystemorfromtheresuscitationbagwithoutintroducing

F
r"
o
o
any invasive apparatus (e.9. an endotrachealtube) into the patient
lt is placed on the patient's face covering his mouth and nose (face mask) or only the nose (nasal mask)
Nasal masks are smaller in size than face masks and generally used only for conservative dentistry for

rl-. dental chair anaesthesia

Parts : Connector or mount
-
-
Body
Edge or seal

t:
r
 \

Section Vl Anaesthesia 391

.\

Sizes : 1 ,2,3, 4, 5
\
2. AIRWAY \
o Prevents fall of tongue on posterior pharyngeal wall and helps to maintain airway
e Made up of metal / rubber / plastic
\
Uses:
\
e To maintain airway in unconscious or heavily sedated patient
* To obtain a better mask fit \
o To prevent a patient from biting and occluding an orotracheal tube
o To protect the tongue from being bitten
\
o To facilitate oropharyngeal suctioning tl'rrough the air or suction channel
o To provide oxygen through air or suction channel
-
ORAL: Lies from lips to pharynx i
Parts : Flange, bite portion, air / suction channel (curved portion)
Sizes : 1,2,3, 4 -
Method of insertion :After lubrication, it is held with concave side facing upper lip, advanced and rotated
through 1800 so that it lies posterior to tongue. -
o Pharyngeal and laryngeal reflexes should be depressed before placement of an oral airway to avoid coughing i
or laryngospasm.
s Selection of the correct size is very important as too small an airway may cause the tongue to kink and push \
part of it against the roof of the mouth, causing obstruction, and too large an airway may cause obstruction
by displacing the epiglottis posteriorly and may traumatize the larynx. \
IdASOPHARYNGEAL : Lies from nose to pharynx
Parts : Flange or a movable drsc at proximal end to prevent migration to nose. A safety pin can also be used
as a flange.
\
Sizes (diameter) : - 7.0 I 7.5 for adult males
- 6.5 I 7 .0 for adult females \
- same / one size smaller than an approprrate endotracheal tube for children
'{t
- Resembles a shortened endotrachealtube
- Better tolerated in the patient with intact airway reflexes than an oral airway \
- The flanges lies outside the nostril and the tube in the nasal cavity
-
The pharyngeal end of the tube may be straight or beveled and it lies below the base \
of the tongue br:t above the epiglottis
Method of insertion : After lubricating thoroughly along its entire length, it is passed through the patent nostril
\
(vasoconstrictor may be applied before insertion to reduce bleeding) with the bevel against the septum and
inserted perpendicularly, in line with the nasal passage. lt is then gently advanced posteriorly. lf resistance is felt
\
during insertion, the other nostrilor a smaller size should be used.
e The airway length may be adjusted by sliding it in or out till the pharyngeal end rests below the base of the -
tongue but above the epiglottis \
* lf it is inserted too inside, laryngeal reflexes may be stimulated and if it is too outside, airway obstruction
may not be relieved \
Contraindications to the use of a nasopharyngeal airway :

o Patients with haemorrhagic disorders \

o Coagulopathy
\
o A history of epistaxis requiring medical treatment
o Patients on anticoagulants -l
o Patients with basilar skull fracture
r!
o Sepsis or deformity of tlre nose/nasopharynx

{
E!

(o \l iid,: e:! e sr r ddje-ree< irrr

{(,l(.)J (.)J ON
1' o, Ut SONJ =()
1O
@
N N N
o.
rlt: .il il
RRssssss
ililililltIllil Tq
I dddo,cD(Doo
ll'11 l r il il il ir
o@e@
ir
'r
trl- ir
5&
lr l
19
ir
o
if
5
rr
NJoew
rr rr ir tr rr lr il il IIilil
t2
t<
n
n 392 ClinicalENT

l: 3. LARYNGEAL MASKAIRWAY (LMA)

n
l-
o
o
Versions
Parts :
A device which is midway between mask and endotrachealtube
Makes an airtight low-pressure seal around laryngeal inlet after inflation of the cuff
: Plain, Reinforced, lntubating and Proseal

tl
Mask, tube at an angle of 30 degrees, black line on tube to face upper incisors and pilot balloon.
Sizes : 1, 1.5,2,2.5,3, 4, 5

t:
l:
-
-
-
To be autoclaved before every use
Deeper level of anaesthesia is required for insertion to avoid laryngospasm
Can be passed with / without use of muscle relaxants
Method of insertion : With patient in position as for laryngoscopy and with cuff deflated it is held like a pen and

IT with its aperture facing anteriorly it is pressed against hard palate and advanced till it goes beyond the base of

I-
the tongue. Cuff is inflated and then connected to the breathing circuit.
Advantases

n
t:
- i;,:il1:;:T,i::::il1"r
-
-
Useful in failed intubation to ventilate the patient
lntubating LMA is useful (endotracheal tube can be passed through it) in intubating

t:
patients with difficult airway
Disadvantages : - Does not prevent aspiration

t-
t: 4. ENDOTRACHEALTUBES
- Can cause gastric distention

rt:
Types
o Red rubber (reusable)/ PVC (disposable)
r Oral / nasal
o Plain / cuffed - High volume low pressure cuff (PVC)
- Low volume high pressure cuff (red rubber)

F
Sizes : 2,2.5,3, 3.5, 4,.........'10, 10.5 (internal diameter in mm.)
- Bevel at patient end

t: Uses:
-
-
Connector to be placed at machine end
Passed with direct laryngoscopy under vision after anaesthetising the patient

F
o Procedures in which it is not feasible to administer anaesthetic gases via mask
o Procedures which are long lasting
o Procedures in which there are chances of having blood, secretions, pus, vomitus etc. in the oral cavity
o Procedures in which patients need to be given muscle relaxants and controlled breathing

F
n
Special tubes : Oxford (L-shaped), Tehran (S-shaped), Precurved e.9., Ring Adair Ellwyn (RAE) Nasal (North
Pole)/ Oral (South Pole), Reinforced (armoured / flexometallic) etc.

r
o For laser surgery various 'laser-resistant'tubes are available. Each has its own advantage and disadvantage.
o Nasal tubes are characterized by a longer bevel, a softer tip, a streamlined cuff and no side port
5. LARYNGOSCOPE
It is designed for direct laryngoscopy and to pass an endotracheal tube into the larynx under vision

tr
r
Parts :
Sizes (for the blades) :
Method of insertion
.
:
Handle, blade with light bulb
neonate (infant), paediatric (child), adult and extra large

l-
1 Patient supine with flexion of the lower cervical spine and extension of the head at the atlanto-occipital level.

n
r
 Section Vl Anaesthesia
- 393

2 Head should rest on a small pillow or a ring.- 'sniffing the

morning air position,
3. Mouth of the patient is then opened by the right hand of the
operator
4. Laryngoscope is introduced
5' The tip of the curved blade is advanced up to the
iunction of the base of the tongue with the epiglottis and the
blade then lifted upwards and forwards along the axis
of the handle so as to tr'" base of the tongue and
the epiglottis forwards "ui,y
6 The tip of the straight blade is passed posterior to the
epiglottis so as to pick up the epiglottis with the tip of
the blade and the blade is then lifted anterioriy, thereby el"evating
the epiglottis'direcly to expose the laryn-
geal inlet

6. MAGILL'S FORCEPS
It is L-shaped and it has no catch
Sizes : Adult and paediatric
Uses:
'l Guiding an endotracheal tube from the pharynx into
the larynx during nasal iniubation
2. To pack the throai with a roiler gauze during orar and pharyngear surgery
3. To pick up a broken or disrodged tooth i foreign bocry rying in the
orar cavity
4. To pass a ryles (naso gastric)tube
7. BITE BLOCK (Mouth Bite / Gag / prop)
It is placed between the molar teeth or gums to prevent
them from occluding an endotracheal tube and to
keep the mouth open for suctioning' It does not extend
into the pharynx and is tlierefore less irritating than
r:ral airway an

8. ANAESTHESIA MACHINE
It consists of a metaliic frame having a faciliiy
to connect central piperines as well as cylinders of gases
oxygen' nitrous oxide, air etc', flow meters, vaporizers like
and a facility to deliver nigrr rilw of oxygen (oxygen
or emergency oxygen knob) in the event of any leak flush
or an emergency situation. iialso has a working piatform
keep various drugs and small equipmerrt, and at to
iimes a tray on the top to keep various mon jtors. The gas
can be either intermittent (gases flow only on demand flow
by the patient e.g. walton s) oi continuous gases
using flow meter continuously e.g. Boyie machine. flow by
ln continuous flow machines oxygen, nitrous oxide,
have individual flow meters for settingdesired flow air etc.
of each gas. Vaporizers are ror iitting desired percentage
output concentration of the liquid anaesthetic agents
like ilalothane, isoflurane, sevoflurane etc (ether and
trilene in older mociels of the machines)' Florv tuiur.
for gases and vaporizers for lrquid anaesthetrc agents
gas/agent specific and the one meant for a particutar are
gJs or anaesthetic agent cannot be used for the
Mosi of the newer anaesthesia machines have devices"which other.
in the event of delivery of a hypoxic gas mixture
activate an alarm, either auditory or visualwhich tells
the operator that a hypoxic
so that immedrate action can be taken' Anaesthesia machines aas mixture is being delivered
have been evJtved from simple pneumatic
devices to complex computer based integrated systems with numerous
controls, displays, indjcators and
alarrns' The prevailing trend is to incorporate and integrate
ventilators and vigilanc"'"iou srct, as airway pres-
sure monitors, respiratory gas monitors, pulse oximeiers,
monitors into the machine
electro.rtorgi";rlnl*torutic blood pressure
L BREATHTNG SYSTEM (CtRCUtl)
It is an assembly of equipment, that not only carries
anaesthetic mixture from the ouilet of anaesthesia
machine to the patient, but also allows to monrtor ancl
control patient,s breathing.
Cornponents : (in addition to various connectors and
adaptors)
1. A bag mount with a reservoir bag (1.S to 2 iitre capacity)
2 Long (one meter) corrugated rubber cr prastic tubingis (breathing tube/s)
3. Expiratory valve, orcjinary spring loaded/non re_breathing valve

(O{66J
(o {(,lOd
o o .o q) o) 6- NNNNN
N N NNNN
oc)oatri q @
\ gIOJJ
!OOJ
-bdd
,I: il llililil o 6 Ot O) ct) or o) o) N-o)A
=s)N ru-o@O!'OOSONr
llltililil I il I ll ltil|
1,, llll|il llI
rn
rn 394

Types:
1.
2.
Breathing system can be re-usable or disposable
lt can have a single simple corrugated tubing (e.g., Magill's system)or can have a co-axialtubing i.e.
ClinicalENT

one
tubing within the other (e.9., Bains System) or can have double tubing, inspiratory and expiratory (e.g.,

F
closed circuit)
3' lt can allow entire exhaled gases to vent to the atmosphere (e.g., Magill's system with NRV) or allow minimal
I parlial rebreathing (e.g., MaEill's system with Heidbrink valve or Bain System) or it can allow exhaled gases
from the patient to be re-used (re-breathed) after getting rid of carbon dioxide from the exhaled gase.

F
1e.g.,
circle absorber / carbon dioxide absorber / closed system)

oPEN SYSTEM (MAGtLL'S) CLOSEDSYSTEM

1. Less economical 1. Economical as low flow of anaesthetic gases

F
H
2. lncrease heat and moisture loss from patient's body 2.
are required
Less heat and moisture loss from patients
body

n
3. lncreased theatre pollution which can be reduced by 3. Operation theatre pollution is almost nil.
using scavenging system that gets rid of exhaled

n
r
gases entering into the operation theatre atmosphere.

RESUSCITATION AND OXYGENATION EQU IPMENT

rr 1. RESUSCITATION BAG
o An assembly of equipment consisting of a self-inflating bag with a nipple for connecting an oxygen source,
a non-rebreathing valve and a facemask

rft:-
o Useful for ventilating a patient in an ernergency situation / during transport
o Can also be used for adminisiering anaesthesia ih the absence of an anaesthesia machine e.g., in
rural
setup or field situations
o They are generally re-usable, but even disposable resuscitation bags are available
Sizes : Three sizes are available; for infants, children and adults.
Method of use :

After proper positioning of the patient, the mask has to be placed on the patient's face and the bag
can be

rr-
intermittently compressed and released while watching the inflation and deflation of the patient's
chlst. The
exhalation blast can be heard or felt from the expiratory port of the non-rebreathing valve

2. OXYGEN CYLINDER
o Oxygen cylinders are available in various sizes

t:
rn
o They are black in colour with a shoulder painted white
o Those meant to be used on anaesthesia machines have a flushed valve and it is not possible to use a flushed
o
r
valve cylinder in the wards
Those meant for ward use have a bull-nose valve
On the ward cylinder, oxygen flow meter can be attached and there is also a facility to attach
a humidifier to
the flow meter

3. OXYGEN FLOWMETER
o lt allows the operator to deliver a desired flow of oxygen to the patient

F
rt:
o Generally, 3 to 4 liters per minute of flow is given but it varies from patient to patient depending upon
Type of oxygen delivery system (poly mask, venti mask, nasal cannula, nasal catheter, T-piece
Type of surgery done, age of the patient and general condition of the patient
etc.)
:

n
r '-_:€-J-€r=
Sro frl'dr u el (/t:
,:ft5:,,;€p,,,;,:-j .:.rt rt_''
 Section Vl Anaesthesia 395

4. OXYGEN MASK
o These are generally facemasks of different varieties
o Poly mask is a semi oval shaped mask, available in two sizes, for children and for adults. lt is a loosely
fiiting mask around the mouth and nose through which moderate flows of oxygen (3 to 6 liters) can be
delivered. Too little oxygen flow will allow rebreathing and too high flow may obstruct exhalation. Oxygen
percentage cannot be judged and not more than 35% can ever be given t
o Venti rnasks are designed to work on venturi principle. Here the delivered oxygen flows through a jet and
entrains room air from the surrounding entrainment port while it approaches the patient. Various flow rates of
oxygen with its approximate delivered oxygen concentrations are written on the device and hence it be-
comes easy for the operator to choose the mask and deliver the desired concentration of oxygen
o There are some oxygen facemasks that have a reservoir bag for oxygen, and some have even directional
valves. Recommended flow rates are 10-15 liters/min. of oxygen. With reservoir bag, one can deliver up to
65% oxygen and if they have directional valves also, then one can deliver even up to 90% oxygen

5. NASAL CATHETER/ PRONGS

o These are the most simplest, most commonly used and easily available devices
o Not more than 1 to 3 liters of oxygen per minute can be delivered as high flows make the pattent uncomfort-
able due to wheezing sound and a feeling of dry mouth
o Concentration of delivered oxygen is generally low and can never be judged
c Generally with oxygen flow rate of 1-2lilerlmin., these devices provide 24-28% oxygen.
o lf a nasal catheter is used, its tip should be advanced up to the fold of the soft palate. lf it is introduced too
far, it can produce gaseous distension of the stomach
o Nasal prongs (two short plastic prongs that fit into the external nares) are preferred by some as they are
comfortable for the patients

USEFUL MONITORS
1, BLOOD PRESSURE MONITOR
It is necessary to monitor patient's blood pressure as most of the anaesthetic agents are vasodilators and /
or myocardial depressants, giving rise to hypotension.
It is a available in various forms :

1. Simple sphygmomanometer/anaeroid dial

2. Non-invasive automatic blood pressure monitor (NIBP)
3. lnvasive direct arterial blood pressure monitor (IABP)

2. CARDIOSCOPE
Drugs used for anaesthesia have effects on rate, rhythm and contractility of the heart and hence it is a vital
monitor. Cardioscope with a defibrillator is useful as it allows to defibrillate the heart on the spot, if the need
arises.
Uses:
1. To monitor the electrocardiogram (E.C.G.) of the patient
2. To monitor patient's heart rate, rhythm, the type of arrhythmias and ST-segment changes (important to
diagnose myocardial ischaemia)
3. To alarm the anaesthesiologist about cardiac arrest well in advance as generally slowing of the heart rhythm
or rntractable arrhythmias occur before cardiac arrest

3. PULSE OXIMETER
It is a non-invasive equipment that allows to monitor the oxygen saiuration of the patient and also the heart
rate continuously. lt has a small probe which can be attached on any of the fingers or toes or on the ear lobule.

,a5*:;S$* ;-oss .!ti s a ! il: ;f,ooilotrrsoNr

(O \t (, o.+ tO-r(,ro-
lgJ+JJ
ii
o o.o. o 6) .o o6000
N NNNNN NNNNN
!I z
2
n ClinicalENT

r:
r: 1. To detect hypoxia (breathing of hypoxic gas mlxture or circuit disconnection)

n 2. To detect hypotenslon / peripheral vasoconstriction

CAPNOMETER / CAPNOGRAPHS (End Tidal COr'ETCO,
Monitor)
r" 4.
It continuously records the carbon dioxide tension
(in mm Hg.or %) of the expired gas mixture (only numeri-

n cal values as in capnometer or numericat vatue with

monitor having a probe or an adaptor that can be attiched
graphical recording as in capnograph)' A non-invasive
to an endotiacheal tube' a facemask or a nasal
the patient is breathing adequately (if on spontane-
r. catheter. lt allows the anaesthesiologist to monitor whether
ous breathing) or whether the patient is being ventilated
Also allows the anaesthesiologist to know :-
adequately (if he is on cpntrolled breathing)

F 1

2.
. lnadvertentoesophageal intubation
Breathing circuit disconnection / function (e'g'' re-breathing)

n
r, 5.
3.
4.
Adequacy of fresh gas flow from anaesthesia machine
PulmonarY air embolism

RESPIRATORY GAS MONITOR

the concentration of the inspired as well as
r^ It allows the anaesthesiologist to monitor the contents and
anaesthetic gases (inhalational agent), oxygen and

n
n
expired gas mixture and thereby the concentration of the
carbon dioxide of the inspired gases. lt is a non-invasive
attached to an endotracheal tube, a facemask or a nasal
mixture and also concentration of anaesthetic gases'
monitor naving a probe or an adapter that can be
catheter. lt helps preventing delivery of a hypoxic gas

I:
t:
n
I:
n
n
F
t:
n
rn
F
H
rr^
 SffiffiTEffiru E VEffi
AUDIOLOGY
- Mrs. Geeta B. Gore
- Mrs. DeePa A. Valame

I:
r^
 PURE TONE AUDIOMETRY

lntroduction
Audiology is built on the foundations of physical, biologic and social sciences.
Hearing is one of the vital senses used by all of us in our every day life. However, nature of "hearing" is elusive
in the sense that it cannot be seen, but only be "experienced". lt is obligatory i.e. occurs constantly. The process
of quantification of "hearing" is even more elusive, in that it encompasses the quantification of various facets of
hearing like detection, discrimination, recognition, auditory memory, loudness perception, localisation, compre-
hension etc
"Hearing" takes place at all these levels simultaneously and each can be tested using different materials and
methbds.
The present chapter focuses on the most basic element of "hearing" i.e the stage of detection, absolute
sensitivity.
Detection refers to the capacity of the auditory system to discern the presence or absence of sound. The
procedure carried out routinely for measuring person's ability to detect sound is "pure tone audiometry." Thus,
PTA is a test of "hearing sensitivity" & not a test of hearing. The quantification of sensitivity can be done by
determination of threshold of audibility or threshold of detection of change.

HOW CAN THE HEARING SENSITIVITY BE MEASURED?

To answer this question we must first look at what is SOUND and its characteristics. Here we are concerned
with the response of the human ear to auditory stimuli. Hence it is necessary to study the physical nature of
sound.
Sound is a form of energy, which is propagated in a medium in the form of longitudinal waves comprising of
alternating condensations & rarefactions. Whenever a force acts on an elastic medium, the particles of that
medium move to and fro causing alternating compression & rarefaction. .This results in a pressure wave that
emanates from the source. When these pressure variations are within the range of human sensitivity, one can
perceive the presence of "sound"
Sound can be characterised by two main features viz. frequency and intensity.

FREQUENCY
Humans can "hear" frequencies in the sonic range of 20Hz-20,000H2.
Frequencies below this range are called infrasonic and those above this range are known as ultrasonic.
ln PTA the hearing sensitivity is determined for the range of frequencies from 250 Hz to 8000H2 in Octave
intervals (An Octave is a band of frequencies F2-F1 such that F2 = 2 Fl ) because most of the speech sounds
occur in this range.

397
398 Clinisal INT

INTENSITY
The human ear is responsive to a wide range of sound pressures. l-he difference between the pressures -lc
of llte
quietest sound which can be heard and the loudest soLind tlrat can be tolerated is several nrillion-folcl. acconltno-
"ihre decibei".
date this !,ast range of values on a conveilient scale, a logarithrnic scale ls used with its unit
Figure : Tire decibelScale
rf
Micropas,rals {|rPa} irlts I

'1
OO,()OO,OOO "I lrrnsholrJ of

l O"OOO.OOO

roacl

1.OOO,O00

I crlrJ shout

1 00, ooo

{ronve-.sat!orral ievei
backcround ?foise

1 0, oo()
h
living
1,oo0

Screening for hearing inrpairment in young children Barry Mlccormick Croonr l-lelm l-and 1988
The decibel is a logarithmic ratio of two quantities. Say lor dBSPL. it is the ratio of the reference sound
pressure (P2) and the sound pressure of interest (Pl), l-'.{ere the reference is the sound pressure required by
normal hearing adults to perceive the presence of sound. ri
P2 = 0 0002 dyneslcm2 or 20 u Pa.
n dBSPL = 20 log (P1lP2)
Thus. if P1 = P2 = 20 u Pa rt
n dB SPL = 20 x log (1)
-0 i

I *. t .A'{-:aB A J
Section Vll 399
-Audiology
Thus 0 dBSPL rneans thai the sound pressure is equal to the reference pressure.
The dB sound pressure level scale is a logarithrnic scale that compresses the million to one pressure values
in the audible range into a 0- 120 dB SPL range.
The unit decibel should alvrays be used w.r.t. its reference, otherwise it is meaningless. e.g''A sound
is 20dB in intensity' is a meaningless sentence. lt means "A sound is 20 times. Unless the reference is
stated, the phrase 20 times has no meaning. Various references are used w.r.t. the decibel scale Viz.
dBSPL, dBlL, dBHL, dBA etc.

Nature of Hearing SensitivitY

Absolute hearing sensitivity varies as a function of numerous factors such as the psychophysical method used'
whether testing is done in sound field conditions or under earphones, type of earphone etc.
The graph 6f audibility of pure tone signals is called the "minimum audibility curve". lt is a graph of the SPL
requireJby normal hearing individuals to reach audibility as a function of frequency. The minimum audibility curve
is not a straight line indicating thai hearinE sensiiivity varies as a function of frequency. lt is clearly seen that more
SpL is required to reach "threshold' in iow and lrigh frequency ranges as compared to mid frequencies, thus the
ear is most sensitive to mid frequencies.

130

120

$ 110
o
100
C)
c'l
90
itL
m BO

.g 7J
6
c)
J
q,, 50
:1
a 40
s1
OJ

0- 30
E
c 20
o
a 10

125 250 500 1 K 2K 4K BK 16K

Frequency in Hz

Figure. Auditory response area from the threshold of audibility to the threshold of feeling across the frequency
range that encompasses most of human hearing.

The MAp curve serves as the basis for PTA in which a patient's thresholds of audibility is measured and
compared to this normal curve. For clinicai purpose, this curve is converted into
"straightened" graph using a unit
- the dB hearing level. This straighi line is the "Audiometric zero".
 a
400 Clinical ENT

Thus "Audiometric zero" is the SPL at which the threshold of audibility occurs for normal listeners i.e. at each
frequency, the sound pressure level (in dB SPL) required for normal listener to achieve audibility is designated as
0 dB HL for that frequency. This is shown in the figures given below:
Fr.qu{fi ln H:
!

o \
T
J

a t t.-0 to-s e
7.5 ltl
I

iltl

250 500 1K 7K 4X r(
!( 25a 5*o 1K 2K lK
Fr@ery ttr fti 'K
Fbquect ln H:

Figure : The conversion frorn sound pressure level to hearing level to an audiogram

The conversion from sound pressure level to hearing level to an audiogram

Audiogram is a graph of auditory sensitivity as function of frequency. lt uses the "dBHL" scale.
:t
PURE TOf'IE AUOIOGRAM
FN6OU6NCY IN H€RIZ

^ 123

\
if

gl
g \
6
J
trJ
s}
6
lrj \
o
r!
7
lu
UJ
\
J
c, \
zE
UJ
\
I
\
\
\
Audiogram recommended by the American Speech-Language-Hearing Association 1990
\
<
<
l-r

(o{6@r
(o{oo \
(, o.o. o o o QOOOO
N NNNN NNNNN
(,rgtJ (o
(t) o)
ooJ
or o) ('t
{(Jlror
;-<e<;
oJ
.o<; S t B i1;1
oloo
n
r Section Vll 401

n
-Audiology
PURETONE TESTING

n
r-
The basic audiologic evaluation has several purposes, such as diagnosis, determining the need for non-
surgical rehabilitation, deciding subsequent audiological test battery approaches and determining disability and
compensation. One of the tests in a basic evaluation is PTA, which is a test of hearing sensitivity as a function of

n
frequency.

Obtaining Pure Tone Audiometry (PTA).

A. Preparation
1) Case history: - A detailed case history is mandatory before obtaining a PTA. lt covers the following points:

F
r
i)
ii)
Hearing loss - in which ear, since when, progression, etc.
Otorrhoea

rH
iii) Otalgia
iv) Tinnitus
v) Giddiness and vertigo

rn
vi) Family history
vii)Medical history
viii)History of noise exposure etc.

n
Above information is useful
i) To estimate the patients approximate hearing difficulty so as to determine at what level to start testing.

rr ii) To determine mode of communication needed to give instructions for audiometry

iii) To validate audiometric findings
2) Otoscopic Examination:
.

n r Prior to audiometric testing, Otoscopic examination is a must in order to rule out presence of wax or
cotton in the ear which if unnoticed can lead to an apparent conductive hearing loss on the pure tone
audiogram. Further an Otoscopy can also reveal presence of collapsible ear canals. This is very important
because it can cause a spurious conductive hearing loss esp. in the high frequencies

r
H
3) Seating the patient
The patient should be seated is such a way that - he/she cannot see the face of the audiometer & he/
she cannot see the clinician's movements. These visual cues must be avoided as they can lead to false
responses by the patient. lt would be ideal if the patient's face were visible to the clinician (at least in profile
so as to observe his/her reactions to presentation of the stimulus.

tr
4) lnstructions
The patient should be given clear instructions to raise his hand in response to the tone and to lower his

n
n
hand as soon as he stops hearing the tone. The client should respond to the softest audible tone. At times
during case history taking, it may be seen that the patient appears not to hear even very loud sounds. ln
such cases the instructions can be given either using gestures or in written form (if patient can read).
5) Placement of Transducers

n Transducers used during audiometry are:

1. Earphones during air conduction testing
2. Bone vibrator during bone conduction testing.
To get valid thresholds, proper placement of transducers is mandatory.
Earphone placement

F
r
- By convention, the earphone marked in red must be placed over the right ear and the one marked in blue
must be placed over the left ear. By adjusting the swiveljoints earphones must be placed on the client so
that he/ she is comfortable. Ensure that the diaphragm of the earphone lies in front of the opening of the

rr
EAC. Client must be asked to remove glasses, earring, headbands or any such thing which can cause
discomfort and comes in the way of proper placement.

T^
Uti{.r:-r\r\\ :-R,'=**f€;€;
 402 Clinical ENT \
Bone Vibrator Placement \
- lt is conventionally placed on the mastoid process of the ear with better air conduction hearing. However. \
vibration of the BC vibrator will stimulate both the cochlea simultaneously, hence vibrator can be placed on
any mastoid process.
- Care must be taken to avoid the BC vibrator touching the pinna or sound trarrsmission ma\1 occur via the air
\
conduction route.
\
C. TESTING i!
After preparing the patient, actuai testing can be undertaken.
The testing can be divided into 2 parts: :rf

- AC testing: - First AC testing is attempted in which the pure tone is presented via the earphones. The tone
E
travels from the outer ear to middle ear to the cochlea and thus AC testing provides an overall estimate of the
peripheral hearing sensitivity.
After AC testing, BC testing is undertaken using the BC vibrator. Here the assumption is that the BC
i
presented tone directly stimulates the cochlea bypassing the outer and middle ears and thus provides an E!
estimate of the cochlear reserve.
rf
Which ear to test?
One should always start testing the patient's better ear as suggested in case history. ln absence of ear
difference, any ear can be tested first.
i
Frequency sequencing
-
Testing is begun at 1000 Hz except in case of profound losses when patient doesn't respond at 1000 Hz even hl
at maximum audiometric output, testing can begin with 500 Hz. The sequence of testing is '1000 Nz - 2400 Az -
4000 Hz - 8000 Hz. Then recheck at 1000 Hz, The obtained threshold should be within +/- 5 dB of threshold
obtarned earlier. Then proceed to 500 Hz and 250 Hz. After this, the other ear can be tested. \
For BC testing, the same sequence is followed except that BC testing is not carried out at B000Hz.
\
Note: lf the thresholds at adjacent octaves differ by greater than 20d8, mid octaves should be tested.
-!
Method Used
PTA can be carried out using various methods such as - Ascending method rt
- Descending method
- Bracketing method
\
The procedure routinely used to determine thresholds of hearing \
Sensitivity is the Hughson-Westlake Ascending technique modified by Carhart & Jerger, 1959. The important
features of this approach are: \
1. The starting level
During the case history interview, the audiologist can make some estimate of the patient's hearing capac- \^
ity; based on which the starting level can be decided.

lf the patient appears to have Start at

Normal hearing sensitivity 30-40 dBHL \
- Moderate hearing loss 70 dBHL
\
- Severe hearing loss 1OO dBHL
2. After the initial response :- h!
Decreasethe intensity in 10-15 dB steps untilno response is obtained i.e. inaudibilrty is reached.
It is important to remember that the tone duration should be 1 to 2 seconds and the interstimulus interval -a
should be no shorter than the duration of the test tone.
\

-
nI

-
if;,:ersa= d6jle (n
{gloJ
$-<-<-
o-
S t B i1;;'o6{'oq5@N-
o
N N RRBssssss \\\j
;;;o, (t) O) ('r XF
 Section Vll-Audiology 403

3. Once inaudibility is reached:

We can begin the threshold search using ascending technique. lncrease the intensity of the signal in 5dB
steps. until the patient responds i.e. the threshold of audibility. When the patients responds again carry out the
5 dB up, 10 dB down procedure tillthreshold is obtained.

Criterion for Threshold

As per ANSI (1 978, 1986) standards:-
Threshold is the lowest hearing level at which responses occur in at least one-half of a series of
ascencling trials, with a minimum of two responses out of three required at a single level".

Examples:
1. Presentation level (dBHL) Response/ No response (R/NR)
70 R
EE
JJ R
40 NR
il
Threshold search begins
AE
AJ
,il NR
50 NR

rt
EE
R _(i)
45 NR
rt 50 NR
55 R (ii)
Therefore Threshold is 55dBHL
-
I
40 R
- .J tr.
NR
Threshold search begins
30 NR
J5 R
(i) response. at 35 dBHL
25 NR
JU R
(i)response at 30dBHL
ZU NR
uq NR
30 NR
'E R
(ii) Response at 35 dBHL
Therefore Threshold is 35 dBHL.

RECORDING OF RESULTS
The pure tone thresholds obtained during air conduction and bone conduction testing is recorded graphically
.t on the "audiogram".
! The audiogram is a graph of a patient's hearing thresholds across the frequencies in octaves from 250 Hz to
8000 Hz.
-,
This graph has on its abscissa - the frequencies (in Hertz) plotted on an Octave (i.e. logarithmic) scale and on
its Ordinate - intensity level in dBHL (i.e. logarithmic scale). Thus an audiogram is graph of log-log nature.
 \

404
ClinicalENT \
\
The symbols for thresholds as recommended by ASHA (1990) are:
Right UnsPecified Left \
Ac. - Earphones \
Unmasked O X
\
Masked A I
Bc - Mastoid < A

-
-' Unmasked trr
-Masked t I +
Note:
-
<= Bc threshold obtained with vibrator on R' Mastoid
Not necessarilY resPonse of R. ear -
>= Bc threshold obtained with vibrator on Left Mastoid El

Not necessarily response. of Left ear

A1 Common/Unmasked bone conduction i.e response of the betier cochlea'
-
'I

INTERPRETATION
about patient's hearing loss'
The audiogram provides us with both qualitative and quantitative information i!

Quantitative - Degree of loss

qr
Qualitative - TYPe of hearing loss
(PTA is the average of the patient's
euantitative -The degree of hearing loss is calculated based on the PTA
threshold at the frequencies 500 Hz, 1O00Hz and 2000H2)'
\
PTA (dBHL) Description \
- 10 to 15 Normal Hearing SensitivitY
ir
- 16to25 Mild Hearing Loss
- 41 to55 Moderate hearing loss *\
- 56to70 Moderately severe hearing loss
- 7'1 to 90 Severe hearing loss \r
- >91 Profound hearing loss
\
Qualitative: Helps in topological diagnosis
The type of hearing loss can be determined using
- AC PTA
\
- BC PTA
Air bone gap (AC PTA - BC PTA) -!

Conductive hearing loss

pathway
Here the lesion lies in the outer/middle ear or both i.e. in the AC
worse than normal i'e' 25 dBHL However' \
Therefore Due to lesion in the AC pathway, patient's AC threshold is
BC thresholds will be normal because the inner ear is intact.
Therefore in conductive loss \
- BC threshold- With in normal limits \
- AC threshold-Worse than normal
- Presence of airborne gap (> I 0d B) i
t!

E
Section Vll 405
-Audiology
Sensorineural hearing loss
Here, the lesion is in the inner ear and / or the auditory nerve
As seen above as the inner ear has a lesion, transmission of sound is affected in both the AC as well as the BC
pathway. Therefore in SN Loss,
- the BC threshold is worse than normal i.e. worse than 25 dBHL,
- the AC threshold is worse than normal i.e. worse than 25dBHL
Therefore A-b gap < 10 dB.

Mixed Hearing Loss.

Here the lesion lies in O.E/M.E and l.E./nerve .

Thus, AC pathway has 2 lesions. Therefore AC threshold is worse than that in normal i.e. worse than 25
dBHL. BC threshold will also be worse than that in normal hearing. However, to a lesser extent as compared to
AC thresholds. Therefore there is presence of an air bone gap> 10d8.

NOTE
The validity of results obtained in pure tone Audiometry depend upon various factors, of which, the test
environment is very important.

Test Environment
An idealtest environment must meet the requirements of
- Sufficient space
- Adequate comfort to the patient
**-
Adequate quiet
This is most important as ambient noise levels can cause serious errors in interpretation. Noise levels that are
greater than those permissible can lead to an apparent hearing loss since noise will mask the tone.

TABLE 1. Octave and one{hird octave band maximum permissible ambient noise levels for three test frequency
ranges specified in ANSI 53.1-1 999 for ears not covered

Octave Band One-Third Octave Band

Center 125 to 250 to 500 to 125 to 250 to 500 to

Frequency 8000 Hz 8000 Hz 8000 Hz 8000 Hz 8000 Hz 8000 Hz
125 29.0 35.0 44.0 24.0 30.0 39.0
250 21.0 21.0 30.0 16.0 16.0 25.0
500 16.0 16.0 16.0 11.0 11 .0 11.0
800 10.0 10.0 10.0
1 000 '13.0 13.0 13.O 8.0 8.0 8.0
1600 9.0 9.0 9.0
2000 14.0 14.0 14.0 9.0 9.0 9.0
31 50 8.0 8.0 8.0
4000 11 .0 11 .0 11 .0 6.0 6.0 6.0
6300 8.0 8.0 8.0
8000 14.0 14.0 14.0 9.0 9.0 9.0

Note : Values are in dB re:20 pPato the nearest 0.5 dB and have been reprinted by permission
of the Acoustical Society of America, New York, U.S.A.
 \
CIinicalENT
.l
-tl
406 rrl
-1
noise levels for three test frequency ranges as
TABLE 2. octave band ears covered maximum permissible ambient -l
using a supra-aural or insort earphone
specified in ANSI 53.1-1999 for ears covered testing is done
Supra-aural EarPhone lnsort EarPhone :1
\
1251o 250 to 500 to
?"j:"J ^l
l

125 ro 250 to 500 to

8000 Hz 8000 Hz 8000Hz 8000 Hz 8000 Hz
lntervals Booo Hz
\
125 35.0 39.0 49.0 59.0 67.0 78.0 -t
530 53.0 64.0
250 25.0
21.0
25.0
21.0
35.0
21.0 500 500 500 :'r
500 47.0 47 .0 47.0 -
26 o 26.0 26.0
iooo 34.0 490 49.0 49.0 r!
34.0
2000 34.0
37.0 500 50.0 50.0
37.0
4000 37.0
370 56.0 56 0 56.0 Et
37.0
6000 37.0

A/"f" .'vrk*r
"*i"
dB re:2}prPa to the nearest 0.5 dB and have been reprinted
New York, U'S'A'
by permission t
of the Acoustical Society of America,
i
Remember:-
- To compensate for high ambient noise levels in ihe
Test rooms, some people use correction factor' This is i
completelY erroneous because
to varying degrees'
lr
1. Noise is not constant. lt varies from time to time and affects different frequencies
A particular noise level may affect the .t
2. Effects of noise also depend upon the patient's hearing sensitivity.
to testing of a severely hearing impaired
threshold of a person with mild loss but may be insignificant
person.Thereforeuseofacommoncorrectionfactoriserroneous. i
:-
i
r!
q

!r
i
i
i
\
i
rf
i
i
.t
q

tr
 *l/u
te,tr:lr is i,t /)ertltt ,:tuice"
"Krtu,ut)u)ye i,
f)u,ruz, {,f ,ryr'1l1),iu)"
*l/u
ls,z r:otts o:t,s tts o,f tltrtl
ryott trta iytr,t?tt/t t ir' ,t y:ruttt st,t7t t0 /etutul,iV

fi-JE i/\l-lir\l I Fi;\L'Ui'.i lill'J ?)ci< JJ lf s VVlli Cc'Vi.i',A,g= OF -l)p)t;. l-i-

"F =.D F)i, -t >t)tltA--i'-)t=.t J=.r, j:tt) lF pi,-i (: i),i| t_.
, :, J J ) ilt,l E.t j.t D=.tpll= frli t_t-)i jF i.,, l=.t)-:l.lJ Dl_l-, -f'rli.i,7. t.> +-,1
r\J) i-.Di(--t--. J r) r J JrJ __

FrlJpj-i;-\,ijg ?j.l jil\/J,21 E F?ill!u!l B I \yttl c)F ci-l-ri,.IJ, Ji:/'la't)t:3,;\r.lD

-#\-31-
F;.

I' /^,.
)'.incly :'=t),-) llJ /t)l ' ) lt) f))a l) /,,,U C)a)"tl )C l)', Cl I
-tl' '
'-))rt)r:1)-)
14 'l
IJ- ('! I

1I t')') .'-': I (
/ J

la--', l, .,,1 .)-/.1-t,t .)t) .'

J)r)), tJ-tI ll t"!'j-i

liii

/4"
tl)\
{ iltts tti il[
\U-elf
B!{AIANI"BOOK DEPOT
'..'i, i',tl',t:rir.-tt, J,-J!., D'-t,-l',t:'.t!ttlt litit,l-e ii,,-.t,-1,
- I "'.in,-l
l':-t; D':t,-l'=tt ii.,-tiiun lc.ii.),lA'-tttit'.it - :It)U t) l:i-
-i,l: _l:,.i-,'-'t'rt:, I 2.'t l:t '.'.'.t't l i., ,. 1'2r_.,'1i)iijJr,
, ,

IXtH X'i;ji; iiro:.rsip- i f i lror s,!,.