ENT TICKETS - FINALS 2022

EAR
1) The External ear anatomy and physiology

It is made up of three parts:

1. Auricle (pinna)
2. External acoustic meatus (ear canal)
3. Tympanic membrane (eardrum)
Auricle
 The pinna is made up of an irregularly shaped plate of elastic cartilage that is covered by thin skin.
 The auricle has several depressions and elevations which help amplify the receiving sound waves.
 The non-cartilaginous lobule (ear lobe) consists of fibrous tissue, fat, and blood vessels.
 Arterial supply
✓ posterior auricular artery
✓ superficial temporal artery.
 Nervous innervation - main nerves to the skin of the auricle are
✓ great auricular nerve
✓ auriculotemporal nerve
External acoustic meatus
 It is an ear canal that leads inward through the tympanic part of the temporal bone from the auricle to the tympanic
membrane, a distance of 2–3 cm in adults.
 The lateral third of this slightly C-shaped canal is cartilaginous and is lined with skin that is continuous with the
auricular skin.
 The medial two thirds of the meatus is bony and lined with thin skin that is continuous with the external layer of the
tympanic membrane.
 The ceruminous and sebaceous glands in the subcutaneous tissue of the cartilaginous part of the meatus produce
cerumen (earwax).
Tympanic membrane (eardrum)
 Its a thin, oval semitransparent membrane at the end of the external acoustic meatus.
 This membrane forms a partition between the external acoustic meatus and the tympanic cavity of the middle ear.
 The tympanic membrane is covered with thin skin externally (Epithelial), Fibrous tissue in the middle and mucous
membrane of the middle ear internally.
 Superior to the lateral process of the malleus, the membrane is thin and is called the pars flaccida
 Nervous innervation
o external surface - auriculotemporal nerve
o internal surface - glossopharyngeal nerve (CN-9)

2) The Middle Ear Anatomy & Physiology

3) The Inner Ear Anatomy & Physiology
4) Clinical tests of hearing
 A hearing test provides an evaluation of the sensitivity of a person's sense of hearing and is most often performed
by an audiologist using an audiometer.
 An audiometer is used to determine a person's hearing sensitivity at different frequencies.
 Prior to the hearing test itself, the ears of the client are usually examined with an otoscope to make sure they are
free of wax, that the eardrum is intact, the ears are not infected, and the middle ear is free of fluid (indicating middle
ear infection).
 There are other hearing tests as well:
1. Weber test - The tuning fork is placed on the forehead. The patient is then asked if the sound is localised in the
centre of the head or whether it is louder in either ear. If there is conductive hearing loss, it is likely to be louder in
the affected ear; if there is sensorineural hearing loss, it will be quieter in the affected ear.

2. Rinne test - In order to determine what kind of hearing loss is present, a bone conduction hearing test is
administered. In this test, a vibrating tuning fork is placed behind the ear, on the mastoid process. When the patient
can no longer feel/hear the vibration, the tuning fork is held in front of the ear; the patient should once more be able
to hear a ringing sound. If they cannot, there is conductive hearing loss in that ear. BC>AC in Conductive Hearing
loss. AC>BC in sensorineural hearing loss.

3. Hearing in Noise Test (HINT) - measures a person's ability to hear speech in quiet and in noise. In the test, the
patient is required to repeat sentences both in a quiet environment and with competing noise being presented from
different directions.

5) Audiometery subjective tests

Subjective audiometry requires the cooperation of the subject, and relies upon subjective responses which may be
both qualitative and quantitative, and involve attention (focus), reaction time, etc.
● Differential testing is conducted with a low frequency (usually 512 Hz) tuning fork. They are used to assess
asymmetrical hearing and air/bone conduction differences. They are simple manual physical tests and do
not result in an audiogram.
● Weber test
● Bing test
● Rinne test
● Schwabach test, a variant of the Rinne test
● Pure tone audiometry is a standardized hearing test in which air conduction hearing thresholds in decibels
(db) for a set of fixed frequencies
● Threshold equalizing noise (TEN) test
● Masking level difference (MLD) test
● Psychoacoustic (or psychophysical) tuning curve test
● Speech audiometry is a diagnostic hearing test designed to test word or speech recognition. It has become
a fundamental tool in hearing-loss assessment

6) Audiometery objective tests

Objective audiometry is based on physical, acoustic or electrophysiological measurements and does not depend
on the cooperation or subjective responses of the subject.
● Caloric stimulation/reflex test uses temperature difference between hot and cold water or air delivered into
the ear to test for neural damage.
● Electronystagmography (ENG) uses skin electrodes and an electronic recording device to measure
nystagmus
● Acoustic immittance audiometry - Immittance audiometry is an objective technique which evaluates middle
ear
 ● Evoked potential audiometry
● Otoacoustic emission audiometry - this test can differentiate between the sensory and neural components
● In situ audiometry: a technique for measuring not only the affliction of the person's auditory system.

7) Hearing assessment in young children

• Play audiometry. A test that uses an electrical machine to send sounds at different volumes and
pitches into your child's ears. The child often wears some type of earphones. This test is changed
slightly in the toddler age group and made into a game. The toddler is asked to do something with
a toy (such as touch or move a toy) every time the sound is heard. This test relies on the child's
cooperation, which may not always be possible.
• Visual reinforcement audiometry (VRA). A test where the child is trained to look toward a
sound source. When the child gives a correct response, the child is rewarded through a visual
reinforcement. This may be a toy that moves or a flashing light. The test is most often used for
children between 6 months to 2 years old.
• Pure tone audiometry. A test that uses an electrical machine that makes sounds at different
volumes and pitches in your child's ears. The child often wears some type of earphones. In this
age group, the child is simply asked to respond in some way when the tone is heard in the
earphone.
• Tympanometry (impedance audiometry). A test that can be done in most healthcare providers'
offices to help find out how the middle ear is working. It does not tell if the child is hearing or not.
But it helps to find any changes in pressure in the middle ear. This is a hard test to do in younger
children because the child needs to sit very still and not be crying, talking, or moving.

8) Vestibulometry
Vestibular testing involves a series of tests that are administered when you are experiencing dizziness. They are
used to determine whether symptoms of dizziness are being caused by the balance system of the inner ear.
● Electronystagmography (ENG). This series of tests measures eye movements via electrodes placed
around the eyes
● Videonystagmography (VNG). This is similar to ENG testing, but an infrared video camera attached to a
pair of goggles is used in place of electrodes.
● Rotary Chair Tests. The rotary chair test measures eye movements in response to corresponding head
movements; it is used to determine whether symptoms are related to an inner ear disorder or a brain
disorder.
● Computerized Dynamic Posturography (CDP). CDP tests measure how well the visual, vestibular and
sensory systems work together to maintain balance. With this test, you stand on a platform and follow a
visual target while platform movements record the degree to which your body Vestibular Evoked Myogenic
Potential (VEMP). VEMP testing is used to determine whether the saccule (an inner ear organ) and
vestibular nerves are functioning properly. Electrodes are attached to the neck and sounds are transmitted
through a pair of headphones.

9) Hearing loss in children

 Young children can lose their hearing after they get some illnesses, including meningitis, encephalitis,
measles, chickenpox, and the flu. Head injuries, very loud noises, and some medications can also cause
hearing loss.

10) Radiology of the ear

• Pathology of the external and middle ear is the third most common reason of visiting a general
practitioner or a family doctor.
• In children and teenagers, inflammatory conditions of the middle ear are the most frequent
reasons to prescribe antibiotics and perform surgery.
• In complicated and recurrent conditions, imaging plays an important role; imaging findings may
fundamentally influence the treatment. Also, in non-inflammatory conditions of external and
middle ear CT or MRI would provide a diagnosis and/ or necessary information for surgery in a
significant number of cases.
• Usually, patients with temporal bone pathology first undergo clinical examination, often with
audiology tests.
• High-resolution CT (HRCT) of the temporal bone is the method of choice. Since atretic external
auditory canal does not allow visualization of tympanic membrane and middle ear structures,
hence, imaging studies are mandatory

11) Otitis media with effusion AND

12) Otitis media with effusion – treatment
• Thick or sticky fluid behind the eardrum in the middle ear. It occurs without an ear infection
• Causes:
o After most ear infections have been treated, fluid (an effusion) remains in the middle ear
for a few days or weeks.
o When the Eustachian tube is partially blocked, fluid builds up in the middle ear. Bacteria
inside the ear become trapped and begin to grow. This may lead to an ear infection.
• Symptoms: muffled hearing or a sense of fullness in the ear, hearing loss.
• Treatment- Surgery

13) Conductive hearing loss

 Any disease process which interferes with the conduction of sound to reach cochlea causes
conductive hearing loss.
 The lesion may lie in the external ear and tympanic membrane, middle ear or ossicles up to
stapedio-vestibular joint.
 The characteristics of conductive hearing loss are:
1) Negative Rinne test, i.e. BC > AC.
2) Weber’s test is lateralized to affected ear.
3) Normal absolute bone conduction.
4) Low frequencies affected more.
5) Audiometry shows bone conduction better than air conduction with air-bone gap.
Greater the air-bone gap, more is the conductive loss.
6) Loss is not more than 60 dB.
7) Speech discrimination is good.
14) Sensorneural hearing loss
 • Sensorineural hearing loss (SNHL) results from damage to the tiny hair cells in the inner ear. Causes of
SNHL can be age, noise and diseases.
• The symptoms may vary and depend on the degree of the SNHL and which frequencies are affected by
the hearing loss.
• There are different types:
o unilateral hearing loss o Low frequency hearing loss
o bilateral hearing loss o High frequency hearing loss
• A SNHL can be a sudden SNHL. o

15) Sudden (idiopathic) hearing loss

• Idiopathic sudden sensorineural hearing loss (ISSNHL) is defined as sensorineural hearing loss of 30
decibels (dB) or more over at least three contiguous audiometric frequencies with an onset of fewer than 3
days.
• The etiology and pathogenesis of ISSNHL remain unknown.
• Aka sudden deafness
• Might hear a pop sound
• Dx: tuning fork tests, whisper tests, Audiometry, weber and rinne test

16) AIDS To Hearing

• There are 2 main types of hearing aids
o Analog hearing aids : convert sound waves into electrical signals and then make them louder.
o Digital hearing aids: convert sound waves into numerical codes similar to computer codes,
then amplify them. The code includes information about the direction of a sound and its pitch
or volume.

17) Cochlear implants

• A cochlear implant is an electronic device that can provide useful hearing abilities for persons who
have severe to profound SNHL and cannot benefit from hearing aids.
• A cochlear implant works by producing meaningful electrical stimulation of the auditory nerve where
degeneration of the hair cells in the cochlea has progressed to a point such that amplification provided
by hearing aids is no longer effective.
• A cochlear implant has an external and internal component.
External component. Consists of an external speech processor and a transmitter.
Internal component. Surgically implanted and comprises the receiver/stimulator package with an electrode array.
18) Otoscopia
Otoscopy is a clinical procedure used to examine structures of the ear, particularly the external auditory
canal, tympanic membrane, and middle ear. Clinicians use the process during routine wellness physical
exams and the evaluation of specific ear complaints.
19) Otalgia
 • Aka ear pain
• Pain that originates from the ear is called primary otalgia, and the most common causes are
otitis media and otitis externa. Examination of the ear usually reveals abnormal findings in
patients with primary otalgia.
• Pain that originates outside the ear is called secondary otalgia, and the etiology can be difficult
to establish because of the complex innervation of the ear. The most common causes of
secondary otalgia include temporomandibular joint syndrome and dental infections.
• Primary otalgia is more common in children, whereas secondary otalgia is more common in
adults. History and physical examination usually lead to the underlying cause; however, if the
diagnosis is not immediately clear, a trial of symptomatic treatment, imaging studies, and
consultation may be reasonable options. Otalgia may be the only presenting symptom in several
serious conditions, such as temporal arteritis and malignant neoplasms

20) Otorhhoea from ear canal disease AND

21) Otorrhea from middle ear disease
• Otorrhea is a medical term for ear drainage. In order for there to be drainage from middle ear into
the ear canal there must be a connection present. This connection can result from a perforation in
ear drum or if an ear tube was perviously placed.
• Otorrhea is a typical sign of infection. If there is an outer ear infection it could lead to swimmers
ear.
• Treatment is done by using antibiotic ear drop or oral meds.

22) Cholesteatoma
• It is a skin lined cyst that begins at the margin of eardrum and invades the middle ear and
mastoid.
• These grow aggressively because it retains bacteria. They have the capacity to eat away bone.
• Bone erosion can lead to hearing loss by destroying the small hearing ossicles. Bone erosion can
lead to a serious complication mastoiditis, labyrinthitis, facial nerve paralysis, meningitis.
• Treatment - surgery and involves mastoidectomy to remove the disease from bone and
tympanoplasty to repair the ear drum.

23) Fractura of the temporal bone

• Temporal bone fractures can occur after severe blunt trauma to the head and sometimes involve
structures of the ear, causing hearing loss, vertigo, balance disturbance, or facial paralysis.
• Fractures of temporal bone may be longitudinal, transverse or mixed
• Facial palsy is seen more often in transverse fractures (50%). Paralysis is due to intraneural
haematoma, compression by a bony spicule or transection of nerve.
• Treatment is based on managing facial nerve injury, hearing loss, vestibular dysfunction, and CSF
leakage.
• If immediate facial nerve paralysis occurs with loss of electrical response, surgical exploration
should be done.
 24) Reconstruction operations of the ear – Tympanoplasty
• A tympanoplasty is a surgical procedure that repairs or reconstructs the eardrum (tympanic
membrane) to help restore normal hearing.
• This procedure may also involve repair or reconstruction of the small bones behind the tympanic
membrane (ossiculoplasty) if needed.
• Both the eardrum and middle ear bones (ossicles) need to function well together for normal
hearing to occur.
25) Complications of middle ear infection
• ACUTE SUPPURATIVE OTITIS MEDIA - presence of purulent fluid in the middle ear
• ACUTE NECROTIZING OTITIS MEDIA - severe invasive infection of the tympanic cavity which
can spread rapidly to involve the surrounding soft tissue, adjacent neck spaces and skull base
• OTITIS MEDIA WITH EFFUSION - collection of non-infected fluid in the middle ear space
• RECURRENT ACUTE OTITIS MEDIA - having at least 3 episodes of acute otitis media in a
period of 6 months, or four or more episodes in 12 months.
• AERO-OTITIS MEDIA (OTITIC BAROTRAUMA) - ear pain or damage to the tympanic membrane
caused by rapid changes in pressure

26) Intracranial Complications

Intracranial complications of diseases of the ear, nose or throat are not common, but pose a significant risk if they
are not recognised and treated urgently. The most common presentations are meningitis or intracranial suppuration
secondary to an infection from the ears or paranasal sinuses.
1. Meningitis
2. Osteomyelitis
3. Brain abscess, subdural and extradural abscess
4. Sinus thrombosis
5. Cystic arachnoiditis
6. Intranasal encephalomeningocele
7. Cerebrospinal rhinorrhea and repair of dural defects

27) Facial palsy

• Fractures of temporal bone may be longitudinal, transverse or mixed.
• Facial palsy is seen more often in transverse fractures (50%).
• Paralysis is due to intraneural haematoma, compression by a bony spicule or transection of
nerve. In these cases, it is important to know whether paralysis was of immediate or delayed
onset. Delayed onset paralysis is treated conservatively like Bell’s palsy while immediate onset
paralysis may require surgery in the form of decompression, re-anastomosis of cut ends or cable
nerve graft.
(A) Longitudinal fracture runs along the axis of petrous pyramid. Typically, it starts at squamous part of temporal
bone, runs through roof of external ear canal and middle ear towards the petrous apex, and to foramen lacerum.

(B) Transverse fracture. It runs across the axis of petrous. Typically, it begins at foramen magnum, passes through
occipital bone, jugular fossa, petrous pyramid ending in middle cranial fossa. It may pass medial, lateral or through
the labyrinth.
Facial nerve is injured during stapedectomy, tympanoplasty or mastoid surgery. Paralysis may be immediate or
delayed and treatment is the same as in temporal bone trauma.

28) Meniere,s disease

Meniere’s disease is a disorder that affects the inner ear. The inner ear is responsible for hearing and balance. The
condition causes vertigo. It also leads to hearing problems and a ringing sound in the ear. Meniere’s disease usually
affects only one ear.
The cause of Meniere’s disease isn’t known, but scientists believe it’s caused by changes in the fluid in tubes of
the inner ear. Other suggested causes include autoimmune disease, allergies, and genetics
Factors that affect the fluid, which might contribute to Meniere's disease, include:

• Improper fluid drainage, perhaps because of a blockage or anatomic abnormality

• Abnormal immune response
• Viral infection
• Genetic predisposition

29) Tinnitus
Tinnitus is a common condition in which sound (whistling, hissing, buzzing, ringing, pulsating) is perceived in the
absence of an external source. It can be unilateral or bilateral, acute or chronic, and intermittent or constant.
Patients should also undergo a complete audiological examination. Imaging is recommended for patients with
unilateral tinnitus, asymmetric tinnitus, pulsatile tinnitus, and/or focal neurological deficits.

• More common in men and smokers

• Tinnitus is a symptom, not a specific disease
• Objective tinnitus: tinnitus that can perceived by others
• Subjective tinnitus: tinnitus that is only perceived by the affected individual

TREATMENT:
Treat any underlying conditions.
30) The auricular and ear wax
• Wax is composed of secretion of sebaceous glands, ceruminous glands, hair, desquamated epithelial
debris, keratin and dirt.
• Wax has a protective function as it lubricates the ear canal and entraps any foreign material that happens
to enter the canal. It has acidic pH and is bacteriostatic and fungistatic.
• Normally, only a small amount of wax is secreted, which dries up and is later expelled from the meatus by
movements of the jaw. As some people sweat more than others, the activity of ceruminous glands also
varies; excessive wax may be secreted and deposited as a plug in the meatus. It may dry up and form a
hard impacted mass.
• Patient usually presents with impairment of hearing or sense of blocked ear. Tinnitus and giddiness may
result from impaction of wax against the tympanic membrane.
Treatment of wax consists in its removal by syringing or instrumental manipulation. Hard impacted
mass may sometimes require prior softening with wax solvents.

31) Otological trauma and foreign bodies

Trauma to the auricle:
a) Hematoma of the auricle: It is collection of blood between the auricular cartilage and its perichondrium.
b) Lacerations: The perichondrium is stitched with absorbable sutures.
c) Avulsions of the pinna: Auricular avulsion injuries were defined as cases involving the complete or partial
separation of a segment of the auricle due to mechanical trauma
d) Frostbite
e) Keloid of auricle: It may follow trauma or piercing of the ear for ornaments.
Trauma to the ear canal:
a) Minor lacerations: Results from Q-tip injury or unskilled instrumentation by the physician.
b) Major lacerations: Result from gunshot wounds, automobile accidents or fights.
Foreign bodies:
(a) Nonliving: In children; the common ones often seen are: a piece of paper or sponge, grain seeds, slate
pencil, piece of chalk or metallic ball bearings. Adult; broken end of matchstick or cotton swab.

(b) Living: Flying or crawling insects

NOSE
32) Nose anatomy and Physiology

• The nose contains the human olfactory system, which is responsible for the sense of smell.
• The nasal cavity assists in respiration, olfaction, conditioning of inspired air, and immune defense

• The nose and paranasal sinuses fulfill the following functions:

o Help provide resonance to the voice
o Warm and humidify air that is inhaled
o Are part of the mucosal immune system

Bones
• Frontal, ethmoid, maxilla, nasal, palatine, sphenoid, vomer

Boundaries
• Roof: composed of the nasal, frontal, cribriform plate (ethmoid), and sphenoid bone
• Floor
o Composed of the maxilla (palatine process) and the palatine bone (horizontal plate)
o Transmits branches of the sphenopalatine artery and the nasopalatine nerve through
the incisive foramen
• Medial wall (nasal septum): composed of septal cartilage, the vomer, and the perpendicular plate of
the ethmoid bone
 • Lateral wall: composed of the nasal bone, lacrimal bone, medial pterygoid plate of the sphenoid bone,
perpendicular plate of the palatine bone, frontal process of the maxilla, nasal surface of the maxilla, and
the inferior, middle, and superior meatus

33) Nose- Vascular and nerve supply

• Innervation - trigeminal nerve - sensory innervation
facial nerve - motor innervation
• Blood supply
o Int carotid artery (ant and post ethmoidal arteries- ophthalmic arteries)
o Ext carotid artery (greater palatine artery,sphenopalatine artery, superior labial artery and
lateral nasal arteries)
• Venous drainage: Pterygoid plexus, facial vein

34) The paranasal sinuses - anatomy and Physiology

Anatomy

• The paranasal sinuses are air-filled extensions of the nasal cavity. There are four paired sinuses –
maxillary, frontal, sphenoid and ethmoid.
• Each sinus is lined by a ciliated pseudostratified epithelium, interspersed with mucus-secreting goblet cells.
• Nerve supply
o Maxillary sinuses – maxillary nerve
o Frontal sinuses - Ophthalmic nerve
o Ethmoidal sinuses – ethmoidal nerves
o Sphenoidal sinuses - ophthalmic and maxillary nerve
• Blood supply- internal and external carotid arteries
Physiology
Functions:

• Air-conditioning of the inspired air by providing large surface area over which the air is humidified and
warmed.
• To provide resonance to voice.
• To act as thermal insulators to protect the delicate structures in the orbit and the cranium from variations of
intranasal temperature.
• To provide local immunologic defense against microbes

35) Nose and paranasal sinuses – symptoms, sings and investigations AND
36) Nose and paranasal sinuses- investigations
Nose
• Symptoms: nasal congestion, runny nose
 • Investigations: Using thin, flexible nasal endoscope to look at the nasal passages, CT scan, nasal swab for
culture
Paranasal Sinuses
• Symptoms: sinus pressure, Headaches or pain in the sinus areas, runny nose
• Investigation:CT scan

37) Nasal polyps

• Nasal polyps (NP) are noncancerous growths within the nose or sinuses.
• Symptoms include trouble breathing through the nose, loss of smell, decreased taste, post nasal
drip, and a runny nose.
• The growths are sac-like, movable, and nontender, though face pain may occasionally occur.
• They typically occur in both nostrils in those who are affected.
• Complications may include sinusitis and broadening of the nose

38) Allergic and Vasomotor rhinitis

Rhinitis is the irritation and swelling of the mucous membrane of the nose.
ALLERGIC RHINITIS
• acute or chronic rhinitis caused by exposure to an inhaled allergen (e.g., dust, animal dander, mold spores,
plant pollen). Most common form of rhinitis.
• Signs and symptoms include a runny or stuffy nose, sneezing, red, itchy, and watery eyes, and swelling
around the eyes.The fluid from the nose is usually clear. Symptom onset is often within minutes following
allergen exposure, and can affect sleep and the ability to work or study.

VASOMOTOR RHINITIS
• a type of nonallergic rhinitis that is caused by an increase in blood flow to the nasal mucosa.

Etiology
• Most often idiopathic
• Irritant odors; (e.g., cigarette smoke, perfumes, car exhaust)
• Temperature change (e.g., cold and dry air, changes in humidity)
• Certain drugs (e.g., aspirin, NSAIDs, alpha-1 blockers, beta blocker, Oral contraceptives (OCPs))
• Emotional stimuli (e.g., anxiety, excitement)

39) Nasal foreign bodies

• Nasal foreign bodies are found occasionally in young children, the intellectually impaired, and
psychiatric patients. Common objects pushed into the nose include cotton, paper, pebbles,
beads, beans, seeds, nuts, insects, and button batteries (which may cause chemical burns).
• A nasal foreign body is suspected in any patient with a unilateral, foul-smelling, bloody, purulent
rhinorrhea.
• Types of objects:
✓ Nonirritating type. Plastic, glass or metallic foreign bodies are relatively
nonirritating and may remain symptomless for a long time.
✓ Irritating type. Vegetable or foreign bodies like peanuts, beans, seeds, etc. set
up a diffuse violent reaction leading to congestion
 • Laboratory evaluation is usually unnecessary. However, in the case of animate objects, the white
blood cell count might be increased.

• Imaging may be needed for suspicion of battery or magnet if suspected or poorly visualized.

40) nasal vestibulitis

• It is diffuse dermatitis of nasal vestibule. Nasal discharge is the predisposing factor. The causative
organism is S. aureus.
• Vestibulitis may be acute or chronic.
• In acute form, vestibular skin is red, swollen and tender; crusts and scales cover an area of skin
erosion or excoriation.
• In chronic form, there is induration of vestibular skin with painful fissures and crusting.
• Treatment consists of cleaning the nasal vestibule of all crusts and scales with cotton applicator
soaked in hydrogen peroxide and application of antibiotic-steroid ointment.

41) atrophic rhinitis

• Atrophic Rhinitis also called as Ozaena, it is a chronic inflammation of nose characterized by
atrophy of nasal mucosa including the glands, turbinate bones, and the nerve elements supplying
the nose.
• Ciliated columnar epithelium of the nasal mucosa is replaced by stratified squamous epithelium.
Atrophy of mucosa, turbinal bones, seromucinous glands tend to occur. This is due to obliterative
endarteritis causing decreased blood supply hence the supplying area atrophy.

42) Nasal furunculosis

• Nasal vestibular is a bacterial infection which occurs in the vestibule of nose. When hair follicle is
involved in the infection, then it is termed as nasal vestibular furunculosis.
• Cause-Staphylococcus aureus
• The common symptoms of nasal vestibular furunculosis are:
o Inflammation of nostril
o localized redness
o severe pain accompanying inflammation
o pain also occurs on the skin covering nasal vestibule.
o Redness occurs according to the area involved because it is a localized infection.

43) Nasal septal pathologies and choanal atresia

a. nasal septal pathologies
• deviated nasal septum
• fracture of nasal septum
• septal hematoma
• septal abscess
• septal perforation
 • nasal synechia
b. choanal atresia

• Choanal atresia is a condition in which nasal tissue blocks the nasal airway makes difficulty in breathing.
• Choanal atresia can affect one or both sides of your nose, and the blockage may be made completely of
bone or a combination of bone and soft tissue.
• The condition is congenital.
• With unilateral choanal atresia symptoms can go unnoticed and surface later in adulthood.
• Bilateral choanal atresia is often recognized and treated at birth

44) Facial Trauma

• It is an injury of the face including bones such as maxilla. Also known as maxillofacial injury.
• Facial injury can affect the upper jaw, lower jaw, cheek, nose, eye socket or forehead. Causes
can be blunt force or wound.
• Symptoms may include changes in feeling over the face, double vision, difficulty breathing,
swelling.
• Diagnosis- Exams and test to be performed which may show nasal blockage, changes in vision,
improper aligned upper and lower teeth. A CT may be done.
• Treatment is surgery. Complication can be uneven face, bleeding, infection, nervous system
problems, loss or double vision.

45) Epistaxis
 Bleeding from inside the nose is called epistaxis.
 It is fairly common and is seen in all age groups—children, adults and older people.
 It often presents as an emergency.
 They may be divided into:
o Local, in the nose or nasopharynx.
o General (CVS, disorders of blood and blood vessels, liver disease, etc.)
o Idiopathic.
 Classification of epistaxis:
Anterior epistaxis: When blood flows out from the front of nose with the patient in sitting position.
Posterior epistaxis: Mostly from posterosuperior part of nasal cavity; often difficult to localize the
bleeding point

46) Acute and chronic sinusitis

ACUTE SINUSITIS

• Acute inflammation of sinus mucosa

• Less than 4 weeks
• 4-12 weeks – subacute sinusitis
 • Sinusitis may be “open” or “closed” type depending on whether the inflammatory products of sinus cavity
can drain freely into the nasal cavity through the natural ostia or not. A “closed” sinusitis causes more
severe symptoms and is also likely to cause complications.
• Causes
o EXCITING CAUSES:
▪ Nasal infections
▪ Swimming and diving
▪ Trauma
▪ Dental infections
o PRE-DISPOSING CAUSES:
▪ Obstruction to sinus ventilation and drainage
▪ Stasis of secretions in the nasal cavity
▪ Previous attacks of sinusitis
• Clinical features: Headache, Pain, Tenderness, Redness and oedema of cheek, Nasal discharge
• Diagnosis: Transillumination test and X-rays
• Treatment:
o Medical: Antimicrobial drugs, Nasal decongestant drops, Steam inhalation, Analgesics
o Surgical: Antral lavage.

CHRONIC SINUSITIS

• Sinus infection lasting for months or years (More than 12 weeks) is called chronic sinusitis. Most
important cause of chronic sinusitis is failure of acute infection to resolve. Persistence of infection causes
mucosal changes, such as loss of cilia, oedema and polyp formation
• Symptoms-. Purulent nasal discharge is the most common complaint. Foul-smelling discharge suggests
anaerobic infection. Some patients complain of nasal stuffiness and anosmia.
• Diagnosis- X-ray of the involved sinus may show mucosal thickening or opacity.
• Treatment-Culture and sensitivity of sinus discharge helps in the proper selection of an antibiotic.
Initial treatment of chronic sinusitis is conservative, including antibiotics, decongestants, antihistamines
and sinus irrigation.

THROAT

47) Pharynx anatomy and physiology

 Pharynx is a conical fibromuscular tube forming upper part of the air and food passages.
 It is 12–14 cm long, extending from base of the skull (basiocciput and basisphenoid) to the lower
border of cricoid cartilage where it becomes continuous with the oesophagus.
 Anatomically, pharynx is divided into three parts
o Nasopharynx
o Oropharynx
o Hypopharynx or laryngopharynx.
 From inside-outside, Pharyngeal wall consists of four layers:
 o Mucous membrane
o Pharyngeal aponeurosis (pharyngobasilar fascia)
o Muscular coat:
It consists of two layers of muscles with three muscles in each layer:
(a) External layer. It contains superior, middle and inferior constrictor muscles.
(b) Internal layer. It contains stylopharyngeus, salpingopharyngeus and
palatopharyngeus muscles.
o Buccopharyngeal fascia

 Functions of pharynx: deglutition, respiration, vocal resonance, secretion of mucus by mucous

membrane to lubricate the pharynx and provides drainage to nose, oral cavity and middle ear.

48) Larynx anatomy and physiology

• Aka voice box
• larynx is a part which is responsible for air conduction, voice protective, function -Connects the
pharynx with trachea
• The skeletal framework compromises the hyoid bone, 3 paired and unpaired cartilages
o Unpaired cartilages -epiglottis, thyroid and cricoid
o Paired - arytenoid, cuneiform and corniculate
• The movements of the laryngeal skeleton open and close the glottis and regulate the degree of
tension in the vocal folds. When air passes through the folds, they produce sound. Tension levels
control pitch and volume.
• The laryngeal muscles are a set of muscles in the anterior neck responsible for sound production. The
intrinsic muscles of the larynx function to move the vocal cartilages and control tension. They are
innervated by the vagus nerve.
• Vascular supply: superior laryngeal artery <branch of superior thyroid artery>, inferior laryngeal
artery <branch of thyrocervical trunk>
• Venous drainage: superior and inferior laryngeal veins
• Innervation: motor and sensory from branches of vagus nerve <superior laryngeal nerve and
recurrent laryngeal nerve>

49) The throat symptoms, sings and investigations

Symptoms and signs

• People with a throat infection have severe pain with swallowing and usually speaking.
• The pain is sometimes also felt in the ears. Some people have fever, headache, and an upset stomach.
• The tonsils are red and swollen (viral) and sometimes have white patches (bacterial) on them.
• Lymph nodes in the neck may become swollen and tender.
 • In people who have frequent tonsil infections, the normal small pits in the tonsils sometimes become
filled with white, hardened secretions that resemble tiny stones.

Investigations

 Using a lighted instrument to look at the throat, and likely the ears and nasal passages
 Gently feeling the neck to check for swollen glands (lymph nodes)
 Listening to your or your child's breathing with a stethoscope
 Throat swab for any bacterial growth.

50) Tracheotomy
 A tracheotomy is a surgical procedure in which an incision is made in the front of the neck and a
breathing tube is placed into the trachea.
 The main indications of tracheostomy
❖ Obstruction of the upper airway, eg foreign body, trauma, infection, laryngeal tumour, facial
fractures.
❖ Impaired respiratory function, eg head trauma leading to unconsciousness, bulbar
poliomyelitis.
❖ To assist weaning from ventilatory support in patients on intensive care.
❖ To help clear secretions in the upper airway.
 Types of tracheostomy:
1- Upper tracheostomy; (In the 1st and 2nd tracheal rings above the isthmus of the thyroid
gland)
2- Middle tracheostorny; (In the 3rd and 4th trachea rings behind the isthmus (operation of
choice).
3- Inferior tracheostomy (in the 5th and 6th rings below the isthmus.)

51) Stridor
Stridor is noisy respiration produced by turbulent airflow through the narrowed air passages and may be heard
during inspiration, expiration or both. Stridor may arise from lesions of nose, tongue, mandible, pharynx, larynx or
trachea and bronchi. Stridor is always associated with respiratory distress. 3 types:
• Inspiratory stridor suggests a laryngeal obstruction
• Expiratory stridor implies tracheobronchial obstruction
• Biphasic stridor suggests a subglottic or glottic anomaly
Associated characteristics of stridor.

• Snoring or snorting sound—nasal or nasopharyngeal cause.

• Gurgling sound and muffled voice—pharyngeal cause.
• Hoarse cry or voice—laryngeal cause at vocal cords. Cry is normal in laryngomalacia and subglottic
stenosis.
• Expiratory wheeze—bronchial obstruction.
Microlaryngoscopy can be done without intubation with patient on spontaneous breathing and oxygen and gases
being delivered through a catheter via the laryngoscopy.

52) Laryngotracheal Injury

 1.Most common cause is automobile accidents when neck strikes against the steering wheel
or the instrument panel.
2. Blow or kick on the neck.
3. Neck striking against a stretched wire or cable.
4. Strangulation.
5. Penetrating injuries with sharp instruments or gunshot wounds.
The degree and severity of damage will vary from slight bruises externally or the tear and laceration of
mucosa internally to a comminuted fracture of the laryngeal framework. The wound may be compounded
externally due to break in the skin or internally by mucosal tears. Laryngeal fractures are common after 40
years of age because of calcification of the laryngeal framework. In children, cartilages are more resilient
and escape injury.

Symptoms of laryngotracheal injury would vary, greatly depending on the structures damaged and the
severity of damage. They include:
1. Respiratory distress.
2. Hoarseness of voice or aphonia.
3. Painful and difficult swallowing. This is accompanied by aspiration of food.
4. Local pain in the larynx. More marked on speaking or swallowing.
5. Haemoptysis, usually the result of tears in laryngeal or tracheal mucosa.

External signs include:

1. Bruises or abrasions over the skin.
2. Palpation of the laryngeal area is painful.
3. Subcutaneous emphysema due to mucosal tears. It may increase on coughing.
4. Flattening of thyroid prominence and contour of anterior cervical region. Thyroid notch may
not be palpable.
5. Fracture displacements of thyroid or cricoid cartilage or hyoid bone. Gap may be felt between
the fractured fragments.
6. Bony crepitus between fragments of hyoid bone, thyroid or cricoid cartilages may sometimes
be elicited.
7. Separation of cricoid cartilage from larynx or trachea.

53) Maintenance and protection of the airway

 Airway management is the practice of evaluating, planning, and using a wide array of medical
procedures and devices for the purpose of maintaining or restoring a safe, effective pathway for
oxygenation and ventilation.

 For patients with airway obstruction, respiratory failure, or a need for airway protection (eg, for
general anesthesia or due to an aspiration risk).

 Basic airway maneuvers are the most important first step and consist primarily of positioning,
supplemental oxygen, and bag mask ventilation with or without adjuncts. Patients with serious or
persistent airway compromise typically require advanced airway devices, which consist of
supraglottic devices, endotracheal tubes, and surgical airway devices.

 In endotracheal intubation, a tube is inserted orally (or nasally) into the trachea to allow gas
exchange, often via mechanical ventilation. The tube can be placed under direct visualization with
 the help of a laryngoscope or with video-assisted laryngoscopy. Correct placement is established
based on multiple measurements, including exhaled CO₂ and evidence of bilateral breath sounds
on auscultation. Common complications of endotracheal intubation include hypoxia, hypotension,
airway trauma, accidental esophageal intubation, and aspiration.

 Surgical airways may be performed in an emergency, particularly as part of a cannot intubate,

cannot ventilate (CICV) scenario, or placed for long-term mechanical ventilation. Patients with
surgical airways are vulnerable to a sudden loss of the airway due to displacement or blockage of
the tubes with secretions.

54) sore throats

Sore throat, also known as throat pain, is pain or irritation of the throat. Usually, causes of sore throat include

• viral infections,
• group A streptococcal infection (GAS) bacterial infection,
• pharyngitis (inflammation of the throat),
• tonsillitis (inflammation of the tonsils),
• dehydration, which leads to the throat drying up.
•

55) Tonsillectomy
Tonsillectomy is the surgical removal of the tonsils
They are divided into:
A. ABSOLUTE
1. Recurrent infections of throat. This is the most common indication.
(a)Seven or more episodes in 1 year, or
(b) Five episodes per year for 2 years, or
(c) Three episodes per year for 3 years, or
(d) Two weeks or more of lost school or work in 1 year
2. Peritonsillar abscess.
3. Tonsillitis. It causes febrile seizures.
4. Hypertrophy of tonsils. It causes airway obstruction, difficulty in deglutition and speech interference
5. Suspicion of malignancy
B. RELATIVE
1. Diphtheria carriers, who do not respond to antibiotics.
2. Streptococcal carriers, who may be the source of infection to others.

C. AS A PART OF ANOTHER OPERATION

• Usually done under general anaesthesia with endotracheal intubation. In adults, it may be done under local
anaesthesia.
• Rose’s position, i.e. patient lies supine with head extended by placing a pillow under the shoulders. A
rubber ring is placed under the head to stabilize it. Hyperextension should always be avoided.
STEPS
1. Boyle–Davis mouth gag is introduced and opened. It is held in place by Draffin’s bipods or a string over a
pulley
2. Tonsil is grasped with tonsil-holding forceps and pulled medially.
3. Incision is made in the mucous membrane
4. A blunt curved scissor may be used to dissect the tonsil from the peritonsillar tissue
5. Wire loop of tonsillar snare is threaded over the tonsil, tightened, and the pedicle cut and the tonsil removed.
6. A gauze sponge is placed in the fossa and pressure for a few minutes.
7. Bleeding points are tied with silk. Procedure is repeated on the other side.

56) Adenoidal condition

• Adenoiditis is inflammation and enlargement of the adenoid tissues which is accompanied by
breathing difficulty and recurrent respiratory infections
• This condition is most commonly seen in children before puberty
• Found behind the nasal cavity and above the roof of oral cavity
• Symptoms: sore throat, stuffy nose , swollen glands in neck, ear pain, speaking with nasal sound,
difficult sleeping
• Tx: antibiotics, adenoidectomy

57) Snoring and Sleep apnea

• Snoring: It is an undesirable disturbing sound that occurs during sleep.
• Sites of snoring may be soft palate, tonsillar pillars or hypopharynx (laryngopharynx).
• It is estimated that 25% of adult males and 15% of adult females snore. Its prevalence increases with age.
• Snoring may be primary, i.e. without association with obstructive sleep apnoea (OSA) or complicated, i.e.
associated with OSA.
• Sleep apnoea. It is cessation of breathing that lasts for 10s or more during sleep. Less than five such
episodes is normal.