MEE

My PG
Notes

Spaces

Acute and Chronic Inflammation of Larynx

/e
ACUTE LARYNGITIS
• May be infectious [starts as viral → 2o bacterial infection] or non-infectious [due to vocal abuse, allergy,

,1
laryngeal burns or trauma]
• Hoarseness, throat pain and dry irritating cough are present

es
• Treatment includes Vocal rest + anti allergic + antibiotic + analgesic
ACUTE EPIGLOTTITIS/SUPRAGLOTTIC LARYNGITIS ot
• Acute inflammation of supraglottic structures [epiglottis, aryepiglottic folds
and arytenoids]
N
• Acute epiglottitis is most commonly caused by Staphylococcus > H.Influenzae;
‘thumb sign’ on Xray lateral view
EE

• Immediate hospitalisation required as danger of respiratory obstruction

present
• Tracheostomy may be required
M

• Antibiotics + steroids + adequate hydration given

ACUTE LARYNGOTRACHEOBRONCHITIS/CROUP
PG

• Croup is most commonly caused by Parainfluenza I and II

• ‘barking seal’ like cough present
• ‘steeple sign’ on AP view
• hospitalisation required because of respiratory difficulty
y

• Antibiotics[Ampicillin 50mg/kg/day in divided doses for 2o infections] +

M

humidification + parenteral fluids

LARYNGEAL DIPHTHERIA
• Occurs 2o to Faucial diphtheria [Fauces are spaces between soft palate and base of tongue] in <10 yr old
children
• Tough pseudomembrane is formed over larynx + trachea → completely obstructs airway
• Diagnosis is clinical → confirmed by smear and culture
ENT

• Treated with Diphtheria anti-toxin + anti-bacterials

EDEMA OF LARYNX/ EDEMA GLOTTIDIS
• Involves loose mucosa of supra and sub-glottic region
• Caused due to infections,trauma, cancers, allergy, radiation and systemic diseases
• Treatment includes treating the cause
612

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CHRONIC HYPEREMIC LARYNGITIS/ CHRONIC LARYNGITIS WITHOUT HYPERPLASIA

• Symmetrically involves whole of Larynx
• May occur as a sequelae of infections of larynx or PNS or occupational factors
• Hoarseness + constant hawking is seen
• Hyperemia of laryngeal structures on laryngeal examination
• Treatment includes treat the cause + voice rest + steam inhalation
CHRONIC HYPERTROPHIC LARYNGITIS/ CHRONIC HYPERPLASTIC LARYNGITIS
• May occur as a diffuse and symmetrical process or May occur as a localised process which may present as
vocal nodule, vocal polyp, Reinke’s edema and contact ulcer

PACHYDERMA LARYNGITIS
• Characterstic feature is presence of heaped up reddish granulation tissue in the region of interarytenoids
and posterior part of vocal cords and presence of contact ulcer in vocal cords.
• Treatment is microscopy aided removal of granulation tissue + control of acid reflux + Speech therapy

/e
ATROPHIC LARYNGITIS/LARYNGITIS SICCA
• Atrophy + foul smelling crust formation in laryngeal mucosa

,1
• Treatment – treat the cause + laryngeal sprays with glucose + glycerine
TUBERCULOSIS OF LARYNX

es
• MC ENT manifestation → cervical lymphadenopathy
• MC site → posterior commissure
• MC symptom → weakness of voice
ot
• Impaired adduction of cords
N
• Mouse nibbled ulceration of vocal cord
• Pseudoedema of epiglottis → TURBAN EPIGLOTTIS [Turban tumor → Cutaneous cylindrinoma]
• Treated with anti-Tubercular drugs
EE

LUPUS LARYNX
• Involves anterior larynx (TB involves posterior structures)
M

• Epiglottis is the first structure to get involved (may be destroyed fully)

• Mamillated appearance of interarytenoid region is seen
PG

• Painless and usually asymptomatic

• Treated with anti-Tubercular drugs
SYPHILIS OF LARYNX
• Seen only in3o stage of syphilis
y

LEPROSY OF LARYNX
M

• Rare condition associated with leprosy of nose and skin

SCLEROMA OF LARYNX
• Chronic inflammatory disease caused by Klebsiella rhinoscleromatis
• Nasal involvement is common
• Treated with tetracycline + streptomycin + Steroids (to prevent fibrosis)
LARYNGEAL MYCOSIS
• Caused by Blastomycosis, Candidiasis or Histoplasma
ENT

613

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Notes

CONGENITAL LESIONS OF LARYNX

LARYNGOMALACIA
• Laryngomalacia is the most common congenital anomaly of larynx
• Omega shaped epiglottis
• Presence of stridor that increases on crying but decreasing when put on prone
• Conservative treatment
CONGENITAL VOCAL CORD PARALYSIS- occurs as a result of birth trauma
CONGENITAL SUBGLOTTIC STENOSIS
• Occurs due to abnormal thickening of Cricoid cartilage
• Cry is Normal
• Diagnosis made when subglottic diameter is <4mm in full term neonate or <3mm in premature neonate
• MC Caffey’s classification and Cotton Meyer Classification is used
• Treatment conservative → no recovery → surgery (excision + reanastomoses)
LARYNGEAL WEB

/e
• Due to incomplete recanalisation of larynx
• Mostly seen in Vocal cords

,1
• Can be cut with a CO2 laser or knife
• COHN’S classification is used

es
SUBGLOTTIC HEMANGIOMA
• 50% have associated cutaneous hemangiomas ot
• Asymptomatic till 3-6 months
• Stridor + normal cry
N
• Treated with: tracheostomy + observation or steroid therapy or CO2 laser according to the case
LARYNGOCELE-dilation of laryngeal saccule,may be internal, external or both
EE

LARYNGEAL CYST- bluish fluid filled smooth swelling in supragllotic larynx, treated with needle aspiration.
LARYGOESOPHAGEAL CLEFT- failure of fusion of cricoids lamina
M

Stridor
PG
y
M
ENT

614

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Notes

Laryngeal Paralysis
zz Semon’s law: in all organic lesions, abductor fibres are more susceptible and paralyzed earlier
than the adductors
zz Wagner and Grossman hypothesis: Cricothyroid receives innervations from SLN, keeps the vocal
cord in paramedian position
U/L RLN PARALYSIS
• 1/3 patients asymptomatic
• voice gradually improves due to compensation by the other cord
• no treatment required
B/L RLN PARALYSIS
• Caused by surgical trauma or Neuritis
• Both cords lie in median/paramedian position
• Inadequate airway thus stridor present and voice is good

/e
• Treatment is tracheostomy and lateralisation of cord
U/L SLN PARALYSIS

,1
• Isolated lesions rare
• SLN # → cricothyroid paralysis

es
• Weak voice + pitch cannot be raised
• Shortening of cord with loss of tension ot
B/L SLN PARALYSIS
• Inhalation of food particles due to anaesthesia + paralysis → choking fits + cough
N
• Neuritis may recover spontaneously
• Repeated aspiration may need cuffed tracheostomy
EE

U/L COMBINED RLN+SLN PARALYSIS

• MCC thyroid surgery
• Vocal cord lie in cadaveric position[3.5 mm from midline]
M

• Hoarseness + aspiration +
• Treatment is speech therapy + medialisation of cord
PG

B/L COMBINED RLN+SLN PARALYSIS

• Rare condition
• Total anaesthesia + paralysis
y

• Cant cough + aphonia + aspiration + recurrent aspiration leading to bronchopneumonia

M

• Treatment options are tracheostomy / Epiglottoplexy/ Vocal cord plication / diversion

procedures

Thyroplasty

4 TYPES
• Type I: MEdialization
ENT

• Type II: LA teralization

• Type III: SHOrtening, relaxation (lower pitch)
• Type IV: LEngthening, tension (raise pitch)

615

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Notes

Tumors of Larynx

BENIGN
VOCAL NODULES/ • Occur symmetrically in junction of ant1/3 and post2/3 [2018]
SINGER’S NODULE/ • Hoarseness + pain in neck + vocal fatigue
SCREAMER’S NODULE • Treatment is Speech therapy + voice rest + analgesics
VOCAL POLYP • Typically is unilateral
• Mostly in men of 30-50 year age
• Hoarseness + dyspnoea + stridor
• Treatment is Speech therapy + voice rest + analgesics
REINKE’S EDEMA • Cause may be vocal abuse or smoking
• Due to collection of fluid in subepithelial space of Reike
• Treatment is vocal cord stripping + allowing it to re epithelise
CONTACT ULCER • May occur due to faulty voice production or gastric reflux

/e
• U/L or B/L ulcer with congestion of arytenoids
INTUBATION • Due to rough intubation

,1
GRANULOMA • Mucosal ulceration → granuloma formation
• Treatment is voice rest + granuloma removal endoscopically

es
LEUKOPLAKIA/ • White plaque or warty growth on vocal cords
KERATOSIS • Precancerous condition
• Treatment is stripping the vocal cord + histopath examination of removed
ot
sample
LARYNGOCELE • Air filled cystic swelling due to dilation of saccule
N
• Marsupialisation of internal laryngocele is done
MALIGNANT
EE

JUVENILE PAPILLOMA • Viral in origin and multiple (Juvenile love to play together)
• Glistening white irregular growth, easily bleed
• Recurr after removal
M

ADULT ONSET • Viral in origin and single (Adults prefer to stay alone)
PG

PAPILLOMA • Less aggressive

• Does not recur after removal
CHONDROMA • Arise from Cricoid cartilage
• Mostly affects men of 40-60 year age group
y

GRANULAR CELL TUMOR • Arises from SCHWANN cell and is submucosal

M

Carcinoma Larynx
zz MC site- Glottis (59%)
zz MC type- squamous cell carcinoma
zz MC predisposing factor-Smoking
zz Treatment of Glottic ca → Radiotherapy
ENT

zz SUPRAGLOTTIC Ca-
ƒƒ MC part involved in supraglottic Ca → Epiglottis>false vocal cord
ƒƒ Pain on swallowing is most frequent initial symptom
ƒƒ Large tumors → HOT POTATO/ Muffled voice
zz Treatment of Supraglottic/subglottic Ca → Surgery
616
zz Stroboscopy and Toluene Blue dye can be used to differentiate b/w benign and Malignant
zz All glottic cancers are mostly Radiosensitive
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Treatment of Laryngeal Cancer

Tis→Microlaryngeal stripping with CO2 laser

GLOTTIC SUBGLOTTIC SUPRAGLOTTIC

T1→RT T1-T2→RT T1→Radiation/CO2 laser
T2→Partial Laryngectomy T3-T4→Total laryngectomy T2→Supraglottic laryngectomy
+ Post operative RT T3& T4→Total laryngectomy + Post operative RT
zz MC site of distant mets is lungs
zz MC complication of Tracheostomy- surgical emphysema
zz Electrolarynx → external hand held device which converts neck vibration to speech
zz Laryngeal carcinoma is the only indication of high tracheostomy[2018]
zz Blom singer prosthesis:
 Vocal rehabilitation after total laryngectomy
Life 2 years

/e


 1 way valve → allows air to go to esophagus from trachea but not vice versa

,1
 Surgically placed between trachea and esophagus

Voice and Speech Disorders

es
DYSPHONIA PLICA VENTRICULARIS
ot
• Faulty use of false vocal cord
N
• Seen in mimicry artists
• Treated with vocal rest and speech therapy
EE

HYSTERICAL APHONIA/FUNCTIONAL APHONIA

• Larynx normal but no voice • Psychogenic causes
• Seen in young females • Cough is normal
M

• Treatment is Psychotherapy
PG

PUBERPHONIA/ MUTATIONAL FALSETTO VOICE

• Child like voice at puberty → high pitch voice
• Seen in emotionally immature boys
• Treatment is training to produce low pitch voice
y

• Gutzman procedure- low pitch voice on pressing thyroid prominence

M

PHONESTHENIA
• Weakness of muscles causing vocal weakness
• Causes include weak thyroarytenoid/Interarytenoid/ both
• Treatment – wait and watch
ANDROPHONIA
• Male like voice in females
MOGIPHONIA
ENT

• Abnormal voice infront of Public

RHINOLELIA CLAUSA/HYPONASALITY
• Lack of nasal resonance for words due to blockage of nose or nasopharynx
RHINOLELIA APERTA/HYPERNASALITY
• Seen when words with little nasal resonance are resonated through nose due to abnormal communication
617
between nasal and oral cavities

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Notes

EAR

History
zz JULIUS LEMPERT: Father of Modern Otology
zz William House: Father of Neuro Otology
zz John shea: Performed 1st stapedectomy
zz Von Bekesy: gave wave travelling theory of sound

/e
,1
es
ot
N
EE
M
PG

Anatomy of External Ear

y
M

Nerve Supply of External auditory Canal

zz Anterior wall + roof → Auriculotemporal (V3)

zz Posterior wall and Floor → Auricular branch of
vagus(X)

Nerve of Tympanic Membrane

ENT

zz Anterior half of Lateral surface → auriculotemporal

(V3)
zz Posterior half of lateral surface → Auricular
Branch of Vagus(X)
618
zz Medial surface → Tympanic branch of Vagus
   Figure:  Nerve Supply of External Ear (Jacobson’s nerve)
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Notes

Anatomy of Middle Ear

Boundaries of Middle Ear

zz ANTERIOR- IT Fossa (Infratemporal fossa)

zz POSTERIOR- Mastoid Cavity
 Has a bony projection called PYRAMID
 Also has a Facial recess/Posterior recess lateral
to pyramid
zz MEDIAL WALL- Labyrinth
ff Promontory due to basal coil of Cochlea
ff Oval window[1.75mm x 3.25 mm] fixed
to footplate of Stapes
ff Round window is covered by secondary

/e
Tympanic membrane
zz LATERAL WALL-Tympanic membrane

,1
zz ROOF- Tegmen Tympani (Middle cranial Fossa)    Figure:  Division of Middle Ear

zz FLOOR- Jugular Bulb

es
Muscles of Middle Ear ot
Tensor tympani Stapedius
N
• Origin at cartilage of EAC + Sphenoid+Petrous • Pulls the stapes in posterior direction
temporal bone • Supplied by Facial nerve
EE

• Innervated by mandibular division of • Origin from pyramidal apex on posterior wall

Trigeminal and inserted in neck of stapes.
• Inserts into handle of malleus • Development completes by 20-22 weeks
M

Anatomy of Inner Ear

PG
y
M

ENT

619

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Notes

Three Walls of Cochlear Duct is Formed by

zz Basilar membrane → supports organ of corti

zz Reissner’s membrane → separates duct from scala vestibule
zz Stria vascularis → secretes Endolymph
 eNdoLymph rich in Potassium, has Natrium (Sodium) in Lesser concentration
 PeriLymph is rich in Natrium (Sodium), has Potassium in Lesser concentration
 Prussak’s space of middle ear
zz Above malleus and Below Epitympanum
zz MC site for Cholesteroma formation

Important Land Marks

Donaldson’s line Endolymphatic sac Decompression

/e
Facial recess Post tympanotomy
Mc Evan’s triangle/Suprameatal triangle Mastoid surgery

,1
Trautman’s triangle Posterior cranial fossa Tumor

es
Physiology of Hearing and Equilibrium ot
zz Total area of Tympanic Membrane- 90mm2
N
zz Effective area of Vibration – 55mm2
zz Areal ratio- 14:1/ 17:1
EE

zz Lever ratio- 1.3:1

zz Total trans. Ratio- 14 X 1.3 = 18:1
THIRD WINDOW EFFECT- Loss of sound by virtue of Fistula present on Promontory
M

zz
zz Round window is pressure releaser of Inner ear
PG
y
M
ENT

620
Figure:  Structure of organ of corti

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Peripheral Receptors

Crista

zz Present in ampulla of semicircular ducts

zz Respond to angular acceleration
zz Has Type I (Flask shaped) and Type-II (Cylindrical) cells

Maculae

zz Present in Otolith organ (Utricle and Saccule)

zz Respond to gravity and linear acceleration
zz Has TypeI and Type II cells and An Otolithic membrane consisting of Otoliths + Gelatinous
substance

/e
Hearing Loss

,1
Conductive Hearing Loss

HEARING LOSS IN LESIONS OF CONDUCTIVE APPARATUS

es
ot
Complete obstruction of ∑ar canal 30 dB [3 looks like mirror image of ∑]
N
Perforation of tympanic membrane 10-40 dB
Ossicular interruption with intact tympanic membrane 54 dB
EE

Ossicular interruption with perforation of tympanic membrane 38 dB

Malleus fixation 10 -25 dB
M

Closure of oval window 60 dB

PG

Management of Conductive Hearing Loss

zz Myringotomy: Incision over TM (in Serous otitis media andbulging tympanic membrane of ASOM)
zz Myringoplasty: Repair of tympanic membrane (with temporal fascia)
y

zz Ossiculoplasty: Reconstruction of ossicular chain

M

zz TymPANoplasty: Repair of TM and ossicles [PAN → all are repaired]

Wullstein’s Classification of Tympanoplasty

ENT

621

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Notes

Sensory Neural Hearing Loss [SNHL]

Etiology

zz Congenital → due to anomalies of inner ear or damage to hearing apparatus

zz Acquired[NO FAT IMP] → Noise-induced HL, Ototoxic Drugs, Famalial SNHL, Acoustic neuroma,
Trauma, Infections, Meniere’s disease, Presbycusis.
zz Diagnosis: by history, audiometric tests and Laboratory tests.
zz Treatment- treat the cause
zz Noise induced hearing loss
 A frequency of 2000-3000Hz can produce more damage than higher or lower frequencies
 Continuous noise is more harmful than interrupted noise

Presbycusis

/e
zz It is SNHL due to Physiological ageing process
It can be sensory/ neural/ strial or metabolic / Cochlear conductive

,1
zz

Sudden Snhl

es
zz >30 dB in any 3 frequencies for 3 days ot
zz Treatment- Start steroid + Carbogen (95% O2 + 5% CO2) / Hyperbaric O2
N
Degree of Hearing Loss
EE

MILD 26-40 Db
MODERATE 41-55 Db
M

MODERATELY SEVERE 56-70 Db

SEVERE 71-91 Db
PG

PROFOUND >91 Db

Assessment of Hearing
y
M

A.Clinical Tests of Hearing

FINGER FRICTION TEST • Rough but quick method
• Tubbing or clicking thumb and a finger close to ear of patient.
WATCH TEST • A clicking watch is used
• Obsolete now
SPEECH TEST Lack of standardisation is a big disadvantage thus not used
TUNING FORK RINNE TEST • To compare AC with BC of one ear
ENT

TESTS • AC>BC → RINNE(+) → Normal/SNHL

(Explained in • AC<BC → RINNE() → Conductive deafness
next page) • Positive Rinne indicates a minimum air-bone gap
of 15 dB for 256 Hz, 30dB for 512 Hz, 45 dB for
1024 Hz tuning fork.
622 Figure:  Barany’s box
• False negative Rinne → Severe SNHL
(correct diagnosis made by blocking other ear by BARANY’S box)
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TUNING FORK WEBER TEST • To compare BC of both ears

TESTS • Equally in both ears → Normal
• 512Hz tuning • Lateralised to worse ear → Conductive deafness in ipsilateral ear
fork is ideal • Lateralised to better ear → SNHL in contralateral ear
to test Air ABSOLUTE • A measure of Cochlear function.
conduction(AC) BONE • WITH MEATUS OCCLUDED, Patient’s and Examiner’s BC are compared
placed 2cm CONDUCTION • Both hear for same time → Conductive deafness
lateral to (ABC) TEST • Pt hears for shorter duration → SNHL
external SCHWABACH’S • SAME AS ABC test but meatus not occluded
auditory TEST • Shorter duration → SNHL
canal(EAC) • Longer duration → CD
• To test Bone BING TEST • Tests BC and effect of EAC occlusion on hearing
conduction • Hears louder when occluded and softer when open → SNHL(Bing +)
(BC) stem • NO change → CD(Bing negative)
of vibrating GELLE’S TEST • Test of BC and effect of ↑ pressure on hearing

/e
tuning fork • Uses Siegle’s Speculum to ↑ pressure
placed in • ↑ pressure → ↓hearing NORMAL/SNHL (TEST+)

,1
mastoid • ↑ pressure → No change → TEST() → Ossicular chain fixed/
process. disconnected

es
Audiometric Tests

PURE TONE AUDIOMETRY

ot
• Audiometer (produces Pure tones) is used
N
• Intensity can be↑/↓ in steps of 5Hz
• Threshold of BC → assesses cochlear function
EE

• A-B Gap → measure of degree of CD

• Uses:
ƒƒ Measures degree and type of hearing loss
M

ƒƒ Essential for prescription of hearing aid and to know degree of handicap for medicolegal purpose

SPEECH AUDIOMETRY
PG

• Measures Ability of patient to hear and understand speech

• Parameters used are:
ƒƒ Speech reception threshold(SRT) → minimum intensity at which 50% words are repeated correctly,
y

Normally it is within 10 dB for an average of 500, 1000 and 2000 Hz frequencies.

ƒƒ Speech discrimination score(SD score) →
M

ff Ability to understand speech and its relation to speech discrimination (SD) score
ff A list of 50 PB words is presented and the number correctly heard is multiplied by 2.

SD score Ability to understand speech

90-100% Normal
76-88% Slight difficulty
60-74% Moderate difficulty
40-58% Poor
ENT

<40% Very poor

• Rollover phenomenon- seen in Retrocochlear hearing Loss/neural patient → continuous stimulation of 8th
nerve causes fatiguability and nerve gets exhausted → cant sustain Plateau and falls down
• Uses:
ƒƒ To find SRT
623
ƒƒ Differentiate between organic and non organic cause of hearing loss

ƒƒ Differentiate between cochlear and retrocochlear disease

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IMPEDENCE AUDIOMETRY
• Objective test, particulary useful in Children
• Consists of:
ƒƒ Tympanometry
ff Based on principle that TM absorbs as well as reflects sound thus a stiffer Tm reflects more sound as
compared to a normal one.
ff Types of tympanogram

/e
,1
ƒƒ Acoustic reflex measurements
Based on principle that loud sound cause contraction of both stapedial muscles which is detected by

es
ƒƒ
tympanometry
ƒƒ Uses: ot
ff To test hearing in infants
ff To test Malingerers
N
ff To detect cochlear or 7th or 8th nerve pathology or brainstem pathology

BEKSEY AUDIOMETRY
EE

• Self recording audiometry with automatically ↑/↓ frequencies

• Not done nowadays
* High frequency audiometry is done for Ototoxicity
M

Special Tests for Hearing

PG

RECRUITMENT
• Phenomenon of abnormal growth of Loudness
y

• Thus a loud sound can becomes intolerable for patient

M

• Recruitment is a phenomenon seen in cochlear lesions (Meniere’s disease, Presbycusis) [RMP]

SHORT INCREMENT SENSITIVITY INDEX [SISI]

• Patients of cochlear pathology can differentiate short changes in intensity better than Normal individuals
• CD → rarely >15%
• Cochlear deafness → 70-100%
• Nerve deafness → 0-20%
ENT

THRESHOLD TONE DECAY TEST

• Measures nerve fatigue and thus used to detect retrocochlear lesions
• Normal individual can hear a tone for 60 seconds but in fatigue of nerve he hears for lesser time

624

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EVOKED RESPONSE AUDIOMETRY

• Electrocochleography
ƒƒ Measures electric potentials of first 5 miliseconds coming
from cochlea and 8th nerve in response to auditory stimuli
ƒƒ INVASIVE TECHNIQUE- thin needle passed through TM
onto promontory
ƒƒ Useful to find threshold of hearing in infants and children
and in diagnosis of Menier’s disease
ƒƒ Resting endolymphatic potential of Normal cochlea is
(+)85mV
• AUDITORY BRAINSTEM RESPONSE(ABR) Figure:  Waves of BERA
ƒƒ Also called BERA- Brainstem evoked response audiometry)
Wave Origin
ƒƒ NON-INVASIVE PROCEDURE
I Distal cochlear nerve
ƒƒ Measures hearing sensitivity between 1000-4000 Hz range
II Proximal cochlear nerve
ƒƒ Normally 7 waves are produced of which 1st,3rd and 5th are
III Cochlear nucleus

/e
most stable. IV Superior olivary complex
• Uses: V Lateral lemniscus

,1
ƒƒ Screening procedure for infants VI Inferior colliculus
ƒƒ To measure the hearing threshold in infants, children VII Medial geniculate body

es
and malingrers
ƒƒ Diagnose retrocochlear and brainstem pathology

OTOACOUSTIC EMISSIONS
ot
• In a normal ear, Low intensity sounds are produced by Outer hair cells which can be elicited by a
N
sensitive microphone placed in External ear canal and analysed by Computer
• Types:
ƒƒ Spontaneous OAEs
EE

ff Present in Normal/ <30% hearing loss,

ff May be absent in 50% of normal individuals

ƒƒ Evoked OAEs
M

• Transient evoked OAEs- response recorded after a series of click stimuli

• Distortion produced OAEs- Two tones are presented together to cochlea
PG

ƒƒ Uses:

ff Used as a screening test for Infants → Transient evoked OAEs

ff Distinguishes between cochlear and retrocochlear hearing loss

y

ff Useful to diagnose retrocochlear pathology.

M

CENTRAL AUDITORY TESTS

Used to find defects in the central auditory pathways and temporal cortex
HEARING ASSESSMENT IN CHILDREN

Neonatal Behaviour observation Distraction Conditioning Objective tests

screening audiometry techniques techniques
procedures
• Arousal test • Moro’s reflex → Movement of • For 6-7 • Visual • ABR
ENT

• Auditory limbs and extension of Head in months old reinforcement • Otoacoustic

response audiometry emissions
response to 80-90 dB sound infants
cradle • Play audiometry • Impedance
• Cochleopalpebral reflex→ Child
• ABR/OAE’s audiometry
responds by blinking to loud
sound
• Cessation reflex
625

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Assessment of Vestibular Functions

Clinical Tests

SPONTANEOUS NYSTAGMUS
• Nystagmus is an involuntary, rhythmic, oscillatory movement of eyes
• Vestibular nystagmus types:
ƒƒ Peripheral Nystagmus- when due to lesion of Labyrinth or 8th nerve

ƒƒ Central nystagmus- when lesion is in central neural pathways[vestibular nuclei, brainstem or

cerebellum]
ƒƒ Torsional nystagmus → lesion of brainstem/vestibular nuclei, as in Syringomyelia

ƒƒ Vertical downbeat nystagmus → lesion of Pons-medulla junction/Pons-midbrain junction

FISTULA TEST
• TEST(+)

/e
ƒƒ Erosion of Horizontal SCC as in Cholesteatoma

ƒƒ Abnormal opening in oval window as in fistula/post stepedectomy

,1
ƒƒ Round window rupture

• FALSE (–) → Cholesteatoma

• FALSE(+) → congenital syphilis and Menier’s disease [hennebert’s sign]

es
ROMBERG TEST
• Patient standing with feet together with arms by the side first with eyes open then closed
ot
• Central vestibular disorder → patient unstable
• Peripheral vestibular lesion-Patient sways to the side of lesion
N
GAIT
• Patient asked to walk on a straight line
EE

• If patient deviates to affected side with eyes closed → uncompensated lesion of vestibular system
PAST-POINTING AND FALLING
M

• Acute vestibular failure → nystagmus opposite to side of past pointing and falling
DIX-HALLPIKE MANOEUVRE
PG

• A positional test for patients complaining vertigo at certain head positions

• Done in central lesions(nystagmus produced immediately), appears immediately, is without any latency
and is non fatiguable
• In BPPV:
y

ƒƒ Nystagmus appears after 2-20seconds and is fatiguable

M

ƒƒ BPPV MC involves Posterior SCC

ƒƒ Remember for BPPV→Dix for Diagnosis & Epley for Treatment

Laboratory Tests of Vestibular Functions

CALORIC TEST
• Modified Kobark Test:
ENT

ƒƒ Ear irrigated with ice water

ƒƒ If responds + with ↑ quantities of ice water → Hypoactive labyrinth

• Fitzgerald-hallpike test (bithermal caloric test)-

ƒƒ Water at temperature 70 above and below is used

ƒƒ Cold water induces nystagmus to opposite side and warm water to the same side (remember : C O W

626 S: Cold – Opposite, Warm - Same ).

• Cold air caloric test- Done in perforation of TM

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Notes

• ELECTRONYSTAGMOGRAPHY- method of detecting and recording nystagmus

• OPTOKINETIC TEST- Patient is instructed to follow a series of stripes on a moving drum → produces
Nystagmus
• ROTATION TEST- Patient rotated in Barany’s chair and stopped suddenly → produces nystagmus for 25-
40 seconds in normal individual
• GALVANIC TEST- ONLY TEST that differentiates between end organ lesion and vestibular nerve lesion.
• POSTUROGRAPHY- Measure postural stability to evaluate vestibular function
• VEMP[vestibular evoked myogenic potential]
ƒƒ Originates from saccule
ƒƒ Pathway: saccule→inferior vestibular nerve→lateral vestibular nucleus→lateral vestibular tract→scm
muscle

Meniere’s Disease/Endolymphatic Hydrops

Symptoms- Tinnitus (1st symptom) → Vertigo → Sensory Deafness [remember Mera TVS]

/e
zz

zz Symptoms of meniere’s in reverse order → Lermoyez syndrome (reverse Meniere’s disease

,1
zz Tulio’s phenomenon → tinnitus aggravated in presence on loud sound → Patient avoids Noisy
environment

es
zz SHEA classification is used
zz Electrocochleography is Gold standard for diagnosisot
zz Treatment
Medical management is the main treatment
N


 Low salt diet,

 Labyrinthine sedative,
EE

 Intratympanic injection of Gentamycin-Mainly vestibulotoxic

(symptomatic t/t in refractory cases)
 Positive pressure therapy Figure:  MENIETT’S DEVICE
M

 Surgical treatment includes: endolymphatic sac decompression (M/M Home based therapy for Meniere’s
of choice) or Shunt surgery disease
PG

Diseases of External Ear

Hematoma of auricle → Cauliflower Ear

y

zz

Leprosy- Mouse nibbled ulceration of pinna

M

zz

zz In Wildermuth’s ear, antihelix is more prominent than helix

zz Darwin’s tubercle is a pointed tubercle on the upper part of helix
zz Otomycosis presents with ‘wet blotting paper’ like greyish white debris
zz MALIGNANT OTITIS EXTERNA
 Caused by Pseudomonas auruginosa
 Otitis externa is also called as Singapore ear/swimmer’s ear/Telephonist ear
ENT

 MC presenting symptom- severe pain

 Diagnosis by Tc99 scan and prognosis by Gallium scan
 Presence of granulations at bony-cartilagenous junction
 Multiple cranial palsies are characteristic (MC – facial nerve)
 Treatment- 3rd generation cephalosporins
627

notes
 MEE
My PG
Notes

Keratosis Obturans

zz Young patient usually B/L cavity filled with Keratin plug

zz Presence of pearly white large expansile mass of desquamated epithelial cells in deep meatus
zz Severe pain
zz Cleaning under microscope every 6 months is treatment of choice
 Preauricular sinus- formed due to the faulty union between first and second branchial arches
 Myringitis bullosa is MC caused by Mycoplasma pneumonia
 Most common cancer of pinna – Basal cell carcinoma

Eustachian Tube Assessment

Various Tests Available Are (T V PEN)

/e
zz Tympanometry
Toynbee

,1
zz

zz Valsalva
zz Politzer

es
zz Pneumatic otoscopy
ET catheterization
zz
ot
zz Nasopharyngoscopy
N
Disorders of Middle Ear
EE

ASOM GLUE EAR Tubercular Otitis Media

• Mucus + pus • Aka secretory Otitis Media • No blood stained discharge
M

• In 6 months – 2 year age • Pain + hearing loss • Painless otorrhoea

PG

group • Thick sticky non purulent fluid without • Pale granulations

• Bulging TM, no malleus infection • Multiple TM perforations
seen • MCC of childhood hearing loss • Facial nerve palsy is a common
• Pulsatile otorrhea is seen • Cartwheel appearance of TM complication
y

• High grade fever present • B/L always ( If presents with U/L glue • Treatment is MRM + ATT
M

• Treatment is ear → Nasopharyngeal Ca)

Myringotomy with a • Treatment- Myringotomy ( antero
Posteroinferior incision inferior Quadrant) + Grommet insertion
• Can lead to CSOM [postero inferior in Acute serous OM]

CSOM and Complications

ENT

zz Chronic suppurative otitis media (CSOM)

zz long - standing infection of the middle ear cleft characterised by ear discharge + permanent
perforation
zz Adenoids cause B/L CSOM
628 zz Carcinoma causes Unilateral CSOM

notes
 My PG
MEE
Notes

zz Long process of incus is the most common ossicular structure undergoing necrosis
zz Round window shielding effect: Patient hears better in the presence of discharge than when the
ear is dry
TUBOTYMPANIC ATTICOANTRAL
• Profuse,Mucoid, Odourless • Scanty, purulent,Foul smelling
• Involves anteroinferior part of middle ear • Involves posterosuperior part of the cleft(Attic + Antrum
cleft(Eustachian tube + Mesotympanum) +mastoid)
• Associated with central perforation • Associated with Attic or Marginal perforation
• No risk of serious complication thus called • Associated with Bone eroding processes like Cholesteatoma
as Safe/Benign type or Osteitis thus called as Unsafe/Dangerous type
• Hearing loss rarely exceeds 50dB • Treatment :
• Treatment: ƒƒ Surgery is the main treatment

ƒƒ Aural Toilet ƒƒ Canal wall down procedure-Diseased ear is fully

ƒƒ Systemic antibiotics Ear drops + exteriorised by cpening the Mastoid to External auditory
canal.

/e
ƒƒ Canal wall up procedure- diseased ear is not exteriorised,

,1
only the disease is removed But there is risk of residual
disease

es
Cholesteatoma ot
zz It is the presence of Keratinising Squamous epithelium in middle ear or mastoid
zz Most common site of cholesteatoma: Posterior epitympanum
N
zz Derlaki classification and levanson criteria-for cholesteatoma
Origin: WI SdM HE RB
EE

zz

Wittmaack’s theory: Invagination of TM as retraction pockets

Sade’s theory: Metaplasia
M

Habermann’s theory: Epithelial invasion through TM perforation

Ruedi’s theory: Basal cell hyperplasia
PG

By congenital cell rests

Theories regarding origin of cholestetoma:

y

zz
Types:
M



ff Congenital- arises from embryonal cell rests

ff Primary acquired-no history of previous Otitis Media
ff Secondary acquired history of OM present
 Expansion and destruction of bone-occurs due to presence of various enzymes such as
collagenase, acid phosphatases and proteolytic enzymes
zz Multiple perforations in TM with painless ear discharge is characteristic of Tuberculous otitis
media
ENT

zz Bezold abscess is the tracking of pus which presents as a swelling in the upper neck along Sterno
Cleido Mastoid [BSc]
zz Luc abscess is the meatal abscess
zz Citelli’s abscess is pus behind the mastoid towards the oCCipital bone
629

notes
 MEE
My PG
Notes

Lateral Sinus Thrombophlebitis

zz Toby Ayer test[pressing Jugular vein at Neck does not ↑ ICP] is positive
zz Crowe beck test [pressing IJV causes Retinal Vein Engorgement seen on fundoscopy] is positive
zz Delta sign in CT /MRI is diagnostic of the condition
zz HECTIC PICKET FENCE type fever is seen
* Griesinger’s sign: Edema over posterior part of mastoid due to emissary vein thrombosis

Labyrithitis

zz 3 types: Circumscribed, Diffuse serous, Diffuse suppurative

zz In diffuse serous labrynthitis, there is spontaneous nystagmus with quick component towards
affected side while in diffuse suppurative labrynthitis, quick component is towards the normal
side

/e
Otosclerosis/Otospongiosis

,1
zz Normal enchondral layer of bony otic capsule replaced by spongy bone
Made worse by pregnancy, menopause or an accident or trauma

es
zz

zz MC site is footplate of stapes

Blue mantles of Manasse- Immature focus seen histologically
zz
ot
zz SCHWARTZ SIGN/ FLAMINGO PINK SIGN: an active focus indicated by reddish hue seen on
N
promontory through TM .
zz Van der hoeve syndrome: Osteogenesis imperfecta, Blue sclera, Otosclerosis
EE

zz PARACUSIS WILLISI- Patients with otospongiosis tend to hear better in noisy surroundings
zz Carhart’s notch:
Dip in the bone conduction curve at 2000 Hz
M



 Disappears after a successful stapedectomy

PG

zz BEZOLD’S TRIAD:
 Raised lower tone limit,
 Absolute negative Rinne’s,
y

 Prolonged bone conduction

M

zz Sodium Flouride is used in the medical therapy of otosclerosis

zz Stapedectomy/Stapedotomy with placement of prosthesis is the treatment of choice

Acoustic Neuroma
zz Due to Inferior division of vestibular nerve (8th CN)
zz MC cerebropontine angle tumor(80% of all CP angle tumor)
ENT

zz 1st nerve affected Trigeminal → corneal sensation lost

zz Hitzelberg sign: Hyposthesia of Posterior meatal wall due to 7th CN involvement
zz Investigation of choice- BERA
zz Radiological investigation of choice – Gadolinium enhanced MRI
630 zz Treatment- Surgery always
zz Gamma knife for Unfit patient

notes
 My PG
MEE
Notes

Glomus Tumor/Paraganglionoma/Hemodectoma

zz MC vascular tumor of middle ear

zz MC site – Tip of nail bed
zz FISCH Classification is used
GLOMUS TYMPANUM GLOMUS JUGULARE
• MC vascular tumor of middle ear • MC site- Floor of Middle ear
• MC site- Promontory • Conductive deafness is seen
• RISING SUN SIGN- TM appears RED in color • PHELP SIGN(+)- Erosion of bony part due to
• BROWN SIGN- Blanching of redness on ↑pressure glomus jugulare
from outside
• Treatment → surgery

Tinnitus

/e
OBJECTIVE TINNITUS SUBJECTIVE TINNITUS

,1
• Patient and doctor both can hear the sound • Only patient hears the sound
• Causes include: • All other causes
ƒƒ Palatal myoclonus

es
ƒƒ AV malformation

ƒƒ Jugular bulb ot
ƒƒ ICA malformation
N
Rehabilitation of Deaf Person
EE

Hearing Aids
M

zz Used for mild deafness

zz Cannot be given in
PG

 Bilateral anotia
 EAC atresia
 Chronic discharging ear
 EAC stenosis
y
M

Cochlear Implant
zz Used for severe deafness
zz Mondini Dysplasia → 1.5 turns
in cochlea → MC indication for
Cochlear implant
zz Michel aplasia → Absent cochlear
→ contraindication for Cochlear
ENT

implant
zz Post-lingual candidates are best
candidates
zz Internal device placed in
Scalatympani through round 631
window
notes
 MEE
My PG
Notes

Brainstem Implants

zz Implant placed in IVth ventricle [2018]

zz Indications:
 Michel aplasia of cochlea
 NF-II
 Congenital absence of 8th nerve

Bone-anchored Hearing Aid (BAHA)

zz Based on the principle of bone conduction.

zz Suitable for Patients with:
 Conductive hearing loss
 Chronic inflammation or infection of the ear canal Figure:  Bone-anchored hearing
Malformed or absent outer ear and ear canals (microtia or canal

/e
 aid (BAHA)
atresia)

,1
Miscellaneous in Ear

es
zz Korner’s septum: persisting petrosquamosal suture that overlies the mastoid antrum Citelli’s
angle is situated between sigmoid sinus and middle fossa dura plate
ot
zz Oort’s anastomosis: Vestibulocochlear nerve anastomosis [Oort → Octa → 8th nerve]
N
zz Bill’s bar: separates facial nerve from the superior vestibular nerve in the internal acoustic meatus
zz Stenger’s test is used to detect malingering /non organic hearing loss
EE

zz Best graft for myringoplasty is temporal fascia

zz Gradenigo syndrome is apical petrositsis characterised by triad of ear discharge, diplopia and
retro orbital pain
M

zz Tullio phenomenon, Diplacusis, Tumarkin’s otolith crisis etc are associated with Meniere’s disease
PG

zz Incus is MC ossicle to be affected as a result of Trauma

ORAL CAVITY AND PHARYNX

y
M

Juvenile Angiofibroma
zz Seen exclusively in males
zz MC site- Sphenopalatine foramen
zz MC symptom-Epistaxis
zz Antral sign/Holman muller sign on CT, broadening of nasal bridge, frog face deformity etc
zz Its main blood supply is Internal Maxillary Artery [Source of Bleed] and Ascending Pharyngeal
ENT

Artery
zz Treatment is Excision without Biopsy

Ludwig’s Abscess
632
zz It is infection of Submandibular space

notes
 My PG
MEE
Notes

zz Etiology includes Dental infection in 80% of cases and rest 20% cases are due to # mandible,
infection of oral mucosa and Submandibular sialadenitis
zz Mixed flora present
zz Treatment includes Systemic antibiotics + Incision and drainage of Abscess
zz Gradeneigo syndrome (Apical Petrositis) → 5th CN # (Retroorbital pain) + 6th CN # (Diplopia) +
Ear Discharge
zz Trotter’s Triad (Nasopharyngeal Ca) → 5th CN # + 10th CN # + Condunctive Deafness

Tonsil and Tonsillitis

/e
,1
es
ot
N
EE
M
PG
y
M

Acute tonsillitis
MC bacteria- Hemolytic streptococci
MC virus- Adenovirus
Types:
ENT

• Acute catarrhal type→Generalised Pharyngitis(seen in viral infections)

• Acute follicular type→Yellow spots due to purulent material in Crypts
• Acute parenchymatous type→Swollen & enlarged tonsilar parenchyma
• Acute Membranous type→Membrane over tonsil due to exudates from Crypts.
Clinical features: Fever, headache, Earache & difficulty in swallowing
Treatment: Analgesic + Antibiotics(for 7-10 days) 633
*Pain in ear in case of acute tonsillitis is due to involvement of glossopharyngeal nerve[2018]
notes
 MEE
My PG
Notes

Chronic tonsillitis
May be a complication of acute tonsillitis
Types:
Chronic follicular tonsillitis- very large tonsil +Difficulty in speech, deglutition and respiration.
Chronic Fibroid tonsillitis- small but infected tonsil with H/O repeated sorethroats
Treatment:
Conservative management for milder cases
Tonsilectomy for cases interfering with speech, deglutition or respiration

Tonsilectomy:

Indications Contraindications
Absolute Relative

/e
• Recurrent infections of throat: • Diphtheria carriers • Hb < 10mg%
ƒƒ >7 episodes in a year • Streptococcal • Acute URTI

,1
ƒƒ 5 episodes/year for 2 year carriers • Children < 3years
ƒƒ 3 episodes/year for 3 years • Chronic tonsillitis • Overt/Submucus
ƒƒ >2 weeks of lost school/work in one year. with dysgusia or Cleft palate

es
• Peritonsillar abscess Halitosis • Bleeding disorders
• Tonsilitis causing febrile seizures • Recurrent • Polio epidemic
• Hypertrophy of Tonsil causing: airway obstruction,
ot streptococcal
difficulty in swallowing & interference with speech tonsilitis
N
• Suspicion of Malignancy
Done under general anesthesia in Rose position
EE

zz

zz Dissection and snare method is MC method

zz MC complication is Hemorrhage(Paratonsilar vein is MCC of bleeding during tonsillectomy)
M

Miscellaneous in Oral Cavity and Pharynx

PG

zz Aphthous ulcer spares hard palate and gingiva

zz Vincent’s angina is caused by Borrelia vincenti and Fusobacterium fusiformis
y

zz Buccal mucosa and oral commissure are the most common sites of Leukoplakia
M

zz Malignant potential of erythroplakia is 17 times more than that of leukoplakia

zz Hairy leukoplakia is associated with EBV infection
zz Gateway of tears: Increased chance of perforation occurring through Killian’s dehiscence during
esophagoscopy
zz Fossa of Rosenmuller: recess present above and behind the torus tubaris; most common site of
nasopharyngeal carcinoma
zz Parapharyngeal abscess- Trismus due to spasm of medial Pterygoid muscles
ENT

zz Gerlach tonsil: Tubal tonsil

zz Passavant’s ridge is the mucosal ridge raised by the fibres of PalatoPharyngeus
zz Bocca sign: absence of laryngeal crepitation as in post cricoids malignancy and perichondritis
[BROCA’S Sign → In LP, Patient does not scratches even when pruritus is present since it is very
634 painful]

notes