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Image Bank
 Index
Sl.No. Chapter Pg.No.
I Ear
Anatomy & Physiology of Ear and Hearing 09
Hearing Loss & Assessment of hearing loss 18
Vestibular System 27
Diseases of External Ear 33
Diseases of Middle Ear 39
Otosclerosis 53
Facial Nerve and its Lesions 56
Vertigo and Meniere’s Disease 59
Tumors of the Ear 63
Rehabilitative Methods 67

II Nose and Paranasal sinuses

Anatomy and Physiology of Nose 69
Diseases of External Nose and Nasal Septum 74
Granulomatous Disorders and Foreign Body in Nose 79
Inflammatory Disorders of Nasal Cavity 82
Epistaxis 87
Anatomy and physiology of PNS 92
Diseases of Paranasal Sinus 94
Tumors of Nose and Paranasal Sinus 99

III Oral cavity, Pharynx & larynx

Diseases of Oral Cavity & Salivary Glands 103
Anatomy of Pharynx and Larynx 108
Inflammatory Diseases of Pharynx, Nasopharynx, Tonsils 112
Congenital lesions and Inflammation of Larynx 117
Tumors of Oropharynx , Hypopharynx, Larynx 120
Thyroid gland and its disorders 123

IV Instruments 126
 9

Ear
Anatomy & Physiology of Ear and Hearing

THE EXTERNAL EAR

AURICLE OR PINNA
There is no cartilage
between the tragus and
crus of the helix, and this
area is called incisura
terminalis

[ NEET 118 ]

Nerve responsible for

referred otalgia:-
Glossopharyngeal nerve

[NEET 2020]

Cough on
scratching the
external auditory
canal is due to
auricular branch
of vagus nerve
(Arnold’s nerve)
Nerve supply of pinna.
Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 3, 15 )
Textbook of Ear, Nose and Throat, BS Tuli (Pg 3, 19)
 10

EXTERNAL ACOUSTIC (AUDITORY) CANAL

Extends from the bottom of the concha to the tympanic membrane
Measures about 24 mm Meatoplasty is the surgery
Cartilaginous Part done to widen the
cartilaginous part of EAC.
Outer one-third (8 mm) of the canal
"Fissures ofSantorini" deficiencies in the cartilage and through them the
parotid or superficial mastoid infections can appear in the canal or vice versa.
Bony Part
Inner two-thirds (16 mm)
6 mm lateral to tympanic membrane, the bony meatus has a narrowing called
isthmus. Foreign bodies get impacted here, and are difficult to remove.

TYMPANIc MEMBRANE

Pars Tensa
Forms most of tympanic membrane.
Periphery is thickened to form a fibrocartilaginous ring called annulus tympanicus.
Central part of pars tensa is tented inwards at the level of tip of malleus - umbo.
A bright cone of light radiating from the tip of malleus to the periphery in the
anteroinferior quadrant- cone of light
Pars Flaccida (Shrapnell's Membrane)
Situated above the lateral process of malleus between the notch of Rivinus and the
anterior and posterior malleal folds
Nerve supply
1. Anterior half of lateral surface: auriculotemporal (V3).
2. Posterior half of lateral surface: auricular branch of vagus (CN X).
3. Medial surface: tympanic branch of CN IX (Jacobson’s nerve).
 11

The middle ear

Divisions of middle ear

(i) mesotympanum
- lying opposite the pars tensa,
(ii) epitympanum or the attic
- lying above the pars tensa but
medial to Shrapnell’s membrane and the
bony lateral attic wall
(iii) hypotympanum
- lying below the level of pars tensa

Boundaries of Middle Ear

Lateral wall: tympanic membrane

The roof is formed by a thin plate of bone called tegmen tympani.

The floor is a thin plate of bone, which separates tympanic cavity from the jugular bulb.
The anterior wall has a thin plate of bone, which separates the cavity from internal
carotid artery.
The posterior wall lies close to the mastoid air cells.
The medial wall is formed by the labyrinth.
The lateral wall is formed largely by the tympanic membrane and to a lesser extent by
the bony outer attic wall called scutum
 12

MASTOID AND ITS AIR CELL SYSTEM

Mastoid develops from the squamous and petrous bones.

The petrosquamosal suture may persist as a bony plate— the Korner’s septum,
separating superficial squamosal cells from the deep petrosal cells.
Mastoid antrum cannot be reached unless the Korner’s septum has been removed.
MASTOID ANTRUM
large, air-containing space in the upper part of mastoid and communicates with the
attic through the aditus.
Its roof is formed by tegmen antri, which is a continuation of the tegmen tympani and
separates it from the middle cranial fossa.
The lateral wall of antrum is formed by a plate of bone which is on an average 1.5 cm
thick in the adult.
It is marked externally on the surface of mastoid by suprameatal (MacEwen’s) triangle

MacEwen’s (suprameatal) triangle.

It is bounded by
Temporal line
÷ Posterosuperior segment of bony
external auditory canal
c) The line drawn as a tangent to the

external canal.
It is an important landmark to locate the
mastoid antrum in mastoid surgery.
 13

Ear ossicles and their parts

Malleus, incus and stapes are connected to each other by synovial joints forming ball
and socket and saddle joint respectively
Malleus and incus develops from mesoderm of first branchial arch, while stapes from
second branchial arch. Footplate of stapes develops from otic capsule.
The ossicles conduct sound energy from the tympanic membrane to the oval window
and then to the inner ear fluid.

Facial recess lies lateral and sinus

tympani medial to the pyramidal
eminence and vertical part of the facial
nerve.
Facial recess also called suprapyramidal
recess
Sinus tympani also called infrapyramidal
recess.
Prussak’s Space also called superior recess of TM.
It lies between neck of malleus (internally) and pars flaccida (externally).
Most common site of cholesteatoma.
 14

The internal ear

Bony labyrinth

Membranous labyrinth

The internal ear or the labyrinth is an important organ of hearing and balance.
It consists of a
The bony labyrinth
The membranous labyrinth- filled with a clear fluid called endolymph
The space between membranous and bony labyrinths is filled with perilymph.
Bony Labyrinth Membranous Labyrinth
It consists of It has the following parts:
a. Vestibule a. Utricle
b. Semicircular canals b. Saccule
c. Cochlea. c . Semicircular ducts.

cochlear Duct
Also called membra- nous cochlea or the scala media.
The canal enclosed between scala vestibuli and scala tympani is the
cochlear duct (or scala media).

[NEET 2020] Saccule develops from Pars Inferior

 15

A diagrammatic representation of the

A section through the cochlea to show perilymphatic system. CSF passes into the
scala media (cochlear duct), scala scala tympani through the aqueduct of the
vestibuli and scala tympani. cochlea.

DEVELOPMENT OF EAR

Development of pinna.
Six hillocks of His around the first
branchial cleft and the corresponding
parts of pinna which develop from them.

Development of the
external auditory canal
and middle ear.
The cochlea is developed sufficiently by
20 weeks of gestation and the fetus
can hear in the womb of the mother.
 16
Physiology of Hearing

Auditory cortex
superior temporal gyrus
(Brodmann’s area 41)

Medial geniculate
body

Inferior colliculus

mnemonic
lateral lemniscus
E.COLI-MA
Superior olivary
complex
(Decussition of left and right
impulses)

Cochlear
nuclei
[17-1119520]

Cochlear division of Q. Sequence of

viii (eight) cranial auditory Pathway?
nerve
 17

ELECTRICAL POTENTIALS OF COCHLEA AND CN VIII

} ;
1. Endocochlear potential
2. Cochlear microphonic from cochlea
3. Summating potential
4. Compound action potential from nerve fibres
 18

Hearing Loss & Assessment of hearing loss

Examination of Ear

Examination of ear without speculum Examination of ear with speculum

Otoendoscope : Advantage of being quick and the findings can be recorded.

Discharge from middle ear
Discharge from external auditory meatus • Serous discharge
• Scanty and watery—Otitis externa —nonsuppurative otitis media.
• Brownish—Liquefied wax • Mucoidal discharge
• Blackish—Otomycosis —secretory otitis media,
• Watery and clear—CSF leak. - CSOM without active infection
• Blood stained— • Mucopurulent—suppurative otitis media
Malignant OE, trauma, external • Purulent foul smelling
auditory canal tumor, ASOM —atticoantral or unsafe ear
• Blood stained —atticoantral or unsafe ear
• Pulsatile discharge
—ASOM with pinhole perforation or
coexisting vascular tumor.
Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 23, 31)
Textbook of Ear, Nose and Throat, BS Tuli (Pg 32)
 19
Assessment of hearing
Assessment of hearing

Subjective Objective
Tunning fork test Tympanometry
i. Weber
ii. Rinne BERA
iii. ABC BRAINSTEM AUDITORY '

iv. Schwabach EVOKED RESPONSE [ Aunts 20]

Audiometry
i. Speech audiometry ELECTROCOCHLEOGRAPHY Q.
Objective
ii. Pure tone audiometry
OAE- OTOACOUSTIC EMISSION tests for
hearing ?

TUNNING FORK TEST

Test Conductive SENSORYNEURAL

Normal deafness deafness
AC > BC BC > AC
Rinne (Rinne positive) (Rinne negative)
AC>BC
Lateralized to Lateralized to
Weber Not lateralized poorer ear better ear
ABSOLUTE Same as Same as
BONE Reduced
CONDUCTION examiner’s examiner’s
Schwabach Equal Lengthened Shortened

PTA EcoG OAE BERA

Measure of threshold of Measures electrical Screening test of Eliciting brain stem
hearing by air and bone potentials arising in the hearing in neonates. potentials in
conduction and thus the cochlea and CN VIII in Distinguish cochlear response to
degree and type of response to auditory from retrocochlear audiological click
hearing loss. stimuli. hearing loss. stimuli.

bing test
Test of bone conduction and examines the effect of occlusion of ear canal
on the hearing.

gelle’s test
Test of bone conduction and examines the effect of increased air pressure
in ear canal on the hearing.
 20

Rinne’s test

air conduction bone conduction

Rinne’s test in a normal person Rinne’s test with conductive

hearing loss

Rinne’s test showing false

Rinne’s test with perceptive hearing loss
negative Rinne
 21

Weber’s Test
A vibrating tuning fork is placed
in the middle of the forehead or
the vertex and the patient is
asked in which ear the sound is
heard.
Normally, it is heard equally in both
ears.
Lateralized to the worse ear in
conductive deafness and to the
better ear in sensorineural
deafness.

Two-room audiometry setup.

Audiometrician watches responses of
the patient sitting across a glass
partition.

Normal audiogram
 22

Audiogram showing Audiogram showing

conductive hearing loss sensorineural hearing loss

Audiogram showing mixed hearing loss

 23

(A) Impedance audiometry in (B) Impedance audiometer.

progress.
brainstem evoked
response audiometry

Various waves seen in brainstem evoked response audiometry

Anatomic site of neural generators

Wave I Distal part of CN VIII
Wave II Proximal part of CN VIII near the brainstem
Wave III Cochlear nucleus
Wave IV Superior olivary complex
Wave V Lateral lemniscus
Waves VI and VII Inferior colliculus
 24

Hearing Loss

Conductive
• Disease process is limited to external ear and middle ear, including footplate of stapes
• Rinne –ve
• Weber lateralized to worse ear
• Absolute bone organization (ABC) is equal
• Pure tone audiometry (PTA) shows bone air gap
• Low frequencies involved
• Hearing loss up to 50–60 dB
• Speech discrimination score (SDS) is good (95–100%)
• Test for recruitment is –ve
• Short increment sensitivity index (SISI) of 15%
• No tone decay
• Impedance audiometry is a useful parameter
• Brainstem evoked response audiometer (BERA) not of much use
 25

Sensorineural
• Disease process is beyond the oval window in the inner ear
• Rinne +ve
• Weber lateralized to better ear
• ABC shortened
• PTA shows no bone air gap
• High frequency hearing loss
• Hearing loss more than 60 dB
• Poor SDS in cochlear (low score) and retrocochlear (very low score)
• Recruitment test +ve in cochlear lesion
• SISI above 60% in cochlear lesion
• A tone decay of 30 dB seen in retrocochlear lesions
• Impedence audiometry is not of much use
• BERA is a very useful diagnostic tool

Classification of acquired deafness

Conductive type Sensorineural

Mixed
• External ear • Head injuries
Wax/otomycosis/foreign bodies/ • Viral infections • Blast injury
otitis externa atresia/tumors • Mumps, measles, •CSOM, senile
• Middle ear • Otosclerosis
• Herpes
– Congenital defects • Noise trauma
– Traumatic • Tumors – Acoustic neuroma Sudden
– Otitis media (OM) • Ménière disease • Vascular
– Nonsuppurative OM • Ototoxicity • Trauma
– Tuberculosis/syphilis • Presbycusis • Viral infection
– Otosclerosis • Hypertension • Ménière disease
– Tumors • Cerebrovascular accident • Ototoxicity
– Eustachian tube (E tube) • Diabetes • Meningitis
– E tube catarrh • Hypothyroidism • CVA
– Barotrauma • Smoking and alcoholism • Functional
• Psychogenic deafness
 26

CONGENITAL CAUSES OF CONDUCTIVE HEARING LOSS

• Meatal atresia
• Fixation of stapes footplate
• Fixation of malleus head
• Ossicular discontinuity
• Congenital cholesteatoma

DEGREE OF HEARING LOSS

 27

Vestibular System
Assessment of Vestibular Functions
1. Clinical tests
2. Laboratory tests
Clinical tests
SPONTANEOUS NYSTAGMUS
Involuntary, rhythmical, oscillatory movement of eyes.
1st degree
It is weak nystagmus and is present when patient looks in the direction of fast
component.
2nd degree
It is stronger than the 1st degree nystagmus and is present when patient looks
straight ahead.
3rd degree
It is stronger than the 2nd degree nystagmus and is present even when patient
looks in the direction of the slow component.

POSITIONAL NYSTAGMUS IN PERIPHERAL AND CENTRAL LESIONS OF VESTIBULAR

SYSTEM. POSITIONAL NYSTAGMUS IS ELICITED BY HALLPIKE MANOEUVRE

GAIT
The patient is asked to walk along a straight line to a fixed point, first with eyes open
and then closed. In case of un- compensated lesion of peripheral vestibular system,
with eyes closed, the patient deviates to the affected side.

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 43, 47 )

Textbook of Ear, Nose and Throat, BS Tuli (Pg 32)
 28

Dix-Hallpike manoeuvre

In this test, patient is sitting on a

couch, examiner turns the head of
patient to 45° right side and puts him
in supine with head hanging 30° below
horizontal. Nystagmus is seen.
Test is repeated with head turned to
left side and parameters of nystagmus
are seen like duration, latency,
direction and fatigability.
In BPPV, the test is very useful and
also helps to find out if the lesion is
peripheral or central.
In central lesions nystagmus is
produced immediately without any
latency period.

FISTULA TEST
Nystagmus is induced by producing pressure changes in the external canal which
are then transmitted to the labyrinth.
A positive fistula - labyrinth is still functioning;
Absent when labyrinth is dead.
False negative fistula test - when cholesteatoma covers the site of fistula and does not
allow pressure changes to be transmitted to the labyrinth.
False positive fistula test-In congenital syphilis and Ménière’s disease (Hennebert’s sign).
ROMBERG TEST
The patient is asked to stand with feet together and arms by the side with eyes first
open and then closed.
In peripheral vestibular lesions, the pa- tient sways to the side of lesion. In central
vestibular disorder, patient shows instability.
 29

TEST OF CEREBELLAR DYSFUNCTION

1. Asynergia (abnormal finger-nose test)
2. Dysmetria (inability to control range of motion)
3. Adiadochokinesia (inability to perform rapid alternating movements)
4. Rebound phenomenon (inability to control movement of extremity when
opposing forceful restraint is suddenly released)
LABORATORY TESTS
CALORIC TEST
FitZgerald–hallpike test (bithermal caloric test)

It tests the integrity of horizontal

semicircular canal (HSCC).
• External canal of ear is irrigated
with 30°C or 44°C (7° above and below
normal body temperature) of 200 to
300 cc water for 40 seconds.
• In a healthy person, the patient has
a feeling of vertigo and nystagmus
appears. The response is measured in
seconds between start of irrigation
and cessation of nystagmus. About 5
minutes gap is given between cold
and hot caloric test and the result is
recorded in a calorigram

A) Patient is in supine position and head

raised by 30° to make horizontal canal
vertical. (B) Position of canal and the
direction of flow of endolymph.
 30

Electronystagmography

Method of detecting and recording of nystagmus, which is spontaneous or induced by

caloric, positional, rotational or optokinetic stimulus.

VESTIBULAR DISORDERS

Peripheral Central
(Lesions of end organs (Lesions of brainstem and
vestibular nerve) central connections)
• Ménière’s disease • Vertebrobasilar insufficiency
• Benign paroxysmal positional vertigo • Posterior inferior cerebellar artery
• Vestibular neuronitis syndrome
• Labyrinthitis • Basilar migraine
• Vestibulotoxic drugs • Cerebellar disease
• Head trauma • Multiple sclerosis
• Perilymph fistula • Tumours of brainstem and fourth ventricle
• Syphilis • Epilepsy
• Acoustic neuroma • Cervical vertigo

benign paroxysmal positional Vertigo (bppV)

• Sudden vertigo, which occurs only in certain positions of the
head while changing the position or getting from the bed
• It is seen between 30 and 50 years of age [AIIMS
2020]
• In both sexes equally
Gold standard for diagnosing BPPV-
• May follow head injury Dix Hallpike manouvure
• Labyrinthitis Therapeutic manoeuver- Epley’s
Maneuver.
• No apparent cause may be found.
The lesion is in the maculae of utricle or saccule on one side. Otolithic membrane may
be damaged.
Epley maneuver is being used to displace the otoliths by placing the head and in
turn SCC in different positions for immediate relief.
 31
Epley’s manoeuvre for BPPV of posterior canal showing position of patient and
corresponding position of otolith debris in the posterior canal.

(A) Patient sitting facing forward.

(B) Patient lying down in Dix-Hallpike position with head hanging and turned 45 ̊ to
right (the affected ear).
(C) Head turned to left Dix-Hallpike position with affected ear up.
(D) Head and body both turned as a unit to unaffected side so that face is turned to
the ground.
(E) Patient is made to sit with head bent forward by 20 ̊.

wallenberg syndrome
posteroinFerior cerebellar artery syndrome
Lateral medullary syndrome
Thrombosis of the posterior inferior cerebellar artery cuts off blood supply to lateral
medullary area.
There is violent vertigo along with diplopia, dysphagia, hoarseness, Horner syndrome,
sensory loss on ipsilateral side of face and contralateral side of the body, and ataxia.
There may be horizontal or rotatory nystagmus to the side of the lesion
 32

• Inferior cerebellar peduncle Vertigo, nausea, vomiting and nystagmus

• Spinocerebellar tracts Ataxia
• Nucleus ambiguus (CN X, IX) Hoarseness and dysphagia
• Descending sympathetic tract Horner’s syndrome
• Uncrossed fibres of spinothalamic tract Loss of pain and temperature on ipsilateral face
• Descending nucleus and tract of CN V Pain and numbness over ipsilateral face
• Contralateral spinothalamic tract Contralateral loss of pain and temperature of
(crossed fibres) arm, trunk and leg

MÉNIÈRE'S DISEASE
• Recurring attacks of episodic vertigo
• Fluctuating lowtone sensorinural hearing loss (SNHL)
• Tinnitus
• Seen over the age of 30 years
• Affects both sexes equally
• Unilateral in 50 percent cases and later may become bilateral (3–8%)
 33

Diseases of External Ear

DISEASES OF THE PINNA

CONGENITAL DISORDERS

anotia
complete absence of pinna and lobule, and
usually forms part of the first arch
syndrome

Microtia right ear

(peanut ear).
small deformed pinna
Degree of microtia may vary.
Frequently associated with anomalies of
external auditory canal, middle and
internal ear.
The condition may be unilateral or
bilateral. Hearing loss is frequent.

bat ear
(syn. prominent ear or protruding ear).

Abnormal anteriorly placed pinna

The concha is large with poorly developed
antihelix and scapha. The deformity can be
corrected surgically any time after the
age of 6 years, if cosmetic appearance so
demands.

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg51, 61 )

Textbook of Ear, Nose and Throat, BS Tuli (Pg 48 )
 34

preauricular tags or
appendages

They are skin-covered tags that appear

on a line drawn from the tragus to the
angle of mouth.
They may contain small pieces of
cartilage

preauricular pit or sinus

Depression in front of the crus of helix

or above the tragus.
An epithelial track and is due to
incomplete fusion of tubercles.
It may get repeatedly infected causing
purulent discharge. Abscess may also
form.
Treatment is surgical excision of the
track if the sinus gets repeatedly
infected

Darwin’s tubercle— Wildermuth’s ear (Mozart’s ear)—

Small elevation on the posterosuperior Antihelix is more prominent than helix;
part of helix and is an inherited condition lobule may be absent or adherent to the
skin of neck
 35

TRAUMA TO THE AURICLE

Cauliflower ear (pugilistic or boxer’s ear)

Collection of blood between the auricular

cartilage and its perichondrium.
Result of blunt trauma seen in boxers,
wrestlers and rugby players.

Treatment is by incision and drainage and proper

compression of the wound to prevent accumulation
of blood or fluid.

keloid oF auricle
May follow trauma or piercing of the ear
for ornaments.
Usual sites are the lobule or helix .
Surgical excision of the keloid usually
results in recurrence.
Some prefer local injection of steroid
after excision.
Battle’s sign
[MEET 2020 ]
Q. Identify the pic?

mastoid ecchymosis, is an
indication of fracture of middle
cranial fossa of the skull.
 36

INFLAMMATORY DISORDERS

perichondritis
Inflammation of the perichondrium covering
the cartilage of the pinna and may follow
trauma leading to hematoma and infection or
may also follow otitis externa or a furuncle
of the pinna or follow operations such as
cutting the cartilage in the presence of
infection
chondrodermatitis nodularis chronica helicis
Small painful nodules appear near the free border of helix in men (50 years).
Nodules are tender and the patient is unable to sleep on the affected side.
Treatment is excision of the nodule with its skin and cartilage.
Tumors

Basal cell carcinoma (rodent ulcer)

Arises from basal layer of epidermis and starts as a
nodule on pinna.
Margins of ulcer are not everted and no lymph node
metastasis is seen

Squamous cell
carcinoma with
secondaries neck

Occur on pinna or in external auditory canal.

Chronic otorrhea may be a predisposing factor.
Facial nerve may be involved. Margins of the ulcer are everted.
 37
DISEASES OF EXTERNAL AUDITORY CANAL

Congenital Atresia
Due to the failure of canalization of
ectodermal core that fills the distal part
of first branchial cleft. Outer meatus
may be filled with fibrous tissue or bone

Furunculosis

Staphylococcal infection of hair follicles,

which are present in cartilaginous part of
the external auditory meatus

Otitis externa
Generalized infection of skin of the
external auditory canal and may be acute
or chronic. It is also called Swimmer ear

Malignant Otitis Externa or

Necrotizing Otitis Externa
Fulminating severe form of otitis externa
caused by pseudomonas seen in elderly
diabetic patients.
 38

DISORDERS OF EUSTACHIAN TUBE

tubal blockage

Acute tubal blockage

↓
Absorption of ME gases
↓
Negative pressure in ME
↓
Retraction of TM
↓
Transudate in ME/haemorrhage (acute OME)
Prolonged
Prolonged tubal blockage/dysfunction
↓
OME (thin watery or mucoid discharge)
↓
Atelectatic ear/perforation
↓
Retraction pocket/cholesteatoma
↓
Erosion of incudostapedial joint

CAUSES OF EUSTACHIAN TUBE OBSTRUCTION

• Upper respiratory infection (viral or bacterial)
• Allergy
• Sinusitis
• Nasal polyps
• Deviated nasal septum
• Hypertrophic adenoids
• Nasopharyngeal tumour/mass • Cleft palate
• Submucous cleft palate
• Down syndrome
• Functional
 39

Disorders of Middle Ear

ACUTE SUPPURATIVE OTITIS MEDIA
Acute inflammation of the mucosa of middle ear, eustachian tube, and mastoid antrum

Routes of Infection
• Through eustachian tube opening Most common organisms in infants and
young children are Streptococcus
• Ruptured TM pneumoniae
• Hematogenous (sometimes only).

Pathology
stage oF tubal occlusion.
Oedema and hyperaemia of nasopharyngeal end of eustachian tube blocks the tube leading
to absorption of air and negative intratympanic pressure.
There is retraction of tympanic membrane with some degree of effusion in middle ear.
stage oF presuppuration.
If tubal occlusion is prolonged, pyogenic organisms invade tympanic cavity causing
hyperaemia of its lining.
Inflammatory exudate appears in the middle ear. Tympanic membrane becomes congested.
stage oF suppuration.
Marked by formation of pus in the middle ear and to some extent in mastoid air cells.
Tympanic membrane starts bulging to the point of rupture.
stage oF resolution.
The tympanic membrane ruptures with release of pus and subsidence of symptoms.
Inflammatory process begins to resolve.
If proper treatment is started early or if the infection was mild, resolution may start
even without rupture of tympanic membrane.

stage oF complication.
If virulence of organism is high or resistance of patient poor, resolution may not take
place and disease spreads beyond the confines of middle ear.
It may lead to acute mastoiditis, subperiosteal abscess, facial paralysis, labyrinthitis,
petrositis, extra- dural abscess, meningitis, brain abscess or lateral sinus
thrombophlebitis.

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 67,73 , 83 )

Textbook of Ear, Nose and Throat, BS Tuli (Pg 59, 65, 74)
 40

(A) Stage of tubal catarrh; (B) Stage of Acute congestion of

presuppuration;(C) Stage of suppuration; tympanic membrane
(D) Stage of resolution with perforation
TREATMENT

Light house sign

It may be seen when there
is pulsating discharge seen
on otoscopy showing
reflecting light
intermittently.
 41
ACUTE NECROTIZING OTITIS MEDIA

Variety of acute suppurative otitis media, often seen in children suffering from measles,
scarlet fever or influenza.
Causative organism is β-haemolytic streptococcus.
There is rapid destruction of whole of tympanic membrane with its annulus, mucosa of
promontory, ossicular chain and even mastoid air cells.
There is profuse otorrhoea.
In these cases, healing is followed by fibrosis or ingrowth of squamous epithelium from
the meatus (secondary acquired cholesteatoma).

OTITIS MEDIA WITH EFFUSION

SEROUS OTITIS MEDIA, SECRETORY OTITIS MEDIA, MUCOID OTITIS MEDIA, “GLUE EAR”

Accumulation of nonpurulent effusion in the middle ear cleft.

Often the effusion is thick and viscid but sometimes it may be thin and serous.
The fluid is nearly sterile.Commonly seen in school-going children.
[NEET 2020]

PATHOGENESIS
Tubercular otitis media
Malfunctioning of Eustachian tube present as painless, foul
Increased secretory activity of middle ear mucosa. smelling discharge, multiple
perforation in pars tensa and
pale granulations.
otoscopic Findings
Tympanic membrane is often dull and
opaque with loss of light reflex.
Thin leash of blood vessels may be seen
along the handle of malleus or at the
periphery of tympanic membrane
Tympanic membrane may show varying
degree of retraction.
Fluid level and air bubbles may be seen
when fluid is thin and tympanic
membrane transparent
 42

myringotomy and aspiration oF Fluid. grommet insertion.

An incision is made in tympanic membrane Grommet is inserted to provide
and fluid aspirated with suction. continued aeration of middle ear
To aspirate thick mucus, two incisions may It is left in place for weeks or months
be required in the tympanic membrane. or till it is spontaneously extruded

AERO-OTITIS MEDIA (OTITIC BAROTRAUMA)

It is a nonsuppurative condition resulting from failure of eustachian tube to maintain

middle ear pressure at ambient atmospheric level.
The usual cause is rapid descent during air flight, underwater diving or compression in
pressure chamber.
Sudden negative pressure in the middle ear causes retraction of tympanic membrane,
hyperaemia and engorgement of vessels, transudation and haemorrhages.

RECURRENT ACUTE OTITIS MEDIA

Usually in Infants and children between the age of 6 months and 6 years
Usually occur after acute upper respiratory infection,
Other causes are recurrent sinusitis, velopharyngeal insufficiency, hypertrophy of
adenoids, infected tonsils, allergy and immune deficiency.
Feeding the babies in supine position without propping up the head may also cause the
milk to enter the middle ear directly that can lead to middle ear infection.

Q. Cause of recurrent otitis media

in feeding babies?
 43

CHOLESTEATOMA
skin in the wrong place Cholesteatoma consists of two parts:
(i) the matrix, which is made up of
keratinizing squamous epithelium resting
on a thin stroma of fibrous tissues
(ii) a central white mass, consisting of
keratin debris produced by the matrix
'
GLEET 19 ]

Keratosis obturans is a rare external auditory

canal (EAC) disease characterized by
abnormal accumulation and consequently
occlusion and expansion of the bony portion
of the EAC by a plug of desquamated keratin.

Genesis of a cholesteatoma
Wittmaack's theory
Invagination of tympanic
membrane from the attic or
posterosuperior part of pars
tensa in the form of retraction
pockets
Ruedi's theory
The basal cells of germinal
layer of skin proliferate
under the influence of
infection and lay down
keratinizing squamous
epithelium.
Habermann's theory
The epithelium from the meatus
grows into the middle ear through
a preexisting perforation
especially of the marginal type
where part of annulus tympanicus
has already been destroyed.
Metaplasia (Sade's theory).
Due to repeated infections and transforms into squamous epithelium.
 44
Types of Cholesteatoma
Congenital Cholesteatoma
Arises from congenital embryonic cell rests in the middle ear or temporal bone
Acquired Cholesteatoma

Once cholesteatoma enters the middle ear cleft, it invades the surrounding
structures, first by following the path of least resistance, and then by enzymatic
bone destruction.
 45
CHRONIC SUPPURATIVE OTITIS MEDIA
Long-standing infection of a part or whole of the middle ear cleft characterized by
ear discharge and a permanent perforation.
CSOM

tubotympanic atticoantral
SAFE TYPE UNSAFE TYPE

FEATURES tubotympanic atticoantral

Profuse, mucoid, Scanty, purulent,
Discharge odourless foul smelling
Central Attic or
Perforation marginal
Granulations Uncommon Common
Polyp Pale Red and fleshy
Cholesteatoma Absent Present
Complications Rare Common
Audiogram Mild to moderate Conductive
conductive deafness or mixed deafness

A) Polyp in the ear canal.

(B) polyp arising from the
promontory passing through the
perforation and presenting in
the ear canal.
 46

Attic and posterosuperior marginal perforation are seen

in dangerous type of CSOM and are often associated
with a cholesteatoma.
 47

Retracted tympanic membrane with A large central perforation.

attic retraction pocket (arrow) due to
negative pressure in the middle ear.

(A) Attic perforation. (B) Case with double perforation (1) in the pars tensa posterior to the
handle of malleus and (2) in the attic area with destruction of the lateral attic wall (arrows).

Anterior perforation Subtotal perforation

 48
Management

Sometimes, the patient reports of a paradoxical effect,

:
tubotympanic i.e. hears better in the presence of discharge than when
the ear is dry. This is due to “round window shielding
effect” produced by discharge which helps to maintain
phase differential.

Hearing is normal when ossicular chain is intact or when

atticoantral cholesteatoma, having destroyed the ossicles, bridges the
gap caused by destroyed ossicles (cholesteatoma hearer).
 49

COMPLICATIONS
Patient with history of chronic mild ear
infection now presents with neurological
manifestation, headache and vomiting. CT
brain is shown. Probable diagnosis is.
A. Extra dural abscess
B. Cerebral abscess
C. Temporal lobe abscess
D. Meningitis [NEET 21]

COMPLICATIONS

INTRATEMPORAL INTRACRANIAL
1. Mastoiditis 1. Extradural abscess
2. Petrositis 2. Subdural abscess
3. Facial paralysis 3. Meningitis
4. Labyrinthitis 4. Brain abscess
5. Lateral sinus thrombophlebitis
6. Otitic hydrocephalus.
PATHWAYS OF SPREAD OF INFECTION
Venous
direct bone erosion thrombophlebitis preFormed pathways

1. Acute infections Veins of 1. Congenital dehiscences

- Hyperaemic Haversian canals
2. Patent sutures
decalcification Dural veins 3. Previous skull fractures
2. Chronic infection 4. Surgical defects
- Osteitis Dural venous sinuses 5. Oval and round windows.
-Erosion by
6. Labyrinth -> internal acoustic meatus
cholesteatoma or Superficial veins
-> aqueducts of the vestibule ->
granulation tissue. of brain
cochlea -> meninges.
 50

Mastoiditis

Spread of infection from mucosal lining the mastoid air cells to involve the bony
walls of the mastoid air cell system.
Pathological processes:
1. Production of pus under tension. empyema
2. Hyperaemic decalcification and osteoclastic of mastoid
resorption of bony walls.
Pus may break through mastoid cortex leading to sub- periosteal abscess.
The abscess may even burst on surface leading to a discharging fistula.
Abscesses of mastoiditis

postauricular - Commonest abscess; pus travels along the lamina cribrosa.

abscess - Pinna is displaced forwards, outwards and downwards.

Zygomatic - Due to infection of zygomatic air cells

abscess - Pus collects either superficial or deep to the temporalis muscle

beZold - Neck swelling over sternocleido mastoid muscle

abscess - Pain, fever, a tender swelling in the neck and torticollis

meatal abscess - Swelling is seen in deep part of bony meatus

(luc abscess)

citelli’s abscess - Neck swelling over posterior belly of digastric muscle

behind the mastoid

parapharyngeal or - Infection of the peritubal cells due to acute coalescent

retropharyngeal
abscess mastoiditis.

1. postauricular
abscess
2. Zygomatic
1 abscess
3 3. beZold
abscess
4 4. citelli’s
abscess
 51

Mastoid fistula on right side in a 5-year-old child Natural fistula in mastoid

Zygomatic abscess (lateral view) Zygomatic abscess (posterior view)

Acute mastoiditis. Pinna is pushed Burst mastoid abscess exuding pus

downward and forward.
 52

LATERAL SINUS THROMBOPHLEBITIS

Inflammation of inner wall of lateral venous sinus with formation of a thrombus
PATHOLOGY
1. Formation of perisinus abscess.
2. Endophlebitis and mural thrombus formation.
3. Obliteration of sinus lumen and intrasinus abscess.
4.Extension of thrombus.
Clinical Features
1. Hectic picket-Fence type oF Fever with rigors
2. Headache as intracranial pressure rises due to venous obstruction.
3. Progressive anaemia and emaciation
4. Griesinger’s sign:- Oedema appears over the posterior part of mastoid due to
thrombosis of mastoid emissary vein.
5. Papilloedema- Fundus may show blurring of disc margins, retinal haemorrhages or
dilated veins
6. Tobey-ayer test- Compression of jugular vein on healthy side produces rapid
rise in CSF pressure
7. Crowe-beck test- Pressure on jugular vein of healthy side produces engorgement of
retinal veins and supraorbital veins
8. Tenderness along jugular vein and torticollis

Delta sign
Can be visualised in contrast enhanced CT and MRI
Triangular area with rim enhancement and central low density area
Seen in posterior cranial fossa on axial cuts
Filling defect in the right internal jugular vein and
sigmoid sinus

[11-111×18120]

Q. Signs seen in Otitis media?

 53

Otosclerosis
otospongiosis
Primary disease of the bony labyrinth.
Fissula ante fenestram
- In front of the oval window
—The site of predilection for stapedial type of otospongiosis.
TYPES OF OTOSCLEROSIS
stapedial otosclerosis.
Cause stapes fixation and conductive deafness is the most common variety.
Anterior focus- Lesion starts just in front of the oval window “fissula ante fenestram.”
Posterior focus- Lesion may start behind the oval window
Circumferential- Around the margin of the stapes footplate
Biscuit type- In the footplate but annular ligament being free
Obliterative type- Completely obliterate the oval window niche

cochlear otosclerosis
Involves region of round window or other areas in the otic capsule,
May cause sensorineural hearing loss probably due to liberation of toxic materials
into the inner ear fluid.
histologic otosclerosis
Remains asymptomatic
Causes neither conductive nor sensorineural hearing loss.

A young female presenting with bilateral

conductive hearing loss (CHL) with intact drum
should be investigated for otospongiosis.

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 95 )

Textbook of Ear, Nose and Throat, BS Tuli (Pg 86 )
 54
SYMPTOMS
1. Hearing loss.
Painless and progressive with insidious onset.
Often it is bilateral conductive type.
2. Paracusis willisii.
An otosclerotic patient hears better in noisy than in quiet surroundings. This is
because a normal person will raise his voice in noisy surroundings.
3. Tinnitus. It is more commonly seen in cochlear otosclerosis and in active lesions.
4. Vertigo. It is an uncommon symptom.
5. Patient has a monotonous, well-modulated soft speech.

SIGNS
• Tympanic membrane is normal and mobile
• Schwartze’s sign +ve (10% cases)
Reddish hue due to an active focus covered by vascular mucous membrane
of otospongiosis on the promontory. (Flamingo pink appearance of tympanic membrane)
• Tuning fork tests show CHL
• Gelle test is positive and pure tone audiometry (PTA) shows normal BC and Carhart notch
Carhart’s notch
Dip in bone conduction curve.
It is different at different frequencies but maximum at 2000 Hz

[11-11^9517]

Q. Identify the
disease from
audiogram?
 55

TREATMENT
Stapedectomy/stapedotomy
0tosclerotic stapes is removed and a prosthesis inserted between the incus
and oval window

(A) Before removal of stapes.

(B) Stapes removed and
replaced by a teflon piston

Stapes prostheses

At Teflon piston

B) Platinum– teflon piston

c) Titanium–teflon piston.

Complications
Intraoperative: Postoperative:
• Bleeding • Acute otitis media
• Facial nerve injury • TM perforation
• Perilymph gusher. • CHL
• Fracture/dislocation of incus • SNHL and vertigo, tinnitus
• Floating footplate (Iatrogenic). • Facial nerve palsy
• Chorda tympani nerve injury (dysgeusia).
 56

Facial Nerve and its Lesions

Facial Nerve

Facial nerve is a mixed nerve of second branchial arch and develops during 3rd week
from fascio acoustic primordium, which gives rise to VII and VIII cranial nerves
• Four nuclei of facial nerve are situated in lower part of pons
• These four nuclei are
Motor nucleus,
Superior salivary nucleus,
Lacrimatory nucleus
Nucleus of tractus solitarius (gustatory nucleus)
• Motor root of the facial nerve winds around the abducens nucleus from medial to
lateral side and emerges at the cerebellopontine angle and at the base of brain
• Sensory root(nerve of Wrisberg) and motor root lie medial to VIIIth nerve to
reach the internal acoustic meatus.
Course of facial nerve

Intratemporal
(1) Meatal
(2) Labyrinthine,
(3) Tympanic
(4) Mastoid

Branches of facial nerve on face.

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 99 )

Textbook of Ear, Nose and Throat, BS Tuli (Pg 92 )
 57
FACIAL NERVE PALSY

CAUSES OF FACIAL PARALYSIS

Supranuclear and nuclear
• Cerebral vascular lesions
• Poliomyelitis
• Cerebral tumors.
Infranuclear
• Bell’s palsy
• Trauma (birth injury, fractured temporal bone, surgical)
• Tumors (Acoustic neuroma, parotid and tumors of middle ear)
• Acute or chronic otitis media
• Ramsay Hunt syndrome
• Multiple sclerosis
• Guillain–Barré syndrome
• Sarcoidosis.

BELL’S PALSY
Idiopathic, peripheral facial paralysis or paresis of acute onset
Ischemia due to vasospasm leading to edema of the connective tissue in the facial
nerve canal compresses the nerve.
Theory of vasospasm also substantiates the palsy following exposure to cold.
clinical Features

Bell phenomenon
Patient is unable to
close his eye. On
attempting to close
the eye, eyeball turns
up and out.
 58

Facial nerve palsy right side Facial nerve palsy

(lower motor neuron type)
Bilateral Facial Paralysis
• Guillain-Barré syndrome
(demyelinating polyneuro-pathy)
• Leukemia
• Bulbar palsy
• Skull fracture
• Sarcoidosis
• Moebius syndrome
• Bell’s palsy.

Ramsay–Hunt syndrome
Vesicles appear in the ear canal
along with VII nerve weakness and
pain in the area
In severe form, sensorineural
hearing loss (SNHL), disturbed
vestibular function and signs and
symptoms of viral encephalitis.
Cause: virus Varicella, which affects
geniculate ganglion.
 59

Vertigo and Meniere’s Disease

VERTIGO
Aural Causes
External ear
a. Wax
b. Furuncle.
Middle ear
a. Eustachian tube catarrh
b. Otitis media (usually unsafe).
Inner ear
1. Trauma:
2. Infections:
3.Thromboembolism of the vessels supplying labyrinth.
4. Acoustic neuroma.
5. Motion sickness.
6. Ototoxic drugs like streptomycin.
7. Others:
a. Ménière'sdisease:Benign paroxysmal positional vertigo (BPPV).
b. Vestibular neuritis: Lermoyez syndrome.

Extra Aural
Hypertension with atherosclerotic changes in the blood vessels
supplying the labyrinth.
Disseminated sclerosis.
Tumors or abscess of cerebellum.
Increased intracranial tension.
Head injury
Diabetes mellitus causing neuronitis of the VIII nerve.
Hypoglycemia.
High refractive error.
Diplopia.
Cervical spondylosis Anemia.

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 111 )

Textbook of Ear, Nose and Throat, BS Tuli (Pg 111)
 60

MÉNIÈRE'S DISEASE
endolymphatic hydrops
Disorder of the inner ear where the endolymphatic system is distended with endolymph.
Characterized by
(i) vertigo,
(ii) sensorineural hearing loss,
(iii) tinnitus
(iv) aural fullness.

(A) Normal cochlear duct. (B) Cochlear duct is distended with

endolymph pushing the Reissner’s
membrane into scala vestibuli.
Aetiologic factors and symptomatology
 61

STAGING OF MÉNIÈRE’S DISEASE

Based on pure
tone average in
dB in previous
6 months.

(A) Audiogram in early Ménière’s disease.

Hearing loss is sensorineural and more in
lower frequencies—the rising curve.

(B & C)As the disease progresses, middle

and higher frequencies get involved and
audiogram becomes flat or falling type

Treatment of Ménière’s disease

 62

Tinnitus
Sound sensation perceived by the patients
1. Subjective, which can only be heard by the patient.
2. Objective, which can even be heard by the examiner with the use of a stethoscope.

Nonsurgical measures for control of tinnitus

Anxiolytics, hypnotherapy, biofeedback,
control of allergy
Use of tinnitus maskers.
Surgical measures
Cervical sympathectomy,
Cochlear nerve section,
Labyrinthectomy,
Chorda tympani nerve section
Pulsatile tinnitus is seen in glomus
Prefrontal lobotomy. jugulare and arteriovenous shunts.
 63

Tumors of the Ear

Tumours of External Ear

Keloid following piercing of an ear lobule. Squamous cell carcinoma of pinna

Venolymphatic malformation of the pinna

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 117 )
Textbook of Ear, Nose and Throat, BS Tuli (Pg 103)
 64

osteoma arising from the anterior wall Carcinoma. External auditory

of right external auditory canal. meatus eroding mastoid cortex

Malignant melanoma of Malignant mass in the ear canal

pinna and meatus

TUMORS OF MIDDLE EAR

1. Primary tumours
(a) Benign: Glomus tumour
(b) Malignant: Carcinoma, sarcoma
2. Secondary tumours
(a) From adjacent areas, e.g. nasopharynx, external meatus and the parotid.
(b) Metastatic
Glomus Tumors
Arises from paraganglionic cells of the neuroectoderm, which are found in abundance
on the jugular bulb, along the aorta and its main branches or on the promontory
arising from tympanic branch of glossopharyngeal nerve (Jacobson’s nerve)
 65

Otoscopy shows Rising sun sign behind the bluish tympanic membrane.
‘Brown’s sign’ is seen when pressure is applied with Siegle’s speculum,
tumor pulsates and even blanches on increasing the pressure.

rhabdomyosarcoma of
the right middle ear and
mastoid
- Arises from the embryonic
muscles tissue or the
pluripotential mesenchyme.

TUMOR OF INTERNAL EAR

Acoustic Neuroma
Neurinoma, neurilemmoma, schwannoma; neurofibroma or VIII nerve tumor.
Originates from Schwann cells of the vestibular nerve
Benign, encapsulated, extremely slow-growing tumour of the VIIIth nerve.
Acoustic neuroma and its
expansion.
(A) Intracanalicular.
(B) Tumour extending into
cerebellopontine angle.
(C) Tumour pressing on CN V.
(D) Very large tumour pressing
on CN V, IX, X, XI, and
brainstem and cerebellum.

A 60 yr old male presented with complaints of bilateral hearing loss and occasional
episodes of vertigo, HPE is shown below. What is the diagnosis?
a. Vestibular schwannoma c. Epidermis cyst
b. Meningioma d. Glomus tumour [INICET 21]
 66

CT scan of acoustic
MRI cerebellopontine angle neuroma
showing acoustic neuroma
Auditory Symptoms
• Progressive unilateral sensorineural hearing loss, sudden onset (10%)
• Unilateral tinnitus (earliest symptom)
• Difficulty in understanding speech [poor speech discrimi nation score (SDS)]
• Recruitment is not present
• Short increment sensitivity index (SISI)—low score
• Tone decay of more than 30 dB is present.
Vestibular Symptoms

• Vague imbalance may be a feature

• Canal paresis present
• Nystagmus of first degree
• Past pointing and positive Romberg’s test
• Ataxia occurs, if tumor is very large.
Cranial Nerve Lesions
• Absent or reduced corneal reflex indicates a large tumor going into CP angle involving V
nerve (earliest sign)
• Sensory disturbances of face
• Facial tic may be present before actual facial nerve palsy
• Hypoesthesia of posterior canal wall (Hitselberger’s sign)
• Reduced taste threshold
• Reduced lacrimation
• IX and X nerve involvement - dysphagia and hoarseness of voice
• Raised intracranial tension (late feature) - papilledema, headache and vomiting
• Cerebellar symptoms - ataxia, nystagmus, incoordination
• Weakness, numbness of arms and legs, increased tendon reflexes- brainstem involvement
• Ultimately, stupor, respiratory failure and coma
 67

Rehabilitative Methods
Hearing Aids

(A) Body-worn. (B) Behind-the-ear type. (C) Spectacle type. (D) In-the-ear type.
Bone-anchored hearing aid (BAHA).

INDICATIONS FOR BAHA

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 135)

Textbook of Ear, Nose and Throat, BS Tuli (Pg 119 )
 68
Cochlear Implants

It is an electronic device, detects mechanical

sound energy and converts it to electrical
signals, stimulates the cochlear nerve
directly and therefore replaces the function
of cochlea
[NEET ! 8 ]

Electrode is place in Scalia tympani.

Parts of cochlear implant

Principle of cochlear implant

MED-EL cochlear implants Nucleus cochlear implant

Advanced bionics cochlear implant system.

 69

Nose and Paranasal sinuses

Anatomy and Physiology of Nose

Parts of nose and related facial structures

Osteocartilaginous framework of nose. (A) Lateral view. (B) Basal view.

Cartilaginous and bony septum of nose

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 149, 157 )
Textbook of Ear, Nose and Throat, BS Tuli (Pg 137)
 70

Lateral wall of nose

The lateral wall has 3 conchae or turbinates:
1. Inferior turbinate- Independent bone
2. Middle turbinate- Projection from the medial surface of the ethmoidal labryrinth.
3. Superior turbinate- Projection from the medial surface of the ethmoidal labryrinth.
The space below each conchae is meatus.

Inferior meatus Middle meatus Superior meatus

Largest meatus Ethmoidal bulla-
Smallest meatus
Opening of nasolacrimal rounded elevation
Opening of posterior
duct Hiatus semilunaris-
ethmoidal sinus
Hasner’s valve/ lacrimal semicircular sulcus below bulla
fold present at the Infundibulum-
opening passage of anterior end of hiatus

Openings of middle meatus

Opening of the frontal air sinus Sphenoethmoidal
recess
at anterior part of the hiatus semilunaris Triangular fossa above superior
Opening of the maxillary sinus turbinate.
at posterior part of the hiatus semilunaris Opening of sphenoidal air sinus
Opening of the middle ethmoidal air sinus
at the upper margin of the bulla
 71

[11-11145120]

Q. Identify
inferior
turbinate?

CT view of lateral wall of nose;

FS: Frontal sinus; ***indicates hiatus semilunaris;

ST: Superior turbinate; MT: Middle turbinate;
IT: Inferior turbinate; A: Aggar cells;
B: Bullar cell
 72

Little’s area
kisselbach plexus
Situated over the anteroinferior part of nasal septum
Most common site of epistaxis Mnemonic
Anastomoses of 4 arteries Gass
1. Greater palatine artery
2. Anterior ethmoidal artery
3. Sphenopalatine artery
4. Septal branch of superior labial artery

Internal carotid artery

Ophthalmic artery
Anterior ethmoidal Posterior ethmoidal
artery artery

Little’s area

sphenopalatine
Septal branch artery

Superior labial
artery

Greater palatine Maxillary

Facial artery artery artery

External carotid artery

[ AIIMS 2020]

Q. Branches of Kisselback plexus arteries?

Woodruff’s plexus
Situated at the posterior end of inferior turbinate.
Site of posterior epistaxis in adults
 73

Physiology of nose

Inspiratory air currents Expiratory air currents

Olfactory pathways and olfactory bulb

“Conveyor belt”
mechanism of mucus
blanket to entrap and
carry organisms and dust
particles.
 74

Diseases of External Nose and Nasal Septum

DISEASES OF EXTERNAL NOSE

Frog face deformity of nose Congenital hemangioma of nose

Congenital anomaly of external nose Saddle nose deformity

Congenital swelling with a sinus of nose Triple nares with congenital buphthalmos

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 161, 165 )
Textbook of Ear, Nose and Throat, BS Tuli (Pg 156, 162)
 75

DISEASES OF NASAL VESTIBULE

FURUNCLE OR BOIL

Acute infection of the hair follicle by

Staphylococcus aureus. Trauma from
picking of the nose or plucking the
nasal vibrissae is the usual
predisposing factor.

Furuncle right nasal vestibule.

Acute vestibulitis (left side). Stenosis left naris following smallpox.

Dangerous triangle of face
 76

Diseases of Nasal Septum

DEVIATED NASAL SEPTUM (DNS)
Depending upon the site it may be:
• Anterior or cartilaginous deviations
• Posterior or bony deviations
• Superior deviations
• Anterior dislocation of septum.
Depending upon the shape:
• May be C shaped or S shaped
• Impacted nasal septum:septum is touching the lateral wall of the nose.
Cottle’s classification of deviated nasal septum (DNS):
• Simple DNS (Mild)
• Obstructed DNS (Moderate)
• Impacted DNS (Severe form).

DNS may lead to:

• Repeated middle ear infection
• Chronic sinusitis
• Mouth breathing with dental anomalies
• Atrophic rhinitis sometimes
• Recurrent infection of lower respiratory tract.
 77

Deviated nasal septum with

deviation of external nose

Anterior dislocation. Caudal border of

septal cartilage projects into right naris.

As goes the septum, so goes the nose

Cottle test
Used in nasal obstruction due to abnormality of nasal valve.
Cheek is drawn laterally while the patient breathes quietly.
If the nasal airway improves on the test side, the test is
positive and indicates abnormality of the vestibular
component of nasal valve
 78

Septal abscess.
Collection of pus between the nasal
septum and its perichondrium and
periosteum, while septal hematoma is a
collection of blood only.

Septal perforation

Septal button for closure of

Causes of septal perforation
perforation.
L: Leprosy/Lupus;
W–Wegener’s Ds; mneumonic
T: Traumatic; Lets walk Thru An MRI
A: Abscess;
M: Myiasis;
R: Rhinolith;
I: Idiopathic.

Bony septal perforation is

seen in syphilis
 79

Granulomatous Disorders and Foreign Body in Nose

Granulomatous Disorders

Rhinoscleroma nose

Rhinoscleroma showing foamy Mikulicz cells

(arrow) and lymphocytic infiltration (arrowheads)
Chronic granulomatous disease caused by Gram- negative bacillus called
Klebsiella rhinoscleromatis or Frisch bacillus.

Mikulicz cells are large foam cells with a central nucleus and vacuolated cytoplasm
containing causative bacilli.
Russell bodies are homogenous eosino- philic inclusion bodies found in the plasma cells.
They occur due to accumulation of immunoglobulins secreted by the plasma cells.

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 175 )

Textbook of Ear, Nose and Throat, BS Tuli
 80
Leprosy nose.

Infection starts in anterior part of nasal septum and anterior end of inferior turbinate.
Initially, there is excessive nasal discharge with red and swollen mucosa.
Later, crusting and bleeding supervene.
Nodular lesions on the septum may ulcerate and cause perforation.
Late sequelae of disease are atrophic rhinitis, depression of bridge of nose
and destruction of anterior nasal spine with retrusion of the columella

Rhinosporidiosis

(A) a polypoidal mass protruding (B) multiple sites of involvement,

through the naris viz. nose, conjunctiva and tongue.

(A) rhinosporidiosis (blue arrow) (B) sporangium (blue arrow) with immature
evoking mixed inflammatory response sporoblasts at periphery and mature ones at centre
 81
FOREIGN BODIES
If a child presents with unilateral, foul-smelling nasal discharge, foreign
body must be excluded
COMPLICATIONS

1. nasal infection and sinusitis.

2. rhinolith formation.
3. inhalation into the tracheobronchial tree.

Maggot nose.

(A) Swelling of the nose and puffy eyelids with serosanguinous nasal discharge.
(B) Maggots have practically destroyed the cheek and eye
(C) Perforation of the palate

NASAL SYNECHIA
Adhesion formation between the nasal septum and
turbinates by scar tissue is often the result of
injury to opposing surfaces of nasal mucosa.
 82

Inflammatory Disorders of Nasal Cavity

1. Acute inflammatory conditions:
- Acute rhinitis
- Acute nasal diphtheria.
2. Chronic inflammatory conditions:
• Specific:
– Nasal syphilis, tuberculosis, lupus and leprosy
– Rhinoscleroma
– Rhinosporidiosis
– Sarcoidosis
– Midline granulomas.
• Nonspecific:
– Atrophic rhinitis
– Chronic hypertrophic rhinitis
– Rhinitis sicca
– Rhinitis caseosa
• Allergic:
– Seasonal allergic rhinitis
– Perennial allergic rhinitis
– Vasomotor rhinitis.

ATROPHIC RHINITIS (OZAENA) A woman is presented to ENT OPD with complaints of

nasal obstruction. O/E greenish black crust seen in
nasal cavity covering turbinate and septum. She also
had merciful anosmia. What other sign will you find
in this case on examination : [NEET 21]
A. Roomy nose C. Foreign body
B. Nasal polyp D. Inferior turbinate hypertrophy
^

Chronic inflammation of nose

characterized by atrophy of
nasal mucosa and turbinate
bones
Wide nasal cavity in atrophic rhinitis

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 171)

Textbook of Ear, Nose and Throat, BS Tuli (Pg 167)
 83

Symptoms
It is a bilateral condition mostly in females present with:
• Nasal obstruction
• Nose bleed
• Headache
• Merciful anosmia—foul smell, which the patient herself is unable to perceive due to
atrophy of olfactory nerves and excessive crusting of nose.
Signs
• Grayish black crusts in the nose
• Nasal passages are roomy
• Turbinates are shrivelled and detachment of crusts- bleeding and ulcerated mucosa
• In late cases, septal perforation and saddle nose may be present
• Eustachian tube catarrh is present and paranasal sinuses and pharynx may be affected.

Treatment
• Medical treatment includes: Complete or partial closure
– Regular nasal cleaning [NEET'2O]
of nostril is done for which
condition?
– Antibiotic in antiozaene solution
– Application of 25 percent glucose in glycerine which inhibits the growth of
proteolytic organisms.
• Surgical treatment
Young’s (complete closure of nostril)or modified Young’s operation(partial closure)
Allergic Rhinitis
IgE-mediated immunologic response of nasal mucosa to airborne allergens and is
characterized by watery nasal discharge, nasal obstruction, sneezing and itching in nose.
CLASSIFICATION OF ALLERGIC RHINITIS (ARIA)
 84

Nasal Polypi
Non-neoplastic masses of oedematous nasal or sinus mucosa.
Types
1. Simple polypi
– Ethmoidal polypi
– Antrochoanal polypi.
2. Fungal polypi.
3. Malignant polypi.
 85

Origin of multiple ethmoidal polypi Antrochoanal polyp

Antrochoanal polyp projecting

through the left nostril A polyp protruding from the left nostril in a
patient with bilateral ethmoidal polypi.

An antrochoanal polyp seen hanging Polyp after removal

in the oropharynx from behind the
soft palate on the right side of uvula
 86

Endoscopic view of a choanal Endoscopic view of multiple nasal polypi.

polyp on the right side.

NASAL OBSTRUCTION

UNILATERAL BILATERAL
 87

Epistaxis
Bleeding from inside the nose

Blood supply of the nasal septum

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 197 )
Textbook of Ear, Nose and Throat, BS Tuli (Pg 185 )
 88

Blood supply of the lateral wall of the nose.

SITES OF EPISTAXIS
1. Little’s area(90% cases)
2. Above the level of middle turbinate (anterior and posterior ethmoidal vessels )
3. Below the level of middle turbinate. (branches of sphenopalatine artery)
4. Posterior part of nasal cavity- directly into the pharynx.
5. Diffuse. Both from septum and lateral nasal wall.
6. Nasopharynx.
[AIIMS 19]

Q. Identify the arteries and branches?

 89

management of nosebleed
• Nasal packing: Anterior and posterior nasal packing or nasopharyngeal balloon
• Cauterization of bleeding area A 35 year old male presents with epistaxis. Conservative management
• Pterygopalatine fossa block was done to stop the bleeding but it failed which will be the next step of
• Laser photocoagulation management.
A. Endoscopic sphenopalatine artery ligation
• Pharmacologic treatment
B. Maxillary artery ligation
• Arterial ligation C. ICA ligation
• Embolization D. ECA ligation [NEET 21]
anterior nasal packing

(A) Packing in vertical layers. (B) Packing in horizontal layers.

 90

Technique of postnasal pack.

Epistaxis balloon for

posterior epistaxis.
Posterior balloon (A) is inflated with
10 mL and anterior balloon (B) with
30 mL.
Catheter provides nasal airway.
Q. Identify the method of
management of epistaxis?

Complications Trotter's method of

management of epistaxis
'
[MEET 19]
Death in 0.6 percent cases may be due to:
• Cerebral hemorrhages
• Aspiration
• Shock
• Septicemia
• Pneumonia
• Coronarythrombosis
• Intestinal infarction.
 91

FRACTURES

B
C

(A) Fracture of nasal bones with

(B) Fracture after manual correction.
displacement of bridge to right.

CT scan showing blow out fracture A) Jarjaway Fracture

of the right orbital floor. B) Chevallet fracture
 92

Anatomy and physiology of PNS

Paranasal sinus
Air containing spaces surrounding the nasal cavity
Lined by Ciliated pseudo stratified columnar epithelium
Sinusitis- Inflammation of the mucosa of sinuses
Paranasal sinuses
Anterior group Posterior group
Posterior Superior meatus
Maxillary Open in middle ethmoidal
Frontal meatus
Anterior ethmoidal Sphenoid Sphenoethmoidal recess

Development
Maxillary & Ethmoid At birth ; pneumatized at 7yrs [-11111×152020]
Sphenoid 3 yrs
Frontal 6yrs Agger nasi- Anterior most
air cell of anterior
ethmoidal air cell

Nerve supply
Maxillary Maxillary branch of Trigeminal nerve
Frontal Ophthalmic branch of Trigeminal nerve
Ethmoidal Ethmoidal nerve <- Nasociliary nerve <- Ophthalmic branch of Trigeminal nerve
Sphenoid Ophthalmic and Maxillary branch of Trigeminal nerve

CT nose and PNS.

PEC: Posterior ethmoidal cells;
B: Bulla;
IT: Inferior turbinate;
SUT: Superior turbinate;
MIT: Middle turbinate

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 209 )

Textbook of Ear, Nose and Throat, BS Tuli (Pg 190)
 93
X-ray views of pns
Caldwell’s view Water’s view
1. Occioitofrontal view 1. Occipitomental view with mouth closed
2. Better assessment of frontal sinus 2. Better assessment of maxillary sinus

Pierre’s view
1. Water’s view taken with mouth open Lateral view
2. Better assessment of sphenoid sinus 1. All 4 sinuses can be visualised

FUNCTIONS [ AIIMS 20 ]

1. Air conditioning, i.e. warming and moistening. Q. Identify Caldwell view?

2. Reduction of skull weight.
3. Increases the olfactory area (in animals). [NIEETÉO]

4. Heat insulation.
Q. Occipito mental view with
5. Vocal resonance. mouth closed is called?
6. Provides mechanical rigidity to skull.
7. Pressure dampening.
[NEET 118]
8. Secretion of mucus to keep nasal chambers moist.
9. Absorption of shock to face and skull during injuries. Q. Water’s view is used for
assessment of ?
10. Regulation of intranasal pressure.
 94

Diseases of Paranasal Sinus

Rhinosinusitis

• Acute RS: Symptoms lasting for less than 4 weeks with complete resolution.
• Subacute RS: Duration 4-12 weeks.
• Chronic RS: Duration ~ 12 weeks.
• Recurrent RS: Four or more episodes of RS per year;
each lasting for 7-10 days or more with complete resolution in between the episodes.
Symptoms
• Nasal obstruction.
• Nasal discharge/congestion
• Facial pain or pressure.
• Alteration in the sense of smell, hyposmia or anosmia.
• cough, fever, halitosis, fatigue, dental pain, pharyngitis, headache or ear fullness.

Pathophysiology of acute viral rhinosinusitis

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 213)

Textbook of Ear, Nose and Throat, BS Tuli (Pg 195)
 95

Sequence of acute viral to acute bacterial rhinosinusitis

Sequence of events
following sinus ostial
obstruction leading to
chronic rhinosinusitis.

Pain in the sinuses

a. Antral pain:
Along the infraorbital margins and referred to upper teeth or gums on affected side.
b. Ethmoidal pain:
Localized over bridge of nose and inner canthus of eye referred to parietal eminence.
c. Frontal sinus pain:
Localized to forehead and pain is periodical in nature
d. Sphenoidal pain:
Gives rise to occipital or vertical headache and is referred to mastoid process.
 96

Causative factors and pathophysiology of chronic sinusitis

X-ray paranasal sinuses (PNS)

Endoscopic view of a case of
showing air-fluid levels in both antra
acute maxillary sinusitis
 97
COMPLICATIONS OF PARANASAL SINUS INFECTION

'
[NEET 19 ]

Pott’s puffy tumour is

subperiosteal abscess of
frontal bone.

Mucocele of the frontal sinus Osteomyelitis of maxilla with fistula

formation in infraorbital region
 98

Chronic frontal sinusitis presenting with a

CT scan of mucocele of the left fistula exuding pus in the floor of the sinus
frontoethmoid region.
SOURCE AND ROUTE OF INFECTION IN CAVERNOUS SINUS THROMBOSIS
 99

Tumors of Nose and Paranasal Sinus

TUMOURS OF EXTERNAL NOSE

Basal cell carcinoma of the nose

Rhinophyma

Carcinoma nose

Carcinoma nose

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 227)

Textbook of Ear, Nose and Throat, BS Tuli (Pg 210)
 100

TUMOURS OF NASAL CAVITY

Squamous papilloma nose Inverted papilloma

Capillary haemangioma (bleeding

polypus of the septum).

An inverted papilla
masquerading as a simple polyp
 101
Neoplasms of Paranasal Sinuses

Carcinoma maxilla Carcinoma maxilla with

extension into the oral cavity

Carcinoma maxilla with

Squamous cell carcinoma ethmoids
extension into the orbit

frontoethmoidal osteoma Osteoma right frontal sinus

with invasion of the orbit
 102

Fibrous dysplasia of maxilla

Antroethmoidal carcinoma left side.(B) expansion of alveolus and palate.

Ohngren’s line extends from medial

canthus of eye to the angle of mandible.
Weber–Fergusson’s incision
Growths anteroinferior to this plane have
[AIIMS 17 ] used in maxillectomy
a better prognosis than those
Q. Identify the line?
posterosuperior to it
 103

Oral cavity, Pharynx & larynx

Diseases of Oral Cavity & Salivary Glands
CAUSES OF ULCERS

Aphthous ulcers
Multiple aphthous ulcers on
the uvula and faucial pillars

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 241)

Textbook of Ear, Nose and Throat, BS Tuli (Pg 223, 230)
 104

A large exophytic mass with ulceration

at the top on the left side of tongue in a
58-year-old male, habituated to chewing
tobacco and “pan.” It was due to sharp
gagged teeth; healed on extraction of
teeth.

Ulcer on lateral border of tongue simulating carcinoma (arrowheads). It was caused by a

sharp jagged tooth (A) and healed com- pletely following tooth extraction (B).

ulcerations on the palate Oral thrush

 105

Tongue-tie. Geographical tongue.

Oral submucous fibrosis

(A) blanched appearance of the soft palate and faucial pillars.

(B) Marked trismus due to submucous fibrosis.
 106

Lesions of oral cavity

ranula
Cystic lesions is a mucous retention
cyst in the floor of mouth arising from
minor salivary glands.
If it penetrates the myelohyoid muscle,
it is called plunging ranula

Fibroepithelial polyp in the left cheek

It is a smooth, mucosa-covered
pedunculated tumour pyogenic granuloma
It is a reactive granuloma usually occurs in
response to trauma or chronic irritation.

mucocele
Leukoplakia at the site of
Retention cyst of minor ‘quid’ (of tobacco and lime)
salivary glands of the lip
 107

(A) A haemangioma on the lateral border of the tongue.

(B) Multiple haemangiomas involving both lips, buccal mucosa and tongue

Carcinoma of the upper lip and Carcinoma of the buccal mucosa

oral commissure

Ulcerative type of squamous cell

carcinoma of the tongue Mixed salivary tumour palate
 108
Anatomy of Pharynx and Larynx
Pharynx
Divisions of pharynx

Waldeyer’s ring

Subepithelial collection of
lymphoid tissue in the
pharynx forms Waldeyer’s
ring.
It has no afferents and
efferents drain into
cervical lymphnodes.
It consists of
nasopharyngeal tonsil,
tubal tonsil, faucial tonsil
and lingual tonsil

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 269, 319 )
Textbook of Ear, Nose and Throat, BS Tuli (Pg 237, 285 )
 109

Pharynx opened from behind

Zenker’s diverticulum
Killian’s dehiscence is a gap
between oblique and transverse
fibers of inferior constrictor
muscle

Endoscopic view of nasopharynx showing

torus tubarius in the lateral wall of
nasopharynx.
Fossa of Rosenmüller is the commonest
site for the origin of carcinoma
nasopharynx.
 110

Larynx

Coronal section of larynx

Laryngeal framework
MUSCLES OF LARYNX

Acting on vocal cords

Acting on laryngeal inlet
 111

LARNGEAL CARTILAGES

Unpaired Paired

Thyroid Cartilage(largest) Arytenoid Cartilage

Cricoid Cartilage Corniculate Cartilage of Santorini
Epiglottis Cuneiform Cartilage of Wrisberg

- Thyroid, Cricoid and Arytenoid Cartilages are Hyaline cartilages.(undergo ossification)

- Epiglottis, Corniculate and Cuneiform are Elastic fibrocartilage

Laryngeal Membranes

EXTRINSIC INTRINSIC

Thyrohyoid membrane Cricovocal membrane

Cricotracheal membrane Quardrangular membrane
Hyoepiglottic ligament Cricothyroid ligament
Thyroepiglottic ligament
 112

Inflammatory Diseases of Pharynx, Nasopharynx, Tonsils

ADENOIDS
nasopharyngeal tonsil
Adenoid facies.
Chronic nasal obstruction and mouth breathing lead to
characteristic facial appearance .
The child has an elongated face with dull expression,
open mouth, prominent and crowded upper teeth and
hitched up upper lip.
Nose gives a pinched-in appearance due to disuse
atrophy of alaenasi’
Hard palate is highly arched as the moulding action of
the tongue on palate is lost.
A 10 yr child with crowded teeth’s and apparently mouth breather
came to the opd. Identify the condition from the image given?
a. Horse facies
b. Adenoid facies
c. Frog face
d. Goldenhar syndrome

Enlarged adenoids Adenoid mass after removal with curette

Adenoid tissue is seen on MRI in all infants by

age of 5 months, gradually it increases in size
and is at its maximum on 6–7 years. Starts
regressing at puberty and disappears by the
age of 15 years. Persistence of tissue may be
seen beyond 15 years in cases of allergy or
infection.

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 275 )

Textbook of Ear, Nose and Throat, BS Tuli (Pg 246)
 113

PHARYNGITIS
ACUTE PHARYNGITIS

Keratosis pharyngis showing keratotic

excrescences appearing like follicular tonsillitis.
Chronic hypertrophic (granular) pharyngitis.

Tonsillitis

1. Acute catarrhal or superficial tonsillitis.

Tonsillitis is a part of generalized pharyngitis and is mostly seen in viral infections.
2. Acute follicular tonsillitis.
Infection spreads into the crypts which become filled with purulent material,
presenting at the openings of crypts as yellowish spots
3.Acute parenchymatous tonsillitis.
Tonsil substance is affected. Tonsil is uniformly enlarged and red.
4. Acute membranous tonsillitis.
It is a stage ahead of acute follicular tonsillitis when exudation from the crypts
coalesces to form a membrane on the surface of tonsil.
 114

Acute follicular tonsillitis.

Pus beads on the surface of left tonsil.
On the right pus beads have coalesced
together to form a membrane.

Parenchymatous tonsillitis.
The two tonsils are almost touching
each other causing problems of
deglutition, speech and respiration.

Tonsillar cyst
Due to blockage of a tonsillar crypt and
appears as a yellowish swelling over the
tonsil. Very often it is symptomless.

Complications
• Peritonsillitis and quinsy
• Parapharyngeal and retropharyngeal abscesses in the throat
• Laryngeal edema
• Otitis media
• Septicemia
• Septic foci leading to subacute bacterial endocarditis (SABE), nephritis or
rheumatic fever, brain abscess, mediastinitis aspiration pneumonia.
 115

Head and Neck Space Infections

Ludwig’s angina
Infection of submandibular space
Submandibular space lies between
mucous membrane of the floor of
mouth and tongue on one side and
superficial layer of deep cervical fascia
extending between the hyoid bone and
mandible on the other
PERITONSILLAR ABSCESS OR QUINSY

CNIEETKO ]
Collection of pus in the peritonsillar space Site of drainage is just lateral to the junction
which lies between the capsule of tonsil of vertical line through anterior pillar and
and the superior constrictor muscle. horizontal line through base of uvula.

Q. A 9 year old boy presents with sore throat/

dysphgia, drooling of saliva, trismus, ipsilateral
otalgia and fever. Identify the condition from the
pic? [NEET 120 ]
 116

Spaces in relation to pharynx where abscesses can form

A) Prevertebral abscess (tubercular) (B) An X-ray of the same.

Retropharyngeal abscess.
Radiograph of soft tissue, lateral view of the
neck shows widening of prevertebral shadow and
possibly even the presence of gas
 117

Congenital lesions and Inflammation of Larynx

Stridor
Noisy respiration produced by turbulent airflow through the narrowed air passages.
Types of stridor and their site of origin

'
[ MEET 19 ]

Q. Inspiratory stridor origin is form ?

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 333)

Textbook of Ear, Nose and Throat, BS Tuli (Pg 295)
 118

LaryngoMaLacia
Excessive flaccidity of supraglottic
larynx which is sucked in during
inspiration producing stridor and
sometimes cyanosis.
Direct laryngoscopy shows elongated
epiglottis, curled upon itself (omega-
shaped Ω), floppy aryepiglottic folds
and promi- nent arytenoids.

LaryngeaL weB
Due to incomplete
recanalization of larynx.

laryngotracheitis (croup) and epiglottitis

 119

acute epiglottitis
Lateral soft tissue X-ray of neck may show
swollen epiglottis (thumb sign).

Vocal nodule

Singer’s nodes consists of localized epithelial hyperplasia of

the free edge of both vocal cords usually at the junction of
X-ray showing foreign
anterior one-third and posterior two-thirds.
body larynx

Vocal polyp
Single, smooth, pink and pedunculated
mass arising from one cord
It produces cough due to up and down
movements of mass during
respiration.
 120

Tumors of Oropharynx , Hypopharynx, Larynx

Tumours of Nasopharynx

Carcinoma nasopharynx Secondaries lung–Cannon Ball appearance

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 305, 343 )
Textbook of Ear, Nose and Throat, BS Tuli (Pg 272, 320)
 121
Tumors of Oropharynx
Carcinoma right tonsil

Pleomorphic adenoma palate 4. What is the most common salivary gland tumors?
a. Adenocarcinoma
b. Pleomorphic adenoma
c. Mucoepidermoid tumor
d. Basal cell carcinoma [NEET 2021]

TUMOURS OF LARYNX
BENIGN TUMOURS OF LARYNX

Vocal nodules Sessile vocal polyp on the left cord

 122

Supraglottic papillomatosis
Juvenile papillomatosis is the most common
benign neoplasm of the larynx in children.
Caused by human papilloma DNA virus
type 6 and 11
Papillomas mostly affect supraglottic
and glottic regions of larynx but can
also involve subglottis, trachea and
bronchi [NEET119 ]

Q. Identify the condition from pic?

Supraglottic cancer also invading the

Supraglottic cancer involving
right piriform fossa (arrow).
epiglottis and right aryepiglottic fold.

Cancer involving supraglottic, glottic and subglottic areas

on the left of the larynx, as seen in rigid endoscopy.
 123

Thyroid Gland and Its Disorders

Anatomy of thyroid gland

LINGUAL THYROID

Surgical removal should be done, if lingual thyroid causes symptoms of airway

obstruction or dysphagia by suprahyoid transpharyngeal approach.
It requires lifelong replacement of thyroid hormone, if it was the only thyroid tissue.

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 369 )

Textbook of Ear, Nose and Throat, BS Tuli (Pg 355)
 124

HYPOTHYROIDISM

HYPERTHYROIDISM

CAUSES OF HYPERTHYROIDISM AND THYROTOXICOSIS

• Graves’ disease (autoimmune disorder)
• Toxic multinodular goitre
• Autonomous nodule
• TSH-secretory pituitary tumour
• Functioning thyroid cancer/ metastases
• Exogenous intake of thyroid hormone (thyrotoxicosis factitia)
• Thyroiditis
 125

Large thyroid goiter Solitary thyroid nodule

Massive thyroid goiter

MEDULLARY CARCINOMA

MULTIPLE ENDOCRANIAL NEOPLASIA syndrome

 126

Instruments
Ear Instruments
Myringotome

[NEET18]

Used for myringotomy. A sickle knife used in myringoplasty can Q. Identify

also be used to perform myringotomy. the
instrument ?

Mollison’s mastoid retractor.

[1111×15120]
Q. Identify the instrument ?

Used in mastoidectomy to retract

soft tissues after incision and
elevation of flaps.
It is self-retaining and haemostatic.

Jansen’s self-retaining mastoid retractor

Used in mastoidectomy similar

to Mollison’s retractor.

Lempert’s endaural retractor.

Used for endaural approach to ear surgery.
It has two lateral blades which retract the flaps and a
third central blade with holes.
The central blade retracts the temporalis muscle.
The central blade can be fixed to the body of the
retractor by its hole.

Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 513)

Textbook of Ear, Nose and Throat, BS Tuli (Pg 503)
 127

Lempert’s endaural speculum.

It is like Vienna model nasal

speculum but curved.
It is used to spread open the
meatus when giving local
injection or making an endaural
incision.

Mastoid gouge.

Used to remove bone in mastoid surgery. Various sizes are available.

However, it is not used now. A drill is preferred to gauges.

Lempert’s curette (scoop).

Used for removal of bony septa and granulations in mastoid surgery.

MacEwen’s curette and cell seeker.

Used in mastoid surgery to explore the air cells with one end, and to curette
the intervening septa and granulations with the other.
Farabeuf’s periosteal elevator.

Used for elevation of periosteum from the mastoid cortex in mastoidectomy.

 128
NOSE INSTRUMENTS
Lichtwitz trocar and cannula.

Used for proof puncture (antral lavage).

Puncture is done in the inferior meatus as this site is easily accessible and safe.
Rose’s sinus douching cannula.

Used in irrigation of maxillary sinus, which already has a nasoantral window due to
intranasal antrostomy or Caldwell-Luc operation.
Direction of the tip is indicated by the hook outside (arrow).

Luc’s forceps.
Used in Caldwell-Luc operation (to
remove mucosa), submucosal
resection (SMR) operation (to remove
bone or cartilage), polypectomy (to
grasp and avulse polyps) and to take
biopsy from the nose or throat.

Nasal snare (Krause’s).

Used for removal of nasal polypi. Polyp is engaged in the wire loop and avulsed. Wire
used in this snare is 30 SWG.
With the advent of endoscopic surgery, its use has declined.
 129

St. Clair Thomson’s nasal

speculum.
It has long blades which are
concave from inside. Used in
nasal surgery, e.g. SMR
operation or septoplasty.

Killian’s long-bladed
nasal speculum. Used in
SMR or septoplasty operation to
keep mucoperiosteal flaps away.

Hartmann’s dressing forceps. Tilley’s dressing forceps.

Similar to above forceps. It has a Used for nasal packing, ear dressing,
screw joint. The jaw is serrated and removal of foreign bodies from the nose.
grooved It has a box joint.
 130

Wilde’s dressing forceps.

Used for packing the nasal cavity or ear canal.
It acts on spring action.

Ballenger swivel knife.

Used in removal of septal cartilage in SMR operation. The blade of knife revolves
automatically and changes direction when cutting the cartilage anteroposteriorly
downwards, and posteroanteriorly. Different sizes of blades are also shown. Can be used
to harvest septal cartilage as a graft for reconstruction.

Killian’s nasal gouge (bayonet-shaped).

Used for removal of septal spurs or bony crests and ridges in SMR operation.

Walsham’s forceps.
Used for disimpacting and
reducing fractures of nasal
bone.

Asch’s septum forceps.

Used for reducing fractures of
nasal septum.
 131

THROAT INSTRUMENTS

Boyle-Davis mouth gag. Doyen mouth gag

Used to keep the mouth open for intraoral

Used for opening the mouth and
surgery when retraction of the tongue is not
depressing the tongue.
required

Jenning’s mouth gag.

Use is similar to the one above.
It is applied in the centre of
the mouth.

Tonsil holding forceps (Denis Browne’s).

Used for holding the tonsil during tonsillectomy by dissection method.

 132

Tonsil dissection forceps with teeth (Waugh’s)

For incision in mucous membrane and dissection of tonsil.

Yankauer suction tube.

Used for suction in tonsillectomy and other oral or oropharyngeal operations.

Nowadays disposable plastic ones are available.

Tonsil dissector and anterior pillar retractor.

One end is used to dissect the tonsil and the other end to retract the
anterior pillar to inspect the tonsillar fossa for any bleeding point.

Negus artery forceps.

Its tip is sharply curved. The forceps is used as replacement forceps to

ligate the bleeding point.
 133

Negus knot tier.

Helps to carry the ligature knot deep up to the tip of artery forceps holding the
vessel and tie it.

Eves’ tonsil snare.

Used for tonsillectomy.

After the tonsil has been dissected till its lower pole, snare is passed round the
tonsil to engage the pedicle and then firmly closed.
It crushes and cuts the pedicle thereby minimizing bleeding. Wire used in snare is
number 25 SWG.
Peritonsillar abscess forceps.

Used for drainage of peritonsillar abscess. Not used these days.

A number 11 blade covered with micropore plaster except at its tip and distal part is
used to stab the abscess and then it is opened with an artery forceps.

St. Clair Thompson’s adenoid curette with guard.

Used in adenoidectomy. Curette shaves off the adenoid mass while the guard holds
this tissue and prevents slipping. With the advent and use of debrider and coblation
techniques, use of the curette is declining.
 134

Leighton tonsillotome (Guillotine).

Used for tonsillotomy or tonsillectomy. Not used these days. Tonsillotomy cuts away
projecting and obstructive part of tonsils.

(A) Anterior commissure laryngoscope;

(B) Rigid 90° endolaryngoscope
 135

Negus laryngoscope Chevalier Jackson Laryngoscope

Bronchoscope

It is used for examination of

trachea and bronchi for
diagnostic as well as
therapeutic purposes.

Fiberoptic hypopharyngoscope

Fiberoptic hypopharyngoscope
is a fiberoptic device to examine
the upper and lower
aerodigestive system.
 136

Chevalier Jackson’s tracheostomy tube

'

EET 18 ]

Q. Indication of
tracheostomy?

Inner tube of Jackson tracheostomy tube is longer than outer tube (by 2–3 mm)
and gets blocked by tracheobronchial secretions, which can be removed, cleaned
and reinserted.
when the inner tube is removed, the outer tube remains in place and so airway
remains patent

(A) Bivalve tracheostomy tube; (B) Portex tracheostomy tube cuffed

Laryngeal mask airway.

Laryngeal mask airway (LMA) is a device with a tube and a laryngeal mask
which fits over the supraglottic region.
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