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and the greater palatine artery (posteriorly). The Kiesselbach plexus, or the Little area,
represents a region in the anteroinferior third of the nasal septum, where all 3 of the chief
blood supplies to the internal nose converge.
Veins in the nose essentially follow the arterial pattern. They are significant for their direct
communication with the cavernous sinus and for their lack of valves; these features potentiate
the intracranial spread of infection
Lymphatics arise from the superficial mucosa and drain posteriorly to the retropharyngeal
nodes and anteriorly to the upper deep cervical nodes and/or submandibular glands
Clinical significance
The nasal septum can depart from the centre line of the nose
in a condition is known as a deviated septum caused by
trauma. However, it is normal to have a slight deviation to one
side.
A perforated nasal septum can be caused by an ulcer, trauma
due to an inserted object, excessive nose-picking, long-term
exposure to welding fumes,[3] or cocaine use. There is a
procedure that can be of help to those suffering from
perforated septum. A silicone button can be inserted in the
hole to close the open sore. An operation to the nasal septum
is known as a septoplasty.
The nasal septum can be affected by both benign (fibroma,
inflammatory hemangioma of the nasal septum"bleeding
polyp" etc.) and malign tumors (squamous cell carcinoma,
esthesioneuroblastoma etc.)
11)ALLERGIC RHINITIS
is an allergic inflammation of the nasal airways. It occurs
when an allergen, such as pollen, dust or animal dander
(particles of shed skin and hair) is inhaled by an individual
with a sensitized immune system. In such individuals, the
allergen triggers the production of the antibody
immunoglobulin E (IgE), which binds to mast cells and
basophils. IgE bound to mast cells are stimulated by allergens,
causing the release of inflammatory mediators such as
histamine (and other chemicals). This usually causes sneezing,
itchy and watery eyes, swelling and inflammation of the nasal
passages, and an increase in mucus production
Allergic rhinitis may be seasonal or perennial. Seasonal
allergic rhinitis occurs particularly during pollen seasons. It
does not usually develop until after 6 years of age. Perennial
allergic rhinitis occurs throughout the year. This type of
allergic rhinitis is commonly seen in younger children
Signs and symptoms
The characteristic symptoms of allergic rhinitis are: rhinorrhea
(excess nasal secretion), itching, and nasal congestion and
obstruction Characteristic physical findings include
conjunctival swelling and erythema, eyelid swelling, lower
eyelid venous stasis (rings under the eyes known as "allergic
shiners"), swollen nasal turbinates, and middle ear effusion.[6]
. Diagnosis
Laboratory tests:
Allergy skin tests (immediate hypersensitivity testing):
An in vivo method of determining immediate (IgEmediated) hypersensitivity to specific allergens
Radioallergosorbent test (RAST): Indirectly measures the
quantity of immunoglobulin E (IgE) serving as an
antibody to a particular antigen
Total serum IgE:
Total blood eosinophil count: Imaging studies used in the
diagnosis and evaluation of allergic rhinitis include the
following:
Radiography: Can be helpful for evaluating possible
structural abnormalities or to help detect complications
or comorbid conditions, such as sinusitis or adenoid
hypertrophy
Computed tomography scanning: Can be very helpful for
evaluating acute or chronic sinusitis
Management
The management of allergic rhinitis consists of the following
3 major treatment strategies:
Environmental control measures and allergen avoidance:
These include keeping exposure to allergens such as
pollen, dust mites, and mold to a minimum
Etiology
Heredity factors: the disease runs in families
Endocrine imbalance: the disease tends to start at puberty
and mostly involves females
Racial factors: whites are more susceptible than natives
of equatorial Africa
Nutritional deficiency: vitamins A or D, or iron[citation needed]
Infection: Klebsiella ozaenae, diphtheroids, Proteus
vulgaris, E. coli, etc.
Autoimmune: viral infection or some other unidentified
insult may trigger antigenicity of the nasal mucosa
Pathology
The ciliated columnar epithelium of the nasal mucosa is
replaced by stratified squamous epithelium. Atrophy of
mucosa, turbinal bones and seromucinous glands tends to
occur, due to obliterative endarteritis causing decreased blood
supply, hence the supplying area atrophies.
Clinical manifestations
The disease is most commonly seen in females, and tends to
appear during puberty. It can occur, however, as early as 12
months of age. The nasal cavities become roomy and are filled
with foul smelling crusts which are black or dark green and
dry, making expiration painful and difficult. Microorganisms
are known to multiply and produce a foul smell from the nose,
though the patients may not be aware of this, because their
elements (responsible for the perception of smell) have
become atrophied. Patients usually complain of nasal
obstruction despite the roomy nasal cavity, which can be
caused either by the obstruction produced by the discharge in
the nose, or as a result of sensory loss due to atrophy of nerves
in the nose, so the patient is unaware of the air flow. In the
case of the second cause, the sensation of obstruction is
subjective. Bleeding from the nose, may occur when the dried
discharge (crusts) are removed. Septal perforation and
dermatitis of nasal vestibule can occur. The nose may show a
saddle-nose deformity. Atrophic rhinitis is also associated
with similar atrophic changes in the pharynx or larynx,
producing symptoms pertaining to these structures. Hearing
impairment can occur due to Eustachian tube blockage
causing middle ear effusion.
Permanent loss of smell and impairment of taste may also be a
result of this disease, even after the symptoms are cured.
Secondary atrophic rhinitis
Specific infections, such as syphilis, lupus, leprosy and
rhinoscleroma, may cause destruction of the nasal structures
leading to atrophic changes. Atrophic rhinitis can also result
from long-standing purulent sinusitis, radiotherapy of the nose
or excessive surgical removal of turbinates.
Unilateral atrophic rhinitis
Extreme deviation of nasal septum may be accompanied by
atrophic rhinitis on the wider side
used
4. Antihistamines can be considered if allergy is suspected
to be the cause
Surgical:
1. Antral lavage
2. Middle meatal antrostomy
3. FESS
18) Describe the etiology, signs, symptoms &management
of Acute maxillary sinusitis.
SinusitisCan be defined as inflammation of the mucosa
lining the paranasal sinuses Can be classified into acute
and chronic Allergic & infective types Pan sinusitis is the
term used to indicate inflammation of all the paranasal
sinuses
. Acute sinusitis Acute inflammation of mucosa lining
paranasal sinuses of less than 4 weeks duration. Infection
is said to be closed if the inflammatory exudate cannot
escape from the sinus because of blocked ostium or viscous
secretion Infection is said to be open if the exudate escapes
from the sinuses due to normal functioning mucociliary
clearence mechanism
Pathophysiology Acute sinusitis is caused when the normal
defence mechanisms like lysozymes and mucociliary
clearance mechanism is breached due to viral infection. After
the defences are breached, secondary bacterial infection
follows.
. Aetiology InfectionsSwiming / bathingTrauma to
paranasal sinuses As a component of general disease.
InfectionsNasal infectionsPharyngeal infectionsDental
infections
mucoceles
10.
11.
12.
13.
14.
15.
16.
17.
Acute laryngitis.
Laryngeal polyp.
Causes of left vocal cord paralysis.
Branchial sinus in the neck.
Tic-doloreaux (trigeminal neuralgia).
Carina.
Laryngocoele.
Acute epiglottitis.
VINDICATE
VVascular(thoracicaneurysm)
IInflammation
NNeoplasm
DDegenerative(Amyotrophiclateralsclerosis)
IIntoxication(smoking/alcohol)
CCongenital
AAllergies(angioneuroticoedema)
TTrauma/Thyroidsurgery
EEndocrinology(Reidel'sstruma)
Inflammatory causes:
This is one of the commonest causes of hoarseness of voice.
Inflammatory causes could either be acute / chronic.
Acute inflammatory causes: include acute laryngitis, acute
Hyperkeratosis
Pachydermia
Leukoplakia
Malignant tumors of larynx:
Carcinoma vocal cords
Congenital conditions:
Congenital vocal cord webs
Foreign bodies
Reinke's oedema
1. Change in voice
2. Cough
3. Fever
4. Vocal fatigue
5. Irritation / soreness of throat
6. Weight loss
7. Painful vocalization
8. Difficulty in swallowing
9. Breathy voice
10.
Neck swelling
11.
Painful swallowing
12.
13.
Haemoptysis
14.
Noisy respiration
Diagnosis:
Evaluation of hoarseness of voice should include:
Assessment of
Anatomy
Physiology
Behavioral factors
A complete history should be elicited.
Laryngeal visualization :
Indirect laryngoscopy / Direct laryngoscopy
Objective voice assessment: simplest method would be a
tape recording of the voice in question. This method should
be considered to be subjective.
Acoustic analysis: In this test voice is examined as electrical
Introduction:
FESS is an acronym for Functional Endoscopic Sinus Surgery.
This surgery aims at restoring the normal function of paranasal
sinuses
.Indications for FESS:
1. Chronic sinusitis resistant to medical management
2. Repeated acute exacerbations of chronic sinusitis
3. In order to remove resistant focal infections from the paranasal
sinuses
4. In the management of fungal sinusitis in an effort aimed at
ventilation of paranasal sinuses
Aim of FESS - is to remove paranasal sinus drainage block there by
facilitating faster recovery of the mucociliary mechanism of nose and
paranasal sinuses. Experiments have shown that drainage of sinuses
always occur through their natural ostium because cilia always beat
towardstheir natural ostium
.Procedure:This surgery is usually performed under local / general
anesthesia.The nasal cavity is packed with 4% xylocaine mixed with 1
in 100,000 units of adrenaline. Xylocaine anesthetizes the nasal
mucosa while adrenaline decongests the nasal mucosa thereby
increasing the dimensions of nasal cavity and reduces bleeding during
surgery.
0 degree nasal endoscope is used to perform the surgery
.Steps of surgery:
1. Medialization of the middle turbinate. This is done gently
using a freer's elevator. Infiltratingthe root of middle
turbinate with cc of 2% xylocaine mixed with 1 in
100,000 units adrenaline will ensure anesthesia of the
middle meatus which is the area of surgery.
2. Uncinectomy: Uncinate process is identified and
medialized using a probe. It is completely removed using a
sickle knife / back biting forceps. It is important that the
uncinate process is removed completely including its
inferior horizontal portion. Natural ostium of maxillary
sinus can be seen when the horizontal portion of inferior
scarlet fever was one of the most dreaded epidemics. With the advent
of excellent antibiotics this condition is not threatening anymore.
Incidence: This condition frequently affects children between 4-8
years. This infection is rare in children under the age of 2 because of
the presence of maternal antibodies
.Clinical features:Scarlet fever has an incubation period ranging from
1-4days. Evolution and presentation of thisdisease is usually dramatic.
These patients complain of: Sudden onset fever Throat pain Malaise
Myalgia Characteristic skin rash appears within 12 48 hours after
the onset of fever.If these patients are untreated the fever peaks by 48
hours.Condition abates within a couple of days after starting treatment
with appropriate antibiotics.
On examination :Exudative tonsillitis usually precede this
condition.Tonsillar infections are usually accompanied by
erythematous oral mucous membrane along with petechiae / punctate
red macules over hard palate/soft palate/uvula. These spots are known
as Forchheimer's spots. The tongue appears coated and reddish
raspberry tongue.
Features of skin rash:1. Rash generally appears within 12 48 hours
after the onset of fever. In the beginning it appearsas erythematous
patches below the pinna, chest and axilla. Dissemination to the trunk
andextremities occur within the first day.
2. The rashes typically consist of scarlet macules over generalized
erythema (Boiled lobster appearance).
3. The skin lesion later evolves to become more diffuse, and later turn
punctate resembling sunburn / goose pimples.
4. Fragile capillaries under the skin ruptures displaying arrays of
petechiae known as (Pastialines).
5. Circumoral pallor is another distinguishing feature seen in these
patients.
6. Peeling of skin occurs in the skin of axilla, groin, and toes
.Blood count shows predominant leucocytosis. Eosinophilia
develops during the first week of infection.Throat culture is
diagnostic. It also helps in deciding the sensitivity of the organism to
the specific ntibiotic.
Management:The goals in managing this disease are
1. Prevention of acute rheumatic fever
these turbinates may contain a large air cell in which case they are
termed as concha. These turbinates are named according to their
positions: Superior turbinate Middle turbinate Inferior turbinate
Supreme turbinate rarely A prominence can be seen commonly
anterior to the attachment of middle turbinate. This is known as
aggernasi. This projection usually over lie the lacrimal sac. This
prominence may be of varying shapes in different individuals. This
prominence is considered to be remnants of nasoturbinal bones seen
in animals.Under each of these turbinates and lateral nasal wall a
space is enclosed. The space between inferior turbinate and lateral
nasal wall is known as the inferior meatus. The nasolacrimal duct
drains into the inferior meatus in its anterior third. This opening is
covered by mucosal valve known as Hassner's valve. The course of
the nasolacrimal duct lie under the agger nasi cell.Middle meatus:This
critical space lies between the middle turbinate and the lateral nasal
wall . In this space opens the drainage channels of the anterior group
of paranasal sinuses.
These include:1. Frontal sinus
2. Maxillary sinus
3. Anterior ethmoidal sinus
4. Middle group ethmoidal sinus It is this space which is critical in the
pathophysiology of sinusitis. It is this space that is relevant in
functional endoscopic sinus surgery.
Uncinate process: This boomerang shaped (L) shaped bone forms the
first layer (lamella) of middle meatus. This bone should be removed
in its entirety in order to visualize the natural ostium of maxillary
sinus and frontal sinus drainage channel.
Ethmoidal infundibulum: This is a cleft like three dimensional space
in the lateral wall of the nose.This space is bounded medially by the
uncinate process and the mucosa covering it. Major portion of its
lateral wall is bounded by lamina papyracea, and the frontal process
of maxilla to a lesser extent. Defects in the medial wall of
infundibulum is covered with dense connective tissue and periosteum.
These defects are known as anterior and posterior fontanelles
.Hiatus semilunaris: This lies between the anterior wall of bulla and
the free posterior margin of uncinate process. This hiatus semilunaris
leads to the ethmoidal infundibulum.
of this triad is a must for the diagnosis of atrophic rhinitis. This triad
include:
1. Fetor
2. Crusting
3. Atrophy
Age of onset This disorder commonly occurs at puberty. Females are more
commonly affected than males Bernat postulated that iron deficiency could
probably cause this condition.
Histopathology:
1. Metaplasia of ciliated columnar epithelium into squamous epithelium
2. There is a decrease in the number and size of nasal compound alveolar glands
3. Dilated capillaries can be seen
Pathologically atrophic rhinitis has been divided into two types:
Type I This is characterized by the presence of endarteritis and periarteritis of
terminal arterioles.Usually this type could be caused by chronic infections.
These patients benefit from the vasodilator effects of oestrogen. Majority of
these patients belong to this categoty.
Type II This type is characterised by vasodilatation of capillaries and these
patients are likely to worsen with oestrogen therapy. The endothelial cells of
these capillaries contain more cyto-plasm than those of normal capillaries.
These cells also show active reaction for alkaline phosphatase indicating rapid
bone destruction.
Clinical classification of atrophic rhinitis:
Clinically atrophic rhinitis can be classified into primary and secondary types
.Primary atrophic rhinitis:This is the classic form of atrophic rhinitis and is
supposed to arise denovo. Diagnosis of this type of atrophic rhinitis is by the
process of exclusion. All the known causes of atrophic rhinitis should be ruled
out before branding the patient to be suffering from primary atrophic rhinitis.
The causative organisms in these patients are usually klebsiella ozenae.
Secondary atrophic rhinitis:This is the most common form of atrophic rhinitis
seen in developed countries. The most common causes of this form of atrophic
rhinitis include:
1. Extensive destruction of nasal mucosa and turbinates during nasal surgery
2. Following irradiation
3. Following granulomatous infections like syphilis, leprosy and tuberculosis
Clinical features:
1. Nasal obstruction
2. Epistaxis
3. Anosmia (Merciful)
4. Foul smelling greenish yellow crust can be seen inside the nasal cavity
5. Roomy nasal cavity due to atrophy of nasal mucosa and turbinate bones
4 Role of ear drum in sound conduction:The ear drum conducts sound from
external ear to middle ear. According to Bekesey the ear drum moves like
a stiff plate up to the frequency levels of 2 KHz. Above this frequency the
vibrating pattern gets broken up and becomes more complex. The ear
drum serves to conduct sound preferentially in the frequency ranges
between 2-5 Khz. The handle of the malleus is attached to the centre of
the ear drum. This relationship helps in conduction of sound from the
external ear to the middle ear.
Role of middle ear in sound conduction:The middle ear serves to couple
sound energy to the fluids of cochlea. It should be borne in mind that sound gets
reflected from the interface separating two media with different impedances.
Thisis true of the middle and inner ear interface because the cochlear fluids
have higher impedanceto sound when compared to that of air in the middle ear
cavity. In order to conduct sound efficiently without loss, the middle ear should
function as an impedance matcher. The middle ear serves to convert low
pressure high displacement vibrations to high pressure low displacement ones
which is favorable for sound conduction via cochlear fluids. The middle ear
apparatus couples sound preferentially to one window of the cochlea there by
creating differential pressure between the oval and round windows which
pushes the cochlear fluid in a forward direction
.Components of middle ear transformer mechanism:
1. The surface area of ear drum is 55 mm
2. , while the surface area of foot plate of stapes is
3. 3.2 mm 2. The difference between these surface areas happens to be
roughly 17 times. Thus the forces collected by the ear drum are
concentrated over a small area causing movementof cochlear fluids
towards round window
4. .2. Ossicular lever ratio. This roughly works out to 2.1 times. The incus is
shorter than the malleusand this is very important for lever action of
ossicles. This lever action increases the force and decreases the velocity
at the level of stapes.
5. 3. Buckling effect of ear drum: The ear drum curves from its rim to its
attachment to the manubrium.This buckling effect causes greater
displacement of the ear drum and lesser displacement of the
manubrium.This middle ear transformer mechanism ensures that at least
50% of the incident sound energy gets transmitted to the cochlea
.Role played by cochlea:Sound traveling through cochlea causes a
mechanical traveling wave which forms the basisof frequency selectivity.
Features of cochlear traveling wave:
1. As the wave travels along the cochlea it reaches a peak and dies down
rapidly
2. The basilar membrane vibrates at a constant frequency for all low
frequency sounds and drops abruptly above certain frequency levels.It has
been shown that basal turn of cochlea responds best to high frequency
sounds and the apex of cochlea responds better to low frequency sounds
.Role of auditory fibers:In response to stimulus, neurotransmitter is
released in the synapses at the base of inner hair cells.This gives rise to
action potentials in the auditory nerve fibers. Single auditory nerve
stimuli is always excitatory and never inhibitory. This action potential is
conveyed to the auditory centers of brain by the auditory division of the
8th nerve.The following are the proposed theories of hearing
:Place theory of Helmontz - This theory proposes that frequency
resolution occurs at the levelof basilar membrane. The various zones of
basilar membrane are sensitive to different frequenciesand this spatial
relationship play a role in frequency resolution.
Telephone theory of Rutherford This theory assumes that the whole
cochlea responds as a whole to all the frequencies. This theory assumes
that cochlea reacts to various frequencies like a telephone cable.
Volley theory of weaver This theory proposed by Wever assumes that
several neurons acting as a group can fire in response to the frequency to
which they are sensitive to.
Place theory of Lawrence Lawrence combined both volley and place
theories to explain how sounds are perceived.
Traveling wave theory of Bekesy This theory assumes that frequency
coding took place at the level of cochlea.Auditory center of brain is
located at the superior gyrus of temporal lobe
.Functions of auditory center:Sound localization and lateralization
Speech discrimination Auditory performance with competing acoustic
signals
Auditory performance with degraded signals
.. Pure tone audiometry
Introduction:This procedure is performed to measure the auditory
threshold of an individual. The instrument used for this purpose is known
as the audiometer.
Components of a pure tone audiometer:Oscillator:The function of an
oscillator is to generate electronically standardized sound whose
frequencies liewithin + / - 3% of their supposed value.
The frequencies generated include: 125, 250,500, 750,1000,1500, 2000,
3000, 4000, 6000 and 8000 Hz
.Interrupter switch: This switch helps in turning on and off the sounds
which are presented to the patient from the oscillator. This is important
because presenting a continuous tone to a patient may cause auditory
decay causing problems with interpretation of results. This switch
provides the option of presenting the sound in a continuous / interrupted
manner.
straightening of cervical spine (Ram Rod spine) due to the presence of cervical
paraspinal muscle spasm.In almost all these patients a small air pocket could be
seen above the prevertebral soft tissue mass in the lateral view. This air shadow
could be caused due to entrapment of swallowed air, or due to gas formed by
organism likeclostridia.
CT Scan / MRI Really clinches the diagnosis. CT scan helps in differentiating
cellulitis from abscess. It should ideally be performed using contrast.
Contrast CT will show a hypodense lesion in the posterior pharyngeal wall with
ring enhancement along with obliteration of normal fat planes
.Management:
1. Incision & drainage should be performed at the earliest if it is acute
retropharyngealabscess. It should ideally be performed under local anesthesia
taking precaution that the childdoesn't aspirate pus during the procedure.
2. If the abscess points in the neck then it should be incised through the neck
and the incision should ideally be sited behind the sternomastoid muscle
.3. In chronic retropharyngeal abscess if tuberculosis is suspected then surgery
is deferred andthe patient is immediately started on anti TB drugs
.4. After surgical drainage a course of antibiotics should be ideally started. The
drug of choicebeing drugs belonging to cephalosporin group. Metronidazole
should also be administered becauseof its efficacy against anaerobes
.Complications:The following complications may occur if these patients
remain untreated.
1. Mediastinitis
2. Airway compromise
3. Atlanto occipital dislocation
4. Jugular venous thrombosis
5. Cranial nerve deficits especially the last three nerves
Hemorrhage secondary to involvement of carotid artery
A male patient aged 60, chronic smoker, comes with c/o Hoarseness of voice
of 1 year of 1 yr duration. How do you investigate and treat him?
Introduction:Vocal cord undergoes changes due to exposure to pollutants and
cigarette smoke. Cigarette smokeis supposed to contain carcinogens which
causes the vocal folds to undergo excess keratinization.This excess
keratinization causes whitish thickening of the vocal folds with loss of normal
mucosal wave pattern leading on to hoarseness of voice. It should be borne in
mind that hoarseness of voice in a chronic smoker should always be viewed
with caution as there is likelihood of malignancy.
Investigations:
Videolaryngoscopy This is performed under local anesthesia. It helps in the
assessment of vocal fold status in real time.
Thickening of the vocal folds can be clearly documented and recorded.
Mobility of vocal cords can be assessed.
Hyperkeratosis of the vocal folds / carcinoma in situ can only be identified after
studying the histopathology of the lesion for which biopsy of the suspicious
looking lesion is a must.
Direct laryngoscopy under GA / LA should be performed if there is a suspicious
looking lesion in the vocal fold as seen in videolaryngoscopy examination
.Smoker's laryngitis This is chronic inflammation of vocal folds commonly
seen in chronic smokers.Since these patients have bronchitis they constantly
keep coughing putting the vocal folds under tremendous amount of stress. This
causes inflammation of vocal folds leading on to hoarseness of voice. These
patients will benefit from cessation of smoking and improved hydration.
Hyperkeratosis of vocal folds can be managed by cessation of smoking,
encouraging the patient toconsume lots of fluids and providing absolute rest to
the voice.
Keratotic patches can be stripped away from the vocal folds by performing
microlaryngeal surgery under general anesthesia.This condition also goes by the
term leukoplakia.
Premalignant conditions Vocal fold dysplasias should be considered as
premalignant lesion. If thebiopsied material from the vocal fold is reported as
dysplasia then the whole suspicious looking lesion should be surgically
removed. If necessary the whole mucosal lining of the vocal fold can be
stripped leaving it bare for fresh mucosa to regenerate.
Management of these premalignant lesions should include complete abstinence
from smoking
.Carcinoma in situ This is the early malignant change which takes place on the
surface of the vocalfolds. This lesion if treated properly carries the best
prognosis. Since these patients develop hoarseness of voice they seek treatment
at an early stage. This type of lesion is limited to the epithelial layer of the vocal
fold and doesn't show invasion of lamina propria. Since vocal cords don'thave
lymphatic supply metastasis to regional nodes is not a risk at all. Regional
metastasis is possible only when the lamina propria is breached and the lesion
comes into contact with vocalis muscle. These lesions are best managed by
vocal cord stripping. This is performed using a Direct laryngoscope under
general anesthesia. Laser when used for this purpose reduces the morbidity and
mortality of the surgery. Irradiation is not indicated in these patients as these
borderline lesions may undergo malignant transformation when exposed to it.
Major clinical difference between carcinoma in situ and carcinoma of vocal fold
is that in carcinoma in situ the affected cord is still mobile since the vocalis
muscle is not involved. In carcinoma of vocal fold the cord is fixed due to
involvement of vocalis muscle. This vocalis muscle is richly supplied with
lymphatics and hence involvement of this muscle could lead to nodal
metastasis.
Malignant growth vocal cord In this condition the vocal cord appears fixed.
This is due to the fact that vocalis muscle is involved by the lesion. If there is
of the anterior wall has two openings i.e. for the entry of superior and inferior
caroticotympanic nerves. The smaller upper part of this wall has two tunnels
placed one above the other.The superior tunnel is for tensor tympani muscle and
the inferior one is for the bony portion of the eustachean tube
.Medial wall This wall separates the middle ear from the inner ear. The most
prominent portion of the medial wall of middle ear is the promontary which
overlies the basal turn of the cochlea.
.7.Hearing loss : Is also known as difficulty in hearing / hard of hearing.
Types of deafness:1. Conductive This type deafness is caused due to a
disruption in the sound conduction mechanism.2. Sensorineural This type of
deafness is caused due to pathology involving the end organ of hearing
(cochlear hair cells) or nerves conducting the sound to brain or sound perception
centers of brain.3. Mixed In this type of hearing loss both conductive and
sensorineural mechanisms areinvolved.Conductive deafness
:Causes are enumerated here
Vocal nodule Also known as Singers nodule / Teacher's nodule.This disorder
frequently affects children and adults. In children it appears as spindle
shapedthickenings of the edges of the vocal cords, whereas in adults they appear
as more localised thickenings, varying from small points - nodules. These
nodules typically appear at the junction of the anterior and middle 1/3 of the
vocal cords. They appear almost aways symmetrically.
Pathophysiology Vocal nodules are caused by a combination of overtaxing
and incorrect use of the voice. This is also aggravated by the presence of
infections in the para nasal sinuses, tonsils,and adenoids. Patients with habitual
dysphonia frequently encounter this condition. This conditioncan be effectively
prevented or cured by voice rest or by using the voice properly. Infact the
nodules can appear and disappear in a matter of weeks. If the aggravating
factors persist for a long time then these nodules become permanent.
Stages of vocal nodule formation :
Stage of transudation - Oedema occurs in the submucosal plane in this stage.
This occur during the acute phase of the disorder. This stage is reversible in
nature and may become normal ongiving voice rest
.Stage of in growth of vessels - In this stage neovascularisation of the area
occur. This phase is also reversible, but takes a long time to become normal.
Stage of fibrous organization - In this stage the transudate in the submucosal
area is replaced by fibrinous material. This stage is more or less resistant to
conservative line of management.These stages can be clearly observed by
laryngoscopy under stroboscopic light. Local oedematous swelling of recent
onset vibrates in phase with the whole vocal fold, whereas an older and more
fibrous swelling can impede the vibrations so much that only a part of the cord
Nasal myasis
acute diphtheria
Age
between 6-20
onset
Temperature
Throat pain
Toxiemia
Pulse rate
Acute onset
Very high temperature
Severe throat pain
No evidence of toxemia
proportionate to rise in
bodytemperature
Membrane
Throat swab
Slow onset
High temperature
Mild throat pain
Toxemia present
Bradycardia
common
In early stages
of myocarditis
tachycardia is
pssible
Extensive
membrane
formation on
tonsils,pillars and
uvula. Can be
removed only
withdifficulty. On
removal leaves
behind rawbleeding
areas
Throat swab shows
corynebacterium
diphtheria
Massive cervical
adenopathy (Bull's
neck)
test positive
JD nodes
Schick test
Schick test negative
^No albuminuria Albuminaria present
6.Buccal sulcus
7.Infratemporal fossa by erosion of posterior wall of antrum
Management:Of malignant tumors of maxillary antrum is
dependent on tissue diagnosis and extent of the lesion. Tissue
biopsy is a must. All these patients should under go tissue
biopsy procedures like endoscopic antrostomy / caldwell luc
surgery to obtain tissue sample for histopathological diagnosis.
Role of imaging: Imaging plays a vital role in the assessment of
anatomical site of the lesion,extensions if any can also be clearly
seen. CT scanning and MRI scanning performed before surgery
assists in staging of the disease and in planning the optimal
surgical treatment modality.CT scans are highly accurate in
identifying bony erosion / remodelling. Bony remodelling is
commonly seen in malignant tumors involving salivary glands,
large cell lymphoma and melanoma. It is also very accurate in
accessing orbital involvement as it shows clear delineation of
the lamina papyracea. It is more accurate than MRI scanning in
identifying orbital invasion / invasion of anterior skull base.
MRI scans are pretty useful in the study of perineural invasion
of tumors like adenocystic carcinoma
.Surgical management:The following are the various surgical
modalities:1.Total maxillectomy
2.Medial maxillectomy
3.Lateral rhinotomy (limited malignancies)
4.Anterior craniofacial resection
5.Anterior midfacial degloving
Irradiation:Patients with stage I antral malignancies can be
subjected to full curative dose of radiotherapy. Pre operative /
post operative radiation can be followed according to the
prevailing portocol of the institution.
Sandwich therapy:In this type of therapy these patients receive
half the dose of curative radiotherapy and surgery is performed
after 6 weeks. Six weeks following surgery these patients
receive the remaining half of the curative dose of radiotherapy.
The advantage of this treatment modality is the tumor gets down
staged following radiotherapy making the process of surgery
that much easier. Post operative radiotherapy helps in the
Ethmoidal polypi
adults
Allergy
mutiple
Arises from
ethmoidal labyrinth
Seen easily on
anterior rhinoscopy
Mostly bilateral
Antrochoanal polyp
Children and
adolescents
Infection
solitary
Seen commonly in
post nasal exam
Usually unilateral
Recurrence is
common
Recurrence is
uncommon
Polypectomy Caldwel
luc surgery in
recurrent cases
2. Grade II: The retracted pars flaccida is in contact with the neck of
the malleus to such an extentthat it seems to clothe the neck of the
malleus.
3. Grade III: Here in addition to the retracted pars flaccida being in
contact with the neck of the malleus there is also a limited erosion of
the outer attic wall or scutum
.4. Grade IV: In this grade in addition to all the above said changes
there is severe erosion of the outer attic wall or scutum.
4. Metaplastic theory: This theory was first suggested by Wendt in
1873. He took into considerationthe histological changes seen in
various portions of the middle ear cavity. The attic area of the
middle ear cavity is lined by pavement type of epithelium. This
epithelium undergoes metaplastic changes in response to
subclinical infection. This metaplastic mucosa is squamous in
nature thereby forming a nidus for cholesteatoma formation in
the attic region.Of all the above mentioned theories, the theory
of invagination appears to be the most plausible one currently
explaining the various pathologic features of cholesteatoma.
Clinical features of acquired cholesteatoma:Ear discharge: is
scanty and foul smelling. Infact the odur is best described as
musty in nature. This is due to the presence of saprophytic
infection and osteitis.Hearing loss: is commonly conductive in
nature. Some patients may even surprisingly have a normal
hearing despite the presence of a huge cholesteatoma. This
normal hearing could be attributed to the bridging effects of
cholesteatomatous mass.Sensorineural hearing loss if present
could be attributed to the absorption of toxins through the round
window membrane, or may be due to use of ototoxic antibiotics
topically on a long termbasis.
Ear ache: if present could be attributed to the presence of co
existing otitis externa, or presence of extradural abscess.Tinnitus
if present may indicate imminent sensorineural hearing
loss.Vertigo may be present if there is erosion of lateral
semicircular canal by the cholesteatomatous matrix. Fistula test
if performed is positive in these patient.
Fistula test: This test is positive if there is a third window is
present in the laryrinth due to the erosion of the labyrinthine
Figure showing the various tunnels which are created during septal
surgery Correction of septal pathology: If the deviation of the septum
is caused by excessive tension to the septal cartilage, it can be
corrected by removing an inferior cartilagenous strip. Dislocations
due tofractures can be corrected intraseptally by mobilizing or
resection of parts of nasal septum.Removal of septal pathology:
Severe deformities involving the nasal septum may rarely require
complete removal of septal cartilage. The resected area is
reconstructed using the cartilaginous elements removed from the
septum.Indications for resection include duplications, spines, crests
and convexities present in the septum.All the cartilagenous material
removed should be saved for reconstruction. The parts of nasalseptum
that are straight are preserved to support the dorsum, tip and
columella of the nose.Reshaping cartilage and bone: Reshaping of
nasal septal cartilage should be done with as littletrauma as possible,
with maximum preservation of straight portions of nasal septum.
Cerebellar abscess which occupy the posterior fossa cause raised intra
cranial tension earlier thanthose above the tentorium. This rapidly
raising intra cranial pressure cause coning or impaction of the
the pack snugly sits inside the nasopharynx, the two silk threads tiedto
its end would have reached the anaterior nares along with thefree end
of the nasal suction catheter.
Drtbalu's otolaryngology online
Figure showing postnasal pack in situThe two silk threads tied to the
suction catheters are untied. Thecatheters are removed from the nose.
The silk thread is used tosecure the pack in place by tying both the
ends to the columella of the nose. The silk tied to the middle portion
of the gauze pack isdelivered out through the oral cavity and taped to
the angle of thecheek. This middle portion silk will help in removal of
the nasal pack. In addition to the postnasal pack anterior nasal
packing mustalso be done in these patients.Postnasal pack using
baloon catheters: Specially designed balooncatheters are available.
This can be used to perform the post nasal pack. Foleys catheter can
be used to pack the post nasal space.Foley's catheter is introduced
through the nose and slid up to thenasopharynx. The bulb of the
catheter is inflated using air throughthe side portal of the catheter. Air
is used to inflate the bulb because even if the bulb ruptures
accidentally there is absolutelyno danger of aspiration into the lungs.
After the foleys catheter isinflated the free end is knotted and
anchored at the level of theanterior nares.Problems of nasal packing:1.
Epiphora (watering of eyes) occur due to blocking of the nasalend of
the nasolacrimal duct.2. Heaviness /headache due to blocking of the
normal sinusostium.3. Prolonged post nasal pack can cause
eustachean tube block andsecretory otitis media.4. Prolonged nasal
packing can cause secondary sinusitis due to blockage of sinus