Extra dural abscess

Always asymptomatic

Therefore aka silent complication of unsafe ear

Sub dural abscess

Meningitis: most common intracranial complication

Brain abscess : 2 nod most common

Temporal lobe most commonly involved

Otic hydrocephalus : least common complication

Lateral sinus thrombophlebitis

Greisinger sign: engorged mastoid veins

Crowe beck sign: engorged retinal veins

Tober Auer: no change in pressure on pressing jugular

Picket fence fever

Delta sign: on CT, we see a thrombus

Neurosurgeon/ physician opinion compulsory on intracranial

complication

Treatment of choice: MRM

Thyroplasty

Type 1: mediallization(SLN palsy)

Type 2: lateralization( recurrent laryngeal palsy)

Type 3: shortening( relaxation), decreasing the pitch, used in refractory

cases of puberphonia

Type 4: lengthening(tensing the cord), androphonia

Given by isshika

Cohn's classification for webs

Mc afee: stenosis

Levanson criteria:

Congenital cholestoma

Malignant otitis externa

Tracheostomy

Indication: severe dyspnoea

Best area : between 2 and 3rd tracheal ring

Vertical incision for emergency

Horizontal for elective

High level tracheostomy indicated for Ca larynx

Laryngeal diphtheria(infectious larynx): stay away from larynx

Low level done

Most common complication: haemorrhage

Most common physiological complication: apnea( coz of CO2 washout)

Bjork's flap

Inferior side

Decreases chances of dislodgement

laryngeal papillomatosis: always do tracheostomy and don't intubate as it

would spread the infection

Nose

Largest meatus: inferior

Length of nasal cavity: 8 cm

pH of nose: neutral

Para nasal sinus: any cavity surrounding the nasal cavity

Sphenoid sinus is postero superior to nasal ethmoidal sinus

Out of 6, 4 open in middle meatus

Ant ethmoidal

Middle ethmoid

Maxillary is the largest PNS

Capacity: 15 ml

Wall of mastoid: 15mm

Age at which mastoid matures: 15

Most functional PNS: ethmoidal

15 air cells in ethmoidal sinus

Foramen of Breschet

Present in the roof of frontal sinus

FESS

IOC= treatment of choice= FESS, if problem is in nasal cavity

Most common complication of FESS: synechiae formation

2.7 mm: pediatric

4 mm : adult age group, diameter of endoscope

Zero degree, 30,70,90 : types of endoscopes

90 degree: endoscope for larynx

Zero degree: ear

30 degree: for nasal cavity( FESS)

70 degree : for larynx if 90 does not help

Back to FESS

1st pass: inferior meatus

Naso lacrimal duct

Both Eustachian tubes

Posterior part of palate

2nd pass: super and superior

3rd pass: middle meatus

Retro orbital/ bulbar hematoma: artery involved: anterior ethmoidal artery

Very rare complication of fess

Open surgery from anterior wall of sinus

Endoscopy is always done from medial wall of sinus( lateral wall of nasal
cavity)

12 important terms

Onodi cell: posterior most cell of ethmoidal sinus, optic nerve very close

Haller cell plus floor of orbit= roof of maxillary sinus

Haler cell: bottom most air cell

Anterior most air cell of ethmoid, lying in anterior ethmoid is called

Agger nasi aka fourth turbinate

Bulla ethmoidalis: largest air cell of ethmoidal sinus, present in anterior

ethmoidal sinus

Largest turbinate: concha bullosa

Pathological finding involving most commonly middle turbinate

Most common symptom: nasal obstruction

Pneumatization of the turbinate is a cause of this

Pneumatization of orbital floor is a false impression of Haler cell

Supero anterior attachment of uncinate process: middle turbinate

Postero inferior attachment: inferior turbinate

Anterior ethmoid opens in anterior compartment

Rest 3 in posterior compartment

Hiatus semilunaris

Area behind the uncinate bone

ethmoidal infundibulum: area just behind the uncinate

It touches the posterior wall of uncinate bone

Maximum ostium open in this

Not the hiatus semilunaris

Glabella: most prominent part of the forehead

Radix is the uppermost edge of the nasal bone or root of the nose

Nasion: Angle between glabella and Radix

Rhinion: junction between bony and cartilage part of nose

Malignancies

Most common benign tumor: papilloma

Most cam,on site is vestibule

Aka vestibular papilloma

Most common site for papillary hemangioma: little's area

Mc site forCavernous hemangioma: inferior turbinate

Mc site for malignant melanoma: septum

If asked in PNS: maxillary sinus

Mc site for inverted papilloma: lateral wall of nose

Mc malignant tumor: squamous ca

Mc site for squamous cell ca: lateral wall of nose

Inverted papilloma is a pre malignant condition, focus on the site

PNS

Most common benign tumor: osteoma

Mc site: frontal

Mc malignant tumor: squamous

Site : maxillary

Most common benign tumor of sino nasal tract: osteoma

Maxillary sinus ca

All are squamous except wood Industory, there adenocarcinoma

Soft wood: squamous

Hard wood: Adeno

Most common site involved in wood industry

Adenocarcinoma, therefore, ethmoidal sinus

Mc for squamous cell ca. Maxillary

All ca treated by surgery

Maxillary cell Ca

Ohgren's. Lederman's

facial fracture

Trauma: from 5 sides

Superior and posterior trauma: skull fracture

Anterior, inferior and multidirectional: facial fracture

Mc fracture: nasal bone

Zygoma is second most common aka tripod fracture

From the frontal bone, Go to temporal bone through the zygoma

Fronto zygomatic suture

zygomatic arch

Zygomatic temporal suture

Tear drop sign : orbital floor fracture

Lee Fort classification

Based on direction of fracture line

Type 1. Type 2. Type 3.

low maxillary fracture

floating palate fracture

Gurein fracture

classification based on direction of trauma

Total possible: 3

Class 1: below, spared: orbit, ethmoid, septum aka Chevailet

Class 2: front, spared: orbit and ethmoid aka Jarjaway

Class 3: multidirectional

Always reduce immediately

If edema starts, wait for 5 days

Within first 21 days, closed reduction

After 21 days, open reduction

Rhinophyma

Hypertrophy of sebaceous glands

Mx of choice: surgery

Rhinoscleroma

Caused by bacteria Klebsiella Rhinoscleromatis

Klebsiella: streptomycin/ tetracycline

Word woody mentioned, it is rhinoscleroma

Woody swelling: Ludwig abscess

Rhinosporodiosis( south India)

Protozoal infection

Rhino Seebri

Doc: dapsone

Cautery at the base is followed by surgery because bleeds

Aka Mulberry like polyp

Other mulberry

Like mucosa: inferior turbinate Hypertrophy

Vocal cords: rhinosporodiosis

Russell bodies: plasma cell, eosinophils

Mickuliz cell: macrophage

Word diabetic is a clue for

Ear: malignant otitis externa

Nose: muco mycosis

Oral: Ludwig abscess

Bernoulli principle= obstruction= negative pressure= polyp formation

Nasal polyposis, bronchiectasis and dextrocardia: kartagener syndrome

If azoospermia instead of dextrocardia: young syndrome

Nasal polyposis, br asthma, sensitivity to aspirin: sampter's triad

Nasal polyposis

Focus on age

Less than two years: intra cranial mass, IOC is CT brain

2-10 years: recurrent polyposis, cystic fibrosis

Adolescent 10-14: antro choanal polyp

10-14 boy: angiofibroma

20-40: ethmoidal polyp

40-60: inverted papilloma

More than 60: sq cell ca

Q. All of the following landmark of sphenoid ostium during FESS except

1. Is at the junction of lower one third and upper two third

2. Is 1.5 cm from the nasal floor

3. Is 5 cm in front of nasion

4. Is at the angle of 30 degrees from the nasal floor

Rhinitis

Hypertrophic rhinitis

Inferior turbinate most commonly involved

Mx of choice: laser excision

If everything atrophied,

Atrophic rhinitis

Due to multiple factors

Atrophy of mucosa and nerves

One liter of water secreted by mucosa everyday

The secretions change to crust due to lack of water

Nerve fibre

Helps in smell and sensation

Crust turns to foul smelling crust

Thus this is due to atrophy of nerve fibre

Klebsiella could be involved

Treat by strep/ tetra

Nerve affected so no sense of smell

Merciful anosmia

Most common symptom is nasal obstruction

Sodium:

Bicarbonate

Biborate

Chloride

1:1:2

Alkaline solution

Rest to nasal mucosa: youngs operation

Close one nostril for 6 months

Modified youngs operation: Partial closure

3 mm opening left for 8 months

Lautens lager: medialize the lateral wall to partially obstruct

Neither atrophy, nor Hypertrophy

Drug induced

Anti hypertensive:

Anti cholinesterase:

OCP's:

Another pt.

No atrophy, no Hypertrophy, no current drug but history of drug intake

Rhinitis medicamentosa

Withdrawal of any vasoconstrictor leads to watery discharge

Steroid is the DOC

Another pt.

No Hypertrophy, no atrophy, no drugs,

Nerves involved

Vaso motor rhinitis

Vidian neurectomy is the tt of choice

Sinusitis

Definition of acute sinusitis < 2 weeks

2-12 : acute on chronic

Chronic is > 12 weeks

Adult: maxillary

Pediatric: ethmoid

First radiological appearance of the sinus

M: 4 month

E: 1 year

F: 6

S: 4

Frontal rarely seen in children

waters view best for max sinus

Caldwells view: ethmoidal and frontal

Lateral view or waters with open mouth for sphenoid

Lateral view: all the sinus are visible

IOC= TOC= FESS

CHEEK/ dental: max: lower eyelid swelling

Root of nose/ radix/ dorsum: ethmoid: both eyelid swelling

Occipital>retro orbital>vertex: sphenoid: post nasal drip

Office headache: frontal: upper eyelid swelling

ENT infections

Viral> bacterial> fungal

Rhinovirus> beta hemolytic strep> aspergillosis

CT is the radiological IOC for sinusitis

In fungal sinusitis, there is a fungal ball formation which is very difficult to

differentiate from a soft tissue tumor, therefore, we order MRI

Fungal sinusitis has two hallmarks

Fungal ball

Bony destruction

Both are absent in allergic fungal sinusitis

Fungal sinusitis has spread propensity

Sinusitis

Major

A: anosmia

B: blockage

C: congestion

D: discharge

F: facial pain(acute)

F: fever

Minor

Halitosis

Fever( chronic)

Any pain in the body except facial pain

Purulent discharge is the hallmark

Complications

Mucocoele

Pyocoele

Osteomyelitis

Sino cutaneous fistula

Most commonly seen in frontal sinus

POTT puffy tumor: osteomyelitis of frontal bone

Orbital cellulitis/ orbital abscess: most commonly seen in ethmoid

Most common site of fungal ball : maxillary sinus

CSF rhinorrhea

Most common site for CSF rhinorrhea: fovea ethmoidalis

But if non traumatic given: go for cribriform plate

Single ring sign: CSF, non traumatic CSF rhinorrhea aka dot sign

Double ring sign: CSF and blood

IOC: CT

Mx: wait and watch with IV antibiotics

Base of skull can not be operated

DNS: septum straight but deviated from midline: septoplasty( birth

trauma)

Crooked: septum curved and nose also curved:

septorhinoplasty( congenital)

Saddle nose:external nasal deformity, augmentation rhinoplasty( leprosy,

syphilis, TB, iatrogenic), iliac crest is the best graft

Hump nose: external nasal deformity, reduction rhinoplasty( congenital)

Epistaxis

Arteries

For septum

Ant ethmoid: branch of ophthalmic

Post ethmoid: branch of ophthalmic

Spheno palatine: maxillary( artery of epistaxis)

Greater palatine: maxillary

Sup labial: facial

For lateral wall

All same

Sup dental ( branch of maxillary) in place of sup labial

Area of epistaxis

Little area/ kisselbach plexus: anterior, septal, children, arterial, nose

picking

1 cm behind columella on septum: retro columellar vein, adult, venous,

septal

Woodruff's plexus: lateral wall, posterior, old age, venous, hypertension

Posterior is less common but more severe and vice versa

Mx of epistaxis

1% Silver nitrate: chemical cautery

Threads for removal in posterior pack

Endoscopic Arterial ligation of Spheno palatine artery( maxillary artery) is

the last resort

If above the middle turbinate: ligate the ant ethmoidal artery

External carotid ligated: old age, chemotherapy, tumor

Trotters method

Let the pt. bleed

Has nothing to do with pinching

Septum divided into 3 parts

Columellar

Membranous

Septum proper

Septum proper divided into major and minor

Major are

Perpendicular plate of ethmoid

Vomer

Qudrangular cartilage

Rostrum of sphenoid contributes and not the spine

Maximum airflow is via middle meatus in a parabolic flow

Parabolic flow limen nazi aka internal nasal valve

The three boundaries are

Junction of upper lat cartilage and lower lat cartilage

Inferior turbinate

Septum

Narrowest space of the nasal cavity

University of Pennsylvania smell inventory test

Strongest stimulus: ammonia

Osmia: small

Geusia: taste

Phantosmia: perception of smell without an odor

Kallman syndrome: hypogonadism and anosmia

Turner also has anosmia

PD is also asso with anosmia

Strawberry appearance of nose: sarcoidosis

Olfactory esthenioneuroblastoma

Neuro endocrine tumor

Olfactory mucosa tumor

Upper part of nasal cavity

Rhino clausa: hyponasality, obstruction

Rhino aperta: hypernasality, velopharyngeal insufficiency and cleft palate

Pharynx

Plane at the level of palate divides naso and oro pharynx

Oropharynx and hypopharynx divided at the level of hyoid bone

Pehle ko 1, doosre ko 2, teesre ko teen

1. Mucosa

Squamous, non keratinizing, stratified( no absorption needed here),

except in naso pharynx, ciliated columnar epithelium

2. Inner fascia: pharyngo basilar( inner so pharyngo first***)

3. Inner Muscle: stylopharyngeus, salphingopharyngeus and

palatopharyngeus

4. Outer muscle: sup, middle and inferior constrictors

All the 6 ms are laryngeal elevators

5. Outer fascia: bucco pharyngeal

pyriform sinus: most c site for hypopharynx malignancy

Internal br of SLN passes thru hypopharynx

Pyriform block is used for examination of glottis

Hypopharynx malignancy with poor prognosis: post cricoid malignancy

These are more common in females suffering from Plummer Winson

retropharyngeal space divided into rt and lt space of Gillette by fibrous

tissue

This has lymph node of Rounviere

Dysphasia and dyspnoea are common features of abscess

How to differentiate between the two

Diffuse: vertebral

Localized on one side: retro pharyngeal

Most common cause of

Prevertebral abscess: TB spine

Ch retro pharyngeal abscess: TB lung/ TB spine

Ac retro pharyngeal abscess:

In children: adenoid tonsil

In adult: penetrating iatrogenic trauma

TOC: I and D

If TB suspected, go for ATT

Intra oral approach for acute

Extra oral approach for chronic

Boundary:

Base of skull to bifurcation of trachea of retro pharyngeal abscess

Para pharyngeal abscess

Abscess on the lateral wall of pharynx from base of skull to hyoid bone

Tt is I and D at the level of hyoid bone

Space is Divided into pre and post styloid compartment

Pre styloid has pterygoid ms: trismus

Post styloid: carotid artery, jugular vein, last four CN( 9,10,11,12)

Ludwig abscess

Submandibular abscess

This space is between the floor of the mouth and deep cervical fascia

Myohyoid ms passes

Divides into upper sub lingual

Lower: sub maxillary

Diabetes

Woody

Roots of premolars: sub lingual space

Roots of molars: sub maxillary

I and D, long incision

Angiofibroma. Nasopharyngeal ca

Tonsils

Palatine tonsil: palate

Lingual tonsil: base of tongue

Tubal tonsil : surrounding Eustachian tube

Adenoids: junction. Of base of skull and C 1

Faucial tonsil: lateral wall of Oropharynx, extension of palatine tonsil

Luschka tonsil: adenoids

Gerlach: tubal tonsil

Anatomy of tonsil

Medial wall: mucosa

Lateral wall: capsule( internal fascia)

Bed: inner ms, outer ms, outer fascia

Ant pillar: palatoglossus

Post pillar: palatopharyngeus

Bed also contains

9th nerve passes

Styloid process

Tonsillitis/ pharyngitis

Adeno virus

Beta hemolytic strep

Amoxiclav is the doc

625 mg adult

375 mg children

Tonsillectomy

Rose position

Indication of tonsillectomy

Absolute

Malignancy: lymphoma and mucoepidermoidoma

Recurrent attacks

7 into 1

More than 5 for two year

Three attacks for three years

More than four episodes of tonsillitis with a single episode of cervical

LNpathy or a single episode of peri tonsillar abscess(quinsy)

Quincke disease: edema of palate and surrounding area

Relative indications

Non responding diphtherial inf

Non responding rheumatic fever

Misc indications

Eagle syndrome: elongated styloid process

Glossopharyngeal Neuralgia

Contraindications:

Acute attack: postpone Sx for three weeks

Age less than 3 years

Hb less than 10

Epidemic of polio

Bleeding of disorder

Complications

Most common: haemorrhage

On table: primary haemorrhage

Ligate the vessel

Venous bleed

Descending palatine vein aka peri tonsillar vein aka Dennis brown vein

Second source is

Tonsillar branch of facial artery

Reactionary haemorrhage

Slippage of the ligature

In first 24 hours

Religate the pt

Bleeding after 24 hours

Secondary haemorrhage

Infection

IV antibiotics

6th day is the most common day in secondary bleeding

Grisel syndrome

Atlanto axial subluxation

Rare complication of tonsillectomy

Neuro physician opinion is mandatory

Treatment is wait and watch

Facial nerve

Originates from pons

Exits from BS

Intracranial

Extra cranial

facial nerve make a loop around 6th nerve

Most common asso symptom will be Diplopia

In new born, möbius syndrome: congenital palsy of 6th and 7th

Unsafe ear: tympanic part affected

Geniculate ganglion: landmark for first genu

Semicircular canal for second genu

Shortest and the thinnest segment: labyrinthine segment

Most common part to be involved in Bell's palsy

Rehabilitation of a deaf patient

Conduction defect pt.

Amplifier gone

So pick and amplify sound: hearing aid

Indicated for mild deafness

Young female: completely in the canal hearing aid(CIC)

Behind the ear(BTE) , for old age

ITE: in the ear

BAHA: bone anchored hearing aid

Coz it can not be kept in the canal

Due to

Canal atresia

Canal stenosis

Pus in the canal

Sensory deafness pt.

Internal device kept in the scala tympani is called

Stimulator/ receiver

External device kept in mastoid aka processor/ microphone/ transmitter

Severe deafness

Goes through aditus to middle ear

From round window to scala tympani

Pre lingual deaf

Post lingual deaf: best candidates

Mondini dysplasia( one and a half turn) is common indication

Aplasia is a contraindication for cochlear implants

Therefore give brain stem implants

Neural deafness

Brain stem implants

Lateral recess of fourth ventricle is the area where it is placed

High power hearing aid is the first step in all deafness pt.

Important point

Grommet is never removed

white brilliant granule behind tympanic membrane: congenital cholestoma

Levenson criteria is used???

Traumatic perforation

Always wait and watch

Battle sign seen in hemotympanum

Middle cranial fossa fracture

Incision behind sternocleidomastoid: retro pharyngeal abscess

Anterior: para pharyngeal abscess

Wilde: post aural incision

In septal abscess: incision given on both sides

Within 48 hrs drainage

Syphilis always damages bony part

Leprosy damages cartilage

Lateral rhinotomy incision

Any thing coming out of nose

Weber fergusson incision

Maxillary conditions