drkamalkv’s CLASSES for Foreign Medical Graduates

Demo class matter for new students would be sent for 1 week only. Those who don’t pay/ communicate regarding
continuing the classes would be presumed to be not interested in classes and hence would be removed from the email
group.

Then please read like this:

1. Finish these notes first
2. MCQs of respective segments from SELF ASSESSMENT, 7th edition (FMGE pattern)
3. MCQs of respective segments from MASTERING NBE SERIES (DNB pattern)

While you are reading title 2 and 3, if you find something useful or which you tend to forget, write it in your notes (1).
Make a folder and keep compiling these notes. They will be very handy in the end.

If u finish this much easily, and if some time is left, u can either move on to next segment or u can read about upper
extremity in detail from some other sources.

Believe me, your level of preparation would be perfect (as per NatBoard pattern). In this first cycle, please read MCQ
statement properly, evaluate the options and then read the explanation to derive the answer. Whatever u find different
from notes, kindly write it along the notes so as to get good, concise notes of your own.

I am trying to force you into a habit of self studying.

Classroom & Online@Skype class students would have extra advantage of revising this entire content on Sundays.
So I would request to please upgrade to either classroom/ online@Skype course.

EXTERNAL EAR

Nerve supply of external auditory canal:

Anterior wall & roof: Auriculotemporal nerve &
Posterior wall & floor: Vagus (auricular branch)

Length of external auditory canal:

24 mm;
It is cartilaginous in:
Outer third
It is bony in:
Inner two-thirds

External acoustic (auditory) canal:

Outer part is directed upwards, backwards and medially
Inner part is directed downwards, forwards and medially
Therefore, to see the tympanic membrane, the pinna has to be pulled
upwards,
backwards &
laterally
so as to bring the two parts in alignment

Cartilaginous portion of EAC:

8 mm
Skin is thick

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Contains ceruminous & pilosebaceous glands

Hair is present so furuncles are seen

Bony part of EAC:

16 mm (inner 2/3rd)
Thin skin & continues over tympanic membrane
Devoid of hair & ceruminous glands

TYMPANIC MEMBRANE

Parts of tympanic membrane:

Pars tensa &
Pars flaccida (Shrapnel’s membrane)

Location of cone of light:

Antero-inferior

Nerve supply of tympanic membrane:

Auriculotemporal nerve (anterior half of lateral surface),
Auricular branch of vagus (posterior half of lateral surface)
Medial surface: Tympanic branch of CN IX (Jacobson’s nerve)

Normal appearance of tympanic membrane:

Pearly white

Surface area of tympanic membrane:

2
Total: 90 mm
2
Functional: 55 mm

Tympanic membrane/ Drumhead:

Partition between the EAC & middle ear
Obliquely set
Posterosuperior part if more lateral than its anteroinferior part.
9 mm tall
9 mm wide
0.1 mm thick

Pars tensa:
Forms most of TM
Annulus tympanicus at periphery
Central part is tented inwards at the level of tip of malleus (umbo)
Bright cone of light radiating from the tip of malleus

Pars flaccida/ Shrapnel’s membrane:

Situated above the level of lateral process of malleus
Not so taut

Layers of TM:
3 layers
Outer epithelial layer
Inner mucosal layer
Middle fibrous layer

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MIDDLE EAR

Attic/ Epitympanum is:

Part superior to the level of tympanic membrane

Which space lies in the epitympanum:

Prussak’s space

Narrowest part of middle ear:

Hypotympanum

Location of mesotympanum (lies opposite):

Directly medial to the tympanic membrane

Location of tegmen/ roof of the tympanum:

Opposite the middle cranial fossa

Hyperacusis is prevented by:

Stapedius

Middle ear/ ME:

Middle ear cleft: Mastoid air cells + mastoid antrum + aditus + attic + middle ear + eustachian tube
MEC is lined by mucous membrane & filled with air

ME is divided into:
Mesotympanum
Epitympanum/ attic
Hypotympanum

Walls of ME:
ME is a 6 sided box with roof, floor, 4 walls (medial, lateral, anterior & posterior)

Roof of ME:
Formed by tegmen tympani
Separates tympanic cavity from middle cranial fossa

Floor of ME:
A thin plate of bone which separates tympanic cavity from the jugular bul

Anterior wall of ME:

A thin plate of bone, which separates the tympanic cavity from the internal carotid artery
Has openings for eustachian tube & tensor tympani muscle

Posterior wall of ME:

Lies close to mastoid air cells
Bony projection ‘pyramid’ is seen, through which appears the tendon of stapedius (attaches to the neck of stapes)
Aditus lies above the pyramid, through which attic communicates with antrum
Facial nerve runs in the posterior wall just behind the pyramid
Facial recess/ posterior sinus is present lateral to pyramid

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Medial wall of ME:

Formed by labyrinth
Has a bulge known as ‘Promontory’ which is due to basal coil of cochlea
Round window/ fenestra cochleae
Oval window into which the footplate of stapes is fixed
Above the oval window is the canal for facial nerve
Above the canal for facial nerve is the prominence of lateral semicircular canal
Anterior to the oval window is processus cochleariformis (important for facial nerve surgery)

Lateral wall of ME:

Formed by tympanic membrane
TM is semitransparent
One can see long process of the incus, incudostapedial joint & the round window through it

Mastoid antrum:
Large, air-containing space in the upper part of mastoid
Communicates with attic through aditus
Roof is formed by tegmen atri
Lateral wall is formed by a plate of bone (suprameatal triangle)

Development of mastoid:
From squamous & petrous bones
Petrosquamosal suture may persists as Korner’s septum
Leads to incomplete removal of disease at mastoidectomy

Ossicles of ME:
Malleus
Incus
Stapes

Malleus:
Has head, neck, handle (manubrium), a lateral and an anterior process
Head & neck lies in attic
Handle is embedded in TM

Incus:
Has body and a short process
Both lies in attic
Has a long process which hangs vertically & attaches to the head of stapes

Stapes:
Has a head, neck, anterior and posterior crura and a footplate
Footplate is held in oval window by annular ligament

Ossicles conduct sound energy from the tympanic membrane to the oval window and then to the inner ear fluid.

Intratympanic muscles:
Tensor tympani
Stapedius

Tensor tympani:
Attaches to the neck of malleus

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 drkamalkv’s CLASSES for Foreign Medical Graduates

Tenses the tympanic membrane

Supplied by mandibular nerve (V3)

Stapedius:
Attaches to the neck of stapes
Dampens very loud sounds
Prevents noise trauma to the inner ear
Supplied by CN VII

INNER EAR

Location of inner ear:

Petrous part of temporal bone

Nerve which gets injured in inner ear (transverse fractures of temporal bone):
Facial nerve

Location of organ of Corti:

Organ of Corti (with its hair cells) rests on Basilar membrane

Content of perilymph:
Resemble ECF;
+ +
Low K & high Na

Angular acceleration is sensed by:

Semi-circular canal

Internal ear/ Labyrinth:

Important organ for hearing & balance
Consists of bony & a membranous labyrinth
Membranous labyrinth is filled with a clear fluid called endolymph
Space between the bony & the membranous labyrinth is filled with perilymph

Bony labyrinth:
Has 3 parts: the vestibule, the semicircular canals (SCC) and the cochlea

Vestibule:
Central chamber of the labyrinth
In its lateral wall lies the oval window
Inside of it has 2 recesses for utricle and saccule, one opening for passage of endolymphatic duct & 5 openings of SCC

SCC:
3 in numbers
Lateral, posterior & superior
Lies at right angle to each other
Opens into vestibule by ampullated (3 in number) & non-ampullated ends (2 in number as posterior and superior canals end unite)

Cochlea:
Coiled tube making 2.5 to 2.75 turns
3 compartments: scala vestibuli, scala tympani and scala media/ membranous cochlea
Cochlea is developed sufficiently by 20 weeks of gestation & fetus can hear in the womb of the mother

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Scal vestibuli & scala tympani is filled with perilymph

Scala media is filled with endolymph

Membranous labyrinth:
Consists of the cochlear duct, the utricle and the saccule, the 3 semicircular ducts, and the endolymphatic duct and sac

Cochlear duct:
Also known as membranous cochlea/ scala media
Contains stria vascularis (produces endolymph)
It is connected to the saccule by ductus reuniens

Utricle & saccule:

Utricle receives 5 openings of SCC
Saccule lies opposite to stapes footplate
Senses linear acceleration & deceleration (macula is the sensory epithelium)

Semicircular ducts:
3 in number & corresponds to 3 bony canals
Open in utricle

Endolymphatic duct & sac:

ELD is formed by ducts of utricle & saccule
ELS is the terminal dilated portion of ELD
ELS is surgically important as it is exposed in drainage/ shunt operation in Meniere’s disease

EUSTACHIAN TUBE

Development of eustachian tube:

st
1 pharyngeal pouch

Special feature of eustachian tube:

Opens during swallowing
(Tensor palati)

Eustachian tube:
3-3.8 cm in length
Lateral 1/3 bony
Medial 2/3 is cartilaginous
Runs forwards, downwards and medially
Shorter, wider & more horizontal in childrens

Cauliflower ear:
Haematoma of auricle
(due to repeated trauma in Boxers & wrestlers);

infection of haematoma may result in perichondritis (usually by Pseudomonas)

INFECTIOUS DISEASES

Special feature of malignant otitis externa:

Infection with P. aeruginosa,
Elderly diabetics with poor metabolic control (uncontrolled diabetes) or immuno-compromised patients

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 drkamalkv’s CLASSES for Foreign Medical Graduates

Feature: Dark ear discharge

Management: Systemic antibiotics, aural toilet

Special features of serous otitis media/ secretory otitis media/

glue ear/ otitis media with effusion:
Marginal perforation,
Medical treatment ineffective &
Myringotomy with Ventilation tube (grommet) insertion/ myringotomy with adenoidectomy

Dysfunction of eustachian tube (nasopharyngitis, adnoid hyperplasia) resulting in fluid collection in middle ear

Features:
Minimal/ absent pain
Sense of fullness in ear
Hearing loss (inattentive behaviour)

Findings:
Straw/ amber colored eardrum
Air bubbles/ multiple fluid levels behind eardrum
Reduced mobility of eardrum

Investigations:
X-ray will show cloudy mastoid air cells
Conductive type of hearing loss on audiometric examination

Location of perforation in CSOM:

Safe CSOM:
Central/ tubotympanic,
Absent cholesteatoma
Complications are rare
Granulation is not seen
Odourless, intermittent & copious discharge
Management with systemic antibiotics, ear drops, aural toilet
Surgery: Myringoplasty

Unsafe CSOM:
Marginal/ atticoantral
Cholesteatoma present
Complications are commonly seen
Granulation is common
Foul smelling, continuous, scanty discharge
Management with systemic antibiotics, ear drops, aural toilet
Surgery: Modified radical mastoidectomy

Complications of CSOM:
Mastoiditis (MC complication of CSOM),
Brain abscess (MC cause of brain abscess
is CSOM),
Bezolds abscess (after erosion of mastoid tip, the pus give rise to abscess in the sternocleidomastoid muscle),
Gradenigo’s syndrome (Retro-orbital pain, diplopia because of CN VI palsy, deep temporal headache, ear discharge)

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Subperiosteal abscess:
Citelli’s abscess (forms in the digastric triangle)
Zygomatic & Luc’s abscess (Pus from zygomatic air cells reach deep to temporalis muscle)
Post-auricular abscess

Other extra-cranial complications:

CN VII palsy
Temporal bone osteomyelitis
Labyrinthitis

Other intra-cranial complications:

Subdural abscess
Extradural abscess
Temporal lobe abscess
Cerebellar abscess
Meningitis
Lateral (sigmoid) sinus thrombosis

Cholesteatoma/epidermosis/keratoma:
Pathology:
Basically a bony erosion

Location (Bone):
Usually found in apex of petrous temporal bone

Associated perforation:
Attic/ posterior-superior marginal region is usually involved

Rx:
Modified radical mastoidectomy is done (spares the tympanic membrane & ossicles)

MC procedure done for CSOM:

Modified radical mastoidectomy

Lateral sinus thrombosis:

Pathognomic sign of lateral sinus thrombosis (LST):
Tenderness & edema over mastoid process and upper part of internal jugular vein (due to extension of thrombosis) (Griesinger’s sign)

Clinical test for lateral sinus thrombosis:

Tobey-Ayer/ Quickensteadt test:
Lumbar puncture needle is introduced into spinal canal
Needle attached to manometer
Jugular vein of both sides are compressed
Rise in CSF pressure is noted on normal side, whereas no change on thrombosed side

Hectic rise of temperature (in between episodes of fever, patient is symptoms free)
CECT scan: Delta sign

Ramsay Hunt syndrome is:

Varicella zoster infection (head & neck region)
involving oftenly, the facial nerve

OTOSCLEROSIS

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Otosclerosis begins in:

Fissula ante-fenestram in front of the oval window

Type of deafness in otosclerosis:

Progressive conductive deafness, usually bilateral

Family history:
Positive in 70% of cases
Autosomal dominant

Important clinical finding:

Paracusis Willsii (Lombard effect) (ability to hear better in noisy environment as people talk louder in noisy surroudings)

Appearance of tympanic membrane in otosclerosis:

Flammingo pink tympanic membrane (Schwartze’s sign)
Seen in 2% of cases
Because of vascular otospongiotic mass

Audiometric finding of otosclerosis:

Carhart’s notch at 2000 Hz

Tuning fork tests:

Rinne’s test is negative
Weber lateralized to the affected ear

Surgery of choice for otosclerosis:

Stapedectomy (stapes including its footplate) + artificial prosthesis (Surgery of choice)

Drug which can retard the progression:

Sodium fluoride for cochlear otosclerosis

MC site of otosclerosis:
Oval window
There is vascular spongy bone formation near the oval window resulting in ankylosis/ fixation of stapes footplate

MC bone affected in otosclerosis:

Stapes

Otosclerosis:
MC cause of non-suppurative conductive deafness in adult males
Common in Indians & Whites
MC in males (in India)
MC in females (Worldwide)
15-36 year age group
May be aggravated by pregnancy
Normal intact & freely mobile eardrum

MENIERE’S DISEASE

Also known as:

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Endolymphatic hydrops/ Ear glaucoma

Disorder of inner ear where there is dilatation of endolymphatic sac.
Increased endolymph secretion
Affects scala media (cochlear duct) & saccule

Triad of meniere’s disease:

Unilateral fluctuating/ episodic hearing loss
(low frequency sensori-neural),
Tinnitus (non pulsatile) &
Recurrent episodic prostrating vertigo

Pathologic change in the inner ear in meniere’s disease:

Generalized dilatation of the membranous labyrinth
Pathological endolymph production & decreased absorption

Meniere’s disease:
Associated with syphilis
MC in males
Affects 35-60 years
Unilateral
Sense of fullness/ pressure in ear
Distortion of sound (Diplacusis)
Intolerance to amplified or loud sounds (Recruitment phenomenon)
Noise or loud sounds produces vertigo (Tullio phenomenon)
Tone decay test >20 dB
Rising type of curve on pure tone audiometry (sensorineural hearing loss with loss of lower frequencies)

Management:
Vasodilators
Surgery (stellate ganglion block, vestibule neurectomy)
Decompression

BELL’S PALSY

Features:
Unilateral facial palsy,
Lower motor neuron lesion,
Acute onset &
Increased predisposition in DM

ACOUSTIC NEURINOMA/
VESTIBULAR SCHWANNOMA

They arise from:

Vestibular division of the eight nerve
Benign tumour from neurilemmal sheath

MC involved structure:
Superior vestibular nerve???
Some books say inferior vestibular nerve

Earliest symptom:
Unilateral progressive sensorineural deafness with tinnitus

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Other features:
CN V involvement,
Loss of corneal reflex (earliest sign)
Difficulty in balancing

Most sensitive & specific test:

Gadolinium enhanced MRI (head)
BERA is preferred audiological investigation

Acoustic neuroma:
MC cerebellopontine angle tumour
Affects 40-60 years
Bilateral acoustic neuromas are associated with neurofibromatosis –II (central type)
Hypoesthesia of posterior meatal wall (Hitzeliberger’s sign)
Surgery/ Stereotactic surgery

DEAFNESS (SYNDROMES)

Pendred syndrome:
Deafness,
Goitre

Ushers syndrome:
Deafness,
Mental retardation,
Seizures,
Retinitis pigmentosa,
Cataracts

Alports syndrome:
Progressive sensorineural loss,
Progressive severe glomerulonephritis

TESTS

Brainstem auditory evoked responses (BAER’s):

BAER is useful in differentiating:
The site of sensori-neural hearing loss
Objective test used for hearing assessment in neonates/ infants for congenital deafness or mentally retarded children

Tobey Ayer test:

Lateral sinus thrombosis

Hallpike test:
Used to diagnose benign paroxysmal positional vertigo (BPPV)

Recruitment phenomenon:
Meniere’s disease

Caloric test:
Vestibular function

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Caloric test/ Fitzgerald & Hallpike technique:

Thermal stimulation of lateral/ horizontal SCC with water
7 degree minus & plus from normal temperature
Cold water induces nystagmus to opposite side & vice versa
In SCC paresis, duration of nystagmus is reduced for both cold & hot water
No nystagmus if labyrinth is dead

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