1.

Anatomy, Physiology and Pathophysiology of the Ear

(10-Mark Answer – PL Dhingra)
Introduction
The ear is the organ of hearing and balance. It converts sound waves into neural impulses
and maintains equilibrium. Anatomically it is divided into:
1. External Ear
2. Middle Ear
3. Inner Ear

1. Anatomy of the Ear

A. External Ear
It consists of:
1. Auricle (Pinna)
Elastic cartilage covered by skin.
Parts
• Helix
• Antihelix
• Tragus
• Antitragus
• Concha
• Lobule (no cartilage)
Functions
• Collects sound waves
• Helps in sound localization
2. External Auditory Canal (EAC)
Length: 24 mm
Divided into:
Part Length Features

Outer cartilaginous 8 mm Hair follicles, ceruminous glands

Inner bony 16 mm Thin skin

Functions
• Conducts sound
• Protects tympanic membrane
Cerumen (Ear wax)
Produced by ceruminous + sebaceous glands.
Functions:
• Lubrication
• Antibacterial
• Traps dust

B. Tympanic Membrane
Thin semi-transparent membrane separating external and middle ear.
Diameter
• Vertical: 9–10 mm
• Horizontal: 8–9 mm
Parts
1. Pars Tensa
o Large part
o Fibrous layer present
2. Pars Flaccida (Shrapnell’s membrane)
o Small superior part
o No fibrous layer
Layers
Outer → Skin
Middle → Fibrous layer
Inner → Mucosa
Landmarks
 • Handle of malleus
• Umbo
• Cone of light
• Anterior & posterior malleolar folds

C. Middle Ear (Tympanic Cavity)

Air-filled cavity inside temporal bone.
Boundaries

Wall Structure

Roof Tegmen tympani

Floor Jugular bulb

Anterior Eustachian tube

Posterior Mastoid antrum

Lateral Tympanic membrane

Medial Promontory, oval window

Contents of Middle Ear

1. Ossicles
Three smallest bones:

Bone Function

Malleus Attached to tympanic membrane

Incus Middle ossicle

Stapes Footplate in oval window

Function:
Amplify sound 20–25 times

2. Muscles
Muscle Nerve Function

Tensor tympani Trigeminal Tenses TM

Stapedius Facial nerve Dampens sound

3. Eustachian Tube
Length: 36 mm
Functions:
• Ventilation of middle ear
• Equalizes pressure
• Drainage

D. Inner Ear (Labyrinth)

Located in petrous temporal bone.
Two parts:
1. Bony labyrinth
2. Membranous labyrinth
Bony labyrinth contains
• Cochlea
• Vestibule
• Semicircular canals

Cochlea
Spiral shaped organ with 2.5 turns.
Contains:
• Scala vestibuli
• Scala tympani
• Scala media

Organ of Corti
Located in scala media
Contains:
• Inner hair cells
• Outer hair cells
• Supporting cells
Function: Sound transduction

Vestibular System
Responsible for balance.
Structures:
• Utricle
• Saccule
• Semicircular canals
Detect:
• Linear acceleration
• Angular acceleration

2. Physiology of Hearing
Step 1: Sound collection
Auricle collects sound.
Step 2: Sound conduction
Sound travels through external canal.
Step 3: Tympanic membrane vibration
TM vibrates according to sound waves.
Step 4: Ossicular chain movement
Malleus → Incus → Stapes.
Step 5: Oval window vibration
Stapes footplate pushes perilymph.
Step 6: Cochlear wave
Wave moves along basilar membrane.
Step 7: Hair cell stimulation
Hair cells bend → electrical signal.
Step 8: Auditory nerve transmission
Signal carried by cochlear nerve (VIII nerve) to brain.

3. Physiology of Balance
Balance maintained by:
• Vestibular system
• Visual system
• Proprioception
Semicircular canals
Detect angular movements
Utricle & Saccule
Detect linear acceleration
Signal transmitted via vestibular nerve → brainstem → cerebellum

4. Pathophysiology of Ear Disorders

Ear diseases affect:
1. Sound conduction
2. Sound perception
3. Balance

A. Conductive Hearing Loss

Problem in:
• External ear
• Middle ear
Examples:
• Wax
 • Otitis media
• Tympanic membrane perforation
• Otosclerosis
Mechanism:
Reduced transmission of sound to cochlea.

B. Sensorineural Hearing Loss

Problem in:
• Cochlea
• Auditory nerve
• Brainstem
Examples:
• Presbycusis
• Noise trauma
• Ototoxic drugs
Mechanism:
Hair cell damage.

C. Mixed Hearing Loss

Combination of:
• Conductive
• Sensorineural
Example:
Chronic otitis media.

D. Vestibular Disorders
Cause vertigo.
Examples:
• Meniere disease
• Vestibular neuritis
 • Labyrinthitis

Clinical Importance
Understanding ear anatomy is essential for:
• Diagnosis of hearing loss
• Otoscopic examination
• Ear surgeries
• Vestibular disorders

2. Anatomy, Physiology and Pathophysiology of the Nose

(10-Mark Answer)
Introduction
The nose is the organ of smell and respiration. It forms the uppermost part of the
respiratory tract and performs important functions such as air filtration, humidification,
olfaction and voice resonance.
The nose is divided into:
1. External nose
2. Nasal cavity
3. Paranasal sinuses

1. Anatomy of the Nose

A. External Nose
The external nose is a pyramidal structure projecting from the face.
Parts
1. Root
2. Dorsum
3. Tip
4. Ala
5. Nostrils (nares)
Framework
Upper one-third (bony part)
Formed by:
• Nasal bones
• Frontal process of maxilla
• Nasal part of frontal bone
Lower two-thirds (cartilaginous part)
Cartilages include:
• Septal cartilage
• Upper lateral cartilage
• Lower lateral cartilage
• Minor alar cartilages

Blood Supply
Arterial supply mainly from:
• Facial artery
• Maxillary artery
• Ophthalmic artery
Important vascular area:
Little’s area (Kiesselbach plexus)
Common site of epistaxis.

Nerve Supply
Sensory nerves:
• Ophthalmic division of trigeminal nerve
• Maxillary division of trigeminal nerve
Olfactory nerve:
• Responsible for smell.

B. Nasal Cavity
The nasal cavity extends from:
Anterior: Nostrils
Posterior: Choanae opening into nasopharynx.
It is divided by the nasal septum into two cavities.

Nasal Septum
Formed by:
Cartilage
• Septal cartilage
Bone
• Perpendicular plate of ethmoid
• Vomer
Functions:
• Divides nasal cavity
• Supports nose

Lateral Wall of Nose

Contains three turbinates:
1. Inferior turbinate
2. Middle turbinate
3. Superior turbinate
Under each turbinate lies a meatus.

Meatus and their openings

Meatus Opening

Inferior Nasolacrimal duct

Middle Maxillary sinus, frontal sinus, anterior ethmoid sinus

Superior Posterior ethmoid sinus

Nasal Mucosa
Two types:
1. Respiratory mucosa
2. Olfactory mucosa

Respiratory mucosa
Characteristics:
• Ciliated epithelium
• Goblet cells
• Rich blood supply
Functions:
• Warm air
• Humidify air
• Filter particles

Olfactory mucosa
Located in:
• Roof of nose
• Upper septum
• Superior turbinate
Contains olfactory receptors.

C. Paranasal Sinuses
Air-filled cavities within skull bones.
Types:
1. Maxillary sinus
2. Frontal sinus
3. Ethmoid sinus
4. Sphenoid sinus
Functions:
 • Reduce skull weight
• Voice resonance
• Mucus secretion

2. Physiology of the Nose

A. Respiration
The nose conditions inhaled air by:
1. Warming
2. Humidifying
3. Filtering
Cilia move mucus toward nasopharynx.

B. Olfaction (Sense of smell)

Odor molecules dissolve in mucus → stimulate olfactory receptors → signals transmitted via
olfactory nerve to brain.

C. Defense Mechanism
Protection against pathogens by:
• Nasal hair
• Mucociliary clearance
• Immunoglobulins (IgA)

D. Resonance in Speech
Nasal cavity acts as resonating chamber affecting voice quality.

3. Pathophysiology of Nasal Disorders

Diseases affect:
• Airflow
• Smell
• Drainage of sinuses
A. Nasal Obstruction
Causes:
• Deviated nasal septum
• Nasal polyps
• Tumors
• Adenoid hypertrophy
Mechanism:
Reduced airway → mouth breathing.

B. Rhinitis
Inflammation of nasal mucosa.
Types:
• Infective
• Allergic
• Vasomotor
Symptoms:
• Sneezing
• Rhinorrhea
• Nasal obstruction

C. Sinusitis
Blockage of sinus drainage → infection.
Symptoms:
• Facial pain
• Nasal discharge
• Headache

D. Epistaxis
Bleeding from nose.
Commonly from Little’s area.

Clinical Importance
Knowledge of nasal anatomy is essential for:
• Diagnosis of nasal obstruction
• Sinus surgery
• Management of epistaxis
• Endoscopic procedures

3. Anatomy, Physiology and Pathophysiology of the Throat

(10-Mark Answer)
Introduction
The throat consists of the pharynx and larynx. It plays an important role in:
• Respiration
• Deglutition
• Speech

1. Anatomy of the Pharynx

The pharynx is a fibromuscular tube extending from skull base to C6 vertebra.
Length: 12–14 cm
Divided into three parts.

A. Nasopharynx
Located behind nasal cavity.
Important structures:
• Opening of Eustachian tube
• Adenoids
• Rosenmüller fossa
Functions:
• Air passage
• Pressure equalization

B. Oropharynx
Extends from soft palate to epiglottis.
Contains:
• Palatine tonsils
• Base of tongue
Function:
• Passage for food and air.

C. Laryngopharynx
Extends from epiglottis to esophagus.
Contains:
• Pyriform fossa
Functions:
• Food passage
• Protection of airway

2. Anatomy of the Larynx

The larynx extends from C3–C6 vertebrae.
Functions:
• Voice production
• Air passage
• Protection during swallowing

Cartilages of Larynx
Single cartilages:
 • Thyroid
• Cricoid
• Epiglottis
Paired cartilages:
• Arytenoid
• Corniculate
• Cuneiform

Vocal Cords
Two folds:
1. True vocal cords
2. False vocal cords
Function: Voice production

3. Physiology of Throat
A. Deglutition (Swallowing)
Three phases:
1. Oral phase
2. Pharyngeal phase
3. Esophageal phase

B. Voice Production
Sound produced by vibration of vocal cords.
Pitch depends on:
• Length
• Tension
• Thickness

C. Airway Protection
Epiglottis prevents food from entering airway.

4. Pathophysiology
Common disorders include:
• Tonsillitis
• Laryngitis
• Adenoid hypertrophy
• Vocal cord paralysis

4. Anatomy, Physiology and Pathophysiology of Head & Neck

(10-Mark Answer)
Introduction
The head and neck region contains vital structures responsible for:
• Sensory functions
• Respiration
• Digestion
• Speech

Important Structures
1. Skull bones
2. Salivary glands
3. Lymph nodes
4. Cranial nerves
5. Airways
6. Blood vessels

Lymphatic Drainage
Important lymph node groups:
• Submental
 • Submandibular
• Jugulodigastric
• Posterior cervical
Clinical importance:
Used in staging of head and neck cancers.

Cranial Nerves in ENT

Important nerves:
• Olfactory nerve (I)
• Facial nerve (VII)
• Vestibulocochlear nerve (VIII)
• Glossopharyngeal nerve (IX)
• Vagus nerve (X)

Pathophysiology
Common diseases:
• Head and neck cancers
• Lymphadenopathy
• Thyroid disorders
• Salivary gland diseases

5. Anatomy and Physiology of the Ear

(10-Mark Answer)
Introduction
The ear is the organ of hearing and balance. It converts sound waves into electrical
impulses interpreted by the brain and maintains equilibrium through the vestibular system.
The ear is divided into:
1. External ear
2. Middle ear
3. Inner ear
Anatomy of the Ear
1. External Ear
Auricle (Pinna)
Elastic cartilaginous structure projecting from the side of the head.
Parts
• Helix
• Antihelix
• Tragus
• Antitragus
• Concha
• Lobule
Functions
• Collects sound waves
• Helps in sound localization

External Auditory Canal

Length: 24 mm
Divided into:

Part Length Features

Cartilaginous 8 mm Hair follicles, ceruminous glands

Bony 16 mm Thin skin

Functions
• Conducts sound waves
• Protects tympanic membrane
Cerumen protects ear by lubrication and antibacterial action.

2. Middle Ear
Air-filled cavity inside temporal bone.
Boundaries

Wall Structure

Roof Tegmen tympani

Floor Jugular bulb

Medial Promontory

Lateral Tympanic membrane

Anterior Eustachian tube

Posterior Mastoid antrum

Ossicles
Three bones:

Bone Function

Malleus Attached to tympanic membrane

Incus Transmits vibrations

Stapes Footplate fits into oval window

They amplify sound 20–25 times.

Eustachian Tube
Length: 36 mm
Functions:
• Equalizes middle ear pressure
• Ventilation of middle ear
• Drainage of secretions

3. Inner Ear
Located in petrous temporal bone.
Two parts:
Bony labyrinth
 • Cochlea
• Vestibule
• Semicircular canals
Membranous labyrinth
Contains:
• Endolymph
• Sensory receptors

Cochlea
Spiral shaped with 2.5 turns.
Contains:
• Scala vestibuli
• Scala tympani
• Scala media

Organ of Corti
Contains:
• Inner hair cells
• Outer hair cells
Function: Transduction of sound waves into electrical signals.

Vestibular Apparatus
Responsible for balance.
Structures:
• Utricle
• Saccule
• Semicircular canals

Physiology of Hearing
Steps:
1. Sound collected by auricle
2. Conducted through external canal
3. Tympanic membrane vibrates
4. Ossicles transmit vibrations
5. Stapes moves oval window
6. Cochlear fluid moves
7. Hair cells stimulated
8. Impulse carried via vestibulocochlear nerve to auditory cortex

Physiology of Balance
Maintained by:
• Vestibular system
• Vision
• Proprioception
Semicircular canals detect rotational movements.
Utricle and saccule detect linear acceleration.

Clinical Importance
Disorders may lead to:
• Hearing loss
• Vertigo
• Tinnitus
• Balance problems

6. Common Diseases of the Ear

(10-Mark Answer)
Introduction
Ear diseases can affect external ear, middle ear or inner ear and may lead to hearing
impairment or vestibular symptoms.
Diseases of External Ear
1. Impacted wax
2. Otitis externa
3. Furunculosis
4. Foreign body
5. Trauma
Symptoms
• Ear pain
• Ear discharge
• Hearing loss
• Itching

Diseases of Middle Ear

1. Acute otitis media
2. Otitis media with effusion
3. Chronic otitis media
4. Otosclerosis
Symptoms
• Hearing loss
• Ear discharge
• Ear pain

Diseases of Inner Ear

1. Meniere’s disease
2. Labyrinthitis
3. Acoustic neuroma
Symptoms:
• Vertigo
 • Tinnitus
• Sensorineural hearing loss

Complications of Ear Diseases

• Mastoiditis
• Facial nerve paralysis
• Brain abscess
• Meningitis

Management Principles
1. Proper diagnosis
2. Medical treatment
3. Surgical management if needed
4. Rehabilitation of hearing

7. Otoscopic Examination of Tympanic Membrane

(10-Mark Answer)
Definition
Otoscopic examination is the visual inspection of the external auditory canal and tympanic
membrane using an otoscope.

Indications
• Ear pain
• Hearing loss
• Ear discharge
• Trauma
• Suspected infection

Instrument Used
Otoscope
Components:
• Light source
• Magnifying lens
• Speculum

Procedure
1. Patient seated comfortably
2. Auricle pulled upwards and backwards in adults
3. Speculum inserted gently
4. Tympanic membrane visualized

Normal Tympanic Membrane Features

• Pearly grey color
• Translucent
• Cone of light present
• Handle of malleus visible

Abnormal Findings

Condition Findings

Otitis media Bulging TM

Perforation Hole in membrane

Retraction Inward pulled TM

Cholesteatoma White mass

Advantages
• Simple
• Non-invasive
• Essential for ear diagnosis
8. Otomicroscopic Examination of Tympanic Membrane
(10-Mark Answer)
Definition
Otomicroscopy is examination of ear using an operating microscope providing magnified
view.

Advantages
• Better illumination
• High magnification
• Accurate diagnosis

Indications
• Detailed examination of TM
• Ear surgery
• Removal of foreign bodies
• Suction of discharge

Procedure
1. Patient seated
2. Microscope positioned
3. Ear canal visualized under magnification

Findings
Helps detect:
• Small perforations
• Retraction pockets
• Cholesteatoma
• Ossicular damage

Clinical Importance
Essential for:
• Ear surgery
• Diagnosis of chronic ear disease
• Microsuction procedures

9. Tuning Fork Tests

(10-Mark Answer)
Introduction
Tuning fork tests are bedside hearing tests used to differentiate:
• Conductive hearing loss
• Sensorineural hearing loss
Common tuning fork frequency: 512 Hz

Types of Tuning Fork Tests

1. Rinne test
2. Weber test
3. Schwabach test
4. Absolute bone conduction test

1. Rinne Test
Compares air conduction and bone conduction.
Procedure:
1. Vibrating tuning fork placed on mastoid
2. When sound disappears, moved near ear canal
Result:

Result Interpretation

AC > BC Normal or SNHL

BC > AC Conductive loss

2. Weber Test
Fork placed on forehead.
Result:

Condition Lateralization

Conductive loss To affected ear

Sensorineural loss To normal ear

3. Schwabach Test
Compares patient’s bone conduction with examiner.

Clinical Importance
Useful screening test before audiometry.

10. Tympanic Membrane

(10-Mark Answer)
Introduction
The tympanic membrane (ear drum) separates external ear from middle ear and plays a
vital role in sound transmission.

Structure
Shape: Oval
Diameter:
• Vertical: 9–10 mm
• Horizontal: 8–9 mm
Thickness: 0.1 mm

Parts
1. Pars tensa
2. Pars flaccida
Layers
1. Outer epithelial layer
2. Middle fibrous layer
3. Inner mucosal layer

Landmarks
• Handle of malleus
• Umbo
• Cone of light
• Anterior malleolar fold
• Posterior malleolar fold

Blood Supply
From:
• Deep auricular artery
• Anterior tympanic artery

Nerve Supply
• Auriculotemporal nerve
• Glossopharyngeal nerve

Functions
1. Transmits sound vibrations
2. Protects middle ear
3. Amplifies sound energy

Clinical Importance
Diseases include:
 • Perforation
• Retraction
• Tympanosclerosis

11. Acute Suppurative Otitis Media (ASOM)

(10-Mark Answer)
Definition
Acute suppurative otitis media is an acute infection of the middle ear cleft characterized by
rapid onset of ear pain, fever, and suppuration, commonly following an upper respiratory
tract infection.

Etiology
Predisposing Factors
1. Upper respiratory tract infections
2. Adenoid hypertrophy
3. Cleft palate
4. Poor Eustachian tube function
5. Immunodeficiency
6. Bottle feeding in infants

Causative Organisms
Common bacteria:
• Streptococcus pneumoniae
• Haemophilus influenzae
• Streptococcus pyogenes
• Staphylococcus aureus

Pathogenesis
1. Infection spreads from nasopharynx via Eustachian tube.
2. Eustachian tube obstruction causes negative middle ear pressure.
 3. Fluid accumulates in middle ear.
4. Bacterial growth leads to pus formation.
5. Pressure may lead to tympanic membrane perforation.

Stages of ASOM
1. Stage of Tubal Occlusion
Features:
• Ear blockage
• Mild hearing loss
• Retraction of tympanic membrane

2. Stage of Hyperemia
Symptoms:
• Severe ear pain
• Fever
• Red congested tympanic membrane

3. Stage of Suppuration
Features:
• Bulging tympanic membrane
• Severe pain
• Hearing loss

4. Stage of Perforation
Features:
• Sudden relief of pain
• Ear discharge
• Visible perforation
5. Stage of Resolution
Inflammation subsides and membrane heals.

Clinical Features
Symptoms:
• Severe ear pain (otalgia)
• Fever
• Hearing loss
• Ear discharge
Signs:
• Congested tympanic membrane
• Bulging TM
• Perforation with pus

Investigations
Usually clinical diagnosis.
Additional tests:
• Otoscopy
• Culture of discharge
• Audiometry (if hearing loss persists)

Complications
Intratemporal
• Mastoiditis
• Facial nerve palsy
• Labyrinthitis
Intracranial
• Meningitis
• Brain abscess
 • Lateral sinus thrombosis

Management
Medical Treatment
1. Analgesics (paracetamol, ibuprofen)
2. Antibiotics
Common drugs:
• Amoxicillin
• Amoxicillin-clavulanate
• Cephalosporins
3. Nasal decongestants
4. Antipyretics

Surgical Treatment
Myringotomy
Indications:
• Severe pain
• Bulging tympanic membrane
• Failure of medical therapy

Prevention
• Treat URTI early
• Improve nutrition
• Vaccination
• Proper feeding techniques in infants

12. Otitis Media with Effusion (OME)

(10-Mark Answer)
Definition
Otitis media with effusion is the presence of non-purulent fluid in the middle ear without
signs of acute infection.
Also called Glue Ear.

Etiology
1. Eustachian tube dysfunction
2. Adenoid hypertrophy
3. Allergy
4. Upper respiratory infection
5. Cleft palate

Pathogenesis
1. Eustachian tube blockage causes negative pressure.
2. Fluid accumulates in middle ear.
3. Fluid becomes thick and mucoid.

Clinical Features
Symptoms
• Hearing loss
• Ear fullness
• Delayed speech in children
• Mild ear discomfort

Signs
Otoscopy shows:
• Retracted tympanic membrane
• Fluid level
• Air bubbles
• Dull TM
Investigations
1. Audiometry
Shows conductive hearing loss.

2. Tympanometry
Shows Type B tympanogram.

3. Nasopharyngeal examination
To detect adenoids.

Management
Conservative Treatment
1. Treat nasal infection
2. Antihistamines
3. Decongestants
4. Auto-inflation techniques

Surgical Treatment
Myringotomy with Grommet Insertion
Indications:
• Persistent OME > 3 months
• Hearing loss > 30 dB

Adenoidectomy
Indicated if adenoid hypertrophy present.

Complications
• Hearing impairment
• Speech delay
 • Chronic otitis media

13. Chronic Otitis Media – Mucosal Type

(10-Mark Answer)
Definition
Chronic otitis media is a chronic inflammation of middle ear and mastoid cavity with
persistent perforation of tympanic membrane.
The mucosal type is also called safe type because it rarely causes serious complications.

Etiology
1. Recurrent acute otitis media
2. Upper respiratory infection
3. Poor Eustachian tube function
4. Malnutrition
5. Overcrowding

Pathology
Features:
• Central perforation of tympanic membrane
• Inflammation of middle ear mucosa
• Mucopurulent discharge

Clinical Features
Symptoms
• Ear discharge
• Hearing loss
• Occasionally ear pain
Discharge is:
• Mucoid
• Non-foul smelling
Signs
• Central perforation
• Conductive hearing loss
• Granulation tissue sometimes present

Investigations
1. Otoscopy
2. Pure tone audiometry
3. X-ray mastoid
4. Culture of discharge

Complications
Though rare:
• Mastoiditis
• Tympanosclerosis

Management
Conservative Treatment
1. Aural toilet
2. Antibiotic ear drops
3. Systemic antibiotics

Surgical Treatment
Tympanoplasty
Purpose:
• Repair tympanic membrane
• Improve hearing
14. Chronic Otitis Media – Squamosal Type
(10-Mark Answer)
Definition
Squamosal type of COM is a dangerous form associated with cholesteatoma and bone
destruction.

Etiology
1. Retraction pocket of pars flaccida
2. Epithelial migration
3. Recurrent infections

Pathology
Cholesteatoma consists of:
• Keratin debris
• Squamous epithelium
It causes:
• Bone erosion
• Spread of infection

Clinical Features
Symptoms
• Foul-smelling ear discharge
• Hearing loss
• Ear pain

Signs
• Attic perforation
• Retraction pocket
• Cholesteatoma
Complications
Intratemporal
• Facial nerve palsy
• Labyrinthitis
• Mastoid abscess
Intracranial
• Brain abscess
• Meningitis
• Lateral sinus thrombosis

Investigations
1. Otoscopy
2. CT scan temporal bone
3. Audiometry

Treatment
Definitive treatment is surgery.
Mastoidectomy
Types:
• Modified radical mastoidectomy
• Radical mastoidectomy
Goal:
• Remove cholesteatoma
• Create safe ear

15. Hearing Loss

(10-Mark Answer)
Definition
Hearing loss is partial or complete inability to hear sounds.
Classification
1. Conductive Hearing Loss
Problem in:
• External ear
• Middle ear
Examples:
• Wax
• Otitis media
• Otosclerosis

2. Sensorineural Hearing Loss

Problem in:
• Cochlea
• Auditory nerve
Examples:
• Presbycusis
• Noise-induced hearing loss
• Ototoxic drugs

3. Mixed Hearing Loss

Combination of conductive and sensorineural loss.

Causes
External Ear
• Wax
• Foreign body
• Otitis externa
Middle Ear
• Otitis media
• Tympanic membrane perforation
• Ossicular damage

Inner Ear
• Meniere’s disease
• Acoustic neuroma
• Presbycusis

Clinical Features
• Difficulty hearing
• Asking others to repeat
• Tinnitus
• Poor speech understanding

Investigations
1. Tuning fork tests
2. Pure tone audiometry
3. Impedance audiometry
4. Brainstem evoked response audiometry

Management
Depends on cause.
Medical treatment
• Antibiotics
• Steroids

Surgical treatment
 • Tympanoplasty
• Stapedectomy

Rehabilitation
• Hearing aids
• Cochlear implant

1. TINNITUS
Definition
Tinnitus is defined as the perception of sound in the ear or head in the absence of an
external acoustic stimulus. It may be perceived as ringing, buzzing, hissing, roaring, clicking
or pulsating noise.

Types
1. Subjective Tinnitus
• Heard only by the patient
• Most common form
• Caused by pathology in cochlea, auditory nerve, or central auditory pathways
2. Objective Tinnitus
• Heard by both patient and examiner
• Rare
• Usually due to vascular or muscular origin

Etiology
1. Otological Causes
• Impacted cerumen (ear wax)
• Foreign body in ear
• Acute otitis media
• Chronic suppurative otitis media
• Otosclerosis
 • Presbycusis
• Meniere’s disease
• Acoustic trauma
• Noise induced hearing loss

2. Neurological Causes
• Vestibular schwannoma
• Multiple sclerosis
• Head injury
• Brainstem lesions

3. Metabolic and Systemic Causes

• Anaemia
• Hypertension
• Hypothyroidism
• Hyperlipidemia
• Diabetes mellitus

4. Ototoxic Drugs
• Salicylates
• Aminoglycosides
• Loop diuretics
• Quinine
• Chemotherapeutic agents

5. Vascular Causes
• Arteriovenous malformation
• Glomus tumour
• Carotid artery stenosis
 • Hypertension

6. Psychological Causes
• Anxiety
• Depression
• Emotional stress

Pathophysiology
Several mechanisms have been proposed:
1. Cochlear hair cell damage
Damage to hair cells causes abnormal spontaneous neural discharge.
2. Central auditory pathway hyperactivity
Loss of normal auditory input causes increased neuronal firing in auditory cortex.
3. Deafferentation theory
Loss of cochlear input leads to central neural plasticity resulting in tinnitus perception.

Clinical Features
• Ringing sound in ear
• Buzzing noise
• Roaring or humming sound
• Clicking sound
• Pulsatile sound
• May be unilateral or bilateral
Associated symptoms:
• Hearing loss
• Vertigo
• Ear fullness
• Sleep disturbance
• Irritability
 • Anxiety

Clinical Evaluation
History
• Onset
• Duration
• Character of sound
• Relation with pulse
• Associated hearing loss
• Drug history

Examination
• Otoscopic examination
• Cranial nerve examination
• Cardiovascular examination

Investigations
1. Pure Tone Audiometry
Detects hearing loss.
2. Impedance Audiometry
Evaluates middle ear function.
3. Otoacoustic Emissions
4. Imaging
• CT temporal bone
• MRI brain and internal auditory canal
5. Laboratory Tests
• Hemoglobin
• Thyroid function tests
• Blood sugar
 • Lipid profile

Management
1. Treatment of underlying cause
• Wax removal
• Treat ear infections
• Control hypertension
• Stop ototoxic drugs

2. Medical Treatment
• Vasodilators
• Betahistine
• Antidepressants
• Anxiolytics
• Vitamin B complex

3. Tinnitus Masking
• White noise generators
• Hearing aids

4. Tinnitus Retraining Therapy (TRT)

Uses sound therapy + counselling to reduce perception.

5. Cognitive Behavioural Therapy

Used for psychological distress.

Complications
• Depression
• Insomnia
 • Anxiety
• Reduced quality of life

2. OTOSCLEROSIS
Definition
Otosclerosis is a primary localized disease of the otic capsule characterized by abnormal
bone remodeling leading to fixation of the stapes footplate resulting in conductive hearing
loss.

Epidemiology
• Common in young adults
• More common in females
• Usually bilateral
• Onset between 20–40 years

Etiology
Exact cause is unknown.
Predisposing factors
1. Genetic factors
o Autosomal dominant inheritance
2. Hormonal factors
o Pregnancy aggravates disease
3. Viral infection
o Measles virus infection
4. Autoimmune mechanisms

Pathology
Two phases occur:
1. Otospongiosis (active phase)
• Highly vascular
 • Spongy bone formation
2. Sclerotic phase
• Dense sclerotic bone replaces spongy bone

Sites of Lesion
Most common site:
Fissula ante fenestram (area anterior to oval window)
Other sites:
• Round window
• Cochlea
• Stapes footplate

Types
1. Stapedial otosclerosis
o Conductive hearing loss
2. Cochlear otosclerosis
o Sensorineural hearing loss
3. Mixed type

Clinical Features
1. Progressive hearing loss
• Gradual
• Conductive
• Bilateral in most cases
2. Tinnitus
Present in about 70% patients
3. Paracusis Willisii
Patient hears better in noisy surroundings
4. Absence of ear discharge
Otoscopic Findings
• Tympanic membrane usually normal
• Sometimes Schwartze sign
o Pinkish glow due to vascular otospongiosis

Tuning Fork Tests

Rinne Test
Negative (conductive loss)
Weber Test
Lateralized to affected ear

Investigations
1. Pure Tone Audiogram
Shows conductive hearing loss with Carhart notch at 2000 Hz

2. Impedance Audiometry
• Type As tympanogram
• Absent acoustic reflex

3. CT Scan Temporal Bone

Detects focus of otosclerosis.

Management
Medical Treatment
Used mainly in early disease.
• Sodium fluoride
• Calcium supplements
• Vitamin D
Hearing Aids
Used when surgery not possible.

Surgical Treatment
1. Stapedectomy
Removal of stapes footplate and replacement with prosthesis.
2. Stapedotomy
Small hole made in footplate and prosthesis inserted.
Stapedotomy is preferred nowadays.

Complications of Surgery
• Sensorineural hearing loss
• Vertigo
• Perilymph fistula
• Facial nerve injury
• Taste disturbance

Prognosis
• Surgery successful in 90–95% patients

3. FACIAL NERVE PALSY

Definition
Facial nerve palsy is weakness or paralysis of the muscles of facial expression due to
damage to the facial nerve (VII cranial nerve) anywhere along its course from the nucleus in
the pons to its peripheral branches.

Anatomy of Facial Nerve (Brief)

The facial nerve has:
Intracranial course
Originates from pons
Intratemporal course
Passes through temporal bone in three segments:
1. Labyrinthine segment
2. Tympanic segment
3. Mastoid segment
Extratemporal course
Emerges from stylomastoid foramen and divides into terminal branches:
• Temporal
• Zygomatic
• Buccal
• Marginal mandibular
• Cervical

Functions of Facial Nerve

1. Motor supply to muscles of facial expression
2. Taste sensation from anterior 2/3 of tongue
3. Secretomotor to lacrimal and salivary glands
4. Motor supply to stapedius muscle

Causes of Facial Nerve Palsy

1. Congenital
• Birth trauma
• Developmental anomalies

2. Inflammatory
• Bell’s palsy
• Herpes zoster oticus (Ramsay Hunt syndrome)
• Otitis media
3. Traumatic
• Temporal bone fracture
• Surgical trauma

4. Tumors
• Parotid gland tumor
• Acoustic neuroma
• Facial nerve schwannoma

5. Neurological
• Stroke
• Multiple sclerosis

Types
1. Upper Motor Neuron Lesion
Example: stroke
Features:
• Forehead spared
• Lower face affected

2. Lower Motor Neuron Lesion

Example: Bell’s palsy
Features:
• Entire side of face affected

Clinical Features
Facial asymmetry
Affected side droops.
Loss of forehead wrinkles
Inability to close eye
Leads to lagophthalmos
Drooping of mouth
Saliva dribbling occurs.
Loss of nasolabial fold
Loss of taste
Anterior 2/3 tongue.
Hyperacusis
Due to stapedius paralysis.
Reduced lacrimation

Grading of Facial Palsy

House–Brackmann grading system
Grade I – Normal
Grade II – Mild dysfunction
Grade III – Moderate dysfunction
Grade IV – Moderately severe
Grade V – Severe dysfunction
Grade VI – Total paralysis

Investigations
1. Electromyography (EMG)
2. Nerve conduction studies
3. CT temporal bone
4. MRI brain
5. Audiometry

Management
Medical treatment
• Corticosteroids
 • Antivirals (acyclovir)
• Analgesics
• Vitamin B complex

Eye care
• Artificial tears
• Eye patch
• Lubricating ointment

Physiotherapy
• Facial muscle exercises
• Electrical stimulation

Surgical treatment
Indicated in severe cases.
Procedures include:
• Facial nerve decompression
• Nerve grafting
• Hypoglossal-facial anastomosis

Complications
• Exposure keratitis
• Corneal ulcer
• Synkinesis
• Facial contracture

4. VERTIGO
Definition
Vertigo is a false sensation of movement of either the patient or the surroundings, usually
described as a spinning sensation.
Types
1. Peripheral Vertigo
Due to pathology of inner ear or vestibular nerve
Examples:
• Meniere’s disease
• Benign paroxysmal positional vertigo (BPPV)
• Vestibular neuritis
• Labyrinthitis

2. Central Vertigo
Due to pathology of brainstem or cerebellum
Examples:
• Cerebellar stroke
• Multiple sclerosis
• Brain tumors

Causes
Peripheral Causes
• Meniere’s disease
• BPPV
• Vestibular neuritis
• Labyrinthitis
• Acoustic neuroma

Central Causes
• Brainstem tumors
• Cerebellar infarction
• Multiple sclerosis
 • Migraine

Clinical Features
Vertigo (spinning sensation)
Nausea and vomiting
Nystagmus
Imbalance
Sweating
Hearing loss (in peripheral causes)

Clinical Examination
Romberg test
Patient sways when eyes closed.
Unterberger test
Dix-Hallpike test
Diagnostic for BPPV.

Investigations
1. Pure tone audiometry
2. Electronystagmography
3. Caloric test
4. MRI brain
5. CT scan temporal bone

Management
General measures
• Bed rest
• Avoid sudden head movements
Medical treatment
• Betahistine
• Antihistamines (meclizine)
• Antiemetics
• Benzodiazepines

Vestibular rehabilitation
Exercises to improve balance.

Surgical treatment
In refractory cases.

5. MENIERE’S DISEASE
Definition
Meniere’s disease is a disorder of the inner ear characterized by recurrent episodes of
vertigo, fluctuating sensorineural hearing loss, tinnitus and aural fullness.

Etiology
Exact cause unknown.
Possible factors:
• Endolymphatic sac dysfunction
• Viral infections
• Autoimmune mechanisms
• Allergy

Pathology
The disease is caused by endolymphatic hydrops, which means excess accumulation of
endolymph in the membranous labyrinth.
This leads to:
• Distension of membranous labyrinth
 • Damage to hair cells

Clinical Features
Classic Meniere’s tetrad
1. Episodic vertigo
2. Fluctuating hearing loss
3. Tinnitus
4. Aural fullness

Vertigo
• Severe spinning sensation
• Lasts minutes to hours
• Associated with nausea and vomiting

Hearing Loss
• Sensorineural
• Initially reversible
• Later becomes permanent

Tinnitus
Usually roaring type

Aural Fullness
Feeling of pressure in ear.

Investigations
Pure Tone Audiometry
Shows sensorineural hearing loss
Electrocochleography
Detects endolymphatic hydrops.

MRI Brain
To rule out acoustic neuroma.

Management
Medical treatment
Dietary modification
• Low salt diet
• Avoid caffeine
• Avoid alcohol

Drugs
• Betahistine
• Diuretics (hydrochlorothiazide)
• Vestibular suppressants
• Antiemetics

Intratympanic therapy
• Gentamicin injection
• Steroid injection

Surgical treatment
Endolymphatic sac decompression
Vestibular nerve section
Labyrinthectomy
Done in severe cases with complete hearing loss.
Complications
• Permanent hearing loss
• Chronic imbalance
• Anxiety disorders

6. OTALGIA (Ear Pain)

Definition
Otalgia refers to pain in the ear. It may arise from diseases of the ear itself or may be
referred from other structures supplied by the same sensory nerves.

Types
1. Primary Otalgia
Pain arising from pathology within the ear.
2. Referred Otalgia
Pain referred to ear from other anatomical structures sharing nerve supply.

Nerve Supply of Ear (Important for Referred Pain)

• Trigeminal nerve (CN V)
• Facial nerve (CN VII)
• Glossopharyngeal nerve (CN IX)
• Vagus nerve (CN X)
• Cervical nerves (C2, C3)

Causes
A. Causes within Ear (Primary Otalgia)
External ear
• Otitis externa
• Furunculosis
• Impacted wax
• Foreign body
Middle ear
• Acute otitis media
• Chronic otitis media
• Mastoiditis
Inner ear
Inner ear diseases rarely cause pain.

B. Referred Otalgia
Dental causes
• Dental caries
• Impacted molars
Throat causes
• Tonsillitis
• Pharyngitis
Laryngeal causes
• Laryngeal carcinoma
Temporomandibular joint disorders
Cervical spine disease

Clinical Features
• Ear pain
• Fever (if infection)
• Hearing loss
• Ear discharge
• Difficulty chewing
• Tenderness around ear

Investigations
1. Otoscopic examination
 2. Audiometry
3. X-ray mastoid
4. CT scan temporal bone
5. Dental examination

Management
General treatment
• Analgesics
• Anti-inflammatory drugs

Specific treatment
Otitis externa
• Antibiotic ear drops
• Aural toilet
Acute otitis media
• Antibiotics
• Nasal decongestants
Impacted wax
• Wax removal
Dental causes
• Dental treatment

Complications
• Mastoiditis
• Spread of infection
• Chronic ear disease

7. DISEASES OF EXTERNAL EAR

Diseases affecting auricle and external auditory canal.
A. Congenital Conditions
Microtia
Small malformed auricle.
Anotia
Complete absence of auricle.
Preauricular sinus
Congenital tract near ear.

B. Inflammatory Conditions
1. Otitis Externa
Definition
Inflammation of external auditory canal.

Causes
• Bacterial infection (Pseudomonas)
• Fungal infection
• Trauma from cotton buds
• Swimming

Clinical Features
• Severe ear pain
• Ear discharge
• Itching
• Tender tragus
• Narrow ear canal

Treatment
• Antibiotic ear drops
 • Analgesics
• Aural toilet

2. Furunculosis
Infection of hair follicle.
Features
• Severe localized pain
• Swelling in ear canal
Treatment
• Antibiotics
• Incision and drainage

3. Otomycosis
Definition
Fungal infection of ear.
Common organisms
• Aspergillus
• Candida
Features
• Severe itching
• Ear discharge
• Black or white fungal debris
Treatment
• Cleaning of ear
• Antifungal drops

C. Traumatic Conditions
• Lacerations
• Auricular hematoma
 • Foreign bodies

D. Tumors
Benign
• Osteoma
• Exostosis
Malignant
• Squamous cell carcinoma

8. PRINCIPLES OF MANAGEMENT OF DISCHARGING EAR

Ear discharge is medically termed Otorrhea.

Causes
External ear causes
• Otitis externa
• Otomycosis

Middle ear causes

Acute otitis media
Chronic suppurative otitis media (CSOM)
Two types:
1. Tubotympanic (safe type)
2. Atticoantral (unsafe type)

Principles of Management
1. Aural Toilet
Cleaning of ear canal.
Methods:
• Dry mopping
 • Suction clearance

2. Antibiotics
Topical antibiotics
• Ciprofloxacin ear drops
Systemic antibiotics
Used in severe infections.

3. Control of infection
• Treat nasal infections
• Nasal decongestants

4. Surgical Treatment
Myringoplasty
Repair of tympanic membrane.
Tympanoplasty
Reconstruction of middle ear.
Mastoidectomy
Removal of diseased mastoid air cells.

Complications if untreated
• Mastoiditis
• Brain abscess
• Facial nerve palsy
• Labyrinthitis

9. FOREIGN BODY REMOVAL FROM EAR

Types of Foreign Bodies
Inanimate
 • Beads
• Cotton
• Paper
• Seeds
Animate
• Insects

Clinical Features
• Ear pain
• Hearing loss
• Ear discharge
• Irritation

Management
Insect in ear
First kill insect using:
• Mineral oil
• Alcohol
• Lidocaine

Methods of Removal
1. Instrumental removal
Using:
• Forceps
• Hook
• Suction

2. Syringing
Used if object is small and non-hygroscopic.
3. Removal under microscope

4. Removal under general anesthesia

Used in uncooperative children.

Complications
• Tympanic membrane perforation
• Ear canal injury
• Infection

10. SYRINGING OF WAX (EAR WAX REMOVAL)

Definition
Ear syringing is a procedure used to remove impacted cerumen from external auditory
canal using warm water irrigation.

Indications
• Impacted wax causing hearing loss
• Ear discomfort
• Tinnitus
• Before ear examination

Contraindications
• Perforated tympanic membrane
• Acute ear infection
• Previous ear surgery

Procedure
1. Explain procedure to patient.
2. Patient sits upright.
 3. Use body temperature water.
4. Pull pinna upwards and backwards (adult).
5. Direct water stream towards posterior wall of canal.
6. Wax comes out with water.

Complications
• Vertigo
• Tympanic membrane rupture
• Otitis externa

11. INTERPRETATION OF PURE TONE AUDIOGRAM (PTA)

Definition
Pure Tone Audiometry (PTA) is a subjective hearing test that measures the hearing
threshold of an individual for pure tones at different frequencies.
It is the most common audiological test used to assess hearing loss.

Principle
The test determines the minimum intensity of sound that a person can hear at different
frequencies.
Sound intensity is measured in decibels (dB)
Frequency is measured in Hertz (Hz).

Equipment
• Audiometer
• Headphones
• Bone vibrator
• Soundproof room

Frequencies Tested
Standard frequencies tested are:
250 Hz
500 Hz
1000 Hz
2000 Hz
4000 Hz
8000 Hz
Speech frequencies lie between 500–2000 Hz.

Types of Hearing Tested

1. Air Conduction (AC)
Sound conducted through:
• External ear
• Middle ear
• Inner ear

2. Bone Conduction (BC)

Sound transmitted directly to cochlea through skull bones, bypassing external and middle
ear.

Audiogram
An audiogram is a graphical representation of hearing thresholds.
X-axis
Frequency (Hz)
Y-axis
Intensity (dB)

Normal Hearing Threshold

Normal hearing is 0–25 dB.

Degree of Hearing Loss

Hearing Level Hearing Loss

0–25 dB Normal

26–40 dB Mild

41–55 dB Moderate

56–70 dB Moderately severe

71–90 dB Severe

>90 dB Profound

Types of Hearing Loss in PTA

1. Conductive Hearing Loss
Features:
• Air conduction decreased
• Bone conduction normal
• Air-bone gap present
Causes:
• Wax
• Otitis media
• Otosclerosis

2. Sensorineural Hearing Loss

Features:
• Air conduction decreased
• Bone conduction decreased
• No air-bone gap
Causes:
• Presbycusis
• Noise-induced hearing loss
• Meniere’s disease
3. Mixed Hearing Loss
Features:
• Both AC and BC reduced
• Air-bone gap present

Special Findings
Carhart Notch
Seen in otosclerosis at 2000 Hz.

Clinical Importance
• Detects type of hearing loss
• Assesses severity
• Guides treatment
• Helps in hearing aid fitting

12. INTERPRETATION OF IMPEDANCE AUDIOGRAM (TYMPANOMETRY)

Definition
Impedance audiometry is an objective test used to assess the function of middle ear and
mobility of tympanic membrane.

Components of Impedance Audiometry

1. Tympanometry
2. Acoustic reflex measurement
3. Eustachian tube function test

Principle
Measures compliance (mobility) of tympanic membrane by varying air pressure in external
auditory canal.
Tympanogram
Graph representing middle ear compliance against air pressure.

Types of Tympanograms
Type A (Normal)
Peak at 0 pressure
Indicates:
• Normal middle ear function

Type As (Shallow)
Reduced compliance.
Seen in:
• Otosclerosis
• Tympanosclerosis

Type Ad (Deep)
Excess compliance.
Seen in:
• Ossicular dislocation
• Flaccid tympanic membrane

Type B (Flat)
No peak.
Seen in:
• Middle ear effusion
• Tympanic membrane perforation

Type C
Negative pressure peak.
Seen in:
• Eustachian tube dysfunction

Acoustic Reflex
Contraction of stapedius muscle in response to loud sound.
Absent in:
• Otosclerosis
• Facial nerve palsy
• Severe hearing loss

Clinical Uses
• Diagnose middle ear disease
• Detect ossicular abnormalities
• Identify Eustachian tube dysfunction
• Assess facial nerve function

13. ASSESSMENT AND REHABILITATION OF HEARING IMPAIRED

Definition
Hearing impairment refers to partial or complete inability to hear sounds.

Causes
Congenital causes
• Genetic disorders
• Intrauterine infections
Acquired causes
• Chronic otitis media
• Noise exposure
• Ototoxic drugs
• Presbycusis
Assessment
1. Clinical history
• Onset
• Duration
• Family history
• Drug history

2. Physical examination
• Otoscopy
• Neurological examination

3. Audiological tests
Subjective tests
• Pure tone audiometry
• Speech audiometry
Objective tests
• Otoacoustic emissions
• Brainstem evoked response audiometry

Rehabilitation Methods
1. Hearing Aids
Types:
• Behind the ear (BTE)
• In the ear (ITE)
• Completely in canal (CIC)

2. Cochlear Implant
Indicated in severe to profound sensorineural hearing loss.
Components:
• External microphone
• Speech processor
• Internal electrode

3. Auditory training
Helps patient interpret sounds.

4. Speech therapy
Important for children with congenital hearing loss.

5. Educational rehabilitation
• Special schools
• Inclusive education

Prevention
• Vaccination (rubella)
• Avoid ototoxic drugs
• Early screening

14. NPPCD
(National Programme for Prevention and Control of Deafness)
Introduction
NPPCD is a national health programme in India aimed at preventing hearing loss and
providing early detection and treatment.
Launched by the Ministry of Health and Family Welfare.

Objectives
1. Prevent avoidable hearing loss
2. Early detection of hearing impairment
 3. Provide treatment and rehabilitation
4. Create awareness about ear care

Target Population
• Children
• Elderly people
• Industrial workers exposed to noise

Strategies
1. Strengthening ENT services
At district hospitals.

2. Early detection
Through screening programs in schools.

3. Medical and surgical treatment

• Ear infections
• Hearing loss

4. Provision of hearing aids

For needy patients.

5. Public awareness
Education about:
• Ear hygiene
• Avoiding noise exposure
• Avoiding self ear cleaning

Levels of Implementation
Primary level
Health centers provide basic ear care.
Secondary level
District hospitals provide ENT services.
Tertiary level
Medical colleges provide advanced care.

Expected Outcomes
• Reduction in preventable deafness
• Improved quality of life
• Early treatment of ear diseases

15. ANATOMY, PHYSIOLOGY AND PATHOPHYSIOLOGY OF THE NOSE

ANATOMY OF THE NOSE
The nose is divided into two main parts:
1. External nose
2. Nasal cavity

1. External Nose
The external nose is a pyramidal structure projecting from the face.
Parts
• Root
• Dorsum
• Tip
• Ala
• Nostrils (nares)

Framework
Bony Part
Formed by:
• Nasal bones
• Frontal process of maxilla
• Nasal part of frontal bone
Cartilaginous Part
• Septal cartilage
• Upper lateral cartilage
• Lower lateral cartilage

2. Nasal Cavity
Divided into two halves by nasal septum.
Extends from:
• Anterior nares → Posterior choanae

Boundaries of Nasal Cavity

Roof
Formed by:
• Nasal bone
• Cribriform plate of ethmoid
• Sphenoid bone
Floor
Formed by:
• Palatine process of maxilla
• Palatine bone
Medial Wall
Formed by nasal septum
Components:
• Septal cartilage
• Perpendicular plate of ethmoid
 • Vomer

Lateral Wall
Contains three turbinates (conchae):
1. Superior turbinate
2. Middle turbinate
3. Inferior turbinate

Meatus
Spaces below turbinates:
Superior meatus
Drains:
• Posterior ethmoidal sinus
Middle meatus
Drains:
• Maxillary sinus
• Frontal sinus
• Anterior ethmoid sinus
Inferior meatus
Drains:
• Nasolacrimal duct

Blood Supply
Arterial supply from both internal and external carotid systems.
Major arteries
• Sphenopalatine artery
• Greater palatine artery
• Anterior ethmoidal artery
• Superior labial artery
Kiesselbach’s Plexus (Little’s Area)
A vascular area in anterior nasal septum where arteries anastomose.
Most common site of epistaxis.

Nerve Supply
Olfactory nerve
Responsible for smell.
Trigeminal nerve
Provides sensory innervation.

Physiology of Nose
1. Respiration
Air passage for breathing.

2. Air Conditioning
The nose performs:
Warming
Air warmed by vascular mucosa.
Humidification
Moistening of inspired air.
Filtration
Dust particles trapped by mucus and cilia.

3. Olfaction
Smell sensation via olfactory receptors in superior nasal cavity.

4. Resonance of Voice
Nasal cavity contributes to voice resonance.
Pathophysiology of Nasal Disorders
Nasal diseases occur due to:
Infection
Rhinitis, sinusitis
Allergy
Allergic rhinitis
Structural defects
DNS, polyps
Tumors
These lead to:
• Nasal obstruction
• Discharge
• Sneezing
• Loss of smell

16. NASAL OBSTRUCTION

Definition
Nasal obstruction refers to difficulty in breathing through the nose due to blockage of nasal
passages.

Causes
1. Structural Causes
• Deviated nasal septum
• Nasal polyps
• Adenoid hypertrophy
• Tumors
• Foreign body

2. Inflammatory Causes
 • Rhinitis
• Sinusitis

3. Allergic Causes
• Allergic rhinitis

4. Congenital Causes
• Choanal atresia
• Congenital septal deviation

Clinical Features
• Difficulty breathing through nose
• Mouth breathing
• Snoring
• Nasal speech
• Reduced sense of smell
• Headache

Examination
Anterior Rhinoscopy
Examination of nasal cavity with nasal speculum.

Posterior Rhinoscopy
Examines posterior nasal cavity.

Nasal Endoscopy
Direct visualization using endoscope.

Investigations
 • X-ray paranasal sinuses
• CT scan PNS
• Allergy tests

Management
Medical Treatment
• Antihistamines
• Nasal decongestants
• Steroid nasal sprays

Surgical Treatment
Depending on cause:
• Septoplasty
• Polypectomy
• Adenoidectomy

Complications
• Sinusitis
• Sleep apnea
• Recurrent infections

17. ADENOIDS
Definition
Adenoids are lymphoid tissue located in the roof and posterior wall of nasopharynx.
They form part of Waldeyer’s ring.

Waldeyer’s Ring Components

• Adenoids
• Palatine tonsils
 • Lingual tonsils
• Tubal tonsils

Etiology of Adenoid Hypertrophy

• Recurrent infections
• Allergies
• Genetic predisposition

Age Incidence
Common in children aged 3–10 years.

Clinical Features
Nasal obstruction
Mouth breathing
Snoring
Hyponasal speech
Recurrent ear infections
Hearing loss

Adenoid Facies
Characteristic facial features:
• Open mouth
• Elongated face
• High arched palate
• Protruding upper teeth

Complications
• Otitis media with effusion
• Chronic sinusitis
 • Sleep apnea

Investigations
• Lateral X-ray nasopharynx
• Nasal endoscopy

Treatment
Medical
• Antibiotics
• Nasal steroids

Surgical
Adenoidectomy
Indications:
• Severe nasal obstruction
• Recurrent ear infections
• Sleep apnea

18. NASAL POLYPS

Definition
Nasal polyps are benign, pale, edematous masses arising from nasal mucosa due to chronic
inflammation.

Types
1. Ethmoidal Polyps
• Multiple
• Bilateral
• Common in adults

2. Antrochoanal Polyp
 • Single
• Arises from maxillary sinus
• Extends into nasopharynx
• Common in children

Etiology
• Allergy
• Chronic sinusitis
• Asthma
• Aspirin sensitivity

Pathology
Polyp consists of:
• Edematous stroma
• Inflammatory cells
• Covered by respiratory epithelium

Clinical Features
• Nasal obstruction
• Nasal discharge
• Hyposmia or anosmia
• Mouth breathing
• Headache

Examination
On rhinoscopy:
Polyps appear:
• Pale
• Soft
 • Non-tender
• Insensitive to touch

Investigations
• CT scan paranasal sinuses
• Nasal endoscopy

Treatment
Medical
• Intranasal corticosteroids
• Antihistamines
• Antibiotics

Surgical
Functional Endoscopic Sinus Surgery (FESS)
Removes polyps and restores sinus drainage.

19. DEVIATED NASAL SEPTUM (DNS)

Definition
Deviated Nasal Septum is a condition in which the nasal septum is displaced from the
midline, resulting in narrowing of one nasal cavity and widening of the other.

Anatomy of Nasal Septum

The nasal septum is composed of:
1. Cartilaginous Part
• Septal cartilage
2. Bony Part
• Perpendicular plate of ethmoid
• Vomer
• Maxillary crest
 • Palatine crest

Etiology
1. Developmental Causes
• Unequal growth of nasal septum and palate
2. Traumatic Causes
• Birth trauma
• Nasal injury during childhood
3. Compensatory Causes
Deviation due to enlargement of turbinates or nasal masses.

Types of Septal Deviation

Common forms include:
• C-shaped deviation
• S-shaped deviation
• Septal spur
• Septal thickening

Pathophysiology
Septal deviation causes:
• Narrowing of nasal passage
• Disturbance of airflow
• Impaired sinus drainage
This predisposes to sinus infections and nasal obstruction.

Clinical Features
• Nasal obstruction (usually unilateral)
• Headache
• Nasal discharge
 • Recurrent sinusitis
• Epistaxis
• Reduced sense of smell

Examination
Anterior Rhinoscopy
Shows deviation of septum.
Nasal Endoscopy
Provides detailed view.

Investigations
• CT scan paranasal sinuses
• X-ray PNS (less commonly used)

Management
Medical Treatment
Used only for symptomatic relief.
• Antihistamines
• Nasal decongestants
• Nasal steroid sprays

Surgical Treatment
Septoplasty
Correction of deviated septum while preserving mucosa.
Submucous Resection (SMR)
Removal of deviated part of septum.
Septoplasty is preferred in modern practice.

Complications
 • Chronic sinusitis
• Recurrent epistaxis
• Middle ear infections
• Nasal obstruction

20. ALLERGIC RHINITIS

Definition
Allergic rhinitis is an IgE-mediated hypersensitivity reaction of nasal mucosa caused by
exposure to allergens.

Etiology
Allergens include:
• House dust mites
• Pollen
• Animal dander
• Fungal spores
• Food allergens

Pathophysiology
The disease occurs in two phases:
1. Early Phase Reaction
Occurs within minutes.
Features:
• Sneezing
• Nasal itching
• Rhinorrhea

2. Late Phase Reaction

Occurs after several hours.
Features:
 • Nasal congestion
• Persistent inflammation

Types
Seasonal Allergic Rhinitis
Occurs during pollen seasons.
Perennial Allergic Rhinitis
Occurs throughout the year.

Clinical Features
Classic allergic triad:
1. Sneezing
2. Nasal discharge
3. Nasal obstruction
Other features:
• Nasal itching
• Watery eyes
• Postnasal drip
• Reduced smell

Signs
• Pale bluish nasal mucosa
• Watery discharge
• Allergic salute
• Allergic shiners

Investigations
Blood tests
• Eosinophilia
 • Raised IgE levels
Skin prick test
Identifies specific allergens.

Management
Allergen Avoidance
Avoid exposure to allergens.

Medical Treatment
Antihistamines
• Cetirizine
• Loratadine
Intranasal corticosteroids
Most effective treatment.
Leukotriene antagonists
• Montelukast
Nasal decongestants
Used short-term.

Immunotherapy
Allergen-specific immunotherapy.

Complications
• Sinusitis
• Otitis media
• Nasal polyps
• Asthma

21. VASOMOTOR RHINITIS

Definition
Vasomotor rhinitis is a non-allergic rhinitis caused by imbalance of autonomic nervous
control of nasal mucosa.

Etiology
Triggers include:
• Cold air
• Strong odors
• Smoke
• Alcohol
• Emotional stress
• Hormonal changes

Pathophysiology
Autonomic imbalance leads to:
• Vasodilation
• Increased nasal secretion
• Nasal congestion

Clinical Features
• Nasal obstruction
• Watery rhinorrhea
• Postnasal drip
• Sneezing (less prominent)

Examination
Nasal mucosa appears:
• Red
• Congested
Investigations
Diagnosis mainly clinical.
Allergy tests usually negative.

Treatment
Medical Treatment
• Intranasal corticosteroids
• Anticholinergic sprays (ipratropium)
• Antihistamines

Surgical Treatment
If refractory:
• Vidian neurectomy
• Turbinate reduction

22. ALLERGY (ENT PERSPECTIVE)

Definition
Allergy is an exaggerated immune response to harmless environmental substances called
allergens.

Mechanism
Most ENT allergies are Type I hypersensitivity reactions mediated by IgE antibodies.

Common ENT Allergic Disorders

• Allergic rhinitis
• Allergic sinusitis
• Nasal polyps
• Allergic otitis media

Pathogenesis
Steps include:
1. Allergen exposure
2. IgE production
3. Mast cell activation
4. Release of inflammatory mediators
Mediators include:
• Histamine
• Leukotrienes
• Prostaglandins

Clinical Features
• Sneezing
• Nasal obstruction
• Rhinorrhea
• Itching of nose and eyes

Diagnosis
• Skin prick test
• Serum IgE levels
• Nasal smear for eosinophils

Management
Avoidance of allergens
Pharmacotherapy
• Antihistamines
• Steroid nasal sprays
• Leukotriene antagonists
Immunotherapy
Gradual exposure to allergen to induce tolerance.
23. EPISTAXIS
Definition
Epistaxis refers to bleeding from the nose due to rupture of blood vessels in the nasal
mucosa.

Etiology
Local Causes
• Trauma
• Nose picking
• Deviated septum
• Nasal tumors
• Infections

Systemic Causes
• Hypertension
• Blood disorders
• Liver disease
• Anticoagulant drugs

Common Site of Bleeding

Kiesselbach’s Plexus
Located in Little’s area on anterior nasal septum.
Most common site in children and young adults.

Woodruff’s Plexus
Posterior nasal cavity; common in elderly patients.

Clinical Features
• Bleeding from nostril
 • Blood flowing into throat
• Dizziness
• Weakness

Management
First Aid
1. Patient sits upright.
2. Lean head forward.
3. Apply pressure to nose for 10 minutes.

Medical Treatment
• Nasal decongestants
• Topical vasoconstrictors

Cauterization
Chemical cautery
Using silver nitrate.
Electrical cautery

Nasal Packing
Anterior nasal packing
Posterior nasal packing

Surgical Treatment
• Arterial ligation
• Endoscopic sphenopalatine artery ligation

24. PARANASAL SINUSES

Definition
Paranasal sinuses are air-filled cavities within the bones of the skull that communicate with
the nasal cavity and are lined by respiratory mucosa.

Types of Paranasal Sinuses

There are four paired sinuses:
1. Maxillary sinuses
2. Frontal sinuses
3. Ethmoidal sinuses
4. Sphenoidal sinuses

Development of Sinuses
• Present at birth: Maxillary and ethmoid sinuses (small)
• Develop later: Frontal and sphenoid sinuses
Full development occurs by puberty.

Anatomy
1. Maxillary Sinus
Largest sinus.
Location
Body of maxilla.
Opening
Drains into middle meatus via ostium in hiatus semilunaris.
Relations
• Orbit (superior)
• Teeth roots (inferior)

2. Frontal Sinus
Location
Frontal bone above orbit.
Drainage
Via frontonasal duct → middle meatus.

3. Ethmoidal Sinuses
Divided into:
• Anterior ethmoidal cells
• Middle ethmoidal cells
• Posterior ethmoidal cells
Drainage:
• Anterior and middle → middle meatus
• Posterior → superior meatus

4. Sphenoid Sinus
Location
Body of sphenoid bone.
Drainage
Into sphenoethmoidal recess.

Functions of Paranasal Sinuses

1. Reduce weight of skull
2. Improve resonance of voice
3. Humidify inspired air
4. Protect intracranial structures
5. Act as thermal insulators

Blood Supply
• Branches of maxillary artery
• Ethmoidal arteries

Nerve Supply
 • Branches of trigeminal nerve

Clinical Importance
Diseases affecting sinuses include:
• Sinusitis
• Polyps
• Tumors

25. ACUTE SINUSITIS

Definition
Acute sinusitis is acute inflammation of paranasal sinus mucosa usually caused by
infection.

Etiology
Predisposing factors
• Upper respiratory infection
• Nasal obstruction
• Deviated nasal septum
• Allergy
• Dental infections

Causative organisms
Common bacteria:
• Streptococcus pneumoniae
• Haemophilus influenzae
• Staphylococcus aureus

Pathophysiology
Sequence of events:
1. Viral infection causes mucosal edema.
 2. Sinus ostium becomes blocked.
3. Mucus accumulates inside sinus.
4. Secondary bacterial infection occurs.

Types
Depending on sinus involved:
• Maxillary sinusitis (most common)
• Frontal sinusitis
• Ethmoid sinusitis
• Sphenoid sinusitis

Clinical Features
Facial pain
Headache
Nasal obstruction
Purulent nasal discharge
Fever
Postnasal drip

Examination
Tenderness over affected sinus
Examples:
• Maxillary sinus → cheek tenderness
• Frontal sinus → forehead tenderness

Investigations
• X-ray paranasal sinuses
• CT scan PNS
• Nasal endoscopy
Management
Medical Treatment
• Antibiotics
• Nasal decongestants
• Steam inhalation
• Analgesics

Surgical Treatment
If medical treatment fails:
Antral washout
Functional Endoscopic Sinus Surgery (FESS)

Complications
• Orbital cellulitis
• Brain abscess
• Meningitis

26. CHRONIC SINUSITIS

Definition
Chronic sinusitis is inflammation of the paranasal sinuses lasting more than 12 weeks.

Etiology
• Recurrent acute sinusitis
• Allergic rhinitis
• Nasal polyps
• Deviated nasal septum
• Dental infections
Pathology
Chronic inflammation leads to:
• Thickened mucosa
• Polyp formation
• Impaired sinus drainage

Clinical Features
• Persistent nasal obstruction
• Chronic nasal discharge
• Headache
• Postnasal drip
• Reduced sense of smell

Investigations
CT scan PNS
Gold standard.
Nasal endoscopy
X-ray PNS

Management
Medical Treatment
• Long-term antibiotics
• Nasal steroid sprays
• Antihistamines
• Steam inhalation

Surgical Treatment
Functional Endoscopic Sinus Surgery (FESS)
Goal:
 • Remove diseased mucosa
• Restore sinus drainage

27. TONSIL
Definition
Tonsils are masses of lymphoid tissue located in the oropharynx forming part of
Waldeyer’s ring.

Components of Waldeyer’s Ring

1. Palatine tonsils
2. Adenoids
3. Lingual tonsils
4. Tubal tonsils

Anatomy of Palatine Tonsil

Location
Between:
• Palatoglossal arch (anterior pillar)
• Palatopharyngeal arch (posterior pillar)

Surfaces
1. Medial surface
2. Lateral surface

Blood Supply
Arteries supplying tonsil:
• Tonsillar branch of facial artery
• Ascending palatine artery
• Lingual artery
• Ascending pharyngeal artery
Venous Drainage
Via paratonsillar vein.

Functions
• Immune defense
• Production of lymphocytes
• Antibody formation

28. TONSILLITIS
Definition
Tonsillitis is inflammation of palatine tonsils caused by bacterial or viral infection.

Etiology
Bacterial
• Streptococcus pyogenes (most common)
Viral
• Adenovirus
• Epstein-Barr virus

Types
1. Acute tonsillitis
2. Recurrent tonsillitis
3. Chronic tonsillitis

Clinical Features
• Sore throat
• Fever
• Pain on swallowing
 • Enlarged tonsils
• White exudates on tonsils
• Enlarged cervical lymph nodes

Complications
Local complications
• Peritonsillar abscess (Quinsy)
• Parapharyngeal abscess
Systemic complications
• Rheumatic fever
• Glomerulonephritis

Management
Medical Treatment
• Antibiotics
• Analgesics
• Antipyretics
• Warm saline gargles

29. TONSILLECTOMY
Definition
Tonsillectomy is surgical removal of palatine tonsils.

Indications
Recurrent tonsillitis
(≥7 episodes in one year)
Peritonsillar abscess
Obstructive sleep apnea
Tonsillar hypertrophy causing dysphagia
Suspected malignancy

Surgical Techniques
1. Dissection method
2. Guillotine method
3. Electrocautery
4. Coblation tonsillectomy

Steps of Operation (Dissection Method)

1. Mouth gag inserted.
2. Tonsil grasped with forceps.
3. Dissection from tonsillar bed.
4. Hemostasis achieved.

Complications
Primary hemorrhage
Within 24 hours.
Secondary hemorrhage
After 5–10 days.
Other complications:
• Infection
• Pain
• Airway obstruction

30. ADENOID HYPERTROPHY

Definition
Adenoid hypertrophy refers to enlargement of adenoid lymphoid tissue in the nasopharynx
leading to airway obstruction.

Etiology
 • Recurrent infections
• Allergies
• Genetic factors

Clinical Features
• Nasal obstruction
• Mouth breathing
• Snoring
• Hyponasal speech
• Sleep apnea
• Recurrent ear infections

Adenoid Facies
Characteristic facial appearance:
• Open mouth
• Long face
• High arched palate
• Prominent upper teeth

Complications
• Otitis media with effusion
• Hearing loss
• Sinusitis
• Sleep apnea

Investigations
• Lateral X-ray nasopharynx
• Nasal endoscopy
Treatment
Medical
• Antibiotics
• Nasal steroid sprays

Surgical
Adenoidectomy
Indications:
• Severe nasal obstruction
• Recurrent ear infections
• Obstructive sleep apnea