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Marrow

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ENT

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World of Revision

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Instructions

• Notes are to be used in conjunction with Marrow videos.

Please note:
• The information in this book has been printed based on the transcript of the Marrow videos. This
book has to be used in conjunction with the Marrow videos and not as a standalone material.

• The information contained in this book is for educational purposes only. The content provided is
not intended to substitute for professional medical advice, diagnosis or treatment.

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•

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This book cannot be sold separately. It has been made available to only select eligible users who

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have an active subscription to Marrow videos.

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• The text, images, slides, and other materials used in this book have been contributed by the
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faculty, who are subject matter experts. We have merely reproduced them as video transcripts in
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this book.
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• The notes have been consciously designed in a way that is concise and revisable. To ensure this,
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we have intentionally added only the most relevant modules and images that are needed for you.
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• The notes contain blank spaces primarily for labelling diagrams, completing cycles and more to
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promote active engagement and reinforce learning.

©

• Red icons, wherever present, serve as cues to faculty-emphasised sections, intended to guide
focused learning.

• Reasonable care has been taken to ensure the accuracy of the information provided in this book.
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©Marrow
Contents

ENT
Ear : Part 1  1
Embryology  Anatomy of inner ear  Auditory pathway  Overview: Inner ear

Ear : Part 2 8
Anatomy of middle ear  Medial wall of middle ear  Posterior wall of middle ear 
Anterior wall of middle ear  Floor & roof of middle ear  Cavity of middle ear 
Semicircular canals (SCC)  Nerve supply of the ear

Ear : Part 3 17
Physiology of hearing & hearing loss  Tuning fork tests (TFT) 

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Pure tone audiometry (PTA)  Audiograms in different conditions  Grading of HL

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Ear : Part 4 23

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Tympanometry  Brainstem evoked response audiometry (BERA)  gm
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Otoacoustic emissions (OAE)/KEMP echoes  Behavioural observation audiometry 
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Electrocochleography  Speech audiometry  Auditory neuropathy spectrum disorder

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Ear : Part 5 30
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Acute otitis media  Bullous myringitis  Tympanic membrane perforation 

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Chronic otitis media/chronic suppurative otitis media (CSOM) 

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Chronic mucosal otitis media  Tympanoplasty & myringoplasty 

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Chronic squamous otitis media (CSOM)  Complications of otitis media 

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Tubercular otitis media  Conditions of EAC

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Ear : Part 6 42
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Serous otitis media (SOM)  Retraction of TM : classifications 

Otosclerosis/otospongiosis

Ear : Part 7  47
Benign paroxysmal positional vertigo (BPPV)  Vestibular neuritis 
Meniere’s disease  Superior semicircular canal dehiscence (SSCD)

Ear : Part 8 53
Glomus tumor  Acoustic neuroma/vestibular schwannoma  Facial nerve 
Hearing rehabilitation

Nose : Part 1 60
Anatomy of external nose  Anatomy of lateral wall of nose  Middle meatus 
Variations in Turbinate Appearance  Paranasal Sinuses  X-ray views for sinuses 
Rhinosinusitis  Fungal sinusitis  Polyps
Nose : Part 2 74
Nerve supply of nose  Rhinitis  Arterial supply of the nose  Epistaxis 
Rhinosporidiosis  Atrophic rhinitis/Ozaena  Rhinoscleroma  Fractures of face 
CSF rhinorrhea  Inverted papilloma  Carcinoma of nose & PNS

Pharynx : Part 1 86
Nerve supply of tongue  Anatomy of pharynx  Pharyngeal constrictors 
Posterior pharyngeal spaces  Lateral pharyngeal spaces 
Peritonsillar vs parapharyngeal abscess  Submandibular space

Pharynx : Part 2 94
Anatomy of nasopharynx  Adenoid hypertrophy  Angiofibroma 
Nasopharyngeal carcinoma  Oropharynx and tonsils  Acute tonsillitis 
Laryngo/hypopharynx

Larynx : Part 1  102

Cartilages & membranes  Divisions  Muscles  Adult vs. child larynx 
Infections  Congenital conditions  Structural disorders of glottis  Larynx examination :
instruments & positions

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Larynx : Part 2 110

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Nerve supply of larynx  Positions of vocal cords  Vocal cord palsy 
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Vocal cord dysfunction  Carcinoma larynx  Newer techniques in laryngeal endoscopy 
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Tracheostomy  Foreign body  Pathological breath sounds
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©
 Ear : Part 1 1

EAR : PART 1 ----- Active space -----

Embryology 00:01:03

Structure Origin
Tragus & ascending crus of helix 1st arch
Pinna
Rest of the pinna 2nd arch
Primitive
EAC (External auditory canal) 1st cleft
tympanic
External acoustic meatus 1st arch cavity
• Eustachian tube (ET) 1st cleft Auditory tube
• Tympanic/middle ear (ME) (EAC) 1st pouch
Middle ear 1st pouch
cavity
cleft (Tubotympanic recess)

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• Mastoid antrum :

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Largest mastoid air cell

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Malleus & incus gm
1st arch mesoderm
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Suprastructure of stapes
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Ossicles (Head, neck, anterior & posterior 2nd arch mesoderm

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crura)
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Otic capsule/ Pharyngeal pouch & cleft

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Footplate of stapes
Bony labyrinth
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Outer layer 1st cleft (Ectoderm) Mastoid antrum

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Tympanic
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Middle layer 1st arch (Mesoderm) Middle ear cavity

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membrane
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Inner layer 1 pouch (Endoderm)

st

Membranous labyrinth : Otic vesicle (Ectoderm) :

• SCC, utricle, endolymphatic sac • Pars superior ET
• Saccule, cochlea • Pars inferior
Inner ear Middle ear cleft
Endochondral ossification
Bony labyrinth of mesoderm around otic
vesicle

Surface ectoderm Bony labyrinth

Utricular portion
Ossicles
of otic vesicle
(Mesoderm)
Saccular portion
Cartilaginous
1st pharyngeal cleft part of EAC
Tubotympanic
recess Auditory tube
Inner ear development Middle ear development

ENT • World of Revision • v1.0 • Marrow • 2025

 2 ENT

----- Active space -----

Development of membranous labyrinth

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Anomalies of Pinna : @
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Preauricular sinus : Malformations :
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• M/c location : Root of helix. • Microtia (Small pinna).

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• Fusion defect of auricular tubercles. • Anotia (Pinna absent).

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Autologous
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rib
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cartilage
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Pre-auricular sinus Microtia Otoplasty/pinnaplasty

(Min age : 6 yrs)
Development by Birth :

Completed : Not completed :

• Middle ear : • Bony part of EAC
- Ossicles • Mastoid tip (Develops at 2 yrs)
- Mastoid antrum
• Inner ear :
Organ of Corti
(By 20 - 25 weeks intrauterine life)
• Cartilaginous part of EAC

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 1 3

----- Active space -----

Tympanic
membrane

Bony EAC

Mastoid
Stylomastoid
tip
foramen
Adult skull Skull at < 2 y/o
Note :
Child < 2 yrs :
Post-auricular incision ↑Risk of facial nerve injury (Not protected by mastoid tip).

Anatomy of Inner Ear 00:10:56

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Bony labyrinth

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gm
Perilymph
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Membranous labyrinth
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(Complete sac)
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Endolymph
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Schematic representation of inner ear

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Membranous Labyrinth :
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Parts :
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2 Utricle
Superior 3 Saccule
1 Semi- Crus commune Apical turn
circular
canals Posterior
(SCC) Lateral
(Towards ME) 4 Scala media
(2 /12 turns around modiolus)
5 Endolymphatic sac Basal turn
(Absorbs endolymph)
Membranous labyrinth

Openings of SCC :
• 5 openings into utricle.
• Crus commune :Common opening of Modiolus
posterior & superior SCC.
Scala media

ENT • World of Revision • v1.0 • Marrow • 2025

 4 ENT

----- Active space ----- Functions :

Function Sensory end organ Location
Rotational acceleration Cristae SCC
Balance
Linear acceleration Maculae (Otoconia/Otolith) Utricle & saccule
High frequency Basal turn of organ of Corti
Hearing Scala media
Low frequency Apical turn of organ of Corti

Bony Labyrinth :
Parts :

1 Bony SCC
3 Bony cochlea :
• Scala vestibuli (SV)
Oval window
• Scala tympani (ST)

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2 Vestibule

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(Around utricle &

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saccule)
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Round window
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Scala media
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Helicotrema
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(Connects SV & ST) Bony labyrinth

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Openings :
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1. Connecting to middle ear :

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Transmission of vibrations : Opposing movement

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Round window :
©

• Covered by secondary
Oval window : tympanic membrane
• Connects to vestibule. • Connects to scala
• Vibrations transmitted tympani
to scala vestibuli. • Electrodes of cochlear
implant & drugs
administered here

2. Connecting to brain :
• Internal acoustic meatus : CN VII & VIII entry.
• Cochlear aqueduct (CA) :
- Connects to scala tympani.
- CSF CA Perilymph (Resembles ECF; > Na+).
• Clinical significance :
- Meningitis Openings Labyrinthitis.
- Infant with meningitis : Check for hearing loss.

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 1 5

Scala Media & Organ of Corti : ----- Active space -----

Scala vestibuli
Scala media
modiolus
RM
BM Scala tympani
cochlear nerve
Cochlea Cochlear section
Organ of Corti :
• Lies on basilar membrane
• Function : T
 ransduction of sound (Mechanical energy Electrical energy).

Parts of 0rgan of Corti :

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• Reissner’s membrane (RM) :

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Separates SM & SV superiorly. SV
gm RM
• Basilar membrane (BM) :
@
S. vasc
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SM
Separates SM & ST inferiorly.
ns

TM
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• Stria vascularis (S. vasc) :

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OHC
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- Produces endolymph. IHC

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- Maintains electrochemical ST BM
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gradient of endolymph. Organ of Corti

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- Resembles ICF : > K+ (+80 mV).

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• Tectorial membrane (TM) :

Receives projections from OHC.

Inner hair cells (IHC) Outer hair cells (OHC)

Arrangement 3500 cells in a single row 12,000 cells in 3 - 4 rows
Damage by noise
Less prone More prone
& ototoxic drugs
Primary nerve
Afferent (Cochlear nerves) Efferent
fibres
Function Transmit auditory stimuli Modulate function of IHC
Excitatory
Glutamate -
neurotransmitter

ENT • World of Revision • v1.0 • Marrow • 2025

 6 ENT

----- Active space ----- Auditory Pathway 00:31:07

Afferent nerves from IHC

Spiral ganglion
Fuse
Cochlear nerve
Modiolus Auditory cortex (41)
Internal acoustic meatus
Medial geniculate
nucleus of thalamus
Cochlear nuclei Inferior colliculus

Nucleus of
Superior olivary complex : lateral lemniscus Pons-midbrain
• 1st area for sound localization junction

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• Centre for stapedial reflex Lateral lemniscus

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Mid-pons

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Superior olivary
CN VIII gm
Lateral lemniscus complex
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(Cochlear nerve)
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Inferior colliculus Cochlea

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Spiral ganglion (Within

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bony modiolus)
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Auditory pathway
Medial geniculate body
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Auditory cortex.
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(Area number : 41)

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 1 7

Overview: Inner Ear 00:33:19 ----- Active space -----

Auditory cortex (41) : Superior temporal gyrus

S. tympani S. vestibuli Afferents

Auditory pathway
Round Oval fuse
window window IHC
Organ of Corti
Semicircular OHC :
canals Connects • Receive efferents
to middle • Prone to damage
Stria vascularis
ear • More in number
Bony Overview Cochlea
Vestibule
Parts labyrinth
Membranes :
• Basilar

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Bony • Tectorial

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cochlea • Reissner’s

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gm
Membranous labyrinth
@
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Hearing : Organ of Corti Balance (SCC)

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(S. media)
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Maculae : Linear
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Cristae : Rotational
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Basal turn : Apical turn : acceleration acceleration

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↑Frequency ↓Frequency
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Endolymph
Produces Absorption
Stria vascularis Endolymphatic
(Scala media) sac

ENT • World of Revision • v1.0 • Marrow • 2025

 8

----- Active space ----- EAR : PART 2

Anatomy of Middle Ear 00:00:54

6-walled cavity.

Wall Relation
Anterior wall Pharynx, exit of chorda tympani
Posterior wall Mastoid (Access for middle ear Sx)
Medial wall Inner ear
Lateral wall External auditory canal
Roof Middle cranial fossa (Temporal lobe)

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Floor Base of skull

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Superior
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Lateral Wall :
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Anterior
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Upper part of
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Scutum handle of malleus

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Upper 1/3 (Antero-superior)

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Pars flaccida
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Cone of light
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Tympanic (Shrapnell’s
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membrane membrane) (Antero-inferior)

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Pars tensa
Lower 2/3 Identification
Lateral wall of middle ear Left tympanic membrane of side

Medial Wall of Middle Ear 00:06:44

Tensor tympani (From anterior wall)

Bulge of lateral SCC
Processus cochleariformis
Oval window

Promontory
Horizontal segment of facial nerve

Round window

Medial wall structures

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 2 9

Structures on the Medial Wall : ----- Active space -----

Oval window :
• Connects to scala vestibuli.
• Footplate of stapes lies over it.

Round window :
• Connects to scala tympani.
• Site of drug administration & electrode placement.

Bulge of lateral semicircular canal (SCC) :

• M/c SCC eroded by cholesteatoma.
• Stimulated by caloric test.

Promontory :
Bulge produced by basal turn of cochlea.

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Processus cochleariformis :
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gm
• Bony projection on anterior part of medial wall.
@
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• Site of lateral turn of tensor tympani.

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Facial nerve :
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• 1st genu :
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Horizontal/tympanic segment
|

- Above processus cochleariformis. landmarks :

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- Geniculate ganglion present. - Superiorly : Bulge of SCC.

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- Inferiorly : Oval window.

©

Horizontal segment Long process of incus

of facial nerve
Handle of malleus
Oval window
Promontory
Round window
Right middle ear

ENT • World of Revision • v1.0 • Marrow • 2025

 10 ENT

----- Active space ----- Posterior Wall of Middle Ear 00:16:51

Common wall between middle ear & mastoid.

Aditus

2nd genu Stapedius

Chorda tympani
Vertical segment
of facial nerve

Posterior wall
Structures :

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Aditus : Opening connecting middle ear to mastoid.

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Facial nerve : @
gm
• 2nd genu.
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• Vertical/descending/mastoid segment.
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• Chorda tympani :
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- Branch of vertical segment.

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- Middle ear Entry : Posterior wall.

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Exit : Anterior wall.

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Fossa incudis : Depression produced by short process of incus (Under aditus).

Facial recess :
• AKA suprapyramidal recess.
• Boundaries :
- Medial : Vertical segment of facial nerve.
↑risk
- Lateral : Chorda tympani. o
injury f
- Superior : Fossa incudis.
• Significance :
- Posterior tympanotomy/Intact canal wall surgery :
Site of entry into ME from mastoid.

Pyramid :
• Origin of stapedius muscle Inserts to neck of stapes.
- Significance : Stapedial reflex (Protects from noise trauma).

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 2 11

Sinus tympani : ----- Active space -----

• AKA Infrapyramidal recess/hidden area of middle ear.
• M/c site of residual cholesteatoma.

Note :
↑Risk of injury during posterior tympanotomy to :
• Vertical segment of facial nerve.
• Chorda tympani.
• Ossicles.

Posterior

Chorda tympani Medial Short process

Facial recess of incus
Mastoid Facial recess
VII nerve

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Chorda tympani

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antrum
Pyramid

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Sinus tympani Sigmoid Vertical segment
gm of facial nerve
sinus
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Transverse section of middle ear

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Posterior wall structures

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( L ear)
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Short process of incus

Facial recess Aditus
Fossa incudis
Round window Chorda tympani
(Easy access to IE)

Cochlear electrode Facial recess (Supine patient)

ENT • World of Revision • v1.0 • Marrow • 2025

 12 ENT

----- Active space ----- Anterior Wall of Middle Ear 00:30:44

• Common wall between ME & pharynx.

• AKA carotid wall.

Structures :
Eustachian tube : Connection between middle ear & pharynx.

Chorda tympani : Exits through Huguier canal on anterior wall.

Tensor tympani :

Tensor tympani origin

Eustachian tube

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Eustachian tube gm Chorda tympani
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Right middle ear Anterior wall

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Floor & Roof of Middle Ear

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00:32:47
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Floor/Inferior Wall :
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Formed by the base of skull (Temporal bone). Sigmoid sinus

Structures related : Jugular bulb

• Jugular bulb :
Glomus jugulare projects from floor.
• IX, X, XI cranial nerves : Relations of jugular bulb

Tympanic plexus on promontory.

Tympanic branch
(Jacobson’s nerve) Enters through the floor

Roof/Superior Wall :
Tegmen
• AKA tegmen tympani. tympani
• Separates middle ear from
middle cranial fossa (Temporal lobe).
Roof of middle ear

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 2 13

HRCT-Temporal Bone : ----- Active space -----

Radiological IOC for ear.

Ear cavity
Ear cavity

Mastoid
Mastoid
Internal acoustic meatus Sigmoid sinus region
Transverse sinus region
Jugular foramen

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HRCT - Temporal bone

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Cavity of Middle Ear @
gm 00:39:32
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Compartments :
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Compartment Characteristic Measurement

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• Widest
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Epitympanum 6 mm
• Lateral wall : Pars flaccida + scutum
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Narrowest (D/t TM concavity

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Mesotympanum 2 mm
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laterally & promontory medially)

©

Hypotympanum Smallest 4 mm

Prussak space :
• Space in epitympanum.
• M/c site for retraction pockets Primary cholesteatoma.

Epitympanum

Prussak space

Upper and lower

borders of pars tensa
Mesotympanum
Hypotympanum
Middle ear cavity

ENT • World of Revision • v1.0 • Marrow • 2025

 14 ENT

----- Active space ----- Anatomy of Ossicles :

Incus
Malleus Short process

Head Body
Neck
Lateral process Long process
(Towards TM) Stapes
Anterior process Head Posterior crus

Handle of malleus Footplate

Anterior crus
Lenticular process

Incudomalleolar joint : Saddle joint.

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Incudostapedial joint : Ball & socket joint (Least blood supply).

co
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M/c site of necrosis Long process of incus (Lenticular process).
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Semicircular Canals (SCC) 00:45:55
h9
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Points of Identification :
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• Seen in upper part of mastoid.

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• Superior SCC : Lies superiorly in mastoid.

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• Lateral SCC : Lies towards middle ear; close to posterior SCC.

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©

Superior SCC
Lateral SCC
Posterior SCC

Semicircular canals Semicircular canals

Superior Superior

Incus
Facial recess
Lateral SCC
Superior SCC
Posterior SCC

Operative view (Supine) Operative view (Supine)

ENT • World of Revision • v1.0 • Marrow • 2025
 Ear : Part 2 15

Nerve Supply of the Ear 00:50:56 ----- Active space -----

Pinna :
Lesser occipital Auriculotemporal
nerve (C2) nerve (V3) Greater auricular
nerve (C2, C3)
2

1
1 3

1 3

4 & 5
4

CN VII and X

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Greater auricular CN VII and X

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nerve (C2, C3)
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Mnemonic : GOAA-F
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Nerve Branch of Supplies Referred pain from

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1. G
 reater auricular Cervical plexus Greater part of pinna • Angle of jaw (Shaving area)
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nerve (C2, C3) (Medial & lateral surface) • Cervical spine degeneration
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2. Lesser occipital Superior part of medial

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C2 -
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nerve surface of pinna

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• TMJ (Costen’s syndrome)

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©

3. A uriculotemporal • Tragus • Mandible

Mandibular nerve
nerve • Ascending crus of helix • Anterior 2/3rd of tongue
• Parotid (Infections)
CN X
4. Arnold’s nerve Concha -
(Auricular branch)
5. F acial nerve
Small part of external
(Nervus intermedius/ - -
acoustic meatus (EAM)
N. of Wrisberg)
Hitselberger sign :
Acoustic neuroma CN VII compression Anesthesia/hypoesthesia at EAM.

External Auditory Canal :

Supplied by :
• Auriculotemporal nerve : Anterior & superior wall.
• Arnold’s nerve : Causes cough on cleaning.

ENT • World of Revision • v1.0 • Marrow • 2025

 16 ENT

----- Active space ----- Tympanic Membrane :

Lateral surface :
• Auriculotemporal nerve (V3).
• Arnold’s nerve (X).

Medial surface : Jacobson’s nerve (IXth nerve).

Middle Ear :
Supplied by : Jacobson’s nerve.

Referred Pain :

Condition causing referred pain Nerve responsible

• Ca larynx
Arnold’s nerve
• Ca hypopharynx
(Vagus)

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• Ca thyroid

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• Acute tonsillitis
gm Jacobson’s nerve
• Peritonsillar abscess
@

(Glossopharyngeal)
h9

• Ca base of tongue
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ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 3 17

EAR : PART 3 ----- Active space -----

Physiology of Hearing & Hearing Loss 00:00:58

Hearing :
Function Site
Conduction of sound External & middle ear (ME)
Amplification of sound AC
Middle ear
(Impedance matching)
Transduction of sound Inner ear BC
Air conduction (AC) : Conductive + sensorineural pathway.

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Bone conduction (BC) : Sensorineural pathway.

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Types of Hearing Loss (HL) : @
gm
Type of HL Site of pathology
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Conductive hearing loss (CHL) Pinna Footplate of stapes

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Sensory HL Cochlea
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Mixed hearing
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Sensorineural Auditory nerve

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loss Neural/­
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(SNHL)
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retrocochlear HL
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Auditory cortex
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©

Uses of Hearing Tests :

• To determine site of involvement :
- Conductive vs. sensorineural.
- Cochlear vs. retrocochlear.
• Degree of HL.

Ear anatomy
ENT • World of Revision • v1.0 • Marrow • 2025
 18 ENT

----- Active space ----- Tuning Fork Tests (TFT) 00:08:13

Subjective test.

Tuning Forks Used :

256 Hz : ↑Sense of vibration.
512 Hz : M/c, lies in speech frequency range (500, 1000, 2000 Hz).
1024 Hz : Dampens fast.

Rinne’s Test :
Compares AC & BC.
Rinne’s Test Diagnosis
• Normal
AC > BC +ve
• SNHL

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• CHL

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BC > AC -ve gm • U/L severe SNHL (> 70dB) :
False -ve d/t transcranial stimulation
@
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Degree of CHL :
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256 Hz 512 Hz 1024 Hz HL

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- + +
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15 - 20 dB
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Rinne’s test - - + Upto 30 dB

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- - - 45 - 60 dB
©

Max CHL possible

Weber’s Test :
Method :
• Tuning fork placed over forehead/vertex.

Check lateralization of sound.

• Lateralization + : Minimum 5 dB difference of hearing between ears.

Result :
• SNHL vs. CHL (Mnemonic : SOCS) :
- SNHL : Opposite to diseased ear (Better ear).
- CHL : Same as diseased ear (Worst ear).
• Centralized : Normal/equal HL in both ears.
• Lateralization : I/L CHL or C/L SNHL.

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 3 19

Absolute Bone Conduction (ABC) : ----- Active space -----

Method :
• Compare BC of patient with examiner.
• BC of examiner : Considered normal.

Result :
• ABC shortened : SNHL.
• ABC same as examiner : Normal.

Gelle’s Test :
Tuning fork on mastoid + ↑ing EAC pressure (Siegelisation) Ossicular fixity.
Negative Positive
Hearing No change Changed (↓)
Diagnosis Ossicular fixation (Otosclerosis : M/c) Normal

m
co
l.
Pure Tone Audiometry (PTA)

ai
00:36:30
gm
@

Subjective test.
h9
ans

Uses :
vy
di

• Confirmation of CHL/SNHL.
i
ra
|

• Determine frequency affected.

w
ro

• Degree of hearing loss.

ar
M

PTA
©

Audiogram :
Frequencies measured :
• AC : 125 - 8000 Hz.
• BC : 250 - 4000 Hz.

Normal hearing threshold/loss : ≤ 25 dB.

0 dB : Reference.
Audiometer
Symbols used :
Right ear Left ear
AC unmasked X
AC masked
BC unmasked < >
BC masked [ ]
No response
Masking : C/L ear.
ENT • World of Revision • v1.0 • Marrow • 2025
 20 ENT

----- Active space ----- Steps of reading :

1. Right/left ear.
2. Within 25 dB/not.
3. A-B gap present/absent. Frequency in Hertz

AC only

Hearing loss in DB
Normal right ear Normal right ear

m
l. co
ai
gm
Audiograms in Different Conditions
@
00:43:49
h9
ns

Right CHL : Right SNHL :

a
vy
di
i
ra

BC N AC & BC equally
|
w

defective
ro

A-B gap + (A-B gap < 15 dB)

ar
M
©

Common pathway defect

Left Mixed HL :

AC defect > BC defect

A-B gap +

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 3 21

----- Active space -----

Early NIHL : B/L Symmetrical SNHL (↑Frequencies) :

Hearing loss in dB
Boiler’s notch/
acoustic dip at
4000 Hz
(AC & BC)

• Basal turn of cochlea affected.

• Downsloping audiogram d/d :

m
Safe limit : 85 db, 8 hrs/day.

co
- Noise-induced hearing loss

l.
ai
(NIHL) : Late.
gm
- Ototoxicity.
@
h9

- Presbycusis.
ans
vy
di

Left CHL (Otosclerosis) : Left SNHL (↓Frequencies) :

i
ra
|

Frequency in Hertz
w
ro

Carhart’s notch :
ar

Dip at 2000 Hz in BC
M
©

Hearing loss in dB

A-B gap +

• Upsloping audiogram.
• Apical turn of cochlea affected.
• Example : Meniere’s disease.

ENT • World of Revision • v1.0 • Marrow • 2025

 22 ENT

----- Active space ----- Grading of HL 00:55:56

Normal Sounds :
• Whisper : 30 dB.
• Normal conversation : 60 dB.
• Shout : 90 dB.

WHO Grading :
HL on PTA in dB Degree of HL Disability
25 or better 0 - None Able to hear whisper
26 - 40 1 - Slight Able to hear normal voice at 1 m
41 - 60 2 - Moderate Able to hear raised voice at 1 m
61 - 80 3 - Severe Able to hear words when shouted

m
4 - Profound, including Unable to hear words even when

co
81 or greater
deafness shouted

l.
ai
gm
ASHA Grading :
@
h9
ns

HL on PTA in dB Degree of HL
a
vy

-10 – 25 Normal hearing sensitivity

di
i
ra

26 – 40 Mild HL
|
w

41 – 55 Moderate
ro
ar

56 – 70 Moderately severe
M
©

71 – 90 Severe
>91 Profound

Degree of HL in Specific Conditions :

Condition HL in dB
Complete obstruction of EAC 40
TM perforation (Size ∝ HL) 10 - 40
Ossicular TM perforation 40
­discontinuity Intact TM 55
Complete fixation of footplate of stapes 60

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 4 23

EAR : PART 4 ----- Active space -----

Tympanometry 00:00:22

Impedance audiometry : Tympanometry + stapedial reflex.

IOC :
• To determine pathology in middle ear :
Serous otitis media/Ossicular discontinuity/Ossicular fixation.
• Best for assessment of ET function.

Indications :

m
Intact tympanic membrane + CHL on tuning fork test & PTA.

co
l.
ai
Procedure : @
gm
• Objective test.
h9
ns

• Sound produced by probe placed in EAC

a
vy
di
i
ra

Graph (Tympanogram) plotted based on

|
w

reflected sound.
ro

Tympanometry
ar

Tympanogram :
M
©
Compliance

Determined by
ease of TM mobility

Middle ear pressure

Determined by ET :
• Normal : +100 to -100
• ET obstruction : -ve

ENT • World of Revision • v1.0 • Marrow • 2025

 24 ENT

----- Active space -----

Types of tympanogram curves :
Middle ear
Curve Compliance Diagnosis
pressure
A type Normal Normal Normal ear
AD type Normal ↑ Ossicular discontinuity
Ossicular fixation :
As type Normal ↓ • Otosclerosis (M/c)
• Tympanosclerosis
C type -ve Normal Early ET obstruction (SOM)
B type (Dome) -ve ↓ Serous otitis media (SOM)
Flat -ve ↓↓ SOM (Fluid completely fills middle ear)

m
co
Compliance

Compliance
il.a
gm
@
h9
a ns
vy

Pressure (daPa) Pressure

di

B type curve As type curve

i
ra
|

Brainstem Evoked Response Audiometry (BERA)

w

00:08:20
ro
ar

Objective test.
M
©

Determine :
• Retrocochlear vs. Cochlear disease.
• Site of retrocochlear pathology.

Procedure :
BERA
Sound produced by a probe in EAC

Waves produced as sound travels

through auditory pathway

Recorded by electrodes placed

over head.

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 4 25

Characteristics of BERA : ----- Active space -----

• Measures sound stimulus to 10 milliseconds (ms).
• Auditory pathway level : Upto inferior colliculus.
• For levels above inferior colliculus :
- Middle latency response (MLR).
- Cortical evoked response audiometry (CERA).

Waves of BERA :
Cochlear nerve
Superior Lateral
Distal part Proximal part Cochlear olivary lemniscus Inferior
(Inner ear) (IAM) nucleus complex (Largest) colliculus

m
co
l.
ai
gm
@

VI, VII
h9
ans
vy
di
i
ra
|
w
ro
ar

• Timing & delay in appearance of waves : Indicates levels/areas of lesion.

M
©

Indications :
Adults :
• SNHL on PTA.
• Differentiate cochlear & retrocochlear pathology : IOC.
• Retrocochlear pathology (E.g. : Acoustic neuroma) : Best audiometric test.
• Malingering : IOC.
Children :
• Audiometric IOC for :
- Screening hearing loss in neonates in ICU.
- Confirming hearing loss in neonates & infants.
• Assists in hearing rehabilitation :
- Identify hearing threshold (∝ Loudness at which wave ‘V’ is seen)

Severity of HL.
- Identify functionality of nerve Yes Cochlear implant possible.
ENT • World of Revision • v1.0 • Marrow • 2025
 26 ENT

----- Active space ----- Otoacoustic Emissions (OAE)/KEMP Echoes 00:18:13

Objective test.

Principle :
Emissions produced by outer hair cells in response to sound.
OAE
Pathway :
Perilymph
(Scala vestibuli)

Oval window Perilymph

(Scala tympani)

m
co
EAC Middle ear

l.
ai
gm
@
h9
ns

Recorded
a
vy

Basilar membrane
di

(Scala media)
i
ra
|
w

Outer hair cells

ro

: External sound
ar

(OHC) movement
M

: Sound of OHCs
©

Types :
Spontaneous :
• Emissions recorded without producing sound in EAC.
• Absent in 50%.

Evoked :
• Emissions recorded in response to sound produced.
• Present in all normal hearing individuals.
• Types :
- Transient evoked :
Tests entire organ of Corti/All frequencies.
- Distortion product : Frequency specific.

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 4 27

Results : ----- Active space -----

OAE
Pass Absent

N conductive & sensory > 30 dB HL in conductive

components. and/or sensory
component
(Very sensitive)
‘Refer’

BERA : Tympanometry :
Sensorineural component Middle ear test
(Conductive component).

m
SNHL + N

co
• Qualitative

l.
ai
• Quantitative gm
@

(Specific amount)
h9
ans
vy
di

Severe to profound HL : Mild to moderate HL :

i
ra

Cochlear implant. Hearing aid.

|
w
ro
ar
M

Uses :
©

Children :
IOC for screening neonates, except in ICU.
• Transient evoked type.
• Within 48 hrs of birth or max < 1 month.

Adults :
• To differentiate cochlear (OAE - ) & retrocochlear (OAE + ) hearing loss.
• To determine early ototoxicity.
Distortion product type (Check ↑frequencies).
• To determine early NIHL.
Since OHC : ↑Prone to damage.
1 - 3 - 6 Rule of Rehab :
• OAE ≤ 1 month.
• Referred test ≤ 3 months.
• Hearing rehabilitation ≤ 6 months.
• Cochlear implant : 1 yr.

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 28 ENT

----- Active space ----- Behavioural Observation Audiometry 00:31:29

Replacement of PTA in children < 5 yrs.

Based on Age :
5 months
• Free field audiometry
• Visual reinforcement
2 yrs Behavioural observation tests :
If inconclusive
Play audiometry

5 yrs. OAE
Objective tests
BERA

m
co
l.
ai
gm
@
h9
a ns
vy
di

Free field audiometry Visual reinforcement audiometry Play audiometry :

i
ra

Child follows
|
w

Turning of head to localize sound simple instructions

ro
ar
M

Electrocochleography
©

00:35:37

• Objective test.
Probe on
• IOC for cochlear pathology (Meniere’s disease). promontory
Waves :
Cochlear microphonic : Invasive
From outer hair cells.
Electrocochleography
Summation potential (SP) :
• Sum of activity of hair cells.
• ↑ed in Meniere’s d/t irritative
activity.

Action potential (AP) :

Potential in nerves.
Waves
ENT • World of Revision • v1.0 • Marrow • 2025
 Ear : Part 4 29

SP/AP : ----- Active space -----

• Normal : < 30%.
• Meniere’s : > 45%.

Speech Audiometry 00:38:07

1. Speech reception threshold :

Hearing threshold tested by the loudness of speech.
2. Discrimination score :
Sound louder than threshold

Patient’s ability to discriminate between words

↓ed in neural/retrocochlear pathology.

m
co
l.
ai
Auditory Neuropathy Spectrum Disorder gm 00:40:03
@
h9

• Retrocochlear hearing loss.

ns

• ↑Incidence in neonates in ICU.

a
vy
idi

Pathogenesis :
ra
|
w

Partial dysfunction Partial demyelination of

ro
ar

at inner hair cells nerves of auditory pathway

M
©

Dys-synchrony

Sound is perceived but

speech identification is lost.
Investigations :
Ix Results
Normal/mild to moderate SNHL (Easy
PTA
identifications of pure tones)
Recognition Very poor
Speech audiometry
Discrimination Very poor
OAE Normal
BERA Abnormal
MLR/cortical response Abnormal

ENT • World of Revision • v1.0 • Marrow • 2025

 30

----- Active space ----- EAR : PART 5

Acute Otitis Media 00:00:32

Etiopathogenesis :
Eustachian tube
Pharyngitis (M/c) Middle ear.
(Viral > Bacterial : Pneumococcus)

Stages :
Stage of hyperemia/pre-suppuration :
• Inflammation of middle ear mucosal lining

m
co
Congested, hyperemic mucosa.

l.
ai
• Tympanic membrane (TM) : Cartwheel appearance
@
gm
(Red & congested).
h9

• Exudation of fluid (D/t ↑vascularity).

a ns

• C/f : Severe, acute onset otalgia following URTI.

vy

Cartwheel appearance of TM
di
i
ra

Stage of suppuration :
|
w
ro

• Bulging TM Stage of maximum pain Rupture of TM

ar
M
©

Pulsatile otorrhoea/ Pain↓.

Lighthouse sign.
• O/e : Cartwheel TM with/without slight bulge.
Management :
Stage Mx Bulging TM
Slightly bulging TM Antibiotics + decongestants
Full & bulging TM
Antibiotics + decongestants
ASOM with complications :
Facial N. palsy/ +
Myringotomy
labyrinthitis
Antibiotics + decongestants
Wait & watch x 3 months
Ruptured TM
Spontaneous No healing
healing
Repair of perforation Ruptured TM
ENT • World of Revision • v1.0 • Marrow • 2025
 Ear : Part 5 31

Myringotomy : ----- Active space -----

• J shaped curvilinear incision.
• Site : Posteroinferior quadrant.
• C/i in : CN VII.
- Anterior quadrant Less accessible. Long process of incus.
- Posterosuperior quadrant ↑Risk of injury to
Incudostapedial joint.
Oval window.

Bullous Myringitis 00:08:35

AKA Myringitis bullosa/Otitis externa haemorrhagica.

Etiology :

m
co
• M/c organism : Pneumococcus.

l.
ai
• Others : @
gm
- Influenza virus.
h9

- Mycoplasma pneumoniae.
ans
vy

C/f : Acute onset otalgia following URTI.

di
i
ra
|

O/e : Bullous myringitis

w
ro

Red, congested TM with bullae If ruptured Serosanguinous/

ar
M

haemorrhagic discharge.
©

Management : Antibiotics.

Tympanic Membrane Perforation 00:10:45

Acute Traumatic TM Perforation :

Causes : ASOM/trauma.
Management : Spontaneously heal by 2 layers (Fibrous
layer absent) in 3 months.

TM Injuries following Blast Injuries :

Primary injury : D/t blast wave.
Rupture at air filled regions
TM perforation
TM. Bowels. Lungs.
Secondary injury : D/t blast wave debris.

ENT • World of Revision • v1.0 • Marrow • 2025

 32 ENT

----- Active space ----- Chronic Otitis Media/Chronic Suppurative Otitis Media (CSOM) 00:13:45

Etiology : Permanent defect in TM.

Salient feature : Painless.
Types :

Chronic mucosal otitis media Chronic squamous otitis media

Chronic Mucosal Otitis Media 00:15:00

AKA Safe CSOM/tubotympanic CSOM.

Pathophysiology :
Perforation 12w non-healed Epithelialization of margins Permanence Exposure

m
co
l.
Infections.
ai
gm
@
O/e :
h9
a ns
vy
idi
ra

Permanent perforation
|
w

of pars tensa
ro

Central
ar

+
M

Annulus spared
©

Subtotal central perforation TM perforation

C/f :
• Recurrent ear discharge :
- Profuse.
- Mucoid/mucopurulent.
- Painless (Pain/headache Complication).
- Non-foul smelling.
• Hearing loss : CHL of around 10 - 40 dB.

Note :
Ossicular necrosis 40 dB hearing loss.

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 5 33

Management : ----- Active space -----

+
Active infection Medical Mx to↓infection
- (for 6 weeks)
Ossicular necrosis
- +

Myringoplasty Tympanoplasty :
(M/c graft : Temporalis fascia) Myringoplasty + ossiculoplasty

Tympanoplasty & Myringoplasty 00:23:00

Tympanoplasty :

Approach Incision

m
1. Postaural approach Wilde’s postaural incision

co
l.
ai
Pinna retracted forward gm
@
h9

TM/middle ear approached via

ns

EAC Wilde’s postaural incision

a
vy

2. Endaural approach Lempert’s incision

di
i
ra
|

Incision at incisura terminalis

w

(Devoid of cartilage)
ro
ar

3. Transcanal approach Rosen transcanal incision

M
©

Incision at EAC lateral to TM

Temporalis fascia graft

Incisura
terminalis

Site of Lempert’s incision

Self retaining hemostatic

mastoid retractor

Endaural approach Rosen transcanal incision

ENT • World of Revision • v1.0 • Marrow • 2025
 34 ENT

----- Active space ----- Myringoplasty :

Tympanomeatal flap
(TM + epithelium of EAC)

Overlay method : Underlay method :

Graft placed over (Lateral to) Graft placed under (Medial to)
the fibrous layer & annulus the fibrous layer & annulus

Wullstein Classification of Tympanoplasty :

m
co
l.
ai
Type Name Mx : Salient features
gm
Type 1 Myringoplasty Graft over malleus
@
h9

Type 2 Myringoincudopexy Graft over incus

a ns

Graft over stapes + prosthesis

vy
di

Myringostapediopexy/
i

Type 3
ra

Columella tympanoplasty PORP : TORP :

|
w

If suprastructure + If suprastructure -
ro
ar

• Graft over round window. PORP : Socket end

M

Cavum minor/round
Type 4 • Oval window left open to maintain
©

window shielding
phase difference
Type 5 : Fenestration operation : Fenestra + graft over lateral SCC
Obsolete In otosclerosis (Caused vertigo)

PORP : Partial ossicular replacement prosthesis.

TORP : Total ossicular replacement prosthesis.

TORP : Flat end

Oval
window

Round
window
Type 1 Type 2 Type 3 Type 4 Type 5

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 5 35

Chronic Squamous Otitis Media (CSOM) 00:38:16 ----- Active space -----

AKA Unsafe CSOM/Atticoantral CSOM.

Pathophysiology :
Habermann theory
Permanent marginal p. tensa defect
(Eroded annulus) : M/c postero superior

Migrates
EAC : Squamous epithelium 2° cholesteatoma
Macrophages
Accumulates Chronic
in inflammation of ME

m
Osteoclasts

co
Untreated Prolonged ET P. flaccida 1° cholesteatoma

l.
ai
chronic obstruction retraction pocket gm Bone erosion d/t :
@
serous OM (M/c : Prussack’s • Collagenase.
h9
ns

space) • Acid phosphatase.

a
vy
di

Wittmaack’s/Invagination theory
i
ra
|
w
ro
ar
M
©

Marginal perforation with Postero-superior marginal Prussack's space

eroded annulus perforation

Scutum
Debris in
Pars flaccida pars flaccida
Retraction
pocket in pars
Pars tensa
flaccida

Chronic squamous otitis media/1o cholesteatoma

ENT • World of Revision • v1.0 • Marrow • 2025

 36 ENT

----- Active space -----

C/f :
• Ear discharge :
- Scant. - Blood tinge +/-.
- Purulent. - Granulations (Red fleshy polyp) :
- Foul smelling. Never to be avulsed.
- Painless.
• Hearing loss : CHL/mixed.

Management : Antrum Attic

Always surgical.
Prussack
Aim of Sx : To render a safe ear > dry ear space
> restore hearing.

Preoperative investigation :

m
co
• PTA.

l.
ai
• HRCT temporal bone (Bone erosion). gm Atticoantral/Unsafe CSOM
@
h9

Surgery/Mastoid exploration :
a ns
vy
di
i
ra

Intact canal wall : Canal wall down : Atticotomy :

|

Posterior tympanotomy/ Lowering of Indicated for limited disease in

w
ro

Facial recess approach posterior canal wall attic/pars flaccida

ar
M

+
©

Modified radical mastoidectomy (MRM) : Radical mastoidectomy :

Removal of disease + reconstruction of > Only stapes footplate preserved
middle ear hearing by tympanoplasty (Only in extensive spread of disease)
EAC
Middle ear
Mastoid

Mastoid
antrum

Sigmoid
sinus

Intact canal wall Intact canal wall Canal wall down

ENT • World of Revision • v1.0 • Marrow • 2025
 Ear : Part 5 37

Intact canal wall Canal wall down ----- Active space -----

Visualization during Sx Limited in certain areas of middle ear Good

Healing Fast Slow
Tolerance of water Poor
Better
(Water entry to be avoided)
Cavity complications Collection of wax/debris/
- discharge requiring periodic
cleaning
Hearing rehabilitation
Well tolerated Not useful
by hearing aids
Incidence of residual ↑
↓
disease (In hidden areas : Sinus tympani)

Meatoplasty :
• Widening cartilaginous part of EAC.

m
• Part of canal wall down surgery.

co
l.
ai
gm
@
h9
ns

Meatoplasty
a
vy

MRM vs. RM :
di
i
ra

Radical mastoidectomy Modified radical mastoidectomy

|
w

Mastoid air cells removed Removed

ro
ar

Meatoplasty Done
M

• Healthy mucosa of middle ear

©

Extent of removal of Only stapes footplate

• Tympanic membrane
middle ear structures preserved
• Healthy ossicles
Eustachian tube Closed Left open
Tympanoplasty
(Reconstruction of middle Not done Done
ear hearing mechanism)

Complications of Otitis Media 01:01:09

M/c in : Squamous otitis media > Mucous otitis media.

Spread via
IAM.
Bony erosion by • Hematogenous spread Cochlear aqueduct.
cholesteatoma. • Natural dehiscence Round window.
Oval window.

ENT • World of Revision • v1.0 • Marrow • 2025

 38 ENT

----- Active space ----- Intratemporal Complications :

Zygomatic
Facial nerve Labyrinthitis Mastoiditis Petrositis abscess
palsy Post auricular
abscess
Mixed hearing
loss + Vertigo Citelli/Bezold
abscess
Abscesses following mastoiditis
Acute mastoiditis :
• Coalescence of mastoid air cells Single pus-filled cavity.
Spread
• Abscesses following mastoiditis :
- Postauricular (M/c). - Luc's abscess : Posterior

m
co
- Zygomatic. wall of EAC.

l.
ai
- Citelli abscess : Posterior - Bezold abscess :
@
gm
belly of digastric/occipital Sternocleidomastoid.
h9

region. Ironed out mastoid

a ns
vy

• C/f :
di
i
ra

- Fever. - Ironed out mastoid.

|
w

- Post auricular edema. - EAC : Reservoir sign &

ro
ar

- Mastoid tenderness. sagging of postero-

M
©

- Ear discharge. superior meatal wall.

• Management :
No response/ Schwartze operation
IV antibiotics x 48 hours Schwartze operation/
Worsening
(M/c : Pneumococcus) Cortical or simple
mastoidectomy
Petrositis :
• Gradenigo triad :
Ear discharge + retro-orbital pain (5th CN) + diplopia
(6th CN).
• Management : IV antibiotics + MRM.

Intracranial Complications : Mastoiditis Petrositis

Extradural/ Meningitis Temporal lobe abscess/ Sigmoid sinus/

subdural abscess (M/c) Cerebellar abscess Lateral sinus
thrombosis
ENT • World of Revision • v1.0 • Marrow • 2025
 Ear : Part 5 39

Temporal lobe abscess : ----- Active space -----

• C/f : Features of OM (Ear discharge/pain) + features of temporal

lobe involvement.
• Features suggesting temporal lobe involvement :
- Headache.
- Nominal aphasia.
- Homonymous supra quadrantanopia.
- Seizure.
- C/L hemiparesis. Ring enhancing lesion
• Imaging : CT > MRI (Ring enhancing lesion in temporal lobe).
• Management :
- Abscess drainage + IV antibiotics.
- MRM when stable.

m
co
Homonymous supra quadrantanopia

l.
ai
gm
Sigmoid sinus/Lateral sinus thrombophlebitis :
@
h9
ans

Mastoiditis Peri-sinus Intra-sinus

vy
di

abscess abscess
i
ra
|
w
ro

Thrombosis
ar

Sigmoid sinus thrombophleblitis

M
©

Embolization Mastoid emissary IJV blockade

vein thrombosis
Picket fence/ Griesinger's sign : Tenderness over the
hectic fever Tenderness & jugular vein area
edema over mastoid
• Diagnostic tests On compression of N jugular vein
Tobey Ayer/ Crowe beck sign +
Queckenstedt's test +
↑CSF pressure. Papilledema.
• CT/MRI (Confirmatory) :
Delta/empty triangle sign.
• Management :
IV antibiotics + MRM.
Delta sign Papilledema

ENT • World of Revision • v1.0 • Marrow • 2025

 40 ENT

----- Active space ----- Note :

Otogenic tetanus :
• C/f : H/o CSOM + tonic spasm of the limbs/trismus (Lockjaw).
• CSOM Perforation of TM Open wound providing access to
Clostridium tetani

Tetanus.

Tubercular Otitis Media 01:20:34

C/f :
• Painless, foul-smelling ear discharge.
• Hearing loss out of proportion to symptoms.

O/e :

m
co
• Multiple TM perforations.

l.
ai
• Pale granulation tissue. gm
• Ossicular necrosis.
@
h9

• +/- Facial palsy. Tubercular otitis media

a ns
vy

Management :
di
i
ra

• ATT.
|
w

• Facial nerve palsy Surgical debridement to remove sequestrum.

ro
ar
M

Conditions of EAC 01:21:38

©

Keratosis Obturans :
↓↓Epithelial migration of EAC Keratin collection in laminar onion skin
arrangement.

C/f : Severe otalgia.

O/e :
• White mass with wax in deep meatus.
• Widening of EAC.
• Ulceration/granulations.
• Facial nerve palsy.

Management : Removal by instrumentation. Keratosis obturans

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 5 41

Malignant Otitis Externa/Skull Base Osteomyelitis : ----- Active space -----

Infection of EAC with Pseudomonas.

High-risk group : Immunocompromised patient (Elderly/Uncontrolled diabetes).

C/f : Severe otalgia + ear discharge.

O/e :↑↑Granulations & necrosis in EAC (D/d : Malignancy).

Investigations :
• Early diagnosis : Tc 99 bone scan (High uptake d/t
↑osteoclastic activity).
• Resolution detected via :
- Gallium 67.
- Indium 111.

m
Malignant otitis externa
- Serial ESR.

co
l.
ai
Complications : Cranial nerve involvement VII (M/c) : D/t spread of infection
@
gm
via fissure of Santorini.
h9
ns

IX
a
vy
di

X
i
ra

XI
|
w
ro

XII
ar

Management :
M
©

• Antibiotics (6 weeks) + debridement.

• Correct immunosuppression.

Note :
Tc 99 bone scan : ↑Uptake on osteoclastic/blastic activity
Poor marker of MOE resolution.

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 42

----- Active space ----- EAR : PART 6

Serous Otitis Media (SOM) 00:00:55

AKA otitis media with effusion/glue ear.

Pathophysiology :
Non-infective obstruction of eustachian tube Negative pressure in Transudation & collection of
• M/c in children : middle ear serous fluid in middle ear.
Adenoid hypertrophy (B/L SOM).
• M/c in adults :
Nasopharyngeal carcinoma (U/L SOM). Bubbles

m
co
C/F :

l.
ai
Retracted TM
gm
Child presenting with :
@

• B/L painless hearing loss (Few days to months).

h9
ns

• Features of adenoid hypertrophy : Serous otitis media

a
vy

H/o :
di
i
ra

- Snoring. - High arched palate.

|

- Nasal obstruction. - Poor growth.

w
ro

- Sleep apnea.
ar
M
©

O/E :
• Dull, retracted TM ± bluish tinge.
• Air bubbles.
• Fluid level.

Investigations :
Tympanometry : B curve
• Tuning fork test : CHL Rinne’s : -ve.
Weber’s : Lateralised to I/L (Worse ear).
• PTA : A-B gap + .
• Tympanometry (Confirmatory test) :
B type curve (Negative pressure + low compliance).
Myringotomy.
Management : +
> 3 months without Adenoidectomy.
Medical management x 3 months : +
resolution
• Anti-allergics. Grommet insertion
• Auto-inflation (Valsalva). (Replaces ET temporarily).
ENT • World of Revision • v1.0 • Marrow • 2025
 Ear : Part 6 43

Note : ----- Active space -----

Myringotomy c/i in posterosuperior quadrant

Risk of injury to :
• Incus.
• Incudostapedial joint.
• Oval window.
• Facial nerve.
Grommet Myringotome

Radial incision
(Anteroinferior quadrant)

m
co
l.
ai
gm
Grommet in-situ :
@
h9

Extrusion ≤ 6 months
ns

Retraction of TM : Classifications
a

00:14:03
vy
di
i
ra

Chronic ET obstruction/dysfunction TM retraction.

|
w
ro
ar
M

Pars flaccida retraction Pars tensa retraction

©

TOS classification. Sade classification.

Normal tympanic membrane

ENT • World of Revision • v1.0 • Marrow • 2025

 44 ENT

----- Active space ----- Sade’s Classification :

Stage Description Features Image
• Cone of light : Absent/distorted
- Appearance of TM : Dull
• Malleolar features :
Retraction of TM not in contact
1 - Handle : Foreshortened
with incus/stapes
- Lateral process : Prominent
- Anterior and posterior
malleolar folds : Sickled

• Long process of incus

Retraction of TM in contact with ↑Visibility
2 • Stapes
incus/stapes
• ↑↑Enhanced malleolar features

m
co
Atelectasis :

l.
ai
• Incus
• TM touching the promontory gm
↑↑Prominent
3 • Stapes
• ME space obliterated
@
• Prominent promontory
h9

• Mobile on siegelisation
a ns
vy
di
i
ra
|

Adhesive otitis media :

w

• Stapes head visible

ro

• TM adherent to the
ar

4 • Prominent promontory
promontory
M

• Incus not seen (Necrosed)

©

• Immobile on siegelisation

Head of stapes

Siegel pneumatic speculum/Pneumatic Stage 2

otoscope : ↑/↓EAC pressure

Note :
Ossicle most prone to necrosis : Incus.

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 6 45

TOS Classification : ----- Active space -----

Stage Description
Pars flaccida retracted but not adherent to neck of
1
malleus Retraction pocket
2 Adherent to neck of malleus in pars flaccida
Part of retraction pocket hidden
3 ±
Erosion of scutum
Definite erosion of outer attic wall + full extent of Primary cholesteatoma
4 (Sequelae of SOM)
retraction pocket not seen

Otosclerosis/Otospongiosis 00:24:56

Disorder of bone remodelling affecting the otic capsule (Bony labyrinth).

m
Pathophysiology :

co
l.
ai
Stimulus Cartilaginous areas Bony overgrowth over
gm Stapes footplate
of bony labyrinth footplate of stapes fixation.
@
h9

actively divides (Derived from otic capsule)

ans
vy
di

M/c site of origin :

i
ra

Fissula ante fenestrum (Anterior to stapes footplate).

|
w
ro
ar
M
©

Features :
Fixation of footplate of stapes
• Age group : 20 - 30 yrs.
• Females (Aggravated in pregnancy) > Males.
• Autosomal dominant inheritance.
• Associations :
- Similar history in mother.
- Measles.
- Van Der Hoeve syndrome :
• Blue sclera.
• Osteogenesis imperfecta.
• Otosclerosis.

C/F :
• B/L progressive CHL.
• Paracusis willisii : Hearing improves in noisy environment. Flamingo pink TM

ENT • World of Revision • v1.0 • Marrow • 2025

 46 ENT

----- Active space ----- O/E :

• 90% Normal (Pearly white) intact TM.
• 10% Flamingo pink TM (Schwartze sign) : S/o active disease.

Investigations :
• Tuning fork test :
- Rinne’s -ve.
< 5 dB Centralized
- Webers HL b/w (Almost equal HL). Carhart’s chart
2 ears > 5 dB
Lateralised to worse ear.
• Gelle’s test -ve : No changes in hearing with change in EAC pressure.
• PTA (Confirmatory) :
- A-B gap + .
- Carhart’s notch : Dip in bone conduction curve

m
co
at 2000 Hz.

l.
ai
• Tympanometry (Best test) : As curve. ↓Compliance
@
gm
• Stapedial reflex - .
h9
ns

N ME pressure
Management :
a

Tympanometry : As curve
vy
di
i

Active disease :
ra
|

NaF (Inhibits bone destruction + Accelerates maturation) :

w
ro

• - Proteolytic enzymes Hooks around incus

ar
M

• ↑Osteoblasts ↑Bone formation.

©

• ↓Osteoclasts ↓Bone destruction.

Mature disease : Stapedotomy.

• Worse ear first On stapes footplate
Teflon piston
• Not done if diseased ear is the only hearing ear :
Explore hearing aids or cochlear implants.
Rosen endomeatal Tympanomeatal flap Stapedotomy Teflon piston b/w oval
incision created and raised on footplate window and incus

Indications : Complications :
• Stapedotomy. • Fistula.
• Explorative tympanotomy • Perilymph leak.
(ME exploration + Intact TM). • Labyrinthitis.

Stapedotomy
ENT • World of Revision • v1.0 • Marrow • 2025
 Ear : Part 7 47

EAR : PART 7 ----- Active space -----

Vertigo with no hearing loss

BPPV : Hyperactive labyrinth Nystagmus : 1/L.
Vestibular neuritis : Hypoactive labyrinth Nystagmus : C/L.

Benign Paroxysmal Positional Vertigo (BPPV) 00:01:22

Pathophysiology :
Positional changes Dislodgement of otolith Irritation of SCC Episodic vertigo :
(CaCO3 crystals) • Lasting for seconds.
from maculae of • Triggered by certain

m
utricle into SCC head positions.

co
l.
ai
Tests of BPPV : @
gm
h9

SCC tested Procedure & nystagmus seen Mx

ans

Head tilted posteriorly

vy

(Affected side)
di
i
ra

Dix Hallpike Posterior SCC

|

Observe for vertigo Epley’s maneuver

w

maneuver (M/c affected)

ro

& vertical/upbeating
ar

torsional peripheral
M
©

nystagmus

Patient supine with 30°

head elevation
Horizontal SCC • Gufoni maneuver
Supine roll
(2nd M/c involved Head tilted horizontally • Barbecue roll
test
SCC) maneuver
Observe for vertigo & horizontal
peripheral nystagmus

Supine roll Dix-Hallpike

ENT • World of Revision • v1.0 • Marrow • 2025

 48 ENT

----- Active space ----- Peripheral vs. Central Nystagmus :

Nystagmus : Always towards more active side.
Peripheral nystagmus Central nystagmus
Latency + -
Duration Limited (1.5 - 2 mins) Not limited
Fatigability + -
Direction of nystagmus (Fast component) Fixed Changing
Optic fixation Nystagmus disappears Nystagmus persists
Pure horizontal/Pure
Torsion with horizontal/Vertical +
vertical/Pure torsional

Vestibular Neuritis 00:10:20

m
Acute inflammation of vestibular nerve Sudden hypoactivity of labyrinth.

co
l.
ai
C/f : gm
• Vertigo : Acute onset
@
Lasts for days to weeks.
h9

• Hearing : Normal.
a ns

• Horizontal nystagmus with torsion (D/t complete involvement of labyrinth).

vy
di
i
ra

Direction : C/L (More active).

|

Management :
w
ro

• Labyrinthine sedatives.
ar
M

• Vestibular rehabilitation exercises.

©

Head Impulse Test :

Test of VOR (Vestibulo-ocular reflex) :
Eyes remain on target ahead Brisk head movement to side being tested
N Hypoactive labyrinth
Eyes remain fixed on target : 1/L eye slowly fixates on target
Intact VOR. (To the opposite direction) with
saccadic movement.
Head
Head
Eye Eye

Evaluation of left side Neutral position Evaluation of right side

ENT • World of Revision • v1.0 • Marrow • 2025
 Ear : Part 7 49

Caloric Test : ----- Active space -----

• Each labyrinth can be tested separately.

• Lateral SCC stimulated.
• Procedure : 30° elevation of head

Different temperatures of water

pumped into EAC (Bithermal)

Body temp ± 7°C Caloric test

30°C : Cold 44°C : Warm

Hypoactive labyrinth Hyperactive labyrinth

Nystagmus : Nystagmus :
Opposite side (Horizontal). Same side (Horizontal).

m
co
• Mnemonic : CO - WS.

l.
ai
gm
@
Meniere’s Disease 00:26:40
h9
ns

AKA Endolymphatic hydrops.

a
vy
di

Order of involvement : Scala media (Apex affected first) Utricle & saccule.
i
ra
|

C/F :
w
ro

Symptoms d/t dilation of scala media :

ar
M

• Vertigo : • U/L diplacusis.

©

- Lasts for 20 mins - 24 hours. • Recruitment : Intolerance

- A/w vagal symptoms & aura. to loud sounds.
• Hearing loss : • Tinnitus.
- Fluctuating & U/L. • Fullness in ear.
- Low frequency SNHL.
Symptoms d/t dilation of utricle & saccule :
• Tumarkin crisis (Drop attacks) :
Sudden fall + no loss of consciousness
• Vertigo :
Scala media
- On loud sounds : Tullio’s phenomenon.
- On pressure changes : Hennebert sign.

Involved in Meniere’s disease

Note :
Lermoyez syndrome : Hearing loss followed by Vertigo (Reverse Meniere’s).
ENT • World of Revision • v1.0 • Marrow • 2025
 50 ENT

----- Active space ----- Investigations :

Rt. side : Normal
• Tuning fork test :
Lt. side : Low
- Rinne’s : Positive. frequency SNHL
- Weber’s : Lateralised to C/L side.
• PTA : Low frequency SNHL.
• ECOG (Electrocochleography) :
Summation potential
> 0.45 (Confirmatory). Meniere’s disease :
Action potential
Upsloping audiogram
• Glycerol (Hygroscopic) test : Improvement of vertigo.

Management :
Prevention :
• Low salt diet.

m
• Caffeine restriction.

co
l.
ai
Acute attack : gm
@
• Labyrinthine sedatives.
h9
ns

• Diuretics.
a
vy

• Vasodilators : Betahistine (M/c used).

di
i
ra
|

Intractable vertigo with good hearing :

w
ro

• Transtympanic steroids.
ar
M

• Chemical labyrinthectomy :
©

ECOG
- With vestibulotoxic drugs :
Gentamicin (Selectively vestibulotoxic) > streptomycin.
- Route : Through round window by microwick.
• Vestibular nerve section (Specific).
• Endolymphatic sac decompression.

No good hearing left :

Total labyrinthectomy.

Note :
Cochleotoxic drugs :
1. Kanamycin. Round window
2. Amikacin.
Microwick soaked
3. Neomycin. in gentamicin

Microwick microcatheter device

ENT • World of Revision • v1.0 • Marrow • 2025
 Ear : Part 7 51

D/D of Vertigo with SNHL : ----- Active space -----

Specific features of vertigo Other features

• Tinnitus
• Ear fullness
• Fluctuating HL
Meniere’s • Diplacusis
disease Vertigo x 20 mins - 24 hrs followed by SNHL • Intolerance to loud sounds
• Tumarkin crisis
• Tullio sign
• Hennebert sign
• SNHL/mixed HL
• H/o :
Labyrinthitis Continuous vertigo for days
- Otitis media (Acute/chronic)
- Meningitis
• Hearing loss :

m
co
- SNHL/mixed

l.
- Sudden & persistent/fluctuating

ai
Transient vertigo induced by gm
Perilymphatic • Fullness in ears
pressure changes/loud sounds
@
fistula • Past H/o :
h9

(Hennebert/Tullio sign)
- Surgical or baro/acoustic
ans

trauma
vy

- Erosion by cholesteatoma
di
i
ra
|
w
ro

Superior Semicircular Canal Dehiscence (SSCD) 00:40:58

ar
M
©

AKA 3rd window.

Pathology : Dehiscence of arcuate eminence following trauma/congenitally present.
Presentation :
Vestibular symptoms :
• Vertigo :
- On pressure changes intracranially/in middle ear :
Hennebert’s sign (Coughing/lifting weights).
- On loud sounds : Tullio’s sign. Arcuate eminence

Cochlear symptoms :
• ↑Bone conduction : Autophony.
- Abnormal ↑auditory perception of
eye movements/footsteps.
- Pulsatile tinnitus.
• ↓Air conduction.
SSCD
ENT • World of Revision • v1.0 • Marrow • 2025
 52 ENT

----- Active space ----- Examination :

Tuning fork tests : Normal
Rinne’s : Negative (BC > AC) CHL. AB gap

PTA : A-B gap + .

Tympanometry
Normal.
Stapedial reflex
PTA of SSCD : BC > AC
CT : Confirmatory.

Management :
• Symptomatic :
Surgical repair.
• Manageable symptoms :

m
Conservative (Avoid pressure changes/loud sounds).

co
CT scan showing SSCD

l.
ai
gm
@
h9
a ns
vy
di
i
ra
|
w
ro
ar
M
©

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 8 53

EAR : PART 8 ----- Active space -----

Glomus Tumor 00:00:30

AKA Paraganglioma

Types based on Origin :

Paraganglioma Arise in relation to
Glomus tympanicum • Tympanic plexus
(M/c benign tumor of middle ear) • CN IX
• Jugular bulb/floor of middle ear
Glomus jugulare
• CN IX & X

m
co
l.
Features :
ai
gm
• Benign tumor. • Age group : 40 - 60 yrs.
@
h9

• Locally invasive. • Female > Male.

ns

• Slow growing.
a
vy
di
i

Presentation :
ra
|
w

Pulsatile tinnitus > CHL.

ro
ar
M

Signs :
©

Glomus tympanicum : Red reflex.

Glomus jugulare : Rising sun/Setting sun sign.
• Brown/pulsation sign : Alternate blanching & pulsations on siegel’s maneuver.
• Aquino sign : Compression of ICA Stoppage of pulsatile tinnitus.
• Bleeding polypoid mass in EAC (Avulsion : C/I).
• Multiple cranial nerve palsies : CN IX, X, XI, XII. Glomus jugulare

Investigations :
1. CECT : Erosion of
• Mass in the middle ear : jugular
G. tympanicum. foramen
Jugular
• Phelp’s sign : G. jugulare ; foramen
Erosion of crest of bone b/w area
ICA & jugular bulb. CT scan : Phelp sign MRI : Salt & pepper sign
Glomus jugulare
2. MRI : Salt & pepper appearance.
ENT • World of Revision • v1.0 • Marrow • 2025
 54 ENT

----- Active space ----- Management :

• Elderly patient/Slow growing tumor : Observation.
• < 3 cm : Stereotactic radiosurgery/Gamma knife.
• > 3 cm : Surgical excision with pre-op embolization.

Preoperative investigation : Urinary catecholamines & VMA.

Rare cases : Chromaffin tumors.

Note :
10% head & neck paragangliomas : Multicentric.

Acoustic Neuroma/Vestibular Schwannoma 00:11:20

• M/c tumor of cerebello-pontine (CP) angle.

m
Site of origin : Vestibular nerve in the internal acoustic meatus (IAM).

co
l.
ai
S
Presentation : gm
@

• 40 - 70 y/o A P
h9

U/L SNHL.
ns

• M>F I
a
vy

Superior
di

D/t growth of tumor in IAM : Facial &

i
ra

intermedius vestibular
• Cochlear nerve compression :
|

nerve nerve
w
ro

U/L SNHL + tinnitus. Inferior

ar

• Facial nerve compression vestibular

M

Cochlear
©

nerve nerve

Hitzelberger’s sign (25%) :

Internal acoustic meatus
Anesthesia over the postero-
superior part of external meatus.
• Vestibular symptoms absent : D/t slow growing nature of tumor.

Note :
• U/L SNHL in young : ↑Risk of NF-2.
• B/L SNHL in old : Presbycusis.

D/t growth of tumor in CP angle :

Cranial nerves involved C/f
CN V : Earliest cranial nerve involved Loss of corneal reflex : Earliest ocular sign
Upper pole of tumor
CN VI Diplopia
Lower pole of tumor CN IX, X, XI -
Sequence of nerve involvement : CN VIII CN V.
ENT • World of Revision • v1.0 • Marrow • 2025
 Ear : Part 8 55

Investigations : ----- Active space -----

PTA : U/L (or) asymmetric SNHL.

BERA :
• Best audiometric test.
• Findings :
- ↑Latency b/w waves I - V.
- If only wave V + : ↑Interaural
latency of wave V > 0.2 ms.

Gadolinium enhanced MRI : BERA findings of MRI : Ice cream

acoustic neuroma cone appearance
• Best diagnostic investigation.
• Ice cream cone appearance.

Management : Histopathology :

m
co
• Elderly patient/ < 1.5 cm : Observation.

l.
Compactly packed cells

ai
• < 3 cm : Stereotactic radiosurgery/ gm
@
gamma knife.
h9
ns

• Large tumors : Surgical excision.

a
vy

• NF-2 with B/L acoustic neuroma :

di
i

Auditory brainstem implant (ABI)

ra

Loosely arranged cells

|
w
ro

Placed in lateral recess of 4th ventricle.

ar
M
©

Facial Nerve 00:23:26

Mixed cranial nerve Sensory branch : Nerve of Wrisberg/Nervus intermedius.

Motor branches.

Part of facial nerve within temporal bone :

Segment Significance
1. Meatal segment Within internal acoustic meatus
2. Labyrinthine segment Narrowest part of fallopian canal (Involved in viral infections d/t edema)
3. Horizontal segment Most dehiscent (M/c site of dehiscence : Above oval window)
4. Vertical/mastoid segment M/c injured in mastoid Sx

ENT • World of Revision • v1.0 • Marrow • 2025

 56 ENT

----- Active space ----- Intratemporal Branches :

Branch Function Defect d/t injury
1. Greater superficial • Lacrimation
petrosal nerve (Given • Nasal secretions Dry eye Schirmer test
off from 1st genu) • Palatine secretions
2. Nerve to stapedius Stapedial reflex Hyperacusis
Taste & salivation to anterior Loss of taste & salivation in
3. Chorda tympani
2/3rd of tongue anterior 2/3rd of tongue
4. Postauricular Sensory supply to EAM Hyperaesthesia in EAM
: Topodiagnostic tests.

Bell’s Palsy :
• M/c cause of facial nerve palsy.
• M/c site-labrynthine segment (Narrowest).

m
co
l.
Etiology :
ai
gm
• Idiopathic.
@
h9

• 60% Viral prodrome with HSV-1 + .

a ns
vy

C/f :
di
i

• Acute onset LMN facial palsy.

ra
|

• Dry eye.
w

Labyrinthine segment
ro

• Hyperacusis.
ar

(M/c).
M

• Loss of taste & salivation in anterior 2/3rd of tongue.

©

Management :
• Steroids.
• Antivirals within 3 days.
• Eye care (Lubrication/Eye patch).
• Physiotherapy ↓Recovery Nerve stimulation.
• Vit B12.
Deviation of face
Susceptible population : to one side
• Diabetics.
Bell’s palsy
• Pregnancy.
• Immunocompromised (AIDS).

Recurrence : < 10%.

ENT • World of Revision • v1.0 • Marrow • 2025

 Ear : Part 8 57

Petrous Temporal Bone Fractures : ----- Active space -----

Longitudinal Transverse
Incidence M/c (80%) L/c (20%)
Relation of fracture line to
Parallel Perpendicular
petrous part of temporal bone
Hearing loss CHL (TM rupture) SNHL (CN VIII injury)
CSF otorrhoea CSF rhinorrhoea
CSF leak
(Tegmen fracture) (Through ET)
Less common
Facial nerve injury Common
(M/c site : 1st genu)
Investigations : HRCT.
Battle sign :
• Ecchymosis behind the pinna.

m
• External findings seen :

co
l.
- Base of skull fractures.

ai
- Petrous temporal bone fracture. gm
@
h9

Iatrogenic Facial Nerve Injury : Battle sign Petrous temporal bone fracture :
ns

: Transverse
a
vy

Causes : Parotid Sx > Mastoid Sx : Longitudinal

di
i

(M/c site : 2nd genu > Vertical segment).

ra
|
w

Management :
ro
ar

• Late onset palsy : Steroids.

M
©

• Sudden onset palsy : Immediate re-exploration & repair (Probable transection).

Graft :
• M/c used : Great auricular nerve.
• Longer graft :
- Sural nerve.
- Lateral cutaneous nerve of thigh.
Herpes Zoster Oticus :
C/f : Painful vesicles over
- TM.
- EAC.
- Pinna & surrounding skin.

Ramsay hunt syndrome : Herpes zoster oticus

• Herpes zoster oticus + facial palsy.
• D/t reactivation of herpes zoster in geniculate ganglion.
• Other cranial nerves involved : CN V, VIII, IX, X.
ENT • World of Revision • v1.0 • Marrow • 2025
 58 ENT

----- Active space ----- Hearing Rehabilitation 00:38:15

Bone Anchored Hearing Aid (BAHA) :

Parts : Sound processor
1. Titanium screw/fixture.
2. Abutment. Abutment
3. Sound processor. Titanium screw

Prerequisite : > 5 yrs of age/Skull thickness 3mm

(Adequate osseo-integration).
Indications :
• Hearing aids C/I :
- Atresia of external ear.
- Discharging ear.

m
- Big cavity following canal wall down Sx.

co
BAHA

l.
• Single side deaf/severe SNHL.
ai
gm
@
Cochlear Implant :
h9
ns

Invented by William F. House (Father of neuro-otology).

a
vy
di

Indications : B/L severe to profound SNHL (Not benefitted by hearing aids).

i
ra

• Prelingual (Congenital) deafness : Implanted earliest at 1 yr of age.

|
w

• Postlingual deafness :
ro
ar

- Ototoxicity.
M
©

- NIHL.
- Presbycusis.
Across skin Digital signals
Transmitter coil Receiver-stimulator
Electrical impulses
Microphone Antennae Magnet Magnet Antennae

Speech processor

Curved electrode Cochlea

Reference/ground/ball electrode :
External components Internal components • Regulates power consumption &
stimulus intensity
• Placed in temporalis fascia
ENT • World of Revision • v1.0 • Marrow • 2025
 Ear : Part 8 59

----- Active space -----

Reference electrode

Mastoid
Facial
recess
Middle ear
Round
window

Scala tympani
(Replaces organ of corti)

m
co
l.
Stimulates CN VIII.

ai
Placement of cochlear implant @
gm
h9

C/I :
ns

• Absence of cochlea (Michel aplasia).

a
vy
di

• Absence of cochlear nerve.

i
ra

• Central auditory lesions.

|
w
ro
ar

Receiver- Antenna
M

stimulator
©

Magnet
Reference electrode Passage of
electrodes
Intracochlear electrode

Cochlear implant
Note :
Any antennae seen on imaging are internal only.

ENT • World of Revision • v1.0 • Marrow • 2025

 60

----- Active space ----- NOSE : PART 1

Anatomy of External Nose 00:00:53

Parts :

Nasal bone
Bony upper 1/3 rd
Frontal process
of maxilla Upper lateral cartilage
Sesamoid cartilage Cartilaginous
Lower lateral cartilage lower 2/3rd

m
co
Upper border of septal cartilage

l.
ai
External nose
gm Paired
@
Unpaired
h9
ns

Anatomy of Lateral Wall of Nose

a

00:02:06
vy
di
i
ra

Superior turbinate
|
w

Superior meatus
ro

Middle turbinate
ar

Middle turbinate
M

Middle meatus
©

Septum
Inferior turbinate
Inferior turbinate

Inferior meatus Septum

Turbinates & meatus Endoscopic view

Turbinates :
Projections of bones from lateral wall.

Superior : Posterior 1/3rd

Middle : Posterior 1/2

Inferior : Inferior
& anteriormost
(Independent bone)
Lateral wall
ENT • World of Revision • v1.0 • Marrow • 2025
 Nose : Part 1 61

Parts of Ethmoid Bone : ----- Active space -----

Crista galli
Cribriform plate

Lamina papyracea Superior turbinate

Middle turbinate
Ethmoid air cells
Perpendicular plate (Anterior)
of ethmoid
Parts of Ethmoid (Part of septum) Ethmoid

Uncinate process :
• Sickle shaped.
• Attachments :
- Superiorly : Lamina papyracea/middle turbinate/base of skull.

m
co
- Inferiorly : Inferior turbinate.

l.
ai
Meatus : gm
@
h9

Present between lateral wall & turbinates.

ans

Sphenoethmoidal recess
vy
idi
ra

Superior meatus
|
w

Middle meatus
ro

Inferior meatus
ar
M
©

Lateral wall of nose

Openings :
Inferior meatus Middle meatus (Most congested) Superior meatus
Anterior group of sinuses :
• Frontal sinus :
Nasolacrimal duct Through frontal recess Posterior ethmoid
• Maxillary sinus
• Anterior ethmoid
Note :
Sphenoid sinus opens into sphenoethmoidal recess.

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 62 ENT

----- Active space ----- Middle Meatus 00:09:22

• M/c meatus approached in surgeries.

• M/c sinusitis : Maxillary > ethmoid.

Osteomeatal Complex :
Medial Lateral
Bulla ethmoidalis
Lamina papyracea
Middle turbinate
Hiatus semilunaris
Septum Uncinate process
Infundibulum
Inferior
turbinate Maxillary

m
sinus

co
l.
Osteomeatal complex Lateral wall

ai
Bulla ethmoidalis (BE) : gm
@

Bulge produced by most prominent/largest anterior ethmoidal cell.

h9
ans

Uncinectomy : 1st step in FESS.

vy
i di
ra

Cribriform plate
|
w
ro

Lamina papyracea
ar
M

Middle meatus BE
©

Hiatus semilunaris
Middle turbinate
Inferior turbinate Infundibulum
Inferior meatus Uncinate process
Septum
CT nose & PNS

Variations in Turbinate Appearance 00:18:42

Concha bullosa

Deviated septum
Hypertrophic turbinate

CT Concha bullosa
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Concha bullosa Hypertrophic turbinate ----- Active space -----

Hypertrophy of mucosa &

Pneumatised ­submucinous tissue seen in :
Pathology
­turbinate • DNS
• Chronic inflammatory conditions
M/c turbinate affected Middle turbinate Inferior turbinate
Appearance Smooth polypoidal Irregular

Note :
Polyps do not bleed/cause pain on probing.

Paranasal Sinuses 00:21:49

Lined by respiratory epithelium.

m
co
Maxillary Sinus :

l.
ai
• M/c site of sinusitis. gm
• Opens into infundibulum of middle meatus.
@
h9
ans
vy
di
i
ra
|
w
ro
ar

Maxillary sinus
M
©

CT of paranasal sinuses Inflamed maxillary sinus

Frontal Sinus :
Superiormost.

CT findings :

Frontal sinuses
seen
Maxillary sinuses
appear small

Sagittal section Coronal section

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 64 ENT

----- Active space ----- Anterior Ethmoid :

Site : Medial wall of orbit. Bulla
ethmoidalis
Extension in excessive pneumatisation :
• Supraorbital.
• Infraorbital : Haller cell.
CT nose & PNS
Causes recurrent maxillary sinusitis.
• Anterior : Agger nasi.
- Anteriormost cell.
- Opens anterior to the attachment
of middle turbinate.

Excessive pneumatisation of

m
co
anterior ethmoid

l.
ai
Posterior ethmoid gm
Anterior ethmoid
@
h9
ns

Agger nasi
a

Agger nasi
vy
di
i
ra

Sphenoid sinus
|
w
ro

CT : Sagittal section CT : Coronal section

ar
M
©

Sphenoid Sinus :
Posteriormost sinus. Sella turcica
Site : Body of sphenoid. Sphenoid sinus

Relations :
• Superiorly :
- Sella turcica.
- Optic nerve.
CT : Sagittal section
• Laterally :
- Cavernous sinus. Sella turcica
- Internal carotid artery.

Sphenoid
sinus
Sphenoid
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 Nose : Part 1 65

----- Active space -----

Sella turcica
Optic nerve
Cavernous sinus (With ICA)
Sphenoid sinus

Tail end of turbinates

CT : Coronal section Schematic representation of

sphenoid sinus

Optic nerve Roof of sphenoid sinus

Cavernous sinus Cavernous sinus

m
co
l.
ai
gm
@
h9

Relations of sphenoid sinus

ns

Posterior Ethmoid :
a
vy
di

Site :
i
ra

• Anterior to sphenoid sinus.

|
w
ro

• Surrounds sphenoid sinus if excessively pneumatized.

ar

E.g. : Onodi cell.

M
©

Onodi cell : Onodi cell

• Part of : Posterior ethmoid.
• Related to : Optic nerve
Sphenoid sinus
- Sphenoid sinus.
- Optic nerve.
- Internal carotid artery.
CT coronal section

Frontal sinus

Anterior ethmoid
Posterior ethmoid
Maxillary sinus

Paranasal sinuses Pneumatised superior turbinate

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 66 ENT

----- Active space ----- X-ray Views for Sinuses 00:37:49

1. Water’s View/Occipitomental View :

• Position :
Nose-chin :
- Chin touches X-ray plate.
- Mouth closed.

Frontal

Anterior ethmoid
Maxillary (Best seen)

Lower border of

m
mandible : U-shaped

co
l.
Water’s view

ai
Maxillary sinusitis : Hazy
2. Pierre’s View : gm
@
h9

• Water’s view + open mouth.

ns

• Additional sinus seen : Sphenoid sinus.

a
vy
di
i
ra
|

Frontal sinus
w
ro
ar

Anterior ethmoid
M
©

Maxillary sinus

Sphenoid sinus

Pierre’s view Positioning

3. Lateral View :
All sinuses seen.
Frontal sinus

Anterior ethmoid
Sphenoid sinus
Posterior ethmoid

Lateral view

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 Nose : Part 1 67

4. Caldwell View/Occipitofrontal View : ----- Active space -----

X-ray detector

X-ray beam Frontal sinus

(Best seen)

Forehead on radiograph plate Caldwell view

5. Towne View : X-ray detector

Structures viewed :
• Occipital bone.

m
co
• Mastoid air cells. X-ray beam

l.
ai
• Petrous part of temporal bone. @
gm
h9
ans
vy

Towne view
di
i
ra

Rhinosinusitis
|

00:41:55
w
ro

Presentation :
ar
M

• Nasal obstruction.
©

• Nasal discharge.
• Pain & pressure over sinus affected.
• Hyposmia.

Anterior Rhinoscopy/Endoscopy Findings :

• Congested nasal mucosa.
• Edema in middle meatus.
• Mucopurulent discharge in middle meatus.

Types :
Acute rhinosinusitis Chronic rhinosinusitis
Duration < 12 weeks > 12 weeks
• Endoscopy
Ix Clinical diagnosis
• IOC : NCCT nose & PNS

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----- Active space ----- Acute rhinosinusitis Chronic rhinosinusitis

• 1 line : Medical (1 month)
st

- Steroid spray
- Saline irrigation
• Nasal decongestants :
No resolution
Management < 7 days
• Functional endoscopic sinus
• Antibiotics
surgery (FESS) : Restores
ventilation & drainage of
sinuses

Note :
Rhinitis medicamentosa :
• Prolonged use of nasal decongestants.
• Mx :

m
co
- Stop nasal decongestants.

l.
ai
- Steroids : Local nasal spray > systemic steroids (Short course).
@
gm
h9

Complications :
a ns
vy
di

Acute : Chronic :
i
ra

• Orbital complications (M/c). • Mucocele.

|
w
ro

• Osteomyelitis of frontal bone. • Pyocele.

ar

• Intracranial complications.
M
©

Orbital complications :
• Most common following : Ethmoid sinusitis.
• M/c age group : Children (↓Pneumatization)
Chandler staging :
Preseptal Postseptal Subperiosteal Orbital Cavernous sinus
cellulitis cellulitis abscess abscess thrombosis
Eyelid edema + + + + +
Chemosis - + + + +
Proptosis - + Non-axial + + U/L
Restricted ocular B/L Abducens
- + + +
movement palsy
Vision Normal ↓ ↓ ↓/Complete loss ↓

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 Nose : Part 1 69

----- Active space -----

Postseptal/orbital cellulitis Subperiosteal abscess

Preseptal cellulitis Cavernous sinus thrombosis

m
co
l.
ai
gm
@
h9
ans
vy
di
i
ra

Orbital abscess
|

Management :
w
ro

• IV antibiotics.
ar
M

• Surgical intervention indications :

©

- Abscess/features of optic nerve compression.

- No response to IV antibiotics.
Osteomyelitis of frontal sinus :
• Osteomyelitis Subperiosteal abscess.
• Soft doughy swelling (Pott’s puffy tumor).

Pott’s puffy tumor Subperiosteal abscess

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 70 ENT

----- Active space ----- Mucocele :

• Collection of secretions in the
frontal sinus (M/c).
• C/f :
- Swelling superomedial to orbit.
- Non-axial proptosis Mucocele Frontal Mucocele
(Downward & laterally).
• Cause :
- Chronic sinusitis.
- Trauma Obstruction of frontal recess.
Fungal Sinusitis 00:56:40

Fungal ball Allergic fungal sinusitis Acute invasive fungal sinusitis

m
Normal + Immunocompromised (DM/steroid

co
Immune status Normal
Type I hypersensitivity use/neutropenia)

l.
ai
gm • Acute sinusitis
@
• Chronic rhinosinusitis • Angioinvasion
h9

• Chronic sinusitis • Nasal polyps D/t narrowed • Spread to :

ns

Presentation
• M/c maxillary osteomeatal region (Bernoulli’s - Orbit
a
vy

principle) - Palate
di
i

• Highly fatal
ra
|

• Mucinous secretions
w

Endoscopy
ro

Cheesy material (↑↑Eosinophils) Black necrotic areas

findings
ar

• Polyps
M
©

Nasal microscopy/biopsy (Best

investigation) :
Nasal smear • Mucormycosis : Ribbon like
(Stains : PAS & - +ve aseptate hyphae branching at
GMS) right angles.
• Aspergillosis : Septate hyphae
branching at acute angles.
Double density sign :
CT finding Heterogeneous Double density sign Determines extent of involvement
appearance
• Mucormycosis :
• FESS
IV Amphotericin B
• Post op steroids (Local + short
Management FESS • Aspergillosis : Voriconazole
course systemic)
• Local debridement
• Poor response : Antifungals
• Rx immunosuppression

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 Nose : Part 1 71

----- Active space -----

Cheesy material : Fungal ball Black necrotic areas

m
co
Mucormycosis Aspergillus

l.
ai
gm
Bent & Kuhn Major Criteria :
@
h9

Diagnosis of allergic fungal sinusitis.

ans
vy

Criteria :
di
i
ra

• ↑IgE.
|
w

• Mucinous secretions.
ro
ar

• Polyps.
M

• Fungal smear +ve.

©

• Double density sign on CT.

Double density sign on CT Nasal polyps

Types of Mucormycosis :
Rhino-cerebro-ocular : M/c.
Pulmonary.
Gastrointestinal.
Disseminated.
Cutaneous :
• Seen in immunocompetent.
• H/o injury with vegetative matter.
• Percutaneous implantation.

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----- Active space ----- Polyps 01:08:11

Causes of U/L Polyps in Adults :

• Allergic fungal sinusitis.
• Chronic bacterial rhinosinusitis.

Causes of U/L Polyps in Young :

Antrochoanal polyp :
• Pathogenesis :
Obstruction of maxillary sinus ostia
Single polyp from maxillary sinus
Grows into choana.

m
• Management : FESS. AC polyp

co
l.
ai
Causes of B/L Polyps in Adults : gm
@

1. Allergy :
h9
ns

• M/c.
a
vy

• High recurrence rate.

di
i
ra

• C/f :
|
w

- Sneezing. - Nasal discharge.

ro
ar

- Itching. - Nasal obstruction.

M

• Management :
©

Medical Mx :
• Antihistaminics No benefit FESS + continue medical Mx.
• Topical steroids

2. Aspirin hypersensitivity :
• Samter’s triad :
- Aspirin hypersensitivity (Non-allergic and non IgE mediated).
- Nasal polyps.
- Asthma.
• Pathogenesis :
- Cyclooxygenase pathway.
Aspirin or any ↑Bronchoconstriction Asthma.
other COX I - ↑Lipoxygenase pathway ↑Leukotriene
production
↑Mucus production Polyps.
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 Nose : Part 1 73

• Management : ----- Active space -----

Medical Mx :
• Desensitisation No benefit FESS.
• Leukotriene -

Causes of B/L Polyps in Children :

1. Cystic fibrosis/mucoviscidosis :
• Pulmonary infections. • Intestinal obstruction.

2. Kartagener’s syndrome/primary ciliary dyskinesia :

• Chronic sinusitis
• Bronchiectasis Triad.
• Situs inversus

m
co
l.
ai
gm
@
h9
ns
a
vy
di
i
ra
|

Chronic sinusitis Bronchiectasis Situs inversus

w
ro

Tests for Mucociliary Function :

ar
M

1. Saccharin test :
©

• Procedure : Saccharin placed on inferior turbinate

Time taken for reporting sweet taste.

• Normal : < 30 minutes.
• Objective Test : Saccharin + color (Methylene blue/indigo/charcoal).

2. Nuclear testing/scintigraphy :
• Procedure : Radiolabelled Tc-99 albumin colloid particles
placed on inferior turbinate

Migration followed by gamma camera.

• Normal : < 30 minutes.

3. Electron microscopy :
• Test ciliary ultrastructure.
• Function not tested.
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 74

----- Active space ----- NOSE : PART 2

Nerve Supply of Nose 00:00:20

Olfaction :
Olfactory mucosa : Upper 1/3rd of nasal cavity.

Nerves involved :
Flavour

Smell : Taste : Temp/irritants :

m
I

co
l.
ai
(Olfactory) VII IX X V
gm
@
Ant 2/3rd Post 1/3rd Ant 2/3rd
h9
ns

tongue
a
vy
di
i

Tests for olfaction :

ra
|

• UPSIT : University of Pennsylvania Smell Identification Test.

w
ro

- 40 scratch & sniff questions.

ar
M

• Cross-cultural smell identification test/Brief smell identification test.

©

• Smell diskette.
• Sniffin sticks : Pen-like odour dispensing devices.

Smell diskettes Sniffin sticks

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 Nose : Part 2 75

Sensory Supply : ----- Active space -----

Trigeminal

Ophthalmic (V1) Maxillary (V2)

Superior orbital fissure
Foramen rotundum
Sphenopalatine
Lacrimal Frontal Nasociliary fossa

Sphenopalatine
Lamina papyracea Infraorbital
foramen
canal
Posterior ethmoid : (Into nose)
Infraorbital
• Lateral wall. foramen
• Septum. Lateral & medial Infraorbital nerve :

m
co
Anterior ethmoid nasal branches : • Ala of nose.

l.
ai
gm Posterior 2/3rd • Vestibule.
Infratrochlear : Internal nasal : External nasal :
@
of lateral wall &
h9

• Root of nose. • Lateral wall. • Dorsum. septum.

ns

• Dorsum.
a

(Anterior & (Lower part)

vy
di

(Upper part) superior part) • Tip of nose.

i
ra

• Septum.
|
w
ro
ar
M
©

Anterior ethmoid
nerve
Maxillary nerve
(Via sphenopalatine
foramen 1 cm behind
middle turbinate)

Lateral wall of nose Infraorbital foramen

Lateral
Foramen pterygoid
rotundum plate Maxilla

Pterygoid canal
(AKA Vidian canal)
Sphenoid bone Sphenopalatine fossa
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----- Active space ----- Nerve Blocks :

Medial end
of eyebrow
1.5 cm deep : Anterior ethmoidal
2.5 cm deep : Posterior ethmoidal

Move
Infratrochlear nerve block Nasociliary nerve block
laterally

External nasal (Branch of

m
Anterior ethmoid) block

co
l.
ai
gm
@
h9
a ns
vy
di
i
ra

External nasal (Branch of Maxillary nerve block at Infraorbital nerve block Infraorbital nerve block
|
w

anterior ethmoid) block sphenopalatine foramen (Sublabial approach)

ro
ar
M

Parasympathetic Supply :
©

Vidian nerve :
Greater superficial petrosal (GSP) + Deep petrosal (DP)

Vidian nerve
Via vidian canal
Sphenopalatine fossa

Sphenopalatine ganglion
(Only GSP relays)

Greater superficial petrosal

(Parasympathetic fibres)

Vessels Mucosal glands

Irritants
Vasodilatation. ↑Nasal secretion.
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Rhinitis 00:19:23 ----- Active space -----

Etiology :
• Viral. • Drugs.
• Allergy. • Vasomotor (Idiopathic).
• Chemical.

Pathogenesis :
Irritant enters nose

Sensory nerves + : Parasympathetic nerves + :

• Itching. • ↑Nasal secretions.
• Sneezing. • Vasodilatation Nasal obstruction.

Allergic Rhinitis vs. Vasomotor Rhinitis :

m
co
l.
ai
Allergic rhinitis Vasomotor rhinitis
gm
Etiology Allergy Idiopathic
@
h9

Family history + -
ans
vy

Anterior rhinoscopy Pale boggy mucosa Congested nasal mucosa

idi

• Allergic crease
ra
|

• Allergic salute
w

+ -
ro

• Allergic shiners
ar
M

• Dennie Morgan lines

©

Tests of allergy :
• IgE (RAST) +ve -ve
• Skin prick test
• Anti-allergics Intranasal steroid sprays
Management • Intranasal steroid sprays (No benefit)
• Leukotriene inhibitors Vidian neurectomy

Allergic shiners :
Dark discolouration &
puffiness below eyes

Allergic crease Allergic salute Dennie Morgan lines

(Crease in lower eyelid)

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 78 ENT

----- Active space ----- Arterial Supply of the Nose 00:23:19

Internal carotid artery External carotid artery (Major)

Ophthalmic artery Maxillary artery Facial artery

Optic canal Sphenopalatine Sphenopalatine
fossa foramen
1. Posterior ethmoidal Septal branch of
2. Anterior ethmoidal superior labial.

Lamina papyracea Greater palatine. Sphenopalatine.

Ant. ethmoidal (Main artery)
notch
Supplies
Roof of nose
lateral wall

m
co
l.
ai
Septum. @
gm
Anterior Ethmoidal Artery :
h9
ns

Anterior ethmoidal notch :

a
vy

• On piercing lamina papyracea.

di
i
ra

• CT finding : Nipple sign.

|
w
ro

Significance :
ar
M

Injury during FESS Orbital hematoma.

©

Management : Nipple sign (CT of nose & PNS)

i. Drain hematoma.
ii. Lynch-Howarth incision Ligate artery.
(Supero-medial quadrant of orbit)
Kiesselbach’s Plexus :
Site :
• Anteroinferior part of septum (Little’s area).
• M/c site of epistaxis in children (Nose picking)
Arteries forming the plexus : 1
1. Anterior ethmoidal artery. Little’s
2. Sphenopalatine artery. area
2
3. Greater palatine artery. 4
4. Septal branch of superior labial artery. 3

Kiesselbach’s plexus
Artery not contributing : Posterior ethmoidal.
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 Nose : Part 2 79

Epistaxis 00:30:20 ----- Active space -----

Artery of epistaxis : Sphenopalatine artery.

Cause :
In children :
• Trauma by nose picking (M/c).
• Foreign body.

Note :
Child with foreign body :
U/L foul smelling nasal discharge > Epistaxis. Trotter’s/Hippocratic manoeuvre :
• Pinch nose tight
In adults : • Sit bending forward
Idiopathic (M/c).

m
co
Recurrent epistaxis :

l.
ai
In young male Rule out angiofibroma. gm
@
h9

Management :
ans

Trotter’s method
vy
di

No stoppage
i
ra

Cauterize vessels : Silver nitrate/Bipolar

|

Cauterised vessel
w
ro

No stoppage
ar

Anterior packing : Gauze/merocel

M

Nasal packing.
©

Posterior packing : Foley’s catheter

TESPAL :
Transpalatine endoscopic sphenopalatine
artery ligation : At sphenopalatine foramen
Anterior packing

Maxillary : Endoscopic.
Ligate vessels. Approaches
In sphenopalatine fossa
Caldwell Luc : Sublabial.
External carotid

Anterior ethmoidal.
: If no response seen.

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 80 ENT

----- Active space -----

Caldwell Luc Posterior packing Merocel

Rhinosporidiosis 00:34:53

Etiopathogenesis :
Causative organism : Rhinosporidium seeberi (Aquatic protozoa).

m
Seen in : Cattle breeders, farmers.

co
l.
Endemicity : South India.
ai
gm
@
Presentation :
h9
ns

• H/o bathing in ponds frequented by animals.

a
vy

• Epistaxis.
di
i
ra

On examination :
|
w

• Nose : Mulberry/strawberry mass with white dots.

ro

Mulberry mass
ar

• Skin : Subcutaneous nodules.

M
©

Biopsy :
Multiple sporangium filled with sporangiospores.

Management :
• Excision of mass + cauterisation of base.
• Post-op : Dapsone ↓Chances of recurrence. Biopsy

Atrophic rhinitis/Ozaena 00:38:02

Etiology :
Primary : Idiopathic.

Secondary :
• Granulomatous conditions.
• Destructive surgery : Empty nose syndrome.

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 Nose : Part 2 81

Presentation : ----- Active space -----

B/L roomy nasal cavity

Crusting d/t drying

Infection Nasal obstruction

Foul smelling nasal discharge Crusting

+
Merciful anosmia.

Management :

m
Alkaline nasal douching : Antibiotics : Surgery :

co
l.
• Contents : • Kemicetine solution : • Young’s surgery :

ai
NaCl, NaHCO3 & sodium (Mnemonic : COPD) gm - Complete closure. (Obsolete)
@

• Modified young’s surgery :

h9

biborate in distilled - Chloramphenicol.

ns

water in ratio of 2 : 1 : 1. - Oestradiol. - Partial closure of nostrils.

a
vy

- Propylene glycol.
di
i
ra

- Vitamin D.
|
w

• 25% glucose in glycerine spray.

ro
ar
M
©

Rhinoscleroma 00:41:51

Granulomatous condition.
Causative Organism :
Klebsiella rhinoscleromatis/Frisch bacillus.

Presentation :
• Atrophy.
• Crusting. Mikulicz cells
• Hard/woody nose.

Biopsy :
Mikulicz cells : Macrophages with intracytoplasmic
bacilli.
Russell bodies : Plasma cells with inclusion bodies.
Russell bodies
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 82 ENT

----- Active space ----- Management :

Antibiotics :
• Ciprofloxacin : DOC. • Tetracycline.
• Streptomycin. • Rifampicin.

Fractures of Face 00:43:38

M/c facial fracture : Nose.

Diagnosis :
Examination : Crepitus + .
X-ray : Not diagnostic.

Management :
Wait for edema to subside (5 - 7 days)

m
co
Fracture of nose

l.
ai
No deformity Deformity +
gm
@
h9

Symptomatic Rx Closed reduction :

ns

• Nasal bone : Walsham forceps

a
vy
di

• Septum : Asch’s forceps

i
ra
|
w
ro
ar
M
©

Closed reduction Asch’s forceps Walsham forceps

Late presentation : >3 weeks + deformity Rhinoplasty/septorhinoplasty.

Fractures of Nasal Septum :

Classification :
• Class 1/Chevallet : • Class 2/Jarjaway :
- Vertical fracture. - Horizontal fracture.
- Less severe deformity. - Severe deformity.

Class 1 fracture Class 2 fracture Columellar incision

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 Nose : Part 2 83

Anatomy of nasal septum : ----- Active space -----

Columellar Membranous Septum proper :

septum septum • Perpendicular plate of ethmoid.
• Vomer.
• Septal/quadrangular cartilage :
Surgeries for DNS : Support to lower 2/3rd.
Septoplasty Submucosal resection (SMR)
Freer’s/hemitransfixion incision : Killian’s incision : 1 cm above lower
Incision
Lower border of septal cartilage border of septal cartilage
Complete septum,
Resection Only deviated part
except : L shaped strip.
Complications
Less More
(Perforation, saddling of nose)

m
[Link]
ai
Septal gm
@
cartilage
h9

Perpendicular
ns

plate of
a
vy

ethmoid bone
di

Vomer bone
i
ra
|
w
ro
ar

Nasal septum Septoplasty SMR

M
©

Blowout Fractures :
Site : Inferior wall/Floor of orbit.
CT finding : Tear drop sign.

CSF Rhinorrhea 00:54:10

• M/c cause : Trauma.

• M/c site : Cribriform plate (Lateral lamella).

Presentation :
• Watery discharge.
• Increases on leaning forward. Blood
• Not able to sniff back.
CSF
• Handkerchief test : No stiffening.
• Halo sign/Target sign/Double ring sign. Halo sign
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 84 ENT

----- Active space ----- Ix :

Biochemical IOC : β2 transferrin.
Overall IOC : HRCT.

Management :
Conservative : No resolution Fracture repair :
To ↓CSF pressure : • Endoscopic repair.
Lateral lamella of cribriform plate
• Propped up position. • External repair.
• Avoidance of straining
(Stool softener).
Inverted Papilloma 00:58:38

Benign + locally invasive.

Causative Organism :

m
co
l.
HPV (6, 11 : ↓Virulence).

ai
gm
Presentation :
@
h9

• Elderly.
ns

Inverted papilloma Biopsy

a

• Nasal obstruction.
vy
di

• Blood tinged discharge.

i
ra

• Polypoidal mass from middle meatus.

|
w
ro
ar

Biopsy :
M
©

Epithelium growing into stroma.

Management : Local invasion on CT

Wide local excision : Endoscopic/external.

Note :
High virulence strains of HPV (16, 18) cause :
• Cervical cancer. • Oropharyngeal cancer (Tonsil, base
• Anal cancer. of tongue).
Carcinoma of Nose & PNS 01:00:52

• M/c Ca of external nose : Basal cell carcinoma/Rodent ulcer.

• M/c Ca of PNS/nasal cavity : Squamous cell carcinoma.
• M/c Ca with h/o working in wood furniture
industry : Adenocarcinoma (Ethmoid sinus).
• M/c PNS involved : Maxillary sinus.
BCC of external nose
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 Nose : Part 2 85

Esthesioneuroblastoma : ----- Active space -----

Arise from olfactory mucosa.

Esthesioneuroblastoma

Carcinoma of Maxillary Sinus :

Ohngren’s classification :

Root of nose

m
co
Better prognosis Worse prognosis

l.
Ohngren’s line

ai
Infrastructure
gm
Suprastructure
@
h9

Angle of mandible
ans
vy
di

Ohngren’s classification
i
ra
|

Management :
w
ro

• Based on stage :
ar
M

- Stage 1 & 2 : Only surgery.

©

- Stage 3 & 4 : Surgery + radiotherapy.

• Incisions :
- Weber Ferguson incision (Removal of maxilla).
- Moure’s incision : Lateral rhinotomy.
- Sublabial incision : Midfacial degloving (No scar).
- Denker’s : Lateral wall of nose.

Sublabial incision Total maxillectomy

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 86

----- Active space ----- PHARYNX : PART 1

Nerve Supply of Tongue 00:00:52

Posterior most part CN X

of base of tongue
Taste + general sensation

Posterior 1/3rd/ CN IX
base of tongue

Circumvallate CN IX

m
co
papillae

l.
Taste : Chorda tympani (Branch of facial nerve)

ai
Anterior 2/3 rd gm
@
h9

General sensation : Lingual nerve (Branch of V3)

a ns
vy
di
i
ra
|
w
ro

Referred otalgia :
ar
M

Site Nerve Involved

©

Anterior 2/3rd of tongue Lingual Mandibular Auriculotemporal nerve

Base of tongue CN IX > X

Anatomy of Pharynx 00:03:50

Extent of pharynx : Base of skull to lower border of cricoid.

Parts of pharynx :
Base of skull
Nasopharynx/Epipharynx
Hard palate
Oropharynx
Hyoid bone
Larynx/Hypopharynx
Lower border
of cricoid

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 Pharynx : Part 1 87

Layers of Pharyngeal Wall : ----- Active space -----

Epithelium lining :
Part of pharynx Epithelium
Nasopharynx
Pseudostratified ciliated columnar
(Adenoid)
Oropharynx
(Tonsils) Stratified squamous non-keratinised
Hypopharynx

Waldeyer’s ring : Mucosa associated lymphoid tissue (MALT).

Adenoids/Luschka/Nasopharyngeal tonsil

Tubal tonsil/Gerlach’s tonsil

m
co
l.
Lateral pharyngeal band

ai
gm
@
Nodules on posterior Palatine tonsil/Faucial tonsil
h9

pharyngeal wall
ans

Lingual tonsil
vy
di
i
ra

Components of Waldeyer’s ring

|
w
ro
ar

Pharyngeal wall : Musculofascial tube.

M
©

1 Anterior fascia : 2 Muscle layer : 2 layers 3 Posterior fascia :

Pharyngobasilar Buccopharyngeal
fascia Longitudinal muscles : Circular muscles : fascia
Thickens • Stylopharyngeus • Superior constrictor
to form • Salpingopharyngeus • Middle constrictor
• Palatopharyngeus • Inferior constrictor
Capsule of tonsils

Superior constrictor
Middle constrictor
Inferior constrictor

Circular muscles
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 88 ENT

----- Active space ----- Pharyngeal Constrictors 00:12:00

Origin & Insertion :

Origin Insertion
Superior constrictor Pterygomandibular raphe Midline
Posterior midline
Middle constrictor Hyoid bone fibrous
fibrous raphe raphe
Inferior constrictor Thyroid

Site of insertion of
pharyngeal constrictors

Structures Traversing b/w Pharyngeal Constrictors :

Site Traversing structures

m
Mnemonic : TAALA

co
l.
• Tensor veli palatini

ai
Sinus of Morgagni : B/w upper gm
• Ascending palatine artery
@
border of superior constrictor &
• Ascending pharyngeal artery : Palatine branch
h9

base of skull
ns

• Levator veli palatini

a
vy

• Auditory/Eustachian tube
di
i
ra

• CN IX
|

B/w superior & middle constrictor Supplies

w

• Stylopharyngeus
ro
ar

B/w middle & inferior constrictor : • ILN : Pierces thyrohyoid membrane

M

Covered by thyrohyoid membrane • Superior laryngeal vessels

©

B/w inferior constrictor & • RLN

esophagus • Inferior laryngeal vessels

Note :
RLN
CN X ILN
SLN
ELN

Sinus of
Morgagni
CN IX & stylopharyngeus

Thyrohyoid membrane Thyropharyngeus

Inferior
Cricopharyngeus constrictor

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 Pharynx : Part 1 89

Killian’s Dehiscence : ----- Active space -----

• AKA Gateway of tears.

• M/c site of pharyngeal pouch formation : Zenker’s diverticulum.

Superior pharyngeal constrictor

Middle pharyngeal constrictor

Thyropharyngeus
Killian’s dehiscence
Cricopharyngeus

Circular fibres

m
co
Killian’s dehiscence

l.
ai
gm
Pathophysiology :
@
h9
ns

Neuromuscular ↑Tone of ↑Intraluminal False pulsion diverticulum

a
vy

incoordination cricopharyngeus pressure containing mucosa &

di
i

during deglutition
ra

pharyngobasilar fascia.
|
w
ro

Presentation : Elderly patient with c/o

ar
M

• Dysphagia.
©

• Regurgitation.
• Halitosis.
• Hoarseness of voice.
• Cough.
• Complications : Laryngeal infections, LRTIs.
Zenker’s diverticulum
Investigations :
1. Endoscopy : 2. Barium swallow : Lateral view (Best Ix)

Upper esophagus 2nd lumen

Lumen

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 90 ENT

----- Active space ----- Posterior Pharyngeal Spaces 00:24:10

Posterior
Key :
Lateral
: Pre-vertebral space
Pre-vertebral fascia
: Danger space Alar fascia
: Retropharyngeal space
Fibrous raphe Buccopharyngeal fascia
Midline
division into Superior constrictor

: Retropharyngeal spaces Pharyngobasilar fascia

of Gillette Tonsillar capsule

Transverse section at the level of

tonsils

m
Extent of Pharyngeal Space :

co
l.
ai
Upper limit Lower limit gm
Retropharyngeal space T4
@
h9

Base of
Danger space Diaphragm
ns

skull
a

Pre-vertebral space T2/T3

vy
di
i
ra

Clinical significance :
|

Mediastinitis.
w
ro

Spread
• Infection of danger space
ar

Mediastinum Pericarditis.
M
©

• Node of Rouvière : Pleuritis.

- Content of retropharyngeal space of Gillette.
- Site of drainage of Waldeyer’s ring.
- Adenoiditis/Tonsillitis Lymphadenitis of node of Rouvière.
Posterior Pharyngeal Wall Swelling : Pharyngeal spaces

Retropharyngeal space abscess Prevertebral space abscess

• Fever + sore throat
C/f • Dysphagia
• Stridor
Type of swelling U/L paramedian swelling (Lateral to midline) Diffuse midline swelling
• Children : Lymphadenitis
- Adenoiditis
M/c cause TB spine
- Tonsillitis
• Adult : Penetrating injuries
Management IV antibiotics + intraoral incision & drainage ATT

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 Pharynx : Part 1 91

----- Active space -----

Straightening of spine
(D/t spasm of
prevertebral muscles) ↑Thickness of
prevertebral shadow

X-ray

Retropharyngeal space
Buccopharyngeal fascia

m
Alar fascia

co
Pre-vertebral space

l.
Pre-vertebral fascia

ai
Danger space gm
@
h9
ans
vy
di
i
ra

Pharyngeal fasciae & spaces

|
w
ro
ar

Lateral Pharyngeal Spaces

M

00:34:42
©

Peritonsillar Space :
• B/w capsule of tonsil & superior constrictor.
• Oropharyngeal infection Via Peritonsillar Tonsil pushed medially
crypta magna
abscess (Not pharyngeal wall)
Parapharyngeal/Lateral Pharyngeal Space :
Lateral continuation of retropharyngeal space.

Boundaries :
• Medial : Lateral pharyngeal wall. Medial pterygoid.
• Lateral : Mandible & mandibular attachments Masseter.
Parotid.
Extent : Base of skull Hyoid.

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 92 ENT

----- Active space -----

Compartments :
Compartment Relation to styloid Content Associated findings/conditions
Anterior
Pre styloid Fat Abscess
compartment
• IJV • Neurogenic tumor Parotid
Posterior • CN IX, X, XI, XII • Horner’s syndrome bulge
Post styloid
compartment • ICA • Bulge behind
• Cervical sympathetic chain posterior pillar

Posterior
Anterior

m
co
l.
ai
gm
@
h9

Parapharyngeal compartments
ns
a
vy
di

Peritonsillar vs Parapharyngeal Abscess 00:41:48

i
ra
|
w
ro
ar

Peritonsillar abscess/Quinsy Parapharyngeal abscess

M

• H/o fever & sore throat

©

• Odynophagia
C/f
• Otalgia
• Trismus (Superior constrictor spasm Spasm of mastication muscle)
Additional Swelling at the angle of jaw :
Hot potato voice (D/t pain)
feature Differentiating feature
O/e Tonsil pushed medially
• IV antibiotics (GABHS/Anaerobes)
• Aspiration
• Incision & drainage IV antibiotics +
Management
• Interval tonsillectomy : incision & drainage
- Children : 6 weeks after 1st episode
- Adults : 6 weeks after 2nd episode
2 - 3 cm below lower border
Site of Lateral to point of intersection b/w
of mandible : Prevent injury to
incision anterior pillar & base of uvula
marginal mandibular nerve

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 Pharynx : Part 1 93

----- Active space -----

Tonsil pushed medially Parapharyngeal abscess

Peritonsillar abscess Parapharyngeal abscess

m
co
l.
ai
Submandibular Space 00:48:57
gm
@

Compartment :
h9
ans
vy
di

Sublingual
i
ra
|

Mylohyoid
w
ro

Submaxillary/submandibular
ar
M
©

Ludwig’s Angina :
• Cellulitis of B/L submandibular space.
• M/c source of infection : Dental caries.

O/e :
• If submandibular compartment affected : Tense submandibular
swelling Brawny edema (Woody appearance). B/L
• If sublingual compartment affected : Raised floor of mouth.

Management :
• IV antibiotics against :
- Alpha hemolytic streptococcus.
- Staph. aureus.
- Anaerobes.
• Incision (Horizontal) & drainage To relieve pressure Ludwig’s angina
(From one angle of mandible to another).
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 94

----- Active space ----- PHARYNX : PART 2

Anatomy of Nasopharynx 00:00:25

Extent :

Base of skull
Nasopharynx

Hard palate

m
co
Examination Methods :

l.
ai
• Nasal endoscopy. gm
@

• Posterior rhinoscopy.
h9
a ns

Tilts prevent
vy
di

gag by
i
ra

avoiding uvula Posterior rhinoscopy mirror Posterior rhinoscopy

|
w

Lateral Wall of Nasopharynx :

ro
ar
M
©

Fossa of Rosenmuller/
Lateral pharyngeal recess
Posterior
pharyngeal
Torus tubaris (With tubal wall :
tonsils) Origin of
Eustachian tube opening : adenoids.
(1.25 cm behind inferior
turbinate)

M/c site of nasopharyngeal Ca. : Fossa of Rosenmuller.

Nasopharyngeal Mass Symptoms :

1. Nasal obstruction Rhinolalia clausa/Hyponasality.
2. Serous otitis media.

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 Pharynx : Part 2 95

Passavant’s Ridge : ----- Active space -----

• Formed by :
- Superior constrictor.
- Palatopharyngeus.
• Separates nasopharynx from oropharynx along
with soft palate during speech/swallowing.
Velopharyngeal Insufficiency :
Cleft palate Incomplete closure of • Rhinolalia aperta/
Palatal paralysis nasopharyngeal isthmus Hypernasality.
• Food regurgitation.
Adenoid Hypertrophy 00:07:35

Normal adenoid morphology :

m
• Vertical ridges +

co
l.
ai
• Capsule
Absent. gm
• Crypts
@
h9

C/f :
ans

• Blockage of eustachian tube

vy

B/L serous otitis media (Hearing loss, B type

di

tympanogram etc.)
i
ra
|

• Rhinolalia clausa.
w
ro

• Adenoid facies :
ar
M

- Pinched up nose. - Crowding of teeth.

©

- Absent nasolabial fold. - High arched palate.

- Mouth breathing.
Diagnosis :
Adenoid facies

Nasopharyngeal mass

Endoscopy X-ray : Lateral view

Management :
1st line : Medical management
No response/Chronic symptoms (> 3 months)
Sx : Adenoidectomy +/- Grommet insertion.
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 96 ENT

----- Active space -----

C/I to surgery :
• Cleft palate (Unmasks velopharyngeal insufficiency).
• Acute infections.
• Bleeding diathesis.

Angiofibroma 00:11:30

Features :
• M/c benign tumour of nasopharynx.
• Locally invasive.
• Seen in pubertal males.
Site of origin :
Medial
growth
Nasal cavity,

m
Sphenopalatine foramen Lateral nasopharynx.

co
Grows superiorly
Orbit.

l.
(1 cm behind middle turbinate) growth

ai
Sphenopalatine
gm
Lateral extension Infratemporal fossa.
fossa
@
h9

Presentation :
a ns

• U/L nasal obstruction.

vy
di

• Recurrent epistaxis.
i
ra

Red
• Frog facies :
|

fleshy
w
ro

- Swelling of cheek. mass

ar

- Proptosis.
M
©

- Broadening of nose.
Frog facies Nasal endoscopy
Investigations :
• Nasal endoscopy.
• CECT scan (Best Ix) : Holman Miller/Antral sign.
• Digital palpation. C/i : Can lead to
• Biopsy. fatal bleeding
Angiofibroma Normal side
Widening of Sphenopalatine
sphenopalatine foramen
foramen
Infratemporal
fossa Sphenopalatine
Antral sign fossa
Pterygoid plate

Axial CT
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 Pharynx : Part 2 97

Radkowski staging : ----- Active space -----

Stage Description
1 Medial spread
1a Limited to nose
1b Extension into sinuses
2 Lateral spread
Limited extension into sphenopalatine
2a Management :
fossa
• Preop embolization of maxillary artery
Completely fills Sphenopalatine fossa & followed by
2b
spreads to orbit Surgical excision.
2c Extension into infratemporal fossa
3 Intracranial extension
3a Limited spread

m
co
3b Extensive spread • Unresectable : Radiotherapy.

l.
ai
@
gm • Recurrence : Surgical excision.
h9

Nasopharyngeal Carcinoma 00:20:00

ans
vy

M/c carcinoma of nasopharynx.

di
i
ra
|

Site of origin : Fossa of Rosenmuller.

w
ro
ar

Etiology :
M
©

1. Genetic predisposition :
- Mongolians/Nagaland (M/c in India).
- Southern China (M/c overall) : Guangdong
(AKA Guangdong carcinoma).
2. Epstein Barr virus.

Presentation : Cervical lymphadenopathy

• Bimodal distribution (Elderly/young).
• Cervical lymphadenopathy (70%)
U/L ET obstruction
• U/L serous otitis media (B type tympanogram)
• Nasal obstruction Rhinolalia clausa. Mandibular Neuralgia.
• Sinus of Morgagni syndrome : Trotter’s triad Palatal palsy.
CHL (D/t SOM).
• Horner’s syndrome : Involvement of cervical sympathetic chain in
parapharyngeal posterior compartment.

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 98 ENT

----- Active space -----

Investigations : Biopsy to confirm diagnosis.

Management : Radiosensitive tumor.

• Early stage : Radiotherapy.
• Late stage : Concurrent chemoradiation.

Oropharynx and Tonsils 00:25:30

Oropharynx :

Soft palate

Anterior and
Posterior pharyngeal wall
posterior pillars
Palatine tonsil
Base of tongue

m
co
l.
ai
Sensory nerve supply : Glossopharyngeal nerve.
gm
@

Note :
h9
ns

Referred otalgia from base of tongue carcinoma : CN IX.

a
vy
di

Tonsils :
i
ra
|

Venous Drainage : External palatine/Para tonsillar vein.

w
ro

Clinical significance : Peritonsillar space

ar
M
©

Paratonsillar
M/c site of hemorrhage vein
following tonsillectomy.

Arterial supply : Derived from ECA.

Ascending pharyngeal artery
Maxillary artery

Descending palatine artery

Tonsillar branches of ascending
pharyngeal artery
Ascending palatine artery

Tonsillar artery
Facial artery
Dorsal lingual branches
Lingual artery
External carotid artery
Arterial supply of tonsil
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 Pharynx : Part 2 99

Acute Tonsillitis 00:28:10 ----- Active space -----

Presentation :

Follicular exudate
Fuse Pseudomembrane
in crypts

Follicular tonsillitis Membranous tonsillitis

D/d of Membrane over Tonsil :

m
co
l.
ai
Acute tonsillitis Diphtheria
gm
@

Diphtheria :
h9
ns

• Unimmunized child.
a
vy

• Bull neck appearance.

di
i
ra

• Membrane over tonsil :

|
w

- Dirty gray appearance.

ro
ar

- Extends beyond tonsil.

M

- Tightly adherent.
©

- Bleeds on removal.
• Management : Antitoxin + Antibiotics
(Beta lactam/Macrolide).
• Complication d/t exotoxin : Myocarditis/Neuritis.
Club shaped gram
Dirty gray appearance positive rods

Bull neck appearance Diphtheria : Membrane Microscopy

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 100 ENT

----- Active space ----- Management of Acute Tonsillitis :

Mainstay of Rx : Antibiotics against group A β-hemolytic strep. (M/c).

Indications of tonsillectomy :
1. Recurrent infections : Any 1 of the following
- 3 episodes/yr x 3 yrs.
- 5 episodes/yr x 2 yrs.
- 7 episodes in a single year.
2. Obstructive sleep apnea d/t tonsillar enlargement.

Rose Position :
• Extension at : • Indications :
- Atlanto-occipital joint. - Tonsillectomy.
- Cervico-thoracic joint. - Adenoidectomy.

m
- Tracheostomy.

co
l.
ai
Boyle’s tongue depressor
gm
@
h9
a ns
vy
di
i
ra
|
w
ro

Rose position Boyles Davis mouth gag : Keeps mouth open

ar
M

Methods of Tonsillectomy :
©

Cold methods : Hot methods :

• Dissection & snare (M/c) • Cautery
• Microdebrider • Coblation (Cold ablation) : M/c ; least
• Harmonic scalpel heat produced
• Cryosurgery Rare • Laser

Eve’s tonsillar snare : Coblator wand Microdebrider

Cut & crush lower pole

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 Pharynx : Part 2 101

Complications of Tonsillectomy : ----- Active space -----

M/c complication following Sx : Hemorrhage (M/c source : Paratonsillar vein)

Primary hemorrhage Reactionary hemorrhage Secondary hemorrhage
Onset During surgery After Sx up to 24 hours > 24 hours - 10 days
• Slippage of ligature/clot
Causes Vessel injury Infection
• Normalization of BP
In to OT Shift to OT

Removal of clots
No stoppage
Management Pressure applied with vasoconstrictor Antibiotics
No stoppage
Cautery
No stoppage

m
co
Ligation

l.
ai
gm
Laryngo/Hypopharynx
@
00:37:47
h9
ns

Components : 3Ps
a
vy
di
i
ra
|
w
ro
ar

Larynx * Pyriform fossa

M
©

Postcricoid
Pharynx
*
Posterior pharyngeal wall

Visualization methods :
• Indirect laryngoscopy • Endoscopy
Pyriform Fossa :
• M/c site of lodgement of foreign body.
• Nerve lying superficially : ILN.
• Richest lymphatic supply in hypopharynx.
• Pyriform fossa carcinoma :
- Referred otalgia : Mediated by ILN.
- Extensive lymph node metastasis : II, III (Upper & middle deep cervical) > IV.

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 102

----- Active space ----- LARYNX : PART 1

Cartilages & Membranes 00:00:40

Cartilages of Larynx :

Paired cartilages : Unpaired cartilages :

1. Cuneiform 1. Epiglottis : Leaf shaped
2. Corniculate
2. Thyroid : Ala angle
3. Arytenoid
• Males : 90˚(Adam’s apple)
(Pyramidal)
• Female : 120˚

m
co
Key : 3. Cricoid :

l.
ai
: Hyaline cartilage • Signet ring shaped
(Calcify later in life)
gm
• Only complete cartilaginous ring
@

Injury
h9

: Elastic cartilage
ns

(Does not calcify) Laryngeal stenosis

a
vy
di

Laryngeal Membranes :
i
ra
|
w
ro
ar

Extrinsic membranes : Intrinsic membranes :

M
©

Connect laryngeal cartilages Connect laryngeal cartilages

to other structures. with each other.

Hyoepiglottic Aryepiglottic fold

Thyrohyoid membrane
Quadrangular

False vocal cord

Ventricle True vocal cord

Conus elasticus/cricovocal
Anterior
Cricotracheal thickening
Cricothyroid membrane

Key :
: Extrinsic membrane
: Intrinsic membrane
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 Larynx : Part 1 103

Divisions 00:05:40 ----- Active space -----

Supraglottis. Glottis. Subglottis.

Supraglottis :
Epiglottis

False V.C Aryepiglottic folds Inlet of larynx

Ventricle (B/w
false & true V.C)
Arytenoids
True V.C

Saccule :

m
co
• Sac like structure formed by lateral extension of ventricle.

l.
ai
• Contains mucous glands Lubrication of VC. @
gm
• Obstruction Laryngocele (Air trapping).
h9
ns

Lymphatic supply
a

Upper deep cervical (II).

vy
di

Middle deep cervical (III).

i
ra
|

Glottis :
w
ro

• At the level of true vocal cord.

ar
M

• Narrowest part of larynx in adults.

©

• Lining epithelium : Stratified squamous non-keratinized (Exception).

• No lymphatics (Watershed area).

Subglottis :
• Narrow part of larynx in children.
• Drains into level IV lymph nodes.

Note :
Lining epithelium of larynx : Pseudostratified ciliated columnar (Except glottis).

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 104 ENT

----- Active space ----- Muscles 00:10:05

Act on true VC Tensors

Adduct : • ↑Tension/pitch/length :
All except Cricothyroid
• ↓Tension/pitch/length :
Abduct : Vocalis (Innermost part of
Posterior cricoarytenoid thyroarytenoid)

Only intrinsic muscle lying outside :

Cricothyroid. Muscles of larynx

Adult vs. Child Larynx 00:14:11

m
Child Adult

co
l.
• Higher up : Opposite C2, C3 • Lies opposite to C3 - C6 in adults

ai
gm
• Epiglottis can meet soft palate when swallowing • Epiglottis moves down Closes inlet
@
• Can either swallow/breathe
h9

Milk goes into Air from nasopharynx

a ns

hypopharynx goes to larynx

vy
di

• They can suckle & breathe at same time

i
ra
|
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M
©

Infections 00:16:12

Symptoms d/t involvement of different parts :

Symptoms Structure affected
Inspiratory Supraglottis
Inspiratory/biphasic Glottis
Biphasic Subglottis
Stridor Altered by posture change :
• ↑ : Supine
Epiglottis
• ↓ : Prone
• Preferred posture : Bending forward
Hoarseness/dysphonia/aphonia Glottis
Odynophagia/drooling of saliva Infective involvement of epiglottis
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 Larynx : Part 1 105

Acute Epiglottitis vs. Croup : ----- Active space -----

Acute epiglottitis/supraglottitis Laryngotracheobronchitis/croup

Parainfluenza virus
Etiology Streptococcus (M/c) > H. influenzae
(Mainly involves subglottis)
• Acute onset
• Fever, toxic look
• Inspiratory stridor
- ↑ : Supine • Gradual onset
- ↓ : Leaning forward/Tripod • Hoarseness
Symptoms • Odynophagia, drooling of saliva • Barking cough (Seal like)
• Normal cry • Inspiratory/biphasic stridor

Tripod position

m
co
• Thumb sign :

l.
Steeple sign/pencil tip sign

ai
gm
@
h9
ans
vy
di

Ix
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X-ray lateral view X-ray AP view

©

• C/I investigation :
Pharyngeal/laryngeal examination (Laryngeal spasm)
• Secure airway : Intubation (1st choice) • Steroids
• IV antibiotics • Adrenaline nebulisation
Mx • IV fluids (Vasoconstriction &
• Steroids bronchodilation)
Severe
• Adrenaline nebulisation • IV fluids

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 106 ENT

----- Active space ----- Congenital Conditions 00:28:15

M/c : Laryngomalacia > Vocal cord palsy > Subglottic stenosis.

Laryngomalacia :
M/c cause of stridor in neonates (Congenital laryngeal stridor).

Symptoms :
• Inspiratory stridor : At/shortly after birth.
- ↓ : Prone.
- ↑ : Supine.
• No respiratory distress/cyanosis.
• Odynophagia : Absent.

Endoscopic examination :

m
co
l.
ai
Long, large, Ω gm
@
shaped epiglottis
h9
ns
a
vy
di

Short, floppy
i
ra

aryepiglottic folds
|
w

Prominent arytenoids
ro
ar
M

Endoscopy
©

↑↑Redundant tissue in subglottis by 2 yrs of age Disappears.

Management : Reassurance.

Subglottic Stenosis :
Acquired variety :
• M/c cause : Prolonged intubation > 3 weeks (D/t pressure at cricoid).
- D/t cuff induced necrosis & fibrosis.

Symptom : Biphasic stridor.

Examination : Rigid endoscopy.

Subglottic stenosis
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 Larynx : Part 1 107

Meyer-Cotton grading system : ----- Active space -----

Endoscopic
Classification From To
appearance

Grade I

No obstruction 50% obstruction

Grade II

51% 70%

Grade III

m
co
l.
71% 99%

ai
gm
@
h9

Grade IV No detectable lumen

ans
vy
idi
ra

Mitomycin C : ↓Fibrosis & prevents re-stenosis.

|
w
ro

Juvenile Laryngeal Papillomatosis/Recurrent Respiratory Papillomatosis :

ar
M

Etiology :
©

Low malignant potential HPV : 6 & 11 (More virulent) H/o vaginal delivery + .

Symptoms : Papillomas develop at

squamocolumnar junction (V.C.)
Hoarseness of voice Stridor.
Months later
Management :
• Microlaryngoscopic excision : Microdebrider/CO2 laser.
• Tracheostomy avoided.
• To ↓recurrence :
ABC :
- Alpha interferon (Immunomodulator).
- Bevacizumab.
- Cidofovir : Intralesional.

Note : Dx : Endoscopy
High malignant potential HPV : 16 & 18.
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 108 ENT

----- Active space ----- Structural Disorders of Glottis 00:41:02

Presentation :
• Hoarseness of voice.
• H/o voice abuse.

Disorders :
Vocal cord nodules Reinke’s edema/
Vocal cord polyp
(Teacher’s/singer’s nodules) Smoker’s larynx
Lesion :
• Bilateral Lesion :
• Bilateral
Features • <3 mm • Solitary
• Symmetrical edema
• Sessile • Large size
• Symmetrical
Site Junction of anterior 1/3rd & posterior 2/3rd Whole length of VC

m
Excised by MLS

co
• Voice rest
Mx (Microlaryngeal -

l.
• Speech therapy

ai
@
gm surgery)
h9
a ns
vy
di
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Vocal nodule Vocal polyp : Reinke’s edema

©

Sudden trauma

Larynx Examination : Instruments & Positions 00:44:00

Indirect Laryngoscopy :

Indirect laryngoscopy mirror

Indirect laryngoscopy

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 Larynx : Part 1 109

Endoscopy : ----- Active space -----

Rigid endoscope Flexible endoscope

Stroboscopy :
• Used along with rigid/
flexible endoscopes.
• Helps visualise mucosal waves.
• Accurately assesses lesions

m
co
& movements of VC.

l.
ai
@
gm Stroboscopy

Boyce Position :
h9
ns

• AKA Chevalier Jackson/barking dog/sniffing morning air position.

a
vy

• Flexion at cervical spine & extension at atlanto-occipital joint.

di
i
ra

• Used in MLS & direct laryngoscopy (Intubation).

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©

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 110 ENT

----- Active space ----- LARYNX : PART 2

Nerve Supply of Larynx 00:00:33

Vagus

At base of skull
1. Superior laryngeal nerve (SLN) 2. Recurrent laryngeal nerve (RLN)

At greater cornu of hyoid

Right Left
(Winds around arch of aorta)
Internal branch (ILN) External branch (ELN)

m
co
l.
ai
Pierces thyrohyoid Motor supply : Along tracheoesophageal groove
membrane Cricothyroid. gm
@
Enters larynx
h9

Enters larynx behind cricothyroid joints

ns

Sensory supply to supraglottis.

a

(Responsible for cough reflex

vy
di

& prevents aspiration) Sensory supply : Motor supply :

i
ra

Below true VC. All muscles except

|

(Glottis, subglottis) cricothyroid.

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Applied aspect :
©

ILN anaesthesia : Below greater cornu of hyoid

SLN
Anaesthetized at ILN
thyrohyoid membrane. ELN
Cricothyroid
Nerve Injury :
Left RLN
• M/c affected RLN overall : Left RLN Right RLN
(Longer course).
• Injury d/t thyroid Sx :
Nerve supply of larynx
- ELN > RLN.
- M/c cause of B/L RLN palsy.

Site Artery ligated Nerve injured

Upper pole of thyroid Superior thyroid artery ELN
Lower pole of thyroid Inferior thyroid artery Right > Left RLN

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 Larynx : Part 2 111

Effects of injury/nerve palsy : ----- Active space -----

Supply Features in injury/palsy

ILN Sensory to supraglottis Aspiration
SLN
ELN Cricothyroid (Tensor & adductor) Inability to ↑pitch
• U/L palsy : Asymptomatic/hoarseness
RLN All muscles except cricothyroid
• B/L palsy : Stridor (Life threatening)
• U/L palsy : Aphonia with aspiration
RLN + SLN Complete palsy
• B/L palsy : Aphonia with chronic aspiration

Positions of Vocal Cords 00:08:23

Position of vocal cord Normal activity

Median (M) Speech
Paramedian (PM) : 1.5 mm lateral Whisper

m
co
Intermediate/Cadaveric (C)/

l.
None

ai
Neutral : 3.5 mm lateral
gm
Slight : 7 mm (SA) Normal respiration
@
Abduction
h9

Full : 9 mm (FA) Forced respiration Positions of vocal cords

ans
vy
di

Vocal Cord Palsy 00:10:15

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Types :
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Palsy of VC position
©

Complete/Adductor palsy SLN + RLN Cadaveric/neutral position D/t intact

Complete Median cricothyroid :
Abductor palsy RLN
Partial Paramedian Wagner &
Grossman theory.

Clinical Features :
RLN/Abductor palsy Complete/Adductor palsy
U/L B/L U/L B/L
Speech Normal Aphonia
Normal
Respiration Stridor Normal
Aspiration - - Occasional Chronic
Aphonia + Aphonia + chronic aspiration
Overall Asymptomatic/ Stridor
occasional
presentation mild hoarseness (Life threatening palsy)
aspiration Recurrent chest infections
If hoarseness + : • Immediate tracheostomy Medialisation Tracheostomy +
Management
Gradually improves • Lateralisation of 1 VC of VC epiglottopexy

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 112 ENT

----- Active space ----- Commonly Injured Nerves During Surgery :

Site of Sx Nerves with ↑ed risk of injury
• Complete palsy
Base of skull
• SLN
• SLN
Carotid triangle • ILN
• ELN
• RLN (Inability to extubate)
Thyroid surgery
• ELN (Inability to ↑pitch)
Mediastinal surgery Left RLN

Note :
Ortner’s/Cardiovocal syndrome :
Mitral stenosis Hypertrophy of left atrium Compression of left RLN.

m
co
l.
Treatment :

ai
gm
B/L RLN palsy :
@
h9

Emergent tracheostomy + lateralization procedures

ans
vy
i di
ra

Cordectomy Woodman’s Kashima Thyroplasty

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procedure procedure type II

ro
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Complete palsy (Medialization procedure) :

©

• Teflon/fat/hydroxyapatite injection.
• Thyroplasty type I.

Note :
Isshiki thyroplasty (Mnemonic Plasty) :
• Proximalisation : Medialisation (Type I).
• Lateralisation (Type II).
• Shortening/relaxing (Type III) Indication : Puberphonia.
• Tightening/tensing (Type IV) Indication : Androphonia.

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 Larynx : Part 2 113

Vocal Cord Dysfunction 00:25:40 ----- Active space -----

Puberphonia :
Adult male with an unnaturally high pitch voice.

Management :
• Speech therapy.
• Gutzmann’s pressure test If positive Type III thyroplasty.

Hysterical Aphonia/Functional Aphonia :

• Functional disorder.
• M/c affects emotionally labile females Only talks by whispering.
O/e :
• No VC adduction on speech. • Normal VC movement on cough.

m
co
Management : Psychotherapy + reassurance.

l.
ai
gm
Spasmodic Dysphonia :
@
h9

• Neuromuscular disorder of vocal cords.

ans

• Spasms of vocal muscles only during speech.

vy
di

• Focal dystonias + : Blepharospasms/Oromandibular dystonias.

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Types :
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Type of voice Rx : Site of botulinum toxin injection

©

Adductor spasm (M/c) Strained & strangled Thyroarytenoid

Abductor spasm Breathy & whispery Cricoarytenoid

Carcinoma Larynx 00:29:40

• Squamous cell Ca.

• M/c in males, smokers.

Clinical Features :

Glottic Ca : M/c Site Supraglottic Ca

Referred pain to the ear (Via vagus nerve).
Presentation
Hoarseness : Earliest Dysphagia
Lymphatic • Maximum (Upper, middle deep cervical)
Least
metastasis • B/L : Epiglottic involvement
Prognosis Best -

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 114 ENT

----- Active space ----- TNM Staging :

Stage Extent Management
Limited to one site (Glottis/subglottis)
-
or one subsite of supraglottis
T1 T1a One VC involved T1a glottis : TLM

If glottic
T1b glottis/T1 supraglottis :
T1b Both VC involved
TLM + RT
T2 Adjacent subsite/sites with normal VC mobility TLM/RT
• Vocal cord fixation (Clinical Dx)
• Involves any of :
- Pre-epiglottic space
T3 Concurrent CRT
- Paraglottic space
- Post-cricoid area
- Inner cortex : Thyroid cartilage
• Complete thyroid cartilage invasion

m
• Local invasion beyond larynx into :

co
l.
- Strap muscles

ai
Total laryngectomy +
T4a - Thyroid gm adjuvant RT
@
T4 - Trachea
h9

- Esophagus
ns

- Tongue
a
vy

Distal invasion
di

T4b Palliative
i
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(Prevertebral space/mediastinum/carotid)
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RT : Radiotherapy
ro

Thyroid cartilage
ar

TLM : Transoral laser microsurgery

M

CRT : Chemoradiotherapy Lumen of larynx

©

CT : T4 stage
Investigations :
• MRI : Best for cartilage invasion.
• CT : Tumor extent & spread.

Neck Nodes Involved in Ca Larynx :

• Lateral group :
Upper, middle, lower deep cervical (II, III, IV).
• Delphian/anterior/prelaryngeal (VI).

: Neck nodes involved in Ca larynx

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 Larynx : Part 2 115

Rehabilitation Following Laryngectomy : ----- Active space -----

Permanent tracheostome :
Trachea pulled to an external opening Sutured to skin.

Speech rehabilitation :
1. Oesophageal speech :
Regurgitation of swallowed air
Permanent tracheostome
Vibration of hypopharyngeal segment.
2. Tracheoesophageal valve/
Voice prosthesis : Best.
Blom singer valve placed in
tracheoesophageal puncture

m
co
Closure of tracheostome opening

l.
ai
Via the valve gm
Air directed towards Voice prosthesis : Blom singer valve
@
h9

hypopharyngeal segment during

ans

expiration
vy
di
i
ra
|

Production of sound.
w

Electrolarynx
ro

3. Electrolarynx : External vibrations Speech.

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M

Humidification : Heat & moisture exchanger (HME).

©

Olfactory rehabilitation : Polite yawning.

• Nasal airflow-inducing maneuver.

HME
Newer Techniques in Laryngeal Endoscopy 00:43:55

Contact Endoscopy & Microlaryngoscopy :

• Noninvasive procedure of microscopic assessment
of the laryngeal epithelium in vivo.
• Lesion stained with Lugol’s iodine/methylene blue
(Supravital stain)

Visualized with Hopkins rod laryngoscope Contact endoscopy

(Magnification : 60 - 120 times).

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 116 ENT

----- Active space -----

• First 3 layers of epithelium visualized :
- Cytological features.
Determines benign/malignant
- Microvasculature.

Tracheostomy 00:45:05

Indications :
Mnemonic : Occupy most seats in medical association.
• Obstruction : Above tracheal rings 2-4.
• Mechanical ventilation :
M/c indication for elective tracheostomy.
• Secretion removal/pulmonary toilet (In coma).
• Maxillofacial trauma, head and neck surgeries.
• Prevent aspiration (B/L complete VC palsy).

m
co
l.
Note : Tracheostomy

ai
Work of breathing : ↓ in tracheostomy gm
@
h9

(Compared to intubation/bag & mask).

a ns
vy

Position :
di
i
ra

Rose’s position :
|

Extension at cervical & atlanto-occipital joint.

w
ro

Rose’s position
ar

Incision :
M
©

Emergency Elective

Vertical incision : Horizontal incision/

From lower border skin crease incision :
of cricoid to 2.5 cm above
suprasternal notch. suprasternal notch. Types of incision

Tracheal incision : Tracheal rings 2, 3, 4.

High tracheostomy : Incision at T1.

• Complication : Tracheal ring 1
Incision in trachea Tracheal ring 2
Subglottic stenosis. Trachea Tracheal ring 3
Thyroid isthmus Tracheal ring 4
• Indication : Ca larynx.
Vertical & horizontal incisions
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 Larynx : Part 2 117

Tracheostomy Tube : ----- Active space -----

• Function of cuff : Prevent aspiration.

• High volume, low pressure for air-tight seal.

Management of blocked tube :

Change tracheostomy tube immediately.
• Suction : Prevents obstruction. Portex cuffed tube

Surgical emphysema following tracheostomy :

• M/c cause : Tight sutures around tracheostomy tube.
• Management : Loosen the sutures.

Foreign Body 00:51:30

M/c age : 1 - 4 yrs of age.

m
co
l.
ai
M/c foreign body : Nuts & peanuts.
gm
@
Symptoms :
h9
ns

Sudden onset paroxysmal coughing/choking/gagging : Earliest.

a
vy
di

Stages of Cough Reflex :

i
ra
|

Irritant/foreign body in larynx sensed by ILN

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Deep inspiration
©

Closure of glottis

↑Intrathoracic pressure

Abdominal & intercostal muscles contract

Forceful expiration against closed glottis

Harmful substances removed.

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 118 ENT

----- Active space ----- Management :

First aid :

No respiratory Infants Conscious + universal choking sign :

distress, speaks Inability to speak, breathe, cough
Alternative sequence
• Encourage coughing of 5 back blows & Heimlich maneuver : Sudden
• Back blows 5 chest thrusts thrusts given to sub-diaphragmatic
area (Inward & upward)

↑Intrathoracic pressure.

Back blows

C/I of abdominal thrusts/Heimlich maneuver :

m
co
• Age < 1 yr.

l.
ai
• Pregnancy. Chest thrusts. gm Heimlich maneuver
• Obese.
@
h9

• Unconscious : CPR (30 chest compressions : 2 breaths).

ns
a
vy

CPR
idi
ra

Inspection of oral cavity

|
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ro
ar

Thyroid cartilage
M

Foreign body Foreign body not visible

©

visible
Cricoid cartilage
Direct laryngoscopy
Finger sweep
Cricothyrotomy
maneuver Object visible above
vocal cords

Remove with Magill forceps.

CICO (Can’t intubate can’t oxygenate) :

First aid fails Cricothyrotomy (Through cricothyroid membrane).

Surgical Needle cricothyrotomy :

cricothyrotomy : • Indication : Child < 10 yrs.
Sustains respiration • Sustains respiration for 30 mins.
x 24 - 48 hrs. • Followed by foreign body removal/tracheostomy.

Definitive Mx : Foreign body removal (or)

better method of ventilation (Tracheostomy).
ENT • World of Revision • v1.0 • Marrow • 2025
 Larynx : Part 2 119

Investigations : ----- Active space -----

AP view Lateral view

Rim
Laryngeal
foreign body Round

Airway

m
Esophageal Rim

co
foreign body Round

l.
Airway

ai
gm
@
h9
ans

M/c site of foreign body in esophagus : At or just below cricopharyngeal sphincter.

vy
di
i
ra

Button battery :
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©

Double density/
halo appearance/ Bi-levelled
double ring shadow + step-off
at the edge
AP view Lateral view
Pathological Breath Sounds 01:01:10

Site involved C/f

Supraglottis Inspiratory stridor
Glottis Inspiratory/biphasic stridor
Subglottis to cervical trachea Biphasic stridor
Cervical trachea to 2° bronchi Expiratory stridor
3° bronchi Wheeze
Trachea Palpatory thrill/Audible slap
Complete obstruction of bronchi Atelectasis, ↓breath sounds

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 120 ENT

----- Active space -----

Note :
• Calcification of laryngeal cartilage : Visualised on lateral view
(AP view : Overlap vertebral bodies).
• Identification of pyriform fossa :

Vallecula

Pyriform
fossa

Lateral view AP view

m
co
Barium swallow

l.
ai
gm
@
h9
a ns
vy
di
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ar
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©

ENT • World of Revision • v1.0 • Marrow • 2025