ENT ESSENTIALS

Antriksh Wahi 2k14

OTOLOGY
1. Define CSOM – Tubotympanic disease (Safe).
Chronic inflammation of the muco-periosteal layer of the middle ear cleft characterized
by ear discharge and a permanent perforation of pars tensa.

2. Define CSOM – Atticoantral disease (Unsafe).

Chronic inflammation of the muco-periosteal layer of the middle ear cleft characterized
by presence of skin in the middle ear (cholesteatoma), scanty foul smelling ear discharge
and a permanent perforation of the attic (pars flaccida) or a marginal perforation.

3. Define Cholesteatoma.
A 3-dimensional epidermal sac in the middle ear cleft, lined by stratified squamous
epithelium which has lost its self-cleansing property causing accumulation of keratin
and desquamated cells inside the sac, having the property of expansion of the sac at the
expense of surrounding structures and can give rise to various intra/extra cranial
complications. (Hegde sir).

4. Criteria to diagnose congenital cholesteatoma (Hegde sir):

1. The patient should not have had previous episodes of middle ear disease.
2. Skin mass present behind an intact and normal tympanic membrane.
3. Patient should not have a history of ear trauma and/or surgery.

5. Why does the cone of light appear in the anterio-inferior quadrant of the
tympanic membrane?
The handle of malleus tents on the pars tensa of tympanic membrane thereby causing
anterio-inferior quadrant to lie perpendicular to the floor of external auditory canal.
A normal cone of light tells that the pressure in the middle ear is normal.
NOTE: SOME PROFESSORS WANT TO HEAR THE WORD TOTAL INTERNAL
REFLECTION.

6. Why is there a permanent perforation in CSOM?

In CSOM, the epithelium and endothelium meet each other and healing occurs at their
junction (Edges get covered by squamous epithelium) leading to creation of a permanent
perforation.

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 7. Stages of TTD.
Based on time span of disease and not on pathological appearance of middle ear cleft.
Active – Last discharge < 6 weeks
Quiescent – Last discharge b/w 6 weeks to 6 months
Inactive – Last discharge beyond 6 months
Healed – closed Tympanic membrane
PRESENCE OR ABSENCE OF PUS DOES NOT SIGNIFY ACTIVE DISEASE
Healed TM– middle fibrous layer is lost forever; fused epithelium and endothelium.
NEVER DO TYMPANOPLASTY IN PATIENTS WITH ACTIVE DISEASE.

8. Why is there foul smell in unsafe CSOM?

Osteitis of middle ear cleft is present leading to anaerobic bone infection causing the foul
smell.

9. Why is there blood tinged discharge in unsafe CSOM?

Granulation tissue is present in middle ear cleft in Unsafe type of CSOM. They have
fragile capillaries.
Polyps can also be responsible for bleeding.

10. Which ear ossicle is most prone to erosion?

Incus > Malleus > Stapes
Incus is more prone due to poorest blood supply.

11. Why is there profuse ear discharge in safe type CSOM and scanty ear discharge
in unsafe CSOM?
The anterio-inferior part of the middle ear cleft is line by ciliated columnar epithelium with
abundant mucous glands and goblet cells. Their irritation leads to production of profuse
mucoid(/mucopurulent) discharge.
The attic and the mastoid air cells are lined by flat squamous pavement epithelium. The
no of mucous glands is very less and thus scanty discharge.

12. Causative organisms for Tubotympanic disease.

Pseudomonas aeruginosa is the most common organism involved. Another common
organism is Staphylococcus aureus.
Antibiotic of choice TTD: Fluoroquinolones (CIPROFLOXACIN) ear drops 5-7 days;
Antibiotic ear drops should not be given persistently. It will lead to death of normal flora
and predisposes to fungal infection.

13. Causative organisms for ASOM.

Strep. pneumoniae, H. influenza, Moraxella catarrhalis in order.

14. Investigations for TTD.

1. Examination under microscope – confirm the findings, ear suctioning, check the
ossicular status.
2. Ear swab for culture and sensitivity - Done only in cases of active discharge.
3. Pure tone audiogram

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 4. X-Ray mastoid – Law’s view (tells whether mastoidectomy is needed or not)

15. Importance of PTA

1. Tells about degree of hearing loss
2. Tells about type of hearing loss
3. Serves as a documentary evidence
4. Helps to monitor progression of disease or recovery.

16. Define tympanoplasty. Prerequisites for tympanoplasty.

Tympanoplasty can be defined as eradication of disease from middle ear with ossicular
reconstruction with grafting of tympanic membrane.
Prerequisites for tympanoplasty:
1. Dry ear (Entered Quiescent stage)
2. No focus of infection in tonsils, adenoids, PNS present
3. Normal Eustachian Tube function
4. Good cochlear reserve

17. Grafts that can be used for tympanoplasty. Which is the ideal graft?
Temporalis fascia, Fascia lata, Vein graft, Loose areolar tissue, Tragal and conchal
cartilage, Bovine Pericardium, Cadaver dura
Temporalis fascia is the ideal graft for the following reasons:
1. available at the same surgical site
2. has low BMR (survives longer with less nutrient supply)
3. is large in size
SELECTION OF TEMPORALIS HAS NOTHING TO DO WITH CONCEPT OF
GRAFT REJECTION.

18. Function of Mastoid

The primary function of mastoid in human body is to serve as an air reserve for
middle ear. Normally, the middle ear is aerated by the Eustachian tube.

air sucked in by
middle ear middle ear cavity
ET block
mucosa (highly pressure falls
vascular)

Prevents Rapid
some air enters
variation of
from the mastoid
pressure in the
RESERVE
midde ear

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 19. Name the tuning fork we use. Why do we use 512 Hz tuning fork and not 256 Hz
for tuning fork tests?
Gardner Tuning fork.
Reasons for using 512 Hz tuning fork
1. falls in mid-speech frequency range
2. lesser overtones
3. lower frequencies like 256 Hz produce more vibratory effect.
4. optimal tone decay time (higher frequencies like 1024 Hz have faster decay)

20. Characteristic findings in TB Otitis Media

Pale middle ear mucosa with presence of multiple perforations in the tympanic
membrane; Painless foul smelling ear discharge; severe hearing loss out of
proportion to symptoms (mostly conductive).

21. Round window baffling effect and Round window shielding effect.
Intact tympanic membrane protects the middle ear cleft from infections and shields the
round window from direct sound waves which is referred to as 'round window baffle'.
This shield is necessary to create a phase difference so that the sound wave does not
impact on the oval and round windows simultaneously. This would dampen the flow of
sound energy being transmitted in a unilateral direction from the oval window through the
perilymph.

In patients with CSOM, the Round window baffling effect is lost due to the
permanent perforation present in the tympanic membrane which leads to sound waves
simultaneously striking both oval and round window. The phase difference between the
two is lost and this leads to simultaneous transmission of sound wave through the oval
and round windows leading to destructive interference and decreased vibration of
perilymph and the basilar membrane. This causes hearing loss.

With time, the accumulation of secretions in the middle ear cleft leads to creation of a
barrier which protects the round window from the sound waves and re-establishes the
phase difference leading to an improvement in hearing. Thus, patient hears better in
the presence of ear discharge rather than dry ear in such cases. This is known as
Round window shielding effect.

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 When the ear discharge is removed, the patient complaints of paradoxical
decrease in hearing.

22. Cholesteatoma hearers

Sometimes, the bone eroded in AAD may be bridged by the cholesteatoma itself and
hearing loss is not apparent (Cholesteatoma hearers). After surgical removal of
cholesteatoma, hearing will reduce.

23. Define Tinnitus

Sensation of hearing in the absence of an external electromechanical stimulus.
Pathophysiology of Tinnitus – (Medscape)
Tinnitus is the consequence of brain’s response to input deprivation from auditory
periphery. When a region of the cochlea is damaged, the subcortical and cortical
projections adjust to the chronic lack of output (plasticity), and the tonotopic organization
(specific sound frequencies are received by specific receptors in the inner ear with nerve
impulses traveling along selected pathways to specific sites in the brain) is altered. The
area of auditory cortex that corresponds to the damaged cochlear zone (so called
LESION PROJECTION ZONE – LPZ) shows 2 important changes – an increase in
the spontaneous firing rate and an increase in the frequency representation of the
neurons that border the region of damage.

24. Define Vertigo

Hallucination of rotation.

25. Traumatic ear perforation

Examination reveals
1. irregularly shaped perforation
2. raw margins of perforation
3. presence of blood clots

Patient comes mainly with complaint of tinnitus.

Management – Keep the ear dry and wait for 3 months or more till the perforation heals
itself (raw margins do not get epithelized and hence have scope of healing).

NOTE – Patient comes with tinnitus with severe giddiness post trauma – Suspect
Perilymphatic fistula.

26. Ear pain in TTD

1. Acute exacerbation
2. Pus causing otitis externa

27. Ear pain in AAD

1. Mastoiditis
2. Petrositis
3. Sigmoid sinus thrombosis

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 28. Hearing loss in CSOM
1. Loss of Round Window Baffle effect in TM perforation (especially post-inferior)
2. Loss of effective surface area of TM (decreased amplification)
3. Loss of tension in Pars tensa (decreased vibration)
4. Ossicular disruption in long standing cases
5. Release of toxins into inner ear causing SNHL

29. Types of incision in myringotomy

1. Radial incision – given in Serous otitis media. Such an incision separates the fibres
rather than cutting them, it heals rapidly and prevents heaping of epithelium. (THIS
REASONING IS FROM INTERNET AND IS YET TO BE CONFIRMED)
Radial incision is suited for grommet insertion as it keeps the grommet fixed in
position. The incision should be just enough to admit the grommet.
Beer-Can principle – 2 incisions made in the TM, one in the anterio-inferior quadrant
and the other in the anterio-superior quadrant to aspirate thick, glue like secretions.
2. Curvilinear incision – given in ASOM in the posterior-inferior quadrant (dependent
part – pus collection occurs here).
Why curvilinear incision? – Epithelial migration and healing occurs in a radial fashion
from the umbo to the periphery, circumferential incision disturbs this pattern more
than the radial incision. Hence circumferential incision takes longer time to heal than
radial incision. (THIS REASONING IS FROM INTERNET AND IS YET TO BE
CONFIRMED).
[Link]
or_serous_otitis_media_and_circumferential_for_acute_otitis_media

30. Types of grommets

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 31. When do you remove the grommet?
No need to remove the grommet. It gets extruded on its own.

32. The entire chapter on Complications of CSOM is important and was taken by
Arun sir. Dhingra is enough to answer the questions. Some important points are –
1. Citelli’s abscess – Digastric muscle abscess
2. Labyrinthitis ossificans - Labyrinthitis ossificans (LO) is the pathologic formation
of new bone within the lumen of the otic capsule and is associated with
profound deafness and loss of vestibular function. Usually caused by
Streptococcus pneumoniae meningitis leading to ossification of labyrinth.
3. Picket fence fever – intermittent episode of remittent fever (peak >105 C) – Lateral
sinus thrombophlebitis
4. Tobey-Ayer test also known as Queckenstedt test
5. Lateral sinus thrombophlebitis – Contrast Enhanced CT Scan – Empty Delta sign

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 33. How does Measles cause Otosclerosis?

Penetration into
Infection of
bone/labyrinth via
Measles virus fibrocytes,
oval/round window,
infection via ET tube chondrocytes,
perivascular spaces,
osteoblasts
lymphatic vessels

Expression of
Inflammation Cellular and humoral
Measles virus at cell
causing otosclerosis immune response
surface

34. Salient features of Otosclerosis

There is slowly progressive hearing loss, b/l asymmetrical, most commonly affects 15 to
45 age group; More common in women especially those who are pregnant or on
estrogen therapy.

35. Schwartze sign

Flamingo pink tympanic membrane. Through the TM, the active focus of otosclerotic
disease can be seen (initially vascular) over the promontory giving a reddish hue.
CLINICAL IMPORTANCE – increased vascularity – do not operate till it matures.

36. Management of Otosclerosis

1. Amplification
2. Medical therapy
3. Stapes surgery
Amplification and Stapes surgery do not change the course of the disease but
decrease the symptoms.

Amplification – Hearing aids for conductive hearing loss; for those who refuse surgery or
those who are poor candidates for surgery.

37. Medical management of Otosclerosis

1. Sodium fluoride – 20 mg tablet bd for 2-3 years; helps in conversion of immature
focus to mature focus; stabilizes the disease in 80% patients such that hearing
loss will not worsen;

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 We give NaF in JIPMER to Otosclerosis patients presenting with tinnitus.
s/e – Extreme gastritis; It can be given in pregnancy in 2nd and 3rd trimester.
2. Vitamin D
3. Calcium carbonate

38. Surgical management of Otosclerosis

Goals – 1. Open oval window for sound transmission
2. Reconstruct sound conserving mechanism
3. Prevent complications
Types – 1. Total stapedectomy and replacement by graft.
2. Partial stapedectomy and addition of a piston
3. Anterior crurotomy
4. Stapedotomy
Pistons used – made of Nickel titanium alloys
Best candidate for surgery –
1. Good health; socially unacceptable Air-Bone gap (atleast 15dB – Dhingra)
2. Rinne –ve (for 256 and 512 Hz – Dhingra)
3. Excellent Speech discrimination score (60% or more – Dhingra)
4. Desire for surgery after appropriate period of deliberation
5. Dhingra – Hearing threshold for air conduction 30 dB or more

Read Complications from Dhingra

Post op management –
1. No bathing till the ear gets dry
2. No Valsalva maneuver
3. Post op audiogram 3 months later
4. Do not fly

39. When to operate the 2nd ear in Otosclerosis?

Wait for 6 months to 2 years before operating the second ear.
If only 1 hearing ear is present, stapes surgery is contraindicated.

40. Why is there episodic vertigo in Ménière’s disease?

Distension of endolymphatic system occurs in Meniere’s disease (distended scala media
and saccule); bulging of Reissner’s membrane into Scala vestibuli; micro-tears in
Reissner’s membrane; mixing of endolymph and perilymph; Episodic vertigo.

41. Citelli’s angle

Another name for Sinodural angle (present between sigmoid sinus [sinus plate]
and middle fossa dural plate/tegmen tympani.)
Clinical significance - is the landmark for the superior petrosal sinus. It is used to
identify it while doing surgeries on this area.

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 42. Trautman's triangle
This is a triangular space bounded by –
a. Bony labyrinth anteriorly
b. Sigmoid sinus posteriorly
c. Dura containing superior petrosal sinus superiorly.

Clinical significance - This triangle is a potential weak spot through which infections of
temporal bone may traverse and affect cerebellum. Extra dural abscess involving the
posterior cranial fossa is also possible when thin bone in this triangle gets breached in
infections / cholesteatoma involving mastoid cavity. Since bone in this area is rather thin
it can be drilled out to enter into the posterior cranial fossa. This can be used as an
approach to posterior cranial fossa lesions.

43. Costen syndrome

A disorder caused due to abnormality of the Temporo-Mandibular joint with a defective bite
(malocclusion). Patient develops Tinnitus, Vertigo, Ear ache (referred pain via CN V)
and Blocked feeling of ear. There is associated pain in ipsilateral frontal, parietal and
occipital region.

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NOSE

1. Woodruff’s plexus
It is an arterial plexus present at the posterior end of the middle turbinate formed by
anastomoses of sphenopalatine artery with the posterior pharyngeal artery. It is
the most common site of posterior epistaxis.

2. Cottle’s line
A vertical line between the nasal process of frontal bone and the nasal spine of maxillary
crest. It divides the septum into anterior and posterior segments.
When septal deviation is present anterior to Cottle’s line – Septoplasty
When septal deviation is present posterior to Cottle’s line – Both Septoplasty and SMR

3. Cottle’s classification of DNS

a. Simple deviation (commonest)
[Link] there is mild deviation of nasal septum
[Link] nasal obstruction
[Link] no treatment

b. Obstruction
[Link] severe deviation of nasal septum which may touch the lateral nasal wall
[Link] vasoconstriction, the turbinate shrinks away from the nasal septum
[Link] is not indicated even in these cases

c. Impaction
[Link] angulation of nasal septum with a spur in contact with the lateral nasal wall
[Link] is not increased even on vasoconstriction
[Link] is indicated in these patients

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 4. Areas of nasal cavity (Cottle’s classification)
These areas can be the probable sites of nasal obstruction –
— Vestibule
— Nasal valve
— Attic
— Turbinal
— Choanal

5. Haejeck’s area – site where the tenderness is elicited for the anterior ethmoidal sinus
by pressing over the lateral side of bridge of nose.

6. Sludder’s neuralgia/Anterior Ethmoidal syndrome

High DNS and spur pressing the middle turbinate causes pressure on the anterior
ethmoidal nerve (continuation of nasociliary nerve, a branch of ophthalmic division of
trigeminal nerve). It causes pain from eyebrows down the nasal bone.

7. Septoplasty and SMR

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 Inverted L- Strut
In both Septoplasty and SMR, preserve a strip of 1.5 cm wide cartilage along the dorsal
and caudal borders of nasal septum i.e. along the bony cartilaginous junction and along
the nasal floor – This will preserve the structural integrity of the dorsum of nose and
prevent its collapse.

8. Killian’s incision and hemitransfixion/Freer’s incision

Killian incision is created approximately 3 to 5mm posterior to the caudal septal

margin within the respiratory epithelium. It is used in SMR and is useful when septal
deviation is only found in the middle to posterior third of the nasal cavity. Its greatest
downfall, however, is in its relative inaccessibility to the caudal septal edge and the
higher potential for membrane tearing as a result of its location within the delicate
respiratory lining.
Freer’s incision – hemitransfixion/transfixion incision – Incision made at the caudal
end of the septum through the highly vascular area in the membranous septum. It
provides easy access to nasal spine and the premaxillary crest, has least tendency for
perforation and provides easy access to caudal dislocation.

9. Trotter (Sinus of Morgagni) triad or syndrome

It is seen in Nasopharyngeal Carcinoma which spreads laterally to involve the sinus of
Morgagni involving mandibular nerve. Characterized by –

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 a. Conductive hearing loss (d/t Eustachian tube obstruction)
b. Ipsilateral immobility of soft palate
c. Neuralgic pain in distribution of V3 (Ipsilateral Temporoparietal pain)

Also, trismus and pre-auricular fullness may be present.

10. Define polyp (Sivaraman sir)

Hypertrophied, prolapsed and edematous mucosa of nose and paranasal sinuses.

11. Why does AC polyp/Killian’s polyp grow posteriorly?

a. Maxillary sinus ostium is directed posteriorly
b. Cilia beat posteriorly
c. Air current flows posteriorly
d. Nasal floor slopes posteriorly
e. Posterior nasal cavity is larger
f. Negative oropharyngeal pressure while swallowing.

12. Samter’s triad

Nasal polyp + Asthma + Aspirin intolerance

13. Polyp Vs Hypertrophied turbinate

POLYP HYPERTROPHIED TURBINATE
1. Insensitive to pain 1. Sensitive to pain
2. Probe can be passed all around 2. Probe cannot be passed all around

3. Mobile 3. Non-mobile
4. Soft to touch 4. Hard to touch

INSTRUMENTS & SURGERIES

1. Mastoid gouge
Name - Jenkin’s Mastoid gouge

2. Lichtwitz trochar and cannula – Proof puncture/Antral lavage (Saxena sir)

Indication- Acute sinusitis not responding to antibiotics
Done in siting position with head tilted a little down; under LA (4% Xylocaine) through
inferior meatus (easily accessible and safe)
Direction of trochar should be towards ipsilateral tragus.

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Why does the tip of the cannula extend slightly outside the trochar?
The tip of the cannula is pointed and is the one used to do proof puncture while the tip of
trochar is blunt. Since the tip of cannula projects out only slightly from the trochar, the depth of
tissue it can pierce through gets restricted. THIS WILL LIMIT DEVELOPMENT OF
COMPLICATIONS.
Complications - 1. Pierces through orbital floor – Proptosis
[Link] – cheek damage

3. Tongue depressor is called Lack’s tongue depressor

4. Luc’s forceps
Can be used to remove mucosa (Caldwell-Luc operation), bone/cartilage (septoplasty
and SMR), polyp removal; also, used for taking biopsy

Why are there holes present at the cutting end?

They help to visualize the tissue being held.

5. Boyle-Davis mouth gag

DAVIS GAG

RACHETTE
BOYLE’S BLADE

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 Read uses and insertion/placement from Dhingra

How will you stabilize the Boyle-Davis mouth gag?

No assistant is needed to hold the Boyle-Davis mouth gag during the surgery (Self-
retaining). It is held in position by using Draffin’s bipod. Each pod has 4 rings that can
be assembled to vary the height at which the tongue blade of the Boyle-Davis mouth gag
can be suspended.

6. Arrange the instruments used for tonsillectomy in the order of their use.
a. Boyle-Davis mouth gag fixed in position using Draffin’s bipod
b. Denis browne’s tonsil holding forceps or Tonsil Holding Valsellum– hold the
tonsil superio-inferiorly and pull it medially.
c. Waugh’s single toothed tennaculum tonsil dissecting forceps – incise the mucous
membrane over tonsils.
d. Mollison’s tonsil dissector and anterior pillar retractor – One end used to dissect
the tonsil; first release the anterior pillar. Use the other end to retract the anterior pillar to
inspect the fossa for any bleeding point.
Now, change the direction of holding Denis browne’s tonsil holding forceps from superio-
inferior to anterio-posterior and maintain the medial traction.
Continue dissecting with the Mollison’s tonsil dissector and anterior pillar retractor till you
reach the lower pole (Pedicle).
e. Eve’s tonsillar snare – Catch, Cut and Crush the lower pole of tonsil. It crushes the
blood vessels and provides hemostasis.
f. Yankauer’s suction tube – suction out the blood. (Multiple pores are present at the
anterior end – this decreases the pressure and reduces the chances of clogging)

After finishing the above steps of surgery or during the surgery, if there is presence of
any bleeder, we use the 1st and 2nd artery forceps
Birkett’s 1st artery forceps – Straight – used to catch the bleeder and provides
instant control of bleed
Negus 2nd artery forceps – Curved – used to hold tightly and lock the bleeding
sight.
Remove the 1st artery forceps and now tie with a ligature.

7. St. Clair Thompson’s adenoid curette with guard/without guard –

[Link] will face you
[Link] posteriorly to touch the posterior nasal septum
[Link] the adenoid mass
[Link] a scooping action and give force at wrist and not your elbow else you might
damage the mouth cavity or dislocate the TM joint.
Note – The scooping action has to be performed thrice – once in exact center then
slightly medially and slightly laterally (Arun sir). DO NOT GO TOO LATERALLY AS
IT CAN DAMAGE THE EUSTACHIAN TUBE.

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 What is the advantage of using St. Clair Thompson’s adenoid curette with guard
over the one without guard? How to decide which instrument has to be used?
St. Clair Thompson’s adenoid curette with guard protects the torus tubarius on lateral
wall from injury.
The nasopharynx should be of enough size to allow St. Clair Thompson’s adenoid
curette with guard to enter. For a smaller nasopharynx, use St. Clair Thompson’s
adenoid curette without guard so that Eustachian tube is protected from damage.

How does adenoid feel on palpation?

Bag of worms like

Endoscopic grading for adenoid enlargement – CLEMENS McMURRAY grading

Depends on examiner’s subjective perception.
Grade 1 – < 1/3 obstruction of posterior choane
Grade 2 – > 1/3 but <2/3 obstruction of posterior choane
Grade 3 – > 2/3 but not complete obstruction of posterior choane
Grade 4 – complete obstruction of posterior choane

Name the procedure done for removal of adenoids?

Adenoid curettage and NOT ADENOIDECTOMY
The reason is that “-dectomy” term is used for removal of tissues having a CAPSULE.
Adenoid lacks a capsule and so the term ADENOIDECTOMY is invalid.

Why can you do adenoid curettage but not tonsil curettage?

Adenoid is resting against roof and posterior wall of nasopharynx. Thus, it gets a rigid
bony support by the base of skull. So, curettage can be done against this hard support.

Tonsil does not have any hard-structural support against which curettage can be done.
Also, it has a tonsillar bed which contains several delicate structures. Doing curettage
can damage these tonsillar bed structures.

8. Tracheostomy tubes
Types – Plastic and Metallic tubes
Read the classifications from Dhingra

Plastic tracheostomy tube

PVC, Silicone, etc.
Single tube – so chance of sudden blocking of the tip is higher
Cuff is present – prevents aspiration of pharyngeal secretions (useful for
unconscious/comatose patients)
Better tubes for children – because metal tubes have a narrow lumen; metal tubes can
damage the trachea in children

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 Cuffed plastic tube (with bulb) – used for positive pressure ventilation
Can be used for patients undergoing Radiotherapy
IF CUFFED TUBE IS USED, IT SHOULD BE PERIODICALLY DEFLATED TO
PREVENT PRESSURE NECROSIS OR DILATATION OF TRACHEA.

Can you see a plastic tracheostomy tube on X-ray?

A blue colored radiopaque line is present in the plastic tracheostomy tube. This helps
to visualize the tube on an X-ray.

Metallic tracheostomy tube

Made of an alloy of German Silver, Cu and P (prevents rusting)
Cuff cannot be attached
Cannot be connected to the circuit
>1 tube present
The inner tube is longer than the outer tube so that secretions can only block the tip of
the inner tube. The inner tube can be taken out and cleaned. The outer tube will keep the
lumen patent and allow air to pass till then.

Types of metallic tracheostomy tube

1. Jackson’s tracheostomy tube –
3 parts – outer tube, inner tube, obturator
Obturator guides the entry of outer tube into the trachea. It is then removed and now
the inner tube is entered.
2. Fuller’s tracheostomy tube –
2 parts – Outer tube and Inner tube
Outer tube is biflanged – the blades have self-dilating property – so only an incision
is needed in the anterior tracheal wall and no need for removal of a piece of cartilage
– useful during emergencies

Inner tube has hole present in it. Functions –

a. Helps in phonation
b. Can be used as a test to assess fitness for decannulation. Close the opening of
the tracheostomy tube from outside. If the patient is able to breathe normally by

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 himself (passage to air provided by the hole in the inner tube) then he is fit for
decannulation.

9. Rigid scopes
Jackson’s distal illumination – blurring of view can occur due to spillage of
blood/secretions over the light source
Negus proximal illumination – proximally illuminated but since the light source is
proximal, less light reaches the distal end. To overcome this, we use double proximal
illumination

10. Position for Rigid bronchoscopy, Oesophagoscopy and Laryngoscopy

Barking Dog position/Boyce position – extension at atlanto-occipital joint and flexion
at neck
Patient lies on the flat end of the table and the head is raised by 10 cm by using a pillow
or folded bedsheet under it.
In rigid oesophagoscopy, once you reach the hypopharynx break the head of the
table. This will ensure that you only enter into the oesophagus and not the larynx.

11. Position for tonsillectomy, and adenoid curettage

Rose position – Extension at both neck and atlanto-occipital joint
Put a sand bag under the shoulder blade.

12. Grading of trismus

4 cm mouth opening is adequate (DISTANCE MEASURED BETWEEN THE LEVEL OF
UPPER AND LOWER INCISORS)
Grade 1 – 2.5 - 4 cm
Grade 2 – 1 - 2.5 cm
Grade 3 – >0 but <1cm
Grade 4 – 0 (mouth does not open at all)

13. Tonsillectomy

Indications –
Paradise criteria
— Frequency criteria: 7 episodes in 1 year or 5 episodes/year for 2 years or 3
episodes/year for 3 years.
— Clinical features (one or more):
— Cervical LAD (>2cm) or tender LAD
— Tonsillar/pharyngeal exudate
— Positive culture for GABHS
— Antibiotic treatment non-responsive.

Absolute indications
• Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep disorders,
or cardiopulmonary complications
• Peritonsillar abscess

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 • Tonsillitis resulting in febrile convulsions
• Tonsils requiring biopsy to define tissue pathology

Relative indications
• Three or more tonsil infections per year despite adequate medical therapy
• Persistent foul taste or breath due to chronic tonsillitis that is not responsive to medical
therapy
• Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-
lactamase-resistant antibiotics
• Unilateral tonsil hypertrophy that is presumed to be neoplastic
Contraindications
• Bleeding diathesis – Best way to elicit presence of bleeding disorders is a good
clinical history and a positive family history (Arun sir)
• Anemia
• Poor anesthetic risk
• Uncontrolled medical illness
• Acute infection
• Polio epidemic – Why?
If a single patient develops polio then there will be presence of numerous sub-
clinical cases in the community having Wild poliovirus. Under such conditions, if
tonsillectomy is performed on a patient in that community, there is risk of spread
of Wild poliovirus from the exposed tonsillar bed to the Cranial nerves (Faeco-oral
spread) – Patient can develop BULBAR POLIOMYELITIS.

Grading of tonsillar enlargement (FRIEDMANN CLASSIFICATION)

Grading is done in relation to posterior pillar only
Grade 1 - Tonsil reaches the posterior pillar
Grade 2 - Tonsil covers the posterior pillar
Grade 3 - Between 2 and 4
Grade 4 - Tonsil reaches the midline

What is Tonsillotomy?
Intracapsular excision of tonsils
— Powered microdebrider.
— Coblation.
— Bipolar Scissors.
— Laser tonsillotomy.

— Advantages
— Less post-operative pain
— Probably lower PTH rate

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 — Disadvantages
— Opportunity for tonsillar regrowth
— Still serves as a nidus for infection
— May require formal tonsillectomy in future

Principle of Coblation technique

— Ionize NaCl in a saline medium using RF
— Energy of these ions (plasma) used to break molecular tissue bonds
— May also be used for direct hemostasis
— Lower temperatures (40°C to 70°C)

Principle of thermal welding technique

— No electric current passes through the tissue
— At the tip of the cautery forceps, a low voltage current activates a heating element.
— Tissue that is grasped using the forceps is vaporized (temperatures 300°C to 400°C)
— Vessels are sealed with heat & clamping pressure of the forceps.

Principle of Harmonic scalpel technique

— Blade vibrates at 55,500 hertz
— This vibration is in the RF range and causes proteins to denature and form a coagulum
which seals small vessels and divides tissue
— Larger vessels can be sealed by continuous contact and secondary heating

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 Adjunctive therapy
— Perioperative steroids - 1 dose given (0.1-1 mg/kg) – reduction in post-op pain
and 24 hr emesis rates
— Post-operative antibiotics – narrow spectrum (Amoxicillin) for 5-7 days –
decrease post-op pain and post-op healing time
— Local Anesthetic
— Post-operative pain control – paracetamol/Narcotics/NSAIDS – also less post-
op nausea and vomiting.

Post-operative care
§ Immediate care:
§ Coma position,
§ watch for bleeding
§ check vitals.
§ Diet:
§ Liquids,
§ ice cream,
§ semi-solid food,
§ normal food.
§ Oral hygiene with Betadine gargles.
§ Analgesics
§ Antibiotics

1st day post-op- check the tonsillar fossa for any- (Shivakumar sir)
— reactionary haemorrhage
— presence of clots (clots will not allow the muscles to contract and hence will
prevent vessel constriction)
— slough formation (usually develops within 72 hrs post-op)
a. Good slough – light yellow – replaced by granulation tissue – then
fibrotic tissue – healing
b. Bad slough – infected, unhealthy, dirty white slough – foul smelling
— Look for any fever, hypotension

Complications of tonsillectomy
— Bleeding:
§ Primary,
§ Reactionary (occurring within the first 24 hours) – may be due to
dislodgement of clot or slipping of ligature (due to retching, vomiting, coughing)
§ Secondary (occurring between 24 hours and 10 days) – because of secondary
infection of the tonsillar fossa – Streaks of blood may be seen in saliva (Herald
saliva) – Rx- Admission and iv antibiotics administration
§

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 — Control bleeding by:
§ pressure application.
§ Application of dilute adrenaline or H2O2,
§ Ligation or electrocoagulation
§ Approximation of the pillars with mattress sutures,
§ External carotid ligation.

Other complications
§ Injury to adjacent structures.
§ Infection: fever, parapharyngeal abscess. otitis media etc.
§ Pain.
§ Dehydration.
§ Weight loss.
§ Postoperative airway obstruction (because of uvular edema, hematoma, aspirated
material).
§ Recurrence due to tonsillar remnants.
§ Anesthetic complications.
§ Velopharyngeal Insufficiency, Nasopharyngeal stenosis (when done with
adenoidectomy).
§ Atlantoaxial subluxation (DOWN’S SYNDROME).
§ Lung complications following aspiration.
§ Depression.
§ Laceration of ICA/ pseudoaneursym of ICA.

Tonsillar fossa examination in a post tonsillectomy patient (Shivakumar sir)

Examine for –
— Tonsillar tissue remaining in tonsillar fossa especially at lower pole
— Check for intactness of the tonsillar pillars – damaged of posterior tonsillar pillar-
Velopharyngeal insufficiency – Hypernasal voice and Nasal regurgitation
— Any soft palate injury
— Any uvula, posterior pharyngeal wall injury

GRANULOMATOUS DISEASES OF NOSE

1 RHINOSPORIDIOSIS (Arun sir)
ATROPHIC STAGE: b/l foul smelling nasal discharge – Carpenter glue discharge
GRANULATION STAGE:
Bluish red & rubbery non-ulcerative nodules that later become woody hard (pale and
indurated)

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 CICATRIZING STAGE:
Tapir nose
Stenosis of nares
Distortion of upper lip
Adhesions in the nose, & pharynx

2 STEWARTS GRANULOMA (Arun sir)

Called Lethal midline granuloma
Vasculitis: Endarteritis obliterans type,
Associated with tissue necrosis and infection
Probably due to T cell lymphomas
Stages:
a. Prodromal
b. Active
c. Terminal
Treatment: debridement
d. Radiation
e. Prednisolone
f. Alkylating agent

RADIOLOGY
1. What all to comment on the X-ray provided?
— Label the X-ray (X-ray of; view; area exposure; plain/contrast; normal structures
seen)
— Findings in the X-ray
— DDx and probable diagnosis
— Management

2. Water’s view
Aka Submento-occipital view/Nose-chin view/Standard view of PNS
Modified Water’s view – Water’s view with mouth open

3. Law’s view
Plain X-ray Lateral oblique view Mastoid
Why is lateral oblique view needed?
It prevents the 2 mastoids from being viewed simultaneously;
Also, if only Lateral view is taken then Petrous part of Temporal bone will obscure the
view (thick bone)

4. Whenever you get a mastoid X-ray always and you see sclerosis, do not jump on a
conclusion – You should first look at X-ray of the contralateral mastoid as well because
about 20% individuals have normally sclerosed mastoid.

5. Cavity in mastoid ddx

• Subperiosteal abscess

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 • Post-surgical cavity in mastoid (irregular)
• Erosion due to Attico-Antral disease (comparatively smoother)
• Normally larger Antrum (Mega Antrum)
• Langerhans Cell HIstiocytosis
• Eosinophilc granuloma

6. Steeple sign and Thumb’s sign

The steeple sign, also called the wine bottle sign, refers to the tapering of the
upper trachea on a AP chest radiograph reminiscent of a church steeple. The appearance is
suggestive of croup, which should be obvious clinically.
The thumb sign in epiglottitis is a manifestation of an oedematous and enlarged epiglottis
which is seen on lateral soft-tissue radiograph of the neck, and it suggests a diagnosis of
acute infectious epiglottitis.

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 7. Double lumen sign

8. Whenever you get an X-ray of a foreign body comment on the location of the
foreign body but not its shape. For knowing the exact shape, you need multiple
views of the X-ray – lateral view, Lateral oblique view and PA view neck and thorax
to get 3D idea about the shape of foreign body.

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