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Comprehensive Otology and Rhinology Guide

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Comprehensive Otology and Rhinology Guide

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Section I: Ear (Otology)

1)Basic Science of Ear .......................................................................................................................................... 4
A) Anatomy of the Ear ..................................................................................................................................... 4
B) Physiology of Hearing & Equilibrium ........................................................................................................... 5
2)Assessment....................................................................................................................................................... 7
A) Audiology – PTA & Tympanometry ............................................................................................................... 7
B) Tuning Fork Tests (Rinne, Weber) ................................................................................................................ 8
C) Vestibular Assessment – Caloric Test ....................................................................................................... 10
3)Diseases of External Ear .................................................................................................................................. 11
A) Otitis Externa ............................................................................................................................................ 11
B) Wax & Foreign Bodies in External Ear ........................................................................................................... 12
4)Dieases of External Ear .................................................................................................................................... 13
A) Eustachian Tube Disorders ......................................................................................................................... 13
B) Acute Suppurative Otitis Media (ASOM) ....................................................................................................... 14
C) Secretory Otitis Media (Glue Ear) ................................................................................................................ 15
D) Chronic Suppurative Otitis Media (CSOM) ................................................................................................... 16
E) Complications of CSOM ............................................................................................................................ 18
F) Cholesteatoma – Pathogenesis & Management ........................................................................................... 19
G) Otosclerosis (Otospongiosis) ..................................................................................................................... 20
5)Dieases Of Inner Ear ........................................................................................................................................ 22
A) Ménière’s Disease ..................................................................................................................................... 22
B) Sensorineural Hearing Loss (SNHL) ............................................................................................................ 23
6)Miscellaneous Otology .................................................................................................................................... 24
A) The Deaf Child – Evaluation & Management .............................................................................................. 24
B) Nerve Disorders (Facial) ........................................................................................................................... 25
C) Ear Tumours – Glomus & Acoustic Neuroma ............................................................................................ 27

Section II: Nose (Rhinology)

1)Basic Science of Nose ..................................................................................................................................... 28
A) Anatomy of Nose & Paranasal Sinuses ........................................................................................................ 28
B) Physiology of Nose .................................................................................................................................... 29
2)Diseases of External Nose & Septum ............................................................................................................... 30
A) Diseases of Vestibule................................................................................................................................. 30
B) Nasal Septum Disorders ............................................................................................................................ 31
3)Rhinitis & Sinusitis .......................................................................................................................................... 32
A) Acute & Chronic Rhinitis ............................................................................................................................ 32
B) Allergic vs Vasomotor Rhinitis..................................................................................................................... 34
C) Acute Sinusitis (Maxillary & Frontal) ............................................................................................................ 35
D) Chronic Rhinosinusitis & Functional Endoscopic Sinus Surgery (FESS) .......................................................... 36
E) Complications of Sinusitis ......................................................................................................................... 38
4)Masses & Tumours........................................................................................................................................... 39
A) Nasal Polyps – Antrochoanal vs Ethmoidal .................................................................................................. 39
B) Epistaxis – Causes, Anatomy & Management ............................................................................................... 40
C) Granulomatous Diseases of Nose............................................................................................................... 41
D) Tumours of Nose & PNS ............................................................................................................................. 43
5)Miscellaneous ................................................................................................................................................. 44
A) CSF Rhinorrhea (Dhingra Ch. 29) ................................................................................................................ 44
B) Facial Trauma (Dhingra Ch. 34) ................................................................................................................... 45

Section III: Throat (Head & Neck)

1)Oral Cavity and Salivary Glands ....................................................................................................................... 46
A) Anatomy of Oral Cavity (Dhingra Ch. 42) ................................................................................................... 46
B) Oral Ulcers – Types, Features & Key Differentiators (Dhingra Ch. 43) ......................................................... 47
C) Oral Submucous Fibrosis (OSF) ............................................................................................................ 48
D) Leukoplakia .......................................................................................................................................... 49
E) Tumours of Oral Cavity (Dhingra Ch. 44) ................................................................................................... 50
F) Salivary Glands ........................................................................................................................................ 51
a) MUMPS ................................................................................................................................................. 51
b) Sialolithiasis (Salivary Stones) .............................................................................................................. 52
c) Salivary Gland Tumours – “Rule of 80s” .................................................................................................... 52
2)Pharynx (Nasopharynx, Oropharynx, Hypopharynx) ......................................................................................... 53
A) Anatomy of Pharynx (Dhingra Ch. 47) ........................................................................................................... 53
B) NasoPhyrnx ................................................................................................................................................ 54
Adenoids (Nasopharyngeal Tonsil) ................................................................................................................. 54
Juvenile Nasopharyngeal Angiofibroma (JNA) .................................................................................................. 55
Nasopharyngeal Carcinoma (NPC) ................................................................................................................. 55
C) OROPHYRNX .............................................................................................................................................. 56

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Medical Library Which is According To KMU Syllabus All Minors etc available in App. For App WhatsApp
03189459627 .
Acute Tonsillitis............................................................................................................................................. 56
Chronic Tonsillitis ......................................................................................................................................... 56
Peritonsillar Abscess (Quinsy) .......................................................................................................................... 57
D) Deep Neck Space Infection ......................................................................................................................... 58
Retropharyngeal Abscess .............................................................................................................................. 58
Parapharyngeal Abscess ............................................................................................................................... 58
E) HYPOPHYRNX ............................................................................................................................................ 59
Hypopharyngeal Tumours .............................................................................................................................. 59
Pharyngeal Pouch (Zenker’s Diverticulum) ...................................................................................................... 60
3)LARYNX And Trachea ....................................................................................................................................... 61
A) General Anatomy And Physiology of Larynx .............................................................................................. 61
B) INFECTIONS ............................................................................................................................................. 62
Acute Laryngitis........................................................................................................................................... 62
Acute Epiglottitis (Supraglottic Laryngitis) ................................................................................................... 63
Acute Laryngo-Tracheo-Bronchitis (Croup) .................................................................................................. 63
Epiglottitis vs Croup (Differentiation) ........................................................................................................... 63
C) Disorder Of Voice.................................................................................................................................. 64
Vocal Nodules (Singer’s/Screamer’s Nodes) ................................................................................................ 64
Vocal Polyp .................................................................................................................................................. 65
Reinke’s Edema (Polypoid Degeneration) ..................................................................................................... 65
D) Neurological Disorder........................................................................................................................... 66
Vocal Cord Paralysis .................................................................................................................................... 66
E) Tumours ................................................................................................................................................... 67
Squamous Papilloma (Benign Tumour) ........................................................................................................ 67
Carcinoma Larynx (Malignant Tumour) ........................................................................................................ 68
F) Air Way Management ............................................................................................................................... 69
Stridor ......................................................................................................................................................... 69
Tracheostomy .............................................................................................................................................. 69
Foreign Bodies in Air Passages ..................................................................................................................... 70
4)Oeasaphagus .................................................................................................................................................. 71
General Anatomy ............................................................................................................................................ 71
Physiological Constrictions (Critical for MCQs) ............................................................................................... 71
Histology & Muscle Type ................................................................................................................................ 71
Physiology of Swallowing (Deglutition) ............................................................................................................ 72

Reviewed (According to KMU Syllabus) By :

Dr Shabir Ahmad .

Dr Burhan Ali

Dr Bahar Ullah (USMLE Step 1).

1)Basic Science of Ear

A) Anatomy of the Ear
Main Part Subtopic Details Clinical / Exam Significance

- Made of yellow elastic cartilage (except lobule: fat &

- Incisura terminalis →
External Ear Auricle (Pinna) fibrous tissue)
Endaural incision site
- Incisura terminalis: gap between tragus & crus of helix

- Great Auricular (C₂,₃): Medial surface & posterior lateral

surface - Arnold’s nerve → Ear-cough
- Lesser Occipital (C₂): Upper medial surface reflex
Nerve Supply
- Auriculotemporal (V₃): Tragus & adjacent helix - Jacobson’s nerve → referred
- Arnold’s Nerve (CN X): Concha otalgia
- Facial Nerve (VII): Concha & retroauricular groove

- Length: 24 mm
- Furuncles only in
- Outer 1/3 cartilaginous (hair, sebaceous & ceruminous
cartilaginous part
glands)
External Auditory - Fissures → Spread of parotid
- Inner 2/3 bony (thin skin, no glands)
Canal (EAC) infection
- Isthmus: Narrowest point (6 mm from TM)
- Foramen → Infection spread
- Fissures of Santorini: Gaps in cartilage
to parotid
- Foramen of Huschke: Defect in bony wall (children)

- Position: Oblique, 55° angle

- Pars Tensa: Thick, annulus tympanicus
Tympanic - Pars Flaccida → Retraction
Middle Ear - Pars Flaccida: Upper triangular, lacks fibrous layer →
Membrane pocket cholesteatoma
cholesteatoma site
- Cone of Light: Antero-inferior quadrant

- Roof: Tegmen Tympani (middle cranial fossa)

- Floor: Jugular wall (jugular bulb)
- Anterior: Carotid wall (ICA, ET opening, tensor tympani
Walls of Tympanic canal) - Facial nerve canal above oval
Cavity - Posterior: Mastoid wall (pyramid, aditus, facial nerve) window
- Lateral: TM
- Medial: Labyrinthine wall (promontory, oval & round
windows, facial nerve canal)

- Malleus: Handle in TM
- Transformer ratio: 18:1 (Areal
Ossicles - Incus: Between malleus & stapes
14:1 × Lever 1.3:1)
- Stapes: Footplate in oval window

- Tympanic Plexus on promontory (Jacobson’s nerve, CN

Nerve Supply - Referred otalgia in tonsillitis
IX)

- Vestibule: Utricle & saccule

- Basal turn → High frequency
Inner Ear Bony Labyrinth - Semicircular canals: Detect angular acceleration
- Apical turn → Low frequency
- Cochlea: 2.5 turns, hearing

- Endolymph: High K⁺
- Cochlear duct (Organ of Corti)
Membranous (resembles intracellular fluid)
- Utricle & saccule: Linear acceleration
Labyrinth - Perilymph: High Na⁺
- Semicircular ducts: Inside bony canals
(communicates with CSF)

- Referred pain: CN IX (tonsil → ear), CN X (ear cleaning →

cough)
KMU High- - Fissures of Santorini: Infection spread
- Frequently repeated in KMU
Yield MCQ Exam Traps - Cochlea: Base = high freq, apex = low freq
papers
Tips - Fluids: Endolymph vs Perilymph composition
- Dimensions: EAC = 24 mm, TM area = 90 mm²
- Facial nerve landmark: Processus cochleariformis

B) Physiology of Hearing & Equilibrium

Main Concept Subtopic Details Clinical / Exam Significance

1. Conduction – External & Middle Ear

Basis for CHL vs SNHL
Hearing Stages 2. Transduction – Inner Ear
differentiation
3. Neural Transmission – Auditory Nerve

- Collection: Pinna collects sound waves Resonance frequency often

External Ear Function
- Resonance: EAC amplifies ~3000 Hz asked in MCQs

Problem: Air → Fluid impedance mismatch (loss

~30 dB)
Middle Ear Solution: Middle ear amplifies sound using: Transformer ratio = 18:1 (KMU
Transformer 1. Areal Ratio: TM area (45 mm²) vs stapes favorite MCQ)
Mechanism footplate (3.2 mm²) → 14:1
2. Lever Ratio: Malleus vs incus → 1.3:1
3. Total Gain: 14 × 1.3 ≈ 18:1

4. Phase Differential: Oval window leads round

window → prevents wave cancellation

- Traveling Wave Theory (Von Bekesy): Stapes →

Perilymph wave → Basilar membrane
displacement
Cochlear Physiology Noise-induced loss affects high
- Tonotopic Organization: Base = High freq; Apex
(Transduction) frequencies first
= Low freq
- Hair Cell Activation: Shearing force bends
stereocilia → depolarization

- Endocochlear Potential: +80 mV in Scala

Media (Stria Vascularis) EP acts as “battery” for
Electrical Potentials
- Cochlear Microphonics: AC potential by outer transduction
hair cells

- Semicircular Canals: Detect angular

acceleration; Cupula deflection by endolymph
lag
- Ewald’s Law: Horizontal canal – Ampullopetal = Basis for caloric test & vertigo
Equilibrium Vestibular Receptors
stimulatory physiology
- Otolith Organs: Utricle (horizontal), Saccule
(vertical); detect linear acceleration & gravity via
otoconia

- Vestibulo-Ocular Reflex (VOR): Eyes move

opposite to head to stabilize vision Direction of nystagmus is a
Vestibular Reflexes
- Nystagmus: Slow phase = vestibular; Fast common MCQ
phase = central; Named after fast phase

- Resonance: EAC = 3000 Hz; Middle ear = 800

Hz
- Fluids: Endolymph = High K⁺; Perilymph = High
Na⁺
- Caloric Test (COWS): Cold → Opposite; Warm →
Same
KMU High-Yield These are repeat MCQs in KMU
Golden Points - Tuning Fork Tests: CHL = Rinne negative,
Tips papers
Weber to diseased ear; SNHL = Rinne positive,
Weber to normal ear
- Recruitment: Present in cochlear lesions (e.g.,
Meniere’s)
- Clinical Scenarios: Tullio phenomenon;
Yawning opens ET via Tensor Veli Palatini

- Measured in Hz
MCQ: Speech frequencies =
Basics of Acoustics Frequency (Pitch) - Human range: 20–20,000 Hz
500, 1000, 2000 Hz
- PTA tests: 125–8000 Hz

- Measured in dB
Intensity
- Audiometric Zero = 0 dB (threshold for normal 0 dB ≠ no sound
(Loudness)
young adult)

Pure Tone Audiometry Subjective test measuring hearing threshold via

Purpose Differentiates CHL vs SNHL
(PTA) AC & BC

- Air Conduction (AC): Headphones; tests entire

pathway AC vs BC comparison → Type of
Procedure
- Bone Conduction (BC): Mastoid vibrator; hearing loss
bypasses outer/middle ear

- AC: Mask if difference ≥ 40 dB

Masking Rules Prevents “shadow curve”
- BC: Always mask (0 dB attenuation)

Audiogram - Right Ear: Red Circle (○) Standard KMU diagram

Plotting - Left Ear: Blue Cross (×) question

- CHL: BC normal, AC impaired → Air-Bone Gap

- SNHL: Both AC & BC impaired, overlap → No AB
Interpretation Gap Common MCQ patterns
- Mixed: Both impaired, AC worse → AB Gap
present

Impedance
Objective test of TM compliance & middle ear Detects ET dysfunction, fluid,
Audiometry Principle
pressure (not hearing) ossicular issues
(Tympanometry)

- Type A: Normal peak at 0 pressure → Normal

middle ear
Types of - Type As: Shallow peak → Stiff system
Tympanograms (Otosclerosis) KMU favorite MCQ
(Jerger) - Type Ad: Deep peak → Flaccid TM (Ossicular
discontinuity)
- Type B: Flat → No mobility (Glue ear,
7

perforation, wax)
- Type C: Peak shifted negative → ET dysfunction

- Recruitment: Reflex at <60 dB

→ Cochlear lesion (Meniere’s)
- Loud sound (70–100 dB above threshold) →
Acoustic Reflex - Reflex Decay: Cannot sustain
Stapedius contracts bilaterally
→ Retrocochlear lesion
(Acoustic neuroma)

- Carhart’s Notch: BC dip at 2000 Hz →

Audiogram “Dip”
KMU High-Yield Tips Otosclerosis Frequently repeated
Patterns
- Boiler’s Notch: AC & BC dip at 4000 Hz → NIHL

- Recruitment: Loudness grows abnormally →

Cochlear pathology
- Tone Decay: Cannot sustain tone →
Special Tests Site of lesion differentiation
Retrocochlear lesion
- Roll-Over: Speech discrimination worsens at
high volume → Acoustic neuroma

- Type B + Normal Volume → Glue Ear

Tympanometry
- Type B + High Volume → TM perforation Diagnostic clues
Pearls
- Type C → ET block

Masking - AC: Mask if ≥40 dB difference

Prevents false results
Simplified - BC: Always mask

B) Tuning Fork Tests (Rinne, Weber)

Clinical / Exam
Test Principle & Procedure Interpretation
Significance

- Ideal frequency: 512 Hz (standard)

- Lower forks (128/256 Hz): Vibrotactile
sensation (not pure sound)
KMU MCQ: Why 512 Hz is
General Principles - Higher forks (1024/2048 Hz): Short –
preferred
decay time
- Activation: Strike gently on elbow or
rubber heel

- Positive (AC > BC): Normal or SNHL Indicates Air-Bone Gap

Rinne Test Compares Air Conduction (AC) vs
- Negative (BC > AC): Conductive Loss ≥15–20 dB
Bone Conduction (BC) in same ear
- False Negative: Severe unilateral

Procedure: Mastoid (BC) → then near SNHL (sound heard by good ear via
canal (AC) bone)

- Central: Normal or symmetrical loss

Compares BC between both ears Always correlate with
Weber Test - Lateralizes to poorer ear: CHL
Procedure: Fork on forehead/vertex Rinne
- Lateralizes to better ear: SNHL

Compares patient’s BC with

Absolute Bone - Same as examiner: Normal or CHL
examiner’s BC (assuming examiner Tests cochlear reserve
Conduction (ABC) - Reduced: SNHL
normal)

Similar to ABC but without occluding - Lengthened: CHL

Schwabach Test Older bedside test
meatus - Shortened: SNHL

For Otosclerosis - Positive (Normal): Sound decreases

Gelle’s Test Procedure: Increase canal pressure - Negative: No change → Ossicular Classic otosclerosis test
using Siegel’s speculum fixation

- Positive: Sound louder

Bing Test Occlude canal during BC (Normal/SNHL) Tests occlusion effect
- Negative: No change (CHL)

Detects malingering (feigned unilateral If patient stops responding when

Stenger Test KMU MCQ favorite
loss) louder tone given to “bad” ear → faking

- Quantifying AB Gap:
• Rinne negative for 256 Hz only → 15–
20 dB
• 256 & 512 Hz → 30–45 dB
• All three (256, 512, 1024 Hz) → 45–60
KMU High-Yield dB These patterns are repeat questions
MCQ Tips - False Negative Rinne: Dead ear + in KMU papers
Weber to good ear
- Summary Table:
Normal: Rinne +, Weber central
CHL: Rinne –, Weber to bad ear
SNHL: Rinne +, Weber to good ear

- Thermal stimulation creates convection currents in endolymph of

lateral semicircular canal
- Warm water (44°C): Endolymph rises → Ampullopetal flow → Mnemonic: COWS = Cold →
Principle
Stimulates crista → Nystagmus to same side Opposite, Warm → Same
- Cold water (30°C): Endolymph sinks → Ampullofugal flow → Inhibits
crista → Nystagmus to opposite side

- Position: Supine, head elevated 30° (makes lateral canal vertical)

Procedure (Fitzgerald- - Irrigation: Each ear with water for 40 sec (30°C & 44°C) Head elevation is a KMU
Hallpike) - Gap: 5 min between tests favorite MCQ
- Measure: Duration of nystagmus (start to end)

Normal Response Nystagmus lasts 90–140 sec Baseline for interpretation

- Canal Paresis (CP): Total nystagmus duration (warm + cold) from

one ear is ≥20–25% less than other → Peripheral lesion (Meniere’s,
Acoustic Neuroma, Vestibular Neuritis)
- Directional Preponderance (DP): Nystagmus beating in one CP = localizes lesion side; DP
Abnormalities
direction lasts longer → Seen in peripheral & central lesions (less = less specific
localizing)
- Combined Lesion: CP + DP (e.g., Meniere’s: CP on affected side +
DP to healthy side; Acoustic Neuroma: CP + DP to affected side)

- Cold Air Caloric: For perforated TM (water contraindicated) Used when water irrigation is
Modified Tests
- Kobrak’s Test: Ice-cold water (0°C) for screening not possible

- COWS Mnemonic: Cold → Opposite, Warm → Same

- CP = Indicates lesion side
- DP = Indicates direction of stronger nystagmus
These points are repeat MCQs
KMU High-Yield Tips - Acoustic Neuroma: 96% show CP or absent response
in KMU papers
- Why 30° head elevation? To make lateral canal vertical
- Why nystagmus? Thermal gradient → convection currents in
endolymph

- Diffuse inflammation of
- Ear Toilet: Most important
meatal skin ± pinna & TM
- Acute: Burning → severe step
epidermis
pain (worse on jaw - Medicated Wick:
- Predisposing Factors: Golden Point:
movement), serous → Ichthammol + Glycerine
Diffuse Otitis Trauma (scratching, Drops won’t
purulent discharge, meatal - Topical Drops:
Externa (Swimmer’s cleaning), Moisture work unless
swelling → CHL Gentamicin +
Ear) (swimming, sweating), pH debris is
- Chronic: Intense itching, Hydrocortisone
change cleaned
thick fissured skin, meatal - Systemic Antibiotics:
- Organisms: Pseudomonas,
stenosis Only if
Staph aureus, Proteus, E.
cellulitis/lymphadenitis
coli

- Aggressive infection →
osteomyelitis of temporal - Strict diabetes control Investigation:
- Severe deep-seated pain
bone - IV antipseudomonal CT (extent),
(out of proportion)
Malignant - Risk: Elderly diabetics antibiotics (Ciprofloxacin, Gallium-67
- Granulation tissue at bony-
(Necrotizing) Otitis (>90%), immunosuppressed Ceftazidime, Tobramycin) (monitoring)
cartilaginous junction
Externa - Organism: Pseudomonas for 6–8 weeks First CN
- Facial nerve palsy = poor
- Spread: Through Fissures - Surgery only for necrotic affected: Facial
prognosis
of Santorini → skull base → tissue nerve
CN involvement

- Severe pain, tenderness

- Pain on tragus pressure or Differentiation
- Staphylococcal infection of
pinna pull from
hair follicle - Incision & drainage if
Furuncle (Localized - Retroauricular groove Mastoiditis: TM
- Location: Cartilaginous fluctuant
Otitis Externa) obliterated (mimics normal, hearing
part only (bony part has no - Analgesics & antibiotics
mastoiditis) but pinna normal unless
hair)
pushed forward (not canal blocked
downward)

KMU High-Yield MCQ Pearls

1. Diabetes + Severe Ear Pain + Granulation → Malignant Otitis Externa (Pseudomonas).

2. Investigation of Choice: CT for extent; Gallium-67 for monitoring.

3. Furuncle vs Mastoiditis Table:

o Mastoiditis: Mastoid tenderness, TM congested/perforated.

4. Most effective treatment for Diffuse Otitis Externa: Ear Toilet.

5. First cranial nerve involved in Malignant OE: Facial nerve (VII).

B) Wax & Foreign Bodies in External Ear

Definition &
Condition Clinical Features Treatment KMU High-Yield Points
Etiology

- Mixture of
- Ceruminolytics: 5%
sebaceous & - Conductive hearing loss
NaHCO₃, H₂O₂, - Water must be at body
ceruminous gland - Blocked sensation,
Paradichlorobenzene temp → Avoid caloric effect
Impacted Wax secretions, hair, tinnitus
- Syringing: Sterile water at (vertigo)
(Cerumen) keratin, dirt - Giddiness (if pressing TM)
37°C (body temp) - Arnold’s nerve → Ear-cough
- Produced only in - Reflex cough via Arnold’s
- Instrumental removal: reflex
cartilaginous part nerve
Jobson-Horne probe
of EAC

- Pearly white keratin

mass in deep Differs from
- Severe pain, widening of
Keratosis meatus - Removal by Cholesteatoma: Keratosis in
canal
Obturans - Causes pressure → instrumentation or syringing EAC; Cholesteatoma in
- TM usually intact
bone absorption → middle ear
canal widening

- Forceps: For soft/irregular

- Non-living: Beads, objects
seeds, toys, cotton - Pain, irritation, hearing - Syringing: For smooth - Never use forceps for
Foreign swabs loss objects/seeds smooth round objects →
Bodies (FB) - Living: Insects - Insects → severe pain, - Kill insect first: Oil, spirit, Pushes deeper past isthmus
(mosquito, beetle, discharge chloroform water - Use hook or syringe
ant) - Microscopic removal: For
impacted FB or children

- Flies (Chrysomyia)
lay eggs in foul- - Severe pain, swelling, - Instill chloroform water →
Maggots Common in neglected CSOM
smelling discharge blood-stained watery kill maggots → remove with
(Myiasis) cases
(CSOM) → larvae discharge forceps
hatch

KMU High-Yield MCQ Pearls

1. Why water at 37°C for syringing? To prevent caloric stimulation → vertigo & nystagmus.

2. Arnold’s nerve reflex: Ear cleaning → cough; rarely vasovagal attack.

4. Smooth round FB: Do NOT use crocodile forceps → use hook or syringe.

5. Keratosis Obturans vs Cholesteatoma:

o Keratosis: Keratin plug in EAC, canal widening, TM intact.

o Cholesteatoma: Keratin sac in middle ear, attic erosion.

4)Dieases of External Ear

A) Eustachian Tube Disorders
Aspect Details Clinical / Exam Significance

- Length: 36 mm
- Parts: Bony (posterior 1/3, 12 mm, always open) +
Cartilaginous (anterior 2/3, 24 mm, normally closed)
- Isthmus: Narrowest point (junction of bone & cartilage) Important for infection spread
Anatomy
- Direction: Downward, forward, medial and ventilation
- Openings: Tympanic end (middle ear), Pharyngeal end
(nasopharynx, behind inferior turbinate → Torus Tubarius)
- Lining: Ciliated columnar epithelium

Infant: Short (13–18 mm), Wide,

KMU MCQ: Why
Horizontal (10°) → Easy infection
Infant vs Adult infants get
spread
Tube recurrent
Adult: Long (36 mm), Narrow,
ASOM?
Oblique (45°) → Less prone

- Ventilation: Equalizes middle ear pressure

- Opening: Active by Tensor Veli Palatini during
swallowing/yawning (supplied by V₃)
KMU favorite: Muscle opening
Physiology - Closing: Passive recoil + Ostmann’s pad of fat
ET = Tensor Veli Palatini
- Protection: Prevents nasopharyngeal secretions & loud
sounds
- Clearance: Mucociliary drainage to nasopharynx

- Valsalva: Blow against closed nose → TM bulges

outward
- Toynbee: Swallow with nose pinched → TM retracts
Function Tests Common viva questions
- Politzerization: Air blown during swallowing (children)
- Tympanometry: Type C curve = ET dysfunction
- Saccharine Test: Time to taste sweet → clearance

- Obstruction (ET Dysfunction): Causes = Adenoids,

Sinusitis, Tumors, Cleft palate → Negative pressure →
Retracted TM → Fluid (Glue Ear)
Patulous ET triad: Weight loss +
Disorders - Patulous ET: Tube abnormally open
Autophony + TM movement
Causes: Rapid weight loss, Pregnancy, Atrophic rhinitis
Symptoms: Autophony (hearing own voice/breath)
Sign: TM moves with respiration

- Muscle Trap: Tensor Veli Palatini opens ET (V₃)

- Infant Anatomy: Short, wide, horizontal → recurrent
otitis media
KMU High-Yield - Patulous Tube: Autophony + TM moves with breathing
Repeat MCQs in KMU papers
Tips (stops when lying down)
- Blue Drum: Cholesterol granuloma or
haemotympanum; ET dysfunction → dull amber TM with
bubbles

B) Acute Suppurative Otitis Media (ASOM)

Clinical / Exam
Aspect Details
Significance

Acute pyogenic inflammation of the middle ear cleft (Eustachian tube, middle Common pediatric ENT
Definition
ear, aditus, antrum, mastoid air cells) emergency

Routes of Infection:
- Eustachian tube (most common, esp. infants)
KMU MCQ: Most common
- External ear (traumatic perforation)
Aetiology organism = Strep.
- Blood-borne (rare)
pneumoniae
Organisms: Streptococcus pneumoniae (30%), H. influenzae (20%), Moraxella
(12%), Strep. pyogenes, Staph. aureus

Stage 1: Tubal Occlusion

Stages & Clinical - Pathology: ET edema → negative pressure → TM retraction
Seen early in viral URTI
Features - Symptoms: Mild earache, fullness, deafness
- Signs: Retracted TM, absent light reflex

Stage 2: Presuppuration
- Pathology: Hyperemia, congestion
Classic SEQ question
- Symptoms: Throbbing pain, fever
- Signs: TM congested, radial vessels → “Cart-wheel” appearance

Stage 3: Suppuration
- Pathology: Pus under tension Indicates need for
- Symptoms: Severe pain, fever, vomiting (children) myringotomy
- Signs: TM red, bulging, landmarks lost, yellow spot (impending rupture)

Stage 4: Resolution
- TM ruptures → pus drains → pain relieved “Patient feels better”
- Signs: Purulent otorrhea, small perforation (anteroinferior)

Stage 5: Complication Mastoiditis, facial palsy,

- Spread to mastoid, facial nerve, meninges intracranial abscess

- Antibiotics: Amoxicillin (40 mg/kg/day × 10 days); Co-amoxiclav if resistant

- Decongestants: Nasal drops (Xylometazoline)
- Analgesics KMU MCQ: Myringotomy
Treatment - Ear Toilet: Dry mopping site = Postero-inferior
- Myringotomy: Indicated for bulging TM, severe pain, persistent fluid, or quadrant
complications
- Incision site: Postero-inferior quadrant (safe & dependent)

- Cause: β-hemolytic Streptococcus

Acute
- Seen in measles, scarlet fever, influenza High mortality in children
Necrotizing OM
- Rapid destruction of TM & ossicles → total perforation & profound deafness

- Light House Sign: Pulsatile pus through perforation → ASOM

- Reservoir Sign: Pus refills after cleaning → Mastoiditis
KMU High-Yield Frequently repeated
- Myringotomy knife: Sickle knife (Myringotome)
Tips MCQs
- Organism: Strep pneumoniae (ASOM), β-hemolytic Streptococcus (Necrotizing
OM)

C) Secretory Otitis Media (Glue Ear)

Aspect Details Clinical / Exam Significance

Accumulation of non-purulent sterile effusion in the middle ear Common cause of conductive
Definition
cleft (Eustachian tube, middle ear, mastoid air cells) deafness in school children

- ET Malfunction: Negative pressure → fluid transudation

KMU MCQ: Adult unilateral SOM →
- Causes: Adenoid hyperplasia (most common in children), chronic
Aetiology Rule out nasopharyngeal
rhinitis/sinusitis, cleft palate, nasopharyngeal tumors (adults),
carcinoma
allergy, unresolved ASOM, viral infections

- Age: 5–8 years

- Symptoms: Insidious hearing loss (20–40 dB), inattentiveness,
Often detected during school
Clinical Features delayed speech, mild earache/fullness
screening
- Otoscopic Signs: TM dull, opaque, yellow/grey/blue; retracted;
loss of light reflex; air bubbles/fluid level; restricted mobility

- Tuning Fork: CHL pattern

- PTA: 20–40 dB CHL
Investigations - Tympanometry: Type B (flat) curve = Glue Ear Tympanometry = Gold standard
- Type C: ET dysfunction before fluid accumulates
- X-ray: Clouded mastoid air cells

Medical: Decongestants, antihistamines, antibiotics for URTI,

autoinflation (Valsalva, chewing gum)
KMU MCQ: Grommet site = Antero-
Treatment Surgical: If persists >12 weeks or fails medical therapy →
superior quadrant
Myringotomy + aspiration; Grommet insertion (antero-superior
quadrant); Adenoidectomy/Tonsillectomy if indicated

Sequelae Atrophic TM, Atelectasis, Ossicular necrosis, Tympanosclerosis,

Leads to permanent hearing loss
(Untreated) Cholesterol granuloma

- Adult unilateral SOM = Red flag → NPC

- Tympanogram: Type B = Glue Ear; Type C = ET dysfunction
- Blue Drum: Cholesterol granuloma, haemotympanum, glomus
KMU High-Yield Tips tumor, high jugular bulb Frequently repeated MCQs
- Beer Can Principle: Thick glue → two incisions for aspiration
- Myringotomy vs Grommet site: ASOM = postero-inferior; Glue
Ear = antero-superior

D) Chronic Suppurative Otitis Media (CSOM)

Clinical / Exam
Aspect Details
Significance

Common cause
Long-standing infection of middle ear cleft with persistent discharge and permanent
Definition of chronic ear
perforation (edges epithelialized, won’t heal spontaneously)
discharge

- Tubotympanic (Safe/Benign): Anteroinferior cleft (ET + mesotympanum). No KMU MCQ: Safe

Classification
serious complications. vs Unsafe types

- Atticoantral (Unsafe/Dangerous): Posterosuperior cleft (Attic + Antrum + Mastoid).

Associated with cholesteatoma & bone erosion. High risk of complications.

- Etiology: Sequela of AOM or ascending infection via ET

- Perforation: Central (pars tensa), may be anterior/posterior/subtotal
A. Tubotympanic - Discharge: Profuse, mucoid/mucopurulent, non-foul smelling Rare
(Safe) - Hearing Loss: Conductive (<50 dB) complications
- Polyp: Pale, smooth
- Ossicles: Usually intact; necrosis of incus long process possible

- Medical: Aural toilet + topical antibiotic drops (Ciprofloxacin, Neomycin) Goal = Restore
Treatment (Safe)
- Surgery: Myringoplasty (TM repair) or Tympanoplasty (TM + ossicular reconstruction) hearing

- Pathology: Cholesteatoma + granulation + osteitis

- Cholesteatoma: “Skin in wrong place” (keratinizing squamous epithelium in middle High risk of
B. Atticoantral
ear/mastoid). Misnomer: No cholesterol, not a tumor. Structure = Matrix + keratin intracranial
(Unsafe)
debris complications
- Bone erosion: Enzymatic activity (collagenase, acid phosphatase)

- Discharge: Scanty, foul-smelling

Marginal
Clinical Features - Hearing Loss: Conductive; sometimes normal (“Cholesteatoma Hearer”)
perforation =
(Unsafe) - Bleeding: Granulations/polyps
unsafe
- Signs: Attic or marginal perforation; retraction pocket

- Aim: Make ear safe (hearing secondary)

- Surgery: Mastoidectomy Standard for
Treatment (Unsafe) • Canal Wall Down (CWD): Modified Radical Mastoidectomy (MRM) – exteriorizes cholesteatoma =
cavity MRM
• Canal Wall Up (CWU): Combined approach (preserves canal wall)

- Invagination (Wittmaack): Retraction pocket (most accepted)

Theories of
- Epithelial Invasion (Habermann): Skin migrates through perforation Common viva
Cholesteatoma
- Basal Cell Hyperplasia (Ruedi): Pars flaccida basal cells proliferate question
Origin
- Metaplasia (Sade): Mucosa transforms into squamous epithelium

Different from
Bacteriology Pseudomonas, Proteus, E. coli, Staph aureus, anaerobes (Bacteroides) ASOM (Strep
pneumoniae)

- Safe vs Unsafe Table:

Frequently
KMU High-Yield Tips • Pathology: Mucosal vs Cholesteatoma
• Discharge: Profuse vs scanty foul-smelling repeated MCQs
• Perforation: Central vs attic/marginal

• Surgery: Tympanoplasty vs Mastoidectomy

- Cholesteatoma Hearer: Normal hearing despite disease → still operate
- Marginal perforation: Unsafe (skin migration → cholesteatoma)
- Myringotomy site: Postero-inferior quadrant (ASOM)
- MRM definition: Removes disease but preserves ossicles/TM remnants

E) Complications of CSOM
Classification Condition Key Features Clinical Significance

- Infection spreads to mastoid bone → coalescence of air

cells
- Signs: Persistent postauricular pain, profuse discharge,
Reservoir Sign, sagging posterosuperior canal wall, Common
“Ironed-out” mastoid skin complication; may
Intratemporal Acute Mastoiditis
- Abscesses: progress to
• Postauricular (pinna forward & downward) intracranial
• Bezold’s (neck swelling deep to SCM)
• Citelli’s (occipital/digastric triangle)
• Luc’s (into EAC)

- Occurs with inadequate antibiotics

Often missed
Masked Mastoiditis - Silent destruction of mastoid
clinically
- Presents as persistent hearing loss, dull TM

- Spread to petrous apex

Petrositis - Gradenigo’s Syndrome Triad: Ear discharge + Retro- KMU MCQ favorite
orbital pain (CN V) + Diplopia (CN VI)

- Acute: Dehiscence of fallopian canal Facial palsy = poor

Facial Nerve Paralysis
- Chronic: Cholesteatoma erosion prognosis

- Circumscribed: Fistula in horizontal SCC → vertigo on

pressure (Positive Fistula Test)
Life-threatening if
Labyrinthitis - Diffuse Serous: Chemical irritation (reversible)
suppurative
- Diffuse Suppurative: Bacterial invasion → dead ear +
severe vertigo

Lateral Sinus Thrombosis - Sigmoid sinus thrombosis Septicemia risk;

Intracranial
(LST) - Signs: Hectic “Picket-Fence” fever, Griesinger’s Sign needs urgent surgery

(mastoid edema), Tobey-Ayer test (CSF pressure

change), Delta sign on CT

- Temporal Lobe: Nominal aphasia, upper quadrantic

hemianopia, hemiplegia High mortality if
Brain Abscess
- Cerebellar: Ataxia, intention tremor, past-pointing, untreated
nystagmus

Most common
- Fever, headache, neck rigidity, Kernig’s sign,
Meningitis intracranial
photophobia
complication

- Raised ICP with normal CSF (papilledema) due to

Otitic Hydrocephalus Rare but important
sagittal sinus thrombosis

- Gradenigo’s Triad: Ear - LST Buzzwords: Picket-Fence fever, Griesinger’s sign,

discharge + CN V pain + CN VI Delta sign Frequently repeated
KMU High- palsy (5 + 1 = 6 mnemonic) - Blue Drum Differential: Cholesterol granuloma, MCQs
Yield Tips - Abscess Name Game: haemotympanum, glomus tumor, high jugular bulb
Bezold = SCM neck swelling; - Brain Abscess Table: Temporal vs Cerebellar (Speech,
Citelli = occipital; Luc = EAC Vision, Motor differences)

F) Cholesteatoma – Pathogenesis & Management

Clinical / Exam
Aspect Details
Significance

Presence of keratinizing squamous epithelium in middle ear/mastoid Misnomer: Not a tumor, no

Definition
(“Skin in the wrong place”) cholesterol

- Matrix: Stratified squamous epithelium

Structure Seen in unsafe CSOM
- Central Mass: Keratin debris

Congenital Cholesteatoma:
- Origin: Embryonic epidermal cell rests KMU MCQ: Intact TM +
Types & Pathogenesis
- Criteria: White mass behind intact TM, no discharge, no prior surgery white mass → Congenital
- Presentation: Conductive hearing loss in child

Acquired Cholesteatoma:
- Primary: No pre-existing perforation; starts in Prussak’s Space KMU MCQ: Most accepted
• Invagination Theory (Wittmaack): Negative attic pressure → Pars theory = Invagination
flaccida retracts → keratin sac
• Basal Cell Hyperplasia (Ruedi)

• Squamous Metaplasia (Sade)

- Secondary: Associated with perforation
• Migration Theory (Habermann): Skin migrates through marginal
perforation
• Metaplasia

Bone Destruction Enzymatic osteolysis (collagenase, acid phosphatase, proteolytic

NOT pressure necrosis
Mechanism enzymes) → erodes ossicles, labyrinth, facial canal, tegmen

Medical: Limited role (cleaning, antibiotics pre-op)

Surgery is mandatory even
Surgical: Only definitive treatment
Management if hearing is normal
- Goal 1: Make ear safe & dry
(“Cholesteatoma Hearer”)
- Goal 2: Preserve/reconstruct hearing

- Canal Wall Down (CWD): Modified Radical Mastoidectomy (MRM) →

removes posterior canal wall, exteriorizes cavity KMU MCQ: Standard for
Surgical Options
- Canal Wall Up (CWU): Intact canal wall mastoidectomy → preserves cholesteatoma = MRM
anatomy but higher recurrence risk

- Prussak’s Space: Site of primary acquired cholesteatoma

- Congenital vs Acquired: Intact TM + white mass = congenital
- Bone erosion: Enzymatic, not pressure
KMU High-Yield Tips - Radical vs Modified Radical Mastoidectomy: Radical = complete Frequently repeated MCQs
clearance + no hearing preservation; MRM = preserves ossicles/TM
remnants
- Attic perforation: Unsafe → direct access for skin migration

G) Otosclerosis (Otospongiosis)
Aspect Details Clinical / Exam Significance

Primary disease of the bony labyrinth where spongy bone replaces

Most common cause of progressive
Definition normal dense bone of otic capsule → stapes footplate fixation →
CHL in young adults
Conductive Hearing Loss

- Heredity: Autosomal dominant (50% family history)

- Sex: Female > Male (2:1)
- Age: 20–30 years onset KMU MCQ: Association with
Aetiology
- Pregnancy: Worsens hearing Osteogenesis Imperfecta
- Associated: Osteogenesis Imperfecta → Van der Hoeve Syndrome
(Blue sclera + Otosclerosis + Fragile bones)

- Stapedial Otosclerosis: Most common; stapes fixation

- Anterior Focus: 80% (Fissula Ante Fenestram)
KMU MCQ: Most common site =
Types - Posterior Focus, Circumferential, Biscuit, Obliterative
Anterior to oval window
- Cochlear Otosclerosis: Involves otic capsule → SNHL
- Histologic: Asymptomatic, found at autopsy

- Hearing Loss: Bilateral, progressive, conductive

- Paracusis Willisii: Hears better in noise (conductive loss) Differentiates from cochlear lesions
Clinical Features
- Tinnitus: Roaring type (Recruitment)
- Speech: Monotonous, soft voice

- TM: Normal & mobile

- Schwartz Sign: Flamingo pink blush on promontory → active
KMU MCQ: Schwartz sign = active
Signs otosclerosis
disease
- Tuning Fork: Rinne negative, Weber lateralizes to worse ear
- Gelle’s Test: Negative (no change with canal pressure)

- PTA: CHL with Carhart’s Notch (dip at 2 kHz in BC curve) →

disappears after stapedectomy
Investigations Carhart’s Notch = hallmark
- Tympanometry: Type As (shallow) curve → stiffness
- Acoustic Reflex: Absent

- Medical: Sodium Fluoride (halts progression in active/cochlear type)

- Hearing Aids: Alternative if surgery contraindicated
Contraindications: Only hearing ear,
Treatment - Surgical: Stapedectomy/Stapedotomy (Treatment of choice)
Meniere’s, active infection
• Remove stapes superstructure → make hole in footplate → insert
Teflon piston connecting incus to oval window

- Carhart’s Notch: Dip at 2 kHz → mechanical artifact → disappears

after surgery
- Paracusis Willisii vs Recruitment: Otosclerosis = better in noise;
Cochlear lesions = worse in noise
KMU High-Yield
- Schwartz Sign: Active disease → risk of floating footplate → treat with Frequently repeated MCQs
Tips
sodium fluoride first
- Complications of Stapedectomy: Facial nerve palsy, perilymph
fistula, dead ear (1%)
- Site of lesion: Fissula Ante Fenestram

Classic tetrad: Vertigo +

Disorder of inner ear due to endolymphatic hydrops (distension of
Definition Fluctuating SNHL +
membranous labyrinth)
Tinnitus + Aural fullness

- Increased endolymph volume → distension of cochlear duct & saccule

Pathology - Rupture Theory: Reissner’s membrane rupture → mixing of K⁺-rich endolymph Explains sudden attacks
with perilymph → vestibular paralysis → vertigo

- Defective absorption by endolymphatic sac (most accepted)

- Vasomotor disturbance
Aetiology - Allergy (50%) Multifactorial
- Sodium retention
- Autoimmune/Viral

- Age: 35–60 yrs; usually unilateral

- Vertigo: Sudden, rotatory, lasts >20 min, ± nausea/vomiting
KMU MCQ: Recruitment =
Clinical Features - Hearing Loss: Fluctuating SNHL (low frequency early) → progressive
cochlear lesion
- Tinnitus: Roaring type
- Other: Diplacusis, Recruitment, Tullio phenomenon, Tumarkin’s drop attacks

- Audiogram: Low-frequency SNHL (rising curve early)

- Glycerol Test: Hearing improves by ≥10 dB → positive Diagnostic criteria: ≥2
Investigations
- Electrocochleography (ECoG): SP/AP ratio >30% (most sensitive) vertigo episodes >20 min
- Caloric Test: Reduced response (canal paresis)

General: Low salt diet, avoid caffeine/stress

Acute Attack: Vestibular sedatives (dimenhydrinate, prochlorperazine), bed rest
Chronic: Betahistine (H1 agonist, H3 antagonist), diuretics
Chemical Labyrinthectomy: Intratympanic gentamicin (vestibulotoxic) Betahistine = drug of
Treatment
Surgical: choice
- Hearing preserved: Endolymphatic sac decompression, vestibular nerve
section
- Hearing lost: Labyrinthectomy

- Lermoyez Syndrome: Hearing improves after vertigo attack

Variants - Cochlear Hydrops: Only auditory symptoms KMU MCQ favorite
- Vestibular Hydrops: Only vertigo

- Recruitment vs Tone Decay: Recruitment = Ménière’s; Tone Decay = Acoustic

neuroma
- ECoG: SP/AP >30%
KMU High-Yield Frequently repeated
- Glycerol Test: Positive in hydrops
Tips MCQs
- Audiogram: Low-frequency SNHL early
- Tumarkin’s Crisis: Drop attacks without LOC
- Betahistine: Standard drug

B) Sensorineural Hearing Loss (SNHL)

Clinical / Exam
Aspect Details
Significance

Permanent hearing loss in

Definition Hearing loss due to lesions of cochlea (sensory) or VIII nerve (neural)
adults

- Onset: >65 years

- Types (Schuknecht):
• Sensory: Organ of Corti degeneration (basal turn) → good speech
discrimination Buzzword: “I hear you but
A. Presbycusis (Age-
• Neural: Spiral ganglion degeneration → poor speech discrimination can’t understand” → Neural
related)
(Phonemic Regression) type
• Strial: Atrophy of stria vascularis → flat audiogram
• Cochlear Conductive: Basilar membrane stiffening → sloping
audiogram

Bilateral, symmetrical, progressive SNHL

Common cause of elderly
Clinical Features Phonemic Regression
deafness
Recruitment positive

Treatment Hearing aids, lip reading No surgical cure

Drugs & Effects:

- Aminoglycosides:
• Vestibulotoxic: Streptomycin, Gentamicin (Type I hair cells of crista)
KMU MCQ: Streptomycin →
• Cochleotoxic: Neomycin, Kanamycin, Amikacin (outer hair cells)
B. Ototoxicity vestibule; Amikacin →
- Loop Diuretics: Furosemide (reversible)
cochlea
- Salicylates: Tinnitus + reversible flat SNHL
- Quinine: Vasoconstriction (reversible or permanent)
- Cytotoxic: Cisplatin (permanent high-frequency loss)

Risk Factors Renal failure, elderly, combined ototoxic drugs Important for prevention

- Acoustic Trauma: Single exposure >140 dB → mechanical damage

C. Noise-Induced Max safe limit: 90 dB for 8
- Chronic NIHL: Long-term >85 dB → outer hair cell damage (basal turn)
Hearing Loss (NIHL) hrs/day (5 dB rule)
- Audiogram: 4 kHz dip (Boiler’s Notch) → hallmark

Prevention Ear plugs/muffs Occupational health

- Definition: ≥30 dB loss in ≥3 contiguous frequencies within ≤3 days

(30-3-3 rule)
Prognosis poor if vertigo
D. Sudden SNHL - Causes: Idiopathic (most common), viral, vascular, membrane rupture
present
- Treatment: Emergency → Steroids (oral/intratympanic), Carbogen
inhalation, antivirals

- Sudden SNHL: Treat

- Audiogram Dips: 4 kHz dip = NIHL; 2 kHz dip = Carhart’s notch (Otosclerosis) immediately with steroids
KMU High-Yield Tips - Ototoxicity: Aminoglycosides & Cisplatin = permanent; Salicylates & Quinine - Noise limits: 90 dB for 8
= reversible hrs; 140 dB = no exposure
- Phonemic Regression: Neural presbycusis hallmark
Frequently repeated MCQs

6)Miscellaneous Otology
A) The Deaf Child – Evaluation & Management
Aspect Details Clinical / Exam Significance

Speech development depends on hearing in first 5 years. “Deaf-mutism”

Introduction Early detection is critical
= misnomer (child is mute because they never heard speech to imitate).

Prenatal:
- Genetic (50%) – Syndromic & Non-syndromic
- Inner Ear Anomalies: Scheibe (cochleosaccular dysplasia), Mondini (1.5
turns), Michel (complete absence)
KMU MCQ: Most common
Aetiology - TORCH infections (Rubella, CMV, etc.)
anomaly = Scheibe Dysplasia
- Ototoxic drugs (Aminoglycosides, Thalidomide)
Perinatal: Hypoxia, Kernicterus, Prematurity
Postnatal: Meningitis (ossifies cochlea), Mumps (unilateral SNHL),
Measles, Trauma, Drugs

Screening: KMU MCQ: OAE = screening;

Evaluation
- Universal Neonatal Hearing Screening (OAE → ABR if fail) ABR = diagnostic

- High-risk registry (family history, TORCH, low birth weight, ventilation >5
days)
Behavioral Audiometry:
- 0–6 mo: BOA (Moro reflex, blink)
- 6–18 mo: Distraction Test
- 18 mo–2.5 yrs: VRA (visual reinforcement)
- 2.5–5 yrs: Play Audiometry
- >5 yrs: Pure Tone Audiometry
Objective Tests: OAE (outer hair cells), ABR/BERA (neural pathway),
ASSR (frequency-specific), Tympanometry

- Counseling: Parental guidance

- Hearing Aids: Fit early (as early as 6 months)
- Cochlear Implant: Bilateral severe-profound SNHL, no benefit from Early intervention prevents
Management
aids; ideal age = 12–24 months; prerequisite = intact auditory nerve speech delay
- Rehabilitation: Auditory-Verbal Therapy, Total Communication (speech
+ lip reading + sign language)

- Syndrome Match:
• Waardenburg = White forelock + heterochromia
• Usher = Retinitis pigmentosa
• Pendred = Goitre
• Jervell & Lange-Nielsen = Deafness + prolonged QT (risk of sudden
KMU High-Yield
death) Frequently repeated MCQs
Tips
• Alport = Nephritis
• Treacher-Collins = Mandibulofacial dysostosis
- Test by Age: Neonate = OAE/ABR; 6–18 mo = Distraction; 3–5 yrs = Play
Audiometry; >5 yrs = PTA
- Auditory Neuropathy: OAE normal, ABR absent

B) Nerve Disorders (Facial)

Clinical / Exam
Aspect Details
Significance

CN VII = Nerve of 2nd branchial arch

Important for
Anatomy Overview - Motor root: Facial muscles
topodiagnosis
- Sensory/Parasympathetic root: Nervus intermedius

- Definition: Acute idiopathic LMN facial paralysis

- Etiology: HSV reactivation (most accepted), ischemia, Most common cause of
Bell’s Palsy
autoimmune LMN facial palsy
- Risk Factors: Pregnancy, diabetes, hypertension

- Sudden unilateral facial weakness

Clinical Features - Bell’s Phenomenon: Eye rolls up when trying to close Diagnosis of exclusion
- Epiphora, drooling, hyperacusis, loss of taste (chorda tympani)

- Eye care: Artificial tears, eye taping

- Medical: Prednisolone (within 72 hrs), ± Acyclovir Early steroids improve
Treatment
- Surgical decompression: Only if >90% degeneration on ENoG recovery
within 14 days

- Definition: Herpes Zoster infection of Geniculate Ganglion

- Triad: Facial paralysis + Vesicular rash (concha/EAC/palate) + KMU MCQ: Ramsay Hunt
Ramsay Hunt Syndrome
Vestibulocochlear symptoms (SNHL, vertigo, tinnitus) triad
- Prognosis: Worse than Bell’s

Treatment High-dose steroids + Acyclovir Recovery ~50%

- Schirmer’s Test: ↓ lacrimation → lesion proximal to Geniculate

Ganglion
Topodiagnostic Tests - Stapedial Reflex: Absent → lesion between GG & stapedius Helps localize lesion
nerve
- Taste Test: Loss of taste → lesion in mastoid segment

- Synkinesis: Eye closes when smiling

Complications of Faulty
- Crocodile Tears: Gustatory lacrimation (misdirected Common viva question
Regeneration
parasympathetic fibers)

- Landmarks: Cochleariform process = surgical landmark for GG

- Shortest segment = Labyrinthine (narrowest → Bell’s palsy site)
- Longest = Mastoid segment
- Fracture correlation: Transverse → immediate palsy;
Frequently repeated
KMU High-Yield Tips Longitudinal → delayed palsy
MCQs
- Melkersson-Rosenthal Syndrome: Recurrent palsy + fissured
tongue + lip edema
- Frey’s vs Crocodile Tears: Gustatory sweating vs gustatory
lacrimation

Most common benign middle ear tumour; arises

Benign, encapsulated tumour from Schwann
Definition from glomus bodies (non-chromaffin
cells of CN VIII (vestibular division)
paraganglionic cells)

- Glomus Tympanicum: Promontory (Jacobson’s

- Arises from Superior Vestibular nerve inside
nerve – CN IX)
Origin & Types Internal Auditory Canal (IAC) → expands into
- Glomus Jugulare: Jugular bulb (Arnold’s nerve –
CPA
CN X)

Demographics Middle-aged women (F:M = 5:1) Adults (30–60 yrs), unilateral

- Pulsatile tinnitus (earliest, stops with carotid

pressure) - Unilateral SNHL (progressive or sudden)
Symptoms - Conductive or mixed hearing loss - Tinnitus (high-pitched)
- Ear bleed if polyp present - Imbalance (vertigo rare)
- CN palsies (IX, X, XI in jugulare type)

- Rising Sun Sign: Red-blue mass behind TM (lower

part) - Loss of Corneal Reflex (CN V) = earliest sign
Signs - Brown’s Sign: Tumour blanches on pneumatic - Hitzelberger’s Sign: Loss of sensation in
pressure posterosuperior canal wall (CN VII sensory)
- Red reflex through TM

- CT: Bone erosion (Phelps’ sign)

- Audiometry: Roll-over phenomenon (speech
- MRI: “Salt & Pepper” appearance
discrimination worsens with loudness), Tone
Investigations - Angiography: Tumour blush; feeding vessels
Decay positive, Recruitment absent
(Ascending Pharyngeal artery)
- MRI with Gadolinium: Gold standard
- Never biopsy (bleeding risk)

- Surgery: Translabyrinthine, Retrosigmoid,

- Surgery: Tympanotomy/Mastoidectomy
Treatment Middle Fossa
- Radiotherapy: Palliative for elderly
- Gamma Knife: For small tumours or elderly

- Roll-over phenomenon: Retrocochlear

- Signs: Rising Sun = Glomus; Brown’s Sign =
lesion hallmark
KMU High-Yield Glomus; Salt & Pepper MRI = Glomus
- Earliest CN sign: Loss of corneal reflex (CN V)
Tips - Pulsatile tinnitus: Glomus hallmark
- Recruitment absent: Differentiates from
- Contraindication: Biopsy in clinic
Meniere’s

1)Basic Science of Nose

A) Anatomy of Nose & Paranasal Sinuses
Clinical / Exam
Aspect Details
Significance

- Framework: Upper 1/3 bony (nasal bones), lower 2/3 cartilaginous (upper
Important in nasal
External Nose lateral, lower lateral/alar, sesamoid)
obstruction & rhinoplasty
- Nasal Valve (Limen Nasi): Narrowest part of nasal airway; regulates airflow

- Divided by septum into two fossae

- Lateral Wall: Turbinates (inferior, middle, superior) & meatuses
- Openings:
Ostiomeatal Complex
• Inferior meatus → Nasolacrimal duct (Hasner’s valve)
Internal Nose (OMC): Key area for FESS;
• Middle meatus → Frontal sinus (via frontal recess), Maxillary sinus (natural
blockage → chronic sinusitis
ostium), Anterior ethmoid cells
• Superior meatus → Posterior ethmoid cells
• Sphenoethmoidal recess → Sphenoid sinus

- Little’s Area (Kiesselbach’s Plexus): Anterior ethmoidal (ICA), septal

branch of superior labial (facial), septal branch of sphenopalatine (maxillary), KMU MCQ: Posterior
Blood Supply greater palatine (maxillary) ethmoidal NOT part of
- Woodruff’s Plexus: Venous plexus behind inferior turbinate → posterior Kiesselbach’s
epistaxis

- Maxillary: Present at birth; floor = alveolar process → dental sinusitis risk

- Ethmoid: Present at birth; separated from orbit by lamina papyracea →
Paranasal orbital cellulitis risk Clinical: Frontal sinusitis
Sinuses - Frontal: Develops at 4 yrs; visible at 6 yrs impossible in <4 yrs child
- Sphenoid: Related to cavernous sinus (ICA, CN III, IV, VI, V1, V2), pituitary
gland, optic chiasm

- Uncinate Process: First structure removed to expose maxillary ostium

FESS Landmarks - Basal Lamina of Middle Turbinate: Separates anterior & posterior ethmoid Common viva question
cells

Autonomic - Vidian Nerve: Deep petrosal (sympathetic) + Greater superficial petrosal KMU MCQ favorite
Supply (parasympathetic)

- Parasympathetic → rhinorrhea; Sympathetic → vasoconstriction

- Clinical: Vidian neurectomy for vasomotor rhinitis

- Sinus development: Maxillary & Ethmoid at birth; Frontal & Sphenoid absent
- Lamina Papyracea = dangerous route for orbital cellulitis
KMU High-Yield
- Little’s Area arteries (Posterior ethmoidal excluded) Frequently repeated MCQs
Tips
- Blue drum differential: Cholesterol granuloma, haemotympanum, glomus
tumour, high jugular bulb

B) Physiology of Nose
Function Details Clinical / Exam Significance

- Nose = natural airway

- Inspiration: Laminar airflow between turbinates & septum
Respiration & Nasal Alternating nasal blockage = normal
- Expiration: Eddy currents ventilate sinuses
Cycle cycle (not pathology)
- Nasal Cycle: Alternating congestion/decongestion of
turbinates every 2.5–4 hrs (ANS-controlled)

- Filtration: Vibrissae trap large particles; mucus traps fine

particles (0.5–3 µm)
- Temperature Control: Turbinates adjust air to 37°C in 0.25 Dry air after tracheostomy → crusting &
Air Conditioning
sec ciliary damage
- Humidification: >75% humidity; ~1000 mL water
evaporated daily

- Mucociliary Clearance: “Conveyor belt” moves mucus

backward at 5–10 mm/min
Kartagener’s Syndrome = immotile cilia
Protection - Cilia beat: 10–20/sec
→ sinusitis + bronchiectasis
- Enzymes & Ig: Lysozyme (muramidase), IgA, IgE
- Sneezing: Reflex to expel irritants

- Region: Upper 1/3 of nasal cavity (roof, septum, superior

turbinate)
Kallmann Syndrome = anosmia +
Olfaction - Pathway: Olfactory receptors → filaments through cribriform
hypogonadism
plate → bulb → tract → cortex (pre-pyriform & amygdaloid)
- Disorders: Anosmia, Hyposmia, Parosmia

Vocal Resonance Nose acts as resonator for nasal consonants (M, N, NG) Common viva question
- Rhinolalia Clausa: Hyponasality (blocked nose) → M

sounds like B
- Rhinolalia Aperta: Hypernasality (open nose) → cleft palate

- Normal nasal pH = 7.0 (drops should be buffered)

- Kartagener’s Triad: Bronchiectasis + Sinusitis + Situs
inversus
KMU High-Yield Tips Frequently repeated MCQs
- Ciliary beat direction: Nose → nasopharynx; Sinuses →
natural ostium (why inferior meatus antrostomy fails)
- Lermoyez vs Meniere’s: Reverse sequence of symptoms

2)Diseases of External Nose & Septum

A) Diseases of Vestibule
Condition Definition & Etiology Clinical Features Treatment KMU High-Yield Points

- Acute infection of hair

- Severe pain & tenderness - Systemic antibiotics: Anti-
follicle in nasal
- Swelling of tip/dorsum of staph
vestibule (skin-lined
nose ± upper lip (Flucloxacillin/Amoxiclav) Danger Area of Face:
area)
- Complications: - Analgesics, warm Facial vein → cavernous
Furuncle (Boil) - Organism:
Cellulitis, Septal abscess, compresses sinus via valveless
Staphylococcus aureus
Cavernous sinus - Incision & drainage: Only if veins
- Predisposing: Nose
thrombosis (via valveless abscess points
picking, plucking
facial vein) - Never squeeze (risk of CST)
vibrissae

- Diffuse dermatitis of
vestibule
- Cause: Secondary to - Acute: Red, swollen, - Clean crusts (H₂O₂)
nasal discharge crusts - Antibiotic-steroid ointment Common in chronic
Vestibulitis
(rhinitis/sinusitis) or - Chronic: Induration, - Treat underlying nasal rhinitis
trauma painful fissures discharge
- Organism: Staph
aureus

- Acquired: Trauma,
burns, destructive
Stenosis & infections (smallpox, - Reconstructive surgery Rare but important for
- Nasal obstruction
Atresia of Nares lupus) (Meatoplasty) SEQs
- Congenital: Failure of
canalization

1. Danger Area Concept: Furuncle can cause Cavernous Sinus Thrombosis via facial vein → deep facial vein →
pterygoid plexus → emissary veins → cavernous sinus.

2. Site Specificity: Furuncles occur only in vestibule (skin + hair follicles). Cannot occur in nasal cavity proper
(mucosa-lined).

3. Septal Abscess vs Furuncle:

o Septal abscess: Bilateral obstruction, boggy septal swelling, trauma history.

o Furuncle: Unilateral pain, red tip, vestibular tenderness.

4. Treatment Warning: Do NOT incise early; incision only when fluctuant. Never squeeze boil.

5. Clinical Buzzword: “Exquisitely painful swelling of nasal tip + upper lip involvement” → think furuncle.

B) Nasal Septum Disorders

Condition Definition & Etiology Clinical Features Treatment KMU High-Yield Points

- Displacement of septum
- Nasal obstruction - Septoplasty:
from midline
(uni/bilateral) Conservative, safe for
Deviated - Causes: Trauma (lateral Types: C-shaped, S-shaped,
- Headache (spur pressing children
Nasal blows → displacement; frontal Spur, Anterior dislocation
on turbinate) - SMR: Radical,
Septum blows → buckling), Cottle Test: Improves airflow
- Sinusitis (OMC block) contraindicated <17
(DNS) developmental errors (high- if obstruction at nasal valve
- Epistaxis (dry mucosa) yrs (affects facial
arched palate in mouth
- Anosmia growth)
breathers)

- Bilateral obstruction,
- Blood collection between
frontal headache - Immediate incision Complication: Untreated →
Septal perichondrium & cartilage
- Exam: Smooth, soft, & drainage + nasal abscess → cartilage necrosis
Haematoma - Cause: Trauma or septal
fluctuant swelling both packing + antibiotics → Saddle Nose
surgery
sides

- Severe obstruction, pain,

tenderness over nasal Complications: Saddle
Septal - Infection of haematoma or - Emergency drainage
bridge, fever nose, cavernous sinus
Abscess spread from furuncle + systemic antibiotics
- Septum: Red, boggy thrombosis
swelling

- Causes: Trauma (SMR

- Symptomatic:
Septal surgery most common), nose - Small: Whistling sound Location clues: Cartilage =
- Large: Crusting, Alkaline nasal TB/Lupus; Bone = Syphilis;
Perforation picking, cocaine abuse,
epistaxis douche, silastic Total = Wegener’s
steroid sprays
button
- Pathological: Syphilis (bony),

TB/Lupus (cartilage), - Surgical flap repair

Wegener’s granulomatosis (difficult)

Septum = Columellar + Nutrition Fact: Cartilage

Membranous + depends on
Anatomy
Osteocartilaginous (Ethmoid, – – mucoperichondrium →
Note
Vomer, Quadrangular haematoma separates →
cartilage) necrosis in 24–48 hrs

KMU High-Yield MCQ Pearls

1. Danger Concept: Haematoma → necrosis → saddle nose (due to avascular cartilage).

2. Fracture Names:

o Jarjaway = Horizontal fracture (frontal blow).

o Chevallet = Vertical fracture (blow from below).

3. SMR vs Septoplasty:

o SMR = Radical, contraindicated <17 yrs, risk of perforation & supratip depression.

o Septoplasty = Conservative, safe for children.

4. Little’s Area (Kiesselbach’s Plexus): Anteroinferior septum; formed by 4 arteries (Anterior ethmoidal,
Sphenopalatine, Greater palatine, Superior labial).

5. Perforation Etiology:

o Cartilage = TB/Lupus/nose picking.

o Bone = Syphilis.

o Total = Wegener’s granulomatosis.

3)Rhinitis & Sinusitis

A) Acute & Chronic Rhinitis
KMU High-Yield
Type Definition & Etiology Clinical Features Treatment
Points

- Viral: Rhinovirus, Symptomatic: Rest, Common cold =

Adenovirus, Coronavirus Sneezing, watery →
fluids, antihistamines; viral; Diphtheritic
Acute Rhinitis - Stages: Ischaemic (dryness) mucopurulent discharge, antibiotics only for rhinitis = grey
→ Hyperaemic (watery nasal blockage
bacterial membrane
discharge) → Secondary

infection (mucopurulent)
- Bacterial: Secondary or
primary (e.g., Diphtheritic
rhinitis)

Congested mucosa,
Hyperaemia & oedema of Treat cause Shrinkage Test:
Chronic Simple turbinates swollen but
mucosa (early reversible (sinusitis/adenoids), Positive (shrinks with
Rhinitis pit on pressure; shrink
stage) nasal douching vasoconstrictor)
with vasoconstrictors

Turbinates thick, do not

pit, no shrinkage with Surgical: Linear
Chronic Permanent thickening of Shrinkage Test:
vasoconstrictors; cautery, Submucosal
Hypertrophic mucosa, submucosa & bone Negative; Mulberry
Mulberry hypertrophy at diathermy, Partial
Rhinitis (irreversible) turbinate hallmark
posterior inferior turbinectomy
turbinate

- Medical: Alkaline
nasal douche, 25%
Chronic degenerative disease;
glucose in glycerine,
Klebsiella ozaenae;
Triad: Foetor (foul smell), Kemicetine solution Buzzwords: Merciful
Atrophic Rhinitis metaplasia of ciliated →
green crusts, roomy - Surgical: Young’s anosmia, Klebsiella,
(Ozaena) squamous epithelium;
nose; Merciful anosmia operation (nostril Young’s operation
turbinate bone resorption →
closure for 6 months),
roomy nose
Modified Young’s,
narrowing operations

Crusting confined to
Seen in bakers,
Rhinitis Sicca Occupational (hot/dusty jobs) anterior third; no foul Local care
goldsmiths
smell

Unilateral cheesy, offensive

Rhinitis Caseosa Foul-smelling discharge Surgical clearance Rare but important
material accumulation

KMU High-Yield MCQ Pearls

1. Simple vs Hypertrophic Rhinitis:

o Shrinks with vasoconstrictor = Simple

o No shrinkage = Hypertrophic

2. Atrophic Rhinitis Buzzwords:

o Merciful anosmia (olfactory atrophy)

o Roomy nose but paradoxical obstruction

3. Young’s Operation:

o Concept = Rest mucosa by closing nostrils → revert squamous metaplasia

4. Mulberry Turbinate: Posterior end of inferior turbinate hypertrophy → best treated by partial turbinectomy

5. Rhinitis Sicca vs Atrophic:

o Sicca = Anterior crusting only, no smell

o Atrophic = Generalized crusting + foul smell + roomy nose

B) Allergic vs Vasomotor Rhinitis

Aspect Allergic Rhinitis Vasomotor Rhinitis (VMR)

IgE-mediated Type I hypersensitivity reaction of Non-allergic rhinitis due to autonomic imbalance

Definition
nasal mucosa to allergens (parasympathetic overactivity)

Seasonal (Hay fever – pollens) Chronic, triggered by nonspecific stimuli

Types
Perennial (Dust mites, molds, animal dander) (temperature, humidity, smoke, stress)

Sensitization → IgE on mast cells → allergen

exposure → degranulation → histamine release
Parasympathetic overactivity via Vidian nerve →
Pathophysiology - Early phase: Sneezing, itching, watery discharge
vasodilation + rhinorrhea
- Late phase: Eosinophilic infiltration →
congestion

- Symptoms: Paroxysmal sneezing, watery

- Symptoms: Obstruction + rhinorrhea (sneezing
rhinorrhea, nasal itch
Clinical Features less prominent), alternating blockage
- Signs: Pale bluish boggy turbinates, allergic
- Signs: Turbinates congested, red (not pale)
salute (transverse nasal crease), allergic shiners

- Skin prick test (gold standard)

Investigations - RAST (specific IgE) Allergy tests negative
- Nasal smear: Eosinophils

- Avoid allergens
- Intranasal corticosteroids (INCS): Most
- INCS, antihistamines
effective
Treatment - Surgical: Turbinectomy for obstruction; Vidian
- Antihistamines (good for sneezing/itching)
neurectomy for intractable rhinorrhea
- Decongestants (short-term)
- Immunotherapy (desensitization)

Key Differentiator Positive allergy tests, pale mucosa Negative allergy tests, red mucosa

Other Related Forms

• Rhinitis Medicamentosa: Rebound congestion from prolonged topical decongestant use (>5–7 days).
Treatment: Stop drops immediately; systemic steroids if severe.

• NARES (Non-Allergic Rhinitis with Eosinophilia): Allergy-like symptoms but IgE normal, skin tests negative;
nasal smear shows >20% eosinophils. Responds to steroids.

KMU High-Yield MCQ Pearls

1. Colour of Mucosa:

o Allergic = Pale, bluish, boggy

o Vasomotor = Red, congested

2. Vidian Nerve:

o Parasympathetic → rhinorrhea + vasodilation

o Sympathetic → vasoconstriction

o Vidian neurectomy treats severe rhinorrhea.

3. Allergic Salute: Upward rubbing of nose → transverse crease.

4. Rhinitis Medicamentosa: Rebound congestion after prolonged nasal drop use.

5. NARES: Allergy-like symptoms but negative IgE; eosinophils present.

C) Acute Sinusitis (Maxillary & Frontal)

Aspect Acute Maxillary Sinusitis Acute Frontal Sinusitis

Definition Acute inflammation of maxillary sinus mucosa Acute inflammation of frontal sinus mucosa

- Viral rhinitis (spread via ostium)

- Dental infection (10%) – roots of premolars/molars
- Post-viral rhinitis
Aetiology penetrate sinus floor
- Swimming/diving (water entry)
- Swimming/diving (infected water)
- Trauma

Streptococcus pneumoniae (most common), H.

Organisms influenzae, Moraxella, Staph aureus, anaerobes Same organisms
(dental origin)

- Pain: Cheek, upper teeth; worse on - Pain: “Office headache” – starts morning, peaks
Clinical Features stooping/coughing midday, subsides evening
- Discharge: Purulent in middle meatus - Tenderness: Floor of sinus (above medial

- Tenderness: Over canine fossa canthus – Ewing’s sign)

- Redness/oedema of cheek/lower lid - Oedema of upper eyelid

- X-ray (Waters’ view): Opacity/air-fluid level

Diagnosis Same
- CT scan: Preferred

- Medical: Antibiotics (Amoxiclav/Doxycycline),

- Medical: Antibiotics + decongestants
decongestants, analgesics, steam inhalation
Treatment - Surgical: Trephination (below medial eyebrow)
- Surgical: Antral lavage via inferior meatus if medical
if pain persists >48 hrs or lid swelling increases
fails

Orbital cellulitis, cavernous sinus thrombosis, Pott’s Puffy Tumor (frontal bone osteomyelitis),
Complications
osteomyelitis intracranial abscess

• Ethmoiditis: Common in children; pain between eyes, lid edema → risk of orbital cellulitis.

• Sphenoiditis: Headache at vertex/occiput; postnasal discharge on nasopharyngeal roof.

KMU High-Yield MCQ Pearls

1. Office Headache: Frontal sinusitis pain subsides in afternoon due to gravity aiding drainage.

2. Dental Connection: Foul-smelling unilateral discharge + cheek pain after tooth extraction → dental maxillary
sinusitis (anaerobes).

3. Pott’s Puffy Tumor: Doughy forehead swelling = frontal bone osteomyelitis.

4. Trephination Site: Floor of frontal sinus, medial to supraorbital nerve (2 cm from midline).

5. Antral Lavage Site: Inferior meatus (1.25 cm behind anterior end of inferior turbinate).

D) Chronic Rhinosinusitis & Functional Endoscopic Sinus Surgery (FESS)

Main Topic Details & Explanation

Chronic Rhinosinusitis (CRS) = Inflammation of nose & paranasal sinuses lasting >12 weeks. This
Definition
chronicity differentiates it from acute sinusitis.

- CRS without Polyps: Usually bacterial; structural deformities (DNS, Concha Bullosa) obstruct ostia.
Classification - CRS with Polyps: Associated with systemic inflammation (Asthma, Aspirin Sensitivity, Cystic
Fibrosis).

Key event: Obstruction of Ostiomeatal Complex (OMC) → Stasis of secretions → Bacterial

Pathophysiology
superinfection → Ciliary damage → Mucosal edema → Further obstruction. This cycle perpetuates
(Vicious Cycle)
disease.

Bacteria (e.g., S. aureus, Pseudomonas) form a polysaccharide layer → Antibiotic resistance →

Biofilms
Chronicity.

Major symptoms: Nasal obstruction, Purulent discharge (anterior/posterior), Facial pain/pressure,

Clinical Features
Hyposmia/Anosmia.

Diagnosis Requires ≥2 major symptoms + confirmatory evidence (Endoscopy or CT scan).

- Fungal Ball: Non-invasive; dense Aspergillus hyphae in one sinus; Tx = surgical removal.
- Allergic Fungal Sinusitis (AFS): Allergic reaction to fungal antigens; polyps + thick “peanut butter”
Fungal Sinusitis Types mucin; CT shows Double Density sign.
- Invasive Fungal Sinusitis: Aggressive; often in immunocompromised patients; can cause
complications.

Based on Messerklinger’s concept: Disease of larger sinuses is secondary to ethmoid obstruction.

FESS Principle
Clearing ethmoids restores drainage.

Chronic sinusitis refractory to medical therapy, recurrent acute sinusitis, nasal polyposis,
Indications for FESS
complications (orbital/intracranial), fungal sinusitis.

1. Uncinectomy (first step; exposes infundibulum).

2. Maxillary Antrostomy (enlarge natural ostium).
Surgical Steps 3. Bullectomy (remove Bulla Ethmoidalis).
(Anterior → Posterior) 4. Posterior Ethmoid Clearance (via Basal Lamina).
5. Sphenoidotomy.
6. Frontal Recess Clearance (last step).

Basal Lamina: Separates anterior & posterior ethmoids.

Lamina Papyracea: Thin bone between ethmoid & orbit; breach → orbital fat herniation (yellow fat =
Key Landmarks
STOP).
Onodi Cell: Posterior ethmoid cell near optic nerve → risk of blindness if mistaken for sphenoid.

Major: Orbital injury, CSF leak, meningitis, carotid injury.

Complications
Minor: Synechiae, ecchymosis.

- First step in FESS = Uncinectomy.

- Basal Lamina = key landmark.
High-Yield Exam Tips - AFS signs = Double Density + Peanut Butter mucin.
- Lamina Papyracea danger: yellow fat → STOP.
- Onodi cell = optic nerve risk.

Infection spreads beyond sinus walls → complications:

Local: Mucocele, Osteomyelitis.
Classification Orbital: Cellulitis, Abscess.
Intracranial: Meningitis, Brain Abscess, Cavernous Sinus Thrombosis.
Descending: Pharyngitis, Otitis Media, Laryngitis.

Mucocele: Cystic expansion due to ostial obstruction → mucus accumulates → bone

destruction.
Sites: Frontal > Ethmoid > Maxillary > Sphenoid.
Frontal Mucocele: Painless swelling above medial canthus; eye displaced down & out →
Local Complications diplopia.
Ethmoid Mucocele: Swelling on medial orbital wall; eye displaced forward & out.
Treatment: Fronto-ethmoidectomy or Endoscopic marsupialization.
Osteomyelitis: Frontal bone → Pott’s Puffy Tumour (soft, doughy forehead swelling + fever).
Maxilla → common in children (dental source).

Infection spreads via Lamina Papyracea or venous thrombophlebitis.

Stage I: Inflammatory edema → lid swelling only; eye movements normal.
Stage II: Orbital cellulitis → proptosis, chemosis, painful ophthalmoplegia.
Orbital Complications Stage III: Subperiosteal abscess → pus between periorbita & bone; globe displaced (depends
(Chandler’s Classification) on sinus).
Stage IV: Orbital abscess → pus inside orbit; severe proptosis, total ophthalmoplegia,
blindness risk.
Stage V: Cavernous sinus thrombosis (see below).

Cavernous Sinus Thrombosis (CST): Spread from ethmoid/sphenoid or danger area of face.
Features: Abrupt onset, high fever, rigors, toxemia.
Eye: Severe chemosis, proptosis, bilateral involvement within 24–48 hrs.
Nerves: CN III, IV, VI palsy (total ophthalmoplegia); CN V₁, V₂ → hypoesthesia.
Intracranial Complications First nerve affected: CN VI (Lateral Rectus) → runs inside cavernous sinus.
Treatment: High-dose IV antibiotics (heparin controversial).
Other intracranial: Meningitis, Frontal lobe abscess (from frontal sinus).
Superior Orbital Fissure Syndrome: CN III, IV, VI + V₁ palsy.
Orbital Apex Syndrome: Above + Optic nerve (blindness).

- Pott’s Puffy Tumour: Osteomyelitis of frontal bone + subperiosteal abscess.

- Mucocele displacement: Frontal → eye down & out; Ethmoid → eye forward & out.
KMU High-Yield Tips - Orbital Cellulitis vs CST:
• Laterality: Cellulitis = unilateral; CST = rapidly bilateral.
• CN involvement: CST → III, IV, VI palsies + V₁/V₂ sensory loss.
• Onset: CST abrupt (septic shock); Cellulitis gradual.

• Pupil: CST → dilated & fixed.

- First sign of CST: CN VI palsy.

4)Masses & Tumours

A) Nasal Polyps – Antrochoanal vs Ethmoidal
Aspect Antrochoanal Polyp (Killian’s Polyp) Ethmoidal Polyps

Non-neoplastic, oedematous mucosal Non-neoplastic, oedematous mucosal masses arising from

Definition
mass arising from Maxillary sinus Ethmoid air cells

Age Group Children / Young Adults Adults

Aetiology Infection or Allergy Multifactorial; often allergic

Number Solitary Multiple (grape-like clusters)

Laterality Unilateral Bilateral

Origin Maxillary Antrum near accessory ostium Ethmoid sinus (uncinate process, bulla, middle turbinate)

Backwards → Choana → Nasopharynx (may

Growth Direction Forward → Nares
hang behind soft palate)

Trilobed:
• Antral (thin stalk)
Structure Multiple smooth, glistening masses
• Nasal (flat part)
• Choanal (round part)

• Unilateral nasal obstruction (bilateral if • Bilateral nasal obstruction

large) • Anosmia (complete loss of smell)
Clinical Features
• Thick, dull voice (hyponasality) • Long-standing cases → Frog Face Deformity (broad nose, ↑
• Large polyp may be seen in oropharynx intercanthal distance)

Signs Smooth, greyish, insensitive, does not bleed Same: pale, soft, insensitive, probe passes all around

• FESS (preferred)
• Medical: Antihistamines, steroids (“medical polypectomy”)
Treatment • Caldwell-Luc (rare, for recurrence)
• Surgical: FESS (standard), intranasal ethmoidectomy
• Simple avulsion (high recurrence)

Recurrence Uncommon if root removed Common

Associated Systemic Diseases

• Asthma: ~7% have polyps

• Cystic Fibrosis: 20% cases

• Kartagener’s Syndrome: Bronchiectasis + Sinusitis + Situs inversus

• Young’s Syndrome: Sinopulmonary disease + Azoospermia

• Allergic Fungal Sinusitis

KMU High-Yield Tips

Exam Point Explanation

Simple polyp = no bleeding; Bleeding polypus = capillary hemangioma; Malignancy = red, friable,
Bleeding Differential
unilateral in elderly

Child Warning Nasal polyp in child → rule out glioma/encephalocele; Never biopsy without imaging

CF Rule Multiple polyps in child → investigate for cystic fibrosis

Probe Test Polyp: pale, soft, mobile, insensitive; Turbinate: pink, hard, fixed, painful

B) Epistaxis – Causes, Anatomy & Management

Aspect Details & Explanation

Definition Bleeding from inside the nose. Most common ENT emergency.

Nasal Septum:
• Internal Carotid: Anterior & Posterior Ethmoidal arteries.
• External Carotid: Sphenopalatine, Greater Palatine, Septal branch of Superior Labial.
Little’s Area (Kiesselbach’s Plexus): Site of anastomosis of 4 arteries:
Blood Supply • Anterior Ethmoidal
Anatomy • Septal branch of Superior Labial
• Septal branch of Sphenopalatine
• Greater Palatine.
Clinical: Most common site (90%).
Posterior Site: Woodruff’s Plexus (venous) – common in adults.

Anterior Epistaxis:
• Site: Little’s Area.
• Age: Children/Young adults.
Classification • Cause: Trauma (nose picking).
• Bleeding: Mild, flows out front.
Posterior Epistaxis:
• Site: Woodruff’s Plexus.
40

• Age: >40 yrs.

• Cause: Hypertension/arteriosclerosis.
• Bleeding: Severe, flows back → swallowed → coffee-colored vomit.

Local: Trauma (nose picking), infections (viral rhinitis, atrophic rhinitis), foreign bodies, neoplasms
(angiofibroma, carcinoma), atmospheric changes.
Causes General: Hypertension, arteriosclerosis, blood disorders (aplastic anemia, leukemia,
thrombocytopenia), liver disease, drugs (aspirin, anticoagulants), systemic infections (typhoid,
dengue), vicarious menstruation.

First Aid (Trotter’s Method): Sit up, lean forward, pinch nose for 5 min, cold compress.
If site visible: Cauterize (Silver nitrate or electric cautery).
Anterior Nasal Packing: Ribbon gauze with paraffin/antibiotic ointment; remove after 24 hrs.
Posterior Nasal Packing: Gauze cone or Foley’s catheter; nasal balloons available.
Endoscopic Cauterization: Locate & cauterize bleeder.
Step-Ladder Surgical Ligation:
Management • External Carotid artery.
• Maxillary artery (transantral or endoscopic).
• Ethmoidal arteries (Lynch incision).
TESPAL: Endoscopic sphenopalatine artery ligation (high success).
Embolization: For inaccessible sites.
Special: Hereditary hemorrhagic telangiectasia → Laser or Septodermoplasty.

- Little’s Area MCQ: Posterior Ethmoidal artery does NOT contribute.

- Woodruff’s Plexus: Posterior end of inferior turbinate; venous.
- Angiofibroma: Adolescent male with recurrent epistaxis → Do NOT biopsy.
KMU High-Yield Tips - Management Hierarchy: Resuscitation → Pressure → Cautery → Anterior packing → Posterior packing
→ Ligation/Embolization.
- Artery Ligation Rule: Above middle turbinate → Ethmoidal (ICA); below → Sphenopalatine/Maxillary
(ECA).

C) Granulomatous Diseases of Nose

Aspect Rhinoscleroma (Scleroma) Wegener’s Granulomatosis

Chronic granulomatous disease of nose & nasopharynx Autoimmune disorder with necrotizing
Definition
caused by Klebsiella rhinoscleromatis (Frisch bacillus) granulomas & vasculitis

Epidemiology Endemic in Northern India Systemic disease

Atrophic: Foul-smelling discharge, crusting (resembles Triad:

Stages atrophic rhinitis) • Nose: Crusting, septal perforation, saddle
Granulomatous: Woody hard swelling of nose & upper nose

lip (non-tender) • Lungs: Cough, haemoptysis, cavitating

Cicatricial: Fibrosis → stenosis of nares, deformity lesions
• Kidneys: Glomerulonephritis → renal failure

Mikulicz Cells: Large foamy histiocytes with bacilli Necrotizing granulomas + vasculitis of small
Histology
Russell Bodies: Eosinophilic inclusions in plasma cells vessels

Diagnostic Marker Frisch bacillus (Gram-negative) c-ANCA positive (specific), ESR ↑

Antibiotics: Streptomycin + Tetracycline (4–6 weeks)

Treatment Systemic steroids + Cyclophosphamide
Surgery for stenosis

Clinical Clue Woody nose, painless swelling, foul discharge Saddle nose + haemoptysis + hematuria

Other Granulomatous Diseases & Septal Perforation Sites

Disease Key Feature Site of Perforation

Syphilis (Tertiary) Gumma, saddle nose Bony part (vomer necrosis)

Tuberculosis Painful ulcer, pale granulations Cartilaginous part

Lupus Vulgaris “Apple-jelly” nodules Cartilaginous part

T-Cell Lymphoma
(Midline Lethal Rapid midface destruction, no vasculitis Extensive
Granuloma)

KMU High-Yield Tips

Exam Point Explanation

Mikulicz Cell Histiocyte loaded with bacteria

Russell Body Plasma cell loaded with immunoglobulins

Septal Perforation
Bony: Syphilis; Cartilage: TB/Lupus; Total: Wegener’s/T-cell lymphoma
Rules

Diagnostic Marker c-ANCA → Wegener’s; ACE ↑ → Sarcoidosis

Clinical Scenarios Woody nose → Rhinoscleroma; Saddle nose + haemoptysis + hematuria → Wegener’s

• Benign tumour of Schneiderian

membrane.
• Medial Maxillectomy (via
• Epithelium grows inward into stroma • Unilateral nasal obstruction.
Lateral Rhinotomy or Midfacial
Inverted (“Inverted”). • Epistaxis or blood-stained
Degloving).
Papilloma • Origin: Lateral nasal wall (Middle discharge.
• Endoscopic resection
(Ringertz Meatus). • Pale, firm, polypoidal mass
(preferred for limited lesions).
Tumour) • Age: 40–70 yrs; M > F. (resembles simple polyp but
Never simple polypectomy
• Associated with SCC in 10–15% cases. unilateral).
(high recurrence).
• High recurrence if incompletely
excised.

• Benign but locally invasive vascular • Triad: Adolescent male + Profuse

tumour. recurrent epistaxis + Progressive
• Occurs in adolescent males. nasal obstruction. • Surgery: Transpalatal,
• Origin: Superior margin of • Frog Face deformity (widened Lateral Rhinotomy,
Juvenile
Sphenopalatine foramen. nasal bridge + proptosis). Endoscopic.
Nasopharyngeal
• Testosterone-dependent. • CT Scan: Investigation of choice; • Pre-op embolization (24–48
Angiofibroma
• Vessels lack muscular coat → shows Holman-Miller Sign hrs before surgery).
(JNA)
torrential bleeding. (anterior bowing of posterior • Radiotherapy for
• Spread: Pterygopalatine fossa → maxillary wall). intracranial/inoperable cases.
Infratemporal fossa → Orbit → • Biopsy contraindicated (risk of
Intracranial. massive hemorrhage).

• Most common malignancy of PNS.

• Histology: Squamous Cell
Carcinoma (>80%). • Medial spread: Nasal
• Risk factors: Nickel refining (SCC), obstruction, epistaxis.
Wood dust (Adenocarcinoma – • Anterior: Cheek swelling, skin
• Combination therapy:
Carcinoma of Ethmoid), Chronic sinusitis, Snuff. invasion.
Total/Partial Maxillectomy +
Maxillary Sinus • Ohngren’s Line: Medial canthus → • Inferior: Loose teeth, palate
Post-op Radiotherapy.
Angle of mandible. swelling.
• Suprastructure (posterosuperior) → • Superior: Proptosis, diplopia.
Poor prognosis. • Posterior: Trismus.
• Infrastructure (anteroinferior) → Better
prognosis.

KMU High-Yield Tips

Adolescent male + severe epistaxis + nasal mass → Angiofibroma. Do NOT biopsy; order CT
Bleeding Boy Rule
scan.

• Holman-Miller Sign: Anterior bowing of posterior maxillary wall (Angiofibroma).

Radiological Signs
• Ohngren’s Line: Prognostic division for maxillary carcinoma.

• Wood dust → Adenocarcinoma (Ethmoid).

Occupational Cancers
• Nickel → SCC (Maxilla).

Suspicious for: Antrochoanal polyp, Inverted papilloma, or Malignancy → Always send for
Unilateral Polyp in Adult
histopathology.

• Arises from lateral wall.

Inverted Papilloma Facts • High recurrence.
• Associated with SCC.

5)Miscellaneous
A) CSF Rhinorrhea (Dhingra Ch. 29)
Aspect Details & Explanation

Leakage of CSF into the nose due to breach in dura, arachnoid, and bone separating subarachnoid space
Definition
from nasal cavity.

Traumatic (Most common):

• Accidental: Head injury (anterior cranial fossa fracture).
Aetiology • Iatrogenic: FESS, Septoplasty, Hypophysectomy.
Non-traumatic: Tumors (pituitary/sinus), Congenital (meningoencephalocele), Spontaneous (BIH in
obese women).

• Cribriform Plate (most common).

• Frontal sinus (posterior table fracture).
Sites of Leak
• Sphenoid sinus (middle cranial fossa fracture).
• Temporal bone → paradoxical rhinorrhea (CSF via Eustachian tube).

• Clear watery discharge, sweet taste.

• Usually unilateral.
• Postural: Drips on bending forward.
Clinical Features
• Reservoir Sign: Wet pillow in morning.
• Handkerchief Test: CSF does not stiffen cloth.
• Cannot sniff back.

• Gold Standard: Beta-2 transferrin assay.

• Beta-trace protein.
Diagnosis
• Glucose >30 mg/dL (or >60% blood sugar).
• Halo Sign: Drop on filter paper → central blood spot + peripheral clear ring.

Localization HRCT, CT cisternography, MRI, Intrathecal fluorescein (during surgery).

Conservative: Bed rest (head elevated 30°), stool softeners, acetazolamide.

Treatment
Surgical: Endoscopic repair with fat/fascia graft if leak persists >7–10 days or is spontaneous.

B) Facial Trauma (Dhingra Ch. 34)

Fracture Type Key Features Clinical Signs

Most common facial fracture. Swelling, tenderness, epistaxis, deformity.

Nasal Bone Depressed (frontal blow) or angulated Treatment: Closed reduction immediately or after 5–7
(lateral blow). days.

Break at 3 sutures: Zygomatico-frontal,

Flattened cheek, infraorbital step deformity, trismus,
Zygoma (Tripod Fracture) Zygomatico-maxillary, Zygomatico-
infraorbital nerve hypoaesthesia, diplopia.
temporal.

Orbital floor fracture (maxilla) due to blunt

trauma; rim intact. Enophthalmos, diplopia on upward gaze, Tear-drop
Blow-Out Fracture
Inferior rectus + fat herniate into maxillary sign on X-ray.
sinus.

Le Fort I: Horizontal fracture above teeth →

floating palate.
Le Fort II: Pyramidal fracture involving
Maxillary (Le Fort
nasal bridge, lacrimal bones, orbital floor.
Classification)
Le Fort III: Craniofacial dysjunction →
entire face separates → dish-face
deformity.

Common sites: Condyle > Angle > Body >

Symphysis.
Mandible Malocclusion of teeth.
Guardsman Fracture: Fall on chin →
symphysis + both condyles.

KMU High-Yield Tips

CSF Leak Gold Standard Beta-2 transferrin assay.

Halo Sign Blood + CSF on filter paper → central red spot + peripheral clear ring.

Blow-Out Fracture Buzzwords Tear-drop opacity + diplopia on upward gaze.

Most Common Fractures Facial: Nasal bone; Mandible: Condyle.

Le Fort Mnemonic I = floating palate; II = pyramidal; III = dish-face.

Section III: Throat (Head & Neck)

(From KMU Themes: Sore Throat, Dysphagia, Hoarseness, Neck Swellings)

1)Oral Cavity and Salivary Glands

A) Anatomy of Oral Cavity (Dhingra Ch. 42)
Aspect Details & Explanation

From lips (vermilion border) → oropharyngeal isthmus (junction of hard & soft palate
Extent
above, anterior tonsillar pillars below).

1. Lips – anterior boundary.

2. Buccal Mucosa – inner cheek lining up to pterygomandibular raphe.
3. Alveolar Ridges – upper & lower gums.
4. Retromolar Trigone (RMT) – triangular mucosa behind last molar; apex = maxillary
tuberosity.
Subsites (7)
5. Hard Palate – roof of oral cavity.
6. Floor of Mouth – crescent-shaped area between gum & tongue; contains frenulum &
Wharton’s duct openings.
7. Oral Tongue (Anterior 2/3) – tip, dorsum, lateral borders, ventral surface; separated
from base by circumvallate papillae.

Significance of RMT “Crossroads” for tumor spread → mandible, maxilla, pterygoid muscles → early trismus.

Oral Tongue (Ant 2/3) = Oral cavity.

Boundary Concept
Base of Tongue (Post 1/3) = Oropharynx.

Oral Tongue: Sensation = Lingual (V₃); Taste = Chorda Tympani (VII); Motor = Hypoglossal
Nerve Supply (XII).
Base of Tongue: Sensation & Taste = Glossopharyngeal (IX).

Lip (Lower midline): Submental (IA).

Lip (Upper/lateral): Submandibular (IB).
Tongue tip: Submental + Jugulo-omohyoid (Level IV).
Lymphatic Drainage (Key for
Tongue lateral border: Ipsilateral submandibular + deep cervical.
Cancer Spread)
Tongue dorsum/central: Bilateral deep cervical.
Floor of mouth: Submandibular (crosses midline).
Hard palate: Upper deep cervical + retropharyngeal.

Skip Metastasis Tip of tongue → can drain directly to Level IV (Jugulo-omohyoid), bypassing Levels I–III.

Clinical Correlation Carcinoma of tongue/floor → referred otalgia via auriculotemporal nerve (V₃).

KMU High-Yield Tips

Exam Point Explanation

Oral tongue = oral cavity; Base = oropharynx (bilateral lymphatic drainage → high contralateral
Tongue Division
metastasis risk).

RMT Tumor Spread Invades bone & muscles early → trismus.

Lymph Node Levels Level I = oral cavity; Level II = oropharynx; Level IV = skip metastasis from tongue tip.

Referred Otalgia Via V₃ (lingual nerve shares origin with auriculotemporal nerve).

B) Oral Ulcers – Types, Features & Key Differentiators (Dhingra Ch. 43)
Type Etiology & Site Clinical Features Treatment

• Autoimmune association; linked to Minor: Small (2–10 mm), shallow, painful,

stress, trauma, vitamin deficiencies red halo; heal in 10–14 days without scar. Topical steroids
Aphthous Ulcers (B₁₂, folate, iron). Major: >1 cm, deep, painful; heal slowly (Triamcinolone), silver
(Canker Sores) • Site: Movable mucosa (lip, buccal with scarring. nitrate cautery,
mucosa, tongue, soft palate). Rare on Herpetiform: Multiple tiny ulcers multivitamins.
keratinized mucosa. (resembles herpes but not viral).

• Primary: Children; generalized

vesicles on gums + oral mucosa;
Painful vesicles → ulcers; recurrent
Herpetic Ulcers fever, lymphadenopathy. Acyclovir (early),
episodes.
(HSV-1) • Secondary: Reactivation → fixed supportive care.
Tzanck smear: Multinucleated giant cells.
mucosa (hard palate, gingiva) or
vermilion border (cold sores).

• Fusiform bacillus + spirochaete. “Punched-out” interdental papilla ulcers Metronidazole +

Vincent’s
• Predisposed by poor oral hygiene, with grey necrotic membrane; foul breath, Penicillin; hydrogen
Infection (ANUG)
malnutrition. metallic taste, severe pain. peroxide mouthwash.

• Physical: Jagged tooth, denture, Common on lateral tongue; painful, soft

cheek bite. edges. Remove cause;
Traumatic Ulcers
• Chemical: Aspirin burn. Rule: Non-healing >2–3 weeks → biopsy (to symptomatic care.
• Thermal: Hot food/liquid. rule out carcinoma).

Herpangina Vesicles on soft palate, uvula, tonsillar

• Viral infection in children. Supportive care.
(Coxsackie A) pillars; sore throat, fever.

KMU High-Yield Differentiators

Exam Point Explanation

Mucosa Rule Aphthous = movable mucosa; Herpetic = fixed mucosa (hard palate, gingiva).

Behçet’s Syndrome Triad: Oral aphthous ulcers + genital ulcers + uveitis (eye inflammation).

Vincent’s Angina Diagnosis Smear shows fusiform bacilli & spirochaetes; treat with Metronidazole.

Traumatic vs Malignant Ulcer Traumatic = painful, soft edges; Malignant = painless initially, indurated edges.

Tzanck Smear Diagnostic for herpes → multinucleated giant cells.

C) Oral Submucous Fibrosis (OSF)

Aspect Details & Explanation

Chronic, progressive fibrosis of oral submucosa → rigidity & trismus. Precancerous (3–7.6% malignant
Definition
transformation).

Areca Nut (Betel Nut): Arecoline stimulates fibroblasts → ↑ collagen.

Aetiology
Chillies (hypersensitivity), Nutritional deficiency (Vit B, iron, protein), Autoimmunity.

Pathogenesis ↑ Collagen synthesis + ↓ Collagen degradation → fibrotic bands.

Inflammatory: Vesicles, ulcers.

Stages Fibrosis: Blanching, stiffening.
Sequelae: Trismus, tongue atrophy.

Symptoms: Burning on spicy food, progressive trismus, dryness, dysphagia.

Clinical Features Signs: Pearly white mucosa, palpable fibrous bands (buccal mucosa, soft palate), hockey-stick uvula,
smooth atrophic tongue.

Habit cessation: Stop Pan/Areca nut.

Treatment Medical: Intralesional steroids + hyaluronidase, antioxidants (Vit A, E, C, Lycopene), placental extract.
Surgical: Severe trismus → excision of bands + reconstruction (nasolabial flap/skin graft).

D) Leukoplakia
Aspect Details & Explanation

White patch/plaque that cannot be characterized as any other disease (diagnosis of

Definition (WHO)
exclusion).

Tobacco (smoking/chewing), Alcohol (synergistic), Chronic irritation (sharp tooth, denture),

Aetiology
Candidiasis, Vit A deficiency.

Homogenous: Smooth/wrinkled white patch → low risk.

Clinical Types & Malignant
Ulcerated: White patch + ulcer → high risk.
Potential
Speckled (Erythroleukoplakia): Red & white nodules → highest risk.

Hyperkeratosis + epithelial dysplasia (mild/moderate/severe). 5–15% may already have

Histology
invasive carcinoma.

Biopsy mandatory.
Treatment Conservative: Stop tobacco/alcohol, correct irritants, Vit A.
Surgical: CO₂ laser or excision for moderate/severe dysplasia.

Erythroplakia

Aspect Details
Definition Bright red velvety patch; cannot be classified as other
disease.
Significance Most dangerous premalignant lesion → 90% carcinoma in
situ/invasive carcinoma.
Treatment Wide excision.

Exam Point Explanation

Areca Nut Clue Trismus + fibrotic bands + Pan chewing → OSF.

Leukoplakia = single patch, tobacco-related; Lichen Planus = bilateral lace-like striae

Leukoplakia vs Lichen Planus
(Wickham’s).

Malignant Potential Hierarchy Erythroplakia > Speckled Leukoplakia > Homogenous Leukoplakia.

Hairy Leukoplakia EBV-related, HIV/AIDS, lateral tongue; not premalignant.

Carcinoma in Situ Dysplasia through full epithelial thickness; basement membrane intact.

E) Tumours of Oral Cavity (Dhingra Ch. 44)

Aspect Details & Explanation

Histology Squamous Cell Carcinoma (SCC) = >90% of oral malignancies.

Smoking, Spirits (Alcohol), Spices (Chronic irritation), Sepsis (Poor hygiene), Sharp tooth (Trauma),
Risk Factors (6 S Rule) Syphilis.
Additional: Tobacco chewing, Betel quid (major cause in South Asia).

Lip: Lower > Upper.

Buccal Mucosa: Gingivobuccal sulcus (Indian oral cancer).
Common Sites
Oral Tongue: Lateral border > ventral > dorsum.
Retromolar Trigone: High-risk “Trojan horse” site.

Carcinoma Risk Factor / Aetiology Clinical / Features Lymphatics / Spread Treatment

Type
Lip Sun exposure (farmers), pipe Midline → Submental Wedge excision (up to 1/3
Lower lip smoking (IA); Lateral → lip) or Radiotherapy for
(90%) Submandibular (IB) cosmesis
Buccal Tobacco/betel quid in Leukoplakia/Erythroplakia Invades mandible, Wide excision + Neck
Mucosa gingivobuccal sulcus precedes cancer; trismus maxilla, cheek skin dissection ± Radiotherapy
(pterygoid involvement);
bleeding/pain late
Oral Tongue Painless ulcer early; Tip → Submental → T1/T2: Wide excision or
Lateral referred otalgia (via V₃); Jugulo-omohyoid brachytherapy. T3/T4:
border (most tongue fixation (deep (Level IV skip Commando operation
common) infiltration); dysphagia, metastasis). Lateral → (glossectomy +
speech defects Submandibular (IB) + mandibulectomy + neck
Upper deep cervical dissection) +
(II). Central → Bilateral Radiotherapy
drainage

KMU High-Yield Tips

Exam Point Explanation

Referred Otalgia Tongue cancer → Lingual nerve → Auriculotemporal nerve (both V₃).

Skip Metastasis Tip of tongue → Jugulo-omohyoid (Level IV).

Trojan Horse Retromolar trigone → early bone invasion.

Plummer-Vinson Syndrome Associated with post-cricoid carcinoma + oral cancers.

F) Salivary Glands
a) MUMPS
Condition Key Features Clinical Clues Treatment

Fever, malaise, parotid swelling

Mumps (Viral Paramyxovirus; droplet spread; incubation (bilateral), ear lobule pushed Symptomatic
Parotitis) 2–3 weeks. up/out, congested Stensen’s (analgesics, hydration).
duct.

Orchitis (unilateral, rare sterility),

Sudden hearing loss post-
Complications Pancreatitis, Meningoencephalitis, Supportive care.
mumps.
Sensorineural hearing loss (permanent).

Site Submandibular (90%) > Parotid (10%).

Why Submandibular? Thick mucinous saliva, alkaline pH, long tortuous duct, flow against gravity.

Clinical Mealtime syndrome: Pain & swelling during meals; stone palpable in floor of mouth.

X-ray (Occlusal view): 80–90% submandibular stones radio-opaque; parotid stones often
Diagnosis radiolucent.
Sialography contraindicated in acute infection.

Treatment Intraoral removal (near duct opening); gland excision if intraglandular/recurrent.

c) Salivary Gland Tumours – “Rule of 80s”

Rule Explanation

80% of salivary tumours Occur in Parotid.

80% of parotid tumours Are Benign.

80% of benign parotid tumours Are Pleomorphic Adenoma.

80% of pleomorphic adenomas Lie in Superficial lobe.

Common Tumours

Tumour Features Treatment

Most common benign; mixed epithelial + mesenchymal; Superficial parotidectomy (never

Pleomorphic Adenoma
capsule with pseudopods → recurrence if enucleated. simple shelling out).

Elderly male smokers; tail of parotid; cystic, bilateral (10%);

Warthin’s Tumour Surgical excision.
Hot spot on Tc-99m scan.

Mucoepidermoid Most common malignant parotid tumour; low grade = good

Surgery ± radiotherapy.
Carcinoma prognosis; high grade = aggressive.

Most common malignancy of submandibular/minor glands;

Adenoid Cystic Carcinoma Wide excision + radiotherapy.
perineural invasion → severe pain; late lung metastasis.

Frey’s Syndrome (Gustatory Sweating)

KMU High-Yield Tps

Exam Point Explanation

Radio-opacity Rule Submandibular stones = radio-opaque; parotid stones = radiolucent.

Tumour Associations Warthin’s = smokers + Tc-99m uptake; Adenoid cystic = pain + nerve palsy.

Overall/parotid = Pleomorphic adenoma; malignant parotid = Mucoepidermoid; malignant

Most Common Tumours
submandibular/minor = Adenoid cystic.

Frey’s Syndrome Nerve Auriculotemporal nerve (V₃) carrying parasympathetic fibers from otic ganglion.

2)Pharynx (Nasopharynx, Oropharynx, Hypopharynx)

A) Anatomy of Pharynx (Dhingra Ch. 47)
Aspect Details & Explanation

Base of skull (basiocciput) → lower border of cricoid (C6). Length: 12–14 cm; widest at base (3.5 cm),
Extent & Dimensions
narrowest at C6 (1.5 cm).

1. Mucosa: Ciliated columnar (nasopharynx), stratified squamous (oro/hypopharynx).

2. Pharyngobasilar fascia: Fibrous layer.
Layers (Inside → Out) 3. Muscular coat: Circular (Superior, Middle, Inferior constrictors) + Longitudinal (Stylopharyngeus,
Salpingopharyngeus, Palatopharyngeus).
4. Buccopharyngeal fascia: Outer covering.

Nasopharynx: Base of skull → soft palate.

• Eustachian tube opening (behind inferior turbinate).
• Fossa of Rosenmüller: Common site for nasopharyngeal carcinoma.
• Sinus of Morgagni: Gap for Eustachian tube + Levator & Tensor veli palatini.
• Passavant’s ridge closes nasopharyngeal isthmus during swallowing.
Divisions Oropharynx: Hard palate → hyoid bone.
• Palatine tonsils between anterior (palatoglossus) & posterior (palatopharyngeus) pillars.
• Valleculae between tongue base & epiglottis.
Hypopharynx: Hyoid → cricoid (C6).
• Pyriform fossa (internal laryngeal nerve runs here).
• Postcricoid region (common cancer site in Plummer-Vinson syndrome).

Weak area between thyropharyngeus & cricopharyngeus → site for Zenker’s diverticulum; risk of
Killian’s Dehiscence
perforation during esophagoscopy (“Gateway of Tears”).

Motor: Pharyngeal plexus (CN IX, X, sympathetic) → all muscles except Stylopharyngeus (CN IX).
Nerve Supply
Sensory: Nasopharynx = CN V₂; Oropharynx = CN IX; Hypopharynx = CN X (internal laryngeal).

Lymphoid ring guarding air & food passages: Adenoids (roof), Palatine tonsils (lateral), Lingual tonsil
Waldeyer’s Ring
(base of tongue), Tubal tonsils (near Eustachian tube).

KMU High-Yield Tips

Exam Point Explanation

Nerve Exceptions Stylopharyngeus = CN IX; Tensor veli palatini = CN V₃ (others via pharyngeal plexus).

Sinus of Morgagni Contents Eustachian tube + Levator veli palatini (primary MCQ answer) + Tensor veli palatini.

Killian’s Dehiscence Site for Zenker’s diverticulum; perforation risk in esophagoscopy.

Epithelium Transition Nasopharynx = respiratory epithelium; oro/hypopharynx = stratified squamous.

Most common site for nasopharyngeal carcinoma; inspect in adult with unilateral secretory
Fossa of Rosenmüller
otitis media.

B) NasoPhyrnx
Adenoids (Nasopharyngeal Tonsil)
Aspect Details & Explanation

Junction of roof & posterior wall of nasopharynx; vertical ridges with deep clefts; no capsule, no
Location & Structure
crypts.

Development Present at birth → hypertrophies till 6 yrs → atrophies at puberty → disappears by 20 yrs.

Nasal: Mouth breathing, nasal obstruction, rhinolalia clausa.

Aural: Eustachian tube block → glue ear, recurrent otitis media.
Clinical Features
General: Adenoid facies (open mouth, high-arched palate, crowded teeth), aprosexia, pulmonary
hypertension (rare).

Diagnosis X-ray lateral neck or nasal endoscopy.

Adenoidectomy (indicated for obstruction, sleep apnea, recurrent sinusitis, glue ear).
Treatment
Contraindication: Cleft palate (risk of velopharyngeal insufficiency → hypernasal speech).

Definition Benign, vascular, locally invasive tumour in adolescent males (10–20 yrs).

Origin Superior margin of sphenopalatine foramen.

Vascular spaces without muscular coat → cannot constrict → torrential bleeding.

Pathology
Testosterone-dependent.

Adolescent male + recurrent severe epistaxis + progressive nasal obstruction.

Clinical Triad
Frog face deformity (proptosis + widened nasal bridge).

Biopsy contraindicated (bleeding risk).

Diagnosis
CT scan: Holman-Miller sign (anterior bowing of posterior maxillary wall).

Surgery (transpalatal, lateral rhinotomy, endoscopic).

Treatment Pre-op embolization (24–48 hrs before surgery).
Radiotherapy only for intracranial/inoperable cases.

Nasopharyngeal Carcinoma (NPC)

Aspect Details & Explanation

Definition Malignant tumour of nasopharyngeal epithelium; common in China.

Etiology EBV infection, genetic (HLA-A2, B17), environmental (smoking, nitrosamines).

Site Fossa of Rosenmüller (pharyngeal recess) – most common.

Type I: Keratinizing SCC.

WHO Types Type II: Non-keratinizing differentiated.
Type III: Non-keratinizing undifferentiated (most common; best prognosis with RT).

Neck mass: Upper deep cervical nodes (first sign in 60–90%).

Otologic: Unilateral glue ear (adult = NPC until proven otherwise).
Nasal: Epistaxis, obstruction.
Clinical Features
Neurologic: Trotter’s Triad = conductive deafness + palatal paralysis (CN X) + trigeminal neuralgia (CN
V).
CN VI palsy → diplopia (first nerve in intracranial spread).

Radiotherapy = treatment of choice (primary + neck nodes).

Treatment Chemotherapy for advanced disease.
Surgery only for residual/recurrent neck nodes.

Exam Point Explanation

Adolescent male + severe epistaxis + nasal mass → JNA → Do NOT biopsy, order CT
Bleeding Boy Rule
scan.

Holman-Miller Sign Anterior bowing of posterior maxillary wall (JNA).

Trotter’s Triad Ear (deafness), Palate (immobility), Pain (neuralgia).

Adenoidectomy Contraindication Cleft palate → risk of hypernasal speech.

NPC Metastasis Early bilateral neck node involvement → prophylactic RT even if N0.

C) OROPHYRNX
Acute Tonsillitis
Aspect Details & Explanation

Definition Acute inflammation of palatine tonsils (common in school-aged children).

Most common: Group A β-haemolytic Streptococcus.

Aetiology
Others: Staphylococcus, Pneumococcus, H. influenzae.

• Catarrhal: Mild redness.

• Follicular: Yellow pus spots in crypts.
Types
• Parenchymatous: Tonsil substance inflamed.
• Membranous: Coalescent exudate forming membrane.

Symptoms: Severe sore throat, odynophagia, fever, earache (referred), constipation.

Clinical Features Signs: Red swollen tonsils, yellow spots or membrane, enlarged jugulodigastric nodes, coated tongue,
foetid breath.

Treatment Bed rest, hydration, Penicillin (drug of choice) or Erythromycin (if allergic), analgesics.

Chronic Tonsillitis
Aspect Details & Explanation

Aetiology Recurrent acute attacks or subclinical infection → micro-abscesses in follicles.

• Follicular: Crypts full of cheesy debris.

Types • Parenchymatous: Hyperplastic tonsils.
• Fibroid: Small, fibrotic tonsils.

Recurrent sore throat, halitosis, thick speech, difficulty swallowing.

Clinical Features Signs: Irwin Moore’s sign (pus on squeezing anterior pillar), flush of anterior pillars, enlarged
jugulodigastric nodes.

Treatment Tonsillectomy indicated for recurrent infection or obstruction.

Peritonsillar Abscess (Quinsy)

Aspect Details & Explanation

Definition Pus in peritonsillar space (between tonsil capsule & superior constrictor).

Aetiology Complication of acute tonsillitis; mixed flora.

High fever, severe odynophagia, drooling, “Hot Potato” voice, trismus, referred earache.
Clinical Features
Signs: Swollen soft palate, uvula pushed to opposite side, tonsil displaced medially & downwards.

Hospitalization, IV antibiotics (Penicillin + Metronidazole).

Incision & Drainage: At intersection of horizontal line through base of uvula & vertical line through anterior
Treatment
pillar (or point of maximum bulge).
Interval tonsillectomy (4–6 weeks later).

KMU High-Yield Tips

Exam Point Explanation

Quinsy Drainage Site Intersection of base of uvula (horizontal) & anterior pillar (vertical).

Diphtheria: Dirty grey adherent membrane, bleeds on removal, severe toxemia.

Diphtheria vs Membranous Tonsillitis Tonsillitis: White/yellow non-adherent membrane, confined to tonsil, moderate
toxemia.

Unilateral Tonsillar Enlargement Rule out lymphoma or SCC → excisional biopsy (tonsillectomy).

Infectious Mononucleosis EBV; huge tonsils with membrane, generalized lymphadenopathy; Ampicillin → rash.

Hot Potato Voice Seen in Quinsy & large oropharyngeal tumors.

Space between buccopharyngeal fascia (anterior) & prevertebral fascia (posterior). Contains
Anatomy
Nodes of Rouviere (atrophy by age 3–4). Extent: Base of skull → T4.

Cause: Suppuration of retropharyngeal nodes (secondary to adenoid/nasopharyngeal

infection).
Features: Dysphagia, stridor, torticollis, unilateral posterior wall bulge (Space of Gillette).
Acute (Children <3 yrs) Diagnosis: Lateral neck X-ray → widened prevertebral shadow (>7 mm at C2 or >14 mm at C6 in
children).
Treatment: Intraoral vertical incision (Rose’s position), IV antibiotics, tracheostomy if airway
compromised.

Cause: Tuberculosis (Pott’s disease).

Chronic (Older Features: Mild dysphagia, midline bulge.
children/adults) Treatment: ATT + External drainage (behind sternomastoid). Intraoral drainage contraindicated
(risk of fistula & mixed infection).

Parapharyngeal Abscess
Aspect Details & Explanation

Inverted pyramid (base at skull, apex at hyoid). Divided by styloid process into:
Anatomy • Anterior (Pre-styloid): Tonsil & medial pterygoid.
• Posterior (Post-styloid): Carotid sheath + CN IX–XII + sympathetic chain.

Aetiology Spread from tonsils (Quinsy), lower molar teeth, parotid, or mastoid tip (Bezold’s abscess).

Anterior compartment: Triad = Tonsil pushed medially + severe trismus + external swelling behind jaw
angle.
Clinical Features
Posterior compartment: Bulge behind posterior pillar + CN IX–XII palsies (hoarseness, dysphagia) +
Horner’s syndrome; minimal trismus.

Laryngeal edema → airway obstruction; jugular vein thrombophlebitis (Lemierre’s syndrome); carotid
Complications
blowout.

IV antibiotics + External drainage (horizontal incision below mandible). Intraoral drainage

Treatment
contraindicated (risk to great vessels).

KMU High-Yield Differentiators

Age Adults Adults Children (<3 yrs)

Trismus Severe Severe Mild/Absent

Tonsil Position Medial & down Medial Normal

Neck Swelling Minimal Prominent (angle of jaw) Minimal

Uvula Deviated Deviated Normal

Key MCQ Pearls

• X-ray rule: Prevertebral shadow >7 mm at C2 or >14 mm at C6 (child) / >22 mm (adult) = Retropharyngeal
abscess.

• Drainage approach: Acute RPA = intraoral; Chronic TB RPA = external.

• Styloid process significance: Divides parapharyngeal space → anterior = trismus; posterior = CN palsies +
Horner’s.

• Lower molar infection: Common source for parapharyngeal abscess or Ludwig’s angina.

E) HYPOPHYRNX
Hypopharyngeal Tumours
Subsite Key Features Clinical Clues Treatment

Early: Pricking sensation,

referred otalgia.
Surgery: Total laryngectomy +
Most common site (≈60%). Silent area → Late: Dysphagia,
partial pharyngectomy + neck
large growth before symptoms. Rich hoarseness, neck mass.
Pyriform Fossa dissection.
lymphatics → 75% present with neck Laryngeal invasion →
Radiotherapy for early/palliative
nodes early. hemilarynx fixation.
cases.
Thyroid cartilage
tenderness (lateral spread).

30% cases; common in females; strongly Surgery: Laryngo-pharyngo-

Progressive dysphagia, loss
linked to Plummer-Vinson Syndrome esophagectomy + stomach pull-
Postcricoid Region of laryngeal crepitus
(iron deficiency anemia + dysphagia + up.
(tumor cushions cricoid).
koilonychia). Radiotherapy: Poor response.

Posterior Least common; often advanced at

Dysphagia, weight loss. Surgery + RT (combined).
Pharyngeal Wall diagnosis.

• Type I: Keratinizing SCC.

• Type II: Non-keratinizing differentiated.

• Type III: Non-keratinizing undifferentiated (best RT response).

Pharyngeal Pouch (Zenker’s Diverticulum)

Aspect Details & Explanation

Pulsion diverticulum (false) → mucosa herniates through Killian’s dehiscence (between

Definition
thyropharyngeus & cricopharyngeus).

Aetiology Cricopharyngeal sphincter fails to relax → ↑ intrapharyngeal pressure → mucosa bulges out.

Patient Profile Elderly males (>60 yrs).

Dysphagia, regurgitation of undigested food (hours later), aspiration pneumonia.

Clinical Features Boyce’s Sign: Gurgling on neck pressure.
Soft compressible swelling (usually left side).

Barium swallow: Shows sac.

Diagnosis
Contraindication: Esophagoscopy (risk of perforation).

Endoscopic (Dohlman’s): Divide party wall with diathermy/laser/stapler.

Treatment
External: Diverticulectomy + cricopharyngeal myotomy.

KMU High-Yield Tips

Exam Point Explanation

Plummer-Vinson Syndrome Triad: Dysphagia + Iron deficiency anemia + Koilonychia → high risk of postcricoid carcinoma.

Zenker’s Diverticulum False diverticulum (mucosa only), pulsion type, through Killian’s dehiscence.

Loss of laryngeal crepitus = postcricoid carcinoma.

Clinical Signs Gurgling neck = Zenker’s.
Referred otalgia = pyriform fossa cancer.

Pyriform fossa → upper deep cervical (75% early).

Lymph Node Spread
Postcricoid → paratracheal (Level VI).

Extent Epiglottis (C3) → lower border of cricoid (C6).

Unpaired: Thyroid (largest; Adam’s apple; angle 90° in males, 120° in females), Cricoid (only complete
ring), Epiglottis (elastic).
Cartilages (9)
Paired: Arytenoid (vocal process anterior, muscular process lateral), Corniculate, Cuneiform.
Calcification: Hyaline (thyroid, cricoid, arytenoid) calcify after 25 yrs; epiglottis never calcifies.

Thyrohyoid (pierced by internal laryngeal nerve & superior laryngeal vessels).

Membranes Cricovocal (conus elasticus) → forms vocal ligament.
Quadrangular → forms aryepiglottic fold & vestibular ligament (false cord).

Intrinsic Muscles & Actions (MCQ Hotspot)

Action Muscle

Abductor (opens glottis) Posterior Cricoarytenoid (PCA) – Safety muscle of larynx.

Adductors (close glottis) Lateral cricoarytenoid, transverse arytenoid, thyroarytenoid (external part).

Tensor (elongates cord) Cricothyroid, vocalis (internal thyroarytenoid).

Relaxer (shortens cord) Thyroarytenoid.

Cavity & Narrowest Part

Region Extent

Supraglottis Epiglottis → ventricle (vestibule + false cords).

Glottis Space between true cords (rima glottidis) – narrowest in adults.

Subglottis Vocal cords → lower border of cricoid – narrowest in children.

Nerve Supply

Type Nerve

All intrinsic muscles by Recurrent Laryngeal Nerve (RLN) except Cricothyroid (External branch of Superior
Motor
Laryngeal Nerve).

Above cords: Internal laryngeal nerve.

Sensory
Below cords: RLN.

Lymphatic Drainage

Supraglottis Rich → upper deep cervical (early metastasis).

Glottis No lymphatics → late metastasis (good prognosis).

Subglottis Prelaryngeal (Delphian) & pretracheal nodes.

Paediatric Larynx Differences

• Position: Higher (C3 vs C6 in adults).

• Shape: Funnel-shaped (adult cylindrical).

• Narrowest part: Subglottis (cricoid ring).

• Epiglottis: Omega (Ω) shaped, floppy.

KMU High-Yield Tips

Exam Point Explanation

Safety Muscle PCA – only abductor; bilateral paralysis → airway obstruction.

Singer’s Nerve External laryngeal nerve injury → Cricothyroid paralysis → loss of high pitch.

Galen’s Anastomosis Internal laryngeal (sensory) ↔ RLN (motor) on posterior wall.

Between epithelium & vocal ligament; edema → Reinke’s edema; no lymphatics → late
Reinke’s Space
metastasis of glottic cancer.

Dimensions Male cord: 17–23 mm; Female: 15–19 mm.

Loss of Laryngeal
Postcricoid carcinoma or retropharyngeal abscess.
Crepitus

B) INFECTIONS
Acute Laryngitis
Aspect Details & Explanation

Viral (post-URI) → secondary bacterial (Strep. pneumoniae, H. influenzae, Staph. aureus). Non-infectious:
Aetiology
Vocal abuse, allergy, burns, trauma.

Clinical Features Hoarseness → aphonia, throat discomfort, dry nocturnal cough.

Signs Red, swollen laryngeal mucosa; vocal cords appear red (normally white).

Vocal rest (most important), steam inhalation (Tr. Benzoin Co.), antibiotics if secondary infection,
Treatment
steroids for burns/chemical injury.

Acute inflammation of supraglottic structures (epiglottis, aryepiglottic folds, arytenoids). Life-

Definition
threatening emergency.

Aetiology H. influenzae type B; age 2–7 yrs (can affect adults).

Abrupt onset, rapid progression.

Clinical
Children: Dyspnoea, stridor, drooling, high fever.
Features
Adults: Severe sore throat, dysphagia.

Signs Tripod position (child leaning forward, mouth open), red swollen epiglottis (seen only in OT).

Diagnosis X-ray lateral neck: Thumb sign (swollen epiglottis).

Precaution Do NOT use tongue depressor in OPD → risk of fatal laryngospasm.

Hospitalization, IV antibiotics (Ceftriaxone/Ampicillin), IV steroids (Hydrocortisone), airway management

Treatment
(intubation/tracheostomy if needed).

Acute Laryngo-Tracheo-Bronchitis (Croup)

Aspect Details & Explanation

Definition Inflammation of larynx, trachea, bronchi; obstruction at subglottis (narrowest part in children).

Aetiology Viral (Parainfluenza type I & II); age 6 months–3 yrs.

Gradual onset (URI prodrome), barking “seal-like” cough, inspiratory stridor, hoarseness, low-grade
Clinical Features
fever.

Diagnosis X-ray AP neck: Steeple sign (subglottic narrowing).

Humidification (mist tent), steroids, nebulized adrenaline (racemic), antibiotics for secondary
Treatment
infection.

Epiglottitis vs Croup (Differentiation)

Feature Epiglottitis Croup

Organism Bacterial (H. influenzae B) Viral (Parainfluenza)

Age 2–7 yrs 6 months–3 yrs

Site Supraglottis Subglottis

Onset Sudden, rapid Gradual (URI prodrome)

Fever High (>39°C) Low grade

Cough Absent Barking (croupy)

Dysphagia/Drooling Present Absent

X-ray Sign Thumb sign (lateral view) Steeple sign (AP view)

Treatment IV antibiotics + airway Humidification + steroids

KMU High-Yield Tips

Exam Point Explanation

Thumb vs Steeple Sign Thumb = epiglottitis; Steeple = croup.

Do Not Touch Rule Child with stridor + drooling → never depress tongue in OPD; secure airway first.

Organism Epiglottitis = H. influenzae B; Croup = Parainfluenza virus.

Subglottis Danger Narrowest pediatric airway → 1 mm edema reduces lumen by 50%, causing severe stridor.

C) Disorder Of Voice
Vocal Nodules (Singer’s/Screamer’s Nodes)
Aspect Details & Explanation

Definition Bilateral, symmetrical, whitish nodules on vocal cords due to chronic vocal abuse.

Aetiology Teachers, singers, hawkers; misuse (shouting in children).

Site Junction of anterior 1/3 and posterior 2/3 of vocal cord (maximum vibration point).

Pathology Trauma → edema & hemorrhage → hyalinization & fibrosis → epithelial hyperplasia.

Hoarseness, vocal fatigue, neck pain after prolonged speaking.

Clinical Features
Signs: Small bead-like nodules, bilateral & symmetrical.

First line: Speech therapy + voice rest (soft nodules may regress).
Treatment
Surgery: Microlaryngeal excision for hard nodules failing therapy.

Definition Localized, usually unilateral swelling on vocal cord.

Aetiology Sudden vocal abuse (shouting), smoking, allergy.

Site Same as nodules (junction of anterior 1/3 & posterior 2/3), but unilateral.

Pathology Edema/hemorrhage in Reinke’s space → soft, smooth, often pedunculated.

Hoarseness, Diplophonia (double voice), choking/dyspnoea if large polyp flops into glottis.
Clinical Features
Signs: Smooth pale/reddish mass on one cord.

Treatment Surgery: Microlaryngeal excision (first line). Post-op speech therapy to prevent recurrence.

Reinke’s Edema (Polypoid Degeneration)

Aspect Details & Explanation

Definition Bilateral, diffuse, fusiform swelling of entire membranous vocal cord.

Aetiology Smoking (most common), chronic vocal abuse, reflux.

Involves Reinke’s space (between epithelium & vocal ligament; no lymphatics → late metastasis in
Anatomy
glottic cancer).

Middle-aged smokers; low-pitched, husky voice (masculinization in females).

Clinical Features
Signs: Cords look like pale, water-filled bags.

Treatment Stop smoking; Decortication (strip edematous mucosa, one cord at a time to prevent webbing).

KMU High-Yield Differentiators

Feature Vocal Nodules Vocal Polyp

Laterality Bilateral Unilateral

Cause Chronic abuse Sudden abuse

Treatment Speech therapy first Surgery first

Other MCQ Pearls

• Diplophonia: Seen in vocal polyp (and paralysis).

• Contact Ulcer/Granuloma: Posterior cord (vocal process of arytenoid); cause = reflux or intubation trauma.

• Microlaryngeal Surgery: GA with microlaryngeal tube + suspension laryngoscope + operating microscope (400
mm lens).

D) Neurological Disorder
Vocal Cord Paralysis
Nerve Supply Recap
Type Nerve

All intrinsic muscles by Recurrent Laryngeal Nerve (RLN) except Cricothyroid (External branch of Superior
Motor
Laryngeal Nerve).

Sensory Above cords: Internal Laryngeal Nerve; Below cords: RLN.

Types of Paralysis & Cord Position

Type Cord Position Clinical Features Treatment

Paramedian (1.5 mm from Hoarse/breathy voice; Wait & watch (6–12 months), speech
Unilateral RLN
midline) due to intact Cricothyroid airway normal; aspiration therapy; if persistent → Thyroplasty Type I
Palsy
pulling cord medially. rare. (medialization) or injection laryngoplasty.

Median/Paramedian (both cords Tracheostomy; later airway-widening

Bilateral RLN Stridor + good voice
close) → airway severely surgery (cordotomy, arytenoidectomy,
Palsy (emergency).
compromised. Thyroplasty Type II).

Loss of high pitch, vocal

Cricothyroid paralyzed → loss of
SLN Palsy fatigue; wavy cord & Voice therapy; rarely surgical.
tension.
oblique glottis.

Combined (RLN Cadaveric position (3.5 mm from Aphonia + severe Epiglottopexy or total laryngectomy (for
+ SLN) midline; intermediate). aspiration. intractable aspiration).

Cord Positions (Gold Standard)

Position Distance from Midline Seen In

Median 0 mm Phonation / Bilateral RLN palsy

Paramedian 1.5 mm Unilateral RLN palsy

Cadaveric 3.5 mm Combined palsy

Gentle Abduction 7 mm Quiet respiration

Full Abduction 9.5 mm Deep inspiration

KMU High-Yield Tips

• Semon’s Law vs Wagner-Grossman: Progressive lesions → abductor fibers fail first (old concept). Modern:
Cricothyroid intact → cord pulled medially (paramedian).

• Clinical Scenarios:

o Stridor + good voice → Bilateral RLN palsy.

o Breathy voice + normal airway → Unilateral RLN palsy.

o Singer loses high pitch → External SLN injury.

• Ortner’s Syndrome: Left RLN palsy due to enlarged left atrium (mitral stenosis).

• Thyroplasty Types (Isshiki):

o Type I: Medialization (unilateral palsy).

o Type II: Lateralization (bilateral palsy).

o Type III: Shortening (lowers pitch).

o Type IV: Lengthening (raises pitch).

• Left vs Right RLN: Left loops around aortic arch → vulnerable to thoracic pathology; Right loops around
subclavian artery.

E) Tumours
Squamous Papilloma (Benign Tumour)
Type Key Features Treatment

• HPV types 6 & 11 (viral origin).

• Acquired at birth from mother with genital warts.
Microlaryngeal surgery (MLS) with CO₂
• Age: 3–5 yrs.
laser or microdebrider.
Juvenile Papillomatosis • Multiple grape-like growths on cords, false cords,
Adjuvants: Interferon, Cidofovir.
(RRP) subglottis; may spread to trachea/bronchi.
Avoid tracheostomy (risk of distal
• Symptoms: Hoarseness → stridor → aphonia.
seeding).
• High recurrence; regresses after puberty.
• Malignant change rare (except after RT).

• Usually single, smaller, less aggressive.

Adult-Onset Papilloma • Site: Anterior half of cord/anterior commissure. Surgical excision.
• Recurrence rare.

Carcinoma Larynx (Malignant Tumour)

Feature Supraglottic Glottic Subglottic

Epiglottis, aryepiglottic folds,

Site True vocal cords (anterior half). Below cords → cricoid.
false cords, ventricle.

Scanty → late nodal spread

Rich → early nodal metastasis Spreads to pretracheal/paratracheal
Lymphatics (Reinke’s space has no
(often bilateral). (Delphian node).
lymphatics).

Vague: throat pain, dysphagia,

Hoarseness = early (classic
Symptoms referred otalgia, neck mass. Stridor (late).
sign).
Hoarseness = late.

Poor (late detection + early Excellent (early detection + no

Prognosis Poor (advanced at diagnosis).
metastasis). nodes).

Spread

• Anterior commissure: Crosses to opposite cord → horseshoe lesion.

• Posterior: Invades arytenoid → fixed cord (T3).

Management of Carcinoma Larynx

Stage Treatment

Early (T1/T2 mobile cord) Radiotherapy (preserves voice) or transoral laser microsurgery.

Conservation laryngectomy (vertical hemilaryngectomy for glottic; supraglottic

Intermediate (T2/T3)
laryngectomy for supraglottic).

Advanced (T3 fixed cord/T4 cartilage

Total laryngectomy + neck dissection ± RT.
invasion)

Vocal Rehabilitation After Total Laryngectomy

• Oesophageal speech: Swallow air → burp sound (hard to learn).

• Electrolarynx: External vibrator → robotic voice.

• Tracheo-oesophageal puncture (TEP): Gold standard; one-way valve (Blom-Singer prosthesis) allows near-
normal speech.
68

Exam Point Explanation

Glottic = early hoarseness, scanty lymphatics → good prognosis.

Glottic vs Supraglottic Prognosis
Supraglottic = vague symptoms, rich lymphatics → poor prognosis.

Fixed Cord (T3) Indicates cricoarytenoid joint/muscle invasion → surgery required.

Juvenile Papilloma Warnings Avoid RT (induces malignancy); avoid tracheostomy (virus seeding).

Node Levels Supraglottic → Level II/III; Subglottic → Level VI (Delphian node).

T1a = one cord; T1b = both cords mobile; T3 = fixed cord; T4 = cartilage
Staging Pearls
invasion/extralaryngeal spread.

F) Air Way Management

Stridor
Type Site of Obstruction Examples

Inspiratory Supraglottis / Pharynx Laryngomalacia, Epiglottitis

Expiratory Trachea / Bronchi Tracheal stenosis, Bronchial FB

Biphasic Glottis / Subglottis / Cervical trachea Laryngeal papilloma, Vocal cord paralysis, Subglottic stenosis

Common Pediatric Causes:

• Congenital: Laryngomalacia (most common), subglottic stenosis, web, cord paralysis

• Infectious: Epiglottitis, Croup

• Traumatic: Foreign body, edema

Diagnosis:

• Flexible laryngoscopy, X-ray neck (AP/Lateral), Direct laryngoscopy/bronchoscopy under GA.

Tracheostomy
Aspect Details & Explanation

Definition Opening in anterior tracheal wall → stoma on skin.

Respiratory obstruction: Ludwig’s angina, epiglottitis, trauma, Ca larynx, bilateral abductor palsy.
Indications Retained secretions: Coma, head injury.
Respiratory insufficiency: Chronic bronchitis, emphysema.

Functions Alternative airway, suction, prevents aspiration (cuffed tube), reduces dead space (30–50%).

Mid-tracheostomy (2nd–4th rings). Avoid high tracheostomy → risk of cricoid perichondritis & subglottic
Site
stenosis.

Immediate: Apnoea (CO₂ washout), hemorrhage, RLN/esophagus injury, pneumothorax.

Complications Intermediate: Tube blockage/displacement, infection, subcutaneous emphysema.
Late: Tracheal stenosis, tracheo-esophageal fistula, decannulation difficulty.

Tube Types:

• Cuffed: Prevent aspiration, ventilation.

• Fenestrated: Allows speech/weaning.

• Metal (Jackson’s): Permanent stoma, easy cleaning.

Foreign Bodies in Air Passages

Site Clinical Features

Larynx Dyspnoea, hoarseness, aphonia; large FB → sudden death.

Trachea Audible Slap (heard at mouth), Palpatory Thud (felt over trachea), asthmatoid wheeze.

Most common site = Right bronchus.

Vegetal bronchitis: Peanuts → severe mucosal reaction.
Bronchi
Check-valve: Air enters but cannot exit → obstructive emphysema.
Stop-valve: Complete block → atelectasis.

X-ray Findings:

• Obstructive emphysema: Hyperinflated lung, mediastinum shifts to healthy side.

• Atelectasis: Collapsed lung, mediastinum shifts to affected side.

Management:

• Laryngeal FB: Heimlich maneuver; cricothyrotomy if needed.

• Tracheobronchial FB: Rigid bronchoscopy under GA.

KMU High-Yield Tips

• Apnoea after tracheostomy: Due to sudden CO₂ washout (loss of respiratory drive).

• Emergency airway: Cricothyrotomy is fastest in “cannot intubate, cannot ventilate” scenario.

• Subglottis = danger zone: Narrowest pediatric airway → 1 mm edema reduces lumen by 50%.

• X-ray signs: Thumb sign = epiglottitis; Steeple sign = croup.

4)Oeasaphagus
General Anatomy
Feature Details

Length ~25 cm in adults

Extent Lower border of cricoid (C6) → Cardiac orifice of stomach (T11)

Course Passes through superior mediastinum → pierces diaphragm at T10

Physiological Constrictions (Critical for MCQs)

Constriction Distance from Incisors Level

Upper (Pharyngo-esophageal junction) 15 cm C6

Middle (Aorta & Left bronchus crossing) 25 cm T4

Lower (Diaphragmatic hiatus) 40 cm T10

Clinical Significance:

• Common sites for foreign body impaction (coins in children).

• Caustic strictures form here due to pooling.

• Important landmarks for rigid esophagoscopy.

Histology & Muscle Type

Layer Details

Mucosa Stratified squamous epithelium

Submucosa Connective tissue

Muscular coat Outer longitudinal + inner circular

Upper 1/3: Striated

Muscle type Middle 1/3: Mixed
Lower 1/3: Smooth

Outer covering Fibrous (NO serosa → early spread of cancer & poor healing)

Physiology of Swallowing (Deglutition)

Phase Key Events

Oral (Voluntary) Tongue pushes bolus into pharynx

Soft palate closes nasopharynx; larynx elevates; respiration stops; cricopharyngeal

Pharyngeal (Reflex)
sphincter relaxes

Oesophageal
Peristalsis pushes bolus; LES relaxes
(Involuntary)

Sphincters
Sphincter Function

Upper (UES) Cricopharyngeus muscle; prevents air entry & aspiration

Lower (LES) Physiological high-pressure zone; prevents GERD

KMU High-Yield Tips

• Distance Rule:

o 15 cm = Cricopharyngeus (C6)

o 25 cm = Aorta/Bronchus (T4)

o 40 cm = Diaphragm (T10)

• Killian’s Dehiscence: Weak area → Zenker’s diverticulum; “Gateway of Tears” during esophagoscopy.

• No Serosa: Explains rapid mediastinal spread of esophageal cancer & poor anastomotic healing.

• Nerve Supply:

o Parasympathetic (Vagus) → peristalsis

o Sympathetic → pain (shares roots with heart → angina mimic).

Dysphagia Difficulty in swallowing

Odynophagia Painful swallowing

Causes of Dysphagia

Category Examples

Oral phase: Trismus, TMJ disorders, xerostomia (Sjogren’s), tongue paralysis, cleft
Pre-oesophageal palate, stomatitis.
(Oral/Pharyngeal phase) Pharyngeal phase: Tonsillar tumors, retropharyngeal abscess, acute tonsillitis,
Quinsy, bulbar palsy, diphtheria, tetanus, rabies.

Internal obstruction: Foreign body, atresia, benign stricture, carcinoma.

Mural lesions: Oesophagitis (reflux/corrosive), motility disorders (achalasia, spasm,
Oesophageal phase scleroderma).
Extrinsic compression: Pharyngeal pouch, hiatus hernia, cervical osteophytes,
thyroid enlargement, mediastinal masses, vascular rings (dysphagia lusoria).

History – Diagnostic Clues

Pattern Likely Cause

Solids → Liquids (progressive) Mechanical obstruction (stricture, carcinoma)

Liquids > Solids Paralytic lesions

Both solids & liquids (intermittent) Motility disorder (achalasia, spasm)

Sudden onset Foreign body

Progressive + weight loss Carcinoma

Intermittent + chest pain Diffuse oesophageal spasm

Investigations

Best initial test; shows strictures, filling defects, diverticula.

Barium swallow
Signs: Bird beak/rat tail = achalasia; Corkscrew = spasm; Apple core = carcinoma.

X-ray chest/neck Foreign body, osteophytes, mediastinal widening

Oesophagoscopy Direct visualization + biopsy

Manometry Gold standard for motility disorders

Endoscopy precautions Avoid in suspected Zenker’s pouch (risk of perforation)

KMU High-Yield Tips

• Plummer-Vinson Syndrome: Dysphagia + iron deficiency anemia + koilonychia → risk of postcricoid carcinoma.

• Dysphagia Lusoria: Aberrant right subclavian artery compressing esophagus.

• Globus Hystericus: Sensation of lump without true dysphagia (functional).

• Achalasia vs Scleroderma:

o Achalasia = high LES pressure + failure to relax.

o Scleroderma = low LES pressure + absent peristalsis → severe reflux.

• Radiological Signs:

o Bird beak/rat tail = achalasia.

o Corkscrew = spasm.

o Apple core = carcinoma.

Disorders
Corrosive Burns of Esophagus
Aspect Details & Explanation

Aetiology Accidental (children) or suicidal (adults); acids or alkalis (alkalis worse → liquefactive necrosis).

Stages Acute necrosis → granulation → fibrosis → stricture (starts at 2 weeks).

Immediate: Hospitalize, neutralize (within 6 hrs), gentle NGT for feeding, IV antibiotics, steroids (within
48–96 hrs, controversial), avoid vomiting/gastric lavage.
Management
Assessment: Gentle oesophagoscopy (do not pass beyond severe burn), later barium swallow.
Follow-up: Detect strictures early.

Foreign Bodies in Food Passage

Aspect Details
Common Sites Cricopharyngeal sphincter (C6), broncho-aortic
constriction (T4), LES (T10)
Clinical Sudden dysphagia, drooling, localized pain, respiratory
distress (large FB compressing trachea)
X-ray Signs Coin: Face visible on AP view (esophagus); slit on lateral
view. Disc battery: Double contour/halo sign (step-off)
Special Emergency Disc battery: Causes liquefactive necrosis + perforation
in 4–6 hrs → Immediate removal
Management Rigid/flexible oesophagoscopy under GA; cervical
oesophagotomy for impacted/sharp FBs. Avoid: Foley
catheter removal (aspiration risk)
KMU High-Yield Tips

• Dysphagia patterns:

o Solids → liquids = mechanical obstruction (stricture/cancer).

o Solids & liquids = motility disorder (achalasia).

o Intermittent = spasm.

• Radiology pearls:
75

o Apple Core = carcinoma.

o Corkscrew = spasm.

• Disc battery danger: Perforation in hours; X-ray shows halo sign.

• Coin orientation mnemonic: “Food goes flat” → face visible on AP view in esophagus.

• Corrosive ingestion: Never induce vomiting or gastric lavage.

5)Neck Mass
Classification of Neck Masses
Midline Masses Lateral Masses

Thyroglossal duct cyst Branchial cyst

Sublingual dermoid Branchial fistula

Submental lymph nodes Cystic hygroma

Prelaryngeal/pretracheal nodes Lymph nodes (TB, metastatic, lymphoma)

Thyroid isthmus tumor Carotid body tumor

Thymic cyst Laryngocele

Plunging ranula —

Midline Masses
Condition Key Features Diagnostic Sign Treatment

Sistrunk’s operation (remove cyst +

Thyroglossal Cystic, midline swelling; Moves with swallowing
central hyoid + tract to foramen
duct cyst common in children AND tongue protrusion
caecum)

Doughy swelling in
Sublingual Does NOT move with
submental region or floor of Surgical excision
dermoid tongue protrusion
mouth

Smooth, fluctuant, non-transilluminant;

Branchial cyst Contains cholesterol crystals Surgical excision
anterior to SCM

Branchial External opening at lower 1/3 of SCM; Track passes between internal &
Surgical excision
fistula internal opening at tonsillar fossa external carotid arteries

Cystic Soft, compressible, brilliantly Excision or

Present at birth
hygroma transilluminant; posterior triangle sclerotherapy

Carotid body Firm, pulsatile, mobile side-to-side but Lyre’s sign (splaying of carotids on Surgery (vascular
tumor fixed vertically angiography) expertise)

TB: Matted, cold abscess; Metastatic:

Lymph nodes — Depends on cause
Hard, fixed; Lymphoma: Rubbery

KMU High-Yield Tips

• Movement Rules:

o Moves with swallowing: Thyroid, thyroglossal cyst, laryngocele, pretracheal nodes.

o Moves with tongue protrusion: Only thyroglossal cyst.

• Transillumination:

o Positive: Cystic hygroma, ranula.

o Negative: Branchial cyst, thyroglossal cyst.

• Sistrunk’s Key Step: Remove central hyoid bone to prevent recurrence.

• Branchial fistula track: Between internal & external carotids.

• Carotid body tumor: Pulsatile, side-to-side mobility, Lyre’s sign.

• Ludwig’s angina vs plunging ranula: Ludwig’s = woody hard, inflammatory; Ranula = bluish, cystic, dumbbell-
shaped.

Thyroid Gland
Anatomy & Physiology
Feature Details

Isthmus Lies over 2nd–4th tracheal rings

Berry’s
Connects thyroid to cricoid & upper trachea; RLN passes through → danger zone in surgery
Ligament

Superior thyroid artery (ECA) → related to External Laryngeal Nerve; Inferior thyroid artery
Blood Supply
(thyrocervical trunk) → related to RLN

Cells Follicular → T₃/T₄; Parafollicular (C cells) → Calcitonin (origin of Medullary Ca)

Solitary Thyroid Nodule – Work-up

Step Key Points

History Risk factors: Age <20 or >60, male, radiation exposure, rapid growth, hoarseness

TFTs TSH first: Low TSH → hot nodule (benign); Normal/high TSH → cold nodule (higher malignancy risk)

USG Solid vs cystic, calcifications, halo

FNAC Gold standard; cannot differentiate follicular adenoma vs carcinoma

Radioiodine
Hot vs cold nodule
Scan

Benign → observe or thyroxine suppression; Malignant → surgery; Follicular neoplasm →

Management
hemithyroidectomy (diagnostic)

Thyroid Carcinomas
Type Key Features Spread Treatment

Most common (60–70%); radiation risk; Lymphatic (cervical Total thyroidectomy + neck
Papillary
Psammoma bodies, “Orphan Annie” nuclei nodes) dissection; Radioiodine ablation

15–20%; iodine deficiency; FNAC cannot Haematogenous

Follicular Total thyroidectomy + I¹³¹
confirm (bone, lung)

From C cells; marker = Calcitonin; MEN Total thyroidectomy + central neck

Medullary Early nodal spread
IIa/IIb; amyloid in stroma dissection; No radioiodine

Elderly; rapidly growing hard mass; stridor, Aggressive local

Anaplastic Palliative (tracheostomy, RT)
RLN palsy invasion

Haemorrhage Tension hematoma → airway obstruction → open wound immediately

Respiratory obstruction Laryngeal edema or bilateral RLN palsy

RLN injury Unilateral → hoarseness; Bilateral → aphonia + stridor

External Laryngeal Nerve injury Loss of high pitch (cricothyroid paralysis)

Hypoparathyroidism Hypocalcemia → Chvostek’s & Trousseau’s signs

Thyroid storm In toxic goiter patients without proper pre-op prep

KMU High-Yield MCQ Pearls

• FNAC limitation: Cannot diagnose follicular carcinoma (needs capsular invasion on histology).

• Markers: Thyroglobulin → papillary/follicular; Calcitonin → medullary.

• Papillary buzzwords: Psammoma bodies, Orphan Annie nuclei.

• MEN syndromes:

o MEN IIa = Medullary Ca + Pheochromocytoma + Hyperparathyroidism.

o MEN IIb = Medullary Ca + Pheochromocytoma + Mucosal neuromas + Marfanoid habitus.

• Nerve injuries: RLN → hoarseness; SLN → loss of high pitch.

• Berry’s ligament: RLN danger zone during surgery.

Master Table: ENT Clinical Triads, Signs & Golden Rules

SECTION I: OTOLOGY

Triads/Tetrads Details

Meniere’s Tetrad Vertigo + Fluctuating SNHL + Tinnitus + Aural fullness

Gradenigo’s Triad CN VI palsy + Retro-orbital pain (CN V) + Persistent ear discharge

Van der Hoeve Triad Osteogenesis imperfecta + Blue sclera + Otosclerosis

Important Signs:

• Hennebert’s: Positive fistula test without fistula (Congenital syphilis, Meniere’s)

• Griesinger’s: Mastoid edema (Lateral sinus thrombosis)

• Battle’s: Mastoid bruising (Middle cranial fossa fracture)

• Hitzelberger’s: Posterior meatal wall anesthesia (Acoustic neuroma)

Golden Rules:

• Facial nerve landmark = Processus cochleariformis

• Cholesteatoma site = Prussak’s space

• Unsafe CSOM = Marginal/attic perforation

• Carhart’s notch = 2 kHz dip in BC (Otosclerosis)

SECTION II: RHINOLOGY

Triads Details

Samter’s Nasal polyps + Asthma + Aspirin intolerance

Kartagener’s Bronchiectasis + Sinusitis + Situs inversus

Trotter’s Deafness + Palatal paralysis + Neuralgia

Important Signs:

• Holman-Miller: Posterior maxillary wall bowing (JNA)

• Halo sign: CSF + blood separation

• Thumb sign: Swollen epiglottis (Epiglottitis)

• Steeple sign: Subglottic narrowing (Croup)

Golden Rules:

• FESS first step = Uncinate process removal

• Artery of epistaxis = Sphenopalatine

• Little’s area = Kiesselbach’s plexus

SECTION III: THROAT

Triads Details

Plummer-Vinson Dysphagia + IDA + Koilonychia

Behçet’s Oral ulcers + Genital ulcers + Uveitis

Important Signs:

• Trismus = Pterygoid involvement

• Boyce’s sign = Gurgling in Zenker’s pouch

Golden Rules:

• Unilateral tonsil enlargement → rule out malignancy

• Quinsy incision = Base of uvula × anterior pillar

• Tonsil bed = Superior constrictor + Styloglossus

SECTION IV: LARYNX & AIRWAY

Cord Positions Cause

Median/Paramedian RLN palsy

Cadaveric Combined RLN + SLN palsy

Golden Rules:

• Safety muscle = PCA (only abductor)

• Nerve supply = All by RLN except Cricothyroid (External SLN)

• Pediatric narrowest = Subglottis

• FB common site = Right bronchus

SECTION V: OESOPHAGUS

Dysphagia Pattern Cause

Solids → liquids Mechanical obstruction

Solids + liquids Motility disorder

Radiology Signs:

• Bird’s beak = Achalasia

• Corkscrew = Spasm

• Apple core = Carcinoma

Constrictions:

• 15 cm = Cricopharyngeus

• 25 cm = Aorta/Bronchus

SECTION VI: NECK & THYROID

Diagnostic Rules Details

Moves with tongue Thyroglossal cyst

Moves with swallowing Thyroid, thyroglossal cyst

Transilluminates Cystic hygroma

Pulsatile Carotid body tumor

Thyroid Cancer Buzzwords:

• Papillary = Psammoma bodies, Orphan Annie nuclei

• Medullary = Calcitonin, Amyloid stroma, MEN II

• Follicular = Hematogenous spread

• Anaplastic = Aggressive, elderly

Complications:

• RLN injury → hoarseness

• SLN injury → loss of high pitch

• Hypocalcemia → Chvostek/Trousseau

• Frey’s syndrome = Gustatory sweating

• Crocodile tears = Gustatory lacrimation

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