Anatomy of EAR

28 March 2021 13:21

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Tympanic Membrane

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 Middle Ear Anatomy

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Sadé Grading
1- Slight retraction NOT upto Incus
2- TM onto the incus or incudos-tapedial joint, but NOT
promontary
3- TM onto the promontory
4- TM adherent onto promontary
5- Atelectatic tympanic membrane is perforated

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 Inner Hair Cells Outer HC Supporting Cells
Flaske shaped Tubular
Less/3500 More/12000
Single Row Multiple Rows
No Emission Otoacoustic emission (OAE)
Not Damaged Easily Damaged
Loud sound
Ototoxic drugs
Aminoglycosides
Diuretics
NSAIDS
Quinine
Cisplatin

Nerves

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Ext--> Middle--> Cochlea--------------------> cochlear--->SON---> Lateral----> Inferior---> Medial------> Auditory
Ear Ear VII nerve Nucleus Lemniscus Colliculi Geniculate Cortex
Ganglion

Facial Nerve

1. Greater Superior Petrosal Nerve (GSPN)

2. Nerve to stapedius

3. Auricular/Sensory branch of Facial

4. Corda Tympani nerve

5. Nerve to stylohyoid muscle

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4. Corda Tympani nerve

5. Nerve to stylohyoid muscle

6. Nerve to posterior belly of digastric muscle

7. Terminal branch (Pes Anserinus)

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Investigations of ear-
01 April 2021 20:14
Hearing test Vestibular function Test
Tuning Fork Test Caloric test
Audiometry Fistula test
Tympanometry Electronystagmography
BERA Optokinetic test
OAE HINT
Galvanic test
Posturography
VEMP-Vestibular evoked myogenic potential

Tuning fork tests

1. Rinne test
2. Weber test
3. ABC test/Schwabach’s test
4. Bing test
5. Gelle test
6. Stenger’s test
7. Chimani-Moos test
8. Teal

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Normal Hearing SNHL SEVERE SNHL CHL

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 Pure Tone Audiometry

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Normal Hearing

CHL

SNHL

Mixed HL

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 A. B/L AC>BC, Weber's to left side

B. Right AC>BC, Left BC>AC, Weber's to right side

C. B/L AC>BC, Weber's to right side

D. B/L BC>AC, Weber's to left side

Presbycusis
NIHL
Ototoxicity
Acoustic Neuroma

Impedance Audiometry aka Tympanometry

Adult- 220/226Hz
Child- 600Hz
New born- 1000Hz

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Brainstem evoked response audiometry (BERA)-
Otoacoustic emissions (OAE)

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 Otoacoustic emissions (OAE)

Brainstem evoked response audiometry (BERA)-

Ext--> Middle--> Cochlea--------------------> cochlear--->SON---> Lateral----> Inferior---> Medial------> Auditory

Ear Ear VII nerve Nucleus Lemniscus Colliculi Geniculate Cortex
Ganglion

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 Auditory neuropathy-
Causes:
• Hyperbilirubinemia
• Neurodegenerative disorders
• Demyelinating disorder
• Hereditary- Charcot marie tooth diseases with deafness
• Inflammation neuropathy
• Development delays
• Ischaemic-hypoxic neuropathy
• Meningitis
• Cerebral palsy
/ Bithermal Caloric test

Fitzgerald Hallpike test

Modified Kobrak test
Dundas grand test/Cold Air CT

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 ○ Check the mobility of membrane
○ Instillation of powered medication in ear
○ Elicit signs like fistula sign
○ Elicit signs like Brown’s sign.
During a tuning fork test called Gelle’s test

true positive fistula test false positive fistula test false negative fistula test
(Hennebert’s sign)
1. Labyrinthine fistula, or CSOM 1. Meniere’s disease 1. Dead labyrinth/EAR

2. Fenestration surgery 2. Fistula which is blocked

Type V tympanoplasty by cholesteatoma

3. Post stapedectomy

4. Perilymph fistula

1. HINT- quick, bed side test

• head impulse
• nystagmus
• test of skew
2. Galvanic test- end organ vs neural pathology
3. VEMP-Vestibular evoked myogenic potential-
Inferior vestibular nerve

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EAR inflammation Otitis Externa

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 1. Acute suppurative otitis media/ Acute otitis media/ASOM/AOM

2. Otitis media with effusion/Serous otitis media/Non-suppurative otitis media/Glue ear

3. Acute mastoiditis

4. Chronic otitis media and their complications

5. Tuberculosis of the middle ear

1. ASOM

2. Serous otitis media

3. Acute mastoiditis

4. Chronic otitis media

5. Tuberculosis of the middle ear

Tubal occlusion pre-suppuration suppuration Resolution

or or
Hyperemia Complication

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BULGING TM CARTWHEEL APPEARANCE FLUID LEVEL

Serous Otitis Media/Glue Ear/Otitis Media with Effusion

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Safe CSOM/Tubo-Tympanic disease Unsafe CSOM/Attico-Antral disease

Cholesteotoma

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 Cholesteotoma

Levenson's criteria
A- whitish mass medial to the normal TM;
B- normal pars flaccida and tensa;
C- no prior history of otorrhea/ perforation;
D- no prior ear surgery;
E- prior bouts of otitis media were not grounds for exclusion

Stages
stage I- Confined to a single quadrant;
stage II- Multiple quadrants, No ossicular involvement;
stage III- Ossicular involvement without mastoid extension;
stage IV- mastoid involvement.

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Retraction pocket or Negative pressure Wittmack’s theory
Basal cell hyperplasia Ruede’s theory
Metaplasia Sade’s theory
Invasion/Migration Habermann’s theory

Tubercular Otitis Media

Extracranial/Intratemporal complications Intracranial complications

Meningitis
Ossicular damage Lateral sinus thrombophlebitis
Mastoiditis sub dural abscess
Petrositis extra dural abscess
Gradenigo’s syndrome Cerebral abscess
Labyrinthine fistula otitis hydrocephalus
Labyrinthitis
Facial nerve palsy

Acute Mastoiditis

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 Petrositis

Labyrinthine Fistula

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 Lateral Sinus Thrombosis

Fever, foul smelling D/S

Headache, Aphasia, Convulsions

Facial Palsy

Causes of facial palsy

Bell’s palsy
Trauma
infections
Tumour
Neurological
Syndromes- Ram Say Hunt synd
Melkersson Rosenthal synd
Millard Gubler synd

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 LMN Palsy UMN Palsy

1. Entire face on the same side is paralysed 1. The lower half on opposite side is paralysed
and the opposite side is normal and the same side is Normal
2. Face is deviated to the Opposite side 2. Mouth is deviated to the same side of
damage( opposite to paralysis side)

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Surgeries
23 January 2020 17:43

Surgeries Surgeries
Myringotomy
Myringotomy with grommet insertion
Myringoplasty
Ossiculoplasty
Tympanoplasty
Mastoidectomy

Myringoplasty/Type I Tympanoplasty

Ossiculoplasty

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 Battle sign

Hydroxyapitite Titanium
TORP- Total ossicular replacement prosthesis
PORP- Partial ossicular replacement prosthesis

Tympanoplasty
Modified Wullstein classification:

Type I: Myringoplasty- Graft over head of malleus

Type II: Absent malleus handle;

TM over incus

Type III: Collumela

Stapedo-myringopexy
Only stapes present
TM reconstructed to lie on stapes head (myringostapediopexy)

Type IV: TM placed over round window & E tube to create Cavum minor with baffle effect

Type V: Fenestration surgery

Fixed footplate;
Fenestrate/Fistula on lateral Semi circular canal

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 Fixed footplate;
Fenestrate/Fistula on lateral Semi circular canal

Mastoidectomy

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Self-Retaining, Hemostatic mastoid Retractors

Mollison's retractor

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 Self-Retaining, Hemostatic mastoid Retractors

Mollison's retractor

CWU CWD
TM in normal place Residual disease
ME space is seen on follow up
normal/sufficient No recurrence
No cavity problem Total
Recurrence common exteriorisation of
Facial recess may not facial recess
be exteriorised Cavity problem
Second stage surgery Less ME space
may be required Hearing not as good

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Glomus tumour
23 January 2020 18:13

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 Trans canal Confined to middle ear and
approach whole tumour visible
Hypotympanic Extending into hypotympanum
Extended facial Into mastoid
recess app
Mastoid neck app Glomus jugulare not in ICA, Neck,
Post fossa
Infratemporal app Large glomus jugulare
Transcondylar app Towards foramen magnum

Fisch classification
Type A - Tumor limited to middle ear

Type B - Tumor limited to the tympano-mastoid area with no infra-labyrinthine

compartment involvement

Type C - Tumor involving the infra-labyrinthine compartment of temporal bone with

extension to petrous apex
C1 -Tumor with limited involvement of the vertical portion of the carotid canal
C2 -Tumor invading the vertical portion of the carotid canal
C3 -Tumor invasion of the horizontal portion of the carotid canal

Type D – Intracranial spread

D1 - Tumor with an intracranial extension less than 2 cm in diameter
FacialD2 -Tumor with an intracranial Most
nerve extension greater
common than
nerve 2 cm in
involved diameter
Glomus tympanicum
(VII)
X & XI Schmidt syndrome Glomus jugulare
X & XII Tapia syndrome
IX, X, XI Vernet syndrome
X, XI, XII Jackson syndrome
IX, X, XI, and XII Collet-Sicard syndrome
X, X, XI, and XII+sympathetic chain Villeret syndrome

Otosclerosis

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 Cholesterol Granuloma

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Inner ear diseases
23 January 2020 18:47

Meniere's Disease

• Fluctuating tinnitus
• Fluctuating hearing loss (SNHL)
• Episodic vertigo/ nausea & nystagmus ( 20 min to 24 hrs)
• Ear fullness

• Hennebert’s sign
• Tulio’s phenomena
• Diplacussis (monoaural diplacusis)
• Recruitment phenomena
• SISI

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 • SISI

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• Histamine analogue

• H1 and H2 agonist & H3 antagonist

• It is central vasodilator and improves microcirculation.

• Increases turnover & release of histamine in vestibular nucleus

• It inhibits vestibular nucleus/vestibular sedative

Surgeries

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 Benign paroxysmal positional vertigo -BPPV

A 45 years old lady with positional vertigo lasting for few seconds

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 Dix Hallpike Epleys maneuver

• Geotropic tortional and up-beating

nystagmus
• Latency (a few seconds)
• Limited duration (< 20 s)
• Reversal upon return to upright position
Canalith repositioning
Epley Maneuver
Semont Maneuver
Half-Somersault or Foster Maneuver
Brandt-Daroff Exercise

Superior semi-circular canal dehiscent Syndrome

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Meniere's disease Superior canal dehiscent Presbycusis BPPV
Syndrome

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Neural diseases

Acoustic Neuroma/ Vestibular Schwannoma

M/C nerve- Inferior Vestibular Nerve

M/C site- Cerebro-pontine angle- C-P Angle

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Assistive Device for Hearing

1. Hearing Aid-

2. Brainstem Implant

3. Cochlear Implant

BAHA (Bone anchored HA)

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Throat anatomy
24 January 2020 21:21
Throat Anatomy

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 PalatineTonsils Adenoids
Two in number Single
Non-keratinising squamous epithelium Ciliated columnar epithelium
Has crypts Does not have crypts
Has capsule No capsule

Arteries of Tonsil

1. main: Tonsillar or of facial Art

2. Ascending Pharyngeal
3. Ascending Palatine
4. Descending palatine
5. Dorsal Lingual

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 Nasopharynx

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Nasopharynx and oropharynx
25 January 2020 21:05
Nasopharynx

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 Choanal Atresia

Nasopharyngeal Carcinoma

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 HO's triangle

T1 Tumor confined to the nasopharynx, or extenion to oropharynx and/or nasal cavity without parapharyngeal involvement
T2 Tumor with extension to parapharyngeal space, and/or adjacent soft tissue involvement (medial pterygoid, lateral pterygoid, prevertebral muscles)
T3 Tumor with infiltration of bony structures at skull base, cervical vertebra, pterygoid structures, and/or paranasal sinuses
T4 Tumor with intracranial extension, involvement of cranial nerves, hypopharynx, orbit, parotid gland, and/or extensive soft tissue infiltration beyond
the lateral surface of the lateral pterygoid muscle

.
N0 No regional lymph node metastasis

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 T4 Tumor with intracranial extension, involvement of cranial nerves, hypopharynx, orbit, parotid gland, and/or extensive soft tissue infiltration beyond
the lateral surface of the lateral pterygoid muscle

.
N0 No regional lymph node metastasis
N1 Unilateral metastasis in cervical lymph node(s) and/or unilateral or bilateral metastasis in retropharyngeal lymph node(s), 6 cm or
smaller in greatest dimension, above the caudal border of cricoid cartilage
N2 Bilateral metastasis in cervical lymph node(s), 6 cm or smaller in greatest dimension, above the caudal border of cricoid cartilage
N3 Unilateral or bilateral metastasis in cervical lymph node(s), larger than 6 cm in greatest dimension, and/or extension below the caudal
border of cricoid cartilage
.

Distant metastasis
(M)
cM0 No distant metastasis
cM1 Distant metastasis
pM1 Distant metastasis, microscopically confirmed
Stag T N M
e
0 Tis N0 M0
I T1 N0 M0
II T0– N1 M0
T1
T2 N0– M0
N1
III T0– N2 M0
T3
T3 N1– M0
N2
IVA T4 N0– M0
N2
T N3 M0
Juvenile
Any Nasopharyngeal Angiofibroma/JNA
IVB T N Any M1
Any

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.

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 Flutamide

Muscles of Mastication
1. Temporalis- Elevation & Retraction
2. Lateral Pterygoid- Protraction & Depression
3. Medial Pterygoid- Elevation
4. Massateric- Elevation

Oropharynx

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Oropharynx

Spaces of Pharynx

Quincy/Peritonsillar Abscess Ranula Ludwig's Angina

Tonsillitis
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 Tonsillitis

Types:
1. Catarrhal tonsillitis
2. Follicular
3. Membranous
4. Parenchymatous
5. Fibrinoid

Greyish white
Causes of Membrane in throat Pseudo membrane
Spreads to adjoining tissue
Bleed on removal
1. Membranous tonsillitis Bull's Neck
Toxic child
2. Diphtheria Vocal cord palsy
3. Infectious mononucleosis
4. Candidiasis
5. Agranulocytosis/leukemia
6. Aphthous ulcer etc.

Tonsillectomy

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Boyle's Davis mouth gag

Eve's Tonsillar Snare

St. Clair Thompson Adenoid Curette

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Eagle's Disease

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Carcinoma Tongue

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Anatomy Larynx
Laryngopharynx

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 Vocalis Muscle

1. Shortens & Thickens 2. Tenses ant part 3. Relaxes post part

Changes Tonal quality High pitch

Thyroepiglottitis- opens the inlet of larynx

Aryepiglottitis- closes the inlet of larynx

Zenker's Diverticulum

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 Grades
I Entire laryngeal aperture seen
II Post commissure seen
III Epiglottis seen
IV Soft palate seen

Vocal cord palsy

• Thyroidectomy surgery.
• Idiopathic
• Tumours
• Brochogenic CA
• Esophageal CA
• Laryngeal CA
• Trauma /Neck or chest injury
• Cardiac problems
• Ortner’s syndrome
• Systemic conditions like Diabetics
• Stroke.
• Inflammation.
• Infections
• Arthritis
• Neurological conditions.
• multiple sclerosis
• Parkinson's disease etc

RLN Palsy/Abductor palsy Vagus Palsy/Adductor Palsy

U/L Palsy B/L Palsy U/L Palsy B/L Palsy

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 RLN Palsy/Abductor palsy Vagus Palsy/Adductor Palsy
U/L Palsy B/L Palsy U/L Palsy B/L Palsy

ELN Palsy SLN Palsy

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 Laryngeal diseases
26 January 2020 06:24

Dysphonia plica Ventricularis

Spasmodic Dyphonia

Functional Aphonia

Puberphonia
1. Voice therapy/Psychotherapy
2. Gutzmann's technique
3. Type III thyroplasty/Relaxation T

Androphonia
1. Voice therapy/Psychotherapy
2. Type IV thyroplasty
3. Reduction Glottoplasty

Phonasthenia

Rhinolalia Aperta/Hypernasality
Rhinolalia Clausa/Hyponasality

Rhinolalia Aperta Rhinolalia Clausa

• cleft Palate Decrease space in nose & nasopharynx
• soft Palate Palsy Nasal Polyp
• velopharyngeal Insufficiency Adenoid HT
• Adenoidectomy Inf turb. HT
• Palatoplasty

Thyroplasty What is done Indication

Type I Medialisation U/L Adductor palsy------------improve voice
Type II Lateralization B/L Abductor palsy------------relieve dyspnoea
Type III Shorten/loosen Puberphonia---------------------decrease Pitch of voice
Type IV Lengthen/tighten Androphonia --------------------Increase pitch

Laryngomalacia

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 Sub glottic Stenosis
Myer- Cotton grading
Grade I 0-50% stenosed
Grade II 5o-70% stensed
Grade III 70-99% stenosed
Grade IV Complete
obstruction

Glottic Web

Cohen's classification & Benzamin's classification

Type I- Anterior web involving </- 35 %

Type II- involving 35-50 %
Type III- 50-75%, anterior end thickened
Type IV- 75-90%, may involve sub-glottis

Laryngitis /Inflammatory diseases

Acute Epiglottitis CROUP (Acute Laryngo-tracheo-bronchitis)

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 Thumb Sign Steeple Sign

Chronic Laryngitis

Grading
I. Mild erythema, stasis of secretion, string sign, piling up of inter arytenoid mucosa
II. Diffuse oedema & mucosal thickening, but little erythema
III. Diffuse erythema with granular friable mucosa or ulceration
IV. Discrete granuloma with or without oedema & erythema

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Laryngeal growth
09 June 2020 21:11

ss

/Singer's nodule

V.C Nodule/ Singer's nodule V.C Polyp

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• Laryngeal Papilloma/ Multiple papilloma of larynx
• Juvenile onset recurrent respiratory papillomatosis (JORRP)

Prevention of Recurrance
1. Intralesional injections of Cidofovir, Acyclovir
2. Interferons alpha 2A
3. Indole 3 carbinol
4. Bevacizumab
Latest treatment option- Photodynamic therapy

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 • Endoscopic surgery
• RT is C/I

T1 Tumor limited to 1 subsite of the supraglottis, with normal vocal cord mobility

T2 Tumor invades mucosa of more than 1 adjacent subsite of the supraglottis or glottis or region outside the supraglottis (eg,
mucosa of base of the tongue, vallecula, medial wall of piriform sinus), without fixation of the larynx

T3 Tumor limited to the larynx, with vocal cord fixation, and/or invades any of the following: postcricoid area, preepiglottic
space, paraglottic space, and/or inner cortex of the thyroid cartilage

T4 Moderately advanced or very advanced

T4a Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea,
cricoid cartilage, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or
esophagus)

T4b Very advanced, local disease

Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structure
N1 Metastasis in a single ipsilateral lymph node ≤ 3 cm in greatest dimension and no extranodal extension (ENE [-])

N2 Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension and ENE
(-);
N2a Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension and ENE ( -)

N2b Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension and ENE (-)

N2c Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension and ENE (-)

N3 Metastasis in a lymph node > 6 cm in greatest dimension

N3a Metastasis in a lymph node > 6 cm in greatest dimension and ENE (-)

N3b Metastasis in any node(s) and clinically overt ENE (+)

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TOUSS-SL: Transoral Ultrasonic surgery assisted supraglottic Laryngectomy
TOUSS-TL: " " " " Total Laryngectomy
TORS-TL-Transoral Robotic Total Laryngectomy

Tracheostomy
*Breathing bypass
*Decrease dead space
*Protection
*Aspirate secretion
*IPPR
*For other surgeries
s

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 Tracheostomy high volume , low pressure

Speech Rehabilitation

Speech rehabilitation
Oesophageal
Tracheo-oesophageal
Electrolarynx
Transoral pneumatic device- vibrating rubber diaphragm in plastic tube in back of oropharynx

Muir Passay valve

Blom Singler's valve

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 Nose and sinuses
Nose and Sinuses 24 January 2020 21:21

Bacterial/

Halo sign/target sign/ Double ring sign

Glucose > 30 gm

Beta 2 Transferrin

Nasal Septum

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 Epistaxis
-

• Trauma to the nose/Nose Picking (M/C)

• Idiopathic
• Foreign Body
• Hypertension- Adult
• Disorders of platelet, Clotting factor, blood
vessels
• Drugs-Aspirin
• Tumours & Malignancy
• Anatomical defects like DNS, Spur
• Chronic infection

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 Hematoma of Septum

Septal Perforation
1. Surgical (Sub Mucosal Resection-SMR)-M/C cause

• Other trauma

2. NK lymphoma/T-cell/ Non healing Midline

3.Chronic inflammatory conditions

• Wegener's granulomatosis
• Tuberculosis/Lupus/Leprosy
• Syphilis -Bony perforation
• Sarcoidosis

4. Cocaine abuse

5. Topical decongestants

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 Lateral Wall

Nasolacrimal Duct

Maxillary > Ethmoidal > Sphenoidal > Frontal

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 Maxillary > Ethmoidal > Sphenoidal > Frontal

Nerve supply of nose

1. Olfactory nerve

2. Sensory supply
1. Nasopalatine Nerves ----- Maxillary nerve
2. Greater palatine nerve ---- Maxillary nerve
3. Anterior ethmoidal nerve--Ophthalmic nerve
4. Posterior Ethmoidal nerve-Ophthalmic nerve

3. Autonomic nervous system (parasympathetic)- Vidian nerve

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 Function of Nose

Measurement of Muco-ciliary clearance of Nose:

1. Saccharine test

2. Rhinoscintigraphy- 99m Tc-labelled particles (Resins)

3. Radiopaque teflon disks

4. Combined dye and saccharin

5. Gamma scintigraphy – total nasal clearance

Smell Tests
• Burghard sniffing sticks (ODOFIN)
• UPSIT Smell test (university of Pennsylvania SI test)
• Sensonic smell test
• Cross culture smell identification
• Screen 12/ 16 tests
• Smell diskette

Rhinosinusitis
a. Allergic rhinitis

b. Vasomotor rhinitis

c. Infective rhinitis

d. Irritative rhinitis
□ Simple chronic rhinitis
□ Hypertrophic rhinitis
□ Rhinitis medicamentosa
□ Rhinitis caseosa
□ Rhinitis sicca
□ Atrophic rhinitis

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 □ Atrophic rhinitis

Fungal rhinosinusitis

1. Aspergillosis

2. Fulminant fungal sinusitis

3. Mucormycosis or
Rhino-Orbito-Cerebral mucormycosis (ROCM)

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 4. Allergic fungal rhinitis

Hirtz view

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 Onodi Cell Onodi cell Heller cell Concha Bullosa Agar nasi cell

• Tilley- lichtwiz trocer and cannula

Deviated Nasal Septum

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 SEPTOPLASTY SUBMUCOSAL RESECTION (SMR) +/_ Turbinoplasty

Conservativ Radical
Freer's/Hemitransfixation Incision Killian's incision
From one side From both sides
Less complications More complication

After 16-17 years After 16-17 years

Nasal Polyps

SAMTER’S TRIAD KARTEGENNER’S SYND YOUNG’S SYND

• Ethmoidal polyp • Polyp/Sinusitis • Polyp/Sinusitis
• Asthma • Bronchiectasis • Bronchiectesis
• Aspirin sensitivity • Situs inversus/dextrocardia • Azoospermia/infertility

Maxillary Polyp Ethmoidal Polyp

Child Adult
Infection Allergy
U/L & Single B/L & Multiple
Not Recurrent Recurrent
CT Scan CT Scan
Antibiotic + FESS Steroids + FESS

Ethmoidectomy

Rhinolith
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 Rhinolith
Rhinophyma
Rhinoscleroma
Rhinosporidiosis

Rhinophyma

Rhinosporidiosis

Fractures of Facial bones

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 Fractures of Facial bones

Le Fort fractures/Maxillary fractures/Midfacial fractures

Blow Out fracture

Tumours

Benign Ossifying fibroma

Osteoma
Hemangioma

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 Hemangioma
Neurofibroma
Intermediate Inverted papilloma/ Ringertz tumour
Ameloblastoma
Malignant Different carcinomas
Esthesioneuroblastoma

MRI- Convoluted cerebriform pattern/Cerebral cortical gyrations (both T2 and contrast-

enhanced T1 weighted images).

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