Ear, Nose & Throat Review Booklet by Dr. Aryan

Ear, Nose & Throat Review
A Free Booklet Series by Dr. Aryan

Preface:
• This is the study material designed by Dr. Aryan with creation and compilation of the best
of the best and the most finest slides on the subject. I would like to offer a billion heartily
thanks for everyone who contributed directly or indirectly to the creation of the material
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Best of luck WORK & SUCCESS! Dr. Aryan
(Anish Dhakal)

False positive in about 25% cases of Meniere’s disease (Hennebert’s sign).
Dr. Aryan (Anish Dhakal)

Otoscopic Findings in OME
•Tympanic membrane:
• often dull and opaque with loss of light reflex
• yellow, grey or bluish in colour
• may show varying degree of retraction
• Mobility is restricted
•Thin leash of blood vessels may be seen along the handle of
malleus or at the periphery of tympanic membrane
•Fluid and air bubble may be seen when fluid is thin and the
tympanic membrane transparent

Longitudinal fracture Transverse fracture
Frequency More common( 80% ) Less common ( 20%)
Type of injury Parietal blow Occipital blow
Fracture line Runs parallel to long axis of petrous
pyramid , starts at squamous part of
temporal bone at end at foramen
lacerum
Runs across petrous , start at foramen
magnum or jugular foramen towards
foramen spinosum
Bleeding from ear Common due to injury to tegmen and
tympanic membrane
Absent because tympani membrane intact .
Haemotympanum can be seen
CSF otorrhoea Present often mixed with blood Absent or unmanifested
Structures injured Tegmen, ossicles and tympanic
membrane
Labyrinth or CN VIII
Hearing loss Conductive Sensineural
Vertigo Less often; due to concussion Severe, due to injury to labyrinth or CN 8
Facial paralysis Less ; delayed onset . Nerve is injured
in tympanic segment , distal to
geniculate ganglion
Most common, immediate onset . Injury to
nerve in meatal labyrinthine segment
proximal to geniculate ganglion

Sunderland’s Classification of Nerve Injury:

Treatment for Otomycosis
A. Ear toilet debris favors to growth of fungus
Syringing, suction, or mopping
B. Antifungal for a week, even after cure
 Nystatin Candida
 Broad spectrum  Clotrimazole, povidone iodine
 2 % salicylic acid in alcohol  keratolytic  epithelial debris with fungal mycelia
removed
C. Topical Antibiotic and steroid Bacterial superinfection
Inflammation & edema subside better antifungal penetration
D. Ear must be kept dry (personal hygiene, no oil or water & avoid erratic
use of antibiotics)

Furunculosis Acute mastoiditis
Preceding ASOM absent History of previous ASOM
Pain is common. Pressure over tragus or below
cartilaginous part would cause excruciating pain
Mastoid tenderness reported
Conductive deafness mild due to occlusion of
meatus. Hearing improves if ear speculum
inserted
Altered hearing and is not affected by speculum
insertion
Tympanic membrane absolutely normal Congested tympanic membrane
X ray mastoid reveals no abnormalities (clear air
cell system)
Cloudiness of mastoid air cells is noted
Retroauricular groove is obliterated by furuncle
in posterior meatal wall
Intact retroauricular groove
Scanty discharge usually seen if furuncle bursts Mucoid discharge often pulsatile (light house
effect)
Pinna pushed forward Pinna pushed forward, downward and outward
Sagging of posterosuperior meatal wall and
smooth ironed out appearance over mastoid
No such findings

Treatment of Furunculosis (localized acute otitis externa)
Early cases without abscess formation
o Systemic antibiotics cloxacillin
o Analgesics
o Local heat
Abscess incision & drainage
Ear pack of 10% ichthammol glycerine
o Provides Splintage & reduce pain
o Glycerine hygroscopic action reduce edema
o Ichthammol mildly antiseptic
For recurrent furunculosis, exclude diabetes and any source of infection like nasal vestibule or
skin infection.

Treatment of ASOM:
Antibiotic therapy
• Amoxycillin 90mg/kg/day PO TDS for 10 days
• Ampicillin 90mg/kg/day IV QID for 10 days (IV until symptoms resolves)
Decongestant nasal drops
• Oxymetazoline or xylometazoline to reduce eustachian tube edema & to promote
ventilation of middle ear
Myringotomy
Bulged drum and acute pain
Incomplete resolution despite antibiotics
Persistent effusion beyond 12 weeks
Suppurative complication: facial palsy

Types of CSOM
• Tubotympanic (Mucosal)
• Safe or benign type
• Involves anteroinferior part – eustachian tube and mesotympanum
• Associated with central perforation
• Atticoantral (Squamosal)
• Unsafe or dangerous type
• Involves posterosuperior part – attic, antrum and mastoid
• Associated with an attic or a marginal perforation
• Often associated with cholesteatoma, granulation and osteitis

Lateral sinus thrombosis signs:

Grading of jerk Nystagmus
• Grade 1: present only when looking in the direction of the quick
component.
• Grade 2 : also present when looking straight ahead.
• Grade 3 : present when looking in the direction of the quick component,
when looking straight ahead and when looking in the direction of the slow
component
Alexander’s law:
Jerk nystagmus usually increases in intensity when looking in the direction of
the fast phase.

Grades of TM retraction Features
Grade I Dull, lusterless, absence of cone of light,
prominent markings (e.g. anterior malleolar
folds)
Grade II TM in contact with incudostapedial joint
Grade III Moves on sigelization (Atelectatic)
Grade IV TM contact with promontory, does not move on
sigelization (Adhesive otitis media)

Causes of SNHL & Conductive Hearing loss
P-Presbycusis
O-Ototoxic drugs
I-Infections of labyrinth
N-Noise induced
T-Trauma to labyrinth
M-Meniere's disease
A-Acoustic neuroma
S-Sudden hearing loss
S-Systemic disorders
@POINT MASS

Tympanogram

Central Vs Peripheral Vertigo
Central Peripheral
Sudden onset of weakness or sensory loss in one
half of the body
Recurrence of vertigo lasting less than a minute
(BPPV)
Impairment of gait and posture Ear symptoms
Associated with headache or other migrainous
phenomenon
Drugs like aminoglycosides, cisplatin, phenytoin,
benzodiazepines
Risk factors: HTN, DM, smoking or vascular disease
Nausea, vomiting, ataxia and nystagmus (cerebellar
lesion)
Similar drugs causing cerebellar toxicity
Brainstem lesion features like diplopia, visual loss,
dysphagia, dysarthria, weakness, ataxia, etc.

Conductive hearing loss Sensorineural Hearing loss
Rinne negative Rinne positive (normal). False negative Rinne: In
severe unilateral loss, due to transcranial
transmission sound is heard by opposite ear in
bone conduction while not responding to air
conduction at all.
Hears when sound is increased Shows irritation. Hears but cannot understand
Hears better in noisy environment (market, fair)
due to masking effect
No improvement in such condition
Speech discrimination normal Speech discrimination impaired
Speech may be monotonous later Speech becomes louder

Tonsillectomy indications

It includes inspecting the middle ear for any disease and also ensuring ossicular integrity.

Blood supply for Tonsil
1) Tonsillar branch of facial artery
2) Ascending palatine, branch of facial artery
3) Descending palatine, branch of maxillary artery
4) Ascending pharyngeal, branch of external carotid
artery
5) Dorsal linguae branches of lingual artery

Tracheostomy Care

Nasal polyp Vs. Hypertrophied turbinate: In polyp, probe can be passed
all around, mobile, insensitive to pain, does not bleed, gray and glistening

Probe test in anterior rhinoscopy:
1. Attachment
2. Sensitivity
3. Mobility
4. Friability
5. Bleeding to touch (Vascularity)
6. Consistency (@ ACMS FB)

Hemorrhage in Tonsillectomy:
Primary hemorrhage: bleeding
vessels
Reactionary hemorrhage (up to
24 hours): superior constrictor
vessels pressure on vessels
Secondary hemorrhage (5th to
10th POD): sepsis or premature
membrane separation

Views in Plain X-Rays
• Towne’s view: B/L antero-posterior view showing both mastoids &
internal auditory canals
• Law’s view: 150 lateral oblique view
• Schuller’s view: 300 lateral oblique
Trace the ascending ramus of mandible to locate glenoid fossa then EAC and superimposed internal
auditory canal, then arcuate eminence (superior semicircular canals), sinus and dural plate.

Skull X-Rays
 Occipito-mental (Water) view: best for maxillary sinus
 Occipito-mental view with mouth open (Pierre): part of sphenoid sinus
 AP or fronto-occipital (Caldwell) view: best for frontal sinus
 Lateral oblique of orbit (Rhese) view: best for ethmoid sinus
 Submento-vertical (base skull) view: best for sphenoid sinus

• Benign growth of the periosteal bone causing swelling in the EAC
Exostoses Osteoma
Arises from compact bone Arises from cancellous bone
Multiple Single
Bilateral Unilateral
Sessile Pedunculated
Deep part of bony EAC, adjacent to TM Outer part of bony EAC
Exposure to cold water -

Sinusitis Complications:

Allergic Rhinitis:

Surgical modalities include Young’s operation (two circumferential flaps- inner mucosal and outer cutaneous
raised in vestibule & suturing them in midline) or modified young (3 mm opening in between).

Mastoiditis:

Pathology
1. Production of pus under tension
• Drainage of pus through a small perforation of tympanic membrane
and/or eustachian tube cannot keep pace with the amount being
produced
2. Hyperaemic decalcification and osteoclastic resorption of
bony walls
• Causes dissolution of calcium from the bony walls of the mastoid air cells
Cause destruction and coalescence of mastoid air cells, converting them into a single irregular cavity filled
with pus (Empyema of mastoid)

Cholesteatoma
Normal middle ear lining
• Anterior and inferior: Ciliated
columnar
• Middle part: Cuboidal
• Attic: Pavement-like
No keratinizing squamous epithelium
Keratinizing squamous epithelium in the
middle ear or mastoid - Cholesteatoma.
 “Skin in the wrong place”

Tubotympanic (Mucosal) Atticoantral (Squamosal)
Profuse (goblet cells) Scanty
Mucoid (goblet cells) Purulent
Odourless Foul smelling (bone putrefaction,
enzymatic action of cholesteatoma,
anaerobic organisms)
Intermittent Continuous
Non-bloody Bloody (granulation tissue present)
Aggravating & relieving factors No aggravating & relieving factors
(cholesteatoma is always present)

Canal wall up Technique Canal wall down Technique
Meatus Normal appearance Widely open meatus
communicating with mastoid
Dependence Does not require routine cleaning Dependence on doctor for
cleaning mastoid cavity once or
twice a year
Recurrence or residual disease High rate of recurrent or residual
cholesteatoma
Low rate of recurrent or residual
cholesteatoma (thus a safe
procedure)
Second look surgery second look surgery after 6
months or so to rule out
cholesteatoma
Not required
Patient limitation No limitation. Patient allowed
swimming.
Swimming can lead to infection
of mastoid cavity
Auditory rehabilitation Easy to wear a hearing aid if
needed
Problems in fitting a hearing aid
due to a large meatus and
mastoid cavity which sometimes
get infected

Labyrinthitis
• Three types:
1. Circumscribed
• Thinning or erosion of bony capsule of labyrinth—usually horizontal semicircular canal
2. Diffuse serous
• Diffuse intra labyrinthine inflammation without pus formation
• Reversible if treated early
3. Diffuse suppurative
• Diffuse pyogenic infection of the labyrinth
• Permanent loss of vestibular and cochlear functions

Treatment of Diffuse Otitis Externa:
• Acute phase
• Ear toilet
• Remove exudates & debris by suctioning, dry mopping or irrigating canal with warm NS
• Anteroinferior meatal recess drainage which forms a blind pocket where discharge is accumulated
• Medicated wicks:
• Gauze wick soaked with antibiotic & steroid insert in canal
• Instill the same drug twice or thrice
• Change daily for 2-3 days
• Aluminium acetate(8%) or Silver nitrate (3%) mild astringents
• Antibiotics (Broad spectrum) & Analgesic
• Chronic phase
• Treatment aim
• Meatal swelling reduction for effective ear toilet
• Alleviate itching stop scratching & control recurrence

Treatment Contd..
• Gauze wick soaked in 10% ichthammol glycerine to reduce swelling 
followed by ear toilet
• Itching  topical antibiotics & steroid cream
• Chronic stenotic otitis externa or resistance to medical treatment
• Surgical excision bony meatus widened with drill & lined by split
skin graft

Surgical Landmark of Facial Nerve
Middle ear and mastoid
1. Processus Cochleariformis
2. Oval window and horizontal canal
3. Short process of incus
4. Pyramid
5. Tympanomastoid Suture
6. Digastric ridge
Parotid surgery
1. Cartilaginous Pointer
2. Tympanomastoid suture
3. Styloid process
4. Posterior belly of digastric

Types of Otosclerosis

AAO-HNS Criteria for Diagnosis of Meniere's Disease:
Certain Definitive Probable Possible
Confirmed by
histopathology
Two spontaneous
episodes of rotational
vertigo lasting at least
20 minutes
One definitive episode
of vertigo
Episodic vertigo of
Meiniere’s type
without hearing loss
or,
(vestibular variant)
Audiometric confirmation of SNHL SNHL, with
disequilibrium but
without definitive
episodes (cochlear
variant)
Tinnitus and/or a perception of aural fullness
Other causes excluded

Treatment for OME
• Medical
1. Decongestants
2. Antiallergic measures
3. Antibiotics
4. Middle ear aeration
• Surgical
1. Myringotomy and aspiration of fluid
2. Grommet insertion
3. Tympanotomy or Cortical mastoidectomy
4. Surgical treatment of causative factor

The deaf child

Etiology of Deaf Child
• Prenatal
• Infant factors
• Sheibe’s dysplasia
• Alexander’s dysplasia
• Bing-Siebenmann dysplasia
• Michel aplasia
• Mondini’s dysplasia
• Enlarged vestibular apparatus
• Semicircular canal malformation

Etiology
• Postnatal causes
• Genetic
• Waardenburg’s syndrome
• Treacher-Collins syndrome
• Branchio-oto-renal sydnrome
• Van-der Hoeve’s syndrome
• Pierre-Robin sequence
• Down’s syndrome

Tracheostomy is making an opening in the anterior
wall of trachea and converting it into stoma on the
skin surface.
Indications of tracheostomy:
1. Respiratory obstruction
2. Retained secretions
3. Respiratory insufficiency
4. Respiratory paralysis
5. Reduction of dead space

Plunging ranula
• Pseudocyst caused by extravasation of mucus
from obstruction to sublingual salivary gland
• Isolated swelling in submandibular area
• Often painless and slow-growing,
transilluminant
• When they extend through mylohyoid muscle
into neck they are referred as “plunging ranula”
• Treatment: Total excision along with removal of
sublingual gland

Thyroglossal cyst:
Moves upward with the protrusion of tongue
Sistrunk’s operation:
• Complete surgical excision, including the body of hyoid and core of
tongue tissue around the tract in suprahyoid tongue base to the
foramen caecum
• Simple excision without removal of its tract leads to recurrence

Stertor is noisy breathing due to turbulent air flow in narrow airway above the level of larynx.

Retropharyngeal abscess.
Lateral view neck showing widening of
the prevertebral space with gas
formation (C2 > 7mm; C6 > 14 mm child
and 22 mm adult)
Acute retropharyngeal abscess: URTI causing
LN suppuration, penetrating injury,
endoscopic trauma. Tubercular cause in
chronic abscess
Grisel syndrome is positive: rare
cause of torticollis following
subluxation of atlanto-axial joint

In 2003, the RTF’s definition was amended to require confirmatory
radiographic or nasal endoscopic or physical examination findings
in addition to suggestive history
• Above criteria for >12 weeks with one of the following
1. Discoloured nasal drainage from the nasal passages, nasal polyps, or
polypoid swelling as identified on physical examination with anterior
rhinoscopy after decongestion or nasal endoscopy
2. Edema or erythema of the middle meatus or ethmoid bulla on nasal
endoscopy
3. Generalized or localized erythema, edema, or granulation tissue (If the
middle meatus or ethmoid bulla is not involved, radiologic imaging is
required to confirm a diagnosis)

Anterior Epistaxis Posterior Epistaxis
Incidence More common Less common
Site Mostly from Little’s area or anterior
part of lateral wall
Posterosuperior part of nasal
cavity; often difficult to localize
the bleeding point
Age Children or young adults After 40 years of age
Cause Trauma Spontaneous, HTN or
arteriosclerosis
Bleeding Mild, can be controlled by local
pressure or anterior pack
Bleeding is severe, requires
hospitalization, postnasal pack
often required

Epistaxis systemic causes:

Epistaxis Management Sequence
Pinch nose with thumb and index finger for 5 minutes
Trotter’s method (sit, lean forward, spit, mouth breathing, cold
compressions)
Cauterization (silver nitrate or electrocautery)
Anterior nasal packing (ribbon gauze with liquid paraffin 1cm*25
or 12 mm: horizontal or vertical layers)
Posterior nasal packing (gauze, Foley, nasal balloon)
Endoscopic cautery, Submucous Resection, ligation of vessels,
Transnasal Endoscopic Sphenopalatine Artery ligation,
Embolization (surgical measures)

Epistaxis Management: 5 Steps
1) First aid or shock stabilization if required
2) Estimate the amount of blood loss
3) Find the cause of bleeding
4) Control of epistaxis
5) Control of cause of epistaxis

Adenoidectomy

Acknowledgements:
Best of the best slides, pictures and information on the web. Special
thanks to all those brilliant minds for their act of creation and
compilation of scientific material without which this work would not
be possible
• PL Dhingra, et al. Diseases of EAR, NOSE and THROAT & HEAD and
NECK SURGERY
• R.P. Shrivastav, An Illustrated Textbook: EAR, NOSE & THROAT and
Head & Neck Surgery
• Otolaryngology, A Surgical Notebook
• Logan Turner’s Diseases of Nose, Throat and Ear: Head and Neck
Surgery

How to stop lying in bed all day and doing nothing
productive during holidays?
https://medium.com/@anishdhakal718/how-to-stop-lying-in-bed-all-day-
and-doing-nothing-productive-during-holidays-4541a2018798

Ear, Nose & Throat Review Booklet by Dr. Aryan

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Ear, Nose & Throat Review Booklet by Dr. Aryan