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ent

Types of tympanograms

Type A Normal
As Otosclerosis
B Serous otitis media
Ad Ossicular disruption
C Eustachian tube block
Mechanical advantage / ossicular leverage ratio Handle of malleus is 1.3 times longer than the long process of incus
Hydraulic action of tympanic membrane / hydraulic / areal ratio The effective vibratory area of tympanic membrane is 14 times larger than the stapes footplate
Transformer action Therefore there is 18 times amplification of sound

Audiogram

Normal Threshold between 1-20 db normal for air conduction and bone conduction closely follows
Sensorineural deafness Deafness more sever in higher in frequencies

ac as well bc are reduced

Conductive deafness Greater loss of hearing in lower frequencies by ac

bc is normal, wide gap between ac and bc

Mixed deafness ac is reduced and bc is partially reduced with some gap between ac and bc

*Carhart’s notch- In otosclerosis, audiogram shows a notch characterised by slight reduction in the bone conduction at 2000 Hz.

Rinne test Atleast 15 db of hearing loss should be present for it to become negative
Positive Normal and sensorineural deafness
Negative Conductive deafness
Equivocal Very mild conductive deafness
False negative Unilateral severe sensorineural deafness
Weber test Atleast 5 db  of hearing loss should be present for it to become lateralized
Normal Equal on both sides
Conductive deafness Lateralised to the affected ear
Sensorineural deafness Sound is lateralized to the better ear

*Tuning fork frequency used for testing-512 Hz

QUOTE CORNER

We all have ability. The difference is how we use it. – Stevie Wonder

ELEVENTH HOUR ENT                                                                                                                               85

Mild deafness Hearing loss between  20-30 db
Moderate deafness Hearing loss between 30-60 db
Severe deafness Hearing loss above 60 db
TYMPANOPLASTY TYPE DESCRIPTION
Type 1 Ossicular chain is intact, only inspection and grafting is done
Type 2 Incus / malleus are damaged, transposition / ossicular grafting done
Type 3( Columella effect) Incus / malleus are absent, drum grafted on stapes head
Type 4 (Baffle effect) Stapes superstructure is absent, drum grafted on round window and Eustachian tube opening
Type 5 Stapes fixed, fenestration on lateral semicircular canal done
Angular acceleration Semicircular canal
Linear acceleration Utricles and saccules
Horizontal linear acceleration Saccules
Vertical linear acceleration Saccules
Gravity Utricles and saccules
Position of head in space Utricle and saccules

Asom

Cartwheel appearance Radially placed dilated blood vessels on the surface of tympanic membrane
Lighthouse sign Pulsatile discharge of the exudate under pressure, synchronized with pulse.

*Most common organism causing acute otitis media is pneumococcous

*Diffuse otitis externa is also known as Singapore ear/ tropical ear/ swimmers ear/ Telephonists’ ear.

Commonest causative agent of otitis externa is staphylococcus aureus

Investigation of choice in malignant otitis externa is gallium CT scan

*Glue ear-serous otitis media

Potbelly tympanic membrane is seen in serous otitis media

*Boxer’s ear/ cauliflower ear – haematoma of the auricle

Bezold’s abscess Deep to sternomastoid
Luc’s abscess Roof of bony canal, subtemporal
Citelli’s abscess Digastric triangle, posterior belly of digastric

TRIVIAL TRUTH

The human nose can remember 50,000 different smells.

ELEVENTH HOUR ENT                                                                                                                               86

Sigmoid sinus thrombosis

Greisinger’s sign Thrombosis of mastoid emissary vein

Edema over posterior part of mastoid.

Tobey-Ayer test / Queckenstedt’s test Compression of vein on the thrombosed side produces no effect, while on healthy side it leads to rapid rise in CSF pressure
Crowe-beck test Pressure on jugular vein of healthy side produces engorgement of retinal veins.

*Erection of pinna- outward downwards and forwards pushing of pinna due to mastoid abscess

Suprameatal triangle/ Macewen’s triangle Surface marking for mastoid antrum
Boundaries
Anterior Posterosuperior border of bony external auditory canal along with the Suprameatal spine of Henle
Superiorly Supramastoid crest
Posteriorly Vertical line drawn tangential to the posterior margin of the external auditory canal
Gradenigo’s syndrome
Mastoiditis, with otorhhoea

Retro-orbital pain (trigeminal neuralgia)

Sixth nerve palsy

Tulio phenomenon
Loud sound induces vertigo

Seen in congenital syphilis, fistula of semicircular canal and in fenestration operation with mobile stapes

Trotter’s triad
Unilateral deafness

Fixation of soft palate

Homolateral neuralgia and anesthesia  of the 3rd division of trigeminal nerve

Contraindications for ear syringing
Ear perforation

CSF otorrhoea

Hygroscopic foreign body

*For ear syringing the direction is towards the anterior or posterior wall

QUOTE CORNER

Whether you think you can or whether you think you can’t, you’re right.- Henry Ford

ELEVENTH HOUR ENT                                                                                                                               87

Glomus tumor Commonest Benign neoplasm of the middle ear
Glomus jugulare Arises from jugular bulb
Glomus tympanicum Arises from the promontory of middle ear
Rising sun sign Tumor arising from the floor of middle ear
Brown’s sign On sieglisation , blanching occurs

*Investigation of choice in Glomus jugulare tumor CT angiogram

Van der Hoeve syndrome
Otosclerosis

Blue sclera

Osteogenesis imperfecta

*Paracusis willisi

In otosclerosis, patient hears better inn noisy surroundings

* Commonest complication of mumps in children in aseptic meningitis

H. influenza B meningitis leads to residual auditory deficits

*External auditory canal is cartilaginous in its outer 1/3rd and bony in the inner 2/3rd

*Ramsay Hunt syndrome

Herpes zoster in the external auditory canal causes otalgia and when it is accompanied by ipsilateral facial nerve palsy, due to the involvement of geniculate ganglion

* Cold water moves eyes to opposite direction

Warm water moves eyes towards the same side.

*Investigation of choice in acoustic neuroma is mri

*Earliest simple test for detecting congenital deafness is startle reflex

Startle reflex: A reflex seen in normal infants in response to a loud noise. The infant with make a sudden body movement, bringing the legs and arms toward the chest.

Openings in the lateral wall of nose

Spheno-ethmoidal recess Opening of sphenoid sinus
Superior meatus Opening of posterior ethmoidal sinus
Middle meatus Frontal sinus

Maxillary sinus

Anterior ethmoidal sinus

Middle ethmoidal sinus

Inferior meatus Nasolacrimal duct

TRIVIAL TRUTH

If you sneeze too hard, you can fracture a rib.If you try to suppress a sneeze,you can rupture a blood vessel in your head or neck and die.If you keep your eyes open by force,they can pop out.

ELEVENTH HOUR ENT                                                                                                                               88

Dangerous area of face Dangerous area of nose
Lower part of external nose and upper lip

Infection may spread to the cavernous sinus through the inferior ophthalmic veins via the anterior facial vein

Also olfactory area may infect the meninges along the piamater and arachnoidmater sheath of the olfactory nerves passing through the cribriform plate  of the ethmoid causing meningitis, encephalitis and brain abscess
Antrochoanal polyp ethmoidal polyp
From maxillary sinus Ethmoidal sinus
Usually single Multiple and bilateral
Seen in children and adults After puberty
Due to infection Allergy and infection
Extends backwards Extends forwards
Recurrence unlikely Recurrence likely
Sleuder’s neuralgia
Anterior ethmoidal syndrome

Pain around the bridge of nose radiating to the forehead

Due to middle turbinate pressing on the septum

Submucous resection Septoplasty
Radical operation, most of the cartilage is removed Conservative, most of the cartilage is preserved
Not done in children Done in children
Higher risk of perforation Lower risk of perforation
Revision surgery difficult Revision surgery easier
Stigmata of allergic rhinitis
Allergic salute

Rabbit nose

Dennie lines

Allergic shiners

*Nose picking is the commonest cause of epistaxis

Commonest cause of epistaxis in elderly is hypertension

Commonest site of epistaxis is Little’s area / Kiesselbach’s plexus, followed by Woodruff’s plexus

*Dish face deformity is seen in fracture of facial bones

QUOTE CORNER

The difference between a successful person and others is not a lack of strength, not a lack of knowledge, but rather a lack in will.Vince Lombardi

ELEVENTH HOUR ENT                                                                                                                               89

*Battles sign- bruising over mastoid region, seen in fracture of base of skull

*Investigation of choice in angiofibroma is CT with or without contrast

Waldeyer’s ring
Palatine tonsil

Nasopharyngeal tonsil

Tubal tonsils

Lingual tonsils

Lateral pharyngeal bands

Pharyngeal nodules

Radical neck dissection

STRUCTURES REMOVED STRUCTURES PRESERVED
Lymph nodes Carotids
Submandibular gland and tail of parotid gland Brachial plexus
External jugular vein Hypoglossal nerve
#Internal jugular vein Vagus
#Sternomastoid Phrenic nerve
#Accessory nerve Facial nerve
Sympathetic trunk

# – Preserved in modified / functional neck dissection

sound cause remarks
Snoring Oropharyngeal obstruction Inspiratory sound
Grunting Partial closure of glottis Expiratory , hyaline membrane disease
Rattling Tracheobronchial secretion Inspiratory
Stridor Laryngotracheal obstruction Inspiratory
Wheeze Bronchial obstruction Expiratory

Brassy or barking cough is seen in Laryngotracheal diseases

Hacking cough -postnasal drip

Triad of Ramsay Hunt syndrome
Herpes zoster of tympanic membrane / external ear

Tinnitus / ear pain

Facial palsy

*Acute epiglottitis

Main cause of acute epiglottitis in children is Hemophilus influenza B

Thumb sign and Tripod sign are seen in acute epiglottitis

TRIVIAL TRUTH

Wearing headphones for just an hour will increase the bacteria in your ear by 700 times.

ELEVENTH HOUR ENT                                                                                                                               90

*Acute laryngotracheobronchitis

Main cause in children is parainfluenza virus.

Steeple sign- X- ray sign seen in it.

*Infective laryngitis is the commonest cause of hoarseness

*Singer’s nodes

Vocal nodules

In persons who misuse or overuse their voice

Excision by microlaryngoscopy

*Reinke’s edema

Bilateral polyps of vocal cord along the whole length

Edema of subcutaneous Reinke’s space

*Glottic diameter of 3mm indicates that the patient is having laryngeal paralysis

For quite respiration it should be 14 mm

*Barking dog position

Neck flexed on thorax and head extended on atlanto-occipital joint

Position of the patient for direct laryngoscopy

*Commonest cause of tracheostomy is head injury with unconsciousness

*Lemierre disease is infection of parapharyngeal space caused by fusobacterium necrophorum

*Eagle’s syndrome is Glossopharyngeal neuralgia due to enlarged styloid process

QUOTE CORNER

The block of granite which was an obstacle in the pathway of the weak, became a stepping-stone in the pathway of the strong.- Thomas Carlyle

ELEVENTH HOUR ENT                                                                                                                               91

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