ENT Notes on Acoustic Neuroma, Acute Pharyngitis, and Chronic Pharyngitis - PDF

DR MURAD KHAN Hangzhou Normal University ACOUSTIC NEUROMA Acoustic neuroma is also known as Vestibular Schwannoma, Neurilemmoma Or Eighth Nerve Tumour. Acoustic neuroma constitutes 80% Of All Cerebellopontine Angle...

DR MURAD KHAN Hangzhou Normal University ACOUSTIC NEUROMA Acoustic neuroma is also known as Vestibular Schwannoma, Neurilemmoma Or Eighth Nerve Tumour. Acoustic neuroma constitutes 80% Of All Cerebellopontine Angle Tumours and 10% Of All The Brain Tumours. ORIGIN AND GROWTH OF TUMOUR The tumour almost always Arises From The Schwann Cells Of The Vestibular, but rarely from the cochlear division of VIIIth nerve within the internal auditory canal. As it expands, it causes widening and erosion of the canal and then appears in the Cerebellopontine Angle. Here, it may Grow Anterosuperiorly To Involve Vth Nerve or Inferiorly To Involve The IXth, Xth And XIth Cranial Nerves. In later stages, it causes Displacement of Brainstem, Pressure on Cerebellum And Raised Intracranial Tension. The growth of the tumour is extremely slow and the history may extend over several years. CLINICAL FEATURES 1. Age and sex. Tumour is mostly seen in age group of 40–60 years. Both sexes 2. Cochleovestibular Symptoms. They are the earliest symptoms Progressive Unilateral Sensorineural Hearing Loss, Often accompanied by Tinnitus, is the presenting symptom in majority of cases. There is marked Difficulty In Understanding Speech Some patients may get Sudden Hearing Loss Characteristic Feature of AN Vestibular symptoms are Imbalance Or Unsteadiness & True Vertigo. 3. Cranial Nerve Involvement Vth Nerve. This is the earliest nerve to be involved. There is Reduced Corneal Sensitivity, Numbness Or Paraesthesia of face. Involvement of this nerve indicates that the tumour is roughly 2.5 cm in diameter and occupies the cerebellopontine angle. VIIth Nerve. Sensory fibres are affected early. There is hypoaesthesia of posterior meatal wall Hitzelberger’s Sign Loss Of Taste as tested by Electrogustometry December 15, 2017 Reduced lacrimation  Schirmer test. Motor fibres are more resistant and are affected late. Delayed blink reflex may be an early manifestation. IXth and Xth Nerves. There is Dysphagia And Hoarseness due to Palatal, Pharyngeal And Laryngeal Paralysis. Other Cranial Nerves. XIth and XIIth, IIIrd, IVth and VIth are affected when tumour is very large. 1|Page ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University 4. Brainstem Involvement. Ataxia Weakness and numbness of the arms and legs with exaggerated tendon reflexes. 5. Cerebellar Involvement. Pressure symptoms on cerebellum are seen in large tumours. This is revealed by Fingernose Test, Knee-Heel Test, Dysdiadochokinesia, Ataxic Gait And Inability to walk along a straight line with tendency to fall to the affected side. 6. Raised Intracranial Tension. This is also a late feature. Headache, Nausea, Vomiting, Diplopia Due To Vith Nerve Involvement Papilloedema With Blurring Of Vision. INVESTIGATIONS AND DIAGNOSIS Computed tomography (CT) scan. MRI With Gadolinium Contrast. It is superior to CT scan and is the Gold Standard for diagnosis TREATMENT SURGERY Surgical removal of the tumour is the treatment of choice. RADIOTHERAPY X-Knife Or Gamma Knife Surgery.. Cyber Knife. It is totally frameless and more accurate December 15, 2017 2|Page ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University ACUTE PHARYNGITIS AETIOLOGY  Acute pharyngitis is very common and occurs due to varied aetiological factors like viral, bacterial, fungal or others.  Viral causes are more common.  Acute streptococcal pharyngitis (due to Group A beta-haemolytic streptococci) has received more importance because of its aetiology in rheumatic fever and poststreptococcal glomerulonephritis. CLINICAL FEATURES  Milder Infections  Discomfort in the Throat, Malaise and Low-Grade Fever.  Pharynx in these cases is Congested but there is No Lymphadenopathy.  Moderate And Severe Infection Present With  Pain in Throat, Dysphagia, Headache, Malaise and High Fever.  Pharynx in these cases shows Erythema, Exudate and Enlargement of Tonsils and Lymphoid Follicles on the Posterior Pharyngeal Wall.  Very Severe Cases Show  Edema of soft palate and uvula with enlargement of cervical nodes.  It is not possible, on clinical examination, to differentiate viral from bacterial infections but, viral infections are generally mild and are accompanied by rhinorrhoea and hoarseness while the bacterial ones are severe. DIAGNOSIS  Culture of throat swab is helpful in the diagnosis of bacterial pharyngitis. It can detect 90% of Group A streptococci.  Diphtheria is cultured on special media.  Swab from a suspected case of gonococcal pharyngitis should be cultured immediately without delay.  Failure to get any bacterial growth suggests a viral aetiology. TREATMENT 1. General measures. Bed rest, plenty of fluids, warm saline gargles or pharyngeal irrigations and analgesics form the mainstay of treatment. December 15, 2017  Local discomfort in the throat in severe cases can be relieved by lignocaine viscous before meals to facilitate swallowing. 2. Specific treatment.  Streptococcal Pharyngitis is treated with  Penicillin G, 200,000 to 250,000 units orally four times a day for 10 days or  Benzathine Penicillin G, 600,000 units once i.m.  In penicillin-sensitive individuals  Erythromycin  Diphtheria is treated by Diphtheria Antitoxin and Penicillin or Erythromycin.  Gonococcal pharyngitis responds to Penicillin or Tetracycline. 3|Page ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University CHRONIC PHARYNGITIS  It is a chronic inflammatory condition of the pharynx.  Pathologically, it is characterized by hypertrophy of mucosa, seromucinous glands, subepithelial lymphoid follicles and even the muscular coat of the pharynx. Chronic Pharyngitis Is Of Two Types: 1. Chronic catarrhal pharyngitis. 2. Chronic hypertrophic (granular) pharyngitis. AETIOLOGY A large number of factors are responsible: 1. Persistent infection in the neighbourhood. 2. Mouth breathing. Breathing through the mouth exposes the pharynx to air which has not been filtered, humidified and adjusted to body temperature thus making it more susceptible to infections. 3. Chronic irritants. Excessive smoking, chewing of tobacco and pan, heavy drinking or highly spiced food can all lead to chronic pharyngitis. 4. Environmental pollution. Smoky or dusty environment or irritant industrial fumes 5. Faulty voice production. Less often realized but an important cause of chronic pharyngitis is the faulty voice production. 6. Excessive use of voice or faulty voice production seen in certain professionals or in “pharyngeal neurosis” where person resorts to constant throat clearing, hawking or snorting, and that may cause chronic pharyngitis, especially of hypertrophic variety. SYMPTOMS  Discomfort or Pain in the Throat. This is especially noticed in the mornings.  Foreign Body Sensation in Throat.  Tiredness of Voice. Patient cannot speak for long and has to make undue effort to speak as throat starts aching.  The voice may also lose its quality and may even crack.  Cough. Throat is irritable and there is tendency to cough. Mere opening of the mouth may induce retching or gagging. SIGNS  Chronic Catarrhal Pharyngitis.  Congestion of posterior pharyngeal wall with engorgement of vessels;  Faucial pillars may be thickened.  increased mucus secretion which may cover pharyngeal mucosa.  Chronic Hypertrophic (Granular) Pharyngitis  Pharyngeal Wall Appears Thick and Oedematous with Congested Mucosa and Dilated Vessels.  Posterior pharyngeal wall may be studded with reddish nodules (hence the term granular December 15, 2017 pharyngitis).  These nodules are due to hypertrophy of subepithelial lymphoid follicles normally seen in pharynx  Lateral pharyngeal bands become hypertrophied.  Uvula may be elongated and appear oedematous. TREATMENT 1. Warm saline gargles, especially in the morning, are soothing and relieve discomfort. 2. Mandl’s Paint may be applied to pharyngeal mucosa. 3. Cautery of Lymphoid Granules is suggested. 4. Electrocautery or Diathermy of Nodules may require general anaesthesia. 4|Page ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University ACUTE RHINITIS  Acute rhinitis can be Viral, Bacterial or Irritative type. VIRAL RHINITIS Common Cold (Coryza) Aetiology.  Adenovirus, Picornavirus, Rhinovirus, Coxsackie Virus, Influenza Virus  Incubation period is 1–4 days and illness lasts for 2–3 weeks. Clinical features. Burning Sensation At The Back Of Nose soon followed by Nasal Stuffiness, Rhinorrhoea and Sneezing. Low-Grade Fever, Malaise, Anorexia Initially, Nasal Discharge Is Watery and Profuse but may become Mucopurulent due to secondary bacterial invasion. Secondary invaders include Streptococcus haemolyticus, pneumococcus, Staphylococcus, Haemophilus influenzae, Klebsiella pneumoniae and Moraxella catarrhalis. Treatment Bed rest is essential to cut down the course of illness. Plenty of fluids are encouraged. Symptoms can be easily controlled with Antihistaminics and Nasal Decongestants. Analgesics are useful to relieve headache, fever and myalgia. Antibiotics are required when secondary infection supervenes. BACTERIAL RHINITIS 1. Nonspecific Infections. It may be primary or secondary. Primary Bacterial Rhinitis is seen in children and is usually the result of infection with Pneumococcus, Streptococcus Or Staphylococcus.  A Greyish White Tenacious Membrane may form in the nose, which with attempted removal causes bleeding. December 15, 2017 Secondary Bacterial Rhinitis is the result of bacterial infection supervening acute viral rhinitis. 2. Diphtheritic Rhinitis. Diphtheria of nose is rare these days.  It may be primary or secondary to faucial diphtheria and may occur in acute or chronic form.  A Greyish Membrane is seen covering the inferior turbinate and the floor of nose; membrane is tenacious and its removal causes bleeding.  Excoriation of anterior nares and upper lip may be seen.  Treatment is isolation of the patient, Systemic Penicillin and Diphtheria Antitoxin. 5|Page ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University IRRITATIVE RHINITIS This form of acute rhinitis is caused by exposure to dust, smoke or irritating gases such as ammonia, formaline, acid fumes, etc. or it may result from trauma inflicted on the nasal mucosa during intranasal manipulation, e.g. removal of a foreign body. There is an immediate catarrhal reaction with sneezing, rhinorrhoea and nasal congestion. The symptoms may pass off rapidly with removal of the offending agent or may persist for some days if nasal epithelium has been damaged. Recovery will depend on the amount of epithelial damage and the infection that supervenes. CHRONIC RHINITIS 1. CHRONIC SIMPLE RHINITIS AETIOLOGY Recurrent attacks of acute rhinitis in the presence of predisposing factors leads to chronicity. The predisposing factors are: 1. Persistence of nasal infection due to Sinusitis, Tonsillitis and Adenoids. 2. Chronic irritation from dust, smoke, cigarette smoking, snuff, etc. 3. Nasal obstruction due to deviated nasal septum, synechia leading to persistence of discharge in the nose. 4. Vasomotor rhinitis. 5. Endocrinal or metabolic factors, e.g. hypothyroidism, excessive intake of carbohydrates and lack of exercise. PATHOLOGY  Simple chronic rhinitis is an early stage of hypertrophic rhinitis.  There is Hyperaemia and Oedema Of Mucous Membrane with Hypertrophy Of Seromucinous Glands And Increase In Goblet Cells.  Blood sinusoids particularly those over the Turbinates Are Distended. CLINICAL FEATURES Nasal Obstruction. Nasal Discharge. It may be Mucoid Or Mucopurulent Headache. It is due to swollen turbinates impinging on the nasal septum. Swollen Turbinates. Nasal mucosa is dull red in colour. Postnasal Discharge. Mucoid or mucopurulent discharge is seen on the posterior December 15, 2017 pharyngeal wall. TREATMENT 1. Nasal Irrigations with alkaline solution help to keep the nose free from viscid secretions 2. Nasal decongestants help to relieve nasal obstruction and improve sinus ventilation. Excessive use of nasal drops and sprays should be avoided because it may lead to Rhinitis Medicamentosa. 3. A short course of Systemic Steroids helps to wean the patients already addicted to excessive use of decongestant drops or sprays. 4. Antibiotics help to clear nasal infection and concomitant sinusitis. 6|Page ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University 2. HYPERTROPHIC RHINITIS  It is characterized by Thickening Of Mucosa, Submucosa, Seromucinous Glands, Periosteum and Bone. Changes are more marked on the turbinates. SYMPTOMS Nasal Obstruction is the predominant symptom. Nasal Discharge is thick and sticky. Some complain of Headache, Heaviness of Head or Transient Anosmia. SIGNS Examination shows Hypertrophy Of Turbinates. Turbinal Mucosa Is Thick and does not pit on pressure. It shows little shrinkage with vasoconstrictor drugs due to presence of underlying fibrosis. TREATMENT Attempt should be made to discover the cause and remove it. Nasal obstruction can be relieved by reduction in size of turbinates. The various methods are: 1. Linear Cauterization. 2. Submucosal Diathermy. 3. Cryosurgery of Turbinates. 4. Partial or Total Turbinectomy.  Hypertrophied inferior turbinate can be partially removed at its anterior end, inferior border or posterior end.  Middle turbinate, if hypertrophied, can also be removed partially or totally.  Excessive removal of turbinates should be avoided as it leads to persistent crusting. 5. Submucous Resection of Turbinate Bone.  This removes bony obstruction but preserves turbinal mucosa for its function. 6. Lasers have also been used to reduce the size of turbinates. 3. ATROPHIC RHINITIS (OZAENA)  It is a chronic inflammation of nose characterized by Atrophy of Nasal Mucosa and Turbinate Bones.  The nasal cavities are Roomy and Full of Foul-Smelling Crusts.  Atrophic rhinitis is of two types: primary and secondary. December 15, 2017 PRIMARY ATROPHIC RHINITIS Aetiology (Remember Mnemonic HERNIA) 1. Hereditary factors 2. Endocrinal disturbance. 3. Racial factors. 4. Nutritional deficiency. Deficiency of vitamin A, D or iron. 5. Infective. Klebsiella, diphtheroids, Proteus vulgaris, E.coli, staphylococci and streptococci. 6. Autoimmune process. 7|Page ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University Pathology  Ciliated columnar epithelium is lost and is replaced by stratified squamous type.  There is atrophy of seromucinous glands, venous blood sinusoids and nerve elements. Arteries in the mucosa, periosteum and bone show obliterative endarteritis.  The bone of turbinates undergoes resorption causing widening of nasal chambers. Paranasal sinuses are small due to their arrested development. Clinical Features Disease is commonly seen in females and starts around puberty. Foul Smell from the Nose patient himself is unaware of the smell due to Marked Anosmia (Merciful Anosmia). Nasal Obstruction  due to large crusts filling the nose. Epistaxis may occur when the crusts are removed. Examination shows nasal cavity to be Full of Greenish or Greyish Black Dry Crusts covering the Turbinates And Septum. Nose may show a Saddle Deformity. Atrophic changes may also be seen in the Pharyngeal Mucosa which may Appear Dry and Glazed With Crusts. Similar changes may occur in the larynx with Cough and Hoarseness of Voice (atrophic laryngitis). Hearing impairment may be noticed because of obstruction to eustachian tube and middle ear effusion. Paranasal sinuses are usually small and underdeveloped with thick walls. They appear opaque on X-ray. Antral wash is difficult to perform due to thick walls of the sinuses. Treatment 1. Medical. Complete cure of the disease is not yet possible. a. Nasal Irrigation and Removal Of Crusts b. 25% Glucose in Glycerine. After crusts are removed, nose is painted with 25% glucose in glycerine. This inhibits the growth of proteolytic organisms which are responsible for foul smell. c. Local Antibiotics. Kemicetine™ antiozaena solution contains Chloromycetin, Oestradiol And Vitamin D2 and may be found useful. December 15, 2017 d. Oestradiol Spray. Helps to increase vascularity of nasal mucosa and regeneration of seromucinous glands. e. Placental extract injected submucosally in the nose may provide some relief. f. Systemic Use Of Streptomycin. 1 g/day for 10 days has given good results in reducing crusting and odour. It is effective against Klebsiella organisms. g. Potassium Iodide given by the mouth promotes and liquefies nasal secretion. 8|Page ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University 2. Surgical. It includes: a. Young’s Operation. Both the nostrils are closed completely just within the nasal vestibule by raising flaps.  They are opened after 6 months or later. In these cases, mucosa may revert to normal and crusting reduced.  Modified Young’s Operation. To avoid the discomfort of bilateral nasal obstruction, modified Young’s operation aims to partially close the nostrils. It is also claimed to give the same benefit as Young’s. b. Narrowing the Nasal Cavities. Nasal chambers are very wide in atrophic rhinitis and air currents dry up secretions leading to crusting. Narrowing the size of the nasal airway helps to relieve the symptoms. Among the techniques followed, some are: I. Submucosal injection of teflon paste. II. Insertion of fat, cartilage, bone or teflon strips under the mucoperiosteum of the floor and lateral wall of nose and the mucoperichondrium of the septum. III. Section and medial displacement of lateral wall of nose. SECONDARY ATROPHIC RHINITIS  Specific infections like syphilis, lupus, leprosy and rhinoscleroma may cause destruction of the nasal structures leading to atrophic changes.  Atrophic rhinitis can also result from long-standing purulent sinusitis, radiotherapy to nose or excessive surgical removal of turbinates.  Unilateral atrophic rhinitis. Extreme deviation of nasal septum may be accompanied by atrophic rhinitis on the wider side. December 15, 2017 9|Page ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University VASOMOTOR RHINITIS (VMR)  It is Nonallergic Rhinitis but clinically simulating Nasal Allergy with Symptoms of Nasal Obstruction, Rhinorrhoea and Sneezing. PATHOGENESIS ☃ Nasal mucosa has rich blood supply. ☃ Sympathetic stimulation causes vasoconstriction and shrinkage of mucosa, while parasympathetic stimulation causes vasodilation and engorgement. ☃ Overactivity Of Parasympathetic system also causes excessive secretion from the nasal glands. ☃ Autonomic nervous system is under the control of hypothalamus and therefore emotions play a great role in vasomotor rhinitis. ☃ Autonomic System Is Unstable In Cases Of Vasomotor Rhinitis. ☃ Nasal mucosa is also hyper-reactive and responds to several nonspecific stimuli, e.g. change in temperature, humidity, blasts of airand small amounts of dust or smoke. SYMPTOMS  Paroxysmal Sneezing. Bouts of sneezing start just after getting out of the bed in the morning.  Excessive Rhinorrhoea  It is profuse and watery  Nasal Obstruction  Postnasal Drip SIGNS Nasal mucosa over the Turbinates Is Generally Congested and Hypertrophic. TREATMENT MEDICAL 1. Antihistaminics and oral Nasal Decongestants are helpful in relieving nasal obstruction, sneezing and rhinorrhoea. 2. Topical Steroids (e.g. Beclomethasone Dipropionate, Budesonide Or Fluticasone), used as December 15, 2017 spray or aerosol, are useful to control symptoms. 3. Systemic Steroids can be given for a short time in very severe cases. 4. Tranquillizers may be needed in some patients. SURGICAL 1. Nasal obstruction can be relieved by measures which reduce the size of nasal turbinates 2. Excessive rhinorrhoea, not corrected by medical therapy and bothersome to the patient, can be relieved by sectioning the parasympathetic secretomotor fibres to nose  Vidian Neurectomy 10 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University ACUTE TONSILLITIS Primarily, the tonsil consists of 1. Surface epithelium which is continuous with the Oropharyngeal lining, 2. Crypts which are tube-like invaginations from the surface epithelium and 3. The lymphoid tissue. Acute infections of tonsil may involve these components and are thus classified as: 1. Acute Catarrhal or Superficial Tonsillitis:  Here tonsillitis is a part of Generalized Pharyngitis and is mostly seen in viral infections. 2. Acute Follicular Tonsillitis:  Infection spreads into the crypts which become filled with purulent material, presenting at the openings of crypts as yellowish spots. 3. Acute Parenchymatous Tonsillitis:  Here tonsil substance is affected. Tonsil is uniformly enlarged and red. 4. Acute Membranous Tonsillitis:  It is a stage ahead of acute follicular tonsillitis when exudation from the crypts coalesces to form a membrane on the surface of tonsil. AETIOLOGY  Acute tonsillitis often affects school-going children, but also affects adults.  It is rare in infants and in persons who are above 50 years of age.  Haemolytic Streptococcus is the most commonly infecting organism.  Other causes of infection may be staphylococci, pneumococci or H. influenzae.  These bacteria may primarily infect the tonsil or may be secondary to a viral infection. SYMPTOMS  Sore Throat  Difficulty in Swallowing  Fever  It may vary from 38 to 40°C and may be associated with Chills and Rigors.  Sometimes, a child presents with an unexplained fever and it is only on examination that an acute tonsillitis is discovered.  Earache. December 15, 2017  It is either referred pain from the tonsil or the result of AOM which may occur as a complication.  Constitutional symptoms.  Headache, General Body Aches, Malaise and Constipation.  There may be Abdominal Pain due to Mesenteric Lymphadenitis simulating a clinical picture of acute appendicitis. 11 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University SIGNS 1. Often the Breath is Foetid and Tongue is Coasted. 2. There is Hyperaemia of pillars, soft palate and uvula. 3. Tonsils are Red and Swollen with Yellowish Spots of purulent material presenting at the opening of crypts (Acute Follicular Tonsillitis) or there may be a Whitish Membrane on the Medial Surface of Tonsil which can be easily wiped away with a swab (Acute Membranous Tonsillitis). 4. The Tonsils may be Enlarged and Congested so much so that they almost meet in the midline along with some oedema of the uvula and soft palate (Acute Parenchymatous Tonsillitis). 5. The Jugulodigastric Lymph Nodes are Enlarged and Tender. TREATMENT 1. Bed Rest and encouraged to take plenty of fluids. 2. Analgesics  Aspirin or Paracetamol  Relieve local pain and bring down the fever. 3. Antimicrobial Therapy  Penicillin is the DOC.  Patients Allergic to Penicillin can be treated with Erythromycin.  Antibiotics should be continued for 7–10 days. COMPLICATIONS 1. Chronic Tonsillitis with recurrent acute attacks. This is due to incomplete resolution of acute infection. 2. Peritonsillar Abscess. 3. Parapharyngeal Abscess. 4. Cervical Abscess due to suppuration of jugulodigastric lymph nodes. 5. Acute Otitis Media  Recurrent attacks of AOM may coincide with recurrent tonsillitis. 6. Rheumatic Fever  Often seen in association with tonsillitis due to Group A beta- haemolytic Streptococci. 7. Acute Glomerulonephritis. Rare these days. 8. Subacute Bacterial Endocarditis  Acute tonsillitis in a patient with valvular heart disease may be complicated by endocarditis. ☃ It is usually due to Streptococcus viridans infection. December 15, 2017 12 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University DIFFERENTIAL DIAGNOSIS OF MEMBRANE OVER THE TONSIL 1. Membranous Tonsillitis. ☃ An exudative membrane forms over the medial surface of the tonsils, along with the features of acute tonsillitis. 2. Diphtheria. ☃ Unlike acute tonsillitis which is abrupt in onset, diphtheria is slower in onset with less local discomfort, the membrane in diphtheria extends beyond the tonsils, on to the soft palate and is Dirty Grey In Colour. ☃ It is adherent and its removal leaves a bleeding surface. ☃ Urine May Show Albumin. ☃ Smear and culture of throat swab will reveal Corynebacterium Diphtheriae. 3. Vincent Angina. ☃ It is insidious in onset with less fever and less discomfort in throat. ☃ Membrane, which usually forms over one tonsil, can be easily removed revealing an irregular ulcer on the tonsil. ☃ Throat swab  Fusiform Bacilli and Spirochaetes. 4. Infectious Mononucleosis. ☃ This often affects young adults. ☃ Both tonsils are very much enlarged, congested and covered with membrane. ☃ Local discomfort is marked. ☃ Lymph nodes are enlarged in the posterior triangle of neck along with splenomegaly. ☃ Attention to disease is attracted because of failure of the antibiotic treatment. ☃ Blood smear may show more than 50% lymphocytes, of which about 10% are atypical. ☃ White cell count may be normal in the first week but rises in the second week. ☃ Paul–Bunnell test (mono test) will show high titre of heterophil antibody. 5. Agranulocytosis. ☃ It presents with ulcerative necrotic lesions not only on the tonsils but elsewhere in the oropharynx. December 15, 2017 ☃ Patient is severely ill. ☃ In acute fulminant form, total leucocytic count is decreased to 100,000/cu mm. It may be normal or less than normal. ☃ Anaemia is always present and may be progressive. ☃ Blasts cells are seen on examination of the bone marrow. 7. Aphthous Ulcers. ☃ They may involve any part of oral cavity or oropharynx. ☃ Sometimes, it is solitary and may involve the tonsil and pillars. ☃ It may be small or quite large and alarming. ☃ It is very painful. 8. Malignancy Tonsil 9. Traumatic Ulcer ☃ Any injury to oropharynx heals by formation of a membrane. ☃ Trauma to the tonsil area may occur accidently when hit with a toothbrush, a pencil held in mouth or fingering in the throat. ☃ Membrane appears within 24 h. 10. Candidal Infection of Tonsil Diagnosis of ulceromembranous lesion of throat thus requires: 1. History. 2. Physical examination. 3. Total and differential counts (for agranulocytosis, leukaemia, neutropenia, infectious mononucleosis). 4. Blood smear (for atypical cells). 5. Throat swab and culture (for pyogenic bacteria, Vincent angina, diphtheria candidal infection). 6. Bone marrow aspiration or needle biopsy. 7. Other tests. Paul–Bunnell or mono spot test and biopsy of the lesion. December 15, 2017 14 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University FAUCIAL DIPHTHERIA AETIOLOGY  It is an acute specific infection caused by the Gram-positive bacillus, C. Diphtheriae.  It spreads by droplet infection.  Incubation period is 2–6 days.  Some persons are “carriers” of this disease, i.e. they harbour organisms in their throat but have no symptoms. CLINICAL FEATURES  Children are affected more often though no age group is immune.  Oropharynx is commonly involved and the larynx and nasal cavity may also be affected.  In the oropharynx, a Greyish White Membrane forms over the tonsils and spreads to the soft palate and posterior pharyngeal wall.  It is Quite Tenacious and causes Bleeding When Removed.  Cervical lymph nodes, particularly the Jugulodigastric, become Enlarged And Tender, sometimes presenting a “Bull-Neck” Appearance.  Patient is ill and toxaemic but fever seldom rises above 38°C. COMPLICATIONS  Exotoxin produced by C. diphtheriae is toxic to the heart and nerves.  It causes Myocarditis, Cardiac Arrhythmias and Acute Circulatory Failure.  Neurological complications usually appear a few weeks after infection and include Paralysis of Soft Palate, Diaphragm and Ocular Muscles.  In the larynx, diphtheritic membrane may cause airway obstruction. TREATMENT  Antitoxin is given by i.v. infusion in saline in about 60 min.  Antibiotics used are Benzyl Penicillin 600 Mg 6 hourly for 7 days.  Erythromycin is used in penicillin-sensitive individuals (500 mg 6 hourly orally). December 15, 2017 15 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University CHRONIC TONSILLITIS AETIOLOGY  It may be a complication of acute tonsillitis.  Pathologically, Microabscesses walled off by fibrous tissue have been seen in the lymphoid follicles of the tonsils.  Mostly affects children and young adults. Rarely occurs after 50 years.  Chronic infection in sinuses or teeth may be a predisposing factor. TYPES 1. Chronic Follicular Tonsillitis.  Here tonsillar crypts are full of infected cheesy material which shows on the surface as yellowish spots. 2. Chronic Parenchymatous Tonsillitis.  There is hyperplasia of lymphoid tissue.  Tonsils are very much enlarged and may interfere with speech, deglutition and respiration.  Attacks of sleep apnoea may occur.  Long-standing cases develop features of cor pulmonale. 3. Chronic Fibroid Tonsillitis.  Tonsils are small but infected, with history of repeated sore throats. CLINICAL FEATURES  Recurrent Attacks of Sore Throat or Acute Tonsillitis.  Chronic irritation in throat with cough.  Bad Taste in mouth and Foul Breath (halitosis) due to Pus in Crypts.  Thick Speech, Difficulty in Swallowing and Choking spells at night (when tonsils are large and obstructive). EXAMINATION 1. Tonsils may show varying degree of enlargement. Sometimes they meet in the midline (Chronic Parenchymatous Type). 2. There maybe yellowish beads of pus on the medial surface of tonsil (Chronic Follicular Type) 3. Tonsils are small but pressure on the anterior pillar expresses frank pus or cheesy material (Chronic Fibroid Type). December 15, 2017 4. Flushing of anterior pillars compared to the rest of the pharyngeal mucosa is an important sign of chronic tonsillar infection. 5. Enlargement Of Jugulodigastric Lymph Nodes Is A Reliable Sign Of Chronic Tonsillitis. During acute attacks, the nodes enlarge further and become tender. TREATMENT  Tonsillectomy is indicated when tonsils interfere with speech, deglutition and respiration or cause recurrent attacks 16 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University COMPLICATIONS 1. Peritonsillar Abscess. 2. Parapharyngeal Abscess. 3. Intratonsillar Abscess. 4. Tonsilloliths. 5. Tonsillar Cyst. 6. Focus of Infection in Rheumatic Fever, Acute Glomerulonephritis, Eye and Skin Disorders. Tonsilloliths (Calculus of the Tonsil).  It is seen in chronic tonsillitis when its crypt is blocked with retention of debris.  Inorganic salts of calcium and magnesium are then deposited leading to formation of a stone.  It may gradually enlarge and then ulcerate through the tonsil.  Tonsilloliths are seen more often in adults and give rise to local discomfort or foreign body sensation.  They are easily diagnosed by palpation or gritty feeling on probing.  Treatment is simple removal of the stone or tonsillectomy, if that is indicated for associated sepsis or for the deeply set stone which cannot be removed. Intratonsillar abscess  It is accumulation of pus within the substance of tonsil.  It usually follows blocking of the crypt opening in acute follicular tonsillitis.  There is marked local pain and dysphagia.  Tonsil appears swollen and red.  Treatment is administration of antibiotics and drainage of the abscess if required; Later Tonsillectomy should be performed. Tonsillar Cyst  It is due to Blockage Of A Tonsillar Crypt and appears as a Yellowish Swelling over the tonsil.  Very often it is symptomless.  It can be easily drained. December 15, 2017 17 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University Acute Sinusitis Inflammation of sinus mucosa is called acute sinusitis. The sinus most commonly involved is the maxillary followed in turn by ethmoid, frontal and sphenoid. Very often, more than one sinus is infected (multisinusitis). Sometimes, all the sinuses of one or both sides are involved simultaneously (pansinusitis unilateral or bilateral). AETIOLOGY OF SINUSITIS IN GENERAL A. EXCITING CAUSES 1. Nasal infections 2. Swimming and diving 3. Trauma 4. Dental infections B. PREDISPOSING CAUSES LOCAL 1. Obstruction to sinus ventilation and drainage. 2. Stasis of secretions in the nasal cavity. 3. Previous attacks of sinusitis. GENERAL Environment Poor general health BACTERIOLOGY Most cases of acute sinusitis start as viral infections followed soon by bacterial invasion.  Streptococcus Pneumoniae, Haemophilus Influenzae, Moraxella Catarrhalis, Streptococcus Pyogenes, Staphylococcus Aureus and Klebsiella Pneumoniae. ACUTE MAXILLARY SINUSITIS CLINICAL FEATURES 1. Constitutional Symptoms. Fever, Malaise and Body Ache. They are the result of toxaemia. 2. Headache December 15, 2017 3. Pain. Typically, it is situated over the upper jaw, but may be referred to the gums or teeth. Pain is aggravated by stooping, coughing or chewing. 4. Tenderness. Pressure or tapping over the anterior wall of antrum produces pain. 5. Redness and Oedema of Cheek. The lower eyelid may become puffy. 6. Nasal Discharge. Anterior rhinoscopy/nasal endoscopy shows pus or mucopus in the middle meatus. Mucosa of the middle meatus and turbinate may appear red and swollen. 7. Postnasal Discharge. Pus may be seen on the upper soft palate on posterior rhinoscopy or nasal endoscopy. 18 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University DIAGNOSIS Transillumination Test. Affected sinus will be found opaque. X-rays. Waters’ view will show either opacity or a fluid level in the involved sinus. CT scan is the preferred imaging modality to investigate the sinuses. TREATMENT MEDICAL 1. Antimicrobial drugs.  Ampicillin and Amoxicillin are quite effective and cover a wide range of organisms.  Erythromycin or Doxycycline or Cotrimoxazole are equally effective and can be given to those who are sensitive to penicillin.  β-lactamase-producing strains of H. influenza and M. catarrhalis may necessitate the use of Amoxicillin/ Clavulanic Acid or Cefuroxime Axetil. 2. Nasal decongestant drops.  Ephedrine 1% or 0.1% xylo- or oxymetazoline 3. Steam inhalation & Hot fomentation 4. Analgesics. Paracetamol should be given for relief of pain and headache. SURGICAL Antral Lavage.  Most cases of acute maxillary sinusitis respond to medical treatment.  Lavage is rarely necessary.  It is done only when medical treatment has failed and that too only under cover of antibiotics. ACUTE FRONTAL SINUSITIS CLINICAL FEATURES 1. Frontal headache. It shows characteristic periodicity, i.e. comes up on waking, gradually increases and reaches its peak by about mid day and then starts subsiding. It is also called “Office Headache” because of its presence only during the office hours. 2. Tenderness. Pressure upwards on the floor of frontal sinus, just above the medial canthus, causes exquisite pain. 3. Oedema of upper eyelid with suffused conjunctiva and photophobia. 4. Nasal discharge. A vertical streak of mucopus is seen high up in the anterior part of the middle meatus. December 15, 2017 5. X-rays. Opacity of the affected sinus or fluid level can be seen. Both Waters’ and lateral views should be taken. 6. CT scan is the preferred modality. TREATMENT MEDICAL This is same as for acute maxillary sinusitis A combination of Antihistaminic with an Oral Nasal Decongestant SURGICAL Trephination of frontal sinus 19 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University ACUTE ETHMOID SINUSITIS CLINICAL FEATURES 1. Pain. It is localized over the bridge of the nose, medial and deep to the eye. It is aggravated by movements of the eye ball. 2. Oedema of Lids. Both eyelids become puffy and swollen. There is increased lacrimation. Orbital cellulitis is an early complication in such cases. 3. Nasal Discharge. On anterior rhinoscopy, pus may be seen in middle or superior meatus depending on the involvement of anterior or posterior group of ethmoid sinuses. 4. Swelling of the Middle Turbinate. TREATMENT Medical treatment is the same as for acute maxillary sinusitis. Visual deterioration and exophthalmos indicate abscess in the posterior orbit and may require drainage of the ethmoid sinuses into the nose through an External Ethmoidectomy Incision. ACUTE SPHENOID SINUSITIS CLINICAL FEATURES 1. Headache. Usually localized to the occiput or vertex. Pain may also be referred to the mastoid region. 2. Postnasal Discharge. It can only be seen on posterior rhinoscopy. A streak of pus may be seen on the roof and posterior wall of nasopharynx or above the posterior end of middle turbinate. 3. X-rays  Opacity or fluid level may be seen in the sphenoid sinus 4. CT scan is more useful. TREATMENT Treatment is the same as for acute infection of other sinuses. December 15, 2017 20 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University December 15, 2017 21 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University CHRONIC SINUSITIS CHRONIC SINUSITIS IN GENERAL ☃ Sinus infection lasting for months or years is called chronic sinusitis. ☃ Most important cause of chronic sinusitis is failure of acute infection to resolve. PATHOPHYSIOLOGY  Acute infection destroys normal ciliated epithelium impairing drainage from the sinus.  Pooling and stagnation of secretions in the sinus invites infection.  Persistence of infection causes mucosal changes, such as loss of cilia, oedema and polyp formation, thus continuing the vicious cycle. PATHOLOGY  In chronic infections, process of destruction and attempts at healing proceed simultaneously.  Sinus mucosa becomes thick and polypoidal (hypertrophic sinusitis) or undergoes atrophy (atrophic sinusitis).  Surface epithelium may show desquamation, regeneration or metaplasia.  Submucosa is infiltrated with lymphocytes and plasma cells and may show microabscesses, granulations, fibrosis or polyp formation. CLINICAL FEATURES  Clinical features are often vague and similar to those of acute sinusitis but of lesser severity.  Purulent Nasal Discharge is the commonest complaint.  Foul-Smelling Discharge suggests anaerobic infection.  Local Pain and Headache are often not marked except in acute exacerbations.  Some patients complain of Nasal Stuffiness and Anosmia. DIAGNOSIS  X-ray of the involved sinus may show mucosal thickening or opacity.  X-rays after injection of contrast material may show soft tissue changes in the sinus mucosa.  CT scan is particularly useful in ethmoid and sphenoid sinus infections and has replaced studies with contrast materials. December 15, 2017  Aspiration and irrigation: Finding of pus in the sinus is confirmatory. TREATMENT  Culture and sensitivity of sinus discharge helps in the proper selection of an antibiotic.  Initial treatment of chronic sinusitis is conservative, including Antibiotics, Decongestants, Antihistaminics and Sinus Irrigations.  More often, some form of surgery is required either to provide free drainage and ventilation or radical surgery to remove all irreversible diseases so as to provide wide drainage or to obliterate the sinus. 22 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University SURGERY FOR CHRONIC SINUSITIS CHRONIC MAXILLARY SINUSITIS 1. Antral Puncture and Irrigation.  Sinus cavity is irrigated with a cannula passed through the inferior meatus.  Removal of pus and exudates helps the sinus mucosa to revert to normal. 2. Intranasal Antrostomy.  It is indicated if sinus irrigations fail to resolve infection.  A window is created in the inferior meatus to provide aeration to the sinus and its free drainage. 3. Caldwell–Luc Operation.  In this operation, antrum is entered through its anterior wall by a sublabial incision.  All irreversible diseases are removed and a window is created between the antrum and inferior meatus. CHRONIC FRONTAL SINUSITIS 1. Intranasal Drainage Operations.  Correction of deviated septum, removal of a polyp or anterior portion of middle turbinate, or intranasal ethmoidectomy provide drainage through the frontonasal duct.  Treatment of associated maxillary sinusitis also helps to resolve chronic frontal sinusitis. 2. Trephination Of Frontal Sinus (See P. 193). 3. External Frontoethmoidectomy (Howarth’s Or Lynch Operation).  The frontal sinus is entered through its floor by a curvilinear incision round the inner margin of the orbit. Diseased mucosa is removed, ethmoid cells exenterated and a new frontonasal duct created. 4. Osteoplastic Flap Operation.  It may be unilateral or bilateral.  A coronal or a brow incision is used. The anterior wall of frontal sinus is reflected as an osteoplastic flap, based inferiorly.  The diseased tissues are removed and the sinus drained through a new frontonasal duct.  If it is desired to obliterate the sinus, all diseased as well as healthy mucosa are stripped off and the sinus obliterated with fat. CHRONIC ETHMOID SINUSITIS December 15, 2017 1. Intranasal Ethmoidectomy.  This operation is done for chronic ethmoiditis with polyp formation.  The ethmoid air cells and the diseased tissue are removed between the middle turbinate and the medial wall of orbit by the intranasal route.  The frontal and sphenoid sinuses can also be drained by this operation. 2. External Ethmoidectomy.  In this operation, ethmoid sinuses are approached through medial orbital incision.  Access can also be obtained to sphenoid and frontal sinuses and the operation is called fronto-spheno-ethmoidectomy. 23 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University CHRONIC SPHENOIDITIS Sphenoidotomy.  Access to the sphenoid sinus can be obtained by removal of its anterior wall.  This is accomplished by external ethmoidectomy or trans-septal approach, usually the former, because of the coexistence of ethmoid disease with chronic sphenoiditis. COMPLICATIONS OF SINUSITIS A. Local Mucocele/Mucopyocele Mucous retention cyst Osteomyelitis Frontal bone (more common) Maxilla B. Orbital Preseptal inflammatory oedema of lids Subperiosteal abscess Orbital cellulitis Orbital abscess Superior orbital fissure syndrome Orbital apex syndrome December 15, 2017 24 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University C. Intracranial Meningitis Extradural abscess Subdural abscess Brain abscess Cavernous sinus thrombosis D. Descending infections E. Focal infections ACUTE SUPPURATIVE OTITIS MEDIA It is an Acute Inflammation Of Middle Ear by pyogenic organisms. Here, middle ear implies middle ear cleft, i.e. Eustachiantube, Middle Ear, Attic, Aditus, Antrum and Mastoid Air Cells. AETIOLOGY It is more common especially in infants and children of lower socioeconomic group. Typically, the disease follows viral infection of upper respiratory tract but soon the pyogenic organisms invade the middle ear. ROUTES OF INFECTION 1. Via Eustachian Tube. It is the most common route. Eustachian tube in infants and young children is shorter, wider and more horizontal Breast or bottle feeding in a young infant in horizontal position may force fluids through the tube into the middle ear Swimming and diving can also force water through the tube into the middle ear. 2. Via External Ear. Traumatic perforations of tympanic membrane due to any cause open a route to middle ear infection. 3. Blood-borne. This is an uncommon route. December 15, 2017 PREDISPOSING FACTORS Anything that interferes with normal functioning of Eustachian tube predisposes to middle ear infection. It could be: Recurrent attacks of common cold, upper respiratory tract infections and exanthematous fevers like measles, diphtheria or whooping cough. Infections of tonsils and adenoids. Chronic rhinitis and sinusitis. Nasal allergy. 25 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University Tumours of nasopharynx, packing of nose or nasopharynx for epistaxis. Cleft palate. Bacteriology. Most common organisms in infants and young children are Streptococcus pneumoniae (30%), Haemophilus influenzae (20%) Moraxella catarrhalis (12%). Streptococcus pyogenes, Staphylococcus aureus December 15, 2017 26 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University PATHOLOGY AND CLINICAL FEATURES The disease runs through the following stages: 1. Stage Of Tubal Occlusion. Oedema And Hyperaemia Of Nasopharyngeal End Of Eustachian Tube blocks the tube leading to absorption of air and Negative Intratympanic Pressure. There is Retraction of Tympanic Membrane with some degree of effusion in the middle ear but fluid may not be clinically appreciable. Symptoms. Deafness Earache No Fever. Signs. Tympanic membrane is retracted Tuning fork tests show Conductive Hearing Loss 2. Stage Of Presuppuration. If Tubal Occlusion Is Prolonged, pyogenic organisms invade tympanic cavity causing Hyperaemia of its lining. Inflammatory Exudates appears in the middle ear. Tympanic Membrane Becomes Congested. Symptoms. Earache which may disturb sleep and is of throbbing nature. Deafness and Tinnitus are also present, but complained only by adults. Usually, child runs high fever and is restless. Signs. Tympanic Membrane  Red, Congested And Edematous Cart-Wheel Appearance Tuning fork tests Conductive Hearing Loss 3. Stage Of Suppuration. Formation of pus in the middle ear Tympanic membrane starts bulging to the point of rupture. Symptoms. Earache becomes excruciating Deafness increases December 15, 2017 Child may run fever of 102–103°F This may be accompanied by vomiting and even convulsions. Signs. Tympanic membrane appears red and bulging with loss of landmarks. A Yellow Spot may be seen on the tympanic membrane. X-rays of mastoid will show clouding of air cells because of exudate. 27 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University 4. Stage Of Resolution. The tympanic membrane ruptures with release of pus and subsidence of symptoms. Inflammatory process begins to resolve. If proper treatment is started early or if the infection was mild, resolution may start even without rupture of tympanic membrane. Symptoms. With evacuation of pus, earache is relieved, fever comes down and child feels better. Signs. External auditory canal may contain blood-tinged discharge which later becomes mucopurulent. Usually, a small perforation is seen in anteroinferior quadrant of pars tensa. Hyperaemia of tympanic membrane begins to subside with return to normal colour and landmarks. 5. Stage Of Complication. If virulence of organism is high or resistance of patient poor, resolution may not take place and disease spreads beyond the confines of middle ear. It may lead to acute mastoiditis, subperiosteal abscess, facial paralysis, labyrinthitis, petrositis, extradural abscess, meningitis, brain abscess or lateral sinus thrombophlebitis. TREATMENT 1. Antibacterial therapy PenicillinAmpicillin and Amoxicillin If Allergic to Penicillin  Give Cefaclor, Co-Trimoxazole Or Erythromycin In Cases Of Β-Lactamase  Amoxicillin Clavulanate, Augmentin, Cefuroxime Axetil Or Cefixime Antibacterial therapy must be continued for a minimum of 10 days 2. Decongestant Nasal DropsTo relieve eustachian tube oedema Ephedrine Nose Drops (1% in adults and 0.5% in children) or Oxymetazoline Or Xylometazoline 3. Oral nasal decongestants. Pseudoephedrine Antihistaminic 4. Analgesics and antipyretics. Paracetamol helps to relieve pain and bring down temperature. 5. Ear toilet. If there is discharge in the ear, it is dry-mopped with sterile cotton buds and a December 15, 2017 wick moistened with antibiotic may be inserted. 6. Dry local heat helps to relieve pain. 7. Myringotomy. It is incising the drum to evacuate pus and is indicated when Drum Is Bulging and there is acute pain, incomplete resolution despite antibiotics when drum remains full with persistent conductive deafness There is persistent effusion beyond 12 weeks. 28 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University OTITIS MEDIA WITH EFFUSION Aka Serous Otitis Media, Secretory Otitis Media, Mucoid Otitis Media, “Glue Ear” Accumulation of Non-Purulent Effusion in the middle ear cleft. Often the effusion is thick and viscid but sometimes it may be thin and serous. The fluid is nearly sterile. The condition is commonly seen in school-going children. PATHOGENESIS Two main mechanisms are thought to be responsible. 1. Malfunctioning of Eustachian tube. Eustachian tube fails to aerate the middle ear and is also unable to drain the fluid. 2. Increased secretory activity of middle ear mucosa. Biopsies of middle ear mucosa in these cases have confirmed increase in number of mucus or serous-secreting cells. Aetiology 1. Malfunctioning of eustachian tube. The causes are: Adenoid Hyperplasia. Chronic Rhinitis and Sinusitis. Chronic tonsillitis  Enlarged tonsils mechanically obstruct the movements of soft palate and interfere with the physiological opening of Eustachian tube. Benign And Malignant Tumours Of Nasopharynx this cause should always be excluded in Unilateral Serous Otitis Media in an adult. Palatal defects, e.g. cleft palate, palatal paralysis. 2. Allergy 3. Unresolved otitis media. Inadequate antibiotic therapy in acute suppurative otitis media may inactivate infection but fail to resolve it completely. 4. Viral infections. Various adeno- and rhinoviruses of upper respiratory tract may invade middle ear mucosa and stimulate it to increased secretory activity. Clinical Features 1. Symptoms. The disease affects children of 5–8 years of age. The symptoms include: Hearing loss. This is the presenting and sometimes the only symptom December 15, 2017 Delayed and defective speech. Because of hearing loss, development of speech is delayed or defective. Mild earaches. There may be history of upper respiratory tract infections with mild earaches. 29 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University 2. Otoscopic Findings. Tympanic membrane is often dull and opaque with loss of light reflex. It may appear Yellow, Grey Or Bluish In Colour. Thin leash of blood vessels may be seen along the handle of malleus or at the periphery of tympanic membrane and differs from marked congestion of ASOM. Tympanic membrane may show varying degree of retraction. Fluid level and air bubbles may be seen when fluid is thin and TM transparent Mobility of the tympanic membrane is restricted. HEARING TESTS 1. Tuning fork tests show Conductive Hearing Loss. 2. Audiometry. There is Conductive Hearing Loss of 20–40 dB. Sometimes, there is associated Sensorineural hearing loss due to fluid pressing on the round window membrane. 3. X-ray mastoids. There is Clouding Of Air Cells Due To Fluid. TREATMENT The aim of treatment is removal of fluid and prevention of its recurrence. 1. MEDICAL Decongestants to Relieve Oedema Of Eustachian Tube. Antiallergic Measures  Antihistaminics or Steroids may be used in cases of allergy Antibiotics useful in cases of URT Infection or unresolved ASOM Middle Ear AerationPatient should repeatedly perform Valsalva manoeuvre.  Sometimes, politzerization or Eustachian tube catheterization has to be done.  This helps to ventilate middle ear and promote drainage of fluid.  Children can be given chewing gum to encourage repeated swallowing which opens the tube. 2. SURGICAL When fluid is thick and medical treatment alone does not help, fluid must be surgically removed. Myringotomy and Aspiration of Fluidincision is made in TMfluid aspirated e suction. Grommet Insertion If Myringotomy and Aspiration combined with medical measures December 15, 2017 have not helped and fluid recursa Grommet Is Inserted To Provide continued aeration of middle ear. It is left in place for weeks or months or till it is spontaneously extruded. Tympanotomy Or Cortical Mastoidectomy. It is sometimes required for removal of loculated thick fluid or other associated pathology such as cholesterol granuloma. Surgical Treatment Of Causative Factor. Adenoidectomy, Tonsillectomy and/or wash-out of maxillary antra may be required. This is usually done at the time of Myringotomy. 30 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University AERO-OTITIS MEDIA (OTITIC BAROTRAUMA) It is a non suppurative condition resulting from Failure Of Eustachian Tube To Maintain Middle Ear Pressure At Certain Atmospheric Level. The usual cause is Rapid Descent During Air Flight, Underwater Diving Or Compression In Pressure Chamber. MECHANISM When nasopharyngeal air pressure is high, air cannot enter the middle ear unless tube is actively opened by the contraction of muscles as in swallowing, yawning or Valsalva manoeuvre. When Atmospheric Pressure Is Higher Than That Of Middle Ear by critical level of 90 mm Hg, Eustachian Tube Gets “Locked,” i.e. soft tissues of pharyngeal end of the tube are forced into its lumen. Sudden negative pressure in the middle ear causes retraction Of Tympanic Membrane, Hyperaemia and Engorgement Of Vessels, Transudation and Hemorrhages. Sometimes, though rarely, there is rupture of Labyrinthine Membranes with Vertigo And Sensorineural Hearing Loss. CLINICAL FEATURES Severe Earache, Hearing Loss and Tinnitus are common complaints. Vertigo is uncommon. Tympanic Membrane Appears Retracted And Congested. It may get ruptured. Middle ear may show Air Bubbles or Haemorrhagic Effusion. Hearing Loss Is Usually Conductive but Sensorineural Type Of Loss May Also Be Seen. TREATMENT Mild  Decongestant with Antihistaminics are helpful. Above Tx Failed then Myringotomy PREVENTION Aero-otitis can be prevented by the following measures: Avoid air travel in the presence of upper respiratory infection or allergy. Swallow repeatedly during descent. Sucking sweets or chewing gum is useful. December 15, 2017 Do not permit sleep during descent as number of swallows normally decrease during sleep. Autoinflation of the tube by Valsalva should be performed intermittently during descent. Use Vasoconstrictor Nasal Spray and a tablet of Antihistaminic and Systemic Decongestant, half an hour before descent in persons with previous history of this episode. In recurrent barotrauma, attention should be paid to nasal polyps, septal deviation, nasal allergy and chronic sinus infections. 31 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University CHRONIC SUPPURATIVE OTITIS MEDIA Chronic suppurative otitis media (CSOM) is a long-standing infection of a part or whole of the middle ear cleft characterized by Ear Discharge and a Permanent Perforation. A perforation becomes permanent when its edges are covered by squamous epithelium and it does not heal spontaneously. A permanent perforation can be likened to an epithelium-lined fistulous track. TYPES OF CSOM Clinically, it is divided into two types: 1. Tubotympanic. Also called the safe or benign type;  It involves Anteroinferior Part of middle ear cleft, i.e. Eustachian tube and mesotympanum and is associated with a central perforation.  There is no risk of serious complications. 2. Atticoantral. Also called unsafe or dangerous type;  It involves Posterosuperior Part of the cleft (i.e. attic, antrum and mastoid)  Associated with an attic or a marginal perforation.  The disease is often associated with a bone eroding process such as cholesteatoma, granulations or osteitis.  Risk of complications is high in this variety. TUBOTYMPANIC TYPE AETIOLOGY 1. It is the Sequela of Acute Otitis Media usually following exanthematous fever and leaving behind a large central perforation. 2. Ascending infections via the eustachian tube 3. Persistent Mucoid Otorrhoea is sometimes the result of allergy BACTERIOLOGY  Common Aerobic Organisms are Pseudomonas aeruginosa, Proteus, E.coli and S.aureus.  While Anaerobes include Bacteroides fragilis and anaerobic Streptococci. December 15, 2017 CLINICAL FEATURES 1. Ear Discharge.  It is Nonoffensive, Mucoid or Mucopurulent, constant or intermittent. 2. Hearing Loss It is conductive type 3. Perforation  Always central, it may lie anterior, posterior or inferior to the handle of malleus 32 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University 4. Middle Ear Mucosa.  It is seen when the perforation is large.  Normally, it is Pale Pink and Moist; when inflamed it looks Red, Oedematous and Swollen. Occasionally, a polyp may be seen. INVESTIGATIONS 1. Examination under Microscope. 2. Audiogram. ☃ It gives an assessment of degree of hearing loss and its type. ☃ Usually, the loss is conductive but a sensorineural element may be present. 3. Culture and Sensitivity of Ear Discharge. ☃ It helps to select proper antibiotic ear drops. 4. Mastoid X-Rays/CT Scan Temporal Bone. ☃ Mastoid is usually sclerotic but may be pneumatized with clouding of air cells. ☃ There is no evidence of bone destruction. ☃ Presence of bone destruction is a feature of atticoantral disease. TREATMENT 1. Aural Toilet.  Remove all discharge and debris from the ear.  It can be done by dry mopping with absorbent cotton buds, suction clearance under microscope or irrigation (not forceful syringing) with sterile normal saline.  Ear must be dried after irrigation. 2. Ear Drops.  Antibiotic ear drops containing Neomycin, Polymyxin, Chloromycetin or Gentamicin are used.  They are combined with steroids which have local anti-inflammatory effect. 3. Systemic Antibiotics.  They are useful in acute exacerbation of chronically infected ear, otherwise role of systemic antibiotics in the treatment of CSOM is limited. 5. Surgical Treatment.  Polypectomy 6. Reconstructive Surgery.  Once ear is dry, Myringoplasty with or without ossicular reconstruction can be done to restore hearing. December 15, 2017  Closure of perforation will also check repeated infection from the external canal. 33 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University ATTICOANTRAL TYPE  It involves Posterosuperior Part of Middle Ear Cleft (attic, antrum, posterior tympanum and mastoid) and is associated with Cholesteatoma, which, because of its Bone Eroding Properties, causes risk of serious complications.  For this reason, the disease is also called Unsafe or Dangerous Type. AETIOLOGY Aetiology of atticoantral disease is same as of cholesteatoma and has been discussed earlier. SYMPTOMS 1. Ear Discharge.  Usually Scanty, but Always Foul-Smelling due to bone destruction. 2. Hearing Loss.  Hearing loss is Mostly Conductive but sensorineural element may be added. 3. Bleeding.  It may occur from granulations or the polyp when cleaning the ear. SIGNS 1. Perforation It is either Attic or Posterosuperior Marginal Type. 2. Retraction Pocket.  An invagination of tympanic membrane is seen in the attic or posterosuperior area of pars tensa. 3. Cholesteatoma.  Pearly-white flakes of cholesteatoma can be sucked from the retraction pockets. INVESTIGATIONS 1. Examination Under Microscope. ☃ All patients of chronic middle early disease should be examined under microscope. 2. Tuning Fork Tests and Audiogram. ☃ They are essential for preoperative assessment and to confirm the degree and type of hearing loss. 3. X-Ray Mastoids/CT Scan Temporal Bone. December 15, 2017 ☃ They indicate extent of bone destruction and degree of mastoid pneumatization. ☃ Cholesteatoma causes destruction in the area of attic and antrum (key area), better seen in lateral view. ☃ CT scan of temporal bone gives more information and is preferred to X-ray mastoids. 4. Culture And Sensitivity Of Ear Discharge. ☃ It helps to select proper antibiotic for local or systemic use. 34 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University TREATMENT 1. Surgical.  It is the mainstay of treatment.  Two types of surgical procedures are done to deal with cholesteatoma: a. Canal Wall Down Procedures.  They leave the mastoid cavity open into the external auditory canal so that the diseased area is fully exteriorized.  The commonly performed operations for atticoantral disease are Atticotomy, Modified Radical Mastoidectomy and rarely, the radical mastoidectomy. b. Canal Wall Up Procedures.  Here disease is removed by combined approach through the meatus and mastoid but retaining the posterior bony meatal wall intact, thereby avoiding an open mastoid cavity.  It gives dry ear and permits easy reconstruction of hearing mechanism.  Incidence of residual or recurrent cholesteatoma in these cases is very high and therefore long-term follow-up is essential. Some surgeon’s even advise routine re- exploration in all cases after 6 months or so.  Canal wall up procedures are advised only in selected cases.  In combined approach or intact canal wall mastoidectomy, disease is removed both permeatally, and through cortical mastoidectomy and posterior tympanotomy approach, in which a window is created between the mastoid and middle ear, through the facial recess, to reach sinus tympani. 2. Reconstructive surgery.  Hearing can be restored by Myringoplasty or Tympanoplasty. 3. Conservative treatment.  Repeated suction clearance and periodic checkups are essential.  It can also be tried out in elderly patients above 65 and those who are unfit for general anesthesia or those refusing surgery.  Polyps and granulations can also be surgically removed by cup forceps or cauterized by chemical agents like silver nitrate or trichloroacetic acid.  Other measures like aural toilet and dry ear precautions are also essential. December 15, 2017 35 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University ADENOIDS  The Nasopharyngeal Tonsil, commonly called “Adenoids”, is situated at the Junction Of The Roof And Posterior Wall Of The Nasopharynx.  It is composed of vertical ridges of lymphoid tissue separated by deep clefts.  Covering epithelium is of three types:  Ciliated Pseudostratified Columnar  Stratified Squamous Epithelium  Transitional Epithelium  Unlike palatine tonsils, adenoids have no crypts and no capsule.  Adenoid tissue is present at birth, Shows Physiological Enlargement Up To The Age Of 6 Years, and then tends to atrophy at puberty and almost completely disappears by the age of 20.  Blood Supply. Adenoids receive their blood supply from: Ascending Palatine Branch of Facial. Ascending Pharyngeal Branch of External Carotid. Pharyngeal Branch of the Third Part of Maxillary Artery. Ascending Cervical Branch of Inferior Thyroid Artery of Thyrocervical Trunk.  Lymphatics from the adenoid Drain Into Upper Jugular Nodes directly or indirectly via retropharyngeal and parapharyngeal nodes.  Nerve supply is through CN IX and X. They carry sensation. Referred pain to ear due to adenoiditis is also mediated through them. AETIOLOGY  Adenoids are subject to Physiological Enlargement In Childhood. Certain children have a tendency to Generalized Lymphoid Hyperplasia in which adenoids also take part.  Recurrent attacks of rhinitis, sinusitis or chronic tonsillitis may cause chronic adenoid infection and hyperplasia.  Allergy of the upper respiratory tract may also contribute to the enlargement of adenoids. CLINICAL FEATURES 1. NASAL SYMPTOMS December 15, 2017  Nasal Obstruction is the commonest symptom.  This leads to mouth breathing.  Nasal obstruction also interferes with feeding or suckling in a child.  As respiration and feeding cannot take place simultaneously, a child with adenoid enlargement fails to thrive.  Nasal Discharge. It is partly due to choanal obstruction, as the normal nasal secretions cannot drain into nasopharynx and partly due to associated chronic rhinitis.  The child often has a Wet Bubbly Nose. 36 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University  Sinusitis. Chronic maxillary sinusitis is commonly associated with adenoids. It is due to persistence of nasal discharge and infection. Reverse is also true that a primary maxillary sinusitis may lead to infected and enlarged adenoids.  Epistaxis. When adenoids are acutely inflamed, epistaxis can occur with nose blowing.  Voice Change. Voice is toneless and loses nasal quality due to nasal obstruction. 2. AURAL SYMPTOMS  Tubal Obstruction. Adenoid mass blocks the Eustachian tube leading to Retracted Tympanic Membrane And Conductive Hearing Loss.  Recurrent Attacks Of Acute Otitis Media may occur due to spread of infection via the eustachian tube.  Chronic Suppurative Otitis media may fail to resolve in the presence of infected adenoids.  Serous Otitis Media. Adenoids form an important cause of serous otitis media in children. The waxing and waning size of adenoids causes intermittent eustachian tube obstruction with fluctuating hearing loss. 3. GENERAL SYMPTOMS  Adenoid Facies. Chronic nasal obstruction and mouth breathing lead to characteristic facial appearance called adenoid facies. The child has an Elongated face with dull expression, open mouth, prominent and crowded upper teeth and hitched up upper lip. Nose Gives A Pinchedin Appearance due to Disuse Atrophy Of Alaenasi. Hard palate in these cases is highly arched as the  Moulding Action Of The Tongue On Palate Is Lost.  Pulmonary hypertension. Long-standing nasal obstruction due to adenoid hypertrophy can cause pulmonary hypertension and cor pulmonale.  Aprosexia, i.e. lack of concentration. DIAGNOSIS  Examination of postnasal space is possible in some young children and an adenoid mass can be seen with a mirror.  A Rigid or a Flexible Nasopharyngoscope is also useful to see details of the nasopharynx in a cooperative child.  Soft tissue lateral radiograph of nasopharynx will reveal the size of adenoids and also the extent to which nasopharyngeal air space has been compromised. December 15, 2017 TREATMENT Mild Breathing Exercises, Decongestant Nasal Drops And Antihistaminics Severe Adenoidectomy 37 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University ADENOIDECTOMY Adenoidectomy may be indicated alone or in combination with tonsillectomy. In the latter event, adenoids are removed first and the nasopharynx packed before starting tonsillectomy. INDICATIONS 1. Adenoid Hypertrophy causing Snoring, Mouth Breathing, Sleep Apnoea Syndrome or Speech Abnormalities, i.e. (rhinolalia clausa). 2. Recurrent Rhinosinusitis. 3. Chronic Otitis Media with Effusion associated with Adenoid Hyperplasia. 4. Recurrent Ear Discharge in benign CSOM associated with adenoiditis/adenoid hyperplasia. 5. Dental Malocclusion. Adenoidectomy does not correct dental abnormalities but will prevent its recurrence after orthodontic treatment. CONTRAINDICATIONS  Cleft palate or submucous palate. Removal of adenoids causes velopharyngeal insufficiency in such cases.  Haemorrhagic diathesis.  Acute infection of upper respiratory tract. ANAESTHESIA  Always General, with Oral Endotracheal Intubation. POSITION Same As For Tonsillectomy. Hyperextension of neck should always be avoided. STEPS OF OPERATION 1. Boyle–Davis Mouth Gag is inserted.  Before actual removal of adenoids, nasopharynx should always be examined by retracting the soft palate with curved end of the tongue depressor and by digital palpation, to confirm the diagnosis, to assess the size of adenoids mass and to push the lateral adenoid masses towards the midline.  A laryngeal mirror helps to assess the size and extent of adenoid mass. 2. Proper size of “Adenoid Curette with Guard” is introduced into the nasopharynx till its free December 15, 2017 edge touches the posterior border of nasal septum and is then pressed backwards to engage the adenoids. At this level, head should be slightly flexed to avoid injury to the odontoid process. 3. With gentle sweeping movement, adenoids are shaved off. Lateral masses are similarly removed with smaller curettes; small tags of lymphoid tissue left behind are removed with punch forceps. Take care not to injure pharyngeal ends of eustachian tubes. 4. Haemostasis is achieved by packing the area for sometime. Persistent bleeders are electrocoagulated under vision. If bleeding is still not controlled, a postnasal pack is left for 24 h. 38 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University ENDOSCOPIC ADENOIDECTOMY These days adenoids can be removed more precisely by using a debrider under endoscopic control. POSTOPERATIVE CARE Same As In Tonsillectomy. There is no dysphagia and patient is up and about early. COMPLICATIONS 1. Haemorrhage.  It usually seen in immediate postoperative period.  Nose and mouth may be full of blood or the only indication may be vomitus of dark- coloured blood which the patient had been swallowing gradually in the postoperative period.  Rising pulse rate is another indicator.  Treatment is same as for preoperative haemorrhage.  Postnasal pack under general anaesthesia is often required. 2. Injury to Eustachian Tube Opening. 3. Injury to Pharyngeal Musculature and Vertebrae.  This is due to hyperextension of neck and undue pressure of curette.  Care should be taken when operating patients of Down syndrome as 10–20% of them have atlantoaxial instability.  An X-ray neck in extension and flexion should be taken to rule out atlantoaxial instability. 4. Grisel Syndrome.  Patient complains of neck pain and develops torticollis.  Mostly it is due to spasm of paraspinal muscles, but can be due to atlantoaxial dislocation requiring cervical collar and even traction. 5. Velopharyngeal insufficiency.  It is necessary to check for submucous cleft palate by inspection and palpation before removal of adenoids. 6. Nasopharyngeal Stenosis. It occurs due to scarring. 7. Recurrence. This is due to regrowth of adenoid tissue left behind. December 15, 2017 39 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University December 15, 2017 40 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University NASAL POLYPI Nasal polypi are Non-Neoplastic Masses Of Oedematous Nasal Or Sinus Mucosa. They are divided into two main varieties: 1. Bilateral ethmoidal polypi. 2. Antrochoanal polyp. BILATERAL ETHMOIDAL POLYPI Finger like projection from Ethmoidal Sinus Mucosa. AETIOLOGY 1. Chronic Rhinosinusitis. seen in both allergic and nonallergic origin. 2. Asthma. 70% of the patients with asthma of atopic or nonatopic origin show nasal polypi. 3. Aspirin intolerance. 36% of the patients with aspirin intolerance may show polypi. Samter’s Triad consists of Nasal Polypi, Asthma And Aspirin Intolerance. 4. Cystic Fibrosis. It is due to abnormal mucus. 5. Allergic Fungal Sinusitis. Almost all cases of fungal sinusitis form nasal polypi. 6. Kartagener Syndrome. This consists of Bronchiectasis Sinusitis, Situs Inversus And Ciliary Dyskinesis. 7. Young Syndrome. It consists of Sinopulmonary Disease And Azoospermia. 8. Churg–Strauss Syndrome.Consists of Asthma, Fever, Eosinophilia, Vasculitis & Granuloma. 9. Nasal Mastocytosis. It is a form of chronic rhinitis in which Nasal Mucosa Is Infiltrated With Mast Cells But Few Eosinophils. Skin tests for allergy and IgE levels are normal. PATHOGENESIS Nasal mucosa, particularly in the region of middle meatus and turbinate, becomes oedematous due to collection of extracellular fluid causing polypoidal change. Polypi which are sessile in the beginning become pedunculated due to gravity and excessive sneezing. SITE OF ORIGIN Multiple nasal polypi always arise from the lateral wall of nose, usually from the middle meatus. Common sites are uncinate process, bulla ethmoidalis, ostia of sinuses, medial surface December 15, 2017 and edge of middle turbinate. Allergic Nasal Polypi almost NEVER arise from the septum or the floor of nose. 41 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University SYMPTOMS  Nasal stuffiness leading to Total Nasal Obstruction may be the presenting symptom.  Partial or total loss of sense of smell.  Headache due to associated sinusitis.  Sneezing and watery nasal discharge due to associated allergy.  Mass protruding from the nostril. SIGNS 1. On Anterior Rhinoscopy, Polypi Appear As Smooth, Glistening, Grape-Like Masses Often Pale In Colour. They may be sessile or pedunculated, insensitive to probing Do not bleed on touch. Often they are Multiple And Bilateral. A polyp May Protrude From The Nostril And Appear Pink. Nasal cavity may show purulent discharge due to associated sinusitis. Probing of a solitary ethmoidal polyp may be necessary to differentiate it from hypertrophy of the turbinate or cystic middle turbinate. DIAGNOSIS Computed Tomography (CT) Scan Of Paranasal Sinuses is essential to exclude the bony erosion and expansion suggestive of neoplasia. Simple nasal polypi may sometimes be associated with malignancy underneath, especially in people above 40 years and this must be excluded by histological examination of the suspected tissue. CT scan also helps to plan surgery. TREATMENT CONSERVATIVE  Antihistaminics To Control Allergy.  A Short Course Of Steroids may prove useful in case of people who cannot tolerate antihistaminics and/or in those with asthma and polypoidal nasal mucosa. SURGICAL  Polypectomy. One or two polyps which are pedunculated can be removed with snare. Multiple and sessile polypi require special forceps.  Intranasal Ethmoidectomy. When polypi are multiple and sessile, they require uncapping December 15, 2017 of the ethmoidal air cells by intranasal route..  Extranasal Ethmoidectomy. This is indicated when polypi recur after intranasal procedures and surgical landmarks are ill-defined due to previous surgery.  Transantral Ethmoidectomy. This is indicated when infection and polypoidal changes are also seen in the maxillary antrum. In this case, antrum is opened by Caldwell–Luc approach and the ethmoid air cell approached through the medial wall of the antrum.  Endoscopic Sinus Surgery. These days, ethmoidal polypi are removed by endoscopic sinus surgery more popularly called functional endoscopic sinus surgery (FESS). 42 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University Antrochoanal Polyp (Syn. Killian’s Polyp) This polyp arises from the mucosa of maxillary antrum near its accessory ostium, comes out of it and grows in the choana and nasal cavity. Thus it has three parts. 1. Antral, which is a thin stalk. 2. Choanal, which is round and globular. 3. Nasal, which is flat from side to side. AETIOLOGY Exact cause is unknown. Nasal allergy coupled with sinus infection is incriminated. Antrochoanal Polypi Are Seen In Children And Young Adults. Usually They Are Single And Unilateral. SYMPTOMS Unilateral Nasal Obstruction is the presenting symptom. Obstruction may become bilateral when polyp grows into the nasopharynx and starts obstructing the opposite choana Voice may become thick and dull due to hyponasality. Nasal discharge, mostly mucoid, may be seen on one or both sides. SIGNS As the Antrochoanal Polyp Grows Posteriorly, it may be missed on anterior rhinoscopy. When Large, A Smooth Grayish Mass Covered With Nasal Discharge may be seen. It is soft and can be moved up and down with a probe. A large polyp may protrude from the nostril and show a pink congested look on its exposed part. Posterior Rhinoscopy may reveal a Globular Mass Filling The Choana Or The Nasopharynx. A large polyp may hang down behind the soft palate and present in the oropharynx Examination Of The Nose With An Endoscope may reveal a choanal or antrochoanal polyp hidden posteriorly in the nasal cavity X-Rays Of Paranasal Sinuses may show Opacity Of The Involved Antrum. TREATMENT December 15, 2017  Specific Polypectomy  If RecurrenceCaldwell– Luc operation may be required to remove the polyp completely from the site of its origin and to deal with coexistent maxillary sinusitis.  These days, endoscopic sinus surgery has superceded other modes of polyp removal. Caldwell–Luc operation is avoided 43 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University DIFFERENTIAL DIAGNOSIS 1. A blob of mucus often looks like a polypus but it would disappear on blowing the nose. 2. Hypertrophied middle turbinate is differentiated by its pink appearance and hard feel of bone on probe testing. 3. Angiofibroma has history of profuse recurrent epistaxis. It is firm in consistency and easily bleeds on probing. 4. Other neoplasms may be differentiated by their fleshy pink appearance, friable nature and their tendency to bleed SOME IMPORTANT POINTS TO REMEMBER IN A CASE OF NASAL POLYPI 1. If a polypus is red and fleshy, friable and has granular surface, especially in older patients, think of malignancy. 2. Simple nasal polyp may masquerade a malignancy underneath. Hence all polypi should be subjected to histology. 3. A simple polyp in a child may be a glioma, an encephalocele or a meningoencephalocele. It should always be aspirated and fluid examined for CSF. Careless removal of such polyp would result in CSF rhinorrhoea and meningitis. 4. Multiple nasal polypi in children may be associated with mucoviscidosis. 5. Epistaxis and orbital symptoms associated with a polyp should always arouse the suspicion of malignancy December 15, 2017 44 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University DEVIATED NASAL SEPTUM (DNS) This is an important cause of Nasal Obstruction. AETIOLOGY 1. Trauma. A Lateral Blow on the nose may cause displacement of septal cartilage from the vomerine groove and maxillary crest, while a Crushing Blow from the Front may cause buckling, twisting, fractures and duplication of nasal septum with telescoping of its fragments. commonly in childhood at birth during difficult labour 2. Developmental error. Unequal growth between the palate and the base of skull may cause buckling of the nasal septum. Seen in Cleft Lip and Palate and in those with Dental Abnormalities. 3. Racial factors. Caucasians are affected more than black Americans. 4. Hereditary factors. Several members of the same family may have deviated nasal septum. TYPES OF DNS Deviation may involve only the cartilage, bone or both the cartilage and bone. 1. Anterior Dislocation. Septal cartilage may be dislocated into one of the nasal chambers. This is better appreciated by looking at the base of nose when patient’s head is tilted backwards. 2. C-Shaped Deformity. Septum is deviated in a simple curve to one side. Nasal chamber on the concave side of the nasal septum will be wider and may show Compensatory Hypertrophy Of Turbinates. 3. S-Shaped Deformity. Either in vertical or anteroposterior plane. Such a deformity may cause bilateral nasal obstruction. 4. Spurs. A spur is a shelf-like projection often found at the junction of bone and cartilage. A spur may press on the lateral wall and gives rise to headache. It may also predispose to repeated epistaxis from the vessels stretched on its convex surface. 5. Thickening. It may be due to organized haematoma or overriding of dislocated septal December 15, 2017 fragments. 45 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University CLINICAL FEATURES 1. Nasal Obstruction.  Obstruction may be unilateral or bilateral.  Cottle Test. It is used in nasal obstruction due to abnormality of the nasal valve. In this test, cheek is drawn laterally while the patient breathes quietly. If the nasal airway improves on the test side, the test is positive and indicates abnormality of the vestibular component of nasal valve 2. Headache. Especially a spur may press on the lateral wall of nose giving rise to pressure headache. 3. Sinusitis. May obstruct sinus ostia resulting in poor ventilation of the sinuses. 4. Epistaxis. Mucosa over the deviated part of septum is exposed to the drying effects of air currents leading to formation of crusts, which when removed causes bleeding. 5. Anosmia. Failure of the inspired air to reach the olfactory region may result in total or partial loss of sense of smell. 6. External deformity. Septal deformities may be associated with deviation of the cartilaginous or both the bony and cartilaginous dorsum of nose, deformities of the nasal tip or columella. 7. Middle ear infection. DNS also predisposes to middle ear infection. TREATMENT Mainstay tx is surgery Submucous Resection (SMR) Operation  It is generally done in adults under local anaesthesia.  It consists of elevating the mucoperichondrial and mucoperiosteal flaps on either side of the septal framework by a single incision made on one side of the septum, removing the deflected parts of the bony and cartilaginous septum, and then repositioning the flaps. Septoplasty  It is a conservative approach to septal surgery.  In this operation, much of the septal framework is retained.  Only the most deviated parts are removed.  Rest of the septal framework is corrected and repositioned by plastic means.  Mucoperichondrial/periosteal flap is generally raised only on one side of the septum, retaining the attachment and blood supply on the other. December 15, 2017  Septoplasty has now almost replaced SMR operation.  Septal Surgery Is Usually Done After The Age Of 17 so as not to interfere with the growth of nasal skeleton.  However, if a child has severe septal deviation causing marked nasal obstruction, conservative septal surgery (septoplasty) can be performed to provide a good airway. 46 | P a g e ENT NOTES FROM DHINGRA  DR MURAD KHAN Hangzhou Normal University EPISTAXIS  Bleeding from inside the nose is called Epistaxis. BLOOD SUPPLY OF NOSE NASAL SEPTUM INTERNAL CAROTID SYSTEM 1. Anterior Ethmoidal Artery 2. Posterior Ethmoidal Artery  Branches of Ophthalmic Artery EXTERNAL CAROTID SYSTEM 1. Sphenopalatine Artery 2. Septal branch of Greater Palatine Artery  Branch of Maxillary Artery 3. Septal branch of Superior Labial Artery Branch of Facial Artery LATERAL WALL INTERNAL CAROTID SYSTEM 1. Anterior Ethmoidal & Posterior Ethmoidal  Branches of Ophthalmic Artery EXTERNAL CAROTID SYSTEM 1. Posterior lateral nasal branches → from sphenopalatine artery 2. Greater palatine artery → from maxillary artery 3. Nasal branch of anterior superior dental → From infraorbital branch of maxillary artery 4. Branches of facial artery to nasal vestibule LITTLE’S AREA It is situated in the anterior inferior part of nasal septum, just above the vestibule. Four arteries—Anterior Ethmoidal, Septal Branch of Superior Labial, Septal Branch of Sphenopalatine and the Greater Palatine, anastomose here to form a vascular plexus called “Kiesselbach’s plexus.” This area is exposed to the drying effect of inspiratory current and to finger nail trauma, and December 15, 2017 is the usual site for epistaxis in children and young adults. Retrocolumellar Vein. This vein runs vertically downwards just behind the columella, crosses the floor of nose and joins venous plexus on the lateral nasal wall. This is a common site of venous bleeding in young people. WOODRUFF’S PLEXUS It is a plexus of veins situated inferior