ENT

1.01 EXTERNAL EAR

Parts: auricle (elastic cartilaginous, no subcutaneous tissue) & external auditory canal (outer 1/3 cartilaginous, inner 2/3 bony)
Innervation: Greater auricular nerve branches – cervical plexus (sensory supply), auricotemporal, auricular branch of vagus (concha, ear canal; may induce coughing
upon stimulation)
Anatomic relationship: TMJ anteriorly, parotid gland anteroinferiorly, mastoid posteriorly, temporalis / temporal bones superiorly

Disease Description / Etiology Clinical Manifestations Diagnostics Management Notes

CONGENITAL MALFORMATIONS OF THE EXTERNAL EAR

Aural Atresia • Malformation from 1st • Inflammatory osteoclastic • Keratinizing • Not usually treated surgically • 1 / 10,000 live births
and Stenosis and 2nd branchial arches process -> Destroyed bone squamous epithelium • Predisposes to canal
and 1st branchial cleft • With auricular anomalies at an abnormal cholesteatoma
• 1/3 of cases are bilateral location

CLASSIFICATION OF EXTERNAL EAR ANOMALIES

Group 1: • Craniofacial dystoses • Normal auricle

Minor • Defect in ossification • Normal / hypoplastic EAC
• Normal tympanic membrane
• Malleum deformed and
abnormal position
• Rare: Abnormal inner ear

Group 2: • Mild microtia • Small rudimentary auricle Majority of ear deformities

Moderate (Microtia)
• EAC either hypo or aplastic
• (+) / (-) tympanic bone
• Anomalous / malpositioned
ossicles
• Most: Abnormal inner ear

Group 3: • Microtia and Anotia • Absent / malformed auricle May have conductive or
Severe • Severe craniofacial • Absent / slit-like middle ear sensorineural hearing loss
malformations and mastoid
• Absent ossicles
• Involvement of semicircular
canals, cochlea & vestibule

FIRST BRANCHIAL CLEFT ANOMALY

Type 1 • Ectoderm • Duplication of membranous Rare, 1%

EAC
• Posterior, inferior and medial
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to conchal cartilage

Type 2 • Ectoderm and • Anterolateral neck anterior

mesoderm from first and to SCM
second branchial arches • Over mandible, through
parotid towards the bony
cartilaginous junction of the
EAC

NON-INFLAMMATORY DISEASES OF THE EXTERNAL EAR

Impacted • Disturbance of normal • Obstruction • Otoscopy: • Mechanical extraction • Cerumen: mildly acidic,
Cerumen self cleansing • Pressure sensation obstruction by a • Aural irrigation (Hydrogen fr sebaceous glands
mechanism • Vertigo and tinnitus yellow brown black peroxide, irrigate ear with • Complications: Otitis
• Excess secretion material pure water at 37oC using externa
• Imprudent cleaning • DDx: cholesteatoma, ear syringe
cuticle obstruction, posterosuperiorly at
tumors, foreign typmapnic membrane)
bodies • Instrumental removal of
impacted cerumen
• Migrating ink dot (6-8 wks)

Lacerations • D/t manipulation, foreign • Tender meatal skin • Hx of ear trauma • Minor: No intervention • Complications:
and other bodies • Bleeding ear canal • Otoscopy: epithelial • Severe: Exploration Secondary infection,
Injuries injury, bleeding, • Prophylactic antibiotics if cyst formation, stenosis
hemorrhagic bulla, with contamination
crusted blood • Pack ear canal with gelfoam

Frostbite Direct cellular damage -> • Frozen soft tissue and • PE: White skin • Rapid warming • Pinna: first to freeze
microvascular insult -> cartilage discoloration, check • Antibiotics • Complications: May
local ischemia -> thermal • Frequently affected: Auricle for involvement of ear • Delayed surgical cause cartilage necrosis
injuries canal and tympanic debridement and permanent
membrane • Circulatory stimulants: deformity, helical rim with
• Grade I: Localized • DDx: Caustic Dextran or pentoxifyline ulceration, perichondritis
erythema chemical / electrical • Reconstructive surgery: after
• Grade II: Blistering of the injuries six months of healing
skin

Burns • 90% of facial burns • First degree: conservative • 25% develop chondritis
• Second: Silver sulfadiazine
with mesh dressing
• Third: Extensive debrided,
closed with grafts
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Hematoma Blunt trauma -> skin and • Cauliflower ears • PE: Swelling and • Aspiration, evacuation of • Complications: When
perichondrium separation • Pain d/t trauma fluctuation over lateral hematoma, placement of infected, can be the most
from auricular cartilage auricular cartilage skin pressure dressings difficult to treat, may
• Blood/ serous fluid • DDx: Recurrent • Anti-staph antibiotics necessitate removal of
between perichondrium polychondritis ear and replacement with
and auricular cartilage an artificial ear
• Seen in wrestlers /
boxers

Foreign • Usual: cockroach, ant, • Otoscopy • Careful removal of foreign • Complications: Middle /
Bodies match stick, pearl, toys • Hx: Difficulty rom body with an extraction hook inner ear damage,
secondary injury, • Done under general secondary otitis externa
swelling or anesthesia
inflammation • Insects: 10% lidocaine

INFECTIOUS AND INFLAMMATORY DISEASES OF THE EXTERNAL EAR

Otitis Externa • Inflammation involving • Pain upon pulling of pinna • Inspection: Eczema • Meticulous repeated • Complications:
EAC skin • Myringitis of ear canal cleansing and drying Perichondritis,
• D/t Change in pH, • Itching, crusting, purulent • Otoscopy: dry • Antiseptic, antibiotic drops cellulitis, abscess,
environmental changes, discharge, obstruction cracked scaly skin necrotizing otitis
mild trauma externa
• Bacterial: Gram (-) and
anaerobes

ACUTE OTITIS EXTERNA

Furunculosis • S. aureus of S. albus • Incision and drainage

• Outer third of EAC • Systemic antibiotics and
• Pilosebaceous follicles analgesics

Diffuse Otitis • “Swimmer’s ear” • Tragal tenderness

Externa • Pseudomonas • Severe pain
• Canal wall swelling
• Scanty discharge
• Slightly diminished hearing

Otomycosis • Aspergillus niger (warm • Severe Itching, pain • Velvety grayish • Thorough cleaning and Complications: Tympanic
moist climate conducive • Feeling of illness in the membrane on medial drying membrane perforation
for growth) affected ear 2/3 of EAC, mycelia • Aural toilette with hydrogen
peroxide
• Local antimycotics (soften
upper epith layer with
salicylate-containing
solutions)
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Herpes • Geniculate ganglion • Facial paralysis with otalgia • Symptomatic
Zoster Oticus and herpetic eruptions
• Progressive involvement of
vestibular and acoustic fibers
of CN VIII

Dermatoses • Eczematous Dermatosis • Swelling, redness, itching, • Wet dressing

• External canal, meatus, watery exudates, crusting • Fluorinated steroid
concha ointment
• 24- 48 h solution

CHRONIC OTITIS EXTERNA

Necrotizing • Malignant otitis externa • Very painful, nonresponsive • PE: Ulcer, brownish • Local debridement, regular • Complications: Otitis
External • Pseudomonas to medications bone, fetid discharge cleaning media, mastoiditis,
Otitis • Immunocompromised / • Insidious persistent otitis • Smear: (+) P • Minimal bone involvement: petositis, abscess,
diabetic externa that does not heal aeruginosa high antibiotic dose for six cranial nerve deficits,
• Radionuclide bone weeks sepsis
scan, CT: extent of • Control and monitor DM
infection and bone • Severe: Ear removal
destruction

Relapsing • Resembles acute • Tinnitus • Salicylates Middle-aged men with

Polychondriti infectious perichonditis • Vertigo • Corticosteroids excessive alcohol intake
s • Loss of cartilage -> • Hearing loss
floppy ears, saddle nose
deformities

CYSTS AND TUMORS

Tumors of • Due to exposed location • Histology • Reconstruction, excision • Men over 60 y/o
the Auricle • 90% auricular tumors • DDx: Cyst, keloid, • Prophylaxis: Lessen sun
otophymas, nevoid exposure

Tumors of • Most common: • Pain • Biopsy • Surgery

EAC Carcinoma of canal skin • Ulcer • DDx: Chronic otitis • Post-operative irradation
• Others: Adenoid cystic • Non-healing externa, necrotizing
ca, adenocarcinoma, • Bleeding otitis externa etc
BCC

Exostoses • Benign bony outgrowth • Asymptomatic • Excision if symptomatic

Osteoma • Benign bone tumors • Headache, sinusitis d/t • CT

• Isolated masses obstruction of drainage tracts • Skull Xray
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Basal Cell • Proliferation of basal cell • Wide surgical excision • Does not metastasize
Carcinoma

Malignant • Dark pigmented nevus • Rare

melanoma • Elevation and bleeding

Adenoid • Perivascular and • Pain • Surgery • Complications: fulminant

Cystic perineural infiltration • Nerve deficits with rapid recurrence
Carcinoma • Benign, slow growing and hematogenous
• ( +) LN metastases spread

Squamous • Excision
Cell • Radical en bloc resection if
Carcinoma with LN involvement

1.02 MIDDLE EAR

rd
Prevalence: Most common consult for below 5, highest incidence 6-24 mos, at least one episode before 3 bdayz
RF: Passive smoking, inhalant allergy, viral URTI, non-breastfeeding
Anatomy: Eustachian tube connects tympanic membrane with nasopharynx, opened by tensor veli palatini (fxn: ventilation, protection, pressure equalization, drainage)
Pathogenesis: ET obstruction (ET straighter shorter and wider in children) d/t acute URTI, allergy, enlarged adenoids, failure of physiologic opening (palatal clefts)
Myringotomy: Small incision is made on the TM in both ears -> fluid in the middle ear can be drawn out through the incision, indicated for persistent effusion > 12 w,
failure to respond to tx, severe OM, severe conductive HL, impending cholesteatoma, otitis media prone child, cleft palate

Disease Description / Etiology Clinical Manifestations Diagnostics Management Notes

OTITIS MEDIA

Acute Otitis • ~ 4wks • Otalgia, ear tagging • Otoscopy: opaque, • DOC: Amox 40 mg/kg 7d Complications:
Media • Children: H influenza, • Restlessness, feeding thickened bulging • Coamoxiclav / macrolides if • Mastoiditis: Most
adults: S pneumonia difficulty, rhinitis, cough, erythematous TM w/ refractory common, inflammation
• Others: GAS, fever (first 24h) purulent exudates • Tympanocentesis / Surgery of air cells, Δ auricle
Bronhamella catarrhalis, • Stage 1: Hyperemia of ET • Pneumatic otoscopy: • Myringotomy (if extreme prominence with
Gram (-) enteric bacteria and TM, earache, fullness, ê mobility of TM toxicity, febrile convulsions, retroauricular swelling,
• Infection ascends to loss of luster, thickened • PE: Mastoid immunocompromised, tenderness, otorrhea,
middle ear through ET eardrum tenderness, severe pain, failure of tx) suspect if OM does not
• 2: Exudation, outpouring of conductive HL • Prevention: breastfeeding, resolve within 2-3w, Tx:
serum w/ fibrin&RBC&PMN pneumococcal vaccine mastoidectomy with
with é pain and fever, red antibiotics, paracentesis,
thickened bulging TM myringotomy
• 3: Suppuration, perforation • Petrositis: Trigeminal
of pus from pars tensa, symptoms and
mucopurulent, relief of pain abducens nerve palsy
d/t ear drainage, hearing with otologic symptoms
impairment and diplopia, irritation of
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• 4: Coalescence and CN V root with neuralgia
Surgical Mastoiditis, or hyposthesia
progressive hyperemia, • Meningitis: Most
profuse purulent discharge, common intracranial
mastoid tenderness, complication presenting
abscess formation with severe HA, fever,
• 5: Complication, extention clouding of
beyond middle ear into consciousness, nuchal
adjacent structures, spread rigidity
by bone or thrombophlebitis
• 6: Resolution, eventual
resolution with normal
hearing

Recurrent • >5 acute middle ear • Same course as AOM • Same as AOM Differentiation of AOM from
Otitis Media infections in 1 year • Pneumococcal vaccination ROM: Detection of normally
• 3 inflammations in 6 mos • Adenotomy aerated tympanic cavity

Chronic otitis • More than 4 wks • Hearing loss, foul smelling

media • Staphylococcus discharge
• Irritability, restlessness,
vertigo, tinnitus, fullness

Chronic • COM with chronic TM • Chronic otorrhea • Otoscopy: Central • Topical antibiotic ear drops:
suppurative perforation • Variable degrees of hearing perforation in the TM, DOC: Ciprofloxacin for 3 d
otitis media • Dry (w/o active loss does not involve • Oral antibiotics for acute
inflammatory signs), wet • Recurrence of infection fibrocartilaginous exacerbation
(w/ discharge) leads to pain, aural ring, with • Aural toilette
• Usually a mixed infection discharge calcification, atrophic • Surgery: Mastoidectomy
• Common pathogens: • Chronic drainage: odorless, area, retractions or
Staph, Proteus vulgaris, stingy mucus or fetid smell if ossicular destruction
Pseudomonas, Pseudomonas infection • PE: Valsalva: (+) air
Klebsiella, Anaerobic bubble (+)
Conductive HL

TM • Safe: central and tubal • Complications of unsafe:

Perforation (wider) meningitis, brain
• Unsafe: marginal, attic abscess,
encephalopathy

Otitis media • Secretory / serous / Children Otoscopy • Antibiotics, antihistamines, Types

with effusion mucoid OM, glue ear • Hearing loss • Children: TM opaque, decongestants, ET • Partial: serous effusion
• (+) fluid inside middle • Learning difficulties thickened, retracted, ventilation exercises, allergic behind slightly retracted
ear w/ intact TM and w/o • Inattentiveness in school pale/red/yellow/blue, hyposensitization unimpaired TM , (+)
clinical signs of infection • ê language perception ê or (-) mobility • Myringotomy and ventilation airfluid level, subacute
• Causative factors: ET • ê cognitive ability • Adults: TM opaque tube adenoidectomy serous inflammation
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dysfunction (ê or Adults with poor mobility found after viral URTIs
excess tubal patency), • Clogged / pressure Tympanogram • Complete: (-) air,
hypertrophy of adenoids, sensation • Children: Flat curve Children: immobile TM upon
cleft palate, barotrauma, • Popping / sloshing sound (B) or negative • Improve nasal breathing: otoscopy, flat
rhinitis, sinusitis, allergy • Troublesome hearing loss pressure peak (C) decongestant nose drops, tympanogram, é
• If persistent for more than • Adults: Flat curve moisturizing and hygienic mucoid, é goblet cells,
3w, endoscopy of nose and Hearing tests measures, topical steroids amber to grayish
nasopharynx should be done • Adults: Rinne • Paracentesis + ventilation Complications
to r/o tumor negative, weber tube myringotomy, • Children: AOM
lateralizes to affected adenectomy • Adults: AOM, serous
ear, pure tone Adult: Conservative Tx, labyrinthitis via round /
audiometry show air Myringotomy oval window
bone gap

1.03 INNER EAR

Mostly SNHL: pathology at the level of the hair cells (outer: weaker, more prone to problems, sound amplifiers; inner: turns sounds into nerve signals)
Cochlear Fluids: Perilymph (scala tympani & vestibule, like ECF), endolymph (scala media, K rich, like ICF, from perilymph by stria vascularis, positive potential)

Disease Description / Etiology Clinical Manifestations Diagnostics Management Notes

CONGENITAL CAUSES

Endogenous • Trisomy 21 (Down) • US / Retinitis pigmentosa

/ Hereditary • Usher syndrome dysascusis syndrome:
• Waardenburg syndrome SNHL, visual impairment
(retinal discoloration)
• WS: Facial abnormalities,
hypopigmentation of hair,
skin & iris, deaf since birth

Exogenous / • Prenatal: Maternal

Acquired Rubella Syndrome, RH
incompatibilities,
Anoxia/hypoxia, HIV,
syphilis
• Perinatal: Anoxia,
hyperbilirubinemia,
prematurity, high noise
levels, head trauma

TRAUMA

Head trauma: • Fracture in the same • (+) CSF otorrhea, TM • More common, 80%
Longitudinal direction as the axis of perforation, CHL with SNHL
ENT
fracture the petrous pyramid: secondary to concomitant
Temporal or parietal inner ear concussion,
trauma hemotympanum, less
intense nystagmus,
otorrhagia, less intense
vertigo

Head trauma: • Fracture across the • Severe facial nerve famage, • 20%
Transverse petrous pyramid axis: SNHL, nystagmus, vertigo
fracture Frontal or occipital • Possible hemotympanum
trauma • Rare TM perforation / CSF
otorrhea / Otorrhagia

Barotrauma • Sudden change in • Conductive hearing loss • Surgery • Complications: Fistula /

middle ear pressure • Rupture of round window perilymph leak
• Tearing of oval window
annulus

Noise • Direct mechanical trauma • Acute: Muffled sensation, • Temporary threshold • No known effective • Higher incidence in men,
induced to cochlea from exposure tinnitus, improvement after shift: threshold treatment increasing incidence in
hearing loss to high level sounds withdrawal of noise improves after an • Corticosteroids, improve children
• Extent of damage • Chronic: SNHL and tinnitus initial impairment metabolic conditions,
depends on acoustic • Permanent threshold microcirculation, oxygen
energy of noise shift: irreversible supply

INFECTIONS

Measles • Rubeola • Sudden SNHL, usually

bilateral
• Affects cochlea

Mumps • Parotid gland • Bilateral / unilateral HL

inflammation • Can go to the inner ear via
Santorini’s fissure

Otitis media • Bacteria from middle ear

enter inner ear via round
/ oval window

Bacterial • Inflammation of • May cause total deafness

meningitis meninges when labyrinth is full of pus

DRUG OTOTOXICITY
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Cochleotoxic • Dihydrostreptomycin, • Aminoglycosides: high Neomycin: Don’t use if
Viomycin, Neomycin, frequency HL, mild to perforated TM
Kanamycin profound range

Vestibulotoxi • Streptomycin, • Affecting vestibular organs

c Gentamicin

Quinine • For malaria, fever and • HL at all frequencies, tinnitus,

pain of common cold dysequilibrium

Aspirin • If used for prolonged • HL

period / large amounts

Loop • Furosemide • Stria vascularis

diuretics • ê endocochlear potential
• HL at all frequencies

Salicylates • Dose dependent • Impairment for all frequencies

Cisplatin • Against HCs, w/ • Cochlear high-tone loss

neurotoxic properties • Reversible

OTHER CAUSES

Otosclerosis • Bony labyrinth disease • SNHL / mixed HL • Audiometry: Flat • No known treatment for • Site of predilection:
caused by toxic • Slowly progressive HL graph structural bone changes anterior portion of oval
metabolite deposits from • Unilateral / bilateral • Weber: Lateralizes to • Sodium fluoride may halt window
bone capsular sclerosis • Tinnitus affected ear inner ear change progression • 20 – 50 y, female
• Surgical: stapes replacement

Sudden • Woke up to find that • Spasm in internal auditory • Blood test • Steroids to internal ear via • Adults
Idiopathic their hearing has artery -> no blood supply for • MRI trans-tympanic injections
Sensorineura changed stria vascularis • Neurological testing
l Hearing • D/t: Autoimmune dse, • Electrocochleography
Loss viral infection, BM
rupture, vascular
disorder, tumors

Endolymphat • Endolymph • Tinnitus, hearing loss • Diuretics

ic Hydrops Oversecretion / • Vertigo • Sedatives, tranquilizers,
underabsorption -> vestibular suppressants
é pressure on hair • Hearing aids
ENT
cells • Surgery
• Overstimulated
vestibular apparatus

Autoimmune • Inflammatory • Blateral fluctuating and • Steroids via a wick

Inner Ear • Immune system causes progressing SNHL
Disease body to attack its own • Tinnitus, aural fullness,
tissues (attack inner ear) vertigo

Presbycusis • HL d/t age progression • M: HL above 1000 Hz • Hearing aid • M: early 60s F: late 60s
• 35 db HL • F: HL below 1000 Hz, have • D/t ê hair cell activity,
• Phonemic regression: poorer sensitivity strial degeneration, organ
Speak slow not loud of Corti degeneration

Tinnitus • Auditory sensation in the • Circulatory stimulants

absence of an electrical • Noise generators
stimulus

VERTIGO

Vertigo • You (subjective) / your • Peripheral: sensory system • History • Physical maneuvers • Acoustic neuroma
environment (objective) dysfunction, sudden onset, • MRI to r/o tumor • Common meds: Betahistine, • ê blood flow to the base
is spinning with tinnitus, HL, mixed / • Hearing tests Cinnarizine, Meclizine of the brain
• Sensory systems: visual, horizontal / unidirectional • ENG / VNG hydrochloride, Promethazine • Multiple Sclerosis
vestibular, nystagmus • Blood tests for blood hydrochloride, Diazepam • Head trauma, neck injury
somatosensory • Central: incorrectly processed sugar • Migraine
by the brain, gradual onset, • ECG Diabetes complication
with diplopia, cortical
blindness, pure nystagmus

BPPV • Canalolithiasis: • Severe recurrent attacks of • Dix Hallpike: sitting to • Therapeutic exercises • Most common form of
é mass of otoconia -> rotatory vertigo lasting 1 head hanging 10 • Repositioning of canaliths vertigo
unphysiologic deflection minute degrees below • Surgery • Women
of cupula horizontal; (+) test with
• Sensation of motion nystagmus
initiated by sudden head
movements or moving
head in a certain
direction
• D/t: head trauma,
vestibular neuronitis,
inner ear disorders

Labyrinthitis • Vestibular neuritis • Sudden onset of vertigo • Antibiotics

• Inflammation within the associated with HL
inner ear (viral / bacterial) • Sudden SNHL
ENT
Meniere’s • Disease within the • Δ vertigo, tinnitus, unilateral • Low salt diet, diuretics • Elderly
Disease labyrinth HL
• Lermoyez phenomenon:
tinnitus becomes louder while
hearing poorer
• Drop attack: Falls to the
ground without losing
consciousness

1.04 RADIOLOGY
Paranasal sinuses: Invaginations of nasal mucosa, sphenoid sinus – cranial cavity separated by thin sella turcica floor (where pit and planum sphenoidale are)
PA view: canthomeatal line perpendicular to film axis, best for ear (transorbital) and ethmoid sinuses
Caldwell’s: Xray tube at 20 degrees caudal, best for frontal and anterior ethmoid sinuses, orbits, midline structures of skll and face
Granger’s: Xray tube at 20 degrees cephalad, best for sphenoid sinuses and posterior portion of maxillary sinus
Water’s: Most used, nose 2-3 cm away from xray film, canthomeatal line 37 degrees from axis of the film while xray is perpendicular, best for frontal anterior ethmoid and
maxillary sinuses, can present air fluid levels
Lateral: J ç , best for sphenoid, nasopharyngeal soft tissues of the posterior wall of the nasopharynx, anterior and posterior wall of frontal sinus, pterygopalatine fossa,
hard palate, clivus, odontoid process-foramen magnum, used for trauma patients
Towne’s: Xray 30 degrees cephalocaudal for a view of the posterior portion of the skull, occiput and mastoid air cells
Diagnosis of disease: Thickened mucosal line (> 4mm bacterial), opacification of the sinus (haziness), air leaks (+ fluid), (+) soft tissue mass (cyst: smooth, convex,
borders area of sclerosis around bone, polipoid lesions - allergy; malignancy: lytic lesions, destroys bone faster)
Changes in the bony walls: Infection (osteitis / area surrounded by sclerosis, if chronic -> thick/sclerosing bony walls, may progress to osteomyelitis), tumors (lytic +
sclerotic change), invasion of surrounding structures (watch out: co-existing hyperplasia, nasal septum deviation)

Disease Description / Etiology Clinical Manifestations Diagnostics Management Notes

TRAUMA

Mandibular • Symphysis menti, body, • XRay: Modified

Fracture angle, ramus, coronoid, lateral and PA View
subcondylar, condylar • CT: better view

Nasal Bone • Fracture and • Soft tissue technique

Fracture displacement of the
fracture

Tripod • Fracture in the maxillary

Fracture sinus roof and
inferolateral wall,
zygomatic arch
• Separation of fronto-
zygomatic suture
ENT
Blowout • Communication between • Black eye • Xray: Teardrop sign
Fracture of maxillary sinus and orbit • Changes: bony fragments, (prolapsed orbital
the Orbit • Contents herniate in soft tissue mass, opacity of contents)
maxillary sinus maxillary sinus, emphysema
of orbit

Le Fort • Severe, d/t vehicular • Lower pterygoids always

injury involved!
Course:
1: Transverse • Nasal septum, maxillary • Base of maxilla -> nasal
sinus, pterygoid plates septum -> other side
2: Pyramidal • nasal & lacrimal bones,
medial orbital wall, • Zygomaticomaxillary
zygomaticomaxillary suture, suture -> base of orbit ->
anterior maxillary wall, medial wall -> glabella ->
pterygoid plates other side
3: • Most severe • Root of nasal bone, lacrimal • If maxilla is moved up
Craniofacial bone, medial orbital wall, floor and down, it would • Zygomatic bone ->
Dysjunction of orbits, interior orbital seem to be separate lateral orbital wall ->
fissure, lateral orbital walls, from cranial vault base of orbit -> medial
zygomatic arch, pterygoid wall -> glabella -> other
plates side

TMJ Fracture • Limitation of movement of • CT

TMJ Xray: mandibular
condyle stays within
glenoid fossa

Foreign • Safety pin, coin etc • Calcified or metallic to be • • Complications:

Bodies seen Retropharyngeal
abscess, recurrent
aspirations, bronchial
pneumonia

TUMORS

Ameloblasto • Multicompartmentalized • Hard painless lesions near • Xray/CT: • High recurrence rate
rd
ma cystic destruction of the angle of mandible (3 molar) Multiloculated,
mandible or along alveoulus of expansile soap
mandible bubble leasion with
• Erode roots of teeth well demarcated
borders

Acoustic • CN 7 and 8 • • CT (funnel shaped •

Neuroma • Intracranial tumor, CP enlargement) and
angle mass MRI
ENT
• Abscess: (+) ring
enhancing
• LN evaluation: CT
scan

MASTOIDS

Mastoiditis • Infratemporal • Edema, erythema of • CT scan: Lateral

complication of AOM postauricular soft tissues, loss sinus plate
of post auricular creases destruction,
discontinuity of
posterior wall,
abscess,
thrombophlebitis

Cholesteato • Filling defect, bone • Primary: Retraction of TM • CT: bone erosion

ma destruction with • Secondary: Squamous
hypodense substance epithelial migration from TM or
with a background of implantation of squamous
sclerosis epithelium into middle ear
• Attic of middle ear:
Antrum and central
portion of mastoir

1.05 AUDIOLOGY
HL in Infants:
• RF: (+) family history, CNS infections, ENT defects, ototoxic drugs, prematurity, hyperbilirubinemia, LBW
• 136: 1 month tested, 3 months diagnosed (if failed @ 1 month) with specialist, 6 months habilitated with hearing aid, implants
• Window: critical window is 5-6 y/o, difficult habilitation past 2 y/o
HL in Children:
• D/t infection (AOM) because of ET
Air fluid Impedance Mismatch: Air and fluid have different acoustic impedances, sound travelling in air reflected back -> 30 dB loss
• TM ossicular chain – “impedance matching device“
o Areal mechanism: hydraulic action of TM – stapes in oval window, TM 17x larger than stapes, disrupted by eardrum perforation, 25 db gain
o Lever mechanism: lever arm by the malleus rotates about its pivot longer than the incus’ -> 1.3 pressure increase, disrupted by serous OM, 2.5 db gain
• Total transformer ration: 27.5 – 29 dB amplification gain
HL in Adults:
• RF: Atherosclerosis, noise exposure, drug exposure, diet and metabolism, genetic
• Presbycusis:
o Sensory: Organ of corti degeneration, high tone hearing loss, good speech discrimination, audiogram down sloping, amenable to habilitation
o Neural: Loss of auditory neurons, poor speech discrimination, audiogram flat, cannot be habilitated
o Metabolic: Secondary to DM, atrophy of stria vascularis, slow progressive HL, speech discrimination good, flat audiogram, can habilitate
o Mechanical: Motion of cochlear partition, poor speech discrimination, down sloping audiogram, cannot be habilitated
• Problems: ê audibility (muffled, unable to hear high pitched sounds, male voices preferred), ê dynamic range, ê frequency selectivity (function of outer hair
cell)
ENT
Audiometric tests:
• OAE: Test for neonates, pass (+ startle reflex) or refer (perform within a month, if still refer do ABR), tests integrity of outer hair cells of cochlea
• ABR: Gold standard, children asleep with electrodes
Tuning fork (512 Hz) tests:
• Weber: Test for lateralization, tuning fork at midline of vertex / forehead. Normal: midline, Unilateral CHL: lateralizes to poorer ear, Unilateral SNHL: to better ear
• Rinne: Air and bone hearing, fork near bone then ear. Normal/ USNHL AC>BC (Rinne positive), UCHL BC>AC (Rinne negative)