MEE

My PG
Notes

NOSE
Anatomy of Nose

/e
,1
es
zz Nasal cavity communicates with nasopharynx through choanae
zz Sinus lateralis of Grunwald: It is a lateral sinus formed by space above and below the bulla
ot
ethmoidalis.
trium is a shallow depression infront of iddle turbinate
N
zz

zz gar nasi is the elevation just nterior to the attachment of iddle turbinate
ntral puncture is done through iddle meatus
EE

zz

zz Picadli’s circle is the osteo-meatal complex

zz Excessive rhinorrhea in vasomotor and allergic rhinitis can be controlled by section of Vidian
M

nerve (nerve of pterygoid canal)

Superior meatus Posterior Ethmoidal sinus
PG

middle meatus MAxillary sinus, Frontal sinus, Anterior & Middle Ethmoid sinus (MA FAME)
inferior meatus Nasolacrimal duct
sphenoethmoidal Sphenoid sinus
y

recess
M

zz Nerve supply- [Om SAI]

 Olfactory Nerve: central filaments of olfactory cells arranged into 12-20 nerves [along with
3 meninges of brain] which pass through Cribriform plate and end in Olfactory bulb
 Sphenopalatine palatine ganglion: Posterior 2/3rd of nasal cavity[ both septum and lateral
wall]
 Anterior Ethmoidal nerve: Supplies anterior and superior part of nasal cavity [both septum
and lateral wall]
Infraorbital nerve’s Branches supplies Vestibule of nose [both medial and lateral side]
ENT



Physiology of Nose
zz Air flow is Laminar in Inspiration and Turbulent in Expiration.
zz Main current of air flow is through middle part of cavity in Middle meatus in a parabolic curve
600 zz Maximum tubrulency present at LIMEN NASI/Internal nasal valve since it is the narrowest part
of nasal cavity

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Notes

zz NASAL CYCLE
 Rhythmic cyclical congestion and decongestion to control airflow in nasal chambers.
 Occurs every 2.5-4 hours

Diseases of External Nose and Vestibule

Cellulitis

zz Infection of nasal skin by Streptococci/Staphylococci leading to red, tender and swollen nose
zz Treated with Systemic Antibacterials + hot fomentation + Analgesics

Nasal Deformities

/e
,1
es
ot
N
EE
M
PG

Tumours
y
M

Dermoid Cyst

zz Congenital Tumor
zz Simple dermoid is just a midline swelling infront of nasal bone
zz Dermoid associated With a sinus- may have intradural connection which requires neurosurgical
+ Oropharyngeal surgery to close the defect
ENT

zz Encephalocele/Meningoencephalocele
 Herniation of Brain tissue with meninges through bony congenital defect,
 Three types- Nasofrontal → midline in root of nose, Nasoethmoid → side of nose and Naso-
orbitalantero-medial aspect of orbit
 Treated neurosurgically
ff Glioma- Pinched off portion of Encephalocele, 60% extranasal, 30% intranasal and 10% 601
both.

notes
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My PG
Notes

Benign Tumors

Rhinophyma/Potato tumor
zz Due to hypertrophy of SEBACEOUS GLANDS of tip of nose
zz Usually after long standing case of Acne rosace
zz Treated by excision of tumor [by CO2 laser] and allowed to reepithelise.

Malignant Tumors

zz BASAL CELL CARCINOMA/RODENT ULCER

 MC malignant tumor involving skin of Nose (87%)
 Presents as cyst/papulo-pearly nodule/ ulcer with ROLLED EDGES
 Slow growing and remains limited to skin, nodal mets are rare
 Early cases treated with cryosurgery/Irradiation/Surgical excision with 3-5mm margin
SQUAMOUS CELL CARCINOMA/EPITHELIOMA

/e
zz
 2nd MC malignant tumor of nasal skin (11%)
Presents as infiltrating nodule with rolled out edges

,1


 Nodal mets in 20% cases

MELANOMA-

es
zz
 Least common variety
Superficial spreading type

ot
Lateral wall of Nose Nasal Septum
N
EE
M
PG
y
M
ENT

zz Asch’s forceps is used for reducing fractures of Nasal Septum [ANS]

602
zz Walsham forceps is used for disimpacting and reducing fractures of Nasal Bone [WNB]

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Notes

zz Treatment of nasal bone fracture:

 If no swelling → reduce immediately
 If swelling present → closed reduction done within 21 days
 Open reduction after 21 days

Deviated Nasal Septum

zz Causes nasal obstruction

zz Can occur due to Trauma, Developmental, Racial or Hereditary factors
zz MCC is birth trauma
zz SPUR type DNS is associated with Headache and Epistaxis
zz S shaped DNS causes B/L nasal Obstruction.
zz Treatment options are Submucous resection [SMR] or Septoplasty

Septal Hematoma

/e
Collection of blood under Perichondrium or periosteum of Nasal septum due to Trauma or

,1
zz

surgery
Small hematoma → aspirated with wide bore needle + packing of nose on both sides

es
zz

zz Large hematomas → IandD by antero-posterior incision parallel to nasal floor + packing of nose
on both sides
ot
Septal Abscess
N
zz Due to 2o infection of septal hematoma or Furuncle of nose/upper lip
EE

zz Severe B/L nasal obstruction + Tenderness

zz Drain ASAP + necrosed part removed_systemic antibiotics
M

Nasal Septal Perforation

PG

zz Traumatic → due to surgery or Habitual Nose picking

zz Pathological
Septal abscess
y



[Link] and Lupus Involve Cartilagenous part

M


(Remember as: TLC)
 Syphilis involves Bony part
 Wegner’s granuloma → total septal perforation
 Drugs → Prolonged steroid spray, Cocaine abuse Figure:  Sialistic buttons
 Idiopathic
zz Small perforations Treated with Plastic flaps while larger by Thin sialistic buttons
ENT

Acute Rhinitis
zz Coryza/Common cold- caused by Viruses (Rhinovirus, ECHO, Coxsackie, Adeno, Picorna virus),
resolves spontaneously in 2-3 weeks
zz Influenzal rhinitis- Caused by Influenza Virus A, B or C
603
zz Rhinitis with exanthems
zz Irritative Rhinitis can occur due to exposure to Dust, SMOKE or irritating gases.
notes
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Notes

Chronic Rhinitis
zz CHRONIC SIMPLE RHINITIS
 Due to recurrent attacks of acute Rhinitis
 It is an early stage of Hypertrophic rhinitis
 Treat the cause + nasal irrigation + nasal decongestants
zz HYPERTROPHIC RHINITIS
 Thickening of Mucosa, Submucosa, Seromucinous glands, periosteum and bone mainly
turbinates
 Mulberry like nasal mucosa is hallmark
 Treatment: Partial/Total turbinectomy or Excision with CO2 laser therapy
zz ATROPHIC RHINITIS/OZAENA
 Atrophy of Mucosa + nerve fibre
 Comes with NASAL OBSTRUCTION
Occurs in 50-60 years old and MC in female

/e


 Multifactorial disease- Racial,Autoimmune,Nutritional deficiency, Infective, Hereditary and

,1
Endocrinal disturbances
 Bone atrophy → Foul smelling
MERCIFUL ANOSMIA
Nerve fiber affected → cannot smell   

es


 Treatment-
Irrigation(with Na Bicarbonate + Na biborate+ NaCl)
ff

ff 25% glucose in glycerine

ot
Antibiotics
N
ff

ff Estradiol spray → ↑ vascularity os mucosa

Surgical- Total closure of One U/L nose for 6 months in Young’s Operation OR Partial
EE

ff
B/L closure with a 3mm opening in Modified Young’s Opeartion
zz RHINITIS SICCA
Squamous metaplasia of ciliated columnar epithelium with seromucinous gland atrophy
M



 Crust forming disease in patients who work in hot,dry and dusty environment
PG

 Treatment is changing occupational surroundings + Antibiotics + Steroid

zz RHINITIS CASEOSA
 Also called as Nasal Cholesteatoma
Rare condition, usually U/L and affects Males mostly
y



Offensive purulent Cheesy discharge from nose

M



 Granulomatous Sinus mucosa is seen and bony wall may be destroyed

 Treatment is removal of debris and granulation tissue

Granulomatous Diseases of Nose

Type Cause Features Management
Bacterial
ENT

Rhinoscleroma Klebsiella Crusting + foul smelling discharge Diagnosed by Mikulicz cells

rhinoscleromatis/ Woody feel of nose (Macrophages) and Russel bodies
Frisch bacillus (Eosinophils) in biopsy
Treated by: Tetracycline (2 g/day)
604 + Streptomycin (1g/day) for 4-6
weeks

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Type Cause Features Management

Syphilis Treponema Nose involved in Tertiary Diagnosed by VDRL test
pallidum acquired syphilis Treated by:benzathine penicillin 2.4
Gumma on Nasal septum million IU/week X 3 weeks
Destruction of Nasal septum
HUTCHINSON'S TRIAD
Early congenital form → Snuffles
[HIDE]
Late congenital form →
Hutchinson’s teeth, Interstitial Hutchinson’s teeth,
keratitis DEafness and corneal
Interstitial keratitis
opacities
DEafness
Tuberculosis Mycobacterium Occurs secondary to Lung TB Diagnosis by Biopsy and Acid fast
tuberculi Anterior part of nasal septum + staining
Inferior Concha are affected Treated with Anti tubercular drugs
Lupus APPLE JELLY NODULE- Brown, Diagnosis by Biopsy
gelatinous nodules Treated with Anti tubercular drugs

/e
Perforation of nasal cartilage
Leprosy Mycobacterium May proceed to Diagnosis by Acid fast staining of

,1
leprae -Atrophic rhinitis nasal scrapings
-saddle nose deformity Treated with Dapsone, Rifampicin

es
-retrusion of columella and isoniazid
Fungal ot
Rhinosporidiosis Rhinosporidium Mostly affects nose and Diagnosis by biopsy
seeberi nasopharynx, pink to purple Treated by exicision with diathermy
N
colored polypoidal mass attached knife and cauterisation of base
to nasal septum/lateral wall
EE

Mulberry like polyp

Aspergillus [Link] Black/Greyish membrane in Treatment is surgical debridement +
[Link] nasal mucosa Ampho-B + repeated irrigation
M

[Link] Fungal balls in maxillary sinus on

exploration
PG

Mucormycosis Fungal infection Black necrotic mass filling nasal Treatment is amphotericin B
Seen in cavity
uncontrolled DM
Pt on immuno-
y

suppressives
M

Candidiasis, RARE
Histoplasmosis,
Blastomycosis
Unspecified
Wegner’s Idiopathic Anaemia, night sweats,fatigue Treated with systemic steroids +
granulomatosis and migratory arthralgia cytotoxic drugs
Non healing Polymorphic lymphoid Diagnosis by immunohisto chemical
ENT

midline tissue with angiocentric and studies

granuloma angioinvasive features Treated with radiation [+chemotherapy
Rapidly destructive in disseminated cases]
Sarcoidosis Idiopathic Submucous nodules in septum/ Systemic steroids
granulomatous inferior turbinate
disease Strawberry appearance of nasal 605
mucosa
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My PG
Notes

Choanal Atresia
zz Due to persistence of Bucconasal membrane
zz Bony (90%) and membranous (10%)
zz U/L mostly, B/L cases require emergency management

CSF Rhinorrhea
zz Definition
zz Causes iatrogenic - MCC:
 Traumatic- head injuries or surgery
 Tumors- large osteomas of nasal region/ tumor of pituitary
 Congenital defects
 Spontaneous

/e
zz Diagnosis:
 Double ring sign in Traumatic CSF Rhinorrhea and single Ring sign/Dot sign in Spontaneous

,1
CSF Rhinorrhea should be differentiated from nasal discharge

es
Features CSF fluid Nasal discharge
Flow Suddenly In a gush of drops on forward
ot Continuous
bending or straining, SNIFFING NOT
POSSIBLE
N
Character of discharge Thin watery clear and sweet in taste Slimy (mucus) or clear(tears), salty in
taste
EE

Sugar content >30mg/dl <10mg/dl

ß2 transferrin By Always present, specific for CSF Always absent
M

ELECTROPHORESIS
zz Treatment-Managed conservatively in early cases with Bedrest and antibiotics, endoscopic repair
PG

done in patients with high fever etc

Allergic Rhinitis/Pollenosis/Hay Fever

y

zz Type I HS
M

zz Seasonal type → due to pollen and Perennial type due to House dust mite
zz Phase-I → Mediators are Histamine, PAF, Il-1,2,3,4,5, INF. LT B4,C4,D4
zz Phase-II → PAF is main mediator
zz C/F- nasal mucosa is pale, boggy and hypertrophic and may appear bluish
zz Treatment:
 Avoid allergen, Medical treatment
Sx treatment- Turbinate reduction/Laser cautery/RFA
ENT



Vasomotor Rhinitis
zz Non allergic Rhinitis Due to imbalance between Sympathetic and Parasympathetic system
606 zz Paroxysmal sneezing, Excessive rhinorrhea and nasal obstruction are symptoms
zz Treatment is Vidian Neurectomy
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Notes

Nasal Polyps

ANTROCHOANAL POLYPS/KILLIAN'S POLYP THMOIDAL POLYPS

M
Age Common in Children Common in adults
Number/laterality Single/unilateral (A → Akela) Multiple/Bilateral
Growth Grows backwards Grows forwards
Size and shape Trilobed with Nasal, Choanal and Antral parts Small grape like mass
Treatment Polypectomy by endoscopy or Cald well-luc Polypectomy endoscopic or nasal
operation (recurrent cases) surgery
Recurrence Uncommon if removed completely Common

zz ANTERIOR ETHMOIDAL SYNDROME/SLUDER’S NEURALGIA

 Originates from middle turbinate pressing on nasal septum

/e
 Causes pain around bridge of nose
 Treatment: Anatomical correction.

,1
Epistaxis

es
Blood supply of nasal cavity
ot
N
EE
M
PG

AREAS OF EPISTAXIS
y

Little’s area/Kiesselbach's area Anterior part of Septum child MCC-Nose picking Arterial blood
M

Retrocollumellar vein Anterior part of Septum Young adult Non specific cause Veinous blood
Woodruff’s area Posterior part of lateral Oldage Htn arterial
wall
zz Anterior epistaxis → MC (90% cases) and less severe
zz Posterior Epistaxis → less common and more severe
zz Treatment:
 Usually Bleeding in Little’s area can be controlled by pinching the nose for 5 minutes
ENT

 If bleeding point located → cauterisation

 If bleeding site cannot be located and bleeding profusely → anterior nasal packing
 Ligation of arteries:
ff Uncontrollable posterior epistaxis → Maxillary artery is ligated
ff Anterosuperior bleeding → Ethmoidal artery is ligated
607
ff Aged patient on chemotherapy → external carotid is ligated

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Notes

Paranasal Sinuses and its Diseases

Development of Sinuses and X-ray View

Name Development X-ray view

Maxillary Present at birth, Completely developed by 9 years Water’s View [2018]
Ethmoid Present at birth, Completely developed by Puberty Cald well luc view
Frontal Starts developing at 2 years, Completely developed by late [2018]
adolescence
Sphenoid Lateral view/Side
Starts developing at 3-5 years, Completely developed by 12-
15 years
view

zz Among all PNS, Frontal sinus shows maximum variation and develops till late adolescence
Types of Sinusitis:

/e
zz

ACUTE SINUSITIS CHRONIC SINUSITIS

,1
• Acute inflammation of sinus mucosa • Sinus infection lasting for months or years
• Most commonly involves: • Clinical features are often vague and similar to those

es
Maxillary>Ethmoid>Frontal>Sphenoid of acute sinusitis but of lesser severity.
• Starts as Viral infection that is followed • Purulent nasal discharge is the commonest complaint.
ot
by bacterial invasion (Strep. pneumoniae, • Initial treatment of chronic sinusitis is conservative,
[Link], Moraxellacataralis) including antibiotics, decongestants, antihistaminics
N
• Types: and sinus irrigations
ƒƒ Acute Maxillary sinusitis • SURGERY FOR CHRONIC SINUSITIS
EE

ff Clinical features; ƒƒ Chronic Maxillary Sinusitis

ff Constitutional symptoms ff Antral puncture and irrigation

ff Headache ff Intranasal antrostomy

M

ff Pain ff Caldwell luc operation

ƒƒ Chronic Frontal Sinusitis

Tenderness and nasal discharge
PG

ff
ff External frontoethmoidectomy (howarth’s or
ff Diagnosis by CT Scan.
Lynch operation)
ff Treatment includes antibiotics (ampicillin/
ff Osteoplastic flap operation
Amoxicillin) + nasal decongestants +
analgesics ƒƒ Chronic Ethmoid Sinusitis
y

ƒƒ Frontal sinusitis ff Intranasal Ethmoidectomy

M

ff Causes OFFICE HEADACHE [maxi. In ff External Ethmoidectomy

morning and Less in evening i.e. periodicity
present]
ff Pneumatocoel may be seen
ff Rarely found in pediatric age group as it is
formed after birth
ƒƒ Acute Ethmoid sinusitis presents with Pain +
Edema of Lids + nasal discharge + swelling of
the middle turbinate
ENT

• Complications of Sinusitis
ƒƒ MC complication- Orbital Cellulitis

ƒƒ Pott’s puffy tumor → osteomylitis of Frontal sinus

ƒƒ Chandler classification used for Orbital complications

608 ƒƒ Mucocele (MC in frontal) → Pyocele → Osteomylitis → Sinocutaneous Fistula

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Notes

zz Most anterior cell of Ethmoid sinus → AGGER NASI

zz Haller cell is related to Orbital floor
zz Osteoma
 MC benign tumor of PNS
 MC site of osteoma- Frontal sinus> ethmoid sinus
 MC malignancy in osteoma
ff Maxillary sinus → Squamous cell carcinoma
ff Ethmoidal sinus → Adenocarcinoma
zz Maxillary sinus carcinoma
 Treated with Surgery + RT
 1st Lymph node involved is Submandibular L.N.

/e
,1
es
ot
N
EE

Figure:  Classification used for prognosis of maxillary sinus carcinoma (A) Ohngren's classification (B) Lederman's Classification
M

zz Woodworker’s carcinoma- Adenocarcinoma of Ethmoid.

PG

zz Smoking is Risk factor for squamous cell carcinoma of PNS.

zz Nose picker’s cancer - Squamous cell carcimoma of nasal septum.
zz Esthesioneuroblastoma is also known as olfactory neuroblastoma or olfactory placode tumor.
y

zz Most common site for malignant melanoma of nasal cavity is the anterior part of nasal septum
M

zz Maxillary sinus is MC site for Fibrous dysplasias.

zz Among the paranasal sinuses, maxillary sinus is most common site for carcinoma
zz Malignancy of PNS is strongly associated with working in furniture and nickel refining industries

Nasal Cavity Neoplasms

zz CAPILLARY HEMANGIOMA/BLEEDING POLYPUS
ENT

 MC benign tumor of Nose- Capillary hemangioma

 MC site – Little’s area/Kisselbach’s area
zz MC site for Papilloma- vestibule
zz MC site for malignant melanoma- anterior part of septum
zz CT and RT are C/I in malignant melanoma as they further make the patient immunocompromised 609
predisposing the patient to Squamous cell cancer

notes
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Notes

zz INVERTED PAPILLOMA/SCHNEIDERIAN PAPILLOMA/RINGERTZ TUMOR

 So called because of its microscopic appearance → grows towards underlying stroma
 Unilateral and MC in Lateral wall of nose
 HPV is thought to be a risk factor
 Age -40-70 years MC in males
 It is a premalignant condition
 Treated with wide surgical excision
 Medial maxillectomy is the treatment of choice.

Facial Trauma
zz MC # bone in face → nasal bone
zz 2nd MC # bone in face → Zygomatic #(Tripod #)
zz Teardrop sign seen in Orbital #

/e
,1
es
ot
N
EE
M

LARYNX
PG

Anatomy of Larynx
y
M
ENT

610

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Notes

/e
,1
es
ot
N
EE
M
PG
y
M

zz Opener of laryngeal inlet→ Thyro-epiglottic (part of thyroarytenoid)

zz Closers of laryngeal inlet→ Inter arytenoids (oblique and ary-epiglottic parts)
zz All intrinsic muscles are supplied by recurrent laryngeal nerve except Cricothyroid which is
ENT

supplied by External laryngeal nerve

zz Sensory innervations up to the level of vocal cords is by Internal laryngeal nerve, below the level
of vocal cords is by Recurrent laryngeal nerve

611

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Notes

Spaces

Acute and Chronic Inflammation of Larynx

/e
ACUTE LARYNGITIS
• May be infectious [starts as viral → 2o bacterial infection] or non-infectious [due to vocal abuse, allergy,

,1
laryngeal burns or trauma]
• Hoarseness, throat pain and dry irritating cough are present

es
• Treatment includes Vocal rest + anti allergic + antibiotic + analgesic
ACUTE EPIGLOTTITIS/SUPRAGLOTTIC LARYNGITIS ot
• Acute inflammation of supraglottic structures [epiglottis, aryepiglottic folds
and arytenoids]
N
• Acute epiglottitis is most commonly caused by Staphylococcus > [Link];
‘thumb sign’ on Xray lateral view
EE

• Immediate hospitalisation required as danger of respiratory obstruction

present
• Tracheostomy may be required
M

• Antibiotics + steroids + adequate hydration given

ACUTE LARYNGOTRACHEOBRONCHITIS/CROUP
PG

• Croup is most commonly caused by Parainfluenza I and II

• ‘barking seal’ like cough present
• ‘steeple sign’ on AP view
• hospitalisation required because of respiratory difficulty
y

• Antibiotics[Ampicillin 50mg/kg/day in divided doses for 2o infections] +

M

humidification + parenteral fluids

LARYNGEAL DIPHTHERIA
• Occurs 2o to Faucial diphtheria [Fauces are spaces between soft palate and base of tongue] in <10 yr old
children
• Tough pseudomembrane is formed over larynx + trachea → completely obstructs airway
• Diagnosis is clinical → confirmed by smear and culture
ENT

• Treated with Diphtheria anti-toxin + anti-bacterials

EDEMA OF LARYNX/ EDEMA GLOTTIDIS
• Involves loose mucosa of supra and sub-glottic region
• Caused due to infections,trauma, cancers, allergy, radiation and systemic diseases
• Treatment includes treating the cause
612

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Notes

CHRONIC HYPEREMIC LARYNGITIS/ CHRONIC LARYNGITIS WITHOUT HYPERPLASIA

• Symmetrically involves whole of Larynx
• May occur as a sequelae of infections of larynx or PNS or occupational factors
• Hoarseness + constant hawking is seen
• Hyperemia of laryngeal structures on laryngeal examination
• Treatment includes treat the cause + voice rest + steam inhalation
CHRONIC HYPERTROPHIC LARYNGITIS/ CHRONIC HYPERPLASTIC LARYNGITIS
• May occur as a diffuse and symmetrical process or May occur as a localised process which may present as
vocal nodule, vocal polyp, Reinke’s edema and contact ulcer

PACHYDERMA LARYNGITIS
• Characterstic feature is presence of heaped up reddish granulation tissue in the region of interarytenoids
and posterior part of vocal cords and presence of contact ulcer in vocal cords.
• Treatment is microscopy aided removal of granulation tissue + control of acid reflux + Speech therapy

/e
ATROPHIC LARYNGITIS/LARYNGITIS SICCA
• Atrophy + foul smelling crust formation in laryngeal mucosa

,1
• Treatment – treat the cause + laryngeal sprays with glucose + glycerine
TUBERCULOSIS OF LARYNX

es
• MC ENT manifestation → cervical lymphadenopathy
• MC site → posterior commissure
• MC symptom → weakness of voice
ot
• Impaired adduction of cords
N
• Mouse nibbled ulceration of vocal cord
• Pseudoedema of epiglottis → TURBAN EPIGLOTTIS [Turban tumor → Cutaneous cylindrinoma]
• Treated with anti-Tubercular drugs
EE

LUPUS LARYNX
• Involves anterior larynx (TB involves posterior structures)
M

• Epiglottis is the first structure to get involved (may be destroyed fully)

• Mamillated appearance of interarytenoid region is seen
PG

• Painless and usually asymptomatic

• Treated with anti-Tubercular drugs
SYPHILIS OF LARYNX
• Seen only in3o stage of syphilis
y

LEPROSY OF LARYNX
M

• Rare condition associated with leprosy of nose and skin

SCLEROMA OF LARYNX
• Chronic inflammatory disease caused by Klebsiella rhinoscleromatis
• Nasal involvement is common
• Treated with tetracycline + streptomycin + Steroids (to prevent fibrosis)
LARYNGEAL MYCOSIS
• Caused by Blastomycosis, Candidiasis or Histoplasma
ENT

613

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Notes

CONGENITAL LESIONS OF LARYNX

LARYNGOMALACIA
• Laryngomalacia is the most common congenital anomaly of larynx
• Omega shaped epiglottis
• Presence of stridor that increases on crying but decreasing when put on prone
• Conservative treatment
CONGENITAL VOCAL CORD PARALYSIS- occurs as a result of birth trauma
CONGENITAL SUBGLOTTIC STENOSIS
• Occurs due to abnormal thickening of Cricoid cartilage
• Cry is Normal
• Diagnosis made when subglottic diameter is <4mm in full term neonate or <3mm in premature neonate
• MC Caffey’s classification and Cotton Meyer Classification is used
• Treatment conservative → no recovery → surgery (excision + reanastomoses)
LARYNGEAL WEB

/e
• Due to incomplete recanalisation of larynx
• Mostly seen in Vocal cords

,1
• Can be cut with a CO2 laser or knife
• COHN’S classification is used

es
SUBGLOTTIC HEMANGIOMA
• 50% have associated cutaneous hemangiomas ot
• Asymptomatic till 3-6 months
• Stridor + normal cry
N
• Treated with: tracheostomy + observation or steroid therapy or CO2 laser according to the case
LARYNGOCELE-dilation of laryngeal saccule,may be internal, external or both
EE

LARYNGEAL CYST- bluish fluid filled smooth swelling in supragllotic larynx, treated with needle aspiration.
LARYGOESOPHAGEAL CLEFT- failure of fusion of cricoids lamina
M

Stridor
PG
y
M
ENT

614

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Notes

Laryngeal Paralysis
zz Semon’s law: in all organic lesions, abductor fibres are more susceptible and paralyzed earlier
than the adductors
zz Wagner and Grossman hypothesis: Cricothyroid receives innervations from SLN, keeps the vocal
cord in paramedian position
U/L RLN PARALYSIS
• 1/3 patients asymptomatic
• voice gradually improves due to compensation by the other cord
• no treatment required
B/L RLN PARALYSIS
• Caused by surgical trauma or Neuritis
• Both cords lie in median/paramedian position
• Inadequate airway thus stridor present and voice is good

/e
• Treatment is tracheostomy and lateralisation of cord
U/L SLN PARALYSIS

,1
• Isolated lesions rare
• SLN # → cricothyroid paralysis

es
• Weak voice + pitch cannot be raised
• Shortening of cord with loss of tension ot
B/L SLN PARALYSIS
• Inhalation of food particles due to anaesthesia + paralysis → choking fits + cough
N
• Neuritis may recover spontaneously
• Repeated aspiration may need cuffed tracheostomy
EE

U/L COMBINED RLN+SLN PARALYSIS

• MCC thyroid surgery
• Vocal cord lie in cadaveric position[3.5 mm from midline]
M

• Hoarseness + aspiration +
• Treatment is speech therapy + medialisation of cord
PG

B/L COMBINED RLN+SLN PARALYSIS

• Rare condition
• Total anaesthesia + paralysis
y

• Cant cough + aphonia + aspiration + recurrent aspiration leading to bronchopneumonia

M

• Treatment options are tracheostomy / Epiglottoplexy/ Vocal cord plication / diversion

procedures

Thyroplasty

4 TYPES
• Type I: MEdialization
ENT

• Type II: LA teralization

• Type III: SHOrtening, relaxation (lower pitch)
• Type IV: LEngthening, tension (raise pitch)

615

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Notes

Tumors of Larynx

BENIGN
VOCAL NODULES/ • Occur symmetrically in junction of ant1/3 and post2/3 [2018]
SINGER’S NODULE/ • Hoarseness + pain in neck + vocal fatigue
SCREAMER’S NODULE • Treatment is Speech therapy + voice rest + analgesics
VOCAL POLYP • Typically is unilateral
• Mostly in men of 30-50 year age
• Hoarseness + dyspnoea + stridor
• Treatment is Speech therapy + voice rest + analgesics
REINKE’S EDEMA • Cause may be vocal abuse or smoking
• Due to collection of fluid in subepithelial space of Reike
• Treatment is vocal cord stripping + allowing it to re epithelise
CONTACT ULCER • May occur due to faulty voice production or gastric reflux

/e
• U/L or B/L ulcer with congestion of arytenoids
INTUBATION • Due to rough intubation

,1
GRANULOMA • Mucosal ulceration → granuloma formation
• Treatment is voice rest + granuloma removal endoscopically

es
LEUKOPLAKIA/ • White plaque or warty growth on vocal cords
KERATOSIS • Precancerous condition
• Treatment is stripping the vocal cord + histopath examination of removed
ot
sample
LARYNGOCELE • Air filled cystic swelling due to dilation of saccule
N
• Marsupialisation of internal laryngocele is done
MALIGNANT
EE

JUVENILE PAPILLOMA • Viral in origin and multiple (Juvenile love to play together)
• Glistening white irregular growth, easily bleed
• Recurr after removal
M

ADULT ONSET • Viral in origin and single (Adults prefer to stay alone)
PG

PAPILLOMA • Less aggressive

• Does not recur after removal
CHONDROMA • Arise from Cricoid cartilage
• Mostly affects men of 40-60 year age group
y

GRANULAR CELL TUMOR • Arises from SCHWANN cell and is submucosal

M

Carcinoma Larynx
zz MC site- Glottis (59%)
zz MC type- squamous cell carcinoma
zz MC predisposing factor-Smoking
zz Treatment of Glottic ca → Radiotherapy
ENT

zz SUPRAGLOTTIC Ca-
ƒƒ MC part involved in supraglottic Ca → Epiglottis>false vocal cord
ƒƒ Pain on swallowing is most frequent initial symptom
ƒƒ Large tumors → HOT POTATO/ Muffled voice
zz Treatment of Supraglottic/subglottic Ca → Surgery
616
zz Stroboscopy and Toluene Blue dye can be used to differentiate b/w benign and Malignant
zz All glottic cancers are mostly Radiosensitive
notes
 My PG
MEE
Notes

Treatment of Laryngeal Cancer

Tis→Microlaryngeal stripping with CO2 laser

GLOTTIC SUBGLOTTIC SUPRAGLOTTIC

T1→RT T1-T2→RT T1→Radiation/CO2 laser
T2→Partial Laryngectomy T3-T4→Total laryngectomy T2→Supraglottic laryngectomy
+ Post operative RT T3& T4→Total laryngectomy + Post operative RT
zz MC site of distant mets is lungs
zz MC complication of Tracheostomy- surgical emphysema
zz Electrolarynx → external hand held device which converts neck vibration to speech
zz Laryngeal carcinoma is the only indication of high tracheostomy[2018]
zz Blom singer prosthesis:
 Vocal rehabilitation after total laryngectomy
Life 2 years

/e


 1 way valve → allows air to go to esophagus from trachea but not vice versa

,1
 Surgically placed between trachea and esophagus

Voice and Speech Disorders

es
DYSPHONIA PLICA VENTRICULARIS
ot
• Faulty use of false vocal cord
N
• Seen in mimicry artists
• Treated with vocal rest and speech therapy
EE

HYSTERICAL APHONIA/FUNCTIONAL APHONIA

• Larynx normal but no voice • Psychogenic causes
• Seen in young females • Cough is normal
M

• Treatment is Psychotherapy
PG

PUBERPHONIA/ MUTATIONAL FALSETTO VOICE

• Child like voice at puberty → high pitch voice
• Seen in emotionally immature boys
• Treatment is training to produce low pitch voice
y

• Gutzman procedure- low pitch voice on pressing thyroid prominence

M

PHONESTHENIA
• Weakness of muscles causing vocal weakness
• Causes include weak thyroarytenoid/Interarytenoid/ both
• Treatment – wait and watch
ANDROPHONIA
• Male like voice in females
MOGIPHONIA
ENT

• Abnormal voice infront of Public

RHINOLELIA CLAUSA/HYPONASALITY
• Lack of nasal resonance for words due to blockage of nose or nasopharynx
RHINOLELIA APERTA/HYPERNASALITY
• Seen when words with little nasal resonance are resonated through nose due to abnormal communication
617
between nasal and oral cavities

notes