MPMSU ENT 2021 question paper with answers

Definition: It is a collection of pus in the peritonsillar space which lies between the capsule of tonsil and the superior constrictor muscle.

Aetiology

Peritonsillar abscess usually follows acute tonsillitis though it may arise de novo without previous history of sore throats. First, one of the tonsillar crypts, usually the crypta magna, gets infected and sealed off. It forms an intratonsillar abscess which then bursts through the tonsillar capsule to set up peritonsillitis and then an abscess.

Culture of pus from the abscess may reveal pure growth of Streptococcus pyogenes, S. aureus or anaerobic organisms. More often the growth is mixed, with both aerobic and anaerobic organisms.

Clinical Features

Peritonsillar abscess mostly affects adults and rarely the children though acute tonsillitis is more common in children. Usually, it is unilateral though occasionally bilateral abscesses are recorded. Clinical features are divided into:

1. General

• Fever (up to 104 °F)
• Chills and rigors
• General malaise
• Body aches
• Headache
• Nausea and constipation

2. Local

• Severe unilateral throat pain
• Odynophagia – patient cannot swallow saliva, leading to dribbling and dehydration
• Muffled “hot potato” voice
• Foul breath due to sepsis and poor hygiene
• Ipsilateral earache (referred via CN IX)
• Trismus due to spasm of pterygoid muscles

Examination

• Tonsil, pillars and soft palate on the involved side are congested and swollen. Tonsil may appear buried in oedematous pillars.
• Uvula swollen, oedematous and pushed to opposite side.
• Bulging of soft palate and anterior pillar above the tonsil.
• Mucopus may cover the tonsillar region.
• Cervical lymphadenopathy (jugulodigastric nodes).
• Torticollis – neck tilted to side of abscess.

Investigation

• Contrast-enhanced CT or MRI shows abscess and its extent.
• Needle aspiration provides pus for culture and sensitivity.

Treatment

1. Hospitalization.
2. Intravenous fluids to combat dehydration.
3. Large dose IV antibiotics covering aerobic and anaerobic organisms.
4. Analgesics like paracetamol for pain and fever; pethidine if needed. Avoid aspirin (risk of bleeding).
5. Maintain oral hygiene with hydrogen peroxide or saline mouth washes.

The above conservative measures may cure peritonsillitis. If a frank abscess has formed, incision and drainage will be required.

Incision and Drainage of Abscess

A peritonsillar abscess is opened at the point of maximum bulge above the upper pole of tonsil or just lateral to the point of junction of anterior pillar with a line drawn through the base of uvula. With a guarded knife, a small stab incision is made and a sinus forceps inserted to open the abscess. The forceps may be reinserted the next day to drain any reaccumulation.

Interval Tonsillectomy

Tonsils are removed 4–6 weeks following an attack of quinsy.

Abscess or Hot Tonsillectomy

Some prefer “hot” tonsillectomy instead of incision and drainage. Abscess tonsillectomy carries the risk of rupture of abscess during anaesthesia and excessive bleeding at the time of operation.

Complications

• Parapharyngeal abscess (potential extension).
• Oedema of larynx – may require tracheostomy.
• Septicaemia, endocarditis, nephritis, brain abscess.
• Pneumonitis or lung abscess from aspiration of pus after spontaneous rupture.
• Jugular vein thrombosis.
• Spontaneous haemorrhage from carotid artery or jugular vein.

It is the most common congenital abnormality of the larynx. It is characterized by excessive flaccidity of supraglottic larynx which is sucked in during inspiration producing stridor and sometimes cyanosis. Stridor is increased on crying but subsides on placing the child in prone position; cry is normal.

The condition manifests at birth or soon after, and usually disappears by 2 years of age. Direct laryngoscopy shows elongated epiglottis, curled upon itself (omega-shaped Ω), floppy aryepiglottic folds and prominent arytenoids. Flexible laryngoscope is very useful to make the diagnosis. Laryngomalacia cannot be diagnosed in a paralyzed patient.

Mostly, treatment is conservative. Tracheostomy may be required for some cases of severe respiratory obstruction. Supraglottoplasty is required in cases of severe laryngomalacia.

Closure of perforation of pars tensa of the tympanic membrane is called myringoplasty.

CONTRAINDICATIONS

1. Active discharge from the middle ear.
2. Nasal allergy. It should be brought under control before surgery.
3. Otitis externa.
4. Ingrowth of squamous epithelium into the middle ear. In such cases, excision of squamous epithelium from the middle ear or a tympanomastoidectomy may be required.
5. When the other ear is dead or not suitable for hearing aid rehabilitation.
6. Children below 3 years.

ANAESTHESIA

Local or general, the former is preferred.

POSITION

Supine with face turned to one side; the ear to be operated is up.

Graft materials used are:

1. Temporalis fascia (most common)
2. Areolar fascia overlying the temporal fascia
3. Perichondrium from the tragus
4. Cartilage
5. Vein
6. Periosteum

Incision for exposure of tympanic membrane depends on the size of the ear canal; it may be endomeatal, endaural or postaural.

TECHNIQUE

UNDERLAY TECHNIQUE

1. Harvesting the graft, e.g. of temporalis fascia; or perichondrium from the tragus.
2. Preparing the tympanic membrane for grafting. An incision is made along the edge of perforation and the ring of epithelium removed. Remove also a strip of mucosal layer from the inner side of perforation.
3. Inspecting the middle ear. A stapes-type incision is made and the tympanomeatal flap raised to see the integrity and mobility of the ossicular chain and to ensure that no squamous epithelium has grown into the middle ear.
4. Placing the graft. Middle ear is packed with gelfoam soaked with an antibiotic. A proper-sized graft is placed so that its edges extend under the margins of perforation all round and a small part also extends over the posterior canal wall. Tympanomeatal flap is replaced. An underlay technique has the advantage that the squamous epithelium is not buried in the middle ear.

OVERLAY TECHNIQUE

1. Temporal fascia or perichondrial graft is harvested as above.
2. Incision is made in the meatus and meatal skin raised along with all epithelium from the outer surface of tympanic membrane remnant and preserved to be used later.
3. Graft placed on the outer surface of tympanic membrane. A slit is made in the graft to tuck it under the handle of malleus.
4. Meatal skin removed earlier is now replaced, covering the periphery of the graft.
5. Ear canal packed with gelfoam and then with a small antibiotic pack.
A modification of the overlay technique is to place the anterior edge of fascia graft under the annulus after removing the epithelium from its undersurface. This prevents blunting of anterior canal which is seen as a complication of overlay technique.
6. Closure of endaural or postaural incision.
7. Mastoid dressing.

POSTOPERATIVE CARE

1. Stitches are removed after 5–6 days.
2. Ear pack is removed after 5–6 days without disturbing the gelfoam.
3. Patient is seen at 3 and 6 weeks after operation.
4. Complete epithelialization of graft takes 6–8 weeks.

COMPLICATIONS

UNDERLAY TECHNIQUE

1. Middle ear becomes narrow.
2. Graft may get adherent to the promontory.
3. Anteriorly, graft may lose contact from the remnant of tympanic membrane leading to anterior perforation.

OVERLAY TECHNIQUE

1. Blunting of the anterior sulcus.
2. Epithelial pearls. They are epidermal cysts, when squamous epithelium is buried under the graft.
3. Lateralization of graft. Graft loses contact from the malleus handle resulting in conductive loss. It is prevented by tucking the graft under the handle.

Oesophagus. Usual foreign bodies that get lodged in the oesophagus are a coin, piece of meat, chicken bone, denture, safety pin or a marble. Sometimes other object like nails, screws, plastic objects or pieces of glass may also be seen. Disc batteries are also becoming common these days due to their wide spread usage. Most of oesophageal foreign bodies lodge just below the cricopharyngeal sphincter. If they lodge lower down, an underlying condition such as congenital or acquired stricture or a malignancy (in adults) should be suspected and/or a follow-up barium swallow should be done when oedema due to foreign body removal has subsided.

AETIOLOGY

1. Age. Children are most often affected. Nearly 80% are below 5 years. They have a tendency to put anything in the mouth. Playing while eating is another factor. Education of parents is important to prevent such accidents in toddlers and young children.
2. Loss of protective mechanism. Use of upper denture prevents tactile sensation and a foreign body is swallowed undetected. Loss of consciousness, epileptic seizures, deep sleep or alcoholic intoxication are other factors.
3. Carelessness. Poorly prepared food, improper mastication, hasty eating and drinking.
4. Narrowed oesophageal lumen. Pieces of food may be held up in cases of oesophageal stricture or carcinoma. The first symptom of carcinoma oesophagus may be sudden obstruction from a foreign body such as a piece of meat, fruit or vegetable.
5. Psychotics. Foreign body may be swallowed with an attempt to commit suicide.

3. Dysphagia. Obstruction to swallowing may be partial or total. Partial obstruction becomes total with time due to oedema.
4. Drooling of saliva. It is seen in cases of total obstruction. Saliva may be aspirated causing pneumonitis.
5. Respiratory distress. Impacted foreign body in the upper oesophagus compresses posterior wall of trachea causing respiratory obstruction especially in children. Laryngeal oedema can develop.
6. Substernal or epigastric pain. It may occur due to oesophageal spasm or incipient perforation.
7. In partial obstruction, patient may still be taking normal food with little or no discomfort for a few days. Even X-rays may be normal. No complacency should be observed and an endoscopic examination performed when history and physical examination strongly suggest a foreign body.

SIGNS

Sometimes a foreign body may be seen protruding from the oesophageal opening in the postcricoid region.

INVESTIGATIONS

Posteroanterior and lateral views of neck and similar views of the chest including abdomen are taken. They reveal most of the radio-opaque foreign bodies and their location. Foreign bodies of the oesophagus lie in the coronal plane in PA view and edge on in the lateral view. It is just the reverse in tracheal foreign bodies because of orientation of vocal cords. Radiolucent foreign bodies may show as an air bubble in cervical oesophagus in X-ray soft tissue lateral view of neck. Failure to see a foreign body on X-ray does not rule it out as small fish bones, pieces of wood or plastics are radiolucent. Barium swallow is avoided as it may spill over into the larynx and thus delay the subsequent endoscopic procedure and also make it more difficult. Also look for multiple foreign bodies (as coins). A disc battery may elude as it may cast a double shadow or stacked coin appearance.

MANAGEMENT

1. Endoscopic Removal. Most of the foreign bodies in oesophagus can be removed by oesophagoscopy under general anaesthesia. Both rigid and flexible scopes have been used to remove foreign bodies from the oesophagus. Rigid oesophagoscope, appropriate for the size of patient with proper type of forceps is preferred. Soft (meat pieces without bone, vegetable matter) and blunt objects can be removed with flexible scopes. A hypopharyngeal speculum resembling a laryngoscope with long blade is less traumatic and more useful.

2. Cervical Oesophagotomy. Impacted foreign bodies or those with sharp hooks such as partial dentures located above thoracic inlet may require removal through an incision in the neck and opening of cervical oesophagus.

3. Transthoracic Oesophagotomy. For impacted foreign bodies of thoracic oesophagus, chest is opened at the appropriate level.

A foreign body which has passed the pylorus of stomach may pass through rest of gastrointestinal tract without difficulty; stool should be examined daily for 3–4 days for spontaneous expulsion. Patient should take a normal diet and no purgative should be administrated to hasten the passage of foreign body. Operative interference is required when:
(a) Patient complains of pain and tenderness in abdomen.
(b) Foreign body is not showing any progress on periodic X-rays taken at a few days interval.
(c) Objects are sharp and likely to penetrate or get obstructed, e.g. nails, pins, needles, sharp bones, denture fragments, razors and long thin wires.
(d) Foreign body is 5 cm or longer (e.g. hair pin) in a child of 2 years; it is unlikely to pass through turns of duodenum. A disc battery larger than 1.5 cm in a child of 6 years and remaining in stomach for 48 h.
(e) There is pyloric stenosis.

COMPLICATIONS OF OESOPHAGEAL FOREIGN BODY

1. Respiratory obstruction. This is due to tracheal compression by the FB in the oesophagus, or laryngeal oedema especially in infants and children.
2. Perioesophageal cellulitis and abscess. It occurs in the neck.
3. Perforation. Sharp objects may perforate the oesophageal wall, setting up mediastinitis, pericarditis or empyema. They may perforate the aorta and prove fatal.
4. Tracheo-oesophageal fistula. Rare.
5. Ulceration and stricture. Overlooked foreign bodies may cause slow ulceration and stricture formation.

Cortical mastoidectomy, known as simple or complete mastoidectomy or Schwartz operation, is complete exenteration of all accessible mastoid air cells and converting them into a single cavity. Posterior meatal wall is left intact. Middle ear structures are not disturbed.

INDICATIONS

1. Acute coalescent mastoiditis.
2. Incompletely resolved acute otitis media with reservoir sign.
3. Masked mastoiditis.
4. As an initial step to perform:
    a. Endolymphatic sac surgery
    b. Decompression of facial nerve
    c. Translabyrinthine or retrolabyrinthine procedures for acoustic neuroma.

ANAESTHESIA

General anaesthesia.

POSITION

Patient lies supine with face turned to one side and the ear to be operated uppermost.

STEPS OF OPERATION

1. Incision. A curved postaural incision about 1 cm behind but parallel to the retroauricular sulcus, starting at the highest attachment of pinna to the mastoid tip.
In infants and children up to 2 years, the incision is short and more horizontal. This is to avoid cutting facial nerve which is superficial in the lower part of mastoid.
Incision cuts through soft tissues up to the periosteum. Temporalis muscle is not cut in the incision.

2. Exposure of Lateral Surface of Mastoid and Macewen’s Triangle.
Periosteum is incised in the line of first incision. A horizontal incision may be made along the lower border of temporalis muscle for more exposure.
Periosteum is scraped from the surface of mastoid and posterosuperior margin of osseous meatus. Tendinous fibres of sternomastoid are sharply cut and scraped down. A self-retaining mastoid retractor is applied.

3. Removal of Mastoid Cortex and Exposure of Antrum.
Mastoid cortex is removed with burr, or gouge and hammer. Mastoid antrum is exposed in the area of suprameatal triangle. In an adult, antrum lies 12–15 mm from the surface. Horizontal semicircular canal is identified. Keep in mind the presence of Korner’s septum which would need removal to explore the antrum.

4. Removal of Mastoid Air Cells.
All accessible mastoid air cells are removed leaving behind the bony plate of tegmen tympani above, sinus plate behind and posterior meatal wall in front.

5. Removal of Mastoid Tip and Finishing the Cavity.
Lateral wall of the mastoid tip is removed, exposing muscle fibres of posterior belly of digastric. Zygomatic cells situated in the root of zygoma and retrosinus cells lying between sinus plate and bony cortex behind the sinus are removed. A finished cavity should have bevelled edges so that soft tissue can easily sit in and obliterate the cavity.

6. Closure of Wound.
Mastoid cavity is thoroughly irrigated with saline to remove bone dust and the wound is closed in two layers. A rubber drain may be left at the lower end of incision for 24–48 h in case of infection or excessive bleeding. A meatal pack should be kept to avoid stenosis of ear canal. Mastoid dressing is applied.

POSTOPERATIVE CARE

1. Antibiotics started preoperatively are continued postoperatively for at least 1 week. Culture swab taken from the mastoid, during operation, may dictate a change in the antibiotic.
2. Drain, if put, is removed in 24–48 h and sterile dressing done.
3. Stitches are removed on the sixth day.

COMPLICATIONS

1. Injury to facial nerve.
2. Dislocation of incus.
3. Injury to horizontal semicircular canal. Patient will have postoperative giddiness and nystagmus.
4. Injury to sigmoid sinus with profuse bleeding.
5. Injury to dura of middle cranial fossa.
6. Postoperative wound infection and wound breakdown.

APPLIED ANATOMY

Submandibular space lies between mucous membrane of the floor of mouth and tongue on one side and superficial layer of deep cervical fascia extending between the hyoid bone and mandible on the other. It is divided into two compartments by the mylohyoid muscle:

1. Sublingual compartment (above the mylohyoid).
2. Submaxillary and submental compartment (below the mylohyoid).

The two compartments are continuous around the posterior border of mylohyoid muscle. Ludwig’s angina is infection of submandibular space.

AETIOLOGY

1. Dental Infections. They account for 80% of the cases. Roots of premolars often lie above the attachment of mylohyoid and cause sublingual space infection while roots of the molar teeth extend up to or below the mylohyoid line and primarily cause submaxillary space infection.
2. Submandibular sialadenitis, injuries of oral mucosa and fractures of the mandible account for other cases.

BACTERIOLOGY

Mixed infections involving both aerobes and anaerobes are common. Alpha-haemolytic Streptococci, Staphylococci and bacteroides groups are common. Rarely Haemophilus influenzae, Escherichia coli and Pseudomonas are seen.

CLINICAL FEATURES

There is marked difficulty in swallowing (odynophagia) with varying degrees of trismus.

When infection is localized to the sublingual space, structures in the floor of mouth are swollen and tongue seems to be pushed up and back.

When infection spreads to submaxillary space, submental and submandibular regions become swollen and tender, and impart woody-hard feel. Usually, there is cellulitis of the tissues rather than frank abscess. Tongue is progressively pushed upwards and backwards threatening the airway. Laryngeal oedema may appear.

TREATMENT

1. Systemic antibiotics.
2. Incision and drainage of abscess.
    (a) Intraoral — if infection is still localized to sublingual space.
    (b) External — if infection involves submaxillary space. A transverse incision extending from one angle of mandible to the other is made with vertical opening of midline musculature of tongue with a blunt haemostat. Very often it is serous fluid rather than frank pus that is encountered.
3. Tracheostomy, if airway is endangered.

COMPLICATIONS

1. Spread of infection to parapharyngeal and retropharyngeal spaces and thence to the mediastinum.
2. Airway obstruction due to laryngeal oedema, or swelling and pushing back of the tongue.
3. Septicaemia.
4. Aspiration pneumonia.

Adenoid facies, seen in adenoid hyperplasia, consists of crowded teeth, high-arched palate and underdeveloped pinched nostrils.

COMPLICATIONS

1. Immediate (at the time of operation)

(a) Haemorrhage.
(b) Apnoea — occurs after opening the trachea in a patient with prolonged respiratory obstruction due to sudden washout of CO₂ (loss of respiratory stimulus). Treated by administering 5% CO₂ in oxygen or assisted ventilation.
(c) Pneumothorax due to injury to apical pleura.
(d) Injury to recurrent laryngeal nerves.
(e) Aspiration of blood.
(f) Injury to oesophagus — commonly due to the knife while incising the trachea, may lead to tracheo-oesophageal fistula.

2. Intermediate (during first few hours or days)

(a) Bleeding, reactionary or secondary.
(b) Displacement of tube.
(c) Blocking of tube.
(d) Subcutaneous emphysema.
(e) Tracheitis and tracheobronchitis with crusting in trachea.
(f) Atelectasis and lung abscess.
(g) Local wound infection and granulations.

3. Late (with prolonged use of tube for weeks and months)

(a) Haemorrhage due to erosion of a major vessel.
(b) Laryngeal stenosis due to perichondritis of cricoid cartilage.
(c) Tracheal stenosis due to tracheal ulceration and infection.
(d) Tracheo-oesophageal fistula due to prolonged use of cuffed tube or erosion of trachea by the tube tip.
(e) Problems of decannulation — common in infants and children.
(f) Persistent tracheocutaneous fistula.
(g) Keloid or unsightly tracheostomy scar.
(h) Corrosion of tracheostomy tube and aspiration of its fragments into the tracheobronchial tree.

INDICATIONS

1. Deviated septum causing nasal obstruction on one or both sides.
2. As a part of septorhinoplasty for cosmetic reasons.
3. Recurrent epistaxis usually from the spur.
4. Sinusitis due to septal deviation.
5. Septal deviation making contact with lateral nasal wall and causing headaches.
6. For approach to middle meatus or frontal recess in endoscopic sinus surgery when deviated septum obstructs the view and access to these areas.
7. Access to endoscopic dacryocystorhinostomy operation in some cases.
8. As an approach to pituitary fossa (trans-septal transsphenoidal approach).
9. Septal deviation causing sleep apnoea or hypopnoea syndrome.

COMPLICATIONS

1. Bleeding.
2. Septal haematoma and abscess.
3. Septal perforation.
4. Supratip depression.
5. Saddle nose deformity.
6. Columellar retraction.
7. Persistence of septal deviation, or external nasal deformity.
8. Cerebrospinal fluid rhinorrhoea (rare, occurs if perpendicular plate of ethmoid is avulsed).
9. Toxic shock syndrome.

A. Aminoglycoside Antibiotics

• Streptomycin
• Dihydrostreptomycin
• Gentamicin
• Tobramycin
• Neomycin
• Kanamycin
• Amikacin
• Netilmycin
• Sisomycin

B. Diuretics

• Furosemide
• Ethacrynic acid
• Bumetanide

C. Antimalarials

• Quinine
• Chloroquine
• Hydroxychloroquine

D. Cytotoxic Drugs

• Nitrogen mustard (Mechlorethamine)
• Cisplatin
• Carboplatin

E. Analgesics

• Salicylates
• Indomethacin
• Phenylbutazone
• Ibuprofen

F. Chemicals

• Alcohol
• Tobacco
• Marijuana
• Carbon monoxide poisoning

G. Miscellaneous

• Erythromycin
• Ampicillin
• Propranolol
• Propylthiouracil
• Deferoxamine