Long Answer Questions
Q.1 Describe the pathophysiology of unsafe chronic suppurative otitis media and its management?
+Atticoantral Type (Unsafe / Dangerous CSOM)
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.
Pathophysiology / Pathology
Atticoantral diseases are associated with the following pathological processes:
- Cholesteatoma
-
Osteitis and Granulation Tissue:
Osteitis involves outer attic wall and posterosuperior margin of the tympanic ring. A mass of granulation tissue surrounds the area of osteitis and may even fill the attic, antrum, posterior tympanum and mastoid. A fleshy red polypus may be seen filling the meatus.
-
Ossicular Necrosis:
It is common in atticoantral disease. Destruction may be limited to the long process of incus or may also involve stapes superstructure, handle of malleus or the entire ossicular chain. Therefore, hearing loss is always greater than in disease of tubotympanic type. Occasionally, the cholesteatoma bridges the gap caused by the destroyed ossicles and hearing loss is not apparent (cholesteatoma hearer).
-
Cholesterol Granuloma:
It is a mass of granulation tissue with foreign body giant cells surrounding the cholesterol crystals. It is a reaction to long-standing retention of secretions or haemorrhage, and may or may not coexist with cholesteatoma. When present in the mesotympanum, behind an intact drum, the latter appears blue.
Management
1. Surgical Treatment
Surgical treatment is the mainstay. Primary aim in surgical treatment is to remove the disease and render the ear safe, and second in priority is to preserve or reconstruct hearing but never at the cost of the primary aim. 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. However, there is danger of leaving some cholesteatoma behind. Incidence of residual or recurrent cholesteatoma in these cases is very high and therefore long-term follow-up is essential.
Some surgeons 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. It can be done at the time of primary surgery or as a second stage procedure.
3. Conservative Treatment
It has a limited role in the management of cholesteatoma but can be tried in selected cases, when cholesteatoma is small and easily accessible to suction clearance under operating microscope. 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 anaesthesia 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.
Q.2 Describe carcinoma of the larynx and its management
+Epidemiology
10× more common in males than females (4.79% vs 0.47%).
Incidence:
- 3.29 new cases/100,000 males
- 0.42 new cases/100,000 females
- (National Cancer Registry, ICMR, April 2005)
Aetiology
- Tobacco and alcohol: well-established risk factors.
- Cigarette smoke contains benzopyrene and carcinogenic hydrocarbons.
- Combined alcohol + smoking → 15-fold increased risk (vs 2–3 fold individually).
- Previous neck radiation (for benign lesions/laryngeal papilloma) may induce carcinoma.
- Familial cases reported (Japanese & Russian workers), suggesting genetic factors.
- Occupational exposures (asbestos, mustard gas, chemicals, petroleum products) linked but not conclusively proven.
Histopathology
- 90–95%: Squamous cell carcinoma with various differentiation grades.
- Cordal lesions → well differentiated.
- Supraglottic lesions → anaplastic.
- 5–10%: Verrucous carcinoma, spindle cell carcinoma, malignant salivary gland tumors, sarcomas.
Classification of Laryngeal Sites (AJCC 2002)
Supraglottis
- Suprahyoid epiglottis (lingual + laryngeal surfaces)
- Infrahyoid epiglottis
- Aryepiglottic folds (laryngeal aspect)
- Arytenoids
- Ventricular bands (false cords)
Glottis
- True vocal cords (including anterior & posterior commissure)
Subglottis
- Area from glottis to lower border of cricoid cartilage
1. Supraglottic Cancer
Less common than glottic cancer. Common sites: epiglottis → false cords → aryepiglottic folds.
Spread
- Local spread to vallecula, base of tongue, pyriform fossa.
- Infrahyoid epiglottis/anterior ventricular band → pre-epiglottic space → thyroid cartilage penetration.
- Nodal metastasis occurs early to upper & middle jugular nodes; epiglottic cancers may be bilateral.
Symptoms
- Often silent initially.
- Hoarseness is a late symptom.
- Throat pain, dysphagia, referred otalgia.
- Neck lymph node mass.
- Late symptoms: weight loss, airway obstruction, halitosis.
2. Glottic Cancer
Most laryngeal cancers originate here. Common site: free edge and upper surface of vocal cord (anterior/middle third).
Spread
- Anterior → anterior commissure → opposite cord.
- Posterior → vocal process, arytenoid region.
- Upwards → ventricle, false cord.
- Downwards → subglottis.
- Early: vocal cord mobility normal; cord fixation indicates thyroarytenoid muscle invasion and poor prognosis.
- Lymphatics sparse → nodal metastasis rare unless tumor spreads beyond membranous cord.
Symptoms
- Hoarseness – early sign due to vibratory impairment.
- Larger tumors → edema or fixation → stridor and airway obstruction.
3. Subglottic Cancer (1–2%)
Rare; extends from glottis to lower border of cricoid cartilage.
Spread
- Starts on one side → circumferential spread to other side.
- Downwards → trachea.
- Upwards → cords (late), so hoarseness is delayed.
- Can invade cricothyroid membrane, thyroid gland, neck ribbon muscles.
Lymphatic Spread
- Prelaryngeal, pretracheal, paratracheal, lower jugular nodes.
Symptoms
- Early: stridor or obstruction (often late in tumor progression).
- Hoarseness late → due to undersurface cord involvement, thyroarytenoid infiltration, or recurrent laryngeal nerve involvement.
Diagnosis of Laryngeal Cancer
1. History
Symptoms vary by location. Rule: hoarseness > 3 weeks in cancer age group → mandatory laryngeal exam.
2. Indirect Laryngoscopy
Appearance of Lesion:
- Suprahyoid epiglottis → exophytic.
- Infrahyoid epiglottis → ulcerative.
- Vocal cords → raised nodule, ulcer, thickening.
- Anterior commissure → granulation-like.
- Subglottic → raised submucosal nodule (anterior half).
Vocal Cord Mobility: impairment or fixation suggests invasion of muscle, joint, or recurrent laryngeal nerve.
Extent of disease: note spread to vallecula, base of tongue, pyriform fossa.
3. Flexible Fibreoptic / Rigid / Video Laryngoscopy
Outpatient procedure; provides detailed documentation.
4. Neck Examination
- Detects extralaryngeal spread and nodal metastasis.
- Anterior commissure/subglottic tumors → midline swelling via cricothyroid membrane.
- Thyroid cartilage invasion → tenderness due to perichondritis.
- Evaluate nodal status: size, mobility, laterality.
5. Radiography
- Chest X-ray: lung disease, metastasis, mediastinal nodes.
- Lateral soft tissue neck: epiglottis, folds, arytenoids, pre-epiglottic space, cartilage destruction (CT/MRI preferred).
- CT scan: tumor extent, pre-/paraglottic space, cartilage destruction, nodes.
- MRI: useful in recurrent cancers post-radiotherapy.
6. Direct Laryngoscopy
Visualizes hidden areas: infrahyoid epiglottis, anterior commissure, subglottis, ventricle.
7. Microlaryngoscopy
For small cord lesions → better visualization and precise biopsy.
8. Supravital Staining + Biopsy
Toluidine blue: carcinoma in situ and superficial cancers take dye; leukoplakia does not. Helps biopsy selection.
Treatment of Laryngeal Cancer
1. Radiotherapy
Curative radiotherapy is reserved for early lesions which neither impair cord mobility nor invade cartilage or cervical nodes.
Cancer of the vocal cord with normal mobility → 90% cure rate. Preserves voice.
Superficial exophytic lesions (tip of epiglottis, aryepiglottic folds) → 70–90% cure rate.
Not effective in lesions with fixed cords, subglottic extension, cartilage invasion, nodal metastases → these need surgery.
2. Surgery
(a) Conservation Laryngeal Surgery
Preserves voice and avoids permanent tracheal opening. Only selected cases qualify.
- Cordectomy (cord excision via laryngofissure)
- Partial frontolateral laryngectomy (cord + anterior commissure excision)
- Partial horizontal laryngectomy (excision of supraglottis: epiglottis, aryepiglottic folds, false cords, ventricle)
(b) Total Laryngectomy
Entire larynx including hyoid bone, pre-epiglottic space, strap muscles and tracheal rings removed.
Indicated in:
- T3 lesions (cord fixation)
- All T4 lesions
- Thyroid or cricoid cartilage invasion
- Bilateral arytenoid involvement
- Posterior commissure lesions
- Failure after radiotherapy or conservation surgery
- Transglottic cancers
Contraindicated in distant metastasis.
3. Combined Therapy
Surgical ablation may be combined with pre-/postoperative radiation to reduce recurrence. Preoperative radiation may render fixed nodes resectable.
4. Endoscopic Resection with CO₂ Laser
Used for mobile membranous vocal cord carcinoma. Offers precise excision, lower cost, shorter treatment duration, and less morbidity.
Also used for T1 lesions of supra- or infrahyoid epiglottis with/without neck nodes (nodes managed surgically).
5. Organ Preservation
Induction chemotherapy + radiotherapy or concurrent chemoradiation may preserve the larynx in stage III/IV cancers.
Better locoregional control than laryngectomy + postoperative radiotherapy.
Concurrent chemoradiation → more toxicity; proper patient selection required.
Short Answer Questions
Q.1 Describe emergent surgical management of the airway in brief.
+Procedures for Immediate Airway Management
When airway obstruction is so marked as to allow no time to do an orderly tracheostomy, following measures are taken:
1. Jaw Thrust.
Lifting the jaw forward and extending the neck improves the airway by displacing the soft tissues. Neck extension should be avoided in spinal injuries.
2. Oropharyngeal Airway.
It displaces the tongue anteriorly and relieves soft tissue obstruction. Ventilation can be carried out by face mask placed snugly over the face and covering both nose and mouth. Ambu bag can be used for inflation of air or oxygen.
3. Nasopharyngeal Airway (Trumpet).
It is inserted transnasally into the posterior hypopharynx and relieves soft tissue obstruction caused by the tongue and pharynx. It is better tolerated than oropharyngeal airway in awake patients.
4. Laryngeal Mask Airway.
It is a device with a tube and a triangular distal end which fits over the laryngeal inlet. Oxygen can be delivered directly into the trachea. Though most commonly used for nonemergent airway control, it can be used as an alternative if standard mask ventilation is inadequate and intubation unsuccessful.
5. Transtracheal Jet Ventilation.
It is an invasive procedure. An intravenous catheter of 12 or 14 gauge with a syringe attached is inserted into the cricothyroid membrane and directed caudally. Once intraluminal placement is confirmed by aspiration, needle is withdrawn leaving the catheter in position and jet ventilation started. In thin individuals where trachea can be palpated, catheter can be inserted easily. Expiration of air should be insured otherwise pulmonary barotrauma with pneumothorax, pneumomediastinum and surgical emphysema can result.
6. Endotracheal Intubation.
This is the most rapid method. Larynx is visualized with a laryngoscope and endotracheal tube or a bronchoscope inserted. No anaesthesia is required. This helps to avoid a hurried tracheostomy in which complication rate is higher. After intubation, an orderly tracheostomy can be performed.
7. Cricothyrotomy or Laryngotomy or Mini Tracheostomy.
This is a procedure for opening the airway through the cricothyroid membrane. Patient’s head and neck is extended, lower border of thyroid cartilage and cricoid ring are identified. Skin in this area is incised vertically and then cricothyroid membrane cut with a transverse incision. This space can be kept open with a small tracheostomy tube or by inserting the handle of knife and turning it at right angles if tube is not available. It is essential to perform an orderly tracheostomy as soon as possible because perichondritis, subglottic oedema and laryngeal stenosis can follow prolonged laryngotomy.
“Mini tracheostomy is an emergency procedure to buy time to allow patient to be carried to operation theatre. Commercial emergency kits are also available for this. As an elective procedure it has been done to clear the bronchial secretions following thoracic surgery.”
Cricothyroid needle puncture is a procedure where a large-bore intravenous catheter is introduced through the cricothyroid membrane. It is only an emergency procedure till patient can be intubated or tracheostomized. The procedure does not provide adequate ventilation.
8. Emergency Tracheostomy.
Technique of emergency tracheostomy is as follows: Patient’s neck is extended, trachea identified and fixed between surgeon’s left thumb and index finger. A vertical incision is made from lower border of thyroid to suprasternal notch cutting through skin and subcutaneous tissues. Lower border of cricoid cartilage is identified and a transverse incision made in pretracheal fascia. The thyroid isthmus dissected down to expose upper three tracheal rings. Vertical tracheal incision is made in second and third rings, opened with a haemostat and the tube inserted. Bleeding can be controlled by packing with gauze.
Emergency tracheostomy on a struggling patient with inadequate lighting, suction and instruments is fraught with many complications. If possible, an endotracheal tube should be put for a more orderly procedure to be carried out.
Q.2 Discuss in brief ATROPHIC RHINITIS and its management.
+Definition
A chronic nasal condition marked by progressive atrophy of the nasal mucosa, glands, nerves, and turbinate bones, leading to roomy nasal cavities filled with dry, foul-smelling crusts.
Types
Primary Atrophic Rhinitis
Secondary Atrophic Rhinitis (due to infections, surgery, radiotherapy, etc.)
Primary Atrophic Rhinitis
Aetiology
Mnemonic: HERNIA
- Hereditary factors
- Endocrine imbalance (puberty onset, female predominance, improves after menopause)
- Racial susceptibility (common in white/yellow races)
- Nutritional deficiencies (Vit A, D, iron)
- Infective factors (Klebsiella ozaenae, etc.—secondary invaders)
- Autoimmune mechanisms
Pathology
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
- Onset around puberty; more common in females
- Foetid nasal smell (patient unaware due to merciful anosmia)
- Paradoxical nasal obstruction due to thick crusts
- Epistaxis when crusts are removed
Examination shows:
- Green/grey dry crusts
- Roomy nasal cavities; turbinates appear as ridges
- Pale mucosa, possible septal perforation
- Saddle-nose deformity
May also have:
- Atrophic pharyngitis, laryngitis, Eustachian dysfunction, conductive hearing loss
Secondary Atrophic Rhinitis
Occurs due to:
- Specific infections (syphilis, lupus, leprosy, rhinoscleroma)
- Extensive sinusitis
- Radiotherapy
- Excessive turbinectomy
- Severe DNS causing unilateral form
Management
A. Medical Treatment (mainstay)
Goals: remove crusts, control smell, prevent new crust formation.
Nasal irrigation
- Warm saline or alkaline solution (soda bicarb + biborate + NaCl)
- Loosens and removes crusts
25% glucose in glycerine
- Reduces bacterial proteolysis → less foul smell
Local antibiotics
- E.g., chloramphenicol-based anti-ozaena solutions
Oestradiol nasal spray
- Improves vascularity and glandular function
Placental extract injections
Systemic streptomycin (1 g/day × 10 days)
- Useful against Klebsiella; reduces odour and crusting
Potassium iodide orally
- Liquefies secretions
Note: Cure is difficult; aim is long-term symptomatic control.
B. Surgical Treatment
Indicated when medical therapy fails.
Young’s operation
- Temporary complete closure of nostrils for 6–12 months → mucosal healing
Modified Young’s: partial closure to reduce discomfort
Narrowing of nasal cavities (to reduce drying)
- Submucosal Teflon paste injection
- Implantation of fat, bone, cartilage, or Teflon strips under mucoperiosteum
- Medial displacement of lateral nasal wall
Prognosis
Long-standing disease; may improve spontaneously in middle age.
Q.3 What are the indications of Functional Endoscopic Sinus Surgery?
+Indications
- Chronic bacterial sinusitis unresponsive to adequate medical treatment.
- Recurrent acute bacterial sinusitis.
- Polypoid rhinosinusitis (diffuse nasal polyposis).
- Fungal sinusitis with fungal ball or nasal polypi.
- Antrochoanal polyp.
- Mucocele of frontoethmoid or sphenoid sinus.
- Control of epistaxis by endoscopic cautery.
- Removal of foreign body from the nose or sinus.
- Endoscopic septoplasty.
Q.4 Discuss the management of epistaxis
+MANAGEMENT
In any case of epistaxis, it is important to know:
- Mode of onset. Spontaneous or finger nail trauma.
- Duration and frequency of bleeding.
- Amount of blood loss.
- Side of nose from where bleeding is occurring.
- Whether bleeding is of anterior or posterior type.
- Any known bleeding tendency in the patient or family.
- History of known medical ailment (hypertension, leukaemia, mitral valve disease, cirrhosis and nephritis).
- History of drug intake (analgesics, anticoagulants, etc.).
FIRST AID
Most of the time, bleeding occurs from the Little’s area and can be easily controlled by pinching the nose with thumb and index finger for about 5 min. This compresses the vessels of the Little’s area. In Trotter’s method patient is made to sit, leaning a little forward over a basin to spit any blood and breathe quietly from the mouth. Cold compresses should be applied to the nose to cause reflex vasoconstriction.
CAUTERIZATION
This is useful in anterior epistaxis when bleeding point has been located. The area is first topically anaesthetized and the bleeding point cauterized with a bead of silver nitrate or coagulated with electrocautery.
ANTERIOR NASAL PACKING
In cases of active anterior epistaxis, nose is cleared of blood clots by suction and attempt is made to localize the bleeding site. In minor bleeds, from the accessible sites, cauterization of the bleeding area can be done. If bleeding is profuse and/or the site of bleeding is difficult to localize, anterior packing should be done. For this, use a ribbon gauze soaked with liquid paraffin. About 1 m gauze (2.5 cm wide in adults and 12 mm in children) is required for each nasal cavity. First, few centimetres of gauze are folded upon itself and inserted along the floor and then the whole nasal cavity is packed tightly by layering the gauze from floor to the roof and from before backwards. Packing can also be done in vertical layers from back to the front. One or both cavities may need to be packed. Pack can be removed after 24 h, if bleeding has stopped. Sometimes, it has to be kept for 2-3 days; in that case, systemic antibiotics should be given to prevent sinus infection and toxic shock syndrome.
POSTERIOR NASAL PACKING
It is required for patients bleeding posteriorly into the throat. A postnasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the shape of a cone. A rubber catheter is passed through the nose and its end brought out from the mouth. Ends of the silk threads are tied to it and catheter withdrawn from nose. Pack, which follows the silk thread, is now guided into the nasopharynx with the index finger. Anterior nasal cavity is now packed and silk threads tied over a dental roll. The third silk thread is cut short and allowed to hang in the oropharynx. It helps in easy removal of the pack later.
Patients requiring postnasal pack should always be hospitalized. Instead of postnasal pack, a Foley’s catheter size 12-14 F can also be used. After insertion balloon is inflated with 5-10 mL of saline. The bulb is inflated with saline and pulled forward so that choana is blocked and then an anterior nasal pack is kept in the usual manner. These days nasal balloons are also available. A nasal balloon has two bulbs, one for the postnasal space and the other for nasal cavity.
ENDOSCOPIC CAUTERIZATION
Using topical or general anaesthesia, bleeding point is localized with a rigid endoscope. It is then cauterized with a malleable unipolar suction cautery or a bipolar cautery. The procedure is effective with less morbidity and decreased hospital stay. The procedure has a limitation when profuse bleeding does not permit localization of the bleeding point.
ELEVATION OF MUCOPERICHONDRIAL FLAP AND SUBMUCOUS RESECTION (SMR) OPERATION
In case of persistent or recurrent bleeds from the septum, just elevation of mucoperichondrial flap and then repositioning it back helps to cause fibrosis and constrict blood vessels. SMR operation can be done to achieve the same result or remove any septal spur which is sometimes the cause of epistaxis.
LIGATION OF VESSELS
1. External carotid. When bleeding is from the external carotid system and the conservative measures have failed, ligation of external carotid artery above the origin of superior thyroid artery should be done. It is avoided these days in favour of embolization or ligation of more peripheral branches of sphenopalatine artery.
2. Maxillary artery. Ligation of this artery is done in uncontrollable posterior epistaxis. Approach is via Caldwell-Luc operation. Posterior wall of maxillary sinus is removed and the maxillary artery or its branches are blocked by applying clips. This procedure is now superceded by transnasal endoscopic sphenopalatine artery ligation.
3. Ethmoidal arteries. In anterosuperior bleeding above the middle turbinate, not controlled by packing, anterior and posterior ethmoidal arteries, which supply this area, can be ligated. The vessels are exposed in the medial wall of the orbit by an external ethmoid (Lynch) incision.
Transnasal Endoscopic Sphenopalatine Artery Ligation (TESPAL)
The procedure can be done with rigid endoscopes under topical anaesthesia with sedation or under a general anaesthesia. A mucosal flap is lifted in posterior part of lateral nasal wall, sphenopalatine artery (SPA) is localized as it exits the foramen and closed with a vascular clip. Distal branches of the artery can be additionally cauterized and the flap then reposited. Anterior ethmoidal artery can also be ligated by Lynch incision as an adjunctive procedure. SPA ligation gives high success in control of refractory posterior bleed.
Embolization
It is done by an interventional radiologist through femoral artery catheterization. Internal maxillary artery is localized and the embolization is performed with absorbable gelfoam and/or polyvinyl alcohol or coils. Both ipsilateral or bilateral embolizations may be required for unilateral epistaxis because of cross circulation. Embolization is generally a safe procedure but may have potential risks like cerebral thromboembolism, haematoma at local site. Ethmoidal arteries cannot be embolized.
GENERAL MEASURES IN EPISTAXIS
- Make the patient sit up with a back rest and record any blood loss taking place through spitting or vomiting.
- Reassure the patient. Mild sedation should be given.
- Keep check on pulse, BP and respiration.
- Maintain haemodynamics. Blood transfusion may be required.
- Antibiotics may be given to prevent sinusitis, if pack is to be kept beyond 24 h.
- Intermittent oxygen may be required in patients with bilateral packs because of increased pulmonary resistance from nasopulmonary reflex.
- Investigate and treat the patient for any underlying local or general cause.
Hereditary Haemorrhagic Telangiectasia. It occurs on the anterior part of nasal septum and is the cause of recurrent bleeding. It can be treated by using Argon, KTP or Nd: YAG laser. The procedure may require to be repeated several times in a year as telangectasia recurs in the surrounding mucosa. Some cases require septodermoplasty where anterior part of septal mucosa is excised and replaced by a split-skin graft.
Q.5 Discuss in brief the pathophysiology and management of vocal nodules and polyp.
+1. Vocal nodules (Singer’s or Screamer’s nodes)
They appear symmetrically on the free edge of vocal cord, at the junction of anterior one-third, with the posterior two-thirds, as this is the area of maximum vibration of the cord and thus subject to maximum trauma. Their size varies from that of pin-head to half a pea. They are the result of vocal trauma when person speaks in unnatural low tones for prolonged periods or at high intensities. They mostly affect teachers, actors, vendors or pop singers. They are also seen in school going children who are too assertive and talkative.
Pathologically, trauma to the vocal cord in the form of vocal abuse or misuse causes oedema and haemorrhage in the submucosal space. This undergoes hyalinization and fibrosis. The overlying epithelium also undergoes hyperplasia forming a nodule. In the early stages, the nodules appear soft, reddish and oedematous swellings but later they become greyish or white in colour.
Patients with vocal nodules complain of hoarseness. Vocal fatigue and pain in the neck on prolonged phonation are other common symptoms.
Early cases of vocal nodules can be treated conservatively by educating the patient in proper use of voice. With this treatment, many nodules in children disappear completely. Surgery is required for large nodules or nodules of long standing in adults. They are excised with precision under operating microscope either with cold instruments or laser avoiding any trauma to the underlying vocal ligament.
Speech therapy and re-education in voice production are essential to prevent their recurrence.
2. Vocal polyp
It is also the result of vocal abuse or misuse. Other contributing factors are allergy and smoking. Mostly, it affects men in the age group of 30–50 years. Typically, a vocal polyp is unilateral arising from the same position as vocal nodule. It is soft, smooth and often pedunculated. It may flop up and down the glottis during respiration or phonation. Hoarseness is a common symptom. Large polyp may cause dyspnoea, stridor or intermittent choking. Some patients complain of diplophonia (double voice) due to different vibratory frequencies of the two vocal cords.
Vocal polyp is caused by sudden shouting resulting in haemorrhage in the vocal cord and subsequent submucosal oedema. Treatment is surgical excision under operating microscope followed by speech therapy.
Q.6 Discuss rehabilitation of various common causes of hearing impairment.
+Rehabilitation depends on whether the loss is conductive, sensorineural, or mixed, and aims to restore hearing, improve communication, and prevent progression.
1. Conductive Hearing Loss
Otitis Media
- Medical therapy (antibiotics, steroids in selected cases)
- Myringotomy with ventilation tube insertion
- Hearing aids for persistent effusion
- Speech therapy in children with prolonged loss
Tympanic Membrane Perforation
- Tympanoplasty for closure and hearing restoration
- Temporary amplification until surgery
Otosclerosis
- Stapedectomy / stapedotomy
- Hearing aids if surgery contraindicated
Cerumen Impaction
- Wax removal (irrigation, cerumenolytics, manual removal)
Canal Atresia / Malformations
- Canal reconstruction surgery
- Bone-conduction or bone-anchored hearing aids (BAHA)
2. Sensorineural Hearing Loss (SNHL)
Presbycusis
- Digital hearing aids
- Assistive listening devices
- Auditory training, communication strategies
Noise-Induced Hearing Loss
- Hearing aids
- Tinnitus management
- Strict noise protection to prevent progression
Ototoxicity
- Serial audiometric monitoring
- Modification/cessation of offending drug
- Hearing aids or cochlear implants
Genetic / Congenital SNHL
- Early detection (newborn screening)
- Hearing aids or cochlear implants
- Speech and language therapy, family counseling
Sudden SNHL
- Prompt high-dose corticosteroids (oral/intratympanic)
- Hearing aids or cochlear implantation for residual loss
Menière’s Disease
- Diet modification (low salt)
- Hearing aids, tinnitus therapy
- Vestibular rehabilitation; surgical options for refractory cases
3. Mixed Hearing Loss
- Treat conductive component first (infection, perforation, wax, surgery)
- Hearing aids for residual SNHL
- BAHA or cochlear implants in selected cases
4. Auditory Neuropathy Spectrum Disorder
- Hearing aids may help
- Cochlear implants often more effective
- Auditory-verbal therapy and assistive listening devices
5. Central Auditory Processing Disorders
- Auditory training
- Environmental modifications (reduced noise, preferential seating)
- Assistive listening systems (FM systems)
Very Short Answer Questions
Q.1 Laryngomalacia
+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.
Q.2 Pure Tone Audiometry
+Pure Tone Audiometry (PTA) is a test that measures hearing thresholds for air and bone conduction using pure tones at various frequencies. The results are plotted on an audiogram, which helps determine the degree and type of hearing loss (conductive, sensorineural, or mixed) by noting the thresholds and the air–bone gap.
Q.3 ACUTE EPIGLOTTITIS (SYN. SUPRAGLOTTIC LARYNGITIS)
+It is an acute inflammatory condition confined to supraglottic structures, i.e. epiglottis, aryepiglottic folds and arytenoids. There is marked oedema of these structures which may obstruct the airway.
Q.4 Samter's Triad
+Definition: Samter's triad consists of nasal polypi, bronchial asthma and aspirin sensitivity.
Q.5 Adenoid Facies
+Adenoid facies, seen in adenoid hyperplasia, consists of crowded teeth, high-arched palate and underdeveloped pinched nostrils.
Q.6 Stapedotomy
+Stapedectomy/stapedotomy with a placement of prosthesis is the treatment of choice. Here the fixed otosclerotic stapes is removed and a prosthesis inserted between the incus and oval window. Prosthesis employed may be a teflon piston, stainless steel piston, platinum–teflon or titanium–teflon piston.
Q.7 Ototoxic Drugs
+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
Q.8 Ludwig’s Angina
+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 (80% of 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.
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.
Q.9 Gradenigo's Syndrome
+Gradenigo syndrome consists of:
(i) Ear discharge (suppurative otitis media),
(ii) Diplopia (CN VI paralysis), and
(iii) Retro-orbital pain (CN V involvement).
It is due to petrositis—a complication of otitis media.
Q.10 Eagle Syndrome
+Eagle syndrome (syn. syndrome of elongated styloid process) is manifested with discomfort in the throat, pain in the ear and upper neck, and dysphagia.
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