MPMSU ENT 2023 question paper with answers

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 Once intraluminal placement is confirmed by aspiration, needle is withdrawn leaving the catheter in position and jet ventilation started.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.

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.

Indications

1. Chronic bacterial sinusitis unresponsive to adequate medical treatment.
2. Recurrent acute bacterial sinusitis.
3. Polypoid rhinosinusitis (diffuse nasal polyposis).
4. Fungal sinusitis with fungal ball or nasal polypi.
5. Antrochoanal polyp.
6. Mucocele of frontoethmoid or sphenoid sinus.
7. Control of epistaxis by endoscopic cautery.
8. Removal of foreign body from the nose or sinus.
9. Endoscopic septoplasty.

MANAGEMENT

In any case of epistaxis, it is important to know:

1. Mode of onset. Spontaneous or finger nail trauma.
2. Duration and frequency of bleeding.
3. Amount of blood loss.
4. Side of nose from where bleeding is occurring.
5. Whether bleeding is of anterior or posterior type.
6. Any known bleeding tendency in the patient or family.
7. History of known medical ailment (hypertension, leukaemia, mitral valve disease, cirrhosis and nephritis).
8. 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

1. Make the patient sit up with a back rest and record any blood loss taking place through spitting or vomiting.
2. Reassure the patient. Mild sedation should be given.
3. Keep check on pulse, BP and respiration.
4. Maintain haemodynamics. Blood transfusion may be required.
5. Antibiotics may be given to prevent sinusitis, if pack is to be kept beyond 24 h.
6. Intermittent oxygen may be required in patients with bilateral packs because of increased pulmonary resistance from nasopulmonary reflex.
7. 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.

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.

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)