1. AFMC 2011 – MCQ 10
2. AFMC 2011 – MCQ 32
3. Indicators of housing – Physical, Economic, Social

Middle ear ossicles

Weight of the middle ear ossicles are as follows:

• Malleus – 25mg
• Incus – 27mg
• Stapes – 3mg

Reference: Middle ear surgery: recent advances and future directions By Klaus Jahnke

1. Obstetrics & Gynaecology – MCQ 3 – Factors influencing birth weight
2. Prevention of low birth weight – Direct and Indirect Interventions
3. Psychiatry – MCQ 9 – A middle aged person with the complaints of fear of leaving home

• Laryngeal papillomas constitute 80% of the neoplastic lesions of the larynx
• Juvenile laryngeal papillomas are a type of squamous papillomas seen in infants and children

Etiology:

• It is believed to be viral in origin (Human papilloma virus)
• Association with maternal condylomata acuminata is seen

Pathology:

• Proliferation of squamous epithelium

Sites involved:

• Epiglottis
• True vocal cords
• False vocal cords
• Other areas of larynx
• Trachea

Clinical Features:

• Hoarseness of voice
• Stridor

Treatment:

• Endoscopic removal by cup forceps
• Cryotherapy
• Microelectrocautery
• CO2 laser – preferred method – less bleeding, precise removal possible

Recurrence:

• There is high chance of recurrence
• Interferon therapy is useful in preventing recurrence

Image credits: Otolaryngology Houston

1. Vocal nodule – Etiology, Pathogenesis, Clinical features and Management
2. Juvenile nasopharyngeal angiofibroma – Etiology, Pathology, Clinical Features and Management
3. Ringertz tumour (Inverted Papilloma) – Epidemiology, Clinical Features, Treatment

Etiology:

• Since it occurs in the second decade of life, it is proposed that nasopharyngeal angiofibroma is a testosterone dependent tumour
• A nidus of hamartomatous vascular tissue in the nasopharynx undergoes proliferation in response to hormonal stimulation

Site of occurence:

• The site of occurrence was initially thought to be the posterior wall and roof of nasopharynx
• But recent studies indicate that the site of origin is in fact the posterior part of nasal cavity, near sphenopalatine foramen

Pathology:

• Angiofibroma as the name suggests is composed of both fibrous and vascular elements
• The vascular elements are composed of endothelium lined blood vessels without muscle coat
• Hence there is increased risk of bleeding which is not responsive to application of adrenaline

Pathways of spread:

• Nasal cavity
• Paranasal sinuses
• Pterygomaxillary fossa
• Orbit – through superior or inferior orbital fissure
• Infratemporal fossa
• Cranial cavity
  • Usually the middle cranial fossa is involved. Spread can be through:
    • In front of foramen lacerum – lateral to carotid artery
    • Through wall of sphenoid sinus to region of sella turcica – medial to carotid artery
  • Anterior cranial fossa spread can occur through
    • Roof of ethmoid sinus
    • Cribriform plate

Clinical features:

• The usual presentation is one of recurrent, profuse epistaxis which is not necessarily associated with any provocative factor
• Nasal blockage and denasal speech
• Blockage to the eustachian tube opening results in conductive hearing loss and serous otitis media
• Extension to the orbit results in proptosis and involvement of II, III, IV and VI cranial nerves
• Swelling of cheek and broadened nasal bridge

Investigations:

• X-ray lateral view nasopharynx reveals the presence of a mass
• X-ray paranasal sinuses
• CT scan of head with contrast enhancement shows the extend of involvement and bony destruction – it is the investigation so choice
  • Anterior bowing of posterior wall of maxillary sinus – Holman Miller sign – is pathognomonic of angiofibroma
• MRI helps to better understand the soft tissue involvement
• Carotid angiography helps to ascertain the level of vascularity and has to be done before attempting embolization

Treatment:

• Surgical resection
  • There are different approaches available
    • Transpalatine
    • Transmaxillary
    • Intracranial – Extracranial
    • Extended lateral rhinotomy
    • Extended Denker’s approach
    • Infratemporal fossa
    • Endoscopic
  • Endoscopic resection is the preferred method
  • Blood loss during surgery is a major problem
  • Blood loss can be minimised by decreasing the vascularity of the tumor by any of the following methods
    • Hormonal therapy with diethyl stilbestrol
    • Cryotherapy
    • Embolization
• Hormonal therapy
  • Since nasopharyngeal angiofibroma is a androgen dependent tumour, diethyl stilbestrol or flutamide can be tried
• Radiotherapy
• Chemotherapy
  • For treatment of recurrence or residual lesions after surgery

1. Juvenile laryngeal papillomatosis – Etiology, Pathology, Clinical Features, Management
2. Rhinitis caseosa – Epidemiology, Pathology, Clinical features, Treatment
3. Ringertz tumour (Inverted Papilloma) – Epidemiology, Clinical Features, Treatment

Etiology:

• Voice abuse is the most important etiological factor
  • Speaking in low tones or high intensity for long periods to time
• It is seen in people who tend to use their voice a lot like singers, singers and children
• Hence it is also known by the following alternate names:
  • Singer’s nodules
  • Speaker’s nodules
  • Minister’s nodules
  • Teacher’s nodules
  • Screamer’s nodules

Pathogenesis:

• Voice abuse initially results in oedema and haemorrhage in the submucosal space
• Later it undergoes hyalinisation and fibrosis
• The overlying epithelium undergoes hyperplasia and forms a nodule

Clinical features:

• Hoarseness of voice is the main complaint
• Voice fatigue
• Pain in neck

Laryngoscopy findings:

• Bilaterally symmetrical nodules on both vocal cords in their free border
• Location – At the junction of anterior one third and posterior two third (this is the area which undergoes maximum vibration during speech)
• Size – Pin head sized to half the size of a small pea
• Appearance – Initially appear red and oedematous, later changing to grey and fibrosed

Management:

• Voice rest is the most important intervention
• The patient should be advised on how to use their voice properly
• Early lesions, especially in children heal well with voice rest alone
• Late lesions, especially in adults may require excision under operating microscope
• Speech therapy is essential to prevent recurrence

1. Juvenile laryngeal papillomatosis – Etiology, Pathology, Clinical Features, Management
2. Bronchiolitis obliterans – Etiology, Pathogenesis, Clinical Features, Investigations and Management
3. Juvenile nasopharyngeal angiofibroma – Etiology, Pathology, Clinical Features and Management

• Traumatic perforation
  • Septal surgery
  • Cautery for epistaxis
  • Habitual nose picking
  • Deliberate perforation for putting ornaments
• Pathological perforation
  • Septal abscess
  • Nasal myiasis
  • Rhinolith
  • Chronic granulomatous diseases
    • Leprosy, Lupus, Tuberculosis – perforation of cartilaginous septum
    • Syphilis – perforation of bony septum
  • Wegener’s granuloma
• Drugs and Chemicals
  • Long term use of steroid nasal sprays
  • Exposure to certain chemicals in industry
    • eg: chromium
  • Cocaine addicts
• Idiopathic

Clinical features:

• Small perforations result in a whistling sound
• Large perforations cause crusting which bleed upon removal

Management:

• The identification of the cause is essential
• Small perforations can be closed by using plastic flaps
• In case of large perforations, removal of crusts can be done using alkaline nasal douche and application of bland ointment
• Silastic buttons can be used to close large perforations

1. Splint placement after septal surgery
2. Juvenile laryngeal papillomatosis – Etiology, Pathology, Clinical Features, Management
3. Vocal nodule – Etiology, Pathogenesis, Clinical features and Management

• Congenital Laryngeal Stridor

1. CNPAS – Acronym
2. Laryngomalacia
3. RDI – Acronym

• Nasal signs
  • Transverse nasal crease (allergic crease)
    • A black transverse line across the middle of nose
    • Occurs due to constant rubbing of the nose in the upward direction resembling a salute – allergic salute
  • Swollen turbinates
  • Pale, oedematous, bluish nasal mucosa
  • Thin watery discharge
• Ocular signs
  • Lid oedema
  • Cobblestone appearance and congestion of conjunctiva
  • Dark circles under eyes – allergic shiners
• Otologic signs
  • Retraction of tympanic membrane and serous otitis media due to eustachian tube dysfunction
• Pharyngeal signs
  • Granular pharyngitis due to hyperplasia of submucosal lymphoid tissue
• Laryngeal signs
  • Hoarseness of voice
  • Oedema of vocal cords

1. Nasal polyp – Differential diagnosis
2. Tympanic membrane – central perforation
3. Bullous myringitis

1. Ringertz tumour (Inverted Papilloma) – Epidemiology, Clinical Features, Treatment
2. Juvenile nasopharyngeal angiofibroma – Etiology, Pathology, Clinical Features and Management
3. Clinical signs in allergic rhinitis – nasal, ocular, otologic, pharyngeal, laryngeal

Alternate names:

• Transitional cell papilloma
• Schneiderian papilloma

1. Rhinitis caseosa – Epidemiology, Pathology, Clinical features, Treatment
2. Juvenile nasopharyngeal angiofibroma – Etiology, Pathology, Clinical Features and Management
3. Aphakia – Causes, Optics, Clinical features and Treatment

1. Sanctuary sites in Acute Lymphoblastic Leukemia
2. AIIMS November 2011 – MCQ 5
3. Anatomy of palatine tonsil

• Obstructive Sleep Apnoea

1. Respiratory Disturbance Index (RDI)
2. Difficult Ventilation – Medical mnemonic
3. Physiology – MCQ 10 – Delta waves are seen in?

1. OSA – Acronym
2. SPM – MCQ 77 – Scale of measurement in disease classification
3. Difficult Ventilation – Medical mnemonic

• Respiratory Disturbance Index

1. AERD – Acronym
2. WMF – Acronym
3. Respiratory Disturbance Index (RDI)

Synonyms / Alternate names:

• Aqueduct of Falloppio
• Canalis nervi facialis
• Facial canal
• Aqueductus fallopii
• Fallopian aqueduct

1. Anatomy – MCQ 17 – Facial Nerve stimulation
2. Anatomy – MCQ 11 – Which part of vertebral canal will show secondary curves with concavity backwards?
3. Forensic medicine – MCQ 8 – Shape of nulliparous cervical canal

• Anterior inferior cerebellar artery – at the cerebellopontine angle
• Labyrinthine artery  (branch of anterior inferior cerebellar artery) – within internal acoustic meatus
• Superficial petrosal artery (branch of middle meningeal artery) – geniculate ganglion and nearby parts
• Stylomastoid artery (branch of posterior auricular artery) – mastoid segment

The arteries form a external plexus lying within the epineurium and an internal plexus which in intraneural.

1. RGUHS Karnataka PGET 2011 – MCQ 19
2. Blood supply of tonsil
3. Anatomy – MCQ 57 – Branches of external carotid artery

1. Galeazzi’s Fracture – X-ray
2. Nasal polyp – Differential diagnosis
3. Anterior wedge compression fracture – Xray

• Medical polypectomy refers to medical treatment for nasal polyps
• It is used mostly for ethmoidal polyp as allergy is considered as an etiological factor in them
• Drugs used for medical polypectomy are systemic and topical steroids
• Other anti allergic medications like leukotriene antagonists can also be used
• Medical treatment can be used before surgical intervention and in those not consenting for surgery
• Nowadays, the definitive treatment for nasal polyps is Functional Endoscopic Sinus Surgery (FESS)

Treatment schedule

• A short couse of systemic steroids (prednisolone) is given
• This is accompanied by long term use of topical steroids (spray / drops)  like fluticasone or mometasone

1. Samter’s triad
2. Nasal polyp – Differential diagnosis
3. Otitic hydrocephalus

Clinical course

• Starts as nasal symptoms of sneezing, running nose and congestion
• Progresses to asthma and nasal polyposis (especially ethmoidal polyps)
• Aspirin intolerance comes last
• Allergic reaction to aspirin in these patients may cause
  • Exacerbation of asthma
  • Uriticaria
  • Angioedema – It is a life threatening condition and hence a medical emergency

Pathophysiology:

• Aspirin being a cyclooxygenase inhibitor, causes increased activity of the leukotriene synthesis pathway
• The excess production of leukotrienes cause allergic reactions like asthma

Treatment:

• Each component of Samter’s triad is treated separately
  • Aspirin intolerance
    • Stop aspirin intake
    • Leukotriene antagonsits (montelukast, zafirlukast)
    • Aspirin desentisation therapy
    • Steroids
  • Asthma – treat according to severity
  • Nasal polyps – treat if they are symptomatic
    • Steroids – medical polypectomy
    • Surgical removal

Samter’s triad is also known as:

• Samter’s syndrome
• Aspirin triad
• Asthma triad
• Acetyl salicylic acid triad
• Widal-Abrami-Lermoyez triad
• Widal-Lermoyez syndrome
• Widal’s syndrome
• Francis’ triad

1. Ethmoidal polyp – etiological factors
2. Medical polypectomy
3. Macdonald triad by John Marshall Macdonald

1. Nasal polyp – Differential diagnosis
2. Left ventricular hypertrophy
3. Why antrochoanal polyp grows posteriorly?

• Hypertrophic turbinates – (see how How to differentiate nasal polyp from turbinate hypertrophy?)
• Blob of mucus – disappears on blowing the nose
• Angiofibroma – history of recurrent epistaxis
• Rhinosporidiosis
• Hamartoma
• Transitional cell carcinoma
• Squamous cell carcinoma
• Meningocoele
• Other malignancies of nose

1. Differential diagnosis of post coital bleeding
2. How to differentiate nasal polyp from turbinate hypertrophy?
3. Ophthalmology – MCQ 16 – Malignancy in a recurrent chalazion

• History
  • CSF rhinorrhoea – head injury, surgical procedures, intracranial tumours
  • Allergic rhinitis – sneezing, head cold, itching, lacrimation
• When the discharge occurs
  • CSF rhinorrhoea – when straining or bending forward
  • Allergic rhinitis – no relation to straining or bending forward, continuous flow
• Whether discharge can be sniffed back
  • CSF rhinorrhoea – cannot be sniffed back
  • Allergic rhinitis – can be sniffed back
• Character of discharge
  • CSF rhinorrhoea – clear, thin, watery
  • Allergic rhinitis – slimy (mucus), watery (tears)
• Taste
  • CSF rhinorrhoea – sweet
  • Allergic rhinitis – salty
• Glucose levels
  • CSF rhinorrhoea – more than 30mg/dl. Should be compared to the levels in CSF obtained after lumbar puncture as glucose levels decrease in intracranial infections)
  • Allergic rhinitis – less than 10mg/dl
• Specific test – Beta 2 transferrin
  • CSF rhinorrhoea – invariably present
  • Allergic rhinitis – absent

1. Causes of watery nasal discharge
2. Clinical signs in allergic rhinitis – nasal, ocular, otologic, pharyngeal, laryngeal
3. Otitic hydrocephalus

• Injection of dye (flourescein / radioisotope) into intrathecal space and placing cotton pledgets in different parts of nasal cavity. Depending on which pledget gets soaked in the dye, site of leak can be determined
  • Olfactory cleft – cribriform plate
  • Sphenoethmoidal recess – Sphenoid sinus
  • Middle meatus – frontal / ethmoid sinus
  • Inferior meatus posteriorly near eustachian tube – Temporal bone – reaches via eustachian tube
• High resolutaion CT scan – head –  coronal cuts – bone window
• CT cisternogram – taken after injection of radioopaque dye into intrathecal space via cisterna magna
• MRI cisternogram – T2 weighted – does not require injection of dye and is hence non invasive

1. ENT – MCQ 19 – Most common site of leak in CSF rhinorrhoea
2. Sinus of Morgagni
3. RGUHS Karnataka PGET 2011 – MCQ 105

Synonyms / alternate names:

• Olfactory cleft

1. Canthus
2. Determination of site of leak in CSF rhinorrhoea
3. Forensic medicine – MCQ 39 – Cyanide poisoning

Pathogenesis

• Middle ear infection can predispose to lateral sinus (transverse sinus) thrombosis
• The thrombus can extend into the superior sagittal sinus and impede the drainage of CSF
• This results in increased intracranial tension

Clinical features

Features of increased intracranial tension are present:

• Headache, nausea, vomiting
• Diploplia due to lateral rectus palsy (abducent nerve is usually the first nerve to be affected in increased intracranial tension)
• Blurred vision – due to papilloedema / optic atrophy

Signs:

• Papilloedema
• Nystagmus
• Lumbar puncture – shows increased CSF pressure, but normal levels of cells, protein and glucose. It is sterile

Treatment:

• Measures to decrease the intracranial tension
  • Medical
    • high dose steroids
    • acetazolamide
    • mannitol
  • Surgical
    • repeated lumbar puncture
    • lumbar drain
    • lumboperitoneal shunt
• Treating the ear infection
  • antibiotics – topical and intravenous
  • mastoid surgery

1. Pseudotumor cerebri (Benign intracranial hypertension)
2. Etiology of papilledema
3. Cerebrospinal fluid (CSF) vs Nasal discharge – Differences

• Asthma
• Chronic rhinosinusitis
• Kartagener’s syndrome
• Young’s syndrome
• Churg Strauss syndrome
• Cystic fibrosis
• Aspirin intolerance
• Allergic fungal sinusitis
• Nasal mastocytosis

1. Samter’s triad
2. Nasal polyp – Differential diagnosis
3. Clinical signs in allergic rhinitis – nasal, ocular, otologic, pharyngeal, laryngeal

1. Anatomy – MCQ 58 – Paralysis of 3, 4, 5, 6 cranial nerves
2. Blood supply of tonsil
3. RGUHS Karnataka PGET 2011 – MCQ 74

Anterior view of skull – pyriform aperture is highlighted
Click on image for an enlarged view

• Pyriform aperture is the anterior most and narrowest area of the bony part of nose
• Boundaries of pyriform aperture:
  • Superior – Nasal bone
  • Lateral – Frontal (nasal) process of maxilla
  • Inferior – Premaxilla, anterior nasal spine of maxilla
• Clinical importance:
  • Congenital Nasal Pyriform Aperture Stenosis
    • stenosis of pyriform aperture resulting in significantly increased nasal airway resistance

1. CNPAS – Acronym
2. Anatomy – MCQ 39 – Structures passing through the superior aperture of thorax
3. Denis’ three column concept of spine stability

• Congenital Nasal Pyriform Aperture Stenosis

1. Pyriform aperture
2. CLS – Acronym
3. NALT – Acronym

• Aspirin Exacerbated Respiratory Disease

1. RDI – Acronym
2. NCD – Acronym
3. IDSP – Acronym