The Tongue:

A.Nerve

 Motor supply:

Somatomotor – Hypoglossal nerve, except palatoglossus by cranial accessory nerve

Secretomotor – Submandibular ganglion from superior salivatory nucleus of facial nerve

Vasomotor - Superior cervical sympathetic ganglion by nerves along lingual artery

 Sensory supply

General sense - Ant. 2/3rd by lingual

Post.1/3rd by glossopharyngeal (IX ) nerve

Special sense (taste) -Ant. 2/3rd by chorda tympani (VII)

Post.1/3rd by IX nerve

Blood supply:

Lingual artery (chief artery), ascending palatine & tonsilar branch of facial artery, ascending pharyngeal artery

Vena comitantes accompanying lingual artery(2) & hypoglossal nerve(1)& deep lingual vein (principal vein)

unites to form lingual vein ends either in common facial or internal jugular vein

Waldeyer's ring

Scattered subepithelial lymphoid tissue in pharynx aggregated at some places to form masses,

collectively called Waldeyer’s ring. The masses are:

Nasopharyngeal tonsil

Palatine tonsil or the tonsil (faucial tonsil )

Lingual tonsil

Tubal tonsil

Lateral pharyngeal bands

Nodules in posterior pharyngeal wall

B lood supply

P alatine tonsil

Main artery – Tonsilar branch of facial artery.

Others – ascending palatine br. of facial, dorsal lingual br. of lingual ,Ascending pharyngeal artery & greater palatine br. of maxillary artery.

Veins – Paratonsilar vein drains into palatine, pharyngeal or facial vein.

 Lymphatic drainage

Lymphatics pass to jugulodiagastric node.

The tonsil Lymph node

1.Lymph channel 

Only efferent 

Both afferent & efferent

2.Crypts  Present

Absent

3.Capsule

Incomplete in lat.wall

Complete

4.Subcapsular space

Absent

Present

5.Differentiation

Not differentiated into cortex & medulla

Differentiated into cortex & medulla.

Laryngopharynx

 Extends from upper border of epiglottis to lower border of cricoid cartilage,from C3 to C6 vertebra. Anterioly, it communicates with the larynx.

(laryngeal inlet)

 Clinically subdivided into 3 regions

Pyriform fossa Post-cricoid region

Posterior pharyngeal wall.

 Oesophagus

 Constrictions

Pharyngo- oesophageal junction(C 6) 15 cm. from upper incisors(As it is fixed)

 At crossing of arch of aorta & left main bronchus (T 4) – 25 cm.

 Where it pierces the diaphragm (T 10) – 40 cm. from upper incisors.

Dysphagia-Difficulty in swallowing

Odynophagia-Painful swallowing , more marked in ulcerative & inflammatory lesions of the oral cavity, pharynx & oesophagus..

Causes of dysphagia

1.Pre esophageal -

Oral phase –

Disturbance of mastication

Disturbance of lubrication

Disturbance in mobility of tongue

Defects of palate

Lesions of buccal cavity & floor of the mouth.

Pharyngeal phase –

(i) Obstructive lesion of the pharynx

(ii)  Inflammatory  conditions

(iii)  Spasmodic conditions

(iv) Paralytic conditions

2.Esophageal

 In the lumen

Atresia

Foreign body

Stricture

Neoplasm

3. In the wall

Acute or chr.Oesophagitis

Hypomotitity disorder- achalasia, scleroderma

Hypermotility disorder cricopharyngeal spasm diffuse oesophageal spasm

 4.Outside the wall

Hypopharyngeal diverticulum

Hiatus hernia

Cervical osteophytes

Thyroid lesion

Investigation of dysphagia

History

 Onset –

 Nature –

Sudden-  FB, neurological

Progressive  – malignancy

Intermittent – spasm, spasmodic episodes over an organic lesion

Liquid- paralytic,

Solids initially- Ca. or stricture

 Associated symptoms –

Regurgitation & heart burn- hiatus hernia

Regurgitation when lying with cough - Pharyngeal diverticulum

Aspiration into lungs- L.paralysis

Aspiration into nose- Palatal palsy.

Clinical examination

Examination of oral cavity, oropharynx, hypopharynx

Larynx can exclude most of the preoesophageal causes.

Examination of neck, chest, nervous system should also be undertaken.

Blood examination

To diagnose PBK syndrome, acute & chr. Infections, agranulocytosis, leukaemia, infectious mononucleosis

Examination of oral/ oropharyngeal swab

To diagnose patches in the throat

Radiography

X-Ray chest

X-Ray lateral view neck

Barium swallow X-Ray

Endoscopic examination

Other investigations

Bronchoscopy, Thyroid scan

Sore throat

Pain in oropharynx, hypopharynx or larynx

Causes of sore throat/ patch in the throat*

Acute tonsillitis*

Acute pharyngitis

Peri-tonsillar, retropharyngeal & Para pharyngeal abscesses

Infectious mononucleosis*

Aphthous ulcer

Acute epiglottitis

Faucal* & laryngeal diphtheria

Herpes infection

Oral thrush*

Carcinoma tongue, oropharynx, hypopharynx, larynx

Ac.leukaemia*, agranulocytosis*, thrombocytopenia

Vincent’s angina*

AIDS*

 Anatomy of Ear:

Organ of hearing and balance.

First organ of special sense to develop.

Development starts at the 3rd week of Embryonic life and completes by the 25th week.

 Parts of ear

External Ear(Pinna/Auricle External auditory canal)

Middle ear (Middle ear proper /Tympanic cavity, Eustachian tube

Additus ad antrum , Mastoid air cells.)

Inner Ear(Lies in the petrous part of Temporal bone)

Bony Labyrinth-Cochlea ,Vestibule , Semicircular canals

Membranous Labyrinth-Cochlear duct ,Utricle & Saccule, Membranous semicircular canals

,Endolymphatic sac & duct

Pinna

Composed of a single piece of yellow elastic cartilage covered with skin.

Gr. auricular nerve(From cervical plexus C2,3) Less. occipital nerve(From cervical plexus C2)

 External auditory canal

Length-24 mm

S – shaped

Two parts

1.Cartilaginous part - Outer 1/3 (8mm)

2.Bony part    - inner  2/3   (16mm)

 Difference between  two parts –

Cartilaginous part contain hair follicles and ceruminous glands

Bony part has thin skin without any hair follicles and ceruminous glands

Isthmus is the most constricted part of External auditory canal about 6 mm lateral to the tympanic membrane

 Tympanic membrane

Membranous structure which separates the external auditory canal from middle ear

Semitransparent and pearly white

About 9-10 mm tall, 8-9 mm wide

0.1 mm thick

Parts-Pars tensa , Pars flaccida

Layers-

Outer- Epithelial layer

Inner- Mucosal layer

Middle- Fibrous layer

Nerve supply-

Lateral surface

Anterior half: Auriculotemporal nerve(Br. of mandibular division of trigeminal nerve)

Posterior half: Auricular nerve(Br. of vagus nerve)

Medial surface- Tympanic nerve (Br. of glosspharyngeal nerve)

 Middle ear

Situated between the tympanic membrane and Inner ear

Looks like a match box. It has six walls

Contains -

Air

Ossicles

Muscles-

Tensor tympani(Mandibular division of Trigeminal nerve)-Tenses the TM Stapedius(Facial nerve)-Prevent excess vibration of stapes

Nerves-Tympanic plexus and chorda tympani(Br. of facial nerve)

Ligaments

Blood supply-Br. from

Middle meningeal artery

Maxillary artery

Ascending pharyngeal artery

Posterior auricular artery

Contents of middle ear cleft-Middle ear with contents+Eustechian tube+Auditus ad antrum+mastoid air cell

Function-Transmission of sound wave to inner ear

Impedance matching(Prevent excess loud sound by stapes)

 Eustachian tube

Length- 36 mm

Connects nasopharynx with the tympanic cavity

Direction- Downwards, forwards & medially from its tympanic end

Consists of 2 parts:

Bony part-12 mm

Cartilaginous part-24 mm

Function-

Transmission of sound from external ear to inner ear Convert air borne vibration into liquid borne vibration

Superior or Anterior canal

Posterior canal

Lateral canal

 Semicircular canal (4)

Each occupy 2/3rd of a circle

The diameter is 0.8mm

Like a Snail.

 Cochlea

2.5 to 2.75 turns round a central pyramid of bone called modiolus.

Contains-

Scala vestibulai : Corresponds to oval window.

Scala  Tympani: Corresponds  to round window

Scala Media : Membranous cochlear duct.

Scala Tympani is connected with aqueduct of cochlea to sub arachnoid space .

 Organ of corti

It is the end organ of hearing and equilibrium

Contents-

Tunnel of Corti Tectorial membrane Stria Vascularis

Possesses hair cell(receptor action) and supporting cell(nutrition to hair cell and stabilise organ of corti) resting on basement membrane

 Auditory pathway

Receptor-Hair cell of organ of corti

1st order neuron-Cochlear nerve

2nd order neuron-Inferior colliculi

3rd order neuron-MGB of thalamus

4th order neuron-Temporal cortex(Area 41)

[Conductive pathway: Auricle to stapes foot plates] [Sensory pathway : Organ of corti to 41]

 Criteria of normal hearing

AC>BC

Symmetrical

25dB frequency(Tuning fork of 512 is better)

symptoms of external ear

1.Deafness

 2.Otorrhoea

3.Earache

4.Reffered otalgia

5.Tinnitus 

6.Vertigo ,vomiting

Causes

1.Sudden air compression-Slapping ,blast)

2. TM rupture

3.Sudden fluid compression-Syringing ,drowning 3.Unskilled instrumentation

4.Fracture base of skull

Rx

1.No interference with affected ear

2.No interference with blood clot for 10 days(Healing) 3.Remove FB

4.Broad spectrum

5.Analgesics

6.Myringoplasty(When perforation does not heal 3 months)

 FB study

Types

• Living-Insects ,imago ,flies ,fleas ,maggots
• Non living
• Hygroscopic-Rice ,wheat ,pulse ,nuts ,seeds
• Non hygroscopic-Tip of pencil ,metal ball ,rubber ,cotton ,chalks ,sticks

Remove

1.If living FB-1st kill by olive oil ,spirits ,alcohol ; then suction ,FB hook or forceps removal

2.If non hygroscopic-suction ,FB hook ,forceps removing or syringing

If hygroscopic-Avoid syringing

If non co-operative patient-Do under G/A

 Wax study

Definition

Secretion of ceruminous gland(cerumen) and pilo-sebaceous gland(Sebum) along with desquamated epithelium and dirt is called wax

Complication-Growth retardation in children ,infection ,occlusion by granulation tissue

Rx

Physiologic process-Eating ,talking ,chewing

Medial Rx-

1.If hard - Give keratolytic agents i.e. olive oil ,saturated solution of NaHCO3 ,liquid paraffin

,H2O2 solution and make it a soft one ,then suction ,FB hook ,forceps removal or syringing 2.Avoid syringing if hygroscopic impaction within wax ,or any discharge

3.If non co-operative patient-Do under G/A

 Otomycosis

Definition

Fungal infection of external auditory canal due to candida albicans ,or aspergillus niger or aspergillus fumigatus usually in hot and humidified area

Auroscopic examination-

Candida-White lesion(Wet news paper like) Aspergillus niger-Black headed filamentous growth Aspergillus fumigatus-Brown lesion

C/F

Pain ,itching

Conductive deafness if otomycotic plaque s formed

Rx

Remove the plaque by meticulous aural toileting(suction ,mooping)

Anti fungal drop(Ketoconazol/econazol drop)-At least 6 weeks to remove deep hyphae Anti histamine

 Furunculosis

Definition

Staphylococcal infection of hair follicle of cartilaginous part of external auditory canal

C/F-Severe pain (due to non expandable skin ,rich nerve supply) ,pus ,deafness(If huge)

Rx

If large-Incision and drainage ,then aural toileting

Anti staphylococcal antibiotic-Flucoxacillin(250mg 6 hourly) Analgesic

10% ecthamol in glycerine(To reduce edema as it suck up water)-In a gauze pick

[Ecthamol-Bacteriostatic Glycerine-Hygroscopic]

Difference

Trait

Furunculosis

Acute mastoiditis

H/O

No preceding H/O of otitis

media

Yes

Pain

While moving pinna

While pressure over mastoid

Bleeding

No

When pressure over mastoid

X ray

No change in mastoid

Bony erosion of mastoid

 Otitis externa

Definition

Acute/chronic reaction of whole or part of skin of external ear due to local/systemic/both cause

Classification 1.Infective type

Bacterial-Localised otitis externa ,diffuse otitis externa ,otitis externa malignans Viral-Herpes zooster oticus

Fungal-Otomycosis

Reactive type

Eczematous otitis externa(Most common) ,seborrhoeic otitis externa

 Deafness

Definition-Any impairement of hearing

Causes of Sudden deafness 1.Occlusion of external auditory meatus 2.Middle ear effusion

Blast injury

Causes of congenital deafness 1.Bat ear-Abnormally protruded ear 2.Pre auricular appendages

3.Pre auricular sinus 4.Anotia

5.Microtia

Types

1.Organic-Conductive ,sensory-neural and mixed 2.Non organic-Psychogenic ,malignancy

Causes of conductive deafness-(Rinne +ve)

1.Impacted wax 2.ASOM

CSOM

OM with effusion 5.Otomycosis 6.Rupture TM

Causes of sensory-neural deafness Mnemonics-LOMPoT 1.Labyrinthitis

2.Ototoxic drugs-Aminoglycosides(Streptomycin ,gentamycin ,neomycin) ,frusemide ,quinine

,chloroquine ,phenytoin, barbiturates ,tobacco . 3.Meniere's disease

4.Presbyacosis(Common) 5.Trauma to base of skull

Hearing test

Qualitative test-Monoaural free field voice test ,tuning fork test(Rinne ,weber ,ABC , stinger, bing test)

Quantitative test-

Tympanometry/Impedance audiometry

BERA-Brain stem evoked response audiometry CERA-Cortical evoked response audiometry

 Earache

1.Furunculosis 2.Perichondritis 3.Impacted wax 4.FB

5.ASOM

 Otorrhoea

ASOM in perforating stage

CSOM in tubotymoanic and attico-antral type 3.Otomycosis

4.Malignancy 5.CSF otorrhoea

 Reffered otalgia

Via 2nd and 3rd Cr. nerve-Disc prolapse , fibrosis of sternocleiodmastoid muscle

Via 5th Cr. nerve-Lesion from jaw ,teeth ,TM joint ,salivary gland ,sphenopalatine neuralgia 3.Via 9th and 10th Cr. nerve-Lesion from oro/laryngopharynx/tongue

 Tinnitus

Mnemonics-MOLAS 1.Meniere's disease(+Vertigo) 2.Labyrinthitis(+Vertigo) 3.Ototoxic drugs(+Vertigo)

Acoustic nerve tumor(+ vestibular neuritis -Vertigo)

Senile deafness

 Epistaxis

Any bleeding per nose is epistaxis Epistaxis is a sign and not a disease

Little's area is usual site for epistaxis in children and young adults due to frequent nose prick

Causes-

Idiopathic(Mainly)

Local-Trauma ,infection ,FB ,DNS ,atmospheric changes(High altitude ,caisson's disease)

,neoplasm

General-

CVS-HTN ,atherosclerosis ,MS ,CCF ,pregnancy

Blood disorder-Leukaemia ,aplastic anaemia ,ITP ,vit K deficiency ,haemophilia ,VWD Liver cirrhosis

Chronic nephritis Anticoagulants

Vicarious epistaxis-Epistaxis occuring during menstruation

Sites-Little's area , above &below middle turbinate ,septum ,nasopharynx

Types-

Anterior -Bleeding from Kisselebach's plexus ,comes through nose Posterior-Bleeding from woodruff's plexus ,coffee coloured vomitus

Investigation-

History ,examination ,CBC , X ray(Chest ,skull ,PNS) ,liver function test

Managing a case-

Trotter's position(Sitting and leaning forward and breathing from mouth) Pinching the nose with thumb and index finger for about 5 minutes

Ice pack compression

Cautery-Chemical by AgNO3 , electrical(thermal) , endoscopic cautery

If anterior bleeding-Anterior nasal pack with glycerine/paraffin.Pack can be removed after 24 hours if bleeding has stopped

If posterior bleeding-Posterior nasal pack under GA

Ligation-Maxillary and ophthalmic artery>Then external carotid artery

Posterior epistaxis

Site Age

Bleeding

Kisselebach's pl

Woodruff's pl

Children

Elderly

Trauma

HTN ,arteriosclerosis

Mild

Severe ,hospitalisation

 DNS

Gross deviation of nasal septum producing sign-symptoms is DNS Deviation occurs in cartilage/bone/both

Causes-

Trauma-Childbirth and infancy(Main) ,assault ,RTA ,boxing Developemental

Nasal mass

Symptoms-Unilateral/bilateral nasal obstruction , snoring ,sleep apnoea

Types-  Unilateral/C shaped Bilateral/S shaped

Septal spur-Self like projection Anterior septal dislocation Thickening

Rx-(Only when marked symptoms)

 1st choice-

Septoplasty(Any age , less infection ,more re-deviation ,Freyer's incision)-Better Mucoperichondrial/periosteal flap is generally raised only on one side of the septum

Only the most deviated parts are removed, rest of the septal framework is corrected and repositioned

 2nd choice-

SMR under LA(>16 age ,more infection ,less re-deviation ,Killian's incision)

Elevating the mucoperichondrial and mucoperiosteal flaps on either side of the septal framework  by a single incision made on one side of the septum, removing the deflected parts of the bony and cartilaginous septum, and then repositioning the flaps

SMR indication-

DNS with symptoms Repair of septal perforation

Approach OT-Vidian neurectomy ,hypophysectomy

Septoplasty indication-

All  the above and tympanoplasty

Complication  of septal surgery

Per operative-Primary hemorrhage ,anaesthetic hazard ,septal tear ,septal perforation

Post operative-

Early-Reactionary hemorrhage ,secondary haemorrhage ,wound infection ,wound dehiscence Late-Saddle nose ,septal deformity ,thickened septum

 FESS/Functional endoscopic sinus surgery

An endoscopic operation in which normal portion of mucosa is kept while removing damaged portion of mucosa(Instrument is Howkin's rod/teloscope)

Here LA is preferred to GA as of better hemostatic process

It is functional operation as physiologic system of mucosa and ciliary beat is maintained here

Indication-

Chronic maxillary sinusitis Nasal polyposis

Mucocele of sinus

Control of epistaxis is by endoscopic cautery. Removal of foreign body from the nose or sinus.

 Endoscopic septoplasty

Complication-

Per operative-Primary hemorrhage ,anaesthetic hazard , injury to other components like nasolacrimal duct ,CSF leak

Post operative-

Early-Reactionary hemorrhage ,secondary haemorrhage ,wound infection ,wound dehiscence Late-Meningitis ,Brain abcess, epiphora ,blindness ,synaechia

 Tonsilectomy

Indication- Absolute-

1.Recurrent tonsilitis(7/more in 1 year ,or ,5/more in 2 years ,or , 3/more in 1 year for 3 consequetive years)

2.2nd attack of peritonsilar abcess 3.Malignancy

4.Tonsilitis causing febrile seizures ,airway obstruction

Relative- Diphtheria caries Streptococcal caries

Tonsilitis with halitosis

Approach OT-

In Eagles syndrome for avulsion of styloid process ,in glossopharyngeal neuralgia for glossopharyngeal neurectomy

Contraindication/HABCDEF-

Hb<10g/dl

Acute tonsilitis Bleeding disorder

Clotting disorder ,Cervical spondylitis ,children below 3 years ,cleft palate Diphtheria

Endemic poliomyelitis(Virus through nasal path) Failure to control systemic diseases

Complication-

Per operative-Primary hemorrhage ,anaesthetic hazards ,injury to other structures like pillars ,soft palate ,uvula ,teeth ,gum

Post operative-

Early-Reactionary hemorrhage , ,wound infection ,wound dehiscence

Late-Secondary haemorrhage ,parapharyngeal abcess ,otitis media ,hypertrophied lingual tonsil

Methods of tonsilectomy-

Cold dissection

Hot dissection(Diathermy) Coblation surgery

Cryo surgery Laser dissection

Positions-

Patient during surgery-Rose's position(Supine ,head extended ,sand bag between 2 shoulders) Patient after surgery-Tonsilar position(Left lateral ,as right bronchus is short ,so easy aspiration) Surgeon during surgery-Head end and sitting

Assistant during surgery-Left to surgeon

Manage reactionary haemorrhage of tonsilectomy-

Airway patency Examine the throat

Remove any clot with gauze soaked with adrenaline Send blood for grouping and cross matching

Call senior for help Ligate under GA

Indentify reactionary haemorrhage- Bleeding from angle of mouth and nose Frequent deglutition

Gurgling Tachycardia Low BP

Causes of reactionary haemorrhage- Failure to Ligate bleeding point Slippage of ligature

Stress-Cough ,sneezing ,hiccups

Manage secondary haemorrhage of tonsilectomy-

Heals spontaneously Assurance

Broad spectrum antibiotics

When severe bleeding ,do suturing of faucial pillars

 Adenoidectomy

Enlarged nasopharyngeal tonsil producing sign-symptoms(3years to 7 years) is called adenoid

Adenoid facies-

High arched  palate Prominent upper incisor teeth Mouth breathing

Dribbling of saliva Loss of nasolabial fold Flat chest

Rx-

Nasal decongestant Steroid

Breathing and posture exercise Adenoidectomy(If marked symptoms)

Complication-

Per operative-Primary haemorrhage ,anaesthetic hazard ,injury to other structure Post operative-

Early-Reactionary haemorrhage , wound infection ,wound dehiscence Late-Secondary haemorrhage , ASOM

Dx of adenoid-

X ray nasopharynx lateral view

Nasopharyngoscopy

Effects of adenoid-

Effect on nose-Nasal obs. ,hyposmia ,anosmia Effect on ear-CSOM

Adenoid facies

 Tracheostomy

An operation in which an opening is made on trachea(Tracheotomy) and converted into stoma with skin surface

Function/aims-

To bypass upper airway obs. To protect lower airway

To reduce anatomical dead space To administer anaesthesia

To maintain +ve pressure ventillation

 Indication-

Respiratory obstruction-

Inflammatory-Epiglottitis ,acute laryngitis ,laryngotracheo-bronchitis , laryngeal diphtheria

,ludwig's angina

Tumor-Benign(Lipoma ,fibroma ,papiloma) ,malignant(Sq. cell carcinoma ,adenocarcinoma) 3.Trauma-Endoscopy ,intubation ,FB

Bilateral abductor palsy

Congenital-Laryngeal cyst ,web ,laryngomalacia

Retained secretion-Coma ,respiratory spasm(Tetany ,eclampsia) ,resp. paralysis , GBS

,myasthenia gravis ,painful cough(Rib fracture ,chest injury)

Resp. insufficiency-COPDs

Types-

Acc. to severity- Selective Emergency

Acc. to duration-

Permanent(In total laryngectomy ,bilateral abductor palsy) Temporary

Acc. to site-

High-Above 2nd ring(In total laryngectomy) Mid-2nd to 4th ring

Low-Below 4th ring

Procedure-

Supine ,head extended ,sand bag between 2 shoulder GA(Selective)/LA(Emergency)

Incision-

Horizontal(Selective)-2 finger above manubrium and between 2 sternocleidomastoid muscle Longitudinal(Emergency)-Cricoid cartilage to manubrium

Types of tube-

Metalic

Non metalic- Rubber

PVC-With cuff ,without cuff

Post operative care-

Care of patient-Give pen ,pencil ,paper ,calling bell ,supervision under trained nurse ,propped up

,O2 inhalation

Care of tube-

Suction by rubber catheter

Humidification by humidifier ,warm ketly vapour ,keeping wet gauze piece over the tube 2-4 drops Normal saline instillation 30 minutes interval

Clean the tube-Inner tube removed and cleaned for 1st 3 days ,while outer tube should not be removed 3days until blocked/displaced ,then after 3 days outer tube is cleaned every day

Care of wound-Dressing ,gauze between wound and tube ,antibiotics

Complication-

Per operative-Primary haemorrhage ,anaesthetic hazards ,injury to other structures

Post operative-

Early-Reactionary hemorrhage ,tube block ,tube displacement ,atelectasis Late-Secondary haemorrhage ,tracheal stenosis ,laryngeal stenosis ,ugly scar

Decannulation

Process of gradual withdrawal of tracheostomy tube and permanent closure of tracheostome when purpose is subsided.

How done?-

Corcking of tube

Gradual reduce the size of tube

 Hoarseness of voice

Roughness of voice due to variation of voice in intensity of sound wave

Characteristics of normal voice-

Vocal cord should be approximated with each other Proper size and stiffness of cord

Ability of cord to vibrate regularly in response to sound

Causes- 1.Inflammatory- Acute-Laryngitis Chronic-

Specific(TB, syphilis ,fungus)

Non specific-Chronic laryngitis ,atrophic laryngitis

2.Trauma-Endoscopy ,intubation ,sharp /blunt injury ,FB

Tumor(Previous)

Tumor like lesion-Vocal nodule , vocal polyp ,vocal cyst

Congenital-Laryngeal cyst ,web ,laryngomalacia

Others-

Laryngysmus plica ventricularis(Male like voice in female due to false upper vocal cord) Tetany

Hysteria

Investigation-

Indirect laryngoscopy ,FOL ,videostroboscopy(Cord function) ,x ray chest ,neck Rx-Vocal hygiene ,mouth wash ,avoid smoke/alcohol

 Stridor

Noisy respiration due to turbulent airflow through narrow passage

Types-

Inspiratory-Obs. in supraglottic/pharynx(Sturtor-When pharyngeal cause) Expiratory-Obs. in thoracic trachea/bronchi

Biphasic-Obstruction in cervical trachea/subglottic

Causes-

Neonatal and children-Laryngeal web ,cyst ,laryngomalacia ,subglottic stenosis ,vocal cord paralysis ,hemagioma

Acquired-

Afebrile-Papiloma ,injury ,FB ,laryngeal edema

Febrile-

Epiglottitis ,acute laryngitis ,laryngotracheaobrocnhitis , laryngeal diphtheria ,retropharyngeal abcess , peritonsilar abcess

According to site/Adult- Nose-bilateral choanal atresia

Tongue-Macroglossia ,dermoid at the base of tongue

Mandible-Microglothia(Piere robin syndrome-Macroglossia with microglothia)

Pharynx-Dermoid ,retropharyngeal abcess

Larynx-

Inflammatory-Previous

Tumor-Previous(Malignant- + Juvenile resp. papilometosis) Trauma-Endoscopy ,intubation ,FB

Congenital-Laryngeal cyst ,web ,malacia ,cord paralysis Bilateral abductor palsy

Trachea-Malacia ,stenosis ,trauma ,tumor ,tracheitis

Outside airway-Esophageal atresia ,cystic hygroma ,neck mass ,FB esophagus

Investigation-Same as hoarseness

Rx-

Tracheostomy if needed

O2 inhalation ,propped up ,steroid ,antibiotics ,Rx the cause

 Mastoidectomy

Acute mastoiditis-Inflammation of mucosal lining of antrum and mastoid air system

Features of acute mastoiditis-

Symptoms-Pain behind ear ,earache ,discharge

Signs-Mastoid tenderness ,discharge ,sagging of posteriorsuperior meatal wall ,perforation of TM

,swelling over mastoid area ,conductive deafness

Investigation-

X ray mastoid town's view-Clouding airway Conductive deafness

C/S of discharge

DD-

Suppuration of mastoid nodes 2.Furunculosis

Absence of preceding acute otitis media.

Painful movements of pinna; pressure over the tragus or below the cartilaginous part of meatus causes excruciating pain.

Swelling of meatus is confined to the cartilaginous part only.

Discharge is never mucoid or mucopurulent. Mucoid element in discharge can only come from the middle ear and not from the external ear which is devoid of mucus-secreting glands.

Enlargement of pre- or postauricular lymph nodes.

Conductive hearing loss is usually mild and is due to the occlusion of meatus.

X-ray mastoid with clear ai r-cell system excludes acute mastoiditis.

3.Sebaceous cyst Complication of mastoiditis- Subperiosteal abcess

Brain abcess Subdural abcess Extradural abcess Labyrinthitis Petrositis

Facial nerve palsy

Lateral sinus thrombophlebitis

[Myringoplasty-Repair and reconstruction of TM perforation

Tympanoplasty-Operation to eradicate disease of middle ear with/without mastoidectomy]

Indication of mastoidectomy- 1.Cortical-

Acute mastoiditis when S/S not controlled

Masked mastoiditis

Persistent tubotympanic CSOM

Approach OT-Cochlear implantation ,labyrinthectomy

Radical-CSOM with extensive cholesteatoma ,otitis media malignans

Modified radical-

CSOM with limited cholesteatoma Atticoantral CSOM

Incision-

Willium incision/post auricular incision(Post auricular groove to mastoid tip)

Unilateral nasal obstructions

Vestibule-

Furuncle Vestibulitis Atresia Papilloma

Nasal cavity-

Foreign body-Paper , chalk ,rubber ,buttons ,pebbles ,cotton ,maggots DNS

Hypertrophic turbinates Antrochoanal polyp Synechia

Rhinolith-Nasal concretion formed around FB(Exogenous)/blood/mucus/pus(Endogenous)

,remove it under GA

Nasopharynx-

Unilateral choanal atresia

Bilateral nasal obstructions

Vestibule-

Bilateral vestibulitis Collapsing

Stenosis of nares Atresia of nares

Nasal cavity-

Acute rhinitis(viral ,bacterial or allergic) Chronic rhinitis & sinusitis Hypertrophic turbinates

DNS

Nasal polyp Atrophic rhinitis Rhinitis sicca Septal haematoma Septal abscess

Nasopharynx-

Adenoid hyperplasia Large choanal polyp Thornwaldt's cyst

Nasal tumors

Benign

Squamous papilloma Inverted papilloma Schwannoma Dermoid

Malignant

Carcinoma

Squamous cell carcinoma Adenocarcinoma

Malignant melanoma Olfactory neuroblastoma

Nasal polyp

Nasal Polyps are non-neoplastic masses of oedematous nasal or sinus mucosa

Types

Bilateral ethmoidal polyp

Antrochoanal polyp

Traits

Antrochoanal

Ethmoidal

Age

Common in children

Common in adults

Aetiology

Infection

Allergy or multifactorial

Number

Solitary

Multiple

Laterality

Unilateral

Bilateral

Origin

Max. sinus near the ostium

Ethmoidal sinuses, uncinate process, middle turbinate and middle meatus

Growth

Grows backwards to the choana; may hang down behind the soft palate(As Max antrum is backward)

Mostly grow anteriorly and may present at the nares(As ant.&mid. osteum forward)

Size & shape

Trilobed with antral, nasal and choanal parts. Choanal part may protrude

through the choana & fill the nasopharynx obstructing both sides

Usually small and grape-like masses

Recurrence

Uncommon, if removed completely

Common

Treatment

Polypectomy; endoscopic removal or Caldwell-Luc operation if recurrent

Polypectomy Endoscopic surgery or ethmoidectomy

(which may be intranasal, extranasal

or transantral)

Rhinoscopy

Seen by posterior rhinoscopy

Seen by anterior rhinoscopy

Surgery for nasal polyp

Intranasal polypectomy with antral washout with intranasal antrostomy Caldweall luc operation

FESS

Causes of polyp-

Ethmoidal-

Chronic rhinosinusitis Asthma

Allergic fungal sinusitis

Aspirin intolerance(Sampter's triad consists of nasal polyp, asthma and aspirin intolerance)

Antrochoanal-

Unknown

Nasal allergy with sinus infection

HIT/Hypertrophied inferior turbinate

Examination-

Anterior rhinoscopy(Pink) [Hints : Pale in case of polyp]

Probing(Sensitive , attached with lateral surface ,does not bleeds on touch) [Hints ;Opposite in case of polyp]

Surgery-

Submucosal diathermy(Common) Surface electrocautery Turbinectomy

Atrophic rhinitis/Ozaena

It is a chronic inflammation of nose characterised by atrophy of nasal mucosa and turbinate bones

Primary atrophic rhinitis Causes/HERNIA-

Hereditary

Endocrine disturbance Race

Nutrition-Def. of vit A ,D

Infection- Klebsiella ozaenae , (Perez bacillus), diphtheroids, P vulgaris, tfsch. coli, Staphylococci and

Streptococci

Clinical features-

Foul smelling detected by others Anosmia

Sensation of nasal obs.

Epistaxis when crust is removed

Greenish/greyish black dry crust covering turbinate/septum

Rx- Medical-

Irrigation and removal of crust with warm alkaline solution

The ,25% glucose in glycerine to inhibit saprophytic infection (For foul smell) Nasal dushing with 280ml water(Boric acid with NaHCO3 and NaCl)

KI

Antibiotics

Surgical-

1.Young's operation(Both nostrils are closed completely and opened after 6 months) 2.Modified young's operation(Closed partially)

Submucosal injection to teflon paste

Insertion of fat ,teflon strip under mucoperiosteum

Secondary atrophic rhinitis

Due to TB ,syphilis .leprosy ,SLE ,rhinoscleroma

Rhinosporidosis

Granulomatous fungal infection of nasal mucosa caused by R.seberiae or R.kinealy

Features-

Polypoid mass Pink/reddish colour Bleeds on touch Granular surface

White dots causes strawberry appearance

Rx-

Complete and wide excision with cauterisation of base of the polyp and surrounding area Dapsone with amphotericin B for long

Other fungal infections-

Candidiasis ,blastomycosis ,histoplasmosis

Other granulomatous diseases-

TB ,leprosy ,syphilis ,FB granuloma ,midline granuloma , wegener's granulomatous disease

Crusting diseases of nose-

Atrophic rhinitis ,rhinitis sicca ,rhinitis caseosa ,congenital syphilis

Sinusitis

Inflammation of sinus mucosa is sinusitis

Classification-

Acc. to duration- Acute sinusitis-

Acute frontal ,ethmoidal ,maxillary ,sphenoidal sinusitis

Chronic sinusitis-

Chronic frontal ,ethmoidal ,maxillary ,sphenoidal sinusitis

According to number of involvement-

Single-One sinus Multisinusitis->1

Pansinusitis-All sinuses of one/both sides

Acute sinusitis

Causes- 1.Exciting causes-

Nasal infection ,swimming ,diving ,trauma ,dental infection

2.Local-

Obstruction sinus ventillation and drainage-

Nasal packing

Deviated septum

Hypertrophic turbinates

Nasal polyp

Stasis of secretion-Enlarged adenoids

Agents-

Strept. pneumoniae

H. influenzae(Most common) Moraxella catarrhalis

Strept. pyogens Staph.aureus Kleb. pneumoniae

Rx-

Broad spectrum antibiotics for 7 days Analgesics

Nasal decongestants-Xylometazoline ,oxymetazoline ,ephedrine Rx of cause

Chronic sinusitis

Sinus infection lasting for months or years is called chronic sinusitis

Causes-

Loss of cilia-Pollution ,chemicals ,infection Impaired drainage-Polyp ,DNA ,adenoids ,tumor Infection

Mucosal changes-Allergy

Rx-

Broad spectrum antibiotics for 2 weeks Rest are same as acute Rx

Complication of sinusitis 1.Local-

Mucocele/Mucopyocele

Osteomyelitis- Frontal bone(more common)

- Maxilla

Orbital

Subperiosteal abscess Orbital cellulitis Orbital abscess

Superior orbital fissure syndrome Orbital apex syndrome

Intracranial

Meningitis Extradural abscess Subdural abscess Brain abscess

Organism for chronic maxillary sinusitis

Most common-H.influenzae

Gram -ve-Streptococcus ,staphylococcus Gram +ve-Proteus ,E.coli ,K.pneumoniae Anaerobes-Bacteroides ,peptostreptococci

DD. of unilateral opaque maxillary sinus

Antrochoanal polyp Dental cyst Maxillary sinusitis Malignancy Haemoantrum

Acute maxillary sinusitis

X-rays. Waters' view will show either an opacity or a fluid level in the involved sinus

Features-

1.Constitutional features-Fever ,malaise , bodyache 2.Headache

3.Pain ,tenderness ,swollen ,edema of sinus region 4.Nasal discharge posteriorly

Postural test-If no pus seen in the middle meatus, it is decongested with a pledget of cotton soaked with a vasoconstrictor and the patient is made to sit with the affected sinus turned up. Examination after 10-15 minutes may show discharge in the middle meatus.

Surgery-Antral lavage

Chronic maxillary sinusitis

Surgery-

1.Antral puncture and irrigation 2.Intranasal antrostomy 3.Caldwell luc operation

Nasal discharge

Clear-Common cold ,acute rhinitis ,nasal allergy ,vasomotor rhinitis ,CSF rhinorrhoea

Purulent-Acute sinusitis ,chronic suppurative infection of nose and sinus ,nasal diphtheria

,rinolith

Foul smelling-Acute and chronic sinusitis , chronic suppurative infection of nose and sinus

,atrophic rhinitis ,rhinolith

Haemorrhage-Rhinosporidiosis ,atrophic rhinitis ,chronic rhinitis ,malignancy ,rinolith

Dx-

Rhinoscopy

X ray nose lateral view

Rx-

Remove the FB Rx of cause

Neck mass and malignancy

80% neck swelling is node swelling

Midline swelling- 1.Cystic- Thyroglossal cyst

Cyst in relation to thymus Sub hyoid cyst

Dermoid Rannula

2.Solid-

Node-Submental ,submandibular ,prelaryngeal Thyroid-Diffuse goitre ,multinodular goitre Thymus-Persistent thymus ,ectopic thymus Bony growth of manubrium

Lateral swelling- 1.Submandibular triangle-

Cystic-

Plunging rannula

Lateral variety of sublingual dermoid

Cyst in submandibular gland

Solid-

Submandibular tumor(Sialitis ,sialolithiasis ,Szogren syndrome) Lymph node swelling

Carotid triangle-

Cystic- Branchial cyst Carotid aneurysm Cold abcess Laryngocele

Solid- Branchiogenic tumor Carotid body tumor Node tumor

Posterior triangle-

Cystic- Cystic hygroma Cold abcess

Subclavian aneurysm

Solid-

Cervical rib-From C7 Lymph node swelling

Common neck swelling occuring anywhere/DD

Lipoma Fibroma Neurofibroma Sebaceous cyst

Thyroidal tumor

Benign-Follicular adenoma

Malignant-

Primary-

Follicular origin-

Differentiated-Papillary carcinoma(100% curable ,early age) ,follicular carcinoma Undifferentiated-Anaplastic carcinoma(Worst ,late age ,palliative Rx)

Parafollicular origin-Familial and sporadic

Lymphoid origin-Lymphoma

Secondary-

Bone ,breast ,lung ,kidney, colon

Salivary gland tumor

Benign-Pleomorphic adenoma

[Rule of 80- 80% salivary tumor is parotid origin ,80 % of them are benign ,80% of those benign  is pleomorphic adenoma]

Malignant- Mucoepidermoid carcinoma Acinic cell carcinoma Adenoid cystic carcinoma Squamous cell carcinoma Carcinoma ex pleomorphic

Lymph node malignancy

Primary-Hodgkin's and non Hodgkin's lymphoma

Secondary-From larynx ,pharynx ,hypopharynx ,occult primary

[Occult primary-In a metastatic case , when the site of primary lesion is not found]

Causes of congenital neck swelling

Midline-Thyroglossal cyst(Common) ,dermoid cyst

Lateral-Branchial cyst(Common) ,cystic hygroma

Causes of lymphonadenopathy

Inflammatory-Reactive hyperplasia

Infective-

Bacterial-

Acute(Streptococcus ,staphylococcus) Chronic(TB, syphilis)

Viral-Infectious mononucleosis ,AIDS Protozoal-Toxoplasmosis ,actinomycosis

Neoplastic

Approach to thyroid swelling

History

Clinical examination-Inspection ,palpation ,percussion ,auscultation

Investigation-

FNAC  and biopsy

Thyroid function test-T3 ,T4 ,TSH ,autoAb(Hashimoto ,graves diseases) ,thyroid scan USG(Cystic/solid)

X ray neck-Lateral view(Compression) ,A/P view(Tracheal shift)

Types/causes of thyroid swelling/goitre 1.Endemic-Nodular ,multinodular ,diffuse 2.Toxic-Graves disease

Inflammatory-Hashimoto's ,reidel's thyroiditis

Neoplastic-Benign ,malignant

Thyroid surgery 1.Indication-

Neoplasia Recurrent cyst Toxic adenoma Cosmetic purpose Pt wish

Types-

Lobectomy-1 Total lobectomy with isthmusectomy

Subtotal lobectomy-2 subtotal lobectomy with isthmusectomy

Near total lobectomy-1 total lobectomy with 1 subtotal lobectomy with isthmusectomy

Total thyroidectomy-1 total lobectomy with isthmusectomy(Malignancy ,multinodular goitre)

Complication- Per operative- Primary hemorrhage

Injury to recurrent laryngeal nerve

Unilateral-Hoarseness

Bilateral-Stridor/respiratory distress Injury to superior laryngeal nerve

Post operative-

Early-Reactionary haemorrhage ,wound infection ,wound dehiscence ,thyroid crisis ,parathyroid insufficiency(tetany) ,laryngeal edema

Late-Secondary haemorhage ,recurrence ,scar

Ludwig's angina

Infection of submandibular space

Clinical features- Odynophagia ,trismus , Swollen mouth floor ,

Tongue pushed upwards and backwards ,

Submandibular region is swollen ,tender and woody hard

Causes-

Dental infection Submandibular sialadenitis

Rx- Antibiotics Surgery-

Intraoral incision

External transverse incision between 2 mandibular angle Tracheostomy

Thyroglossal cyst

Because of the attachment of thyroglossal duct to foramen caecum at the base of tongue, it moves with tongue protrusion

Thyroglossal cyst can occur anywhere ill the course of thyroid duct

Treatment is complete surgical excision, including with it the body of hyoid bone and core of tongue tissue

Hypothyroidism

Symptoms-

Tiredness

Mental lethargy

Cold intolerance

Weight gain

Constipation

Menstrual disturbance

Carpal tunnel syndrome

Signs-

Bradycardia

Cold extremities

Dry skin and hair

Periorbital puffiness

Hoarse voice

Bradykinesis, slow movements

Delayed relaxation phase of ankle jerks

Hyperthryoidism

Symptoms-

Tiredness

Emotional lability

Heat intolerance

Weight loss

Excessive appetite

Palpitations

Signs-

Tachycardia ,AF

Hot, moist palms ,fine tremor

Exophthalmos

Lid lag/retraction

Agitation

Thyroid goitre and bruit

ASOM

It is an acute inflammation of middle ear cleft by pyogenic organisms.

Age-Infants and children of lower socio-economic group as Eustachian tube in infants and young children is shorter, wider and more horizontal and thus may account for higher incidence of infections in this age group.

Routes-

Eustachian tube (Commonest) -Infection i .e. URTI ,horizontal breast feeding ,swimming through nasopharynx into middle ear(So keep infant propped up during breast feeding)

External ear-When TM perforation Blood borne

Predisposing factors-

Recurrent attacks of common cold, upper respiratory tract infections, and exanthematous fevers like measles, diphtheria, whooping cough

Infections of tonsils and adenoids Chronic rhinitis and sinusitis Nasal allergy

Tumours of nasopharynx, packing of nose or nasopharynx for epistaxis Cleft palate

Organism- S.pneumoniae(30%) H.influenzae(20%) Moraxella catarrhalis(12%)

Others-S.pyogen ,S.aureus ,P.aeruginosa

Stages-

Stage of tubal occlusion-Deafness ,earache ,retracted TM ,conductive deafness

Stage of pre-suppuration-Marked deafness and earache ,congested TM , cart-wheel TM

,conductive deafness

Stage of suppuration-Pus formation ,excruciating earache , high fever ,vomiting ,bulging of TM ,lost landmarks ,yellow spot on TM ,X ray mastoid shows cloudy appearance

Stage of resolution-Rupture TM with evacuation of pus ,relieved earache

Stage of complication-Acute mastoiditis, subperiosteal abscess, facial paralysis, labyrinth itis, petrositis, extradural abscess, meningitis, brain abcess or lateral sinus thrombophlebitis.

Rx-

Antibiotics-Amoxicillin ,co amoxiclav ,erythromycin Nasal decongestants-Ephedrine

Oro-nasal decongestant-Pseudoephedrine Analgesics ,antipyretics

Ear toileting-Dry mopping

Myringotomy-Incision of eardrum to evacuate pus

Indication of myringotomy in ASOM-

Drum is bulging and there is acute pain

Incomplete resolution despite antibiotics when drum remains full with persistent conductive deafness

Persistent effusion beyond 12 weeks

Indication of myringotomy-

OME(Linear incision)

Pre perforative stage of ASOM(Curved) ASOM with facial nerve palsy

ASOM with intracranial complication ASOM with baro tramatic OM

Squeal of ASOM-

Resolution CSOM

Persistent middle ear effusion Sensory-neural hearing loss

CSOM

Chronic suppurative otitis media (CSOM) is a longstanding infection of a part or whole of the middle ear cleft characterised by ear discharge ,deafness and a permanent perforation

Types- Tubotympanic- Atticoantral-

Traits

Tubotympanic

Atticoantral

Involves

Anteroinefrior middle ear

cleft

Posterosuperior middle ear

cleft

Discharge

Profuse ,mucoid and

odourless

Scanty ,purulent and foul

smelling

Perforation

Central

Marginal

Granulation

Uncommon

Common

Cholesteatoma

Absent

Present

Audiogram

Mild to moderate conductive

deafness

Moderate to severe

conductive/mixed deafness

Polyp

Pale

Red and fleshy

X ray mastoid/town's view

Pneumatic

Sclerotic and evidence of

cholesteatoma

Mx

Conservative

Surgical

TM perforation-

Pars tensa-Central and marginal Pars flaccida-Attic type

Dx criteria of CSOM-

Discharge Deafness Perforation X ray

Tubotympanic type

Pathologic changes-

Perforation of pars tensa

Middle ear mucosa-Valvety and edematous Polyp seen on external canal Tympanosclerosis

Fibrosis and adhesion

Investigation-

Examination under microscope Audiogram

Mastoid x ray

Rx-

Aural toileting-Dry mopping ,wet mopping ,suction Antibiotics

Steroids

Nasal decongestant

If improves-Tympanoplasty after 6 weeks If improving-Same Rx for next 14 days

If not improving-Check for sinusitis ,tonsilitis and Rx ,if no cause if found ,do cortical mastoidectomy

Advice-

Use ear plug Aural hygiene Avoid swimming

Pressure over tragus after ear drops

Atticoantral type Pathologic changes- Cholesteatoma

Osteitis and granulation Ossicular necrosis Cholesterol granulation

Rx-

Surgery-Canal wall up surgery and canal wall down surgery Reconstructive surgery-Myringoplasty or tympanoplasty

Features indicating complication of CSOM-

Pain Vertigo

Persistent headache

Facial weakness Neck rigidity Diplopia

Ataxia

Abcess around ear Fever ,nausea ,vomiting

Cholesteatoma

It is the presence of keratinised of epithelium in the middle ear or mastoid

skin in the wrong place It is a misnomer

Cholesteatoma consists of -

1.Matrix, which is made up of keratinising squamous epithelium resting on a thin stroma of fibrous tissues

2.A central white mass, consisting of keratin debris produced by the matrix .For this reason, it has also been named epidermosis or keratoma

Origin of chlesteatoma/Genesis/Theory

1.Presence of congenital cell 2.Invagination of pars flaccida 3.Basal cell hyperplasia 4.Epithelial invasion 5.Metaplasia

Types-

Congenital-Presence of embryonic epidermal cell , occurs at middle ear ,petrous apex

,cerebellopontine angle

Acquired primary-Invagination of pars flaccida ,basal cell hyperplasia ,metaplasia

Acquired secondary-Migration of keratinised cell through perforation of TM ,metaplasia of middle ear lining

Eroding of bone by cholesteatoma-

Chemical theory ,ischaemic pressure theory

Enzymatic theory-Collagenase , phosphatase and proteases

Structures injured by cholesteatoma-

Ossicles

Bony labyrinth Canal of facial nerve Tegmen tympani

Investigation-

Town's view x ray mastoid-Sclerotic mastoid Ear swab-C/S

Ct scan

Hearing assessment Pure tone audiometry

Rx-

Medical Rx is of no use ,as it may be life threatening

Modified radical mastoidectomy-If limited cholesteatoma Radical mastoidectomy-If extensive cholesteatoma Tympanoplasty

Hearing aid

Why cholesteatoma is dangerous?-(Why attico antral CSOM is dangerous)

Due to eroding power

Produce both intracranial and extracranial complications

OME/Otitis media with effusion(5-8 years age)

Accumulation of non-purulent effusion in the middle ear cleft.

Causes-

Malfunction of Eu. tube-Adenoid hyperplasia ,chronic rhinitis ,chronic sinusitis , chronic tonsilitis

,cleft palate ,palatal palsy Allergy

Unresolved OM

Viral infections-Adeno and rhino viruses

Clinical features-

Hearing loss(Conductive) Delayed and defective speech Mild earache

Dx-

Otoscopic findings-Dull ,opaque ,loss of light reflex ,yellow/gray/bluish coloured , bulging ,fluid and air bubbles

X ray mastoid-Clouding of air cells due to fluid Tuning fork test-Conductive  deafness Impedance audiometry

Rx-

Medical Rx-

Valsalva maneuver ,chewing gum , Eu tube catheterization Surgical-Myringotomy ,tympanotomy ,cortical mastoidectomy

Sequelae of OME-

Atrophic  TM Ossicular necrosis Tympanosclerosis Retraction pockets Cholesteatoma Cholesterol granuloma

Recurrent OME-

Children between 6 months to 6 year have 4-5 time per year

Mx-

Antibiotic prophylaxis

Myringotomy and insertion of ventilating tube