- SCC, most common malignancy
- Maxillary 55%
- most common presentation is nasal obstruction

1- Papilloma

a- wart

- nas vestibule (lined by skin)
- sessile or pedunculated
- HPV
- found accidentally
- Treated by surgical excision or by laser treatment
- Recurrence especially in adult should be treated with care.

B- inverted papilloma

- ringert's tumor, transitional cell tumor
- infolding, basement membrane intact
- lateral wall of nose
- recurrence after excision suggests malignancy

2- adenoma

- glandular tissue
- may become malignant

1- fibroma
2- osteoma: 2 types

A) compact osteoma
- mostly frontal sinus in adults
- may be silent
- may cause csf rhinorrhea

B) cancellous osteoma
- maxillary and ethmoid

3- angioma: 3 types

A) capillary

- commonly septum
- present with bleeding
- treated by excision and cautery

B) cavernous
- involve tip on nose

C) multiple telangiectases

- osler's disease
- autosomal dominant
- recurrent bleeding
- seen at tongue and lips

4- chondroma

5- angiofibroma
- adolescent males
- very sever bleeding
- lateral wall of posterior nasal cavity close to sphenopalatine
- shoe orbital and cranial extension
- no biopsy

- males predominance
- wood dust associated with adenocarcinoma (carpenters)

Types
A) epithelial tumor
- SCC is the commonest
- maxillary sinus
- adenoid cystic carcinoma-> spread to nerves ( paraesthesia)
B) connective tissue tumor
C) metastasis

Tumor of ethmoid sinuses causes hypertelerosim (means increased distance between the medial canthi of the eyes by tumor expansion)

Palpable cervical nodal disease? -> periosteal and bone invasion

Vibrations reach cochlea by lever mechanism of ossicles

Whispering test

- 60cm distance
- first test

Tuning fork tests
- 512Hz tuning fork

1- Weber's test
- place it midline of the forehead
- louder in intact ear? -> sensorineural deafness
- louder in affected ear? -> conductive deafness

2- Rinne's test
- in front of ear for testing air conduction
- on mastoid bone for bone conduction
- AC>BC (positive) -> healthy or sensorineural deafness
- BC>AC (negative) -> conductive deafness

Absolute bone conduction (ABC), Schwabach test to compare bone conduction of patient with examiner

Audometry

1- subjective audiometric test:
- pure tone audiometry (PTA)
- speech, visual response, play, behavioral audometry

2- objective audiometric tests:
- impedance audiometry
- tympanometry
- acoustic reflex, oto-acoustic emission, brainstem evoked response audiometry

Tympanometry curves

1- Type A = normal
2- Type Ad = ossicular disarticulation or healed thin scarred TM
3- Type As = ossicular fixation (otosclerosis)
4- Type B = flat (OME)
5- Type C = negative (eustachian tube obstruction)

Palpate the tragus for tenderness associated with otitis externa (furunculosis)

Otoscopy
- Pull the pinna upwards and backwards in adults, while outwards and backwards in children with your other hand to straighten the external auditory canal

Criteria of normal tympanic membrane

1- color: Pearly gray
2- Position 55°
3- integrity: Intact
4- Semi-transparent
5- Mobile
6- Cone of light present
7- Landmarks visible

Traumatic vs Infective TM Perforation

Traumatic
- trauma history
- jagged margin (irregular)
- blood clot
- remaining part of TM normal
- no infection

Infective
- URTI history
- smooth margin
- no blood clot
- inflammed TM
- ear discharge

Most important complication of ear wash is tympanic membrane rupture

Siegel pneumatic ear apparatus (speculum)

1- provide magnified view of TM (diagnostic)
2- test the mobility (diagnostic)
3- suction (therapeutic)
4- induction of medicine such as powder (therapeutic)
5- differentiation between retraction pocket and perforation (diagnostic)
6- identify fistula sign (diagnostic)

Balance mechanism

1- vestibular
2- visual
3- proprioceptive

Vertigo tests
1- romberg test
2- gait test
3- unterberger test

Complication of laceration
- perichondritis
- necrosis of cartilage

Late changes of radiation burns
- dryness, fibrosis, telangiectasia, atrophy, necrosis

Frostbite

- subfreezing temp. = disruption of endothelial layer
- Mx: slow rewarming, Abs, anticoagulants, no pressure dressing

Bites

- commonest site is lobule
- meticulous cleaning
- systemic ABs
- repair

Auricular hematoma

- Blunt
- blood is collected sub-perichondrial, destruction, fibrosis
- mostly external aspect of auricle (less mobility, easily to be deattached)

Mx
- evacuation
- compression by moulded splint to prevent recurrence
- failure? -> cauliflower ear

Foreign body in EAC

-lodge at isthmus
- methods (suction,fps,hook,wash)

Fractures of temporal bone

1- longitudinal fractures
- 80% commonest
- run along the long acis of petrous bone
- conductive deafness
- haemotympanum
- facial paralysis may occur

2- transverse fractures
- 20%
- runs at right angle to the long axis of petrous bone
- sensorineural deafness (permanent)
- vertigo, nystagmus
- facial paralysis is not uncommon

3- mixed: rare

New system

1- otic capsule sparinf
- conductive deafness/mixed
- less facial weakness
- less csf leakage

2- otic capsule disrupting
- SNHL
- facial weakness
- increased csf leakage

Incudostapedial joint separation is the commonest ossicular injury

Facial nerve trauma

1- first degree: neuropraxia (conduction block)
2- second degree: axontmesis (axon cut, endoneurium intact)
3- third degree: neurotmesis (endoneurium disrupted, synkinesis possible)
4- fourth degree: neurotmesis (epineurium intact)
5- fifth degree: neurotmesis (all three layers cut)

In tympanic membrane rupture
- Leave the clots inside do not try to remove it (its clean and used for future healing)
- waith 3 months for spontaneous healing, failed? -> myringoplasty

Definition:- Acute Inflammation of the mucoperiosteal lining of the middle ear cleft (Eustachian tube, tympanic cavity, mastoid antrum and mastoid air cell.

More common in infant and children

Mostly follow viral URTI

most common route of infection via ET

Most common bacteria are
- streptococcus pneumonia
- haemophilus influenzae
- moraxella catarralis

Stage of tubal occlusion

- negative ME pressure
- no fever
- TM retracted
- conductive deafness

Stage of pre-suppuration

- pyogenic organism invade Me
- congested hyperemic
- marked earache (throbbing)
- fever
- cart wheel appearance of TM

Stage of suppuration

- formation of pus in ME&mastoid cells
- TM is bulging
- yellow spot
- x ray shows clouding

Stage of resolution

- rupture, release of pus, subside of symptoms
- may contain blood stained discharge
- antero-inferior quadrent perforation

Stage of complications

Extracranial
- Acute mastoiditis, subperiosteal abscess,facial paralysis,labyrinthitis,petrositis

Intracranial
- extradural abscess , meningitis, brain abscess or lateral sinus thrombosis

Mx

- resolve spontaneously within 24-72h

If persistent, detoriarate, suppurative
- Abs : ampecillin, amoxicillin
- decongestant

Myringotomy if
- bulging of TM persist
- incomplete resolution
- persistent effusion beyond 3 months

Accumulation of non purulent fluid in the middle ear cleft

Other names
- serous otitis media
- secretory otitis media
- mucoid otitis media
- glue ear

Etiology

1- malfunction of ET
2- increased secretory activity

Adenoid hyperplasia is the commonest cause in children

Mass or tumor in nasopharynx are causes in adults

- unilateral or bilateral
- CHL most common feature arounf 40dB loss

Signs

Early
- TM dull, opaque, loss of light reflex
- fluid level and air bubbles
- TM retracted

Late
- grey, yellow, brown color
- TM bulging
- mobility restricted

Ix

- CHL (rinne -ve , weber lateralized to affected ear)
- pure tone audiometry (AB gap)
- tympanometry (type B)
- mastoid x-ray (clouding)

Mx
- conservative
- Abs not given routinely it is

Surgical
- myringotomy if persist more than 3 months
Myringotomy & aspiration for serous
Myringotomy and gromet
- cortical mastoidectomy
- treatment of causative

Normal = lower than 15dB

Disabling = adult >40dB, children >30dB

Hearing impairment
- mild = 21-39dB
- moderate = 40-69dB
- severe = 70-95dB
- profound = >95dB

Conductive hearing loss = outer or middle ear problem
Sensorineural hearing loss = inner ear problem

- Longitudinal temporal fracture = conductive hearing loss
- transverse tempral fracture = SNHL

Ototoxic drugs
- aminoglycoside (gentamicin, streptomycin)
- chemotherapy (cisplatin..)
- loop diuretics (furosemide..)
- antimalarials (quinine..)
- aspirin, NSAIDs, erythromycin

Mixed hearing loss
- cholesteatoma extension
- advanced stage of otosclerosis

Presbycusis

- age related hearing loss
- progressive, bilateral, sensorineural
- 40-60 years
- male
- worse at higher frequencies
- down sloping on PTA

Otosclerosis

- familial history = half of patients
- measles virus
- autosomal dominant
- women 2:1 men
- otoscopy usually normal
- flamingo flush or schwartze's sign = increased vascularity, reddish
- carhart's notch at 2000Hz
- progressive low frequency
- conductive hearing loss

Sudden SNHL

- rapid onset of >=30dB in more than three consecutive frequencies over <=72h
- idiopathic, but may be due to
Infection
Vascular insult
Rupture of membrane
Autoimmune
- poor prognostic signs : age >60y , vertigo, down sloping

Mx
- steroid within 2 weeks (1mg/kg)
- hyperbaric oxygen therapy

Meniere disease

- idiopathic
- recurrent spontaneous vertigo
- progressive sensorineural hearing loss
- tinnitus
- aural fullness
- anatomical variation in temporal bone may be the cause
- endolymphatic hydrops
- vertigo attack 20min-12h

Ix
- audiogram = low frequency
- electrocochleography = increase summating potential/action potential ratio

Mx
- dietary : low salt, caffeine free
- diuretics
- betahistine dihydrochloride
- intratympanic corticosteroids
- intratympanic gentamicin

Surgery
- endolympatic sac surgery
- selective vestibular nerve section

• the external nose is pyramidal •Ant. Nares situated in the base of nose,open downards and separated by columella

•Bony constituents (support the upper part)
-nasal processes of the frontal bones
-nasal bones
-ascending processes of the maxilla

•Cartilaginous constituents (Support the lower part)
-Upper lateral cartilages
-Lower lateral cartilages -Quaderilateral cartilages of the nasal septum

•nasal septum
- Ant-> quadrilateral cartilage and premaxilla
- Post-> perpendicular plate of the ethmoid bone and the sphenoidal crest
- inferiorly-> crests of the vomer, maxillary and palatine bones

•Floor is formed by
-Palatine process of maxilla ->ant. 3 quarters
-Horizontal part of palatine bone -> post. 1 quarter

•Roof (narrow)
- Nasal process of frontal bone anteriorly
- Cribriform plate of ethmoid nerve pass
- Body of sephenoid bone psteriorly

•Lateral wall
- Medial wall of maxilla
- Lateral mass of ethmoid and lacrimal bone
- Ascending process of maxilla anteriorly
- Perpendicular part of palatine bone and behind it medial pterygoid process of sphenoid posteriorly

•Each meatus is below&lateral to it's turbinate

•Sphenoethmoidal recess is medial to the superiorturbinate & lateral to the septum

•Post ethmoidal cells->Sup. Turbinate (mcq)

•maxillary ,anterior ethmoidal ,and frontal sinuse->Middle meatus (most complex)(most important) into it

• bulla ethmodalis Is a smooth rounded mass formed by the anterior ethmoidal cells ostia of these cells open on to the bulla or above it

• Naso lacrima duct->Inf meatus (mcq)

•Pyramidal in shape

•The largest sinus (capacity 15ml in adult)

•Boundries
-Ant.->maxillary face
-Post.->pterygomaxillary space -Medial->ascending process of the palatine bone
-Sup.->orbital floor

•maxillary ostium drains into the ethmoid infundibulum, lateral to the lower one-third of the uncinate process

•ant.&post. compartments seperated by basal lamella of middle turbinate

•Boundries
-Lateral->lamina papyracea
-medial->middle turbinate in anterior ethmoid &superior turbinate in post. Ethmoid
-post.->face of sphenoid
-sup.->ethmoid roof

Frontal sinus
•formed by outgrowth of the ethmoid labyrinth
•Boundries
-lateral->lamina papyracea
-medial-> middle turbinate
-ant.-> posterosuperior wall of the agger nasi
-Post.->ethmoid bulla
•Sphenoid sinus lies adjacent to vital structures
-internal carotid artery
-optic nerve
-Vidian nerve
-the cavernous sinus
-foramen rotundum

•Skin of nasal vestibule ->keratinized squamous epithelium (conatin vibrissae and sebaceous

•At the edge of inferior turbinate, the epithelium transitions into a cuboidal cell type and then to pseudostratified ciliated columnar respiratory epithelium

•Post. nasopharynx ->nonkeratinized squamous epithelium

•Nasal innervation->ophthalmic & maxillary (CNV)

•Blood supply -ant.&post. Ethmoidal artries(branches of opthalmic) -Sphenopalatine artery (terminal branch of internal maxillary)

•Venous drainage->opthalmic plexus and partialt to cavernous sinus

Nasal airways physiological function
->filtration, humidification, and olfaction

•The greatest air resistance at the internal nasal valve

•Nasal cycle present in 80% of individuals

•nasal cycle period=2and half to 4 h

•The total increase in air temperature as air leaves the nasopharynx is approximately 8 C

•humidity increase from 40 to 98% between the nasal vestibule and the glottis

•olfactory neuroepithelium
distribution (olfactory cleft)
-superior septum
- superior aspect of the Superior turbinate
-superior aspect of the middle turbinate(lesser aspect)

•The ciliated cell have 50-200cilia

•Beat frequency 700-800times per min

•Mucocilliary transport time 1cm/min

•The sinonasal cavities are lined with pseudostratified ciliated columnarepithelium
composed of 4 basic cell types:
- Ciliated columnar epithelial cells
- nonciliated columnar cells
- basal cells,
- goblet cells

•Goblet cells
-produce glycoproteins
-responsible for viscosity and
elasticity of mucus
-respond to parasympathetic and sympathetic neural input

•20-40ml of mucus secreted from normal nose daily

•The cilia beat within
the lubricating periciliary layer fluid, termed the sol layer
•The outer more viscous mucus layer, is termed the gel layer

•80% particles larger than 12.5 μg are filtered from the air before they reach the pharynx

Function of Paranasal Sinuses

1-Humidifying and warming inspired air
2-Regulation of intranasal pressure
3-Increasing surface area for olfaction
4-Lightening the skull
5-Resonance
6-Absorbing shock
7-Contribute to facial growth

• inflammation of the mucosal lining of the paranasal sinuses >3 months

•Classified into specific & non specific

•simple infective sinusitis
-Single or repeated attacks of acute sinusitis

•Mixed infective&non-infective
- Obestruction of sinus ostium
Such as
- Allergic rhinitis
- Vasomotor rhinitis.
- Nasal polyposis.
- Structural nasal abnormalities
- Congenital mucocilliary disorders as primary cilliary dyskinesia
- Metabolic derangements (aspirin sensitivity)

•mucosal edema->Thickening of mucosal membrane->chronic
inflammatory reaction->fibrosis of

SUBMUCOSA

&

MUCOSAL

polyposis

•Organisms
-Staph
-Strep
-Pseduomonas
-E.coli

•Rhinorrhea
•postnasal drip -> chronic pharyngitis with halitosis
• Nasal obstruction
• Headache

• Rarely pain, tenderness(mcq)

• Reduced sense of smell and taste
• Constitutional symptoms are usually mild

•Ant. Rhinoscopy & nasal endoscopy shows nin-specific finding

•CT scan is the gold standard (mcq)

•Medical treatment for 4-6w
-Abx+steroid Nasal spray+anti-Histamine
-Analgesic rarely needed (pain is rare)

•Functional endoscopic sinus surgery (FESS)Gold standard operation(mcq)

presenting symptom of pharyngitis is usually sore throat

- Viral is the commonest cause (common cold)
- if bacterial -> due to group A streptococcus

Clinical features
- sore throat, constitutional symptoms, history of exposure

Scarlet fever rash (sandpaper rash) is a feature suggesting bacterial pharyngitis

Treatment is usually symptomatic

Infectious mononucleosis

- glandular fever
- classical triad : sore throat, fever, lymphadenopathy
- EBV
- most common symptom is tender cervical adenopathy
- Pharyngeal signs range from acute follicular tonsillitis indistinguishable from follicular tonsillitis to a grey membrane lining the oropharynx, petechiae on the soft palate and sometimes a PTA, which can be bilateral
- gold standard for diagnosis is EBV IgM to viral capsid antigen

Mx:
- symptomatic
- antiviral if systemic complications

- nasopharyngeal lymphoid aggregate
- part of waldeyer's ring
- In early childhood this is the first site of immunological contact for inhaled antigen
- associated with the persistence of otitis media with effusion

Pathological effect
- upper airways obstruction
- otitis media
- rhinosinusitis
- neoplasia

Adenoid face
- open lip posture
- pinched nose
- narrow upper alvelous, high arched palate
- OME
- sleep apnea, delayed growth

Dx
- nasoendoscopy
- if not tolerated? -> lateral soft-tissue radiography

Grading
- grade 1: adenoid filling 1/3
- grade 2: 1/3-2/3
- grade 3: 2/3-complete
- grade 4: complete choanal obstruction

Mx:
- topical steroid
- adenoidectomy

KTP laser (high risk of nasopharyngeal stenosis)

Pre operative assessment

- bifid uvula? -> marker of submucous cleft -> high risk of velopharyngeal insufficiency (VFI) post op

Palatine tonsils are paired, in tonsillar fossa

Acute tonsillitis

- group A streptococcus
- Dx is clinical
- associated with tender jugulodigastric lymph node enlargement

Mx
- analgesia, hydration
- 48-72h no improvement? -> start Abs (penicillin)
- if severe -> start Abs from the beginning
- steroid in severe cases

Tonsillectomy indications

Absolute indication
- OSA
- suspicion of malignancy

Relative indications
- recurrent acute infection, 7 in 1 year. 5 per year in 2 years, 3 per year in 3 years
- recurrent with complications
- peritonsillar abscess
- mononucleosis unresponsive
- chronic tonsillitis with halitosis . Persistent sore throat, cervical adenitis

Bleeding disorder is not contraindicated

Complications of adenotonsillectomy

- primary post op haemorrhage
- secondary post op haemorrhage
- dehydration (most common)
- mandibular dislocation
- velopharyngial insufficiency
- NP stenosis
- grisel syndrome (torticollis)

creation an artificial opening in the trachea with tracheostomy tube insertion

Indications

1- upper airway obstruction with stridor, air hunger, retraction
2- prolonged intubation
3- inability to manage secretion
4- ventilation support
5- inability to intubate
6- adjunct to manage head and neck surgery
7- adjunct to manage significant head and neck trauma

Advantages of tracheostomy

1-Reduce dead space by 50%
2-Reduction in air resistance
3-Easier tracheobronchial secretion toilet
4-Facilitate using of ventilation support

horizontal incision provides a more cosmetically pleasing postoperative scar

Vertical incision avoids the anterior jugular venous system

Vertical incisions start just below the cricoid cartilage

horizontal incisions are made two finger’s breadths below the cricoid cartilage

Post op care

1- monitor vital signs
2- tracheal suctioning
3- humidification
4- tube replacement : after 72h in adult, after 5-7 days in children
5- wound care
6- post tracheotomy chest x-ray

Early complications

1- Mild bleeding (most common)
2- tube obstruction (most common cause of ventilatory insufficiency )
3- displacement of tube
4- blind reinsertion cary risk of false passage
5- subcutaneous emphysema
6- pneumothorax

Late complications

1- tracheo-innominate fistula (at the tip)
2- infection
3- dysphagia and aspiration
4- granulation tissue
5- subglottic stenosis
6- tracheo-esophageal fistula

Plastic tube

- cheaper, easier, lighter
- can use cuffs for ventilation or in comatose patients

Metal tube

- can't connect to ventilator
- not used in patient with risk of aspiration
- main contraindications is radiotherapy

Sounds breathy, strained, rough, raspy, tremorous, strangled, weak, higher or lower pitch

The larynx is the voice box

Vocal cords should

- be able to approximate properly
- have a proper size and stiffness
- have ability to vibrate regularly in respone to air column

Conditions causing hoarseness

- loss of approximation
- size of cord increases or decreases
- stiffness

Acute laryngitis is the most common cause of hoarseness

Chronic laryngitis persists more than 3 week

Polyp

- is the most common cause of benign tumor of vocal cord
- smoking or voice abuse
- unilateral

Reinke edema

- all surface of vocal cord
- bilateral
- heavy smoking, voice abuse
- Mx: debulking

Vocal nodules

- women, children
- vocal abuse

Laryngeal carcinoma

- mostly squamous
- smoking,alcohol

Vocal haemorrhage

- sudden loss of voice after yell
- vessel rupture
- emergency, absolute voice rest

Gerd

- irritate the vocal cord
- voice worse in morning, improve during day
- excessive desire to clear throat mucous

Fixation of cords

- there is gap between cords

Any hoarsenese persist >3 weeks deserves examination of larynx, malignancy should be excluded in patient>40 yrs old.

Do Bronchoscopy, Oesophagoscopy in case of paralytic lesion to exclude malignancy.

Mx:

- acute laryngitis: hydration, voice rest, spontaneous
- chronic laryngitis: remove offending agent
- reinke's edema: smoking cessation, reflux management, voice therapy, surgical debulking
- polyp : surgical removal
- nodule: correct habits, don't require surgery

Internal superior laryngeal nerve supply the sensation to larynx above the glottis

- External superior laryngeal nerve supply the cricothyroid muscle
- other muscles supplied by recurrent laryngeal nerve

- Right vagus nerve loops around the subclavian
- left vagus nerve loops around the aorta
- left has longer course, more injury

- Posterior cricoarytenoid - only abductor of vocal folds
- the other muscles are adductors

Wegner and gorssman theory

- immobile vocal cord in paramedian position has total pure unilateral recurrent nerve paralysis
- immobile vocal cord in lateral position has a combined paralysis of superior and recurrent nerves (the adductive action of cricothyroid muscle is lost)”

Most common cause of vocal cord paralysis is bronchogenic carcinoma

Most common iatrogenic cause is thyroidectomy

Unilateral superior laryngeal nerve injury

- deviation of posterior commissiure to paralyzed side during phonation
- at rest vocal cord on paralyzed side is slightly shortened and bowed
- loss of sensation to supraglottic larynx
- loss of motor of cricothyroid muscle
- hoarseness, diplophonia

Unilateral recurrent laryngeal nerve injury

- paralysis of muscles except cricothyroid
- paramedian position
- voice is breathy
- airway is adequate

Bilateral recurrent laryngeal nerve injury

- paralysis of muscles except cricothyroid
- both cords in paramedian position
- voice is good
- stridor , dyspnea

Do manual compression test for unilateral paralysis -> voice improved

Mx of unilateral paralysis

- no treatment of compensation occur
- vocal cord injection (medialization):
1- add fullness
2- poor correction of posterior glottic gap
3- temporary (3m)
4- teflon,fat,collagen
- type 1 thyroplasty

Mx of bilateral paralysis

- maintenance of airways is primary goal
- 6 months wait for spontaneous recovery
- acute stridor-> tracheostomy
- don't want tracheostomy? -> do lateralisation of vocal cord:
1- arytenoidectomy
2- endoscopic
3- thyroplasty type 2
4- cordectomy
5- nerve muscle implant

Papilloma is the most common benign tumor
Papilloma is single in adult, multiple in children

Chondroma

- men , 60-70y
- cricoid cartilage
- hoarseness
- difficult to be differentiated from chondrosarcoma on histo

Paraganglioma

- women 40-60y
- laryngeal paraganglia
- highly vascular, hoarseness

Squamous cell carcinoma

- most common malignant tumours in the head and neck region.
- more common in men due to high consumption of tobacco and alcohol although the incidence started to rise in women
- macroscopically: exophytic or endophytic
- microscopically: presence of prickle cells and keratin whorls
- well differentiated: radio resistant
- poor differentiated: radiosensitive

- glottic cancer lack lymphatic-> less spread
- supraglottic rich in lymphatic -> spread rapidly (cervical lymphadenopathy before laryngeal symptoms)

Glottic cancer

- Change of voice or hoarseness is the early symptom
- any patient has hoarseness that continues for more than 3 weeks should be subjected for laryngeal examination by laryngoscope
- Advanced lesions may lead to airway obstruction causing progressive dyspnea and stridor
- Referred otalgia is a sinister sign suggesting deep invasion
- Cervical lymphadenopathy is rare

Supraglottic cancer

- globus, foreign body sensation-> small lesion
- hemoptysis -> exophytic lesion
- hot potato voice -> large lesion
- hoarseness -> extension to vocal cord
- referred otalgia, odynophagia, true dysphagia -> lateral extension
- Cervical lymph adenopathy may be the first presenting sym without laryngeal symptoms
- stridor is late and indicates advanced disease

Subglottic cancer

- Hoarseness
- Progressive dyspnea and stridor in circumferential lesion
- tumour may involve the thyroid and may mimic a thyroid isthmus lesion

Do radiological exam before biopsy

- Endoscopy with biopsy is investigation of choice
- biopsy taken should be representative and not taken from necrotic areas.

single most prognostic factor in head and neck tumours is the presence or absence of lymph adenopathy.

laryngeal cancer is curable disease

Glottic cancer staging

- T2: extend to supraglottic or subglottic with impaired vocal cord mobility
- T3: limited to larynx with vocal cord fixation

Mx

Early: endoscopically or eith radiotherapy
Advanced disease: laryngectomy or chemo radiotherapy

radiotherapy:
- early T1 tumor
- complicated by laryngeal perichondritis

Endoscopic resection
- early lesion
- With CO2 laser

Laryngectomy:
A- partial: vertical(cordectomy) or horizontal
B- total: with partial thyroidectomy, permanent tracheostomy

Lymph node:
- radiotherapy or surgery

abnormal high pitched ,musical sound due to blockage or partial obstruction in the larynx or trachea

Should be differentiated from stertor (low pitched, noisy breath)

Stridor

- inspiratory: due to laryngeal obstruction
- expiratory: due to tracheobronchial obstruction
- biphasic: due to glottic or subglottic obstruction

Stridor in infants and children is more serious than in adults due to:

1- The lymphatic drainage of the larynx is richer in the child and so the submucosa is more likely to swell.
2- The neuromuscular mechanism is more easily upset and spasm
more easily provoked.
3- The child is less able to expel the secretions by coughing.

Grades of stridor

1- exertional stridor: stridor during crying or exercise
2- continuous stridor or stridor at rest : worse with exertion, admit to hospital
3- stridor with retraction: continuous, suprasternal, supraclavicular retraction, hospitalization
4- stridor with cyanosis; continuous, retraction, cyanosis, intubation or tracheostomy needed

If we suspect the child has epiglottitis ,examination by tongue depressor should be avoided for the risk of laryngeal spasm which may be fatal

Laryngomalacia

- commonest cause of chronic stridor in infancy and early childhood
- occurs due to an indrawing of floppy supraglottic structure
- appear within an hour or two of birth
- Stridor may be slight and present in certain positions (supine)
- symptoms gradually improve with time but may take several years to improve
- Diagnosis Is done by endoscopic examination of the larynx
- epiglottis is omega shaped

Mx
- of
- surgical removal of lax mucosa by laser
- try to avoid tracheostomy

Multiple laryngeal papillomatosis

- single in adult, liable for recurrence, malignant changes, should be removed
- multiple in infant, HPV 6,11
- birth to 5 years
- affect the vocal cords ,anterior commissure and vestibular folds
- change of voice or abnormal cry is the presenting symptom
- respiratory obstruction and increasing stridor are late
- diagnosed by endoscopy

Mx
- removal

Medical
1- alpha interferon
2- isotretinoin

Surgical
- laser CO2

Tracheostomy should be avoided if possible as the papillomas can become implanted into the trachea and bronchi

•Nerve is not fully developed until Age of 4

•Develop from 2nd pharyngeal arch
While external&middle ear from the 1st(any abnormalities in the external/middle ear suspect nerve abnormalitie too )

•Motor nucleus
-Facial expression
-stapidus
-stylohyoid
-post.belly of digastric

•Sup. Superior salivatory nucleus
Parasympathetic
•Lacrimal gland
•Submandibular gland
•Sublingual gland

•Closely related to CN VIII in cranial cavity

•Facial palsy alone->trauma to nerve after leaving the skull

•Facial palsy+no taste ->Chorda tympani

•Facial palsy+Hyperacusis->nerve to stapidus

•Facial palsy+Dry eye->greater petrosal nerve

•Facial nerve exits skull through
Stylomastoid foramen

•Neurapraxia->Reversible blockage
->Complete recovery->No walleroan degeneration

•Axontmesis->blockage of axoplasmic flow->distal wallerian degenration occur

•neurotmesis->Total N. Transection

•Progressive facial palsy over 3w or no recovery after 3-6w ,suspect tumor

•UMN(mcq)
-Forehead sparing
-Eye closure preserved

•Complete facial paralysis House-Brackmann grade Grade VI

•5 important issues
-The cause
-The site of lesion
-The severity of lesion
-Plan of treatment
-The prognosis

•Schirmer test->Greater sup. petrosal N. (>75% unilateral decrease in lacrimation abnormal)

•Stapedial reflex->Nerve to stapedius

•Electrogustometry+Salivary flow test->chorda tympani

•A reduction of 25% in salivary flow test is abnormal

•ENoG->Prognostic indicator ,Main indication is acute complete facial paralysis
•EMG->Is there wallerian deveneration,nerve continuity,

REINNERVATION,

intra-OP

•Morbius syndrome ->Facial diplegia (considered as Birth cause)
•Opercular syndrome->UMNL

•Polio,Syphilis,Scleroma,Acute haemorrhagic conjunctivitis and lyme disease are infectious causes of facial nerve palsy

•Anti-Tetanus serum,rabies vaccine can cause iatrogenic CN VII palsy

•Early (1st 5 days)=Congenital dehiscence of facial canal

•Usually in tympanic segment
•incomplete paralysis

->myringotmoy+abx
•Complete->add steroids

Late(10-15 days)
•FN canal only opened in case of osteitis
•Epineurium left intact

•Gradual

•Osteitis of FNC +toxic neuritis

•Erosion of the canal or invasion of the nerve by cholesteatoma or granulation tissue

•Incision and opening of epineurium

•If nerve invaded resection&nerve graft

•commenest site in the mastoid portion at the 2nd genu

•Acute onset (immediatly after surgery)
-Complete paralysis->immediate exploration
-Incomplete->removal of packs

+cortricosteroids+follow up by ENOG

•Delayed onset (by oedema or haematoma)->usually incomplete
->corticosteroid

•Facial paralysis with no identifiable cause

•Diagnosis of exclusion
•LMN
•Features

-

Sudden onset
-Unilateral
-LMN lesion
-No CNS signs
-No ear disease

•

Recurrence

4.5–15%

•2/3 recover within 3m

•Bad prognostic signs
-Old age
-Dry eye
-Loss of taste
-Absent stapedius reflex
-Postauricular pain
-Delayed recovery

-exercise +prednisilone 1mg/kg/day for 5d followed by 10d taper+acyclovir for 10 days

•Melkersson–Rosenthal syndrome
4Fs
-recurrent Facial palsy
-Facial edema
-Fissured tongue
-positive Family histor

•Unilateral recurrence almost always benign
WHILE Bilateral->Systemic condition (Guillian barre syndrome most common)

•Facial palsy,Vesicular rash and otalgia
•Reactivation in the geniculate ganglion
•Small proportion of Pt. Have SNHL
•prognosis is worse than bell's
•Treatment same as bell's palsy (2-3w)

•most otalgia is mediated by unmyelinated pain fibers

•Auriculotemporal branch of CN V
->Ant.Sup. External canal +Pinna + TMJ

•Facial N.->Post. Tympanic membrane +External canal +Bowl of Concha

•CN IX ->posterior external canal + Tympanic +Ipsilateral oropharynx
It's branch (Jacobson's N.) forms tympanic plexus and innervate middle ear cleft

•Arnold's N.(CN X)

•Great auricular N. And lesser occipital N. (C2,C3)

Menieres disease triad of vertigo tinnitus and fluctuating hear loss

•persistent inflammation of the middle ear mucosa and \or mastoid process for more than 3 months

•

Tubotympanic
-Central perforation
-in pars tensa
-SAFE TYPE (mcq)
-less complication

•Attico antral
- perforation is marginal
-in pars flaccida with
-high complications

•Aetiology
-AOM+OME (MCQ)
-more common in DEVELOPING countries (mcq)
-GERD
-ET dysfunction
-Cleft palate

•Microbiology (MCQ all true except)
-Psedumonas (m.c)
-Staph
-proteus
-coliform
-Anaerobic

•permenant perforation of pars tensa
•No inflammation
•Imparied hearing
•incidental finding (mcq)
•Ottorrhea in small amount (not offensive)

•Hearing assesment->tunning fork ,
&PTA

•No treatment ,ear protection from water ,hearing aids &surgery (close perforation +improve hearing)

Myringoplasty it is operation of closing the tympanic membrane perforation by using graft like

temporalis fascia

•may remain active , become inactive ot progress complications
•Pseudomonas is most common organisim
•May develop granulation tissue or aural polyp ,ossicular chain damage &inner ear involvement
•Conductive hearing loss and could have SNHL too due to inner ear involvement or presbycusis

•hearing assesment by PTA & tunning fork ( no role of tympanometry)(mcq)

•mangement
-Aural toilet
-Topical antibiotics more effective than oral/systemic (mcq)
-topical steroids

•Surgery->myringoplasty+Cortical mastoidectomy(shwartz operation) (no role for grommet)(mcq) + aural polypectomy

•retraction of para tensa or flaccida

•ma be damage to occicular chain

•Potential to be active (cholesteatoma)

•The most important point is whether the pocket self
cleaning or not

•Tunning fork +PTA (no tympanometry)

•Presented with hearing loss ,otorrhea & retraction pocket and cholesteatoma

•Mangement
-Aural toilet

•Surgical

•tympanic mangement
-Excision of the pocket with no graft.
-Excision with myringoplasty.
-Excision ,myringoplasty with cortical mastoidectomy
•Ventilating the middle ear by using ventilation tubes (grommet tubes)

•benign keratinizing epithelial
lined cystic structure

•destruction of the osscular chain and otic capsule

•Facial paralysis

•Hearing loss ,vestibular dysfunction and intracranial complication

•Foul smelling otorrhea,offensive and small quantitiy

•Congenital->white pearl behind
intact tympanic membrane(mcq)

•underlying causal factor for acquired Cholesteatoma is Eustachian tube
dysfunction with subsequent tympanic membrane
retraction(mcq)

The aims of surgery are
1.Eradication of disease.
2.An epithelialised,self-cleaning ear.
3.Hearing maintenance or improvement

•Canal wall-down mastoidectomy
->less recurrance + large mastoid cavity
•Canal wall up->high recurrance +small mastoid cavity

•direct spread is most common route (mcq)

•Mastoid abcess is the commenest type , the auricle displased forward outward and downword

•Bezold abscess->sternomastoid m.(mcq)
•citelli abscess->digastric m.