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M.B.B.S. 3rd Prof (Part-2) ENT Examination — 2026

Complete Question-by-Question Explanation

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SECTION A — MCQs (20 Marks)

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Q1. A 25-year-old female with progressive hearing loss that improves in noisy environments (Paracusis Willisii), normal tympanic membrane, and "Flamingo Flush."

• Paracusis Willisii = hearing better in noisy environments — classic for otosclerosis. In noisy places, people raise their voices, which helps the otosclerotic patient hear better, while normal-hearing people are distracted by background noise.
• Flamingo Flush (Schwartze Sign) = a reddish/pink hue seen through the tympanic membrane due to increased vascularity of the active spongiotic bone (otospongiosis) over the promontory. This is pathognomonic of active otosclerosis.
• Tympanic membrane is NORMAL — otosclerosis affects the stapes footplate, not the eardrum.
• Audiometry shows conductive or mixed hearing loss with a Carhart's Notch at 2000 Hz.
• Pathology: Abnormal remodeling of the otic capsule bone → fixation of the stapes footplate → conductive hearing loss.

Menière's — sensorineural loss with vertigo and tinnitus; ASOM — inflamed TM with fever; CSOM — TM perforation with discharge; Cholesteatoma — associated with unsafe CSOM.

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Q2. A 5-year-old child with a whitish mass behind an intact tympanic membrane, no discharge, no prior surgery.

• Congenital cholesteatoma arises from embryonic epithelial rests (squamous epithelial cell rests of Böhm) that fail to involute.
• Diagnostic criteria (Derlacki & Clemens):
  1. White mass medial to an intact TM
  2. No prior ear surgery
  3. No history of ear discharge
  4. No history of TM perforation
• Typically in the anterosuperior quadrant of the middle ear in children.
• Treatment is surgical (tympanomastoidectomy).

Acquired cholesteatoma — needs TM retraction or perforation. Glomus jugulare — vascular, pulsatile, reddish mass. Otomycosis — fungal infection of EAC, not behind TM.

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Q3. The "Safety Muscle" of the larynx — sole abductor of the vocal cords.

• The Posterior Cricoarytenoid (PCA) is the only abductor of the vocal cords (opens the glottis).
• Called the "safety muscle" because if it is paralyzed bilaterally, the glottis closes → life-threatening airway obstruction/stridor requiring emergency tracheostomy.
• Action: Rotates the arytenoid cartilage laterally, swinging the vocal process outward → abduction.
• Innervation: Recurrent Laryngeal Nerve (RLN).

Lateral Cricoarytenoid — adducts cords. Cricothyroid — stretches/tenses cords (innervated by external laryngeal nerve, only intrinsic muscle not by RLN). Interarytenoid — adducts posterior commissure.

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Q4. Head trauma → clear watery nasal discharge increasing on bending forward. Most specific biochemical test for CSF?

• CSF rhinorrhoea occurs due to skull base fractures disrupting the dura (cribriform plate fractures are most common).
• The "reservoir sign" — fluid increases on bending forward — is classic.
• Beta-2 Transferrin (also called tau protein / β₂-transferrin) is produced only in the CNS by neuraminidase activity. It is absent in serum, nasal secretions, and tears, making it highly specific and sensitive for CSF identification.
• Glucose is non-specific (nasal secretions can also contain glucose). Protein and chloride levels are non-specific. Beta-2 transferrin requires electrophoresis and is the gold standard.

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Q5. "Hot Potato Voice," drooling, trismus — most likely anatomical space involved?

• Quinsy (Peritonsillar Abscess) is the most common deep neck space infection.
• "Hot potato voice" = muffled, thick voice due to immobility of the soft palate (the pus pushes the tonsil medially and the soft palate is edematous).
• Trismus = spasm of pterygoid muscles (the infection spreads to the pterygoid muscles or there is reflex spasm).
• Drooling = painful swallowing (odynophagia).
• Other signs: uvular deviation away from the affected side, unilateral bulging of the soft palate, "hot potato voice."
• Treatment: Needle aspiration or Incision & Drainage + antibiotics.

Retropharyngeal abscess — typically in children, causes muffled voice but NO trismus (trismus is a key differentiating clue pointing to peritonsillar space). Parapharyngeal abscess — trismus may occur but less common. Submandibular (Ludwig's angina) — submandibular swelling + floor of mouth elevation.

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Q6. Sensory innervation to the larynx above the level of vocal cords?

• The Internal Laryngeal Nerve (branch of the Superior Laryngeal Nerve, which is a branch of the vagus/CN X) provides sensory innervation to the larynx above the vocal cords (epiglottis, aryepiglottic folds, vestibule, vestibular folds).
• It enters the larynx through the thyrohyoid membrane.
• Below the vocal cords → sensory innervation by the Recurrent Laryngeal Nerve (RLN).
• The External Laryngeal Nerve is motor to cricothyroid muscle (and sensory to subglottis, minimal).

RLN = motor to all intrinsic laryngeal muscles (except cricothyroid) + sensory below cords. Glossopharyngeal = sensory to oropharynx (base of tongue, tonsil, pharynx).

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Q7. 60-year-old diabetic with severe ear pain and granulations in the external auditory canal — most common causative organism?

• This is a classic presentation of Malignant (Necrotizing) Otitis Externa.
• It occurs in elderly diabetic and immunocompromised patients.
• Pseudomonas aeruginosa is the causative organism in >98% of cases.
• Pathognomonic sign: granulations at the bony-cartilaginous junction of the EAC floor.
• Disease spreads to the skull base via Santorini's fissures → skull base osteomyelitis → cranial nerve palsies (most commonly CN VII first).
• Treatment: Prolonged anti-pseudomonal antibiotics (ciprofloxacin IV/oral) for 6–8 weeks + surgical debridement.

Staphylococcus aureus — causes simple (non-malignant) otitis externa. Aspergillus niger — causes otomycosis (black spores). Candida albicans — causes otomycosis (white/creamy).

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Q8. "Delta Sign" on contrast-enhanced CT of the head — characteristic of?

• The "Delta Sign" (also called the "Empty Delta Sign" or "Empty Triangle Sign") is seen on contrast-enhanced CT.
• It appears as a triangular area of enhancement (the walls of the dural sinus enhance with contrast) surrounding a central low-density filling defect (the thrombus does not enhance).
• This is characteristic of Superior Sagittal Sinus Thrombosis (most classic) or Lateral (Transverse/Sigmoid) Sinus Thrombosis.
• In ENT context, Lateral Sinus Thrombosis is a complication of acute/chronic mastoiditis.
• Clinical features: Picket-fence fever (Remittent fever), Tobey-Ayer test positive, Crowe-Beck test positive, Griesinger sign.

Brain abscess = ring-enhancing lesion. Extradural abscess = biconvex hyperdense collection. Mastoiditis = fluid in mastoid cells, sclerosis.

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Q9. "Carhart's Notch" on Pure Tone Audiometry is typically seen at which frequency?

• Carhart's Notch is a characteristic finding in otosclerosis.
• It is a mechanical artifact — NOT a true sensorineural loss — caused by fixation of the stapes, which alters the resonance of the ossicular chain.
• The notch is a dip in bone conduction at 2000 Hz (typically ~15 dB).
• After successful stapedectomy, the Carhart notch disappears (proving it was mechanical, not cochlear).
• Confirmed by textbook (Cummings + KJ Lee's): "distinct notch-like decrease at 2000 Hz, known as a Carhart notch, due to impedance mismatch of the cochlea from stapes fixation."

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Q10. "Little's Area" — which artery does NOT contribute to Kiesselbach's plexus?

• Kiesselbach's Plexus (Little's Area) is located on the anteroinferior nasal septum and is the most common site of anterior epistaxis.
• Four arteries that DO contribute:
  1. Anterior Ethmoidal Artery (from ophthalmic → internal carotid)
  2. Sphenopalatine Artery (from maxillary → external carotid) — largest contributor
  3. Greater Palatine Artery (from maxillary → external carotid)
  4. Superior Labial Artery (from facial → external carotid)
• The Posterior Ethmoidal Artery supplies the posterior-superior septum and does NOT contribute to the anterior Kiesselbach's plexus.

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Q11. 10-year-old boy with unilateral fleshy nasal mass that bleeds on touch + mass hanging in the oropharynx.

• Rhinosporidiosis is caused by Rhinosporidium seeberi (now classified as an aquatic protistan parasite).
• Classic features:
  • Endemic in South India and Sri Lanka
  • Fleshy, vascular, polypoidal mass that is highly vascular → bleeds profusely on touch
  • The mass is strawberry-like in appearance with white dots (sporangia)
  • It can prolapse into the nasopharynx and oropharynx as the child bends the head
  • Seen in children/young adults who bathe in stagnant water
• Treatment: Surgical excision with cauterization of the base (recurrence is common without cauterization).

Antrochoanal polyp — arises from maxillary sinus, pale/grey, does NOT bleed on touch. Ethmoidal polyp — bilateral, pale, does not bleed, associated with allergy/CRS. Inverted papilloma — adults, unilateral, may bleed, but not the "bleeds on touch" vascular presentation.

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Q12. "Griesinger Sign" (edema over the mastoid process) is indicative of?

• Griesinger's Sign = edema and tenderness over the mastoid emissary vein region (posterior to the mastoid process) due to thrombophlebitis of the sigmoid (lateral) sinus.
• The sigmoid sinus is closely related to the mastoid. Thrombosis spreads to the mastoid emissary vein → subcutaneous edema over the mastoid.
• It is a complication of chronic otitis media/mastoiditis.
• Other signs of sigmoid sinus thrombosis: Tobey-Ayer test (no rise in CSF pressure on ipsilateral jugular vein compression), Crowe-Beck test, picket-fence fever.

Acute mastoiditis — post-auricular swelling/edema but Griesinger's specifically points to sinus thrombosis. Citelli's abscess — abscess in the digastric triangle. Bezold's abscess — abscess tracking along sternomastoid muscle.

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Q13. Investigation of choice for suspected Juvenile Nasopharyngeal Angiofibroma (JNA)?

• JNA is a benign but locally aggressive, highly vascular tumor of the nasopharynx in adolescent males.
• Biopsy is ABSOLUTELY CONTRAINDICATED due to the risk of catastrophic hemorrhage (the tumor is hypervascular).
• Investigation of choice:
  • CT with contrast — shows the tumor, bony erosion, and characteristic Holman-Miller sign (anterior bowing of the posterior wall of the maxillary sinus).
  • MRI — better soft tissue delineation, "salt and pepper" appearance on T1.
  • Angiography (DSA) — shows the feeding vessels (mainly internal maxillary artery and its branches) and is used for pre-operative embolization to reduce blood loss during surgery.
• Hence Contrast CT/MRI + Angiography is the investigation of choice.

FNAC/Biopsy — absolutely contraindicated. Nasal endoscopy — can diagnose clinically but risks bleeding if biopsied.

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Q14. "Trotter's Triad" — conductive deafness, trigeminal neuralgia, palatal paralysis — highly suggestive of?

• Trotter's Triad (also called Sinus of Morgagni syndrome) consists of:
  1. Conductive hearing loss — Eustachian tube infiltration → secretory otitis media
  2. Trigeminal neuralgia — V3 involvement at the foramen ovale
  3. Palatal paralysis (ipsilateral) — involvement of the tensor veli palatini (V3) and levator veli palatini
• This triad is classic for Nasopharyngeal Carcinoma (NPC) invading the lateral nasopharyngeal wall and skull base.
• Other features: cervical lymphadenopathy (most common presenting symptom), epistaxis, nasal obstruction.

Glomus tumour — pulsatile tinnitus, conductive hearing loss, Schwartze sign. Acoustic neuroma — sensorineural loss, not Trotter's. Maxillary sinus carcinoma — Ohngren's classification, cheek swelling.

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Q15. "Reinke's Edema" — collection of fluid in the subepithelial space of the:

• Reinke's Edema (Polypoid Corditis) = accumulation of gelatinous/myxoid fluid in the Reinke's space (also called the subepithelial/superficial lamina propria space) of the true vocal cords.
• Reinke's Space lies between the epithelium and the vocal ligament on the true vocal cord.
• Caused by chronic irritation: heavy smoking (most important), voice abuse, GERD, hypothyroidism.
• Clinical features: Bilateral, diffuse, polypoid swelling of the true cords → low-pitched, rough, hoarse voice.
• Predominantly affects middle-aged women who smoke.
• Treatment: smoking cessation + microlaryngoscopy with aspiration/stripping.

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Q16. Treatment of choice for Chronic Rhinosinusitis not responding to medical therapy?

• FESS is the gold-standard surgical treatment for Chronic Rhinosinusitis (CRS) that fails maximal medical therapy (antibiotics, intranasal corticosteroids, saline irrigation, etc.).
• Principle: Restore normal mucociliary clearance by opening the ostiomeatal complex (OMC) — the key drainage pathway of the paranasal sinuses.
• Preserves normal anatomy; minimally invasive (endoscopic).
• Used for: CRS with/without polyps, recurrent sinusitis, fungal sinusitis (non-invasive), mucocele.

Caldwell-Luc — open surgery for maxillary sinus, now largely replaced by FESS. External ethmoidectomy — used for invasive fungal sinusitis, orbital complications. Septoplasty — corrects deviated nasal septum, not sinusitis treatment.

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Q17. Professional boxer with fluctuant, non-tender collection over the pinna after trauma — immediate management?

• This is an Auricular (Aural) Hematoma — collection of blood between the perichondrium and auricular cartilage.
• The cartilage is avascular and depends on the perichondrium for nutrition. Blood collection disrupts this → cartilage necrosis → cauliflower ear (wrestler's ear) if untreated.
• Immediate management: Aspiration of the hematoma + pressure dressing (to prevent re-accumulation and obliterate the dead space).
• For larger/recurrent hematomas: Incision and drainage with bolster/through-and-through sutures.

Systemic antibiotics alone — insufficient, doesn't remove the collection. Incision and drainage with bolster suturing — used if simple aspiration fails or for large hematomas, but aspiration first is immediate management. Observation — will lead to cauliflower ear.

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Q18. "Hennebert's Sign" (nystagmus on applying pressure to the EAC) is positive in the absence of a fistula in which condition?

• Hennebert's Sign = nystagmus and vertigo induced by pressure on the tragus/pneumatic otoscopy without a perilymph fistula.
• Normally, a positive fistula test (Hennebert's sign) indicates a perilymph fistula (e.g., from CSOM with labyrinthine fistula).
• In the absence of a fistula, a positive Hennebert's sign occurs in Menière's Disease because the distended endolymphatic hydrops presses against the stapes footplate → transmitted to the endolymph → stimulates ampullae.
• This is called a false positive fistula test.
• Also seen in: Congenital syphilis (Hennebert originally described it in syphilis), but the question specifies "absence of fistula" pointing to Menière's.

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Q19. Absolute indication for Tonsillectomy?

• Absolute indications for Tonsillectomy:
  1. Obstructive Sleep Apnea (OSA) / upper airway obstruction — most important absolute indication
  2. Suspicion of malignancy (unilateral tonsil enlargement)
  3. Peritonsillar abscess (recurrent Quinsy — relative)
  4. Tonsillar hemorrhage
  5. Diphtheria carrier state not responding to antibiotics
• Relative indications: Recurrent tonsillitis (Paradise criteria: ≥7 episodes/year, or ≥5/year for 2 years, or ≥3/year for 3 years), chronic tonsillitis, halitosis.
• Recurrent sore throat, chronic tonsillitis, and halitosis are relative indications, not absolute.
• Sleep apnea causes cardiac, neurocognitive, and growth complications → absolute indication.

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Q20. 40-year-old female with episodic vertigo lasting 30 minutes, fluctuating hearing loss, and tinnitus.

• Menière's Disease (Endolymphatic Hydrops) is diagnosed by the classic triad:
  1. Episodic vertigo lasting 20 minutes to 24 hours (hallmark: 20 min – 12 hours)
  2. Fluctuating low-frequency sensorineural hearing loss
  3. Tinnitus (low-pitched, roaring)
  4. ± Aural fullness
• Pathophysiology: Distension of the endolymphatic system → rupture of Reissner's membrane → potassium intoxication of hair cells.
• Pure tone audiometry: Low-frequency SNHL; Recruitment present; Electrocochleography (ECochG) shows elevated SP/AP ratio > 0.4.

BPPV — seconds to 2 minutes, no hearing loss, no tinnitus (Dix-Hallpike positive). Vestibular neuronitis — prolonged single episode (days), no hearing loss, no tinnitus. Labyrinthitis — sudden onset, often follows URTI, associated hearing loss but not episodic/fluctuating.

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SECTION B — Long/Short Answer Questions (40 Marks)

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B-Q1. 55-year-old heavy smoker with hoarseness × 3 months, referred earache (otalgia), and on laryngoscopy: exophytic growth on left vocal cord at anterior commissure with FIXED vocal cord mobility.

(a) Provisional Diagnosis — 10 marks

• Site: True vocal cord (glottis) — most common site of laryngeal carcinoma
• Risk factors: Heavy smoking (most important), alcohol, HPV
• Fixed cord → T3 disease (in glottic carcinoma staging):
  • T1 = limited to vocal cord, normal mobility
  • T2 = extension to supra/subglottis or impaired mobility
  • T3 = cord fixation (ipsilateral)
  • T4 = invasion beyond larynx
• Referred otalgia = via Arnold's nerve (auricular branch of CN X) → a hallmark of laryngeal and hypopharyngeal malignancy
• Anterior commissure involvement = poor prognostic sign (limited cartilage → early invasion)

(b) Staging — 2 marks

• T3 (fixed cord) + N0 (no nodes — glottis has sparse lymphatics) + M0 = Stage III
• Clinical staging via: Indirect/direct laryngoscopy, CT/MRI neck (cartilage invasion, nodal status), chest X-ray (metastasis), panendoscopy under GA (subglottic extension)

(c) Management — 5 marks

• Total Laryngectomy = gold standard for T3/T4 glottic cancers with cord fixation
  • Permanent tracheostoma; voice rehabilitation via tracheoesophageal puncture (TEP) + Provox valve or electrolarynx
• Conservation surgery (selected T3): Supracricoid laryngectomy (SCPL) with CHEP/CHP — preserves voice but requires normal contralateral cord and cricoarytenoid unit
• Neck dissection if nodes positive

• Definitive RT: For early T1/T2; combined with surgery for T3
• Post-operative RT for: close/positive margins, perineural invasion, lymphovascular invasion, T4, multiple positive nodes
• Concurrent Chemoradiotherapy (CCRT): Organ-preservation protocol (larynx preservation strategy) for selected T3 patients who refuse or are unfit for surgery — platinum-based chemotherapy (cisplatin) + RT

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B-Q2 Short Notes:

(a) Acute Mastoiditis — Clinical Features and Management

• Post-auricular pain, redness, swelling, and tenderness over the mastoid
• Auricle displaced forward and downward (pinna pushed outward)
• Ear discharge (if TM perforated)
• Sagging of the posterosuperior meatal wall (pathognomonic on otoscopy)
• Fever, hearing loss
• CT mastoid: Coalescent mastoiditis — loss of air cell septa (bony destruction)

• IV antibiotics (antistaphylococcal + cover gram-negatives) — Amoxicillin-clavulanate or Cefuroxime
• Myringotomy (drain middle ear pus, relieve pressure)
• If no improvement in 24–48 hours or complications: Cortical Mastoidectomy (Schwartze operation) — opens and drains the mastoid air cells, removes diseased bone; mastoid antrum drained.

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(b) Epistaxis in a 60-year-old Hypertensive Patient

• Local: Kiesselbach's plexus trauma (Little's area), rhinitis
• Systemic (most important here): Hypertension — causes posterior epistaxis (from sphenopalatine artery territory), which is more severe
• Other systemic: Anticoagulants, atherosclerosis, coagulopathy

1. First Aid (PRICE): Patient seated leaning forward, pinch the soft part of nose for 10–15 minutes, ice pack
2. Control BP urgently (antihypertensives)
3. Identify bleeding point (nasal endoscopy)
4. Anterior epistaxis: Chemical cautery (silver nitrate), electrocautery, anterior nasal pack (Merocel/BIPP)
5. Posterior epistaxis: Posterior nasal pack (Foley catheter/Epistat) or Endoscopic sphenopalatine artery ligation (SPAL) — now gold standard
6. Refractory cases: Maxillary artery ligation (transantral), anterior ethmoidal artery ligation, angiographic embolization

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(c) Laryngeal Cancer — Informed Consent and Patient Autonomy (Ethics)

1. Autonomy — the patient has the right to refuse even life-saving treatment if they are competent (fully informed and decision-making capacity is intact)
2. Beneficence — surgeon's duty is to act in the best interest of the patient
3. Non-maleficence — "do no harm"
4. Justice — fair resource allocation

1. Assess decision-making capacity — Is the patient competent? (understands, retains information, weighs consequences, communicates decision)
2. Detailed counseling — Explain diagnosis, prognosis with and without surgery, alternatives (RT, palliation), complications, and QoL implications in the patient's language
3. Address fears and concerns — Why is the patient refusing? Fear of voice loss, surgery, death? Address specific fears
4. Multi-disciplinary team (speech therapist, oncologist, counselor) involvement
5. Document everything — Written refusal form (informed refusal)
6. Offer alternatives — Organ preservation (CCRT), palliative care
7. Respect the refusal — A competent patient has the legal and ethical right to refuse; do NOT coerce
8. Reassess — Keep door open; patient may change their mind

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(d) Fungal Sinusitis (Mucormycosis) in Immunocompromised Patients

• Non-invasive: Fungal ball (aspergilloma), allergic fungal sinusitis (AFS)
• Invasive: Acute invasive (mucormycosis/zygomycosis), Chronic invasive, Granulomatous invasive

• Causative organism: Mucor, Rhizopus, Absidia (order Mucorales) — opportunistic fungi
• Risk factors: Uncontrolled diabetes mellitus (DKA — acidic environment favors fungal growth), hematological malignancies, post-COVID (steroid overuse), HIV, organ transplant
• Pathology: Angioinvasive → thrombosis → tissue infarction → black eschar → necrosis
• Clinical features: Facial pain, headache, nasal obstruction, black necrotic eschar on nasal turbinates/palate, proptosis (orbital involvement), altered sensorium (cerebral involvement)
• CT findings: Bone erosion, periantral fat stranding, orbital/cerebral invasion
• Treatment:
  1. Correct underlying predisposing condition (control blood sugar, reduce immunosuppression)
  2. Surgical debridement — aggressive endoscopic/open removal of all necrotic tissue
  3. Antifungal: Liposomal Amphotericin B (drug of choice) IV, followed by Posaconazole/Isavuconazole oral maintenance
  4. Hyperbaric oxygen (adjunct)

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B-Q3 Very Short Notes:

(a) Carhart's Notch

(b) Two bones forming the Nasal Septum

1. Vomer (posterior and inferior bony septum)
2. Perpendicular plate of the Ethmoid (superior bony septum) (Anteriorly completed by the quadrilateral cartilage/septal cartilage)

(c) Griesinger's Sign

(d) Two Indications for Tracheostomy

1. Emergency upper airway obstruction (bilateral vocal cord palsy, supraglottitis, Ludwig's angina, laryngeal trauma, foreign body)
2. Prolonged mechanical ventilation / ICU — to reduce dead space, improve comfort, enable weaning from ventilator (Others: laryngeal carcinoma surgery — laryngectomy, head & neck surgery, sleep apnea, neurological conditions causing aspiration)

(e) Light Reflex of the Tympanic Membrane

• Absent/distorted/displaced light reflex suggests: middle ear effusion, retraction, perforation, or TM pathology.

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SECTION C — (40 Marks)

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C-Q1. Chronic Suppurative Otitis Media (CSOM) — Attico-Antral (Unsafe) Type — Pathology, Clinical Features, Complications, and Surgical Management (10 marks)

Definition

Types

Pathology of Attico-Antral CSOM (Cholesteatoma)

• Cholesteatoma = keratinizing stratified squamous epithelium growing into the middle ear/mastoid
• It is self-perpetuating: desquamated keratin accumulates → expands → pressure necrosis + enzymatic bone erosion (matrix metalloproteinases)
• Forms a pearly white mass with a sac (matrix + perimatrix)
• Wullstein's theories of formation: Invagination of TM pars flaccida (Prussak's space) — most common (acquired type)

Clinical Features

• Ear discharge — scanty, purulent, foul-smelling (offensive), blood-stained
• Hearing loss — conductive (ossicular erosion)
• Attic perforation or marginal perforation on otoscopy
• Cholesteatoma debris (pearly white flakes) visible
• Granulations in attic
• No pain usually — but pain suggests complications

Complications

• Facial nerve palsy (erosion of fallopian canal)
• Labyrinthine fistula (horizontal semicircular canal — most common) → vertigo, positive fistula test
• Mastoiditis, petrositis

• Meningitis (most common intracranial complication)
• Brain abscess (temporal lobe or cerebellar)
• Sigmoid sinus thrombosis
• Extradural abscess, subdural abscess, otitic hydrocephalus

Surgical Management

1. Modified Radical Mastoidectomy (MRM) — treatment of choice for attico-antral CSOM
   • Creates an open cavity (mastoid bowl/meatoplasty)
   • Removes all disease (cholesteatoma, diseased bone, granulations)
   • Leaves ossicular remnants if possible
   • The middle ear + mastoid + attic communicate with EAC as one cavity
   • Patient requires lifelong cavity care (water precaution, yearly cleaning)
2. Canal Wall Up (CWU) / Combined Approach Tympanoplasty (CAT):
   • Preserves posterior canal wall; better hearing outcome
   • Higher risk of residual/recurrent disease → requires second-look surgery at 6–12 months
3. Tympanoplasty — Reconstruction of TM (myringoplasty) and ossiculoplasty — done after complete disease eradication (staged procedure)

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C-Q2 Short Notes:

(a) Atrophic Rhinitis (Ozaena)

• Paradoxical anosmia — despite widely patent nasal cavities, patient cannot smell (because airflow does not reach olfactory epithelium properly)
• Foul odor (Fetor) — smelled by others, NOT by the patient (due to anosmia/olfactory fatigue)
• Thick green/brown crusts filling nasal cavities
• Epistaxis on removing crusts
• Atrophied turbinates — "empty nose syndrome" appearance
• Anosmia, nasal obstruction (paradoxically, the wide cavity still feels blocked)

• Medical: Nasal irrigation (saline/alkaline douche — Eustachian tube douche), topical antibiotics, estrogen sprays, glucose-glycerine drops
• Surgical: Young's operation (closure of nasal vestibule for 6 months to allow mucosal regeneration) — most effective; Submucosal injection of Teflon/fat to narrow the nasal cavity

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(b) Tympanoplasty — Principles and Types

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(c) Tonsillectomy — Indications and Complications

• Obstructive Sleep Apnea (OSA) — tonsillar hypertrophy
• Suspected malignancy (asymmetric/unilateral tonsil enlargement)
• Recurrent peritonsillar abscess (Quinsy)
• Tonsillar hemorrhage
• Diphtheria carrier

• ≥7 episodes/year, or ≥5/year for 2 consecutive years, or ≥3/year for 3 consecutive years
• Chronic/recurrent tonsillitis, halitosis, febrile convulsions

• Anesthesia risk
• Velopharyngeal incompetence (hypernasal speech) — rare, due to excessive adenoid removal
• Atlanto-axial subluxation (Grisel syndrome) — rare cervical complication
• Eagle syndrome — elongated styloid (unrelated but can follow)
• Nasopharyngeal stenosis (post-operative scarring)

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(d) Differential Diagnosis of Midline Neck Swelling

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C-Q3 Very Short Notes:

(a) Little's Area

1. Anterior ethmoidal artery (ICA)
2. Sphenopalatine artery (ECA)
3. Greater palatine artery (ECA)
4. Superior labial artery (ECA) It is the most common site of anterior epistaxis (90% of all nosebleeds). Treatment: pinching the nose, chemical cautery with silver nitrate.

(b) Two Findings of Menière's Disease on Pure Tone Audiometry

1. Low-frequency sensorineural hearing loss (rising audiogram — worse at low frequencies initially)
2. Recruitment (disproportionate loudness perception at suprathreshold levels — suggesting cochlear/outer hair cell pathology) (Also: fluctuating threshold; in late stages — flat SNHL pan-frequency)

(c) Hennebert's Sign

(d) Four Types of Nasal Polyps

1. Ethmoidal Polyps (most common) — bilateral, pale, multiple, arise from ethmoid sinuses; associated with allergy, CRS, aspirin sensitivity
2. Antrochoanal Polyp (Killian's polyp) — unilateral, single, arises from maxillary sinus; common in children
3. Allergic Polyps — associated with allergic rhinitis, asthma, aspirin triad (Samter's triad)
4. Inflammatory/Infective Polyps — secondary to chronic sinusitis

(e) Quinsy (Peritonsillar Abscess)

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Key references used: Cummings Otolaryngology Head and Neck Surgery; K.J. Lee's Essential Otolaryngology; Scott-Brown's Otorhinolaryngology; Dhingra's Diseases of Ear, Nose and Throat.