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Eagle Syndrome

Definition and History

• Scott-Brown's Otorhinolaryngology, Vol 2, p. 6843
• K.J. Lee's Essential Otolaryngology, p. 7844

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Epidemiology

• An elongated styloid process is found incidentally in approximately 4% of the general population
• Only about 4% of those with an elongated styloid process actually develop symptoms
• More common in women; usually presents in the 4th-5th decade

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Anatomy and Pathophysiology

1. Compress the hypoglossal nerve
2. Impinge on or irritate the carotid vessels (internal or external carotid artery) - this is the vascular variant
3. Cause inflammatory changes at the insertion of the stylohyoid ligament
4. Irritate cranial nerves V, VII, IX, or X passing nearby

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Clinical Variants

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Clinical Features

• Dull, aching pharyngeal pain - typically in the tonsillar fossa
• Radiation to the ipsilateral ear (otalgia)
• Foreign body sensation in the throat (like a fish bone)
• Odynophagia (pain on swallowing)
• Pain on jaw movement or head turning
• Unilateral headaches and neck pain

• The elongated styloid process may be palpable in the tonsillar fossa
• Palpation of the tonsillar fossa may reproduce and aggravate symptoms
• Local anaesthetic injection into this area provides temporary relief (diagnostic and therapeutic)

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Diagnostic Criteria (ICHD-based, per Cummings)

1. Pain provoked or worsened by digital palpation of the stylohyoid ligament
2. Pain provoked or worsened by head turning
3. Pain significantly improved by local anaesthetic injection into the ligament, or by styloidectomy
4. Pain is ipsilateral to the inflamed stylohyoid ligament

Note: The International Headache Society has previously described this syndrome as "not sufficiently demonstrated," which reflects the ongoing controversy around its diagnosis.

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Imaging

• Orthopantomogram (OPG/panoramic X-ray): First-line, shows elongated styloid process
• CT scan (with 3D reconstruction): Preferred for accurate measurement, surgical planning, and to assess vascular proximity
• Normal styloid length: ~2.5 cm; >3 cm is often considered abnormal; >4 cm is generally accepted as "elongated"

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Management

Conservative (Medical)

• NSAIDs - first-line
• Anticonvulsants (e.g., carbamazepine) - used for neuropathic pain component
• Antidepressants (amitriptyline)
• Corticosteroid + local anaesthetic injection into the tonsillar fossa - both diagnostic and therapeutic, but effects are temporary
• Results are variable; surgery is generally considered definitive

Surgical (Styloidectomy)

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Recent Evidence (2023-2024)

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Key Points Summary

• Eagle syndrome = elongated styloid process (>4 cm) or calcified stylohyoid ligament
• Affects ~0.16% of population (4% have elongation, 4% of those are symptomatic)
• Classic: throat/ear pain, foreign body sensation, odynophagia
• Vascular variant: carotid compression - can cause stroke/TIA
• Diagnose with OPG or CT; palpation in tonsillar fossa reproduces pain
• Conservative treatment (NSAIDs, carbamazepine, steroid injections) offers partial relief
• Definitive treatment: styloidectomy (transoral or transcervical)

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Oro-Antral Fistula (OAF)

Definition

Terminology: An acute, fresh opening is called an oro-antral communication (OAC); once epithelialized and chronic, it becomes an oro-antral fistula (OAF).

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Anatomy - Why It Happens

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Aetiology / Causes

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Clinical Features

• Nasal regurgitation of fluids - pathognomonic; fluid taken orally passes into the nose
• Nasal voice (hyper-nasal speech)
• Unpleasant taste or smell (due to sinus secretions entering the mouth)
• Halitosis
• Pain/pressure over the cheek (associated sinusitis)
• Sense of air passing between mouth and nose on blowing
• Unilateral mucopurulent nasal discharge (odontogenic sinusitis)
• Reduced sense of smell

• Visible opening in the alveolar socket or mucosa
• Nose-blowing test (Valsalva): air passes from mouth into nose through the fistula
• Probe test: a blunt probe passes freely from the oral cavity into the sinus
• CT: loss of sinus floor continuity ± mucosal thickening or opacification of maxillary sinus

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Investigations

1. Clinical exam + probe test - identifies communication
2. OPG (Orthopantomogram) - shows bone loss, relation of roots to sinus floor
3. CT scan (fine-cut coronal) - gold standard for imaging; shows sinus floor defect, mucosal thickening, bony involvement; rules out malignancy
4. Biopsy - mandatory if malignancy is suspected (carcinoma can present as OAF)

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Classification (by size)

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Management

Step 1: Manage Associated Sinusitis

• Antibiotics - broad-spectrum (amoxicillin-clavulanate; metronidazole for anaerobic coverage)
• Nasal decongestants - to improve ostial drainage
• Antral washout or FESS (functional endoscopic sinus surgery) if established chronic sinusitis is present
• Failure to treat sinusitis leads to flap failure

Step 2: Surgical Closure

A. Buccal Advancement Flap (Rehrmann Flap) - Most Common

• A trapezoidal mucoperiosteal flap is raised from the buccal (cheek) side
• Periosteum is incised at the base to allow advancement and tension-free closure
• Fistula edges are freshened, and the flap is advanced and sutured to the palatal mucosa
• Indications: Small to medium OAFs in lateral/anterior position
• Disadvantage: Reduces vestibular depth (may need vestibuloplasty later)
• Success rate: ~90%

B. Buccal Fat Pad (BFP) Flap - Increasingly Preferred

• The buccal fat pad (Bichat's fat pad) is mobilized through a small incision in the upper buccal sulcus
• Fat is laid into the defect and sutured to the margins; epithelializes in ~3-4 weeks
• Indications: Defects in the central/posterior alveolar crest; OAF >5 mm
• Advantages: Rich blood supply, abundant tissue, no donor site morbidity, does not reduce vestibular depth
• Success rate: ~98% (highest of all techniques)
• Can be combined with buccal advancement flap for large defects (double-layer closure)

C. Palatal Rotation-Advancement Flap

• A posteriorly-based palatal mucoperiosteal flap is rotated to cover the defect
• Based on the greater palatine artery
• Indications: Defects in the premolar region; posterior/palatal OAF location; when buccal flap is unsuitable
• Disadvantages: Leaves a raw donor area on hard palate (heals by secondary intention); technically demanding
• Success rate: ~86%

D. Other / Distant Flaps (for large/complex defects)

• Tongue flap (anteriorly or posteriorly based)
• Nasolabial flap
• Temporalis muscle flap
• Free flaps (radial forearm, anterolateral thigh) - for post-oncologic large defects
• Zygomatic implants - for post-maxillectomy oroantral defects

• Buccal flap: 40.1% of cases, 89.8% success
• Buccal fat pad: 28.6% of cases, 98.3% success
• Palatal flap: 19% of cases, 85.7% success

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Flap Selection Algorithm

OAF identified
     │
     ├── Size <5 mm → Conservative (gelatin sponge, suture, observe)
     │
     ├── Size 5-10 mm
     │       ├── Lateral/anterior location → Buccal advancement (Rehrmann) flap
     │       ├── Central alveolar crest → Buccal fat pad flap
     │       └── Palatal side / premolar → Palatal rotation flap
     │
     └── Size >10 mm
             └── Buccal fat pad ± buccal advancement (double layer)
                 or distant/free flap for very large defects

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Post-Operative Care

• Antral precautions: Avoid nose blowing, sneezing with closed mouth, use of straws, smoking for 2-4 weeks
• Antibiotics + nasal decongestants for 1-2 weeks
• Soft diet
• Follow-up to confirm closure at 3 months

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Complications of Untreated OAF

1. Chronic odontogenic sinusitis - most common; unilateral, anaerobic-predominant
2. Antral polyp formation
3. Ascending spread to other sinuses or orbit (rare)
4. Persistent halitosis and social disability

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Important: Always Exclude Malignancy

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Recent Evidence

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Key Points Summary

• OAC = acute, non-epithelialized; OAF = chronic, epithelialized communication
• Most common cause: upper molar extraction (1st molar most at risk)
• Classic symptom: nasal regurgitation of fluids + nasal voice
• Diagnosis: clinical probe test + CT scan; always biopsy to exclude carcinoma
• Small (<5 mm): may close spontaneously
• Surgical repair: buccal fat pad flap has the highest success rate (~98%); choice guided by defect size and location
• Always treat associated sinusitis before/during repair

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Radioactive Thyroid Scanning (Thyroid Scintigraphy)

Overview

Key distinction: Thyroid scintigraphy (the image of the gland) is different from but adjunctive to the radioactive iodine uptake (RAIU) test (which simply measures the fraction of dose taken up at 24 hours as a number).

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Radiotracers Used

• Cummings Otolaryngology, p. 3649; Mulholland & Greenfield's Surgery, p. 4030

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Normal Scan Appearance

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Nodule Classification

• Cummings Otolaryngology, p. 3647

• Goldman-Cecil Medicine, p. 3322

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Scan Patterns in Thyrotoxicosis

• True hyperthyroidism (thyroid overproducing hormone) = INCREASED RAI uptake
• Thyrotoxicosis without hyperthyroidism (hormone released from destruction) = DECREASED RAI uptake

Pattern 1: Diffuse Increased Uptake

Pattern 2: Focal Increased Uptake (Single "Hot" Area)

Pattern 3: Multiple "Hot" Foci

Pattern 4: Absent / Markedly Reduced Uptake

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Summary Table: Scan Patterns in Common Conditions

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Indications for Thyroid Scanning

1. Hyperthyroid patient with thyroid nodule - to distinguish toxic nodule from Graves' disease with co-existing cold nodule (Marine-Lenhart syndrome)
2. Thyrotoxicosis workup - to differentiate causes (see table above)
3. After indeterminate FNA cytology - an I-123 scan should be considered; if a concordant autonomously functioning nodule is found, surgery may be deferred
4. Post-thyroidectomy differentiated thyroid cancer - I-131 whole-body scan for remnant ablation and detection of metastases
5. Suspected substernal/ectopic thyroid - I-123 or I-131 (Tc-99m cannot penetrate sternum)
6. Congenital hypothyroidism - to identify thyroid aplasia, ectopia, or dyshormonogenesis in neonates

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When Thyroid Scanning is NOT Indicated / Limitations

• Routine evaluation of a thyroid nodule in a euthyroid patient: NOT recommended. FNA (fine-needle aspiration biopsy) guided by ultrasound has largely replaced scintigraphy here, as 95% of nodules are cold and the cold nodule classification is not specific enough.
• Pregnancy and breastfeeding: I-131 is absolutely contraindicated. I-123 is relatively contraindicated. Tc-99m pertechnetate is excreted in breast milk; breastfeeding should be suspended for 24 hours.
• Cannot assess anatomy (size, margins, vascularity) - use ultrasound for that
• Cold lesions may be obscured by overlying normal thyroid tissue; oblique views help

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I-131 in Differentiated Thyroid Cancer

• Post-thyroidectomy, I-131 is used for remnant ablation (30-100 mCi) to destroy residual normal thyroid tissue and facilitate future serum thyroglobulin monitoring
• Diagnostic whole-body scan with a low dose (1-5 mCi) at 6-12 months post-ablation to detect functioning metastases
• Therapeutic doses (100-200 mCi or more) for known metastatic disease
• Requires TSH stimulation (either thyroid hormone withdrawal OR recombinant TSH/Thyrogen) to maximize I-131 uptake
• Poorly differentiated thyroid cancers and medullary carcinoma do not take up iodine - FDG-PET is used instead

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Key Points

• Tc-99m pertechnetate: one-day test, low radiation, tests iodine trapping only; confirm hot nodules with I-123
• I-123: two-day test, tests transport + organification, preferred for RAIU measurement; best for scintigraphy
• I-131: therapeutic isotope; diagnostic whole-body scanning for differentiated thyroid cancer
• Hot nodules: rarely malignant (~4%); no FNA needed
• Cold nodules: 10-15% malignancy risk; FNA warranted if meets criteria
• 95% of all scanned nodules are cold
• Most useful clinical role today: differentiating causes of thyrotoxicosis and post-thyroidectomy cancer management
• Scan NOT needed for routine nodule evaluation in euthyroid patients - ultrasound + FNA is preferred

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Powered Instruments in ENT

Overview

1. Microdebrider (powered shaver system) - used in rhinology, laryngology, and head & neck
2. Powered drills (high-speed drills with burrs) - used in otology, skull base, and sinonasal surgery
3. Other powered instruments - coblation, ultrasonic aspirator, etc.

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1. The Microdebrider (Powered Shaver System)

Mechanism of Action

• A powered handpiece connected to a console
• A disposable hollow rotating blade at the tip
• Integrated suction that aspirates tissue into the port as the blade rotates
• Irrigation system in some configurations

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Applications in Rhinology (FESS)

• Simultaneous cutting and suctioning keeps the surgical field clear
• Precise, controlled tissue removal
• Reduces mucosal trauma and bleeding
• Faster dissection
• Reduces risk of polyp/tissue fragment dropping into the airway

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Applications in Inferior Turbinate Surgery

• A submucosal tunnel is created via a small anterior incision
• The erectile tissue is partially resected from the medial and inferior turbinate
• Post-operative nasal packing is not necessary
• The microdebrider can be controlled to preserve all overlying mucosa - a key advantage

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Applications in Adenoidectomy

• 20% faster than traditional curettage technique (RCT evidence)
• Precise removal under visual control; avoids the blind nature of traditional curette adenoidectomy
• Lower risk of velopharyngeal insufficiency when partial adenoidectomy is performed
• Reduced risk of inadvertent eustachian tube orifice trauma
• Disadvantage: High unit cost (microdebrider blade is expensive and single-use)

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Applications in Tonsillectomy / Intracapsular Tonsillectomy

• The tonsil is debulked inside the capsule, leaving the capsule intact
• Preserves the fibrous capsule as a barrier against secondary haemorrhage
• Lower post-operative pain and faster return to normal activities vs. electrocautery
• Lower bleeding rates
• Risk of tonsil regrowth - especially in younger children

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Applications in Laryngology

• No thermal trauma to surrounding tissue
• No laser plume - eliminates risk of viral aerosol transmission to operating room staff
• No risk of airway fire
• Shorter operative times
• Less post-operative pain
• Precise removal with minimal mucosal damage

• Round window (skimmer) blade - for soft, bulky lesions (papillomas, tracheal papilloma)
• Subglottic/tracheal blade - for fibrous scar (subglottic/tracheal stenosis)
• Smaller skimmer laryngeal blade - for true vocal fold lesions

• Internal laryngoceles
• Tumour debulking
• Removal of PTFE granulomas
• Subglottic and tracheal stenosis
• Tracheostomal granulation tissue
• Laryngeal cysts
• Reinke's oedema

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2. Powered Drills in Otology and Skull Base Surgery

Types of Burrs

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Applications in Ear Surgery

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Applications in Rhinology and Skull Base

• Endoscopic skull base surgery: High-speed drill for removal of bony partitions, sella turcica, clivus, orbital apex
• Frontal sinus trephine / drill-out (Lothrop procedure): Powered drill for bony frontal floor removal
• Orbital decompression: Orbital apex decompression using high-speed drill for optic neuropathy in compressive thyroid eye disease
• Sinonasal tumour surgery: Bone removal for access and resection margins

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3. Other Powered Instruments

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Advantages of Powered Instruments - Summary

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Disadvantages

• High unit cost - blades are single-use and expensive (limits use as sole technique for adenoidectomy)
• Learning curve - especially for angled blades
• Suction removes all tissue - no specimen for histology in some techniques (important in tonsillotomy)
• Risk of mucosal stripping if not used carefully - can cause adhesions, stenosis (especially in frontal recess)
• Relative contraindication near vascular structures (laryngeal microdebrider)
• Drill heat generation (diamond burr) - requires continuous suction-irrigation to prevent thermal bone/nerve injury

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Key Points Summary

• Microdebrider = cutting + suction in one instrument; gold standard for laryngeal papillomatosis (RRP) and widely used in FESS and turbinate surgery
• In FESS: straight and angled (40-90°) blades for different sinus regions; circumferential frontal recess injury must be avoided
• In adenoidectomy: 20% faster than curette; preserves direct vision
• Intracapsular tonsillectomy with microdebrider: less pain, faster recovery, but risk of regrowth
• Drill in otology: cutting burr for rapid cortical bone removal; diamond burr near vital structures (facial nerve, ossicles, dura, sigmoid)
• Diamond burr also achieves haemostasis from mastoid bone marrow
• Coblation: alternative powered technique operating at lower temperature (85°C), less thermal spread than diathermy

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Intratympanic (IT) Therapy

Concept and Rationale

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Anatomical Basis: The Round Window Membrane

• It is a three-layered, dynamic biological structure capable of both active and passive transport
• The three layers: outer epithelium (middle ear side), middle fibrous connective tissue layer, inner epithelium (perilymph side)
• It is semipermeable - allows selective passage based on molecular size, charge, and lipid solubility

1. Method of delivery (injection vs. sustained release vs. catheter)
2. Permeability of the substance applied (lipid-soluble agents penetrate better)
3. Rate of clearance from the perilymph (Eustachian tube drainage)
4. Adhesions over the RWM - can significantly reduce drug delivery; some surgeons advocate microscopic removal of adhesions (e.g., round window plug) before therapy
5. Patient head position after injection - affects pooling near the RWM

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Drugs Used in Intratympanic Therapy

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IT Technique (Procedure)

Steps:

1. Patient reclined with head turned ~45° to the treated side (to fill the inferior middle ear near the RWM)
2. Topical anaesthesia applied to the TM (e.g., EMLA cream, phenol, or iontophoresis)
3. Injection with a fine-gauge needle (25-27 gauge) through the anteroinferior or posteroinferior quadrant of the TM
4. Drug is slowly instilled into the middle ear (~0.3-0.5 mL)
5. A separate ventilation hole is sometimes made in the anterosuperior quadrant for pressure equalization as the drug is injected
6. Patient asked to remain still with head tilted for 20-30 minutes to maximize drug contact with the RWM; should avoid swallowing (closes Eustachian tube temporarily)
7. Patient instructed not to blow the nose immediately after

Delivery Variants:

• Single injection - most common outpatient approach
• Repeated injections - multiple sessions (e.g., 3-4 injections over 2 weeks for SSNHL)
• Tympanostomy tube-based delivery - drug instilled through an existing grommet (no injection needed; can be done by patient at home)
• Silverstein MicroWick - a thin wick placed through a myringotomy tube to the RWM niche for continuous drug delivery
• Microcatheter / round window catheter - placed surgically at the RWM for continuous or controlled drug release; used in trials for severe SSNHL
• Sustained-release formulations (gel-based, e.g., hyaluronic acid or poloxamer gels) - under development; prolongs contact time at the RWM

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1. IT Steroids

For Sudden Sensorineural Hearing Loss (SSNHL)

• Primary treatment - when systemic steroids are contraindicated (diabetes, hypertension, peptic ulcer, immunocompromised patients)
• Salvage/rescue treatment - when SSNHL has not responded to initial oral/IV steroid course (most common indication; administered 2-6 weeks after onset)

• RCT evidence shows IT methylprednisolone improves hearing in patients who failed oral steroids for SSNHL (Cummings, p. 70)
• "Strong data support the use of IT steroids as salvage therapy after failure to respond to oral steroids. Results are best when steroids are applied as early as possible." - Cummings, p. 4905
• A 2025 systematic review (PMID 40734818) confirms IT steroids as the leading salvage strategy for refractory SSNHL

• Reduces endocochlear inflammation
• Upregulates Na-K-ATPase in stria vascularis (maintains endocochlear potential)
• Immunomodulation if autoimmune aetiology
• Possible anti-apoptotic effects on cochlear hair cells

For Meniere's Disease (Vertigo Control)

• Small RCT: 82% complete resolution of vertigo with dexamethasone vs. 57% with saline (Cummings, p. 144)
• Scott-Brown's (recommendation grade A): "Repetitive intratympanic injections of dexamethasone enable substantial and long-term vertigo control in 80% of refractory cases without significant hearing loss." - Scott-Brown's, Vol 2, p. 6344

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2. IT Gentamicin

Mechanism

Indications

1. Meniere's disease - refractory to medical therapy AND after failure of IT dexamethasone
2. End-stage / Tumarkin crises (drop attacks) - even in patients with poor hearing, as hearing preservation is less of a concern
3. Recommendation grade A (Scott-Brown's): Used when IT dexamethasone has failed

Protocols (Titration vs. Fixed)

Efficacy

• Meta-analysis (Huon et al., 2012): 87.5% Class A and B vertigo control
• RCT (intratympanic gentamicin vs. dexamethasone): 93.5% vs. 61% substantial vertigo control at 2-year follow-up (Scott-Brown's, p. 6334)
• Effective for drop attacks (Tumarkin crises): IT gentamicin has demonstrated effectiveness (Scott-Brown's, p. 6341)

Risks

• Sensorineural hearing loss: 0-38.7% across series (highly variable; dependent on dose and protocol)
• Vestibular hypofunction / oscillopsia post-ablation
• Imbalance - patient may develop chronic disequilibrium

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Decision Algorithm for Meniere's Disease

Meniere's disease - medical treatment failure
         │
         ▼
IT Dexamethasone (Grade A recommendation)
    → 80% vertigo control; no significant HL risk
         │
    If refractory
         ▼
IT Gentamicin (Grade A recommendation) - "as-needed" titration
    → 87-93% vertigo control; risk of SNHL
         │
    If bilateral or further failure
         ▼
Surgical options: Endolymphatic sac surgery / Vestibular nerve section

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Complications of IT Injection Procedure

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Emerging and Future Directions

• Sustained-release IT formulations (gel-based dexamethasone, OTO-104/OTO-313) - prolonged drug contact at RWM; in clinical trials
• Nano-formulations - nanoparticles for targeted cochlear drug delivery
• Gene therapy via IT route - delivery of vectors (AAV) to cochlea via round window; neurotrophins and hair cell regeneration genes
• IT aminoglycosides for tinnitus - investigational
• IT gels: A 2024 scoping review (PMID 38308599) documents growing clinical trial data for intratympanic gel formulations

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Key Points Summary

• IT therapy bypasses the blood-labyrinth barrier; RWM is the primary drug entry route
• RWM is three-layered, semipermeable; adhesions over it reduce drug entry
• IT steroids: first-line for SSNHL in contraindications to systemic steroids; gold standard salvage for SSNHL after failed systemic steroids; dexamethasone for Meniere's vertigo (80% control, no HL risk)
• IT gentamicin: selective vestibulotoxic; 87-93% vertigo control in Meniere's; used after IT dexamethasone failure; risk of SNHL; titration protocol preferred over fixed dosing
• Complete caloric ablation is NOT the endpoint - associated with high SNHL rates
• IT dexamethasone is preferred when hearing is still useful; IT gentamicin for end-stage or refractory cases
• Drug delivery methods: single injection, grommet instillation, MicroWick, catheter, sustained-release gels

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Direct Laryngoscopy (DL) / Microlaryngoscopy

Definition and Terminology

• Direct laryngoscopy (DL): Visualization of the larynx by direct line-of-sight using a rigid laryngoscope, with the patient's oral, pharyngeal, and laryngeal axes aligned. Can be performed under general anaesthesia (operative/suspension DL) or with topical anaesthesia.
• Microlaryngoscopy (MLB / suspension laryngoscopy): Direct laryngoscopy under general anaesthesia with the laryngoscope suspended on a chest support, leaving both hands of the surgeon free to use microsurgical instruments or an operating microscope.
• Panendoscopy: Combined direct laryngoscopy + rigid oesophagoscopy + bronchoscopy performed under the same anaesthetic.

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Historical Development

• Chevalier Jackson (1865-1958): Father of endoscopy; developed the tubular laryngoscope and systematic approach to laryngoscopy
• Kleinsasser (1968): Developed the wide-bore suspension laryngoscope and microlaryngoscopic technique
• Jako and Strong (1972): First described CO₂ laser surgery of the larynx using microlaryngoscopy
• Dedo: Developed the Dedo laryngoscope widely used for suspension microlaryngoscopy

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Types of Laryngoscopes

For Intubation (Anaesthesia)

For ENT/Operative Laryngoscopy

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Patient Positioning

"Sniffing Position" (Jackson Position)

• Neck flexed on the thorax (pillow under occiput, ~8-10 cm)
• Head extended at the atlanto-occipital joint
• This aligns the three axes: oral axis, pharyngeal axis, and laryngeal axis into one straight line of sight

BURP Manoeuvre

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Cormack-Lehane Grading of Laryngoscopic View

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Anaesthesia for Operative Microlaryngoscopy

Goals (Morgan & Mikhail, p. 776)

1. Immobile surgical field - profound neuromuscular blockade
2. Adequate masseter muscle relaxation for laryngoscope introduction
3. Adequate oxygenation and ventilation
4. Cardiovascular stability despite rapidly varying stimulation levels

Premedication

• Glycopyrrolate (0.2-0.3 mg IM): Minimises secretions to facilitate airway visualization; given 1 hour before surgery
• Avoid heavy sedation in patients with threatened airway obstruction

Neuromuscular Blockade

• Profound paralysis required until end of procedure
• Intermediate-duration agents: rocuronium, vecuronium, cisatracurium
• Sugammadex now allows reversal of profound rocuronium blockade → largely replaced succinylcholine infusions
• Morgan & Mikhail, p. 781

Ventilation Techniques

Laser Precautions (when CO₂ laser used)

• Use a laser-resistant ETT (e.g., Laser-Flex, Lasertubus)
• Fill tracheal cuff with saline (not air) - saline acts as heat sink; add methylene blue to detect cuff puncture
• Pack throat with wet gauze to protect infraglottic structures
• Protect patient's eyes with wet gauze and tape
• Use minimum FiO₂ to support SpO₂ (minimize airway fire risk - avoid FiO₂ >0.3 with flammable gases)

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Indications for Operative Direct Laryngoscopy / Microlaryngoscopy

Diagnostic

• Suspicious laryngeal lesion on flexible laryngoscopy requiring biopsy
• Assessment of dysplasia / carcinoma in situ with mapping biopsies
• Failure of indirect/flexible laryngoscopy to adequately visualize larynx
• Staging of laryngeal/hypopharyngeal malignancy (palpation of cricoarytenoid mobility, tumour extent)

Therapeutic / Operative

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Procedure: Suspension Microlaryngoscopy

1. Anaesthesia induction with TIVA (propofol/remifentanil) ± inhalational agents; profound NMB
2. Patient positioned in Jackson (sniffing) position - shoulder roll, head ring
3. Tooth guard applied to protect upper teeth/gums
4. Laryngoscope introduced via the right side of the mouth, advanced along the right paraglossal gutter
5. Tongue displaced to the left; laryngoscope advanced to visualize epiglottis
6. Tip positioned in vallecula (Macintosh technique) or under epiglottis (Miller technique)
7. Suspension apparatus attached to chest support - hands-free
8. Operating microscope or 0°/30°/70° Hopkins rod telescopes used for magnification
9. Systematic assessment: supraglottis → glottis → anterior commissure → posterior commissure → subglottis
10. Arytenoid mobility palpated with a spatula
11. Biopsies/operative procedures performed with cold instruments, laser, or microdebrider
12. For discrete lesion: excision biopsy preferred over incisional biopsy (microflap technique for vocal cord lesions)
13. For diffuse changes: representative biopsy from area that minimises voice impact (e.g., superior-lateral surface)

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Microflap Technique (for Vocal Fold Surgery)

• A mucosal microflap is raised using a sickle knife
• The lesion is dissected from the superficial lamina propria
• The mucosa is replaced/trimmed conserving as much epithelium as possible
• Avoids injury to the vocalis muscle and preserves vibration of the vocal cord
• Minimises scarring and preserves voice quality

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Post-operative Care

• Voice rest: 48 hours absolute voice rest; 7-10 days strict vocal rest (no control studies, but widely accepted practice) - Scott-Brown's, p. 892-899
• Gradual return to voicing under voice therapy guidance
• Proton pump inhibitors if laryngopharyngeal reflux suspected (reduces granuloma recurrence)
• Follow-up flexible laryngoscopy at 4-6 weeks

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Complications

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Contraindications / Predictors of Difficult DL (LEMON Assessment)

• Look externally - micrognathia, prognathism, short neck, large tongue, obesity
• Evaluate the 3-3-2 rule - mouth opening <3 fingers; hyoid-chin distance <3 fingers; thyroid-floor of mouth <2 fingers
• Mallampati class III/IV
• Obstruction / Obesity
• Neck mobility - cervical spine disease, trauma, ankylosing spondylitis

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Key Points Summary

• Direct laryngoscopy = direct line-of-sight visualization; microlaryngoscopy = DL + operating microscope with suspension
• Jackson (sniffing) position: neck flexed, head extended - aligns oral, pharyngeal, laryngeal axes
• Cormack-Lehane Grade I/IIA = easy; IIB/III = difficult; IV = failed - requires alternative
• BURP manoeuvre improves grade
• Anaesthesia: TIVA preferred; profound NMB; MLT tube (size 5.0-5.5) most common; jet ventilation when posterior commissure/vocal fold exposure needed
• Laser surgery requires laser-safe ETT + saline-filled cuff + minimum FiO₂
• Cold instrument microsurgery preferred for benign vocal fold lesions to preserve voice
• Microdebrider = gold standard for RRP
• Excision biopsy preferred over incisional for discrete lesions
• 48 hours absolute voice rest post-phonosurgery; 7-10 days strict rest
• Most common complication: dental trauma - always use tooth guard

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Epiphora

Definition

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Anatomy of the Lacrimal Drainage System

Physiology of Tear Drainage (Lacrimal Pump)

• With each blink, the pretarsal orbicularis oculi compresses the ampullae and canaliculi and moves the puncta medially
• Contraction of the lacrimal part of orbicularis creates positive pressure, forcing tears down the NLD into the nose
• On eye opening, the canaliculi and sac expand creating negative pressure that draws tears from the canaliculi into the sac
• Kanski's, p. 4371-4373

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Pathophysiology - Two Mechanisms of Epiphora

1. Hypersecretion (Overproduction)

• Secondary to anterior segment disease: dry eye (paradoxical watering), blepharitis, conjunctivitis, keratitis, foreign body, entropion
• Paradox: Dry eye stimulates reflex hypersecretion via the trigeminal-lacrimal reflex - the most common cause of watering eye overall
• Treatment is usually medical (addressing the underlying cause)

2. Defective Drainage (Lacrimal Outflow Failure)

• Malposition of puncta: ectropion, entropion, punctal eversion - "punctal abnormality is the most common cause of lacrimal drainage failure" - Kanski's, p. 4415
• Obstruction at any level from punctum to valve of Hasner
• Lacrimal pump failure: lower lid laxity, orbicularis weakness (facial nerve palsy)

Clinical tip: Drainage failure is exacerbated by cold/windy environments and least evident in warm, dry rooms. Tears overflowing onto the cheek = drainage failure (vs. hypersecretion which causes tears on the lower lid margin). - Kanski's, p. 4410

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Causes at Each Level

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Evaluation

History

• Unilateral vs. bilateral
• Age of onset (congenital vs. acquired)
• Discharge character (watery vs. mucoid vs. mucopurulent)
• Exacerbating factors (cold/wind → drainage failure)
• History of: trauma, nasal/sinus surgery, eye drops (especially glaucoma drops), systemic drugs, radiotherapy, granulomatous disease

Examination

1. Slit-lamp examination of puncta (before any instrumentation - syringing temporarily dilates and masks stenosis)
2. Assess for ectropion, entropion, lid laxity
3. Fluorescein dye disappearance test (FDDT): Instil fluorescein; normal drainage = dye disappears from tear meniscus within 5 minutes; retained dye = drainage failure
4. Tear meniscus height - elevated in drainage failure
5. Regurgitation test: Digital pressure over lacrimal sac - if mucopurulent material regurgitates, indicates chronic dacryocystitis with NLD obstruction

Investigations

1. Lacrimal Syringing (Diagnostic Irrigation)

• Cannulate lower punctum → instil saline
• Normal: Saline tasted in throat = patent system
• Soft stop: Cannula meets resistance before entering sac = canalicular obstruction
• Hard stop: Cannula enters sac but fluid does not pass to nose; reflux through opposite punctum = NLD obstruction
• Reflux through the same punctum = lower canalicular obstruction; through upper punctum = common canalicular obstruction
• Kanski's, p. 4485-4498

2. Jones Dye Tests (for partial/functional obstruction)

• Jones I: Primary dye test - fluorescein instilled; recovered from nose on blowing = patent, functional drainage
• Jones II: Secondary dye test - after Jones I failure; syringe with saline; fluorescein in saline = punctum/canaliculus drains but pump fails; clear saline = canalicular obstruction

3. Dacryocystography (DCG)

• Contrast injection into canalicular system + X-ray/CT
• Shows site and extent of obstruction, sac size, filling defects (dacryoliths, tumour)

4. Lacrimal Scintigraphy (Nuclear DCG)

• Physiological test - radiolabelled technetium-99m drops instilled; gamma camera images
• Shows functional drainage (assesses pump mechanism as well as patency)
• "Nuclear lacrimal scintigraphy showing passage of tracer via the right lacrimal system but obstructed drainage in the left nasolacrimal duct" - Kanski's, Fig. 3.10

5. Nasal Endoscopy

• Assesses inferior meatus, valve of Hasner, septal deviation, nasal polyps, turbinate hypertrophy - important pre-DCR assessment

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Dacryocystitis

Acute Dacryocystitis

• Sudden painful swelling at medial canthus below medial canthal tendon
• Red, tender, hot swelling in the region of the lacrimal sac
• Organisms: Staphylococcus aureus, Streptococcus pneumoniae
• Management: Systemic antibiotics (IV if severe); warm compresses; do NOT incise acutely (risk of fistula formation); DCR once infection resolved

Chronic Dacryocystitis

• Persistent epiphora + mucopurulent discharge
• Regurgitation of pus on pressure over lacrimal sac
• May present as a medial canthal swelling (mucocele/pyocele)
• Management: DCR is definitive

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Congenital Nasolacrimal Duct Obstruction (CNLDO)

• Present in up to 20% of neonates
• Due to persistent membranous obstruction at valve of Hasner (last part to canalize)
• Natural history: Spontaneous resolution in majority; rapid in first year, continues beyond
• Presentation: epiphora + sticky eye from first month of life; increased tear meniscus; mucocele may develop

Treatment - Stepwise

1. Conservative (< 12 months): Observation; Crigler massage (lacrimal sac massage) - 2-3x daily; topical antibiotics for infection
2. Probing (12-24 months): Under GA; stepwise probing from punctum to Hasner valve; success rate ~90%
3. Probing + silicone intubation: For failed probing or older children; stent left for 3-6 months
4. Balloon dacryoplasty: For failed probing
5. DCR: Rarely required in children - for persistent epiphora despite probing, bony atresia, upper NLD involvement

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Dacryocystorhinostomy (DCR)

Three DCR Approaches (Success Rates - Cummings Table 49.1)

A. External DCR

• Incision: vertical skin incision 10 mm medial to the inner canthus (avoiding angular vein)
• Medial canthal tendon and lacrimal sac exposed and reflected
• Intervening bone (anterior lacrimal crest + lacrimal fossa bone) removed
• Sac incised in an H-shaped manner to create anterior and posterior flaps
• Nasal mucosa incised; anterior and posterior flaps sutured together
• Silicone stents passed through canaliculi and NLD into nose (optional, 3-6 months)
• Success >90%
• Complications: Cutaneous scar, haemorrhage, angular vein injury, medial canthal structure injury, infection, CSF rhinorrhoea (if subarachnoid space entered), sump syndrome (ostium too high/small)

B. Endoscopic (Endonasal) DCR

• No skin incision → no external scar
• A light pipe through the canalicular system guides the endonasal approach
• Bone removed endoscopically; lacrimal sac marsupialized into middle meatus
• Transcanalicular laser/drill variants also exist
• Advantages: Less blood loss, no scar, shorter operative time, lower CSF risk, simultaneous nasal pathology addressed
• Disadvantages: Slightly lower success rate in some series; requires rhinological expertise; ~50% need additional nasal procedures
• "This concept allows outcomes of endonasal DCR to be equal or better than those of external DCR." - Cummings, p. 3776

C. Laser-Assisted DCR

• Laser (KTP, holmium, diode) creates ostium transcanalicularly
• Poor long-term results (38% at 5 years) - not recommended as primary approach
• Cummings, p. 3969

Adjunctive Measures

• Silicone stenting: Standard post-DCR; may be optional; little added benefit per recent data
• Mitomycin C / 5-FU: Antimetabolites to prevent scarring; evidence is mixed
• Grommet through medial sac wall / vertical slit without marsupialization: >65% failure rates - to be avoided

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Management of Specific Situations

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Causes of Failed DCR / Recurrent Epiphora after DCR

1. Sump syndrome - ostium too small and too high; lacrimal sac below the stoma retains secretions
2. Unrecognized common canalicular obstruction (pre-existing, not addressed)
3. Ostium stenosis/closure - scar tissue formation
4. Inadequate sac marsupialization
5. Nasal synechiae blocking ostium
6. Residual functional failure - lacrimal pump dysfunction (ongoing despite patent system)

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Key Points Summary

• Epiphora = tear overflow; two mechanisms: hypersecretion (dry eye, inflammation) vs. defective drainage
• Punctal abnormality = most common cause of lacrimal drainage failure
• Paradoxical watering from dry eye is the most common cause of a watering eye overall
• Lacrimal syringing is the key diagnostic test: hard stop + reflux = NLD obstruction; soft stop = canalicular obstruction
• Jones dye tests for functional/partial obstruction
• CNLDO: 20% neonates; observation until 12 months; probing after 1 year; DCR rarely needed
• DCR is definitive for NLD obstruction; external and endoscopic approaches have equivalent ~92-94% long-term success; laser DCR has poor long-term results (38%)
• Post-DCR failure: sump syndrome, canalicular obstruction, ostial scarring
• Canaliculitis (Actinomyces) presents with medial eyelid discharge, pouting punctum - treat with canaliculotomy

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Photodynamic Therapy (PDT)

Definition

1. A photosensitizing agent (photosensitizer)
2. Light of a specific wavelength
3. Molecular oxygen (O₂)

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Mechanism of Action

Photochemical Steps (Jablonski Diagram)

1. Photosensitizer delivered to target tissue (topically or systemically) - exists in ground state
2. Light of appropriate wavelength absorbed → photosensitizer excited to singlet excited state (nanoseconds)
3. Intersystem crossing → more stable triplet excited state (microseconds)
4. Excited triplet photosensitizer transfers energy to molecular O₂ (Type II photochemical reaction):

Triplet PS + ³O₂ → Ground state PS + ¹O₂ (singlet oxygen)

1. Singlet oxygen reacts with cellular biomolecules: lipids, proteins, nucleic acids

Two Pathways of Cell Death

Why Is PDT Selective?

• Increased vascular permeability of tumour vessels (EPR effect)
• Tumour cells have abnormal metabolism with higher PpIX accumulation
• Reduced lymphatic drainage - photosensitizer not cleared quickly
• ALA/mALA penetrate better through abnormal stratum corneum overlying tumour
• Selectivity ratio: >10:1 (tumour vs. surrounding normal tissue) for ALA/mALA

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Photosensitizers

First Generation (Systemic)

Second Generation

Third Generation / Topical Prodrugs

ALA/mALA Mechanism:

• ALA bypasses the rate-limiting step (ALA synthase, feedback-inhibited by heme)
• Pharmacological ALA → overwhelming accumulation of PpIX in mitochondria → PpIX leaks to plasma membrane, ER
• Tumour cells: iron-deficient + rapidly proliferating → produce more PpIX than normal cells

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Light Sources

• Surface illumination: LED panels, lamp heads, diode lasers
• Optical fibres through flexible endoscope: For oesophageal, bronchial, bladder tumours
• Interstitial light propagation: Optical fibre needles inserted into tumour bulk - extends PDT to deeper tumours
• Diffuser tip fibres: For tubular structures (trachea, oesophagus)

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Drug-Light Interval

• Systemic agents (porfimer, temoporfin): Drug-light interval 3-96 hours (allows washout from normal tissue)
• Topical ALA/mALA: Incubation 1-18 hours (allows selective accumulation in target cells)

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PDT in ENT / Head and Neck Surgery

1. Early Laryngeal Cancer (T1/T2)

• Biel treated 25 patients with early SCC of the larynx using PDT; achieved complete response in all - notably in 17 patients in whom prior radiotherapy had failed
• Advantages: organ-preserving; repeatable; not compromised by prior RT, surgery, or chemotherapy

2. Oral Cavity and Oropharynx

• Karakullukcu et al. (170 patients, early-stage oral cavity/oropharynx): 90% response rate, 70% complete response (cure) rate
• Gluckman: oral cavity/oropharynx - 11/13 complete response, 2/13 partial response with dihematoporphyrin ether + 630 nm light
• "The endoscopic access to squamous tumours of the upper aerodigestive tract combined with the tendency to develop field cancerisation make these tumours good candidates for PDT" - Scott-Brown's, p. 3606-3610

3. Oesophageal Cancer

• Phase II RCT (218 patients): palliative PDT (porfimer sodium) vs. Nd:YAG laser
  • Equivalent improvement in dysphagia
  • Fewer perforations with PDT (1% vs. 7%, p<0.05)
• Barrett's oesophagus with dysplasia/early adenocarcinoma: PDT showed ablation in 43/55 patients
  • Oesophageal stricture in 53% - significant complication
• Scott-Brown's, p. 3599-3604

4. Recurrent Respiratory Papillomatosis (RRP)

• Biel reported results of PDT for laryngeal papillomatosis with durable disease control
• Red Book 2021: photodynamic therapy listed as an adjuvant treatment option for RRP alongside interferon, indole-3-carbinol, bevacizumab

5. Endobronchial / Tracheobronchial Tumours

• PDT is an established bronchoscopic intervention for primary or metastatic tracheobronchial neoplasms
• Indications: malignant central airway obstruction, carcinoma in situ of bronchus
• Listed alongside laser, electrocautery, cryotherapy, brachytherapy in bronchoscopic armamentarium
• Fishman's Pulmonary Diseases, p. 3987 (Table 34-1)

6. Nasopharyngeal Carcinoma

• PDT trials for squamous carcinoma of the nasopharynx reported

7. Sinonasal Inverted Papilloma

• Non-malignant application; targeted due to recurrent nature

8. Oral Dysplasia / Leukoplakia (Pre-malignant)

• ALA/mALA-based PDT used for oral epithelial dysplasia

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PDT in Ophthalmology

• IV verteporfin → selectively accumulates in neovascular endothelium
• Activated at 689 nm via low-power diode laser directed at CNV
• Causes thrombosis of choroidal new vessels without damaging overlying retina
• Kanski's Clinical Ophthalmology (dedicated section)

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PDT in Dermatology

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Advantages of PDT

• Organ preservation - no ablative surgery needed for early lesions
• Selectivity - photosensitizer preferentially retained in tumour tissue
• No effect from prior treatments - not affected by prior radiotherapy, chemotherapy, or surgery (Scott-Brown's, p. 3562)
• Repeatable - can be given multiple times without cumulative toxicity
• Minimal long-term side effects
• Minimal scarring compared to surgery
• Can treat field cancerisation (wide area treatment)
• Suitable for patients on anticoagulation
• No dark toxicity - photosensitizer harmless without light activation

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Limitations and Side Effects

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Key Points Summary

• PDT requires three components: photosensitizer + light + oxygen
• Mechanism: photosensitizer → excited triplet state → energy transfer to O₂ → singlet oxygen → cell death by apoptosis (topical) or vascular thrombosis/ischaemia (systemic)
• First-generation: porfimer sodium (Photofrin) - systemic; long phototoxicity; 630 nm
• Second-generation: temoporfin (Foscan) for head/neck; verteporfin for AMD
• Third-generation: ALA/mALA topical prodrugs → PpIX; used in dermatology
• Depth of light penetration: blue light (417 nm) = superficial (<1 mm); red light (630 nm) = deeper (up to 3 mm)
• Drug-light interval (3-96 h for systemic) allows normal tissue washout → selectivity
• ENT applications: early laryngeal SCC, oral cavity/oropharynx carcinoma, oesophageal cancer (palliative), RRP, endobronchial tumours
• PDT is not compromised by prior RT, surgery, or chemotherapy
• Major limitations: skin phototoxicity, limited penetration depth, pain, oesophageal stricture risk

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Bat Ear (Prominent Ear / Prominauris / Protruding Ear)

Definition

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Anatomy of the Normal Ear

Key anatomical norms

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Embryology and Development

• The auricle develops from six hillocks of His on the first and second branchial arches, fusing during weeks 6-12 of gestation
• The antihelix furls during weeks 12-16; failure to do so results in protruding scapha (the most common cause of bat ear)
• The helix furls during the 6th month of gestation
• By age 3: 85% of auricular growth is complete
• By age 5: cartilaginous growth is nearly complete - suitable age for surgery

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Aetiology (Anatomic Causes)

1. Underdeveloped (absent/poorly formed) antihelical fold - MOST COMMON

• Failure of the antihelix to furl produces a flat, featureless ear
• The scapha (flat area between helix and antihelix) flares outward
• Conchoscaphal angle >90° (normal = 90°)

2. Deep/large conchal bowl (conchal hypertrophy)

• A deep conchal bowl pushes the entire auricle laterally away from the head
• Conchal depth >1.5 cm is abnormal
• Conchomastoid angle >90° (normal = 90°)

3. Combination (both)

• Most patients have elements of both antihelical underdevelopment and conchal excess

4. Prominent lobule

• An inferiorly protruding lobule may accompany the above

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Psychosocial Impact

• Significant psychological impact on children from teasing and bullying by peers, particularly after starting school (~age 5)
• "The entity has no significant otologic ramifications; rather, its importance is determined by the psychological disturbance endured by the patient." - Shambaugh Surgery of the Ear, p. 1725
• May lead to low self-esteem, social withdrawal, anxiety

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Assessment

Clinical Evaluation

• Document both ears separately - asymmetry is common; each ear may need a different corrective plan
• Measure auriculocephalic angle and scalp-helix distance
• Identify whether the problem is: antihelix deficiency / conchal excess / both / lobule
• Preoperative photography is mandatory

Surgical Planning Priorities

1. Correct protrusion of helix and lobe
2. Create a smooth, natural-looking antihelical fold
3. Avoid overcorrection (helix should remain visible lateral to antihelix on frontal view)
4. Create bilateral symmetry

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Treatment

1. Non-Surgical / Ear Moulding (Neonates)

• Indicated within the first few weeks of life while auricular cartilage is still pliable (maternal oestrogen maintains cartilage plasticity for 4-6 weeks post-birth)
• External splints, foam moulding devices, or adhesive tape applied to reshape the ear
• Most effective if started within the first 72 hours of birth
• By 3-4 months, the cartilage hardens and moulding becomes ineffective
• Does not require anaesthesia; avoids surgical risks

2. Surgical Otoplasty

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Surgical Techniques

A. Suture-Based Techniques (Cartilage-Sparing)

Mustardé Technique (Most Widely Used)

• Principle: Horizontal mattress sutures placed through cartilage and anterior perichondrium to recreate the antihelical fold by rolling the scaphoid fossa toward the concha
• Approach: Postauricular (posterior auricular skin excision + mattress sutures)
• Steps:
  1. Preoperative ink markings define the crest of the new antihelix; marking sutures placed through anterior skin with ear folded into correct position
  2. Elliptical skin incision in postauricular sulcus
  3. Posterior auricular skin elevated to helical rim and triangular fossa (avoid nicking cartilage)
  4. Tissues elevated from conchal cartilage toward mastoid periosteum; intrinsic/extrinsic muscles divided
  5. 3-4 Mustardé sutures (5-0 or 6-0 non-absorbable, taper needle) placed as horizontal mattress sutures through cartilage and anterior perichondrium
  6. Each suture temporarily tightened to fold antihelix; all placed before tying
  7. Helix should remain visible lateral to new antihelix
  8. Conchomastoid sutures (4-0 or 5-0, >1 stitch): conchal cartilage tacked to mastoid periosteum to reduce conchal depth if needed
  9. Conchal cartilage may be thinned or excised if excessive
  10. Upper pole: stitch between triangular fossa and deep temporal fascia if needed
  11. Redundant posterior skin excised; wound closed
  12. Ear dressed with cotton packing in contours + mastoid pressure dressing

Incisionless Otoplasty (Fritsch / Merck Technique)

• Suture loop passed through small puncture sites - no skin incision
• 4-pass needle technique: horizontal pass through posterior skin and cartilage → under postauricular skin → second horizontal pass → exit through initial entry point
• Advantages: minimal scarring, faster recovery
• Suitable for mild-moderate deformity

B. Cartilage-Cutting / Scoring Techniques

• Gibson's principle: When one surface of cartilage is scored/abraded, it bends away from the scored surface (intrinsic cartilage memory released)
• Cartilage-cutting techniques have higher hematoma rates (~3%) than suture-only techniques

C. Conchal Reduction Techniques

• Conchal bowl shaving/excision: Direct excision of posterior conchal cartilage to reduce depth
• Conchomastoid (Furnas) sutures: Conchal cartilage sutured to mastoid periosteum - brings concha closer to head without excision
• Suitable when conchal hypertrophy is the main cause

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Summary of Technique Selection

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Postoperative Care

• Dressing removed at postoperative day 1 to check for haematoma and pressure injury
• Dressing replaced for a few days
• Headband worn for 3-4 months post-surgery to maintain ear position during healing
• Frequent post-op review to check ear position

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Complications

Early

Late

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Key Points Summary

• Bat ear = prominent ear = prominauris; most common congenital auricular deformity
• Two causes: absent antihelical fold (most common) + deep conchal bowl
• Auriculocephalic angle >40-45° is abnormal (normal 20-35°)
• Ear reaches 85% adult size by age 3; surgery safe at age 5-6
• Non-surgical: ear moulding within first few weeks of life
• Gold standard surgical technique: Mustardé horizontal mattress sutures to recreate antihelical fold (posterior approach, cartilage-sparing)
• Conchal excess: Furnas conchomastoid sutures ± conchal excision
• Most dreaded early complication: haematoma → cauliflower ear
• Most common late complication: relapse (suture failure)
• Notorious aesthetic complications: overcorrection (pinned-back ear) and telephone deformity
• Post-op headband worn for 3-4 months

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Now delivering the full answer above - here is the compiled response:

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Bat Ear (Prominent Ear / Prominauris)

Definition

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Anatomy of the Normal Auricle

Normal measurements

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Embryology and Development

• Auricle arises from six hillocks of His (1st and 2nd branchial arches), fusing during gestation weeks 6-12
• Antihelix furls at weeks 12-16; failure causes protruding scapha - the most common cause of bat ear
• Helix furls at 6 months gestation
• 85% of auricular growth complete by age 3; cartilage growth nearly complete by age 5
• Surgery is safe at age 5-6 without hindering growth

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Causes (Anatomic Defects)

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Treatment

1. Ear Moulding (Non-surgical - Neonates)

• Window: First few weeks of life (maternal oestrogen keeps cartilage pliable; best results within 72 hours of birth)
• External foam/silicone splints reshape the cartilage painlessly
• By 3-4 months, cartilage hardens and moulding becomes ineffective
• No anaesthesia, no scarring

2. Surgical Otoplasty

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Surgical Techniques

A. Mustardé Suture Technique (Gold Standard)

1. Marking sutures through anterior skin with ear manually folded into position to define new antihelix crest
2. Elliptical postauricular skin incision and excision
3. Posterior skin elevated to helical rim and triangular fossa; conchal cartilage elevated to mastoid periosteum
4. Intrinsic/extrinsic auricular muscles divided
5. 3-4 horizontal mattress sutures (5-0 or 6-0 non-absorbable monofilament, taper needle) placed through cartilage and anterior perichondrium - rolls the scaphoid fossa toward the concha, recreating the antihelical fold
6. All sutures placed before tying; tied sequentially with repeated assessment
7. After setting the antihelix, assess residual conchal depth
8. Conchomastoid (Furnas) sutures added if needed: 4-0 or 5-0 non-absorbable stitch tacking conchal cartilage to mastoid periosteum
9. Upper pole addressed with fossa triangularis-temporalis fascia stitch if prominent
10. Lobule addressed if needed
11. Redundant posterior skin excised; wound closed
12. Pressure dressing with cotton conforming to auricular contours

B. Cartilage-Scoring / Cutting Techniques

• Gibson's principle: Cartilage bends away from a scored surface due to release of intrinsic stress
• Cutting techniques have higher haematoma rates (~3%) vs. suture-only

C. Incisionless Otoplasty

• No skin incision - sutures passed through puncture sites only
• 4-pass needle loop technique through posterior auricular skin and cartilage
• Suitable for mild-to-moderate deformity
• Minimal scarring, faster recovery

D. Conchal Reduction

• Furnas (conchomastoid) sutures: conchal cartilage sutured to mastoid periosteum
• Direct conchal bowl excision/shaving: for severe conchal hypertrophy
• Indicated when conchal depth >1.5 cm is the dominant problem

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Technique Selection Summary

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Postoperative Care

• Dressing removed at day 1 to inspect for haematoma and pressure injury
• Dressing re-applied for a few days
• Headband worn for 3-4 months post-surgery to hold ear in position during healing
• Frequent follow-up to assess position

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Complications

Early

Late

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Key Points

• Bat ear = prominauris; auriculocephalic angle >40-45°; normal is 20-35°
• Two mechanisms: absent antihelical fold (most common) + deep conchal bowl
• Antihelix failure to furl (weeks 12-16 gestation) is the root cause in most cases
• No hearing impairment; psychological impact (bullying) drives treatment
• Surgery at age 5-6; non-surgical ear moulding if neonate (<6 weeks)
• Mustardé technique (posterior horizontal mattress sutures) is the gold standard for antihelical fold reconstruction
• Furnas technique (conchomastoid sutures) addresses conchal bowl excess
• Most serious early complication: haematoma (→ cauliflower ear)
• Classic late aesthetic complications: overcorrection (helix hidden) and telephone deformity (poles prominent, mid-ear flat)
• Headband worn for 3-4 months post-operatively

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Monoclonal Antibodies (mAbs) and Their Applications in ENT

What Is a Monoclonal Antibody?

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Nomenclature

• -ci- = cardiovascular
• -li- = immune/inflammatory
• -tu- = tumour
• -ki- = interleukin

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Classification by Target / Mechanism

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ENT Application 1: Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)

Background

• CRSwNP is driven by Type 2 (Th2) inflammation with elevated IL-4, IL-5, IL-13, and IgE
• Key cells: eosinophils, mast cells, innate lymphoid cells type 2 (ILC2)
• Biologics target this eosinophilic/Th2 inflammatory cascade
• Indicated for: severe, refractory CRSwNP that fails topical steroids and/or surgery (or recurs post-surgery)

1. Dupilumab (Dupixent®) - FIRST-LINE BIOLOGIC

2. Omalizumab (Xolair®)

3. Mepolizumab (Nucala®)

4. Benralizumab (Fasenra®)

5. Tezepelumab (Tezspire®)

Biologic Selection for CRSwNP

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ENT Application 2: Head and Neck Squamous Cell Carcinoma (HNSCC)

1. Cetuximab (Erbitux®) - Anti-EGFR

2. Pembrolizumab (Keytruda®) - Anti-PD-1 Checkpoint Inhibitor

3. Nivolumab (Opdivo®) - Anti-PD-1 Checkpoint Inhibitor

4. Panitumumab - Anti-EGFR (Fully Human)

• Fully human IgG2 anti-EGFR antibody (less ADCC than cetuximab due to IgG2 isotype)
• Phase III trial (657 patients): panitumumab + cisplatin/5-FU vs. chemotherapy alone: improved PFS (5.8 vs 4.6 months, p=0.004) but no significant OS improvement
• Less infusion reaction risk than cetuximab (fully human)
• Better OS in HPV-negative (p16-negative) HNSCC (11.6 vs 8.6 months)

5. Ipilimumab (Yervoy®) - Anti-CTLA-4

• Blocks CTLA-4 on regulatory T cells → promotes T-cell activation against tumour
• Used in combination with nivolumab in recurrent/metastatic HNSCC (investigational)
• CTLA-4 inhibition = more systemic, broader immune activation than PD-1 blockade
• Higher irAE rates than PD-1 inhibitors

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ENT Application 3: Recurrent Respiratory Papillomatosis (RRP)

Bevacizumab (Avastin®) - Anti-VEGF

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ENT Application 4: Allergic Rhinitis

Omalizumab (Additional Role)

• Anti-IgE mechanism is directly applicable to allergic rhinitis (IgE-mediated)
• Reduces mast cell and basophil response to allergen
• Useful in patients with severe allergic rhinitis comorbid with asthma and/or CRSwNP
• Not first-line for isolated allergic rhinitis (antihistamines + nasal steroids preferred), but relevant in step-up/refractory disease
• The EXTRA study showed greatest benefit in patients with high FeNO, high serum eosinophils, and elevated periostin

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ENT Application 5: Eosinophilic Granulomatosis with Polyangiitis (EGPA / Churg-Strauss)

• ENT manifestations: nasal polyps, sinusitis, granulomatous nasal obstruction, subglottic stenosis
• Mepolizumab (anti-IL-5): FDA-approved for EGPA; reduces eosinophilic inflammation; reduces steroid dependence; reduces ENT flares
• IL-5 drives eosinophil survival in EGPA - blocking it is pathophysiologically logical

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Application 6: Nasopharyngeal Carcinoma (NPC)

• NPC overexpresses EGFR and PD-L1
• Cetuximab studied in combination with radiotherapy and chemotherapy
• Pembrolizumab and nivolumab evaluated in recurrent/metastatic NPC (PD-L1 highly expressed)
• EBV-associated NPC shows immune evasion through PD-L1 upregulation - rationale for checkpoint inhibitors

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Key Concepts: Immune Checkpoints in HNSCC

• PD-1 is expressed on activated T cells; its ligand PD-L1 is on tumour cells and APCs
• Tumour cells upregulate PD-L1 (stimulated by IFN-γ) → binds PD-1 on T cells → T-cell exhaustion → tumour immune escape
• Anti-PD-1 antibodies (pembrolizumab, nivolumab) block this interaction → restore T-cell killing

• CTLA-4 expressed on regulatory T cells; binds B7 on APCs → downregulates T-cell activation
• Ipilimumab blocks CTLA-4 → removes T-cell suppression → more potent but more toxic immune activation

• MDSCs, tolerogenic DCs, TGF-β, IL-6 secretion all contribute to immune evasion
• Immunoediting: elimination → equilibrium → escape (tumour evades immune system)
• Pseudoprogression: tumour appears larger initially due to immune infiltration - must confirm progression 4 weeks later before stopping therapy (irRC criteria)

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Adverse Effects - Summary

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Summary Table: mAbs in ENT

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Key Points

• mAbs are single-clone antibodies targeting one specific epitope; named by source suffix (-ximab = chimeric, -zumab = humanized, -umab = fully human)
• In CRSwNP: Type 2/eosinophilic inflammation drives disease; dupilumab (anti-IL-4/IL-13) is FDA-approved first-line biologic; omalizumab (anti-IgE) also approved; mepolizumab/benralizumab target IL-5 pathway; tezepelumab targets upstream TSLP
• Biomarker-guided biologic selection: IgE → omalizumab; eosinophilia → mepolizumab/benralizumab; Th2/mixed → dupilumab
• In HNSCC: EGFR overexpressed in >90% - cetuximab (chimeric anti-EGFR) used with RT (Bonner trial) and chemotherapy (EXTREME trial)
• Checkpoint inhibitors: PD-L1 expressed on 45-80% of HNSCCs; pembrolizumab + chemotherapy now first-line for r/m-HNSCC (KEYNOTE-048); nivolumab approved post-platinum failure (CheckMate 141: OS 7.5 vs 5.1 months)
• RRP: bevacizumab (anti-VEGF, 25-50 mg intralesional) reduces papilloma angiogenesis, decreases surgical frequency, can achieve remission
• EGPA: mepolizumab approved; addresses eosinophilic ENT manifestations including nasal polyps and subglottic stenosis
• irAEs from checkpoint inhibitors are distinct from cytotoxic chemotherapy toxicities and require early recognition and steroid treatment