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III-MBBS Otorhinolaryngology — May 2023 (Supp.) Answers

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Section-A

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Q1. Fill in the Blanks

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Q2. Multiple Choice Questions

Answer: (a) Facial palsy

• Petrositis (osteitis of petrous apex)
• Retro-orbital pain (trigeminal neuralgia — V nerve)
• Persistent ear discharge (otorrhoea)
• Also includes VI nerve palsy (lateral rectus palsy causing diplopia), NOT facial (VII) palsy

Answer: (b) Middle ear

Answer: (b) Neck swelling

Answer: (b) 2nd and 3rd tracheal rings

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Q3. 12-Year-Old Boy — Right-Sided Epistaxis + Nasal Obstruction + Reddish Fleshy Mass

a) Differential Diagnosis (3 marks)

• Young male, 12 years
• Recurrent unilateral epistaxis
• Progressive nasal obstruction
• Reddish fleshy vascular mass in nasal cavity

b) Investigations (3 marks)

1. CT scan (CECT) of nose, PNS and nasopharynx — shows extent, bony erosion, "antral bowing" (Holman-Miller sign), sun-ray pattern
2. MRI with contrast — defines soft tissue extent, intracranial extension (salt and pepper appearance on T2)
3. Nasal endoscopy — for direct visualisation (biopsy avoided due to bleeding risk)
4. Angiography (DSA) — identifies feeding vessels; preoperative embolisation done 24–48 hours before surgery
5. Blood investigations — CBC (anaemia), blood grouping and cross-matching
6. Staging — Andrews/Sessions classification based on imaging

Note: Biopsy is contraindicated due to high vascularity and risk of torrential haemorrhage.

c) Management of Active Epistaxis (4 marks)

1. Resuscitation — IV access, IV fluids, blood transfusion if needed; monitor vitals
2. Sit patient upright, lean forward (prevents blood aspiration)
3. Pinch the soft part of nose (Little's area compression) for 10–15 minutes
4. Anterior nasal packing — petroleum jelly-soaked ribbon gauze or Merocel pack; or inflatable balloon (Rapid Rhino)
5. Posterior nasal packing — Foley's catheter balloon if anterior packing fails (pack stays 24–48 hrs)
6. Surgical options if packing fails:
   • Endoscopic sphenopalatine artery ligation
   • External carotid artery ligation
   • Preoperative embolisation of internal maxillary artery
7. Angiographic embolisation — done electively 24–48 hours before definitive surgery for JNA

d) Treatment of the Most Common Disease (JNA) (5 marks)

• Preoperative embolisation (24–48 hours prior) to reduce intraoperative bleeding
• Staged by Andrews/Sessions/Radkowski classification

• Radiotherapy — reserved for unresectable intracranial extension; risk of radiation-induced sarcoma
• Hormonal therapy (anti-androgens: flutamide) — tumour has androgen receptors; adjunctive role
• Bevacizumab (anti-VEGF) — experimental

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Q4. Write Briefly on Any Five (5 × 2 = 10 marks)

a) Midline Neck Swellings

b) Atrophic Rhinitis

• Definition: Progressive atrophy of nasal mucosa and turbinates with formation of thick, foul-smelling crusts
• Also called: Ozaena
• Organisms: Klebsiella ozaenae, E. coli, Coccobacillus foetidus
• Symptoms: Anosmia, merciful anosmia, foetor, epistaxis, large nasal cavity ("empty nose")
• Treatment: Nasal irrigation, glucose-glycerine drops, antibiotics; surgical — Young's operation (closure of nostrils), submucosal Teflon/cartilage implants

c) Levels of Cervical Lymph Nodes

d) Oral Submucous Fibrosis (OSMF)

• Cause: Areca nut/betel nut chewing (arecoline), chilli
• Pathology: Juxtaepithelial fibrosis → progressive submucosal fibrosis → trismus
• Features: Burning sensation, difficulty in mouth opening, blanched mucosa, fibrous bands palpable
• Premalignant condition — 5–10% risk of SCC
• Treatment: Intralesional steroids + hyaluronidase, pentoxifylline, physiotherapy; surgery for severe trismus

e) Vocal Polyp

• Aetiology: Voice abuse, smoking, hypothyroidism
• Pathology: Oedema of Reinke's space (superficial lamina propria)
• Features: Unilateral smooth gelatinous/haemorrhagic mass on free edge of vocal cord (anterior 1/3); hoarseness
• Distinguished from vocal nodule — nodules are bilateral, at junction of anterior 1/3 and posterior 2/3
• Treatment: Voice rest, speech therapy; microlaryngoscopic excision (cold steel or CO₂ laser)

f) Little's Area

• Also called: Kiesselbach's plexus
• Location: Anteroinferior part of nasal septum
• Vessels: Anastomosis of — anterior ethmoidal artery, sphenopalatine artery, greater palatine artery, superior labial artery (branch of facial artery)
• Significance: Most common site of epistaxis (90%); easily accessible for cauterisation
• Treatment of local epistaxis: Cauterisation with silver nitrate, nasal packing

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Q5. Explain Why (Any Three) (3 × 5 = 15 marks)

a) Recurrent Laryngeal Nerve (RLN) Palsy is More Common on the Left Side

• Right RLN loops around the right subclavian artery (in the neck)
• Left RLN loops around the aortic arch (in the mediastinum) — passing below the ligamentum arteriosum near the left hilum

• More vulnerable to mediastinal pathology (aortic aneurysm, bronchogenic carcinoma, mediastinal lymphadenopathy, oesophageal carcinoma)
• More prone to surgical injury during cardiac/thoracic procedures
• Also implicated in Ortner's syndrome (cardiovocal syndrome — left RLN compression by dilated left atrium or pulmonary artery)

b) Parents Should Be Careful Before Giving Peanuts to Children Below 4 Years

1. Poor dentition — cannot chew properly → peanut may slip whole
2. Immature swallowing reflex and lack of coordination
3. Tendency to put objects in mouth and habit of running/playing while eating
4. Round shape of peanut facilitates aspiration into trachea/bronchi

• Peanut oil causes chemical bronchitis/pneumonitis (arachidic bronchitis) due to its fatty acid content
• May swell and fragment → multiple bronchial plugs
• Can cause obstructive emphysema (ball-valve effect) or collapse
• Bilateral involvement possible from fragmentation
• Rigid bronchoscopy under GA needed; peanut cannot be removed by blind forceps (crumbles)

c) Patients with Stridor Due to Growth in Larynx Have Apnoea After Tracheostomy

• A laryngeal growth causes chronic partial obstruction → chronic hypercapnia and hypoxia
• Over time, central chemoreceptors become desensitized to CO₂ (CO₂ drive suppressed)
• Patient relies entirely on hypoxic drive (peripheral chemoreceptors) to maintain respiration
• After tracheostomy, the obstruction is bypassed → PaO₂ suddenly rises
• This removes the hypoxic stimulus → apnoea results

d) Rinne's Test is Negative in a Patient with Right Severe Sensorineural Hearing Loss

• In profound SNHL, the right ear cannot perceive bone conduction or air conduction
• When a 512 Hz tuning fork is placed on the right mastoid (BC), the patient actually hears through the contralateral (left) normal cochlea via transcranial transmission
• This makes bone conduction appear "heard" while air conduction (closer to dead right ear) is not perceived
• Result: BC > AC on the right → false negative Rinne

• Apply Weber test — lateralises to the better (left) ear in SNHL
• Use Stenger test or masking of contralateral ear during Rinne

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Section-B

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Q6. Newborn Hearing Screening, Congenital Hearing Loss, SNHL Management, and Cochlear Implant (20 marks)

Newborn Hearing Screening

• Critical period of auditory cortex development: first 2 years of life
• Without screening, SNHL discovered late → permanent speech, language, and cognitive delay
• "Hear by 3 months, amplify by 6, enrol in intervention by 12 months" (JCIH 1–3–6 guideline)

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Evaluation of Congenital Hearing Loss

• Risk factors: NICU stay, family history, CMV/rubella/toxoplasmosis, ototoxic drugs, prematurity, hyperbilirubinemia, craniofacial anomalies, meningitis

• Behavioural Observation Audiometry (BOA) — <6 months
• Visual Reinforcement Audiometry (VRA) — 6 months–2 years
• Play Audiometry — 2–5 years
• Pure Tone Audiogram — >5 years
• ABR/ASSR — objective thresholds at any age
• Tympanometry — middle ear function

• HRCT temporal bone — cochlear/ossicular anatomy, cochlear nerve canal
• MRI brain/IAM — cochlear nerve, cochlear malformations (Mondini, common cavity)
• Ophthalmology — Usher syndrome
• ECG — Jervell-Lange-Nielsen syndrome (SNHL + prolonged QT)
• Thyroid function — Pendred syndrome
• Urinalysis — Alport syndrome
• Genetic testing — GJB2/GJB6 (connexin 26/30) mutations (50% of hereditary SNHL)
• TORCH titres, CMV urine culture

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Management of SNHL

• Amplify sound; max benefit in mild-moderate SNHL
• Children: BTE with earmould, regular mould changes as ear grows
• Digital hearing aids preferred

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Cochlear Implant Surgery

• Profound bilateral SNHL (>90 dB) with inadequate benefit from hearing aids
• Age: Minimum 12 months (can be done from 6 months in meningitic cases)
• Patent cochlea on HRCT/MRI
• No absolute contraindications

• External: Microphone, speech processor, transmitter coil
• Internal: Receiver-stimulator (implanted in temporal bone), electrode array (inserted into cochlea via round window or cochleostomy)

1. Postauricular incision, mastoidectomy
2. Posterior tympanotomy (facial recess approach)
3. Bed created in temporal bone for receiver-stimulator
4. Cochleostomy anterior to round window niche, or via round window
5. Electrode array inserted into scala tympani
6. Device fixation and wound closure

• Device activation (switch-on): 3–4 weeks post-surgery
• Mapping/Programming: Repeated adjustments of threshold (T) and comfort (C) levels
• Intensive auditory-verbal rehabilitation and speech therapy
• Regular follow-up: audiological monitoring, device checks
• Outcome: With early implantation (< 2 years), children can achieve near-normal speech/language
• Bilateral CI preferred when possible

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Q7. Write Briefly on Any Five (5 × 2 = 10 marks)

a) Sleep Apnoea

• OSAS: Repetitive episodes of upper airway obstruction during sleep → apnoea (>10 sec) or hypopnoea
• Symptoms: Loud snoring, witnessed apnoeas, daytime somnolence, morning headache
• Diagnosis: Polysomnography (gold standard); AHI >5/hr = OSA; >30 = severe
• Causes in children: Adenotonsillar hypertrophy; adults: obesity, retrognathia
• Treatment: CPAP (first-line adults), weight loss, adenotonsillectomy (children), mandibular advancement device, UPPP

b) NPPCD (Nasal Polyposis + Chronic Rhinosinusitis with Polyps)

• NPPCD = Non-Polypoid Paranasal Chronic Disease (or Nasal Polyposis with Chronic Disease)
• Bilateral ethmoidal polyposis associated with CRS
• Associated with aspirin sensitivity, asthma (Samter's triad)
• Treatment: Topical corticosteroids (mainstay), systemic steroids, FESS when medical treatment fails; biologics (dupilumab, mepolizumab) for refractory disease

c) Tympanic Membrane

• Location: At the end of external auditory canal, tilted at 55° to canal axis
• Layers: Outer squamous epithelium, middle fibrous layer (radial + circular fibres), inner mucosal layer
• Parts: Pars tensa (majority) + Pars flaccida (Shrapnell's membrane, superiorly) — no fibrous middle layer in pars flaccida
• Landmarks: Cone of light (anteroinferiorly), handle of malleus, umbo, anterior and posterior malleolar folds
• Blood supply: Deep auricular artery (outer), tympanic branch of maxillary artery (inner)

d) Osteomeatal Complex (OMC)

• Definition: Functional unit of drainage for anterior group of sinuses (maxillary, frontal, anterior ethmoidal)
• Components: Middle turbinate, uncinate process, ethmoid bulla, infundibulum, hiatus semilunaris, middle meatus
• Significance: Obstruction of OMC → stasis, infection → chronic rhinosinusitis
• Basis of FESS: Restoring ventilation and drainage by clearing OMC disease

e) CSF Rhinorrhoea

• Definition: Leakage of cerebrospinal fluid through the nose
• Causes: Trauma (most common — basal skull fracture through cribriform plate/fovea ethmoidalis), iatrogenic (post-FESS, post-pituitary surgery), spontaneous (raised ICP, tumour erosion)
• Diagnosis: β-2 transferrin test (pathognomonic), CT cisternography, intrathecal fluorescein + nasal endoscopy; "halo sign" or "ring sign" on gauze pad
• Features: Clear watery nasal discharge, worse on bending forward; risk of meningitis
• Treatment: Conservative (bed rest, avoid straining) for traumatic; endoscopic repair with fascia/fat/mucosal graft for persistent/spontaneous leaks

f) Nasal Myiasis

• Definition: Infestation of nasal cavity by fly larvae (maggots) — usually Chrysomya bezziana (Old World screwworm)
• Risk factors: Poor hygiene, debilitated/elderly patients, open wounds, atrophic rhinitis
• Features: Unilateral nasal obstruction, foul-smelling discharge, pain, visible crawling maggots; can cause extensive tissue destruction including orbital invasion
• Treatment: Suffocation of larvae with turpentine oil/chloroform drops, manual removal with forceps under endoscopy; nasal irrigation with saline; ivermectin (oral/topical); treat underlying condition

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Q8. Short Notes on Any Four (4 × 5 = 20 marks)

a) Counselling of a Patient Recently Diagnosed with Carcinoma Larynx

1. Breaking bad news — SPIKES protocol; compassionate, private setting
2. Explain diagnosis: Stage-appropriate information about laryngeal carcinoma (glottic/supraglottic/subglottic)
3. Treatment options:
   • Early (T1/T2): Radiotherapy OR endoscopic CO₂ laser excision (voice preservation)
   • Advanced (T3/T4): Total laryngectomy + neck dissection + adjuvant chemoradiation
4. Implications of total laryngectomy:
   • Permanent tracheostome (breathing through neck)
   • Loss of natural voice → alaryngeal communication options: oesophageal voice, tracheoesophageal voice (TEP + Blom-Singer prosthesis), electrolarynx
5. Rehabilitation: Voice therapy, laryngectomy clubs, psychological support
6. Nutritional support: Nasogastric feeding perioperatively, dietician referral
7. Smoking cessation: Mandatory; improves outcomes
8. Follow-up schedule: Regular endoscopy, imaging
9. Address concerns: Prognosis (glottic ca has 80–90% 5-year survival in early stages), quality of life
10. Family involvement: Support network, carer education

b) Tracheostomy

• Emergency (cricothyroidotomy — not true tracheostomy)
• Elective/planned
• Temporary vs. permanent
• Surgical vs. Percutaneous Dilational Tracheostomy (PDT)

• Upper airway obstruction (foreign body, tumour, angioedema, trauma)
• Prolonged mechanical ventilation (> 7–10 days)
• Tracheobronchial toilet (secretion management)
• Prophylactic (major head-neck surgery)

• Patient supine, neck extended
• Horizontal incision between cricoid and sternal notch
• Divide strap muscles, thyroid isthmus retracted/divided
• Trachea entered between 2nd–3rd rings (mid-tracheostomy) — window/inverted-U/vertical incision
• Tracheostomy tube inserted and secured

c) FESS (Functional Endoscopic Sinus Surgery)

• Chronic rhinosinusitis with/without polyps failing medical treatment
• Recurrent acute rhinosinusitis
• Antrochoanal polyp
• Mucocele
• Orbital complications (subperiosteal abscess drainage)
• Optic nerve decompression
• DCR (endoscopic dacryocystorhinostomy)
• Skull base surgery, pituitary surgery, CSF leak repair
• Orbital decompression (Grave's disease)

1. Uncinectomy (removal of uncinate process — first and most important step)
2. Infundibulotomy → opening of maxillary sinus ostium
3. Anterior ethmoidectomy → opening ethmoid bulla
4. Posterior ethmoidectomy
5. Sphenoidotomy (if needed)
6. Frontal recess clearance (Draf I/II/III)

• Minor: Bleeding, synechiae, crusting
• Major: CSF leak (cribriform plate injury), orbital injury (medial wall — fat herniation, diplopia), optic nerve injury (blindness), massive haemorrhage (anterior ethmoidal artery, ICA)

d) Microlaryngeal Surgery (Microlaryngoscopy / MLS)

• Diagnostic: Biopsy of laryngeal lesions (leukoplakia, suspicious lesions)
• Therapeutic: Excision of vocal polyp, vocal nodule (refractory), Reinke's oedema
• Papillomatosis — laser excision
• Laryngeal web division
• Subglottic stenosis — CO₂ laser, balloon dilation
• Arytenoid granuloma, contact ulcer
• Carcinoma in situ / early glottic Ca (T1, T2) — CO₂ laser cordectomy (ELPS)

• Lindholm/Kleinsasser suspension laryngoscope
• Operating microscope (×16 magnification)
• Microlaryngeal instruments (straight/angled cup forceps, scissors)
• CO₂ laser (KTP, thulium laser) with micromanipulator

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