1. Otosclerosis - 10 marks
2. Retropharyngeal abscess - 10 marks
3. Adenotonsillitis - 10 marks
4. Deviated nasal septum (DNS) - 5 marks
5. Middle-ear cavity: four walls - 5 marks
6. Cholesteatoma: congenital and acquired - 5 marks
7. Allergic rhinitis - 5 marks
8. Malignant otitis externa - 5 marks
9. Septoplasty versus SMR - 5 marks
10. Causes of unilateral and bilateral nasal obstruction - 5 marks
11. Vocal polyp - 5 marks
12. McEwan's triangle - 5 marks

1. Otosclerosis - 10 marks
2. Retropharyngeal abscess - 10 marks
3. Adenotonsillitis - 10 marks
4. Deviated nasal septum (DNS) - 5 marks
5. Middle-ear cavity: four walls - 5 marks
6. Cholesteatoma: congenital and acquired - 5 marks
7. Allergic rhinitis - 5 marks
8. Malignant otitis externa - 5 marks
9. Septoplasty versus SMR - 5 marks
10. Causes of unilateral and bilateral nasal obstruction - 5 marks
11. Vocal polyp - 5 marks
12. McEwan's triangle - 5 marks

1. Otosclerosis

Definition

Aetiology and risk factors

• Autosomal dominant inheritance with incomplete penetrance and variable expression.
• More common in females.
• Usually presents between 20 and 40 years.
• May progress during pregnancy.
• Possible associations: measles virus, hormonal factors, and abnormal bone metabolism.

Pathology

1. Otospongiosis or active stage
   • Hypervascular spongy bone replaces normal dense enchondral bone.
   • Commonly begins anterior to the oval window at fissula ante fenestram.
2. Otosclerosis or inactive stage
   • Spongy bone becomes dense, sclerotic bone.
   • Stapes footplate becomes fixed in the oval window.

Types

1. Stapedial otosclerosis
   • Most common.
   • Fixation of stapes footplate causes conductive hearing loss.
2. Cochlear otosclerosis
   • Lesion involves cochlear capsule.
   • Causes sensorineural hearing loss, tinnitus, or mixed hearing loss.

Clinical features

• Slowly progressive, painless deafness, often bilateral but asymmetrical.
• Usually conductive hearing loss initially.
• Patient may hear better in noisy surroundings: Paracusis Willisii.
• Low-pitched tinnitus is common.
• Difficulty hearing whispers.
• Vertigo is uncommon but may occur.
• No ear discharge or earache.

Examination

• External auditory canal is normal.
• Tympanic membrane is usually normal.
• Occasionally, Schwartze sign is seen: a reddish blush over the promontory due to active otospongiosis.
• Tuning-fork tests:
  • Rinne test: negative in conductive loss.
  • Weber test: lateralizes to the poorer ear.
  • Absolute bone conduction: normal in pure conductive loss.
• Gelle test is negative because stapes is fixed.

Investigations

1. Pure-tone audiometry
   • Conductive hearing loss with air-bone gap.
   • Characteristic dip in bone conduction at 2 kHz: Carhart notch.
   • Cochlear disease gives mixed or sensorineural loss.
2. Impedance audiometry
   • Type As tympanogram due to reduced ossicular mobility.
   • Absent stapedial reflex.
3. CT scan of temporal bone
   • Used when diagnosis is doubtful, in cochlear otosclerosis, or before revision surgery.
   • May show a hypodense focus anterior to oval window.

Differential diagnosis

• Congenital stapes fixation.
• Ossicular discontinuity or fixation.
• Tympanosclerosis.
• Chronic otitis media with ossicular fixation.
• Superior semicircular canal dehiscence.

Treatment

1. Observation

2. Hearing aid

3. Medical treatment

• Sodium fluoride and bisphosphonates have been used in active cochlear otosclerosis, but their role is limited and specialist-directed.
• They do not correct mechanical stapes fixation.

4. Surgery

• Conductive hearing loss with significant air-bone gap.
• Good cochlear reserve.
• Patient desires surgery and understands risks.
• Absence of active middle-ear infection.

• Sensorineural hearing loss or dead ear.
• Vertigo.
• Tinnitus.
• Facial nerve injury.
• Chorda tympani injury causing altered taste.
• Tympanic membrane perforation.
• Perilymph gusher.
• Prosthesis displacement or incus erosion.

2. Retropharyngeal Abscess

Definition

Surgical anatomy

• Lies behind pharynx and oesophagus.
• Is between the buccopharyngeal fascia anteriorly and alar fascia posteriorly.
• Extends from base of skull to upper mediastinum.
• Contains retropharyngeal lymph nodes in children.
• Communicates inferiorly with the mediastinum, so infection can spread to cause mediastinitis.

Aetiology

In children

• Acute tonsillitis.
• Adenoiditis.
• Rhinitis and sinusitis.
• Nasopharyngitis.
• Upper respiratory tract infection.

In adults

• Trauma by fish bone or other foreign body.
• Instrumentation, including endoscopy or intubation.
• Tuberculosis of cervical spine causing a cold abscess.
• Spread from deep neck infection.

Causative organisms

• Group A beta-haemolytic streptococci.
• Staphylococcus aureus.
• Streptococcus pneumoniae.
• Haemophilus influenzae.
• Bacteroides and Fusobacterium species.
• Tuberculosis should be considered in chronic cold abscess.

Clinical features

Symptoms

• Fever and toxic look.
• Sore throat.
• Dysphagia and odynophagia.
• Refusal of feeds in children.
• Drooling of saliva.
• Neck pain and stiffness.
• Torticollis, with neck held extended or tilted to one side.
• Muffled or “hot potato” voice.
• Stridor, dyspnoea, or noisy breathing in advanced disease.

Signs

• Cervical lymphadenopathy.
• Tenderness and stiffness of neck.
• Bulge in posterior pharyngeal wall, often unilateral.
• Fluctuation may be difficult to elicit.
• Signs of airway obstruction: stridor, suprasternal recession, cyanosis, restlessness.

Investigations

1. Blood tests
   • Leukocytosis with neutrophilia.
   • Blood culture in toxic or septic patient.
2. Lateral soft-tissue X-ray of neck
   • Taken during inspiration, with neck extended.
   • Shows widening of prevertebral soft tissue.
   • Anterior displacement of airway.
   • Loss of cervical lordosis.
   • Gas shadow may be seen.
   Normal prevertebral soft tissue thickness:
   • At C2: less than 7 mm.
   • At C6: less than 14 mm in children and less than 22 mm in adults.
3. Contrast-enhanced CT neck
   • Investigation of choice in a stable patient.
   • Shows extent of collection, rim enhancement, gas, and complications.
   • Helps distinguish cellulitis/adenitis from a drainable abscess.
4. Culture and sensitivity
   • Culture of aspirated pus if drainage is performed.

Complications

• Acute upper airway obstruction.
• Aspiration of pus after spontaneous rupture.
• Aspiration pneumonia.
• Septicaemia and septic shock.
• Mediastinitis.
• Internal jugular vein thrombophlebitis.
• Carotid artery erosion or rupture.
• Spread to parapharyngeal space.
• Death.

Treatment

1. Admit and assess airway first

• Keep patient propped up and avoid upsetting a child.
• Give oxygen and monitor saturation.
• Secure airway if stridor, severe obstruction, or impending respiratory failure.
• Intubation should be performed by an experienced anaesthesia and ENT team.
• Tracheostomy may be required if intubation is unsafe or unsuccessful.

2. Supportive treatment

• Nil by mouth initially.
• Intravenous fluids.
• Analgesics and antipyretics.
• Correct dehydration.

3. Intravenous antibiotics

4. Surgical drainage

• There is airway compromise.
• A definite, large collection is present.
• The patient is septic or deteriorating.
• No response to intravenous antibiotics within 24-48 hours.
• Foreign body is suspected.

3. Adenotonsillitis

Definition

Aetiology

Viral causes

• Rhinovirus.
• Adenovirus.
• Influenza and parainfluenza viruses.
• Epstein-Barr virus, causing infectious mononucleosis.
• Enteroviruses.

Bacterial causes

• Group A beta-haemolytic Streptococcus pyogenes is an important bacterial cause.
• Staphylococcus aureus.
• Streptococcus pneumoniae.
• Haemophilus influenzae.
• Anaerobic bacteria.

Predisposing factors

• School-going children and close contact.
• Recurrent upper respiratory infection.
• Poor hygiene and overcrowding.
• Allergy.
• Chronic rhinosinusitis.
• Adenoid hypertrophy and bacterial biofilms.

Clinical features

Symptoms of acute tonsillitis

• Sore throat.
• Fever.
• Odynophagia and dysphagia.
• Malaise, headache, and anorexia.
• Referred otalgia.
• Foul breath.
• Voice change.

Symptoms due to adenoid involvement

• Nasal obstruction.
• Mouth breathing.
• Rhinorrhoea or postnasal discharge.
• Snoring.
• Sleep disturbance or obstructive sleep apnoea.
• Hyponasal speech.
• Recurrent otitis media or hearing difficulty due to Eustachian tube dysfunction.

Signs

• Enlarged, congested tonsils.
• Follicular exudates or membrane over tonsils in acute bacterial tonsillitis.
• Erythema of posterior pharyngeal wall.
• Tender jugulodigastric lymph nodes.
• Adenoids are not directly visible through the mouth.
• Mouth breathing, open mouth, and adenoid facies may occur in chronic obstruction.
• Posterior rhinoscopy or nasal endoscopy may demonstrate enlarged/inflamed adenoids.

Types

1. Acute adenotonsillitis.
2. Recurrent acute tonsillitis.
3. Chronic tonsillitis with chronic adenoiditis.
4. Adenotonsillar hypertrophy causing airway obstruction or obstructive sleep apnoea.

Investigations

• Throat swab for culture when bacterial infection is suspected or symptoms are recurrent/severe.
• Rapid antigen test for group A streptococcus where available.
• Complete blood count if severe infection.
• Monospot test or EBV serology if infectious mononucleosis is suspected.
• Flexible nasopharyngoscopy to assess adenoids.
• Lateral X-ray nasopharynx may demonstrate adenoid enlargement, though endoscopy is more informative.
• Audiometry and tympanometry if recurrent otitis media with effusion or hearing loss is suspected.
• Polysomnography when obstructive sleep apnoea is suspected and assessment is uncertain.

Treatment

A. Acute adenotonsillitis

1. General measures
   • Rest.
   • Adequate oral fluids.
   • Warm saline gargles in older children.
   • Paracetamol or ibuprofen for fever and pain.
   • Soft diet.
2. Antibiotics
   • Not required for clearly viral infection.
   • Give appropriate antibiotics for probable or confirmed streptococcal/bacterial tonsillitis, severe disease, or failure to improve.
   • Penicillin/amoxicillin is commonly used when there is no allergy.
   • Avoid amoxicillin when infectious mononucleosis is strongly suspected because of risk of rash.
3. Corticosteroids
   • May be used selectively in severe pain, significant oedema, or threatened airway, under medical supervision.

B. Management of chronic/recurrent disease

• Allergic rhinitis.
• Chronic rhinosinusitis.
• Otitis media with effusion.
• Dental sepsis.
• Gastro-oesophageal reflux, where relevant.

Indications for adenotonsillectomy

Recurrent tonsillitis

• At least 7 significant episodes in the preceding year, or
• At least 5 episodes per year for 2 consecutive years, or
• At least 3 episodes per year for 3 consecutive years.

Obstructive indications

• Obstructive sleep apnoea due to adenotonsillar hypertrophy.
• Significant snoring with sleep disturbance.
• Dysphagia due to enlarged tonsils.
• Failure to thrive, behavioural disturbance, or cardiopulmonary effects attributable to obstruction.

Other indications

• Recurrent peritonsillar abscess.
• Suspicion of malignancy, especially unilateral tonsillar enlargement with concerning features.
• Chronic adenotonsillitis not responding to adequate medical treatment.
• Recurrent otitis media with effusion or chronic rhinosinusitis associated with significant adenoid disease, particularly for adenoidectomy.

Complications

• Peritonsillar cellulitis or abscess, also called quinsy.
• Retropharyngeal or parapharyngeal abscess.
• Cervical lymphadenitis.
• Otitis media and otitis media with effusion.
• Obstructive sleep apnoea.
• Dehydration due to painful swallowing.
• Rheumatic fever and acute glomerulonephritis after untreated group A streptococcal infection.
• Septicaemia, rarely.

4. Deviated Nasal Septum (DNS)

Definition

Causes

1. Developmental: disproportionate growth of septal components.
2. Traumatic: birth trauma, fall, sports injury, road traffic accident.
3. Compensatory: deviation opposite to unilateral hypertrophy of turbinate or nasal mass.

Types

• C-shaped deviation
• S-shaped deviation
• Septal spur
• Caudal dislocation
• Septal thickening

Clinical features

• Unilateral or bilateral nasal obstruction.
• Recurrent rhinitis or sinusitis.
• Headache due to contact point.
• Epistaxis due to crusting over a spur.
• Hyposmia.
• Snoring and mouth breathing.
• Eustachian tube dysfunction, recurrent otitis media.

Examination

• Anterior rhinoscopy shows septal deviation, spur, crusting, turbinate hypertrophy.
• Nasal endoscopy identifies posterior deviation, polyps, mass, or sinus disease.

Treatment

• No treatment if asymptomatic.
• Treat associated rhinitis or sinusitis medically.
• Septoplasty is the operation of choice for symptomatic DNS.
• Septorhinoplasty may be needed if external nasal deformity is present.

5. Middle Ear Cavity: Walls

1. Roof or tegmental wall

• Formed by tegmen tympani, a thin plate of temporal bone.
• Separates middle ear from middle cranial fossa and temporal lobe.
• Defect may allow spread of infection to meninges or brain.

2. Floor or jugular wall

• Formed by thin bone over the jugular bulb.
• Separates hypotympanum from internal jugular vein.
• May be deficient in a high jugular bulb.

3. Lateral wall or membranous wall

• Mainly formed by tympanic membrane.
• Upper part is formed by lateral wall of epitympanum or attic.
• Contains scutum, which may be eroded in attic cholesteatoma.

4. Medial wall or labyrinthine wall

• Promontory: formed by basal turn of cochlea.
• Oval window: occupied by footplate of stapes.
• Round window: closed by secondary tympanic membrane.
• Prominence of facial canal.
• Prominence of lateral semicircular canal.

5. Anterior wall or carotid wall

• Separates middle ear from internal carotid artery.
• Has opening of Eustachian tube below.
• Has canal for tensor tympani muscle above.

6. Posterior wall or mastoid wall

• Has aditus ad antrum in epitympanum.
• Contains pyramidal eminence, from which stapedius tendon emerges.
• Facial canal descends in this wall.
• Facial recess lies between facial nerve and tympanic annulus.

6. Cholesteatoma: Congenital and Acquired

Definition

A. Congenital cholesteatoma

Definition

Aetiology

• Persistence of embryonic epidermoid cell rests within the middle ear, particularly in anterior epitympanum.

Features

• Commonly seen as a pearly white mass behind an intact tympanic membrane.
• Usually occurs in children.
• May present with conductive hearing loss.
• No history of chronic ear discharge in early disease.

Treatment

• Surgical removal, usually tympanoplasty with or without mastoidectomy depending on extent.

B. Acquired cholesteatoma

Types

1. Primary acquired cholesteatoma
   • Due to retraction pocket from Eustachian tube dysfunction.
   • Commonly arises from pars flaccida in attic or pars tensa.
2. Secondary acquired cholesteatoma
   • Squamous epithelium enters middle ear through a pre-existing tympanic membrane perforation.
   • May follow trauma, infection, or surgery.

Clinical features

• Foul-smelling, scanty ear discharge.
• Progressive conductive hearing loss.
• Retraction pocket containing keratin debris.
• Granulation tissue or aural polyp.
• Complications due to bone erosion.

Treatment

• Definitive treatment is surgical eradication, usually tympanomastoid surgery.
• Hearing reconstruction may be performed when feasible.
• Regular postoperative follow-up is necessary because recurrence or residual disease may occur.

7. Allergic Rhinitis

Definition

Types

1. Seasonal allergic rhinitis
   • Caused by pollens, grass, weeds, and trees.
2. Perennial allergic rhinitis
   • Caused by house-dust mites, animal dander, moulds, and cockroaches.

Pathogenesis

• Type I hypersensitivity reaction.
• Initial allergen exposure leads to production of allergen-specific IgE.
• IgE binds mast cells.
• Re-exposure causes mast-cell degranulation and release of histamine, leukotrienes, and other mediators.
• Early phase causes sneezing, itching, and rhinorrhoea.
• Late phase causes persistent blockage, mucosal oedema, and hypersecretion.

Clinical features

• Paroxysmal sneezing.
• Watery rhinorrhoea.
• Nasal itching and obstruction.
• Itching of palate, throat, and eyes.
• Watery eyes and conjunctival redness.
• Postnasal drip.
• Hyposmia.
• Allergic salute and transverse nasal crease.
• Pale, bluish, boggy nasal mucosa with watery secretion.

Diagnosis

• Clinical history and examination.
• Skin-prick test.
• Serum allergen-specific IgE.
• Nasal endoscopy when required to exclude polyps or other pathology.

Treatment

1. Allergen avoidance: dust control, avoid known triggers, reduce pet exposure if relevant.
2. Saline nasal irrigation.
3. Second-generation oral antihistamines.
4. Intranasal corticosteroids: most effective treatment for persistent symptoms.
5. Intranasal antihistamine.
6. Leukotriene receptor antagonist in selected patients.
7. Allergen immunotherapy for selected patients with proven allergen sensitivity and persistent symptoms.

8. Malignant Otitis Externa

Definition

Predisposing factors

• Elderly age.
• Diabetes mellitus.
• Immunosuppression.
• Malignancy or chemotherapy.
• Chronic renal disease.

Causative organism

• Pseudomonas aeruginosa is most common.
• Fungal infection, particularly Aspergillus, may occur in some immunocompromised patients.

Clinical features

• Severe, deep, persistent otalgia, often worse at night.
• Purulent otorrhoea.
• Pain disproportionate to otoscopic findings.
• Granulation tissue at the bony-cartilaginous junction of external auditory canal, especially inferiorly.
• Failure to respond to routine topical treatment.
• Cranial nerve palsies in advanced disease, especially facial nerve palsy.

Investigations

• Ear discharge culture and sensitivity.
• Blood glucose and HbA1c.
• ESR and CRP for monitoring response.
• CT temporal bone for bony erosion.
• MRI for soft-tissue and skull-base spread.
• Nuclear imaging or PET scan may be useful for follow-up.

Treatment

• Urgent ENT referral and admission if severe.
• Strict diabetic control.
• Aural toilet and topical treatment as adjuncts.
• Prolonged systemic antipseudomonal antibiotics, guided by culture.
• Analgesia.
• Surgical debridement is limited and reserved for sequestrum, abscess, or biopsy to exclude malignancy.
• Treat cranial nerve and skull-base complications.

9. Differentiate Between Septoplasty and SMR

10. Causes of Unilateral and Bilateral Nasal Obstruction

A. Unilateral nasal obstruction

Congenital

• Unilateral choanal atresia.
• Pyriform aperture stenosis.

Septal causes

• Deviated nasal septum.
• Septal spur.
• Septal haematoma or abscess.

Inflammatory or infective causes

• Unilateral chronic rhinosinusitis.
• Foreign body, especially in children.
• Rhinolith.
• Antrochoanal polyp.

Neoplastic causes

• Benign tumours: inverted papilloma, haemangioma, osteoma.
• Malignant tumours: carcinoma of nose/paranasal sinus, lymphoma.
• Juvenile nasopharyngeal angiofibroma in adolescent male.

B. Bilateral nasal obstruction

Congenital

• Bilateral choanal atresia.
• Craniofacial anomalies.

Inflammatory or allergic

• Allergic rhinitis.
• Vasomotor rhinitis.
• Acute or chronic rhinosinusitis.
• Bilateral inferior turbinate hypertrophy.

Structural

• Bilateral DNS or severe septal deformity.
• Nasal valve collapse.

Polyps and masses

• Ethmoidal polyps.
• Bilateral nasal polyposis.
• Adenoid hypertrophy in children.
• Nasopharyngeal mass.

Other

• Pregnancy rhinitis.
• Drug-induced rhinitis.
• Rhinitis medicamentosa due to prolonged topical decongestant use.

11. Vocal Polyp

Definition

Aetiology

• Voice abuse or vocal trauma.
• Sudden excessive shouting or coughing.
• Smoking.
• Laryngopharyngeal reflux.
• Chronic irritation.
• Hypothyroidism or allergy may contribute.

Pathology

• Usually unilateral.
• May be sessile or pedunculated.
• May be oedematous, gelatinous, haemorrhagic, or fibrotic.

Clinical features

• Persistent hoarseness.
• Voice fatigue.
• Breathiness or diplophonia.
• Frequent throat clearing.
• Large polyps may cause dyspnoea or stridor rarely.

Diagnosis

• Indirect laryngoscopy or flexible laryngoscopy.
• Video-stroboscopy shows a lesion on free margin of vocal fold and impaired mucosal wave.
• Histopathological examination after excision, especially in smokers, excludes malignancy.

Treatment

• Voice rest and voice therapy.
• Stop smoking and treat reflux.
• Microlaryngoscopic excision is indicated for persistent, large, symptomatic, or suspicious lesions.
• Postoperative voice therapy reduces recurrence.

12. McEwan's Triangle

Definition

Boundaries

• Superiorly: posterior root of zygoma.
• Anteriorly: posterosuperior margin of external auditory canal.
• Posteriorly: a line tangential to posterior wall of external auditory canal.

Importance

• The mastoid antrum lies approximately 1.5 to 2 cm deep to this triangle in an adult.
• It is an important surgical landmark during cortical mastoidectomy.
• The mastoid antrum is entered by drilling through this area.
• Care is required to avoid injury to:
  • Facial nerve.
  • Lateral semicircular canal.
  • Dura of middle cranial fossa.
  • Sigmoid sinus.

Clinical relevance

• It guides the surgeon to the mastoid antrum in mastoidectomy for chronic suppurative otitis media, cholesteatoma, and mastoid abscess.

5-Mark ENT Answers - MBBS Exam Format

4. Deviated Nasal Septum (DNS)

Definition

Aetiology

1. Developmental: unequal growth of septal cartilage and surrounding bones.
2. Traumatic: birth trauma, falls, sports injuries, road traffic accidents.
3. Compensatory: due to hypertrophy of opposite turbinate or intranasal pathology.

Types

• C-shaped deviation
• S-shaped deviation
• Septal spur
• Caudal dislocation
• Septal thickening

Clinical features

• Unilateral or bilateral nasal obstruction
• Recurrent rhinitis or sinusitis
• Headache due to contact point
• Epistaxis due to crusting over a spur
• Hyposmia
• Snoring and mouth breathing
• Eustachian tube dysfunction or recurrent otitis media

Treatment

• No treatment if asymptomatic.
• Treat associated rhinitis, sinusitis, or turbinate hypertrophy medically.
• Septoplasty is the operation of choice in symptomatic DNS.
• Septorhinoplasty is indicated if DNS is associated with external nasal deformity.

5. Middle-Ear Cavity: Walls

1. Roof or tegmental wall

• Formed by tegmen tympani.
• Separates the middle ear from the middle cranial fossa and temporal lobe.
• Infection may spread intracranially through a defect in this wall.

2. Floor or jugular wall

• Formed by thin bone over the superior bulb of internal jugular vein.
• Separates hypotympanum from jugular bulb.
• A high jugular bulb may project into the middle ear.

3. Lateral or membranous wall

• Mainly formed by the tympanic membrane.
• Upper part is formed by lateral attic wall and scutum.
• Scutum erosion is suggestive of attic cholesteatoma.

4. Medial or labyrinthine wall

• Promontory, formed by basal turn of cochlea
• Oval window, occupied by footplate of stapes
• Round window, closed by secondary tympanic membrane
• Prominence of facial canal
• Prominence of lateral semicircular canal

5. Anterior or carotid wall

• Separates middle ear from internal carotid artery.
• Contains Eustachian tube opening below.
• Contains canal for tensor tympani muscle above.

6. Posterior or mastoid wall

• Has aditus ad antrum in its upper part.
• Contains pyramidal eminence, through which stapedius tendon emerges.
• Facial canal descends in this wall.
• Facial recess is situated in relation to this wall.

6. Cholesteatoma: Congenital and Acquired

Definition

A. Congenital cholesteatoma

Definition

Aetiology

• Persistence of embryonic epidermoid cell rests in the middle ear, particularly in anterior epitympanum.

Features

• Pearly white mass behind intact tympanic membrane
• Usually occurs in children
• Conductive hearing loss may be present
• No chronic ear discharge initially

Treatment

• Surgical removal by tympanoplasty with or without mastoidectomy, according to extent.

B. Acquired cholesteatoma

Types

1. Primary acquired cholesteatoma
   • Develops from retraction pocket due to Eustachian tube dysfunction.
   • Usually arises in pars flaccida or pars tensa.
2. Secondary acquired cholesteatoma
   • Squamous epithelium enters middle ear through a pre-existing perforation.
   • May follow trauma, infection, or ear surgery.

Clinical features

• Scanty, foul-smelling ear discharge
• Progressive conductive hearing loss
• Retraction pocket with keratin debris
• Granulations or aural polyp
• Bone erosion and intracranial complications in advanced disease

Treatment

• Definitive treatment is surgical removal by tympanomastoid surgery.
• Reconstruction of hearing mechanism may be done where possible.
• Long-term follow-up is required for residual or recurrent disease.

7. Allergic Rhinitis

Definition

Types

1. Seasonal allergic rhinitis: due to pollens, grass, weeds, and trees.
2. Perennial allergic rhinitis: due to house-dust mites, animal dander, moulds, and cockroaches.

Clinical features

• Paroxysmal sneezing
• Watery rhinorrhoea
• Nasal itching and obstruction
• Itching of palate, throat, and eyes
• Lacrimation and conjunctival redness
• Postnasal drip and hyposmia
• Allergic salute and transverse nasal crease
• Pale, bluish, boggy nasal mucosa with watery secretions

Diagnosis

• Clinical history of exposure to allergens
• Anterior rhinoscopy or nasal endoscopy
• Skin-prick test
• Serum allergen-specific IgE

Treatment

1. Allergen avoidance: dust control and avoidance of identified triggers.
2. Saline nasal irrigation.
3. Oral non-sedating antihistamines.
4. Intranasal corticosteroids: most effective treatment for persistent symptoms.
5. Intranasal antihistamines.
6. Leukotriene receptor antagonists in selected cases.
7. Allergen-specific immunotherapy for selected patients with proven sensitization.

8. Malignant Otitis Externa

Definition

Predisposing factors

• Elderly patient
• Diabetes mellitus
• Immunosuppression
• Chronic renal disease
• Malignancy or chemotherapy

Causative organism

• Pseudomonas aeruginosa is the commonest organism.
• Aspergillus may cause disease in some immunocompromised patients.

Clinical features

• Severe, persistent otalgia, especially at night
• Purulent otorrhoea
• Pain disproportionate to local findings
• Granulation tissue at bony-cartilaginous junction of external auditory canal
• Failure to respond to routine treatment for otitis externa
• Facial nerve palsy or other cranial nerve palsies in advanced disease

Investigations

• Ear discharge culture and sensitivity
• Blood sugar, HbA1c
• ESR and CRP for monitoring
• CT temporal bone for bony erosion
• MRI for soft-tissue spread and skull-base involvement

Treatment

• Strict control of diabetes.
• Aural toilet and local treatment.
• Prolonged systemic antipseudomonal antibiotics according to culture sensitivity.
• Adequate analgesia.
• Limited surgical debridement only when indicated.
• Treat complications such as cranial neuropathy and skull-base osteomyelitis.

Complications

• Skull-base osteomyelitis
• Facial palsy
• Multiple cranial nerve palsies
• Meningitis
• Intracranial abscess
• Death

9. Differentiate Between Septoplasty and SMR

Conclusion

10. Causes of Unilateral and Bilateral Nasal Obstruction

A. Unilateral nasal obstruction

Congenital

• Unilateral choanal atresia
• Pyriform aperture stenosis

Structural

• Deviated nasal septum
• Septal spur
• Septal haematoma or abscess

Inflammatory and infective

• Unilateral chronic rhinosinusitis
• Foreign body in nose
• Rhinolith
• Antrochoanal polyp

Neoplastic

• Inverted papilloma
• Haemangioma
• Osteoma
• Carcinoma of nose or paranasal sinus
• Lymphoma
• Juvenile nasopharyngeal angiofibroma

B. Bilateral nasal obstruction

Congenital

• Bilateral choanal atresia
• Craniofacial anomalies

Inflammatory

• Allergic rhinitis
• Vasomotor rhinitis
• Acute and chronic rhinosinusitis
• Bilateral inferior turbinate hypertrophy

Structural

• Severe bilateral DNS
• Nasal valve collapse

Polyps and masses

• Bilateral ethmoidal polyps
• Nasal polyposis
• Adenoid hypertrophy in children
• Nasopharyngeal mass

Other

• Rhinitis medicamentosa due to prolonged topical decongestant use
• Pregnancy rhinitis
• Drug-induced rhinitis

11. Vocal Polyp

Definition

Aetiology

• Voice abuse or acute vocal trauma
• Excessive shouting or singing
• Smoking
• Chronic cough
• Laryngopharyngeal reflux
• Chronic irritation or allergy

Types

• Sessile polyp
• Pedunculated polyp
• Oedematous, gelatinous, haemorrhagic, or fibrous polyp

Clinical features

• Persistent hoarseness
• Voice fatigue
• Breathy voice
• Diplophonia
• Frequent throat clearing
• Large lesions may rarely cause dyspnoea

Diagnosis

• Indirect laryngoscopy
• Flexible fibre-optic laryngoscopy
• Video-stroboscopy
• Histopathological examination after excision, particularly in smokers

Treatment

• Voice rest and voice therapy
• Stop smoking
• Treat reflux and chronic cough
• Microlaryngoscopic excision for persistent, large, symptomatic, or suspicious polyps
• Postoperative speech therapy

12. McEwan's Triangle

Definition

Boundaries

• Superiorly: posterior root of zygoma
• Anteriorly: posterosuperior margin of external auditory canal
• Posteriorly: tangent drawn along posterior wall of external auditory canal

Surgical importance

• Mastoid antrum lies about 1.5 to 2 cm deep to this triangle in an adult.
• It is an important landmark for entering the mastoid antrum during cortical mastoidectomy.
• It is used in operations for cholesteatoma, chronic suppurative otitis media, mastoiditis, and mastoid abscess.

Structures to be protected during drilling

• Dura of middle cranial fossa superiorly
• Sigmoid sinus posteriorly
• Facial nerve
• Lateral semicircular canal
• Ossicles and middle-ear structures