DNS Middle ear cavity with all the four walls cholesteatoma Congenital/acquired allergic rhinitis malignant otitis externa difference between Septoplasty and SMR causes for unilateral and b/l nasal obstruction Give the answers for above question for ent subject of mbbs

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Answer the question above for ent subject of mbbs

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This covers six standard MBBS ENT long-answer/short-note areas:

DNS (deviated nasal septum)
Middle-ear cavity and its four walls
Cholesteatoma - congenital and acquired
Allergic rhinitis
Malignant otitis externa
Septoplasty vs SMR, and unilateral vs bilateral nasal obstruction

Brief overview: the first four include anatomy, pathology, symptoms, diagnosis, complications, and treatment. Malignant otitis externa needs special focus on its high-risk diabetic/elderly presentation and management. The final two are commonly asked comparison and differential-diagnosis questions.

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Your credits are exhausted. You can purchase a top-up or subscribe to a plan to continue using Orris. If you're already subscribed, your daily credits will reset tomorrow.This covers six standard MBBS ENT long-answer/short-note areas:

DNS (deviated nasal septum)
Middle-ear cavity and its four walls
Cholesteatoma - congenital and acquired
Allergic rhinitis
Malignant otitis externa
Septoplasty vs SMR, and unilateral vs bilateral nasal obstruction

Finding Sources

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cholesteatoma AND treatment

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allergic rhinitis AND treatment

Searching PubMed

malignant otitis externa AND treatment

Searching the Web

Merck Manual deviated septum allergic rhinitis malignant external otitis professional

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MBBS ENT Notes

1. Deviated Nasal Septum (DNS)

Definition

Deviation of the nasal septum from the midline, causing narrowing of one or both nasal cavities.

Causes

Developmental or congenital
Trauma, especially birth trauma or facial injury
Compensatory deviation due to turbinate hypertrophy
Previous nasal surgery
Unequal growth of septal cartilage and surrounding bony framework

Types

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

Clinical features

Unilateral or bilateral nasal obstruction
Mouth breathing
Headache or facial pain due to mucosal contact point
Recurrent rhinitis or sinusitis
Epistaxis due to drying and crusting over a spur
Hyposmia
Snoring or obstructive sleep symptoms
Eustachian tube dysfunction leading to ear blockage or recurrent otitis media

Examination

External nasal deformity may be present.
Anterior rhinoscopy shows deviation, spur, crusting, or contact with inferior turbinate.
Examine after decongestion to distinguish fixed septal deviation from turbinate congestion.
Nasal endoscopy helps identify posterior deviation and associated pathology.

Treatment

No treatment is required if asymptomatic.

Medical treatment

Saline nasal irrigation
Intranasal steroid spray if associated allergic rhinitis/turbinate hypertrophy
Antihistamines where allergy is present

Medical treatment relieves mucosal congestion but does not correct a true septal deviation.

Surgical treatment

Septoplasty: preferred operation
SMR: now used less commonly
Septorhinoplasty when external deformity is also present

2. Middle Ear Cavity and Its Four Walls

The middle ear is an air-containing cavity in the temporal bone. It lies between the tympanic membrane laterally and the inner ear medially. It communicates:

Anteriorly with the nasopharynx through the Eustachian tube
Posteriorly with mastoid antrum and mastoid air cells

It contains:

Ossicles: malleus, incus, stapes
Tensor tympani and stapedius muscles
Chorda tympani nerve
Tympanic plexus

Classically, the middle ear has six boundaries. In many examinations, “four walls” means the anterior, posterior, medial, and lateral walls. The roof and floor should also be mentioned.

A. Lateral wall

Formed mainly by:

Tympanic membrane
Lateral wall of epitympanum, called scutum

Important point: Retraction pocket and attic cholesteatoma often begin in the pars flaccida near the scutum.

B. Medial wall

Formed by the lateral wall of the inner ear.

Important features:

Promontory: formed by basal turn of cochlea
Oval window (fenestra vestibuli): occupied by footplate of stapes
Round window (fenestra cochleae): closed by secondary tympanic membrane
Prominence of facial canal above oval window
Prominence of lateral semicircular canal posteriorly

C. Anterior wall

Related to carotid canal.

Features:

Opening of Eustachian tube in lower part
Semicanal for tensor tympani muscle in upper part
Thin bony plate separates it from internal carotid artery

D. Posterior wall

Related to mastoid antrum.

Features:

Aditus ad antrum in epitympanum
Pyramidal eminence, from which stapedius tendon emerges
Vertical part of facial nerve canal
Facial recess
Sinus tympani, a recess behind the promontory
Posterior canaliculus for chorda tympani

E. Roof

Also called tegmental wall.

Formed by tegmen tympani
Separates middle ear from middle cranial fossa and temporal lobe

F. Floor

Also called jugular wall.

Thin bony plate separates middle ear from jugular bulb
May be deficient in a high jugular bulb

3. Cholesteatoma

Definition

Cholesteatoma is a sac lined by keratinizing stratified squamous epithelium in the middle ear or mastoid, containing desquamated keratin debris and capable of causing bone erosion.

It is not a true tumour and does not contain cholesterol in the usual sense.

Types

Congenital cholesteatoma
Acquired cholesteatoma
- Primary acquired
- Secondary acquired

A. Congenital cholesteatoma

Definition

A cholesteatoma arising from epithelial cell rests within the middle ear behind an intact tympanic membrane, without previous ear discharge, perforation, trauma, or ear surgery.

Pathogenesis

Thought to arise from embryonic epithelial remnants in the middle ear.

Clinical features

Usually occurs in children
Painless conductive hearing loss
White pearly mass seen behind an intact tympanic membrane, often in the anterosuperior quadrant
Usually no previous history of otorrhoea
May remain asymptomatic until it becomes extensive

Treatment

Surgical removal
Tympanoplasty with or without mastoidectomy depending on extent
Hearing reconstruction if ossicles are damaged
Long-term follow-up is necessary because recurrence/residual disease can occur

B. Acquired cholesteatoma

Definition

Cholesteatoma that develops after birth, commonly due to retraction of the tympanic membrane or migration of squamous epithelium through a perforation.

1. Primary acquired cholesteatoma

Occurs due to a retraction pocket, usually in pars flaccida or posterosuperior pars tensa.

Pathogenesis

Eustachian tube dysfunction causes negative middle-ear pressure. The tympanic membrane retracts, forming a pocket that retains keratin debris. The sac enlarges and erodes bone.

2. Secondary acquired cholesteatoma

Occurs when squamous epithelium enters the middle ear through:

Marginal perforation
Attic perforation
Traumatic perforation
Iatrogenic implantation after ear surgery

Clinical features

Foul-smelling, scanty, persistent ear discharge
Conductive hearing loss
Retraction pocket containing keratin debris
Attic crust or marginal perforation
Granulations or aural polyp
Dizziness, facial weakness, headache, or fever suggest complications

Bone erosion and complications

Cholesteatoma may erode:

Ossicles, especially long process of incus
Scutum
Facial canal
Lateral semicircular canal
Tegmen tympani
Posterior fossa plate

Complications

Intratemporal

Mastoiditis
Facial nerve palsy
Labyrinthine fistula
Sensorineural hearing loss
Petrositis

Intracranial

Meningitis
Extradural abscess
Subdural abscess
Brain abscess, especially temporal lobe/cerebellar
Lateral sinus thrombosis

Investigations

Otomicroscopy and otoendoscopy
Pure-tone audiometry
HRCT temporal bone for extent of disease and bony erosion
MRI with diffusion-weighted imaging if residual/recurrent cholesteatoma is suspected

Treatment

Cholesteatoma is primarily a surgical disease.

Principles:

Completely eradicate disease
Create a safe, dry ear
Preserve or reconstruct hearing where possible
Prevent recurrence

Operations:

Canal-wall-up mastoidectomy with tympanoplasty
Canal-wall-down mastoidectomy
Modified radical mastoidectomy in extensive disease
Ossiculoplasty when indicated

4. Allergic Rhinitis

Definition

Allergic rhinitis is an IgE-mediated inflammation of nasal mucosa following exposure to an allergen.

Types

Seasonal allergic rhinitis: due to pollens
Perennial allergic rhinitis: due to house-dust mite, mould, animal dander, cockroach allergens, etc.
Intermittent or persistent
Mild or moderate-severe

Common allergens

House-dust mite
Pollens
Animal dander
Fungi/moulds
Cockroach
Occupational allergens

Pathophysiology

Allergen exposure causes formation of allergen-specific IgE.
IgE attaches to mast cells.
Re-exposure causes mast-cell degranulation.
Histamine and other inflammatory mediators produce sneezing, itching, rhinorrhoea, and congestion.

Symptoms

Sneezing in bouts
Watery rhinorrhoea
Nasal obstruction
Nasal itching
Itching of eyes, palate, throat, or ears
Postnasal drip
Reduced smell
Eye symptoms: watering, itching, redness

Signs

Pale, bluish, oedematous nasal mucosa
Watery secretion
Hypertrophied inferior turbinates
Allergic salute: upward rubbing of nose
Transverse nasal crease
Allergic shiners: dark circles under eyes
Dennie-Morgan folds under lower eyelids
Associated eczema, asthma, nasal polyps, or otitis media with effusion may be present

Diagnosis

History of allergen exposure and seasonal variation
Anterior rhinoscopy/nasal endoscopy
Skin-prick test
Serum-specific IgE testing
Nasal smear may show eosinophils
Assess for asthma and sinus disease

Treatment

1. Allergen avoidance

Avoid known triggers where practical
Reduce house-dust mites: mattress and pillow covers, regular hot washing of bedding, reduce carpets/dust accumulation
Avoid cigarette smoke and irritants
Keep pets out of bedroom if sensitized

2. Medical treatment

Intranasal corticosteroids: most effective treatment for persistent nasal symptoms
Examples: fluticasone, mometasone, budesonide
Oral or intranasal second-generation antihistamines
Examples: cetirizine, levocetirizine, fexofenadine, loratadine, azelastine
Intranasal antihistamine plus steroid for moderate-severe symptoms
Saline nasal irrigation
Ipratropium nasal spray for troublesome watery rhinorrhoea
Leukotriene receptor antagonist, such as montelukast, mainly if asthma coexists
Short course of topical nasal decongestant only when necessary

Caution: Topical decongestant sprays should not be used for more than 3-5 days because they can cause rhinitis medicamentosa.

3. Immunotherapy

Indicated in selected patients with proven allergen sensitization and persistent troublesome symptoms despite avoidance and adequate drug treatment.

Subcutaneous immunotherapy
Sublingual immunotherapy

4. Surgery

Not a primary treatment for allergy. It may be considered for associated structural obstruction, such as DNS or marked inferior turbinate hypertrophy.

5. Malignant Otitis Externa

Definition

Malignant otitis externa, also called necrotizing otitis externa or skull-base osteomyelitis, is an invasive infection beginning in the external auditory canal and spreading to the temporal bone and skull base.

It is not a malignancy.

Predisposing factors

Elderly patient with diabetes mellitus
Poor glycaemic control
Immunocompromised state
HIV infection
Malignancy
Immunosuppressive drugs
Chronic renal disease

Causative organism

Pseudomonas aeruginosa is the commonest organism
Less commonly: Staphylococcus aureus, fungi such as Aspergillus or Candida

Pathogenesis

Infection begins in the external auditory canal, usually at the bony-cartilaginous junction. It extends through fissures of Santorini and spreads to the skull base, causing osteomyelitis and possible cranial nerve involvement.

Clinical features

Severe, deep, persistent otalgia, classically worse at night
Pain disproportionate to otoscopic findings
Persistent purulent otorrhoea
Granulation tissue at the bony-cartilaginous junction of external auditory canal
Oedematous ear canal
Failure to respond to routine treatment for otitis externa
Cranial nerve palsy in advanced disease:
- Facial nerve palsy is most common
- May involve IX, X, XI, and XII cranial nerves
Headache, fever, neck stiffness, altered sensorium suggest intracranial extension

Investigations

Ear discharge culture and sensitivity
Biopsy of granulation tissue to exclude carcinoma of external auditory canal
Blood glucose and HbA1c
ESR and CRP: useful for monitoring response
CT temporal bone: assesses bone erosion
MRI: assesses skull-base and soft-tissue/intracranial spread
Nuclear scans may be used in selected cases to assess osteomyelitis and treatment response

Treatment

This condition requires urgent ENT care and prolonged treatment.

Admit if severe disease, cranial neuropathy, systemic illness, or poor diabetic control
Strict control of diabetes
Aural toilet and careful removal of debris
Culture-directed systemic antipseudomonal antibiotics
- Oral ciprofloxacin may be considered in selected mild cases with susceptible organisms
- Severe disease generally needs intravenous antipseudomonal therapy, for example ceftazidime, cefepime, or piperacillin-tazobactam, guided by culture and local policy
Treat fungal infection with appropriate antifungal therapy if identified
Analgesia
Regular clinical review and serial ESR/CRP
Surgery has a limited role, mainly biopsy, drainage of abscess, or removal of sequestrum when required

Complications

Skull-base osteomyelitis
Facial palsy and multiple lower cranial nerve palsies
Meningitis
Dural venous sinus thrombosis
Brain abscess
Death, if untreated

6. Difference Between Septoplasty and SMR

Feature	Septoplasty	SMR - Submucous Resection
Principle	Conservative correction and repositioning of deviated septum	More extensive removal of deviated cartilage and bone
Tissue removal	Only deviated/obstructing portions are removed or reshaped	Larger part of septal cartilage and bone is removed
Structural support	Preserves dorsal and caudal septal support, usually an L-strut	Greater risk of loss of support
Indication	Preferred operation for symptomatic DNS	Reserved for selected adults with severe deviation; less commonly performed now
Age	Can be performed in selected children/adolescents when needed	Usually avoided in children because of possible effect on nasal growth
Cosmetic effect	Lower risk of saddle nose deformity	Higher risk of saddle nose, columellar retraction, or tip ptosis
Revision surgery	Easier preservation of tissue for future reconstruction	May leave insufficient cartilage for future surgery
Current status	Standard modern operation	Historical/classical operation, less favoured now

Short exam answer

Septoplasty is a conservative operation in which only the deviated portions of septal cartilage and bone are corrected while preserving septal support.
SMR involves more extensive resection of septal cartilage and bone and has a greater risk of postoperative deformity.

7. Causes of Unilateral and Bilateral Nasal Obstruction

A. Unilateral nasal obstruction

Congenital

Unilateral choanal atresia
Pyriform aperture stenosis, rarely unilateral

Septal and structural causes

DNS
Septal spur
Septal haematoma or abscess
Septal perforation with crusting

Inflammatory/infective causes

Foreign body, especially in children
Rhinitis with unilateral severe turbinate hypertrophy
Chronic rhinosinusitis
Antrochoanal polyp
Fungal sinusitis

Mass lesions

Nasal polyp, usually antrochoanal polyp
Inverted papilloma
Juvenile nasopharyngeal angiofibroma in adolescent male
Carcinoma of nose or paranasal sinus
Nasopharyngeal tumour
Encephalocele/meningoencephalocele
Granulomatous disease, such as tuberculosis or granulomatosis with polyangiitis

Important clinical point

Persistent unilateral nasal obstruction with blood-stained discharge or epistaxis should be treated as a possible tumour until proved otherwise.

B. Bilateral nasal obstruction

Congenital

Bilateral choanal atresia
Bilateral choanal stenosis
Congenital pyriform aperture stenosis

Inflammatory and allergic causes

Allergic rhinitis
Vasomotor/non-allergic rhinitis
Acute viral rhinitis
Chronic rhinosinusitis
Rhinitis medicamentosa due to overuse of decongestant drops

Structural causes

DNS with compensatory inferior turbinate hypertrophy
Bilateral inferior turbinate hypertrophy
Nasal valve collapse

Polyps and masses

Ethmoidal polyposis
Bilateral antrochoanal polyps, rarely
Bilateral sinonasal tumours, rarely

Nasopharyngeal causes

Adenoid hypertrophy, especially in children
Nasopharyngeal mass

Systemic causes

Hypothyroidism
Pregnancy-related rhinitis
Drug-induced rhinitis
Granulomatous disease

Important neonatal point

Bilateral choanal atresia presents soon after birth with cyclical cyanosis: cyanosis worsens during feeding or sleep and improves when the infant cries, because crying permits mouth breathing.

Very Short Viva Points

Commonest organism in malignant otitis externa: Pseudomonas aeruginosa.
Typical patient with malignant otitis externa: Elderly diabetic with severe nocturnal ear pain and granulation tissue in external auditory canal.
Commonest site of primary acquired cholesteatoma: Pars flaccida/attic.
Most commonly eroded ossicle in cholesteatoma: Long process of incus.
Most effective drug class in allergic rhinitis: Intranasal corticosteroids.
Preferred modern surgery for DNS: Septoplasty.
Bilateral choanal atresia: Neonatal airway emergency.
Unilateral foul-smelling nasal discharge in a child: Consider nasal foreign body first.

Give answers from standard textbook of ent of mbbs

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cholesteatoma AND treatment

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standard MBBS ENT textbook Dhingra diseases of ear nose throat head neck surgery latest edition

Below are MBBS exam-oriented answers in the usual Dhingra-style format. I do not have the text of Dhingra available to quote verbatim, so these are original notes following the standard Indian MBBS ENT presentation and terminology. Dhingra remains a standard undergraduate reference, with Elsevier listing the 8th edition as an official edition.

1. Deviated Nasal Septum (DNS)

Definition

Deviation of the nasal septum from the midline, producing narrowing of one or both nasal cavities.

Etiology

Developmental: disproportionate growth of septum and surrounding facial skeleton.
Traumatic:
- Birth trauma
- Childhood trauma
- Road traffic accidents, sports injuries, assault
Compensatory: deviation caused by hypertrophy of turbinate or lateral nasal wall.
Hereditary/familial factors.

Types

Anterior dislocation
C-shaped deviation
S-shaped deviation
Septal spur
Septal crest
Caudal deviation
High deviation

Symptoms

Nasal obstruction, unilateral or bilateral
Mouth breathing
Recurrent cold, rhinitis, or sinusitis
Headache due to contact point between septum and turbinate
Epistaxis due to crusting over a spur
Hyposmia/anosmia
Snoring
Eustachian-tube dysfunction, ear blockage, recurrent otitis media

Signs

On anterior rhinoscopy:

Deviation of septum
Spur or crest
Compensatory hypertrophy of opposite inferior turbinate
Crusting or bleeding point
Associated rhinitis, polyp, or sinus disease may be present

Treatment

Conservative

For mild symptoms or associated rhinitis:

Saline irrigation
Antihistamines
Intranasal steroid spray
Treatment of allergy/sinusitis

Surgical

Septoplasty is the operation of choice.

Indications:

Symptomatic nasal obstruction
Recurrent sinusitis due to DNS
Recurrent epistaxis from septal spur
Contact-point headache
To provide access for endoscopic sinus surgery
Before rhinoplasty in selected cases

2. Middle Ear Cavity and Its Walls

The middle ear is an air-containing cavity in the petrous temporal bone. It contains the auditory ossicles and transmits sound vibrations from tympanic membrane to inner ear.

Parts

Epitympanum or attic
Mesotympanum
Hypotympanum

Communications

Anteriorly: Eustachian tube with nasopharynx
Posteriorly: aditus ad antrum with mastoid antrum

Although commonly asked as “four walls,” the tympanic cavity has six walls: roof, floor, lateral, medial, anterior, and posterior.

1. Roof - Tegmental wall

Formed by tegmen tympani
Separates middle ear from middle cranial fossa and temporal lobe
A defect may lead to meningitis, CSF leak, or intracranial spread of infection

2. Floor - Jugular wall

Thin bony plate separating middle ear from jugular bulb
Hypotympanum lies here
May be deficient in a high jugular bulb

3. Lateral wall - Membranous wall

Formed mainly by:

Tympanic membrane
Lateral attic wall, called scutum

Clinical importance:

Pars flaccida retraction and attic cholesteatoma commonly occur in this area.

4. Medial wall - Labyrinthine wall

Separates middle ear from inner ear.

Features:

Promontory: produced by basal turn of cochlea
Oval window: occupied by footplate of stapes
Round window: covered by secondary tympanic membrane
Prominence of facial canal above oval window
Prominence of lateral semicircular canal posteriorly

5. Anterior wall - Carotid wall

Separates middle ear from internal carotid artery
Has opening of Eustachian tube in lower part
Has semicanal for tensor tympani muscle in upper part

6. Posterior wall - Mastoid wall

Features:

Aditus ad antrum in epitympanum
Pyramidal eminence, containing stapedius muscle
Vertical segment of facial nerve canal
Facial recess
Sinus tympani
Posterior canaliculus transmitting chorda tympani

3. Cholesteatoma

Definition

Cholesteatoma is a cystic lesion lined by keratinizing stratified squamous epithelium, containing desquamated keratin debris, located in the middle ear or mastoid and having the capacity to erode bone.

It is not a neoplasm.

Types

Congenital cholesteatoma
Acquired cholesteatoma
- Primary acquired
- Secondary acquired

A. Congenital Cholesteatoma

Definition

A cholesteatoma occurring behind an intact tympanic membrane, with no previous history of ear discharge, tympanic-membrane perforation, trauma, or ear surgery.

Etiology

It is believed to arise from embryonic epithelial cell rests in the middle ear.

Clinical features

Usually seen in children
Conductive hearing loss
Pearly white mass seen behind intact tympanic membrane
Usually located in anterosuperior quadrant
No past history of chronic suppurative otitis media

Treatment

Surgical excision
Tympanoplasty with or without mastoidectomy depending on extent
Ossicular reconstruction if needed
Long-term follow-up for residual or recurrent disease

B. Acquired Cholesteatoma

Primary acquired cholesteatoma

Occurs due to retraction of pars flaccida or posterosuperior pars tensa.

Mechanism

Eustachian tube dysfunction causes negative pressure in middle ear. This produces tympanic-membrane retraction pocket, which accumulates keratin debris and gradually forms cholesteatoma.

Secondary acquired cholesteatoma

Occurs due to migration of squamous epithelium into middle ear through:

Marginal perforation
Attic perforation
Traumatic perforation
Iatrogenic implantation following surgery

Clinical features

Scanty, foul-smelling otorrhoea
Conductive hearing loss
Attic crust
Retraction pocket with keratin debris
Marginal or attic perforation
Aural polyp/granulations
Vertigo, facial weakness, headache, or fever indicate complications

Complications

Intratemporal

Mastoiditis
Erosion of ossicles, especially long process of incus
Facial palsy
Labyrinthine fistula
Labyrinthitis
Petrositis

Intracranial

Meningitis
Extradural abscess
Subdural abscess
Temporal lobe abscess
Cerebellar abscess
Lateral sinus thrombosis

Treatment

Cholesteatoma is treated by surgery.

Aims:

Eradicate disease
Make ear safe and dry
Preserve or restore hearing
Prevent recurrence

Operations:

Atticotomy
Tympanoplasty
Canal-wall-up mastoidectomy
Canal-wall-down mastoidectomy
Modified radical mastoidectomy in extensive disease
Ossiculoplasty where appropriate

4. Allergic Rhinitis

Definition

Allergic rhinitis is an IgE-mediated inflammatory disease of nasal mucosa occurring after exposure to a specific allergen.

Types

Seasonal allergic rhinitis
Perennial allergic rhinitis
Intermittent allergic rhinitis
Persistent allergic rhinitis

Common allergens

House-dust mite
Pollens
Animal dander
Moulds/fungi
Cockroach allergens
Occupational dusts

Symptoms

Sneezing in paroxysms
Watery rhinorrhoea
Nasal blockage
Nasal itching
Itching of palate, throat, ear, or eyes
Postnasal drip
Loss/reduction of smell
Itching, redness, and watering of eyes

Signs

Pale, bluish, oedematous nasal mucosa
Watery nasal secretion
Enlarged inferior turbinates
Allergic shiners
Dennie-Morgan folds
Transverse nasal crease due to allergic salute
Associated asthma, eczema, nasal polyps, or otitis media with effusion

Investigations

History and examination
Skin-prick testing
Serum-specific IgE testing
Nasal smear: eosinophilia may be seen
Assessment for asthma and sinus disease

Treatment

1. Avoidance of allergen

Reduce dust exposure
Use mattress and pillow covers in dust-mite allergy
Wash bedding regularly in hot water
Avoid pets if sensitized
Avoid smoke, perfumes, and irritants

2. Medical treatment

Intranasal corticosteroids: first-line treatment
Examples: fluticasone, mometasone, budesonide
Oral second-generation antihistamines
Examples: cetirizine, levocetirizine, fexofenadine, loratadine
Intranasal antihistamine: azelastine
Saline nasal douching
Ipratropium nasal spray for profuse rhinorrhoea
Montelukast when asthma coexists

Do not use topical nasal decongestant drops for more than 3-5 days, as they may cause rhinitis medicamentosa.

3. Immunotherapy

Indicated when:

Specific allergen is identified
Symptoms are severe/persistent
Avoidance and drugs are inadequate

Types:

Subcutaneous immunotherapy
Sublingual immunotherapy

4. Surgery

Not a primary treatment. It is done only for associated structural disease, such as DNS, turbinate hypertrophy, or polyps.

5. Malignant Otitis Externa

Definition

Malignant otitis externa, also called necrotizing otitis externa, is a severe invasive infection beginning in the external auditory canal and extending to the temporal bone and skull base, causing skull-base osteomyelitis.

It is not a cancer.

Predisposing factors

Elderly age
Diabetes mellitus, especially poorly controlled diabetes
Immunocompromised state
HIV infection
Malignancy
Use of immunosuppressive medication

Causative organism

Pseudomonas aeruginosa is the commonest organism
Other organisms: Staphylococcus aureus, Aspergillus, Candida

Clinical features

Severe persistent otalgia, often worse at night
Pain disproportionate to ear findings
Persistent purulent otorrhoea
Oedema of external auditory canal
Granulation tissue at bony-cartilaginous junction of canal
Failure to improve with ordinary treatment for otitis externa
Facial palsy, the commonest cranial nerve palsy
In advanced disease: involvement of IX, X, XI, XII cranial nerves, headache, meningitis, altered consciousness

Investigations

Ear swab for culture and sensitivity
Fungal culture when appropriate
Biopsy of granulations to exclude carcinoma of external auditory canal
Blood sugar and HbA1c
ESR and CRP for monitoring
CT temporal bone to assess bone erosion
MRI to assess soft tissue, skull-base, and intracranial extension

Treatment

Control diabetes and correct immunosuppression where possible
Aural toilet
Culture-directed systemic antipseudomonal antibiotics
Oral ciprofloxacin may be used in selected susceptible, non-severe cases
Severe disease requires intravenous antipseudomonal treatment according to culture and local policy
Antifungal therapy if fungal infection is identified
Analgesia
Serial clinical examination, ESR, and CRP monitoring
Surgery has limited role: biopsy, drainage of abscess, or removal of sequestrum where required

Complications

Skull-base osteomyelitis
Facial palsy
Multiple cranial nerve palsies
Meningitis
Lateral sinus thrombosis
Intracranial abscess
Death

6. Difference Between Septoplasty and SMR

Feature	Septoplasty	SMR - Submucous Resection
Principle	Conservative correction of deviation	Extensive removal of septal cartilage and bone
Septal tissue	Only deviated/obstructing part is removed, repositioned, or reshaped	Large portion of deviated cartilage and bone is removed
Support	Dorsal and caudal support is preserved	Greater risk of loss of septal support
Deformity risk	Low risk of saddle nose	Higher risk of saddle-nose deformity, tip ptosis, and columellar retraction
Age	Can be performed in selected children	Generally avoided in children
Present role	Standard modern operation	Less commonly done, reserved for selected cases
Future reconstruction	More cartilage is preserved	Less cartilage may remain for future reconstruction

One-line answer: Septoplasty is a conservative operation that corrects deviation while preserving the septal framework, whereas SMR removes a larger part of septal cartilage and bone and therefore carries greater risk of external nasal deformity.

7. Causes of Nasal Obstruction

A. Unilateral Nasal Obstruction

Congenital

Unilateral choanal atresia
Unilateral choanal stenosis

Foreign body

Common in children
Usually causes unilateral foul-smelling purulent nasal discharge

Structural causes

DNS
Septal spur
Septal haematoma or abscess
Nasal valve collapse

Inflammatory/infective

Chronic rhinosinusitis
Fungal sinusitis
Unilateral turbinate hypertrophy
Antrochoanal polyp

Tumours and masses

Inverted papilloma
Juvenile nasopharyngeal angiofibroma
Carcinoma of nose/paranasal sinuses
Nasal vestibular tumour
Nasopharyngeal tumour
Encephalocele/meningoencephalocele
Granulomatous disease

Exam point: Persistent unilateral nasal obstruction with recurrent epistaxis or blood-stained discharge should be considered a tumour until proved otherwise.

B. Bilateral Nasal Obstruction

Congenital

Bilateral choanal atresia
Bilateral choanal stenosis
Congenital pyriform aperture stenosis

Rhinitis

Allergic rhinitis
Vasomotor/non-allergic rhinitis
Acute viral rhinitis
Rhinitis medicamentosa due to decongestant abuse

Structural causes

DNS with compensatory hypertrophy of turbinates
Bilateral inferior turbinate hypertrophy
Nasal valve collapse

Polyps

Ethmoidal polyposis
Extensive bilateral nasal polyps

Nasopharyngeal causes

Adenoid hypertrophy in children
Nasopharyngeal mass

Systemic causes

Hypothyroidism
Pregnancy rhinitis
Drug-induced rhinitis

Neonatal point: Bilateral choanal atresia causes cyclical cyanosis that becomes worse during feeding and improves when the baby cries.

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Dhingra Diseases of Ear Nose Throat Head Neck Surgery Elsevier India 8th edition ENT MBBS

These are MBBS exam-style notes in the standard Indian ENT textbook format used in texts such as Dhingra: Diseases of Ear, Nose and Throat & Head and Neck Surgery. The wording is summarized for revision, not reproduced verbatim.

1. Deviated Nasal Septum (DNS)

Definition

Deviation of the nasal septum from the midline, causing narrowing of one or both nasal cavities.

Etiology

Developmental: unequal growth of nasal septum and facial skeleton.
Traumatic:
- Birth trauma
- Trauma in childhood
- Injury in adult life
Compensatory: due to hypertrophy of turbinate or lateral nasal wall.
Hereditary/familial factors.

Types of septal deviation

C-shaped deviation
S-shaped deviation
Septal spur
Septal crest
Caudal dislocation
High septal deviation
Thickened septum

Symptoms

Nasal obstruction, unilateral or bilateral
Mouth breathing
Headache due to contact of septal spur with turbinate
Recurrent rhinitis and sinusitis
Epistaxis due to crusting over septal spur
Hyposmia
Snoring
Eustachian tube dysfunction and ear blockage

Signs

On anterior rhinoscopy:

Septal deviation, spur, crest, or dislocation
Compensatory hypertrophy of opposite inferior turbinate
Crusting or bleeding point
Coexisting rhinitis, polyp, or sinus infection

Treatment

Conservative

For mild symptoms or associated rhinitis:

Saline nasal wash
Antihistamines
Intranasal steroid spray
Treatment of allergy/sinusitis

Surgical

Septoplasty is the preferred operation.

Indications for septal surgery

Persistent nasal obstruction due to DNS
Recurrent sinusitis
Recurrent epistaxis due to spur
Contact-point headache
To facilitate endoscopic sinus surgery
Associated external nasal deformity, where septorhinoplasty may be needed

2. Middle Ear Cavity - Walls

The middle ear or tympanic cavity is an air-containing cavity in the temporal bone. It is divided into:

Epitympanum/attic
Mesotympanum
Hypotympanum

It communicates:

Anteriorly with nasopharynx through the Eustachian tube
Posteriorly with mastoid antrum through aditus ad antrum

The cavity has six walls. The four main vertical walls are lateral, medial, anterior, and posterior.

1. Lateral wall - Membranous wall

Formed mainly by:

Tympanic membrane
Scutum, which forms lateral wall of attic

Clinical importance: Pars flaccida retraction and attic cholesteatoma commonly occur here.

2. Medial wall - Labyrinthine wall

It separates middle ear from the inner ear.

Features:

Promontory: bulge produced by basal turn of cochlea
Oval window: occupied by footplate of stapes
Round window: covered by secondary tympanic membrane
Prominence of facial canal above oval window
Prominence of lateral semicircular canal posteriorly

3. Anterior wall - Carotid wall

Related to internal carotid artery.

Features:

Opening of Eustachian tube in lower part
Semicanal for tensor tympani muscle in upper part
Thin bony plate separates it from internal carotid artery

4. Posterior wall - Mastoid wall

Related to mastoid antrum.

Features:

Aditus ad antrum in epitympanum
Pyramidal eminence, containing stapedius muscle
Vertical segment of facial nerve canal
Facial recess
Sinus tympani
Posterior canaliculus for chorda tympani

5. Roof - Tegmental wall

Formed by tegmen tympani
Separates tympanic cavity from middle cranial fossa

6. Floor - Jugular wall

Thin plate of bone separating middle ear from jugular bulb
May be dehiscent in a high jugular bulb

3. Cholesteatoma

Definition

Cholesteatoma is a cystic lesion lined by keratinizing stratified squamous epithelium, containing keratin debris, situated in the middle ear or mastoid and capable of causing bone erosion.

It is not a true tumour and does not contain cholesterol.

Types

Congenital cholesteatoma
Acquired cholesteatoma
- Primary acquired
- Secondary acquired

A. Congenital cholesteatoma

Definition

It is cholesteatoma arising behind an intact tympanic membrane in a patient with no past history of ear discharge, tympanic membrane perforation, trauma, or ear surgery.

Criteria

Pearly white mass medial to intact tympanic membrane
Normal pars tensa and pars flaccida
No previous otorrhoea
No previous ear surgery or trauma

Etiology

It arises from embryonic epithelial cell remnants in the middle ear.

Clinical features

Usually found in children
Painless conductive hearing loss
White pearly mass behind intact tympanic membrane
Commonly in anterosuperior quadrant
No history of chronic suppurative otitis media

Treatment

Surgical removal
Tympanoplasty with or without mastoidectomy, depending on extent
Ossicular reconstruction when required
Regular follow-up for residual/recurrent disease

B. Acquired cholesteatoma

Primary acquired cholesteatoma

It develops from a retraction pocket, usually in:

Pars flaccida
Posterosuperior part of pars tensa

Pathogenesis

Eustachian tube dysfunction causes negative middle-ear pressure. This retracts the tympanic membrane, forming a retraction pocket. Keratin collects in the pocket, leading to cholesteatoma formation.

Secondary acquired cholesteatoma

Occurs due to migration of squamous epithelium into middle ear through:

Marginal perforation
Attic perforation
Traumatic perforation
Iatrogenic implantation following ear surgery

Clinical features

Scanty, foul-smelling ear discharge
Conductive hearing loss
Attic crust or keratin debris
Retraction pocket
Attic or marginal perforation
Granulation tissue or aural polyp
Vertigo, facial weakness, headache, or fever suggest complications

Complications

Intratemporal complications

Mastoiditis
Ossicular erosion, especially long process of incus
Facial nerve palsy
Labyrinthine fistula
Labyrinthitis
Petrositis

Intracranial complications

Meningitis
Extradural abscess
Subdural abscess
Temporal lobe abscess
Cerebellar abscess
Lateral sinus thrombosis

Treatment

Cholesteatoma is a surgical disease.

Aims of surgery

Eradicate disease
Create a safe and dry ear
Preserve or restore hearing
Prevent recurrence

Operations

Atticotomy
Tympanoplasty
Canal-wall-up mastoidectomy
Canal-wall-down mastoidectomy
Modified radical mastoidectomy in extensive disease
Ossiculoplasty, when indicated

4. Allergic Rhinitis

Definition

Allergic rhinitis is an IgE-mediated inflammatory disorder of nasal mucosa caused by exposure to an allergen in a sensitized person.

Types

Seasonal allergic rhinitis: commonly caused by pollens
Perennial allergic rhinitis: commonly caused by house dust mite, animal dander, moulds, etc.

It can also be classified as:

Intermittent/persistent
Mild/moderate-severe

Common allergens

House dust mite
Pollens
Animal dander
Moulds
Cockroach allergens
Occupational dusts

Symptoms

Paroxysmal sneezing
Watery rhinorrhoea
Nasal obstruction
Nasal itching
Itching of eyes, throat, palate, or ears
Postnasal drip
Reduced sense of smell
Watering, itching, and redness of eyes

Signs

Pale, bluish, oedematous nasal mucosa
Watery nasal discharge
Enlarged inferior turbinates
Allergic shiners
Transverse nasal crease due to repeated upward rubbing of nose
Dennie-Morgan folds
Associated asthma, eczema, nasal polyps, or otitis media with effusion

Investigations

Detailed history of triggers and seasonal variation
Anterior rhinoscopy/nasal endoscopy
Skin-prick test
Serum-specific IgE assay
Nasal smear may show eosinophilia

Treatment

1. Avoidance of allergen

Minimize house-dust exposure
Regular washing of bedding
Dust-mite-proof mattress and pillow covers
Avoid smoke and irritants
Avoid pets if the patient is sensitized

2. Medical treatment

Intranasal corticosteroids: most effective treatment for persistent symptoms
Examples: fluticasone, mometasone, budesonide
Oral antihistamines
Examples: cetirizine, levocetirizine, fexofenadine, loratadine
Intranasal antihistamines, such as azelastine
Sodium cromoglycate, especially for mild disease
Saline nasal douching
Ipratropium nasal spray for profuse watery rhinorrhoea
Leukotriene antagonists when asthma coexists

Topical nasal decongestants should not be used for more than 3-5 days because they can produce rhinitis medicamentosa.

3. Immunotherapy

Indicated in selected patients with:

Identified allergen
Persistent troublesome symptoms
Inadequate control with avoidance and medication

Methods:

Subcutaneous immunotherapy
Sublingual immunotherapy

4. Surgery

Not a primary treatment. It is considered only for associated lesions such as DNS, marked inferior turbinate hypertrophy, or nasal polyps.

5. Malignant Otitis Externa

Definition

Malignant otitis externa, now also called necrotizing otitis externa, is a severe invasive infection of the external auditory canal that extends to the temporal bone and skull base, producing skull-base osteomyelitis.

It is not a malignancy.

Predisposing factors

Elderly age
Diabetes mellitus, especially poorly controlled
Immunocompromised state
HIV infection
Malignancy
Immunosuppressive therapy

Causative organism

Pseudomonas aeruginosa is the commonest cause
Less commonly: Staphylococcus aureus, Aspergillus, and Candida

Clinical features

Severe, persistent otalgia, often worse at night
Otalgia out of proportion to otoscopic findings
Persistent purulent otorrhoea
Oedema of external auditory canal
Granulation tissue at bony-cartilaginous junction of external auditory canal
Failure to respond to ordinary treatment for otitis externa
Facial palsy is the commonest cranial nerve palsy
Advanced cases may involve IX, X, XI, and XII cranial nerves

Investigations

Ear discharge culture and sensitivity
Biopsy of granulation tissue to rule out carcinoma of external auditory canal
Blood sugar and HbA1c
ESR and CRP for follow-up
CT scan of temporal bone for bone erosion
MRI for skull-base, soft-tissue, and intracranial extension

Treatment

Control diabetes
Aural toilet
Culture-directed systemic antipseudomonal antibiotics
Oral ciprofloxacin in selected mild disease if organism is susceptible
Intravenous antipseudomonal antibiotics for severe disease
Antifungal treatment if fungal cause is identified
Analgesics
Regular clinical examination and ESR/CRP monitoring

Surgery has a limited role and is done for:

Biopsy
Drainage of abscess
Removal of sequestrum, if present

Complications

Skull-base osteomyelitis
Facial palsy
Multiple cranial nerve palsies
Meningitis
Lateral sinus thrombosis
Intracranial abscess
Death

6. Difference Between Septoplasty and SMR

Feature	Septoplasty	SMR - Submucous Resection
Nature	Conservative operation	More radical operation
Principle	Corrects deviated portions while preserving septal support	Removes a large part of cartilage and bone
Cartilage removal	Only obstructing/deviated portion removed or repositioned	Major part of deviated cartilage and bone removed
Septal support	Dorsal and caudal strut preserved	Greater loss of support
Age	Can be done in selected children	Usually avoided in children
Complications	Less chance of deformity	More chance of saddle nose, tip ptosis, and columellar retraction
Present role	Preferred modern procedure	Less commonly performed now

One-line answer: Septoplasty is a conservative correction of deviated septum preserving structural support, whereas SMR involves extensive removal of septal cartilage and bone.

7. Causes of Unilateral and Bilateral Nasal Obstruction

A. Unilateral nasal obstruction

Congenital

Unilateral choanal atresia
Unilateral choanal stenosis

Foreign body

Common in children
Typically causes unilateral foul-smelling purulent nasal discharge

Structural

Deviated nasal septum
Septal spur
Septal haematoma/abscess
Nasal valve collapse

Inflammatory/infective

Chronic rhinosinusitis
Fungal sinusitis
Unilateral turbinate hypertrophy
Antrochoanal polyp

Tumours/masses

Inverted papilloma
Juvenile nasopharyngeal angiofibroma
Carcinoma of nose or paranasal sinuses
Nasopharyngeal tumour
Encephalocele/meningoencephalocele
Granulomatous lesions

Important point: Unilateral persistent nasal obstruction associated with epistaxis or blood-stained discharge must be investigated for malignancy.

B. Bilateral nasal obstruction

Congenital

Bilateral choanal atresia
Bilateral choanal stenosis
Congenital pyriform aperture stenosis

Rhinitis

Allergic rhinitis
Vasomotor/non-allergic rhinitis
Acute infective rhinitis
Rhinitis medicamentosa due to prolonged decongestant use

Structural

DNS with compensatory hypertrophy of inferior turbinates
Bilateral turbinate hypertrophy
Nasal valve collapse

Polyps

Ethmoidal polyposis
Extensive bilateral nasal polyps

Nasopharyngeal causes

Adenoid hypertrophy, especially in children
Nasopharyngeal mass

Systemic causes

Hypothyroidism
Pregnancy-related rhinitis
Drug-induced rhinitis

Important neonatal point: Bilateral choanal atresia causes cyclical cyanosis. Cyanosis worsens during feeding and improves when the child cries.

Reproduce with exact verbatim from standard textbook of ent for above questions

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Exam-ready notes closely following standard MBBS ENT headings from Dhingra/K. J. Lee style, in original wording.
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For standard reference, use:

Diseases of Ear, Nose and Throat & Head and Neck Surgery - P. L. Dhingra and Shruti Dhingra
K. J. Lee’s Essential Otolaryngology
Scott-Brown’s Otorhinolaryngology and Head and Neck Surgery

The notes already provided are original, MBBS-oriented summaries rather than verbatim reproduction.

Exam-ready notes closely following standard MBBS ENT headings from Dhingra/K. J. Lee style, in original wording.

Reading File

Finding Sources

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allergic rhinitis AND treatment

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cholesteatoma AND treatment

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necrotizing otitis externa AND treatment

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Dhingra Diseases of Ear Nose Throat Head Neck Surgery standard MBBS ENT textbook Elsevier India

MBBS ENT Exam-ready Notes

These are original, exam-oriented notes arranged in the usual headings used in standard undergraduate ENT texts such as Dhingra and K. J. Lee. The current Dhingra 9th edition is described by its publisher as revised to the CBME curriculum. See the publisher listing.

1. Deviated Nasal Septum (DNS)

Definition

Deviation of the nasal septum from the median plane, causing narrowing of one or both nasal cavities.

Etiology

Developmental: unequal growth of nasal septum and surrounding facial skeleton.
Traumatic:
- Birth trauma
- Childhood injury
- Trauma in adult life
Compensatory: due to hypertrophy of turbinates or lateral nasal wall.
Hereditary/familial factors.

Types

C-shaped deviation
S-shaped deviation
Septal spur
Septal crest
Caudal dislocation
High septal deviation
Thickened septum

Symptoms

Unilateral or bilateral nasal obstruction
Mouth breathing
Headache due to contact between septal spur and turbinate
Recurrent rhinitis or sinusitis
Epistaxis due to crusting over spur
Hyposmia
Snoring
Eustachian tube dysfunction with ear blockage or recurrent otitis media

Signs

On anterior rhinoscopy:

Deviation of septum
Septal spur or crest
Compensatory hypertrophy of opposite inferior turbinate
Crusting, ulceration, or bleeding point
Associated rhinitis, polyp, or sinus disease

Treatment

Medical treatment helps associated rhinitis but cannot correct a fixed deviation:

Saline nasal irrigation
Antihistamines
Intranasal steroid spray

Surgical treatment: Septoplasty

Indications for septal surgery

Persistent nasal obstruction due to DNS
Recurrent sinusitis
Recurrent epistaxis from septal spur
Contact-point headache
To facilitate endoscopic sinus surgery
Associated external nasal deformity, where septorhinoplasty may be needed

2. Middle Ear Cavity: Four Walls

The tympanic cavity is an air-containing space in the temporal bone. It communicates anteriorly with the nasopharynx through the Eustachian tube and posteriorly with the mastoid antrum through the aditus ad antrum.

For examination, the four vertical walls are as follows.

A. Lateral wall - Membranous wall

Formed mainly by:

Tympanic membrane
Scutum, which forms lateral wall of epitympanum or attic

Clinical importance: Pars flaccida retraction and attic cholesteatoma commonly arise in this region.

B. Medial wall - Labyrinthine wall

This wall separates middle ear from inner ear.

Features:

Promontory: produced by basal turn of cochlea
Oval window: occupied by footplate of stapes
Round window: closed by secondary tympanic membrane
Prominence of facial canal above oval window
Prominence of lateral semicircular canal posteriorly

C. Anterior wall - Carotid wall

Related to internal carotid artery.

Features:

Opening of Eustachian tube in lower part
Semicanal for tensor tympani muscle in upper part
Thin bony plate separates cavity from internal carotid artery

D. Posterior wall - Mastoid wall

Related to mastoid antrum.

Features:

Aditus ad antrum in epitympanum
Pyramidal eminence containing stapedius muscle
Vertical part of facial canal
Facial recess
Sinus tympani
Posterior canaliculus for chorda tympani

Other two walls

Roof or tegmental wall: tegmen tympani, separates middle ear from middle cranial fossa.
Floor or jugular wall: thin bony plate separating middle ear from jugular bulb.

3. Cholesteatoma

Definition

Cholesteatoma is a sac lined by keratinizing stratified squamous epithelium, containing keratin debris, located in the middle ear or mastoid and capable of eroding bone.

It is not a true tumour.

Types

Congenital cholesteatoma
Acquired cholesteatoma
- Primary acquired
- Secondary acquired

A. Congenital Cholesteatoma

Definition

A cholesteatoma occurring behind an intact tympanic membrane in a patient with no previous ear discharge, perforation, trauma, or ear surgery.

Etiology

It is thought to arise from embryonic epithelial cell remnants in the middle ear.

Clinical features

Usually presents in children
Painless conductive hearing loss
Pearly-white mass behind an intact tympanic membrane
Often seen in the anterosuperior quadrant
No history of chronic suppurative otitis media

Treatment

Surgical removal
Tympanoplasty with or without mastoidectomy according to extent
Ossicular reconstruction if necessary
Long-term follow-up for residual/recurrent disease

B. Acquired Cholesteatoma

Primary acquired cholesteatoma

Arises from a retraction pocket, commonly in:

Pars flaccida
Posterosuperior part of pars tensa

Pathogenesis

Eustachian tube dysfunction causes negative pressure in middle ear. The tympanic membrane retracts and forms a pocket. Keratin accumulates in this pocket and produces cholesteatoma.

Secondary acquired cholesteatoma

Occurs due to migration of squamous epithelium into middle ear through:

Marginal perforation
Attic perforation
Traumatic perforation
Iatrogenic implantation after surgery

Clinical features

Scanty, foul-smelling otorrhoea
Conductive hearing loss
Retraction pocket containing keratin debris
Attic crust
Attic or marginal perforation
Aural polyp or granulations
Vertigo, facial weakness, headache, or fever indicate complication

Complications

Intratemporal

Mastoiditis
Ossicular erosion, especially long process of incus
Facial palsy
Labyrinthine fistula
Labyrinthitis
Petrositis

Intracranial

Meningitis
Extradural abscess
Subdural abscess
Temporal lobe abscess
Cerebellar abscess
Lateral sinus thrombosis

Treatment

Cholesteatoma is essentially a surgical disease.

Aims of surgery

Eradicate disease
Produce a safe, dry ear
Preserve or restore hearing
Prevent recurrence

Operations

Atticotomy
Tympanoplasty
Canal-wall-up mastoidectomy
Canal-wall-down mastoidectomy
Modified radical mastoidectomy in extensive disease
Ossiculoplasty, when indicated

4. Allergic Rhinitis

Definition

Allergic rhinitis is an IgE-mediated inflammatory disorder of nasal mucosa following exposure to an allergen in a sensitized individual.

Types

Seasonal allergic rhinitis: commonly due to pollens
Perennial allergic rhinitis: commonly due to house-dust mite, animal dander, moulds, etc.

It can also be classified as:

Intermittent or persistent
Mild or moderate-severe

Common allergens

House-dust mite
Pollens
Animal dander
Moulds
Cockroach allergens
Occupational dusts

Symptoms

Paroxysmal sneezing
Watery rhinorrhoea
Nasal obstruction
Nasal itching
Itching of palate, throat, ears, and eyes
Postnasal drip
Hyposmia
Itching, redness, and watering of eyes

Signs

Pale, bluish, oedematous nasal mucosa
Watery nasal secretion
Enlarged inferior turbinates
Allergic shiners
Transverse nasal crease due to repeated upward rubbing of nose
Dennie-Morgan folds
Associated asthma, eczema, nasal polyps, or otitis media with effusion

Investigations

History of allergen exposure and seasonal variation
Anterior rhinoscopy and nasal endoscopy
Skin-prick test
Serum-specific IgE
Nasal smear may show eosinophilia

Treatment

1. Allergen avoidance

Reduce exposure to dust and smoke
Regular hot washing of bedding
Dust-mite-proof covers for pillow and mattress
Avoid pets if sensitized
Avoid perfumes and environmental irritants

2. Medical treatment

Intranasal corticosteroids: most effective for persistent disease
Examples: fluticasone, mometasone, budesonide
Oral antihistamines
Examples: cetirizine, levocetirizine, fexofenadine, loratadine
Intranasal antihistamine, for example azelastine
Sodium cromoglycate in mild disease
Saline nasal douching
Ipratropium nasal spray for profuse watery rhinorrhoea
Leukotriene antagonist where asthma coexists

Do not use topical nasal decongestants for more than 3-5 days, as they may cause rhinitis medicamentosa.

3. Immunotherapy

Indicated in selected patients with:

A definite identified allergen
Persistent/severe symptoms
Inadequate response to avoidance and drugs

Methods:

Subcutaneous immunotherapy
Sublingual immunotherapy

4. Surgery

Not a primary treatment. It may be used for associated obstruction due to DNS, turbinate hypertrophy, or nasal polyps.

5. Malignant Otitis Externa

Definition

Malignant otitis externa, also called necrotizing otitis externa, is a severe invasive infection beginning in the external auditory canal and extending to temporal bone and skull base, causing skull-base osteomyelitis.

It is not a malignancy.

Predisposing factors

Elderly age
Diabetes mellitus, especially poorly controlled diabetes
Immunocompromised state
HIV infection
Malignancy
Immunosuppressive drugs

Causative organism

Pseudomonas aeruginosa is the commonest causative organism.
Less commonly: Staphylococcus aureus, Aspergillus, Candida.

Clinical features

Severe deep otalgia, classically worse at night
Pain disproportionate to otoscopic findings
Persistent purulent otorrhoea
Oedema of external auditory canal
Granulation tissue at bony-cartilaginous junction of canal
Failure to respond to routine treatment of otitis externa
Facial nerve palsy, the commonest cranial nerve palsy
Advanced cases may involve cranial nerves IX, X, XI, and XII

Investigations

Ear discharge for culture and sensitivity
Biopsy of granulation tissue to exclude carcinoma of external auditory canal
Blood glucose and HbA1c
ESR and CRP for monitoring
CT temporal bone to evaluate bone erosion
MRI to detect skull-base, soft-tissue, and intracranial spread

Treatment

Control diabetes and treat immunosuppression where possible
Aural toilet
Culture-directed systemic antipseudomonal antibiotics
Oral ciprofloxacin in selected mild disease with a susceptible isolate
Intravenous antipseudomonal therapy in severe disease
Antifungal treatment where a fungal cause is confirmed
Analgesics
Clinical and inflammatory-marker monitoring

Role of surgery

Limited role. It is done for:

Biopsy
Drainage of abscess
Removal of sequestrum, if present

Complications

Skull-base osteomyelitis
Facial palsy
Multiple cranial nerve palsies
Meningitis
Lateral sinus thrombosis
Intracranial abscess
Death

6. Difference Between Septoplasty and SMR

Feature	Septoplasty	SMR - Submucous resection
Nature	Conservative procedure	More radical procedure
Principle	Corrects deviated parts while preserving septal framework	Removes a large part of septal cartilage and bone
Cartilage removal	Only obstructing/deviated portions are removed, repositioned, or reshaped	Major part of cartilage and bony septum is resected
Support	Dorsal and caudal support is preserved	Greater risk of loss of septal support
Age	Can be done in selected children if necessary	Usually avoided in children
Complications	Lower chance of deformity	Greater risk of saddle nose, tip ptosis, and columellar retraction
Present role	Preferred modern operation	Used less often now

One-line answer

Septoplasty is a conservative operation that corrects the deviated septum while preserving support. SMR removes a larger portion of septal cartilage and bone, and hence has a higher risk of external nasal deformity.

7. Causes of Nasal Obstruction

A. Unilateral Nasal Obstruction

Congenital

Unilateral choanal atresia
Unilateral choanal stenosis

Foreign body

Common in children
Produces unilateral foul-smelling purulent nasal discharge

Structural

Deviated nasal septum
Septal spur
Septal haematoma
Septal abscess
Nasal valve collapse

Inflammatory/Infective

Chronic rhinosinusitis
Fungal sinusitis
Unilateral turbinate hypertrophy
Antrochoanal polyp

Tumours and Masses

Inverted papilloma
Juvenile nasopharyngeal angiofibroma
Carcinoma of nose or paranasal sinuses
Nasopharyngeal tumour
Encephalocele/meningoencephalocele
Granulomatous lesions

Important exam point: Persistent unilateral nasal obstruction with epistaxis or blood-stained discharge should be investigated for a neoplasm.

B. Bilateral Nasal Obstruction

Congenital

Bilateral choanal atresia
Bilateral choanal stenosis
Congenital pyriform aperture stenosis

Rhinitis

Allergic rhinitis
Vasomotor/non-allergic rhinitis
Acute infective rhinitis
Rhinitis medicamentosa due to prolonged use of decongestants

Structural

DNS with compensatory hypertrophy of inferior turbinates
Bilateral inferior turbinate hypertrophy
Nasal valve collapse

Polyps

Ethmoidal polyposis
Extensive bilateral nasal polyps

Nasopharyngeal Causes

Adenoid hypertrophy, particularly in children
Nasopharyngeal mass

Systemic Causes

Hypothyroidism
Pregnancy-related rhinitis
Drug-induced rhinitis

Important neonatal point

Bilateral choanal atresia produces cyclical cyanosis. Cyanosis is worse during feeding and improves when the child cries.

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