---

🏥 ENT COMPLETE REVISION NOTES

(10-Marker + 5-Marker + 3-Marker Topics)

---

PART A - 10 MARKERS

---

1. CSOM (Tubotympanic / Safe) - Etiology, Clinical Features, Management

• Sequel to acute otitis media (most common)
• Eustachian tube dysfunction (adenoid hypertrophy, cleft palate, URTI)
• Organisms: Pseudomonas aeruginosa (most common), Staphylococcus aureus, Proteus, E. coli, Klebsiella
• Anaerobes: Bacteroides fragilis
• Predisposing: poor socioeconomic status, malnutrition, repeated URTI

• Central (pars tensa) perforation - SAFE type
• No cholesteatoma, no ossicular erosion typically
• Mucosa: goblet cell hyperplasia, granulation tissue

• Discharge: Mucoid/mucopurulent, profuse, intermittent (comes with URTI), NOT offensive
• Hearing loss: Conductive, mild to moderate (15-40 dB)
• No pain (pain = danger sign)
• No tinnitus typically
• Otoscopy: Central perforation, visible middle ear mucosa, may see light reflex loss

• Otoscopy / Microscopy
• Pure Tone Audiometry (CHL)
• Swab C&S
• HRCT temporal bone (if surgery planned)
• X-ray mastoid (Schuller's view) - sclerotic mastoid

• Conservative: Dry mopping, ear drops (ciprofloxacin + dexamethasone), systemic antibiotics during active infection, water precautions
• Surgical: Myringoplasty (repair perforation only, ossicles intact) or Tympanoplasty (Type I-V)
  • Type I (Myringoplasty): only TM repaired
  • Type II: TM + malleus head
  • Type III: TM to stapes head (myringostapediopexy)
  • Type IV: TM to footplate
  • Type V: fenestration

---

2. Atticoantral Disease (Unsafe CSOM) & Cholesteatoma

• Cholesteatoma erodes bone (collagenase enzyme) - can erode: ossicles, semicircular canals, facial nerve canal, tegmen, dural plate
• Risk of intracranial complications

• NOT a true tumor - accumulation of desquamating keratinized squamous epithelium
• Contains: keratin debris + stratified squamous epithelium (matrix) + perimatrix
• Enzymes: Collagenase, protease - bone resorption

1. Invagination theory (Wittmaack) - most accepted - negative middle ear pressure invaginates pars flaccida
2. Migration theory (Habermann) - squamous epithelium migrates through marginal perforation
3. Metaplasia theory (Wendt) - middle ear mucosa undergoes metaplastic change
4. Basal cell hyperplasia theory (Ruedi) - hyperproliferation of basal cells of pars flaccida

• Discharge: Scanty, FOUL SMELLING (offensive), NOT profuse - hallmark
• Hearing loss: Conductive (or mixed if labyrinth involved)
• Attic/marginal perforation on otoscopy
• White pearly mass visible in attic
• Keratin flakes

• Mastoiditis, labyrinthitis (vertigo), facial nerve palsy, meningitis, brain abscess, lateral sinus thrombophlebitis, Gradenigo syndrome, extradural abscess, subdural abscess

• Vertigo
• Facial nerve palsy
• Headache/meningism
• Offensive discharge
• Attic perforation
• Sensorineural hearing loss (labyrinthine erosion)

• Canal Wall Up (CWU) Mastoidectomy - cortical mastoidectomy / modified radical mastoidectomy preserving posterior canal wall
• Canal Wall Down (CWD) / Radical Mastoidectomy - removes posterior canal wall, creates mastoid cavity (open cavity) - more reliable for cholesteatoma removal
• Modified Radical Mastoidectomy (Bondy) - radical but preserves hearing mechanism
• Second-look surgery in 12 months for CWU

---

3. Deviated Nasal Septum (DNS)

• Birth trauma (most common cause) - forceps delivery
• Trauma - nasal fracture
• Differential growth - unequal growth of nasal bones vs. septal cartilage
• Hereditary factors

• Nasal obstruction (most common complaint) - unilateral or bilateral
• Recurrent sinusitis (due to OMC obstruction)
• Recurrent epistaxis (from Little's area on deviated side)
• Headache (contact headache - vacuum headache)
• Hyposmia
• Nasal twang in voice
• Compensatory hypertrophy of inferior turbinate on opposite (concave) side
• Rhinitis sicca on convex side

• Anterior rhinoscopy, nasal endoscopy
• CT scan PNS (for surgery planning)
• X-ray PNS (Water's view, Caldwell view)

• Conservative: Nasal decongestants, treat sinusitis
• Surgical: Septoplasty (preferred) or SMR (Submucous Resection)

---

4. Epistaxis - Causes and Management

• Anteroinferior septum - anastomosis of:
  1. Anterior ethmoidal artery (from ophthalmic a. - ICA)
  2. Sphenopalatine artery (from ECA)
  3. Greater palatine artery (from ECA)
  4. Superior labial artery (from ECA)
• Most common site of epistaxis (90%)

• Local: trauma (nose picking most common), infections, DNS, polyps, tumors (angiofibroma, carcinoma), foreign body, dry climate (rhinitis sicca)
• Systemic: hypertension (most common systemic cause), blood dyscrasias (thrombocytopenia, hemophilia, leukemia), anticoagulants, hepatic disease, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu), arteriosclerosis, drugs (aspirin, NSAIDs)
• Idiopathic: most common overall

1. First Aid: Pinch nose (Little's area), lean forward, ice pack on forehead
2. Local measures: Silver nitrate cautery, electrocautery - for anterior bleeding point
3. Anterior nasal packing: BIPP (Bismuth Iodoform Paraffin Paste) pack / ribbon gauze - 48 hrs
4. Posterior nasal packing: Foley catheter or Brighton balloon or post-nasal pack (Bellocq's cannula) - for posterior bleeding
5. Endoscopic sphenopalatine artery ligation - if packing fails
6. Surgical ligation: Anterior/posterior ethmoid arteries (for HHT or recurrent)
7. Embolization: Interventional radiology - for recurrent/refractory cases

---

5. Acute and Chronic Rhinosinusitis

Acute Rhinosinusitis (ARS):

• Viral (most common): Rhinovirus, Adenovirus, Coronavirus
• Bacterial (secondary): S. pneumoniae (most common), H. influenzae, M. catarrhalis, S. aureus, Anaerobes
• Predisposing: URTI, DNS, OMC obstruction, swimming, dental infection (maxillary)

• Facial pain/pressure (worse on bending forward)
• Nasal obstruction, purulent nasal discharge
• Fever, headache
• Maxillary: cheek/molar pain; Frontal: forehead; Ethmoid: between eyes; Sphenoid: vertex/occiput pain
• Postnasal drip, cough, loss of smell

• Viral: Supportive - steam inhalation, saline nasal irrigation, decongestants
• Bacterial: Amoxicillin (first line), Amox-clav (second line); intranasal steroids; analgesics
• Duration: 10-14 days

Chronic Rhinosinusitis (CRS):

• Persistent nasal obstruction, purulent discharge
• Facial pressure (dull), reduced smell
• Nasal polyps may be present

• Medical: Intranasal corticosteroids (mainstay), saline irrigation, antibiotics (long-term low dose macrolides)
• Surgical: FESS (Functional Endoscopic Sinus Surgery) - opens OMC, restores mucociliary drainage

---

6. Allergic Rhinitis

• Intermittent (< 4 days/week OR < 4 weeks) vs. Persistent (> 4 days/week AND > 4 weeks)
• Mild vs. Moderate-Severe

• Sensitization phase: Antigen → IgE production → IgE bound to mast cells
• Early phase (0-1 hr): Re-exposure → mast cell degranulation → histamine, leukotrienes, prostaglandins → sneezing, rhinorrhea, itch
• Late phase (4-8 hrs): Eosinophil influx → nasal blockage, hyposmia

• Classic triad: Sneezing, watery rhinorrhea, nasal itching
• Nasal obstruction (late phase)
• Pale/bluish congested mucosa (NOT red)
• Allergic salute (upward wiping), allergic crease, allergic shiners (dark circles)
• Associated: allergic conjunctivitis, asthma, eczema

• Skin prick test (gold standard for sensitization)
• Serum specific IgE (RAST/ELISA)
• Nasal smear: Eosinophilia
• Nasal provocation test

1. Allergen avoidance
2. Intranasal corticosteroids (most effective for nasal symptoms - mainstay)
3. Antihistamines (H1-blockers) - for sneezing/rhinorrhea; 2nd gen preferred (loratadine, cetirizine, fexofenadine)
4. Decongestants (oxymetazoline - max 3-5 days to avoid rhinitis medicamentosa)
5. Leukotriene receptor antagonists (montelukast)
6. Immunotherapy (SCIT/SLIT) - only disease-modifying treatment

---

7. Otosclerosis

• Genetic (OTSC1-OTSC10 loci)
• Measles virus (paramyxovirus) - implicated
• Fluoride deficiency
• Hormonal (exacerbated by pregnancy)

• Foci of spongy vascular bone (otospongiosis) at Fissula ante fenestram (most common site - anterior to oval window)
• Stapes footplate fixation → conductive hearing loss
• Cochlear otosclerosis → SNHL

• Bilateral, progressive CHL (insidious onset)
• Paracusis Willisii - hears better in noisy environment (because others speak louder)
• Tinnitus (low frequency)
• Otoscopy: NORMAL TM; Schwartze sign (pink/reddish glow through TM - active otospongiosis, "flamingo pink")
• No discharge, no pain

• CHL with Carhart's Notch (dip at 2000 Hz on bone conduction)
• Carhart's Notch: Mechanical effect of stapes fixation on BC - not true sensorineural loss; disappears after stapedectomy

• Surgical: Stapedectomy / Stapedotomy (definitive)
  • Stapedectomy: Total removal of stapes + vein/fat graft over footplate + prosthesis
  • Stapedotomy (preferred): Small hole drilled in footplate + Teflon/platinum piston prosthesis
  • Rosén's mobilization: historical, rarely done
• Sodium fluoride (stabilizes cochlear otosclerosis - preserves SNHL from progressing)
• Hearing aids (if surgery refused or SNHL dominant)
• Contraindications to surgery: Only hearing ear, active middle ear infection, severe SNHL, elderly

---

8. Meniere's Disease

1. Episodic vertigo: Sudden, severe, rotatory; lasts 20 min to 12 hrs (average 2-4 hrs); prostrating, with nausea/vomiting
2. Fluctuating SNHL: Low frequency initially; worsens with attacks; eventually permanent
3. Tinnitus: Low-pitched roaring/buzzing; worse before/during attack
4. Aural fullness/pressure

• Early: Good inter-attack hearing
• Late: Permanent hearing loss, attacks less severe

• PTA: Low frequency SNHL (up, flat, or pan-frequency later)
• Recruitment (SISI test positive, Fowler's test)
• Tympanometry: Normal (Type A)
• ECoG (Electrocochleography): SP/AP ratio > 0.4 (diagnostic)
• Glycerol test: Hearing improves >10 dB after glycerol administration (confirms hydrops)
• MRI: R/O acoustic neuroma

• Conservative (first-line):
  • Low sodium diet (< 2g/day), avoid caffeine, alcohol, stress
  • Diuretics: Thiazides (bendroflumethiazide), acetazolamide
  • Betahistine (H3 antagonist) - improves microcirculation in stria vascularis
  • Vestibular suppressants for acute attack: Prochlorperazine, diazepam
  • Intratympanic gentamicin (chemical labyrinthectomy - sacrifices vestibular function)
  • Intratympanic dexamethasone
• Surgical:
  • Endolymphatic sac decompression/shunt (hearing-preserving)
  • Vestibular nerve section (hearing-preserving, definitive for vertigo)
  • Labyrinthectomy (destroys all hearing - last resort in non-serviceable ear)

---

9. Hearing Aids - Types, Indications & Care

• Hearing loss > 25-30 dB (mild HL)
• SNHL not amenable to surgery
• Pre-op/post-op CHL
• Elderly presbycusis
• Child: ASAP (for speech development)

• Adults: Severe-profound bilateral SNHL, hearing aid benefit < 50% sentence recognition
• Children: > 12 months old (now even younger), profound SNHL

• Remove at night, open battery door
• Avoid moisture, heat, hairspray
• Clean earmold with mild soap
• Check batteries regularly
• Keep away from pets/small children
• Regular audiologist follow-up

---

10. Carcinoma Larynx

• Glottis: Hoarseness (early, persistent > 3 weeks = red flag) → dyspnea, stridor (late)
• Supraglottis: Throat discomfort, dysphagia, muffled voice (hot potato voice), neck nodes (late)
• Subglottis: Stridor, dyspnea
• Weight loss, referred otalgia (via vagus nerve - Arnold's nerve)

• T1: Limited to site, normal mobility
• T2: Extension to adjacent region, impaired mobility
• T3: Cord fixation
• T4: Cartilage invasion / extralaryngeal spread

• Indirect laryngoscopy (first-line)
• Direct laryngoscopy + biopsy (gold standard)
• CT/MRI neck and chest
• CXR (mets)
• PET scan (metastasis)

• T1-T2: Radiotherapy or partial laryngectomy (organ preservation)
  • T1 glottis: Radiation alone - 90% cure rate
  • Laser cordectomy (CO2 laser) for T1
• T3-T4: Total laryngectomy + neck dissection + post-op radiotherapy
• Neck dissection for nodes: Radical, modified radical, selective
• Chemotherapy: Cisplatin-based, with RT (chemoradiation) for organ preservation
• Induction chemo → larynx preservation protocols

• Tracheoesophageal voice (prosthesis, TEP - most natural)
• Electrolarynx
• Esophageal voice (least satisfying)

---

11. Tracheostomy - Indications, Procedure & Complications

• Upper airway obstruction: Foreign body, tumor, trauma, angioedema, bilateral RLN palsy, subglottic stenosis
• Prolonged ventilation: ICU patients, head injury, neuromuscular disease
• Pulmonary toilet: Inability to clear secretions, retained secretions
• Laryngeal surgery: Pre/post total laryngectomy, laryngeal trauma
• Prophylactic: Before major head/neck surgery
• Neonatal: Subglottic stenosis, choanal atresia

1. Supine, neck extended, sandbag under shoulders
2. Horizontal skin incision between 2nd-3rd tracheal ring (midline)
3. Divide strap muscles, thyroid isthmus divided/retracted
4. Incision in trachea: vertical in children, horizontal flap (Björk flap) in adults
5. Insert tracheostomy tube (cuffed for ventilation, uncuffed for airway protection)
6. Secure with ties/suture
7. Do NOT perform above 1st ring (subglottic stenosis risk)

• Immediate: Hemorrhage, air embolism, esophageal injury, recurrent laryngeal nerve injury, apnea
• Intermediate: Tube displacement, tube blockage, infection, subcutaneous emphysema, pneumothorax
• Late: Tracheal stenosis (most common late complication), tracheomalacia, tracheoesophageal fistula, scar, difficulty decannulation, dysphonia

• Emergency airway through cricothyroid membrane (between thyroid and cricoid cartilage)
• Quicker than tracheostomy
• Converted to formal tracheostomy within 24-72 hrs to prevent subglottic stenosis

---

12. Acute Tonsillitis & Tonsillectomy

Acute Tonsillitis:

• Viral (most common): Adenovirus, EBV, Rhinovirus, Influenza
• Bacterial: Group A beta-hemolytic Streptococcus pyogenes (GABHS) - most important bacterial cause
• Others: Staphylococcus, H. influenzae, mixed anaerobes

• Children: Fever (high), sore throat, odynophagia, dysphagia, referred otalgia
• Tonsillar enlargement, erythematous tonsils
• Exudate (follicular/membrane) - whitish spots on crypts
• Cervical lymphadenopathy (jugulodigastric node - most commonly enlarged)
• Halitosis
• Trismus (peritonsillar extension)

• Viral: Supportive (analgesics, rest, fluids)
• Bacterial: Phenoxymethylpenicillin (Penicillin V) for 10 days (to prevent rheumatic fever)
• If penicillin allergic: Erythromycin
• Avoid ampicillin/amoxicillin (if EBV - causes maculopapular rash)
• Antipyretics, gargles

Tonsillectomy:

• Obstructive sleep apnoea (OSA)
• Peritonsillar abscess (recurrent/2nd episode)
• Suspected tonsillar malignancy
• Chronic tonsillitis with systemic manifestations (nephritis, rheumatic fever)
• Airway/feeding obstruction in children
• Diphtheria carrier

• ≥ 7 episodes/year, or ≥ 5 episodes/year for 2 years, or ≥ 3 episodes/year for 3 years
• • Adequate antibiotic therapy + adequate documentation

• Bleeding diathesis
• Active infection (wait 3 weeks)
• Age < 2 years (tonsils form part of immune tissue)
• Uncontrolled systemic disease

• Primary hemorrhage (within 24 hrs) - surgical failure
• Reactionary hemorrhage (within 24 hrs - 6 hrs) - reactionary bleeding
• Secondary hemorrhage (5-10 days post-op) - most common, due to infection/sloughing eschar; treat conservatively/re-explore

---

13. Peritonsillar Abscess (Quinsy)

• Weber's glands (mucous glands of soft palate) infection may be primary source

• Unilateral sore throat (rapidly worsening)
• Severe odynophagia, dysphagia (drooling of saliva)
• Trismus (spasm of pterygoid muscles - key feature)
• Muffled/hot potato voice
• Uvula displaced to opposite side
• Bulging of anterior pillar and soft palate on affected side
• Ipsilateral jugulodigastric node enlargement
• Fever, malaise

• Needle aspiration (diagnostic + therapeutic) - first line in many centres
• Incision and drainage (I&D) - at point of maximum bulge (above and lateral to tonsil, below uvula)
• Antibiotics: IV penicillin + metronidazole
• Interval tonsillectomy (after 6 weeks) - controversial; immediate "hot" tonsillectomy if repeated or severe

---

14. Foreign Body Bronchus

• History of choking episode (key)
• Asthma triad (Peanut FB): Cough, wheeze, reduced breath sounds on affected side
• 3 Stages:
  • Immediate: Violent coughing, choking, cyanosis, wheeze
  • Asymptomatic interval: FB lodged, symptoms settle (dangerous - delay in diagnosis)
  • Complication stage: Pneumonia, atelectasis, bronchiectasis, abscess, emphysema

• Radio-opaque FB: Visible on plain X-ray
• Radio-lucent FB: Indirect signs - obstructive emphysema (air trapping), atelectasis, mediastinal shift
• Inspiratory-expiratory X-ray: Mediastinal shift away from affected side on expiration (check valve obstruction → air trapping → hyperinflation)

• Rigid bronchoscopy under GA - gold standard for removal
• Heimlich maneuver as first aid (only conscious patients with complete obstruction)
• Back blows for infants < 1 year
• Avoid blind finger sweep
• Post-removal: CXR, bronchodilators, antibiotics if secondary infection

---

15. Facial Nerve Paralysis - Bell's Palsy

• Sudden-onset, unilateral facial weakness (all divisions)
• Inability to close eye (lagophthalmos) → corneal exposure
• Bell's phenomenon - upward/outward rolling of eyeball when closing eye (protective reflex)
• Drooping of mouth angle, nasolabial fold flattening
• Incomplete closure of eye (lagophthalmos)
• Hyperacusis (stapedius nerve involved)
• Loss of taste anterior 2/3 tongue (chorda tympani)
• Decreased lacrimation (if GSPN involved)

• Schirmer's test (lacrimation), ENOG (electroneuronography), EMG
• MRI (to exclude other causes)

• Oral prednisolone (50 mg/day x 10 days) - started within 72 hrs - significantly improves recovery
• Acyclovir (antiviral - for suspected HSV/VZV) - benefit debated, added to steroids
• Eye care: Lubricating eye drops, eye pad at night, dark glasses - CRITICAL to prevent corneal ulceration
• Physiotherapy, facial muscle exercises
• Prognosis: 80-85% recover completely (partial palsy better prognosis); recovery within 3-6 months
• Surgical decompression: Controversial, reserved for ENOG >90% degeneration

---

PART B - 5 MARKERS (EAR)

---

Tuning Fork Tests ⭐⭐⭐

Rinne's Test:

• Principle: Compare air conduction (AC) vs. bone conduction (BC)
• Method: 512 Hz fork - place on mastoid (BC), then 2 cm from EAC (AC)
• Rinne Positive (Normal): AC > BC (AC heard longer) - Normal or SNHL
• Rinne Negative: BC > AC - CHL (air-bone gap > 25-30 dB)
• False Negative Rinne: BC heard on better (contralateral) ear in unilateral deafness; need masking
• Preferred fork: 512 Hz (best compromise sensitivity/specificity)

Weber's Test:

• Principle: Lateralization of bone-conducted sound
• Method: Fork placed on vertex/forehead/upper incisors
• Lateralizes to WORSE ear: CHL (increased BC due to background noise reduction)
• Lateralizes to BETTER ear: SNHL
• No lateralization: Normal or symmetrical loss

Absolute Bone Conduction (ABC) Test:

• Schwabach's Test: Compare patient's BC with examiner's (assumed normal)
• Normal: Equal (normoschwabach)
• Reduced: CHL (enhanced BC) or SNHL (diminished BC)

Stenger's Test:

• For malingering / non-organic hearing loss (unilateral)

Summary Table:

---

Pure Tone Audiometry (PTA)

• Right ear AC: O (red); BC: [ (red, masked), < (unmasked)
• Left ear AC: X (blue); BC: ] (blue, masked), > (unmasked)

• CHL: AC raised, BC normal (air-bone gap)
• SNHL: Both AC and BC raised equally (no air-bone gap)
• Mixed HL: Both raised, BC better than AC (some air-bone gap)

• 0-25 dB: Normal
• 26-40 dB: Mild
• 41-55 dB: Moderate
• 56-70 dB: Moderately severe
• 71-90 dB: Severe

• 90 dB: Profound

---

Carhart's Notch

• Definition: A dip in bone conduction audiogram at 2000 Hz in otosclerosis (±500 Hz and 4000 Hz also affected, but 2000 Hz most consistently)
• Cause: Mechanical resonance of stapes - stapes fixation impairs the mechanical transfer function of BC at these frequencies
• NOT true SNHL - artifact of stapes fixation on BC testing
• Diagnostic significance: Confirms stapes fixation (otosclerosis)
• Reversible: Disappears after successful stapedectomy/stapedotomy
• Key exam point: Sometimes confused with SNHL - remember it is a MECHANICAL artifact

---

BPPV (Benign Paroxysmal Positional Vertigo)

• Canalithiasis: Free-floating particles (most common)
• Cupulolithiasis: Particles adherent to cupula

• Brief vertigo (< 1 minute) with specific positional change
• Common trigger: Turning in bed, bending forward, looking up
• No hearing loss, no tinnitus (labyrinth not involved)
• Nausea/vomiting

• Posterior canal BPPV: Geotropic (upbeat + torsional) nystagmus after latent period (2-5 sec), fatigable, lasts < 60 sec

• Epley's maneuver (canalith repositioning procedure) - 80-90% effective in posterior canal BPPV
• Semont maneuver (liberatory maneuver)
• Brandt-Daroff exercises (for home therapy)
• Horizontal canal BPPV: Barbecue roll (Lempert maneuver)
• Surgery (posterior canal occlusion): Very rarely for intractable cases

---

Ototoxicity

---

Acute Mastoiditis

• Post-auricular swelling, tenderness (most diagnostic sign)
• Pinna displaced forward and downward (auricle pushed anteroinferiorly)
• Post-auricular erythema
• Sagging of posterior meatal wall (pathognomonic of coalescent mastoiditis)
• Fever, ear pain, discharge
• Preceding history of AOM (ear pain improving then worsening = coalescence)

• HRCT temporal bone (gold standard) - clouding of mastoid cells, bony destruction
• Blood: TLC raised, raised CRP
• Ear swab

• IV antibiotics (initial conservative)
• Cortical mastoidectomy if no improvement in 24-48 hrs or abscess
• Incision and drainage of subperiosteal abscess
• Myringotomy if AOM not draining

---

Foreign Body Ear

• Inanimate: Beads, rubber, pencil tips, cotton wool
• Vegetable matter: Seeds, peas (swell with moisture - NEVER syringe)
• Insects: Cockroaches, flies (alive)

• Insects (live): FIRST - instill oil/spirit/xylocaine to kill insect, then remove with forceps/syringe
• Hard smooth objects: Hook/probe/crocodile forceps
• Syringing (if intact TM, NOT for vegetable matter, NOT for button batteries)
• Button battery - EMERGENCY, must remove within 1 hour (alkali liquefaction necrosis)
• Under GA: Children, impacted, failed office removal, risk of TM perforation

---

Keratosis Obturans

• BILATERAL (vs. external ear cholesteatoma - unilateral)
• Severe ear pain (due to pressure on bony canal - erodes bone)
• Conductive hearing loss
• Associated with bronchiectasis and sinusitis (triad)
• EAC: Widened bony canal, pearly white mass filling canal
• Unlike EAC cholesteatoma - no sac, no localized bone erosion, bilateral

---

Myringotomy

• Acute otitis media with bulging TM unresponsive to antibiotics
• Secretory/serous otitis media (with grommet insertion)
• Barotrauma with middle ear effusion
• Myringotomy for middle ear access in acute mastoiditis
• Otitic barotrauma

• Shephard's grommet (most common - stays 6-12 months)
• T-tube (stays 2+ years)
• Equalizes pressure, drains effusion, allows aeration of ME

---

Secretory Otitis Media (Glue Ear)

• Painless CHL (15-40 dB) in a child
• Delayed speech/language development
• Inattention, poor school performance
• Otoscopy: Dull retracted TM, loss of light reflex, air-fluid level/bubbles visible through TM, amber/blue discoloration

• Tympanometry: Type B (flat) curve (most characteristic) - limited or no TM movement
• PTA: CHL
• Hearing in noise test

• Watchful waiting for 3 months (most resolve spontaneously)
• Autoinflation (Otovent balloon)
• Treat underlying cause (adenoids, allergy)
• Myringotomy + Grommet (VT) insertion - for persistent cases > 3 months with bilateral CHL ≥ 25-30 dB
• Adenoidectomy (reduces recurrence)

---

Sudden Sensorineural Hearing Loss (SSNHL)

• Sudden unilateral SNHL (often on waking)
• Tinnitus (frequent)
• Aural fullness
• Vertigo (perilymph fistula or labyrinthitis)
• NO discharge, NO pain

• Oral high-dose corticosteroids (prednisolone 1 mg/kg/day x 10-14 days) - first-line
• Intratympanic dexamethasone (for failed systemic steroids or as adjunct)
• Bed rest, vasodilators (controversial)
• Antiviral (if herpes suspected)
• Prognosis: 33% recover spontaneously; better prognosis with mild loss, low-frequency loss, no vertigo, early treatment

---

Fistula Test

• Positive pressure applied to EAC (by pressing tragus or Siegle's speculum)
• Positive fistula test (Hennebert's sign): Vertigo and nystagmus (fast phase toward pressure for +ve pressure) = perilymph fistula or labyrinthine fistula
• Tullio phenomenon: Sound-induced vertigo/nystagmus (superior canal dehiscence)

• Positive in labyrinthine fistula (cholesteatoma erosion of lateral SCC)
• Positive in superior canal dehiscence syndrome (SCDS)
• Positive in perilymph fistula
• Negative test does NOT rule out fistula (false negative if canal blocked by cholesteatoma)

---

Aural Syringing

• Perforated TM (water can enter middle ear → otitis media)
• Acute otitis externa
• Previous radical mastoid cavity
• History of ear surgery
• Vegetable matter (swells further)
• Button battery (chemical injury)

• Body-temperature water (37°C) - CRITICAL (hot/cold → caloric vertigo)
• Direct jet toward posterosuperior meatal wall (not directly at TM)
• Patient holds a kidney dish
• Check after each syringe

---

PART B - 5 MARKERS (NOSE)

---

Osteomeatal Complex (OMC) ⭐⭐⭐

1. Infundibulum
2. Middle meatus
3. Uncinate process
4. Frontal recess
5. Ethmoid bulla (largest anterior ethmoid cell)
6. Middle turbinate
7. Hiatus semilunaris (cleft between uncinate process and ethmoid bulla)

• Maxillary sinus drains → infundibulum → hiatus semilunaris → middle meatus
• Anterior ethmoid + frontal → frontal recess → middle meatus
• OMC obstruction (DNS, polyps, inflammation) → recurrent rhinosinusitis
• Target of FESS (restore OMC drainage)

---

Anatomy of Lateral Wall of Nose

• Superior turbinate (concha)
• Middle turbinate
• Inferior turbinate (largest - most relevant clinically)

• Superior meatus: Posterior ethmoid sinuses drain
• Middle meatus: Frontal, anterior ethmoid, maxillary (via OMC)
• Inferior meatus: Nasolacrimal duct opens (via valve of Hasner)

• Sphenopalatine artery (Woodruff's plexus posteriorly)
• Anterior and posterior ethmoidal arteries
• Greater palatine, superior labial arteries (Little's area anteriorly)

---

Saddle Nose Deformity

• Septal surgery (SMR - excess cartilage removal)
• Septal hematoma → abscess → necrosis
• Wegener's granulomatosis
• Syphilis (tertiary - saddle nose + perforation)
• Leprosy
• Nasal trauma
• Relapsing polychondritis
• Cocaine abuse (midline destructive granuloma)

---

Rhinosporidiosis

• Slow-growing, polypoid, strawberry-like (lobulated, vascular) mass
• Bleeds easily on touch
• Nasal obstruction, epistaxis
• Nasal polyp that bleeds on touch = Rhinosporidiosis until proven otherwise

---

Fungal Rhinosinusitis

---

Septal Perforation

• Surgical (most common): Post-SMR, septoplasty
• Trauma: Nasal picking, foreign body
• Infections: Syphilis (saddlenose + perforation), TB, Wegener's, leprosy
• Chemicals: Chromic acid (industrial), cocaine
• Neoplastic: Lymphoma, carcinoma

• Anterior perforation: Crusting, epistaxis, whistling sound on breathing
• Posterior perforation: Often asymptomatic or nasal obstruction
• Large perforation: Saddle nose deformity

• Small: Conservative - saline irrigation, petroleum jelly
• Prosthetic button (septal obturator)
• Surgical repair: Bipedicled mucosal flap, cartilage graft

---

Septal Abscess

• Complication of septal hematoma (most common)
• Direct trauma with infection
• Furuncle in vestibule

• Bilateral nasal obstruction (both sides)
• Pain, tenderness, fever
• Fluctuant swelling bulging BOTH sides of septum

• Septal cartilage necrosis → saddle nose deformity
• Cavernous sinus thrombosis (via facial vein → angular vein) - through dangerous area of face
• Meningitis, brain abscess, orbital cellulitis

• URGENT I&D (both sides) through Killian's incision
• IV antibiotics (anti-staphylococcal)
• Nasal pack/quilting sutures to obliterate dead space

---

Rhinolith

• Unilateral nasal obstruction
• Foul-smelling discharge (chronic)
• Epistaxis
• Usually found on floor of nose

---

Anterior vs Posterior Epistaxis (see main Epistaxis section above)

---

Nasal Decongestants

• Topical: Oxymetazoline (Otrivin), xylometazoline - alpha-2 agonists; act within 10 min; DO NOT USE > 3-5 days (rhinitis medicamentosa)
• Oral: Pseudoephedrine, phenylephrine - longer acting, systemic effects (hypertension, tachycardia)

---

Mucociliary Clearance

• Periciliary layer (sol layer): Low-viscosity, allows ciliary beating
• Mucous layer (gel layer): Traps particles/pathogens
• Cilia: 200/cell, beat 10-15 times/second (metachronal rhythm)

• Ciliary dyskinesia (Kartagener syndrome - situs inversus + bronchiectasis + infertility)
• Cystic fibrosis (thick mucus)
• Smoking (paralyzes cilia)
• Viral infections
• Dry air, dehydration
• Rhinosinusitis

---

Olfactory Area

• Olfactory epithelium (bipolar neurons) → olfactory filaments → cribriform plate → olfactory bulb → olfactory tract → primary olfactory cortex (uncus/piriform cortex)

• Pseudostratified with olfactory receptor neurons, sustentacular cells, Bowman's glands

• Anosmia: Loss of smell - trauma (cribriform plate fracture), ZN (zinc deficiency), tumors, COVID-19
• Parosmia: Distorted smell
• Kakosmia: Perception of foul smell
• Olfactory groove meningioma: Foster Kennedy syndrome (ipsilateral optic atrophy + contralateral papilledema)

---

Nasal Myiasis

• Foul-smelling blood-stained discharge
• Nasal obstruction, pain
• Visible crawling maggots in nasal cavity
• Facial swelling, septal/turbinate destruction if severe

• Turpentine oil drops (paralyze/kill maggots)
• Mechanical removal (forceps, suction)
• Ivermectin (systemic)
• Treat underlying necrotic tissue

---

X-ray PNS (Paranasal Sinuses)

• Mucosal thickening (>5mm)
• Air-fluid level (acute sinusitis)
• Opacification
• Displacement of bones (tumor)

---

PART B - 5 MARKERS (THROAT & LARYNX)

---

Waldeyer's Ring ⭐⭐⭐

1. Pharyngeal tonsil (adenoids) - posterior wall of nasopharynx
2. Tubal tonsils (of Gerlach) - bilateral, around Eustachian tube opening
3. Palatine tonsils - most prominent, between anterior and posterior pillars (tonsillar fossa)
4. Lingual tonsil - base of tongue (posterior 1/3)

• Main: Tonsillar branch of facial artery
• Also: Lingual, ascending pharyngeal, greater palatine, descending palatine arteries

• Site of tonsillitis, quinsy, lymphoma
• Most common lymphoma of Waldeyer's ring: NHL (Non-Hodgkin's Lymphoma)

---

Acute Epiglottitis ⭐⭐⭐

• Rapid onset (hours)
• High fever
• 3 D's: Dysphagia, Dysphonia (muffled "hot potato voice"), Drooling
• Odynophagia
• Tripod/sniffing position (child leans forward, neck extended - to keep airway open)
• Stridor (inspiratory) - soft, NOT high-pitched
• Toxicity out of proportion to neck findings

• X-ray neck (lateral view): "Thumb sign" (swollen epiglottis)
• Only after secure airway - blood cultures

1. AIRWAY FIRST - senior anaesthetist + ENT surgeon together
2. Do NOT examine throat of a distressed child
3. Secure airway in OT: oral intubation or nasotracheal intubation (preferred in children)
4. Tracheostomy on standby
5. IV ceftriaxone/cefuroxime (3rd gen cephalosporin) for 7-10 days
6. Steroids (IV dexamethasone) - reduce edema
7. Rifampicin prophylaxis for close contacts

---

Gradenigo Syndrome

1. Otorrhoea (discharging ear - CSOM/AOM)
2. Retro-orbital/retroauricular pain (CN V - trigeminal ganglion irritation)
3. Lateral rectus palsy/diplopia (CN VI - Abducens nerve compression in Dorello's canal)

---

MacEwen's Triangle (Suprameatal Triangle)

• Anterior: Posterosuperior bony canal wall
• Posterior: Posterior root of zygoma (spine of Henle)
• Superior: Supramastoid crest

---

Adult vs. Infant Larynx

---

Congenital Lesions of Larynx

---

Laryngomalacia

• Most common cause of inspiratory stridor in neonates
• Pathophysiology: Immature/floppy supraglottic structures (aryepiglottic folds, arytenoids) collapse inward on inspiration
• Stridor: Inspiratory, high-pitched, "crowing" - better prone, worse supine, worse feeding/crying, worse with URTI
• Associated with GERD (triggers/worsens)
• Diagnosis: Flexible laryngoscopy (gold standard) - collapse of supraglottis on inspiration
• Treatment:
  • Most resolve by 18 months (conservative)
  • Severe (failure to thrive, desaturations): Supraglottoplasty (CO2 laser or cold steel division of aryepiglottic folds)
  • GERD treatment

---

Ludwig's Angina

• Bilateral submandibular swelling (hard, brawny, woody - NOT fluctuant)
• Elevated, displaced tongue
• Trismus, drooling
• "Bull neck" appearance
• Systemic toxicity
• Airway compromise (major risk) - stridor, hoarse voice

• AIRWAY FIRST (awake fibreoptic intubation preferred; tracheostomy standby)
• IV antibiotics: Penicillin + metronidazole OR clindamycin
• Surgical drainage (bilateral neck incision + drain)
• If abscess confirmed: I&D through external neck incision and intraorally

---

Microlaryngeal Surgery (MLS) / Suspension Laryngoscopy

• Biopsy of laryngeal lesions
• Excision of vocal nodules, polyps, cysts
• Arytenoidectomy
• Laser excision of early glottic carcinoma (T1, T2)
• Treatment of stenosis, web, granuloma
• Reinke's edema (microflap technique)

---

Obstructive Sleep Apnea (OSA)

• Mild OSA: AHI 5-14
• Moderate OSA: AHI 15-29
• Severe OSA: AHI ≥ 30

• Weight loss (most effective long-term)
• CPAP (Continuous Positive Airway Pressure) - gold standard treatment
• Mandibular advancement device (MAD) - mild-moderate
• Positional therapy (avoid supine)
• Surgery: Uvulopalatopharyngoplasty (UPPP), tonsillectomy/adenoidectomy (children), genioglossus advancement, maxillomandibular advancement

---

Vocal Nodules

• Voice rest + Voice therapy (first-line for all)
• Surgery (microlaryngoscopy - cold instrument excision) ONLY if conservative fails after 6 months

---

Premalignant Lesions of Larynx

---

Rhinolalia Clausa (Hyponasality)

---

Thornwaldt Disease (Tornwaldt's Cyst)

• Crusting postnasal discharge
• Nasal obstruction
• Posterior head/neck pain, eustachian tube dysfunction
• Visible midline nasopharyngeal cyst on endoscopy/MRI

---

Levels of Neck Nodes

---

Muscles of Larynx

---

PART C - 3 MARKERS (EAR)

---

Ear Wax (Cerumen / Impacted Cerumen)

• Causes: Narrow EAC, excessive hair, improper use of cotton buds (push in), hearing aid use
• Symptoms: Hearing loss (CHL), tinnitus, ear fullness, cough (Arnold's nerve), otalgia

• Softening: Olive oil/sodium bicarbonate drops for 3-5 days before removal
• Irrigation/Syringing: Body-temp water (contraindicated: perforation, previous surgery, vegetable FB)
• Microsuction (safest, no contraindications)
• Wax hook/Jobson Horne probe (under direct vision)

---

Tympanoplasty

• Types I-V (see CSOM section above)
• Myringoplasty = Tympanoplasty Type I

• PORP (Partial): Connects graft to stapes capitulum (intact stapes)
• TORP (Total): Connects graft to stapes footplate

---

Grommet (Ventilation Tube / VT)

• Purpose: Equalize middle ear pressure, drain effusion
• Indication: Persistent secretory otitis media > 3 months with bilateral CHL ≥ 25 dB
• Type: Shephard's (stays 6-12 months, most common), T-tube (long term, 2+ years)
• Complications: Otorrhoea (most common post-grommet), TM perforation (persistent after extrusion), cholesteatoma, tympanosclerosis
• Water precautions: Avoid submerging ears (use plugs for swimming)

---

Mastoid Antrum

• First mastoid cell to develop (present at birth)
• Located 1.25 cm deep to center of MacEwen's triangle
• Communicates with epitympanum via aditus
• Always involved in mastoiditis
• Surgical landmark for mastoidectomy

---

Eustachian Tube Functions

1. Ventilation/Pressure equalization: Maintains equal pressure between middle ear and atmosphere; opens with swallowing, yawning (tensor veli palatini muscle)
2. Drainage/Clearance: Mucociliary drainage of middle ear secretions → nasopharynx
3. Protection: Acts as valve preventing nasopharyngeal secretions/pathogens from entering middle ear

• Length: 35 mm (adult)
• Bony part (1/3): Opens into tympanum
• Cartilaginous part (2/3): Opens into nasopharynx
• Normally CLOSED at rest; opens with swallowing/yawning
• Children: More horizontal, shorter, wider → increased middle ear infections

---

Presbycusis

1. Sensory: Outer hair cell (OHC) loss at basal turn → high-frequency loss
2. Neural: Cochlear neuron degeneration → poor speech discrimination disproportionate to PTA
3. Strial (metabolic): Stria vascularis atrophy → flat audiogram; best prognosis for hearing aids
4. Mechanical (Cochlear): Stiffening of basilar membrane → gradual descending audiogram

---

Noise-Induced Hearing Loss (NIHL)

• Causes bilateral SNHL with 4000 Hz notch (C5 dip)
• Temporary Threshold Shift (TTS) - recovers within 24 hrs after noise exposure
• Permanent Threshold Shift (PTS) - OHC death, permanent
• Safe exposure: 85 dB for 8 hrs (OSHA standard); every 3 dB increase halves safe duration
• Treatment: Hearing protection, hearing aids; no recovery of lost hearing
• 4 kHz notch pathognomonic (resonant frequency of EAC = 3.5 kHz, peak stress to OHC at 4 kHz)

---

Recruitment

• Small increases in intensity perceived as disproportionately loud
• Indicates cochlear (hair cell) pathology - NOT retrocochlear
• Tests: SISI test (>60% = positive recruitment = cochlear); Fowler's alternate binaural loudness balance test (ABLB)
• Clinical: Patient says "Don't shout!" or uses telephone on low volume while needing loud sounds for threshold

---

Vertigo

---

Caloric Test (Hallpike Caloric Test)

• Cold water → nystagmus beats AWAY from stimulated side
• Warm water → nystagmus beats TOWARD stimulated side

• Canal Paresis (CP): Reduced response on one side = vestibular lesion on that side
• Directional Preponderance (DP): Both stimuli produce nystagmus predominantly one direction = central lesion

---

Facial Nerve Course (CN VII)

1. Meatal segment (IAC - 8 mm) - exits brainstem, enters IAC
2. Labyrinthine segment (3-5 mm) - narrowest and most tortuous; geniculate ganglion (first genu); gives off Greater Superficial Petrosal Nerve (GSPN) - lacrimation
3. Tympanic/horizontal segment (10-12 mm) - runs in medial wall of middle ear (above oval window); Nerve to Stapedius branches
4. Mastoid/vertical segment (13-16 mm) - Chorda tympani (taste anterior 2/3 tongue, submandibular/sublingual gland secretion); exits at stylomastoid foramen

---

PART C - 3 MARKERS (NOSE)

---

Little's Area / Kiesselbach's Plexus

• Anteroinferior part of nasal septum
• 4 vessels meet: AEA, SPA, GPA, SLA
• 90% of epistaxes originate here
• Rich submucosal plexus - prone to bleeding with dry air, nose picking

---

Functions of Nose

1. Respiratory passage: Humidification (adds ~1L water/day), warming (to 37°C), filtration (particles >10 µm removed)
2. Olfaction: CN I - smell detection
3. Resonance: Nasal consonants (m, n, ng), voice quality
4. Defense: Mucociliary clearance, IgA secretion, lysozyme
5. Reflex functions: Sneeze reflex (CN V afferent, various efferents)
6. Nasolacrimal drainage: Inferior meatus (valve of Hasner)

---

Paranasal Sinuses

---

Dangerous Area of Face

• Facial veins in this area have NO valves
• Communicate with cavernous sinus via angular vein → ophthalmic vein → cavernous sinus
• Infection (furunculosis, septal abscess) can spread directly to cavernous sinus → Cavernous sinus thrombosis (CST)

---

Nasal Packing

• BIPP ribbon gauze (Bismuth Iodoform Paraffin Paste)
• Layered in anteroposterior direction (from floor to roof)
• Left for 24-48 hours
• Complications: Toxic shock syndrome, sinusitis, pressure necrosis, hypoxia, patient discomfort

• For posterior epistaxis
• Foley catheter (10-12 Fr): Inflate balloon (10-15 mL) in nasopharynx
• Brighton balloon: Dual balloon system
• Bellocq's cannula: Traditional rope pack drawn through nostril

---

FESS (Functional Endoscopic Sinus Surgery)

• CRS not responding to medical treatment
• Nasal polyps (with sinusitis)
• Fungal rhinosinusitis
• Mucocele, retention cysts
• Complications of sinusitis
• Biopsy of lesions
• Access to skull base, pituitary, orbit

• Major: CSF leak (cribriform plate), blindness (orbital fat/nerve injury), intracranial bleeding
• Minor: Bleeding, adhesions, anosmia, epiphora (nasolacrimal duct injury)

---

Rhinoplasty

• Open rhinoplasty: Columellar incision + bilateral rim incisions - better access, longer healing
• Closed rhinoplasty: Endonasal incisions only - no external scar

---

Choanal Atresia

• Bilateral (Neonatal emergency): Neonates are obligate nasal breathers → cyanosis at rest, relieved by crying (opens mouth); diagnosis: failure to pass catheter through nose
• Unilateral: Usually detected later - unilateral nasal discharge, obstruction

• Bilateral: Immediate airway (oral airway/McGovern nipple), then early surgical correction (transnasal endoscopic approach or transpalatal)
• Unilateral: Elective endoscopic surgery

---

Nasal Polyps

• Medical: Intranasal corticosteroids (shrinks polyps, prevents recurrence), oral steroids for large polyps
• Surgical: FESS with polypectomy (high recurrence rate = 60-70%); Ethmoidectomy for recurrent polyps
• Aspirin desensitization for Samter's triad

---

PART C - 3 MARKERS (THROAT/LARYNX)

---

Killian's Dehiscence

• Site of Zenker's diverticulum (pharyngo-oesophageal pulsion diverticulum)
• Zenker's features: Dysphagia (regurgitation of undigested food), halitosis, neck swelling, aspiration pneumonia

---

Tonsillar Bed

• Anterior: Anterior pillar (palatoglossus muscle)
• Posterior: Posterior pillar (palatopharyngeus muscle)
• Lateral: Superior constrictor (pharyngeal wall) - most important surgical plane
• Superior: Soft palate
• Inferior: Tongue base

• Internal carotid artery - lateral (closest major vessel, 2.5 cm from tonsillar fossa)
• Ascending pharyngeal artery
• Glossopharyngeal nerve (IX) - at inferior pole

---

Adenoids

• Nasal obstruction → mouth breathing, rhinolalia clausa, sleep disturbance, OSA
• Snoring, restless sleep
• Hyponasal speech
• ET obstruction → secretory otitis media, recurrent AOM
• Adenoid facies: Open mouth, elongated face, high arched palate, malocclusion, gaping expression

• Persistent nasal obstruction/mouth breathing
• Secretory otitis media/recurrent AOM (with grommet insertion)
• OSA in children (with tonsillectomy)
• Recurrent rhinosinusitis

---

Voice Abuse

• Vocal nodules (most common - teachers, singers, children)
• Reinke's edema (smokers)
• Contact granuloma (posterior glottis - arytenoid granuloma, from hard glottal attacks)
• Vocal polyps

---

Reinke's Space

• Reinke's Edema (Polypoid Corditis): Bilateral diffuse edema of Reinke's space → low-pitched, rough voice, "witch's voice"; associated with heavy smoking + voice abuse + hypothyroidism
• Space allows free vibration of mucosa over underlying vocalis muscle
• Microlaryngoscopy (microflap technique) accesses and evacuates Reinke's space
• Lesions of Reinke's space respond to smoking cessation; microlaryngoscopy for persistent cases

---

Cricothyrotomy

• Needle cricothyrotomy: 14G cannula; temporary (< 30-45 min)
• Surgical cricothyrotomy: Incision + tube; definitive emergency airway

---

Indirect Laryngoscopy (IDL)

• Anterior (in mirror) = POSTERIOR structures (arytenoids, piriform fossae)
• Posterior (in mirror) = ANTERIOR structures (epiglottis, vallecula)

---

Recurrent Laryngeal Nerve (RLN)

• Right RLN: Loops around right subclavian artery
• Left RLN: Loops around aortic arch (ligamentum arteriosum) - LONGER
• Ascends in tracheoesophageal groove to enter larynx posterior to cricothyroid joint

• Unilateral: Hoarseness, breathy voice, aspiration; cord in paramedian position (adductor spasm)
• Bilateral: Stridor (abductors paralyzed first - Semon's law)

---

External Laryngeal Nerve (ELN)

• "High-risk nerve" in thyroidectomy - runs close to superior thyroid vessels
• Crichlow's sign: Loss of high-pitched phonation, cannot sustain high notes (singer's nerve)
• Vocal fatigue, slight change in voice quality, reduced pitch range

---

Safety Muscle of Larynx

• Only ABDUCTOR of vocal cord
• Origin: Posterior surface of cricoid lamina
• Insertion: Muscular process of arytenoid cartilage
• Nerve: Recurrent laryngeal nerve (CN X)
• Function: Lateral rotation of arytenoid → abducts/opens glottis

• Cords in median/paramedian position (adductors overpower)
• Stridor, respiratory distress (acute emergency)
• Aphonia
• Treatment: Tracheostomy (emergency), then arytenoidectomy/laterofixation (long term)

---

Semon's Law

• Partial RLN lesion → cord in paramedian (near midline) position (abductors gone, adductors intact)
• Complete RLN lesion → cord in intermediate/cadaveric position (all fibers gone)
• Bilateral partial RLN palsy (bilateral thyroid surgery) → both cords in median position → acute respiratory distress (requires tracheostomy)

---

Berry's Ligament

• RLN is in close proximity to (or passes through) Berry's ligament - point of maximum risk during thyroidectomy
• Ligation of inferior thyroid artery + dense Berry's ligament dissection = highest RLN risk zone
• Must identify RLN before ligating near Berry's ligament

---

✅ COVERAGE CHECKLIST

10 Markers - ALL COVERED ✅

• CSOM Tubotympanic
• Atticoantral Disease & Cholesteatoma
• DNS
• Epistaxis
• Acute & Chronic Rhinosinusitis
• Allergic Rhinitis
• Otosclerosis
• Meniere's Disease
• Hearing Aids
• Carcinoma Larynx
• Tracheostomy
• Acute Tonsillitis & Tonsillectomy
• Peritonsillar Abscess
• Foreign Body Bronchus
• Bell's Palsy / Facial Nerve Paralysis

5-Marker Ear - ALL COVERED ✅

• Tuning Fork Tests
• Pure Tone Audiometry
• Carhart's Notch
• BPPV
• Ototoxicity
• Acute Mastoiditis
• Foreign Body Ear
• Keratosis Obturans
• Myringotomy
• Secretory Otitis Media
• Sudden SNHL
• Fistula Test
• Aural Syringing
• Theories of Cholesteatoma (under Atticoantral)

5-Marker Nose - ALL COVERED ✅

• Septoplasty vs SMR (under DNS)
• OMC
• Anatomy of Lateral Wall of Nose
• Saddle Nose Deformity
• Rhinosporidiosis
• Fungal Rhinosinusitis
• Septal Perforation
• Septal Abscess
• Rhinolith
• Little's Area
• Anterior vs Posterior Epistaxis (under Epistaxis)
• Nasal Decongestants
• Mucociliary Clearance
• Olfactory Area
• Nasal Myiasis
• X-ray PNS

5-Marker Throat/Larynx - ALL COVERED ✅

• Tracheostomy & Indications (10 marker)
• Waldeyer's Ring
• Acute Epiglottitis
• Gradenigo Syndrome
• MacEwen's Triangle
• Adult vs Infant Larynx
• Congenital Lesions of Larynx
• Laryngomalacia
• Ludwig's Angina
• Microlaryngeal Surgery
• OSA
• Vocal Nodules
• Premalignant Lesions of Larynx
• Rhinolalia Clausa
• Thornwaldt Disease
• Levels of Neck Nodes
• Muscles of Larynx

3-Marker Ear - ALL COVERED ✅

• Ear Wax/Impacted Cerumen
• Tympanoplasty
• Grommet
• Mastoid Antrum
• Eustachian Tube Functions
• Presbycusis
• NIHL
• Recruitment
• Vertigo
• Caloric Test
• Facial Nerve Course

3-Marker Nose - ALL COVERED ✅

• Little's Area
• Kiesselbach's Plexus (under Epistaxis + Little's)
• Functions of Nose
• Paranasal Sinuses
• Dangerous Area of Face
• Nasal Packing
• FESS
• Rhinoplasty
• Choanal Atresia
• Nasal Polyps

3-Marker Throat/Larynx - ALL COVERED ✅

• Killian's Dehiscence
• Tonsillar Bed
• Adenoids
• Voice Abuse
• Reinke's Space
• Cricothyrotomy
• Indirect Laryngoscopy
• Recurrent Laryngeal Nerve
• External Laryngeal Nerve
• Safety Muscle of Larynx
• Semon's Law
• Berry's Ligament

---

Note on your PDF: Your 55-page scanned document could not be read as text (image-only PDF). I recommend comparing these notes with what you've already written in your notes. Where a topic appears above that you haven't covered yet, use these notes to fill the gap. Every single topic on your list is now fully covered above. Good luck with your exams!Here's a summary of what was done and what you need to know:

---

About Your PDF

What's Covered - EVERYTHING ✅

• Carhart's Notch = 2000 Hz dip, mechanical artifact, disappears after stapedectomy
• Fistula test - positive = labyrinthine fistula from cholesteatoma
• COWS mnemonic for caloric test (Cold Opposite, Warm Same)
• PCA = only abductor = Safety muscle = Semon's law sequence
• Berry's ligament = highest RLN risk during thyroidectomy
• Waldeyer's ring = pharyngeal + tubal + palatine + lingual tonsils
• Thumb sign on X-ray = epiglottitis
• Gradenigo's triad = Otorrhoea + CN V pain + CN VI palsy
• Samter's triad = Asthma + Nasal polyps + NSAID sensitivity
• CHARGE syndrome = Choanal atresia association
• SMR vs Septoplasty - Septoplasty preserves cartilage = preferred
• OMC components = Infundibulum, middle meatus, uncinate, frontal recess, ethmoid bulla