Diagnostic features in the X-ray and probable pathology in the Sinus

Hello :)

1. Haziness of sinuses only :- Sinusitis
2. Bony expansion without erosion :- Benign tumefaction e.g Polyposis
3. Decreased air shadow in nasal cavity without bony expansion :- Hypertrophic rhinitis
4. Bony erosion with expansion :- Malignancy
5. Bony defect without expansion of haziness :- Surgically induced (Iatrogenic) or fracture
6. Fluid level in maxillary sinus :- Sinusitis with pus signifying acute bacterial maxillary sinusitis

This question was asked to me by my friend and it was fun to find the answer.
(Source :-Otolaryngology at the eleventh hour By Anupam Mishra)

That's all for today.
-Upasana Y. :)

Image Based MCQ on ENT instruments

Hello guys!

Yesterday we posted an Image based MCQ on ENT instruments.
And here's the answer for it.

#ENT
#Instruments

Q. The instrument shown in the above image is used in?

A. Thyroidectomy
B. Adenoidectomy
C. Tonsillectomy
D. Parathyroidectomy

Ans: c) Tonsillectomy

The instrument shown in the above image is Eve’s Tonsillar Snare, used in tonsillectomy.

Identification of the Instrument:

It consists of a long, thin, hollow tube with a stainless steel wire loop at one end which has Ratchet action. The other end has three large rings. These three rings allow the instrument to be operated using three fingers.

Uses:

It is used to snare the lower pole of Tonsil at the end of dissection. Advantage of using the snare to resect the tonsil is to minimize the bleeding by crushing the vascular pedicle, not cutting unlike scissors.

Procedure:

The instrument is held by inserting the forefinger and the middle finger into two rings on either side of the snare.The thumb is placed in the single ring at the back. This ring is actually located at the end of the plunger. Pulling the plunger with the thumb draws out the wire loop while it can be pulled back in by pressing the plunger with the thumb. The wire loop is first threaded over the Denis Browne tonsil holding forceps. The dissected tonsil is then held with the forceps and the wire loop moved over it until it surrounds the pedicle of the tonsil. The thumb is then pressed down to draw back the loop. The pedicle of the tonsil is crushedby this movement.

That's all!
Thank you.

MD Mobarak Hussain (Maahii)

Nasal Encephalocele vs Nasal Glioma

Both nasal encephalocele and nasal gliomas are congenital conditions in which there is herniation of glial tissues and meninges into the nasal cavity through the foramen cecum.

Both the masses are seen in the nasal cavity as bluish masses with nasal obstruction.

Nasal gliomas have no communication to the brain as the communication gets detached after the fusion of cranial bones in late IUL. Gliomas are firm and non compressible mass.

Encephalocele also presents as nasal mass with obstruction. The swelling increases in size in response to coughing. Most common site is occipital and then frontal.

Bilateral compression of the internal jugular vein also leads to the increase in the size of mass called as Frustenberg Test.
Frustenberg test is positive in encephalocele and negative in gliomas.

Investigation of choice for both is MRI.

Hope this helps!
Ashita Kohli

Mnemonic- Causes of saddle nose

Saddle nose is a nasal deformity due depressed nasal dorsum which may be bony, cartilaginous or may involve both.

Causes- HOT SALT

H- Hematoma
O- Operative (during SMR)
T- Trauma
S- Syphilis
A- Abscess
L- Leprosy
T- Tuberculosis

Hope this helps!
Ashita Kohli

Mikulciz Disease- Rhinoscleroma

Mikulciz disease aka Rhinoscleroma is a chronic granulomatous disease commencing in the nose and extending into the nasopharynx, oropharynx, larynx, trachea and bronchi

This disease may occur in either or the sexes at any age.

Causative organism- Klebsiella rhinoscleromatis (gram negative Frisch bacillius)

Three stages-

1. Atrophic Stage-
This stage typically resembles atrophic rhinitis and presents with nasal discharge which is purulent and foul smelling with nasal crusting.

2. Granulomatous Stage-
This is a proliferative stage. Characterised by granulomatous reaction and presence of mikulciz cells.
Presents as painless nodules in the nasal mucosa.
The subdermal infiltration into the lower part of external nose and upper lip gives a Woody feel to the nose.
There may occur broadening of the nose with thickened skin- Hebra nose

3. Cicatricial Stage-
There occurs fibrotic adhesions and fibrosis of nose, nasopharynx and oropharynx.
The fibrotic deformity of nose is known as- Taper nose.

Most common symptoms-
Nasal discharge and crusting> nasal deformity> epistaxis

Diagnosis-
Diagnosis can be done histopathologically which shows mikulciz cells and Russell bodies in the submucosa which is characteristic of rhinoscleroma.
Mikulciz cells are foam cells with central nucleus and vacuolated cytoplasm containing bacteria.
Russell bodies are eosinophilic inclusion bodies seen in the cytoplasm.

Treatment-
Streptomycin (2g/day) + teracycline (2g/day) for 4-6 weeks

Hope this helps!
Ashita Kohli

Eagle Syndrome

Eagles Syndrome also known as Styalgia is due to elongated process or calcification of the styohyoid ligament.

Symptoms-
1. Pain in tonsillar fossa and upper neck which radiates to upper neck which gets aggrevated during swallowing.
2. Dysphagia

Diagnosis-
1. Transoral palpitation of the styloid process in tonsillar fossa.
2. X Ray of lateral view of skull or AP view with open mouth.

Treatment-
Many people may remain asymptomatic and do not need treatment.

Symptomatic patients may need excisition of styloid process by transoral or cervical approach.

Hope this helps!
Ashita Kohli

CerebelloPontine Angle Syndrome

Rhinosporidium seeberi

Rhinosporidium seeberi

Sinus of Morgagni- Contents

There occurs a gap in the pharyngeal wall between the base of the skull and superior constrictor muscle called as Sinus of Morgagni. This space is closed by the pharyngeobasilar fascia.

Contents- (mnemonic PLATE)

1. Palatine branch of ascending pharyngeal artery
2. Levator palati muscle
3. Ascending palatine artery
4. Tensor vetli palatini
5. Eustatian tube

In nasopharyngeal carcinoma, the tumor may extend laterally and involve this sinus involving the mandibular nerve. This produces a triad of symptoms known as Trotter's Triad. 

These symptoms are:

1) Conductive deafness 

2) Ipsilateral immobility of the soft palate

3) Trigeminal Neuralgia

Hope that helped!

Ashita Kohli

Zenker's Diverticulum

Zenker's Diverticulum is a posterior pulsion diverticulum which occurs through the Killian's Dehiscence.

Killian's Dehiscence is a potential gap between the oblique and transverse fibres of the inferior constrictor muscle. It is also known as the gateway of tears as it is a potential site of perforation during oesophagoscopy. 

Zenker's diverticulum occurs due to the outpouching of the pharyngeal mucosa at the site of Killian's dehiscence.
There is incoordination between the descending peristaltic wave and the cricopharyngeus muscle at the upper oesophageal spincter which leades to high intra luminal pressure and the mucosal herniation through the weak area of Killian's Dehiscence.

It is not a true diverticulum as it has just the herniation of the pharyngeal mucosa. ( A true diverticulum has all the layers of the oesophageal wall)

It is usually seen in elderly above the age of 60.

Symptoms-

1. The most common symptom is Dysphagia, which is intermittent initially and later becomes progressive.
2. Halitosis ( ie. bad breath, well ofcourse because food can get trapped in this pouch)
3. Regurgitation of food and cough.
4. There maybe regurgling sounds in the neck, gurgling sensation on palpation is known as Boyce sign.

Malignancies may develop in 0.5-1% cases.

Diagnosis- Barium Swallow and videofluoroscopy

Treatment-
1. Endoscopic stapling of the diverticulo esophageal sphincter.
2. In patients not fit for major surgeries, Dohlman's surgery may be done.

Hope that helped!
Ashita Kohli

Waldeyer's Ring

Waldeyer's Ring is an aggregation of lymphoid tissue seen in the subepithelial lining of pharynx guarding the nasopharynx and oropharynx in the form of a ring.

The ring is bounded by-

1. Palatine Tonsils ( also called as Faucial Tonsil)- Situated in between the anterior and posterior pillars on each side of oropharynx
2. Adenoids (aka Lushka's Tonsil)- Lies at the junction of roof and posterior wall of nasopharynx
3. Tubal Tonsils ( aka Gerlach's Tonsil)- Lies in the fossa of rosenmuller behind the eustatian tube opening
4. Lateral Pharyngeal Band and Nodules

Hope that helped!
Ashita Kohli

Rhinolalia Aperta

Rhinolalia Aperta is a speech disorder which involves hypernasality in voice.
The defect is seen in the failure of the nasopharynx to cut off from oropharynx.

Some fibres of palatopharyngeus muscle make the posterior pillar, go posteriorly in the posterior wall of nasopharynx and along with the lower fibres of the superior constrictor muscle forms a ridge known as the Passavant's Ridge. 

During swallowing and speaking the passavant's ridge closes the nasopharyngeal isthmus.
When this doesn't happen (eg- cleft lip, paralysis of palate) it leads to nasal regurgitation of food and nasal tone in speech known as Rhinolalia Aperta.

Treatment-

1. In children with cleft palate, special exercises can help in strengthening the muscles so as to reduce the nasality in voice.

2. Surgery- Posterior Pharyngeal Flap
                   Sphincter Pharyngeoplasty


Hope this helps!
Ashita Kohli 

Croup : Review of key points

Here's a short Mnemonic/Review of Important facts about Croup - Acute Tracheobronchitis !

Remember :
CROUPS

C - Common respiratory disease
R - Respiratory viruses like Parainfluenza
O - Oxygen Treatment (Humidified)
U - Ugly Cough - Barking / Seal like cough
P - Prodrome of illness followed by Inspiratory Stridor
S - Steeple sign on X Ray

It's helpful to remember Acute EPIGLOTTITIS as the complete opposite of CROUPS using similar ideas.

- Not as common.
- Caused by Bacteria generally (Strep , Hib)
- Oxygen Therapy + AntiBiotics
- Ugly - Sniffing dog like position + Drooling
- Prodrome not particularly, but Stormy acute onset.
- Shows Thumb print appearance on X Ray.

Hope this helped !
Happy Studying !
Stay awesome.

~ A.P.Burkholderia

Fact of the day : Loss of Olfaction is a prodrome of neurodegeneration

Hey Awesomites

Loss of the sense of smell is one of the first warning signs of neurodegenerative diseases such as Alzheimer's, Parkinson's and other diseases associated with dementia.

One of the common link evidenced in some studies is the damage to neurotransmitter and neuromodulator receptors ( particularly acetylcholine ) in the frontal part of brain.

Also, one of the pathogenic hallmarks of AD, the Neurofibrillary Tangles ( NFTs ) have been found in olfactory bulb, olfactory tract, the transentorhinal and entorhinal cortex, anterior olfactory nuclei and amygdale. The number of NFTs within these areas have been positively correlated with the disease progression.

Thus, olfactory testing at the 'right time' is essential to detect the presence of disease process in its 'preclinical phase' itself. It could help in the differential diagnosis of several neurodegenerative diseases. Early diagnostic interventions such as smell testing, brain imaging procedures like functional MRI and PET scan, olfactory epithelium biopsy, using radioactive neurochemicals help in evaluation.

The anosmic symptoms are much more common in old patients of more than 65 years of age.


Thats all
- Jaskunwar Singh

Mnemonico diagnostico : Direct laryngoscopy in Laryngomalacia

Hey awesomites

Laryngomalacia is the most common congenital anomaly of the larynx characterised by excessive flaccidity of supraglottic larynx which results in inspiratory stridor and cyanosis.

Mnemonic for Direct laryngoscopy findings : FlOP

Fl - Floppy aryepiglottic folds
O - Omega- shaped epiglottis
P - Prominent arytenoids

- The short bands ( aryepiglottic folds ) cause the epiglottis to curl upon itself.
- Epiglottis is elongated and folded longitudinally to form an omega.
- Arytenoids are situated posteriorly and show prominence.

Also check out the mnemonic for differentiating laryngomalacia from tracheomalacia Here .


Thats all
- Jaskunwar Singh

Auditory Transduction simplified

Basics of auditory transduction simplified by Chaitanya Inge in his first awesome video! Check it out! :D

Easy way to memorise Organ of Corti

Hello Everyone!

               Here is a easy way to memorise the Organ of Corti structure.

We've also upload a video explaining the same. Check it out =) 

Thank you,

Chaitanya Inge

The Basics : Deviated Nasal Septum

Hello

Deviated Nasal Septum - "Abnormal and asymmetrical alignment of the nasal septum that results in acute nasal obstruction and other symptoms of upper respiratory tract."

AETIOLOGY -

1. Trauma : Abnormal pressure ( lateral or frontal ) applied to nasal septum results in its deviation to one side or another.
- The lateral blow may cause displacement of septal cartilage from the vomerine groove and maxillary crest.

Groove on which septal cartilage sits ( encircled ) - lateral view
Diagram by IkaN.

- Frontal blow causes crushing injuries to the nose, usually occurs in sportspersons especially the boxers.

2. Developmental anomalies : Palate forms the base of nasal septum. Highly arched palate, cleft palate or lip, and dental abnormalities can all lead to deviation of the septum.

3. Racial factors : Caucasians have more incidence of DNS.

4. Hereditary : Familial predisposition.


TYPES of DNS -

1. Anterior dislocation : dislocation of nasal septum into one of the chambers. ( unilateral nasal obstruction )
2. C - shaped dislocation : simple curve to one side with compensatory hypertrophy of turbinates in other side. It causes unilateral nasal obstruction.
3. S - shaped deformity : causes bilateral nasal obstruction
4. Spurs : shelf - like projections may lead to headache and epistaxis. ( unilateral obstruction )
5. Thickening : due to septal hematoma

CLINICAL FEATURES of DNS mnemonic

TREATMENT - Only required if the symptoms are severe. The procedures are to be done once the patient is more than 17 years old.

- Septoplasty : The most deviated parts of nasal septum are removed and rest of the parts are surgically corrected and repositioned.

- Submucous resection ( SMR ) : Mucoperiosteal and mucoperichondral flaps that overlie one side of the septum are lifted. Most of the septum is removed and flaps repositioned.

Thats all
Hope this helped :)

- Jaskunwar Singh

Mnemonic : Deviated Nasal Septum clinical features

Hey Awesomites

The clinical features ( s/s ) that are presented by a patient with DNS are : NOSE MASH

NO - Nasal Obstruction
S - Septal cartilage and bone deformity
E - Epistaxis

M - Middle Ear infection
A - Anosmia
S - Sinusitis
H - Headache


- Jaskunwar Singh

The Basics : Middle Ear

Hey Awesomites

In this post, I will be talking about the middle ear structures and its relations with its neighbors ( just a summary ).

The Middle Ear is an air filled and bilaterally compressed/ concaved cavity lined by mucous membrane located in between the external and internal parts of ear. It is divided into:
- Epitympanum or the Attic ( 6mm ) - lies  above pars tensa and medial to pars flaccida
- Mesotympanum ( 2mm ) - lies opposite to pars tensa
- Hypotympanum ( 4mm ) - lies below the level of pars tensa

BOUNDARIES of the middle ear ( homologous to structure of a cube ) :-

Roof : Tegmen tympani - a thin bony plate that is a part of petrous part of temporal bone, separates the middle ear cleft from middle cranial fossa.
- Infection in the middle ear may spread superiorly and lead to formation of abscess in the meninges ( especially Extradural abscess ), meningitis or if severe, it may even lead to abscess formation in the temporal lobe.

Floor : Jugular bulb - The middle ear cavity is separated from jugular bulb by a thin piece of bone that if deficient may lead to formation of a layer of fibrotic tissue and mucous membrane in between. The contents of jugular bulb are:
- Internal Jugular vein
- Glossopharyngeal nerve ( IX )
- Vagus ( X )
- Accessory nerve ( XI )

The tympanic branch of glossopharyngeal nerve enters the middle ear at the junction of the floor and medial wall to play an important role in formation of tympanic plexus.

Anterior wall : The upper part of the narrow anterior wall has two openings or tunnels for - ( mnemonic : TEA )
- Canal for Tensor tympani muscle
- Pharyngotympanic ( or Eustachian ) tube

The lower part of anterior wall is separated from the Internal Carotid Artery by a thin plate of bone. The ICA is surrounded by a plexus of sympathetic nerves that enter middle ear through openings in this bony plate to form tympanic plexus.

Posterior wall : Posteriorly, it is related to middle ear cleft ( Aditus, Antrum and mastoid air cells )
- Infection in this region may spread posteriorly into the sigmoid sinus ( in posterior cranial fossa ) and cause thrombophlebitis !!

Medial wall : Medially the middle ear cavity is related to the promontory, oval and round window

Lateral wall : Tympanic membrane separates the middle ear from the external ear.

A brief about the functions of middle ear:
On the incoming of sound waves, the tympanic membrane oscillates and these oscillations are sensed by the strongly attached and faithful middle ear ossicle, the Malleus. The sound energy is transmitted as such by the ossicles ( Malleus - Incus - Stapes ) to the internal ear for further processing.

The major function of these ossicles is amplification of sound waves - Tympanic membrane is 17 times larger than the oval window - So that means the sound energy is picked up by the larger area ( TM ) and impinged over a much smaller area ( oval window ) thus amplifying it 17 times.

In addition, the lever action of the ossicular chain is approx. 1.3 units. Thus the intensity ( force ) of sound waves/ vibrations changes ( increased by ~20 times ) and not the frequency !! If the sound waves are not amplified ( in case OC is removed ), the Air Conduction would be lost. So BC > AC and thus hearing would then be poor.


Thats all
Hope this helped :)
Stay Awesome!

- Jaskunwar Singh