ENT Updates

·         Ketorolac is a recently released potent parenteral nonsteroidal analgesic without opioid-related side effects such as respiratory depression. The disadvantages of its use include a limited analgesic effect beyond the recommended doses and an impaired platelet function. Substantial gastrointestinal mucosal breakdown may occur with use over a period as short as 1 week.

·         The Combitube is one of the more recently developed airways that can be placed without laryngoscopy and in emergency situations. The airway contains two lumens: a distal lumen that sits in the esophagus and a proximal lumen for ventilation.

·         In 2002, Nathan found that the proto-oncogene eIF4E (4E) is elevated in 100% of head and neck squamous cell carcinoma tumors and is of prognostic value in predicting recurrence.

·         Recently, the Er:YAG laser was found safe in middle ear procedures given its high absorption rate by water, weak penetration through the otic bone, and weak transmission through the perilymph. Laser applications in middle ear surgery are not without complications. Facial nerve injury, severe vertigo, chorda tympani burn, and hearing loss can occur.

·         For cases with otosclerosis confined to the fissula ante fenestram only, a novel technique has been described, laser stapedotomy minus prosthesis (STAMP). The technique simply includes vaporization of anterior crus first and later anterior one third of the footplate with a hand-held probe of argon laser. Use of a prosthesis is not needed. If the otosclerosis is limited to the fissula ante fenestram only, this should free the remainder of the stapes. If so, the stapedotomy opening is sealed with adipose tissue. The technique may be converted to classic laser stapedotomy in appropriate cases. With this novel technique, it has been stated that high-frequency hearing (6–8 kHz) was better preserved compared with standard laser stapedotomy and also lasted as long as standard laser stapedotomy. Low incidence of refixation was also noteworthy.

·         Recent studies with topically applied liposomal T4 endonuclease-V indicate that it may show promise in reducing the number of new skin cancers in these children of XP.

·         Nonallergic rhinitis with eosinophilia (NARES) is a recently described syndrome in which patients present with nasal obstruction and congestion; these patients frequently experience more severe exacerbations, including the development of sinusitis and polyposis. These patients also display marked eosinophilia on nasal smears (> 25%) but are not allergic to any inhalant allergens by skin testing or in vitro testing. The cause of NARES remains unknown.

·         Recently, a temporal association between pharyngotonsillitis induced by group A beta-hemolytic Streptococcus and a new onset of obsessive compulsive disorders (OCDs) and other tics has been recognized in a subset of the pediatric population. The disease has been identified as PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections). The symptoms include obsessive thoughts and fears, ritualistic compulsions, tics, and anxiety disorders. The abrupt onset of the disease is clearly within a few weeks of the pharyngotonsillitis caused by group A beta-hemolytic Streptococcus, as opposed to Sydenham chorea, which is characterized by psychological disturbances and abnormal choreiform motor activity that develop many months later. The proposed cause is a cross-reactivity of antistreptococcal antibodies with basal ganglia neurons. The exacerbations of the disease can be monitored by measuring antistreptolysin-O titers. Treatment with either antibiotics or a tonsillectomy has been correlated with a decrease in OCD symptoms.

·         Electroglottography is another method of evaluating vocal cord vibration. This technology uses the principle of electrical impedance across tissue and open space. Electrodes are placed on the neck over the lamina of the thyroid cartilages; a weak current is passed between the electrodes, which generate an impedance curve that corresponds to the shape and nature of the vibratory cycle.

Other forms of glottographic technology include photoelectric and ultrasound glottography. A new technique of assessing vocal cord cycles based on the kymography principle has been recently introduced; however, its clinical value remains questionable at this time.

·         Recent additions to the electrophysiologic battery include ASSR (auditory steady-state response), which allows for a potentially more rapid means of establishing frequency-specific thresholds, stacked ABR (a more sensitive and specific method for the detection of small tumors), and CHAMP (cochlear hydrops analysis masking procedure) for detection of Meniere disease.

·         More recently, OAE, in conjunction with ABR, can be used in identifying individuals with auditory neuropathy, also termed auditory dyssynchrony.

·         Recent findings suggest an association between the measles virus and otosclerosis. Whether the measles virus is a factor that can initiate the otospongiotic process remains to be determined. However, current efforts to immunize against this virus would be expected to drastically reduce the incidence of otosclerosis.

·         Nonsyndromic hereditary hearing impairment is classified by the mode of inheritance. Autosomal recessive transmission (designated by prefix DFNB) is implicated in approximately 80% of cases, autosomal dominant transmission (DFNA) is present in approximately 20% of cases, and X-linked (DFN) and mitochondrial transmission are responsible for < 2% of cases (see Figure 54–1). One single gene, GJB2 (Gap-Junction Beta 2 or connexin 26), has emerged to be the most common cause of recessive deafness, and up to 40% of the onset of sporadic prelingual hearing impairment can be attributed to defects in this gene both in Europe and the United States. The prevalence is higher in southern Europe than in northern Europe, probably owing to one single gene mutation, 35delG. In a stretch of six guanines extending from position 30 to 35, one base pair is deleted. The high incidence of this mutation seems to be due to a common ancestor. Other common mutations include 167delT in Ashkenazi Jews and 235delC in the Japanese population. Recently, a common digenic pattern of inheritance involving GJB2 and GJB6 has been detected. Patients with a monoallelic mutation in GJB2 harbor in addition a deletion of GJB6.

·         Various mutation detection methods exist and are in use. The methods are based on either conformation-based techniques such as single-stranded conformational polymorphism (SSCP) or on base-mismatch recognition such as denaturing gradient gel electrophoresis (DGGE). The former is more common. Both methods—SSCP, because of its simplicity, and DGGE, because of its high sensitivity—are the favored techniques. Recently, a relatively new technology for rapid automated mutation screening, denaturing high-performance liquid chromatography (DHPLC), has been assessed and found to be highly sensitive and specific for detecting GJB2 mutations. However, each of these methods for detecting mutations has significant shortcomings, including expense, time, and limited sensitivity. Direct sequencing of the gene is the only method available to identify any number and type of mutation. Although its use is becoming increasingly automatic, the screening of a large population is expensive.

·         Recent studies have shown a decrease in Type II vestibular hair cells in cases of Meniere disease. The role and significance of the decrease of these Type II hair cells are currently not known. The endolymphatic sac has been shown to be important in inner ear metabolic homeostasis. The endolymphatic sac secretes glycoprotein conjugates in response to osmotic challenges, and preliminary studies have shown an alteration in glycoprotein metabolism in Meniere disease. There has been no conclusive proof of an infectious agent related to this disease.

·         Recent studies have improved our molecular understanding of VS. VS occurs as a result of mutations in a tumor suppressor protein, merlin, located on chromosome 22q12. Merlin is a cytoskeletal protein and may control cell proliferation by regulating the abundance, localization, and turnover of cell-surface receptors. The formation of VS requires mutations of both copies of the merlin gene. One functioning merlin gene prevents the formation of VS. Somatic mutations in both copies of the merlin gene result in sporadic VS. The probabilities of two spontaneous, independent mutations at one locus predict a unilateral VS presenting in the fourth to sixth decades of life.

·         Traditionally, many surgeons rerouted the facial nerve anterior to obtain unobstructed access to the jugular foramen. However, this frequently leads to transient palsy, which does not always recover to normal. More recently, a fallopian bridge technique has gained popularity. In this procedure, the facial nerve remains in situ, and microdissection is carried out around it. Some surgeons use facial nerve rerouting selectively when encasement of the carotid artery necessitates obtaining augmented anterior exposure.

·         Facial contouring is a recent trend in facial aesthetic surgery. Facial implants serve to add volume, providing a more appealing shape to a person's face. Facial injectables have reached tremendous popularity due to their safety, "no-down-time" appeal, and economics.

·         Poly-L-lactic acid (Sculptra) is a volumetric filler currently FDA approved for treatment of lipoatrophy in HIV patients. Lipoatrophy in HIV is due to a number of factors including reverse transcriptase inhibitors and the disease process itself. Recently, poly-L-lactic acid has been used in an off-label capacity as a non-HIV facial filler. The main complication is nodule formation. This can be avoided by injecting deep to subcutaneous tissues and not in areas of significant muscle motion such as the lips. The duration of augmentation with poly-L-lactic acid is up to 3 years.

ENT Facts from Previous Papers

·         HO's Triangle / Supraclavicular fossa --  involvement of this region in Nasopharyngeal carcinoma is N3b irrespective of the size of the tumor. T4 in NP Ca is involvement of orbit, cranial nerves, infratempral fossa, hypopharynx.

NOTE: Even a 6cm node in NP Ca is considered to be N1 and not N2 as in other Head and Neck Cancers.

Extension into the PNS is T3.

·         Diurnal Headache : Frontal Sinusitis.

(Note: Postural headache is seen in Colloid Cyst -Brain)

·         Type of Rhinitis with no use of Nasal Decongestants - HYPERTROPHIC RHINITIS (b'coz of fibrosis)

·         Perez Bacillus - is Klebsiella ozaena.

·         Mass of several Normal tissue at Abnormal site : CHORISTOMA

·         Malformed Normal tissue, at it's Normal site is : HAMARTOMA eg:Hemangioma.

·         Bleeding Polyp of the nose : HEMANGIOMA of NASAL SEPTUM.

·         Commonest virus causing rhinitis : Rhino virus in >50%.

·         Distance between nasal spine and sphenoid sinus -- 7cm in adult, at an angle of 30 degrees.

·         SARDINA's Approach (Transpalatine + Sublabial) and DENKER's Approach are used for - Nasopharyngeal Carcinoma.

·         Indicators of Radiotherapy in NP-Angiofibroma : 

Extension into intracranial cavity.

When the feeding vessel is a branch of Internal Carotid Artery.

·         Sluder's Neuralgia : is Sphenopalatine ganglion neuralgia.

·         STEEPLE Sign is seen in : CROUP / Acute Laryngotracheobronchtis. 

·         THUMB Sign : is seen in Acute Epiglottitis.

·         'Sinus of Morgagni Syndrome' = TROTTER's Triad of Nasopharyngeal Carcinoma.

·         Cholesteatoma of the nose : RHINITIS CASEOSA

·         The pathognomonic radiological sign of Nasopharyngeal Angiofibroma : Antral Sign / Holman - Miller sign - due to involvement of Pterygopalatine fossa.

·         Gateway of tears in esophagoscopy is KILLIAN'S DEHISCENSE - between Cricopharyngeus and Thyropharyngeus parts of Inferior Constrictor muscle.

·         Nasopharyngeal Bursa -----> Pharyngeal Bursitis is called THORNWALDT's Disease

·         Pharyngeal Recess = Fossa of Rosenmuller

·         Pharyngeal Pouch = Zenker's Diverticulum

·         Herpangina is caused by Group A Cox-sackie virus.

·         Pharyngitis + Conjunctivitis + Abdominal Pain mimicking appendicitis + Fever : Diagnosis is PHARYNGO-CONJUNCTIVAL fever caused by Adenovirus.

·         Acute Lymphondoular Pharyngitis - mainly caused by Coxsackie virus.

·         Horny excrescences on tonsils, pharyngeal wall or lingual tonsils are seen in - KERATOSIS PHARYNGITIS. 

(Note : they cannot be wiped off, no inflammation or constitutional symptoms, treatment is Reassurance)

·         Irwin-Moure sign - Pressure on anterior faucial pillar extruding pus in tonsillitis. ( In Mouth )

·         Bad taste in mouth is called as - CAGUS.

·         'Hot Potato Voice' - seen in QUINSY / Peritonsillar Abscess.

·         Potato tumor is Rhinophyma.

·         Spaces of GILLETTE: are the 2 divisions of retropharyngeal space.

·         Styloid process is related to parapharyngeal space and it divides the space into anterior and posterior compartments.

·         Apple Jelly Nodules are seen in LUPUS VULGARIS.

·         MC site of supraglottic ca – Infrahyoid epiglottis

·         Minor cavum effect seen in tympanoplasty – Type IV

Columella effect seen in tympanoplasty – Type III

·         T1 glottic ca limited to middle 1/3rd of vocal fold: Cordectomy via laryngofissure

T1 –T2 supraglottic ca with good PFT: Supraglottic laryngectomy

T1 –T2 glottic ca with good PFT: Vertical partial laryngectomy

·         Post wall of nasopharynx related to – Only 1st cervical vertebrae

·         Supraomohyoid (Anterolateral) neck dissection removes – Levels I – III

·         Lymphatic drainage of ear lobule is into – Superficial cervical nodes

·         Beefy red epiglottis seen in – Epiglottitis

·          

·         Bezold eponyms in ENT

1. Bezold's triad : 1. Diminished perception of the deeper tones,

2. retarded bone conduction, and

3. negative Rinne's test,

pointing, in the absence of objective signs, to otosclerosis

2. Bezold's abscess: abscess deep in the neck parapharyngeal space associated with suppuration in the mastoid cells

3. Bezold's sign / symptom: Inflammatory edema at the tip of the mastoid process in mastoiditis

4. Bezold's ganglion: An aggregation of nerve cells in the interatrial septum

5. Bezold's mastoiditis: Mastoiditis with perforation medially into the digastric groove and forming a deep neck abscess

·         What are the lines of Dolan?

They are three anatomic contours best seen on the Waters view (occipitomental view )of the face, and they were first popularized by Dolan et al.

As you can see, the 3 lines of Dolan lead the eye along some facially important structures.

Lee Rogers pointed out that the 2nd and 3rd lines together form the profile of an elephant.

Miscellaneous Facts for ENT

·         "CARDIOSPASM / ACHALASIA CARDIA---difficulity for swallowing Liquids but not for solids, ass.with DEGENERATION of nerve plexus in the oesophagus, Barium Swallow-shows-Dilatation with smooth narrow ending, "--------((3))

·         "FRACTURES OF ZYGOMA--- undisplaced fracture--no specific Rx

·         An easy way to remember the behavioral complications of OSA: APRIL

Aggression

Poor school performance

Restlessness

Irritability/hyperactivity

Lack of attention

• Teratomas are composed of all three germ layers, consist of tissue that is foreign to their site, and are larger than dermoid cysts. Dermoid cysts are composed of ectoderm and mesoderm, arising from entrapped epithelium, and tend to occur along the lines of embryonic fusion (midline). Dermoid cysts characteristically have an adipose matrix that appears "cheesy." Both are anomalies involving pluripotential embryonal cells and are managed by complete surgical excision.

• Traditionally, the mandibular series has included several views of the mandible to view the entire mandible adequately. These have included anteroposterior and bilateral oblique views to assess the symphysis, parasymphysis, body, angle, and ramus. Special views (Towne's projection) are often required to assess the medial or lateral displacement of the condyle. Currently, the panoramic view (Panorex) has become the single most useful radiograph for assessment of the entire mandible. Computed tomography scans provide the best evaluation of severely comminuted and/or displaced condylar fractures.

• A tripod fracture, also called a zygomaticomaxillary complex (ZMC) fracture, is the most common fracture of the zygomatic bone and usually involves:

1.       Zygomaticofrontal suture (or may involve the frontal process of the zygoma)

2.       Zygomaticomaxillary suture

3.       Zygomatic arch

Fourth and fifth components include fractures of the orbital floor or lateral orbital wall and the anterior and lateral maxillary sinus walls. The typical tripod is usually made of four components, making a "tetrapod" a more apt description of the ZMC fracture.

• COMPLICATIONS OF TEMPORAL BONE FRACTURE THAT MAY REQUIRE EARLY INTERVENTION (CLONE MNEMONIC)

1.       Carotid artery injury (penetrating trauma)

2.       Leakage of CSF

3.       Other intracranial complications (e.g., hematoma, temporal lobe injury)

4.       Nerve injury leading to complete facial paralysis

5.       External auditory canal fracture (with significant displacement of bone fragments that threaten to cause a canal stenosis)

• The H-type TEF (absence of atresia) often presents later with chronic feeding difficulties and recurrent respiratory distress and/or pneumonia. Diagnosis can be made with a barium esophogram.

• Heliox is a mixture of helium and oxygen. The lowered density of this mixture reduces airway resistance to turbulent flow and thus decreases flow-resistive work. In addition, the decreased pressure gradient required to produce a specific flow may decrease the tendency of the airway to collapse distal to the obstruction.

Helium-oxygen treatments have been used in several upper airway conditions, including postextubation stridor, tracheal stenosis or compression, status asthmaticus, and angioedema. They serve as a temporizing measure before definitive intervention can be employed and can be extremely helpful in "buying some time" in the emergency setting.

• Otolaryngologic problems with craniosynostosis syndromes:

Apert, Crouzon, Pfeiffer, Saethre-Chotzen, or Jackson-Weiss syndromes, often have highly arched palates, middle ear disease, and conductive hearing loss. Furthermore, some affected children have upper airway abnormalities, such as choanal atresia and tracheal rings.

• chromosomal defects with otolaryngologic consideration:

Trisomy 21, trisomy 13, cri du chat syndrome (5p-), Wolf-Hirschhorn syndrome (4p-), and deletion of the long arm of chromosome 18 (18q-). Trisomy 13 and Wolf-Hirschhorn syndrome are associated with cleft lips with or without cleft palates. The typical, mewing cry described in infants with cri du chat syndrome is ascribed to abnormal laryngeal development. In patients with 4p deletion, the endolarynx is narrow and diamond-shaped, with a persistent interarythroid cleft. People with 18q- are at risk for narrow or atretic ear canals, contributing to frequent otitis media and deafness.

• Garcia is therefore generally credited with being the first to visualize the human larynx, although it is probably more correct to say that he was the first to popularize the procedure, provided an example of an early marketing success, and is regarded as the "father of laryngology."

• Gyorgy von Békésy, a Hungarian, won the Nobel Prize in 1947 for developing the semiautomatic audiometer. This advancement produced threshold measurements, which were valuable in the differentiation of conductive and sensorineural hearing loss.

Another winner was Robert Bárány, who was awarded the 1914 Nobel Prize for his work on the physiology and pathology of the vestibular apparatus. He was a prisoner of war in Russia (WWI) and was in a prisoner of war camp in Turkestan when he learned of the award and was released to receive it.

• Rhinoplasty is the second most frequently performed surgical operation in facial plastic and reconstructive surgery, exceeded only by blepharoplasty.

• Goode's ratio is the mathematical relationship between nasal projection and nasal length. Projection is typically 0.55-0.6 of length. In rhinoplasty, iatrogenic loss of tip support can unfavorably alter the ratio.

• Dermatochalasis is the redundancy and draping of the eyelid skin in the aged face. It causes pseudoptosis when it progresses to the point that skin drapes over the upper eyelashes and causes visual field defects. Dermatochalasis may occur in younger people who have a familial predisposition for upper eyelid skin redundancy and/or orbital fat hypertrophy.

Blepharochalasis is rare variant of angioneurotic edema in which recurrent episodes of eyelid edema eventually lead to chronic changes in eyelid skin elasticity and pigmentation as well as upper lid ptosis. It should not be confused with dermatochalasis.

• Temporomandibular disorders (TMDs), also called craniomandibular disorders, encompass a variety of disorders affecting not only the temporomandibular joint (TMJ) but also areas extrinsic to the joint. TMD has traditionally been described as a constellation of related pathologic changes that produce musculoskeletal symptoms. These may present as pain associated with jaw function, limited range of mandibular motion, masticatory muscle tenderness, and TMJ tenderness. TMD has a very broad interpretation and describes a general population of patients suffering from abnormal and usually painful function of the jaw muscle and joints. This is not a homogeneous group of patients, as many different causes and mechanisms of pain are responsible for similar presentations. Temporomandibular joint disease (internal derangement) implies intra-articular pathology and dysfunction, which may occur with or without musculoskeletal problems.

• Müller's maneuver is performed as part of an extensive physical examination and involves passing the flexible fiberoptic scope into the hypopharynx to obtain a view of the entire hypopharynx and larynx. The examiner then pinches the nostrils closed, and the patient closes his or her lips while attempting to inhale. If the hypopharynx and/or larynx collapse, then the test result is positive. A positive test result means the site of upper airway obstruction is likely below the level of the soft palate, and the patient will probably not benefit from a uvulopalatopharyngoplasty (UPPP) alone. Tongue base procedures may be necessary.

• tests for OSA: The Epworth Sleepiness Scale, pulse oximetry, home sleep studies, multiple sleep latency tests, sleep endoscopy, and sleep fluoroscopy have all been used to evaluate OSA. But, polysomnography (a "sleep study") is the most sensitive and specific test in the evaluation of OSA.

• Medicinal leeches have been around for 2500 years. In addition to drawing off blood (approximately 50 mL of blood "ooze" in 48 hours for one leech), there are vasodilator and anticoagulant properties to leech saliva, which provide the real therapeutic benefits. The patient should also receive antibiotic prophylaxis for Aeromonas hydrophila, a contaminant of the leech saliva.

• Kasabach-Merritt syndrome is an unusual but feared entity related to large hemangiomas. A disseminated intravascular coagulation-like syndrome with platelet trapping is characteristic. It is treated by transfusion of clotting factors and platelets as necessary, in addition to addressing the responsible lesion.

• Paragangliomas have a low potential for malignancy. They are typically composed of two cell types: epithelioid cells (Zellballen) in nests separated in a trabeculated fashion by vascularized connective tissue and neural elements that are peripherally located. Histologic diagnosis of malignancy is not possible in this tumor. Reported figures range from 2% to 50% based on pathology alone. Thus, most authors agree that histologic appearance does not correlate well with growth behavior. The only admissible criterion for malignancy is the presence of distant metastasis. This runs at a rate of approximately 10%.

Oral Cavity & Neck

·         Adenoid cystic carcinoma is often described as having a Swiss cheese appearance based on its histology.

Tubular: best prognosis

Cribriform: fair to "middlin"

Solid: worst prognosis

·         After patotid,The sites most commonly affected by pleomorphic adenomas of the salivary glands are the lips, tongue, and palate.

·         Verrucous carcinoma is a less aggressive form of locally invasive buccal cancer than the usual epidermoid form. Its frequency is increased in people who chew tobacco. The tumor usually grows very slowly, occurs chiefly in the gingivobuccal gutter, and has a tendency to invade bone. It is identified by its characteristic exophytic, white, shaggy appearance. Wide excision is the best initial treatment for this neoplasm. Even though the tumor may regress in response to radiation, it tends to recur in a more malignant form with metastases. Cervical metastases usually are not present when the lesion is first diagnosed; it is only for the most highly malignant grades of verrucous carcinoma that radical neck dissection and block excision of the cheek are indicated.

·         Acinic cell carcinoma can present bilaterally in 3% of cases.

·         "FACIAL NERVE---secretomotor N.fibres of SphenoPalatine Ganglion supply the Lacrimal gland, Injury to Facial N.at Geniculate Ganglion-->Dryness of eyes, Site of lesion of F.N. causing Lacrimal gland involvement is Matoid Foramen, FACIAL NERVE PALSY---common cause--Bell's Palsy, F.N.P.-due Trauma, Immediate Rx--Decompression,"

·         A Simonart's band is a thin remnant of tissue in the floor of the nasal vestibule bridging the medial and lateral lip elements across the cleft. The tissue may consist of skin and/or mucosa and subcutaneous tissue with or without muscle fibers. The origin of the term is obscure, but many attribute it to Pierre Joseph Cécilien Simonart, a Belgian obstetrician (1817-1847).

·         repair of unilateral cleft lip:

Tennison-Randell repair: The medial lip element is lengthened by introduction of a triangular flap from the inferior portion of the lateral lip element.

Hagedorn-LeMesurier repair: A quadrilateral flap developed from the lateral lip element is introduced to lengthen the medial lip element.

Rose-Thompson repair involves curved or angled paring of the cleft margins to lengthen the lip as a straight-line closure.

Skoog repair: The medial lip element is lengthened through the introduction of two small triangular flaps developed from the lateral lip element.

·         repair of bilateral cleft lip:

Millard rotation-advancement repair: The medial lip element is rotated inferiorly and the lateral lip element is advanced into the resulting upper lip defect. The columellar flap is then used to lengthen the columella or create the nasal sill.

Veau repair: The Veau operation is a straight-line closure without elevation of the prolabial skin and correspondingly without any attempt to restore the continuity of the orbicularis oris.

Millard's repair involves complete elevation of the prolabium and reconstitution of the orbicularis across the premaxilla. In addition, Millard banked lateral segments of the prolabium as "forked flaps" that were meant to add columellar height at a later stage.

Manchester repair: Manchester preferred to maintain the prolabial vermilion to create the cupid's bow and tubercle, but similarly to Veau, Manchester did not repair the orbicularis because he thought it would create an overly tight lip.

·         cleft palate repair:

Two-flap palatoplasty

Wardill-Kilner V-Y advancement

Von Langenbeck palatoplasty

Furlow double-reversing Z-plasty

·         Burning mouth syndrome (BMS):

BMS is an intraoral pain disorder that occurs despite a clinically normal appearance of the oral mucosa. The tongue tip, anterior hard palate, and oral lower lip are most frequently affected. For most patients, the burning pain starts midmorning or early afternoon and is followed by dry mouth, dysgeusia, and thirst. Most patients diagnosed with BMS are postmenopausal women. The etiology is still unclear. The dysgeusia involves either a persistent taste or an alteration in taste perception. The persistent taste is most commonly described as bitter or metallic in quality.

Some patients find relief with clonazepam, a benzodiazepine, which is often used as an anticonvulsant. Treatment starts at 0.25 mg of clonazepam taken at bedtime for 1 week. The daily dose can be increased by 0.25 mg each week, up to a total dosage of 3 mg.

 

·         Zinc is commonly prescribed in the treatment of taste and smell disorders. There is, however, no evidence that it is helpful. A double-blind study demonstrated that it was no more effective than a placebo in the treatment of taste and smell dysfunction. Zinc appears to be helpful only when the patient is zinc deficient.

·         CLINICAL MANIFESTATIONS OF ORAL CANDIDIASIS

1.       Pseudomembranous candidiasis (thrush)

2.       Acute atrophic-erythematous candidiasis

3.       Chronic atrophic candidiasis

4.       Angular cheilitis

5.       Chronic hyperplastic candidiasis

6.       Median rhomboid glossitis

·         Palatal and mandibular tori are smooth swellings of bone along the palate and lingual surface of the mandible, respectively.

·         Herpes zoster oticus, in its simplest form, is characterized by intense ear pain and vesicles on the external auditory canal and concha, thus indicating that the dormant herpes zoster (chickenpox) virus has reactivated to affect sensory afferent neurons. If viral involvement progresses to involve the efferent motor axons of the facial nerve, then Ramsay Hunt syndrome has developed. This syndrome is characterized by the coexistence of (1) a facial nerve palsy and (2) vesicular eruptions on the head and neck in the distribution of the affected cranial nerve or cervical plexus.

·         OPMD (oculopharyngeal muscular dystrophy) is an autosomal dominant form of muscular dystrophy that is asymptomatic until middle age, when it produces ptosis and dysphagia.

The ptosis is treated by surgery to suspend the upper eyelid. The dysphagia can be treated by cricopharyngeal myotomy, esophageal dilation, or botulinum toxin injection into the CP muscle.

·         The salivary glands arise as epithelial outpouchings from the primitive oral cavity, or stomodeum, beginning in the fourth week. The parotids usually arise first (week 4), followed by the submandibular glands (week 6) and the sublingual glands and the minor salivary glands (week 9).

·         The retropharyngeal space lies just anterior to the alar layer and posterior to the esophagus and pharynx. Just posterior to this is a potential space known as the danger space, which lies between the alar fascia anteriorly and the prevertebral space posteriorly. This potential space goes from the skull base to the mediastinum. It has only loose connective tissue and is an easy route of spread into the mediastinum, causing mediastinitis. This may be a point of anatomic minutia. During surgical drainage of these areas, a dissecting finger is used to disrupt and drain the retropharynx and the danger space as one unit. The retropharyngeal space also contains lymph nodes, so occult metastases may occur here.

·         Cherubism is a benign, self-limiting disease of the jaw bones. This rare congenital disorder displays an autosomal dominant inheritance pattern. It is more common in males and usually presents prior to the age of 5 years with premature tooth displacement and loss. Symmetric mandibular enlargement may lead to a mild cosmetic deformity, giving these children a round, cherub-like face. Radiographically, the lesions are bilateral, multiple, multilocular, well-defined radiolucencies with a thin or absent cortex. The prognosis is generally favorable. Some patients may require facial contouring, but the disease features generally regress spontaneously by puberty.

Larynx & Pharynx

·         "TONSILS---/ TONSILITIS / TONSILLECTOMY --- infec.by group A & B streptococcal / strepto.pyogenes-(common org.)-Rxpenicillin for 10 days, pain in the post 1/3 tongue after tonsillectomy is due to injury to / throat pain radiating to the ear following tonsillectomy is due to IX cr. Nerve, tonsil develop embryologically from 2nd.pharyngeal pouch, Hard elongated swelling in the tonsillar fossa after tonsillectomy --elongated styloid process, Tonsillectomy--indications-(1) F.B. tonsil, (2) unilat.enlargement of tonsil with suspected malignancy, (3) atrophic tonsillitis, (4) Recuurent acute tonsillitis , (5) recurrent quincy, postop. complication hemorrhage--Rx antibiotics + saline wash, sec.hemorrhage(5-8hrs)-is due to- infection,& it is the common postop.compli.,hemorrhage after 6hrs --reactionary H., main blood supply to tonsil is facial artery, tonsillectomy is CI in polioepidemic, Palatine tonsil have Efferents but no afferents, After Quincy interval tonsillectomy is done after 6 wks.,commonest L.N. to enlarge in acute tonsillitis is Jugulodiagastric L.N., tonsil reach their max. size by 5yrs.,"

 

·         "VOCAL CORD(S)---is line by stratified sq. epithelium, REINKI'S layer seen, web form'n. post truamatically can be prevented by MC NAUGHT'S KEEL, unilat.V.C. palsy--commonest cause-Idiopathic, left unilat. V.C. palsy-cause-oesophageal ca., Precancerous lesion in V.C.-leukoplakia, localised nodule vocal cord of sq.cell ca. vocal cord-Rx-Excision, earliest symp.of ca.vocal cord--Hoarseness, MOUSE NIBBLED APP.of V.C.--seen in T.B. of V.C., granuloma of V.C.-is due to Intubation, unilat.complete paralysis of V.C. can be corrected by--Teflon inj.,cricoarytenoid arthrodesis,implant procedures, T1N0M0 CA.of V.C.-Rx--radical radiotherapy, Internal tensor lengthening mucosa of V.C. is Cricothyroid, pri.aetiological factor in contact ulcer of larynx--Vocal Abuse, V.C.paralysis--resp.obst., aphonia by adductor paralysis can be overcomed by Arytenoidectomy, 19yrs.old female with aphonia has bilat.abductor paralysis cause is functional,"

·         "CANCER OF LARYNX---Squamous cell cancer of larynx is commonest presentation, it is the commonest cause of Hoarseness of voice in Elderly man of more than 2mths.duration / Laryngeal Stridor in a 60yrs.man, Early fes.of Ca.larynx= Hoarsness of voice, NO neck secondaries-->Rx only Radiation, STAGE-III-->SURGERY+RADIATION,Rx of Glottic cancer-- TOC.-for (T1N0M0)-->EXTRENAL BEAM RADIOTHERPY, Ca larynx with Fully Mobile Cords-TOC.-->RADIOTH.,Rx of Ca.larynx with Stridor-->PLANNED TRACHEOSTOMY,glottic cancer has least chance of Nodal Mets.,Glottic Vocal Cancer has Best Prognosis, Hoarsness Early in Glottic Cancer, INFRAGLOTTIC CA.-->Commonly Spreads to Mediastinal L N'S, Ant.Commissure growth-Rx-->Conservative Laryngectomy, post cricoid growth

·         "ANGIOFIBROMA (NASOPHARYGEAL)---Juvenile angiofibroma is locally enlarging tumour producing destruction of bony structures without producing distal secondaries, Young Males(10 yrs boys), Bilateral Nasal Obstruction, bleeding from nose/ Intermittent profuse Epistaxis, firm pinkish mass in nasopharynx, Inv.=X-ray base of skull, carotid angiography, C.T.SCAN(IOC), Benign but potentially malignant, "

·         "NAOPHARYNGEAL CANCER---EBV is a causative agent, Spreads to Lymph nodes, commonest Presentation--Cervical adenopathy, there is High Incidence of NODAL METASTASIS, "

·         STRIDOR---effect of BILAT. RLN damage, most common cause in adult--malignancy, Rx of congenital laryngeal stridor =reassurance to parents, most common cause pf stridor in newborn—laryngomalacia.

1. Inspiratory stridor reflects airflow impairment above or at the level of the vocal cords. It is generally high pitched when occurring at the vocal cords and may be low pitched when obstruction is above the vocal cords (pharynx or supraglottic larynx).
2. Expiratory stridor is usually produced from airflow limitation in the distal tracheobronchial (intrathoracic) tree. It gives rise to a more prolonged, sonorous sound. This may be confused with wheezing, such as in asthma.
3. Biphasic stridor has both an inspiratory and expiratory component and is localized to the subglottic region.

·         "TRACHEOSTOMY---complication commonly occur in children-is-difficult decannulation, indication--stridor, coma of long duration , diptheria, laryngeal obst.,flail chest, tetanus(cyanotic spells) , It is not used in F.B. / Obst.of post basal lobe /bronchus, commonest compli.of paediatric--Pneumothorax, "--------((6))

·         "RECURRENT LARYNGEAL NERVE---partial RLN palsy produces Vocal cord in PARAMEDIAN position, closely related to Inf.thyroid artery, BILAT.RLN PALSY=ADDUCTED position & stridor, supplies all except cricothyroid( SLN),"----------((5))

·         EPIGLOTTITIS---ACUTE--Commonest Organism causing it is -Hemophilus Influenze, DOC.in children--Ampicillin,commonest cause death-is-Respiratory obstruction, the "tripod" position

·         Bacterial tracheitis (pseudomembranous croup) is a severe form of croup that may occur at any age.

The initial clinical presentation is similar to that of viral croup, but patients subsequently develop high fever, toxicity, pneumonia (up to 60%), and progressive upper airway obstruction that is unresponsive to conventional croup treatment. Localized bacterial invasion of the tracheal mucosa results in edema, purulent secretions, and pseudomembranes.

Management of bacterial tracheitis includes DL&B with removal of secretions. For significant airway compromise the child should remain intubated, and repeated endoscopies are performed for recurrent plugging and crusting. Intravenous antibiotics should follow culture and sensitivity results but should initially cover Staphylococcus aureus.

·         "PLUMMER VINSON'S SYND.---ass. With oesophageal ca., post cricoid growth, IDA, females, premalignant ( for hypopharyngeal ca., "---------((4))

·         "QUINSY---PERITONSILLAR ABSCESS---org.-streptococcus, quinsy+trimus--> Rx for 48 hrs. antibiotics only & then oral drainage,"----------((4))

·         "PATCH IN THROAT--- / MEMBRANE IN THROAT --- (1) vincents angina, Black colour patch in mouth, (2) candida , (3) diptheria, (4) streptococcus, & IN THROAT OF ADULT----> Hemophilus, streptococcus, Neisseria, organism are seen but not E-Coli, "----------((4))

·         "ADENOIDECTOMY--- Indication--Recurrent Otitis Media, Sleep Apnoea synd., Middle ear infec. With deafness, C I --Submucous Cleft Palate, control of Hemorrhage--by Post.Nasal PACK, " ---------((3))

·         "ARNOLD'S NERVE---is a Branch of VAGUS Nerve, Irritation of this causes Ear Cough, Cough response caused while cleaning ear canal is mediated by stimulation of X Cr.N."----------(3)

·         "MULTIPLE PAPILLOMA OF LARYNX---Rx Excision with Laser, common in Infants & Children, Laryngeal papilloma are usaually Multiple & VIRAL in origin, usual site of papilloma is larynx, Rx of single P.= Removal by Direct Laryngoscopy, "---------((3))

·         "TUBERCULOSIS OF LARYNX/TUBERCULOUS LARYNGITIS--- KISS ULCER of Larynx, common site of T.B. Larynx is POST.COMMISSURE OF L."-------((3))

·         "VOCAL FOLDS---& VOCAL FOLD CA.---Vocal folds are abducted by post.cricoarytenoid, in CA. L.N.'Smets never seen,,has good prog.,"----------((3))

·         laryngeal conditions that may present with aspiration during feeds: Unilateral vocal fold paralysis and laryngeal cleft.

·         Benjamin classification for laryngeal tracheal cleft:

I. Dehiscence in interarytenoid muscle

II.Cleft extends into cricoid

III.Extends through cricoid into cervical esophagus

IV.Extension into the thoracic esophagus

·         triad for foreign body presentation: The diagnostic triad of cough, wheeze, and unilaterally diminished breath sounds is present in fewer than 50% of cases. The most sensitive factor is a history of witnessed choking.

·         TONSILLECTOMY:

In "cold" dissection, a superior mucosal incision is created with a knife, then blunt dissection separates the tonsil from the tonsillar bed. The tonsil is then amputated at its inferior aspect, often using a snare.

The "hot" technique employs electrocautery to cut and coagulate simultaneously. Some studies suggest that "cold" dissection may lead to less postoperative pain; however, there may be less intraoperative blood loss with electrocautery.

·         Velopharyngeal insufficiency (VPI) :

VPI occurs when there is incomplete closure of the soft palate against the posterior pharyngeal wall during speech and swallowing. VPI results in hypernasal speech and nasopharyngeal regurgitation. In children, adenoid tissue significantly adds to the bulk of the posterior pharyngeal wall. An adenoidectomy reduces this bulk and can lead to incomplete closure. Most cases are temporary, but persistent or severe cases may require speech therapy and/or surgical treatment.

The incidence of VPI after adenoidectomy ranges from 1/1500 to 1/10,000 in healthy patients.

The incidence is much higher in patients with palatal disorders.A submucous cleft palate is associated with a higher incidence of postadenoidectomy VPI. Signs of a submucous cleft include a bifid uvula, zona pellucida, and notching of the posterior hard palate. In the presence of these findings, a superior pole adenoidectomy is recommended. This procedure removes obstructing tissue from the choanal area but preserves bulk in the posterior pharyngeal wall.

·         The long-term obstruction by adenotonsillar tissue produces a state of increased positive end-expiratory pressure (PEEP). With removal of the obstructing tissue, the excess PEEP is suddenly relieved, and fluid moves into the interstitial and alveolar spaces, resulting in pulmonary edema with decreased blood oxygen saturation. This can occur intraoperatively or a few hours later. Treatment involves diuresis for mild cases, or intubation with reestablishment of increased PEEP in severe cases.

·         COMMON LARYNGEAL ABNORMALITIES

Supraglottic: laryngomalacia, cystic hygroma

Glottic: vocal fold paralysis, web and atresia, posterior laryngeal cleft

Subglottic: congenital subglottic stenosis, subglottic hemangioma

·         Although a rare source of primary pathology, Parapharyngeal space is extremely important as a radiographic landmark because the fat makes it readily visible on MR and CT images of the suprahyoid neck. Due to its central anatomic position, the origin of pathologic processes within the deep fascial spaces of the neck can be identified by the specific displacement pattern of the parapharyngeal space. The parapharyngeal space may provide a path for pathology to extend superiorly to the skull base.

Pleomorphic adenomas of ectopic salivary gland tissue are the most frequently encountered benign tumors of the parapharyngeal space.

·         Diplophonia describes a sound made by vibrating cords at two different frequencies. It indicates that the vocal folds are being affected differently.