ENT LRR by Dr. Vyshnavi Part 2 | For NEET PG, INI-CET & FMGE

Hi everyone.

So we had stopped at this slide and there was some discontinuity in the LRR session, which is why I'm recording this from here.

so that we complete this entire session and you get a quick revision of the entire ENT.

So let's begin with the slide where we're discussing about two images which are very similar to each other but yet very different in the diagnosis.

The first image that you see is that of an antero-coinal polyp.

You see that there is a mass that is present in the nose going into the nasopharynx and clearly there is an air column present between the mass and the posterior pharyngeal wall.

This sign we call it as crescent sign also called as dot sign and this crescent sign or dot sign is a feature of antropoenol polyp.

So this is done.

The next image is showing to you of an adenoid hypertrophy.

There is a mass in the nasopharynx.

Now I will draw two imaginary lines one from the base of the skull and a second imaginary line passing through the palate.

Now look at the airway space.

Is it occupying 25% of the airway space, the soft tissue mass?

No, much more.

50%?

No, much more.

50 to 75%?

Yes, it is about grade 3 adenoid.

So this is an image showing to you a grade 3 adenoid hypertrophy.

So with this image discussion, now let's continue to do an MCQ.

We have a question here where there is a patient having atrophic dry nasal mucosa, extensive crusting, woody hard nodule of the nose.

What is it suggestive to you all?

So atrophic mucosa crusting can be seen in two conditions, which is rhinoscleroma and atrophic rhinitis.

It is not seen in rhinosporidiosis or carcinoma of the nose.

Now when we talk of rhinoscleroma, here we get a word woody hard nodule.

So this should be your answer.

Atrophic rhinitis does not have any woody hard nodule.

So we are now sure the answer is rhinoscleroma.

The following is used to perform a posterior rhinoscopy.

So when we use, when we want to do a posterior rhinoscopy,

Of course, we want to use a mirror, and the name of the mirror is called a Sinclair-Thompson posterior rhinoscopic mirror.

Now, when I want to pass the mirror and place it behind the uvula to see the reflection of the nasopharynx and the posterior end of the nose, the tongue can obscure the view.

The tongue will block the view, and hence, it might be difficult to visualize the structures in the nasopharynx.

So in that situation, what do we do?

We will take a tongue depressor and push the tongue downwards.

and now when the tongue is pushed downwards do i get more space here to visualize inside the mirror

Yes.

So here we require Sinclair-Thompson posterior rhinoscopic mirror and tongue depressor.

So the correct answer is both.

But if I'm trying to do an indirect laryngoscopy, of course, I'll require an indirect laryngoscopic mirror.

But now I want to look inside the mirror, the larynx.

So when I place the mirror behind the tongue and below the uvula facing it downwards, again, the tongue is blocking my view.

So what will I do?

I'll pull the tongue forward.

And now when I pull the tongue forward, there is a good space for reflection of the laryngeal structures into the mirror, giving me a good visualization.

So I will not need a tongue depressor, but I will have to just pull the tongue out.

But what is needed is going to be just the mirror.

So the answer is option A.

So now let's go to the pharynx and let's do some of the questions related to pharynx.

Now we have an endoscopic image of the nasopharynx and this is a PYQ where they have marked the structure here and they're asking you what is this structure.

So the structure that is marked here is nothing but fossa of Rosenmuller.

So the correct answer is option C. In front of it, we have a bulge which is called as torus tuberius.

In front of it, we have the opening of a tube which is called as eustachian tube.

So we have eustachian tube.

Behind that, we have torus tuberius.

And behind that, we have fossa of Rosenmüller.

So the structure that was asked to identify is nothing but the fossa of Rosenmüller.

Next question.

Passivans ridge is formed by.

So passivans ridge is basically a ridge formed by the fibers of palatopharyngeus and this fibers of palatopharyngeus cut off the nasopharynx from that of oropharynx so that when we swallow there is no nasal regurgitation.

What is sinus of morgagni?

Sinus of morgagni is the space between superior constrictor and the base of skull.

So between the base of skull and superior constrictor, we have a space which is called a sinus of morgue acne.

The structures that pass through this can be remembered with the help of a mnemonic lata.

What does L stand for?

L is for levator veli palatini.

A is for auditory tube or eustachian tube.

T is for tensor veli palatini and A is for ascending palatine artery.

Okay, so these are the four structures that pass between the base of skull and superior constrictor.

As we go forward, I will explain to you eventually of all the other structures.

We have a slide for discussion as well.

What is Lushka's tonsil?

Lushka's tonsil is nothing but your adenoid.

Gerlach's tonsil is nothing but that of your tubal tonsil.

So Lushka's tonsil is adenoid and Gerlach's tonsil is nothing but your tubal tonsil.

Let's do a question.

A 38 year old woman presents to you with difficulty in swallowing and mild intermittent sore throat.

A detailed examination reveals no overt abnormalities, but MRI shows you a structure passing between superior and middle constrictor.

So this is what I was telling you.

We learned between the base of skull and superior constrictor lata.

Between superior and middle constrictor, what are the structures passing?

So one is going to be your glossopharyngeal nerve.

Along with that, we have a muscle which is going to be your low pharyngeus muscle.

So pharyngeus muscle and the glossopharyngeal nerve pass.

So here we have between the base of skull and superior constrictor sinus morgagni, the structures we have already remembered with the mnemonic lata.

Between the superior and middle constrictor, we have got the stylopharyngeus muscle and the glossopharyngeal nerve.

Between the middle and inferior constrictor, we have got the superior laryngeal nerve.

and the branch of the superior laryngeal nerve that travels is going to be your internal laryngeal nerve and along with that superior laryngeal vessels and below the inferior constrictors we have recurrent laryngeal nerve and the inferior laryngeal vessels so these are the structures that pass between the various layers or muscles of your pharynx

Now let's do MCQ, a 16 year old presence to you with fever, sore throat and enlarged tonsil with a grayish white exudate and posterior cervical lymphadenopathy.

Very important is monospot test is positive.

Most of the times when we read the first line, we think it is acute bacterial tonsillitis, fever, sore throat, enlarged tonsil with cervical lymphadenopathy.

That's the first thing that we think of.

But they have clearly given to you two things, posterior lymphadenopathy and monospot test positive.

It gives you a diagnosis of

infectious mononucleosis and it is not an acute bacterial tonsillitis so now we are very sure that it is infectious mononucleosis so when we talk of acute tonsillitis the organism is group a beta hemolytic streptococcus this group a beta hemolytic streptococcus has got cross reactive antigens against myocardium glomerulus and the joints as a result it can cause long-term complications like rheumatic fever subacute bacterial endocarditis and glomerulonephritis

there are four phases in acute tonsillitis if you see here this is called as acute superficial type of tonsillitis where it is red

And you see that there is no enlarged tonsil.

The second one you see reddish tonsil with exudates in the crypts which we call it as follicular tonsillitis.

And then you have got parenchymal type where the tonsil is red plus enlarged.

In superficial there is no enlargement.

But here we have enlargement.

And then finally, we will have a membranous tonsillitis where we have got a membrane over the tonsil.

This is a true membrane because it's coming from the tonsillar tissue and the dead bacteria.

On peeling, there will be no bleeding in this membrane.

So that was about your acute tonsillitis.

So let's do one question here.

A 25-year-old patient presents to you with history of recurrent sore throat.

On examination, tonsils are small, shrunken, and firm.

So see here several years, meaning it is a chronic infection.

Whenever you see a small tonsil, what type of tonsillitis will you think of?

Chronic fibroid type of tonsillitis.

And there is multiple crypts on the tonsil which are filled with cheesy, foul-smelling debris.

What is the most appropriate next test?

Next step in the management.

So we know that it's a chronic fibroid type of tonsillitis.

You cannot just wait and watch.

What are we planning to do here?

We are going to do a tonsillectomy because this is a relative indication for tonsillectomy.

Reassure and observe won't work because this is going to recur and patient will have recurrence or throats.

Start a course of oral antibiotics.

It's only temporary measure, not a permanent measure.

Incision and drainage is not necessary because this is not an abscess, but you can do an elective tonsillectomy so that the patient will not have recurrent infections, the patient will not have an abscess and will have a good quality of life.

So with that, let's go to the next question.

A patient with a history of recurrent tonsillitis underwent tonsillectomy and now the patient is presenting to you with secondary hemorrhage.

When is this complication seen?

So when we talk about complications or when we talk of hemorrhage following tonsillectomy, we have primary hemorrhage.

We have reactionary hemorrhage.

we have secondary hemorrhage what is primary hemorrhage if there is a hemorrhage that happens during surgery we call it as primary hemorrhage any bleeding or hemorrhage that occurs after surgery up till 24 hours we will call it as reactionary hemorrhage and then after 24 hours still

your 14 days you will call it as secondary hemorrhage so they're asking you secondary hemorrhage occurs when so can i say six hours after surgery no because that's reactionary 20 hours after surgery no because again 20 hours is within 24 so we will not take that but can i say six days bleeding if there's a six days after surgery can i say this secondary yes this is the most likely and most suitable option 14 days after surgery is not an answer at all

with this let's move on to the next question a five-year-old girl is brought to you with by her mother with complaints of mouth breathing dull expressionless face open mouth high arched palate and crowding teeth what is the diagnosis so you can see here x-rays clearly showing to you a soft tissue in the nasopharynx when you have a soft tissue in the nasopharynx it is blocking the airway and the possible diagnosis with the history and the x-ray is going to be your adenoid hypertrophy

Lingual tonsil is at the base of the tongue.

Quincy's peritonsillar abscess tonsillar hypertrophy will present to you with bulge of the tonsils and all of the three are diagnosed on clinical examination and not by an x-ray.

Let's go to the next question.

A 7-year-old child presented to you with symptoms of recurrent acute otitis, serous otitis media, sorry.

And on examination, there's a high arched palate, crowding of teeth and x-ray showing to you a grade 4 adenoid.

So adenoid hypertrophy with SOM, what will you do?

Of course, you have to remove the adenoid and remove the effusion and ventilate the middle ear by doing a grome insertion.

So the correct answer is option C. This is a PYQ.

We have a next question.

A worried mother brought her six-year-old unimmunized child to ER with complaints of fever, cough, shortness of breath.

And on examination, a pseudomembrane was noted over the tonsil and it is bleeding when we try to remove with a bull neck appearance.

What else do you want when we have a pseudomembrane?

tonsillar surface is bleeding when you're trying to peel the membrane the word bull neck is given this is more than enough for our diagnosis which is nothing but diphtheria i'm sure everyone has got it so i'm not going to discuss this further we have a question where the image itself is giving you out the diagnosis as soon as you see the image you know it is nothing but the ranula what is ranula ranula is an extravasation cyst

of which gland it is an extravasation cyst of the sublingual salivary gland so the sublingual salivary gland will produce a cyst on extravasation of saliva we call it as a granular so is it a hypertrophic lymphoid tissue no

what is the content of the granular it contains saliva so is saliva clear fluid yes so if it contains clear fluid will translimination test be positive yes does it come from submandibular gland no it comes from the sublingual salivary gland is it an abscess in the floor of the mouth no it's a cyst in the floor of the mouth so i'm sure everyone got this now let's go to the next pyq where they're asking you which nerve is responsible for ear pain after tonsillectomy surgery

So if there is a ear pain from a distant site, we call it as referred otalgia.

Referred otalgia after tonsillectomy, after tonsillitis, after any other oropharyngeal procedure is mediated via the glossopharyngeal nerve.

Any lesion from the oral cavity,

So if you have a lesion in the oral cavity, the nerve that is responsible will be the trigeminal nerve.

Any lesion in the oropharynx, the nerve that is responsible is going to be the glossopharyngeal nerve.

From the larynx or the hypopharynx, the nerve that is responsible is going to be your vagus nerve.

So these are the three important nerves and the sites from where they can cause rephrodotalgia.

Of course, C2, C3 is also there.

But exam point of view, this is what I want you to remember at the moment.

JNA is an extremely high yield topic every year there is a question that comes on JNA you should know the buzzwords for JNA JNA will be adolescent male somewhere between 11 to 17 years of age it will be always and always a male and there will be bleeding

that you will see.

If not, unilateral SOM or hearing loss will be the manifestation.

It's an exclusive tumor in males because it is dependent on which hormone?

Testosterone for its growth.

The most common site of origin is spinopalatine foramen and from there it goes into the nasopharynx to produce a red fibrous and a vascular mass.

It can occlude the eustachian tube to result in serious otitis media.

It results in a deformity which we call it as frog face deformity.

Very important.

It will result in a deformity which is called as frog face deformity.

Then it can even invade.

It's a benign tumor, but it is locally invasive tumor.

So it can go superiorly to the base of skull and it can go into the cavernous sinus resulting in second, third, fourth, fifth and sixth nerve palaces.

So these are the nerves that can be involved.

the investigation of choice is a contrast enhanced ct scan now there are some signs that we use in jna the first one is called as hallman miller sign which is a sign that we see on ct or even an x-ray where there is anterior bowing of posterior wall of the maxillary sinus the second sign is called as hondusa sign where there is an increase in the gap between the maxilla and the mandible and there is a sign called as chopstick sign where there is

Erosion of the pterygoid wedge, we call that sign as chopstick sign.

Now, of course, along with CT, we'll do MRI, we'll do angiography to identify the feeding vessel.

And the most common feeder to the tumor is going to be the internal maxillary artery.

And what is the treatment of choice?

The treatment is going to be embolization where you block the blood vessel followed by surgical excision.

What is the name of the staging system that we use for JNA?

The most common one that we use is called as Redkowski's classification.

The second one is going to be your fish classification that we use for JNA.

So you just need to know the names.

Of course, if you know the staging, even better.

But this is what we look for when we're talking to you about JNA.

Now when it comes to nasopharyngeal carcinoma the most common site or the most common site of origin is going to be the fossa of Rosenmuller.

The buzzwords will be a old age man usually presenting to you with neck nodes and you don't know where the primary is.

this will be the commonest manifestation to you sometimes they can ask to you about trotter's triad what is trotter's triad trotter's triad is a patient with nasopharyngeal cancer will have unilateral som resulting in conductive hearing loss along with that there is fifth nerve involvement and tenth nerve involvement this triad is called as trotter's triad so fifth nerve involvement tenth nerve involvement

And if there is a conductive hearing loss, we will call it as Trotter's Tria.

Now, of course, they will also have nasal obstruction, eustachian tubal obstruction, cranial nerve palsies.

But here you will have second, third, fourth, fifth, sixth, seventh, eighth, ninth, tenth.

All these cranial nerves can be involved.

Typically, it can also present to you with Horner's syndrome.

Now diagnosis is established on biopsy and the treatment is usually radiotherapy.

So that is about your nasopharyngeal cancer.

So now let's go and solve an MCQ.

A 60 year old female presented to you with hearing loss in the left ear.

Ipsilateral immobility of the soft palate.

Neuralgic pain on the left side of the face.

Nirinya and Weber were done which concluded that there is a conductive hearing loss.

So hearing loss, immobility of soft palate indicate 10th nerve involvement.

Neuralgic pain on the face indicates 5th nerve involvement.

So what triad are we talking to you about?

It is nothing but your Trotter's triad of nasopharyngeal cancer.

We have a next image of a male who's presenting to you with dysphagia, halitosis and aspiration pneumonia.

Barium swallow is clearly showing to you that there is a pouch.

What is it?

It's pharyngeal pouch, also called as Zenker's diverticulum.

So because the food is going in the pouch, there is halitosis.

And when the contents of the pouch fall in the larynx, there is aspiration.

And because the pouch contents are compressing now on the esophagus, it will present to you with dysphagia.

so all of these are suggestive to you or pharyngeal pouch also called as zenger's diverticulum

Now let's go to the next question.

A 24-year-old woman treated for peritonsillar abscess returns with recurrence after two weeks.

So she had an abscess, you did IND, now she's coming back with an abscess.

What is the definitive way to prevent further recurrence?

You don't want this to occur again.

What will you do?

You will do an interval tonsillectomy.

What is interval tonsillectomy?

First, if a patient is having peritonsillar abscess,

you are going to drain it.

So what will you do?

You will do incision and drainage.

After that, what will you do?

You will wait.

For how long?

Wait for 4 to 6 weeks.

After waiting for 4 to 6 weeks, what you will do?

You will do an elective tonsillectomy.

So this procedure where you wait for 4 to 6 weeks after a peritonsillar abscess, we call it as interval tonsillectomy.

Now let's go to danger space.

What is danger space?

It's a component of the retropharyngeal space which is located posteriorly.

So ideally we say that retropharyngeal space is located between buccopharyngeal fascia anteriorly

and the prevertebral fascia posteriorly so this space we call it as retro pharyngeal space this space begins superiorly from base of skull and inferiorly it ends at t4 vertebra now this is further subdivided into two compartments

by the alar fascia.

So the anterior compartment, this is called as true retropharyngeal space and the posterior compartment is called as danger space.

So danger space is now between which two fascia?

Alar fascia and prevertebral fascia.

So the true retropharyngeal space will end at T4 but danger space will end at the level of diaphragm.

So now we are clear about retropharyngeal space which is located between your buccopharyngeal fascia which is the outermost layer of the pharynx and prevertebral fascia posteriorly.

So this space here is called as dangers, the retropharyngeal space and it is divided into two compartments by the alar fascia.

What is the lower limit of retropharyngeal space?

We know it is T4.

So can you tell me what ends at the level of T4?

It is the bifurcation of trachea that is there at T4.

So that should be your answer.

What is the commonest cause of chronic retropharyngeal abscess?

See if we have an acute retropharyngeal abscess it is usually because of saturation of lymph nodes.

Which lymph nodes?

Lymph node of ruviar and it is secondary to what?

Secondary to adenoid and tonsillar infection.

But if you have a chronic infection it is usually in the danger space and it is usually due to tuberculosis of spine that the disease has gone here.

So it is the caries of the cervical spine that is responsible for chronic retropharyngeal abscess but separation of lymph node will be for acute retropharyngeal abscess.

Now, if you see a median bulging of the pharyngeal wall, where will you get that?

If there is a bulge in the midline of the posterior pharyngeal wall, it is a pre-vertebral abscess.

On the side of the midline will be retro pharyngeal abscess.

And if there is a tonsillar bulge, it could be peritonsillar abscess or para pharyngeal abscess.

We will learn that eventually I have images for discussion.

Commonest cause of para pharyngeal abscess is para pharyngeal space is in very close proximity to the tonsil.

So tonsillitis is the most common cause for para pharyngeal abscess.

Trismus where there is difficulty in opening the mouth is seen in all of the following except

So in Ludwig's angina, there is cellulitis of the submandibular space.

So there will be trismus.

Quincy is peritonsillar abscess.

So there will be trismus.

Parapharyngeal space is located here to the medial pterygoid.

That can cause trismus.

But prevertebral abscess is located posteriorly near the vertebrae.

It has nothing to do with trismus.

Now let's go to the next question.

A diabetic patient with a history of tooth extraction presented with a swelling on the upper third of the sternocleidomastoid with displacement of tonsil to the opposite side.

So whenever we are talking of tonsil, if the tonsil is pushed medially, there can be two differential diagnosis where we see that there is a unilateral bulge of tonsil.

What are the two differential diagnosis?

One, either it can be a peritonsillar abscess

Or second a para pharyngeal abscess.

In peritonsillar abscess there will be no neck swelling.

But in para pharyngeal abscess there will be a neck swelling.

okay so here they're telling to you that there is a swelling in the neck in the upper third of the sternocleidomastoid and there is a displacement of tonsil what should your answer be it is a para pharyngeal abscess to be very specific pre-styloid compartment of the para pharyngeal space if there is a bulge behind the tonsil

then that is how a post-styloid para-pharyngeal abscess would present.

So pre-styloid will produce a tonsillar bulge, post-styloid will present as a bulge behind the tonsil.

So now let's spot the diagnosis.

We've already discussed unilateral bulge of tonsil, two differential diagnosis, peritonsillar abscess or para-pharyngeal abscess.

If there is a neck swelling like this, then we will think of para-pharyngeal abscess, no neck swelling, peritonsillar abscess.

if we have a bulge this is the midline on the side of the midline it is retro pharyngeal abscess if there is a bulge behind the tonsil then it is post styloid para pharyngeal abscess right

This image is descriptive by itself whether cellulitis of the floor of the mouth.

This is nothing but Ludwig's angina which is cellulitis of the submandibular space.

This image is showing to you that there is increase in the pre-vertebral soft tissue column.

There is some air bubbles and there is straightening of the cervical spine.

All of this prompt the diagnosis of pancreatitis.

retro pharyngeal abscess right so now that we've known this let's go quickly to layering so we finished the pharynx very quickly understood everything the abscesses anatomy of pharynx very importantly tonsil and adenoid jn and npc pharyngeal pouch ludwig's engine these are the most important things that you need to revise from pharynx now let's quickly do the larynx larynx basically has some paired cartilages which are the paired cartilages the paired cartilages are arytenoid

corniculate and cuneiform.

Which are the unpaired cartilages?

The unpaired cartilages is thyroid, cricoid and epiglottis.

The hyaline cartilages of the larynx are, so before we go to hyaline, let's just mark out the elastic because it's more easy.

So the epiglottis with the corniculate and cuneiform, these are going to be your elastic cartilages.

Whereas your thyroid, arytenoid and cricoid, these are going to be your epiglottis.

hyaline cartilages.

The largest cartilage on the larynx is your thyroid cartilage.

The only complete cartilaginous ring in the entire airway is which cartilage?

Very importantly, it is your cricoid cartilage.

So now that we've understood

the laryngeal anatomy let's do some of the important images and questions that we can have from here so we have an image here that's talking to us about a muscle that's located on the extrinsic surface of the larynx what is this muscle this muscle is nothing but your cricothyroid so this cricothyroid muscle is the only muscle that lies on the extrinsic surface of the larynx and it has got two bellies the

this muscle is the only tensor of the vocal cord it is supplied by your external branch of superior laryngeal nerve rest all the muscles are supplied by recurrent laryngeal nerve now if we see the posterior surface this muscle that you see here is your posterior crico arytenoid muscle which is the only abductor of the vocal cord so at the moment just focus on these two muscles

then we have got all the muscles are supplied by which nerve recurrent laryngeal nerve except cricothyroid which is supplied by external branch of superior laryngeal nerve only muscle that's lying on the extrinsic surface of the larynx is your cricothyroid muscle

Then we have got only abductor of the vocal cord.

It is your posterior cricoarytenoid.

This has come multiple times, so you should know it.

Only tensor of the vocal cord is cricothyroid.

Only unpaired muscle with dual innervation.

So you see here there is a muscle that is horizontal going from one arytenoid to another arytenoid, but it has got innervation coming from both the sides.

What is this muscle?

It is nothing but your interarytenoid also called as transverse arytenoid.

So what is it called as?

Interarytenoid also called as transverse arytenoid.

so now that completes the basic things of the revision of the laryngeal anatomy quickly let's go through this question as soon as you see the image you should get done with the answer as you see the image there is a thumb sign that you see thumb sign is diagnostic of epiglottitis which is seen between three to six years of patients and here they will have high grade fever and they will also have stridor they will have dysphagia drooling of saliva

So what are we asked in this question?

They're asking you which statement is true regarding the management of this patient.

So here, are we going to do an examination of the ENT?

No, the thorough ENT examination is not required because it can result in laryngospasm if you want to examine.

So this is definitely the true statement and of course your answer.

But let's go through the other options as well.

The child may be sent home and the mother given her advice for paracetamol administration falls because this condition is a medical emergency.

You can't ask the patient to go home.

So this is a false statement.

Antibiotics are not needed as it's mostly a viral infection falls because it's a bacterial infection, not a viral infection.

the child should be made to cry is false because crying will only aggravate the edema aggravate the spasm the vocal cords will come to midline increasing the stridor so all of these statements are false and this is the only true statement so in epiglottitis what are the buzzwords the buzzwords that you get to hear is going to be respiratory difficulty in terms of stridor there will be digestive difficulty like dysphagia or dinophagia drooling of saliva

and there will definitely be sometimes a little bit of change in voice between three to six years of age the organism is a bacterial infection which is most commonly streptococcus pneumonia they present to you with mainly respiratory symptoms and digestive symptoms voice symptoms and cough is usually not seen

diagnosis is made on the basis of x-ray which will show you a thumb sign the treatment is going to be medical therapy and of course you have to secure the airway so airway securement is a priority when it comes to epiglottitis or croup group is laryngotracheobronchitis here also there will be a respiratory difficulty but mainly there will be cough there will be change in voice

digestive symptoms like dysphagia or dinophagia may be present but it is less pronounced it is seen in three months to three years of age it is caused by a viral infection which is para influenza type 1 and type 2 and

Again, you are not going to examine these patients.

The diagnosis is made on x-ray, which will show you a steeple sign.

And if you have a steeple sign, it is suggestive to you of group.

Again, airway securement is most important, but will give cough suppressants, steroids, racemic adrenalin nebulization in both of them.

Intubation and tracheostomy may be needed in both of them.

Now let's see image based diagnosis of quick important lesions.

You see here there is a bilateral nodular swelling of the vocal cord at the junction of anterior 1 3rd and middle 3rd.

This is called as vocal nodule, singer's nodule, teacher's nodule and it is seen at the junction of anterior 1 3rd to middle 1 3rd of the vocal cord.

if you see here there is a polypoidal lesion present on the vocal cord which is unilateral nodules are bilateral whereas vocal polyps are unilateral nodules happen because of gradual abuse in the voice polyps happen because of sudden voice abuse here you can give voice rest in nodules but if it does not respond then you're going to do surgery but in vocal polyps there is no role of voice rest you have to go for surgery

Next image is showing to you that there is bilateral edematous swelling of the anterior two-thirds of the vocal cord giving to you a bag of water appearance.

This is usually seen after smoking, history of smoking will be present, voice abuse will be present and you see that there is edematous tissue, it is nothing but your rinkies edema.

So very important three benign lesions that you should know of.

Pachyderma laryngitis is also called as contact ulcer, also called as kissing ulcer, involves the posterior portion of the larynx where you will see that there is hypertrophic epithelium on one side and a depressed ulcer on the other side.

That is the diagnostic feature of pachyderma laryngitis.

The painful laryngeal condition is going to be a TB laryngitis.

Premalignant condition is going to be keratosis larynx.

also called as leukoplakia.

So keratosis larynx or leukoplakia is a condition where there is a possibility of transforming into malignancy.

What is not a true ulcer?

Pachyderma laryngitis.

Where do you do stripping of the vocal cord?

Stripping of the vocal cord is done either for rinkies edema or for patients who are having keratosis or leukoplakia of the vocal cord.

where is gutsman pressure test used for in those patients who have got puberphonia so during puberty boys have to crack their voice and there should be a male tone in the voice if it doesn't happen then we say that they are having puberphonia and what do we do for puberphonia which type of thyroplasty

type 3 thyroplasty where do you get keyhole appearance of the vocal cord keyhole appearance of the vocal cord is seen in phonoasthenia phonoasthenia is a condition where there is weakness of the phonatory muscles the thyroarytenoid and interarytenoid and as a result the vocal cords instead of being like this they bow

So thyroarytenoid bowing will cause anterior two-third bowing and interarytenoid weakness will cause posterior one-third bowing and this appearance we call it as keyhole appearance of the vocal cord.

Spasmodic dysphonia, there is spasm in adduction and it will result in a change of voice which we call it as spasmodic dysphonia.

It occurs due to spasm of thyroarytenoid muscle if it is adductor.

if they're asking to you about abductors spasmodic dysphonia then it is posterior cricoaretinoid muscle

that is about the basic benign lesions let's do one very important pyq mcq asked multiple times so they're giving to you a history of trumpet blower glass blower swelling on the left side of the neck there is a gurgling sound when you compress the swelling x-ray was inconclusive so ct was taken ct is showing to you that there is a air filled swelling coming from the larynx

How do I know it's airfield?

Because it's black.

And in a trumpet blower, glass blower, weightlifter, a swelling in the neck with gurgling sounds.

What is the diagnosis?

It is nothing but laryngocele.

That gurgling sound, we give it a name.

What is that sign called as?

We call it as Bryce's sign or Bryce sign.

That is the hallmark of laryngocele.

So now comes your laryngeal cancer.

Very important laryngeal cancer.

There are carcinogens like smoking, tobacco, exposure to fumes, exposure to viruses like HPV virus and genetic predisposition.

All of that.

We have supraglottic, glottic and subglottic three subtypes over here.

The best one and the most common one is the glottic cancer and it has the best prognosis.

Why does it have the best prognosis?

Because it has got no lymphatic spread and there is going to be early presentation.

followed by we have got the subglottic cancers which have a better prognosis.

But in terms of occurrence, glottic cancer is followed by supraglottic followed by subglottic.

This is the occurrence.

But in terms of prognosis, glottic followed by subglottic followed by supraglottic.

So this is the prognosis and this is the occurrence.

So when we talk about laryngeal cancer, the staging is very, very important.

TNM staging is again very, very important.

So we'll do an MCQ to revise the TNM staging as well.

A patient presents to you with carcinoma of the parapyriform fossa on laryngoscopy.

The lesion is 5 cm and the right vocal folds are not mobile.

There is no lymph node involvement and there is no distant metastasis.

What is the TNM staging of this tumor?

So first of all, we are not talking about laryngeal cancer TNM staging, but a hypopharyngeal cancer TNM staging, which might look a fresh thing to you in the exam, which you might not be able to answer.

The only thing that you see here is no lymph node, no metastasis indicating to you N0, M0, but all the options are showing to you N0, M0.

Now, how do we go?

see when we have a lesion in the hypopharynx and it has gone to the surrounding structure okay it has spread to the surrounding structure it has left the primary site and there is a local spread then it is always a t4 lesion

Within the primary site will be T3, gone out of the primary site will be T4.

So now we are sure it is not T2, it is not T3.

Now is it T4A or is it T4B?

Local to the adjoining site will be T4A, but if it is going to a distant site, it will be 4B.

Now from piriform fossa or the hypopharynx, if it goes to the larynx, it is a local site.

So it's going to be T4AN0M0 and not T4BN0M0.

So with this, let's go to the next question.

Which sensory nerve supplies the larynx above the level of vocal cords?

So the sensory nerve supply to the larynx above the level of vocal cords is via your internal laryngeal nerve and below the level of vocal cords is via recurrent laryngeal nerve.

All the motor supply is via recurrent laryngeal nerve except trichothyroid which is supplied by external branch of superior laryngeal nerve.

Now, this again is a very important image-based question of PYQ, whether telling to you about a two-year-old child who is having respiratory difficulties, difficulty in speaking and breathing, x-rays performed, what is the best treatment for the following?

So if you see on an x-ray AP view, there is a foreign body.

where is it present is it present in the airway or the foot tract if you see air column tract and if you follow it it is the anterior tract and you don't see the foreign body here but if you follow the digestive tract this pre-vertebral soft tissue shadow it is located there indicating it is at the level of the upper esophagus so what will you do here you will have to do a esophagoscopy and remove the foreign body

hamlet's maneuver is if it is present in the airway then you are going to do the hamlet's maneuver to remove the foreign body from the airway as the initial maneuver bronchoscopy if it has gone into the bronchus and tracheostomy is an emergency manual to secure the airway

So with that, let's go to the next question.

Which type of tracheostomy tube is indicated in an ICU patient?

A PYQ that has been asked previously also.

So when a patient is in ICU, most likely if he is on tracheostomy tube, he is possibly having need for a ventilator.

if not need for a ventilator the patient is sick patient where there is a possibility of aspiration so if a patient is on ventilator or if there is a possibility of aspiration we want a cuffed tube so that there is no aspiration into the lungs so what are we doing here if assume that this is our airway

And we have inserted a tracheostomy tube here.

If I take a tube like this, which does not have a cuff, can the contents from above go around the tube and get aspirated?

Yes, possibly.

But if you take a cuffed tube like this, is there a possibility of aspiration?

No.

So cuffed tube is one that we want.

We don't want a fenestrated tube, uncuffed tube in a patient who's in ICU.

In an emergency, an access to airway is performed with this procedure.

They're asking you to identify this procedure.

So here we're making an emergency access to the airway between the thyroid and the cricoid.

This we call it as cricothyroidomy.

This is the first measure that you do if you want to secure the patient.

In a patient whom you cannot intubate, cannot ventilate, first to do cricothyroidomy and then convert to tracheostomy.

If there is time, you can go directly to tracheostomy as well.

So you can see here, this is how we do a cricothyroidomy.

A five-year-old child at dinner is becoming aphonic and is brought with respiratory difficulty.

So while having dinner, if he becomes aphonic and has respiratory difficulty, it means that the bolus or the food item has gone into the airway tract.

What is the next appropriate maneuver?

First, you are going to do a Himlitz maneuver.

If it fails, you are going to go for cricothyroidomy.

If it fails, you are going to go for tracheostomy, okay?

yes tracheostomy is indicated in all except tracheal stenosis bilateral vocal cord paralysis foreign body in larynx uncomplicated bronchial asthma so tracheostomy is indicated in all patients who have pulmon who need pulmonary toileting in those patients in whom there is a foreign body in the larynx you want to bypass and you want to make an alternative way for airway

if there is a bilateral rln palsy and vocal cords are in the midline so so as to secure the airway you might need it and in tracheal stenosis of course you might require a tracheostomy but for a bronchial asthma do we need tracheostomy no so this should be your answer

What is the normal tracheostomy that we do?

Normally what we do is mid tracheostomy which is between second to fourth tracheal ring.

If you go above this, we call it as high and if we go below this, we call it as low.

So above 2 is high, below 4 is low.

High tracheostomy is indicated in those patients who are undergoing total laryngectomy.

So after doing a laryngectomy, you also want to have a tracheostomy, right?

So you do a high tracheostomy.

Low tracheostomy is indicated in patients with recurrent respiratory papillomatosis.

So high tracheostomy is indicated in which patients see a larynx who are probably undergoing total laryngectomy.

the entire revision for all of you now this is a bonus slides for those who are interested in inict and need pg where they can give you an image based question that after total laryngectomy a patient is showing to you this image what is this patient having this is a tracheoesophageal prosthesis so after total laryngectomy if a patient can't produce voice

this prosthesis that is present between the trachea and the esophagus will help in creation of a voice and this is called as tracheoesophageal prosthesis they can ask you of a classification system for subglottic stenosis and this classification system that we use for subglottic stenosis is called as cotton meyer's classification so what is it called as cotton meyer's classification system

So if there is 0 to 50% obstruction, it is grade 1.

51 to 70% obstruction, it is grade 2.

71 to 99% obstruction, it is grade 3.

And if there is no detectable lumen, then we say that it is a grade 4 obstruction.

very important you need to know some of the important investigations and where are they used for so whenever we want to have a quick office based laryngeal view what will we do indirect laryngoscopic examination with the help of mirror and now because we have endoscopes we can do endoscopic examination as well what is the gold standard for diagnosis of a laryngeal cancer

you have a patient with laryngeal cancer what is the investigation of choice it is to do a examination of the larynx plus biopsy without biopsy can i tell it is malignant or not no if i want to differentiate between benign and malignant lesions

by examination we use a stain which is called as supra vital stain this is a pyq of 24 inact so what is the stain that we use pyq it is your supra vital staining so supra vital stain is taken up by the acidic elements in your cell which is your dna

So in areas where there is malignancy, there will be increased uptake indicating to you the possibility of malignancy.

Of course, conclusive is biopsy.

But before that, with the help of supravital stain, we can understand.

When we want to assess the vibratory pattern and the mucosal wave of the vocal cord, we will use a stroboscopy.

To understand vascular pattern, we will do a narrowband imaging.

For those patients who have laryngeal cancer with

cartilage invasion, we are going to do a CT scan.

And if there is a soft tissue or a perineural spread, we want to do a MRI.

And if there is a distant metastasis, then we do a PET CT.

So I hope all of you have got the important investigations that we do in the larynx and their uses.

They can ask you questions on head impulse test, which was asked in one of the exams.

So what happens is whenever a patient is asked to fixate their eye on an object, usually the tip of the nose of the examiner.

So the patient is fixating both the eyes on the examiner's nose.

And now when we suddenly turn the head

what should happen eyes should be still fixated on the target so the eye should not move the eye should still be fixated on the target that is normal but if there is a vestibular loss like vestibular neuritis what will you see when you move the head the eye moves in the opposite direction and then fixates back that is called as a corrective saccade

So the corrective saccade will be towards the opposite side.

So very important, you will see that the quick movement of the nystagmus is towards the opposite side whenever there is a vestibular neuritis or a vestibular loss.

They can ask you questions on the location of anterior thymoidal, posterior thymoidal, foramen and optic canal.

These are all seen on the medial wall of the orbit.

So this is your medial wall of the orbit.

So on the medial wall of the orbit, you are going to see your...

anterior ethmoidal foramen, posterior ethmoidal foramen and optic canal.

They have asked MCQ in one of the exams recently about what is this fissure.

This is your superior orbital fissure and here what are the nerves that travel.

We have the 3rd

fourth fifth and sixth nerve now if there is a lesion in the superior orbital fissure third fourth and sixth nerve supply the eye so there will be restriction of the eye mobility and fifth nerve involvement will result in loss of sensation and then this fissure is your inferior orbital fissure so these are images that you need to die to be should be able to identify

They can ask you positions.

This is your rose position that is used for tonsillectomy and this is the recovery position that you use post tonsillectomy to make the patient lie on the left lateral position so that if there is a bleeding, it should not get aspirated.

This position which is used for laryngoscopy is called as Boise's position, also called as barking dog position, which will align your larynx with the oropharynx so that you can insert the laryngoscope easily.

So these are common things that are asked.

They can ask you at the upper pole of the thyroid, what nerve is at risk?

It is the external laryngeal nerve.

And what artery will get during dissection of which artery will this nerve get injured?

It is the superior thyroid artery.

At the lower pole of the thyroid, the nerve at risk is recurrent laryngeal nerve.

It is in proximity to which artery?

Inferior thyroid artery.

And at the tubercle of zuckerkandle, we have the recurrent laryngeal nerve.

so remember these three important regions in thyroid surgery and the nerves at risk there they have given this mcq where there is a lesion in the frontal ethmoidal region which is causing proptosis and outward displacement of eye this can happen following sinusitis or even after trauma why after trauma whenever there is a trauma during healing there can be stenosis or narrowing of the frontal recess

This can result in accumulation of mucus within a well-wrapped epithelial sac that we call it as mucocele.

If the mucocele gets infected, it will result in piocele.

Now as the mucocele keeps growing, the overlying bone becomes thin and thin and thin and that feeling on palpation we call it as mucocele.

egg shell cracking feeling so that is the hallmark of mucosal and what is the treatment you can do endoscopic if possible endoscopic fest to remove or marsupialize the mucosal if it is not possible then the external approach is called as lynch hovarth external frontal ethmoidectomy so what is it called as lynch hovarth

external fronto ethmoidectomy right so these are the surgeries that we do for

for myoprocele now you see here this is a procedure where they can give you an image based question and ask you what is this procedure this has come as a pyq so here you see instead of stapes there is a piston that is anchored between the incus and the foot plate of stapes this is nothing but your steppidotomy if you remove the foot plate also then it is steppedectomy so steppedectomy or steppidotomy with placement of processes is what you should identify

This is an image for tympanoplasty where there are six type of tympanoplasty as per Wolstein.

If you place the graft on the malleus and repair the tympanic membrane perforation, it is type 1.

So what is the first ossicle?

Malleus.

What is type 2?

Malleus is absent.

So now you're placing the graft over the incus.

So what is this called as?

Type 2.

Here where is the graft placed on the second ossicle which is incus.

Type 3, malleus and incus both are absent.

So where are you placing the graft on the head of stapes?

So this is going to be your type 3.

If the malleus, incus, stapes are absent, you are placing the graft on the foot plate of stapes.

This is called as type 4.

So foot plate of stapes is going to be your...

Type 4 tympanoplasty.

If you make a opening in the lateral semicircular canal and you will place a graft over it, we call it as type 5, also called as fenestration operation.

And what is type 6?

Instead of placing the graft on the footplate or the oval window, if you place it on round window, then we call it as type 6.

So that completes the bonus revision slides also.

I'm hoping that you're going to benefit from this LRR session where I have tried to complete everything, the PYQs, the PYTs, the upcoming exam questions, and also to give you an in total revision of the entire content of ENT in a very short time.

And I hope this will help you crack the examinations with the best marks.

I'm sorry for that inconvenience caused to you during the live session because of internet issues, which is

absolutely not under my control but what i could do best is to record and give you all this session so i hope that all of you are doing well and will prepare well with this session take care and bye