foreign [Applause] [Music] of the important points of the nose and parallel sentences in ENT the first thing is a little ball of nose very important topic and I'm sure you remember that you know lateral wall of nose when we used to draw it like this in the class also in the app also that there is something called turbinates on the later wall of nose which are the projection on little nose and there are three terminates inferior turbine name middle terminate and Superior turbinate and every turbinate has got a space below that and the space is called meatus this is inferior meatus this is Middle meatus this is superior meatus and the area above the superior turbinate is called sphenoethmoidal recess Superior turbulent no in the real endoscopy picture now please see this is your lateral wall of the nose okay now this is your inferior turbinate and this space is called inferior Meats inferior meat is similarly over here in this picture this is later all of the nose this is your middle turbinate hanging projection from the little wall and this is the middle meters look at this area is called middle meatus now Now One More Concept is what is Conga p-o-n-c-h-e what is conquer conquer is the Bony part of the turbine within the turbine it is a bone and that the bone is called conquer so there are three middle becomes the turbinate and of course you can see over here this one can you see over here beautiful interior conquer yes and if I cover the inferior konka with the mucosa become the inferior turbinate and this space of course my dear friend you know but this space will be what inferior meters now now guys now let us discuss what are the various structures draining into nasal cavity into different different areas now first of all what drained to the inferior meatus in the inferior meters nasolacrimal duct drain into inferior meatus into middle meters what drains maxillary sinus frontal sinus and anterior ethmoid yourself and what drain into this phenoethmoidal rhesus area the answer is sphenoid spinous let's divide once again the nasolacrimal duct drain into the inferior meatus Maxis drain into the middle meat as posterior models area now one important question of ophthalmology let us do an Ophthalmology question also the DCR decorio sister andostomy surgery done for the chronic decreases status patient where do we make the surgical opening of DCR in the middle neatest in the middle meters and one visual cushion of ENT this is characteristics endoscopic DCR bone punch which is used for the endoscopic DCR which is done by EMT Department endoscopically through nose so DCR is being done by ENT people also through nose endoscopically and this is a very famous instrument of that which was asked in the visual question the answer is identify the instrument carousel's endoscopic DCR bone punch so this is a picture of that okay now this liter wall of nose specimen can be shown in the picture now let me label it for you it's a cut section of the lateral wall you can see the directly end on your little wall this is your inferior turbinate and this is your inferior means inferioris okay now this is your mediter billion and of course this is the middle meatus area and this is small one is superior turbinate here and spirometers is little bit visible over here and that's a three notes for the research area the main thing is this is phenot sinus bit so they have asked one question what drain in this area in the sphenoeth models area sphenoid sinus okay fine now again one more little while this they can show you this one also in the paper this is inferior turbinate middle turbinate Superior turbinate and this is which sinus with a sphenoid sinus and drain into which areas we know Earth model research area don't forget to revise the little ball of the nose cut section as a cadaveric specimen which can be often examination now let's go further yes three notion is important but why Advanced question can come and where is the screen art center it's lies in the body of the sphenoid bone where is the body of sphenoid bone this is the body of sphenoid bone in this area there are two Chambers Hollow cavities which are sphenoid sinuses then if you remember the uppermost part of the body of the sphenoid bone has a depression called cellotastica in the celestica we have a gland called the pituitary gland and the patient may develop the adenoma of the pituitary gland so what is the best surgical approach for now the question is what is the best surgical approach for pituitary adenoma surgery unit neurosurgery no we can go through nose how because we know if we go through nodes for example please see in the lateral x-ray if you see you can go through nose like this this trust nasal endoscopically you can enter this is your sphenoid sinus you are either spinosiners can you see this depression this is so you can there's a gland here that gland is a tumor so you can go through sphenoid and reach the gland straight away rather neurosurgery we can do the pituitary adenoma surgery the best surgical approach nowadays is the answer is endoscopic okay so the best surgical approach for pituitary adenoma nowadays is not neurosurgery it is the ENT root actually it's endoscopic transmission hypopysectomy because your clear Anatomy wise that okay on top of this we're not Finance the respitatory gland to reach sphenoid is very easy through the nose and we can go endoscopically through nose we reach the sphenoid and we open the roof of spinoid and we remove the pituitary gland also through this root only so the best surgical approach for pituitary adenoma nowadays is endoscopic translucent transparent hypervisor development of sinuses is important now please understand first of all what is the sequence of development of synthesis answer is m-e-sf maxillary atomoid sphenoid frontal now next question is the first sign is to appear in humans is maxillary the last anastopia in human is frontal which two sinus are present at birth the answer is maxillary and ethmoid which is the most developed Center but ethmoid sphenoid developed at what age four years of age radiologically and the frontal appears at six years of age did logically so there are various points you need to remember about the development of sinuses okay next question what is the posterior opening of the nasal cavity not Conga Conga is the Bony part of the turbinates is the posterior opening of the nasal cavity sometimes the corner may be blocked can you see over here you can see over here the corner may be blocked this is the normal corner and in this case you can see this is the case of quinl atresia it can be unilateral but look at this case very dangerous skin it's a bilateral coinal atresia very famous question of ENT Pediatrics bilateral complete quinolatresia is a neonatal Airway emergency why because neonates are obligatory nasal breathers now this child will be cyanosed right at Birth but the moment babies tries to cry baby cries actually the baby turns pink why crying is a deep inspiration with the open mouth Twitter okay the lungs are normal there's no cyanotic heart disease so client means deep inspiration with open mouth suddenly the blue baby turn that's a very important clue for chronology okay so blueberry term ping pong crying is the clue for chronotresia the pediatrician would be unable to pass the suction catheter through the nose when the baby is received by the pediatrician they clear the amniotic fluid with the catheter in this baby the pediatrician is unable to clear the amniotic fluid properly because the suction character cannot go to the pharynx to the nose because this corner atresia it's a very serious Airway emergency if it is a bilateral complete Corner atresia okay the immediate management is put a wide bore nipple in child's mouth to keep it open and this is called Mac the one technique so Mac the one technique very famous question this is used for the immediate management of coinal atresia baby to save the baby you put a wide bore nipple in child's mouth and wait for the ENT doctor to come after few minutes ENT doctor will come and he will do trickiest the customer and after one year of age we do the proper regionalization surgery and we apply which drug mitomycin C to make sure the opening is still patent after surgery okay very famous question so blue baby turns pink on crying bilateral complete coronary atresia don't forget McGovern technique whiteboard nipple picture also okay now external nose the external nose is only upper part is made by nasal bones but then we have got upper lateral cartilages then we have got lower lateral cartilages what are they in their lower later cartilages and then very small we have got the Lesser Eiler or sesamoid cartilages so only the upper one third is made by the bone remaining whole thing is the cartilage this is also multiple choice portion of the anatomy so this is the design external nose you can see very clearly number one is nasal bone okay and only upper one third part only low two thirds cartilage what is that upper lateral cartilage cartilage and number four these ones are the Lesser Eiler or the Samoyed calculus now quartus there's pictured now it is done to check the blockage of nasal valve so this is nasal valve area sometimes the valve is collapsed if they show you a visual picture keep the two finger in the cheek lifted upward what's the name of this test Cotton's test Cotton's test is done to check the blockage of what nasal verb visual question no needle trauma is a very commonly thing ask there will be always history of trauma followed by some deformity of the nose you order the X-ray of the nasal bone you know lateral view right and lateral view left and in this you can see over here also there is a fracture of the nasal bone in this patient now there are two type of question possible in one question they will say there is no swelling of the patient if the nose swelling is mentioned then the treatment of choices immediate close reduction before edema starts immediate closed lotion before edema starts and this is done with the help of which portion poster it is my dear friend and and if edema is mentioned if swelling is mentioned in the McQ then wait for seven days let the edema subside and then do the same procedure but after swelling has subsided so nasal bone fracture two questions are possible his swelling is not mentioned then immediate fructose production his swelling is mentioned then wait for seven days and then do the fresh reduction but the force that is same the name of forcible forceps is a very important topic the common causes are number one the most common cause nowadays is hydrogenic means surgery life functional endoscopic sinus surgery refresh second common cause is head injury trauma skull based fracture if you remember we discussed the class also lead for two and leave for three fracture and nasal ethmic fractures are very commonly linked with the CSF rhinoriometer and third are spontaneous idiopathic leaks also now one visual question is Target sign or hello sign but a Target sign or hello sign t for Target T4 chromatic Target sign or hello sign is a feature of chromatic CSF leak why in heading 3 in skull based fractures there is a CSF leak but this leak is blood mixed theater so when a drop of that falls in the filter paper after drying Italy leaves a red spot and a hello around that this is called Target sign or hello sign or double hello sign these all are a feature of what not every CSM leak only on chromatic csf3 now what is the commonest side of CSF leak and this can be a visual Anatomy question also this answer is crib reform plate the overall most common side of CSF leak is crib refund plate and this instrument is showing the area of the crib reform plate also but if the McQ particularly asks you what is the commonest site of leak of CSF in traumatic cases traumatic csfly the answer is the fovea F modalis which is the roof of the ethmoid bone okay so the overall communist side of the leak is from plate and the commonest side of particular traumatic CSF leak is fovious now how to confirm it is CSF only coming to your nose number one is you cannot slip back CSF number two CSF is non-sticky like water number three that you can do biochemical analysis look at the glucose level to right level Etc but the still if there is doubt the best confirmatory test for CSF rhinoria is beta 2 transfer in estimation that is beta2 transparent is only found in the CSF it is not found in the nasal secretions now how to find the cytok leak now you can do the nasal endoscopy course you can not see CSA because CSF is actually transparent white and it's like water so before you do endoscopy you can inject which dye through lumbar puncture the name of dials fluorescent diet fluorescent dye so first you give intrathecal lumbar puncture injection of fluorescent dial followed by nasal endoscopy this dye will give green color to CSF it is easy to see on the endoscopy but we do lot of radio logical investigation also to find the site of League the number one will be MRI T2 images T2 images number two is CT systemography which is invasive radiological investigation in which a radio contrast dies injected through lumbar puncture and followed by a city of the head actually but the best radiological investigation for this case is hrct Skull base if they ask you what is the best ideological investigation to find the site of csw is HR city of the skull base high resolution city of the skull base what is the treatment of choice of Cs of renorrhea don't go for surgery better to close it the treatment is conservative treatment with the bed rest and antibiotics for seven to ten days you don't want meningitis to develop give antibiotic but give the nature a chance to heal those fractures because callus formation might prevent the CSF leak in many cases so why to jump on a surgery immediately so the treatment of choice is conservative treatment with bed rest and antibiotic for seven to ten days if League does not stop after a week or so then you think of the surgery but the primary treatment is not surgical conservative treatment now next clinical scenario foreign body in the nose foreign body in the nose again very famous question there is a seven-year-old child presenting with there is this child has put the foreign body few days back now the foreign body in a school-aged child may be missed child must may not tell the parents actually now this infected foreign body will start emitting bad smell with a bad smell seven-year-old child you know with unilateral foul smelling neither discharge and epistle single-sided smell single side past single side blood in a school going a child it's indicative of this inside the nose thumb old foreign body there with a very famous question and don't forget school a child with smell from the nose bleeding from the nose a pass from the one side of the nose is foreign body question for sure disk battery in the nose or in the esophagus or in the Broncos anywhere disk batteries please remove them urgently better because these are active batteries These Are alkaline batteries and alkaline batteries can release you know of course Alkali and Alkali causes necrosis and if a patient has swallowed the battery esophageal foreign body as a battery it can lead to esophageal preparation so batteries should be removed urgently but urgently now look at this picture of you know right you know you remember or driven lazy Beyond these nasal decongestant drops or OTC products actually xylometer oximetazoline they are good drugs for few days but if you do prolong the use of xylometer or oxymetazoline it leads to disease called rhinitis Medica mentosa because if you use these drops for weeks and months your system get dependent on that there is a reflex vasodilatation after the effect of this drug is over and that leads to a huge problem for the patient activity right like this medical mentosa you do prolonged use of topical decongestant drop like xylomet or oximeters or leave again a visual question carcinoma or Ronald ulcer if they ever show you an ulcerative like lesion Like This Bitter like this with you know rolled out edges on the nose or the pinna Skin with on the nose external nose or the pinna anytime they show you ulcerative lesion with rolled out edges on the nose or Pinna the primary thing come to your mind and the First Choice should be basal cell carcinoma or odd servant okay fine now rhinophen another visual question of Dermatology ENT rhinophyma or potato nose it's not a tumor it is hypertrophy of these sebaceous gland of the skin of the external nose it's hypertrophy of the sebaceous glands of the skin of the external nose I mean chlamydipine it's not a tumor it's not a tumor it is a hypertrophy of the sebaceous glands of the skin of the external Hospital now let us do a clinical scenario a young patient mostly a female generally they give a female with a roomy nasal cavity nasal crusting bad smell from nose absolutely it's a case of ectrophic rhinitis my dear friend I'm sure you remember a trophy knighters is more common in females better females and it is also called ozina and the name of the bacteria to be remembered as a culpritis there's a bad smell of it from the patient but patient has anosmia so this is called merciful and osmia don't forget merciful enosmia is a feature of atrophic rhinitis patient emits bad smell but patient cannot smell anything you know generally a female patient with the wide roomy cavity with a lot of casting in the nose bad smell from the patient but patient cannot smell anything this is called anosmia and the treatment of choice is alkaline nasal douching and the alkaline nasal douching powder contains number one sodium carbonate number two sodium biborate and number three sodium chloride sodium bicarbonate sodium biborate sodium chloride and what does surgery is done Young's operation modified Young's operation and lutein slagger operation don't forget this picture of the modified Young's operation when the doctor is teaching the front end of the nose visual cushion also it is modified young or young what is modified young it is partial closure of both nostrils okay so in which disease you Stitch the nostril from the parameter atrophilenitis in the name of surgery we don't do Youngs nowadays we do modified young we do partial to Europe both nostrils at the same time and is the permanent procedure now there's atrophyinitis does not have any external changes in the nose of the skin of the nose from the outside whatever is there is inside the nose but if the McQ looks similar again a young patient with roomy cavity with nasal crusting but along with that there is a hard external nose so it is also mentioned the answer will change to rhinos chroma or wooden hospital or Woody knows yes if you remember rhinos chroma or Woody nose which is caused by klebsella Rhino's pleurometers it is more common in North India like uttar Pradesh and Rajasthan States and it has three stages the first stage is a trophic stage and that stage has got a feature resembling the etrophydonitis second stage is granometer stage and that lead to Heart external knows that is why it is called wooden hospital and third is stageofibrosis okay and don't forget the histopathological finding of rhinos chroma the classical finding are result bodies and Nicholas cells Dazzle bodies are blue cells solid plasma cells like inclusion bodies and Nicolas cell please see over here Nicholas cell are these cellular these are the Macaulay cell they are the large backward itself drug of choice for this patient will be tetracycline plus streptomycin tetrome second plastic so two histopathological findings Loma body and rhinoscleroma R for result chroma M4 cell what are the drug of choice combination tetracycline plus streptomycin what is second line drug foreign let us do another question rhinosporidosis so a lot of rhinosporidosis first of all s it is seen in South India the particularly Coastal part of Tamil Nadu my dear friend rhinos flooma is from North India Rajasthan uttar Pradesh ragnostication history will be South India patient Tamil Nadu Coastal area second is C it is caused by rhinosporidium [Music] is swimming there'll be history of swimming in the ponds basically it is found in the pond water it is an aquatic protozoa it is not a fungus it is as for swimming the history of swimming or bathing in the ponds and fourth s is strawberry light or Mulberry like nasal Mass you can see in the picture also strawberry like on Mulberry like nasal mask with epis Taxi treatment in surgery and the drug of choice which is given after surgery is depths on rhinos producers has got d d for depths on beta rhinos chroma has not D beta dapson is useful which disease rhinosporidosis rhinosphere is the D is there default depths on okay fine okay fine rhinosis now angular line another famous question angular line is used in which cancer cancer of the maxillary sinus is it used for surgery no it is used for assessment of prognosis what is angular line angril line is from medial canthus to the angle of mandible angular line is from what to what is from medial canthus to the angle of mandible it is used in which cancer it is used in cancer of maxillary sinus is it for surgery no it is for the prognosis assessment what is the significance of the line any cancer of the sinus or Max designers annual cancer lying above this line will have poor prognosis because of early orbital involvement so angular line let's revive it's from medial campus to angle of mandible it is for the prognostic assessment of cancerous sinus the cancer lying above this line will have poor prognosis due to early orbital involvement next question inverted with papilloma very famous question also called as ring its tumor inverted paviloma or ringage tumor very famous question again and this is a benign but locally Innovative tumor it's aggressive tumor its inverted means it grows inwards therefore it's a locally spreading tumor and it has got chances of malignant transformation in 10 percent cases once again inverted papilloma of the nose also called ring its tumor it's a popular one of the benign in what it means it grows inward sister pathologically therefore it's called inverted by the way white inverted because it's growing inwards it's called inverted number two it's going inward that is a locally Innovative tumor it's aggressive tumor number three it can show malignant change in some people okay what is the site of origin the site origin is lateral wall of nose please see over there the site of origin is lateral wall of nose like this this is the site of foreign originating from the lateral wall as I told you this grows inward but inward inward so if you want to just remove the tumor only please understand if you remove the tumor only like this don't you think so some tentacles are still left okay so we will have to do bigger surgery but how we'll have to remove the site of origin also we have to remove the site of origin also what is site of origin lateral ball of nose so you remove this much wall also there's a lateral wall of nose is equal to medial wall of maxilla lateral wall of no is equal to medial volume maxilla what is the name of surgery the name of surgery is the medial maxillectomy so in which condition an e and t were doing surgery called middleectomy the answer is inverted knows it arises from lateral wall of nose lateral nose is nothing but middle column maxilla that needs to be removed because a locally aggressive locally spreading tumor so that's why name of this the medial metze electron the most common complication long term the most common long-term complication of nasal surgery is the answer is any key formation the nose or additional formation knows my dear friends you can see in the picture also this is your inferior turbinate this is your septum and this is the signing key signing so most common long term complication of any because raw areas fuse with each other how to prevent the saniki formation and knows the answer is my to my sincere the topical aperture vitamin C reduce the sunny key formation this is a very famous question again vitamin C is used in laryngotrich stenosis also Cornell teresia management also and in this case also better because this is anticancer drug with additional anti-fibroblastic properties okay so which drug is used to prevent the formation of Sunny K Mito methane C parts of a tumor very important question again Parts puffy tumor is a complication of acute frontal sinusitis now frontal sinusitis which is a complexion mucosa of the frontal sinus can go deeper into the frontal bone over here and that will lead to frontal osteomyelitis and that frontal osteomyelitis will lead to the subteriosteal frontal abscess and that is called Parts puffy tumor it's not a tumor it's a pseudo name so that's why it's asked very commonly it's a misnomer Parts puppy tumor is the periosteal frontal abscess which is generally formed as a complication of frontal sinusitis it presents as painful red forehead swelling as visible in this image as well very famous don't forget Parts puppy tumor is not a tumor okay now again very commonly asked in the exam is what is you sinus X3 beta what is the most commonly done x-ray for sinuses Waters view what is the best x-ray for sinuses of water's view water is used technically which view occipital mental View Water view can be done with the open mouth also which is better water view when done with the open mouth is called a PRS View Water view shows which sinus the best answer is maxillary sinus Waterview shows all sinuses except posterior ethmoid once again the best x-ray view for sinus is water through Waterview is occipital mental view it is done mostly with open mouth when you do water view with open mouth it is called a p rescue the best sinus visible on water view is maxillary sinus water view shows all sort of acceptable serious mind okay now please stay over there let us see this is your o for orbit this is your M maxillary sinus okay this is your printer sinus right above the orbit and through the open mouth you are seeing what s what is s sphenoid sign as well so no confusion periods view is nothing but water view with open market okay now another view for sinus is Kyle Double U which is rarely done now Cardinal view is technically occipital frontal view water will occipital mental use occipital frontal is more like this view is the best x-ray view for Parental and ethmoid sinuses the best attribute for the the maxillary is the waters view the best actual View for the frontal and Earth models the Cardinals View and the best extra reverse phenotes and is X crystall lateral view but Cardinal View cannot be confused with the water view why because the terrible view if you see carefully medicine is hardly visible but if you compare both the views over there but actually this is of course message very clearly visible it has to be water screw better so if you ever get that which one is Waterview just look at the Maxi sign is it clearly visible it is water view if it is not clearly visible then it is cardiable view it is highly unlikely cardboard view will be asked the paper generally they ask you water View Water view can be done with open mouth can be done without open mouth when done with open mode which is better so look at the choices okay fine careful TT Scan they can ask you CT scan also this o for orbit okay o for orbit and right below the orbit which sign is the m makes the resign what is this turbinate i t inferior turbinated okay what are these cells between the two orbit a thermoid very good ethmoid so these are ethmoid air cells but okay fine now let us discuss FMS ethmoid is a single bone in the body between the two orbits beta it's a single bone the body between two R this is your ethmoid bone single bone not two bones beta not two bone single bone the body between two orbitals and of course there are many air cell in that but these air cells are called the ethmoidal circuit okay fine wow now let us see at modular cells that model yourself I've got two grouped anterior and posterior anterior and posterior anterior model cell are 2 to 18 number posterior 1 to 18 number posterior one to eight number these two anterior modular cell are constants constant cell let us give name to them better the name of two constant entire cells are the bullet modalis and agar nasai foreign a foreign once again number two cells are constant everybody has it what are the name of these two cells number one cell is what is definition of bullet it is the largest and most constant anterior ethmoid air cell what is agronize is anterior most anteriorate cell a for other if a anterior mostly direct modulation now these are constant cells but in some people there can be anatomical variation and they can have some unusual cell of ethmod at unusual location there can be three unusual location there can be three unusual locations so in some people admire yourself can grow at three unusual location what are these three unusual location one is the orbital floor the ethnology of cell can grow in the orbital floor and then they are called Heller cell then they're called what Heller cell they can grow close to optic nerve optic nerve then they are called oh no D solvent oh no D oh no Diesel and they can grow inside middle turbineade they can grow inside middle terminal if they grow inside will terminate they are called they are called concabolism everybody has but in some people there can be unusual atmosel at unusual location if these unusual cell form in the orbital floor they're called Heller cell in the form and close to optic nerve they are called oh no D cell if they form inside military Billet they call concabolism O for optic and foreign guys let us label together this is O for orbit M for maxillary sinus between the two orbit this is the ethmoid bone area and you can see EB what is the EB largest cellular with and that is now agonizai can only be seen the axial CT beta axialct which is like this because it's an anterior most valid okay so this is orbit orbit and this hole is which bone ethmoid Bone full of ethmoid air Salvador and the the front mostel this one will be agronized agonized most interior of course it can be seen only Excel City like this so front most cell anterior muscle is agronism foreign in the orbital floor and my dear friend you can see over there orbit orbit and this cell is below or in the floor of the orbit and of course this is the header cell okay trust yourself your very intelligent people your smart chats and go to the exam with the confidence with the clarity and you know with the Hope in the heart that you will really excel in the examination because trust yourself that's very important okay Kalman Syndrome again very commonly asking Gynecology also please do revise in Gynecology this part also this is a combination of inosmia there is smell problem patient cannot smell anything plus infertility due to hypogonadism better I'm telling you it's important for gyne also please see from Gynecology so smell problem with fertility problem foreign cannot smell ammonia because ammonia is not a smell ammonia is an irritant an ammonia is sent through which now ammonia transformation very good okay fine operations ammonia ammonia is not a smell ammonia is an irritant it is sensed through trigemilanda smell identification test University of Pennsylvania smell identification test is the best test of infection nowadays just don't forget the saccharine test the saccharine test is not for the smell that is for the motility of the Celia of the nose the current test is not for smell second test is not for Taste also second test is for the ciliary motility of the nose area okay but don't forget the opposite is for the olfaction smell this is the best test of affection nowadays always the history of trauma first of all patient has fallen down somebody hit the nose child cycling the ground he fell down there is some history to you know really start this question first of all and septal hematoma is bilateral can you see both sides there's a hematoma over there the treatment of septal hematoma is aspiration or drainage otherwise it will convert to sector perforation so septalimatoma history will be of trauma trauma followed by swelling of the nose and the bilateral nasal blockage okay trauma to the nose can cause two things structure of the nose bitter fracture nose will be given Hint by deformity of the nose but in septalimatoma no deformity of the nose in septal hematoma there will be trauma followed by bilateral nasal blockage so trauma of the nose followed by nasal deformity think of fracture of the nasal bone problem of the nose followed by bilateral blockage think of septalemitoma it's the bilateral entity treatment is immediate aspiration or drainage otherwise it will convert to subtle perforation in the future okay now subtle perforation what are the question to remember most of the diseases cause perforation of cartilaginous part of septum but tertiary syphilis tertiary is the place causes perforation of bony powder tomato syphilis causes progression of bony photoreceptum The Shield Surplus can cause two things the nose number one said the nose number two the preparation of the Bony part of the sector guest please please please don't forget vegetable mitosis can cause perforation of both cartilagness and bony part of septum the second thing can be epistaxis will be there number three will be symptoms of sinusitis will be there and along with this hemoptysis will be given in the picture vaginal granomatosis as an autoimmune disorder in ENT is very important is the commonest presentation of this patient in ENT would be sinusitis kind of symptoms nasal features are perforation of the cartilage and bony part of septum epistaxis and systemic feature will be hemorganism don't forget this is a possible question of the you know the integrated question actually of ENT bit medicine actually okay now what you use to seal the certain perforation the surgical perforation of the step term is done by septal button this can be visual question please look at the receptacle button keep in mind septal buttons are used for the surgical closure of the circle perforations tempter tribe nobody should forget it but a sentence right very important there'll be history of patient who is actually having nasal polypide nasal blockage and they'll be precipitation of asthma like symptoms upon taking some anesthetic like aspirin that kind of clinical scenario will be created Santa strand let's see why it's a Triad of allergy allergy to aspirin or any other NFL there will be nasal polar Pi both side and it's bronchial asthma over there guys it is not extensive customer beta there's no exposure to pollen or anything over there this is not extrinsic as thermometer and there is no instrument kind of mechanism also over this more a prostagland kind of thing please read it from the pulmonology in medicine also it's a very important topic okay fine there's no extrinsic asthma in this case there's no histamine release kind of phenomenon there's more prostaglandin thing over there keep in mind it's important okay now again very important topic allergic fungal Rhino sinusitis this afrs this fungal infection is in an immunocompetent patients and not immuno immunocompetent anybody can get it and it's a type 1 type of hypersensitivity reaction okay now in afrs what you see the two clinical findings number one the typical allergic mucine in the nose which is very thick which is like resonance which is like peanut butter if you see under microscopy this mucine you will see fungal hydrate you will see eosinophils you will see sharkered Laden crystals over there also and the needle polyp are also very typical these nasal polypyr if you see the nasal polypi have got fungal debris into it so if you do CT scan of this nasal polyp of the fungal patient you will not see homogeneous appearance you will see typical heterogeneous or double density Shadows on the CT scan you see the CT scan showing VPC over here you can see very clearly this is more dense than this one but there are two type of shadow of the poly bitter the fungal polypi contain the fungal debris also that is why not homogeneous opacities it's heterogeneous or double density Shadows on CT scan and this is typical of allergic fungal and sinusitis and please keep this in mind okay there's bent and Cone criteria has been asked the paper which of the following is not the major criteria better the major criteria are important there should be type 1 hypersecutive reaction yes I told you it's a type 1 hypersensitivity yes nasal polyp yes typical CT finding yes eosinophils the mucus yes and fungal hyper on the staining yes but culture is not really culture is not fungal culture is not a major criteria fungal culture is a minor criteria they ask you this question which of the following is not the major criteria of Benton to classify the patient as a forest patient fungal culture is not a major criteria you just should be able to see the fungus in the staining proving it on the culture is not a major criteria to prove it to a case of afrs on the Benton system okay now nuclear mycosis everybody knows very important glucomicosis is a life-threatening disease it is seen in mostly immunocompromised patient and you will be seeing patient propile in the question generally young diabetic patient with the ketosis background HIV positive patient patient on immunosuppressive drugs patient on steroid therapy but Cobain 19 patient all these will be given with it okay now mucer a lot of people think nuclear will give black color only no black color comes yes agreed clinical black pillar but in the initial few days only simple reddish you know tissues are there it's just like any other infection so the early features are different please keep it early which are different the cheek swelling redness over the cheek pain over the cheek and then you know the eye swelling is there blurring more Vision will be there lose upper teeth will be there better that's very important this area is full of fungus now as days perceived this is an engine fungus it blocks the blood vessel causes ischemia necrosis via the blood vessel goes to orbit and brain therefore after few days the black color will come the late feature will be black to like blackish nasal Mass blackish discoloration around the eye and the Brain involvement is also there okay but don't forget every mucophone cause the patient will have you know black color only you think early patients can have the normal type of you know inflammatory picture only okay now what is the best investigation for this patient not the QI smear not like endoscopy the best thing would be Radiology better the you should go for the Contrast MRI of the sinus with orbit and you will see the black turbulate sign please see you can use the black turbinate sign over there the normal turbinate is you know absolutely okay but the disease at turbinate is black why because nuclear is angio-invasive fungus it causes ischemic necrosis and that that shows the black turbinate sign over there what is the treatment plan number one is debridement it's a dead tissue over there ischemia necrosis dead tissue dead tissue to be debrided first of all and number two drug of choice is liposomal M4 teresin B is the drug of choice liposomal and what doesn't B is the drug of choice for this patient okay don't forget the bright Bend also both of them should do together but yes drug of choices B angle in the in the last segment that's like the nose comes from two systems the 80 percent of circulation come from external credit come from internal carotid artery what is the demarcation of these two systems we see the demarcation is Middle terminate above the main turbinate is IC area below the metal element is the EC variable okay fine what are the arteries of the ecl very simple below the nose is what but a lip palette palette from the upper lip comes the superior label artery from the palette greater Valentine and sphenopalatin artery okay let's revise what are three arteries of ECA superior labial greater validines xenobello time and from the ICA two arteries come down with a what are two arteries anteriorth model and posterior model and posterior eth model artery y between the two orbit which bone is there ethmoid bones what the name of artery that's model art NDS models but please don't forget this is 80 percent of the circulation major circulation this is only 20 circulation and this is above the level of military now which is the artery of epislexus my dear friends majority of time the bleeding is from spino pattern artery branches better the artery of Ephesus is Steno Palatine artery okay now epistaxial main point to remember most common area of epistasis is little area what is area little area and literally that contains what little area contain a vascular plexus called the Kiesel black plexus which is made by four arteries better let's remember four arteries number one spinopalatine greater Palatine superior labial and anteriorate model artery so the name of it is little area it contains which plexus Kiesel back plexus it is made by which arteries four arteries spino Valentine greater Palatine superior labial and interior model articles okay now don't forget this picture beta for the packings we use conventional this is the conventional integumental packing okay with the ribbon gauze but don't forget this blue picture this is the new one PVA pack spitter PVA packs you should know as a graduate also that polyvinyl acetate paths also trade name is marrow still pack we put in the nose and this gets swollen they get the pressure so what is the alternative to this nowadays is the conventional pack alternative is what marrow still or PVA nasal packs when you put the path right behind the nose how do you see the posterior pack better please see pursue a pack over there that's the posterior pack over there please see it has got three threads better three threads the one thread second thread and third fret so any any path with three threads is okay fine now the question is if both packings fail to control the bleeding you did interior packing you did posterior packing and they control they are unable to control the bleeding then the further treatment plan is the further treatment plan is endoscopic phenobatin artery ligation the further treatment plan is endoscopic sphenopolitan artery ligation I told you the artery objectives peanut butter and artery and the if both packings fail then you should go for espal endoscopics now one more question if EC ligation fails to control bleeding you type the ECA I told you 20 circulation come from the ICA then the further treatment plan is ethmoidal artery ligation at model artery ligation because if EC has been ligated still bleeding is Continuum then bleeding is coming from IC territory and Ice we can't tie the ice cream okay fine of course and if source of bleeding is from above the level turbinate you do an endoscopy the bleeding source is from a level in the nose above the middle terminate then it has to be from the ICS system then the treatment plan would be again a model arterialization if both packing spill is spelled to be done if EC allegation fails then what is the next plan of management at modularity ligation if the source of bleeding on endoscopy seemed to be an area above the middle turbine then of course at model artery ligation data okay so these were the few concepts of the you know to be revised important concept high yield concept for the nose and sinuses hello my dear friends let us start the revision of important points for larynx topics for the examination first of all the cartilaginous design of the larynx and please see over here this is the thyroid cartilage which is making the outer framework of the larynx it's open book like cartilage this is e e for epiglottis which is there to cover the vocal cords and these are vocal cord of course and a for a retinoid retinoid the paired cartilage and retinoids make posterior one third of the vocal cord and C is cricoid cartilage cricoid is the complete ring-like cartilage which cartilage does not also with age answer is epiglottis okay now this is the real endoscopy picture of the vocal cord and if you see this a is a retinoid these these big you know things are what are retinoids and they make the posterior one third of vocal cord next concept is once again see this and those will be picture of the larynx the whole is pink in color but vocal cords are white in color this will remind me for the exam the larynx is lined by ciliated columnar epithelium except vocal cords which are white in color so vocal cord aligned by stratified squamous epithelium okay now let us talk about a disease which is seen in smokers and the disease is called you know keratosis larynx basically what happened in smokers the you know the vocal cord epithelium starts shedding faster and that lead to this cretinaceous debris kind of picture on the vocal cord which you can see beautifully over here now it's a pre-malignant disease so patient has to undergo surgery the surgery is called the stripping of vocal cord nicosa or decortication also quit smoking the newer treatment the other alternate treatment for this disease is CO2 laser codectomy okay now about vocal cord what is Rinky space my dear friend as we talked about the vocal cord is lined by statified form of epithelium below the steady fights chromosomethelium we have a loose tissue these sub we call the loose connect tissue in the vocal cord this is called rinky space so ring space is what sub mucosa lows connected tissue layer in the vocal cord edema of the space is called rinkus edema very famous question now rinky redema is actually bilateral diffuse swelling of the vocal cord it is more commonly seen in smokers the most common cause is smoking and it's a bilateral entity both called a uniformly swollen and it would also need surgery and the surgery is same as the keratosilary and the name of surgery is stripping of vocal cord mucosa or decortitation okay now so guys let us start the discussion of next very important clinical topic of vocal nodules also called as singers nodule or teachers nodule or screamers nodules the main cause behind it is vocal abuse and the second common cause this Letting Go pharyngeal reflux of the gastric acid and bilateral nodule always vocal nodular unilateral bilateral always bilateral what is the site or vocal nodule Junction of anterior one third with posterior two third beta so please see Junction of anterior one third hand posterior two third and they are bilateral nodes both sides the side also this side also the cheek combined will be horse wise generally history of vocal abuses there are reflux of the acid is there in the history of the patient so how would you treat it treatment is not surgical primarily treatment is voice rest or speech therapy plus minus proton pump inhibitor plus minus proton pump inhibitor okay so don't Mark the degree for the primary treatment of vocal nodule go for voice stress choice or speed therapy along with proton pump inhibitor Also may be given in the choice so be careful now let us talk about another disease of vocal cord intubation intubation galoma and it is due to faulty intubation or prolonged intubation in ICU patients particularly and and entering the Luma is also a bilateral diseasement it's also a bilateral disease can you see both sides okay the site is Junction of anterior two third and posterior one third of vocal cord please don't forget vocal nodule was Junction of anterior one third and posterior two third intuition glenoma is Junction of anterior two third and proceed at one third of the vocal cord in this case the treatment will be surgical the treatment will be micro laryngeal surgery okay so the patient will be you know having a history of some surgery undergone under general anesthesia a couple of weeks back and generacia needs intubation and after that surgery after few weeks patient has developed change in the voice and think about intubation granuloma in such scenario or in issue patient because of prolonged intubation the clinical scenario may be created now again juvenile papilloma blarings now this is a disease of younger children juvenile three to six year old child and this is caused by human papillomavirus 6 and 11. and you can see multiple Watty papillomatous lesion on the vocal cord okay now it's a pre-malignant disease by different you know HPV this is also premalignant disease and these papilloma these you know warts can also grow into trachea and bronchi and the patient would be having chronic hurts to the voice and they may be respective difficulty also and the treatment will be carbon dioxide laser surgery CO2 laser surgery so you do MLS micro linear surgery with which laser carbon natural laser but recrest is a big problem in this patient don't forget carbon isolator is used to you know evaporate these papillomas but they can come back as a patient might need multiple surgeries now a very famous question is what are the agents used to decrease the recurrence rate of the juvenile papillomothers please please don't forget intralism is a famous question of the paper so interlection injection of the cedophobia is used to when the recurrence or decrease the recurrence rate of juvenile packing of the lands second one is inter from alpha 2A and bifazulma mainly please don't forget to do for me okay fine now Supra goddess guys this is the high yield rapid revision of ENT okay Supra glottis talk about that please see now this is of course your epiglottis this is epiglottis this is your true vocal cord and these are the false vocal corporate true vocal cord and false vocal chord over there they are pinkish vocal called are rudimentary they don't have any value okay true woke up at the real vocal kind of white in color false we produce sound from the true vocal cord but if a patient produces sound from false vocal cord the disease is called dysphonia Plica ventricularis the other name of false vocal cord is ventricular bands they are rudimentary but if a patient produces sound from false vocal cord is a disease called dysphonia Plica ventricularis now what is ventricle you see this is your Paul's vocal cord the smaller one okay this is your true vocal cord okay so this is your fvc false vocal cord this is your TVC true vocal cord and then the V this is v v is ventricle so what is ventricle it is spaced between the true vocal cord and the false vocal chords okay my dear friend don't forget this sacral very famous question sacral sacral is a mucosal out pouching from ventricle everybody about sacral sacral is a small mucosal out pouching from ventricle now if stack will become big insides look at this one second pink in size the disease is called laryngo steel so sacral is a normal structure but it's actually become over distended to make a disease called laryngos field now laryngosciel is common in trumpet blower or back Piper blower or people who use wind instruments actually now the history will be a trumpet blower or a saxophone player something like that and that patient has developed a neck swelling now this is the neck swelling in the patient okay fine so basically the circular got like bigger and it's herniating out and this is the of course the disease is very clear laryngos if you press it if you press it the sound of air leak can be heard and this is called Bryce's sign so when you press the laryngo steel it is air filled swelling of the neck if you press it what will happen there will be sound of air League herd and that sign is called prices sign over there now we do x-ray of the neck to diagnose it with while cell walk you know you close your nose and to try to build up the pressure of air it will make the swelling more prominent and this is of course very clearly visible over here this is the Airfield neck sweating over there and treatment is surgery okay now Letting Go Malaysia very famous disease Letting Go Malaysia is the most common congenital anomaly of the larynx it is the most common cause of neonatal Strider it is also called as congenital neonatal Strider okay or congenital laryngeal Strider okay now this is a weakness of supraglottis in the famous clinical pictures you know endoscopy shows Omega shaped epiglottis and in this patient the the chief complaint is Strider and The Strider has got four points to remember number one The Strider is almost since birth the mother will say does this spider sound the noisy breathing sound started in the first week of flight it increases on crying remember it decreases in prone position okay it is in prone position okay and it is inspiratory Strider guys don't forget our class discussion also that these supraglottic problems cause inspiratory Striders okay so Striders since birth increases on crying is less than the prone position and is inspiratory Strider and this indicative learning Malaysia guys letting go Malaysia the sky sound is normal because vocal cord are normal laryngomalacia is the weakness supraglottis vocal cord or normal so Christ normal read the McQ very carefully okay what is the treatment of laryngomination treatment of laryngomalacia is the conservative treatment reassurance to the parents that it is self-limiting disease okay now just for your kind information conservative treatment can be the treatment of choice in four scenarios in ENT number one is of course laryngomalacia number two is the number one is Letting Go Malaysia okay number two is unilateral vocal cord palsy single side quad policy are managed conservatively to begin with number three CSF rhinoria don't go for surgery immediately if you remember ESF leaks can you know stop on their own also and number four is that chromatic rupture or traumatic perforation of the eardrum traumatic perforation of the eardrum okay so let's devise what are the four scenarios in which you marked another way to treatment non-surgical treatment is the primary modality of treatment number one laryngomalacia number two unilateral policy number is number four traumatic perforation of the tympanic membrane now next congenital disorder is congenital subglottic stenosis okay now please see on this side also please see in this side if you see right behind my picture we see over here this is the normal set but here you see can you see the subglottic area has got only small opening and this is a case of congenital sublotted stenosis okay now for this we use a very famous system of breeding it's called cotton mild grading of congenital subnautics gnosis now quarterback grading has got four grades grade one is zero to fifty percent obstruction grade 2 is 51 to seventy percent obstruction okay grade three is 71 to 99 obstruction and grade 4 is no Lumen detectable once it is can be graded okay grade one is not much symptomatic so grade one treatment is conservative treatment conservative treatment okay now grade two would need treatment you will need laser treatment or you will need dilatation and you need to apply the mitomycin C after you dilated with the dilators you apply which drug might do my sincere vitamin C okay and grade three grade four would need grade 3 and grade 4 will need proper surgery called the laryngotracheal reconstruction followed by the placement of a special tube called Montgomery silicon trickility tube Montgomery's silicon trachealthy tube Montgomery silicone trickle tutu now this is the visual question of the paper this is used in the management of laryngotrachal stenosis and its place for few days to support the graft you have created over there guys mitomizen C is a very favorite topic of the examiners mitomizing C is actually having anti-fibroblastic properties it is topically applied and it can come in different multiple choice questions number one in the management of laryngotrachal stenosis as we discussed just now number two it can be used to prevent the formation of saniki in the nose after surgery number three it can also be used in the surgical management of coinal atresia okay so number one is Vitamin C laryngotic stenosis number two is the of course preventing the formation of cynic in the nose after surgery and number three coil atresia management so three questions is over there no pediatric laryngeal infections very very important about ENT and pediatric both acute epiglottitis it is more commonly seen in two to seven year age of children and there's a lot of edema in the larynx it's a bacterial infection the most common bacteria nowadays is second common is hemopolis influenza B now this patient will be having inspiratory Strider a supragmotic problem called inspiratory Strider number two it's a very sick child there is a very severe respiratory difficulty in the child look at the multiple choice cushion scenario and the patient will be having drooling of saliva Hot Potato voice the child be sitting you know bending forward and that is called tripods time tripod sign okay and please don't forget the X-ray of this patient x-ray soft tissue neck lateral view in this patient will be showing thumb side thumb side now what is the number one treatment of epiglottitis so epiglottitis is a very serious pediatric Airway emergency in this patient you should immediately go for Airway management Airway management by intubation is the primary management of this patient number two please keep in mind avoid repeated laryngoscopy because repeated laryngoscopy can lead to more edema of the larynx basically this edema of the larynx don't do laryngoscope again and again it will it will actually lead to more redeem of the larynx now you should give steroids and you must start the antibiotics also but the primary treatment is Airway management now let's say the second disease of pediatric lens infection the name of disease is acute laryngotracheal bronchitis or altv or group group now this is a viral infection of the airway it's caused by para influenza virus and the age group is three months to three years now this patient will be having mild respiratory difficulty there will be Strider but the important thing is there will be barking cough don't forget learning will lead to barking cough in this patient okay now now don't forget the x-ray x-ray of altb patient will show which signs steeple sign and simple sign is what a narrowing of the subglottic area guys in laryngotrachiobronchitis the whole Airway is infected but the most you know affected areas of glottis and if you remember the most narrow part of the Pediatric larynx is sublottis so subclotties get even more narrow this is the narrowing of the subglottic area over here please see over there this is your trachea which is pretty okay but if you see closely the subbulating area has get very narrow this is like a steeple of the church okay is people sign now okay the treatment of aldb generally a patient is not that sick epiglottis baby is more sick this patient will be needing mostly humidified oxygen bronchodilator steroids and antibiotic to prevent secondary bacterial infection I repeat the patient will be needing humidified oxygen number two bronchodilator number three steroids and antibody to prevent secondary bacterial infection now very important topic tensor letting Everybody's scared of this topic canceller is staging mostly is Hospital okay now let us simplify staging P1 only one named structure involved tumor involving epiglottis is T1 you can ask me Rajiv what about vocal cord if one vocal cord is involved it is T one a okay T1 a means one vocal cotton vault t1b means both vocabulary okay till the time one named structure is involved it is actually the T1 tumor involving you know every epiglottic fold only T1 but what about vocal chord the name is vocal cord only so one vocal cotton wall foreign the most important thing to remember about T3 is the vocal cord is immobile or fixed immobile or fixed okay the fixed vocal cord or immobile vocal cord is T3 guys impaired vocal permeability is T2 only with T2 vocal cord has to be fixed or immobile to classified as T3 if the McQ says about the impaired quad Mobility normal quad Mobility it is T1 or T2 okay because impaired quad Mobility is also T2 only okay so to call it T3 it has to be fixed or you know immobile vocal or there may be innovation of some space like pre-epiglottic space or paraglottic space there may be invasion of pre epiglottis space or paraglottic space okay if the MCU mentioned about some space involvement in CT scan that is absolutely the T3 T4 very important question invasion of thyroid cartilage or extra laryngeal extension into next structures for example into the currently okay are you getting a point where T4 means innovation of thyroid cartilage or extra laryngeal extension into next structure like current left so that is T4 now this is the CT scan this is a very commonly asked question also in the CD scan this is T4 T4 why it is T4 please understand over here please see this is the thyroid cartilage Invasion can you see over there can you see over there the tumor has invaded thyroid cartilage is trying to go extra laryngeal this is actually the T4 stage of the laryngeal cancer okay fine now now let us discuss the treatment of this patient of tensor ladies treatment of T1 will be radiotherapy but nowadays recent advances for T1 glottic cancer the treatment of choice is CO2 laser surgery as a number one therapy the second option in that case is radiotherapy overall treatment of T1 cancers of laryngeal malignancies is radiotherapy T1 is blood related therapy but nowadays because of laser getting more and more popular for T1 glottic cancer vocal cord cancer if the question asks you particularly glotic cancer vocal cord cancer T1 then you please mark these CO2 laser or laser chordectomy as the primary modality treatment better therapy than the radiotherapy okay now T2 radiotherapy but second option in this patient is a partial laryngectomy if lung functions are normal partial eject me if lungfish are normal but the primary modality will remain radiotherapy second is the horizontal or vertical partial objectives provided the lung function normal but this is a second option if radiotherapy is not given in the choice P3 T4 bigger tumor bigger you know treatments total laryngectomy along with the radical intersection if required followed by a radiotherapy so T3 D4 there may be neckbone medicines in that case P3 T4 will be requiring total laryngectomy plus one is radical and dissection followed by radiotherapy what is the second option in a patient of T3 T4 in T3 T4 the second option is concurrent chemo radiation the second option is concurrent chemo radiation T3 T4 the second best option will be concurrent chemo radiation let's revise once again T1 is one structure involved T2 is more than once which is involved T3 means vocal cord fixed or you know there is immobility of vocal cord or some space involvement is mentioned T4 is thyroid cartilage invasion is there or extra laryngeal extension into next structure is mentioned T1 T2 radiotherapy but T1 nowadays for T1 glottic cancer we should Mark CO2 laser surgery as the number one choice for T2 radiotherapy is there but alternate treatment number second best option for T2 is partial injectomies for T3 T4 definitely total anectomy with radiotherapy but second best option is concurrent chemo radiation now for T3 T4 after laryngectomy when you do patient develop permanent tracheostomy and the patient cannot speak this is a permanent hole in the neck now these patients can use esophageal voice to speak number two they can use the electro larynx or artificial larynx now this is a handheld battery operated external mechanical vibrator okay handheld battery breed external mechanical vibrator which has to touch it over here to speak the best option to speak after laryngectomy isophageal puncture device Pap device it is actually the unidirectional valve which is surgically placed between trachea and esophagus now this is a famous question if you ever see a plastic nipple like thing on the posterior wall of trachea through the tracheostomy hole it is the tracheo esophageal puncture device and the more common example of TP device is blonde singer prosthesis or number two you can use this of course provokes processor nowadays okay now then three nostril that is getting very popular now now supraglottic area it is played by internal branch of superior laryngeal nerve also called as internal laryngeal nerve okay internal branch of superior laryngeal nerve is a very important thing but uh it is also called as internal laryngeal nerve that gets satisfied to supraglottis the subplot displayed by a recurrential laryngeal nerve and glottis is applied by both these nerves but vocal cords what has been vocal cord once again supraglottis sensory Supply comes from internal branch of superior laryngeal nerve also called as internal laryngeal now now after sensor Supply let us talk about the motor supply of the larynx so guys the larynx has got many muscles one muscle lies outside larynx what is that muscle cricothyroid so guys all muscle larynx lies inside larynx except thyroid therefore all muscle of larynx are supplied by regular laryngeal nerve except cricothyroid so creature described by what it's like outside larynx so let's complete the statement all muscle land is applied by Ricky original nerve except cricothyroid which is played by external branch of superior Angle now let's revise one more time which muscle lies outside larynx is the cricothyroid now therefore all muscle relaxers spread by liquid laryngeal nerve except cricothyroid which is played by external branch of superior laryngeal now now look at this picture rln slnr2 mean of the larynx the branches of Vegas Nobita now guys the recurrent laryngeal nerve please see over here the current means it requires its course because its course right side takes a turn around the subclavian artery it has got a shorter course and left side takes a turn around the arch of your thumb left side take the turn around the arch of your turn okay this is the right side takes a turnaround supplement artery left side takes it turn around arch of your attack since left Ireland got a longer course there are four chances of left chord paralysis are four time more than the right side now what is this gland better what is this gland thyroid gland so thyroid gland is good very important relation with the laryngeal nerve spitter now please see over here now please see over here this is your thyroid gland okay this is thyroid gland larys were two important nerves rln sln both are branches which now Vegas nerve reclineral nerve and small laryngeal nerve are the sensory and the motor supply of the larynx and they both come from the vagus nerve now please see over here the rln lies very close to the lower pole of the thyroid gland and sln lies very close to the upper pole of thyroid gland Superior Angle now so the relation of thyroid gland with the nerves is very important because they can be damaged during the thyroid surgery okay now let us do one discussion that if r l n is cut during damaged both sides are Ln got damage both sides during thyroid surgery bilateral rln injury during thyroid surgery practical mcqs better which muscle is still working cricothyroid why because we just said that all muscle of layering is applied by the requirement of except cricothyroid now what is the function of critical thyroid into a two function it's adapter and tensor also so basically for us it is adductor at the moment a doctor means it will bring the vocal cord to the midline so both vocal cord has got only one muscle left working which is cricothyroid and unfortunately it is adductor muscle now please see this will lead to a situation called bilateral abductor paralysis bilateral abductor parallelism that means both vocal cord have come in the midline and a permanently closed vocal cord guys the famous Golden Rule is we breathe with open vocal cord but we speak with closed vocal cords unfortunately both rln have got damaged all muscle were non-functional only cricketer was functional and that is actually a ductor muscle both vocal cord came in the midline and stopped over there and this is a condition called bilateral abductor paralysis the golden rule is we breathe with open vocal cord we speak with close vocal cord but unfortunately in this situation vocal called a permanently closed so patient cannot breathe but can speak normally so the cheer complaint right after surgery of thyroid is over a patient is being extubated you will have very serious emergency in the operation theater only right after extubation of the patient patient will be having respiratory difficulty and Strider but voice will be normal this patient would need immediate treatment will be tracheostomy to save the patient how many months we wait for the spontaneous recovery for six months if six months shows no recovery then what is the treatment of choice of bilateral abductor paralysis the definitely treatment after six months of this patient will be type 2 theroplasty or lateralization of vocal cord which means that we pull one vocal cord to the side actually to open up the air bit so the treatment of choice of bilateral objective paralysis is Type 2 theroplasty after six months this is lateralization of vocal cord okay fine now this was bilateral abductor paralysis now let us see another condition called bilateral aductor palsy adapter policy means reverse of bilateral abductor what happens is when both vagus are damaged both figures are damaged you know rln and sln are the branch innovation of Vegas now if Vegas is cut large is dead that is dead better it means when both Vegas are damaged it is a complete paralysis of the laryngeal innervation both RL and sln are gone it means that vocal cord will come in cadaveric position when no knob is working and the cadavery position is open position so this is the case of bilateral adapter paralysis it is seen in it's a very rare situation of bilateral vagal paralysis which is a complete paralysis of the vocal cord which means rln and sln both go paralyzed and when Vegas is cut large is dead so vocal cord come in cadaveric position and cadabric positional vocal cord is open vocal cord and if you remember the famous rule we breathe with open vocal cord and we speak with close vocal chords and this patient has got permanently open vocal cord so breathing is not a problem but the main complaint will be aphonia loss of voice patient cannot speak normally is there'll be air lead whatever you eat some part of that will go into your lungs also if you are eating Dosa the sambar will go into your lungs also and we can develop the somber pneumonia also but okay fine to understand so pneumonias can happen in this patient but not a serious emergency so this patient will be requiring again six month wait after six months with no improvement happen the death-free native treatment of bilateral adductor paralysis is the type 1 theroplasty so what the definite treatment of this patient after six months is reverse of the first one it is type 1 thoroplasty type 1 theroplasty is medialization of vocal cord medialization of vocal type 2 was lateralization of vocal cord and type 1 is medialization of vocal cord so these are two thoroplasties guys why not revise all the poor thoroplasties better devise all the four thoroplasties type 1 theroplasty is middleization of vocal cord done for adductor palsy how do you remember it mad mad uh people who come first in the class in time one people come first in the class are mad people people come first in the class are bad people you know sorry don't mind Toppers don't mind it I'm just trying to create something easy for you to remember type one is mad Taiwan and money adapter paralysis type 2 is reverse of the type one so type 2 will be lateralization done for abductor paralysis okay and type 3 and type 4 are done for the pure phonia androphonia you know remember normal voice in male is low pitch voice normal voice in female is high pitch wise but if a male has a high pitch voice like a female it's called puberphonia and the name of surgery is Type 3 theroplasty which is shortening or loosening or vocal cord Type 4 reverse of type 3 Type 4 is done for androphonia androphone is what when a female has got a low pitch voice like a male okay and that is patient is called androphonic patient and that patient would be needing with surgery type potheraplasty and type 4 theroplasty is lengthening or tightening or vocal cord lengthening or tightening of the vocal cord let's revise once again thyroblasties that's very easy but a type 1 and type 2 are opposite to each other type 3 and type for a opposite each other type 1 is mad type 1 is medialization done for adductor pulsing type 2 let's reverse it type 2 is lateralization done for abductor policy type 3 for puberphonia it is actually shortening or losing a vocal cord Type 4 is done for androphonia it is lengthening or tightening a vocal cord okay now one more question of paralysis now now as you know the thyroid gland has got another nerve at the upper pole and it is superior no okay if this gets damaged what will happen which muscle will lose its function three co-third muscle is born is gone gone and I hope you remember it has got two properties but a doctor property and tensor property in fact Rico that is the main tensorovocal cord and if you remember tenses give us quality of the voice so if s l n is damaged muscle functions be lost patient will be having poor quality of the voice and of course there will be aspiration problem also because the supraglottic sensory Supply come from internal branch of superior engine now so once again super residential nerve has got two branches external Branch gives Cricket Supply an internal Branch gives sensory splite to supraglottis so there will be two problem of the patient problem number one will be poor quality of the voice better because already the main tensor of vocal cord and tensor determine the quality of the voice better quality of voice will be poor in this patient and sensory loss will lead to aspiration issue in the patient aspiration issue in the patient okay bye let's go further let us discuss this visual question possible hemlich maneuver so patient you know would be having a history of you know having some food and during eating patient develop choking and euphonia and this is a clear-cut case of some aspiration of the food particle in the larynx it's a case laryngeal foreign body and any type of situation is created like that the first treatment will be hemless maneuver please remember the picture the pressure is given on the epigastric area in the upward and backward Direction Russia during the epigastric area in the upward and backward Direction okay so Hamlet maneuver is used for the laryngeal foreign body in a typical scenario will be the patient having food and developing aphonia and you know choking feeling hemless maneuver and don't do this in children in children we go over what the tight back slaps over there now next thing what are the best trick you ask me to for an ICU patient or otherwise an adult it has to be a cough processity and the complete name is portex PVC foreign can lead to complication like Hemorrhage the most common complication will be Hemorrhage of course but tracheostomy can lead to surgical emphysema also now what is surgical emphysema it is the collection of air beneath the skin so it's a collection of air in the subcutaneous plane on the neck because from the tracheostomy hole some air will leak and start collecting below the planes of the subcutaneous tissue below the skin and the collection of air below the skin of the neck of the patient after tracheostomy or after anything is called a surgical emphysema now one question is what is the cause of surgical emphysema tight skin suture architecture you give a cut when work over here some surgeon apply very tight skin sutures so there is no way for the air collected blue skin to come out so that's why the cause behind surgical emphysema is the tight skin sutures over there the other complication which we see right during tracheostomy is apnea the breathing stock the reason is the the CO2 washout so why acne happens because suddenly carbon head leaks to the body and the drive for the respiratory centers is gone so apnea is due to CO2 washout and surgical emphysema is due tight skin sutures of the neck okay so these were the various you know points I wanted to highlight about the you know concept of the larynx for the exam presents the let us start the revision of the important points to the pharynx now uh you know the pharynx has got three parts nasopharynx oropharynx and laryngopharynx behind the nose is the nasopharynx area right now you're seeing the picture of nasopharynx uh the posterior opening of the nose is called quana and right behind the Quanah you are seeing the NATO carrying in the NATO carrying you were two important landmarks number one is of course the adenoid tissue which is more prominent in children this a represents the adenoid tissue which is a lymphoid tissue and it's more tolerant children and of course this is the use taken tube opening and I hope remember the use taken tool connects the middle ear to Nether pharynx and this is the you know middle ear and that's the musician tube and it's connected to the nasal firing wire you're sticking to and that's the you know rough kind of outline towards the design this m e represent middle ear and if if you remember you know like middle year you know produces mucus and it's a middle ear mucosa is secretary in nature and this mucus comes via the eustachian tube into the fats okay now by chance uh you know the use taken you gets blocked uh there will be a disease in the middle ear which is called a glue here because the accumulation of the mucus and the negative pressure in the middle ear uh the disease is called Blue here also called serastatitis Media or otitis media with infusion so nasopharyngeal diseases can cause middle ear diseases please do keep in mind it's a very commonly integrated question asked actually in which two topics it can be asked in the fairings in the ear please see this is what the endoscopy picture of the child and the adult is the first picture is of the child this is child's picture and adenoids they disappear by 20 years of age this is the normal and slowly picture of the adult nasopharynx but okay now just try to understand if a child suffers from a disease which is called adenoid hypertrophy we see if adenoid become too big in size can you imagine this is a normal adenoid picture and this I do not start becoming bigger in size it will block the use taken to opening and the disease in the middle will be called glue here okay so adenoid hypertrophy causing glue here is a very common entity to be asked similarly an adult patient developing nasopharyngeal carcinoma okay right in the nasopharyngeal area this can also block the you stay Curative opening so the story of the you know the glue ear can be asked in two clinical scenarios in the pharynx in number one is adenine hypertrophy in school age children and number two nasopharyngeal carcinoma in adults it's a very commonly asked integrate question of these two topics of ear and fabrics now let us first of all discuss the uh you know adrenal hypertrophy I did not be the very common problem in children's school age children particularly six years seven year eight children again you see the first picture represents the normal endoscopic picture of the child this is the normal adenoid a for adenoid normal this is a normal the child picture no problem but this is of course adding not the fiber Trophy and you can see the Guana is completely blocked the nose is completely blocked from behind the child will have a mouth breathing pattern and the disease will be seen in school year children the typical look of the child is called adenoid phase and the the main thing in that is the mouth breathing the mouth is always open the teeth are also having dentition problem malcolution of teeth pinched nose and the palate is also going high in these children so remember I did not face mouth breathing child is the clear-cut clue for the adenoid hypertrophy McQ and adenone hypertrophy question will very commonly be asked with the glue here scenario so mouth breathing child with the hearing loss is a definite clue towards adrenal hypertrophy with glue here I repeat mouth breathing child with hearing loss problem its diagnosis first of all number one come to your mind should be the adrenal hypertrophy with blue ear patient needs surgery adenoectomy under general anesthesia and when you do a surgery you have to put the position of the patient and the position is called Rose position and Rose position involves extension of the deck significantly but don't extend the neck too much during Rose position because if you do over extension of neck this can lead to very serious complication of you know atlanto axial subluxation the C1 C2 vertebra can get subluxated due to over extension during giving Rose position to the patient for the Adeno translectomy surgery and this is called bristle syndrome my dear friend please do remember Rose position involves neck extension the rose position is used for the adenose surgery also and tonsillectomy also but over essential neck should be avoided because this can lead to Atlanta axial subluxation and this is called gristle syndrome guys this is a very famous question again whistle syndrome okay now nasopharyngeal carcinoma it's the adult patient please see I do not hypertrophy School a children adult patient mostly this cancer is common in China however it is reported in India also but the main culprit behind this cancer is Epstein Barbers it's proven that virus is a proven etiology behind nasopharyngeal carcinoma what is the site of origin of nasopharyngeal carcinoma the answer is a visual question also of anatomy in your paper how to identify it please see this is used taken to opening if they ever put an arrow right above the issue of opening that area is faster of Rosen mullet and I know this is right behind the nose a very hidden area very you know like not easy to examine area and if by chance cancer develop from this area it will be quiet hidden cancer so it's very unknown kind of primary and very soon it will be covering the use taken to opening also so there will be a glue here on one side in an adult patient my dear friends glue ear is mostly disease of children due to adrenal hypertrophy no problem but if an adult patient develops glue ear only on one side I should have a suspicion in my mind as a clinician that maybe the patient is having a hidden nasopharyngeal customer right behind his nose Okay adult patient single sided glue ear think of nasophaginal gas no and don't forget now as I told you NPC's hidden cancer means occult primarily the soft cancer is actually developing in this area how can you see this area it's very difficult to see until unless you do endoscopy and very soon this cancer is going to metastise the neck nodes will develop metastatic lipidinopathy so patient will come to the clinic and without even knowing patient has got cancer patient will say doctor I've got neck swelling what is this neck swelling and that's the multiple choice question also the most common clinical presentation of nasopharyngeal carcinoma is secondary neck node or metastatic cervical lipidinopathy and this is a very commonly asked clinical question how to remember NPC nasophilia customer what is the first letter of the cancer n the first symptom is most likely been the N is neck neck so the commonest presentation will be metastatic cervical lymphadenopathy or secondary neck node something in the neck how to memorize NPC first letter is n the symptom will also first in the N means neck has to be there in the answer now is the skull based cancer so there's a high chance of cranial nerve involvement in this patient and that green of involvement gives rise to a Triad called a protester so protest trial of NPC Nathaniel customer the good thing is the mnemonic of this is also n p c what is n n for neuralgia in temporoparietal area due to fifth knob involved by General nerve involvement P for palatal policy to Tenth num involvement and C for conductive ring loss due to glue here glue here on one side all these things are unilateral unilateral I told you has got you know High chance of cranial nerve involvements and that green of involvement along with the connective hearing loss due to glue here gives a Triad called protest Triad it is seen in NPC that mnemonic is also NPC n for neuralgia in temporal parietal area due to fifth Norm involvement P for piloted paralysis due to 10 month involvement in C for conductive hearing loss due to glue here and all of these features are unilateral and ipsilateral now the treatment of nasophilia customer will be chemo radiation you will take a biopsy after doing nasopharyngoscopy prove it it's cancer and best treatment modality would be chemo radiation radiotherapy is the main thing nasophageal customer is a radio sensitive tumor but chemotherapy given along with therapy is more effective but if by chance you don't see this in the answer then the answer is radiotherapy only pure chemotherapy has no role in this the best offer is chemodation the second best answer in this question as a treatment modality will be a radiotherapy let us do the next topic of nasopharynx and that is juvenile nasopharyngeal angiofibroma like nasopharyngeal was the malignant entity of the nasopharynx juvenile Nathaniel fibroma popularly called angiofibroma it is the most common benign tumor of nasopharynx NPC was cancer engine problem is the most common benign tumor of nasopharynx what is the site of origin of angiofibroma the Arthur is spino Palatine foramen but this is a highly vascular tumor look at the word angiofibroma it is made of blood vessels this is exclusively seen in adolescent males boys young boys 12 to 16 year maybe 18 also maybe they give it okay but no problem a younger male would be the only clinical you know I would say uh candidate for this particular you know tumor so this tumor is exclusive for adolescent males and so the age profile will be 12 to 16 years generally and remember it's a highly vascular tumor so what will be the clinical scenario given the exam 12 to 14 year 15 year or 16 year old boy boy male patient of course with nasal Mass with perfused epistaxis this young boy with nasal mass and nasal bleeding is angiophobia don't change the answer better please go for the common things in the paper stick to the common you know characteristic of that tumor additional binding may be given they might give you additional funding like cheek swelling some you know ocular issues some may be headache some big glue here etc those are additional things because the tumor is spread and can cause multiple other things but the key characteristic thing would be young male with a nasal mass and profuse epistics it's a benign but locally invasive tumor it can go into the orbit also and that will lead to proptosis and that is called frog face deformity now frog face deformity is typical of angiofibroma basically it depicts the proctosis caused by the orbital extension of the tumor please do remember it's a benign but locally invasive tumor the tumor can also spread to Chi and therefore they can be cheek swelling in this patient also however the primary symptoms of the patient would be nasal Mass profuse epistaxis but yes cheek swelling ocular features came may be given along with it guys don't forget again that it's a highly you know vascular tumor it is seen in adolescent boys basically it's a hormone sensitive tumor means some Androgen dependencies there therefore if you see to decrease the vascularity of the tumor before surgery we can give pre-operative either estrogen or flutamide remember the word flutamide it's anti-androsion these two things will shrink the tumor because surgery is going to have lot of blood loss so if you give estrogen before surgery or flutamide anti-androgen before surgery it's going to shrink the tumor it's going to make the surgery little easier less blood loss will be encountered in this patient so don't forget the word glutamide okay preoperative glutamide to the patient biopsy is contraindicated it's a more of a clinical radiological diagnosis and Battery would not be because it's a highly vascular tumor now CT scan uh would be of course contrasting and CT scan in this case is the vascular tumor so CCT would show Hallman Miller sign now what is polymer sign we see the tumor is growing right behind the maxilla so the tumor will be pushing the posterior wall of maxilla forward this is m is maxillary sinus this is a normal side and this is the disease site okay this red arrow represents the tumor okay can you see the posterior wall of the maxilla on the normal side versus posterior wall of the maxilla on the disease side are at different level tumor is pushing the posterior wall of maxilla forward this anterior bone or perceivable of maxilla is technically called a Hallman Miller sign which is a radiological sign on CCT of angiofibroma along with CCT we always do angiography also preoperatively why do we do angiography to find out the main source of blood splike frenzy fibroma and most common source of blood supply for the angular fibroma is maxillary artery maxillary artery okay and what shall we do pre-operative embolization of this artery will reduce the blood loss during surgery so angiography the most common blood supply for the tumor is maxillary artery what we should we do pre-operative embolization of maxillary artery will reduce the blood loss during surgery treatment of choice of energy problems surgery only that's if the tumor is limited to nasopharynx and nose only if the McQ says it's a stage one angiofibroma the tumor is only in the nasopharynx and knows only the best approach nowadays is endoscopic approach endoscopic approach okay but before surgery we do the pre-operative embolization depending on the finding on the of the angiography let us do the next very important topic of Paris is Queen Z or peritonsler abscess peritonsler basically there's a collection of pus between the tonsil and its bed tonsil and its bed this is the collection of past between tonsil and its bed and that pus is pushing everything on the other side so two clinical findings on examination are number one uvula is pushed to others left number two tonsil is pushed medially so its collection of pus between tonsil and its bet therefore uvula is pushed to other side tonsil is pushed medially guys please do remember in Quincy there is no outer neck swelling here there is nothing over there okay they give you oropharyngeal picture uvula angulated think of Quincy only thing please check in the McQ there should be no outer neck swelling Quincy does not have outer neck swelling okay now so again to revise what are two classical finding uvula is pushed to the other side tonsil is pushed medally but very importantly there's no outer neck swelling in Quincy that's very important thing to remember okay what are the clinical presenting feature of this patient number one Christmas will be there which will have difficulty in mouth opening due to spasm of which muscle medial pterygoid muscle difficulty in mouth opening and what is the cause of Christmas spasm which muscle medial territory muscle and number two classically hot potato Voice or Plumbing Voice or a muffled voice these two feature are always there there will be throat pain they'll be dysphagia always remember in clinical multiple choice question of medicine surgery ENT everywhere it will be additional symptom written in in addition to the common symptom please look for the common symptom first of all muffled boils or Plumbing boys or heart potato voice Christmas is there and this is Quincy bit okay but just make sure there's no outer neck swelling okay now this is a Quincy picture better now in Quincy I think you are absolutely now clear neck is normal outside exemption neck is normal there's nothing over there but if by a chance the same McQ of like Quincy you will have pushed to other side tonsil is pushed immediately that is all all given over there along with that they give you that there is an outer neck spelling also close to angle of mandible or close to sternocleidomastoid muscle then the answer will change to parapharyngeal absence that these two question of value overlapping beta please understand Quincy has got nothing outside in the neck but if Quincy like McQ is asked to you you will have push to other side tonsil pushed middlely Christmas is there hot potato voice everything is same everything is same along with that outer neck swelling close to angle of mandible or close to sternocleidomaster muscle muscle is given then the answer is shift to do paraphernal abscess my dear friend there are two equations in ENT you need to remember Quincy plus outer neck swelling is equal to parapharyngeal abscess in the nose at trophic rhinitis plus hard external nose is equal to rhinoscleroma okay the number two equation of e n Theta okay because these two questions look similar but if you know the fine point you will be able to crack the answer the similar word to Quincy and this is called Queen case disease better don't use spellings they should not be with q u oh Quincy no no read it carefully Queen K is something else this is angio neurotic edema of the uvula it's engineerotic edema of the uvula I will not confuse Queen K with Queen C okay Queen K is something else you will a redeemer and genotic edema the uvula is called Twinkies diseasement okay now Ludwig's angina Ludwig and China is the infection of flow of mouth also called submandibular space infection and one definition is infection of plural mouth or sub mandibular space now what the serpenter space means the chin area basically what please see over here this is your mandible this is your what mandible area and in the mandible we have got molar and premolar one of the molar or premolar got carries and from there the infection came to this side so basically the clinical story will always start with dental infection in this case so what is the clinical story Dental infection leading to Chin swelling Christmas and respiratory difficulty may be there but chin swelling and Christmas after dental infection will be Ludwig in China my dear friend paraphary Labs is also commonly due to dental infection but in paraphernal abscess there is no Chin swelling in paraphragilial absence that the swelling is close to angle of mandible so two question after dental infection Dental infection causing chin swelling and Christmas chin swelling and Christmas is but Dental infection causing angle of mandible swelling and Christmas is paraphernal abscess I will read the question carefully okay I hope it's clear chin swelling infection with Christmas angle of mandible lateral swelling after dental infection with Christmas is paraphernal absolute okay now this is your Oro parental area okay now this is called the posterior pharyngeal wall right behind this wall is a space called the retropharyngeal space retrophing space and right behind that is pre-vertebral space right bend that is vertebrate so this is guys posterior pharyngeal wall right behind this you can see vertebra and there is a retroprenal space preventable space in that space we have got the some lymph node which are called retropharyngeal lymph nodes retrophing lymph nodes Now by chance by chance abscess form pass form infection happen in the retrovision lymph node this will lead to an abscess and that abscess is called acute retropharyngeal absolute so retro finger space has got retrofinjal lymph node if the pulse form in this retro finger lymph node it will lead to a very serious clinical condition called acute retropharyngeal abscess which is common in children younger children two year three year children but please see now what will happen here there will be a big abscess formation in this area now this is a condition called acute retrophinyl abscess which is a pediatric Airway emergency in the Pediatric Airway emergency meter so retrofencial lymph node leading to infection and that leads to acute retinal abscess and that's a disease which is more common in children it's a pediatric Airway emergency what will be the symptom of this patient patient will be having age profile of two or three years very sick patient it will be having lot of respite difficulty there'll be inspiratory Strider noisy breathing difficulty in swallowing patient not taking milk or feeds and all that saliva's drooling out and again the voices hot potato or plummy voice now if you do x-ray of this patient you will see widening of pre-vertebral Shadow now see on the screen everybody the vertebra are absolutely normal but in front of vertebra can you see this white shadow this is depictive of collection of past you know in the retrophing space so this is actually the classical x-ray picture of retropical abscess and this is widening of pre-vertebral Shadow but cervical spine is absolutely normal this child will need immediate Airway management first of all it's a pediatric Airway emergency you can ask me Rajiv why it is not a pre-vertebral abscess so this is acute retrovision what is tree vertebral lapsody now pre-vertebral abscess is a chronic tubercular absence which is orthopedic topic product that is due to TB of cervical spine that is more common in adult patient that's more common in adult patient it's a chronic abscess it is seen in adult patient there's no Airway issue in that because it takes months to develop and more commonly in adults and if you do the MRI of this patient or city of this patient you will see of course abscess in front of the vertebra but more important than that you will be seeing the characteristic feature of the parts parameter you can see Parts Point feature the cervical vertebral bodies are eroded there is decreased intervalid space and straightening of spine all those characteristic Orthopedic feature of pot spine will be visible on that so in the exam I will not confuse acute retrofinjal abscess with preventable absence preventable absence is actually tubercular chronic absence more common in children but acute retropical abscess is a pediatric problem which is a pediatric acute Airway emergency okay let us talk about the laryngo carrying Theory now all of us we know that this is supraglottis above the vocal cord supraglottis if they ever show you two arrows like this or one arrow on the side of the larynx like this this is pyriform sinus right pariform sinus left also called the pyriform fossa don't confuse with the visual question of your paper sinus if they ever show you two arrows on the side of the Supra glottis then that those two Arrow are representing pariform sinus right or parmesanus left and parvision is the same as pariform first please understand internal branch of superior laryngeal nerve which is also called internal laryngeal nerve it gives sensory splite to supraglottis and the same nerve gives sensor Supply to pyriform sinus also are getting a point in terminal branch of superior laryngeal nerve also called internal laryngeal nerve it gives tensor Supply to supraglottis and number two pariform sinuscript okay so if the ever give you an McQ that cell anesthetist has placed a cotton soaked in xylocene in pariform sinus which nerve is being blocked and there is internal laryngeal nerve block okay fine so I hope I will declare internal branch of spirulary nerve also called internal laryngeal nerve it gives sensory Supply to two things the answer is supraglottis and poisonous and this is a very commonly asked clinical question of the paper Okay applied an atomic two structures lie in the bed of tonsil bitter yes please if you remember this is your oropharynx area in the orifying area this is your tonsil area and in the tonsil bed you have a two important structures number one is of course styloid process and number two there is a nerve over there and that nerve is ninth orbital glossopharyngeal nerve is also lying over there okay because two structure lie in the bed of tonsils toilet process and glossopharyngeal nerve but by chance toilet process becomes very long if long toilet process start pressing the ninth Nobita long Standard Process start pressing the ninth nerve it will lead to throat pain referred to ear and this syndrome is called Eagle syndrome or stylegia you have studied process okay everybody has it long studded process elongated soil process pressing the ninth nerve will lead to throat pain referred to ear and this is technically called Eagle syndrome or stylegia how to remember the word Eagle Syndrome look at the Eagle you see eagle has got a long styloid process the claw of the eagle holding the snake the claw of the eagle represent the starter process and snake represents the ninth law okay remember visual the total memory is the best memory better long study process represented by the claw of the eagle snake represents the ninth nerve that will help me record on the paper Eagle syndrome or Styles treatment is styloidectomy now there are two new surgeries in oropharyn which is laser palletoplasty strengthening the palate with laser this is the surgical management of snoring nowadays snoring nowadays some people snore snoring is weakness palette is flood having clutter so if you if you make the palette you know you know strengthened by shooting a laser on that laser palatoplasty this is used for the snoring meter okay now there's another cell division you will know paletto pharyngoplasty Upp surgery this is done for obstructive sleep apnea my dear friends I did not hypertrophy transfer hypertrophy can also lead to obstructive sleep apnea sweater osc the extra amount of tissue in the palate is very low utilized very long tonsil is very big you remove all these tissues to make the breathing better during sleep particularly so you will lower paleto thoringoplasty surgery is being done for which disease nowadays obstructive sleep apnea patient visual questions you know tissue sometimes the keratinaceous debris can get stuck up can you see over here there's a collection of keratinaceous debris in one of the crib and and that lead to tonsil lith formation so what is transfer lith its collection of cretinaceous debris in one of the tonsillocrypts and that disease is called tonsillo lith transplant tonsil the main blood supply of tonsil is tonsillar branch of facial artery there are five artery which slider tonsil let's revise quickly ascending pharyngeal artery ascending Palatine artery descending Palatine artery and branches of lingual artery but what is the most important blood supply of tonsil is tonsillar branch of facial artery now Anatomy question what is the venous drainage of tonsil the venous linear tonsil is para tonsillar vein paranoster vein and peritons to vein is the main source of bleeding during tonsillectomy when you do translate with a lot of bleeding going on over there and the main source of bleeding during tonsillectomy is parathon vein and paratostal vein is the main venous drainage of the tonsil now what are the different type of hemorrhages in translatable the hammering tonsillectomy is of three type primary reactionary secondary primary is during surgery whatever bleeding happen during surgery on the table in the operation theater is primary average now patient comes out of the operation theater in the ward post-operative wall then if the patients start bleeding that is called reactionary Hemorrhage now reaction is within 24 hours of surgery and patient is generally in the post-operative ward okay what you'll get a calls in the evening of the surgery only that tissue is bleeding you know from the mouth and this is due to slippage of ligature luggage on the Stitch whatever Stitch you apply to tie that vessel which was bleeding it was loose it came out and it's a serious emergency patient is vomiting blood patient may aspirate the blood may die immediately so what is the treatment of choice of reactionary Hemorrhage the answer is immediate re-exploration how to remember this word better r e reactionary r e re-explore reactionary Hemorrhage will need re-exploration r e for R okay so reaction number is serious emergency you need to explore the patient at the earliest means take the patient operation theater back apply the Stitch again so re reactionary r e d explored number three secondary average it's after 24 hour mostly after fifth day of service this is actually a delayed average patient has gone home patient has been discharged reaction average was in the world only this is after discharge the patient patient has gone home the story would be like that patient has been discharged and after few days again started bleeding it actually is due to infection of the transfer faster the inside transfer faster but infected but it's a mild bleeding doctor when patient spits there's a red color in that not too much of bleeding without so you need to re-admit the patient to treat and start intravenous antibiotics McQ secondary average need intravenous antibodies lateral device reactionary average re-exploration secondary average intervention antibiotic there's only mild bleeding due to infection so secondary Hemorrhage will be requiring intravenous antibiotic Hemorrhage and translator is a very important McQ source let us do the differential language of Whitefish membrane on tonsil there are n number of possibilities what are the various causes of whitish modern and tonsil number one the most common cause is acute membranous tonsillitis acute membranous translators which is caused by step two cookers biogenus the most common cause of Whitefish membrane tonsil is acute membranous translators which is called the strep pyogenous number two infectious mononucleosis which is caused by Epstein-Barr virus EBV which is called the Epstein-Barr virus button okay now number three very important diphtheria is still very important but don't forget diphtheria diphtheria membrane three point to remember number one it's a studio membrane number two it bleeds on removal number three it extends Beyond tonsil once again diphtheria membrane three point to remember number one it is a pseudo membrane number two it bleeds on removal number three it extends Beyond tonsil to the palette you can see over here also it is extending Beyond tonsil to the planet can you see it to the palette to the posterior pharyngeal wall and all those things but it's going Beyond tonsil now from some point with the patient the theory of patient will be baby a sick child with fever and bull neck don't forget bull neck bilateral cervical lymphadenopathy along with the membrane they still will be a sick child with bilateral cervical lipidulopathy called bull neck don't forget the word bull neck and patient is very sick and patient is febrile also better guys don't forget diphtheria can cause unilateral vocal cord pulsi as a complication and the treatment of unilateral quad policy is conservative additional question of diphtheria this is very popular clinical scenario the treatment of choice of unilateral vocal cord paralysis is conservative because there should be a time six months for spontaneous recovery so that's what keeping diphtheria can cause single-sided chord paralysis also what is the best treatment for that don't its weight and watch policy okay now what are the other causes number one was acute membrane sliders number infection more nucleosis diphtheria number four of course Canadians is number five Vincent angina not a Ludwig angina Ludwig angina was in the chin area with instant Vincent is in the tonsil area whitish memory dirty Grace membrane then malignancy and Leukemia polygons leukemia okay don't forget about Vincent angina okay Vincent t t for tonsil Vincent has Tina T will remind you something in the tonsil Ludwig Fortune now killing dices very famous question it's a weakness in the pharyngeal design basically Killian dices is in the inferior constrictor muscle area between the fibers of pyropharyngees and cricopharyngeus so it's a triangular area in the inferior constrictor muscle between the fibers of thyropharyngees and cricopharynx okay so basically there is no muscle in this area there is no muscular support it's a wake area therefore Killian dices is a site of formation of zenkins the particle once again kylian Dyson is in which muscle inferior constrictor muscle between the fibers of pyropharyngeis and cricopharyngees does not have any muscular coat it's a weak area of pharynx therefore it is the site of formation of zenke diverticular or pharyngeal pouch okay like shadow in the X3 now the biggest dilemma they ask you in the paper is whether it is in the esophagus or in the trachea so in this region two things are there esophagus trick here let us look at this piggy bank okay and you know this pigment has two holes over there and to make it easy for you the front hole this one is for the trachea this was the trachea okay and the back hole this one is for the esophagus esophagus that is why this is the trachea okay this is a trick here okay trick here why because the longest diameter of the trachea is in the anterior posterior plane and the longest diameter of the esophagus is from the side to side now can you imagine if the coin is going through esophagus then on the front x-ray you'll be able to see the full shadow of the coin do you see over there you see okay fine now can you see if coin is an esophagus what will happen the coin would be fully visible on the front x-ray this is the anterior posterior view of the X-ray and this is of course the lateral View how to remember it the rule of 3F which we already discuss in the app also in the class also the rule of three if full coin is visible on the front x-ray means AP view then the coin is in the food pi mean esophagus once again a full point is visible like this one I'm talking about this one if full of coin is visible on the front x-ray means AP view then the coin is in the pool by mean esophagus okay now let's put the coin in the truck here check here like this track here go and you know the longest diameter of the trachea is in the anterior posture plane the coin will go like this so now if you see the front x-ray you'll be stable to see the edge of the coin only please see this is the coin and track cabinet here okay fine so from the front x-ray PC this is the AP view or the front view you can only see the Azure coil edge of the coin like that okay five okay now and on the side you can see the full one it's very easy remember three rule the rule of three full coin visible on front x-ray answer is full pipe guys please remember you will be needing an esophagoscopy to remove it okay it's generally a rigid esophagoscopy but it's not an urgent one better because if patient is stable you can just give some time then maybe in like some chance of you know spontaneous expulsion also but there is no urgency okay no urgency okay fine but if the child has swallowed by chance a disc battery this battery then you would be absolutely having urgent situation because this battery can release Alkali and that can cause esophageal perforation so in disk battery injection you must do Urgent esophagoscopy to remove it in coin you would need it but it's not that urgent please see the essence of the question also and it's a rigid esophaguscopy to remove these foreign bodies these were the few important points of the pharynx for your revision for the examination hello my dear friends let us start the revision of the main points of autology the first thing would be a clinical scenario in which a female which is a young 28 year old with bilateral gradually Progressive hearing loss guys whenever a female is presenting the OPD with bilateral gradually progress hearing loss you should always always think of otosclerosis or just very famous clinical scenario asked in the paper and few points about otosclerosis please do remember this lady can hear better in noisy surroundings and that is called paracosis Village sign what is this called paracusis Williston and the typical question given in the paper sometime is that the hearing loss in this female has worsened during pregnancy yes any hearing loss possibility pregnancy is a clue for otosclerosis the otosclerotic focus is pink in color in early stages therefore in the early stages you will see Schwartz sign what is short sign schwarzen is flamingo pink appearance behind the tympanic membrane and schwarzen indicates the early serial disease and in patients or odors process in which schwarzen is positive we do not do surgery in that case we give sodium chloride so otosclosure patient with positive short sign the treatment of choice is oral sodium chloride therapy otherwise the treatment of choice is of course surgery in which we replace the fixed stapes with artificial stapes piston prosthesis my dear friends this is made of Teflon or it can be made of titanium and this is typically looking like a question mark this middle implant looks like a question mark anything like a middle ear implant which is like a question mark think of stapes piston prosthesis okay and you know the name of surgery is stepy.me or the epidectomy the stepidotomy is a better word and in this picture you'll see very clearly that what we have done is we have first opened the middle ear the first step will be what impenotomy you open the middle ear and then this is malleus this is and in place of Staples you have put an artificial stay peace piston processes so this is Odus process surgical management now let us look at the next clinical scenario again a female patient but this time this lady has got pulset Alternatives our bleeding ear mask there is a marginal year which leads to touch that cannabis tree or some pulsatile tinnitus in the ear is complained by the patient now this is a typical scenario of glomus jugular a highly vascular tumor of ear ents2 vascular tumor one in young males called angiophobroma the second in female is glomer's chocolate any young boy with nasal mass and epistaxis is angiofibroma question any female something with something pulsating or bleeding in the ear is glomer's chocolate question and this tumor typically gives with sign Rising Sun Sign it's a highly vascular tumor it grows below the floor of the middle ear and it's a benign locally invasive tumor so it erodes the fluoro middle ear and grows into hypo Independence and that gives Rising one thing okay and on singularization when you put air pressure on the tympanic membrane the tumor shows blanching and that is called Brown Sun that is called with sign Brown sign okay fine now this is a variant of glomer's euclide called glomer skill panicum the glomus jugular arises from glomer cells lying around the jugular bulb area it's called domus jugular jugular bulb is below the floral middleware if the similar type of tumor arises from glomer cells lying around Promontory and you know what is Promontory Promontory is the projection of the basal turn of the cochlea on the medial wall of metal gear what is Promontory projection of basal turn of the cochlear look at the star projection of basal turn of cochlea on the medial wall of middle ear around that Promontory some glomer cells if the similar tumor rises from the glomer cells lying around Promontory the tumor will be named as glomus timpanicum okay otherwise the more common the radius domus jugular next clinical scenario a long-standing history of foul smelling blood-stained ear discharge pow smelling Blood Stained ear discharge chronic history is there please please think of Antico enteral cs1 more commonly called unsifty years so the other name is okay so foul smelling bloodstained ear discharge for last couple of years it is in in direct hint for the atikuential CSM or unsafe CSM the Hallmark of unsafe CSM is called a stoma they may twist the question like this also they may give a picture to you they give you the history of bloodstained foul smelling ear discharge with the otoscopy finding given the picture guys whenever you see a pearly white mass in the upper part of the tympanic membrane or the past Placida area this is primary acquired colostoma that the cholestoma is the Hallmark of the on six year swim an E coli stoma which is actually being found in the past Placida area or the upper part of the middle ear area it is primary acquired colostoma which is due to retraction pocket which will discuss ample in the app also in the classroom let us go to the next scenario long-standing history of foul smelling bloodstained ear discharge same history with the vertigo it means unsafe cl7 has shown some complication you know answer CSM means cholesteroma cholesteroma has bone eroding properties and vertigo in a patient with the unsafe csmistry is an in direct hint for the labyrinthine fistula what is Labyrinth inner ear what is fistula erosion why there's erosion because cholesterol has got bone eroding properties next question is Labyrinth and fistula is a fistula of which canal of the inner ear the answer is lateral semi silver Canal cholesterol has eroded the outer bony Tower of the lateral semicirconol and this is the Labyrinthian fistula which is the complication of unsafe csom and that leads to vertigo in this case fistula sign is positive if you put air in the ear by signalization patient get vertigo and stigma so positive fistula sign is a feature of Labyrinth and fistula which is a fistula of lateral semicello Canal now next another complication now again long-standing history of foul smelling Blood Stained ear discharge with headache first of all whenever you see a CIA swim patient with headache think of intracranial complication headache is a clue for intracranial complication vomiting again with some increase here's the pressure and convulsions this is definitely conversion means some you know space of combine lesion has been you know over there most probably and this is most probably a case of autogenic brain absence you know answer intracranial complication in the form of brain abscess and which is called orthogenic brain abscess and the most common site of autogenic brain abscess will be rich low beta can you see a CT scan they will give you CT scan also along with the question okay and this is temporal lobe abscess it is photogenic brain abscess and the most common site is of course the lobe above the ear the answer is temporal lobe abscess so convulsions headache home vomiting in a backdrop of ear discharge is the case of photogenic brain abscess and please please please they'll ask you treatment also sometime treatment of this patient will be Neurosurgery neural surgery first of all you have to manage the brain abscess later on you manage the the unsafe season with the mrm now there's another variety of cholesterol called congenital cholesterol yes congenital cholesterol since birth it's in the middle year so cholesterol is purely white in color you can screen the pearly white Mass behind intact tympaniment and the key word is intact the pearly white Mass behind in Tech tier this is a typical question of congenital cholesterol and this radio is called describe anybody this criteria is called this criteria Levinson's criteria to diagnose congenital cholesterol okay so in-tech tympanic membrane behind the that you see a white dish pearly Mass it's a question of congenital cholesterol now great Amigos syndrometer heterocytus okay the this is a very famous Triad how to remember it because you know at the Petrus Apex if you remember at the P trust Apex we have got two nerves what are those two nerves these two nerves are fifth and sixth nerves and they get involved by the disease so patient is having ear discharge okay and there is retro orbital pain due to fifth of involvement and diplopia due to system environment how to remember it easily g e r d gradynical syndrome other name of petrocytus has got three features how to remember gerd G4 dead Nico syndrome e for ear discharge R for retro orbital pain due to fifth num involvement and D for diplopia due to six num involvement because we know fifth and sixth number lie at the Petrus 8X area now next one another clinical scenario six-year-old child school going child with mouth breathing and hearing loss but guys I've told you multiple number of times in the app also class also that mouth breathing child is a clue for adrenal hypertrophy and adenone hypertrophication with the hearing loss will be glue here glue here is the glue here is the root cause of hearing loss in children that's why it's so important topic also okay can you see otoscopy can you see there are air bubbles behind the tympanic membrane there are air bubbles trapped in the glue behind the tympanic membrane and this is the question of glue ear also called as serous otitis media but the new name now is ome the new name is ome what is ome or Titus media with diffusion ome okay fine that's whenever you see air bubbles behind a depending membrane please please mark glue ears glue here so the adenoid hypertrophy and blue ear are married to each other multiple choice question please keep in mind mouth breathing child with hearing loss is the direct clue for Android hypertrophy with the hearing loss with the hearing loss okay fine okay so guys please keep in mind this story of mouth breathing child with the hearing loss it is asked in the paper in the story form it always but okay and for the glue here G for blue G for chromate glue needs chromate and what is the other name of bromate middle ear ventilation tube and we do maringotomy first we give an incision on the tympanic membrane and we put the glominate in glue here we do Marine got me in Antero inferior quadrant this is the auto manic membrane where do you give cut in the anterior quadrant this surgery is called a marine got me you suck the glue out in the same hole you put the grommet within a few months nature will you know push the bromate out you don't need to remove the chromate so glue here also called as serous protective media now the new name is otitis media the fusion whenever you see the air bubbles behind the timbering membrane in the glue it's glue here it definitely air bubbles are indicator of glue here but okay fine and chromate G for glue g for grommet and gromid is placed after doing maringotomy in anterior inferior quadrant of the tympanic membrane somebody is using Matchstick or earbud and the dramatic perforation happen can you see a beautiful population over there they can ask you what is the treatment of choice of traumatic perforationality bearing membrane the answer is wait and watch are a conservative treatment please don't put any ear drops no no surgery should be done it is going to heal spontaneously without any treatment in most of the cases just keep the ear dry so treatment of choice of traumatic professional turmeric membrane is conservative treatment or weight and watch no ear drops no surgery just keep the ear dry next question they can ask you what is Promontory I told you already also the Promontory is a landmark on the medial wall of the middle ear Promontory is the projection of the basal turn of the cochlea on the medial wall of middle ear let me point it out to you this is your the Promontory area why Promontory is the projection of basal turn of the cochlea on the medial wall of middle ear okay can you see the star star represent the basal turn of cochlea and the arrows represent the Promontory area Okay Promontory don't confuse the word Promontory with the pyramid now what is pyramid pyramid is on the posterior volume the medial wall of the middleware pyramid is a projection on the posterior wall of middle ear so this is your pyramid from pyramid which muscle comes out stepidious muscle comes out and this attaches to which ossicle this attaches to Staples so pyramid is a projection on the posterior volar middle ear from pyramid the tendon of stupidious muscle comes out it attaches to Staples okay now there are two bony spectules on the medial wall of middle ear okay what are two bonus pictures number one specul is the particulars particular outer number particular particular is from monetary to Pyramid P for particulars it's from permontery to Pyramid to Montreal to Pyramid PPP ponticulus is from Promontory to Pyramid number two is subiculum subiculum subiculum separates oval window from round window so because between the old window area and the round window area how to remember as for subiculum as for separates okay so there are two bonus pickle on the medial wall or middle ear number one particulars is from Promontory to Pyramid PPP number two subiculum S4 subiculum s for separates subiculum separates over window area from the round window area okay now very scary thing for people is the medial wall of middle ear they ask you landmarks here and there let us know them now yes we all know the floor of the picture right now in front of you is the medial wall of metal here majority Landmark on the medial volume okay so let us keep the this picture let us label it this is the p p is the pyramid this is pyramid is projection on the posterior wall of the middle ear remaining all Landmark around the medial value from pyramid once again which muscle comes out stepidious muscle comes out what is this article stay piece okay what is this article incus okay and what is this joint Inc dostepedial joint incredible joint okay now what is this projection this projection is Promontory I told you per monetary is a projection of basal term of cochlea on the medial wall of middle ear okay what is this window oval window why because oval window is where the state piece footprint is attached okay what is this window this window is the round window Okay then if you can see Promontory this one you can see pyramid then of course this will be what this will be ponticulus I hope remember particulars is from permanently to Pyramid okay then what is this better this is subicular so be good okay so big column area so because uh between the old window area and the round window area between the particular and subiculum look at the star this hidden area is called sinus tympani area sinus tympani area okay you can see particulars you can see subiculum between the particle and subiculum star represents area the sinus limpinide is a hidden area in the middle ear McQ sinus symphony is the most common site of residual cholestoma after measure surgery so once again sinus tympani Superior boundary is lower boundary is subiculum sinus tympinai is a hidden area in the middle middle ear sinus tympani is the most common site of residual cholestoma after muscle surgery is done okay please do revise this picture once again later on okay now next one in a rear development inner ear is the neuroactodermal structure it developed from the neuropter down now please see basically neuropridone makes two components actually now this is of course the division beta this much area developed from parse Superior okay par Superior past Superior develops two things what that semi siliconal and utricle utricle okay the lower area the other area is from parse inferior past inferior it gives origin to cochlea and statute let's revise the inner development is from two things past Superior and past inferior past Superior gives origin to semiciro canals and utricle and pass inferior gives origin to cochlea and sexual it means that cochlea is the neighbor of saccule and Canal the level of Utica let us talk about cochlea my dear friend if you remember cochlea has two three by four tons and this turn of the cochlea is called basal turn of the cochlea it's a pale return of cochlear and Baylor ton of cochle is towards the oval window side okay and of course this is called the Apex of cochlear please do remember Apex of cochlea is technically also called helicore trimmer helico remote now there's a most important rule is the basal turn of cochlea senses a high frequency sounds an apex of sensitive cochlear senses low frequency sounds very commonly asked question the 8000 Hertz and more higher frequencies are heard at the basal turn Apex here low frequency sound please don't forget this video basal turn is towards the oval window area side Apex is also called helicotrima basal turn senses high frequency sounds Apex senses low frequency sounds better okay what is modulus modular is the central core around which the cochlear turns formed modulus is the central core or Central axis around which the cochlear turns form okay the overview of the cochlea normal cochlea has got two three by four turns two three by four turns and if cochlea has got a one and a half turn the deformity is called mondanese dysplasia of cochlea Mountaineers displays the outcome here okay if cochlear normal calculus two three by four terms but if cochlear got only one and a half turn it's called montanese dysplasia or cochlea and my dear friends please do remember that the cochlear implant surgery can be done in dysplastic cochlea also okay so this plastic of cochlea is not a contraindication of cochlear implant surgery it can be done in the dysplastic cochlears also now let's talk about the other part of inner real now DC as you now know this is s what is s that cool what is U utricle sacral and utricle are meant for linear balance and these are what it does semi-surgical Canal they are free canals they are meant for what angular balance okay no saccule and utricle have got macula what is this red thing indicating macula is the sensory end organ of utricle and saccule my dear friend macula is covered by a gelatinous layer this yellow is the gelatinous layer on top of the macula in this gelatinous layer we have got calcium carbonate crystals which are called otoconia or otolithic are calcium carbonate crystals in the gelatinous layer of macula now due to unknown reasons these autoponia autolith might get free from this gel and they enter the canals most commonly they enter posterior Canal this will lead to disease called b b p v if autoponia enter the canal it will lead to disease called benign proximal positional vertigo okay most commonly which canal is involved in bppv posterior canal the disease is more common in females females how do the patient McQ will come clinical scenario clinical Vineyard 40 year old female patient to be the brief episode of vertigo on changing head position the moment doctor I change my head position I feel dizzy for a few seconds only mind you brief episode of vertigo the doctor only when I change on my head position my lying down or I'm sitting I lie down I killed vertigo for few seconds and then I'm all right is there any hearing loss in BBB no isn't it tinnitus in BBB no it's only vertigo is there there may be nausea vomiting which is a feature of vertigo very commonly associated feature but there is no tinnitus no hearing loss in this patient okay pure vertigo with nausea vomiting on changing head position and vertigo for few seconds this is definitely a case of bppv guys please do remember that benign processible positional vertigo it is due to displaced otoconia and autoponia enter these semi-circular okay and which can almost it's more common in female there is no hearing loss no tinnitus in this patient now how do we prove the bbpv bbbv the diagnostic test of bppv is big small pipe manure and this can be a visual question of the paper now Dick's topic maneuver you will have two position in the given in the in the exam the first position is sitting position and suddenly the doctor will bring the body of the patient down and the moment you do this patients get vertigo and stagmus and that proves bppv this visual question with two pictures two positions like this is Dick sole pack maneuver which is a diagnostic test of BPT now the treatment of bppv is atlas maneuver now apple is manure has got five positions okay from sitting to lying down to turn the head to turn the body and to sit up again okay five positions are there you're trying to send the autoponia back and this is that is why apply maneuver is also called the particle repositioning maneuver okay Apple manure is the treatment of choice maneuver for bppb the other maneuver are the mount maneuver and brander of exercises as well for BPP I remember I repeat other maneuver of btdvr it's the mod maneuver and brand The Rock exercises for chronic dptv okay now let us do again for inner ear one more investigation vestibular evoked myogenic potential V for vestibular vestibule method utricle and saccularia vestibular evolved and myogenic potential you have put the electrode on sternocleidomastoid muscle so basically you are giving a stimulation to structure with loud sound and you are recording the activity in sternocleidomastoid muscle vestibular evoked myogenic potential so what is the principle of when you stimulate the Saturn with the loud sound and you record the activity of sternocleidomaster muscle it is that they would call it vestibular evoked myogenic potential muscular thing okay Vamp is a test talk which area of course sacral area Vamp is a test toward Saturn and number two when more importantly when tests which nerve web test inferior vestibular division of eight now very very important question when test inferior restoration of the eight nerve therefore you know Vamp is the useful test why this this knob is being tested by van because this now is supplying the circulation so let us see Vamp tests which structure of the inner ear circuits when tests which particular nerve inferior vegetable division of the eight null and why so because this nerve is the supply of the sacral actually okay now then another important topic is superior semi-circular Canal Dyson syndrome in this area there is an opening created this can be congenital or chromatic my dear friend nature gave you two window oval window and round window because and sound energy is going and you know compression and reduction wave is there but unfortunately another window got created now due to this distance The Sound Energy will not be conducted properly to the inner ear there will be leakage of sound energy from this dices so therefore this patient will be having conductive hearing loss not not snhl conductive hearing loss now this is called third window phenomenon very famous question third window phenomenon don't forget this word third window phenomenon is a feature of superior semi circular Canal Dyson syndrome what do you mean by Third window phenomenon patient suffers conductive hearing loss due to leakage of sound energy from this dead sense this is called third window phenomena this patient also have the problem of vertigo on hearing loud sound this is called tulio's phenomena the patient does not have snhl patient has got conductive hearing loss okay and the patient will also give sometime history of you know vertigo and blowing of nose also basically the doctor when I blow the nose very forcefully I get Vertigo Vertigo and blowing the nose also is a clue for these Superior Canal taxes syndrome how to diagnose this is hrct high residue CT of the temporal bone so this is important topic third window phenomenon phenomenon conductive hearing loss now let us identify the obstacles better this Manlius ankle Staples my dear friend no need to get confused between malleus in cosmeter because people say no CPS is definitely like a you know a horseshoe over a plate like that cup and a plate so how do differentiate Mall yes from inkus because it's very simple Manlius is like a head hand you know hammer and every Hammer has a head this is the head of the Magus filter head can you see head this looks like a head also incus has a body body has to be little flat like that okay like that okay can you see head on one side body somebody's lying down on the beach you know head on one side globular head if it has got a globular head it has to be malleus if the flattened kind of thing on the top it has to be Body English as a body malice as a head actually manly is like a hammer every Hammer has a head so with the head blob of the headlight thing will be barrier with a flat body at the top will be incredible okay fine yes malleus Incas develop wrong first start head of state is developed from second arch foot plate of step is developed from neuro ectoderm okay fine once again malius head developed from second arch foot plate of stable develop from neuroctaw cringing of the ear to remove the wax you know we can do cringing some point about syringing number one direction of syringing is posterior Superior number two never use cold water because it can lead to vertigo due to inner ear stimulation number three during ear syringing or during cleaning the ear with the probe patient might develop cough cough what is the cause behind cough the answer is stimulation of auricular branch of vagus nerve which is also called Arnold snow which is also called Arnold's now and the same nerve stimulation can lead to thin Couple Episode also or vasovician turning unconscious during they may make a very clinical applied Anatomy question you were doing syringing or cleaning the ear of the patient and patiently suddenly developed you know either cough or patient developed you know thin couple or vasovagal or turned unconscious it is due to stimulation original or equal a branch of vagus nerve and that is also called Arnold's now and you know big stimulation is going to cause bradycardia hypotension that's why sometimes people develop thin Couple Episode during syringing or cleaning the ear with the probe very very important applied Anatomy question if somebody gets a live insect in them if cockroach goes in the ear what will you do don't try to catch it like there is no five lakh rupees you know price on catching it live first put oil in the ESC to kill it and then remove it oil put oil in the EAC to kill it and remove it okay somebody asked me which oil is there any oil except kerosene oil okay not kerosene oil of course you know you can you can use mustard oil you know take some more mustard oil put the oil kill it and then remove it because if you try to catch it live it might damage the structure of the ear okay there are arthropods in the three pair of Limbs clinical scenario very commonly we are 60 year old diabetic patient presenting with earache bloodstained ear discharge and facial palsy Also may be there there's old patient with the ear problem is malignant or Titus external that's very very important thing is you know malignant is common in Old diabetic patient and facial nerve is very commonly involved because this is the infection of underlying bone of the ESC okay and the causative organism is pseudomonas facial nerve is very commonly involved now okay because patient passes through the bone of the ear it's the bone infection wound it's infection of underlying bone of that's not recognal it is seen in elderly diabetic patient and the causative organism is pseudomonas and facial nerve is the most commonly involved now it's a skull based osteomyelitis it can spread on the skull base and can damage other green Labs also but the first scan you order for this patient the answer is technetium bone scan the first scan to be done for this patient to see the bone infection technician bone scan the follow-up scan is gallium bone scan gallium bone scan okay fine the first bone scan will be technician bone scan and the follow-ups can will be gallium bone scan in this patient what is the drug of choice for this patient the drug of choice for this patient will be third generation cephalosporins third generations of phosphorus preferably along with Amino glycosides okay please see see the question carefully generally they give third generation several support another choice but in the reality pseudomonas you give combination antibiotic so third generation with Amino glyceride combination is a better answer than pure third generation only okay fine now Anatomy question visual question if they ever show you like this a structure being pointed on the posterior wall of the you know posterior aspect of the temporal bone it is internal auditory canal internal artery Canal is the entry point of seventh and eighth now into the ear and I hope remember builds bar bills bar is a vertical bony septum in the upper part of the internal auditory canal okay so if they ever show you uh with a pointer a hole in the posterior aspect of the temporal bone its internal artery canal and don't forget Bill's Bar is a actually the Bony septum in the upper part of the internal article now trauma may be there some injury happened hematoma guys please drain it or aspirate it immediately should be aspirated or drained immediately because it can lead to necrosis of underlying cartilage if you don't drain it you don't aspirate it it can lead to necrosive underlying cartilage and that can lead to Pinna deformity called boxer ear or caulifloweria which is the post trauma Pinna deformity so boxer ear or cauliflower ear is a cule to Pinna hematoma so Pinna hematoma should be drained immediately otherwise it can lead to cartoon necrosis that will lead to the problem with the shape of the pinna and this is also commonly called cauliflower ear or boxer ear so it is post traumatic pinnar deformity the other name is boxer ear or cauliflower now what is bad here there's normal pin now if you see your Pinna you have a two curvature the outer curvature is you know Helix inner curvature is antiox so you you have a 2C but outer C is inner C is anti-halics but if anti-halves is not not there look at this patient method there's no antihalism this patient the absence of anti-halix is called a bat ear your penis to see outer sea also inner C also if inner curvature ntl is absent it's called Battier and the surgery will be called otoplasty and the the ideal age of this surgery will be six years why let the pinna grow fully by six year Pinna almost attains adult size so that's the best six year or later should be the time of the orthoplasty surgery in these cases is not a disease it's anatomical variation can you see this one this is a you know conical elevation on the Helix Darwin tubercle is not a disease it's a an anatomical variation some people have got a conical elevation on the Helix and that's called darvings to birther okay now again one you know anatomical you know Landmark now this uh surgical specimen uh the temporal bone specimen has got an orange arrow pointing at a structure first of all what is this Big Hollow cavity this is the mastoidectomy cavity so this is this is a temporable specimen so I've labeled like that what you are seeing is a big cavity is the mastoid cavity and you can you see exonometric and all over there yes okay fine this is a master cavity this whole hole is the master cavity now if you see a bulge like this is a bulb they are pointing if you see a bulge or projection or elevation in the floor of the mastoid cavity this is lateral semi circular Canal bulge so any projection or any you can say bulge in the floor of the mastrodectomy cavity is actually lateral semi-circular Canal bulb and it is a landmark for this why it is important for surgeons it's a landmark for second Geno of the facial now you can ask me Raji what is the surgical Landmark for first gen of the facial now the first genu which is the house of geniculate ganglion the first Geno the surgical Landmark is processors cochlear reformers once again lateral semi circular Canal bulge is a surgical Landmark for second genome the processes cochleariformis is the surgical Landmark for the first Genome of the patient now no no question log is one branch in the ear they give three branches total very very important branches called it in Pennine and this can be a visual question for you in the in the exam if they ever show you something like this a nerve passing between the malleus and Incas it has to be correct infinite so if they ever show you a naked nerve passing between the malice incus Vishnu passes like this in the middle ear cavity as a naked nerve between the malice and ankles it is correct infinite nerve which is a branch of vertical segment of the facial nerve okay but now Bell's Palsy very important for neurology medicine also Bell's policy is idiopathic sudden onset lower motor neuron facial palsy okay is it unilateral bilateral it's mostly unilateral okay now are the forehead muscles also involved yes they are involved forehead muscles are also paralyzed better okay fine angle of mouth is divided to normal side right this is normal side okay this is disease side okay the forehead muscle are also paralyzed angle of mouth is divided to normal circuit okay I is continuously open and in the ear patient will be having what hyperacusis is due to loss of stepidial reflex because the PDS muscle is played by the nerve to stipidius which is branch of facial nerve only okay so let's try it once again there is upper the forehead muscle are paralyzed or not yes they are paralyzed angular mothers are devoted to normal side in the ear patient complain of hyperacusis due to loss of stipital reflex okay what is the cause of Bell's Palsy it is edema in the labyrinthine segment of the facial now which is the narrowest segment of the facial nerve and that edema leads to compression how people's hypothetized that this edema is due to herpes simplex virus one infection but it is not proven drug of choice for wealth policy is oral steroid therapy for three weeks okay acyclovir is only given if patients are within three days 85 percent patients show wonderful recovery if patients do not show any recovery after three weeks of steroid therapy then we do next management as electrophysiological nerve testing to assess the degeneration of the facial fibers okay once again there is is there any role of acyclobin only in the first three days what is the drug of choice oral steroid for how many weeks three weeks which segment of the facial is involved labyrinthine segment okay how many patients recover 85 patient recover are foreign muscle paralyzed yes angular mouth is pulled towards normal side in the ear which causes hyperacusis if patients do not show recovery after three week of student therapy the next management is electrophysiological nerve testing which are asked in the exam press by qsys is age related snhl which is bilateral like press biopia press by Q Series age limited sensory neural learning loss depletus doctor I hear same sound in two different frequencies is a feature of menius disease hyperacusis as we discussed just now Bell's Palsy paracously is the future once again let's write press by accuses H related snhl duplicates is a feature of mean years hyperacuses the feature of Bell's palsy and paracously in the future of otosclerosis now very important question for anatomy for ENT medicine both Ramsay Hanson Rome which is due to the reactivation of varicellular zoster virus now in which is what is the site of lesion in this the answer is geniculate ganglion where does this virus reside in the geniculate ganglion at the first Genome of the facial now what are the typical features there is painful vesicles in external ear and number two lower motor neuron facial parallels okay same you know the herpes also involve the nerves so there are painful vesicle and external ear and the lower motor neuron facial paralysis and the patient would need acyclovir plus steroid therapy but facial recovery is seen in 50 cases only okay Ramson syndrome the site of lesion is genocide ganglion of the facial law no meltersin Rosenthal syndrome very possible question of visual question in dermatology also it has got three features number one recurrent facial policy number two Fisher tongue and number three swelling of lips let's revise what is the normal syndrome malkerson Rosenthal syndrome the three features are number one recurrent facial palsy number two is Fisher tongue number three swelling of lips no let us include some devices now cochlear implant a very important topic indication of cochlear implant is bilateral profound SNH bilateral patient is totally deaf both side bilateral profound means more than 90 decibel hearing loss with the normal eight now this is important McQ then this is the pre-recuit of cochlear implant surgery because cochlear implant is going to do the electrical stimulation of the cochlear nerve endings so before doing this implant you must prove that eighth nerve is normal so do an MRI to see it now functional and anatomical Integrity over there so what is the indicio cochlear implant bilateral profound snhl with normal eight now now Cochlear implants are two component one outside the body one inside the body outside body external component and external component has got four parts four parts which you wear over here as a hearing aid number one part is microphone microphone number two is transmitter this can be a question transmitter is on the hair over here transmitter is a circular part it transmits current to the internal component number three is speech processor and number four is battery let's revise once again the external component of cochlear implant has got four parts number one microphone number two transmitter number three speech processor number four battery transmitter is a circular part which transmits current to the internal component this is about the external component let us know the internal component the internal component is called electrode now where do we put the electrode because cochlear got three parts scalar stabilized scalar media scalar tympanic has got two windows over window and round window the answer this question is the cochlear implant electrode is placed into scalar tympani of the cochlear through which window through round window through round window okay so the cochleiver three parts if you remember Scala vestibular scalar media and scalar tympani the electrode displays in scalar tympani through which window through round one two question over there this is cochlear implant cochlear implant can be done in dysplastic cochleas also okay fine now this is another implant where cochlear implant doesn't work we have to go for auditory brainstem implant you have to put the implant right in the brain stem area and what is the primary indication of ABI what is ABI auditory brain stem implant okay the main indication of ABI is neurofibroma type 2. neurofibroma type 2 has got a bilateral vestibular schwannoma or bilateral acoustic Roma acoustic Roma is the old name of vestibular Sonoma means eighth nerve tumor both sides I told you cochlear implant the main prerequisite of surgery is normal it now but in this case both eight nerve are abnormal because both of them have developed the tumor so this patient would not be the good candidate for Cochlear implants agree this patient would be a good candidate for auditory brain stem implant surgery what are the other indication of ABI nowadays the other indication are congenital aplasia of the eight nerve there may be cases in which eight num is not formed since birth okay I told you the main prosecutor of cochlear implant surgery is normal right now so in Europe type 2 8 nerve has gone diseased in congenital Ecclesia of the head now is absent and third indication is a pleasure of the cochlea called Michelle's a pleasure of the cochlear so let's revise once again what are three indication of auditory brainstem implant surgery number one neurofibroma type two number two congenital a plasma of the eight nerve number three the missiles aplacia of the cochlea next question is where do we put the ABI electrode again its electrical device you have to put the electrode in the brain stem area the answer of this question very famous question is lateral recess of fourth ventricle repeat with me what is the location of cochlear implant electrode cochlear implant scalar tympani of the cochlea what is the location of ABA electrode the answer is literal the recess of fourth ventricle okay now next device the third device this very popular device nowadays this is you anchor the hearing aid onto the bone okay it has got the three parts number one the titanium screw first of all it's a specialized surgery in which you put a titanium screw onto the skull bone and then number two sound processor then you attach the external sound processor to the screw through an attachment called abutment abutment let's revise the three parts of Baja are the titanium screw which is fixed on the skull bone and then sound processor is attached to the same screw through an attachment called abutment Baja is a specialized surgery Baja transmits sound directly to cochlea through bone conduction what are the primary most important indication of Baha nowadays number one is EAC atresia when the canal is blocked from outside you cannot use the conventional hearing gate number two chronic discharging ear if ear is full of pus you can't put the hearing aid because hearing it will be spoiled to moisture within one day is not there you cannot support the hearing aid she will have to enter the hearing aid of the skull with the with the screw and number four is unilateral severe SNH unilateral severe SMH so let's divide once again what are the induction of Baja teresia chronic discharging ear and Austria with hearing loss what is your lateral severe snhl gas devices cochlear implant breast implant Baja are very important topics for the examination okay now another new device I can say uh you can say thing we use in the ENT is microwave microviks have been used in ENT what are microwavics for orbital yes please see this is your exonometry canal in front of you this is your ESC okay and this is the wick I'm talking about this is your middle ear and this is your inner earther now when you want to inject some drug in the middle ear you don't need to put injection again and again so micro Wicks are used in ENT for Trans tympanic injections injection you want to put steroids or you want to put anything in the in the inner ear so don't put injection again and again just do one thing ask the patient to put the drops from here at home only this will absorb and this will send that medicine to the inner ear okay fine so micro mixing ENT are used for Trans tympanic injection of the drugs okay now let's talk about something about Audiology now pimpanometry also called impedance or Dimitri it is a five type of Curves but uh type A is normal curved type a normal curve very beautiful curve type B is flat curve and and the type B curve is seen in the glue here and type c curve is seen in the negative side of the zero and type c curve is seen in the retracting depending membrane or use taken to dysfunction cases let's suppose once again the type A can you see type is beautiful curve it's in normal people it's standing on the zero equal on negative and positive side both now important thing is type B curve very famous question glue here the glue here is very important topic I told you type B cover flat curve don't forget this one look at the visual also type B curve flat curve is seen in glue here and there is no movement of temporary membrane this is only on the negative side there is no movement on the Zero side I show the positive side the negative side movement if you see it's type c curve it's taken tube dysfunction or in the retracted tympanic membrane case let's revive type A is normal type B flat curve is glue here the type C curve negative side curve is feature of eustrating dysfunction or retracted demanding membrane and the last two more are a S curve is seen in otosclerosis and a d curve is in an osicular dislocation okay now o a e Auto acoustic emission acoustic emission is a very you know commonly you know used thing in ENT nowadays basically what you do is you give sound to the ear and you record ecos from the outer hair cells of the cochlea can you see over here can you see this baby also you have you're giving sound to the cochlear and you're recording the equals from Outer Gates of the cochlea and those Echoes are called autocosystem if ecos are coming it is actually the normal cochlear okay so one question is ecos are produced by which part of cochlea outer hair cells easy to remember ohc outerational cochlear and they produce o a e O2 acoustic emission very simple test for use for screening of the hearing in babies Auto acoustic emissions are produced by the foreign there is another test which we do very commonly in ENT and when you put the electrode on the forehead and all that and very commonly done the babies also this is better also called abrah or ABR but it's full form better brain stem evoked response audiometry also called auditory brain stem responses why the word brain stem comes very commonly here because the most of the auditory pathway lies in the brainstem area that's why they say the word brainstem brainstem so once again what is full form beta brainstem evoked the response audiometry it's also called ABR auditory brainstem responses very simple test better we give sound to the ear and we can record the electrical activity from brain that's all okay basically it's EEG evoked EEG only now Bera has seven waves you can see seven waves over there the most important wave in beta is wave five okay you give sound to the ear and you record the electrical activity from brain and it's evoked EEG bada records multiple ways there are seven ways and the most important wave of beta is wave 5 and wave 5 is produced by lateral laminiscus lateral lemons plus is the part of the oratory pathway okay so wave 5 is produced by lateral laminis lateral lemons okay fine this auditory pathway is the important question the mnemonic auditory pathway is in the brainstem area majority e for eight now t for Cochlear nucleus o for a library complex Superior L for lateral lemnis curse I for inferior colliculus M for medial geniculate body and a for auditory cortex once again e for the eight nerve e for Cochlear nucleus o for a livery complex Superior Alpha lateral UNESCO I for inferior colliculus M for medogeniculate body and a for the auditory cortex which lies in the superior temporal goddess now they can ask you one Advanced question where does the requisition happens with the crossover of information happen from right to left side and vice versa at the level of the library complex area okay at the level all every complex the crossover information happen from the one clear to the other sphere okay fine because the auditory pathway majorly lies in the brainstorm area that's why better the full form is brainstem evoked response or Dimitri and the source of wave 5 is lateral laminis constant now you question about screening protocols better the ideal investigation for neonatal hearing screening is a neonatal hearing screening is auto poster commission but if the McQ says the high risk hearing screening like a meningitis baby or a new or a low birth weight baby or a syndromic baby then you go for better once again a general question about the neonatal hearing screening the ideal industry would be a simple test like Auto acoustic emission but in a high risk baby like a meningitis baby NICU baby what is the best investigation for screening is better brainstem evoked response audio picture no PTA Neutron audiometry okay now it's a subjective investigation you know patient has to respond to you are you hearing it or not this is air conduction testing and this is of course the bone conduction testing here conduction and bone conduction testing okay now in odometry we have to see the hearing threshold operation like Vision six by six is normal if you can hear starting from 25 decibel you're hearing is normal your hearing should be above 25 decibel Zone it means your hearing is absolutely okay okay fine let six by six is normal we have to Define up to what level if you start hearing you are called as normal hearing person if you're hearing start from 25 decibel Zone you are absolutely having normal hearing it now that's how we look at this thing the automated there are one side is frequency can you see 250 to 8 000 Hertz this is frequency and this is decibel but 0 10 20 25 now this is the normal Zone you can see your hearing result should come in the normal Zone if you come in this Zone you have got mildering loss if your hearing line come in this Zone you have a moderate hearing loss if you're hearing result come in this Zone severe hearing loss and here you are having profound hearing loss means almost that patient better so in this test score more towards zero in this test score more towards zero you are better hearing you have don't score 100 or 100 in this test better don't be oh I scored 100 or 100 don't feel very happy about it 100 out of 100 means you are deaf sorry you have to have better so B towards zero better it is actually okay so hearing lines should be above 25 area now we use some symbols for this but for air conduction we use Circle and cross major limiter circle is for right ear and cross is for the Left End okay and for bone conduction B for bone B for brackets we use these kind of symbols better bracket like symbols are bone conduction circle is for right AC Cross or left AC this must you must remember for the examinator this bracket like symbol of bone connection symbols circle is Right AC and cross is leftistable sometimes give you colorful on the ground button for that red lines are for the right ear blue lines are for the left ear it's a rule okay by chance they give you mostly they give you black and white but if you give colored audiogram red lines are for the right ear blue line for the left now please understand whenever you see a b Gap means that gap between the air conduction permission line its conductive hearing loss and if both acbc are poor then patient is suffering from sensory neural hearing loss very important thing a b Gap if there is a b Gap it's conductive hearing loss if both acbc up to 25 you are suffering from sensory neurological hospital now let me show you normal audiogram don't get scared it's not that difficult this is frequency you can see 250 to 8000 frequency and this is of course decibel decibel now this is left side audiogram why it's blue in color anyway cross is for left ear is the beta cross left AC and and this is of course the bone conduction symbol but this is 800 symbols and up to 25 I told you if you are hearing results are coming this Zone you have got a normal hearing action so this is normal hearing or degrometer okay let me tell you a secret of ENT bone production line is always about upper line is always a bone reduction okay just remember the screwed rule actually over there upper line is always one reduction okay not connectivity loss but please see this again left here y cross cross is for the left AC weather blue color again left here this is bone conduction can you see bracket like symbol better okay any upper line is always BC bracket line symbol is BC it's normal this is of course AC line AC line and this is poor up to 25 is normal so it means that BC is normal in this patient AC is poor and this Gap is called a b Gap a b Gap is feature of conductive hearing loss so this patient is suffering from left conductive hearing loss once again I make your device this is a left audiogram y blue color okay it's a black and white then what cross represent the left AC okay fine now BC is normal why any line above 25 is normal Hallmark of conductive hearing loss okay now in sensory neural learning laws when cochlear is not working properly you go through air conduction or you go through bone conduction both will be poor now so let us see the SNH orbital please see as the natural of the left side okay can you see the blue color okay and please see this is 0 10 20 25 both have come below 25 but the normal Zone was this Zone both AC and BC have come down and this is left SMH a bit that's all it's not that rocket science I don't know why to get confused but if both line are below the 25 it's the natural case why it is left here again blue color left here okay color is not given cross is given this cross means what cross is what left here is 70 okay one now if it is a mixed hearing loss then what mixed drink mixed feature of both means both AC BC poor is CBC poor with a B Gap with a B Gap both acbc4 with a big gap okay fine now let's see this one by one now please see the first one this is normal normal because both line are above the 25 number two this is BC AC I told you upper line always BC beta okay and this is what would have a b Gap so this will be conductivity loss okay now this one number three both acbc are below 25 this will be snhl snhl number four please see this is BC AC both are poor with the a b Gap this is mixed area lost can you see in the fourth one we see both BC and AC are poor but there's the a b Gap also the a b Gap also so when both hdbc are poor with a B Gap it's a case of mixed hearing loss let's find once again first one is normal okay fine second is a b Gap conductive hearing loss third is both acbc poor snhl fourth is acbc poor with a B Gap it's the mixed steering loss band now two dips and two special audiogram in the end two dips are one dip is seen in otosclerosis which is dipped at 2000 Hertz in bone conduction curve in order you see a typical dip at 2000 Hertz in both conditional curve and that tip is called Carhartt's Notch you can see Karate this is not this is the 2000 this is which line but the bone reduction line and this dip is called garage Notch and karat's not the typical of photosterosis otosclerosis the name of dip is what karate knowledge it is seen at 2000 Hertz in AC or BC in BC metal what is this line beta is C what is this Gap called a b Gap a b Gap is feature of what conductive hearing loss and we know otosclerosis patient has got conductive hearing loss you can see beautiful description over there it's not that difficult once again karat's not in the dip pad 2000 Hertz in bone production curve and there is a b Gap also in otosclerosis and a b Gap means conductive hearing loss because we remember photos is a cause of conductive ingredients the second dip is seen in noise inducing laws and this is dipped at 4000 Hertz in AC and BC garage launches dip at 2000 Hertz in BC noise losing loss dip is called the acoustic dip and it is seen in 4000 nuts in AC and BC okay fine so this is non-explicating loss and this dip is called acoustic dip and this is seen at 4000 Hertz and this is the dip in a CBC both let's revise once again carats not dip at 2000 MBC in the future modus process acoustic dip at dip at 4000 Hertz in acbc is a feature of noise induced ring loss this is also called boilers Notch because it's common in the industrial areas actually okay now and then two type of audiogram meter pressed by qsys and mean useful now please see press by two seats is the age related snhl it has to be bilateral both cochlear are damaged okay and it causes high frequency as the nature if you remember I I told you the basal turn of cochlea senses high frequency sounds it means that age damages a high basal term First Age damages basal ton of cochlear first so pressed by Crystal will be having high frequency snhl in early status so there will be a sloping curve now to remember age slopes you down toward your grade better age is sloping you down gradually okay the second one is mean years better that's mean is remember menials is the unilateral disease foreign if you remember Apex of cochlea Apex of cochlea senses the low frequency sound beta so it means that means damages Apex of cochlear First Age damage based return of cochlear first Apex cochlear first so menial patient will be having low frequency isolated in early stages so there will be there therefore there will be rising curved which curve Rising how to remember Rising age sloping age sloping let's see over here mean yourself for God's sake never do in the paper oh very easy little a b Gap it's a conductivity loss no no no no don't do like that I trust you you are very smart people you never do like this mistake better they're two years better red for right here blue for left ear net your friend right ear you see the right ear is absolutely normal left ear has SNH menius is a unilateral disease right here is normal left has got the problem and can you see a beautiful Rising pattern menus is rising curved meaning Rising curve two things over the media unilateral unilateral disease right here is normal and I can see the clear Rising pattern over there okay and please see press Buy close Facebook press by use the sloping curve slope increase both side right and left right for right for right blue for left both are coming down press by q6 is a bilateral disease it involves both the ears and patient with having sloping all the kilometer because it's a high frequency more loss in the OR least interested so these are the important revision points out of our app videos and class lectures out of autologies segment okay thank you very much and God bless you may you excel in your exam and I'm sure you'll do very well [Applause]