Rapid Revision Reignite ENT: Question–Answer Format

Inner Ear Diseases And Facial Nerve

Detailed Questions

Q1.1: What is the benign tumor of the middle ear that arises from paraganglionic cells, and what is its site of origin?

Answer:

• Glomus tumour - Benign, locally invasive, slow growing tumour
• Glomus tumor originates from paraganglionic cells
  • Cells of sympathetic nervous system which secrete catecholamines - epinephrine, norepinephrine, dopamine
  • Usually present across major blood vessels like internal carotid artery, internal jugular vein
  • In the middle ear, floor is related to the internal jugular vein and on the promontory (formed by the basal turn of ganglia), a plexus is formed - tympanic plexus - formed by glossopharyngeal nerve and sympathetic plexus of Carotid
  • From these sympathetic plexus and the sympathetic plexus covering the internal jugular vein the tumor arises.

Q1.2: What is the difference between Glomus jugulare and Glomus tympanicum?

Answer:

• Glomus jugulare: Arising from the sympathetic plexus covering the internal jugular vein
• Glomus tympanicum: Arising from the tympanic plexus

Q.1.3: What is the pattern all paragangliomas have on HPE?

Answer: Typically, all paragangliomas have a pattern on HPE, known as Zellballen pattern.

Q.1.4: What are the symptoms of glomus tumor?

Answer:

• Sweating, flushing, headache, tachycardia (due to excess catecholamines)
• Conductive hearing loss - gradually progressive type(due to the mass growing)
• Pulsatile tinnitus (resembles the heartbeat)
• Pain + bleeding (as tumor lacks tunica media/ smooth muscle layer). Hence, probe test, biopsy, FNAC shouldn't be done th th th o
• If it involves the jugular foramen, it can cause 9 , 10 , 11 nerve palsies
• It can also cause Horner's syndrome

Q.1.5: Describe the signs of Glomus tumor.

Answer: Signs:

• Reddish hue from the floor of the middle ear: Rising sun appearance
• Seen on otoscopy
• Browns sign: When the pressure on the EAC is increased, tumor vibrates vigorously and then becomes pale
• Salt and pepper appearance - seen on a contrast enhanced MRI
• Phelps sign - seen on a CT scan: Tumor eroding the bone between the carotid artery and jugular vein

Q1.6: What is the IOC for glomus tumors?

Answer: IOC: CECT

• MRI can be done to check for intracranial spread
• Angiography to identify the feeding vessel

Q1.7: What is the treatment of glomus tumor? Name the classification of glomus tumor.

Answer:

• Treatment
  • Angiography and embolize the feeding vessel
  • Surgical excision
• Classification of glomus tumors: FISCH classification

Q1.8: Describe the anatomy of the facial nerve.

Answer:

• 7TH cranial nerve that exits from pons
• Facial nerve nucleus is present in the brain stem
• Supranuclear palsy: Any lesion above the level of pons
• Infranuclear palsy: Any lesion below the level of pons
• Forehead is spared as it receives its innervation from bilateral cerebral cortex
• It is a mixed nerve having sensory root (nerve of Wrisberg), motor root and secretomotor root
• Course of facial nerve is divided into 3 parts:
  • Intracranial
  • Intratemporal
  • Extracranial

Q.1.9: Describe the Intracranial route of facial nerve.

Answer: Facial nerve exits from its nucleus takes a turn around the nucleus of 6th nerve (facial colliculus) and emerges outside and enters the internal auditory canal.

Congenital Anomalies/Nasal Polyps/Rhinitis/Sinusitis

Big Question 2: Describe Meningocele, Glioma, and Dermoid swellings.

Broad Answer:

Detailed Questions

Q2.1: What is Meningocele?

Answer: Herniation of meninges +/- brain tissue (meningoencephalocele) into the nasal cavity.

Q2.2: What are the bones forming the roof of the nose from anterior to posterior?

Answer: Frontal bone (Anteriorly), Cribriform plate (Middle), Sphenoid bone (Posteriorly).

Q2.3: Explain the cause of a Meningocele. What happens during development?

Answer:

• It is caused by improper fusion of bones of the base of the skull or roof of the nasal cavity.
• During development, if there is a deficient or dehiscent area in the bones, herniation of meninges (and sometimes brain tissue, meningoencephalocele) can occur through this gap into the nasal cavity.

Q2.4: Describe the consistency and the results of compressibility, reducibility, cough impulse, and transillumination tests for a Meningocele.

Answer:

• Consistency: Soft/Cystic
• Compressibility test: Positive
• Reducibility test: Positive
• Cough impulse test: Positive
• Transillumination test: Positive

Q2.5: What is the treatment for a Meningocele?

Answer: Excision of the herniated mass and reconstruction of the defect.

Q2.6: What is Glioma?

Answer: A condition in which there is presence of glial cells outside the central nervous system.

Q2.7: Explain the cause and formation of a Glioma in the nasal cavity.

Answer: Initially, there is improper fusion of bones in the roof of the nose, leading to herniation of cranial contents into the nose. Later, delayed fusion of bones separates the cranial cavity from the nasal cavity. During this process, CNS tissue (glial cells) gets left behind in the nasal cavity. Nasal immune cells then identify the glioma as foreign, causing an antigen-antibody reaction and subsequent fibrosis.

Big Question 3: Describe Septal Abscess and Septal Hematoma?

Broad Answer:

• Septal Abscess is a collection of pus caused by trauma/infection, presenting with bilateral nasal obstruction, headache, fever, and lymphadenopathy.
• Septal Hematoma is a collection of blood due to trauma, presenting with bilateral nasal obstruction and headache, but typically without fever or lymphadenopathy.
• Presentation for both septal abscess and septal hematoma is same
  • Swelling on either side of septum

Detailed Questions

Q3.1: What are the typical causes of a Septal Abscess versus a Septal Hematoma?

Answer:

• Septal Abscess: Trauma, nasal infection, iatrogenic, nasal picking.
• Septal Hematoma: Trauma (direct, surgical, iatrogenic).

Q3.2: How do the clinical presentations of Septal Abscess and Septal Hematoma differ, particularly regarding headache, lymphadenopathy, and fever?

Answer:

Q3.3: Why is early intervention more crucial for a Septal Abscess compared to a Septal Hematoma?

Answer: Early intervention is more crucial for a septal abscess because it is located in the danger triangle of the face (between the nasion and angle of the lips), meaning infection can spread to the cavernous sinus, leading to cavernous sinus thrombosis.

Q3.4: What is the treatment for a Septal Abscess, and what is the treatment for a Septal Hematoma?

Answer:

• Septal Abscess: Incision and drainage + Intravenous (I.V.) antibiotics.
• Septal Hematom: Incision and drainage + Pressure packing.

Q3.5: Compare Septal Abscess and Septal Hematoma regarding risk of complications and recurrence.

Answer:

• Septal Abscess: Higher risk of complication, higher risk of recurrence.
• Septal Hematoma: Lower risk of complication, lower risk of recurrence.

Anatomy of Ear

Big Question 4: What are the anatomical components and features of the human ear?

Broad Answer:

The human ear is anatomically divided into three main parts: the external ear, middle ear, and inner ear. Each part has specific structures that play roles in hearing and balance. The external ear includes the pinna, external auditory canal, and tympanic membrane. The middle ear involves air-filled cavities, ossicles, and the Eustachian tube, while the inner ear consists of the bony and membranous labyrinth involved in hearing and equilibrium.

Detailed Questions:

Q4.1: What are the three parts of the external ear?

Answer:

1. Pinna
2. External auditory canal (EAC)
3. Tympanic membrane

Q4.2: What are the anatomical features of the pinna?

Answer:

• Made up of elastic cartilage
• Areas devoid of cartilage:
  • Incisura terminalis (space between tragus and helix)
  • Ear lobule

Q4.3: What is the external auditory canal (EAC) and what are its features?

Answer:

• Continuation of the pinna
• Length: 24 mm
• Two parts:
  1. Cartilaginous part (outer third) → 8 mm
  2. Bony part (inner two-thirds) → 16 mm
• Shape: S-shaped
• Contains hair follicles, sebaceous glands, and ceruminous glands (in the cartilaginous part only)
• Absent in bony part
• Infections like otitis externa/folliculitis (Staphylococcus) occur in cartilaginous part

Q4.4: What is the clinical relevance of the Incisura terminalis?

Answer:

• It is the site of incision in endaural surgery.
• The incision is called the Lempert endaural incision.

Q4.5: Differentiate between cartilaginous and bony parts of the external auditory canal? 

Fractures of Facial Skeleton And Tumors of Nose And PNS

Big Question 5: How are the facial skeleton fractures classified?

Broad Answer:

• Facial skeleton fractures are classified into
  • Upper
  • Middle: nasal bone fractures are most common
  • Lower

Detailed Questions

Q5.1: What are the types of nasal bone fractures?

Answer

Q5.2: Which type of fracture is most common in the middle third of the facial skeleton?

Answer:

• Fractures of the nose.
• A zygomatic fracture is the second most common fracture after the nasal bone fracture.

Q5.3: Describe the characteristic deformity and risk associated with Naso-orbito-ethmoid (NOE) fracture.

Answer: "Pig nose deformity," where the orbit and ethmoid bone are depressed, and the rest of the dorsum of the nose gets pushed in an upward direction. There is a high chance of CSF leakage because the fracture is very close to the cribriform plate of the ethmoid.

Q5.4: Differentiate between class 1 and class 2 fractures based on direction of blow and fracture.

Answer:

Jarjaway fracture (Class 2) - Direction of fracture - Horizontal

Chevallet fracture (Class 1) - Direction of fracture - Vertical

Q5.5: Name the two specific forceps for reducing nasal and septal fractures?

Answer:

• ASH Septum Forceps (for reducing septum fractures)
• Walsham Forceps (for reducing nasal bone fractures)

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