(QB) Part 2 book Bansal diseases of ear, nose and throat has contents: Oral cavity and salivary glands, pharynx and esophagus, larynx, trachea and bronchus, neck, operative procedures and instruments, related disciplines.
Section : Oral Cavity and Salivary Glands 34 Oral Symptoms and Examination One must not speak unpleasant truths unnecessarily By indulging in rude words one’s nature becomes rude One loses sensitivity without control over one’s words —Holi Mother Sarada Devi Points of Focus ¯¯ Oral Cavity Symptoms: Ulcers, Growth, Pain, Xerostomia, Excessive Salivation, Dysgeusia, Trismus Examination: Findings on examination Tongue Depressor ¯¯ Evaluation of Cancer Lesions History Examination Investigations Imaging ¯¯ Salivary Glands For general scheme of case taking and general set up of Bull’s eye lamp light source and head-mirror see chapter history and examination in section of basic sciences ORAL CAVITY Clinical Features ¯¯ Diagnostic Imaging Sialography Radiosialography Ultrasonography Computed Tomography CT Sialography Magnetic Resonance Imaging MRI sialography ¯¯ Fine-Needle Aspiration Cytology ¯¯ Clinical highlights Symptoms Patients may come to doctor after observing some findings in their mouth, such as an abnormal growth, coating of tongue, cleft lip, cleft palate or oroantral fistula Patient may see their circumvallate papillae of tongue in the mirror or feel by finger and develop cancer phobia G xeros, dry + G stoma, mouth Dys, bad, difficult + G geusis, taste Pain: Pain may be referred to the ear It can occur in any part of the oral cavity Xerostomia:1 Dryness of mouth can result from mouth breathing, radiotherapy, or generalized lesions of the salivary glands Excessive salivation: The common causes of excessive salivation are: ulcers of mouth and pharynx, poor orodental hygiene, ill fitting denture and iodide therapy Dysgeusia:2 Taste buds on the anterior two third of tongue appreciate sweet, sour and salt tastes Patient can have unilateral or bilateral perverted, diminished or loss of taste It may be associated with lesions, such as heavily coated tongue, or injury to chorda tympani or the facial nerve 366 Trismus:1 The common causes of difficulty in opening the mouth, which are related to the local oral cavity are oral submucous fibrosis, ulcerative lesions, dental abscess (Figs and 2), trauma to mandible or maxilla, and malignant lesions of buccal mucosa and retromolar trigone Other: Other oral cavity complaints include ulcers, swelling, ankyloglossia, cleft lip, cleft palate, injury, halitosis, toothache and gums swelling and bleeding Section 4 w Oral Cavity and Salivary Glands Sense of taste: It is highly redundant due to its innervation It is nearly impossible to lose all sense of taste Taste and flavor: They are usually confused with each other The taste includes only the ability to sense sweet, salty, bitter and sour tastes Flavor includes both taste and smell (80%) Patients with taste problems may be having flavor and a smell disorder Fig 2: Trismus in a patient of masticator space abscess Examination Examine all the different parts of oral cavity by both inspection, as well as palpation (Box 1) Tongue depressors (Fig 3) are used in the examination of oral cavity and oropharynx and are available in different sizes for children and adults Fig 1: Masticator space abscess Tender red swelling extending over ramus of mandible and obliterating subangular depression Lips: Lips have an outer (cutaneous), an inner (mucosal) surface and a vermilion border Buccal mucosa: is examined by asking the patient to open the mouth and then retracting the cheek with a tongue depressor Vestibule of mouth: Examine the complete vestibule of mouth Look for not only the change in color but also change in surface appearance Parotid duct opening may be red, swollen and discharging It can be seen opposite the crown of upper second molar tooth Examine the skin of the cheek because carcinoma of buccal mucosa can invade the same (Fig 4) Box 1: Findings on examination of oral cavity •• Lips (upper and lower): Swellings, growths, vesicles, ulcers, crusts, scars, unilateral or bilateral clefts •• Buccal mucosa: Change in color, ulceration, vesicles or bullae (pemphigus), white stria (lichen planus), blanched appearance with submucosal fibrous bands (submucous fibrosis), leukoplakia, erythroplakia, pigmentation, atrophic change in mucosa, swelling or growth •• Opening of parotid duct: Red, swollen, secretions (viral or suppurative parotitis) •• Gums (upper and lower jaws): Red and swollen gums (gingivitis), ulcerated gums covered with membrane (viral ulcers or Vincent’s infection), hyperplasia (pregnancy or dilantin therapy), growths (benign or malignant neoplasms of maxilla or mandible), periodontitis •• Teeth: Number, tartar, loose teeth, carious, malocclusion (fractures of mandible or maxilla, abnormalities of temporomandibular joint), impacted last molar •• Hard palate: Cleft palate, oronasal fistula (trauma or syphilis), high arched palate (mouth breathing in adenoids), swelling (tumors of palate and nose), bony growth in midline of hard palate (torus palatinus), ulcers/growths (benign or malignant) •• Tongue: Macroglossia (hemangioma, lymphangioma, cretinism, edema or abscess), ankyloglossia (congenital tongue tie, cancer tongue or floor of mouth, painful ulcer, abscess), deviation on protrusion (hypoglossal paralysis on the side of deviation), bald or smooth tongue (iron deficiency anemia, median rhomboid glossitis, geographical tongue), fissures (Melkersson’s syndrome, syphilis), ulcers (aphthous, traumatic due to jagged tooth or denture, malignant, syphilitic or tubercular), red/white lesions (leukoplakia, erythroplakia), proliferative growth (malignancy) •• Floor of mouth: Short frenulum (tongue-tie), scar (trauma or corrosive burn), ulcer (trauma, erosion of submandibular duct stone, aphthous ulcer, malignancy), swelling (ranula, sublingual dermoid, calculus of submandibular duct, benign or malignant tumors, Ludwig’s angina) •• Opening of submandibular duct: Red, swollen, secretions L fr G trismus, a creaking, rasping 367 Fig 5: Hard palate hemangioma Source: Dr Amit Goyal, Shillong Fig 4: Skin involvement in buccal mucosa carcinoma Teeth and gums: Examine gums and teeth of both upper and lower jaws Cheeks and lips are retracted with the help of tongue depressor for examining the outer surface of gums while tongue is pushed away for examining the inner surface of gums Hard palate: See for any swelling (Fig 5), ulcer and cleft Anterior two-third tongue: Only anterior two-third tongue, which consists of the tip, dorsum, lateral borders and undersurface, is included in the oral cavity Tongue should be examined in its natural position and then patient is asked to protrude it and move it in different directions (Figs to 11) Floor of mouth: The floor of mouth consists of the area that lies under the tongue and two lateral gutters (Fig 12) The latter are examined by two tongue depressors that retract tongue and cheek The submandibular duct opens on the summit of raised papilla on either side of the tongue frenulum The swellings in the floor of mouth are examined by bimanual palpation, which help in differentiating between submandibular salivary gland and submandibular lymph nodes Fig 6: Hairy leukoplakia tongue Fig 7: White patches on the dorsum of tongue Note on the left side one big patch and two small patches on right side Chapter 34 w Oral Symptoms and Examination Fig 3: Tongue depressor used in the examination of oral cavity and oropharynx Note submucosal cleft palate with bifid uvula Section 4 w Oral Cavity and Salivary Glands 368 Fig 8: Black colored tongue due to the ingestion of iron syrup Fig 11: Carcinoma anterior two-third tongue left lateral margin Note two separate infiltrative lesions involving tip and middle one-third tongue Fig 9: Tongue bite during chewing food Fig 12: Ulcerative lesions involving under surface of tongue and floor of mouth Tongue depressor One blade of Lack’s tongue depressor is slightly bent at the end The bent end is used for holding the depressor and supports the little finger of the examiner The other blade depresses the tongue and is used like a lever to depress anterior two-thirds of the tongue with the fulcrum over the lower teeth Caution: Touching of the posterior one third of the tongue usually leads to the gag reflex and not tolerated by the patient Fig 10: Glossitis involving bilateral margins of the tongue A 38-year-old male patient with complaints of burning sensations on the margins of tongue for days Uses: It is used for examining the oral cavity and the pharynx In addition to the depressing of tongue it can also be used for: Squeezing the tonsil Retraction of cheek Test for gag reflex Checking nasal air blast (cold spatula test) Spatula test for suspected case of tetanus Evaluation of cancer lesions The diagnosis of oral cancer is primarily clinical and confirmed by histopathology A detailed history, physical examination including palpation (Fig 13) and investigations should include the following elements: Need for reconstruction: Explore need for reconstruction and their options, and available free and pedicled flap Dental evaluation: Dental evaluation before radiation treatment, prosthodontic evaluation for surgical obturator in cases of maxillectomy Speech and swallowing: Consultation and counseling with speech and swallowing pathologist 369 History Examination Local lesion: Dimension and extension including crossing midline, adjacent structures involved; fixation to underlying periosteum of mandible (Fig 14) or maxilla, regional lymphatic spread Investigations Routine: ECG, X-ray chest (preferably both posteroanterior and lateral views) and basic laboratory profile, liver profile in alcoholics Biopsy: Punch/incisional biopsy of the perimeter of the tumor including some normal adjacent mucosa confirms the tissue diagnosis Areas of necrosis and infection should be avoided as this tissue may confuse the diagnosis Fine needle aspiration cytology: Fine needle aspiration cytology (FNAC) is indicated in cases of suspicious nodes in the presence of known primary carcinoma Synchronous second primary cancer: Search for synchronous upper aerodigestive tract cancers About 15% patients of the oral cavity cancer have multiple primary cancers, which are present in the upper aerodigestive tract Risk factors (such as smoking and alcohol) are common for all these cancer sites Panendoscopy: It includes bronchoscopy, esophagoscopy and direct laryngoscopy, and has been advocated by many in all head and neck cancer patients Imaging They help in knowing the extent of primary tumor and regional lymphadenopathy Fig 13: Bimanual palpation of floor of mouth and submandibular region Computerized tomography: CT is best for demonstrating cortical bone erosion and lymph node metastases Magnetic resonance imaging: MRI is best for seeing soft tissue invasion by tumor and extension into medullary bone orthopantogram: In patients with suspected mandibular invasion, panorex or orthopantogram facilitates dental evaluation Ultrasound: Abdominal ultrasound detects liver metastasis positron emission tomography and Single-photon emission computed tomography: In stage IV patients, PET and single photon emission computed tomography identify occult distant metastasis Salivary Glands Clinical Features Fig 14:Carcinoma left lower alveolus (premolar to retromolar region) extending to buccal mucosa, floor of mouth and cheek skin Patient is retracting her cheek Surrounding the ear Parotid1 swelling fills the retromandibular hollow region and elevates the lobule of ear (Fig 15) Large swellings involve the preauricular region also Acute painful swelling: An acute painful swelling of the parotid gland usually indicates an inflammatory process Chapter 34 w Oral Symptoms and Examination Symptoms: They include changes in the fit of existing denture, otalgia, oral-dental pain, odynophagia, facial numbness, trismus, dysarthria, dysphagia, bleeding, halitosis or weight loss Personal and past history: Patient is inquired about medications, allergies, medical illnesses, previous surgeries, tobacco and alcohol use Section 4 w Oral Cavity and Salivary Glands 370 Diagnostic Imaging Fig 15: Left parotid swelling in a 10-year-old girl Note the infraauricular fullness in the area between the angle of mandible and mastoid Acute bacterial parotitis: It usually occurs in association with sialolithiasis of the parotid gland or in patients who are elderly, malnourished, dehydrated, or immunocompromised Mumps: Acute viral parotitis is mostly due to mumps Calculus: An obstruction of the Stensen’s duct with a stone may lead to an acute painful swelling of the parotid gland Bilateral parotid swelling: Sjogren’s syndrome and other forms of autoimmune parotitis usually present with bilateral parotid swelling, which may be asymmetrical Painless slow growth: The tumors of the parotid gland usually present as a painless swelling for a long duration and have a slow growth rate Patients incidentally notice the appearance and consider it a “recent” lump Site and extent of swelling: Benign tumors of the parotid are commonly located in its tail They are usually well defined, nontender and freely mobile The parotid tumor may be present either in the superficial or in the deep lobe Tumors can arise from the deep lobe or extend from the superficial to the deep lobe (dumbbell-shaped tumors) in the parapharyngeal space (through the narrow stylomandibular tunnel) and displace oropharyngeal wall medially Rapid increase in size of a longstanding mass: It should raise the suspicion of malignant transformation It may be due to inflammation and cystic degeneration They are most commonly associated with Warthin’s tumor Metastatic: In cases of parotid mass, ask about a history of cancer of the scalp or facial skin Metastasis to the parotid gland can occur from skin cancer including melanoma Malignant: Presence of following features indicate malignancy: Facial nerve paresis or paralysis Pain Fixation of mass to the overlying skin or underlying structures Cervical lymphadenopathy CT and MRI are often used in a complementary fashion when evaluating lesions in and around bone Both CT and MRI are able to detect extrinsic and intrinsic masses of a major salivary gland and determine whether the mass is well circumscribed or infiltrating CT versus MRI: For salivary gland tumors, gadoliniumenhanced MRI is equal or superior to contrast enhanced CT They may even be able to approximate the relative position of the facial nerve in the parotid gland The approximate course of the facial nerve can be estimated on the axial views because nerve exits the stylomastoid foramen and curves around the ascending ramus at a distance of about mm Indications: They are indicated in following conditions: Suspicion of malignancy Tumors of deep lobe of parotid or parapharyngeal space Tumors of submandibular and minor salivary glands A small well-defined mass of superficial lobe of parotid does not need imaging studies Sialography Indications: It is used in the evaluation of following conditions: Radiolucent calculi Obstructive disease Inflammatory lesions Penetrating injuries Mass lesions Contraindications: They include the following: Iodine allergy Acute sialadenitis Contrast: Water-soluble media (such as meglumine diatrizoate) is preferred over oil-soluble media Technique: The ostium is gently dilated after topical anesthesia The duct is cannulated and contrast is injected gently until patient experiences pain For each gland (parotid or submandibular), anteroposterior, lateral and oblique X-rays are taken to eliminate all bony overlapping If contrast medium is retained, the abnormalities provide the diagnosis Several variations include simultaneous xeroradiography, use of pneumography with tomography, secretory sialography and CT sialography Radiosialography This radioactive scanning is most commonly used for parotid gland It usually uses technetium It is used to evaluate parenchymal function and to detect mass lesions Radioisotope scanning is of no use in lesions of the ductal system The scan should be performed in resting state because uptake in the parotid is greater Findings: In a normal study glands are symmetric Warthin’s tumor and rare oncocytoma are the only radiopositive tumors Postradiation and chronic sialadenitis show decreased and delayed uptake 371 CT scanning and MRI are superior in the evaluation of mass lesions Ultrasonography Ultrasonography (US) has been found good at distinguishing glandular from extraglandular masses Ultrasound is quite good at delineating space occupying lesions of the major salivary gland It differentiates between cystic and solid lesions Fig 16: Ultrasonography neck showing echogenicity of normal parotid (P) and submandibular (SM) salivary glands Source: Dr Ritesh Prajapati, Consultant Radiologist, Anand, Gujarat Like radioisotope scanning and sialography, US is being supplanted by CT scanning for the evaluation of masses Computed Tomography Findings Low grade malignant and benign tumors: They tend to have regular and smooth borders High grade neoplasms: They tend to have irregular infiltration into the parenchyma (irregular outlines and diffuse borders) and nodal metastases Pleomorphic adenoma and Warthin’s tumor: They usually have sharp borders Characteristics Good for intrinsic and extrinsic parotid masses but of little use in evaluating generalized parenchymal disease or ductal architecture Far superior in detecting calculi (Figs 18A and B) and in evaluating deep lobe and parapharyngeal space lesions Excellent at separating cystic lesions from solid masses and lymphoma from other neoplastic masses CT Sialography It is found excellent for: Differentiating intrinsic from extrinsic masses Fig 17: Ultrasonography neck showing echogenicity of normal sternocleidomastoid (SCM) muscle Source: Dr Ritesh Prajapati, Consultant Radiologist, Anand, Gujarat A B Figs 18A and B: CT scan neck axial sections showing incidentally detected left submandibular calculus (A) in a case of right aryepiglottic fold mass (B) Source: Dr Swati Shah, Professor, Radio-diagnosis, GCRI Medical College, Ahmedabad Chapter 34 w Oral Symptoms and Examination Normal gland: The normal gland is of homogenous echo texture, appearing more echogenic (reflects the fat interspersed within the glandular tissue) than the adjacent muscle (Figs 16 and 17) Neoplasms: They are usually hypoechoic to normal glandular tissue Malignant tumors: They have a low reflectivity with poorly defined borders Pleomorphic adenomas: They have a variable reflectivity with well-defined borders Inflammatory lesions: They have high reflectivity with diffuse borders US-guided procedure: Ultrasonic imaging has been used to direct needle aspiration of parotid abscesses and localizing calculi (but less accurate than CT) Color Doppler ultrasound: Malignant tumors: They show a higher grade of vascularity than benign tumors Pleomorphic adenoma: Peripheral vascularity with a hypovascular center Limitations: US is unable to evaluate Deep lobe parotid masses, Masses obscured by the mandible, and Masses with parapharyngeal or retropharyngeal extension 372 Differentiating benign from malignant parotid neoplasms Showing the relationship of the mass to the facial nerve and adjacent bone involvement Differentiating superficial from deep lobe tumors Separating parapharyngeal masses from deep lobe parotid tumors Equally good results are seen using intravenous contrast enhancement Malignant and inflammatory salivary gland lesions including abscesses are enhanced by contrast CT Calculi are best detected without contrast material because small blood vessels may simulate small calculi Section 4 w Oral Cavity and Salivary Glands Magnetic Resonance Imaging MRI is excellent at separating adjacent soft tissues MRI is quite sensitive to the presence of masses within the gland (outlining the margins of an intraglandular mass) Normal appearance: The signal is heterogeneous on the T1 weighted signal (the variable fat content of the parotid gland gives it an intermediate to bright intensity) On T2 weighted images also the gland is heterogeneous (because of the serous secretions and water content of the gland) Fast T2 weighted MRI with thin sections can accurately evaluate the ductal architecture Abnormalities: They are: Pleomorphic adenomas: They usually have a homogenous or heterogenous appearance, showing intermediate to low signal intensity on T1 weighting and appearing hyperintense on T2 weighting (because of myxoid tissue) and shows homogenous enhancement following gadolinium Warthin’s tumors: They demonstrate the microcysts on T2 weighting High grade malignant tumors: They are often hypointense on both T1 and T2 weighted images MRI is again good at evaluating the extension of neoplasms beyond the parotid bed Spread: Contrast enhanced T1 weighted images are used to see perineural spread, bone invasion and tumor mapping –– At the skull base, where there is abundant fat around the bony foramina, the hyperintense enhancing tumors show up quite well Limitations:They are: Less sensitive to subclinical inflammation and cystic lesions (such as first arch branchial cleft cysts within the parotid gland) and not sensitive at all to calcification MRI is unable to distinguish between a benign and a malignant salivary gland lesion, except in extreme cases (those with infiltrating borders) MRI sialography It assesses the ductal changes in Sjögren’s syndrome Fine-Needle Aspiration Cytology Overall accuracy (sensitivity and specificity) of FNAC in salivary gland lesions, which can be compared with frozen section depending on the ability of the pathologists, is around 91.1% Cellular elements present in cystic lesions, often allow a definitive diagnosis Either ultrasound, CT or MRI, which differentiate solid from cystic lesions before the needle biopsy, should be used in conjunction with FNAC Clinical Highlights Saliva: 1,000–1,500 ml of saliva is secreted in 24 hours Major amount of saliva, when salivary glands are not stimulated is secreted by submandibular glands Excessive salivation: Some of the causes are oral iodides, poorly fitting denture, ulcers in oral cavity and peritonsillitis Sialography: It is used to diagnose stones, chronic inflammation and tumors in parotid and submandibular glands It is contraindicated in acute inflammation and acute sialectasis FURTHER READING Sandu K, Makharia SM Unusual experience in OSMF Indian J Otolaryngol Head Neck Surg 2004;56:65-6 Naik Chetana, Claussen C Qualitative and quantitative representation of taste disturbances: how we it by pentagon chart Indian J Otolaryngol Head Neck Surg 2010;62:376-80 35 Oral Mucosal Lesions We want that education by which character is formed, strength of mind is increased, the intellect is expanded, and by which one can stand on one’s own feet —Swami Vivekananda points of focus ¯ introduction red/White LeSionS Laboratory Investigations Secondary Herpes Simplex Infection or Recurrent Herpes Simplex Infection ¯ oraL SubmucouS fibroSiS Potential for Malignant Change ¯ hand, foot and mouth diSeaSe ¯ Leukoedema ¯ herpangina ¯ oraL LeukopLakia Histopathology Potential for Malignant Change Molecular Biology Management ¯ acute necrotizing uLceratiVe gingiVitiS ¯ oraL hairy LeukopLakia ¯ traumatic uLcerS ¯ oraL Lichen pLanuS ¯ radiation mucoSitiS ¯ chronic diScoid LupuS erythematoSuS ¯ bLood diSorderS ¯ candidiaSiS Acute Pseudomembranous Candidiasis (Thrush) Chronic Hypertrophic (Hyperplastic) Candidiasis or Candidal Leukoplakia Median Rhomboid Glossitis Other Clinical Forms of Candidiasis 476 ¯ drug-induced oraL LeSionS recurrent aphthouS StomatitiS behỗetS Syndrome erythema muLtiforme ¯ traumatic (eoSinophiLic) granuLoma pigmented LeSionS ¯ meLanotic macuLeS ¯ meLanoma ¯ fordyce'S SpotS ¯ amaLgam tattoo Lesion and its Site ¯ nicotine StomatitiS LeSionS of tongue VeSicuLobuLLouS/uLceratiVe LeSionS ¯ geographicaL tongue ¯ pemphiguS VuLgariS ¯ hairy tongue ¯ mucouS membrane pemphigoid ¯ fiSSured tongue ¯ herpeS SimpLex ViruS Primary Herpes Simplex Infection ¯ tongue tie ¯ cLinicaL highLightS 374 introduction The oral cavity works to keep a person hydrated, nutritionally healthy and well communicated It protect upper aerodigestive tract Impairment to oral health can lead to malnutrition, infection, impaired communication, pain and an impaired quality of life The oral cavity acts as a window into a person’s body as several systemic diseases manifest initially through oral cavity The various oral mucosal lesions are enumerated in the Box The purpose of this chapter is to provide an overview of the oral cavity disorders Section w oral cavity and Salivary glands red/White LeSionS oraL SubmucouS fibroSiS It is an insidious painless oral cavity disease, which is characterized by juxta epithelial deposition of fibrous tissue that sometimes even extends to the pharynx Joshi in 1953 first described this condition in India The disease is prevalent (2–5 per 1,000) throughout the Indian subcontinent pathology etiology Several factors operate together and cause this disorder Exact etiology of this condition is not known but the following factors have been incriminated: Prolonged local irritation: Most of these patients have habit of chewing paan (a specially prepared leaf), betel nut (sopari) and tobacco The hard and rough surface of betel nut causes mechanical irritation Alkaloids in betel nut (such as arecoline) cause chemical irritation and stimulate collagen synthesis and the proliferation of buccal mucosa fibroblasts Tannins in betel nut stabilize the collagen fibrils and render them resistant to degradation by the collagenase Smoking of cigarettes/Bidies also leads to local irritation Excessive amount of chilies and spices in the daily food may also be an additional factor Dietary deficiency: As there occurs recurrent vesicle formation and ulceration of the oral mucosa a dietary deficiency of iron, vitamins B-complex and A has been proposed Cell mediated immune process: Some consider it a cellmediated immune reaction to arecoline Arecanut chewing causes collection of activated T-lymphocytes and macrophages in subepithelial layers of oral mucosa, which result in reduced production of antifibrotic cytokines (less collagenase) and increased production of fibrinogenic cytokines (act on mesenchymal cells and proliferate fibroblasts) These lead to increased production of collagen Localized collagen disease: As the histopathological changes seen in submucous fibrosis are similar to the collagen diseases such as rheumatoid arthritis and scleroderma, some scientists think it to be a localized collagen disorder Racial: Disease usually affects Indians or people of Indian origin living abroad Sporadic cases are also seen in Nepal, Thailand, South Vietnam and Sri Lanka Genetic: As the disease usually affects Indians and not all the people who chew paan, sopari and tobacco, some authorities strongly feel it to be genetic disorder Early cases show polymorphonuclear leukocytes, eosinophils and few lymphocytes while lymphocytes and plasma cells appear in advanced cases The higher population of activated T-lymphocytes mainly T-helper/inducer lymphocytes (minor population of B-cells), macrophages and high CD4+ and CD8+ lymphocyte ratio in subepithelial tissue suggest main role of cellular immune response and minor role of humoral immunity There occurs a fibroelastotic transformation of connective tissues in lamina propria associated with epithelial atrophy, which is sometime preceded by vesicle formation Juxta-epithelial fibrosis occurs with atrophy or hyperplasia of overlying epithelium, which shows areas of epithelial dysplasia potential for malignant change Leukoplakia and squamous cell carcinoma are some time associated with this condition as the predisposing factors for all these disorders are common The malignant transformation (Fig 1) has been observed in 3–7.6% of cases clinical features Age: Though there is no age bar, the disease mostly affects 20–40 years of age group box 1: Oral mucosal lesions • Red/white lesions: Oral submucous fibrosis, leukoedema, oral leukoplakia, oral hairy leukoplakia, oral lichen planus, chronic discoid lupus erythematosus, candidiasis, fordyce spots, nicotine stomatitis • Vesiculobullous/ulcerative lesions: Pemphigus vulgaris, mucous membrane (cicatricial) pemphigoid, primary herpes simplex infection, recurrent herpes simplex infection, herpes simplex infection, hand, foot and mouth disease, herpangina, acute necrotizing ulcerative gingivitis, recurrent aphthous stomatitis, Behcet’s syndrome, erythema multiforme, traumatic (eosinophilic) granuloma, traumatic ulcers, radiation mucositis, blood disorders, drug-induced oral lesions • Pigmented lesions: Melanotic macules, melanoma, amalgam tattoo • Systemic diseases: Cardiovascular, endocrine, gastroenterology, neurological, renal, hematological (leukemia, agranulocytosis, pancytopenia, cyclic neutropenia, sickle cell anemia) • Collagen-vascular and granulomatous disorders: Sjögren’s syndrome, systemic lupus erythematosus, scleroderma, dermatomyositis-polymyositis, sarcoidosis, Wegener’s granulomatosis • Lesions of tongue: Geographical tongue, hairy tongue, fissured tongue, tongue tie of nose 282 of endolymph 25 Fluconazole 94, 100 Fluctuating hearing loss 165 Fluctuation and fluid thrill 113 Flucytosine 94 Fluorouracil 615, 616 Folds of middle ear—after proctor 10f Foley’s catheter 296 Follicular adenocarcinoma 534 cysts 361 Foramen of huschke 4, 27 Fordyce’s spots 379, 386 Foreign bodies 457 of air passages 515 of ear 187 body 131 bronchus 518 nose 349 nose in children 349 throat 465 Fossa of rosenmuller 52 Four incisor teeth 60 vessel angiography 271 Fourth-generation cephalosporins 87 Fracture of angle, body and symphysis 347 condyle 347 nasal septum 333 temporal bone 267 Free amino acid content 246 Frenzel glass 236 maneuver 199 Frequency and pitch 138 Frequency-specific abr thresholds 169 Frey’s syndrome 262, 399, 400 Frontal bone 37, 342, 283, 304, 342 sinusotomy 560 Frontoethmoidal mucocele 306 Frost bite 3, 185 Frozen section diagnosis 528 Fuller’s bivalved tracheostomy tube 592 Functional aphonia 497, 500 divisions of vocal folds 65 Functions of efferents from vestibular nuclei 21 hair cells 24 larynx 68 nasopharynx 52 oropharynx 53 saliva 47 tonsils and adenoids 51 Fundus of right internal auditory canal 19f Fungal infection 303, 426 of temporal bone 189 sinusitis 309, 317 Fungating metastatic neck nodes 111f Fungi 93 Fungus balls 317 Furuncle nasal vestibule 290f nose 112f or boil of nose 290 right nasal vestibule 290f Furunculosis 189 Fusidic acid 89 647 G Gadolinium-enhanced MRI 261, 275 T1W 600 Galen’s anastomosis 71 Gallium-67 scanning 315 Gamma knife surgery 276 Gancyclovir and foscarnet for CMV 461 Gastroesophageal reflux 58, 502 disease 303, 458 Gastrostomy 460 Gelle’s test 142, 148 General anesthesia and tonsillectomy position 561 Genetic association 273 defects 167 sensorineural hearing loss 163 Geographical tongue 385f or migratory glossitis 385 Geotropic nystagmus 239 Gerlach tonsil 199 Giant cell arteritis 120 Gingivitis and periodontitis 105 Gitzgerald-hallpike bithermal caloric test 234 Gliomas 352, 353, 363 Globus hystericus pharyngeus 463 Glomus jugulare 270, 277 tumors 132, 133, 270 paraganglioma 270, 277 tympanicum 277 Glossitis involving bilateral margins of tongue 368f Glossopharyngeal nerve 6 neuralgia 121, 130 Glottic cancer 505 chink 71, 494 Glottis rima glottidis 64 Glucose content 348 Glycerol test 242 Glycopeptides 87 Goiter 523f, 524f Gradenigo’s syndrome 220, 226 Graft materials 554, 555 Grafts in rhinoplasty 3 tympanoplasty 3 Gram-negative bacilli 392 bacteria 82t Gram-positive bacteria 81t Grand (basal) lamella 38 Granular Index implants in children 180 influencing development of complications 217 relieving stuttering 499 tinnitus 135 Facultative anaerobes 90 anaerobic rods 82 Failed mirror examination 468 False negative fistula test 233 positive fistula test 233 Familial 502 progressive sensorineural hearing loss 163 Farabeuf’s periosteal elevator 584 Fasciitis 521f Faucial diphtheria 425, 429 Features of nasal septum 333 Features of central vestibular lesions 233 cerebellar abscess 224 esophageal perforation 579 malignant tumors 533 Fenestra cochlea 15 Fenestration operation 153 Fentanyl 619 Fever 109, 218, 225, 424 Fiberoptic exploration 246 Fiberoptic laryngoscope (telescope) 469 Fibrillar twitching of tongue 526f Fibrous bands 375 dysplasia 352, 353f, 362, 363 Fifth degree injury to epineurium 259 Findings on examination of oral cavity 366f Fine needle aspiration cytology 361, 369, 372, 391, 526, 528 and open biopsy 522 First arch syndrome 58 branchial arch 20 degree neuropraxia 258 generation cephalosporins 87 Fisch adaptor for suction cannula 585f Fissula ante fenestram 155 Fissural cysts 361 Fissured tongue 385, 385f Fissures of santorini 4 Fistula test 232, 236, 246 Fitzgerald hallpike bithermal caloric test 236 Fixation of chest 68 Fixity to skin 112 Flaps and tunnels 564 Flexible bronchoscopy 580 esophagoscopy 579, 579f, 580f fiberoptic bronchoscopy 576 nasopharyngolaryngoscopy 432, 475, 575 procedure 471f rhinolaryngoscope 470 video laryngoscopy 471f Floor 7 of mouth 45, 366, 367 Diseases of Ear, Nose and Throat 648 cell tumor 402 myringitis 132, 191 Granulation tissue 213 Granulomatous stage 315 Greater auricular nerve petrosal nerve 267 superficial petrosal nerve 257 Griesinger’s sign 225, 226 Grommet testing 145 Growth of larynx 68 Guillotine method 568 Gums—upper and lower jaws 366 Gustatory fibers 255 lacrimation 261 rhinitis 331 sweating 262, 399, 400 Gutmann’s pressure test 500 H H influenzae 299 H1N1 flu patients 100 Habenula perforata 155 Habermann 211 Haemophilus influenzae 84, 310 Hair cells 16 and cupula 17f of vestibular organs 18f follicles 4 Hairy leukoplakia 105 lateral margin of anterior two-third 105f tongue tongue 367f tongue 385 Hajek’ lip retractor 588 Half peak level 144 Hallmark finding 191 Hand, foot and mouth disease 381, 386 Hard palate 45, 366, 367 hemangioma 367f Harmonic scalpel 568 Hashimoto thyroiditis 534f Head and neck cancer 502 oncology 620 mirror 109 Headache 109, 115, 122, 225, 280, 302, 335 in children 118 Healed herpes lesions 115f lupus 280 tubercular lesion 115f ruptured cold abscess 115f Hearing aids 130, 135, 153, 171, 173, 174, 175f, 182 dog 177 ear 154, 165 evaluation 137 in infants and children 139 impaired patients 174 impairment in infants and young children 166 in children 176 level 138 loss 152, 158, 190, 274 tests 169, 170, 214 Heartburn 58, 417 pyrosis 58, 417 Heimlich’s maneuver 516f Hemangioma tongue 402f Hemangiomas 354, 396, 400, 402, 488 Hemangiopericytoma 354 Hematoma and edema 517 of auricle 185 Hematopoietic stimulating factors 104 Hemifacial spasm 266 Hemolytic streptococcus 224 Hennebert’s phenomenon 246 sign 158, 233, 236 Herpangina 381, 429 Herpes labialis 380, 381f simplex 262, 461 and zoster 103 stomatitis 105 virus 94, 380, 424 zoster 262 oticus 105, 129, 263 ramsay hunt syndrome 191 Herpetic gingivostomatitis or orolabial herpes 380 perioral skin 380f Herpetiform aphthous ulcers 383 type aphthous ulcer 382 Heymann turbinectomy scissors 586 Hiatus hernia 460 semilunaris 35, 42 Hidden areas of the larynx 70 High cardiac output 133 resolution computerized tomography 261 risk of primary salivary malignancy 395 tracheostomy 510 Highly active antiretroviral therapy 106 Histamine 321 Histogenesis of neoplasms 394 Histoplasma capsulatum 316 Histoplasmosis 189, 316 Hitzelberger’s sign 5, 277 HIV 386, 393 AIDS 101 associated salivary gland disease 393 infection 404 Hoarseness 496 in elderly smokers 476 of voice 472 Holding of scope 574, 576, 578 Holman-miller sign 441 Home care of epistaxis patients 295 sleep studies 432 Homogeneous leukoplakia 376 thin leukoplakia 376 Honeymoon rhinitis 331 Hopkins telescope/sinuscope 586 Hormone-related rhinitis 331 House brackmann system of grading facial nerve palsy 258, 258t Human immunodeficiency virus 102, 106 papillomavirus 94, 404, 502 Humoral immunity 321 Hump nose 291 Hutchinson’s teeth 158 triad 165 Hyaline cartilages 70 Hybrid hearing aids 176 Hydraulic action of tympanic membrane 22 effect of tympanic membrane 23f Hydroxyzine 327 Hyoepiglottic ligament 62 Hyoid myotomy and suspension 434 Hyperacusis 135 Hyperbaric oxygen therapy 191, 629 Hyperemic decalcification and osteoclastic resorption 218 Hyperfunctional disorders 490, 496 Hyperkinetic disorders of facial nerve 266 Hypernasality (rhinolalia aperta) 497 Hyperthyroidism 621 Hypertrophied middle turbinate 309 turbinates 307, 337 Hyperventilation 235, 253 Hypoglossal-facial anastomosis 266 Hyponasality 497 rhinolalia clausa 497 Hypopharyngeal diverticulum 56 Hypopharynx subsites 56, 449 Hyposmia/anosmia 335 Hypotympanum 6 Hyrtl’s fissure 226 Hysterical aphonia 497 I Iatrogenic facial nerve palsy 267 or surgical trauma 265 Identification of mastoid antrum 550 roof of ethmoid 560 IgE-mediated hypersensitivity 322 Immune complex-mediated hypersensitivity 323 Immune-mediated sensorineural hearing loss 163 Immunity 106 Immunoglobulins 40 Immunohistochemical studies 313 Immunologic effects 329 Immunology 321 Infraglottic larynx 64 Infrapyramidal tympani Ingestants 323 Inhaled anesthetics 619 Inhibitors of bacterial cell wall synthesis 86 bacterial protein synthesis (ribosomal) 88 nucleic acid synthesis 88 Initial viremia 102 Injury to endoneurium neurotmesis 259 frontonasal duct 342 olfactory nerves and olfactory bulb 285 perineurium 259 Inlet of larynx 63 Inner ear 20 fluids 16 hair cells 16, 24 mucosal layer Inspiratory stridor 473 Instrumental trauma 455 Instruments for nasal surgery 587 cottle chisel with depth markings 587f cottle mallet 587f jansen middleton septum bone forceps with cutting blades 587f jansen septum bone forceps 587f masing chisel double guarded 587f Instruments for septal surgery 587f Luc’s forceps 587f mallet with both sides plain faces 587f periosteum elevator 587f septum gouge 587f straight, round cutting edge, without notch 587f suction cannula 587f Instruments of adenoidectomy 590f Beckmann adenoid curette 590f Laforce adenotome 590f St Clair thomson's adenoid curette with catcher 590f Instruments of adenotonsillectomy 589f boyle davis mouth gag with tongue depressor 589f draffin suspension apparatus (two bipods) 589f peacock vulsellum 589f St Clair thomson’s adenoid curette with guard 589f Yankauer’s tonsil suction tube 589f Instruments of endoscopic sinus surgery 586f hopkins telescopes 586f suction irrigation tube 586f trocar and cannula for sinuscopy 586f Intensities of different types of speech 138t noise levels 161t Intensity and loudness 138 Intermaxillary segment and primary palate 60 Internal auditory artery 19 See also Labyrinthine artery canal 19 and cerebellopontine angle 273 Internal carotid artery 626 aneurysm 448 system 35 Internal ear 2 jugular vein 73, 626 laryngeal nerve 67 nasal valve 287 nose 30 International classification of headache type (1988) 117t Interpretation of tuning fork tests 140t In-the-ear devices 135 Intra-arterial chemotherapy 616 Intracranial aneurysms 118 complications 307 course 256 meningioma 354 Intranasal antrostomy 563 meningoencephalocele 353 provocation test 326 Intratemporal course 256 of facial nerve 256f Intrathecal fluorescein 348 Intratonsillar abscess 427 cleft 55 Intratympanic muscles 9 nerves 9 tumor 271 Intrinsic muscles of larynx 66f Intubation granuloma 486 Invagination theory 211 wittmaack 211 Invasive fungal sinusitis 93 Inverted papilloma 354 ringertz tumor 363 Ipratropium bromide nasal spray 299 Irritation fibroma 403 Irritative pharyngitis 423 Isolated cerebellar infarction 251 Isoniazid 89 Itraconazole and voriconazole 94 J Jackson’s dictum 516 pattern 590 Jacobson’s nerve 136 Jansen elevator 585f Jargon aphasia 496 agrammatism 496 Jaw swellings 361 thrust 622f Jennings mouth gag 588 Jet ventilation 622f Jobson Horne’s probe 583f 649 Index and host defenses 51 Immunosuppressive therapy 312 Immunotherapy 329 Impedance audiometry 144 tympanogram 155 matching mechanism of middle ear 22 Implantable hearing aids 174, 177 Impure blowout fracture (rim fracture) 345 Inability to cough 510 Inadvertent injury 122 Incision and drainage 336 of quinsy 590 for middle ear effusion 205f for tracheostomy 511f of cartilage 564 Incisura terminalis Indications for adenoidectomy 568, 571 biopsy 104 bronchoscopy 575 grommet 548 immediate referral to otoneurologist 228 myringotomy 547 removal of retained tympanostomy tube 549 tetracyclines 88 tonsillectomy 567 Indigo carmine test/saccharin sodium test 286 Indirect laryngoscopy 503 with laryngeal mirror 468 Indwelling prostheses 508 Infantile hemangioma 488 capillary 488 Infected hematoma 186 Infection 324 and manifestations of systemic disease of larynx 478t and neoplasms within nose and paranasal sinuses 129 of larynx 477 Infectious esophagitis 461 mononucleosis 424, 429 rhinosinusitis 298 Inferior aspect of septum and maxillary crest 335f laryngeal nerve 71 margin 33 meatal antrostomy 562, 585 meatus 32 thyroid artery 79 veins 79 turbinate 31, 325 turbinectomy 330 Inflammatory disorders 387 Inflation deflation test 145 of middle ear 205 Influenza neuraminidase inhibitors 95 650 with ring curette 583 Jugular foramen syndrome 271 wall 7 Juvenile nasopharyngeal angiofibroma 437 papillomas 488 Diseases of Ear, Nose and Throat K Kallmann syndrome 288 Kaposi’s sarcoma 103, 104, 106, 402, 412 of pinna 105 Kartagener’s syndrome 41, 307 immotile cilia syndrome 310 Keloid 127f after postauricular mastoid surgery 269f of auricle 269 Kemicetine antiozaena solution 314 Keratoacanthoma 269 Keratosis 487 obturans 189 pharyngitis 427, 429 Ketamine 619 Kiesselbach’s plexus 293, 297 Killian’s dehiscence 51, 60 Killian-Jamieson’s space 60 Kilovoltage machines 610 Kissing tonsils 427f, 432f Klebsiella 314 rhinoscleromatis 84 frisch bacillus 482 spp 84 Klestadt’s cyst 292 Klippel-Feil syndrome 172 Korner’s septum 11, 13, 27 Kuttner’s tumor 391 L Labyrinth 133 Labyrinthine artery 19, 257 See also Internal auditory artery fistula 244 Labyrinthitis 158, 221 Lack’s L-shaped tongue depressor 582 Lahey’s method 524f Lamier Hackemann’s space 60 Langerhans cell histiocytosis 269 Large vestibular aqueduct syndrome 13 Larger perforations 337 Laryngeal cancer: 503 cartilaginous tumor 489 components of examination 471 crepitus 454 features 499 framework surgery 494 thyroplasty 494 framework—anterior view 62f mask airway 593 mirror 582 warming 469f spaces 71 symptoms and examination 467 trauma 518 tuberculosis 483 videoendoscopy 470 web 518 atresia 515 Laryngocele 487, 489 Laryngoesophageal cleft 515 Laryngomalacia 514, 518 Laryngopharyngeal packing 569 Laryngopharynx 56, 417, 432, 578 Laryngoscopes 590 Laryngoscopes for microlaryngoscopy and surgery 590 Laryngoscopic instruments 591f Holinger anterior commissure laryngoscope 591f Jackson laryngoscope 591f Kleinsasser operating laryngoscope 591f Ricker Kleinsasser laryngoscope holder and chest 591f stange hour glass operating laryngoscope 591f Laryngoscopic parameters and patient’s task 471 Laryngoscopy 497 Laryngotracheal separation 517 trauma 517 Laryngotracheitis 478 Laryngotracheobronchoscopy 475 Larynx 325, 432, 467 and laryngopharynx symptoms and causes 468 Laser 625 and cryosurgery 330 in otolaryngology 626 surgery 565, 625 Lateral cervical nodes 76 superficial and deep 76 Lateral medullary syndrome 253 posterior inferior cerebellar artery occlusion 253 Lateral Pharyngeal space 538 space abscess 542 sinus of grunwald 34 sinus thrombophlebitis 224 view 596 of larynx 62f, 63f of larynx cricothyroid muscle— cartilages and ligaments 66f of neck 597 of pharynx 50f of right lung bronchopulmonary segments 69f wall 11 wall of nasal cavity 30 and nasopharynx 51f wall of nasal cavity of cadaver 32f turbinates and meatuses 32f Lateropulsion 250 Layers of deep cervical fascia 74f, 75f Layers of tympanic membrane 5f Le fort fracture transverse 346 pyramidal 346 craniofacial disjunction 346 Le fort’s classification 350 Lederman’s classification 355, 357f Leiomyoma 465 Lempert’s endaural retractor 584 Length and tension of vocal folds 496 of vocal cords 68t in children 68t in female 68t Leprosy 316 Hansen’s disease 482 Lesion distal to geniculate ganglion 267 Lesions of tongue 385 Lesser alar cartilages 30 occipital nerve Leucovorin 616 Leukemia 246, 272, 386, 425 Leukoedema 375 Leukoplakia 404, 487 lip 407 See also Actinic cheilitis of buccal mucosa 377f tongue anterior two-third lateral margin 377f Leukotriene modifiers 329 Leukotrienes 322 Levator veli palatini muscle 195 Levels of cervical lymph nodes 77, 77t heating and tissue changes 626 Lever action of ossicles 22 ratio 28 Levobupivacaine 623 Lichen planus 404 Lichtwitz trocar and cannula 585 Lifestyle modifications 433 Ligation of internal jugular vein 225 Light signal or vibrations 177 Lignocaine 623 lidocaine 623 Linea alba 376 Linear accelerator 610 Lingual tonsillar abscess 427 tonsils 53 Linings of internal nose 35 Lip 44, 45 366 See also Vermilion surface lower 366 upper 366 Lipomas 530 List of ototoxic agents 159 Little’s area 297, 293 Local anesthesia and sitting position in adults 561 anesthesia with sedation 559 causes (primary otalgia) 129 ice packs 563 injections 494 steroids/hylase 375 M M avium 103 complex 89 intracellulare complex 90 M catarrhalis. 299 M tuberculosis 89, 90 Macewen’s curette 584 triangle 11f Macrolides 329 azithromycin 89 erythromycin 89 Macula of otolith organs 18f saccule 18f utricle 18f Main blood supply to tonsil 60 Main current of nasal airflow inspiration 42 Maintenance of body equilibrium 26 Major and minor factors in chronic rhinosinusitis 303t aphthous ulcer 383f encapsulated organisms 90 ulcers 382 Malfunctioning of eustachian tube 204 Malignancy 309 and chronic nonspecific laryngitis 482t buccal mucosa 410f maxillary sinus 355f of ethmoid sinus 358 of frontal sinus 359 of maxillary sinus 358 of middle ear 132 of sphenoid sinus 359 of tongue right lateral margin of oral submucous fibrosis 375f of tonsil with neck node metastasis 446f paranasal sinuses 363 tongue 408f tonsil 425 Malignant ameloblastoma 362 hyperthermia 621 melanoma 359 mixed tumor 398 neoplasms 354 or necrotizing otitis externa 191 tumors 360t, 371, 443 of external ear 269 of larynx 501 of nasopharynx 436 Malignant tumors of hypopharynx 449 Malleus (hammer) 8, 587 Mallory Weiss syndrome 457 Management of acute otitis media 203f impaired airway 509 needle stick injury 106 snoring 434 temporal bone fracture 264 unknown neck mass 527 unknown primary lesions 527 upper airway obstruction 424 Mandible 346 fracture 347, 350 Maneuver building negative pressure in nasopharynx 198 positive pressure in nasopharynx 197 Manometry 462 Mantoux test 391, 482 Manual communication 171 Marginal resection 361 Masked (latent) mastoiditis 219 Masking 141 Mass in neck 468 in nose 334 movement 261 occluding bronchus 577f Masseter muscle 122, 626 Mast cell stabilizers 328 cromolyn 328 nedocromil 328 Masticator space 540 Masticator muscles disorders 121 space abscess 366f, 544, 545f Mastoid 219 air cells 11 and ear microsurgery 583 antrum 11, 27 curette (scoop) 584 gouges 584 obliteration 553 pneumatization 207 process 48, 258 suction tips 584 surgery 556 tenderness 218 tip 27 wall 7 Mastoidectomy 225, 549 instruments 551f Maternal infections 167 Maxillary antrum of highmore 37 artery 35, 296 crest 565 mucocele 306 sinus 284, 304 sinusitis 565 Maxillofacial trauma 339 Maximal stimulation test 260 Maximum conductive hearing loss 148 McGovern’s technique 338 Measles 424 Measurement of mucociliary flow 286 nasal obstruction 286 neck circumference 525 Measures for preventing spread of swine flu 99t Meatal abscess 219 Medial canal fibrosis 188 geniculate body 25 labyrinthine wall pterygoid 122 muscle 626 surface of left pinna after ear piercing 127f wall 11 of left bony labyrinth 14f of middle ear 8f cleft 8f Median rhomboid glossitis 379 Medullary disorders 490 thyroid carcinoma 534 Melanoma 412 651 Index Localization of CSF leak (CSF tracers) 348 Localized collagen disease 374 Longitudinal section of nerve fiber 258f temporal bone fracture 264 Long-term immunosuppression 404 Loop diuretics 159 Loss and otosclerosis 149 Loss of heterozygosity 377 smell 285 sound during ear transmission 28 weight and anorexia 109 Loudness compression 175 discomfort level 138 Low tracheostomy 510 Lower alveolar ridge 45 alveolus 45 gingiva 45 Lower esophageal sphincter 58 half left facial palsy 259f lateral cartilages 30 motor neuron facial paralysis 259 third of face 341 Lowering of facial ridge 552 Lubrication of scope 576, 578 Luc’s abscess 219 forceps 587 Ludwig’s angina 543, 544, 546 Lumbar puncture 225 Lupus 482 pernio 314 vulgaris 315 Lyme disease 265 Lymph node chains draining hypopharynx 57f of head 75 of head and neck 77f of neck 75 Lymphangiomas 396, 402 Lymphatic drainage 39, 44, 64 of ear 13, 13t Lymphatic metastases 534 spread 410 Lymphoepithelial carcinoma 398 cysts of parotid gland 104 Lymphoma 529, 534 Lymphosarcoma 522 Lyre sign 536 Diseases of Ear, Nose and Throat 652 nose 293 of auricle 270 Melanotic macules 385 Melkersson’s syndrome 261, 263 Melkersson-Rosenthal syndrome 267 Membranes and ligaments 62 Membranous labyrinth 15 Membranous labyrinth 15, 150 endolymphatic labyrinth 150 otic labyrinth 150 Membranous labyrinth of left side 15f Membranous pharyngitis-tonsillitis 425 Membranous septum 33 Ménière’s disease 158, 238, 241f, 242, 246, 276 idiopathic endolymphatic hydrops 241 Ménière’s syndrome 242 Meningiomas 354 Meningitis 222 Meningoencephalocele 291 Meniscal displacement 122 Mesotympanum 6 Messerklinger technique 560 Metastasis via blood stream 406 Metastatic neck nodes 528 level III right side of neck 520f Methicillin-resistant Staphylococcus aureus 83, 85 Method for posterior canal bppv 233 Method of eliciting nystagmus 231 hearing assessment in infants and young children 170 evaluation 139 palpating deep cervical lymph nodes 521f Methotrexate 616 Metronidazole 88 Michel aplasia 167, 172 Microaerophilic bacteria 84 Micrognathia 476 Microlaryngeal surgery 493 Microlaryngoscopy 475 instruments 574f procedure 574f right vocal chord polyp 486f Microtia 184 Mid tracheostomy 510 Midazolam 619 Middle and inferior constrictor muscles 60 cranial fossa 276 ear 2, 7f, 20, 105, 132, 133, 217f anatomy and mastoid 131 surgeries 547 cleft 257 effusion 244 fluid 139 infection 335 mucosa 9, 214 ossicles 8f relations 267 symptoms 417 fibrous layer lobe bronchus 69f meatus 34 third of face 341 third of vocal fold lesion 506 turbinate 31 Migraine 109, 248, 253 and motion sickness 252 Mikulicz’s cells 318 disease 391, 400 Minimal alveolar concentration value 619 Minimizing visual vestibular mismatch 252 Minor aphthous ulcers 382 on nonkeratinized labial mucosa of anterior oral cavity 382f Minor salivary gland tumors 49, 412 Mitomycin-C 616 Mixed disorders 490 hearing loss 139, 143, 153 Mobius syndrome 265 Modified barium swallow 419 dix-hallpike maneuver for lateral canal 234 neck dissection 78 radical mastoidectomy 553 neck dissection 77 young’s operation 314 Modiolus 14, 27 Mold spores 327 Molecular biology 377 Monaural amplification 176 Mondini’s aplasia 167 malformation 172 Monostotic fibrous dysplasia 353 Morexella catarrhalis 84 Moro’s reflex 170 Motor component 26 nerve supply of larynx 71 nucleus of facial nerve 255 Mouth breathers 334, 335 gags and retractors 588 M-protein antigen 90 Mucocele 305, 403 Mucociliary mechanism 40 Mucoepidermoid carcinoma 396 Mucoperichondrial and periosteal flap 564 Mucormycosis 189, 318 Mucosa 69 of eustachian tube 195 Mucositis 612f, 614 Mucous blanket 42 cyst 447 membrane 50 of larynx 64 of paranasal sinuses 38 pemphigoid 379 retention cyst of lower lip 403f vallecula right side 447f Mucus drainage of sinuses 38 Muller’s maneuver 432, 435 Multicellular cell theory 395 Multiorgan disease 313 Multiple juvenile laryngeal papillomatosis 489 neurofibromatosis 274f sclerosis 251, 254 sleep latency test 432 Mumps 94, 387 Murmurs 113 Muscle relaxants 122, 621 Muscles in relation to eustachian tube 195 of larynx 65 Musculoskeletal vertigo 253 Mycobacteria 84 Mycobacterium avium 103 intracellulare 84 kansasii 84 malmoense 84 scrofulaceum 84 tuberculosis 84, 103, 391 Mycoplasma pneumoniae 85 Mycotic diseases of otorhinolaryngology 93 Myoclonus 133, 134, 499 Myogenic disorders 121 Myopathies 490 Myringoplasty 553 Myringotomy 218, 547 incisions 548f N Narcotics 122 Narrow band noise 139 Narrowing nasal cavities 314 Nasal balloon 296 bone fracture 343f bones and septum 342 cautery 295 cavity 282 continuous positive airway pressure 434 cycle 40 decongestants 328 dermoid 353 discharge 280, 283, 302 endoscopes 303, 349 endoscopy examination 300 examination 280 findings 314 fracture patterns 343f reduction forceps 585 furuncle in vestibule of right nose 283f gouges 587 manifestation of systemic diseases 311 mastocytosis 307 musculature 30 myiasis 350 maggots nose 350 obstruction 280, 283, 286, 302, 332, 335 Neoplasms in children 352 of oral cavity 401 of salivary glands 394 Nerve 48 conduction velocity 260 excitability tests 259, 262 graft 266 cable graft 266 preserved in radical neck dissection 79 structure 258f supply 3, 5, 6, 16, 39 of larynx 66 of lateral wall of nose 36f of middle ear 136 of nasal cavity 35 of right pinna—lateral surface; medial surface 4f of tympanic membrane 136 to stapedius 257 Nerves in relation with middle ear 9f Neural 59t, 139 pathways of taste sensation 46f Neurofibroma 269, 352 Neurologic disorders of larynx 490 Neuromuscular blockade 619 junction disorders 490 Neurotologic surgery 131 Nevus of external auditory canal 127f Newer technologies 568 Nicotine stomatitis 379 Nitrous oxide 620 Nodes of upper horizontal chain 76 Nodular leukoplakia 376 Noise 109, 139 induced hearing loss 160, 165 trauma 160 Nomenclature of segmental lobules of pulmonary lobes 70t Non airflow rhinitis 331 Non recurrent laryngeal nerve 71 Nonallergic rhinitis 330 with eosinophilia 330, 332 Non-gram staining 82 Non-Hodgkin’s lymphoma 104 Non-indwelling devices 508 Noninvasive fungal sinusitis 93, 318 Nonmetallic tracheostomy tubes 593, 593f Nonneoplastic and noninflammatory parotid swellings 400 Non-organic hearing loss 163 Nonpulsatile subjective tinnitus 133 Nonspecific antiseptics 90 Nontuberculous mycobacteria 316 cervical lymphadenitis 532 Nontuberculous mycobacterial disease 391 Normal barium swallow of lower esophagus 418f upper esophagus 418f Nose 332, 432, 627 and epistaxis 289 and paranasal sinuses 279, 596 and sinuses 105 and throat infections 85t paranasal sinuses and nasopharynx 294 Nuclei and tests of cranial nerves 116t Nucleoside analogue 95 acyclovir 95 famciclovir 95 ganciclovir 95 valacyclovir 95 Nutcracker esophagus 462 Nystagmus 25, 242 in rotation test 234f Nystatin 100 653 O Obliteration of sinus and intrasinus abscess 224 Obstruction of eustachian tube 198 Obstructive disorders 393 sleep apnea 428, 431 Occlusal view of nasal bone 597 Occupational factors 395 Ocular motor abnormalities 250, 251 Odontogenic keratocyst 361 tumors 352, 354 Odynophagia 417, 420 Ohngren’s classification 355, 357f Ohngren’s line 363 Olfactory epithelium 35 nerves 41 neuroblastoma 359 pathways 41 receptor cells 41 tract 41 Oncocytoma 396 OPD ear instruments 582f barany 582f billeau ear loop 582f boucheron ear speculum 582f hartmann ear speculum 582f heine otoscope with plastic ear specula 582f Jansen dressing forceps bayonet shaped 582f plastic ear speculum 582f tuning fork 582f Open excisional biopsy 528 mastoid cavity otorrhea 132 reduction 344 Opening of facial recess 7f mouth 569 parotid duct 366 Operations of nose 557 paranasal sinuses 557 Operative microscope 556 procedures and instruments 547 Opposite direction nystagmus 236 Optimum discrimination score 144 Optokinetic Index polyps 307 pruritus 325 reflexes 41 regurgitation 347 of fluid 417 septal and sinus surgery 585 septum 33, 333, 42, 587 of cadaver 34f skin 30 smear 326 speculum 587 surgery 435, 587 symptoms 314 and examination 279 synechia 337, 338 temperature 42 valves disorders 287 vestibulitis 290, 290f Nasoalveolar cyst 292 Nasobronchial and nasopulmonary reflexes 41 Nasolabial cyst 292 Nasolacrimal duct 42 Nasomaxillary complex 345 skin 114f Naso-orbital ethmoid 344 Nasopharyngeal airway 593 angiofibroma 441 bursa 51 carcinoma 83t, 438 tonsil (adenoids) 51 Nasopharyngolaryngoscope 470f Nasopharynx 51, 58, 105, 415 Natural killer cells 322 penicillins 86 resonance of external and middle ear 23 Nature of foreign bodies 515 Nebulized l-epinephrine 475 Neck 432, 519 and thoracic inlet 534 dissection 78 larynx and pharynx 597 masses 527 nodes 527 and masses 527 swelling 445 thyroid 527 Necrotizing stomatitis 105 Need of hearing evaluation 139 Negus artery forceps 589 knot tyer 590 pattern 590 Neisseria gonorrhoeae 84 gonococcus 84 Neisseria meningitidis 168 Meningococcus 84 Neisseria species 84 Neodymium:yttrium-aluminium-garnet laser 627 Neonatal suppurative parotitis 390 Neoplasms 104, 261, 308, 371 Diseases of Ear, Nose and Throat 654 test 234 tracking 232 Oral and pharyngeal examination 122 cavity 44f, 105, 365, 432, 44, 627, 365, 404f decongestants 299 hairy leukoplakia 377 leukoplakia 376 lichen planus 378 manifestations of HIV 106 mucosal lesions 373, 374 streptococci 83 Streptococcus viridans 83 submucous fibrosis 374, 375f symptoms and examination 365 thrush in adults 379 Orbital complications 306 hematoma 560 injury and cellulitis 561 Organ of corti 24f preservation 616 therapy 507 Origin insertion and actions of intrinsic laryngeal muscles 65t Orodental fistula 347, 350 Oropharyngeal airway 593 dysphagia 420 symptoms and causes 417 Oropharynx 52, 416, 432, 542, 627 Orthopantogram of mandibular fracture 347f angle fracture 347f parasymphyseal fracture 347f subcondylar fracture 347f Orthopantomogram 598, 598f Orthostatic hypotension 235 Ortner’s syndrome 494 Oseltamivir 95 Oseltamivir-resistant H1N1 virus 98 Osseous spiral lamina 14 Ossicles 8, 27, 150 and eustachian tube 8f Ossicular chain 214 necrosis 213 Ossicular reconstruction 555f malleus-footplate assembly 555f malleus-stapes assembly 55f reshaped incus between stapes footplate and tympanic membrane graft 555f head and tympanic membrane graft 555f Ossifying fibroma 352, 362 and cementoma 354 Osteocartilaginous framework of nose 30 Osteogenesis imperfecta 152 Osteoma 269, 352, 353, 363 Osteomeatal complex 34, 34f Osteomyelitis frontal bone 307 of maxilla 306 osteitis 306 sinus of mandible 522 Otalgia and nerve supply of ear 129f earache 128 history 130 physical examination and investigations 130 Otic capsule bony labyrinth 27 Otitic barotrauma 205 hydrocephalus 225 Otitis externa 130, 131, 186, 187 media with effusion 200, 204, 204f, 206 Otoacoustic emissions 139, 146, 148 Otogenic brain abscess 223 Otolithic membrane 18 Otologic symptoms and examination 125 Otological findings 168 Otomycosis 93, 189, 192 Otorhinolaryngology 107 Otorhinorrhea 348 Otorrhea 130 Otosclerosis 150 Otoscope 6, 126, 133, 128, 582 Otoscopy examination 128f Ototoxic drugs 165 Ototoxicity 159 Outer epithelial layer hair cells 16, 24, 28 Overlay myringoplasty 555f Overtones 147 and timbre 138 Oxazolidinones 89 linezolid 89 Oxygen concentration 620 enhancement ratio 610 P P jiroveci 103 Pachydermia laryngis 483 Pain 218, 365 in throat 468 sensitive structures for headache 117t Palate 60 Palatine tonsils 53 Palliation therapy 505 Palliative chemotherapy 615 Palpation of cervical lymph nodes 521f Pandemic influenza H1N1 (swine flu) 96, 299 Panendoscopy 369 and guided biopsy 528 Paper piece and cotton swab 349 Papillary adenocarcinoma 534 and follicular carcinoma of thyroid 536 cystadenoma lymphomatosum 396 Papilledema 225 Papilloma 401, 447 wart 268 of nose 292 Paracusis willisii 152 Paraesophageal hiatus hernia 460 Paraglottic space 64 Parainfluenza virus 94, 424 Paramedian section larynx 49f mouth 49f nose 49f pharynx 49f Paranasal sinuses 33f, 284, 352t and base of skull 438 sinuses and jaws 351 Parapharyngeal abscess 546 and retropharyngeal abscesses 220 space 538, 626 abscess 542 tumors 448 Parasympathetic preganglionic secretomotor fibers 255 Parathyroid glands 79 Parotid abscess 389 gland 47, 257, 342 relations 267 tumor 400 axial view 396f coronal view 396f Parotitis 130 Paroxysmal sneezing 332 Paroxysms of sneezing 325 Pars flaccida Partial midline glossectomy 434 syndrome 250 Parts hearing aids 174 Parts of ear external 3f internal 3f middle 3f Parts of middle ear cleft 6f on coronal section 6f tympanum 6 Passavant’s ridge 52, 60 Patency of nasal cavities 284 nose 282 Pathogenesis of acquired cholesteatoma 211 Pathophysiology of nerve injury 258 Pathways of spread 217 Patterson brown-Kelly syndrome 461 Patulous eustachian tube 199 Pediatric epiglottitis 476, 479, 479f masses 309 rhinosinusitis 304 Pemphigus vulgaris 379 Pendred’s syndrome 172 Penetrating trauma 186 Penicillin G 91 space 538 Pharynx 49, 325, 332 and esophagus 415 Phase differential between oval and round window 22 Phelps sign 277 Philtrum 60 of upper lip 60 Phobic postural vertigo 253 Phonasthenia 497, 500 Phonation and speech 68 Phonetically balanced words 144, 148 Phonosurgery 493 Photodynamic therapy 507, 628 Physiology of hearing 22, 23f nose 39 paranasal sinuses 41 swallowing 58 vestibular system 25 Picket-fence graph of temperature 226 Pickwickian syndrome 430, 431 Pierre-Robin sequence 58 syndrome 476 Pigmented lesions 384 Pill-induced esophagitis 458 Pinna 22, 27 Pituitary fossa and gland 38f Pizzillo’s technique of examining goiter 524f Plain radiographs 300, 393 Planes of three semicircular canals 25f Plasma exchange and intravenous immunoglobulin 312 Plasmacytoma 354 Pleomorphic adenoma 353, 395, 402, 447 Plester elevator 585f Plester suction tube with finger cut-off and stylet 585f Plummer-Vinson syndrome 404, 454, 461 Pneumocystis carinii pneumonia 102 Pockets and atelectasis tympanic membrane 192 Poliomyelitis 490 Politzer’s bag 583 test 197, 197f Pollens 323, 327 Polymerase chain reaction 392 Polyotia 192 Polyps 325 Polysomnography 432 Polyvinyl chloride tubes 592 Position or height of larynx 472 Positions of vocal cords 491 Positive fistula test 233 Postaural and endaural approaches to mastoid antrum 549f incision 549 Postauricular abscess 219 dermatitis 127f mastoid abscess 226 Postcricoid region 56 Posterior auricular nerve 257 belly of digastric 48, 257 chemotherapy 615 cricoarytenoid muscle 71 epistaxis 294 ethmoidal cells 560 ethmoidectomy 560 fontanelle 42 nasal packing 295, 296f with Foley’s catheter 296f pharyngeal wall 56 rhinoscopy 282, 284, 285f spur of carina 69f tympanotomy 7f facial recess approach 181 view of laryngopharynx 56f wall fractures 342 Posteroinferior cerebellar artery 251 Posterosuperior and lateral view of right tympanic cavity 10f region 13 tract 220 Post-herpetic neuralgia 121 Post-laryngeal crepitus 452f Post-laryngectomy vocal rehabilitation 507 Postnasal drip 332 mirror 582 Postoperative mastoid cavity 131 Post-tonsillectomy earache 571 Post-traumatic headache 119 Posture test 283 Potassium-titanyl-phosphate-532 Potential for malignant change 374, 377 of malignant conversion 461 Pott’s puffy tumor 307, 310 Powered instrumentation 568 Preauricular appendages 184 sinus 192 and cyst 184 pit 185f Precancerous lesions 386 Predisposing factors 381, 392 Pre-eclampsia 267 Pre-epiglottic space 62 of boyer 64 Pre-facial and post-facial lymph nodes 46 Premalignant lesions 502 Prenatal causes 167 Preoperative assessment 557 Prerequisites of antimicrobial therapy 86 Presbycusis 162, 165 Pretracheal layer 75 Prevention of opportunistic infections 104 Prevertebral layer 75 space 540, 626 abscess 543 Prilocaine 623 Primary 655 Index Penicillinase-resistant penicillins 87 Peptic ulcer 109 Peptidoglycan 90 Percutaneous dilational tracheostomy 513, 514f Perennial allergic rhinitis 324 Perforation of esophagus 455 nasal septum 336 tympanic membrane 218 Periapical cysts 361 Perichondritis 186 and chondritis 186 Perilymph 16, 27 Perilymphatic fistula 245 labyrinth or space 151 periotic labyrinth 151 Perineural intracranial spread 37 Periorbital ecchymosis 344 Periosteum elevator 587 Peripheral and central vertigo 236t blood smear 225 branches 48, 258 neuritis 285 Peripheral t-cell neoplasm 313t nonhealing midline granuloma 313 polymorphic reticulosis 313 Peripheral vestibular disorders 237, 238 system 25 Perisinus abscess 224 Peritonsillar abscess 542f, 546 forceps 590, 590f right side 542f infections 541 space 538, 626 Persistence of otorrhea 218 Persistent anatomy 255, 293, 497, 538 CSF rhinorrhea 349 nasal septal bleeding 297 Petrosal artery 257 Petrositis or petrous apicitis 220 Petrous and squamous parts of temporal bone 2f Pharyngeal aponeurosis 50 apparatus 58 arches 58 arches and myotomes 59t bursitis 441 end 195 pouches and grooves 59 spaces 50 symptoms and examination 415 wall 49 coronal section 50f Pharyngitis 423 Pharyngobasilar fascia 50 Pharyngoconjunctival fever 424, 429 Pharyngomaxillary abscess 542 Diseases of Ear, Nose and Throat 656 cholesteatoma 215 herpes simplex infection 380 otalgia 128 palate 60 Sjögren’s syndrome 398 thyrotoxicosis 523 tumor 357t Probe test 283 Procedure of esophagoscopy 578f Processus cochleariformis 257 Progressive retrograde thrombophlebitis of small venules 217 Proliferative verrucous leukoplakia 376 Proof puncture—antral lavage 562f Properties of radiant laser energy 626 Propofol 619 Proptosis exophthalmos 441 Prostaglandins 322 Protection of airway 40 and lips 574, 576, 578 eye 628 lower airways 68 skin 628 teeth 574, 576, 578 Protruding pinna with large concha and poorly developed antihelix 184f Prussak’s space 27 and anterior pouch of von Troeltsch 10f Pseudomonas aeruginosa 84, 390 Psoriasis or seborrhea 188 Psychological counseling 332 PTA and speech audiometry 164 Puberphonia 497 mutation falsetto voice 497 Pug nose 344 Pulsatile tinnitus 133 vascular tinnitus 133 Pure blowout fracture 345 Pure tone and complex sound 138 audiogram 161, 142 audiometry 142f, 143f Push and pull system 26 Pyocele 305 Pyogenic granuloma 403 Pyramid 257 Pyramidal eminence 7f signs 252 Pyrazinamide 90 Pyriform fossa 56 mass 450f sinus 56 Q Quadrangular membrane 63 Queckenstedt’s test 225 Quinine toxicity 159 cinchonism 159 Quinolone antibiotics 88 R Radial flow theory 16 Radiant laser energy 626 Radiation mucositis 384 Radical mastoidectomy 552, 556 neck dissection 77, 78 Radiofrequency surgery 628 Radionuclide cisternography 348 imaging 600 Radiotherapy and chemotherapy 608 Radium dial painters 272 Radkowski classification of juvenile nasopharyngeal angiofibroma 438t Raised intracranial tension 223, 275 Ramsay Hunt syndrome 5, 105, 263, 267 Ranula 403 Rapid strep tests 425 Rathke’s pouch 51 Rebound phenomenon 235 Recalcitrant rhinosinusitis 304 Receptive dysphasia 496 Reconstruction procedures 316 Recovery of facial palsy 262f phase of postinfluenzal anosmia 286 Recurrent acute otitis media 203 aphthous stomatitis 381 aphthous stomatitis 383t facial palsy 263 paralysis 267 herpes simplex infection 380 keloid 269f laryngeal nerve 79 or chronic rhinosinusitis 335 parotitis of childhood 390 respiratory papillomatosis 488 vestibulopathy 244 Red/white lesions 374 Red-man syndrome 87 Reduction of nasal bone fracture 343f Referred causes 129 otalgia 136 secondary otalgia 129 Reflex cough 192 Rehabilitative measures 171 Reichert’s cartilage 20 Reinke’ space 71 Reinke’s edema 486, 489 bilateral diffuse polyposis 486 Reissner’s membrane 15 Relapsing polychondritis 186 Related disciplines 595 Relations of cartilaginous part of eustachian tube 195f CPA 273 deeper part of submandibular gland 48f middle ear cleft sphenoid sinus with cavernous sinus 38 Removal of bridge and facial buttresses 552 cartilage and bone 564 disease 563 mastoid air cells 550 tip 552 mylohyoid muscle 48f uncinate process 560 Repositioning maneuvers 238 Reservoir, diseases and antifungal treatment 93t Respiration 39, 68, 468 Respiratory cilia 42 dead space 518 distress 517 mucosa 35 syncytial virus 94 Restricted mouth opening and soft diet 122 Retention cyst 362 Reticular lichen planus 378 Retracted tympanic membrane 191 Retrocochlear hearing loss 147 Retrocolumellar vein 293 Retrolabyrinthine approach 276 Retromolar trigone 45 Retropharyngeal space 539 Retropharyngeal nodes 37, 539 Retrosternal extension 524 Reversible ototoxicity 165 Rhabdomyosarcoma 272, 360 Rhinitis and asthma 327 caseosa 314 medicamentosa 331, 332 sicca 314 Rhinolalia clausa 310, 429 Rhinolith 349 Rhinomanometry or rhinometry 286 Rhinophyma 297 or potato tumor 292 Rhinoplasty 344 Rhinorrhea 325 Rhinoscleroma 315, 318 Rhinosinusitis 307 Rhinosporidiosis 93, 316, 318 Rhinovirus 94, 424 Ribavirin 95 Rifamycins 88, 89 Rigid bronchoscopy 575, 580 esophagoscopy 578 Rimantadine 95 Rinne’s test 128, 140, 148, 312 Ritonavir 106 Rodent ulcer 292 Rolling hiatus hernia 460 Romberg’s sign 236 test 235 Roof and posterior wall 51 tegmental wall Ropivacaine 623 Rosenthal’s canal 14 Rotating chair test 25, 235 Round window reflex 23 Route of administration and doses 86 Routes of infections 223, 391 Rouviere’s node 60 Rubber tubes 592 Russell bodies 318 S of OSA 432 SHEA teflon piston 154f Short increment sensitivity index test 143 Short process of incus 257 Short-tau inversion recovery 600 Shrapnell’s membrane Shrinkage of mucous membrane 282 Sialadenitis 393 Sialography 370, 372, 390 Sialolithiasis 393 Side effects of indinavir 106 protease inhibitor 106 Sideropenic dysphagia 404 Siegel’s examination 583f pneumatic speculum 136, 583 Sigmoid sinus thrombosis 226 Silastic tubes 592 Silicone tubes 592 Siliconized PVC tubes 592 Simple dermoid: 291 mastoidectomy 549 Singer’s or Screamer’s nodules 485 Single agent doses and toxicity 614t lumen tube 592 Sinus of morgagni 52 operations 557 tympani 7 with facial nerve 7f Sinuscopy 302 Sinuses 325 draining anterior to basal lamella 42 Sinusitis 299 Site and extent of swelling 370 Sites of epistaxis 294 Sites of hypopharyngeal cancer indirect laryngoscopic 450f posterior views of laryngopharynx 450f Six boundaries of tympanum 7f Size of bronchoscope and age of patient 591t endotracheal tube in children 593 tracheostomy tube 593 and age of patient 594t Sjögren’s syndrome 398, 399, 400 Skeletal muscle innervated by cranial nerves 59t relaxants 619 Skew deviation and ocular tilt reaction 251 Skin cancers 405 Skin covered tags between tragus and angle of mouth 184f glands 4 incision 511 involvement in buccal mucosa carcinoma 367f lesions 316 of cartilaginous external auditory canal 4f of nasal vestibule 35 over swelling 112 657 Index S pneumonia 90, 299 Saccades 232 Saccharin sodium 286 Saccular cysts 487 Saccule 15 Saddle nose 290 depressed nasal dorsum 290 Sade classification 199, 209f Sagging of posterosuperior meatal wall 218 Sagittal section head subsites of oral cavity and oropharynx 44f of cadaveric larynx 63f of larynx 63f and laryngopharynx 56f of neck 74 Salicylates 159 Saliva 372 Salivary calculi 400 glands 46, 365, 369 parotid 47f sublingual 47f submandibular 47f neoplasms 529 Salpingopharyngeal fold 52 Samter’s triad 302, 307, 310 Sanguinaria 376 Santorini 62 Saprophytic fungal infection 318 Sarcoidosis 314, 400 Sarcomas 270, 359 Saturation sound pressure level 174 Scala tympani 14 Scala vestibuli 14 Schatzki’s ring 461 Scheibe aplasia 167 Schirmer’s test 260, 261f Schneiderian membrane, mucosa 42 Schullar’s view 595 Schwabach’s test 128, 142 Schwannoma 352 Schwartz sign 155 Scleroderma or progressive systemic sclerosis 463 Scrapings of nasal mucosa and biopsy 316 Screening for bacterial meningitis 90 maternally transmitted infection 170 syphilis 170 torch 170 Seasonal allergic rhinitis 324 Sebaceous adenoma 268 cysts 3, 268, 531f Second arch branchial fistula 536 branchial arch 20 degree axonotmesis 258 pharyngeal pouch 60 Secondary atrophic rhinitis 314 crypts 55 herpes simplex infection 380 metastatic neck 114f nodes 522 otalgia 128 palate 60 Sjögren’s syndrome 398 syphilis 158 thyrotoxicosis 523 Second-generation cephalosporins 87 Sedatives and tranquilizers 618 Segmental resection 361 Selective neck dissection 78 serotonin-reuptake inhibitors 249 Semicircular canals 14, 14f, 27, 236 functions 25 ducts 15 Semont maneuver 239 for right posterior canal 240f Sensation level 138 Sense of blocked ear 190 smell 284 taste 366 Sensorineural hearing loss 105, 139, 141, 143, 144, 156, 157, 159 in adults 157 in children 168f Sensory epithelial hair cells 17 nerve supply of larynx 71 neuroepithelium 18 tracts 252 Sentinels portal of aerodigestive tract 51 Septal abscess 336 cartilage 565 hematoma 336 surgery 336 Septoplasty 336, 564, 564f techniques 565f Septorhinoplasty 344, 565 Septum 282 proper 33 Sequelae/complication of facial nerve palsy 261 Serous labyrinthitis 245 Serum and urinary calcium levels 315 immunoglobulins 321 Severe otalgia and otorrhea 191 Severity 325 of airway obstruction 473 of hearing loss 139, 143 Diseases of Ear, Nose and Throat 658 piercing devices 101 reactions after postoperative radiotherapy 612f tests 326 Sleep apnea 335, 430 patterns in OSA 431 Sleep-disordered breathing 430 Sliding hiatus hernia 460 Sluder’s neuralgia 129, 310 Small multiple ulcers on tongue 382f Small perforations 337 Soft palate 417 Soft tissue injuries 342 neck lateral view 543 windows 599 Solid and rounded foreign bodies 349 angle 27 Sonotubometry 198 Sopari 109, 374 Soreness and burning mouth 375 Sound 138 level meter 138 waves 609 Source of infection 541 Space of body of mandible 540 Spaces of larynx 64 Spasmodic dysphonia 498 or recurrent croup 478 Spatula test 284 for patency of nose 285f Special features of viruses 94 investigations of nasal complaints 285 Specific-IGE antibody tests 326 Spectrum—S aureus 89 Speech 68 audiometry 143, 170 frequencies 147 reading—lip reading 173 reception threshold 143 Speed of propagation 609 Sphenoethmoidal mucocele 306 recess 32 Sphenoid sinus 38, 42, 304 Sphenoid sinusotomy 560 Sphenoidal sinuses coronal section 38f Sphenopalatine ganglion 42 neuralgia 129 Sphincteric closure of laryngeal opening 68 Spirochaetes 85 Spondee words 148 Spontaneous emission of radiation 625 nystagmus 231, 250 otoacoustic emissions 146 rupture 455 Spread of cholesteatoma 212 Spreader grafts 287 Spurs 335 Squamous cell carcinoma 398, 443, 464, 465 of auricle 270 of external nose 293 of paranasal sinuses 363 Squamous metaplasia theory Sade 212 Wendt 212 Squamous papilloma 352, 353 S-shaped deformity deviated nasal septum 334 St Clair thomson’s adenoid curette 590 Stages of tympanic membrane retraction 209f Stapedectomy 153, 154f piston 154f Stapedial otosclerosis 152 reflex 260 Stapedius 9 muscle 27 Staphylococcus aureus 81, 94, 131 Stenger test 164 Stenosis and atresia of nares 291 Stensen’s duct opening of right side parotid gland 390f Stenver’s view 596 Sternocleidomastoid muscle 73 Sternomastoid tumor 522 Stimulated emission of radiation 625 Stokes method 86 Strap muscles 511 Streptococcal tonsillitis-pharyngitis 424 Streptococcus 188 pneumoniae 168 pneumonia—Pneumococcus 83 pyogenes 423 Streptogramins 89 Streptomycin 90 Stria vascularis 15, 16 Stridor 431, 473, 496 in adults 476 Striola 26 Stroboscopy 472 Structure of cholesteatoma 210 cochlear canal 15f hypopharynx 56f organ of corti 17f oropharynx 53f pharynx sagittal section 53f Structures and parts of larynx 471f Strychnine poisoning 545 Stuttering 498 Stylalgia 448 Styloid process 257 Stylomastoid artery 13 Subclavian steal syndrome 250 Subcutaneous emphysema 560 Subdural abscess or empyema 221 Subglottic cancer 507 hemangiomas 515 region 64 Sublingual salivary glands 48 Submandibular lymph nodes 37 salivary flow 261 glands 48, 597 space 540, 540f Submentovertical view 596 Submucosal vascular plexus 35 Submucous fibrosis 404 resection 335 of nasal septum 564 Subsites of cancer in oral cavity 45 oral cavity 405 Succinylcholine 619 See also Suxamethonium, Depolarizing muscle relaxant Sudden sensorineural hearing loss 161, 165 Sulphonamides and trimethoprim 88 Sulzberger’s powder 90 Summating potential 25 Sunderland classification 258 Superadded infection 325 Superficial cervical fascia 74 parotidectomy 400 ulcers and inflammation 280 Superior and middle constrictors 60 thyroid veins 79 cerebellar artery 251 laryngeal nerve 67, 493 mediastinum tumor 494 orbital foramen 363 thyroid artery 78 turbinate 31 Suppuration of mastoid lymph nodes 218 Suppurative labyrinthitis 245 otitis media 216 complications 542 Supraglottic cancer 506, 508 Supraorbital ridge 342 Suprapyramidal recess Supratonsillar fossa 54 Supreme turbinate 31 Surface anatomy of neck 72, 73f Surgery for CPA tumors 276 Surgery of nasal septum 563 Surgical management of vascular tinnitus 136t Suxamethonium 619 See also Succinylcholine, Depolarizing muscle relaxant Swelling moved with deglutition 113f moving with deglutition 521 of cheek 561 of parotid gland 394f of tail of parotid gland 396f over mastoid region 218 Swimmer’s otitis externa 192 Swimming 109 Swine flu 96, 299 Sympathetic fibers 9 trunk 626 Sympathomimetic drugs 328 Symptoms of obstructive sleep apnea 431 swellings and ulcers 111t Synchronous second primary 508 cancer 369 Syndromes with genetic hearing loss 167t, 168 with infertility and sinopulmonary disease 310 Synkinesis 261 Syphilis 158, 404, 482, 482t and tuberculosis 318 Systemic antibiotics 336 diseases 303, 388 involving nose 311t sialogogues 399 steroids 332 T needle 589 scissors 589 Tonsillar concretions/tonsilloliths 426 crypts 55 cyst 426, 427 Tonsillectomy 570f dissection 569 snare method 569 Tonsillectomy and adenoidectomy 330 Tonsils and pillars 417 Topical ear drops 159 isopropyl alcohol 132 nasal decongestant 282 steroids 332 Topodiagnostic tests 260 Tornwald’s disease 51 Torsional diplopia 251 Torus 403 tubarius 195 Total intravenous anesthesia 619 Tourette’s syndrome 499 Towne’s view 596 Toxic goiter 535f manifestations 525 Toxicity of anticancer drugs 615 Toxoplasma gondii 102 Toxoplasmosis 393 Trachea 467, 511 and bronchi 68, 627 Tracheal cartilages 68 dilator 511, 591 hook 511, 591 blunt 511 sharp 511, 591 Tracheobronchial tree 576 Tracheobronchial tree and bronchopulmonary segments 69f larynx 71, 476, 580 Tracheoesophageal fistula speech 508 Tracheomalacia 621 Tracheostomy 591 in infants and children 511 or endotracheal intubation 338 tracheotomy 510 tube 511, 512f Tracheotomy 510 Traditional screening tests 140 Tragal cartilage pointer 47, 257 Transformer action of middle ear 22 function of middle ear 23f Transfusion of blood and products 101 Transient evoked otoacoustic emission 169 Transillumination 284 test 288, 300 Translabyrinthine approach 276 Translucent 113 Transmastoid exposure of left facial nerve 266f Transorbital view 596 Transtemporal supralabyrinthine 659 Index T cell-mediated hypersensitivity 323 T1 and T2 tumors 358 T3 and T4 tumors 358 Tachycardia 525 Tandem walking 235 Taste buds 46, 386 test or electrogustometry 260 Techniques of indirect laryngoscopic examinations 470t Tectorial membrane 16 Tegmen tympani 27 Telecommunication devices 177 Temporal 258 bone 2, 269, 595 fracture 263, 264, 267 imaging 170 lobe auditory cortex 25 or cranial arteritis 120 Temporalis muscle 118, 122 Temporary tracheostomy 510 Temporomandibular disorders 121 joint 128 disease 133 Tender and erythematous swelling 186 jugular lymph nodes 225 Tenderness 284 along jugular vein 225 of maxillary sinuses 285f Tension headache 118 Tension-type headache 118 Tensor of vocal cord 71 Tensor tympani 9 veli palatini muscle 195 Teratomas 441 Terminal branches 257 of facial nerve in parotid gland 257t Tertiary syphilis 158 Tests for eustachian tube function 197 mucociliary drainage/clearance 198 smell 286 Tests of IgE antibody 327 Tetracyclines 88, 90 Therapeutic window 610 Thin watery discharge 325 Thiopental 619 Third degree neurotmesis 259 Third-generation cephalosporins 87 Thoracic esophagus 57 Thornwaldt’s disease 441 Three-dimensional shape of vocal folds 496 Throat culture 425 pain 424 Thudicum nasal speculum 281, 582 Thyroglossal cyst 113f, 522, 526, 530, 530f, 536 and fistula 79, 522 Thyrohyoid membrane 62 Thyroid angle 70 autoantibodies 526 cartilage 73 function tests 526 gland 59, 73, 78, 523 isthmus 511 and tracheostomy 512f neoplasms 528, 532 nodule left side 113f nodules 533 palpation from behind 524f scan salivary glands 601f surgery 621 Thyroplasty types 494 Tics and spasms 261 Tinnitus 132, 152, 190 management program 134 Tissue effect 626 TNM classification 355, 440 of carcinoma esophagus 465 Tobacco 109 Tobey-Ayer test 225 Tone decay 147 Tongue 45, 60, 366, 424 and floor of mouth 45f depressor 368 tie 386 ankyloglossia 386 Tonotopic gradient in cochlea 24f Tonsil artery forceps curved 590 straight 590 Tonsil dissection forceps with teeth (Waugh’s) 590 dissector and anterior pillar retractor 588 holding 569 forceps 588 Denis browne’s 588 knife 588 Diseases of Ear, Nose and Throat 660 approach 276 Transverse electromagnetic mode 626 fractures of temporal bone 267 temporal bone fracture 264 usually otic capsule disrupting 264 Trapezius muscle 73 Trauma 336 of external auditory canal 187 Traumatic disorders 185 granuloma 384 ulcers 384, 425 Trautmann’s triangle 27, 551 Traveling wave 609 progressive wave 609 Treacher collins syndrome 58 Treatment acute otitis media 202 basal cell carcinoma of auricle 270 for keratoconjunctivitis 399 for opportunistic infections and malignancies 103 melanoma of auricle 270 of acute attacks 249 of allergic rhinitis 332 of facial nerve palsy 266 of OSA 434 of vestibular symptoms 249 squamous cell carcinoma of auricle 270 Trehalose dimycolate 90 Tremors of stretched fingers of stretched out arms 525f Treponema pallidum 85 Treponemal tests 158 Trials of induction chemotherapy 615t Triangles of neck 73, 74f carotid 74f muscular 74f occipital 74f submandibular 74f submental 74f supraclavicular 74f Tricyclic amines 249 Trigeminal nerve 36 neuralgia (tic douloureux) 120 Trimethoprim-sulfamethoxazole 312 Trismus 366, 375, 545 in patient of masticator space abscess 366f in patient with masticator space abscess 545f Tubal tonsil 52 Tuberculosis 109, 315, 481, 482t Tuberculous cervical lymphadenitis 531f scrofula 531 with cold abscess 531f Tuberculous mycobacterial disease 391 sinus or ulcer 522 Tubotympanic CSOM 214 type (safe or benign) 209 Tullio’s phenomenon 236 Tumors and related jaw lesions 360 of ear and cerebellopontine angle 268 of external nose 291 of middle ear and mastoid 270 of nasopharynx 436 of nose 351 and paranasal sinuses 352 of oral cavity 402 of oropharynx 443 of salivary glands 394t Tuning fork 140, 582 and audiogram 214 test and audiogram 213 tests 128, 132, 139, 140, 141, 148 Tunnel of corti 16 Turban epiglottis 483 Tympanic membrane 5, 7f, 20, 27, 150 perforation 139 opening 195 plexus 9 nerve supply of middle ear Tympanomastoid suture 48, 257 Tympanomeningeal hiatus 226 Tympanometry 144 Tympanoplasty 549, 553 IV 555f Tympanosclerosis 192, 214 Tympanostomy tubes (grommet) 547 Type of hearing loss 139 Type of mastoid abscesses 219f Types and features of foreign bodies 187 Types nasal bone and septum 342 septum 333 Types naso-maxillary complex 345 Types of acini 46 allergic response 324 cholesteatoma 211 CSOM 209 deviated nasal septum 335f discharge and causes 131 ear foreign bodies 187 fiberoptic bronchoscope 576 hearing losses 139, 148 immunologic mechanism 322 mastoid 11 acellular 12f cellular 12f diploeic 12f mastoidectomies 549 mouth retractors 588f nasal septum fractures 334f otosclerotic lesions causing fixation of stapes footplate 152f tracheostomy tubes 591 tympanoplasty 554f tubes 548 U Ulcers of buccal mucosa after radiotherapy 612f Ultrasonography neck 371f Ultrasound neck 526 Uncinate process 42 Undifferentiated carcinoma 398 Unilateral nasal obstruction 286 OME in adults 205 recurrent laryngeal nerve paralysis 491 sensorineural hearing loss 148 superior laryngeal nerve paralysis 492 vestibular loss 26 Universal newborn hearing screening 168 Unknown neck mass 523 primary lesions 523 Unsealed radionuclide therapy 611 Upper border of superior constrictor muscle and base of skull 60 curvature of tube 591 esophageal sphincter 58 lateral cartilages 30 motor neuron facial paralysis 259, 267 part of nucleus 256f pinna 185f respiratory infection 619 tract obstruction 510 third of face 341 Uses of PTA 142 Us-guided procedure 371 Usher’s syndrome 172 Utricle 15, 236 and saccule functions 26 Uvulopalatopharyngoplasty 434 V Vacuum headache 122 Vagus nerve 4, 5, Valsalva maneuver 233 test 197 Van der hoeve syndrome 155 Varia technique 181 Varicellazoster virus 191, 263 Vascular ischemia 262 malformations 133 neoplasm 133 Vasovagal reflex Venous drainage 13, 79 hum 134 pulsatile tinnitus 133 Ventilation and regulation of middle ear pressure 196 of mastoid antrum and air cells 208f of middle ear cleft 196 of sinuses 42 tubes 548f Ventricle of morgagni 70 sinus of larynx 64 Virus infection 101 Viruses 92, 94 Visceral layer 75 Visual reinforcement audiometry 169 Vocal cord 481 nodules 489 palsy 71, 494 positions 491f Vocal fold edges 472 paralysis/paresis 490 vascularity 471 Vocal nodules 485 polyp 485 resonance 41 tremor 498 Voice 441 and speech 495 disorders 473, 495 test 128 Vomeronasal organ 42 of jacobson 41 von Recklinghausen disease 273 von Troeltsch anterior pouch 27 W Waardenburg’s syndrome 172 Waldeyer’s ring 51, 60 Wallenberg’s syndrome 250, 251, 253 Walsham’s and Asche’s forceps 343 Walsham’s forceps 343, 585, 586f Warthin’s tumor 396 Water’s view 596 Wax softening agents 190 Weber’s test 128, 141, 147 compares bone conduction of both ears 141f lateralization 148 Wegener’s granuloma 312, 336 Wernicke aphasia 500 sensory or fluent aphasia 500 Wharton’s duct calculus 394f Whiplash vertigo 253 White noise 139 patches on dorsum of tongue 367f tonsils 425, 426 WHO classification of degree of hearing loss 164 epithelial carcinoma based on histopathology 439t Whooping cough 480 Wickham’s striae 386 Wide surgical excision 359 Wigand technique 560 Wilde’s incision 549 Window level 599 Woodruff’s plexus 297 Work-up before chemotherapy 613 Wrisberg’s cartilage 70 661 X Xerostomia 365, 398, 400 X-ray mastoid left–normal 596f X-ray paranasal sinus water’s view 301f Y Yankauer’s suction tube 589 Young’s and kartagener’s syndromes 331 operation 314 syndrome 307 Z Zanamivir 95 Zenker’s diverticulum 463, 465 Zoellner suction tube with finger cutoff 585f Zygoma (tripod fracture) 344 Zygomatic abscess 219, 220f arch 345 front view 220f lateral view 220f Index Ventricular dysphonia 497 Vermilion border 44 surface 45 See also Lip Verrucous carcinoma 410, 507 of larynx 508 Vertebrobasilar angiography 250 insufficiency 250 Vertical diplopia 251 Vertigo 152 Vesiculobullous/ulcerative lesions 379 Vestibular folds (false cords) 64 function tests 28, 236 hair cells 26f nerve 21 neuritis 276 nuclei 21 receptors 16 schwannoma or neurilemmoma 273 symptoms 274 Vestibule 13, 280 of mouth 366 of nose 33 Vestibulocochlear nerve 19 reflex 232 cancellation 232 Vestibuloocular reflexes 22 Vestibulospinal tract 22 Vestibulotoxic drugs 165 Vibrant med-el soundbridge 178 Vibrotactile aids 171 Video esophagography 419 Vidian neurectomy 330, 332 Vinblastine 615, 616 Vincent’s angina 381, 425, 429 Viral 152, 395, 438 infections 426, 462 labyrinthitis 158 pharyngitis 424 rhinosinusitis 299 common cold 299 serology 388 ... salivary glands (80% of parotid and 50–60% of submandibular) while less in minor salivary glands (25 %) Therefore, majority of the minor salivary glands tumors are malignant The sign and symptoms of malignancy... type and duration of the lesion and age of the patient Age and duration: More the age and duration of the lesion greater are the chances of malignant change Site: Leukoplakia of floor of the... Cytogenetically, monoclonal and high frequency of tumor specific chromosome bands abnormalities 3p21, 8q 12 and 12q14-15 are seen in pleomorphic adenomas of the salivary glands Ectopic expression of the PLAG1