Ebook Bansal diseases of ear, nose and throat: Part 2

(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