INI CET ENT Syllabus

What artery is the usual source of posterior epistaxis, and how is it managed?

The sphenopalatine artery (a branch of the maxillary artery). Posterior bleeds may require posterior nasal packing, balloon tamponade, endoscopic sphenopalatine artery ligation, or embolization.

Define allergic rhinitis and its underlying immune mechanism.

IgE-mediated (Type I hypersensitivity) inflammation of the nasal mucosa. Mast cell degranulation releases histamine causing sneezing, rhinorrhea, nasal itching, and congestion. Treatment: antihistamines, intranasal corticosteroids, allergen avoidance.

What are the paranasal sinuses and which is most commonly affected in sinusitis?

Frontal, maxillary, ethmoidal, and sphenoidal sinuses. The maxillary sinus is most commonly affected (its ostium is high, impairing drainage).

Differentiate acute from chronic rhinosinusitis by duration.

Acute rhinosinusitis: symptoms <4 weeks. Subacute: 4–12 weeks. Chronic rhinosinusitis: symptoms ≥12 weeks. Diagnosis requires nasal obstruction/discharge plus facial pain/pressure or hyposmia.

What is the most common cause of unilateral nasal obstruction with foul discharge in a child?

A nasal foreign body. Presents with unilateral foul-smelling, often blood-tinged discharge.

What is the most common cause of bilateral nasal obstruction in children, and what facial appearance results?

Adenoid hypertrophy. Causes mouth breathing, snoring, hyponasal speech, and 'adenoid facies' (open mouth, elongated face, pinched nostrils).

List the three subdivisions of the larynx.

Supraglottis (above the vocal cords—epiglottis, false cords, ventricles), Glottis (true vocal cords), and Subglottis (below the cords to the lower cricoid border).

What nerve provides motor supply to all intrinsic laryngeal muscles except one, and which muscle is the exception?

The recurrent laryngeal nerve supplies all intrinsic muscles EXCEPT the cricothyroid, which is supplied by the external branch of the superior laryngeal nerve.

Which is the only muscle that ABDUCTS (opens) the vocal cords?

The posterior cricoarytenoid muscle. ('PCA = Please Come Apart' — the only abductor.)

Describe the vocal cord position and voice effect of unilateral recurrent laryngeal nerve palsy.

The affected cord lies in the paramedian position; voice is hoarse/breathy but airway is usually adequate. Bilateral RLN palsy causes both cords in paramedian position with stridor and airway compromise (may need tracheostomy).

What is laryngopharyngeal reflux (LPR) and how does it differ from GERD?

Retrograde flow of gastric contents to the larynx/pharynx causing hoarseness, throat clearing, globus sensation, and chronic cough. Unlike GERD, heartburn is often absent ('silent reflux'). Treated with PPIs and lifestyle changes.

List the most common causes of stridor in a neonate versus an older infant.

Neonate/infant: laryngomalacia (most common congenital cause of stridor; inspiratory, worse when supine/feeding, usually self-resolves by 18–24 months). Acquired causes include croup and foreign body.

Differentiate the stridor type for supraglottic, glottic/subglottic, and tracheal obstruction.

Supraglottic lesions: inspiratory stridor. Glottic/subglottic lesions: biphasic stridor. Lower tracheal/bronchial lesions: expiratory stridor (wheeze).

What is acute epiglottitis, its classic organism, and key warning signs?

Life-threatening supraglottic inflammation, classically due to Haemophilus influenzae type B (Hib). Presents with the '4 Ds': Drooling, Dysphagia, Dysphonia, Distress; child sits in tripod position. Avoid examining the throat—secure airway first.

What is croup (laryngotracheobronchitis), its cause, and characteristic features?

Viral (parainfluenza) infection of the subglottis. Features: barking/'seal-like' cough, inspiratory stridor, hoarseness; 'steeple sign' (subglottic narrowing) on neck X-ray. Treated with nebulized adrenaline and corticosteroids.

Give the differential for a neck mass based on age (rule of thumb).

In children/young adults: most neck masses are congenital or inflammatory. In adults >40, a persistent neck mass is malignancy (metastatic squamous cell carcinoma) until proven otherwise.

Where is a thyroglossal duct cyst located and what is its classic clinical sign?

Midline neck mass at/below the hyoid bone. Classic sign: it moves upward with tongue protrusion and swallowing (due to attachment to the foramen cecum via the tract). Treated by Sistrunk procedure (removal with central hyoid).

Where is a branchial cleft cyst typically located?

Lateral neck, anterior to the sternocleidomastoid muscle (most commonly second branchial cleft cyst at the upper third of SCM). Painless, fluctuant; may become infected.

What is the most common malignancy of the head and neck and its primary risk factors?

Squamous cell carcinoma (SCC). Risk factors: tobacco and alcohol (synergistic); HPV (especially type 16) for oropharyngeal/tonsillar cancer (better prognosis); betel nut chewing for oral cancer.

What nerve is at greatest risk during thyroid surgery and what does its injury cause?

The recurrent laryngeal nerve. Unilateral injury causes hoarseness; bilateral injury causes airway obstruction/stridor. The external branch of the superior laryngeal nerve (innervates cricothyroid) is also at risk—injury affects voice pitch/high notes.

What is the most serious immediate complication after thyroidectomy and how does it present?

Post-operative hemorrhage causing an expanding neck hematoma with airway compression—a surgical emergency requiring immediate wound opening at bedside. Also watch for hypocalcemia (parathyroid injury) and bilateral RLN palsy.

What causes hypocalcemia after thyroid/parathyroid surgery and how does it present?

Inadvertent removal or devascularization of the parathyroid glands → hypoparathyroidism → hypocalcemia. Presents with perioral tingling, paresthesia, carpopedal spasm; signs include Chvostek's sign and Trousseau's sign.

What is the most common cause of primary hyperparathyroidism and its indication for surgery?

A solitary parathyroid adenoma (~85%). Causes hypercalcemia ('stones, bones, groans, psychiatric moans'). Surgery (parathyroidectomy) indicated for symptomatic disease, severe hypercalcemia, renal involvement, or low bone density.

What is otitis media with effusion (glue ear) and its main consequence in children?

Non-infected fluid in the middle ear behind an intact eardrum, common after recurrent AOM/Eustachian tube dysfunction. Causes conductive hearing loss that can impair speech/language development. Treated with grommets (ventilation tubes) if persistent.

What is choanal atresia and how does bilateral atresia present in a neonate?

Congenital blockage (bony/membranous) of the posterior nasal aperture. Bilateral atresia presents at birth with cyclical cyanosis (worse with feeding, relieved by crying), as neonates are obligate nasal breathers. Diagnosed by inability to pass a catheter; managed with oral airway then surgery.

Describe the OAE (otoacoustic emissions) test and its primary use.

Measures sounds generated by outer hair cells in response to a stimulus, recorded in the ear canal. Used for universal newborn hearing screening because it is quick, objective, and non-invasive. Absent OAEs suggest cochlear/conductive pathology and need follow-up (BERA/ABR).

What does BERA/ABR (Brainstem Evoked Response Audiometry) assess and when is it used?

Measures electrical activity along the auditory pathway from cochlea to brainstem in response to sound. Used for objective hearing threshold estimation in infants/uncooperative patients, and to screen for retrocochlear lesions (e.g., acoustic neuroma).

What is the head impulse test (HIT) used to differentiate?

It tests the vestibulo-ocular reflex. An ABNORMAL (positive, with corrective saccade) HIT suggests a PERIPHERAL vestibular lesion. A NORMAL HIT in an acutely vertiginous patient is a red flag for a CENTRAL (stroke) cause. Part of the HINTS exam.

Define the Le Fort classification of midface fractures.

Le Fort I: horizontal fracture across the maxilla above the teeth (floating palate). Le Fort II: pyramidal fracture through nasal bones and maxilla (floating maxilla). Le Fort III: craniofacial disjunction—complete separation of midface from skull base.

What is the recommended sequence/priority in emergency airway management (and the surgical airway of choice in 'can't intubate, can't ventilate')?

Follow ABC: assess and secure the Airway first. Stepwise: basic maneuvers (head tilt-chin lift/jaw thrust) → oropharyngeal/nasopharyngeal airway → bag-mask → endotracheal intubation → supraglottic device. In emergency 'can't intubate, can't oxygenate,' perform a cricothyroidotomy (surgical airway); tracheostomy is for longer-term/controlled settings.