Difference between temporal bone fracture types: Longitudinal Vs Transverse: Made Easy

The temporal bone fracture are common with head injury accounting for 30 % of all head trauma and 75 % of all motor vehicle accident. 31% of temporal bone fracture are associated with Motor vehicle accident. 

Longitudinal fracture are common fracture caused by lateral forces over the mastoid and temporal squamosa and fracture line parallels petrous pyramid axis. It is generally anterior and extra-labyrinthine.

NEURAL SYMPTOMS WITH TRANSVERSE #

PHYSICAL SYMPTOMS WITH LONGITUDINAL #

Difference between temporal bone fracture types: Longitudinal Vs Transverse

Nerve Injury or neural component more common with transverse # Facial nerve injury(VII), vertigo(VIII: Vestibular Nerve), Sensorineural hearing loss(VIII: Auditory Nerve) and Nystagmus (vestibular Nerve/ CNS component) are more common and intense with transverse fracture.

Physical damage like bleeding demonstrated as  Hemotympanum and otorraghia , fractures seen as  CSF otorrhea, Conductive hearing loss due o disruption of ossicles and Tympanic membrane perforation, are common with longitudinal fracture. Neural component less common or less intense than it’s contrary.

Differential diagnoses of various otological symptoms

Parameter		Longitudinal Fracture	Transverse Fracture
Direction Of  Fracture		Along The Axis Of Petrous Pyramid	Perpendicular To Petrous Pyramid
Incidence		More Common (80%)	20%
Mechanism		Parieto Temporal Trauma	Fronto Occipital Trauma
Otoraghia	PHYSICAL DAMAGE	Common	Rare
Hemotympanum		Common	Possible
TM Perforation		Common	Rare
CSF Otorrhoea		Common	Occasional
Hearing Loss		Conductive	Sensorineural	NEURAL DAMAGE
Facial Nerve Injury		Less Common (20%) Often Temporary Delayed Onset	More Common (50%) Often Permanent Acute Onset
Vertigo		Common (Less Intense)	More Intense
Nystagmus		Common (Less Intense)	Common Third Degree

Paradise Criteria for Tonsillectomy

The Paradise criteria for tonsillectomy was given by AAO-HNS for tonsillectomy in paediatric and adolscent age group.

Minimum number of sore throat in a year

            Atleast 7 in the previous year

            OR Atleast 5 in each of two previous years

            OR Atleast 3 in each of three previous years

With Clinical feature of Sore throat along with atleast one of the following

            Fever > 100.9^oF (38.3^oC )

            OR Tender Cervical Lympadenopathy of size > 2 cm

            OR Tonsillar exudate

            OR Culture positive for GABH (Group A β Hemolytic Streptococcus)

With Administration of adequate dosing of ANTIBIOTIC for proven or suspected GABH infection. 

Know the difference between membranous tonsillitis and diptheria.

What are the causes of membranes over the tonsils?

Difference between adenoid and Tonsils.

Do you know how your examiner wants to hear the examination of oral cavity during your OSCE and Clinical Skills. Follow link.

Causes of altered sensation of Smell

Learn how to examine the sense of smell.

Anosmia (No smell)

Atrophic rhinitis

Peripheral neuritis

Degenerative Disease of Nose

Injury to factory nerve

Injury to olfactory bulb

Anterior Cranial fossa fracture

Intracranial abscess

Intracranial tumors

Meningitis

Causes of various types of Nasal discharge.

Parosmia (Perversion of smell)

Recovery Phase of post influenza anosmia

Intracranial tumor

Clinical Examination of Nose and PNS

Hyposmia (Decreased Smell)

Nasal Polyp

Enlarged Turbinate

Edema of Mucosal Membrane

Common cold

Vasomotor Rhinitis

Allergic Rhinitis

Membrane over tonsil (Differential diagnoses)

Mnenomics
Membrane Above A Tonsils Can Vary from MILd To Dangerous.

Membranes
Above        Apthous Ulcer
A               Agranulocytosis
Tonsil       membranous Tonsillitis
Can          Candiasis
Vary         Vincents Angina
MILd       Malignancy
                 Infectious Mononucleosis
                 Leukemia
To            Trauma
Dangerous Diptheria

Do you know how your examiner wants to hear the examination of oral cavity during your OSCE and Clinical Skills. Follow link.

Paradise Criteria for Tonsillectomy 

Know the difference between membranous tonsillitis and diptheria.

Difference between adenoid and Tonsils.

Examination of Ear: How to describe

Learn How to describe other systems and pathological conditions.

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The following is the complete examination of ear from pinna up to the tympanic membrane to  be described after the complete ear examination .

PINNA

On examination of external ear (both medially and laterally), the ear looks normal in shape (funnel shaped), size (equal to dorsum of nose) and position (The Frankfurt line divides the ear in upper one third) with normal contour (formed by helix, antihelix, conchae, cymbaconchae, tragus, antitragus and lobule) There is no gross deformity, no swelling or redness. The pre auricuar area looks normal with no sinus, no pits, redness,  swelling or any other mass or skin tags. The post auricular area looks normal. The postauricular area looks normal with no ironed out appearance, and no obliteration of retroauricular groove.   

On palpation there is no local rise in temperature and or tenderness both on the pinna and the mastoid. There is no thickening of tissue. Circumduction can be performed.

EXTERNAL AUDITORY CANAL

On examination of the external auditory canal without speculum, the size of the meatus is adequate 

(normal 8-9mm, stenosed if <4mm) containing wax and debris. The content is (Profuse/scanty in amount)(Foul smelling)(Blood mixed). There is no swelling or any mass.

On examination with otoscope or speculum, there is no furuncles, swelling or mass on the wall of the external auditory canal and contains().

TYMPANIC MEMBRANE

The tympanic membrane on examination under speculum/otoscope looks semitransparent glistening and pearly white in color with visible cone of light and handle of malleus. There is no perforation or bulging of tympanic membrane. There is no perforation, vesicles on the surface of tympanic membrane, the mobility of tympanic membrane is not assessed.

Learn How to describe other systems and pathological conditions.

| Abdominal | Respiratory | Cardiovascular | Nose and PNS | Oral Cavity | Ear | Digital Rectal Examination | Ulcer | 

Differential diagnosis of Nasal discharge

Unilateral Foul Smelling Nasal Discharge	Bilateral Foul Smelling Nasal Discharge
Atrophic Rhinitis	Nasal foreign Body
Rhinoscleroma	Rhinolith
Syphilis	Nasal diphtheria
Leprosy	Nasal Myasis
	Acute Unilateral sinusitis
	Chronic Unilateral Sinusitis

Purulent Nasal Discharge	Watery Nasal Discharge
Rhinitis Caseosa	CSF Rhinitis
Wegeners Granulomatosis	Allergic Rhinitis
Chronic sinusitis	Vasomotor Rhinitis
	Acute Rhinitis

Blood Tinged nasal discharge

Rhinosporiodosis

Wegeners granulomatosis

Foreign Body

Rhinolith

Myiasis

Differential Diagnoses in Ear

Differential Diagnoses in Ear

Polyp In EAR	Character
CSOM TT	Pale
CSOM AA	Red Fleshy
Glomus Tumor
Perforating TB

Purulent Ear Discharge

Diffuse otitis Externa

Primary Cholesteatoma of External Ear Canal

Acute Coalascent Mastoiditis

ASOM (Reservior Sign)

Petrositis

Infected Glomus tumor

 

Itching in Ear

Diffuse Otitis Externa

Eczematous Otitis Externa

Otomycosis

Seborrhagic Otitis Externa

Neurodermatitis

Blood Stained discharge from ear

Otitis Externa Hemorrhagica

Middle Ear Carcinoma

CSOM AA

Trauma to External Ear

ASOM in the stage of Resolution temporal Bone fracture

Foul smelling discharge from Ear

CSOM AA

Otomycosis

TB

Carcinoma Middle Ear

Carcinoma Mastoid

Crust in Ear

Eczematous Otitis Externa

CSOM AA

Chronic Diffuse Otitis Externa

Fluctuating Hearing loss

Meniere's Disease

Perilymph Fistula

Autoimmune

Syphillis

Malingering

Minor Ear Disorders

Satyr Ear

Darwin Tubercle

Stahl's ear

Absent Tragus

Test for Malingering or NOHL (Non Organic Hearing loss)

Suspect when someone shows exaggerated efforts to hear.

Cups around the ear and requests to repeat the question.

Learn how hearing is tested in normal patients.

Tuning Fork Test
STENGER TEST: It is based on the fact that if two tuning forks with same frequency are placed on two sides of the head, the one with the highest intensity is only heard. We need a pair of tuning forks which are placed 25cm from the head and the patient is blindfolded. The malingerer will say he hears on the normal ear. Now the Tuning fork on the side of the defective ear will be brought ahead at 8cm. This time the patient hears the sound but will say he did not hear anything. But if he is genuine he will hear on the normal side.

TEAL TEST: If someone claims of having conductive hearing loss we use this technique. Blindfold the patient and place the tuning fork over mastoid. He claims of hearing. Say you are repeating the test. And place one vibrating tuning fork in front of the ear and next non-vibrating tuning fork over the mastoid. Malingerer will say he hears the sound but the genuine one would not.

Pure Tone Audiometry (PTA) and Speech Discrimination Score (SDS)

·         Inconsistence in results of PTA or when repeated over and over. Variation in results greater than 15dB is diagnostic for NOHL.

·         Inconsistency in PTA and SRT results by 10dB.

·         Generally Shadow Curve is present if CHL is greater than 40dB and if the healthy ear is not masked. Absence means NOHL.

Delayed Speech Feedback
We need a tape recorder and playback system with delaying capacity. The patient is given a book to read and the same is played to his ear with slight delay of around 110-300ms in the (so called) defective ear. In a genuine patient there is no pausing but in real malingerers there will be stammering because our voice production depends upon what we hear. So he gets confused with the variable sound in two sides of the ear.

LOMPARD TEST
 As stated earlier sound of our own voice is necessary for proper regulation of its tone and loudness. Barany box is placed in the patient's sound ear. The patient is asked to read the book aloud and the Barany box is played on and patient is asked to continue. If one has profound hearing loss he will raise his volume. But malingerer claiming of Unilateral Deafness will continue reading.

Acoustic reflex Threshold/ Stapedial Reflex

Reflex is elicited but the patient claims of hearing loss. This means he is feigning.

Electric Response Audiometry

Source: PL Dhingra and Logan and Turner ENT Textbooks

Difference between Membranous Tonsillitis and Diptheria

What are the causes of membrane over the tonsils?

Feature	Membranous Tonsillitis	Diphtheria
Age	>5	2-5
Onset	Acute	Insidious
General Symptoms	More	Less
Odynophagia	More	Less
Temperature	High	Low
Tachycardia	Proportionate with temperature	Disproportionate
Tonsil	Enlarged and congested	Normal
Membrane	Bilateral	Unilateral
	Whitish Yellow	Gray
	Thick	Thin
	Limited to Tonsil	Extends beyond
	Easily removed	Bleeds on removal
Culture	GABH	Corynebacterium diphtheria
Lymphnode	Jugulodiagastric (Woods)	Generalised (Bull Neck)

Paradise Criteria for Tonsillectomy 

Know the difference between membranous tonsillitis and diptheria.

Difference between adenoid and Tonsils.

Do you know how your examiner wants to hear the examination of oral cavity during your OSCE and Clinical Skills. Follow link.

Difference between Adenoids and Tonsils

What are the causes of membranes over the tonsils?

Feature	Adenoid	Tonsils
Capsule	Non Capsulated	Semi Capsulated
Epithelial Lining	Ciliated columnar epithelium	Non Keratinised Statified Epithelium
Number	One	Two
Location	Nasopharynx	Oropharynx
Impressions	Vertical crypts and Clefts	Crypts
Growth Curve	Maximum at 6 and regresses by 20	Maximum at 8 and regresses by puberty
Lymphatic Vessels	Both Efferent and Afferent present	Only Afferent

Do you know how your examiner wants to hear the examination of oral cavity during your OSCE and Clinical Skills. Follow link.

Paradise Criteria for Tonsillectomy 

Know the difference between membranous tonsillitis and diptheria.

What are the causes of membranes over the tonsils?