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Mohammad Shariful Alam (Shohan) Session: 2003-04 Shahabuddin Medical College & Hospital
Name ______________________________________________________________ Roll _______________ Batch ________________ Session __________________ College _____________________________________________________________
Q. Type of hearing loss in otitis media with effusion (OME). Medical management of acute otitis media. What is myringtomy?
The aims of treatment are: (a) (b) (c) (d) To control infection of the middle ear cleft. To give symptomatic relief. To ensure patency of Eustachian tube for drainage and ventilation. To ensure complete resolution and full return of auditory functions.
Medical treatment of acute otitis media: 1. Bed rest and drink plenty of fluid. 2. Application of dry heat helps to relieve pain. 3. Analgesics to relieve earache e.g., Ibuprofen, Paracetamol or Nimusulide tablet.
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4. Systemic antibiotics to control of infection e.g., Amoxycillin, Tetracycline, Roxythromycin, Cephalexin, Co-trimazole etc. 5. Nasal decongestant to maintain patency of the Eustachian tube by 1% ephedrine in normal saline or decongestive nasal drop (e.g., Oxymetazoline), and antihistaminic tablet 6. Sedatives. Myringotomy: It is incision of the tympanic membrane with the purpose to drain suppurative or nonsuppurative effusion of the middle ear or to provide aeration in case of malfunctioning Eustachian tube.
*For curiosity: Antibacterial agents and their dosage in acute otitis media Drug Amoxicillin Ampicillin Co-amoxiclav Erythromycin Cefaclor (II generation) Cefixime (III generation) Cefpodoxime proxetil Ceftibuten (III generation) Co-trimoxazol (Trimethoprim + Sulphamethoxazole) Trade name Fimoxyl Moxacil Amblosin Fimoxiclav Moxaclav Eromycin Etrocin Ceflon Loracef Cef-3 Triocim Starin Taxetil (?) Cotrim Fisat Total daily dose 40 mg/kg 50-100 mg/kg 40 mg/kg 30-50 mg/kg 20mg/kg 8mg/kg 10mg/kg (max 400 mg/day) 9 mg/kg 8 mg (TMP) + 40 mg (SMZ)/kg Divided dose 3 4 2-3 4 2-3 1 or 2 2 1 2
Ans. External ear pathology causing conductive deafness are1. Congenital: Atresia Microtia Treacher-Collins syndrome 2. Impacted wax or cerumen 3. Impacted foreign body 4. Otitis externa: Diffuse otitis externa (when the auditory canal is obstructed) Otomycosis (when mycotic plug is formed) 5. Neoplasm: (i) Benign - Osteoma, chondroma, exostosis. (ii) Malignant - Osteosarcoma, chondrosarcoma.
Q. Sudden pain in the ear of a child after upper respiratory tract infections. What is your diagnosis? How you diagnosed?
Ans. Child is suffering from acute suppurative otitis media, its clinical features are1. Stage of tubal occlusion: Symptoms: i) Acute coryza ii) Mild earache iii) Fullness in the ear iv) Mild conductive deafness Signs: i) Tympanic membrane retracted & lusterless. 2. Stage of exudation or pre-suppuration: Symptoms: i) Severe earache (sharp & stabbing) ii) Deafness increases iii) Bubbling sound (due to serous exudates) iv) General illness: Rise of temperature, Malaise, Vomiting. Signs: i) Tympanic membrane: Red & congested, dilated vessels radiating from the handle of the malleus gives Cart-wheel appearance.
3. Stage of suppuration: Pre-perforation: Symptoms: i) Pain is more acute (throbbing) ii) Deafness is more marked iii) High rise of temperature (101 - 103F) Signs: i) Bulged, congested & yellow spot on the tympanic membrane ii) Mastoid tenderness Perforation: Symptoms: i) ii) iii) iv) Signs: i) Perforation on the tympanic membrane ii) Pulsating discharge reflect light intermittently called Light-house sign iii) Mastoid tenderness disappears Otorrhoea (pus or mucopus or may be blood stained) Pain diminishes Temperature comes down Conductive deafness is more marked
4. Stage of resolution: i) In early cases or in mild infection: Resolution occurs without perforation ii) In cases of perforation: Discharge subsides and perforation heals up or dry small perforation is left behind 5. State of complication: i) Persistence of otorrhoea & deafness ii) Vertigo & headache iii) Increase temperature iv) Facial paralysis. Q. Clinical features of otosclerosis. Treatment of otosclerosis.
Ans. Ototoxic drugs are1) Aminoglycoside antibiotics: Streptomycin & gentamycin mainly vestibulotoxic, Neomycin, kanamycin, vancomycin & tobramycin mainly cochleotoxic. 2) Diuretics: Ethacrynic acid, frusemide, etc. 3) Anti-malarial drug: Quinine, Chloroquine, etc. 4) NSAID: Salicylate, Aspirin, etc. 5) Tobacco and alcohol. Q. Treatment of furunculosis in ear.
Ans. Treatment:
1. The meatus is packed with wick soaked in 10% icthammol in glycerin or smeared with neomycin-steroid ointment. - Wick acts as a splint and prevents movement of cartilaginous part. It also relieves the tension of the furuncle into the canal by counter pressure and thereby relieves pain. - Icthammol is bacteriostatic and irritant. - Glycerin is hygroscopic and reduces oedema. The ribbon-gauze wick should be removed after 48 hours. Repacking may be necessary, if tenderness persists. 2. If furunculosis burst, canal should be cleaned and packed with gauze soaked in antibiotics and kept for 24 hours. 3. Analgesic is administered to reduce the pain. 4. Use of heat in the form of fomentation is soothing. 5. Systemic antibiotic e.g., Erythromycin, roxythromycin, cephalexin, or TrimethoprimSulphonamide group of drug, is administered in severe case or when there is spreading cullulitis. 6. Incision of furuncle is necessary if large boil and pus pointing. 7. In recurrent furunculosis, diabetes should be excluded and treatment should be done accordingly, if present. 8. If the patient is non-diabetic (with recurrent furunculosis), then ear swab culture is performed and a course of autovaccine should be considered. 9. Any other causative factor or focal sepsis should be looked into. Q. 5 pathologies of middle ear causing conductive deafness.
Ans. Middle ear pathology causing conductive deafness are1. Congenital: o Ossicular chain deformity o Fused ossicles
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o Incudo-stapedial joint separation o Congenital otosclerosis 2. Traumatic o Haematomas o Ossicular dislocation 3. Inflammatory o Acute : ASOM o Chronic: - Non-specific: CSOM, Adhesive otitis media, secondary otitis media - Specific: Tubercular and syphilitic. 4. Neoplastic o Glomus jugularae o Carcinoma. Q. What are the causes of discharging ear?
Ans. Causes of discharging ear areA. Causes in the external ear: (a) Inflammatory: i. Bacterial inection- mainly by Staph. Aureus, Streptococcus, Haemophillus, Pseudomonas, Proteus Localized otitis externa due to burst of furuncle (purulent discharge) Diffuse otitis externa due to diseases like DM & the condition is called Otitis Externa Malignance characterized by perichondritis and formation of pus. ii. Fungal disease (Otomycosis)- Caused by Aspergillus nigra black discharge Candida albicans white discharge iii. Viral inflammation- Caused by Herpetic virus Myringitis bullosa blood stained discharge Herpes zoster oticus (due to blood vessel rupture) (b) Neoplastic: Benign osteoma, exostosis. Malignant - squamous cell carcinoma, basal cell carcinoma. (malignant) (c) Impacted wax or foreign body in the ear. B. Causes in the middle ear: (i) Acute suppurative otitis media with perforation (ii) Chronic suppurative otitis media
Discharge is thin mucoid or mucopurulent in safe variety Discharge is purulent in unsafe variety & CSOM with complication Discharge is blood stained in CSOM with infected polyp or granulation tissue Characteristics of discharge: Foul smelling: in conditions like cholesteatoma, infection with gram negative organism (e.g., Pseudomonas, Proteus) fishy smell. Non foul smelling
(iv) Middle ear malignancy (e.g., carcinoma, glomus tumours, haemangioma etc.) (v) Following RTA, in secondary infection blood stained discharge. C. Middle cranial fossa: C.S.F. otorrhoeaHead injury with temporal bone fracture Congenital defect Cholesteatoma Malignancy. Q. Intratemporal complications o CSOM. Intracranial complications of CSOM.
Ans. Complications of otitis media are classified into two main groups:
1. 2. 3. 4. 5. Extra-cranial / Intratemporal Mastoiditis (*) Petrositis, (*) and Gradenigos syndrome Facial paralysis (*) Labyrinthitis (*) Subperiosteal abscess: (a) Post-auricular (b) Zygomatic & Lucs (c) Bezolds abscess (d) Pharyngeal abscess (e) Citellis abscess Osteomyelitis of the temporal bone Blood stream infection: Septicemia and pyemia Otogenic tetanus 1. 2. 3. 4. Intracranial Extradural abscess Subdural abscess Meningitis (*) Brain abscess (a) Temporal lobe (b) Cerebellar abscess (*) Lateral sinus thrombophlebitis (*) Otitic hydrocephalus Peri-sinus abscess Encephalitis (*).
5. 6. 7. 8.
6. 7. 8.
Q. Types of mastoidectomy. Indication of cortical mastoidectomy. Ans. Types of mastoidectomy: I. II. III. IV. V. Cortical mastoidectomy* Radical mastoidectomy* Modified radical mastoidectomy* Mastoidectomy with cavity obliteration Canal-down & Canal-up technique in mastoidectomy.
Indication of cortical mastoidectomy: 1. 2. 3. 4. 5. Acute mastoiditis where there is coalescence of the mastoid air-cells. Masked mastoiditis. Unresolved acute otitis media with persistent otorrhoea. In some cases of persistent or recurrent secretory otitis media. As an imitial step to perform: (a) Endolymphatic sac surgery (b) Decompression of facial nerve (c) Translabyrinthine or retro-labyrinthine procedures for acuostic neuroma.
Ans. Causes of sensory neural deafness areCongenital or prenatal deafness (a) Hereditary group (Genetic): Pendred syndrome Waardenburgs syndrome Klippel Fiel syndrome
(b) Pregnancy group: Rubella Rh-factor Congenital syphilis Severe viral infection of the mother (c) Birth group or prenatal group: Prolonged labour Anoxia or hypoxia Premature birth Birth trauma Phenylketonuria
Acquired or post-natal deafness I. Cause in cochlea or inner ear: i. Traumatic: Fracture temporal bone (*) Head injury Blast injury (*) ii. Operative: Post-stapedectomy (*) Labyrynthectomy iii. Infective: Bacterial: Labyrinthitis (*) Viral: Measles, mumps, influenza, pox, etc. iv. Vascular: Spasm Thrombosis v. Toxic: Streptomycin, quinine, gentamycin, and other ototoxic drugs. (*) vi. Degenerative: Senile deafness or presbyacusis vii. Noise induced: Acute noise trauma Chronic noise trauma viii. Miscellaneous: Diabetes Menieres disease (*) Ramsay Hunt syndrome II. Causes in internal auditory canal and C.P. angle: i. Acuostic neuroma (*) ii. Meningioma iii. Cholesteatoma iv. Tuberculoma v. Basal meningitis III. Cause in central nervous system: Dessiminated sclerosis Vascular accidents Tumours
Characteristically, presbycusis involves bilateral high-frequency hearing loss associated with difficulty in speech discrimination and central auditory processing of information. Here degenerative process usually affects organ of Corti, spiral ganglion or stria vascularis. Treatment: Presbycusis is not curable, but the effects of the disease on patients lives can be mitigated. General nutrition should be improved including administration of Vit. B1, B6, and B12. Amplification devices: Properly fitted hearing aids may contribute to the rehabilitation of a patient with presbycusis. Lip reading and auditory training Cochlear implants Curtailment of smoking and stimulants like tea and coffee may help to decrease tinnitus. Q. What is deafness? What are the types of deafness?
Ans. Deafness:
Partial or complete loss of hearing is called deafness. Types: 1. 2. 3. 4. Conductive deafness Sensory-neural deafness Mixed Psychogenic deafness.
Ans. Cholesteatoma:
The term cholesteatoma is a misnomer, because it neither contains cholesterol crystals nor is it a tumour to merit the suffix oma. *This is a sack or a pocket in the middle ear cleft lined by keratinized squamous epithelium and contains desquamated concentric sheets of keratin (and cholesterol crystals), usually associated with infections. In other words cholesteatoma is a skin in the wrong place. Essentially choesteatoma consists of two parts, (i) The matrix, which is made up of keratinizing squamous epithelium resting on a thin stroma of fibrous tissues and (ii) A central white mass, consisting of keratin debris produced by the matrix. Formation: 1. Congenital cholesteatoma: It arises from the embryonic epidermal cell and rests in th middle ear cleft or temporal bone. 2. Primary acquired cholesteatoma: Retraction pocket theory (most accepted theory):
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Auditory tube dysfunction/obstruction Hypoventilation of middle ear cleft & epitympanum Negative pressure of middle ear cavity produces pocket like depression in pars flaccid or posterosuperior region of pars tensa The pocket turns into pouch Self cleansing property of squamous epithelium is lost So, there is collection of sheets of squamous epithelium in concentric layers in the sac with formation of a tumour like mass called cholesteatoma. 3. Secondary acquired cholesteatoma: a. Migration theory: After perforation squamous cells migrate to the middle ear cavity & break into crystal keratin materials. b. Metaplastic theory: Chronic tonsillitis, adenoid Infection passes into middle ear cavity & break into crystal materials Inadequate treatment causes persistence of infection for years So, squamous cell metaplasia & shedding of cells are broken down to form cholesteatoma c. Implantation theory: Implantation of squamous epithelium from skin pedicle or remnant under the graft may lead to cholesteatoma formation. Q. What is tympanoplasty?
Ans. Tympanoplasty:
A tympanoplasty is a surgical procedure that repairs or reconstructs the eardrum (tympanic membrane) to help restore normal hearing. This procedure may also involve repair or reconstruction of the small bones behind the tympanic membrane (ossiculoplasty) if needed. This procedure is usually not performed (or needed) in children under of age. A tympanoplasty is recommended when the eardrum is torn (perforated), (atelectatic), or otherwise abnormal and associated with hearing loss. Abnormalities drum and middle ear bones can occur through injury, otitis media, congenital deformities, or chronic ear conditions such as a cholesteatoma. four years sunken in of the ear (at birth)
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Ans.
Local causes A. External ear Furuncle Perichondritis Otitis externa Impacted wax & FB Herpetic lesions including bullous myringitis Traumatic rupture of TM & myringitis Malignant growth B. Middle ear Acute otitis media Acute salpingitis Acute mastoiditis Barotraumatic otitis media Haemotympanum Unsafe variety of CSOM with threatening complications Malignant growth Referred causes 1. Via Vth cranial nerve (a) Dental: Caries tooth Apical abscess Impacted molar Malocclusion (b) Oral cavity: Benign or malignant ulcerative lesions of oral cavity or tongue (c) Temperomandibular joint disorder: Bruxism Osteoarthritis Recurrent dislocation Ill-fitting denture (d) Sphenopalatine neuralgia. 2. Via IXth cranial nerve (a) Oropharynx: Acute tonsillitis Peritonsillar abscess Tonsillectomy Benign or malignant ulcer of soft palate, tonsil and its pillars (b) Base of tongue: Tuberculosis or malignancy (c) Elongated styloid process. 3. Via Xth cranial nerve Malignancy or ulcerative lesion of- Vallecula - Epiglottis - Larynx or laryngopharynx - Oesophagus 4. Via C2 and C3 spinal nerves Cervical spondylosis Injuries to cervical spine Caries spine
Ans. Treatment:
1. Immediate treatment: Should be conservative & preventive. Majority cases heal with this treatment alone: Sterile cotton wool is applied at the external meatus. It is to be changed if soaked. No ear drop should be given & syringing of the ear should be avoided. Swimming & bathing in ponds or pools should be avoided.
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If there is chance of infection in traumatic perforation, then administer systemic antibiotic, either orally or perenterally in proper dose and duration. If associated with cold, then nasal decongestant and antihistaminic tablets are to be used. Application of trichlor-acetic acid or silver nitrate at the margin of perforation may help the healing process.
In majority of cases, healing of the TM occurs by epithelialization. 2. If patient attends late with purulent discharge following a perforation, then the case is to be treated like a case of ASOM with perforation. 3. If no healing within 3 to 6 months, myringoplasty operation is to be performed. In this operation, TM is repaired with temporal fascia. Q. Name qualitative hearing test (clinical test).
Ans. Qualitative hearing tests are1) Tuning fork test Rinne test Weber test Absolute Bone-Conduction 2) Impedance audiometry/Tympanometry 3) Stapedeal reflex test (SRT) 4) Vestbulo-cochleography. Q. Causes of tympanic membrane perforation.
Ans. Causes of tympanic membrane perforation are1. 2. 3. 4. 5. 6. While picking the ear with matchstick, pencil, hair-pins, etc. Foreign body trauma or trauma during removal of F.B. Sudden fluid compression or water jet: Syringing, water polo game, diving, etc. Air compression: Slapping, blast, barotraumas. Forceful inflation of Eustachian tube Indirect way: By head injury and fracture of the petrous temporal bone.
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Q. Nasal septoplasty/SMR which one is functionally better? Complications of nasal septal surgery.
Ans. Septoplasty is functionally better because Conservation form of surgery to correct deviation with minimum resection of cartilage and repositioning in midline. Most suitable in children and adolescence as it does not interfere with growth of the nose. It is also preferred in females to avoid cosmetic deformity of nose. Flappy Septum never occurs. Haematoma septum does not occur.
Complications of nasal septal surgery are1. Septal perforation and crusting due to injury and tearing of the muco-periosteal flap of the intact side. 2. Haemorrhage 3. Septal haematoma 4. Septal abscess 5. Depression of the bridge of the nose 6. Retraction of columella 7. Persistance of deviation 8. Synechia between septum and turbinates 9. Flapping of the septum 10. Meningitis 11. Toxic shock syndrome
Ans. Symptoms:
(1) (2) (3) (4) (5) (6) Paroxysmal sneezing followed by watery nasal discharge Nasal obstruction Nasal irritation Anosmia Heaviness of head & headache Irritation and congestion of eyes, respiratory distress, and broncho-spasm.
Management: A. Prophylactic: (a) Avoidance of allergen (b) A course of desensitizing vaccine based on result of skin sensitivity test. (c) Hyposensitisation by vaccine (d) Immuno-therapy by gamma-globulin or immunoglobulin injection.
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B. Curative management: 1. Oral antihistamines: e.g., Pheniramine Terfanadine, Loratidine, Fexofenadine etc.
maleate,
Promethazine,
Cetrizine,
2. Symapthomimetic drugs: Topical use of sympathomymetic drugs cause nasal decongestion e.g., Phenylephrine, Oxymetazoline, Xylometazoline etc. 3. Steroid: Can be used as spray (e.g., Beclomethasone, Fluticasone) or as submucosal injection. 4. Sodium chromoglycate as nasal spray. 5. General body nutrition is to be improved. Vitamin C and B-complex is to be administered. Bowel is to be kept regular. C. Surgical management: (a) Minor surgery: Reduction of nasal turbinates (inferior): (i) Surface electro-cautery (ii) Submucosal diathermy (S.M.D) (b) Other nasal surgery: (i) Submucosal resection (S.M.R) (ii) Fiber-optic endoscopic sinus surgery (FESS). Q. Epistaxis in a child of 3/4 years - cause and management.
Ans. Cause: In children commonest cause is epistaxis from Littles area either spontaneous or
due to1. 2. 3. 4. 5. 6. Picking of the nose Injury to the nose Exanthematous fever (e.g., measles, pox) Foreign body nose Diphtheric rhinitis Enlarged adenoids, etc.
Management: 1. Pinching of nose for 10-15 minutes, as pressure on nostril from outside compresses the vessels on the Littles area and stops bleeding. 2. Traumatic bleeding is often controlled by application of ice on bridge of the nose which causes reflex vaso-constriction. 3. In cases of persistent bleeding, the blood is sucked out including clots with suction machine under direct vision and spraying the nose with 4% xylocane. - If the actual bleeding point is found out, may be cauterized by chemical or electrocautery under G/A. - If bleeding point cannot be seen, then thick cotton wool pledget soaked in 4% Xylocaine solution should be inserted into the nasal cavity and it is removed after several minutes.
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Ans. Causes of nasal obstruction with epistaxis areInfected antro-choanal polyp Foreign body nose and rhinolith Rhinosporidiosis Diphtheric rhinitis DNS with acute rhino-sinusitis Back pressure from enlarged adenoid Juvenile nasopharyngeal angiofibroma Haemangioma Papilloma Carcinoma of nose, paranasal sinuses and nasopharynx Malignant garnuloma Q. Procedure of antral wash out.
7. The index finger acts as a guard to prevent double puncture. 8. The trocar is removed and cannula is advanced till it reaches the opposite antral wall and then withdrawn a little. 9. Now saline or sterile water is passed to the antrum by Higgisons syringe. 10. Syringing is continued until the return is clear. 11. The remaining water in the antrum is cleared out by withdrawing the syringe from saline and pumping-out air. 12. After the puncture is over, cannula is removed and a pack kept in the inferior turbinate to control bleeding. 13. Swab from antral pus may be taken for culture and sensitivity. Q.Types of nasal ployp. Difference between 2 types.
Ans. Nasal polyps are non-neoplastic pedunculated masses of hypertrophied oedematous nasal
or sinus mucosa composed of loose fibro-oedematous tissue lined by ciliated columner epithelium. Types of nasal polyp: Nasal polyps are classified into 3 categories1. Simple mucous polyp: (commonest variety) (i) Antro-choanal polyp (ii) Bilateral ethmoidal polypi. 2. Fungal polyps 3. Neoplastic polyps: (i) Benign tumors such as papilloma, hemangioma, fibroma, inverted papilloma etc. may present as a polyp. (ii) Malignant tumours may present as solid polypoid mass, either of ethmoid or maxillary sinus origin or inverted papilloma with malignant change. Difference between Antrochoanal polypi and Ethmoidal polypi: Traits
1. Age 2. Aetiology 3. Number 4. Laterality 5. Origin 6. Growth
Antrochoanal Polyp Common in children and adolescents. Mainly allergic in origin; may be infective also. Solitary Unilateral Maxillary antrum near the ostium.
Grows backwards to the choana and best seen in P.N.S. by posterior rhinoscopy. May extend into the nasopharynx and 7. Extension oropharynx. Trilobed with antral, nasal and 8. Size & shape choanal parts. 9. X-ray of the sinuses Shows unilateral opacity of the maxillary antrum.
Ans. Treatment:
a. Conservative treatment: 1. Aggravating factors such as dust, smoke, alcohol and tobacco should be avoided. 2. Nutritious diet & Vit. C is helpful. 3. Dental sepsis is to be controlled. 4. Nasal decongestants and antihistamines to control allergy. 5. Steam inhalation helps to loosen mucoid secretion. 6. Broad spectrum antibiotic therapy e.g., with Cephalexin, amoxycillin with clavulanic acid, azythromycin, doxycycline. 7. Steroid nasal spray is helpful to reduce oedematous turbinates and clearing ostiometal complex. b. Surgical treatment: 1. Eradication of sinus: a) Bilateral antral wash out b) Intra-nasal antrostomy or endoscopic maxillary antrostomy c) Caldwell-Luc operation d) Trephnine of frontal sinuses 2. Functional endoscopic sinus surgery (FESS) 3. Removal of associated cause e.g. DNS, polyp, HIT etc.
Q. What is FESS? Ans. FESS: Functional Endoscopic Sinus Surgery (FESS) is a term coined by an American ENT Surgeon, Dr David Kennedy in 1985 to describe the diagnosis and treatment of diseases of the nose and paranasal sinuses using endoscopes and CT scans. *FESS helps to maintain normal physiology, cilliary activity and drainage of the sinuses, thereby clears sinus pathology.ostio-meatal complex area is cleared of all obstructive pathology mainly polypoid mucosa. Anterior end of polypoid middle turbinate is excised, uncinate process is trimmed, osteii of paranasal sinuses are freed from obstruction and helping proper drainage of sinuses. FESS is not one operation, but rather a range of diagnostic and treatment procedures carried out with the help of rigid nasal endoscopes.
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Ans. Causes of nasal septum perforation are1. Traumatic perforation: Following septal surgery Repeated cautery Habitual nose picking To put ornaments 2. Pathological perforation: (a) Delayed drainage of septal abscess (b) Nasal myiasis (c) Rhinolith or neglected foreign body causing pressure necrosis (d) Chronic grnaulomatous condition Catilagenous part lupus, tuberculosis, leprosy Bony part syphilis (e) Wegeners granuloma 3. Chrome perforation (chemical): is an occupational hazard. 4. Idiopathic: No definite cause found. Q. Causes of unilateral nasal obstruction.
Ans. Causes of unilateral nasal obstruction areVestibule Furuncle Vestibulitis Stenosis of nares Atresia Nasoalveolar cyst Papilloma Squamous cell carcinoma Nasal cavity Foreign body DNS Hypertrophic inferior turbinate Concha bullosa Antro-choanal polyp Synechia Rhinolith Bleeding polypus of septum Benign and malignant tumours of nose and paranasal sinuses Sinusitis, unilateral Nasopharynx Unilateral choanal atresia
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THROAT
Signs: 1. Buccal mucosa is dirty and foetor may be present. 2. There is marked congestion, bulging and oedema of the tonsilar, peritonsilar and palatal region on the affected site. 3. A diffuse swelling of the soft palate just superior to the involved tonsil is seen displacing the uvula medially. 4. In more advanced cases, there may be an area of pus pointing underneath the thin mucosa. 5. Tonsillar glands are enlarged and tender on the affected side. 6. If untreated, abscess may burst into pharynx, often through crypta magna. Treatment: a. Hospitalization b. Conservative treatment: In the early stages when no distinct abscess is pointingI. Intravenous fluids to combat dehydration II. Intravenous broad-spectrum antibiotics III. Analgesics like paracetamol, pethidine. IV. Maintenance of oral hygiene by hydrogen per-oxide or saline mouth washes. c. Surgical treatment: If there is frank abscess formationI. Incision and drainage of abscess under local anaesthesia, pt. in upright sitting position. Abscess is opened at the point of maximum bulge above the upper pole of tonsil or just lateral to the point of junction of anterior pillar with a line drawn through base of the uvula. II. Interval tonsillectomy: The tonsils are removed four to six weeks following an attack of quinsy. Abscess or hot tonsillectomy: It has the risk of rupture of the abscess during anaesthesia, and excessive bleeding at the time of operation. Q. Post-operative care immediately after tonsillectomy.
Q. Causes of dysphagia.
Ans. Causes of dysphagia areA. Mechanical causes: 1. Oral causes: Lock-jaw Stomatitis, glossitis and angular stomatitis Submandibular sialo-adenitis Impacted molar, and other dental lesions Inflammation of the floor of the mouth Malignant growth of the tongue, ulcer tongue, etc. Tumors of oral cavity, odontogenic tumours, palatal tumours, etc. 2. Pharyngeal and laryngeal causes: Acute follicular tonsillitis Peritonsillar abscess Retro-pharyngeal and para-pharyngeal abscess Cancer of the pharynx Oedema larynx Advanced laryngeal cancer Foreign body pharynx Pharyngeal diverticulum Specific lesion e.g., kochs, syphilis etc. Palatal and pharyngeal paralysis Agranulocytic angina Paterson-Brown Kelly syndrome 3. Oesophageal causes: (*) (a) Causes in the lumen: Foreign bodies such as coins in the children Meat bones or dentures in adult (b)Causes in the wall: Congenital atresia and other abnormalities Corrosive oesophagitis Peptic oesophagitis (reflux) Traumatic oesophagitis (operative) Acquired strictures Spasm and diverticulum Cardio-spasm or Achalasia Benign tumours : e.g., Adenoma or myoma, etc. Cancer oesophagus Tracheo-oesophageal fistula Oesophageal varix Scleroderma (c) Causes outside the wall: Retro-sternal goiter and enlarged thymus in infants and young children Pressure by mediastinal mass Enlarged heart and aneurysm of the aorta Bronchogenic carcinoma Dysphagia lusoria
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4. Cervical causes: o Enlarged thyroid and malignant thyroid o Metastatic, Hodgkins or other neck node mass o Ludwigs angina o Parotitis o Temporo-mandibular arthritis B. Neuro-muscular causes: i. Central lesions causing vagal paralysis ii. Motor neuron disease iii. Peripheral neuritis iv. Jugular-foramen syndrome v. Myasthenia C. Psychological: Globus hystericus Q. 5 common causes of hoarseness of voice. Ans. Causes of hoarseness of voice: 1. Inflammations Acute: Acute laryngitis, laryngo-tracheo-bronchitis, laryngeal diphtheria Chronic: Specific: Tuberculosis, syphilis, scleroma, fungal infections Non-specific: Chronic laryngitis, atrophic laryngitis. 2. Tumors Benign: Papilloma, haemangioma, chondroma, fibroma, leukoplakia. Malignant: Carcinoma. Tumour-like masses: Vocal nodule, vocal polyp, angiofibroma, amyloid tumour, contact ulcer, cysts, laryngocele. 3. Trauma: External: Strangulation, injury neck, etc. Internal: Instrumentation, fumes, operative. 4. Paralysis: Paralysis of recurrent, superior laryngeal or both nerves. 5. Fixation of cords: Arthritis or fixation of cricoarytenoid joints. 6. Congenital: Laryngeal web, stenosis and atresia Laryngeal malacia Laryngeal arrhythmia 7. Miscellenious: Dysphonia plica ventricularis, myxoedema, gout 8. Functional: Hysterical aphonia Q. Causes and management of reactionary hemorrhage after tonsillectomy.
Ans. Reactionary hemorrhage occurs within 24 hours of the operation, but commonly within first
5/6 hours. Bleeding results from (a) Failure to ligate all bleeding points; (b) Slipping of a loosely tied knot or clot following rise of B.P. after operation;
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(c) Collapsed vessels opening up in the post-operative period; (d) Bleeding from vessels after relaxation of the stretched faucial tissue and muscle on removal of the mouth gag; (e) Failure of a vessel to contract and retract following crushing; and (f) In cases of local anesthesia, as the effect of adrenaline wears off, the vessels dilate. Management: After tonsillectomy operation in post-operative period when the patient is placed in tonsillar position if blood continuously accumulates in the mouth or dribbles through the mouth or repeated gulping specially in the children indicates reactionary hemorrhage. I/V channel should be opened and saline infusion should be started. Patients blood is to be drawn and sent for grouping and cross matching. A strict watch should be kept on the pulse, respiration and blood pressure of the patient. If features of shock develops than treatment of shock. Airway is cleaned by giving suction and it is to be ensured that there is no obstruction or hypoxia. Mouth is opened and tonsillar fossa is inspected. If a bleeding clot is seen, then it has to be removed with a Luc forceps and a piece of gauze soaked in hydrogen-per-oxide or adrenaline is held firmly against the fossa for 10-15 minutes. Usually in many cases bleeding stops by this measure. If the bleeding persists - call the immediate senior consultant and anesthesiologist and make sure the operation theatre is ready - the patient is to be taken to operation theatre immediately and under G/A, the bleeding is controlled by ligation or electro-cauterization of bleeding vessel - a nasogastric tube is to be introduced before anesthesia and swallowed blood is to be sucked out to prevent aspiration Blood transfusion is necessary in severe cases. The patient is then kept under watch and follow-up is given accordingly. Q. Complication after adenoidectomy.
Ans. Complications of adenoidectomy are1. 2. 3. 4. Haemorrhage : Primary, reactionary, & secondary. Eustachian tube injury and stenosis. Injury to pharyngeal musculature and vertebrae. Otitis media : i. Secretory otitis media ii. Acute otitis media. 5. Velopharyngeal insufficiency. 6. Nasopharyngeal stenosis due to scarring. 7. Incomplete removal and recurrence.
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2. Barium swallow X-ray of the oesophagus shows - It usually shows a "birds beak" narrowing at the GO junction and oesophageal dilatation proximal to the narrowing. - Gastric gas bubble is usually absent 3. Oesophagoscopy shows the dilated oesophagus with smooth narrowing of cardiac end containing undigested food. 4. Oesophageal Manometry :( In this test, a thin tube is passed into the esophagus to measure the
pressure exerted by the esophageal sphincter.)
Typical manometrical findings are the absence of oesophageal peristalsis and a hypertensive LOS which fails to relax completely in response to swallowing. Treatment: 1. Medical treatment: Before meal- Nifedipine 2. Botulinum toxin injection. Injected into the sphincter, botulinum toxin paralyzes the muscle and allows it to relax. 3. Forceful dilatation of cardia under general anaesthesia: Oesophagoscopy & dilatation by Plastic balloons Hydrostatic bag 4. Surgical treatments: Hellars myotomy under general anaesthesia Anastomic operation anastomosis between stomach & oesophagus. Q. Causes of white lesion in throat. Ans. Causes of white lesions in throat are1. 2. 3. 4. 5. 6. 7. Acute follicular tonsillitis Faucial diphtheria Vincents angina Agranulocytosis Infectious mononucleosis (Glandular fever) Oral thrush (cadidiasis) Leukaemia
Chemical: Silver nitrate, phenol, aspirin burn Thermal: Hot food or fluid, reverse smoking
4. Neoplasms 5. Skin disorders: Erythema multiforme Llichen planus BMMP Bullous pemphigoid Lupus erythometosus 6. Blood disorders: Leukaemia Agranulocytosis Pancytopenia Cyclic neutropenia Sickle cell anaemia 7. Drug allergy: Mouth washes, tooth paste, etc 8. Vitamin deficiencies 9. Miscellaneous: Radiation mucositis Cancer chemotherapy Ddiabetes mellitus Uraemia Q. Management of hemorrhage after adenoidectomy.
Ans. Management of hemorrhage after adenoidectomyHemorrhage usually seen in immediate post-operative period. Nose and mouth may be full of blood Vomitus of dark coloured blood which the patient had been swallowing gradually in post-operative period. Rising pulse rate. Primary hemorrhage always brisk and stops quickly. Reactionary hemorrhage is common within 24 hours of operation. It is often due to remnant of adenoids. Packing the area for sometimes Conservative treatment: - Decongestive nasal drops - Coagulants and - Sedatives Persistent bleeders are electro-coagulated under vision. If bleeding still not controlled a postnasal pack is left for 24 hours under general anaesthsia. If remnant of the adenoid tissue is present, then it should be removed. Secondary hemorrhage is uncommon.
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Ans. Chronic nasal obstruction and mouth breathing due to enlarged adenoid lead to
characteristic facial appearance of a child called adenoid facies. Features of adenoid facies are1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Elongated face with dull expression Open mouth Dribbling of saliva from angle of the mouth Prominent and crowded upper teeth Hitched up upper lip Pinched nose Highly arched hard palate Rounded shoulder Flat chest Abdomen is protuberant
Q. A woman of 45 years of age with anaemia complains dysphagia. What is your Dx?
Ans. The woman is probably suffering from Plummer-Vinson syndrome (Paterson-Brown Kelly
syndrome). This is a precancerous lesion, commonly seen in woman whom there is chronic superficial pharyngo-oesophagitis. Aetiology: Iron deficiency anaemia Vitamin deficiency Auto-immune disease. Clinical features: 1. Dysphagia more to solids 2. Feeling of lump in the throat 3. Features of iron deficiency anaemia 4. Angular stomatitis, glossitis, and koilonychias. 5. Web formation or cicatrisation in post-carotid region. Diagnosis: (1) By clinical features, signs of vitamin deficiency (2) Hypochromic microcytic anaemia (3) Barium swallow X-ray shows a web at the post-cricoid region. (4) Hypopharyngoscopy and oesophagoscopy to confirm. (5) Serum iron and iron binding capacity to see prognosis after treatment. Treatment: 1. Iron and vitamins are given in large doses. 2. Endoscopic examination and dilatation relieves dysphagia. 3. Follow-up.
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Q. Causes and management of primary hemorrhage after tonsillectomy. Ans. Causes of primary haemorrhage: Occurs at the time of operation 1. Faulty selection of the patient i.e. pt. with high blood pressure, DM, any bleeding disorders. 2. Injury to the surrounding structures 3. Tonsillar fibrosis. Management: It can be controlled by pressure, ligation or electrocoagulation of the bleeding vessels. Q. Types of hemorrhage after tonsillectomy.
Relative
1. Diphtheria carriers, who do 1. Palatopharyngoplasty not respond to antibiotics. 2. Glossopharyngeal neurectomy 2. Streptococcal carriers, who 3. Removal of styloid process. may be the source of infection to others. 3. Chronic tonsillitis with bad taste or halitosis which is unresponsive to medical treatment. 4. Recurrent streptococcal tonsillitis in a patient with valvular heart disease.
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HEAD-NECK
i.
ii. Carcinoma
High grade
iii. Non-epithelial tumors iv. Lymphomas v. Secondary tumors vi. Unclassified tumors vii. Tumor like lesions Solid lesions Cystic lesions
Surgical procedure of parotid: 1. Superficial parotidectomy - Incision and development of a skin flap
(Incision is the lazy S pre-auricular-mastoid-cervical)
- Location of the facial nerve trunk - Dissection of the gland off the facial nerve - Closure 2. Radical parotidectomy Q. What is Ludwigs angina? Ans. Ludwigs angina: This is a rare, virulent and often fatal septic inflammation of the soft tissue of the sublingual space with subsequent extension to the submandibular space and tissues of the neck.
Ans. Symptoms of hyperthyroidism and hypothyroidism are Hypothyroidism Tiredness Mental lethargy Cold intolerance Weight gain Constipation Menstrual disturbance Carpal tunnel syndrome Hyperthyroidism Tiredness Emotional lability Heat intolerance Weight loss Excessive appetite Palpitations
Q. Indication of tracheostomy.
Ans. Indications of tracheostomy areA. Respiratory obstruction 1. Infections - Acute laryngo-tracheo-brochitis, acute epiglottitis, diphtheria - Ludwigs angina, peritonsillar, retropharyngeal or parapharyngeal abscess, tongue abscess 2. Trauma - External injury of larynx and trachea - Trauma due to endoscopies, especially in infants and children - Fracture of mandible or maxillofacial injuries 3. Neoplasms - Benign and malignant neoplasms of larynx, pharynx, upper trachea, tongue and thyroid 4. Foreign body larynx 5. Oedema larynx due to steam, irritant fumes or gases, allergy, radiation 6. Bilateral abductor paralysis 7. Congenital anomalies - Laryngeal web, cysts, tracheo-oesophageal fistula - Bilateral choanal atresia
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B. Retained secretions 1. Inability to cough - Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic overdose - Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain-Barre syndrome, myasthenia gravis - Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning 2. Painful cough - Chest injuries, multiple rib fractures, pneumonia 3. Aspiration of pharyngeal secretions - Bulbar polio, polyneuritis, bilateral laryngeal paralysis C. Respiratory insufficiency - Chronic lung conditions, viz. emphysema, chronic bronchitis, bronchiectasis, atelectasis - Conditions listed in A and B* * In viva voce this point should not be told. Conditions listed in A and B means the points mentioned under the heading
of respiratory obstruction and retained secretions.
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4. Care of tracheostomy tube: Inner cannula should be removed and cleaned as and when indicated for the first 3 days. Outer tube, unless blocked or displaced, should not be removed for 3-4 days to allow a track to be formed when the tube placement will become easy. After 3-4 days, outer tube can be removed and cleaned every day. 5. Feeding: Proper nourishment is essential for recovery of the patient. If the patient is unable to eat, then naso-gastric feeding is to be started. 6. Physiotherapy and change of posture: In ambulatory patient: Coughing out is encouraged and various breathing exercise to be taught. In non-ambulant patient: Posture is to be changed frequently and lung care is to be taken to prevent lower respiratory tract infection. 7. Dressing: Water proof dressing should be applied to prevent maceration of surrounding skin. 8. Decannulation: Tracheostomy tube is plugged and the patient closely observed. If the patient can tolerate it for 24 hours, tube can be safely removed. Q. Causes of midline neck swelling.
Ans. Causes of midline neck swelling are Solid Swelling of the thyroid isthmus and pyramidal lobe Enlarged lymph nodes (submental, prelaryngeal, pretracheal) Cystic Ranula Ludwigs angina Sublingual dermoid Lipoma in the submental region Thyroglossal cyst Subhyoid bursitis Cold abscess in the space of Burns
Protozoan Toxoplasmosis Neoplastic Malignant Primary, e.g. lymphoma Secondary, e.g. squamous cell carcinoma Known primary Occult primary
2. Autoantibody titres
Serum level of antibodies against thyroid peroxidase (TPO) and thyroglobulin are useful in determining the cause of thyroid dysfunction and swelling. Levels above 25 units ml-1 for TPO antibody and titres of greater than 1:100 for anti-thyroglobulin are considered significant.
3. Isotope scan
The uptake by the thyroid of a low dose of either radiolabelled iodine ( 132I) or the cheaper technetium ( Tc) will demonstrate the distribution of activity in the whole gland. In hyperthyroidism both the proportion of the tracer dose taken up and the rate at which this takes place are increased.
99m
4. Ultrasonography
Ultrasongrapphy is used in determining the physical characteristics of thyroid swellings and to demonstrate subclinical nodularity and cyst formation.
6. Radiology
Chest and thoracic inlet radiograph may confirm the presence of significant retrosternal goitre and tracheal deviation, compression or retrosternal extension and are required when either clinical suspicion or FNAC indicates malignancy.
7. Ultrasound scan
High-frequency ultrasound gives good anatomical images of the thyroid and surrounding structures.
8. Other scans
Computed topography (CT), magnetic resonance imaging (MRI) and positron emission topography (PET) are used for the assessment of known malignancy and to assess the extent of retrosternal and, occasionally, recurrent goitres.
9. Laryngoscopy
Flexible laryngoscopy is used preoperatively to determine the mobility of the vocal cord.
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Ans. Causes of unilateral neck swelling areSite Submandibular triangle Carotid triangle Solid Tumor of submandibular gland Sialolithiasis Enlargement of lymph nodes Carotid body tumor Sternomastoid tumor Solidication of lymph nodes Cystic Plunging ranula Sublingual dermoid Carotid aneurysm Branchial cyst Laryngoceal Cyst adenoma of thyroid (lateral lobe) Cold abscess of lymph nodes (e.g., TB lymphnodes) Cystic hygroma Laryngoceal Pharyngeal pouch Subclavian aneurysm
Posterior triangle
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