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Comprehensive key for ENT Cases

CSOM never painful Except in:
1. Acute exacerbation.
2. Malignant transformation.
3. Occurrence of complications.

1. Common in female.
2. Multipra.
Otosclerosis
3. Middle age.
4. More bilateral.
1. Discharging ear.
Petrositis Gradenigo's triad 2. Diplopia & squint (6
th
).
3. Facial pain (5
th
).
1. ASOM.
DD of Pulsating ear discharge 2. Acute exacerbation of CSOM.
3. Extradural abscess.
1. Facial palsy (recurrent).
2. Fissured tongue.
Milkerson Rosenthal syndrome 4F
3. Facio-labial oedema.
4. Familial.
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1. Common in male.
Meniere's disease 2. Around 50 years.
3. More unilateral.

1. Acoustic neuroma (the commonest).
2. Meningioma
CPA lesions
3. Congenital cholesteatoma.
4. Arachnoid cyst.

1. Haemotympanum.
2. High jugular bulb.
3. Carotid aneurysm.
DD of Red Drum 4. Glue ear (SOM).
5. Glomus tumor.
6. ASOM.
7. Active stage of Otosclerosis (Schwartz sign).
1. Secretory otitis media.
2. Adhesive otitis media.
DD of CHL with intact drum 3. Tympanosclerosis.
4. Congenital stapedial fixation.
5. Otosclerosis.
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1. Angiofibroma.
DD of Unilateral Nasal Mass 2. Antro-choanal polyp.
3. Tumor (papilloma).
1. Petrositis.

2. Furunculosis.
Diseases common in Diabetics
3. Diffuse OE.

4. Skull base ostomylities.

1. Unilateral facial pain.
Trotter's triad in : 2. Unilateral palatal immobility.
"Nasopharyngeal carcinoma" 3. Unilateral CHL.

1. Otalgia (pain).
2. Vesicles.
Herpes zoster oticus
(Ramsy Hunt syndrome)
3. Facial paralysis (7
th
).
4. SNHL, vertigo (8
th
).
1. Sudden pain.
2. Bleeding.
Manifestations of Rupture Drum
during Ear Wash 3. Deafness e` tinnitus
4. Fluid trickling in throat.

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Labyrinthitis Positive fistula sign Vertigo, Nystagmus on:
1. Pressure on tragus.
2. EAC pressure by siegalization.
3. Manipulation of aural polyp.


1. The fistula is very small.
2. The fistula is closed by cholesteatoma.
False negative fistula
3. Inadequate sealing of EAC during siegalization.
4. Dead ear.

1. Menier's disease.
False positive fistula
2. Syphilitic OM.

1. Glomus.
DD of pulstile tinnitus 2. High jugular bulb.
3. Carotid aneurysm.

1. Prominent lateral process.
2. Shortened handle of malleus.
Signs of Retracted Drum 3. Disturbed or absent cone of light.
4. Exaggerated ant & post malleolar folds.
5. Limited mobility on siegalization.

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1. FB in nose.
2. Atrophic rhinitis.
DD of Offensive Nasal Discharge
3. Maxillary sinusitis of dental origin.
4. Oroantral fistula.
Single papilloma of larynx is Precancerous.

1. More sever in the morning.
Characters of Headache of sinusitis 2. It site is over the affected sinus.
3. Increase by coughing, straining &
leaning forwards.

1. Invasion of the muscle.
2. Invasion of the nerves.
Causes of VC fixation in cancer larynx
3. Invasion of the joint.
4. Mechanical weight of the tumor.
1. Trismus.
Beck's triad "Parapharyngeal abscess" 2. Internal swelling.
3. External swelling.
1. Pain.
2. Fever.
Warning manifestations of CSOM "complications" are 3. Headache.
4. Vertigo.
5. Facial paralysis.
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Ototoxic drugs
1. Amino glycosides as (Neomycin, Garamycin, Gentamycin,
Streptomycin)
2. Diuretics as frusemide.
3. Salicylates in large doses.
4. Quinine.
5. Chemotherapy (Cisplatin).

Unilateral secretory otitis media with effusion in male old age
suspect Nasopharyngeal tumor until proved otherwise.

The commonest cause of secretory otitis media in children is Adenoid.

Tenderness on pulling auricle or on pressure on the tragus Otitis
externa.

Allergic polypi bilateral & multiple (with allergic manifestations).

Antro-choanal polyp unilateral & single (without allergic
manifestations).

A child with unilateral nasal obstruction & offensive nasal discharge
suspect FB in nose.

Old Male, chronic heavy smoker, with progressive or persistent
hoarseness of voice more than 2 weeks may be Cancer larynx.
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Adenoid is the commonest nasopharyngeal swelling & the commonest
upper respiratory tract infection in children.

Progressive dysphagia, starts for solids then solids & fluids + rat tail
appearance of barium swallow Cancer oesophagus.

Intermittent dysphagia, more for fluids than for solids + dilated lower
2/3 of oesophagus with smooth tapering lower end Achalasia of the
cardia.

Acute non specific laryngitis is the commonest cause of stridor in
children.

Hoarseness of voice with bilateral nodules at the junction between
anterior 1/3 & posterior 2/3 in voice abuser Vocal cord nodules.

Hoarseness of voice with unilateral polyp in the vocal cord in voice
abuser laryngeal polyp.

TB laryngitis occurs in the posterior part of larynx (as the posterior
part is the site of stagnation of saliva w` full of TB bacilli).

Syphilis occurs in the anterior part of the larynx (as it is transmitted
by blood & the anterior part more vascular).

Safe CSOM Intermittent discharge, Central perforation.
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Unsafe CSOM Persistent discharge, Marginal or Attic perforation.
Itching Otomycosis.
Positive reservoir sign Acute Mastoiditis.
History of attacks of coughing, chocking, dyspnea, cyanosis in young
child FB inhalation.
Griesinger's sign
Oedema & Tenderness over the Posterior border of Mastoid process
(occur in lateral sinus thrombophlebitis).
History of trauma with sudden pain in ear, deafness & tinnitus
Traumatic rupture of the drum.

History of flying with sudden pain in ear during rapid descent of
aeroplane, deafness & tinnitus Otitic barotrauma.
Unilateral watery nasal discharge CSF Rhinorrhea.

Pain behind the ear hours before the paralysis + Red chorda tympani
sign Bell's palsy.

The commonest cause of CHL is Wax accumulation.

The commonest cause of SNHL is Presbaycusis.

Sudden SNHL may occur in (Traumatic, Vascular or Autoimmune
diseases).

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The commonest cause of epistaxis Idiopathic.

Hypertension is common cause of epistaxis in elderly.

Young boy around 12 years with unilateral nasal obstruction & history of
epistaxis most probably Angiofibroma.

Loss of corneal reflex is the 1st sign in Acoustic neuroma.

Cystic swelling in the midline, which moves up with deglutition and
protrusion of the tongue Thyroglossal cyst.

Swelling in the lower part of the front of the neck, move up & down
with deglutition but Not with protrusion of the tongue Thyroid
swelling.

Swelling below & in front of the auricle raising the lobule of the auricle
Parotid swelling.








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Cases introduced by:
Dr Essam Abdel Nabi
1. A 12 years old male came to ENT clinic complaining of severe
epistaxis from the nose especially when he tries to play in his nose,
and the bleeding don't stop by itself. On examination of the nose,
there was a big mass occluding the whole cavity.

a. What is your diagnosis?
Juvenile nasopharyngeal angiofibroma.
b. What is the most striking symptom?
The epistaxis, that may be sever to end his life.

c. What is the most important precaution you should take it?
Never touch or manipulate this mass to avoid a new attack of epistaxis.

N.B: In the past, the Pt. of an angiofibroma was applied to radiotherapy to induce
fibrosis of the mass for treatment.
But now obsolete because of the high risk of developing carcinoma especially
because the angiofibroma usually appears in adolescents.

But now: MRA (MRI + Angiography) done to visualize the feeding artery and then
Induce thrombosis of the feeding artery to avoid bleeding during the operation.



2. A 40 years old obese woman came to ENT clinic, complaining of
multiple arousals at night after attacks of apnea & her husband also
complains from hearing abnormal noise while she is sleeping. The
examination of the oropharynx reveals elongated uvula.

a. What are the causes of apnea in general?
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b. What is the cause of apnea in this case?
This obese woman develops apnea due to obstruction of her
nasopharynx by the redundant palate & elongated uvula.


3. A 29 years old man, complaining of bilateral epistaxis with severe
pain following severe trauma to his nose. By the x-ray there was
fracture nose.

a. What are the causes of epistaxis?
b. What is the position that you must put the pt in during the attack?
The Pt. should lean forward to prevent swallowing of the blood, as
the Pt. may develop hypovolemic shock from the blood loss & swallowing
blood on full stomach may irritate it, stimulating vomiting so the Pt.
develops neurogenic shock .


4. A 35 years old man came to ENT clinic complaining of inability to
close his right eye & also from deviation of the angel of mouth to the
left side. After examination we show that the patient had done
cortical mastoidectomy on ttt of chronic otitis media & aural polyp.

a. What is your diagnosis?
Right complete facial paralysis.
b. What is the cause?
This paralysis may be a complication of the operation.



5. A middle aged woman complaining of pain in the right ear & vertigo,
ear examination revealed post auricular scar of previous operation
done for the treatment of Cholesteatoma, the middle ear ossicles
are removed during the operation.

a. What is the cause of vertigo & pain?
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Removal of the ossicles results in formation of radical cavity "the
middle ear cavity communicate with the mastoid" so exposure of the
lateral canal in the radical cavity make it sensitive to weather changes
causing "vertigo & pain ".



6. A 35 years old woman came to the ENT clinic complaining of tinnitus
& diminution of hearing in the left ear. But on examination, there was
intact tympanic membrane.

a. What is the cause of hearing loss?
With intact drum the diminution of hearing may be due to (Otosclerosis
or SNHL).
By the Weber & Rinne tests you can differentiate
If Rinne ve & Weber lateralized to the ear of hearing loss
Otosclerosis.

b. What is the type of deafness in this condition?
CHL.


7. A 29 years old male came to ENT clinic complaining of hoarseness of
voice, on examination of the nose, there was a huge mass occupying
the whole right side of the nose.

a. That is the probable diagnosis of this mass?
The nasal mass is a rhinoscleroma.
b. What is the cause of the hoarseness of voice?
Laryngeoscleroma secondary to rhinoscleroma.
c. Why this case is not a classical laryngeoscleroma?
As the Laryngeoscleroma affects the subglottic area and obstruct the
lumen so the 1st symptom should appear is the stridor not hoarseness
of voice. But in this case the hoarseness precedes the stridor.

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8. A middle aged female complaining of chronic otitis media which is
resistant to treatment with antibiotics.
a. How to manage this case?
Culture & sensitivity of the discharge but after stopping the antibiotics
for 3 days to ensure presence of the organism in the discharge.


9. A 45 years old female complaining of swelling in her face, on
examination it was filling the area between the ramus of the
mandible & the mastoid process and raising the lobule of the ear.

a. What is your diagnosis?
Parotid swelling.


10. A 35 years old male complaining of bilateral nasal obstruction with
complaint of snoring & multiple attacks of sleep apnea, history shows
that he has allergy. On examinations there were multiple nasal
masses.

a. What is your diagnosis?
Allergic nasal polypi.


11. A middle aged male came to ENT clinic complaining of pain and
dysphagia. On examination, there was a membrane covering the right
tonsil.

a. What is the differential diagnosis of a membrane in the throat?
DD of a membrane in the throat = DD of ulcers in the throat. As any
ulcer in the throat will be covered by a membrane.

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N.B: Acute follicular tonsillitis is presented bilaterally.

12. A female patient presented to ENT clinic complaining of neck swelling
that moves up & down with deglutition.

a. What is your diagnosis?
Thyroid swelling.


13. A female patient presented to ENT clinic complaining of neck swelling
move with protrusion of the tongue.

a. What is your diagnosis?
Thyroglossal cyst.



14. A 50 years old male came to ENT clinic complaining of hoarseness of
voice & multiple attacks of sleep apnea, he runs to the window to take
his breath. From history, we found that he suffer from hyperacidity.

a. What is your diagnosis?
It is a typical case of reflux oesophagitis
Acidity from the reflux in the post cricoid area cause :
Reflex spasm of the vocal cord by irritation Stridor.
With long contact with acids sever irritation VC polyps
Hoarseness of voice.






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Important points said in lectures:

1. What is the cause of pulsating aural discharge?
The cause of pulsation is the dilated congested blood vessels in the middle
ear
Occurs in :
a. Chronic supportive otitis media with acute exacerbation.
b. From the Dura when erodes the tegmen in extra dural abscess
c. Newly formed blood vessels in glomus.

2. Weber test is more sensitive than Rinne test; as the Weber can
differentiate the hearing loss between the 2 ears when the
difference is 5 db in between, while the difference between both
ears in Rinne is 20 db.

3. Tensor palati is the main opener of the ET.

4. Why does the posterior perforation of the drum affect hearing
more than the anterior perforation?

The round window is exposed through the posterior perforation during
transmission of sound.
Some sound waves transmitted through the exposed round window to the
inner ear, While the other waves transmitted by the usual pathway to the
oval window.
So both waves oppose each other and finally the movement of the inner ear
fluid becomes minimal.






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Cases introduced by :
Dr Mahmmoud Fawzi

1. A 71 years old male, chronic heavy smoker came to ENT clinic
complaining of hoarseness of voice since 4 months. He denied any problem in
deglutition. On examination, there was a mass occupying the whole left vocal cord,
reaching the anterior commeasure also extends to the right vocal cord.

a. What is your diagnosis?
Cancer larynx (Squamous Cell Carcinoma of vocal cords).
b. What is your management?
Investigations:
Direct laryngescopy to see "site, size, and extension of the
tumor".
CT scan to show the cartilage invasion.
Biopsy for insurance & staging.
Treatment: According to the stage:
o It was left glottic T2a N0.
So partial laryngectomy with temporary tracheostomy is indicated &
follow up of the Pt. for 5 years.
No radical neck dissection as the glottic area has no lymphatic drainage.

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N.B:
5 years survival is an indicator for the success of the operation.
CT scan is the standard technique of imaging in the head & neck.










2. A 42 years old male complaining of hypertrophy of the left ala of nose
& the area around it. It is of short duration a month ago & it is slowly
progressive. From the CT scan there was opacity in the left maxillary
sinus.

a. What is the most probable diagnosis?
Benign mass in the alveolar region causing 2
ry
mucosal oedema in the
maxillary sinus produces hypertrophy around the ala of nose this
appears from the CT scan.


3. A 24 years old female came to ENT clinic complaining of severe facial
pain & headache, also complaining of proptosis & orbital cellulites which
don't respond completely to antibiotics .from the CT scan we noticed a
dense mass occupying the frontal & ethmoid sinuses.

a. What is your diagnosis?
Osteoma in the frontal & ethmoid sinuses.
b. What do you think the cause of orbital cellulites?
It may be because the mass occluding the opening of the frontal sinus
secondary infection secondary mucocele.

c. What is the line of treatment?
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Excisional biopsy through (Nasal endoscopy, Open incision through medial
wall of the orbit "lamina parpratia" or Coronal incision through eye brow).

N.B: Biopsy: never starts ttt of cancer without taking biopsy and by the least
invasive measure.


N.B: Pan Coast tumor: the 1
st
sign produced by is left vocal cord paralysis.

4. A 40 years old male complaining of left unilateral hearing loss of a
month duration by examination of the ear there was otitis media with
effusion while examination of the nasopharynx shows mass occupying
fossa of Rosen-Muller.

a. What is the most probable cause of this case?
Nasopharyngeal tumor occluding the ET.
N.B: Otitis media with effusion is a disease of children when comes in adult may
be due to obstruction of the ET by nasopharyngeal tumor.
So any adult Pt. complaining of OM with effusion & CHL
Suspect nasopharyngeal tumor until proved otherwise.

b. How to manage this case?
Neck examination.
Cranial nerve examination.
Biopsy "Under L.A with endoscope".
Staging.
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Treatment according to stage "Radiotherapy".
No surgical ttt in nasopharyngeal carcinoma.


5. A 50 years old female came to ENT clinic complaining of dysphagia &
hoarseness of voice with loss of her weight. On examination there was
a mass in the postcricoid area.

a. What is your diagnosis?
Postcricoid carcinoma.

b. What is your management?
CT scan.
Investigations:
Direct laryngoscopy.
Treatment:
1
ry
tumor Total laryngectomy followed by radiation.
LNs Radical neck dissection if there was LN enlargement.
Selective neck dissection if not palpated as it commonly
affects the LNs.
If send metastasis Palliative ttt.


6. A 8 years old girl came to ENT clinic with her mother complaining of
high temperature 38.5 C, sore throat, dysphagia & later otalgia. All
these symptoms occur 2 days ago and the recurrence rate: 3 times /
year.

a. What is your diagnosis?
Acute follicular tonsillitis.
b. When you take a decision for tonsillectomy?
If the recurrence rate of tonsillitis is more than 5-6 times / year Do
operation, otherwise Don't do it.
c. What are the criteria should be present to diagnose an attack?
High fever > 38 C.
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Inability to swallow.
Enlargement of upper deep cervical lymph node.

N.B: If there is tonsillitis with rheumatic fever

For ttt:
Give long acting penicillin.
Do tonsillectomy if there is recurrence.


7. A 35 years old male complaining of left painless neck mass 4 months
ago is annoying him because of disfigurement.

a. What is your diagnosis?
Lymph node enlargement in case of occult primary.

b. How can you ensure this case?
History
Examination Write them in details.
Investigations

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All Team
"One vision one mission"



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