Tamil Nadu Dr MGR Medical University ENT MBBS Prefinal Feb 2009 question paper with solution
ENT for General Practice George Vattakuzhiyil MBBS;MS(ENT);FRCS.
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Transcript of ENT for General Practice George Vattakuzhiyil MBBS;MS(ENT);FRCS.
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ENT for General PracticeENT for General Practice
George VattakuzhiyilMBBS;MS(ENT);FRCS
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ObjectivesObjectives
Detailed examination of ENT/H&N
Learn to diagnose & treat common ENT pathology
Recognise serious complication, request additional tests, specialty referral
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Quick recap of ear anatomyQuick recap of ear anatomy
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Hearing testsHearing testsRinne and Weber testsRinne and Weber tests
Rinne Ac better than BCRinne Ac better than BC
Hearing loss
256Hz 512HZ 1024Hz
< 15db
15-30db x x
30-45db x x 45-60db x x x
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Weber testWeber test
Hold the base of the tuning fork in the midline (forehead, incisor teeth)
Laterelising to the left: conductive loss on left or SNHL on right
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Otitis ExternaOtitis Externa
Inflammatory disorder of skin lined EAC
Acute/Chronic Generelised skin disorder Pathogens: staph,
pseudomonas, Fungus Topical antibiotic/steroid Sofradex,otomize
spray,otosporin,GHC, locorten- vioform
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Otitis externaOtitis externa
Extension to pre/post auricular areaMicrosuction/IV antibioticsDiabetic patient/ Pseudomonas inf? Malignant otitis externa
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Acute otitis mediaAcute otitis media
Common in children otalgia/discharge Unwell/pyrexia TM: red,
bulging,oedematous Streptococcus/
Haemophilus Amoxycillin 5-7 days
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complicationscomplications
Acute mastoiditis Chronic otitis media Intracranial
complications
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CSOMCSOM
Recurrent ear discharge Hearing loss Perforation of the TM –
central Presence of cholesteatoma Marginal, Attic
perforation Offensive discharge,
bleeding, granulations
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ComplicationsComplications
Vestibular symptoms
Facial palsy
Intracranial complications
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ManagementManagement
Medical: Dry mopping,suction clearance,/ Ear drops, rarely systemic antibiotics
SurgicalMyringoplasty/ TympanoplastyCombined Mastoidectomy/Tympanoplasty
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Otitis media+effusion-Glue earOtitis media+effusion-Glue ear
Common in childrenReduced hearing noticed by parents/teacherRecurrent ear infectionUnsteadiness- child falling overEffusions persist for weeks after AOM80% clear at 8 weeks
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Signs of OMESigns of OME
Dull retracted TMMay show air-fluid levelConductive hearing loss(whisper test,
Rinne/weber tests)OME persistant over 3 months ENT referral
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TreatmentTreatment
Failed audio Flat tympanograms h/o >3 episodes in
6/12 or >4 in 12/12 Grommet insertion Evaluate adenoids,
especially in recurrent grommet insertions
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Syringing the earSyringing the ear
Which ear needs syringing?
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Occlusive cerumenOcclusive cerumen
Causing pain Hearing loss Tinnitus
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Avoid syringingAvoid syringing
Non occlussive cerumen
Previous ear surgery Only hearing ear Perforated TM Kerotosis obturans
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Acute/Chronic tonsillitisAcute/Chronic tonsillitis
Sorethroat, fever, malaiseTender cervical lymph nodesEnlarged congested tonsils with pusAnalgesiaPenicillinProlonged course, worsening symptoms
consider glandular fever
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Quincy (peritonsillar abscess)Quincy (peritonsillar abscess)
pain + trismus Swelling of the soft
palate Displacement of uvula Refer for I/V
antibiotics drainage
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Allergic rhinitisAllergic rhinitis
Seasonal : allergen usually outdoor perennial: indoor dust, mite, cat dander
O/E pale mucosa, boggy turbinateAvoid allergen, antihistamines, topical
vasoconstrictors, steroidsSurgery- SMD, laser, Turbinectomy
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sinusitissinusitis
Facial pain/ pressure/ fullnessNasal obstruction/ dischargeAltered smellPyrexia in acute sinusitisHeadache, halitosis, dental painMinor factors: cough,ear pressure, fatigue
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sinusitissinusitis
Acute sinusitis < 4/52Chronic >4/52 or 4 or more episodes
O/E nasal congestion, polyps, pus in MMStructural changes: DNS, concha bullosa
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sinusitissinusitis
Sinus X ray usually unhelpfulCT sinuses Acute: amoxicillin clavulonate,
oxymetazolineChronic: Pus c/s,
augmentin+metronidazole, Treat the cause: allergy, surgery(FESS)
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CT sinusesCT sinuses
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EpistaxisEpistaxis
Most common site – littles areaCause: Idiopathic, trauma (nose picking),
dry mucosa, hypertension, coagulopathy, NSAID, Warfarin, tumours
Try naseptin cream for a short courseSilver nitrate cauteryElectrocautery/ packing/ surgery
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Common PathologyCommon PathologyViral laryngitisViral laryngitis
Viral URTI preceding aphonia Hx sorethroat B/L V.c. oedema/erythema voice rest, antibiotics
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HoarsenessHoarseness
Symptom of both local, systemic pathology Often the early symptom of ca larynx Persistent > 2/52 or worsening Associated with loss of weight, smoking,
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Vocal cord nodulesVocal cord nodules
Singer / teacher / children /Often B/L – Junction ant/ middle 1/3Voice rest / speech therapyRarely – MLS excision
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Laryngitis - GORDLaryngitis - GORD
Hx of GORDInflammation of Post larynxTreatment for refluxRaising head end of cot
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Vocal polyp/Reinkes oedema Vocal polyp/Reinkes oedema
Male SmokerIrritant exposureHoarseness DyspnoeaIrritant coughTreatment: Voice rest, speech therapy,stop
smoking, Microlaryngoscopy and vc stripping
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Sq papillomaSq papilloma
Anterior commissure/ true VCComplete excisionLaser treatment
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Laryngeal MalignancyLaryngeal Malignancy
Risk factorsSmokingAlcoholRadiation exposureHPV Nickel exposure
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SymptomsSymptoms
Hoareseness associated withDysphagiaOdynophagiaOtalgiaHaemoptysis
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SignsSigns
Dysplasia/Ca in situ Leukoplakia
Ulcero/Exophytic growthNeck mass
URGENT REFERRAL
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Cord paralysisCord paralysis
Breathy voice (air escape)B/L airway compromiseP/H of thyroid, cardiovascular SxCord in paramedian positionRefer for investigations and treatment
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Functional aphoniaFunctional aphonia
Psychogenic Only able to speak in forced whisper
Normal coughSpastic dysphonia strained/strangled voiceOnset related to major life stressHyperadduction of true/false cordSpeech therapy, ? Botulinum toxin inj
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DysphagiaDysphagia
Progressive dysphagia for solids structural lesion
Dysphagia for liquids NeurologicalPainful swallow spasm of cricopharynx,
ulcerSigns of refluxSigns of aspiration
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Examination-key points Examination-key points
Oral cavity Tongue, gag reflex,soft palatePharynx pooling, lesionslarynx Elevation of larynx, scopyNeck masses
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InvestigationsInvestigations
Ba mealVideo fluroscopyOesophagoscopyImaging CT/MRI
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Salivary glandsSalivary glands
Painful diffuse swelling sailadinitisPlus fluctuation with meals calculiNon painful swelling Tumour
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ExaminationExamination
Unilateral/bilateral ? Diffuse/well
circumscribed? Is it tender? Any discharge from
the ducts? Enlarged nodes? Palpable calculi?
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InvestigationsInvestigations
Plain X-ray lateral view
FNAC CT scan Sialogram
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TinnitusTinnitus
SNHLDrugs-NSAID, Aminoglycosides,
AntidepressantsTumors- Acoustic neuroma, Temporal lobe
tumorAnxiety/ Depression
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TinnitusTinnitus
If unilateral refer: MRISerology: FTA HaematocritLipidsAudiogram/ ABRConsider hearing therapy referral
councilling/ tinnitus masker
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