ENT PAST YEARS QUESTION ACCORDING TO TOPICSShort form  = Sx- Symptom ;CP (clinical picture),Mx(management),Dx(diagnosis),Rx(treatment) ; Ix = investigation

Topic   EAR

1. Basic Anatomy & Physiology of Ear

-causes of referred pain to ear**along any of the following nerves:1. trigeminal (V)

1) nose & sinuses: acute sinusitis (ant. group)2) teeth and gums:

i) impacted wisdom toothii) dental caries and abscesses

3) temporomandibular joint disfunction4) nasopharynx: post-adenoidectomy, nasopharyngeal carcinoma5) trigeminal neuralgia6) Floor of the mouth: ulcer or tumors7) trigeminal neuroma

2. facial (VII): Bell’s palsy3. glossopharyngeal (IX):

1) Tonsils:i) acute follicular tonsilitisii) Quinsyiii) post-tonsillectomy

2) Palate and oropharynx: herpetic eruption or ulcer3) Post 1/3 of tongue base: malignant tumors4) Glossopharyngeal neuralgia

4. vagus (X)1) T.B. laryngitis2) crico-arytenoid arthritis3) laryngeal trauma4) laryngeal and hypopharyngeal carcinoma

5. C2 and C31) trauma to the cervical spine2) cervical spondylosis3) occipital neuralgia

etc...*3 neuralgias.

-referred otalgia by glossopharyngeal n (see previous question)

2. Audiology & vestibular evaluation

-give an account on tuning fork hearing test

3. Diaseas of external ear

-give an account on ear wash(see 3 questions below :) )

-complications of ear wash******

1. Vertigo, nausea, and vomiting - dt. caloric stimulation of inner ear (lat. semicircular canal)

2. Cough and syncope - dt. vasovagal attack3. More impaction of the wax plug or FB4. Traumatic rupture of tympanic membrane - there is sharp pain

and slight bleeding in the ear and the patient may feel water passing to his throat.

5. Trauma to the skin of the external canal - this also causes pain and bleeding from ear but the ear drum is intact.

6. External otitis - dt. contaminated instruments

-indications of ear wash**

wax plug foreign body except:

o vegetable foreign bodyo impacted FBo animated (insect)

scaly debris otomycosis ear discharge

-contraindications ear wash

dry perforation of tympanic membranne recent head trauma with suspected fracture base of skull history of previous tympanic membrane perforation/ head trauma acute inflammation impacted FB

-etiology & clinical picture of malignant otitis media

4. Acute otitis media

-etiology,Cp,Mx ASOM**

Dis organism CP Rx

ASOM

Moraxella Catarrhalis, H influenza, Strept Pneumonia

signs1. Occlusion: retracted congested memb (cart wheel)->c/o : fullness, earache, fever.2. Catarrhal OM: retracted memb, distorted/loss of cone of light, handle of malleus prominent, foreshortened, more horizontal, conductive HL-> ℅: increase ear ache, fever3. Suppuration OM: loss of landmarks, reduced mobility, absent cone of light, yellowish spot, mastoidism - ℅: severe throbbing pain, high fever4. Resolution (after rupture): relief of symptoms, central rounded perforation, mucopurulent odorless discharge ->mucopurulent odorless discharge, relieve fever, pain.

1. analgesics2. antibioticsBefore perforationwarm glyco-phenol preparationmyringotomy*After perforationcleaninglocal antibioticsculture and sensitivity

-indications of myringotomy1. in AOM before perforation:

1) adequate medical treatment but no improvement in 48 hrs2) severe otalgia and high fever3) complication from the start eg. facial palsy4) yellowish colour and bulging5) patient is immunocompromised or is a premature baby

2. in AOM after perforation: very tiny hole with inadequate drainage(kalau ada lagi sila tambah) * asal dah perforate pun nk myringotomy?

-types & Rx of tympanic membrane perforation

5. Chronic suppurative OM

-types & complication of cholesteatomatypes:

congenital acquired

o 1ryo 2ry

complications (same macam CSOM kan?)

cranialo mastoiditis, mastoid abscesso petrositiso labyrinthitiso VII paralysiso osteomyelitis temporal bone

intracranialo extradural, subdural, brain, temporal lobe, cerebellar

ABSCESSo meningitiso lat sinus thrombosiso otitic hydrocephalus

extracranialo ext otitiso lymphadenopathy

-CP & Rx of uncomplicated CSOM**

CSOM (safe)

gram positive bact

central perforation, odorless, intermittent, profuse mucopurulent dischargemiddle ear mucosa thick and edematous/normalpolyp rarelyNO GRANULATION TISSUE/ CHOLESTEATOMARinnes +veWeber lat towards diseasedPTA: CHL

cleandryavoid blowingavoid waterfungal= vinegar+waterlocal antibioticsmyringoplasty / tympanolasty (ossicles intact/not)mastoidectomy +/-

-full account on cholesteatoma (definition,types,CP,investgtion,Rx)

-CP unsafe CSOM

otorrhea: scanty, purulent, continous foul odour cholesteatoma* polyp common granulation tissue (chronic oteitis)*

rinnes -ve weber lat to diseased PTA : CHL/ MHL (involvement of cochlear) XRay CT: intracranial complications

-Rx of CSOMCSOM (safe)

clean dry avoid blowing avoid water fungal= vinegar+water local antibiotics myringoplasty / tympanolasty (ossicles intact/not) mastoidectomy +/-

CSOM (unsafe)

atticotomy closed mastoidectomy open mastoidectomy radical mastoidectomy

-table of differentiation between safe & unsafe CSOM(boleh refer buku m/s 54)

Safe type (tubo-tympanic)

unsafe type (attico-antrum)

1ry site of infection

1. eustachian tube2. tympanic cavity

1. attic2. post wall of middle ear3. antrum

discharge 1. intermittent2.odorless3. profuse4. mucopurulent

1. continuous2. offensive odour3. scanty4. mucopurulent/purulent

perforation central 1. post-sup marginal2. attic

cholesteatoma no present

granuloma and uncommon commmon

polypi

deafness -CHL-mild to moderate

-CHL or mixed- moderate to severe

x-ray cellular mastoid acellular mastoid (sclerosed)

tre 1. medical2.

1. modified radical mastoidectomy2. tympano mastoidectomy3. intact canal wall mastoidectomy4. radical mastoidectomy

6. Complication OM

-enumerate intracranial complication

1. extradural abscess2. subdural abscess3. brain abscess : temporal lobe and cerebellar4. lateral sinus thrombosis5. meningitis6. otitic hydrocephalus

-Cp of acute mastoiditisSymptoms:

Fever Increasing earache Profuse mucopurulent discharge

Signs:

1. In the stage of acute mastoiditis:

o Profuse mucopurulent discharge which may exhibit a positive Reservoir sign i.e. rapid reaccumulation of discharge after cleaning of the ear

o Tenderness and redness over the mastoid

o Sagging (edema) of the postero-superior wall of the bony external ear canal due to periosteitis

2. When the post-auricular develops:

o Post-auricular swellingo The auricle is pushed outwards and downwards

3. When the post-auricular abscess ruptures:

o Mastoid fistula develops draining mucopus

-type of mastoid abscess**

-enumerate cranial complication

1. Acute mastoiditis and mastoid abscess (most common)2. Petrositis3. Labyrinthitis4. Facial paralysis5. Osteomyelitis of the temporal bone

-table of difference between acute mastoiditis & furunculosis**

acute mastoiditis furunculosis

age children any age

history 1) upper respiratory infection2) acute otitis media

1) scratching of the ear2) Diabetes

discharge 1) mucopurulent2) profuse3) maybe reservoir sign

1) purulent2) scanty3) thick

tenderness over mastoid process over the tragus and on pulling the ear

otoscopy sagging of the post-sup wall leading to narrowing of the inner bony part of

narrowing of the outer cartilaginous part of the external

the external canal canal

deafness conductive hearing loss not relieved by insertion of speculum

conductive hearing loss relieved by insertion of speculum

postauricular groove

maintained (due to attachment to the periosteum)

flat

edema of the eyelids

upper if there is zygomatic abscess

lower only if present

culture and sensitivity testing

strept hemolyticus staph aureus

x-ray of mastoid

mastoiditis (haziness and opacity of air cells) or actual abscess cavity (mastoid abscess)

normal

-type of mastoidectomy

-enumerate complication of CSOM,give details about lateral sinus thrombophlebitis

-Rx of acute mastoiditis

7. Ear related facial n paralysis

-diagnostic feature of different level of facial palsy/how to define level of facial pasly**

-etiology/causes of facial palsy**

8. Hearing loss & tinnitus

-causes of conductive hearing loss****

1. Causes in external ear

a. Congenital e.g. congenital meatal atresiab. Acquired

i. Impacted wax (most common in adults)ii. FB

iii. Inflammatory: furunculosis, otomycosisiv. Neoplastic: exostosis

2. Causes in tympanic membrane

a. Stiffness: tympanosclerosis or fibrosis of TMb. Perforation

3. Causes in middle ear

a. Vacuum: ET dysfunction/occlusionb. Fluid: CSF, serum, mucus, pus, bloodc. Adhesionsd. Soft tissue

i. Tumors: glomus tumorii. Cholesteatoma

e. Ossicular pathologyf. Fixation: otosclerosisg. Disconnection incudo-stapedial or incudo-malleal joints

-causes of SNHL/perceptive deafness/inner ear hearing loss*****

Disease of inner ear & acoustic neuroma-Mx of meniere’s disease ****

-CP & invest to dx acoustic neuroma

-full account on meniere’s disease(pathology,CP,invest,Rx) **

Pathology

Accumulation endolymph causes distension and rupture of membranous labyrinth

This lead to leakage endolymph into perilymphatic spaces and results into suppresion neural elements of labyrinth

Membranous rupture responsible for recurrent episodic vertigo and hearing loss

Rupture heals symptoms subside

9. Middle ear effusion,glomus tumor,otosclerosis

-CP of secretory OM **

-Etiology & Mx of secretory OM

-Dx & Rx of secretory OM

-CP & Rx otosclerosis

10. Vertigo

-etiology & how to Dx vertigo **

-investigation in dizzy patient

Topic   NOSE

1. Anatomy,physiology nose,choanal atreasia

-function of nose & paranasal sinusesNose : 1. airway2. air conditioning3. reflex 4. olfaction

Paranasal sinuses : 1.resonance voice 2.air conditioning 3.light wt skull 4.buffer head trauma 5.secretion for mucociliary blanket nose 6.thermal insulators

2. Allergy & nasal polypi

-types,CP,Mx of nasal polypi******Types1-      Solitary (ACP)2-      Multiple (diffuse nasal polyposis,middle meatal polyposis)CP1-      Long history AR or VMR2-      Symp (nasal obs x relieve compltely by VC,hyposmia)3-      Signs (polyp-bilat,multiple,pale,soft gelatinous masses,smooth)(pale,edema mucosa)Mx1-      cp2-      Ix (CT-plan surgical Rx)3-      Rx AR or VMR4-      Drug: top steroid.oral antiH5-      Surgery : bilat complete obs (simple polypectomy,endoscopic polypectomy w ethmoidectomy)

-Rx of antrochoanal polyp

o middle meatal antrostomyo sublabial antrostomy ‘ caldwell-luc approach’

-Dx & Rx allergic rhinitisDx1-      Hx : FH , environment , occupation , sp habit , seasonal variants2-      CP : Symp (sneezer,runner,blocker,hyposmia,itchy throat,irritant cough,itching,watery eyes) signs (pale.moist.edema mucosa,hyperT inf turbn8,polyp)(allergy salute,shiner,gap)3-      Nasal smears : eosinophilia4-      Bld exam : IgE,eosinophilia5-      Skin test6-      Nasal challenge test :spfc Ag to nasal mucosa7-      RAST : circulating Ab for spcfc AgRx1-      Avoidance : most important2-      drug (top steroid,oral antiH,top antiH,top Na+ cromoG,oral steroid)3-      hyposensitization : blocking Ab IgG4-      surgery : better avoid,limited role ONLY relieve gross nasal obs or open significant obs drainage sinus

-give an account on diffuse nasal polyposis

3. Rhinitis,nasal obstruction

-causes of nasal obstructionBilateral:CC n TTNaSAL CAUSECongenital choanal atresiaRhinusitis ( common cold )Nasal polyp / nasal allergyTrauma = septal hematoma, foreign bodyTumour = SCC, inverted papillomaNASOPHARYNGEAL CAUSEsadenoidenasopharyngeal carcinomanasopharyngeal fibroma

Unilateral ..CDDATTCOngenital choanal atresiaDeviated septumDental maxillary sinusitisAntrochoanal polypTumoursTrauma = fb / fracture.

-unilateral NO-etiology & investigations**Etiology:CDDATT1.congenital choanal atresia2.deviated septum3.dental maxillary sinus4.trauma5.tumors

Investigation1.Specific scoring system bout patency of the nasal airways2.Acoustic Rhinometry

4. External nose & nasal septum

-Dx & Rx of nasal septum deviation **

5. Epistaxis

-local Rx of epistaxis

1) Nose packed for 10min with cotton soaked in epinephrine and xylocaine.2)when the bleeding stop we’ll find the bleeding point and do cautery (chemical by silver nitrate, electrical, diathermy)2) anterior nasal packs ( gauze soaked with vasline and ab ointment left for 24h)3) post nasal pack ( epistaxis of nasopharyx origin - post adenoidectomy, angiofibroma, carcinoma)4)nasal balloooon-ant nasal

-causes of epistaxis(local & systemic)***

LOCAL GENERAL

a) Congenital – osler’s disease

a) Blood disease –hemophilia,purapura n leukaemia

b) Deviated septum b) Hypertension – COMMONEST in old age

c) Idiopathic – commonest c) Raised venous pressure –mitral stenosis / mediastinal syndrome

d) Inflammator y –rhinitis( atrophic , acute )

d) Drug – salicylate , anticoagulant

e)Traumatic – nose picking.FB,fracture

e) Hormonal -pregnancy

f) Tumour – malignant ,bleeding poolypus

f) Fever

g) High altitude

-systemic causes of epistaxis

-local causes of epistaxis**

-Mx of severe epistaxis***- Endoscopic cautery of sphenopalatine artery- CLipping [ maxillary artery / ant ethmoidal artery ]

-Mx of epistaxis***First aid measure:- Ask patient to incline forward and breath tru the mouth- squeezing the ala of the nose as it will compress the sphenopalatine artery thus will help to decrease bleeding / stop bleeding

- put ice compresses to the bridge of the nose will lead to reflex VC nasal mucosa- place nasal pack or nasal drop in the nose to induce VC

General Measure in the hospital:- check BP and other vital sign- apply anti shock measure- coagulant n other medication may be given

Local Measure:a) Anterior epistaxis- Nasal pack with vasocontrictor- cautery ( chemical cautery by silver nitrate ; galvanocautery ; coagulation diathermy )- Ant nasal pack with vaselin n Ab for 24-48H to guard against TSS and sinusiti.

b) Post epistaxis-post nasal pack with vaseline and aB-post nasal balloons

c) Superior epistaxis:-ant. nasal packing

if those measure can’t control the bleeding, proceed to:- Endoscopic cautery of sphenopalatine artery- clipping [ maxillary artery & ant. ethmoidal art )

6. Sinusitis

-indication maxillary sinus punctureDiagnostic: - To confirm present of infection in the sinus- Instillation of the radiopaque material to do radiologic examination- For culture and sensitivity procedure- Cytological examination

Theraputic:- Rx the subacute and chronic rhinosinusitis if not respond to medical rx.- fungcal sinusitis- barotaraumatic sinusisit

-enumerate complication acute sinusitis**

-Dx & Rx chronic maxillary sinusitisDx: - nasal endoscopy- CT scan

- c n s

Rx:- Removing the predisposing factors- Medical treatment by antibiotic, decongestant, anti histamine, steroid- surgical is done in case of resistant medical rx ( proetz ; antral washout )

-CP acute sinusitisSymptoms :1-      Paina) Maxillary sinus = below the eye, cheek , refer to the temporal and frontal and upper teeth region.b) Frontal sinus = above the eye , foreheadc) Ehtmoidal sinusitis = on the bridge of the nose, in the between of th eye, and refer to the parietal region.d) Sphenoid sinusitis = deep seated pain ; Vault.occipital.mastoid region and behind the eye as this sinus is posterior sinus. rigth?2-      Nasal obs3-      Nasal discharge n postnasal (mucopurulent/purulent/offensive odour)4-      Fever malaise

Signs :1-      Tender2-      Swelling3-      Middle meatal discharge4-      Postnasal discharge5-      Redness edema nasal mucosa

7. Sinonasal tumor

-stage of rhinoscleroma***

Character C/P

Granulomatous stage

-submucosa infiltrate by lymphocyte and plasma cells.Miculikz cell: large vacoulated foam cell containing scleroma bacilluRussell bodies:Eosin staining degenerated plasma  cells.precursor: mott’s cell.

Firm pale pink granulomatous massCoalesce together forming Hebra nose.

Fibrotic Cellular infiltration replace by fibroblast and dense fibrous tissue giving rise to hardness

The nasal cavities are narrowed n obliteratedExternal deformities are commonly present

Atrophic Atrophy of epihtelium and seromucinous gland

Mucosa pale&atropicNasal cavity

roamy and contain crust

-CP of rhinoscleroma1.granulomatous type- nasal cavity show firm pale pink granulomatous masses, masses coalesce together extend to external nose & upper lip forming Hebra nose2.Atropic type- mucosa pale & atropic, nasal cavity roomy & contain crust3.Fibrotic type- nasal cavities narrowed & maybe obliterated. External deformities commonly present

8. Rhinorrhea,smell disorder,headache

-discuss disorder of smell

-causes of hyposmia & anosmia**

-etiology of anosmia1.conductive anosmia2.Perceptive anosmia

Topic   PHARYNX

1. Nasopharygeal swelling

-enumerate NP swellings***1rycystic1.      Midline : cong – thornwald cyst – rathke pouch cyst : acq – intra adenoidal retention cyst2.      Lateral : cong – branchial cyst,dermoid cyst : acq – seromucinous ret cystSolid

        1.      Benign : adenoid,NPangiofibroma,inverted papilloma,other(teratoma.neurofibroma.paraP abs)        2.      Malignant : NPC

2ry        Antrochoanal polyp   nasal fibroma   meningo encephalocele

-CP of NP angiofibroma***1.      Unilat nasal obs2.      Unilat severe epistaxis3.      Unilat nasal mass4.      Frogface deformity(broad nose.proptosis.swelling cheek)

è Typically in young adult male

-CP of NP carcinoma*** (advance)*1.      UE enlarge Cx LN2.      UE unilat OME (ear ache deaf)3.      UE multiple CN palsies (opthalmoplegia,facial pain,pharynx or larynx paralysis)4.      Nasal obs n epistaxis5.      Trotter triad (immobile uvula,facial pain,unilat CHL)6.      Metastasis (hemoptysis,bone ache)

-types & CP of NP swelling

-Dx & Rx of NP carcinoma**

Dx:

o indirect nasopharyngostomyo direct,flexible fibroscopyo imaging:CT,MRIo measure anti EBV..increase 90%

Rx

o radiotherapy +/- chemoo NB; surgery is limited due to early spread and involvement

of base of skullo indication of surgery: radical neck disection to ensure more

successful control of 1ry radiotherapy

2. Adenoid & adenoidectomy

-Rx of post adenoidectomy bleeding

-complication of adenoidectomy***1.      Bleeding (excess curett or aberrant vsl)2.      Cautery burn3.      Dental injury (intubation or mouthgag)4.      ET injury (torus tubarius)5.      NasoP stenosis (excess removal tissue)6.      Atlantoaxial sublux (grisel syndrome-> torticollis 1-2w after)7.      Lingual n injury (moth gag or tounge blade press)8.      reGrowth (young pt)9.      Hypernasality (temp pain splinting)

-CP of children with adenoids & Rx****

CP1.      Nasal obs (moth breath,nasal tone,diff suckling eat,snore)2.      MP nasal n postnasal discharge3.      Adenoid facies (open mouth,dry upper lip n gum,hitched upper lip,flat expressionless face,protrudrd incisors,inactive ala,receeding chin,high arched palate)4.      Sleep disturbance(snoring,OSA,nocturnal eneuresis,nightmare)5.      Feeding problem(indigestion,vomit,loss app)6.      Resp difficult(irritant cough,rec pharyngitis.laryngitis.chest inf)7.      Recurrent ear ache n deafness(recur OM n OME)8.      Skeletal change(pigeon chest)9.      Impaired mental performance(disturebed sleep,defect hearing,rec resp inf)10.   Egg white secretion behing soft palate + chr tonsilRx  : adenoidectomy

3. Diasease of tonsils(tonsilltis & t.ectomy)

-enumerate complications of tonsillectomy operation**Anasthetic Complication and local complication.

-indications for tonsillectomy*******EIGHT INDICATION:

a. Repeated att ac tonsilitis 7,55,333b. Repeated att with chrn valvular dis and febrile seizurec. 1 att quinzyd. Chrinc tnsilitis xrespond to med Rx causing obstructive

symptom(enumerate sdri)e. TB tonsilf. Beningn tumour tonsil eg fibromag. sUSPICIOUS malignant tonsilh. removal tonsil as part of other operation

-routine investigation before tonsillectomy operation1.Proper History taking.2.General examination

Local ENT ex3.Urine aanalysis,bld analysis.(enumerate sendiri)

-DD membranous tonsils**

1.      GabHs-yg causing acute tonsillitis kita belajar ni2.     Diphteria (must put first after acute tonsilitis,VERY IMPORTANT   DDX,If remove membrane will bleed not like Gabhs)2.      IM3.      Scarlet fever4.      Glandular Fever8.      Angina Vincent 9.      Agranulocytosis9.      Acute leukemia8.      Thrush7.      Behcet

-discuss indications,contraindications & complications of tonsillectomy CONTRAINDICATION: 5 absolute,5 relative

Absolute:Systemic disease eg.1.Cardiac disease2.Pulmonary dis eg TB3.Hypertension Severe4.Chronic rrenal insuff5.Blood cogulapathy

Relative:1Acute tonsilits(tonsil tgh vascular!!) so Rx first because can cause severe bleedig and septicemia

2.Epidemic Polio3.Rheumatic Fever

4.DM5.ASTHMA

+- Cleft Palate (can cause icompetenet velopharyngeal isthmus,see complication*)

COMPLICATIONS. :anasthetic and operative(periop,i/m op,post op)ANASTHETHIC-cARdiac arrest-RESP arres-TOxicity-Intubation granuloma during ett (jgn lupa)

Operative 1)pERI:1.Primary HGE

2.mISHAPE,TRAUMA

2)IMMEDIATE POST OP:1.REACTIONARY HGE2.edema uvula(lupa nk bukak ligateion kat uvula)4.Chest infection5.DM,septicemia

6.Velopharyngeal incomp. (if has cleft plt)

3)LATE POST OP:1.Liabilitiy to catch infction,thats whyl;2.Secondary HGE (dt infection)

3.Dryness throat4.Change voice5.Palatal scaring6.TOnsil remnant7.GP neuralgia

4. Snoring & OSA

-Rx snoring& OSA ( YOU CAN DIVIDE INTO CONSERVATIVE,SIMPLE NASAL,SIMPLE PALATAL,SEVERE )

1.conservative treatment-ie.treat the risk factor[obsity-lose weight,alcohol-stop,smokin-stop]2.For SIMPLE nasal cause of snoring-medical treament-nasal appliances-nasal surgery3.FOR SIMPPLe palatal cause of snoring-UPPP-LAUP-Palatal stiffening operation4.Severe OSA-CPAP-TRACHEOSTOMY

-Rx snoring sahaja macam mana ye?

5. Pharyngeal & neck suppuration

-discuss acute retropharyngeal abscess***DEF: *Suppuration in btw post ph wall and prevetbral fascia.ETIO:-Child,supp. of Henle node.-Adult,need imunocompromised+ trauma eg foreign body

CP:-Fever(diff with chronic;no fever)-Dficult suckling and feeding-Neck rigidityso contraction is at the opposite site(diff with quinsy having spasm of sternomastoid!)-MIdline cystic sweeling UNILATERAL (because have bucopharyngeal and prevetbral fasscia adherence)

Ix-Xray lateral;1.Thickening prevet tissue more than 50% of vetebra2.Air in prevetebral soft tisue3. Normal CUvature of spinal REVERSAL.

Complication.Child may aspirate if rupture,cause death.Child may have laryngeal spasm or mediastinitis if spread.

Rx.No anasthesia,usually relieve after vertical incision,POsition- HEAD MUST LOWERED DOWN,MUST USE SUCTION TO AVOID ASPIRATION(see DANGEROUS complication!!)systemic antibiotic+++IF AIRWAY COMPROMISE=TRACHEOSTOMY

-CP & Rx of quinsy****

CP:-Symptom:General-HIGH fever,malaise,headache etcLocal-Sore throat with refred pain,odynophagia,halitosis,salivation.

Sign:-Diff exam dt trismus-Cx LN swelling

-Pain so spasm of sterno mastoid

when u examine;-uvula edematous then push to midline.-soft palate above and lateral swell-tonsil go medially and downward-salivation acccum and coated tongue-CAN SEE POINT OF SUPPURATION!

Treatment:(QUINSY U MUST DIVIDE Rx to PRE AND SUPP!)Local(pre suppurative)-bed restsoft diet,hydrationantibioticanalgesic

Post suppurative:-Incision and drainge;local anasthesia,intraorally(check 4 site for incision)-systemic antibitioc-Tonsillectomy after 1 month(after cure)

-complication of quinsy***

o Sudden rupture & inhalation of pus can lead to chest complications

o Extension laterally leading to parapharyngeal abscess or downwards leading to laryngeal edema & stridor

o Internal jugular vein thrombophlebitiso Pyemia & septicaemia (very rare)

-discuss quinsy(etiology,CP,Invest,Rx)same as above;ETIOLGY=USUALLY follow attack of acute tonsillitis dt GABHS

6. Neck swelling

7. Hypopharyngeal tumor

-post cricoid tumor (CP,Dx,Rx)**

SOALAN NI PARTICULARLY FOR POST CRICOID TUMOUR RIGHT?so CP:1.DysphagiA-gradual and progressive,to solid food 2.Pain and refrred otalgia3.Hoarseness of voice-infiltrate nerve,cricoarytenoid joint,muscle,or mass on vocal cord.4.Neck mass-thyroid infiltration,LN metatastatisze (post cricoid is to para tracheal LN),extrahypopharyngeal extension5.Hemoptysis6.Weight loss,malignant cachexia,anemia7.Halitosis-dt necrosis and extension to nasopharynx

Dx:--History--Clinical picture--Clinical examination;1.Neck inspection and palpation-Laryngeal box-tender,edema,broader-Neck mass(dt causes mention above)-Moure’s click absent(fix to vet column alreadY)

2.Indirect laryngoscope;(using mirror,rigid 90 laryngoscope,flexible nasopahrygolaryngoscope)-see pooling of saliva,cord mvmnt,mass on cord

3.Direct laryngoscope with esopharyngoscopy-For biopsy-For detection of second primary tumour***** very important to do esophagoscopy to check wether esophagous have extension of tumour or not.--Lab Ix;-liver fx,blood count,iron-Imaging;CT,MRI,Barium Swallow ****-Metastatic work up

TREATMENT:A..Curative1.SurgeryPrimary-For post cricoid!! Total Laryngopharyngectomy + total/partial esophagectomySecondary -Modified selective neck LN disection

2.Radiation/Chemo-if patitnet refuse surgery

3.Combined-maybe preop or post op

B.Palliative

-if already extensive metastatis

c.Rehabilitiation-psychology-reconstruction ie.airway,food passage

Airway reconstruction-Permanent tracheostomyFood passage-partial esophagectomy ie.(nnt tgok la)

  -Total esophagectomy(gold standard= gastric pull up,maybe colon transposition)

8. Dysphagia

-enumerate causes of dysphagia in ENT

Oral cavity Pharynx Oesophagus

Mechanical cause

1. Cleft palate2. Tumour of tongue/floor of mouth

1. Web2. FB3. Post operative stenosis4. Plummer Vinson`s synd.5. Hypertrophied tonsils6. Tumours oro/hypopharynx

1. Inside lumen(FB)2. In Wall (stricture, diverticulum, tumours)3.Outside wall(goiter, mediastinal mass, vasc.compression)

Painful cause

1. Stomatitis2. Ulceration3. glossitis

1. Pharyngitis2. Tonsilitis3. ph.ulcer4. ph. suppurations

1. Esophangitis2. GERD

neurogenic 1. Palatal / tongue paralysis

1. ph.paralysis2. ph.diverticulum3. cricopharyngeus spasm

1. Achalasia of cardia2. Diffuse oeso.spasm.

Topic LARNYX

1. Anatomy,physiology & congenital an larynx

-enumerate congenital anomalies of larynx & explain 1 of themlaryngomalaciacongenital web

congenital cord paralysiscongenital cyst (saccular cyst)(laryngocele)sub Glottic stenosissub Glottic hemangiomaLaryngoTracheo-Oesophageal cleft

2. Paralysis of larynx

-etiology & Mx of recurrent laryngeal n paralysis

ETIOLOGY??

Mx-diagnosis by: -CBC n blood sugar-ct scan from skull base to mediastinum-laryngoscopy visualising-nasopharynx,hypopharynx, larynx, esophagus,bronchial tree..take biopsy for any suspicious lesion

Rx;

unilateral recurrent laryngeal n paralysis--wait for 6m for nerve recovery-if no recovery--> medialisation of the cord:

o injection of teflon, autologous* fat ( autogenous or autologos ? )

o silastic insertion

bilateral recurrent laryngeal n paralysis-(refer to question below)

-etiology & CP of Vocal cord paralysis

-CP & Rx bilateral rec laryngeal n paralysis(recurrent laryngeal n paralysis= abductor paralysis=paramedian vocal cord)

cp:  -stridor       -normal voice but easily fatigueRx:1st- treat STRIDOR by tracheostomy(definitive line of treatment; emergency mx)2- wait 6m-1yr for nerve recovery, if no recovery we do operation  to widen the glottis:

-partial cordectomy +/- arythenoidectomy-arythenoidectomy

3. Benign tumor of larynx

o recurrent respiratory papillomatosiso hemangiomao chondroma

4. Malignant tumor larynx

-CP & Mx early vocal cord cancer***

Early Late

Symptoms

“Freedom of creation”-          FB sensation-          Otalgia-          Obstructed airways-          Change of voice-          Hoarseness-          Cough-irritative

Lump in the neck + dysphagiaPainHoarseness >>>> Hot potato voiceCough >>> blood tinged sputumObstructive airways >>>> STRIDOR

Sign 1.Neck Free, except Marginal Ts2.Laryngeal Examination:• Disturbed Vascular Pattern• Thickening/Mass/Ulcer

1.NeckLump,fullness,laryngeal box ( broad n tender )2.Cord Fixation ( mechanical, infiltrative , paralytic )

Treatment

Conservative therapy-MLS- Open surgery:partial laryngectomyRadiotherapy

Total laryngectomyLPP ( Laryngeal preserve protocol )Postop radiotherapy

c/p

early

a. change of voiceb. hoarsenessc. otalgiad. FB sensatione. irritative coughf. sense of airway obstruction

(F,O,O, C,C) = “ Freedom Oof Ccreation”

-(fb sensation, Otalgia,Obstruction of airway, Cough(irritative type), Changes of voice & hoarseness)

late

a. hot potato voice (supraglottic tumor)b. lump in the neck (lymph node; ++ in supraglottic)c. stridor(biphasic)-  (glottic extend to subglottic)d. dysphagiae. blood tinge sputumf. pain

advanced

1. weight loss2. fetor oris

(DD with hypopharyngeal tumor, these advanced symptoms occur early)

management early:

conservative-endoscopic removal(MLS/CO2 laser)

        -open surgery-partial laryngectomy

radiotherapy

-clinical types,investigations,general Rx of Vocal cord cancer

investigation-chest X-ray     -barium swallow     -CT neck n upper mediastinum     -direct laryngoscopy + biopsy     

general tratment

a. local-early (as mention before)

       -late-total laryngectomy              -laryngeal presevation protocol

b. regional-radical neck dissection

c. distant-chemoraditherapy

d. rehabilitation-voice prosthesis

        -oesophageal speech training       -atificial larynx

e. palliative-tracheostomy

  nasogastric tube/gastrotomy-chemoradiotherapy

 -

-predisposing factors,pathology,Rx of early vocal cord cancer

PPT factor:

o smoker/ex smokero refluxero spicy eatero alcohol drinkero radiation exposureo genetico RRPo exposure to metal,plastic,paint,asbestos

for simplification:o prolong irritation- smoking,alcohol,spices,refluxeso prolong exposure-radiation,metal,plastic,asbestos, RRP

pathology-macroscopic-ulcerative,infiltrative,fungating              -microscopic-well,mod n poorly differentiated

-classifications of cancer larynx-supraglottic-glottic-subglottic

5. Laryngitis

-type of chronic specific laryngitis

o TBo syphliso scleromao leprosyo fungal

-CP of acute laryngitis· General – fever, headache, malaise, anorexia· Local1. Adult – hoarseness, cough (++dry), sore throat2. Child – stridor (airway compromise) à why?

- larynx small + high- lumen narrow- soft cartilage + easy collapse-lax submucosa+more edema-unstable neuromuscular mechanism-weak cough reflex

SignCongestion & thickening VCSubglottic edema in child + stridor (laryngitis stridulosa)

-discuss laryngitis(classification,etiology,CP,invest,Rx)--Q? ni nak kena jawab semua ke.maksudnya chronic acute sekali?

6. Hoarseness of voice

-causes HOV*****

o organic

a. inflammatory:acute n chronic laryngitisb. neoplasticc. neurologicald. spasmodic dysphoniae. systemic-RA,angioneurotic oedema,hypothyroidism

(mnemonics:I,N,N, S,S)

o non organic

a. ventricular dysphonia

b. habitual dysphoniac. mutational falsettod. conversion voice disorder

(Ventricular,conVersion, habiTual,muTational)

7. Laryngeal trauma

8. Tracheostomy

-enumerate COMPLICATIONS of tracheostomy********** (the commonest qs)

-indications of tracheostomyNon obstructive causes ( PPRREE / 2p 2r E ...PRE~ )-Prolonged mechanical ventilation-Protection tracheobronchial tree-Respiratory failure-Retention bronchial secretion-Elective tracheostomy

Obstructive causes# Internal: obstruction ( follow the anat )- oropharyngeal obstruction- laryngeal obstruction- upper tracheal obstruciton )

# External compression: Tentera Laut Malaysia- thyroid gland- ludwig’s angina- mediastinal causes

9. Stridor

-Mx of stridor in children**

maintain airways- non invasive ppv- transtracheal needle ventilation- endotracheal intubation- tracheostomy ( gold standard )- cricothyroidotomy ( extreme situation )

Medical:

- humidified oxygen admin- steroid systemically- recemic epinephrin- bronchodilator- IV fluid- mucolytic- strict obsevation

Dx:- age : newborn = laryngomalacia, child = laryngitis , adult =trauma , old =neoplasm- onset : sudden = trauma,fb aspiration, acute = inflam , chronin = cong anom, neoplasm-assc. sx : feva, neck pain, dysphgia-prev hx : choking, trauma, tracheostomy

Exam:- degree stridor- neck exam- laryngeal- radiological

-Dx & Rx of acute epiglotitis

-table of difference between acte epiglottitis & acute laryngotracheobronchitis

Acute Epiglotitis

Acute laryngiotracheobroncitis

Incidence 2-6y <3y

Microbact H.influenz PARAINfluenza 1-4

Onset Rapid Slow

Mouth sx=cough,stridor,Voice,drooling

#Cough Absent Barking ...wot woott = O

#Stridor Inspiratory Biphasic...

#Voice Muffled Hoarsee

#Drooling Marked None

Misc. sign

Temperature Elevate Elevate

Posture Sitting forward

Lying

Xray Thumbprint Steeple

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sapa nk tambah soalan lagi pon boleh tambah kt bawah ni. soalan2 dari group WaLL_Note ke?