ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Dear Plabber, • • This first ever System Wise 1700 document was created thanks to 3 months of daily hard work by the PLAB Skype group ‘Unity’ which was brought together by Dr Susmita Chowdhury. Please ignore the old versions posted by my new skype member Murtaza as he did so without permission. The team members were: & Susmita (Lead/most ignorant as she is working full time in public health for 13 years) & Asad (Invaluable in IT and all types of support/the heart of the group) & Manu (Volunteered to solve more questions/pathologist/amazing genuine person) & Saima (Most concise clear notes/ photographic memory) & Zohaib (Great research/a surgeon) & Savia (Great research/multi-tasker with two little ones) & Shanu (Very helpful after her March exam for those appearing in June) & Mona (Great contributor in discussions) & Manisha (Gyne/great discussion contributor) & Sitara (Good discussion contributor) & Samreena (Stayed a shorter time but great) & Sami (Contributed the most early on but too brilliant for the group/still great friends) & Komal (Knowledgeable sweet supportive girl) • The main purpose was to break down the 1700 Q Bank System wise. • We did our own reliable research for the options (OHCM/Patient info etc.) and concluded these keys below on skype. This can save you 100s of hours of research. But I suggest you also do your own. • 90% of the document consists of Unity research. We also added information from other circulating documents and they are referenced as Dr Khalid/Dr Rabia (and her Team). • However, several keys may be ‘incorrect’ and so please use your own judgment as we take no responsibility. I suggest cross checking with Dr Khalid’s latest keys (a few of which are still debatable). Finally decide on your own key. • Sorry if some members failed to make their answers thorough. The highlights are mostly as per what the team members wanted to highlight. Blank tables to be ignored. • Note that some 1700 Questions are missing from here (when members did not do their share). Questions may not be in order due to merging of documents and there is excess information than required. Read as much as needed. • This has been circulated by our team as a generous contribution to the Plabbers’ success and must not be ‘sold’. 1 Good luck and best wishes: Sush and Team ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Q: 51 A 5yo girl had earache and some yellowish foul smelling discharge, perforation at the attic and conductive hearing loss. She has no past hx of any ear infections. What is the most appropriate dx? a. Acute OM b. OM with effusion c. Acquired cholesteatoma d. Congenital cholesteatoma e. Otitis externa Clincher(s) A B C D E KEY C Foul smelling discharge , hearing loss, perforation at the attic No discharge except pus and blood exudate in canal Correct answer (perforated tympanic membrane) Foul smelling discharge indicates Cholesteotoma ! lead to Conductive hearing loss Additional Information 2 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal 3 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal 4 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Reference Dr Khalid/Rabia GP Notebook and DOK Notes Q. 1. What is the key? 5 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Q.2. What are the points in favour of your diagnosis? Ans. 1. The key is c. Acquired cholesteatoma. Ans. 2. Ans. 1. The key is c. Acquired cholesteatoma. Ans. 2. acquired cholesteatomas develop as a result of chronic middle ear infection and are usually associated with perforation of the tympanic membrane at the attic (mass is seen in attic with perforation at pars flaccidain contrast to medial to tympanic membrane which is in congenital). Clinical presentation usually consists of conductive hearing loss, often with purulent discharge from the ear In congenital • mass medial to the tympanic membrane • normal tympanic membrane • no previous history of ear discharge, perforation or ear surgery. Q: 246 Clincher(s) A B C D E KEY A Additional Information A man has discharge from his left ear after a fight. Where is the discharge coming from? a. CSF b. Inner ear c. Outer ear d. Brain Perforation (likely fracture base of skull during fight) Due to infection discharge occur Due to Viral or Bacterial infection Base of skull fracture ! CSF discharge via ear 6 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal no history of swimming or anything ! because history of swimming means liquid into the ear ! developing ear infection Reference Dr Khalid/Rabia Patient.co.uk Ear Discharge & Their Source: External ear: Inflammation, ie otitis externa produces a scanty watery discharge, as there are no mucinous glands— Blood can result from trauma to the canal. Liquid wax can sometimes ‘leak’ out. • Middle ear: Mucous discharges are almost always due to middle ear disease.Serosanguinous discharge suggests a granular mucosa of chronic otitis media. An offensive discharge suggests cholesteatoma. • CSF otorrhoea: CSF leaks may follow trauma: suspect if you see a halo sign on filter paper, or its glucose is increased , or Beta2 (tau) transferrin is present. Q: 324 A man presents with muffled hearing and feeling of pressure in ear with tinnitus and vertigo. He also complains of double vision when looking to the right. What is the most appropriate dx? a. Meniere’s disease b. Acoustic neuroma c. Acute labyrinthytis d. Meningioma e. Otosclerosis Clincher(s) A B C D E KEY B Additional Information Muffled hearing, vertigo, tinnitus, double vision Doesn’t effect vision (right abducens nerve) Matches with the symptoms of this disease Problem of inner ear -> vertigo, hearing loss, ringing in ears, nystagmus All symptoms match Acoustic Neuroma 7 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal 8 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Reference Dr Khalid/Rabia Q. 1. What is the key? Q. 2. Justify the key. Ans. 1. The key is B. Acoustic neuroma. Ans. 2. Hearing loss, feeling of pressure in the ear with tinnitus, vertigo and involvement of cranial nerve i.e. right abducent nerve are suggestive of acoustic neuroma. Q: 342 An 8yo returned from Spain with severe pain in one ear. Exam: pus in auditory canal, tympanic membrane looks normal. What is the tx option? a. Gentamicin topical b. Amoxicillin PO c. Analgesia d. Amoxicillin IV Clincher(s) A B C D E Pus in auditory canal, tympanic membrane normal Correct answer Given if pus in tympanic membrane 9 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal KEY A Additional Information Gentamcin Topical Reference Dr Khalid/Rabia 10 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Q: 373 A mentally retarded child puts a green pea in his ear while eating. The carer confirms this. Otoscopy shows a green colored object in the ear canal. What is the most appropriate single best approach to remove this object? a. By magnet b. Syringing c. Under GA d. By hook e. By instilling olive oil Clincher(s) A B C D E KEY C Additional Information Reference Dr Khalid/Rabia Q:1300 Pea Cant remove pea via magnet May swell up Best to avoid injury May push pea deeper Not useful Best tactic to avoid injury A 45yo man has noticed difficulty hearing on the telephone. He is concerned because his father has been moderately hard of hearing since middle age. BC=normal. An audiogram showsmoderate hearing loss in both ears across all frequencies. What is the single most likely dx? a. Acoustic neuroma b. Menieres’ disease c. Noise induced deafness d. Otosclerosis e. Presbyacusis Clincher(s) A B C TWO TYPES: .PTS (Permanent Threshold Shift): the part of the hearing loss subsequent to an acoustic trauma that will never be recovered. PTS is measured in decibels. • • TTS (Temporary Threshold Shift): the hearing loss that will be recovered after a couple of days. Also called auditory fatigue. TTS is also measured in decibels. SYMPTOM: The first symptom of noise-induced hearing loss is usually 11 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal difficulty hearing a conversation against a noisy background In addition to hearing loss, other external symptoms of an acoustic trauma can be: • • • • D E KEY Additional Information Tinnitus Some pain in the ear Hyperacusis Dizziness or vertigo; in the case of vestibular damages, in the inner-ear D Presbycusis is after age of 60 due to degenerative changes..... It's otosclerosis cox it has strong family history in about 50 to 60 percent of cases....secondly it's ...bilateral ....negative rinne's test. autosomal dominant Age - it usually presents between teen years and middle age (typically between the ages of 15 and 35). However, the average age for having surgery is rising Positive family history - there is approximately 1/4 risk if one parent is affected; 1/2 risk if both parents are affected. Patients may have low-volume speech (enhanced bone conduction leads to the perception of their own speech as 'loud'). · Schwartze's sign - reddish-blue discolouration over promontory and oval window niche, due to vascular hyperaemia of immature abnormal bone. · Tuning fork tests (Rinne's and Weber's tests) reveal conductive pattern deafness in the majority of cases. Audiometry is the primary investigation of choice. Bone and air conduction must be tested and typically reveal a purely conductive PRESBYCUSIS · Problems are often first noted in noisy environments; there is usually a slow, insidious onset of symptoms with gradual progression. · The ability to understand speech is often the earliest symptom as highfrequency hearing loss predominates. It may be the patient's friends/relatives who note the problem, rather than the patient. 12 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal · When assessing elderly patients with depression or cognitive impairment, consider hearing loss as a cause of the symptoms. Tinnitus may be a feature of Presbyacusis when the hearing impairment becomes marked. ACOUSTIC NEUROMA Unilateral hearing loss or tinnitus ,Impaired facial sensation ,Balance problems Reference Dr Khalid/Rabia rabia Q:1327 A 34yo man has supra-orbital pain and tenderness and developed tenderness over the maxilla. He also has mild fever. What is the single likely cause for these symptoms? a. Acute sinusitis b. GCA c. Trigeminal neuralgia d. Maxillary carcinoma Clincher(s) A B Supraorbital pain,tenderness on maxilla The most common symptom of giant cell arteritis (GCA) is a headache, although some people also experience jaw pain and vision problems • • • • • mild fever, with a temperature of 37-38C (98.6-100.4F) extreme tiredness loss of appetite weight loss depression investigation temporal artery biopsy is gold standard The management regime consists primarily of systemic corticosteroids (e.g. prednisolone), commencing at a high dose Polymyalgia rheumatica Around half of people with giant cell arteritis also develop a condition that causes inflammation of the muscles called polymyalgia rheumatica. If you have giant cell arteritis, you therefore may also have symptoms of polymyalgia rheumatica, such as shoulder, neck and hip pain, and 13 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal muscle stiffness C Trigeminal neuralgia usually only affects one side of your face. In rare cases it can affect both sides, although not at the same time. The pain can be in the teeth, the lower jaw, upper jaw, cheek and, less commonly, in the forehead or the eye There will be trigerring event like brushing ,vchewing,smiling etc Dental xray is done to look for any dental infection An MRI can also sometimes detect whether a blood vessel in your head is compressing one of the trigeminal nerves, which is one of the main causes of trigeminal neuralgia. D E KEY Additional A Sinusitis describes an inflammation of the mucous membranes of the 14 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Information paranasal sinuses. The sinuses are usually sterile - the most common infectious agents seen in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses. Predisposing factors include: · nasal obstruction e.g. Septal deviation or nasal polyps · recent local infection e.g. Rhinitis or dental extraction · swimming/diving · smoking Features :· facial pain: typically frontal pressure pain which is worse on bending forward · nasal discharge: usually thick and purulent · nasal obstruction: e.g. 'mouth breathing' · post-nasal drip: may produce chronic cough Management of acute sinusitis · analgesia · intranasal decongestants · oral antibiotics are not normally required but may be given for severe Reference Dr Khalid/Rabia Q:1328 presentations. Amoxicillin is currently first-line nhs rabia 8. A 51yo woman presents with painful tongue and complains of tiredness. She is pale and has angular stomatitis and a smooth red tongue. There is no koilonychea. Choose the single cell type you will find on the blood film. a. Numerous blast cells b. Oval macrocytes c. Spherocytes d. Microcytic hypochromic e. Mexican hat cells f. Erythrocytes Clincher(s) 15 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal A B C D E KEY Additional Information Reference Dr Khalid/Rabia These are the features of vit. b12 and folic acid deficiency. Angular stomatitis is the clincher here. B Q:1346 An 89yo man presents with carcinoma of posterior oropharynx. Which is the single most appropriate LN involved? a. Pre-aortic LN b. Aortic LN c. Submental LN d. Submandibular LN e. Deep cervical LN Clincher(s) A B C D E KEY Additional Information Ca posterior oropharynx e Oropharyngeal Lumphatics >>> Retropharyngeal Ln >> Deep cervical LN Reference Dr Khalid/Rabia 16 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Q:1365 5. A 27yo female who had a RTA 7m back now complaints of attacks of sudden onset rotational vertigo which comes on with sharp movements of the head and neck. Which of the following would be most helpful? a. Caloric testing b. Hallpikes maneuver c. Gutenbergers test d. Meniere’s test e. Otoscopy Clincher(s) A Sudden onset of rotational vertigo COWS: PNEUMONIC To test the function of peripheral vestibular system • • B C D If the water is warm (44°C or above) endolymph in the ipsilateral horizontal canal rises, causing an increased rate of firing in the vestibular afferent nerve. This situation mimics a head turn to the ipsilateral side. Both eyes will turn toward the contralateral ear, with horizontal nystagmus (quick horizontal eye movements) to the ipsilateral ear. If the water is cold, relative to body temperature (30°C or below), the endolymph falls within the semicircular canal, decreasing the rate of vestibular afferent firing. The eyes then turn toward the ipsilateral ear, with horizontal nystagmus to the contralateral ear Meniere’s disease TESTING http://www.mayoclinic.org/diseases-conditions/menieresdisease/basics/tests-diagnosis/con-20028251 • MRI Test The main TEST is an overall picture or scan, using CAT (Computed Axial Tomography) or MRI (Magnetic Resonance Imaging). It is done to 17 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal detect any abnormality in the head, specifically the inner ear. Any abnormality that shows up in this picture can then be evaluated further. The MRI provides detailed images of the brain in multiple layers without any blockage by the dense bone/skull. • ECOG Test Transtympanic electrocochleography (ECOG Test) is done to measure inner ear pressure. The sufferer complains of inner ear congestion or pressure. • ENG Test Electronystagmography “ENG“. This evaluates the reaction of the hearing nerve and the eye (optic) nerve to assess predetermined involuntary reactions. There are two versions of this test: ENG and Caloric. • Audiology Test Baseline Audiology testing is measured against normal values. Any the testing will have a specific purpose. Audiometry: “audio” means sound. So “Audiometry” (measures the sound, ability to hear.) and Audiogram (plots the sound on a graph) Audiography is another name for Audiometry. One other aspect of this hearing is also measured by fluctuating hearing. That means you can hear at some point, then lose the hearing, then regain it. And this can happen over a period of time,s E KEY Additional Information Dix–Hallpike test. The Dix–Hall pike test — or Nylen–Barany test — is a diagnostic maneuver used to identify benign paroxysmal positional vertigo (BPPV). Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo encountered. It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it is less common in younger patients. Features: vertigo triggered by change in head position (e.g. rolling over in bed or gazing 18 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal upwards) · may be associated with nausea · each episode typically lasts 10-20 seconds · positive Dix-Hallpike manoeuvre BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months. Symptomatic relief may be gained by: · Epley manoeuvre (successful in around 80% of cases) · teaching the patient exercises they can do themselves at home, for example Brandt-Daroff exercises Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value. Reference Dr Khalid/Rabia Q:1374 Clincher(s) A B C D E KEY Additional Information A 2yo girl is brought to the ED by her mother. The child is screaming that there is something in her ear and she appears agitated. Exam: a plastic bead is seen inside the ear. What is the best method of removal? a. Forceps b. Hook c. Under general anesthesia d. Syringing e. Magnet C as kid is irritable Presentation · Most older children and adults will know that there is something in their ear but sometimes a foreign body may get into the external ear canal 19 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal without the patient realising The patient may present with pain, deafness or discharge. Live insects may cause a buzzing in the ear The appearance will vary according to the object and length of time it has been in the ear: · An inanimate object that has been in the ear a very short time presents with no abnormal finding other than the object itself. ·Pain or bleeding may occur with objects that abrade the ear canal, from rupture of the tympanic membrane, or from the patient's attempts to remove the object. ·With delayed presentation, erythema and swelling of the canal and a foul-smelling discharge may be present. Management A great deal of care is required in order not to push the object deeper into the ear canal and not to damage the ear canal. There is a high failure rate in removal of foreign bodies from the ear. Insects should be killed prior to removal, using 2% lidocaine. · Remove batteries or magnets as soon as possible to prevent corrosion or burns. Do not crush a battery during removal. · Adhesives (eg, Super Glue®) may be removed manually within 1-2 days once desquamation has occurred. Referral to an ear, nose and throat specialist is required if an adhesive is in contact with the tympanic membrane. Methods of removal : Forceps or hook: grasp the object with forceps, or place a hook behind the object and pull it out. Irrigation is often effective. Irrigation with water is contra-indicated for soft objects, organic matter or seeds (which may swell and increase the level of pain and difficulty to remove if exposed to water). 20 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Suction with a small catheter held in contact with the object may be affective Reference Dr Khalid/Rabia Q:857 Clincher(s) A B C D E KEY Additional Information 857. A 13yo girl complains of a 2d hx of hoarseness of voice a/w dry cough. She feels feverish. On direct laryngoscopy, her vocal cords are grossly edematous. What is the single most appropriate inv? a. None req b. Sputum for AFB c. Laryngoscopy d. Bronchoscopy e. XR cervical spine None req Sputum for AFB- For tuberculosis Laryngoscopy- already done Bronchoscopy- Not required XR cervical spine- Not required A Laryngitis: This is often viral and self-limiting, but there may be secondary infection with streps or staphs. It can also be secondary to GORD (see above) or autoimmune disease, eg rheumatoid arthritis. NB: in chronic laryngitis (lasting >3 wks),any bacteria found are likely to be colonizers only.185 Symptoms: Pain (hypopharyngeal, dysphagia;pain on phonation), hoarseness; fever. : Supportive.If necessary, give penicillin V 500mg/6h PO for 1 week. Steam inhalation may help. Chronic cord irritation from smoking } chronic voice abuse may cause Reinke’s oedema (a gelatinous fusiform enlargement of the cords, also associated with hypothyroidism—if conservative treatment fails,laser therapy may help). Functional disorders of speech articulation: (ie cause unknown). Aphonia: Phonation yields no response (or a whisper) in seemingly normal cord adductors, eg in young women at times of stress (NB: there are many functional voice disorders which may result in laryngeal oedema } nodules.) A good diff erentiating test is to ask patients to cough (needs functional adductors). It is a diagnosis by exclusion, eg allergic reactions may cause sudden aphonia, so don’t assume a functional disorder without laryngoscopy. Treatment: Speech therapy is the best, with attention to emotional factors which may be present. Spasmodic dysphonia: Strained, eff ortful, hoarse voice + tremors, 21 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal jerky voice onset, intermittent voice breaks, breathy spasms, hypernasality, failure to maintain voice.186 Children with functional speech disorders have diffi culty with specifi c speech sounds (eg /r/, /s/, /z/, /r/, /l/ and/or ‘th’). Try to distinguish articulation disorders from phonological delay, consistent and varying (‘inconsistent’) phonological disorders and speech dyspraxia. Differential: Before saying ‘no cause can be found’, consider generalized infiltrating entities of the larynx, such as hyperkeratosis ( smoking, alcohol abuse, pollution), leukoplakia, also granulomata, papillomata, polyps, and cysts. Reference Dr Khalid/Rabia Acute laryngitis • Investigations are rarely helpful in primary care. A swab for microbiological analysis may be contributory if excessive exudate is present. • Clinicians with the skill to perform indirect laryngoscopy will typically find redness and small dilated vasculature on the inflamed vocal folds. Q:874 874. A middle aged man who has had a hx of chronic sinusitis, nasal obstruction and blood stained nasal discharge. He now presents with cheek swelling, epiphora, ptosis, diplopia, maxillary pain. What is the single most likely dx? a. Nasopharyngeal ca b. Pharyngeal ca c. Sinus squamous cell ca d. Squamous cell laryngeal ca e. Hypopharyngeal tumor Clincher(s) A Sinusitis, nasal obstruction, blood stained nasal discharge, maxillary pain Nasopharyngeal ca B C D E KEY Additional Information Pharyngeal ca- no nasal symptoms Sinus Squamous cell ca- Blood-stained nasal discharge and nasal obstruction Squamous cell laryngeal ca- nasal obstruction Hypopharyngeal tumor, cheek, nasal, epiphora, C Oropharyngeal carcinoma is often advanced at presentation. : ≈5:1. Histol ogy: 85% are squamous. Typical older patient: Smoker with sore throat, sensation of a lump, referred otalgia, and local irritation by hot or cold foods, with risk factors: chewing or smoking tobacco (alcohol alone is not a risk factor but is synergistic with smoking). 30% of squamous pharyngeal tumours 22 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal will have a 2nd primary within 10yrs. 20% are node +ve at presentation. Reference Dr Khalid/Rabia Q:875 875. A 60yo man with a long hx of smoking and alcohol presents with nasal obstruction, epistaxis, diplopia, otalgia and conductive deafness. What is the single most likely dx? a. Nasopharyngeal ca b. Pharyngeal ca c. Sinus squamous cell ca d. Squamous cell laryngeal ca e. Hypopharyngeal tumor Clincher(s) Smoking, alcohol, nasal obstruction, epistaxis, diplopia, otalgia, conductive deafness Nasopharyngeal carcinomaDiplopia, conductive deafness (Eustachian tube affected), cranial nerve palsy (not I, VII, VIII), nasal obstruction, or neck lumps. Pharyngeal –no conductive deafness Sinus squamous cell carcinoma- Blood-stained nasal discharge and nasal obstruction Sq laryngeal carcinoma- Typical older patient: Male smoker with progressive hoarseness, then stridor, difficulty or pain on swallowing} haemoptysis ear pain (if pharynx involved). Regular cannabis users are at risk. Typical younger patient: HPV +ve.1 Sites: Supraglottic, glottic, or subglottic. Glottic tumours have the best prognosis as they cause hoarseness earlier (spread to nodes is late). Hypopharyngeal tumor- lump in throat, dysphagia for solids then fl uids, or as neck lumps. A Sinus squamous cell cancer (~1% of all tumours) Typical patient: Middle aged or elderly. Suspect when chronic sinusitis presents for the first time in later life. Early signs: Blood-stained nasal discharge and nasal obstruction. A B C D E KEY Additional Information Later: Cheek swelling, swelling or ulcers of the buccoalveolar plate or palate, epiphora due to a blocked nasolacrimal duct, ptosis and diplopia as the floor of the orbit is involved, and pain in maxillary division of the trigeminal nerve. Local spread may be to cheek, palate, nasal cavity, orbit, and pterygopalatine fossa. Patients present late because epistaxis, obstruction and headache only occur with large tumours. Images: MRI/CT endoscopy (with biopsy) is best. NB: coronal CT is needed to show bone erosion (esp. around the cribriform plate). Differential histology: Squamous cell (50%), lymphoma (10%), adenocarcinoma, adenoid cystic carcinoma, olfactory neuroblastoma, or chondrosarcoma, benign tumours.2 Treatment: Radiotherapy } radical 23 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal surgery. 5-yr and 10-yr overall survival rates are 77% and 66% respectively Squamous cell laryngeal cancer ( Incidence: 2000/yr (UK). Typical older patient: Male smoker with progressive hoarseness, then stridor, difficulty or pain on swallowing} haemoptysis ear pain (if pharynx involved). Regular cannabis users are at risk. Typical younger patient: HPV +ve.1 Sites: Supraglottic, glottic, or subglottic. Glottic tumours have the best prognosis as they cause hoarseness earlier (spread to nodes is late). Diagnosis: Laryngoscopy +biopsy. HPV status; MRI staging: Radical radiotherapy (eg IMRT above) or total laryngectomy. Nasopharyngeal cancer 25% of all cancers in China vs 1% in UK. Associations: • HLA A2 allele survival with B17 & BW46) • HPV 1 • Epstein–Barr (EBV) • Tobacco, formaldehyde, wood dust exposure • Weaning on to salted fi sh (?N-nitroso carcinogens). Signs: Diplopia, conductive deafness (Eustachian tube affected), cranial nerve palsy (not I, VII, VIII), nasal obstruction, or neck lumps. Endoscopy/biopsy; PCR for EBV. NB: submucosal spread may mean the area looks normal. Oropharyngeal carcinoma is often advanced at presentation. ≈5:1. Histology: 85% are squamous. Typical older patient: Smoker with sore throat, sensation of a lump, referred otalgia, and local irritation by hot or cold foods, with risk factors: chewing or smoking tobacco (alcohol alone is not a risk factor but is synergistic with smoking). 30% of squamous pharyngeal tumours will have a 2nd primary within 10yrs. 20% are node +ve at presentation. Hypopharyngeal tumours are rare and are usually a disease of the elderly. They can present as a lump in throat, dysphagia for solids then fl uids, or as neck lumps. The anatomic limits of the hypopharynx are the hyoid bone to the lower edge of the cricoid cartilage: the 3 main sites are piriform fossa post cricoid region, and the posterior pharyngeal wall. Note premalignant conditions: leuko plakia and Patterson–Kelly–Brown syndrome (Plummer– Vinson)—in which a pharyngeal web is associated with iron defi ciency, angular stomatitis, glossitis, and koilonychia: 2% risk postcricoid cancer. They are associated with previous irradiation, smoking and alcohol, but not as clearly as laryngeal carcinoma. Treatment options are radiotherapy and surgery in various combinations. The prognosis is poor with 60% mortality at 1 year. 24 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Reference Dr Khalid/Rabia Q:882 882. A 34yo man had a cold 2d back. He now presents with right sided facial pain. What is the single most likely dx? a. Maxillary sinus b. Ethmoid sinus c. Septal hematoma d. Septal abscess e. Allergic rhinitis Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Cold, right sided facial pain Maxillary sinus Ethmoid Sinus Septal Hematoma (infection> hematoma>absecess) Septal Abscess Allergic Rhinitis A Key : a Clincher : age, h/o cold, facial pain Ethmoid sinus ... it is more common in children Septal hematoma ... collection of blood within the septum of the nose, it doesnt cause facial pain Septal abcess ... a serious condition that is caused by bacteria. Trauma to the nose, or even nasal surgery, can leave the patient prone to develop a nasal abscess, which is basically a pocket filled with blood (haematoma) which has become affected by bacteria. Symptoms include nasal blockage, pain, redness over the nasal bridge, difficulty in breathing and fever. Allergic rhinitis ... doesnt cause facial pain MAXILLARY SINUS (source : patient.co.uk) The sinuses are small, air-filled spaces inside the cheekbones and forehead. They make some mucus which drains into the nose through small channels. Sinusitis means inflammation of a sinus. Most bouts of sinusitis are caused by an infection. The cheekbone (maxillary) sinuses are the most commonly affected. Acute sinusitis means that the infection develops quickly (over a few days) and lasts a short time. Many cases of acute sinusitis last a week or so but it is not unusual for it to last 2-3 weeks. Chronic sinusitis means that a sinusitis becomes persistent and lasts for longer 25 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal than 12 weeks. Chronic sinusitis is uncommon. Risk factors : Cold/flu Dental infection Allergic rhinitis Nasal polyp Facial injury or surgery Foreign body Smoking Asthma Pregnancy Poor immune system Symptoms : The most typical symptoms are headache and pain in the face, with the latter increasing when the patient bends down, lifts something, coughs etc., that is, when pressure increases in the sinuses. In case of acute maxillary sinusitis pain is much stronger than in the case of the chronic type. Blocked/runny nose Toothache Fever Headache Cough Tiredness Treatment : Antibiotics are needed only :If your symptoms are severe or if you are very unwell.If you have another illness such as cystic fibrosis, heart problems or a weakened immune system.If your symptoms are not settling within seven days, or are worsening. Treatment to relieve symptoms : Painkillers Decongestant nasal spray or drop Keeping hydrated Warm face packs Saline nasal drops Steam inhalation Q:1017 A 20yo woman with no prv hx of ear complains, presents with 1d hx of severe pain in the right ear which is extremely tender to examine. What is the single most likely dx? a. Chondromalasia 26 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal b. Furuncle c. Myringitis d. OE e. OM Clincher(s) A B C D E KEY Additional Information No prv hx , I day hx, severe pain ear, teder Chondromalacia Furuncle Myringitis OE OM D Chondrodermatitis nodularis chronica helicis et antihelicis This Latin describes an exquisitely tender cartilaginous infl amed nodule dwelling on the upper helix or antihelix (fi g 2). A more convenient name is Winkler’s disease. It is commoner in men who work outdoors. Causes: ?poor blood fl ow (avascular chondritis) from pressure (eg phone addicts) or vasoconstriction from cold. A pressure-relieving prosthesis may help.If not, excise skin and underlying cartilage (eg ‘wide excision’ or ‘deep shave’). Furunculosis This is a very painful staphylococcal abscess arising in a hair follicle. Pathologically it is identical to a boil anywhere else; if there is cellulitis consider fl ucloxacillin. Diabetes is an important predisposing factor Bullous myringitis These are very painful haemorrhagic blisters on deep meatal skin and on the drum ( } serosanginous fl uid behind it). Classically associated with infl uenza infection, but Mycoplasma pneumoniae has also been implicated as have a variety of other organisms. It may simply represent a variant of acute otitis media. Sensorineural hearing loss is much more frequent than previously thought. Treatment is generally supportive only, eg pain relief; oral antibiotics can be considered in cases with middle ear eff usions. Barotrauma (aerotitis) If the Eustachian tube is occluded, middle ear pressure cannot be equalized during descent in an aircraft or diving, so causing damage. Risk factors: Conditions inhibiting function of the Eustachian tube eg infl ammation/infection. Symptoms: Severe pain as the drum becomes indrawn,eg from transudation or bleeding into middle ear. Barotrauma to the inner ear causes vertigo, tinnitus, and deafness. Prevention: Not fl ying with a URTI, decongestants into the nose (eg xylometazoline every 20min), repeated yawns, swallows/jaw movements. Infl ating an OtoventR device is eff ective (it is recommended to air passengers with problems clearing the ears.)29 Positive pressure (higher than Eustachian tube resistance) through mask to the nasopharynx can also help.30 : Supportive if simple barotrauma; eff usions usually clear spontaneously, and most perforations heal. Otitis externa (OE) Minimal discharge, itch, pain and tragal tenderness due to 27 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal an acute infl ammation of the skin of the meatus, eg caused by moisture (swimming),trauma eg fi ngernails (a consequence from conditions causing itch, eg eczema/ psoriasis), high humidity, an absence of wax, a narrow ear canal, and hearing aids.28 Pseudomonas is the chief organism involved, though Staphylococcus aureus is another common off ender. Hearing loss and canal stenosis (making hearing aids diffi cult to wear) can be sequelae. : Contact eczema (fi g 1). Aural toilet is the key to treatment. If severe, the meatus is narrowed. A thin Pope wick can be inserted and hydrated with eardrops, eg SofradexR (framycetin + dexametasone). An alternative is a strip of ribbon gauze soaked in ichthammol glycerine (very soothing) or aluminium acetate (astringent). After a few days, the meatus will open up enough for either microsuction or carefulcleansing with cotton wool. Commercial QtipsR or cotton buds shouldn’t beused: they are too large; instead thin out or make one yourself by wrapping a small piece of cotton wool gently around an orange stick. Use drops only short-term, as troublesome fungal infections can arise. Nonspecialists should not syringe the ear. Beware persistent unilateral otitis externa in diabetics/immunosuppressed/ the elderly: the risk is malignant/necrotizing otitis externa . OE which is resistant to treatment can be a sign of malignancy. Do biopsy. Reference Dr Khalid/Rabia Ans: D Reason : Acute Otitis Externa his produces a similar temperature and lymphadenopathy. Swelling is more diffuse and pain is variable with possible pruritus. Moving the ear or jaw is painful. The canal, external ear, or both, are red, swollen, or eczematous, with shedding of the scaly skin. There may be little,but thick, discharge in the acute stage but it can become bloody if chronic. Hearing is often impaired Management: clean ear canal, keep it dry, Acetic acid 2% ear drops can be very effective against both bacterial and fungal infection Antibiotic drops may be used if infection is present. These are often given in combination with steroids Q:1025 1025. A 34yo man was slapped over his right ear in a fight. There is blood coming from his external auditory canal and he has pain, deafness and ringing in his ears. What is the most appropriate initial inv? a. CT b. MRI c. Otoscopy d. Skull XR e. Facial XR 28 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia C Ans: C Reason : traumatic perforation of the tympanic membrane can causes pain,bleeding,hearing loss,tinnitus and vertigo. Diagnosis is based on otoscopy ,treatment often is unnecessary. Traumatic causes of preparation include Insertion of objects Concussion caused by an explosion or open handed slap across the ear Head trauma with or without Mozilla fracture Sudden negative pressure Barotrauma Diagnosis: otoscopy , audiometry Management: often no treatment required ,for dirty injuries prescribe antibiotics amoxicillin 500 mg tid 8 days.most perforation close spontaneously ,those persisting more than 2 months require surgery Q:1091 A 41yo man presents with long standing foul smelling ear discharge and progressive hearing loss. Otoscopy showed perforation of the pars flaccida and a mass in the upper part of the middle ear. What is the most likely dx? a. ASOM b. CSOM c. Acquired cholesteatoma d. Congenital cholesteatoma e. BarotrauMA Clincher(s) 41 year,foul smelling ear discharge and mass,perforation of tympanic membrane A B C Mass in the ear excludes ASOM and CSOM Otoscopic findings of perforation and mass point towards acquired choleastoma which can also be a complication of asom. 29 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal D E KEY Additional Information C .Secondary acquired cholesteatoma This arises as a result of insult to the tympanic membrane, such as perforation secondary to acute otitis media or trauma, or due to surgical manipulation of the drum. Squamous epithelium may be inadvertently implanted by the insult so triggering the process of cellular growth resulting in cholesteatoma formation. * Frequent or unremitting painless otorrhoea which may be foul-smelling. * Recurrent otitis, poorly responsive to antibiotic treatment. * Progressive, unilateral conductive hearing loss. * Tympanic membrane perforation (~90% of cases) or retracted tympanum. * The only finding may be a pusfilled canal with granulation tissue CT imaging is the investigation of choice if there is a need for assessment of the extent of the lesion and to assess subtle bony defects. Treatment Surgery: Open technique: tympanomastoidectomy Closed technique : tympanoplasty Reference Dr Khalid/Rabia Q.1093(HEMA) A young boy has a hx of epistaxis. CBC=normal, except APTT=47s. What is the most likely dx? a.Hemophilia b.ITP c.Sickle cell d.HUS e.Thalassaem Clincher(s) A Epistaxis and raised APTT Epistaxis and prolonged APTT point toward intrinsic pathway defect , B C D E KEY Additional Information Normal CBC excludes all other options A Hemophilia A IS A FACTOR 8 Deficiency inherited in a x linked recessive pattern. 30 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Presentation early in life or after trauma/surgery. Bleeding into joints leading to crippling arthropathies and muscle causing hematomas with nerve compression and compartment syndrome. Diagnosed by inc APTT and dec factor 8 assay. Treatment with desmopressin which inc factor 8 levels and recombinant factor 8 in major or life threatening bleeds. Hemophilia B is a similar condition arising due to deficiency of factor 9. Also inherited in x linked recessive pattern. Behaves clinically like hemophilia A. Reference Dr Khalid/Rabia Q:1096 A 52 yo male with poorly controlled DM has now presented to his GP with pain in the ear. Exam: skin around the ear is black in color and there was foul smelling discharge from the ear. Pt also had conductive hearing loss. What is the most probable dx? a. Carbuncle b. Folliculitis c. Malignant OE d. Cholesteatoma e. Furuncle Clincher(s) Poorly controlled diabetes,black discolouration of skin around ear,foul smelling discharge Carbuncles are clusters of furuncles connected subcutaneously, causing deeper suppuration and scarring. They are smaller and more superficial than subcutaneous abscesses A B C D E KEY Additional Information this is small with severe pain in the ear and local swelling of the canal. Pyrexia is moderate (less than 38°C). There may be posterior auricular lymphadenopathy. Examination with an auriscope can be very painful. If the lesion bursts there is sudden relief of pain. C Necrotising or malignant otitis externa This is rare but is a life-threatening extension of otitis externa into the 31 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal mastoid and temporal bones. It is usually due to Pseudomonas aeruginosa or S. aureus. It usually affects elderly patients with diabetes or patients who are immunocompromised. It produces pain and headache of greater intensity than clinical signs would suggest. Facial nerve palsy is a red flag sign but is not necessarily associated with a poorer prognosis.[5] Obligatory criteria for diagnosis include:[6] • • • • • • Pain Oedema Exudate Granulation tissue (may be present at the junction of bone and cartilage) Microabscess (when operated upon) A positive bone scan or failure of local treatment and possibly Pseudomonas spp. in culture The occasional criteria are: • • • • • Diabetes Cranial nerve involvement A positive radiograph A debilitating condition Old age Reference Dr Khalid/Rabia Patient.info Q:1154 1154. A 10yo child has got progressive bilateral hearing loss. He has started to increase the TV volume. All other examination is normal. What is the most likely dx? a. Wax b. Foreign body c. Bilateral OM with effusion d. SNHL e. Meningitis due to meningococcus Clincher(s) A B 10yr old,progressive bilateral hearing loss Wax would have been found on examination(normal examination) Normal examination excludes forign body(forign body can’t be present in both ears) Fluctuating conductive hearing loss nearly always occurs with all types of otitis media. In fact it is the most common cause of hearing loss in young children. C 32 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal D E KEY Additional Information No history of meningitis(hearing loss is complication of meningitis). C Otitis media is an inflammation in the middle ear (the area behind the eardrum) that is usually associated with the buildup of fluid. The fluid may or may not be infected.Symptoms, severity, frequency, and length of the condition vary. At one extreme is a single short period of thin, clear, noninfected fluid without any pain or fever but with a slight decrease in hearing ability. At the other extreme are repeated bouts with infection, thick "glue-like" fluid and possible complications such as permanent hearing loss.-Fluctuating conductive hearing loss nearly always occurs with all types of otitis media. In fact it is the most common cause of hearing loss in young children. Reference Dr Khalid/Rabia Q:1165 Clincher(s) A B C D E KEY Additional Information A 2d baby’s mother is worried about the baby’s hearing. Mother has a hx of conductive hearing loss. What is the most appropriate test? a. Brain stem evoked response b. CT c. Fork test d. MRI e. Reassure Auditory brainstem response (ABR) technology is used in testing newborns. Approximately 1 of every 1000 children is born deaf; many more are born with less severe degrees of hearing impairment, while others may acquire hearing loss during early childhood. A Audiologicalbrainstem responses (ABR): The ears are covered with earphones that emit a series of soft clicks. Electrodes on the infant’s forehead and neck measure brain wave activity in response to the clicks. ABR tests the auditory pathway from the external ear to the lower brainstem.used as a screening test in newborns. 33 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal . Reference Dr Khalid/Rabia Ohcs Q:1299 A 16yo boy presents with acute pain in the right ear and little bleeding from the same ear. He had been in a boxing match and had sustained a blow to the ear. There is little amount of blood in the auditory canal and a small perforation of the eardrum. What is the most appropriatemanagement? a. Admission for parental antibiotics b. Nasal decongestant c. Oral amoxicillin d. OPD review e. Packing of ear f. Surgical intervention g. Syringing EN Clincher(s) A B C D E KEY Additional Information Pain and bleeding from ear after being hit in a boxing match Risk of infection due to bleeding C- or skype: OPD reiew? No treatment? A torn (perforated) eardrum will usually heal by itself within -8 weeks. It is a skin-like structure and, like skin that is cut, it will usually heal. In some cases, a doctor may prescribe antibiotic medicines if there is an infection or risk of infection developing in the middle ear whilst the eardrum is healing. Management•no treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is advisable to avoid getting water in the ear during this time• it is common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media. myringoplasty may b may be performed if the tympanic membrane does not heal by itself. Reference Dr Khalid/Rabia Q: Clincher(s) A 34 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: 1545 Clincher(s) A B C D E KEY Additional Information A 19yo man with known hx of OM presents with headache, lethargy, sweating and shivering. What is the single most likely dx? a. Furuncle b. Meningitis c. Myringitis d. Nasopharyngeal tumor e. OM Painful staphylococcal abscess arising in a hair follicle Myringitis is a form of acute otitis media in which vesicles develop on the tympanic membrane. Myringitis can develop with viral, bacterial (particularly Streptococcus pneumoniae), or mycoplasmal otitis media. • A lump or growth anywhere in the neck area that does not go away after 3 weeks (this may be the only sign you have) • Hearing loss – usually on one side only • Tinnitus • Fluid collection in the ear • Blocked or stuffy nose – particularly if only blocked on one side • Blood stained discharge from the nose • Headache • Double vision • Numbness of the lower part of your face • Difficulty with swallowing • Changes in voice – such as hoarseness b Intracranial and extracranial complications of acute and chronic otitis media are possible. A discussion of the diagnosis and management of these complications is the focus of this article. (See the image below.)[2] 35 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Healthy tympanic membrane. Spread of infection from the ear and temporal bone causes intracranial complications of otitis media. Spread of infection occurs through 3 routes, namely, direct extension, thrombophlebitis, and hematogenous dissemination. Extracranial complications are usually direct sequelae of localized acute or chronic inflammation.The complications of otitis media include the following: • • • • • • • • • • • • • • Reference Dr Khalid/Rabia Chronic suppurative otitis media [3, 4] Postauricular abscess Facial nerve paresis Labyrinthitis Labyrinthine fistula Mastoiditis Temporal abscess Petrositis Intracranial abscess Meningitis Otitic hydrocephalus Sigmoid sinus thrombosis Encephalocele Cerebrospinal fluid (CSF) leak Ohcs, wikepedia, cancer research.org A very rare and serious complication of OM is meningitis. This can occur if the infection spreads to the protective outer layer of the brain and spinal chord (the meninges). Symptoms of meningitis can include: severe headache 36 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal being sick a high temperature (fever) stiff neck sensitivity to light rapid breathing AOM is seen frequently in children but is less common in adults. Smoking is a risk factor. Om occurs more commonly in winters. Complications of AOM: Infra-temporal infections can include: Tympanic membrane perforation. Mastoiditis. Facial nerve palsy. Acute labyrinthitis. Petrositis. Acute necrotic otitis. Chronic otitis media. Intracranial infections can include: Meningitis. Encephalitis. Brain abscess. Otitic hydrocephalus (hydrocephalus associated with AOM, usually accompanied by lateral sinus thrombosis but the exact pathophysiology is unclear). Subarachnoid abscess. Subdural abscess. Sigmoid sinus thrombosis. Rarely, systemic complications can occur, including bacteraemia, septic arthritis and bacterial endocarditis. Q: 1555 A 40yo woman on chemotherapy for metastatic breast carcinoma now presents with painful swallowing. Exam: she has white plaques on top of friable mucosa in her mouth and more seen on esophagoscopy. What is the most effective tx for this pt? a. Antispasmodic b. H2 blocker c. Antibiotics d. Antifungals e. I&D Clincher(s) A On chemotherapy, painful swallowing, white plaques in mouth Not required 37 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal B C D E KEY Additional Information Reference Dr Khalid/Rabia ----Anti fungal for oral and esophageal candidiasis --d Q: 1581 . A 35yo woman presents with a swelling in the neck. The swelling has increased in size gradually over the last two years and the patient feels she has difficulty with breathing. Exam: mass measures 8cm by 10 cm, soft and not warm to touch. It moves with deglutition. Which is the most appropriate management of this mass? a. Partial thyroidectomy b. Oral thyroxine c. Oral propylthiouracil d. Excision biopsy Clincher(s) Soft swelling in neck, difficulty breathing, moves with deglutition – thyroid swelling. A B C D E KEY Additional Information Reference Dr Khalid/Rabia Ohcm 533 The immunocompromised state, location of infection, gross picture all point to Esophageal Candidiasis which is treated with antifungals. The treatment of choice is Fluconazole 400mg STAT, then 200mg per day PO. Discussion: * Candidal infection is the most common cause of invasive fungal infections in hospital patients. * Dysphagia, retrosternal discomfort. * Fluconazole 50-100mg PO x 24hourly for 7-14 days. * If invasive, fluconazole 400mg/day. Side effects nausea, raised LFTs, thrombocytopenia. * Severe systemic infection, amphotericin B. Given in hypothyroidism Anti thyroid Soft swelling, unlikely tom be CA A The mass is large and obviously arising from the thyroid. The fact that it is causing difficulty breathing would indicate a thyroidectomy. Thyroxine would be given in hypothyroidism, PTU is given as an antithyroid drug 38 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal and excision biopsy is undertaken if CA is suspected which isn’t the case here as the swelling is not hot. The mass is also soft which doesn’t go towards CA. Discussion: Surgery is indicated in simple goitre if: * There is clinical or radiological evidence of compression of surrounding structures, especially the trachea. * There are substernal goitres, which are best removed surgically, as biopsy is difficult and clinical observation without frequent CT or MRI scans is impossible. * The goitre continues to grow. * There are cosmetic reasons - for example, large or unsightly. Types of thyroid operations: * Thyroid lobectomy to remove a nodule (solitary hot or cold nodules) and goitres that occur in one lobe. * Partial thyroid lobectomy to remove a solitary nodule in one specific part of the thyroid. * Thyroid lobectomy with isthmectomy for benign Hürthle cell tumours and for non-aggressive thyroid cancers. * Subtotal thyroidectomy (leaving enough of the gland to produce some hormones) is now little used and has been replaced by total thyroidectomy or thyroid lobectomy alone. * Total thyroidectomy for thyroid cancers, Hürthle cell tumours and also increasingly for multinodular goitres and patients with Graves' disease. Robotic surgery: advantages include three-dimensional imaging and tremor elimination. Robotic thyroid surgeries include thyroid lobectomy, total thyroidectomy, central compartment neck dissection, and radical neck dissection for benign and malignant thyroid diseases. Thyroid surgery is safe in the elderly, assuming careful preoperative evaluation and risk stratification. Complications: Possible complications following thyroid surgery include: * Minor complications such as collections of serous fluid (they resolve spontaneously if small and asymptomatic but may require single or repeated aspiration if large) and poor scar formation. * Bleeding, which may cause tracheal compression. * Recurrent laryngeal nerve injury: o Innervates all of the intrinsic muscles of the larynx, except the cricothyroid muscle. o Patients with unilateral vocal fold paralysis present with postoperative hoarseness. o Presentation is often subacute and voice changes may not present for days or weeks. o Unilateral paralysis may resolve spontaneously. o Bilateral vocal fold paralysis may occur following a total thyroidectomy and usually presents immediately after extubation. o Both vocal folds remain in the paramedian position, causing partial airway obstruction. * Hypoparathyroidism: the resulting hypocalcaemia may be permanent but is usually transient. The cause of transient hypocalcaemia postoperatively is not clearly understood. * Thyrotoxic storm: is an unusual complication of surgery but is potentially lethal. 39 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal * Superior laryngeal nerve injury: o The external branch provides motor function to the cricothyroid muscle. o Trauma to the nerve results in an inability to lengthen a vocal fold and thus to create a higher-pitched sound. o The external branch is probably the most commonly injured nerve in thyroid surgery. o Most patients do not notice any change but the problem may be career-ending for a professional singer. * Infection: occurs in 1-2% of all cases. Peri-operative antibiotics are not recommended for thyroid surgery. * Hypothyroidism. * Damage to the sympathetic trunk may occur but is rare. Q: 1617 A 38yo man has just returned from a holiday where he went swimming everyday. For the last few days he has had irritation in both ears. Now his right ear is hot, red, swollen and acutely painful. What is the single most likely dx? a. Foreign body b. Impacted earwax c. OE d. OM e. Perforation of eardrum Clincher(s) A B C D E KEY Holiday, swimming history, irritation acutely painful inflamed ear Additional Information Reference Dr Khalid/Rabia Otitis Externa (C) The swimming history, irritation in both ears and ear being hot, red, swollen and painful indicates inflammation of the external acoustic meatus called Otitis Externa. It isn’t otitis media because of the lack of Tympanic membrane signs, perforated eardrum would present with just pain and deafness, impacted earwax would also present with pain and conductive deafness. Foreign body would have history of something being used near or inside the ear and would be seen on examination of the ear canal. 40 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Q: 1653 A pt has loss of sensation on the tip of her tongue and the inner aspect of the lip. Which nerve is most likely to be involved? a. Vagus nerve b. Glossopharyngeal nerve c. Lingual nerve d. Buccal nerve e. Facial nerve Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Nerve supply for the tip of tongue and inner lip C: Lingual Nerve a. Vagus nerve: It leaves the skull through the jugular foramen, passes within the carotid sheath in the neck, through the thorax supplying the lungs, and continues on via the oesophageal opening to supply the abdominal organs. b. Glossopharyngeal nerve: Passes across the posterior fossa, through the jugular foramen and into the neck, supplying tonsil, palate and posterior third of tongue. c. Lingual nerve: lingual nerve is a branch of the mandibular division of the trigeminal nerve (CN V3), which supplies sensory innervation to thetongue. It also carries fibers from the facial nerve, which return taste information from the anterior two thirds of the tongue, via thechorda tympani d. Buccal nerve:brach of mandibular division of trigeminal nerve, supplies the skin and mucous membrane of the cheek e. Facial nerve: Mainly motor (some sensory fibres from external acoustic meatus, fibres controlling salivation and taste fibres from the anterior tongue). Q: Clincher(s) A B 41 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal C D E KEY Additional Information Reference Dr Khalid/Rabia Q: Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: Clincher(s) A B C 42 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal D E KEY Additional Information Reference Dr Khalid/Rabia Q: Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: Clincher(s) A B C D 503 A 26yo woman has become aware of increasing right sided hearing deficiency since her recent pregnancy. Her eardrums are normal. Her hearing tests show: BC-normal. Weber test lateralizes to the right ear. What is the single most likely dx? a. Encephalopathy b. Functional hearing loss c. Tympano-sclerosis d. Otosclerosis e. Sensorineural deafness Hearing def after her pregnancy and BC normal with Webber test lateralise to right ear occurs when the functioning of the ears is normal, but the person is showing a reduced response or not responding at all to sounds. Because there are no functional hearing problems in individuals with functional hearing loss, it is the most difficult type of hearing loss to detect and the most often misdiagnosed. Functional hearing loss is caused by mental health problems, such as ADHD and depression. Ear drums are normal so that's why it's not tympani sclerosis Most common in females in pregnancy, during me trial cycles and 43 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal E KEY Additional Information Reference Dr Khalid/Rabia menopause. BC will not be normal and Webber will lateralise to the normal ear. D In otosclerosis the hearing gets better in background noises whereas in presbycusis which is gradual deterioration of hearing with age due to noise toxicity the hearing gets worse in background noises. Otosclerosis is a conductive deafness whereas presbycusis is a SNHL There are no features of encephalopathy. As Weber test is lateralized it is unlikely to be functional hearing loss . In tympanosclerosis ear drum becomes chalky white. So as the ear drum is normal it is not tympanosclerosis. Weber test is lateralized to right and deafness is also on the right. So it not sensorineural deafness but conductive deafness which makes otosclerosis as the most likely diagnosis. Rinne's test · air conduction (AC) is normally better than bone conduction (BC) · if BC > AC then conductive deafness Weber's test · in unilateral sensorineural deafness, sound is localised to the unaffected side · in unilateral conductive deafness, sound is localised to the affected side Q:544 A 52yo man whose voice became hoarse following thyroid surgery 1 wk ago shows no improvement. Which anatomical site is most likely affected? a. Bilateral recurrent laryngeal nerve b. Unilateral recurrent laryngeal nerve c. Unilateral external laryngeal nerve d. Bilateral external laryngeal nerve e. Vocal cords Clincher(s) A Hoarseness of voice after thyroid surgery and no improvement In bilateral paralysis, both cords generally fixed midway and presents with aphonia. The airway, however, is inadequate, resulting in stridor and dyspnea with moderate exertion as each cord is drawn to the midline glottis by an inspiratory Bernoulli effect. Aspiration is also a danger. In unilateral paralysis, the voice may be hoarse and breathy, but the airway is usually not obstructed because the normal cord abducts sufficiently and fixed in the midline. The ability to produce pitched sounds is then impaired along with easy voice fatigability, (usually mono-toned voice). Inability to make explosive sounds due to paralysis of crick thyroid muscle. Bilateral palsy presents as a tiring and hoarse voice. B C D E KEY B 44 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Additional Information In unilateral vocal cord paralysis, hoarseness or breathlessness may not manifest for days to weeks; other potential sequelae are dysphagia and aspiration Bilateral vocal-fold paralysis usually manifests immediately after extubation; patients may present with biphasic stridor, respiratory distress, or both Reference Dr Khalid/Rabia bilateral injury of the RLN leads to aphonia. In unilateral damage, the patient voice is still preserved but it's harsh ( hoarse ) due to unilateral paralysis of the vocal cords. Direct injury to the vocal cords is unlikely in thyroid procedures since the larynx isn't opened. The external laryngeal nerves are more frequently damaged than the RLN , but they cause only minor changes in voice quality ( pitch changes). Bilateral rln palsy will cause emergency airway obstruction and stridor Vocal cord inj should be transient and improving External laryngeal inj doesnt cause hoarseness B due to close relation of the inferior thyroid artery to the recurrent laryngeal nerve the clamping of artery during surgery might accidentally injured the nerve causing hoarseness of voice if bilaterally affected the nerve it will most likely causing acute respiratory distress Q:559 A 10yo girl has been referred for assessment of hearing as she is finding difficulty in hearing her teacher in the class. Her hearing tests show: BC normal, symmetrical AC threshold reduced bilaterally, weber test shows no lateralization. What is the single most likely dx? a. Chronic perforation of tympanic membrane b. Chronic secretory OM with effusion c. Congenital sensorineural deficit d. Otosclerosis e. Presbycusis Clincher(s) A B C D E KEY Additional Information Hearing difficulty bilaterally and conductive deafness. Mainly unilateral Common cause of hearing problems in children Webber is normal so it's not possible. Common in females during pregnancy, mensturation and menopause. Hearing loss with increasing age. Weber test is normal B 45 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Reference Dr Khalid/Rabia B/L conductive deafness glue ear/ OM e effusion Bc normal means no sn deafness .. there is conductive deafness .. otosclerosis has cd but it usually appears in 3rd decade of life n associated with tinnitus .. perforation on both sides is uncommon .. so we're left with csom with effusion which is most common cause of cd in school going age Glue Ear/ otitis media with effusion: recurrent ear infections, poor speech development, and failing performances at school, typically in children between the ages of 2 and decreasing with advancement of age.. .Causes conductive hearing loss. The clincher also is 'child finding difficulty in hearing in classroom/turning up the volume of Tv' Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and mastoid cavity. Clinical features are recurrent otorrhoea through a tympanic perforation, with conductive hearing loss of varying severity. · CSOM presents with a chronically draining ear (>2 weeks), with a possible history of recurrent AOM, traumatic perforation, or insertion of grommets. · The otorrhea should occur without otalgia or fever. · Fever, vertigo and otalgia should prompt urgent referral to exclude intratemporal or intracranial complications. · Hearing loss is common in the affected ear Treatment options include: · grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months · adenoidectomy Q:560 A thin 18yo girl has bilateral parotid swelling with thickened calluses on the dorsum of her hand. What is the single most likely dx? a. Bulimia nervosa b. C1 esterase deficiency c. Crohn’s disease d. Mumps e. Sarcoidosis Clincher(s) Thin girl with bilateral parotid swelling and thick calluses on the dorsal of her hand. A B Hereditary angioedema (HAE) is a rare, autosomal dominantly inherited blood 46 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal C D E KEY Additional Information Reference Dr Khalid/Rabia disorder that causes episodic attacks of swelling that may affect the face, extremities, genitals, gastrointestinal tract and upper airways. Swellings of the intestinal mucosa may lead to vomiting and painful, colic-like intestinal spasms that may mimic intestinal obstruction. Acquired angioedema present in the fourth decade. Irrelevant here No signs of infection. Not the case. A Bulimia nervosa Presentation : · The history often dates back to adolescence. o Regular binge eating. o Attempts to counteract the binges - eg, vomiting, using laxatives, diuretics, dietary restriction and excessive exercise. o Preoccupation with weight, body shape, and body image. o low self-esteem, and self-harm. o Periods may be irregular. · Physical examination is usually normal and is mainly aimed at excluding medical complications such as dehydration or dysrhythmias (induced by hypokalaemia). o Examination must include height and weight (and calculation of the BMI) and blood pressure. o Salivary glands (especially the parotid) may be swollen. o There may be oedema if there has been laxative or diuretic abuse. o Russell's sign may be present (calluses form on the back of the hand, caused by repeated abrasion against teeth during inducement of vomiting). Q:568 A 4yo has earache and fever. Has taken paracetamol several times. Now it’s noticed that he increases the TV volume. His preschool hearing test shows symmetric loss of 40db. What is the most likely dx? a. OM with effusion b. Otitis externa c. Cholesteatoma d. CSOM e. Tonsillitis Clincher(s) Young boy with ear ache and fever with hearing loss testing and increases the volume of tv. Typical picture Infection of external ear. Pain and watery discharge. A B 47 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal C D Offensive discharge due to active squamous chronic otitis media Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and mastoid cavity. Clinical features are recurrent otorrhoea through a tympanic perforation, with conductive hearing loss of varying severity. CSOM presents with a chronically draining ear (>2 weeks), with a possible history of recurrent AOM, traumatic perforation, or insertion of grommets. E KEY Additional Information Reference Dr Khalid/Rabia It's not going to cause hearing problems. A Q:574 A 15m child is due for his MMR vaccine. There is a fam hx of egg allergy. He is febrile with acute OM. What is the single most appropriate action? a. Defer immunization for 2wks b. Don’t give vaccine c. Give half dose of vaccine d. Give paracetamol with future doses of the same vaccine e. Proceed with standard immunization schedule Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Otitis media infection and MMR vaccine A egg allergy is not contraindication for MMR ...therefore if pt is febrile then wait for the next two weeks until he is afebrile and give the normal dose of immunization. Children in the UK receive two doses of the Measles, Mumps and Rubella (MMR) vaccine before entry to primary school. This currently occurs at 12-15 months and 3-4 years as part of the routine immunisation schedule Contraindications to MMR · severe immunosuppression · Acute illness · allergy to neomycin · children who have received another live vaccine by injection within 4 weeks 48 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal · pregnancy should be avoided for at least 1 month following vaccination · immunoglobulin therapy within the past 3 months (there may be no immune response to the measles vaccine if antibodies are present) Adverse effects · malaise, fever and rash may occur after the first dose of MMR. This typically occurs after 5-10 days and lasts around 2-3 days Note that the following are NOT contra-indications: · Family history of any adverse reactions following immunisation. · Previous history of infection with pertussis, measles, rubella or mumps. · Contact with an infectious disease. · Asthma, eczema, hay fever or rhinitis. · Treatment with antibiotics or locally acting (eg, topical or inhaled) steroids. · The child's mother being pregnant. · The child being breast-fed. · History of jaundice after birth. · Being over the age recommended in the immunisation schedule. · 'Replacement' corticosteroids. · Allergy to eggs · Neurological conditions are not a contra-indication although, if the condition is poorly controlled (eg, epilepsy), immunisation should be deferred. · MMR should ideally be given at the same time as other live vaccines, such as BCG. However, if live vaccines cannot be administered simultaneously, a fourweek interval is recommended. Q: Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: Clincher(s) A 49 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: 586 A 4yo boy who prv had normal hearing, has a mild earache relieved by paracetamol. He has been noticed to turn up the vol on the TV. He has bilateral dull tympanic membranes. His preschool hearing test shows symmetrical loss of 40dB. What is the single most likely dx? 50 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal a. Acute otitis externa b. Acute OM c. Ear wax d. Foreign body e. OM with effusion Clincher(s) A B C D E KEY: E Additional Information Reference Dr Khalid/Rabia turning up the volume of Tv, symmetrical loss of 40dB Minimal discharge, itch, pain and tragal tenderness due to an acute inflammation of the skin of the meatus, eg caused by moisture (swimming) (h/o of holiday), trauma eg fingernails (a consequence from conditions causing itch, eg eczema/psoriasis), high humidity, an absence of wax, a narrow ear canal, and hearing aids. middle ear inflammation; it presents with rapid onset of pain, fever ± irritability, anorexia, or vomiting often after a viral upper respiratory infection. Foreign bodies are common if <5yrs old and in adults with learning difficulty OM with effusion Hearing impairment noticed by parents is the mode of presentation in 80%. The fundamental problem lies with dysfunction of the Eustachian tubes. OME is commoner in boys, Down’s syndrome, winter season, atopy, children of smokers and primary ciliary dyskinesia. OME is the chief cause of hearing loss in young children, and can cause disastrous learning problems (rare). OME may cause no pain, so its presence may not be suspected. History: Focus on poor listening, poor speech, language delay, inattention, poor behaviour, hearing fluctuation, ear infections/URTI, balance and, school work. Tests: Audiograms: Look for conductive defects. Impedance audiometry: Look for flat tympanogram (helps distinguish OME from Eustachian malfunction and otosclerosis). Tx: • reassurance + 3-monthly review • Hearing aids: Reserve for persistent bilateral OME and hearing loss if surgery is not accepted. • Surgery: If persistent bilateral OME + hearing level in better ear of <25– 30dBHL(=decibel hearing loss) confirmed over 3 months then myringotomy + suction of fluid, and insertion of air-conducting grommets ± adenoidectomy (if hearing loss). • NICE also says surgery is an option if hearing loss is less severe but learning difficulties are to the fore. OHCS pg: 546 Glue Ear/ otitis media with effusion: recurrent ear infections, poor speech development, and failing performances at school, typically in children between 51 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal the ages of 2 and decreasing with advancement of age. Causes conductive hearing loss. The clincher also is 'child finding difficulty in hearing in classroom/turning up the volume of Tv' Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and mastoid cavity. Clinical features are recurrent otorrhoea through a tympanic perforation, with conductive hearing loss of varying severity. · CSOM presents with a chronically draining ear (>2 weeks), with a possible history of recurrent AOM, traumatic perforation, or insertion of grommets. · The otorrhea should occur without otalgia or fever. · Fever, vertigo and otalgia should prompt urgent referral to exclude intratemporal or intracranial complications. · Hearing loss is common in the affected ear Treatment options include: · grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months · adenoidectomy Q: 644 A 25yo woman complains of dizziness, nausea, vomiting, visual disturbances and anxiety which keep coming from time to time. Most of the attacks are a/w sudden change in posture. What is the most likely dx? a. Panic disorder b. Carotid sinus syncope c. BPPV (Benign paroxysmal positional vertigo) d. Vertebrobasilar insufficiency e. Postural hypotension Clincher(s) A B attacks are a/w sudden change in posture C D E KEY: C The diagnosis is frequently made in: • men over 50 • patients with atherosclerosis and hypertension Most commonly due to atherosclerosis will have Brain stem symptoms such as diplopia, dysarthria and facial nuumbness A drop in systolic blood pressure upon standing of greater than 20 mmHg BPPV (Benign paroxysmal positional vertigo) Ask about duration of vertigo: • seconds to minutes ≈ BPPV; • 30mins to 30h ≈ Ménière’s or migraine; 52 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal • Additional Information Reference Dr Khalid/Rabia 30h to a week ≈ acute vestibular failure. · vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards) · may be associated with nausea · each episode typically lasts 10-20 seconds · positive Dix-Hallpike manoeuvre BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months. Symptomatic relief may be gained by: · Epley manoeuvre (successful in around 80% of cases) · teaching the patient exercises they can do themselves at home, for example Brandt-Daroff exercises Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value. 53 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Q: 656 Clincher(s) A B C D E KEY: A Additional Information Reference Dr Khalid/Rabia A 56yo male pt presents with intermittent vertigo, tinnitus and hearing loss. What is the best drug tx for this pt? a. Buccal prochlorperazine b. Oral flupenphenazine c. TCA (tricyclic antidepressant) d. Gentamicin patch on the round window e. No med tx available Probable case of Menieres disease. Treated with prochlorperazine OHCM pg: 554 a. Buccal prochlorperazine meiners disease-t/t oral percholperazine Features · recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom · a sensation of aural fullness or pressure is now recognised as being common · other features include nystagmus and a positive Romberg test · episodes last minutes to hours · typically symptoms are unilateral but bilateral symptoms may develop after a number of years Natural history · symptoms resolve in the majority of patients after 5-10 years · the majority of patients will be left with a degree of hearing loss · psychological distress is common 54 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Management · ENT assessment is required to confirm the diagnosis · patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved · acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required · prevention: betahistine may be of benefit Q: 663 Clincher(s) A B C D E KEY: A?? Additional Information Reference Dr Khalid/Rabia Pt had a fight following which he developed bleeding, ringing and hearing loss from one ear. What is the inv of choice? a. CT b. XR skull c. Otoscopy d. MRI vestibule e. Coagulation study CT CT scan to rule out basilar skull fracture esp when there is history of fight, bleeding from ear (hemotympanum) If bleeding and tinnitus is present it is almost certain that the patient has a traumatic perforation... So now our main aim is to rule out fracture base of skull which can be best done by a CT scan. Selection of adults for CT scan CT scan of the brain within one hour (with a written radiology report within one hour of the scan being undertaken): · Glasgow Coma Scale (GCS) <13 when first assessed or GCS <15 two hours after injury · Suspected open or depressed skull fracture · Signs of base of skull fracture* · Post-traumatic seizure · Focal neurological deficit · >1 episode of vomiting All patients with a coagulopathy or on oral anticoagulants should have a CT brain scan within eight hours of the injury, provided there are no other identified risk factors, as listed above. Again, a written radiology report should be available within one hour of the scan being undertaken. 55 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Q: 690 Clincher(s) A B C D E KEY: A A 28yo man complains of vertigo, nausea and vomiting for more than 30 mins and tinnitus, hearing loss in the left ear. What is the tx for this pt? a. Buccal prochlorperazine b. Metachlorpromide c. Cyclazine d. Cotrimazole e. Ondansetron Buccal prochlorperazine 1st line-if vomiting or betahistine or chlorthalidone (OHCS) Additional Information Reference Dr Khalid/Rabia Q: 1052 A 45yo woman has dull pain in her right ear which has been present for several weeks. There is no discharge. Chewing is uncomfortable and her husband has noticed that she grinds her teeth during sleep. The eardrum appears normal. What is the single most likely dx? a. Dental caries b. Mumps c. OM d. Temporomandibular joint pain e. Trigeminal neuralgia Clincher(s) dull pain in her right ear for weeks, no discharge, chewing is uncomfortable, teeth grinding Tooth ache, localised swelling A prodrome of non-specific symptoms like fever, malaise myalgias, and anorexia may be followed by enlargement of one or both parotid glands, developing over a period of 1 to 3 days. Severe and progressive otalgia, discharge A B C D E KEY: D a unilateral disorder characterised by brief electric shock-like pains, abrupt in onset and termination, limited to the distribution of one or more divisions of the trigeminal nerve Temporomandibular joint pain 56 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Additional Information Reference Dr Khalid/Rabia Q:727 Clincher(s) A B C D E KEY OHCS pg: 542 Temporomandibular joint pain may cause pain in ear and teeth grinding as in oromandibular dyskinesia is a recognized cause of this symptom Earache, facial pain, and joint clicking/popping related to malocclusion, teethgrinding (bruxism) or joint derangement. Stress making this a biopsychosocial disorder which may become a chronic pain syndrome Signs: Joint tenderness exacerbated by lateral movement of the open jaw, or trigger points in the pterygoids. Imaging: MRI. Associations: Depression; Ehlers Danlos Rx: NSAIDs (PO or topical, eg Diclofenac); Stabilizing orthodontic occlusal prostheses; cognitive therapy; physiotherapy; biofeedback; Reconstructive Surgery; acupuncture. A 25yo man presents with hoarseness of voice. He has swollen vocal cords. His BMI=32 and he smokes 20-25 cigarettes/day. What would you advise him? a. Stop smoking b. Lose weight a- Stop smoking There are several reasons for hoarsness of voice on of which is CA larynx. Smoking is a big risk factor for it. Additional 57 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Information Reference Dr Khalid/Rabia Q:752 Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Q:769 A 17yo lady presents with a worm in her ear. She is very agitated and anxious. What is the next step? a. Remove under GA b. Suction c. Alcohol drops d. Forceps Alcohol next step Removed eventually with help of forcep c-Alcohol drops . A 45yo woman presents with rotational vertigo, nausea and vomiting, especially on moving her head. She also had a similar episode 2yrs back. These episodes typically follow an event of runny nose, cold, cough and fever. What is the most probable dx? a. Acoustic neuroma b. Meniere’s disease c. Labyrinthitis d. BPPV e. vestibular neuronitis Clincher(s) A B C D E KEY Acoustic neuroma will ve other nerve ivolvement also Meniers characterized by vertigo , SN hearing loss , aural fullness , tinnitus Labyrinthitis resembles vestibular neuronitis but with hearing loss BPPV characterized by vertigo and dizziness related to head movement Rotational vertigo , nausea , vomiting , f/b viral illness e. Vestibular neuronitis above scenario is that of vestibular neuronitis. Symptoms of rotational vertigo nausea and vomiting followed an event of viral 58 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal illness. Presentation: nausea, vomiting and vertigo .moving head aggravates symptoms. Nystagmus Investigations: clinical diagnosis. MRI ct to rule out other causes Differntials: BPPV, labyrinthitis, Meniers Management: reassurance. Bed rest.If severe, antiemetics.Prochlorperazine Additional Information Reference Dr Khalid/Rabia Q:783 . A 2yo girl prv well presents with ahx of vomiting and diarrhea for 4hrs. What is the most suitable indication for IV fluid administration? a. Capillary refill time >4s b. HR >90bpm c. Increased RR d. Stool >10x/d e. Weight of child = 10kgs Clincher(s) A B C D E KEY 2 yr old , vomiting diarrhea for 4hrs Checked in diarrhea In diarrhea – patient might be hypotensive Sign of pneumonia Investigation Not sensible A- CAPILLARY REFILL In diarrhea – you examine the patient and look for signs of dehydration Depressed ant fontanelle , capillary refill time , Additional Information Reference Dr Khalid/Rabia Q:786 A 74yo lady called an ambulance for an acute chest pain. She has ahx of DM and HTN, and is a heavy smoker. Paramedics mentioned that she was overweight and recently immobile because of a hip pain. She collapsed and died in the ambulance. What is the most likely cause of death? a. Pulmonary embolism b. MI c. Stroke d. Cardiac arrhythmia e. Cardiac failure 59 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia 74, DM , HTN , acute chest pain , smoker , over weight , immobile due to hip pain---died Chest pain +/- , tachycardia , sudden , Chest pain Loss of consciousness or focal deficit Palpitations shud ve been there dyspnnea shud be there A- Pulmonary embolism acute onset of chest pain and hx of immobility point towards pul embolism. Causes: DVT After long bone fracture Amniotic fluid Air embolism Immobility Risk factors for venous thromboembolism[3] Major risk factors: relative risk of 5-20 Minor risk factors: relative risk of 24 Cardiovascular: Surgery: · Major abdominal/pelvic surgery or hip/knee replacement (risk lower if prophylaxis used). · Postoperative intensive care. 60 · Congenital heart disease. · Congestive cardiac failure. · Hypertension. · Paralytic stroke. Oestrogens: · Pregnancy (but see major risk factors for late pregnancy and ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Obstetrics: puerperium). · Late pregnancy. · · Puerperium. contraceptive. · Caesarean section. · Lower limb problems: Combined oral Hormone replacement therapy. Haematological: · Fracture. · Varicose veins - previous · Thrombotic disorders (a varicose vein surgery; detailed list is available) superficial thrombophlebitis; Consider this in cases of PE aged varicose veins per se are not a <40 years, recurrent VTE or a risk factor. positive family history. Malignancy: · · Abdominal/pelvic. · Advanced/metastatic. Reduced mobility: Myeloproliferative disorders. Renal: · Nephrotic syndrome. · Chronic dialysis. Paroxysmal nocturnal · Hospitalisation. · · Institutional care. haemoglobinuria. Miscellaneous: Previous proven VTE: · Intravenous (IV) drug use · Chronic obstructive (could be major or pulmonary disease (COPD). minor risk factor: · Neurological disability. no data on relative risk). · Occult malignancy. · Long-distance sedentary Other: · travel. Major trauma. 61 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal · Spinal cord injury. · Obesity. · Central venous lines. · Other chronic diseases: inflammatory bowel disease, Behçet's disease. Symptoms -· Dyspnoea. · Pleuritic chest pain, retrosternal chest pain. · Cough and haemoptysis. · Any chest symptoms in a patient with symptoms suggesting a deep vein thrombosis (DVT). · In severe cases, right heart failure causes dizziness or syncope. Signs include: Tachypnoea, tachycardia. Hypoxia, which may cause anxiety, restlessness, agitation and impaired consciousness. · Pyrexia. · Elevated jugular venous pressure. · Gallop heart rhythm, a widely split second heart sound, tricuspidregurgitant murmur. • · Pleural rub. · Systemic hypotension and cardiac arrest Offer patients in whom PE is suspected and with a likely twolevel PE Wells' score either an immediate computed tomography pulmonary angiogram (CTPA) or immediate interim parenteral anticoagulant therapy followed by a CTPA, if 62 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal a CTPA cannot be carried out immediately. Consider a proximal leg vein ultrasound scan if the CTPA is negative and DVT is suspected. • Offer patients in whom PE is suspected and with an unlikely twolevel PE Wells' score a D-dimer test and, if the result is positive, offer either an immediate CTPA or immediate interim parenteral anticoagulant therapy followed by a CTPA, if a CTPA cannot be carried out immediately. • For patients who have an allergy to contrast media, or who have renal impairment, or whose risk from irradiation is high: o Assess the suitability of a ventilation/perfusion singlephoton emission computed tomography (V/Q SPECT) scan or, if a V/Q SPECT scan is not available, a V/Q planar scan, as an alternative to CTPA. o If offering a V/Q SPECT or planar scan that will not be available immediately, offer immediate interim parenteral anticoagulant therapy. • Diagnose PE and treat patients with a positive CTPA or in whom PE is identified with a V/Q SPECT or planar scan. • Consider alternative diagnoses in the following two groups of patients: • Patients with an unlikely two-level PE Wells' score and either a negative D-dimer test, or a positive D-dimer test and a negative CTPA. • Patients with a likely two-level PE Wells' score and both a 63 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal negative CTPA and no suspected DVT. initial resuscitation · Oxygen 100%. Obtain IV access, monitor closely, start baseline · investigations. · Give analgesia if necessary (eg, morphine). · Assess circulation: suspect massive PE if systolic BP is <90 mm Hg or there is a fall of 40 mm Hg, for 15 minutes, not due to other causes. Anticoagulation therapy[4] · Offer a choice of low molecular weight heparin (LMWH) or fondaparinux to patients with confirmed PE, with the following exceptions: For patients with severe renal impairment or established · chronic kidney disease (estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 m2) offer unfractionated heparin (UFH) with dose adjustments based on the activated partial thromboplastin time (aPTT) or LMWH with dose adjustments based on an anti-Xa assay. For patients with an increased risk of bleeding, consider · UFH. · For patients with PE and haemodynamic instability, offer UFH and consider thrombolytic therapy. · Start the LMWH, fondaparinux or UFH as soon as possible and continue it for at least five days or until the international 64 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal normalised ratio (INR) is 2 or above for at least 24 hours, whichever is longer. Offer LMWH to patients with active cancer and confirmed PE, · and continue the LMWH for six months. At six months, assess the risks and benefits of continuing anticoagulation. Offer a vitamin K antagonist (VKA) to patients with · confirmed PE within 24 hours of diagnosis and continue the VKA for three months. At three months, assess the risks and benefits of continuing VKA treatment. Offer a VKA beyond three months to patients with an · unprovoked PE, taking into account the patient's risk of VTE recurrence and whether they are at increased risk of bleeding. Rivaroxaban:[7] · · Rivaroxaban is recommended by NICE as an option for treating PE and preventing recurrent DVT and PE in adults. · The duration of treatment recommended depends on bleeding risk and other clinical criteria. · Short-term treatment (at least three months) is recommended for people with transient risk factors such as recent surgery and trauma. Longer treatment is recommended for people with permanent risk factors, or idiopathic (unprovoked) DVT or PE. 65 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Q:799 Clincher(s) A B C D E KEY A 2yo child is brought by his mother. The mother had hearing impairment in her early childhood and is now concerned about the child. What inv would you do? a. Audiometry b. Distraction testing c. Scratch test d. Tuning fork Answer: A. Audiometry. Family history of deafness so audiometry should be done. Additional Information Reference Q: 378 Clincher(s) A B C D E KEY A 32yo woman had progressive decrease in vision over 3yrs. She is no dx as almost blind. What would be the mechanism? a. Cataract b. Glaucoma c. Retinopathy d. Uveitis e. Keratitis Cataract is unlikely at this age. Open angle glaucoma. Nothing in the history suggests retinopathy. Uveitis and iritis doesn’t have such degree of vision loss and iritis and anterior uveitis have pain, redness and photophobia. B. Glaucoma. C>? skype Additional Information Reference 66 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Dr Khalid/Rabia Q: 395 Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: 405 Clincher(s) A B C D E KEY A 32yo man presents with hearing loss. AC>BC in the right ear after Rhine test. He also complains of tinnitus, vertigo and numbness on same half of his face. What is the most appropriate inv for his condition? a. Audiometry b. CT c. MRI d. Tympanometry e. Weber’s test features are suggestive of acaustic neuroma, so MRI is the preferred option. it involves basically 8th nerve but 6 7 9 and 10th nerves are also involved with it The key is C. MRI. A 31yo man has epistaxis 10 days following polypectomy. What is the most likely dx? a. Nasal infection b. Coagulation disorder c. Carcinoma HEMORRHAGE AFTER 5 TO 7 DAYS IS SECONDARY HEMORRHAGE [Infection is one of the most important cause of secondary hemorrhage]. The key is A. Nasal infection. Additional 67 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Information Reference Dr Khalid/Rabia Q: 422 Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: 503 A 5yo child complains of sore throat and earache. He is pyrexial. Exam: tonsils enlarged and hyperemic, exudes pus when pressed upon. What is the single most relevant dx? a. IM b. Acute follicular tonsillitis c. Scarlet fever d. Agranulocytosis e. Acute OM Acute follicular tonsillitis. [Tonsillitis is usually caused by a viral infection or, less commonly, a bacterial infection. The given case is a bacterial tonsillitis (probably caused by group A streptococcus). There are four main signs that tonsillitis is caused by a bacterial infection rather than a viral infection. They are: • a high temperature • white pus-filled spots on the tonsils • no cough • swollen and tender lymph nodes (glands). Ans. The key is B. A 26yo woman has become aware of increasing right sided hearing deficiency since her recent pregnancy. Her eardrums are normal. Her hearing tests show: BC-normal. Weber test lateralizes to the right ear. What is the single most likely dx? a. Encephalopathy b. Functional hearing loss c. Tympano-sclerosis d. Otosclerosis e. Sensorineural deafness 68 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia There are no features of encephalopathy. As Weber test is lateralized it is unlikely to be functional hearing loss. In tympanosclerosis ear drum becomes chalky white. So as the ear drum is normal it is not tympanosclerosis. It is conductive deafness which makes otosclerosis as the most likely diagnosis. Rinne's test • air conduction (AC) is normally better than bone conduction (BC) • if BC > AC then conductive deafness Weber's test • in unilateral sensorineural deafness, sound is localised to the unaffected side • in unilateral conductive deafness, sound is localised to the affected side Weber test is lateralized to right and deafness is also on the right. So it not sensorineural deafness key is D. Otosclerosis. Q: Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: Clincher(s) A B 69 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal C D E KEY Additional Information Reference Dr Khalid/Rabia Q: Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia Q: Clincher(s) A B C D E KEY Additional Information Reference Dr Khalid/Rabia 70 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Q: 1383 A pt, a small child presented with URTI and later developed fever, earache and tympanic membrane is dull. What is the likely dx? a. OM b. OE c. Glue ear d. Perforation of the tympanic membrane e. Referred ear ache Clincher(s) A Age, Upper respiratory tract infection, earache and dull tympanci membrane. Correct diagnosis is otitis media. B Oitis externa is associated with swimming and there should be some discharge from ear and hearing impairement. All the signs are present in glue ear except fever. 80% presents with hearing loss. Irrelevant here. Herpes zoster which have signs of blister and pustules around the preauriclar area. A- Otitis media. C D E KEY 71 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Additional Information 72 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Reference Dr Khalid/Rabia Q: 1384 A 72yo male who is a regular smoker has come to the ED with complaints of loss of weight and loss of appetite. He also complains of odynophagia. Exam: actively bleeding ulcer on right tonsil. What is the most appropriate dx? a. Tonsillar ca b. Vincent angina. c. Irritant ingestion d. Paracoccidiodmycosis e. Herpes simplex infection Clincher(s) A B C D E KEY Smoker and odynophagia. Actively bleeding. Correct diagnosis is tonsillar carcinoma. Vinvent angina is tooth abscess Irritant ingestion is associated with corrosive intake. Fungal inflammatory infection. Cause of primary oral infection, signs are herpes labialis, gingivostomatis, pharyngitis. Key A 73 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal Additional Information Reference Dr Khalid/Rabia Q: 1385 A pt with regular episodes of SNHL, vertigo and tinnitus lasting >30min. Neurological exam=normal. What is the likely dx? a. Meniere’s disease b. Acoustic neuroma c. Otosclerosis d. Benign positional vertigo e. Labrynthitis Clincher(s) A B C D E KEY Additional Information Episodes of SNHL vertigo and tinnitus, neurological examination is normal. Correct diagnosis. There should be unilateral progressive unilateral sensorineural loss. Otosclerosis is an autosominal dominant with incomplete penetrance in which vascular spongy bone is replaced with lamellar bone of otic capsule origin particularly around the oval window which fixes the stapes footplate. Disorder of semilunar canal of ear, A- Meniere’s disease. Reference Dr Khalid/Rabia Q: 1410 A 35yo man has been given a dx of allergic rhinitis and asthma. Exam: peripheral neuropathy with tingling and numbness in a glove and stocking’s 74 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal distribution. Skin elsions are present in the form of tender subcutaneous nodules. The pt is responding well to corticosteroids. What is the single most appropriate dx? a. AS b. Churg-strauss syndrome c. Crytogenic organizing d. Extrinsic allergic alveolitis e. Tropical pulmonary eosinophilia Clincher(s) A B C D E KEY Additional Information Allergic rhinitis, asthma, peripheral neuropathy with tingling and numbness in glove and stocking’s distribution. B- Churg-strauss syndrome. churg- strauss syndrome. allergic rhinitis with asthma points towards the diagnosis of churg strauss syndrome. mnemonic : BEAN SAP BE: Blood Eosinophilia A : Asthma N : Neuropathy (mononeuritis multiplex) - usually common peroneal nerve S : Sinus abnormality A : Allergies P : Perivascular eosinophils / vasculitis Churg Strauss Syndrome A triad of adult-onset asthma, eosinophilia, and vasculitis (± vasospasm ± MI ± DVT), affecting lungs, nerves, heart, and skin. A septic-shock picture/systemic inflammatory response syndrome may occur (with glomerulo nephritis/ renal failure, esp. if ANCA +ve). Presentation: The physical findings are specific to organ system involvement. There are three phases: Allergic rhinitis and asthma. Eosinophilic infiltrative disease, such as eosinophilic pneumonia or gastroenteritis. Systemic medium and small vessel vasculitis with 75 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal granulomatous inflammation. Investigations: Antineutrophil cytoplasmic antibodies (ANCA): 70% of patients are perinuclear staining (p-ANCA) positive (anti myeloperoxidase antibodies).Other likely findings include eosinophilia and anaemia on the FBC; elevated ESR and CRP; elevated serum creatinine; increased serum IgE levels Treatment= Steroids; biological agents if refractory disease, eg rituximab. Reference Dr Khalid/Rabia Q: 1447 A 29yo woman has developed and itchy scaly rash particularly over her wrist with fine white streaks overlying the lesion. Her nails have ridges and her buccal mucosa is lined with a lacy white pattern. What is the single most likely dx? a. Psoriasis b. Scabies c. Urtericaria d. Dermatitis herpetiformis e. Hyperthyroidism f. Lichen planus Clincher(s) Scaly itchy rash over wrist and nails and buccal mucosa is lined with a lacy white pattern. A B 76 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal C D E KEY Additional Information F- Lichen Planus. Reference Dr Khalid/Rabia Q: 1504 A 10yo boy develops nasal bleeding. What is the best way to stop the bleeding from the nose? a. Pressure over base of the nose b. Ice packs c. Pressure over the soft tissues d. Nasal packing e. Surgery Clincher(s) A B C D E KEY Additional Information C- Pressure over the soft tissues. The classification of nosebleeds is as anterior or posterior, depending upon the source of bleeding. The blood supply to the nose is derived from branches of the internal (anterior and posterior ethmoid arteries) and external carotid arteries (sphenopalatine and branches of the internal maxillary arteries). Bleeding usually occurs when the mucosa is eroded and vessels become exposed and subsequently break. Epistaxis is usually benign, self-limiting and spontaneous. The majority are caused by simple trauma. Although most incidents are not life-threatening, they can cause significant parental concern when they occur in children. Management of epistaxis: Resuscitate the patient (if 77 ENT-System Wise 1700-by Sush and Team. 2016 Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal necessary) - remember the ABCD(E) of resuscitation. Ask the patient to sit upright, leaning slightly forward, and to squeeze the bottom part of the nose (NOT the bridge of the nose) for 10-20 minutes to try to stop the bleeding. The patient should breathe through the mouth and spit out any blood/saliva into a bowl. An ice pack on the bridge of the nose may help. Monitor the patient's pulse and blood pressure. If bleeding has stopped after this time (as it does in most cases) proceed to inspect the nose, using a nasal speculum; consider cautery. If the history is of severe and prolonged bleeding, get expert help - and watch carefully for signs of hypovolemia. Reference Dr Khalid/Rabia 78