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OSCE NOTES IN
OTOLARYNGOLOGY
Resource you wish you had
6/23/2010
Otolaryngology online
Dr. T. Balasubramanian
www.drtbalu.co.in
Preface
All over the world the examination pattern for medical students is undergoing a sea
change. The basic idea is to make the evaluation process more comprehensive and
objective. OSCE pattern of clinical examination is being implemented almost all
over the world. To my surprise there are very few resources available for the students
to help them to face this examination with confidence. Eventhough excellent
textbooks and reading materials are available for various medical disciplines OSCE
based exercises that are available to the students to practice are far too few.
In order to help the students I am publishing this e book titled “OSCE Notes in
Otolaryngology”. This book can be freely downloaded and used by the students of
otolaryngology.
You are also welcome to visit this website which is totally dedicated to OSCE
exercises in otolaryngology. In fact you will find this site being constantly updated
for your benefit: http://oscenotesent.wikidot.com/start
Dr. T. Balasubramanian
3
Introduction:
www.drtbalu.co.in
Greeting a patient will increase his trust and confidence in you.
Limitations of OSCE:
Any examination method0logy is not foolfroof. Similarly even OSCE also has its
own limitations.
1. Observer fatigue (Examiner in this case)
2. It is difficult to evaluate overall competency of a student
3. Considerable care should be taken while setting up the examination cubicles as
each of the candidate should spend only 4-5 minutes within a cubicle.
The following points should be borne in mind while setting up these examination
cubicles:
1. The questions should be objective in nature
2. The language should be simple and clear
3. There should be standardization i.e. steps to be evaluated, their relative weightage
in terms of marks, and time required to answer the questions posed.
4. Assessment of a student's understanding of theoretical concepts, his skill of
observation and interpretation of signs should also be tested by designing cubicles
which could serve this purpose effectively.
5. Supplemental questions on radiology, graphs, diagrams, specimen should also be
given
6. The examniers should be provided with all the material required, questions, key
sheet containing answers and mark distribution, and a detailed instruction chart on the
steps to be evaluated
7. Students and examiners should be throughly briefed
8. The number of stations should be clearly mentioned at the entrance of the
examination hall
9. Time alloted to each station should also be clearly mentioned
10. Bell should chime the start and end of a station
11. Students should proceed in only one direction
12. In general negative marks are not awarded in this examination pattern
Otology
1. Round window
2. Stapedial tendon
3. Pyramid
4. Long process of incus
1. Nasopharyngeal carcinoma
2. Following adenotonsillectomy (Iatrogenic)
3. Cleft palate
Comment on ear discharge of this patient
What could be the possible diagnosis ?
1. Scanty
2. Foul smelling
3. Blood tinged (sometimes)
4. CSOM with attic cholesteatoma
1. Tympanosclerosis
2. Due to resolved otitis media
3. Trauma
4. Grommet insertion (Iatrogenic)
65 years old man
Known diabetic for 15 years on poor glycemic control
c/o pain left ear - 1 month
Blood stained discharge from left ear - 1 month
Tragal tenderness left side - 15 days
Inability to close left eye - 10 days
Otoscopic finding:
22 year male patient came with c/o swelling over right pinna - 4 days
Mild pain ++
No h/o fever
Name the possible pathology
How will you manage this condition ?
Aural seroma
Needle aspiration with application of compression dressing to prevent
reaccumulation.
30 year old male came with swelling & tenderness over right parotid area - 3 days
duration
H/O Right ear discharge on and off - 3 months.
How could the infection from ear spread to the parotid gland ?
Spread of infections from mastoid and vice versa can occur through fissures of
santorini.
This fissure is present over the cartilagenous portion of the external auditory canal.
Name the incision shown above
Why is this area preferred ?
This is endaural incision used for mastoidectomy.
This area is devoid of cartilage.
30 years old male patient came with complaints of foul smelling discharge from his
right ear - 10 days.
He also complained of mild pain in the right ear. Itching ++ in right ear.
Otoscopy picture is seen below:
Comment on the otoscopy picture. What could be the possible diagnosis?
Otoscopy picture shows a tongue of granualtion tissue over the inferior quadrant of
the ear drum.
Ear drum is probably intact.
Diagnosis - ? Myringitis granulosa.
Mobility of ear drum should be tested to rule out ear drum perforation.
12 years old female patient came with c/o swelling in front of right ear 4 years
duration.
This CT scan temporal bone axial view shows longitudinal fracture of temporal bone
Haematoma could be seen filling the middle ear cavity
These patients commonly manifest with conductive deafness due to the presence of
hematoma in the middle ear, or disruption of ossicular continuity.
This 30 year old patient had C/O left ear discharge - 5 years
Discharge was scanty, blood tinged and foul smelling
Axial CT (plain) of temporal bone is displayed
1. Identify the pathology
2. Why is the discharge foul smelling ?
This CT shows erosion of the outer attic wall on the left side.
This could most probably be due to cholesteatoma.
Foul smelling discharge is caused due to bone erosion
10 year old boy with h/o grommet insertion left ear one month back.
C/O pain in the left ear
Pt underwent CT scan
This CT scan brain shows hypodense mass in the right temporal lobe. This mass is
surrounded by thickened capsule. Probable diagnosis is temporal lobe abscess.
Commonest cause of temporal lobe abscess is chronic suppurative
otitis media.
For grommet incison where will you site the incision ?
What should be the direction of the incision ?
Grommet should always be sited in the antero inferior quadrant close to the
eustachean tube orifice for better ventilatory function.
Incision should be made along the line parallel to the radial fibers of the ear drum.
This will enable the radial fibers to hug the grommet in position. The drum also will
heal well after extrusion of the grommet.
What is the focal length of the objective lens in a microscope used for otological
surgeries ?
Name the major advantage of microscope in otological surgery ?
What is the of magnification used to examine the ear drum ?
200 mm
Both hands are free
6X
Cortical mastoidectomy
1. Posterior canal wall (bridge)
2. Incus
3. Fossa incudis
4. Aditus
5. Mastoid cavity after exenteration of air cells
Name the incison used in this surgery
Name the instrument used
Name any two surgical procedures where this incision is used
Rosen's trancanal incision
Rosen's knife
Myringoplasty
Stapedectomy
Name the
type of
tympanoplasty procedure illustrated
What are the prerequisites for this procedure ?
The diagram shows Type I tympanoplasty.
Prerequisites for Type I tympanoplasty are:
1. Presence of mobile ossicles
2. Patent eustachean tube
3. Perforated ear drum
What is this image?
It is a tympanometry recording showing Type a curve.
What does this curve indicate?
This curve Suggests normal middle ear function. The compliance peak occur between
-150 - +100 dapa. The value of compliance ranging between 0.2 - 2.5 millimhos. This
type of curve is also known to occur in early stages of otosclerosis.
Name the cranial nerves whose functions can be tested by using Impedance
audiometry:
7th cranial nerve and 8th cranial nerve functions can be tested by performing this
investigation.
Tympanometry
Eustachean tube function
Acoustic reflex threshold
Acoustic reflex decay
Tests to identify perilymph fistula
Name the pathologies that can be identified by performing the battery of tests under
Impedance audiometry:
It is a Type As curve. This curve suggests a stiffened middle ear system. As shown
in the figure the compliance value is less than 0.2 mmhos. Commonly this curve is
seen in patients with glue ear / otosclerosis.
Examination of a patient with unsafe ear:
The following points should be borne in mind while taking the history:
Smell emitted by the discharge – Ear discharge in patients with cholesteatoma is foul
smelling (usually musty in odor). It is always prudent to clean the patient's ear with a
cotton swab and physically smell it. Foul smelling discharge is due to the presence of
gram negative and anerobic organisms. Osteitic reaction of the scutum also adds to
the offensive smell.
C/O Head ache with vomiting should be viewed with caution in these patients as it
would indicate intracranial complications.
These patients very rarely complain of hard of hearing. This is because of the fact
that the cholesteatoma mass itself may bridge the defect caused due to ossicular
erosion and could conduct the sound to the oval window. Even audiogram when
performed may show normal or near normal curves.
Pain in the ear in these patients is commonly caused by coexistant otitis externa due
to attempts at cleaning the ear by the patient.
On examination:
This is a Type Ad curve. This curve suggests flaccid ear drum, ossicular chain
disruption etc. The compliance value is more than 2.5 mmhos and may go off the
chart itself.
Shown here is the CT scan (axial cut) of petrous bone area showing glomus jugulare
as marked there. How do you differentiate it from high jugular bulb and aberrant
internal carotid artery?
In patients with glomus jugulare and high jugular bulb the jugular fossa is enlarged.
But in glomus jugulare the cortex of the jugular fossa appears eroded while in
patients with high jugular bulb this erosion is not seen.
To rule out aberrant carotid artery a coronal CT of temporal bone is a must. If the
carotid canal is normally placed then glomus tympanicum should be considered,
whereas if the same is placed laterally then aberrant internal carotid artery is a good
diagnostic possibility.
O/e:
Ear drum on both sides appeared normal. They also showed normal mobility on
siegalization.
10 years old boy came with a reddish granular mass in the right nasal cavity - 4 years
He gave h/o bleeding from the mass
What could be the probable lesion ?
Name the causative organism ?
How is this disease transmitted ?
Name the drug which can be used in this condition to prevent recurrence of the same after surgery
Rhinosporidiosis
This is caused by Rhinosporidium seeberi ( ? Probably a fungus)
It is transmitted by taking bath in common ponds along with cattle
Dapsone is the drug which is used to prevent recurrence following surgical removal
This patient came with c/o swelling over left forehead - 15 years duration
Swelling over left orbit - 20 years duration
Enumerate the clinical findings
What could be the possible diagnosis ?
1. Soft boggy swelling over left forehead.
2. Proptosis with left eye pushed downwards and outwards
3. Ocular movements full / vision normal
Possible diagnosis : Frontoethmoidal mucocele left side
Infections involving nose and paranasal sinuses could cause this condition.
Commonly fungal infections of nose and paranasal sinuses cause this condition.
10 years old child came with c/o nasal block both sides since birth.
Dryness of mouth since birth.
Foul smelling nasal discharge both sides.
CT scan picture showed:
35 years old female patient came with c/o watery discharge from left nasal cavity - 3
years
H/O fever with rigor on and off - 1 year
Head ache on and off - 1 year
You are seeing a coronal ct scan picture of the patient.
Comment on the ct.
How to manage this patient?
Coronal ct shows defect in the cribriform fossa on the left side.
The patient is having csf rhinorrhoea.
Prophylactic antibiotic therapy and closure of csf leak is the ideal managment
modality.
15 year old boy presented with bleeding from right nose - 1 month
Swelling just below the medial canthus of right eye - 15 days
Anterior rhinoscopy showed reddish friable mass occupying the right inferior meatus.
CT scan coronal cut showed:
It shows an expansile lesion involving right maxilla. Lateral wall of maxilla is found
to be eroded.
The floor of the orbit (R) is also eroded with extension of mass into right orbit.
Probable diagnosis could be Malignant growth right maxilla.
Since the patient has kept his mouth open during xray, there is no trismus and hence
pterygopalatine fossa
may not have been involved.
1. What is the name of this surgical procedure ?
2. Name the instrument being used
3. Name one important complication of this procedure
Reduction of fractured nasal bone.
Welsham forceps
Orbital injury
It is performed by applying pressure over eyeball and seeing the bulging movements
of medial orbital wall.
This test is positive in patients in whom lamina papyracea is eroded.
It tells the surgeon on the table that the medial wall of the orbit is lost and the orbital
fat is just a pick away.
Name the structures marked 1 and 2.
1 is type I frontal cell
2 is widened maxillary sinus ostium
Laryngology
In tracheostomy
Where is the exact site of tracheal incision ?
What surgical blade is optimal for this purpose ?
Incision is sited between the 2nd and 3rd tracheal rings.
11 or 15 blade is preferred
What is the name of the flap created ?
What is its advantage ?
It is known as Bjork flap. It is an inferior based flap.
Creation of this flap during tracheostomy helps to prevent tracheal stenosis
This is known as Steeple's sign (The tracheal air column resembles the pointed
steeple of a church)
This sign is a classic feature of acute laryngotracheal bronchitis.
Lateral view neck will help us to rule out acute epiglottitis, if not excluded already
clinically.
This narrowing occurs in the proximal 1 cm of trachea and may extend up to the level
of true cord
Comment on this MRI scan
What can you do for this patient?
This is a MRI scan neck lateral view.
Tracheal stenosis could be seen just below the level of cricoid cartilage.
Tracheostomy tube in situ.
Air column adequate below the tracheostome.
Resection of the stenosed segment of the trachea with anastomosis is the treatment of
choice.
Anastomosis should not be performed under tension. Tracheal lengthening
procedures like laryngeal drop may be performed.
Read the given CT scan.
If it is a malignant lesion what could it be?
This 30 years old female patient came with c/o hoarseness of voice - 6 months
duration.
She gave no h/o voice strain / abuse.
She gave no h/o repeated URI.
Videolaryngoscopic image is given above.
What is yr impression?
What could be the optimal treatment modality?
This patient appears to be having a cyst in the right vocal cord.
Probably it is a cordal cyst.
Treatment is by microlaryngeal marsupialization of the cyst.
Name the incision shown in the picture.
Name the surgery in which this incision is used.
This image shows a Lazy Man S incision.
This incision is used while performing superficial / total parotidectomy