ENT PAST YEARS QUESTION ACCORDING TO TOPICS

Short form = Sx- Symptom ;CP (clinical picture),Mx(management),Dx(diagnosis),Rx(treatment) ; Ix = investigation Topic EAR
1.

Basic Anatomy & Physiology of Ear

-causes of referred pain to ear** along any of the following nerves: 1. trigeminal (V) 1) nose & sinuses: acute sinusitis (ant. group) 2) teeth and gums: i) impacted wisdom tooth ii) dental caries and abscesses 3) temporomandibular joint disfunction 4) nasopharynx: post-adenoidectomy, nasopharyngeal carcinoma 5) trigeminal neuralgia 6) Floor of the mouth: ulcer or tumors 7) trigeminal neuroma 2. facial (VII): Bells palsy 3. glossopharyngeal (IX): 1) Tonsils: i) acute follicular tonsilitis ii) Quinsy iii) post-tonsillectomy 2) Palate and oropharynx: herpetic eruption or ulcer 3) Post 1/3 of tongue base: malignant tumors 4) Glossopharyngeal neuralgia 4. vagus (X) 1) T.B. laryngitis 2) crico-arytenoid arthritis 3) laryngeal trauma 4) laryngeal and hypopharyngeal carcinoma 5. C2 and C3 1) trauma to the cervical spine 2) cervical spondylosis 3) occipital neuralgia etc... *3 neuralgias. -referred otalgia by glossopharyngeal n (see previous question)

2.

Audiology & vestibular evaluation

-give an account on tuning fork hearing test

3.

Diaseas of external ear

-give an account on ear wash (see 3 questions below :) ) -complications of ear wash******
1. Vertigo, nausea, and vomiting - dt. caloric stimulation of inner ear 2. 3. 4.

5. 6.

(lat. semicircular canal) Cough and syncope - dt. vasovagal attack More impaction of the wax plug or FB Traumatic rupture of tympanic membrane - there is sharp pain and slight bleeding in the ear and the patient may feel water passing to his throat. Trauma to the skin of the external canal - this also causes pain and bleeding from ear but the ear drum is intact. External otitis - dt. contaminated instruments

-indications of ear wash**

wax plug foreign body except: o vegetable foreign body o impacted FB o animated (insect) scaly debris otomycosis ear discharge

-contraindications ear wash

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

-etiology & clinical picture of malignant otitis media

4.

Acute otitis media

-etiology,Cp,Mx ASOM**
Dis ASOM organism Moraxella Catarrhalis, H influenza, Strept Pneumonia CP signs 1. Occlusion: retracted congested memb (cart wheel)->c/o : fullness, earache, fever. 2. Catarrhal OM: retracted memb, distorted/loss of cone of light, handle of malleus prominent, foreshortened, more horizontal, conductive HL-> : increase ear ache, fever 3. Suppuration OM: loss of landmarks, reduced mobility, absent cone of light, yellowish spot, mastoidism - : severe throbbing pain, high fever 4. Resolution (after rupture): relief of symptoms, central rounded perforation, mucopurulent odorless discharge ->mucopurulent odorless discharge, relieve fever, pain. Rx 1. analgesics 2. antibiotics Before perforation warm glycophenol preparation myringotomy* After perforation cleaning local antibiotics culture and sensitivity

-indications of myringotomy 1. in AOM before perforation: 1) adequate medical treatment but no improvement in 48 hrs 2) severe otalgia and high fever 3) complication from the start eg. facial palsy 4) yellowish colour and bulging 5) patient is immunocompromised or is a premature baby 2. in AOM after perforation: very tiny hole with inadequate drainage (kalau ada lagi sila tambah) * asal dah perforate pun nk myringotomy? -types & Rx of tympanic membrane perforation
5.

Chronic suppurative OM

-types & complication of cholesteatoma types:

congenital acquired o 1ry o 2ry

complications (same macam CSOM kan?)

cranial o mastoiditis, mastoid abscess o petrositis o labyrinthitis o VII paralysis o osteomyelitis temporal bone intracranial o extradural, subdural, brain, temporal lobe, cerebellar ABSCESS o meningitis o lat sinus thrombosis o otitic hydrocephalus extracranial o ext otitis o lymphadenopathy

-CP & Rx of uncomplicated CSOM**

CSOM (safe)

gram positive bact

central perforation, odorless, intermittent, profuse mucopurulent discharge middle ear mucosa thick and edematous/normal polyp rarely NO GRANULATION TISSUE/ CHOLESTEATOMA Rinnes +ve Weber lat towards diseased PTA: CHL

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

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

otorrhea: scanty, purulent, continous foul odour cholesteatoma* polyp common

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

-Rx of CSOM CSOM (safe)

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

CSOM (unsafe)

atticotomy closed mastoidectomy open mastoidectomy radical mastoidectomy

-table of differentiation between safe & unsafe CSOM (boleh refer buku m/s 54)
Safe type (tubotympanic) 1ry site of infection discharge 1. eustachian tube 2. tympanic cavity 1. intermittent 2.odorless 3. profuse 4. mucopurulent central no unsafe type (attico-antrum) 1. attic 2. post wall of middle ear 3. antrum 1. continuous 2. offensive odour 3. scanty 4. mucopurulent/purulent 1. post-sup marginal 2. attic present

perforation cholesteatoma

granuloma and polypi deafness x-ray tre

uncommon -CHL -mild to moderate cellular mastoid 1. medical 2.

commmon -CHL or mixed - moderate to severe acellular mastoid (sclerosed) 1. modified radical mastoidectomy 2. tympano mastoidectomy 3. intact canal wall mastoidectomy 4. radical mastoidectomy

6.

Complication OM

-enumerate intracranial complication

1. 2. 3. 4. 5. 6.

extradural abscess subdural abscess brain abscess : temporal lobe and cerebellar lateral sinus thrombosis meningitis otitic hydrocephalus

-Cp of acute mastoiditis Symptoms:

Fever Increasing earache Profuse mucopurulent discharge

Signs:
1. In the stage of acute mastoiditis:
o

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

o o

Tenderness and redness over the mastoid Sagging (edema) of the postero-superior wall of the bony external ear canal due to periosteitis

2. When the post-auricular develops:

o o

Post-auricular swelling The auricle is pushed outwards and downwards

3. When the post-auricular abscess ruptures:

o

Mastoid fistula develops draining mucopus

-type of mastoid abscess**

-enumerate cranial complication

1. 2. 3. 4. 5.

Acute mastoiditis and mastoid abscess (most common) Petrositis Labyrinthitis Facial paralysis Osteomyelitis of the temporal bone

-table of difference between acute mastoiditis & furunculosis** acute mastoiditis age history children 1) upper respiratory infection 2) acute otitis media 1) mucopurulent 2) profuse 3) maybe reservoir sign over mastoid process sagging of the post-sup wall leading to narrowing furunculosis any age 1) scratching of the ear 2) Diabetes 1) purulent 2) scanty 3) thick over the tragus and on pulling the ear narrowing of the outer cartilaginous

discharge

tenderness otoscopy

of the inner bony part of the external canal deafness conductive hearing loss not relieved by insertion of speculum maintained (due to attachment to the periosteum) upper if there is zygomatic abscess strept hemolyticus

part of the external canal conductive hearing loss relieved by insertion of speculum flat

postauricular groove edema of the eyelids culture and sensitivity testing x-ray of mastoid

lower only if present staph aureus

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

normal

-type of mastoidectomy -enumerate complication of CSOM,give details about lateral sinus thrombophlebitis -Rx of acute mastoiditis
7.

Ear related facial n paralysis

-diagnostic feature of different level of facial palsy/how to define level of facial pasly** -etiology/causes of facial palsy**
8.

Hearing loss & tinnitus

-causes of conductive hearing loss**** 1. Causes in external ear a. Congenital e.g. congenital meatal atresia b. Acquired i. Impacted wax (most common in adults)

FB Inflammatory: furunculosis, otomycosis Neoplastic: exostosis 2. Causes in tympanic membrane . Stiffness: tympanosclerosis or fibrosis of TM a. Perforation 3. Causes in middle ear . Vacuum: ET dysfunction/occlusion a. Fluid: CSF, serum, mucus, pus, blood b. Adhesions c. Soft tissue . Tumors: glomus tumor i. Cholesteatoma d. Ossicular pathology e. Fixation: otosclerosis f. Disconnection incudo-stapedial or incudo-malleal joints

ii. iii. iv.

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

Disease of inner ear & acoustic neuroma -Mx of menieres disease **** -CP & invest to dx acoustic neuroma -full account on menieres disease(pathology,CP,invest,Rx) ** Pathology

Accumulation endolymph causes distension and rupture of membranous labyrinth This lead to leakage endolymph into perilymphatic spaces and results into suppresion neural elements of labyrinth Membranous rupture responsible for recurrent episodic vertigo and hearing loss Rupture heals symptoms subside

9.

Middle ear effusion,glomus tumor,otosclerosis

-CP of secretory OM ** -Etiology & Mx of secretory OM -Dx & Rx of secretory OM -CP & Rx otosclerosis
10.

Vertigo

-etiology & how to Dx vertigo ** -investigation in dizzy patient Topic NOSE

1.

Anatomy,physiology nose,choanal atreasia

-function of nose & paranasal sinuses Nose : 1. airway 2. air conditioning 3. reflex 4. olfaction Paranasal sinuses : 1.resonance voice 2.air conditioning 3.light wt skull 4.buffer head trauma 5.secretion for mucociliary blanket nose 6.thermal insulators

2.

Allergy & nasal polypi

-types,CP,Mx of nasal polypi****** Types

1Solitary (ACP) 2Multiple (diffuse nasal polyposis,middle meatal polyposis) CP 1Long history AR or VMR 2Symp (nasal obs x relieve compltely by VC,hyposmia) 3Signs (polyp-bilat,multiple,pale,soft gelatinous masses,smooth)(pale,edema mucosa) Mx 1cp 2Ix (CT-plan surgical Rx) 3Rx AR or VMR 4Drug: top steroid.oral antiH 5Surgery : bilat complete obs (simple polypectomy,endoscopic polypectomy w ethmoidectomy) -Rx of antrochoanal polyp
o o

middle meatal antrostomy sublabial antrostomy caldwell-luc approach

-Dx & Rx allergic rhinitis Dx 1Hx : FH , environment , occupation , sp habit , seasonal variants 2CP : Symp (sneezer,runner,blocker,hyposmia,itchy throat,irritant cough,itching,watery eyes) signs (pale.moist.edema mucosa,hyperT inf turbn8,polyp)(allergy salute,shiner,gap) 3Nasal smears : eosinophilia 4Bld exam : IgE,eosinophilia 5Skin test 6Nasal challenge test :spfc Ag to nasal mucosa 7RAST : circulating Ab for spcfc Ag Rx 1Avoidance : most important 2drug (top steroid,oral antiH,top antiH,top Na+ cromoG,oral steroid) 3hyposensitization : blocking Ab IgG 4surgery : better avoid,limited role ONLY relieve gross nasal obs or open significant obs drainage sinus -give an account on diffuse nasal polyposis
3.

Rhinitis,nasal obstruction

-causes of nasal obstruction

Bilateral:CC n TT

NaSAL CAUSE Congenital choanal atresia Rhinusitis ( common cold ) Nasal polyp / nasal allergy Trauma = septal hematoma, foreign body Tumour = SCC, inverted papilloma NASOPHARYNGEAL CAUSEs adenoide nasopharyngeal carcinoma nasopharyngeal fibroma Unilateral ..CDDATT COngenital choanal atresia Deviated septum Dental maxillary sinusitis Antrochoanal polyp Tumours Trauma = fb / fracture.

-unilateral NO-etiology & investigations** Etiology:CDDATT 1.congenital choanal atresia 2.deviated septum 3.dental maxillary sinus 4.trauma 5.tumors Investigation 1.Specific scoring system bout patency of the nasal airways 2.Acoustic Rhinometry

4.

External nose & nasal septum

-Dx & Rx of nasal septum deviation **

5.

Epistaxis

-local Rx of epistaxis 1) Nose packed for 10min with cotton soaked in epinephrine and xylocaine. 2)when the bleeding stop well find the bleeding point and do cautery (chemical by silver nitrate, electrical, diathermy)

2) anterior nasal packs ( gauze soaked with vasline and ab ointment left for 24h) 3) post nasal pack ( epistaxis of nasopharyx origin - post adenoidectomy, angiofibroma, carcinoma) 4)nasal balloooon-ant nasal -causes of epistaxis(local & systemic)*** LOCAL a) Congenital oslers disease b) Deviated septum c) Idiopathic commonest d) Inflammator y rhinitis( atrophic , acute ) e)Traumatic nose picking.FB,fracture f) Tumour malignant ,bleeding poolypus GENERAL a) Blood disease hemophilia,purapura n leukaemia b) Hypertension COMMONEST in old age c) Raised venous pressure mitral stenosis / mediastinal syndrome d) Drug salicylate , anticoagulant e) Hormonal -pregnancy f) Fever g) High altitude -systemic causes of epistaxis -local causes of epistaxis** -Mx of severe epistaxis*** - Endoscopic cautery of sphenopalatine artery - CLipping [ maxillary artery / ant ethmoidal artery ] -Mx of epistaxis*** First aid measure: - Ask patient to incline forward and breath tru the mouth - squeezing the ala of the nose as it will compress the sphenopalatine artery thus will help to decrease bleeding / stop bleeding - put ice compresses to the bridge of the nose will lead to reflex VC nasal mucosa - place nasal pack or nasal drop in the nose to induce VC General Measure in the hospital: - check BP and other vital sign

- apply anti shock measure - coagulant n other medication may be given Local Measure: a) Anterior epistaxis - Nasal pack with vasocontrictor - cautery ( chemical cautery by silver nitrate ; galvanocautery ; coagulation diathermy ) - Ant nasal pack with vaselin n Ab for 24-48H to guard against TSS and sinusiti. b) Post epistaxis -post nasal pack with vaseline and aB -post nasal balloons c) Superior epistaxis: -ant. nasal packing if those measure cant control the bleeding, proceed to: - Endoscopic cautery of sphenopalatine artery - clipping [ maxillary artery & ant. ethmoidal art )
6.

Sinusitis

-indication maxillary sinus puncture

Diagnostic: - To confirm present of infection in the sinus - Instillation of the radiopaque material to do radiologic examination - For culture and sensitivity procedure - Cytological examination Theraputic: - Rx the subacute and chronic rhinosinusitis if not respond to medical rx. - fungcal sinusitis - barotaraumatic sinusisit

-enumerate complication acute sinusitis** -Dx & Rx chronic maxillary sinusitis

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

-CP acute sinusitis

Symptoms :

1Pain a) Maxillary sinus = below the eye, cheek , refer to the temporal and frontal and upper teeth region. b) Frontal sinus = above the eye , forehead c) Ehtmoidal sinusitis = on the bridge of the nose, in the between of th eye, and refer to the parietal region. d) Sphenoid sinusitis = deep seated pain ; Vault.occipital.mastoid region and behind the eye as this sinus is posterior sinus. rigth? 2Nasal obs 3Nasal discharge n postnasal (mucopurulent/purulent/offensive odour) 4Fever malaise

Signs : 123457.

Tender Swelling Middle meatal discharge Postnasal discharge Redness edema nasal mucosa

Sinonasal tumor

-stage of rhinoscleroma***
Character Granulomatous stage -submucosa infiltrate by lymphocyte and plasma cells. Miculikz cell: large vacoulated foam cell containing scleroma bacillu Russell bodies: Eosin staining degenerated plasma cells.precursor: motts cell. Cellular infiltration replace by fibroblast and dense fibrous tissue giving rise to hardness C/P Firm pale pink granulomatous mass Coalesce together forming Hebra nose.

Fibrotic

The nasal cavities are narrowed n obliterated External deformities are commonly present Mucosa pale&atropic Nasal cavity roamy and contain crust

Atrophic

Atrophy of epihtelium and seromucinous gland

-CP of rhinoscleroma
1.granulomatous type- nasal cavity show firm pale pink granulomatous masses, masses coalesce together extend to external nose & upper lip forming Hebra nose 2.Atropic type- mucosa pale & atropic, nasal cavity roomy & contain crust 3.Fibrotic type- nasal cavities narrowed & maybe obliterated. External deformities commonly present
8.

Rhinorrhea,smell disorder,headache

-discuss disorder of smell

-causes of hyposmia & anosmia** -etiology of anosmia 1.conductive anosmia 2.Perceptive anosmia Topic PHARYNX
1.

Nasopharygeal swelling

-enumerate NP swellings*** 1ry cystic 1. Midline : cong thornwald cyst rathke pouch cyst : acq intra adenoidal retention cyst 2. Lateral : cong branchial cyst,dermoid cyst : acq seromucinous ret cyst Solid 1. Benign : adenoid,NPangiofibroma,inverted papilloma,other(teratoma.neurofibroma.paraP abs) 2. Malignant : NPC 2ry Antrochoanal polyp nasal fibroma meningo encephalocele -CP of NP angiofibroma*** 1. Unilat nasal obs 2. Unilat severe epistaxis 3. Unilat nasal mass 4. Frogface deformity(broad nose.proptosis.swelling cheek) Typically in young adult male -CP of NP carcinoma*** (advance)* 1. UE enlarge Cx LN 2. UE unilat OME (ear ache deaf) 3. UE multiple CN palsies (opthalmoplegia,facial pain,pharynx or larynx paralysis) 4. Nasal obs n epistaxis 5. Trotter triad (immobile uvula,facial pain,unilat CHL) 6. Metastasis (hemoptysis,bone ache) -types & CP of NP swelling -Dx & Rx of NP carcinoma** Dx:
o

indirect nasopharyngostomy

o o o

direct,flexible fibroscopy imaging:CT,MRI measure anti EBV..increase 90%

Rx
o o o

radiotherapy +/- chemo NB; surgery is limited due to early spread and involvement of base of skull indication of surgery: radical neck disection to ensure more successful control of 1ry radiotherapy

2.

Adenoid & adenoidectomy

-Rx of post adenoidectomy bleeding -complication of adenoidectomy*** 1. Bleeding (excess curett or aberrant vsl) 2. Cautery burn 3. Dental injury (intubation or mouthgag) 4. ET injury (torus tubarius) 5. NasoP stenosis (excess removal tissue) 6. Atlantoaxial sublux (grisel syndrome-> torticollis 1-2w after) 7. Lingual n injury (moth gag or tounge blade press) 8. reGrowth (young pt) 9. Hypernasality (temp pain splinting) -CP of children with adenoids & Rx**** CP 1. Nasal obs (moth breath,nasal tone,diff suckling eat,snore) 2. MP nasal n postnasal discharge 3. Adenoid facies (open mouth,dry upper lip n gum,hitched upper lip,flat expressionless face,protrudrd incisors,inactive ala,receeding chin,high arched palate) 4. Sleep disturbance(snoring,OSA,nocturnal eneuresis,nightmare) 5. Feeding problem(indigestion,vomit,loss app) 6. Resp difficult(irritant cough,rec pharyngitis.laryngitis.chest inf) 7. Recurrent ear ache n deafness(recur OM n OME) 8. Skeletal change(pigeon chest) 9. Impaired mental performance(disturebed sleep,defect hearing,rec resp inf) 10. Egg white secretion behing soft palate + chr tonsil

Rx : adenoidectomy

3.

Diasease of tonsils(tonsilltis & t.ectomy)

-enumerate complications of tonsillectomy operation** Anasthetic Complication and local complication. -indications for tonsillectomy******* EIGHT INDICATION: a. Repeated att ac tonsilitis 7,55,333 b. Repeated att with chrn valvular dis and febrile seizure c. 1 att quinzy d. Chrinc tnsilitis xrespond to med Rx causing obstructive symptom(enumerate sdri) e. TB tonsil f. Beningn tumour tonsil eg fibroma g. sUSPICIOUS malignant tonsil h. removal tonsil as part of other operation

-routine investigation before tonsillectomy operation 1.Proper History taking .2.General examination Local ENT ex 3.Urine aanalysis,bld analysis.(enumerate sendiri) -DD membranous tonsils** 1. GabHs-yg causing acute tonsillitis kita belajar ni 2. Diphteria (must put first after acute tonsilitis,VERY IMPORTANT DDX,If remove membrane will bleed not like Gabhs) 2. IM 3. Scarlet fever 4. Glandular Fever 8. Angina Vincent 9. Agranulocytosis 9. Acute leukemia 8. Thrush 7. Behcet

-discuss indications,contraindications & complications of tonsillectomy

CONTRAINDICATION: 5 absolute,5 relative Absolute:Systemic disease eg. 1.Cardiac disease 2.Pulmonary dis eg TB 3.Hypertension Severe 4.Chronic rrenal insuff 5.Blood cogulapathy Relative: 1Acute tonsilits(tonsil tgh vascular!!) so Rx first because can cause severe bleedig and septicemia 2.Epidemic Polio 3.Rheumatic Fever 4.DM 5.ASTHMA +- Cleft Palate (can cause icompetenet velopharyngeal isthmus,see complication*) COMPLICATIONS. :anasthetic and operative(periop,i/m op,post op) ANASTHETHIC -cARdiac arrest -RESP arres -TOxicity -Intubation granuloma during ett (jgn lupa) Operative 1)pERI: 1.Primary HGE 2.mISHAPE,TRAUMA 2)IMMEDIATE POST OP: 1.REACTIONARY HGE 2.edema uvula(lupa nk bukak ligateion kat uvula) 4.Chest infection 5.DM,septicemia 6.Velopharyngeal incomp. (if has cleft plt) 3)LATE POST OP: 1.Liabilitiy to catch infction,thats whyl; 2.Secondary HGE (dt infection) 3.Dryness throat 4.Change voice

5.Palatal scaring 6.TOnsil remnant 7.GP neuralgia

4.

Snoring & OSA

-Rx snoring& OSA ( YOU CAN DIVIDE INTO CONSERVATIVE,SIMPLE NASAL,SIMPLE PALATAL,SEVERE ) 1.conservative treatment -ie.treat the risk factor[obsity-lose weight,alcohol-stop,smokinstop] 2.For SIMPLE nasal cause of snoring -medical treament -nasal appliances -nasal surgery 3.FOR SIMPPLe palatal cause of snoring -UPPP -LAUP -Palatal stiffening operation 4.Severe OSA -CPAP -TRACHEOSTOMY -Rx snoring sahaja macam mana ye?

5.

Pharyngeal & neck suppuration

-discuss acute retropharyngeal abscess*** DEF: *Suppuration in btw post ph wall and prevetbral fascia. ETIO: -Child,supp. of Henle node. -Adult,need imunocompromised+ trauma eg foreign body CP: -Fever(diff with chronic;no fever) -Dficult suckling and feeding -Neck rigidityso contraction is at the opposite site(diff with quinsy having spasm of sternomastoid!) -MIdline cystic sweeling UNILATERAL (because have bucopharyngeal and prevetbral fasscia adherence)

Ix -Xray lateral; 1.Thickening prevet tissue more than 50% of vetebra 2.Air in prevetebral soft tisue 3. Normal CUvature of spinal REVERSAL. Complication. Child may aspirate if rupture,cause death. Child may have laryngeal spasm or mediastinitis if spread. Rx. No anasthesia,usually relieve after vertical incision, POsition- HEAD MUST LOWERED DOWN,MUST USE SUCTION TO AVOID ASPIRATION(see DANGEROUS complication!!) systemic antibiotic +++IF AIRWAY COMPROMISE=TRACHEOSTOMY

-CP & Rx of quinsy**** CP: -Symptom: General-HIGH fever,malaise,headache etc Local-Sore throat with refred pain,odynophagia,halitosis,salivation. Sign: -Diff exam dt trismus -Cx LN swelling -Pain so spasm of sterno mastoid when u examine; -uvula edematous then push to midline. -soft palate above and lateral swell -tonsil go medially and downward -salivation acccum and coated tongue -CAN SEE POINT OF SUPPURATION! Treatment:(QUINSY U MUST DIVIDE Rx to PRE AND SUPP!) Local(pre suppurative)bed rest soft diet,hydration antibiotic analgesic

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

Sudden rupture & inhalation of pus can lead to chest complications Extension laterally leading to parapharyngeal abscess or downwards leading to laryngeal edema & stridor Internal jugular vein thrombophlebitis Pyemia & septicaemia (very rare)

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

6.

Neck swelling

7.

Hypopharyngeal tumor

-post cricoid tumor (CP,Dx,Rx)** SOALAN NI PARTICULARLY FOR POST CRICOID TUMOUR RIGHT? so CP: 1.DysphagiA-gradual and progressive,to solid food 2.Pain and refrred otalgia 3.Hoarseness of voice-infiltrate nerve,cricoarytenoid joint,muscle,or mass on vocal cord. 4.Neck mass-thyroid infiltration,LN metatastatisze (post cricoid is to para tracheal LN),extrahypopharyngeal extension 5.Hemoptysis 6.Weight loss,malignant cachexia,anemia 7.Halitosis-dt necrosis and extension to nasopharynx Dx: --History --Clinical picture

--Clinical examination; 1.Neck inspection and palpation -Laryngeal box-tender,edema,broader -Neck mass(dt causes mention above) -Moures click absent(fix to vet column alreadY) 2.Indirect laryngoscope;(using mirror,rigid 90 laryngoscope,flexible nasopahrygolaryngoscope) -see pooling of saliva,cord mvmnt,mass on cord 3.Direct laryngoscope with esopharyngoscopy -For biopsy -For detection of second primary tumour***** very important to do esophagoscopy to check wether esophagous have extension of tumour or not. --Lab Ix; -liver fx,blood count,iron -Imaging;CT,MRI,Barium Swallow **** -Metastatic work up TREATMENT: A..Curative 1.Surgery Primary-For post cricoid!! Total Laryngopharyngectomy + total/partial esophagectomy Secondary -Modified selective neck LN disection 2.Radiation/Chemo -if patitnet refuse surgery 3.Combined-maybe preop or post op B.Palliative -if already extensive metastatis c.Rehabilitiation -psychology -reconstruction ie.airway,food passage Airway reconstruction-Permanent tracheostomy Food passage-partial esophagectomy ie.(nnt tgok la) -Total esophagectomy(gold standard= gastric pull up,maybe colon transposition)

8.

Dysphagia

-enumerate causes of dysphagia in ENT

Oral cavity Mechanical cause 1. Cleft palate 2. Tumour of tongue/floor of mouth Pharynx 1. Web 2. FB 3. Post operative stenosis 4. Plummer Vinson`s synd. 5. Hypertrophied tonsils 6. Tumours oro/hypopharynx 1. Pharyngitis 2. Tonsilitis 3. ph.ulcer 4. ph. suppurations 1. ph.paralysis 2. ph.diverticulum 3. cricopharyngeus spasm Oesophagus 1. Inside lumen(FB) 2. In Wall (stricture, diverticulum, tumours) 3.Outside wall (goiter, mediastinal mass, vasc.compression)

Painful cause

1. Stomatitis 2. Ulceration 3. glossitis

1. Esophangitis 2. GERD

neurogenic

1. Palatal / tongue paralysis

1. Achalasia of cardia 2. Diffuse oeso.spasm.

Topic LARNYX
1.

Anatomy,physiology & congenital an larynx

-enumerate congenital anomalies of larynx & explain 1 of them laryngomalacia congenital web congenital cord paralysis congenital cyst (saccular cyst)(laryngocele) sub Glottic stenosis sub Glottic hemangioma LaryngoTracheo-Oesophageal cleft
2.

Paralysis of larynx

-etiology & Mx of recurrent laryngeal n paralysis

ETIOLOGY??

Mxdiagnosis by: -CBC n blood sugar

-ct scan from skull base to mediastinum -laryngoscopy visualising-nasopharynx,hypopharynx, larynx, esophagus,bronchial tree..take biopsy for any suspicious lesion Rx; unilateral recurrent laryngeal n paralysis-wait for 6m for nerve recovery -if no recovery--> medialisation of the cord:
o o

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

bilateral recurrent laryngeal n paralysis(refer to question below) -etiology & CP of Vocal cord paralysis

-CP & Rx bilateral rec laryngeal n paralysis (recurrent laryngeal n paralysis= abductor paralysis=paramedian vocal cord) cp: -stridor -normal voice but easily fatigue Rx: 1st- treat STRIDOR by tracheostomy(definitive line of treatment; emergency mx) 2- wait 6m-1yr for nerve recovery, if no recovery we do operation to widen the glottis: -partial cordectomy +/- arythenoidectomy -arythenoidectomy

3.

Benign tumor of larynx

o o o 4.

recurrent respiratory papillomatosis hemangioma chondroma

Malignant tumor larynx

-CP & Mx early vocal cord cancer***

Early Late

Symptoms

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

Lump in the neck + dysphagia Pain Hoarseness >>>> Hot potato voice Cough >>> blood tinged sputum Obstructive airways >>>> STRIDOR

Sign

1.Neck Free, except Marginal Ts 2.Laryngeal Examination: Disturbed Vascular Pattern Thickening/Mass/Ulcer Conservative therapy -MLS - Open surgery:partial laryngectomy Radiotherapy

1.Neck Lump,fullness,laryngeal box ( broad n tender ) 2.Cord Fixation ( mechanical, infiltrative , paralytic ) Total laryngectomy LPP ( Laryngeal preserve protocol ) Postop radiotherapy

Treatment

c/p

early
a. b. c. d. e. f.

change of voice hoarseness otalgia FB sensation irritative cough sense of airway obstruction

(F,O,O, C,C) = Freedom Oof Ccreation -(fb sensation, Otalgia,Obstruction of airway, Cough(irritative type), Changes of voice & hoarseness)

late
a. b. c. d. e. f.

hot potato voice (supraglottic tumor) lump in the neck (lymph node; ++ in supraglottic) stridor(biphasic)- (glottic extend to subglottic) dysphagia blood tinge sputum pain

advanced

1. weight loss 2. fetor oris

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

management early:

conservative-endoscopic removal(MLS/CO2 laser)

-open surgery-partial laryngectomy

radiotherapy

-clinical types,investigations,general Rx of Vocal cord cancer investigation-chest X-ray -barium swallow -CT neck n upper mediastinum -direct laryngoscopy + biopsy general tratment
a.

local-early (as mention before)

-late-total laryngectomy -laryngeal presevation protocol

b. regional-radical neck dissection c. distant-chemoraditherapy d. rehabilitation-voice prosthesis

-oesophageal speech training -atificial larynx

e. palliative-tracheostomy

nasogastric tube/gastrotomy -chemoradiotherapy -predisposing factors,pathology,Rx of early vocal cord cancer

PPT factor:
o o o o o o o o

smoker/ex smoker refluxer spicy eater alcohol drinker radiation exposure genetic RRP exposure to metal,plastic,paint,asbestos

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

pathology-macroscopic-ulcerative,infiltrative,fungating -microscopic-well,mod n poorly differentiated -classifications of cancer larynx -supraglottic -glottic -subglottic
5.

Laryngitis

-type of chronic specific laryngitis

o o o o o

TB syphlis scleroma leprosy fungal

-CP of acute laryngitis

General fever, headache, malaise, anorexia Local 1. Adult hoarseness, cough (++dry), sore throat 2. Child stridor (airway compromise) why? - larynx small + high - lumen narrow - soft cartilage + easy collapse -lax submucosa+more edema

-unstable neuromuscular mechanism -weak cough reflex Sign Congestion & thickening VC Subglottic edema in child + stridor (laryngitis stridulosa)

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

6.

Hoarseness of voice

-causes HOV*****
o

organic inflammatory:acute n chronic laryngitis neoplastic neurological spasmodic dysphonia systemic-RA,angioneurotic oedema,hypothyroidism

a. b. c. d. e.

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

non organic ventricular dysphonia habitual dysphonia mutational falsetto conversion voice disorder

a. b. c. d.

(Ventricular,conVersion, habiTual,muTational)
7.

Laryngeal trauma

8.

Tracheostomy

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

Non obstructive causes ( PPRREE / 2p 2r E ...PRE~ ) -Prolonged mechanical ventilation -Protection tracheobronchial tree -Respiratory failure -Retention bronchial secretion -Elective tracheostomy Obstructive causes # Internal: obstruction ( follow the anat ) - oropharyngeal obstruction - laryngeal obstruction - upper tracheal obstruciton ) # External compression: Tentera Laut Malaysia - thyroid gland - ludwigs angina - mediastinal causes 9.

Stridor

-Mx of stridor in children** maintain airways - non invasive ppv - transtracheal needle ventilation - endotracheal intubation - tracheostomy ( gold standard ) - cricothyroidotomy ( extreme situation ) Medical: - humidified oxygen admin - steroid systemically - recemic epinephrin - bronchodilator - IV fluid - mucolytic - strict obsevation Dx: - age : newborn = laryngomalacia, child = laryngitis , adult =trauma , old =neoplasm - onset : sudden = trauma,fb aspiration, acute = inflam , chronin = cong anom, neoplasm -assc. sx : feva, neck pain, dysphgia -prev hx : choking, trauma, tracheostomy Exam:

- degree stridor - neck exam - laryngeal - radiological

-Dx & Rx of acute epiglotitis

-table of difference between acte epiglottitis & acute laryngotracheobronchitis

Acute Epiglotitis Incidence Microbact Onset Mouth sx=cough,stridor, Voice,drooling #Cough #Stridor #Voice #Drooling Misc. sign Temperature Posture Xray Elevate Sitting forward Thumbprint Elevate Lying Steeple Absent Inspiratory Muffled Marked Barking ...wot woott = O Biphasic... Hoarsee None 2-6y H.influenz Rapid Acute laryngiotracheobroncitis <3y PARAINfluenza 1-4 Slow

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