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Cases introduced by Dr Essam Abdel Nabi

1. A 12 years old male came to ENT clinic complaining of severe epistaxis
from the nose especially when he tries to play in his nose, and the
bleeding don't stop by itself. On examination of the nose, there was a big
mass occluding the whole cavity.
a. What is your diagnosis?
Juvenile nasopharyngeal angiofibroma.
b. What is the most striking symptom?
The epistaxis, that may be sever to end his life.
c. What is the most important precaution you should take it?
Never touch or manipulate this mass to avoid a new attack of epistaxis.
N.B: In the past, the Pt. of an angiofibroma was applied to radiotherapy to induce
fibrosis of the mass for treatment.
But now obsolete because of the high risk of developing carcinoma especially because
the angiofibroma usually appears in adolescents.
But now: MRA (MRI + Angiography) done to visualize the feeding artery and then
Induce thrombosis of the feeding artery to avoid bleeding during the operation.

2. A 40 years old obese woman came to ENT clinic, complaining of

multiple arousals at night after attacks of apnea & her husband also
complains from hearing abnormal noise while she is sleeping. The
examination of the oropharynx reveals elongated uvula.
a. What are the causes of apnea in general?
b. What is the cause of apnea in this case?
This obese woman develops apnea due to obstruction of her nasopharynx
by the redundant palate & elongated uvula.

3. A 29 years old man, complaining of bilateral epistaxis with severe pain

following severe trauma to his nose. By the x-ray there was fracture
nose.
a. What are the causes of epistaxis?
b. What is the position that you must put the pt in during the attack?
The Pt. should lean forward to prevent swallowing of the blood, as the
Pt. may develop hypovolemic shock from the blood loss & swallowing
blood on full stomach may irritate it, stimulating vomiting so the Pt.
develops neurogenic shock .

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4. A 35 years old man came to ENT clinic complaining of inability to close

his right eye & also from deviation of the angel of mouth to the left side.
After examination we show that the patient had done cortical
mastoidectomy on ttt of chronic otitis media & aural polyp.
a. What is your diagnosis?
Right complete facial paralysis.
b. What is the cause?
This paralysis may be a complication of the operation.

5. A middle aged woman complaining of pain in the right ear & vertigo,
ear examination revealed post auricular scar of previous operation done
for the treatment of Cholesteatoma, the middle ear ossicles are removed
during the operation.
a. What is the cause of vertigo & pain?
Removal of the ossicles results in formation of radical cavity "the middle
ear cavity communicate with the mastoid" so exposure of the lateral canal
in the radical cavity make it sensitive to weather changes causing "vertigo
& pain ".

6. A 35 years old woman came to the ENT clinic complaining of tinnitus

& diminution of hearing in the left ear. But on examination, there was
intact tympanic membrane.
a. What is the cause of hearing loss?
With intact drum the diminution of hearing may be due to (Otosclerosis or
SNHL).
By the Weber & Rinne tests you can differentiate
If Rinne ve & Weber lateralized to the ear of hearing loss Otosclerosis.
b. What is the type of deafness in this condition?
CHL.

7. A 29 years old male came to ENT clinic complaining of hoarseness of

voice, on examination of the nose, there was a huge mass occupying the
whole right side of the nose.
a. That is the probable diagnosis of this mass?
The nasal mass is a rhinoscleroma.
b. What is the cause of the hoarseness of voice?
Laryngeoscleroma secondary to rhinoscleroma.
c. Why this case is not a classical laryngeoscleroma?
As the laryngeoscleroma affects the subglottic area and obstruct the lumen
so the 1st symptom should appear is the stridor not hoarseness of voice.
But in this case the hoarseness precedes the stridor.
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8. A middle aged female complaining of chronic otitis media which is

resistant to treatment with antibiotics.
a. How to manage this case?
Culture & sensitivity of the discharge but after stopping the antibiotics for
3 days to ensure presence of the organism in the discharge.

9. A 45 years old female complaining of swelling in her face, on

examination it was filling the area between the ramus of the mandible &
the mastoid process and raising the lobule of the ear.
a. What is your diagnosis?
Parotid swelling.

10. A 35 years old male complaining of bilateral nasal obstruction with

complaint of snoring & multiple attacks of sleep apnea, history shows
that he has allergy. On examinations there were multiple nasal masses.
a. What is your diagnosis?
Allergic nasal polypi.

11. A middle aged male came to ENT clinic complaining of pain and
dysphagia. On examination, there was a membrane covering the right
tonsil.
a. What is the differential diagnosis of a membrane in the throat?
DD of a membrane in the throat = DD of ulcers in the throat. As any ulcer
in the throat will be covered by a membrane.
N.B: Acute follicular tonsillitis is presented bilaterally.

12. A female patient presented to ENT clinic complaining of neck swelling

that moves up & down with deglutition.
a. What is your diagnosis?
Thyroid swelling.

13. A female patient presented to ENT clinic complaining of neck swelling

move with protrusion of the tongue.
a. What is your diagnosis?
Thyroglossal cyst.
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14. A 50 years old male came to ENT clinic complaining of hoarseness of

voice & multiple attacks of sleep apnea, he runs to the window to take
his breath. From history, we found that he suffer from hyperacidity.
a. What is your diagnosis?
It is a typical case of reflux oesophagitis
Acidity from the reflux in the post cricoids area cause :
Reflex spasm of the vocal cord by irritation Stridor.
With long contact with acids sever irritation VC polyps
Hoarseness of voice.

Important points said in lectures:

1. What is the cause of pulsating aural discharge?
The cause of pulsation is the dilated congested blood vessels in the middle ear
Occurs in :
a. Chronic supportive otitis media with acute exacerbation.
b. From the Dura when erodes the tegmen.
c. Newly formed blood vessels in glomus.

2. Weber test is more sensitive than Rinne test; as the Weber can
differentiate the hearing loss between the 2 ears when the difference is
5 db in between, while the difference between both ears in Rinne is 20
db.
3. Tensor palati is the main opener of the ET.
4. Why does the posterior perforation of the drum affect hearing more
than the anterior perforation?
The round window is exposed through the posterior perforation during
transmission of sound.
Some sound waves transmitted through the exposed round window to the inner
ear, While the other waves transmitted by the usual pathway to the oval window.
So both waves oppose each other and finally the movement of the inner ear fluid
becomes minimal.

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Cases introduced by Dr Mahmmoud Fawzi

1. A 71 years old male, chronic heavy smoker came to ENT clinic
complaining of hoarseness of voice since 4 months. He denied any problem in
deglutition. On examination, there was a mass occupying the whole left vocal
cord, reaching the anterior commeasure also extends to the right vocal cord.
a. What is your diagnosis?
Cancer larynx (Squamous Cell Carcinoma of vocal cords).
b. What is your management?
Investigations:
Direct laryngescopy to see "site, size, and extension of the tumor".
CT scan to show the cartilage invasion.
Biopsy for insurance & staging.
Treatment: According to the stage:

o It was left glottic T2a N0.

So partial laryngectomy with temporary tracheostomy is indicated &
follow up of the Pt. for 5 years.
No radical neck dissection as the glottic area has no lymphatic drainage.
N.B:
5 years survival is an indicator for the success of the operation.
CT scan is the standard technique of imaging in the head & neck.

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2. A 42 years old male complaining of hypertrophy of the left ala of nose &
the area around it. It is of short duration a month ago & it is slowly
progressive. From the CT scan there was opacity in the left maxillary
sinus.
a. What is the most probable diagnosis?
Benign mass in the alveolar region causing 2ry mucosal oedema in the
maxillary sinus produces hypertrophy around the ala of nose this appears
from the CT scan.

3. A 24 years old female came to ENT clinic complaining of severe facial

pain & headache, also complaining of proptosis & orbital cellulites which
don't respond completely to antibiotics .from the CT scan we noticed a
dense mass occupying the frontal & ethmoid sinuses.
a. What is your diagnosis?
Osteoma in the frontal & ethmoid sinuses.
b. What do you think the cause of orbital cellulites?
It may be because the mass occluding the opening of the frontal sinus
secondary infection secondary mucocele.
c. What is the line of treatment?
Excisional biopsy through (Nasal endoscopy, Open incision through medial
wall of the orbit "lamina parpratia" or Coronal incision through eye brow).
N.B: Biopsy never starts ttt of cancer without taking biopsy and by the least invasive
measure.

N.B: Pan Coast tumor: the 1st sign produced by is left vocal cord paralysis.

4. A 40 years old male complaining of left unilateral hearing loss of a month

duration by examination of the ear there was otitis media with effusion
while examination of the nasopharynx shows mass occupying fossa of
Rosen-Muller.
a. What is the most probable cause of this case?
Nasopharyngeal tumor occluding the ET.
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N.B: Otitis media with effusion is a disease of children when comes in adult may be
due to obstruction of the ET by nasopharyngeal tumor.

So any adult Pt. complaining of OM with effusion & CHL

Suspect nasopharyngeal tumor until proved otherwise.
b. How to manage this case?
Neck examination.
Cranial nerve examination.
Biopsy "Under L.A with endoscope".
Staging.
Treatment according to stage "Radiotherapy".
No surgical ttt in nasopharyngeal carcinoma.

5. A 50 years old female came to ENT clinic complaining of dysphagia &

hoarseness of voice with loss of her weight. On examination there was a
mass in the postcricoid area.
a. What is your diagnosis?
Postcricoid carcinoma.
b. What is your management?
CT scan.
Investigations:
Direct laryngoscopy.
Treatment:
1ry tumor Total laryngectomy followed by radiation.
LNs Radical neck dissection if there was LN enlargement.
Selective neck dissection if not palpated as it commonly
affects the LNs.
If send metastasis Palliative ttt.

6. A 8 years old girl came to ENT clinic with her mother complaining of
high temperature 38.5 C, sore throat, dysphagia & later otalgia. All these
symptoms occur 2 days ago and the recurrence rate: 3 times / year.
a. What is your diagnosis?
Acute follicular tonsillitis.
b. When you take a decision for tonsillectomy?
If the recurrence rate of tonsillitis is more than 5-6 times / year Do
operation, otherwise Don't do it.
c. What are the criteria should be present to diagnose an attack?
High fever > 38 C.
Inability to swallow.
Enlargement of upper deep cervical lymph node.
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N.B: If there is tonsillitis with rheumatic fever

For ttt:
Give long acting penicillin.
Do tonsillectomy if there is recurrence.

7. A 35 years old male complaining of left painless neck mass 4 months ago
is annoying him because of disfigurement.
a. What is your diagnosis?
Lymph node enlargement in case of occult primary.
b. How can you ensure this case?
History
Examination
Write them in details.
Investigations

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"One vision one mission"

All Team "One Vision One Mission"