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1. ENT Part II - Dr Fazna Saleem
3 y/o
Shifted of cone of light, bulging of tympanic membrane
Otitis media with e
ff
usion - conductive hearing loss, delayed speech
Investigation:
1. Pure tone audiometry - con
fi
rm the hearing loss
2. Lateral neck xray - rule out tumor blocking eustachian tube (in old)
3. Tympanometry
4. *Dont need blood investigation
Manage this child:
1. Anti allergic
2. Myringotomy & Vomer incision
3. Nasal decongestant

2. Tympanic membrane is retracted, Handle of malleus - more prominent, long process and short
hand of incus
Pathophysiology: Eustachian tube edema - negative pressure in middle ear
Valsalva manuevre - no movement/ no changes in total perforation, movement present in TM
retraction

3. On right side tympanogram shows curve is
fl
at and no value (type B) -
fl
uid in middle ear or
tympanic membrane perforation
The left side is normal tympanogram - Type A which is Normal

4. Elderly, chronic discharge, foul smelling
Erythema, Cone of light slightly shifted, granulation tissue in (attic) pars
fl
accida, yellowish mass,
no perforation, no pus, no discharge
Most likely - CSOM Atticoantral type Cholesteatoma
Management:
Examination under microscope
Audiometry , Pus culture and sensitivity, Mastoid xray
Tx: Aural toilet, painkillers, systemic antibiotic, removal of granulation tissue by surgery
(mastoidectomy)

5. Grommet tube / Tympanostomy tube
Indication:
4. Otitis media with e
ff
usion
5. Retracted tympanic membrane - to allow ventilation
6.

6. Fever, ear pain, hearing loss
Tympanic membrane shows tense and bulging, no perforation, erythematous
Most likely: Acute otitis media

7. Cotton wool appearance
Most likely: Otomycosis ( fungal infection )
CF: itchiness, irritation, discharge
Investigation: Swab culture ssnsitivity, examination under microscope
Mx: Aural toilet, Topical antifungal

8. Cochlear implant

9. Patient has on and o
ff
persistent discharge for 2 years, hearing loss
Findings: Perforation of tympanic membrane on pars tensa, angle of malleus, pars
fl
accida is
intact
Dx: Inactive CSOM with tubotympanic (central perforation)
Mx: Surgery (myringoplasty) - since it is inactive; no discharge, no fever

10. Pure tone audiometry of right ears shows air bone gap with moderate conductive hearing loss
(Di
ff
erences should be more than 20 to be signi
fi
cant)

11. Pure tone audiometry of both ears is between 70-90, air conduction isair bone gap is present
which suggest bilateral severe mix type of hearing loss of severe degree
Possible causes:
Conductive: Otitis media, externa, impacted ear wax, e
ff
usion, FB
Sensorineural: labyrinthitis, ototoxicity drugs
Audiometry
fi
ndings:
1. Conductive - bone conduction is Normal (C), air conduction is abnormal, (around 20), Positive
Air bone gap
2. Sensorineural - Bone conduction is abnormal, Air conduction is abnormal, no air bone gap
3. Mix - bone conduction abnormal (below 20), air conduction is abnormal, present of air bone
gap

12. Peak on negative zone, shows Type C tympanogram
Causes:
1. Early Otitis media with e
ff
usion
2. Eustachian tube dysfunction

13. Redness/ Eythema on skin over mastoid
Tenderness on mastoid bone
Most likely: Acute mastoiditis
Xray of mastoid bone - looking for air cells
Culture and sensitvity for discharge
Mx: Admit + IV Antibiotic, can change to oral antibiotic later

14. Face - unilateral palsy, angle mouth deviation towards left side, inable to closure of eyelids of
right, nasolabial fold is less prominent on right side
Most likely: Right facial nerve palsy
Ear - redness, crusting, pinna vesicles
Most likely: Herpes Zoster - Ramsay Hunt syndrome

15. Shows tympanic membrane with central perforation on pars tensa, with tympanic sclerosis
(calcium sclerotic patches)
Myringoplasty - graft from tragus/ subcutaneos fascia. Only repair the tympanic membrane
without exploration
Tympanoplasty - done in case when ossciles destroyed, atticoantral - so repair part of the middle
ear with tympanic membrane repair (with exploration of middle ear)

16. Mass with pale, glossy appearance originate from above, no discharge, no mucus
Most likely: Nasal polyp
Nasal polyp vs turbinate
Polyp - pale, glossy appearance
Turbinate -
fl
eshy, originate from lateral wall
Probe the mass - if painful (turbinate)
Gross appearance -
2 types of nasal polyp:
1. Ethmoidal polyp
2. Anthrocoanal polyp

17. CT scan of Paranasal sinus - right maxillary sinus is denser (congested), left side is congested
with hypoechoic area (normal -
fi
lled with air), hypertrophy of right turbinate
Bilateral maxillary sinusitis (right side is more severe)
CF:
1. Fever
2. Purulent nasal discharge
3. Headache

18. There is Perforated nasal septum with eryhthema surrounding peforation, no discharge
Causative of perforation;
1. chronic infection like Tb
2. Sni
ffi
ng drugs
3. Trauma - surgical or nasal bone fracture
Symptoms:
1. Whistling breathing
2. Crusting sensation
3. Epistaxis

19. Discoloration, erythema, swelling of left vestibule, some discharge, crusting formation
Dx: Vestibulitis
Mx:
1. Admit and IV antibiotic (due to Danger’s area)
2. Removal of crusting

20. Showing of bilateral septal hematoma (originate from medial wall)
Causes:
1. Bleeding disorder
2. Nasal trauma
3. Surgery
Investigation:
1. Blood coagulation pro
fi
le
Tx:
1. Aspiration with wide bore needle or
2. Incision and drainage
3. To avoid recurrence - bilateral nasal packing + prophylactic antibiotic
Complications:
1. Septal perforatio
2. Septal abscess

21. Xray of paranasal sinus, Waters view shows hyperdense of right maxillary sinus

22. History: 2 weeks of high fever, purulent nasal discharge
Redness and edema around left eye
Most likely dx: Periorbital cellulitis complication from Ethmoidal sinusitis
Complications:
Orbital cellulitis
Orbital abscess
Cavernous sinus thrombosis
Investigation:
1. CT scan (to rule out complication and extend of diseases)
2. Naso endoscopy (to look for discharge, status of sinus, inferior meatus etc)
Mx:
1. Admit and IV antibiotic
2. Monitor progress - if worsening - incision and drainage

23. Swelling at lower lobe of ear at angle of mandible, rounded swelling, surface is smooth, overlying
skin is …, approximate size 2 by 2 cm,
Di
ff
erential diagnosis:
1. Lymphadenopathy
Investigation:
1. Full blood count
2. FNAC
3. USG of swelling - to see whether its
fl
uid-
fi
lled and rule out other diagnosis

24. A. Posterior Nasal Packing
B. Posterior nasal bleeding due to uncontrolled htn, bleeding disorder,tumors
C.

25. A. Saddle nose deformity
B. Nasal bone fracture, trauma, nasal tumor, septal abscess
C. Surgical procedure - rhinoplasty or septoplasty or septorhinoplasty

26. Nasal endoscopic pictures show middle meatus with purulent discharge
Nasal polyp

27. Greyish, glistening, pale - polyp

28. Findings: Swelling over mandible which is size, shape, surface, skin,
Most likely: Pleomorphic adenoma (swelling of parotid gland)
Investigation;
1. FNAC
2. USG

29. Deviated Nasal Septum (bony projection)
Hematoma - should be on both side

30. Bilateral, Sessile swelling on anterior 1/3 to posterior 2/3 junction of vocal cord
Dx: Vocal cord nodules
Mx: Voice rest, speech therapy
Usually singer, teacher

31. Findings: Uvula is enlarged, tonsils is bilaterally enlarged, no exudate
Grading of tonsils:
1. Grade 1 - cover the anterior pillar
2. Grade 2 - just reach the posterior pillar
3. Grade 3 - cant visualize the posterior pillar
4. Grade 4 - both of tonsils reach midline

32. Lateral neck xray shows Thumb sign appearance
Acute epiglotitis
CF:
1. Stridor
2. Drooling of saliva (severe odynophagia)
3. High fever, toxic looking
4. Sign - tripod sign (chin lifted - to increase airway)
Management:
1. ABC - secure airway, secure IV line
2. Admit the patient
3. IV antibiotics with O2 supplementation
No endoscopy, no tongue depression

33. Tonsillectomy
Indications:
1. Recurrent infection of tonsil
2. Recurrent peritonsilar abscess
3. Obstructive symptoms with chronic hypertrophied tonsils
Contraindications:
1. Bleeding disorder
2. Active infection on going
Complications
1. Injury to other structures (tooth, oropharyngeal)
2. Aspiration
3. Hemorrhage
Late complications: Secondary bleeding, infarction
Check for Hb, coagulation pro
fi
le

34. Findings: Oropharynx wall - edematous vesicular lesion, cobblestone appearance
Diagnosis: Chronic pharyngitis
Features:
1. Uneasiness of throat
2. Foreign body sensation
Management:
Antiseptic gargling
Cauterisation - to remove hypertophy (in very severe cases)

35. 1. Tracheostomy
2. Indication: Epiglotitis, laryngeal edema, prolong intubation, laryngeal tumors, laryngomalacia,
retained secretion in lung, spinal trauma, bulbar palsy, respiratory insu
ffi
ciency,
fi
brosis,
chronic lung diseases
3. 4 complications: Injury to RLN, hemorrhage, injury to thyroid, subcutaneous emphysema (very
common), apnoea (less CO2 to drive for respiration- which lead to paradoxical apnoea)
4. Post operative management and care - make sure no bleeding, daily dressing, supply with
oxygen, regular suction

36. Left side of soft palate is swollen, uvula shifted to right
Diagnosis: Peritonsilar abscess (Quinsy)
Causes;
1. Recurrent tonsillitis
2. Foreign body throat
Management:
1. Admit
2. Analgesics
3. Incision and drainage

37. Single, Unilateral, Pedunculated swelling on anterior 1/3 of right vocal cord
Dx: Vocal cord polyp
Symptoms;
1. Diplophonia
2. Hoarseness of voice
3. Dysphonia
4. Stridor
5. Obstructive symptoms
Treatment:
1. Mainstay - surgery (microlaryngeal surgery with poypectomy)

38. Nasopharynx shows edematous lesion with bleeding, shiny and bulging appearance which arise
from fossa of Rosenmüller
Dx: Nasopharyngeal carcinoma
Symptoms:
Early
1. Unexplained epistaxis
2. Unexplained lymph node swelling
3. Commonest cranial nerve involvement (abducens nerve - lateral rectus palsy - medial squint)
Late presentation
1. Naso obstruction (late presentation, when mass is big)
2. Hearing loss
Treatment:
1. Radiotherapy and chemotherapy