Tamilnadu Dr.

MGR Medical
University

Third (Final) M.B.B.S. Degree Examination

(August 2007) Question paper

with solutions

Dr T Balasubramanian
 Tamilnadu Dr. MGR Medical
University
Third (Final) M.B.B.S. Degree Examination (August 2007)

Time: Three hours

Answer all questions

I. Write Essay:
1. A 50 year old male patient presented with bleeding, fleshy mass from the nasal cavity. Write the
differential diagnosis and investigations required to diagnose. Add a note on chemotherapy and
surgical management of carcinoma maxilla
(3+3+3+6 = 15 marks)

Planning the essay.

Breaking the answers in to separate bits
Being precise and up to the point
Differential diagnosis of fleshy bleeding mass in the nasal cavity of a 50 years old patient:
Classification of the probable lesions:
Benign – congenital / acquired
Malignant

Congenital masses:
Congenital masses inside the nasal cavity which could appear fleshy and can cause epistaxis inlcude
Encephaloceles. In these patients there is herniation of duramater into the nasal cavity via the
foramen caecum / defect in the cribrifom plate of ethmoid. Its contents include CSF / duramater /
brain tissue. If the herniated contents include only the meninges it is known as meningocele and if it
includes meninges and brain tissue also then it is known as menigoencephalocele.
These lesions are usually in midline, increases in size while the child is crying, and is readily
compressible.
Acquired benign intranasal masses:
1. Infected antrochoanal polyp – It may appear fleshy in the exposed portion due to squamous
metaplasia which is caused due to prolonged exposure to drying effects of air. Anteriorly it
appears fleshy, and posteriorly it appears polypoidal. Bleeding is present due to infection
and angiomatous component which is common in these lesions.
2. Hemangiomas / Hemangiopericytomas. These lesions may appear fleshy due to changes in
the surface mucosa due to exposure to the drying effects of atmospheric air.
 3. Inverted papilloma (commonest benign nasal mass seen in elderly)

Malignant tumors presenting as fleshy nasal masses:

1. Carcinomas – These lesions are highly destructive causing involvement of surrounding
structures (Squamous cell carcinoma, adenoid carcinoma, adenoid cystic carcinoma and
undifferentiated carcinoma)
2. Sarcomas (Rhabdomyosarcoma / Fibrosarcoma / Chondrosarcoma)
3. Melanoma – commonly these lesions are pigmented except the very rare amelanotic variety
4. Plasmacytoma
5. Lymphoma
6. Olfactory neuroblastoma – This tumor arises from olfactory epithelium in the superior nasal
vault

Symptoms caused by malignant masses in nasal cavity:

These lesions are diagnosed very late because they tend to be asymptomatic during early stages.
1. Nasal bleeding
2. Nasal block
3. Neuralgias
4. Facial / palatal swelling
5. Orbital symptoms – diplopia / proptosis / decreased vision
6. Loosening of teeth / ill fitting dentures

Imaging:
This is the commonly required investigation in these patients.
CT imaging – Both plain and contrast is performed in both planes (axial / coronal). This reveals the
exact anatomical location of the mass, its extension, bone erosions, vascularity of the mass etc.
Intracranial extension of these masses are better revealed in contrast CT scan pictures. Bone
erosion and involvment are better seen in CT scans.
PET Scan:
This scan really helps in differentiating benign inflammatory lesions from malignant ones. This
scan should be resorted to in cases with diagnostic dilemma.
Tissue biopsy:
This is the gold standard and ultimate in the diagnosis of these lesions. Biopsy report will not only
provide tissue diagnosis but also throws some light on the invasive properties of these lesions.
Immunohistochemistry is vital in diagnosing patients with undifferentiated / poorly differentiated
carcinomas.

MRI imaging – This imaging modality provides excellent soft tissue delineation. Intracranial
extension of these lesions are clearly seen. MRI imaging is superior to CT in assessing the extent of
tumor invasion.
Chemotherapy:
Single agent chemotherapy is preferred for recurrent disease and unresectable squamous cell
carcinoma involving the nasal cavity. Chemotherapeutic agents also have a role as radiosensitizer
before subjecting the patient to irradiation. Chemotherapy should at best considered to be palliative
in the management of malignant tumors of nose and paranasal sinuses.
Cisplatin is the commonly used chemotherapeutic agent in the management of head and neck
malignancies (majority of them being squamous cell carcinoma). It is usually administered in doses
of 50 – 75 mg/kg as single intravenous dose every three to four weeks. This is continued for three
cycles. Serum creatining levels should be monitored. Hydration levels of patients should be
improved by administering intravenous fluid before administering cisplatin. Renal toxicity is a very
important complication of cisplatin use. The whole drug before infusion is diluted in 2 liters of 5%
dextrose and is given as infusion in order to maintain the hydration level of the patient.

5-flurouracil:
Intra arterial administration of 5-flurouracil can be used as radiosensitizer.

Surgical management of cancer maxilla:

Surgery has a role in malignant tumors of maxilla in early lesions. It can also be used in
combination with radiotherapy / chemotherapy. If used in conjunction with chemo and radiotherapy
then it is known as sandwich management of maxilla tumors.
Surgeries that can be performed in managing tumors of maxilla include:
1. Medial maxillectomy
2. Total maxillectomy
3. Cranifacial resection in tumors involving anterior skull base
4. Caldwel Luc surgical procedure can be used selectively in biopsying suspicious lesions
present in the maxillary sinus cavity
5. Maxillary cancers involving the orbit can be managed by total maxillectomy combined with
orbital exenteration
 2. Enumerate the causes of deafness in children. Write the investigations to assess the hearing
in children. Write about auditory training and hearing aids in such children. (3+3+2+2 = 10
marks)
Deafness in children can be classified grossly into conductive and sensorineural types. Conductive
deafness is correctable.

Causes of deafness in children include:

I Causes for congenital deafness
II Causes for acquired deafness

Causes of congenital deafness may be subclassified into:

Genetic: Genetic causes of congenital deafness include:
Autosomal dominantly inherited deafness
Autosomal recessively inherited deafness
X- linked inherited causes of deafness
Mitochondrial
If this type of deafness is not associated with any co existing morbidities then they are known as
Non syndromic deafness.
Congenital deafness associated with other co existant morbidities then they are classified as
syndromic deafness
Non genetic causes of congential deafness:
This type of deafness is usually caused by perinatal infections. These include:
1. Congenital rubella syndrome
2. Cytomegalovirus infections
3. Congenital syphilis
Environmental causes of congenital deafness:
This type of deafness in children is caused due to adverse environmental perinatal factors. These
include:
1. Hypoxia
2. Neonatal jaundice
3. Low birth weight

Acquired deafness in children:

Deafness due to infections :
Acute otitis media – Conductive deafness
Chronic suppurative otitis media – Conductive deafness
Adhesive otitis media – conductive deafness
Otitis media with effusion – Conductive deafness
Meningitis
Mumps
Measles
AIDS
Deafness due to exposure to ototoxic drugs:
Drugs like Neomycin / Gentamycin are ototoxic in nature. Exposure to them may cause
sensorineural hearing loss.
Aspirin ingestion in high doses can damage inner ear causing sensorineural hearing loss.

Investigations:

Audiological investigations include:

1. Pure tone audiometry
2. Free field audiometry
3. Impedance audiometry
4. BERA

Hematological / Biochemical tests:

Serological test for Rubella and cytomegalovirus infections.
Thyroid function tests
Chromosomal analysis
Auditory training:
Children will develop speech only when they hear spoken words. Early use of auditory assisted
devices will help these children to regain speech. Assisted devices include:
1. Hearing aids
2. Implantable hearing aids (BAHA) – Useful in patients with conductive deafness.
3. Cochlear implants
4. Sign language training
 3. What are the causes of hoarseness of voice in a male aged 55 years? How to you proceed
with investigating? Write the role of microlaryngeal surgery in papilloma larynx. (4+3+3 =
10 marks)

Hoarseness of voice is defined as change in voice which is considered as unpleasant by the patient.
Hoarseness should be considered as a symptom and not as a disorder in itself. Factors causing
hoarseness of voice include:
1. Mass lesions (Benign / Malignant)
2. Fixation / paralysis of vocal cords
3. Weakness involving tensors of the vocal cords
4. Loss of vibration of the free edge of vocal folds due to oedema / inflammation / trauma

Laryngeal causes of hoarseness of voice:

1. Congenital – Web / stenosis
2. Inflammation – Acute / chronic
Acute infections include viral / bacterial infections. Laryngitis / Laryngotracheal bronchitis
Specific infections include diphtheria, Herpes zoster and poliomyelitis.
Chronic infections involving larynx include Tuberculous laryngitis, Scleroma, Leprosy and
sarcoidosis.
3. Trauma – Accidents / surgical / Intubation / Irradiation
4. Neoplasm – Benign / Malignant
Benign lesions – Papilloma, chrondroma, vocal polyp, angioma and fibroma
Malignant lesions – Cancer larynx / Cancer thyroid / Ca trachea / oesophagus
5. Miscellaneous – vocal nodule / FB / laryngocele / Leukoplakia / Vocal cord fixation due to
arthritis

Investigations:
Videolaryngoscopy – Is performed to visualize the larynx.
X ray chest PA – Mediastinal disorders / Lung disorders / Left atrial enlargement can be seen
Barium swallow – Oesophageal disorders / Left atrial enlargement
ECG – Left atrial enlargement / cardiac anamolies
Ultrasound thyroid – To rule out thyroid disorders
Biopsy in patients with suspicion of malignancy
ECHO – Left atrial enlargement / Mitral stenosis
Role of Microlaryngeal surgery in the management of papilloma larynx:
Papilloma of larynx may be of two types. Adult papilloma / Juvenile papilloma. Adult papilloma is
solitary while juvenile papilloma is multiple. Since adult papilloma is solitary it can be removed
surgically using microlaryngeal technique.
This surgery is performed under general anesthesia. Endotracheal intubation is performed using a
small size endotracheal tube in order to provide unobstructed view of the mass. Klein sausser
suspension laryngoscope is used to visualize the lesion. The microscope objective lens should be
changed to 400mm in order to provide the necessary working distance.

II. Write briefly on:

a. Absolute bone conduction test :
This test is performed to identify sensorineural hearing loss. In this test the hearing level of the
patient is compared to that of the examiner. The examiner's hearing is assumed to be normal. In this
test the vibrating fork is placed over the mastoid process of the patient after occluding the external
auditory canal. As soon as the patient indicates that he is unable to hear the sound anymore, the fork
is transferred to the mastoid process of the examiner after occluding the external canal. In cases of
normal hearing the examiner must not be able to hear the fork, but in cases of sensori neural hearing
loss the examiner will be able to hear the sound, then the test is interpreted as ABC reduced. It is not
reduced in cases with normal hearing.
b. Leukoplakia:
Is defined as whitish patchy keratotic lesions seen commonly in the oral mucosa / tongue / palatal
mucosa. It is usually seen as adherent whitish patches. These lesions should be differentiated from
oral candidiasis.
Leukoplakia is considered to be a premalignant lesion. It is caused by:
Chronic irritation of oral mucosa
Use of tobacco
Chronic cigarette smoking
Irritation of cheek mucosa by sharp teeth
Betal nut chewing
Hairy leukoplakia is seen in patients with HIV disease.
Leukoplakia with reddish patches are truely premalignant. Malignant transformation is very
common in these lesions. These patches are known as erythroplakia.
Treatment involves ruling out malignant transformation.
Removing the irritants.

c. Allergic fungal sinusitis :

Fungal infections of nose and sinuses are getting common these days. With increasing incidence of
HIV and other diseases like diabetes which compromise host immunity it is no wonder that the
incidence of fungal infections involving nose and para nasal sinuses is on the rise. In India the
incidence of fungal sinusitis in immuno competent patients is also showing a rise. This particular
fact need to be studied further.
Types of fungal sinusitis:
1. Acute fulminant invasive sinusitis

2. Chronic invasive fungal sinusitis

3. Granulomatous invasive fungal sinusitis

4. Fungal ball

5. Allergic fungal rhino sinusitis

6. Eosinophilic allergic fungal sinusitis
Allergic fungal sinusitis:
These patients have a combination of nasal polyposis, crust formation associated with positive sinus
cultures for aspergillus. Robson (1989) introduced the term allergic fungal sinusitis to describe the
findings associated with this disease. These patients consistently demonstrate allergic reactions to
aspergillus proteins.
Bent's criteria for the diagnosis of allergic fungal sinusitis:
1. Demonstrable type I hypersensitivity to fungi
2. Nasal polyposis
3. Radiological findings (Heterodense mass lesion)
4. Presence of eosinophilic mucin mixed with non invasive fungus
5. Positive fungal stain / fungal culture

These patients present with progressive nasal obstruction, crusting, rhinorrhoea, and chronic
rhinosinusitis. These patients can also come with dramatic symptoms like visual loss and total nasal
obstruction.

Classically radiology shows unilateraly expansile lesion of the sinuses associated with bony
erosion. The mass appears as heterodense due to the presence of metallic elements in the fungal
hyphae.

The mechanism of causation of allergic fungal sinusitis is IgE mediated hypersensitivity to fungal
proteins especially to aspergillus.
d. Left vocal cord paralysis:
This is the most common type of vocal cord paralysis due to involvement of left recurrent laryngeal
nerve. Left recurrent laryngeal nerve is commonly involved because of its tortuous intrathoracic
course.
Causes of left vocal cord paralysis:
1. Idiopathic (viral infections)
2. Left atrial enlargement
3. Patent ductus arteriosus
4. Thyroid malignancies
5. Oesophageal malignancies
e. Choanal atresia:
Air passing through the nasal cavity reaches the lungs via the choana (post nasal aperture). In
patients with choanal atresia this aperture is closed. Choanal atresia can be unilateral and bilateral.
In bilateral choanal atresia the child is in acute respiratory distress which improves when the child
starts to cry, since it takes in air through the mouth by passing the obstructed choanal airway.
Neonates are obligate nasal breathers for the first 6 weeks. When bilateral choanal atresia is present
in a neonate, emergency.
Types of choanal atresia:
1. Bony - 90%
2. Membranous - 10%
This atretic plate of bone / membrane are generally situated just in front of the posterior end of nasal
septum. The congenital choanal atresia should not be considered as an isolated plate of bone but as
one component of a skull base anomaly developing between the 4th and 12th weeks of gestation.
Four theories for the development of choanal atresia:

1. Persistence of a buccopharyngeal membrane from the foregut.

2. Persistence of the nasobuccal membrane of Hochstetter - most

commonly accepted theory.

3. The abnormal persistence or location of mesodermal adhesions in the

choanal region.

4. A misdirection of mesodermal flow secondary to local genetic

factors better explains the popular theory of persistent nasobuccal
membrane
Boundaries of the atretic plate:
1. Superior - Under surface of the body of sphenoid
2. Lateral - Medial pterygoid lamina
3. Medial - vomer
4. Inferior - Horizontal plate of palatine bone
Additional anomalies seen are:
1. The palatal arch is accentuated
2. Lateral and posterior nasal walls sweep inwards
3. The naso pharynx is narrowed

In acute emergencies oral airway will be able to save the patient. Definitive surgical approaches
include:
Transnasal approach repair
Transpalatal approach repair
e. Siegle's pneumatic speculum:
A siegel's pneumatic speculum has an eye piece which has a magnification of 2.5 times. It
is a convex lens. The eye piece is connected to a aural speculum. A bulb with a rubber
tube is provided to insufflate air via the aural speculum. The advantages of this aural
speculum is that it provides a magnified view of the ear drum, the pressure of the external
canal can be varied by pressing the bulb thereby the mobility of ear drum can be tested.
Since it provides adequate suction effect, it can be used to suck out middle ear secretions
in patients with CSOM. Ear drops can be applied into the middle ear by using this
speculum. Ear is first filled with ear drops and a snugly fitting siegel's speculum is applied
to the external canal. Pressure in the external canal is varied by pressing and releasing the
rubber bulb, this displaces the ear drops into the middle ear cavity.

f. Acute epiglottitis:
This condition is also known as supraglottitis. This condition affects the epiglottis primarily, but
other adjacent sites like lingual tonsil, aryepiglottic folds and false cords are also
affected. Epiglottitis affects all age groups. In children it could progress rather rapidly leading on to
airway compromise. This feature is rather uncommon in adults. Hemophilus influenza is the
common causative organism.
Clinical features: Drooling, respiratory distress, painful swallowing, change in voice.
Examination will show inflammed epiglottis, aryepiglottic folds, and arytenoid cartilages. These
patients also commonly have cervical adenopathy.
Plain x-ray soft tissue of neck shows enlarged epiglottis ("Thumb sign"), and absence of deep well
defined vallecula ("Vallecula sign").
Amoxycillin administered orally will help these patients recover.
g. Cholesteatoma:
Cholesteatoma is defined as a cystic bag like structure lined by stratified squamous epithelium on a
fibrous matrix. This sac contains desquamated squamous epithelium. This sac is present in the attic
region. Cholesteatoma is also defined as 'skin in wrong place'. Cholesteatoma is known to contain
all the layers of skin epithelium. The basal layer (germinating layer) is present on the outer surface
of cholesteatoma sac in contact with the walls of the middle ear cleft.
Presence of cholesteatoma causes erosion of bone leading on to complications both intra and
extracranial. Facial nerve is also considered to be at risk.
Ear discharge in these patients are scanty and foul smelling.
Types of cholesteatoma:
1. Congenital cholesteatoma
2. Primary acquired cholesteatoma
3. Secondary acquired cholesteatoma
Presence of cholesteatoma in the middle ear cavity is an indication for mastoidectomy.
h. Oesophagoscopy:
Indications of oesophagoscopy:
1. Removal of foreign bodies
2. Examination and biopsy of lesions from oesophagus
3. Dilatation of oesophagal strictures (benign)
4. Treatment of pharyngeal pouch

Anesthesia used:
Local (topical) 4% xylocaine spray, and pyriform fossa block.
General anesthesia is reserved for removal of impacted foreign bodies

Premedication:

1. Injection Glycopyrrolate 0.2 mg intra muscular injection is given as premedication to prevent

excessive secretions in the throat.
2. Injection fortwin 1 ampule intramuscular is given

Instruments used:

1. Rigid oesophagoscope - Two types are available. Negus type and Jackson's type. They differ from
each other in the type of illumination.
Negus type: In this oesophagoscope the illumination is at the Proximal end of the scope. The
biggest disadvantage is that the illuminating tip is present at the proximal end and is not very bright.
Jackson's type: This type of oesophagoscope has distal illumination. The illumination is brighter
than that of Negus type since it is present at the distal end. The major disadvantage is that it could
get soiled with blood and secretions.
2. Flexible oesophagoscope

Position of patient on the table: Boyce position.

In this position the patient lies supine with ring below the head. The neck is flexed and the head is
extended at the atlanto-occipital joint.

Complications:
1. Oesophageal perforation
2. Injury to teeth, lips, gums, and cervical spine
3. Rupture of aortic aneurysm