ENT - Essays - Sun 2016

30 March 2021 09:44

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3. Differences of vocal nodules and vocal polyps?

Vocal nodules Vocal polyps

symmetry Bilateral symmetrical benign white unilateral
masses
location Midpoint of vocal cords Mid 3rd of membranous cords
(at junction of anterior 1/3rd and
posterior 2/3rd)
cause vocal fold tissue trauma caused by
excessive mechanical stress, including
repeated or chronic vocal abuse
Larger and protuberant than nodules
Have dominant surface blood vessels
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 Have dominant surface blood vessels
Rx Voice therapy Surgery
(usually resolve son its own)
Severe - surgery

4. Aetiology of nasal obstruction?

• Congenital:
congenital choanal atresia/nasal septum deviation
• Traumatic :
nasal bone fracture/ nasal septum hematoma or deviation
• Foreign body in the nose.
• Inflammatory:
rhinitis: allergic rhinitis /acute rhinitis/ chronic
rhinitis/ atrophy rhinitis
rhinosinusitis :acute /chronic
• Neoplasm:
benign: nasal polyp/inverted papilloma
malignant: nasal pharyngeal carcinoma
• Other causes of nasal obstruction include:
i. Excessive use of topical vasoconstriction in the nose (ephedrine)
ii. birth control pills/pregnancy
iii. Hypothyroidism
iv. Empty nose syndrome

5. Aetiology for epistaxis?

• The causes of epistaxis may be divided into three broad categories: local, systemic,
idiopathic
• Local causes:
i. Trauma:
Finger nail trauma, injuries of nose, fractures of face and base of skull, violent sneeze,
intranasal surgery
ii. Infection/inflammation
Acute or chronic rhinitis /sinusitis
iii. Anatomic deformities:
deviation/erosion/perforation of the septum
iv. Foreign bodies:
v. Intranasal tumours:
Benign: haemangioma, papilloma, angiofibroma,etc.
Malignant: carcinoma, sarcoma, NPC etc.
vi. Drug: Nasal steroid sprays
vii. Atmospheric change - Cold and dry climates
• Systemic causes :
viii. Cardiovascular system diseases : hypertension, arteriosclerosis,
ix. Blood system diseases : leukaemia, haemophilia, vascular purpura
x. Liver diseases: liver cirrhosis(coagulation disorders）
xi. Kidney diseases: chronic nephritis(toxin damage the blood vessel)
xii. vitamin D,K deficiency
xiii. Drugs: anticoagulant therapy (Aspirin, warfarin）
• Idiopathic cause are the causes where the aetiology is not clear

6. Management of epistaxis?
• First aid:

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 • First aid:
→ Bleeding occurs from the Little‘s area and can be easily controlled by pinching the nose
for about 5 mins
→ Ensure that firm pressure is applied over Little’s area by compressing the soft alar regions
against the septum
 General treatment :
→ Keep the patient seated and the head tilted forward .
→ Keep the patient calm and quiet, prescribe sedatives if necessary.
→ Ask the patient to spit out blood instead of swallowing it.
→ Let the patient lie down if there are signs of shock.
→ Cold compresses is helpful.(forehead, carotid
vessels)
 More several epistaxis should be treated with endoscopic bipolar electrocautery if the
nasal endoscopy is feasible and the bleeding point has been located.
 Chemical cautery with silver nitrate-tipped sticks generally is not quite effective,
especially with active bleeding

 Nasal packs
→ Anterior nasal pack : Merocel nasal pack, Vaseline gauze
→ Posterior nasal pack : Vaseline gauze, epistaxis balloon (water or air balloon).
 anterior pack are made of vaseline gauze coated with an antibacterial ointment
 Cause decongestion and local anaesthesia
 gauze is firmly packed in a layered fashion from the anterior to the posterior
 Easy to grasp and manipulate;
 Effective to anterior bleeding , sometime location unidentified bleeding
 Posterior nasal packing Is indicated for those patient failing anterior nasal packs or who
upon evaluation have known posterior bleeding.
 used in conjunction with an anterior pack.
 Artery ligation or embolization used Only for those with severe bleeding and other
methods failed;
 Generally, otolaryngologist need rapidly judge the artery to be ligated in light of
bleeding area
 The epistaxis is often life-threatening, so the sign of life should be cared simultaneously

7. Indications and contraindications for tonsillectomy

indications
Acute tonsillitis attacks frequently
Tonsils are over-hypertrophy and impede
deglutition, respiration and pronunciation
The chronic tonsillitis have become focus
which arouses pathologic of other organs or
associate with pathologic of adjacent organs
(arthritis, endocarditis or myocarditis or
nephritis）
Complicates with quinsy many times.
For patient who is Diphtheria bacteria-carrier
and the conservative treatment is invalid
contraindications
Acute tonsillitis: should excise the tonsils
when the acute inflammation is extinct by
2-3 weeks.
Haematological system disease :such as
aplastic anaemia, purpura etc.
Serious general disease: such as active
pulmonary tuberculosis, hypertension,
psychosis, etc.
Acute infectious disease: such as
poliomyelitis, influenza etc.
In and prior to female menstrual period and
pregnant stage

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 and the conservative treatment is invalid
Should adopt a prudent policy to the tonsillar
malignant tumour
All kinds of tonsillar benign tumour can be
removed with tonsils.
pregnant stage
The morbidity of immunoglobulin deficiency
and autoimmune disease in the patient’s
relatives is high

8. Describe the classification ad treatment principles of laryngeal obstruction

 Classified in to 4 as 1st 2nd 3rd 4th degree laryngeal obstruction
 I °: No dyspnea in quiet, Mild inspiration dyspnea slightly, stridor and depressed soft
tissue may occur during crying or on exertion
 II °: Mild inspiration dyspnea, stridor and depressed soft tissue in quiet and
exaggeration on exertion, With no influence in sleep and eating, No anoxia
Normal pulse rate
 III °: Evident inspiration dyspnea, loud stridor and depressed soft tissue, With influence
in sleep and eating, With quick pulse
 IV °: Extremely dyspnea, Restless, cold sweat, cyanosis, Pulse is rapid, irregular, weak,
blood pressure decline, Finally circulatory collapse may occur or may die of asphyxia or
cardiac failure
 Principle of treatment is that Not a second to be lost and Remove the blockage
immediately and Assure adequate airway ventilation
 Depending on the cause of the disease and the degree of difficulty in breathing,
medication or surgery may be used
 I °:Find etiology and Treat the etiology
If it is due to an inflammation: Antibiotics, corticosteroid
 II °:
Inflammation
antibiotics, corticosteroid in time, adequate
observe carefully
prepare for the tracheotomy
Tumor, trauma, vocal cord paralysis
tracheotomy if the pathogen cannot be removed quickly
Foreign body - remove ASAP
 III °:
Inflammation:
antibiotics, corticosteroid (in time, adequate, efficient)
observe carefully and prepare for the tracheotomy
If symptoms can not relief quickly then tracheotomy
Tumor: tracheotomy
 IV °:
- Tracheotomy
- Cricothyrotomy
- Intubation
- Treatment etiology: after dyspnea relieved

9. Indications and contraindications for tracheostomy

indications contraindications
Laryngeal obstruction: 3-4 degree skin infection
Decreased/incompetent clearance of prior major neck surgery which complete
tracheobronchial secretions obscures the anatomy

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 Prophylactic tracheotomy Patients with obesity.
Need of Airway access for prolonged Patients with abnormal or poorly palpable
mechanical ventilation midline neck anatomy

10. Thyroglossal cyst and branchial cyst

Thyroglossal cyst Branchial cyst
congenital cyst Congenital cyst
Median neck mass Lateral neck mass
infrahyoidal remnants of the thyroglossal arise from remnants of the second, third
duct apparatus, which normally obliterates and fourth branchial arches
by the end of the eighth embryonic week
and become completely reabsorbed.
site of origin persists as the foramen
caecum at the base of the tongue.
situated anywhere along the midline from
the foramen caecum to the suprasternal
region majority in proximity with hyoid
bone
most common presentation of the well-visible tumour, often of changing
thyroglossal duct cyst is an upper midline size and feelings of pressure.
(fluctuating) cervical mass
Others - mass is painless and non-tender,
10-15% shows infections with redness and
pain and fistula formation after infection
Complications include abcess formation at Abscess, infiltrating phlegmons involving
base of tongue that may cause dyspnea, jugular vein
dysphagia , sore throat In patients older than 40 years, malignant
transformation of branchial cleft cysts is
possible
Rx- Complete surgical excision
Prognosis - if completely removed - Surgical removal usually cures the patient.
considered cured If surgery is not radical with complete
If the middle portion of the hyoid bone in removal of the cyst or fistula, there is a
not resected, high incidence of recurrence
recurrence will usually happen

11. Clinical manifestations of tracheal and bronchial foreign body obstruction

• In Trachea
Severe choking
Dyspnea
wheeze, beat sound
Suffocate
• In Bronchi: Four stages
→ Just enter phase - choking, light dyspnea
→ Asymptomatic period / Silent phase
→ Inflammation phase - cough, fever, pus
→ Complication period - heart failure, pneumothorax, mediastinal emphysema,
subcutaneous emphysema

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 subcutaneous emphysema
 Dx - Hx, PE, imaging - X ray, CT where direct evidence for metal foreign bodies and
indirect evidences for other foreign bodies
 Rx - remove as soon as possible. Bronchoscopy, fiberoptic bronchoscope and
bronchovideoscopes are used
 At home we can use heimlich maneuver

12. Clinical manifestations of oesophageal foreign body obstruction

 Chest pain: especially when swallowing
 Dysphagia
 Saliva secretion increased
 Huge ones can even compress the airway
 Complications:
Oesophageal perforation: subcutaneous emphysema, mediastinal emphysema
Periesophagitis, periesophageal abscess, mediastinal abscess, etc.
Tracheoesophageal fistula: can cause pulmonary infection
Bleeding: aortic arch rupture can lead to fatal bleeding

 Dx - Hx, PE, imaging X ray and CT gives direct evidence for metal foreign body and also
we can use x ray barium meal examination and esophagoscopy
 Rx -
Surgery : Esophagoscopy, Fiboroptic esophagoscope, Upper gastrointestine videoscope
If the condition is Not dangerous we can wait and watch or push into the stomach

13. Otogenic complications of chronic otitis media?

• A Chronic suppurative middle ear infection Caused by Chronic inflammations of nose
spread from eustachian tube , Delayed acute suppurative otitis media , hypo immunity
• A main complication is cholesteatoma. Write about this (SN Q 16)
• Other otogenic compications include Postauricular abscess, Labyrinthitis., Labyrinthine
fistula.
• Mastoiditis.,Temporal abscess.,Petrositis
• Petrositis occurs when infection from the middle ear and mastoid spread to the petrous
cells of the temporal bone by vascular canals or bone resorption.

14. Complications of otitis media?

• Complications can be divided it intracranial complications and extra cranial complications
• Intrcranial complications are Epidural abscess, subdural abscess, suppurative meningitis,
brain abscess, sigmoid sinus thrombophlebitis.
• Extracranial complications includes Subperiosteal abscesses, Bezold abscess, Mouret
abscess, Labyrinthitis, peripheral facial paralysis
• Another fatal compliation of chronic otitis media is cholesteatoma (SN Q 16)

15. Please describe the reasons why children are more susceptible to otitis media?
• Children usually get ear infections more than adults do for several reasons: Their shorter,
more horizontal eustachian tubes let bacteria and viruses find their way into the middle
ear more easily.
• ear symptoms are not obvious (cannot speak), scratching, head shaking, crying, etc.;
• thick eardrums of infants are not easily perforated; because ear drums are very thick in
infants. Therefore can't see pus therefore can stay for a long time
• not easy to occur at the age of 2 to 3 years (the mastoid air chamber is developing and
has extensive space).
• severe systemic symptoms: acute infection appearances, high fever, nausea, vomiting

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