SUMMARY OF SOME IMPORTANT CASES OF ENT

(Presenting features, Causes, Investigations, Treatments and others)

EAR

Wax
Presenting features- Causes of impaction of wax in the EAC- Treatment- Properties of Wax-
- Blockage feeling - Excessive formation - Syringing with water at body temperature - Brown in color
- Itching & irritation - Excessive desquamation - Suction & cleaning: in case of semisolid & soft - Secretion increased: soft
- Deafness - Less oily sebaceous secretion wax Secretion decreased: hard
- Earache - Stiff hair in the external canal - Instrumentation- by ring probe, FB hook and - Blackish in color when oxidation occurs
- Brownish, hard/soft mass in EAC (by otoscopy) - Exostosis Hartman aural forceps
- Canal stenosis
Foreign body in Ear
Presenting features- Cause- Treatment- • Complications-
- Earache Animate: Insects, flies, lice, ant, maggot Animate: Kill (olive oil, spirit, chloroform water)• - Injury to TM
- Irritation Inanimate: & remove by forceps or syringing • - Injury to ossicles
- Noise Vegetative: seed, beans, peas Inanimate: Non vegetative by crocodile forceps/ - Otitis externa
- C. deafness (impacted) Non vegetative: Rubber bits, small stone, tip of syringing. Vegetative & round: foreign body hook - FB in middle ear
- Tinnitus pencil, beads - Otitis media
- Foreign body in otoscopy
Furunculosis
Presenting features- ▪ Predisposing factors- Investigations- Treatment-
- - Severe pain during movement of pina ▪ - Trauma Otoscopy is contraindicated due to pain Without abscess:
- - Painful jaw movement ▪ - DM - - Systemic antibiotics Flucloxacillin 250mg qds
- Earache - S. aureus infection for 7 days/ cloxacillin 500mg qds for 7 days
D/D- - - Analgesics & local heat
Acute mastoiditis, Herpetic lesion - - 10% icthamol glycerine
If abscess is formed: incision & drainage
Otomycosis
Presented features- Aetiology- Investigations- Treatment-
- Intense itching - Hot and humid climate - Wet film preparation: - Removal of the fungal mass thoroughly
- Discomfort/ pain in the ear - Wide spread use of tropical antibiotics (i) Hyphae are found in aspergillus from the external canal by forceps or
- Watery discharge with a musty odor and ear - Aspergillus niger (Black) (ii) Small ovoid budding is found in candida suction
blockage - Aspergillus fumigatus (pale blue/ green) - Aural swab for C/S - Antifungal agent: Nystatin, Clotrimazole,
- Fungal mass is seen - Candida albicans (white) Miconazole
- Meatal skin sodden, red, edematous - 2% salicylic acid in alcohol
- Antihistamine
- Antibiotics and steroid
 ASOM
Presenting features- Aetiology- Investigations- Treatment- Complications-
- - Earache - Age: Infants & child ▪ - Blood RME ➢ Medical - Acute mastoiditis with abscess
- - Deafness - Poor Socio-economic status ▪ - Pus for C/S Bed rest, Analgesics, Antihistamine - Facial paralysis
- - Otorrhea ▪ - Recurrent attacks of common cold - X-ray mastoid towns view Amoxicillin 250mg tds 7days, Nasal decongestant - Intracranial complication
- - Fever ▪ - Infections of tonsils and adenoid - Audiogram in early stage Sedation, Local heat - Labyrinthitis
- Stages: ▪ - S. beta haemolyticus ➢ Local - CSOM
- Tubal occlusion ▪ - S. pneumonia Before perforation:
- Pre suppuration ▪ - S. aureus Myringotomy, wet draping, suction
- Suppuration - H. influenza After perforation:
- Resolution D/D- Aural toileting, anti-histamine, topical gentamicin, advice for
- Complications - Furunculosis in external ear myringoplasty if perforation persists
- Referred otalgia ➢ Surgical:
- Hepatic lesion of ear Cortical mastoidectomy if acute mastoiditis/ medical mx
- Post-auricular adenitis doesn’t response for 48hrs
CSOM (Tubo-tympanic)
Presenting features- Cause- Treatment- Complications-
- Discharge: Profuse, thin, mucoid then purulent, - Residue of ASOM Conservative: - Sub periosteal abscess
odorless, intermittent - Chronic secretory otitis media adenoid - Aural toileting - Osteomyelitis of temporal one
- Central perforation of TM - Recurrent upper RTI and Eustachian tube - Antibiotic ear drops: Gentamicin - Facial nerve paralysis
- Conductive deafness infection - Systemic antibiotics: Amoxicillin 250mg - Acute mastoiditis
- Usually painless - S. aureus - Nasal decongestants: Xylometazoline - Extra dural and brain abscess
- Rinne test –ve Investigations- - Antihistamine: Chlorpheniramine maleate - Meningitis, Encephalitis
- Weber test lateralized to diseased ear - EAR swab C/S - Analgesic: Paracetamol 500mg - Sigmoid sinus
- X-ray mastoid towns view Advice: - Thrombophlebitis
- Audiogram - Keep water out of the ear
- Cochlear function test - Maintain aural hygiene
- Come after 14 days
Follow up:
- Cortical/simple mastoidectomy if discharge present
- Myringoplasty
CSOM (Attico-antral)
Presenting features- Cause- Treatment- Complications-
- Discharge: Scanty, thick purulent, foul smelling, Pseudomonas, E coli, Proteus Conservative- (Same as Tubo-tympanic CSOM) Same as Tubo-tympanic CSOM
continuous Investigations- Advice:
- Attic/marginal - EAR swab C/S - Keep water out of the ear
- perforation of TM - X-ray mastoid towns view - Maintain aural hygiene
- Conductive deafness - Audiogram - Come after 14 days
- Rinne test –ve - CT Scan of temporal bone Surgical-
- Weber test lateralized to diseased ear - Cochlear function test - Modified radical mastoidectomy with exploration
- Cholestetoma: Pearly white - Middle ear reconstruction by myringoplasty and ossiculoplasty
 Otitis Media with Effusion (OME)
Presenting features- Cause- Treatment- ➢ Complications-
- Hearing impairment ▪ - Adenoid, hypertrophied lymph node ➢ Conservative: ➢ - Cholesteatoma
- Tinnitus ▪ - Tubal infection - Systemic antibiotics - Tympano-sclerosis
- Vertigo - DNS - Nasal decongestants - Adhesive otitis media
- Cracking and bubbling noise in ear ▪ - Allergy - Antihistamine
- Delayed and defective speech ▪ - Unresolved otitis media ➢ Surgical:
- TM is dull, intact, retracted - Viral infections - Myringotomy & evacuation of fluid under GA
- Conductive deafness Investigations- - Insertion of grommets
▪ - Pure tone audiogram - Intra tympanic inj. Urea solution
- Tympanometry
Otosclerosis
Presenting features- Cause- Investigations- Treatment-
- Conductive deafness - Hereditary 50% - Pure tone audiometry Bone conduction curve shows Conservative:
- Paracusis Willisi (patient hear better in noisy - Both sex equal a dip at 2kHz (Carhart’s notch) - Regular observation
place) - White>black Fair>dark - Tympanometry - Na-fluoride 50-75mg/ day for 2yrs; 25mg/day whole life
- Monotonous, well- modulated, quiet voice - 20-30yrs of age - Rinne –ve on both sides - Hearing aid
- Flamingo flush may be seen through intact TM - Weber lateralized to deafer ear Surgical:
- Radiography Stapedotomy/stapedectomy with placement of prosthesis
Meniere’s Disease
Presenting features- Incidence- Investigations- Treatment-
- Episodic vertigo - Unilateral in 90% - Recruitment test +ve Conservative in quiescent stage:
- Fluctuating deafness (Sensory Neural type) - More common in male - Vestibular function test - Reassurance
- Tinnitus - 30-55yrs of age - Pure tone audiometry- sensory neural deafness - Low salt and fluid diet
- Nausea, vomiting, headache - No drive or dive, use stick during darkness
- Aural fullness Conservative during attack:
- Absolute Bed rest in a calm room, sedation
- Vasodilators- amyl nitrate
- Diuretics
- Removal of toxic foci
➢ Surgery:
- Stellate ganglion block
- Endolymph- perilymph shunt
- Selective destruction of labyrinth
- Total destruction of labyrinth
 NOSE

DNS
Presenting features- Causes- Treatment- Complications-
- Asymptomatic - Congenital: high arched palate & cleft palate - If asymptomatic no Rx - HIT
- Uni or bilateral nasal obstruction - Trauma: Birth trauma, Boxer & players - If symptomatic: - Nasal obstruction
- Pressure headache <16yrs- septoplasty
- Genetic - Atrophic rhinitis
- Epistaxis, snoring, sleep apnea >16yrs- SMR, Sub perichondreal resection, Sub
- Idiopathic - Acute and chronic sinusitis
- C or S shaped septum, septal spur mucoperiosteal resection
Investigations- - Nasal deformity
- Congested mucosa
- X-ray PNS occipito-mental view -Epistaxis
- HIT
- CSOM
Epistaxis
Presenting features- Causes- Investigations- Treatment-
- Sudden onset - Idiopathic 40% - Blood grouping Rh typing - Reassurance, hospitalization
- Past H/O increased BP & injuries - Nose picking - According to cause - Assessment of BP, pulse
- Bleeding per nose mild to severe - Nasal trauma - If in shock mx by IV fluid or blood
- Anxious - FB - Pressure on nostrils
- Features of shock - Infections - Ice or cold packs, cold water irrigation
- Tumors - Ant. Nasal pack (24hr) followed by post.
- HTN - Nasal pack under GA & removed after 24hrs
- Warfarin & aspirin therapy ➢ - Antibiotics, sedative
- Hemophilia ➢ If not improved,
- Aplastic anemia ➢ - Electro cauterization
- Leukemia ➢ - Arterial ligation
➢ - Hemostatic agent: amino caproic acid
- Vit K, C & Ca++ supplementation
Septal Abscess
Presenting features- Causes- Treatment- Complications-
- Bilateral nasal obstruction - Trauma; secondary to haematoma - Incision & drainage - External deformity
- Pain over bridge of nose - Following Septal surgery - ANS pack - Septal perforation
- Fever with chills - Following measles, scarlet fever - Systemic antibiotics 10days - Meningitis
- Septal swelling, headache - Analgesics: Paracetamol - Cavernous sinus thrombosis/ thrombophlebitis
- Congested septal mucosa - Reconstruction
Foreign Body in Nose
Presenting features- Incidence- Investigations- Treatment-
- H/O FB introduction - Common in children - X-ray nose lateral view Removal of the FB with or without GA. Removal
- Unilateral nasal obstruction - Enter the nose through ant. & post. nares or - X-ray of paranasal sinuses occipito-mental view depends on-
- Foul smelling nasal discharge penetrating injury - Age of the patient
- Nasal bleeding - Type of the patient
- Pin soon after introduction - Type of the FB
- Sneezing due to irritation
 Nasal Obstruction
Causes- Investigations- Treatment-
Unilateral: Unilateral choanal atresia (Congenital), DNS, FB & rhinolith, - X-ray PNS occipito-mental (OM) / lateral view - Systemic Antibiotic: Ampicillin 500mg
Unilateral Sinusitis, Rhinosporidiosis - CT Scan in confirmatory - Nasal decongestant: Oxymetazoline
Bilateral: Bilateral choanal atresia (Congenital), Ethmoidal polyp, Nasal allergy, - Pus for C/S - Steam inhalation
Acute rhinitis & Sinusitis, Chronic sinusitis, Atrophic rhinitis - Antihistamine: Chlorpheniramine
- General: Paracetamol 500mg, Bed rest, Local heat
Ethmoidal Nasal Polyp
Presenting features- History Investigations- Treatment-
- Bilateral nasal obstruction & complain - Allergy - X-ray PNS OF view: Hazy frontal and maxillary air Medical:
during inspiration - Usually elderly PT sinus but no opacity - Antihistamine
- Watery/ mucoid discharge - H/O excessive sneezing for prolong period - Blood for TC, DC, ESR - Steroids
- Sneezing, Anosmia - CT scan of paranasal sinus - Nasal decongestant
- Headache Surgical:
- Ant. Rhinoscopy: Multiple polypoidal - FESS
mass arising from root of nasal cavity - Intra nasal ethmoidectomy Extra nasal ethmoidectomy
Antro-choanal Nasal Polyp
Presenting features- History Investigations- Treatment-
- Unilateral nasal obstruction - Infection of sinuses - X-ray PNS OM view: - FESS
- Purulent/mucopurulent discharge - Common in children & young adult Opacity of respective antrum - <14yrs age: Polypectomy followed by antral washout
- Headache, hyposmia - X-ray nasopharynx; LT view - >14yrs of age: Cald-Well-Luc operation
- Ant. Rhinoscopy: Single polypoidal - Pus for C/S
mass arising from lat. wall of nasal cavity
Atrophic Rhinitis
Presenting features- Causes- Investigations- Treatment-
- Anosmia - Hereditary - X-ray PNS shows hazy sinus (sinusitis) Medical:
- Nasal bleeding (epistaxis) - Endocrine - Blood for TC, DC, ESR, Hb% - Counselling, reassurance
- Nasal obstruction - Race - VDRL - Nasal douche by alkaline solution to remove crusts
- Foul-smelling, filled up with greenish - Nutrition - Blood biochemistry for estrogen & progesterone - 25% glucose in glycerine- prevent formation of crust
crust - Infection - Sys. Antibiotics
- Turbinates are atrophied - Autoimmunity - Vit A&D supplementation
- Orpharyngeal mucosa- dry and glazy - Inj. of placental extracts if endocrine cause
Surgical:
Modified young’s operation
Allergic Rhinitis
Presenting features- Aetiology- Investigations- Treatment-
- Nasal obstruction - Predisposing: hereditary, endocrine, - CBC - Avoidance of precipitating factors
- Rhinorrhea, Sneezing infection, physical, psychological - Skin test (confirmatory) - Desensitization
- Nasal irritation - Precipitating: Exogenous substances - Blood for total IgE level & IgE to specific antigen - Antihistamine: Chlorpheniramine maleate
- Para nasal mucosa - Drugs: Penicillin, Aspirin - Total eosinophil count - Endocrine therapy
- HIT - Infection: Fungus, Parasites - Psychotherapy
- Serous discharge - Endogenous: Tissue portion - Surgery: Removal of polyp, Reduction of HIT
 Acute Maxillary Sinusitis
Presenting features- Aetiology- Treatment- Complications-
- Malaise, headache, fever - Acute Rhinitis Medical- - Cellulitis over sinuses
- Discomfort in posterior nasal space - Pharyngeal infection - Systemic Antibiotic: Ampicillin 500mg - Abscess formation
- Nasal obstruction - Adenoid - Nasal decongestant: Oxymetazoline - Orbital Cellulitis
- Epistaxis - Swimming & diving - Steam inhalation - Osteomyelitis
- Pain in the cheek - Compound fracture in sinus - Antihistamine: Chlorpheniramine maleate - Pharyngitis
- Flushing & swelling of cheek, lower lid - Poor general growth, influenza, measles etc. - General: Paracetamol 500mg, Bed rest, Local heat - Laryngitis
- Tenderness over the neck Investigations- Surgery- - CSOM
- Ant. Rhinoscopy shows pus in middle - X-ray PNS OM/Lateral view - Bilateral antral wash out - Dental sepsis
meatus - Pus for C/S - Frontal sinus wash-Cald well-Luc operation - Meningitis
- CBC with ESR - FESS - Brain abscess
- Coronal CT scan of paranasal sinuses - Extradural abscess
Chronic Maxillary Sinusitis
Presenting features- Causes- Treatment- Complications-
- Nasal obstruction - Recurrent acute sinusitis Medical: Pharyngitis
- Epistaxis - DNS, Nasal polyps - Sys. Antibiotics: Ampicillin 500mg tds 12days Laryngitis
- Nasal discharge - Tonsillitis - Antihistamine Orbital cellulitis
- Abnormality in smell: poor smell, foul - Adenoids - Analgesics Orbital abscess
smell - FB in nose - Nasal decongestants Meningitis
- Headache - DM, AIDS Surgical: Brain abscess
- Dull & swollen nasal mucosa Investigations- - Eradication of sinus (antral washout, Cald- well-Luc Otitis media
- Pus in the middle meatus - X-ray PNS OM view operation)
- Pus for C/S Mucocele of maxilla
- FESS Osteomyelitis
- Coronal CT of PNS
- Removal of associated causes: DNS, Polyp etc.
Rhinosporidiosis
Presenting features- Appearance- Investigations- Treatment-
- Nasal obstruction - Foliated polypoid mass in the nasal cavity - Nasal smear (10% KOH preparation) shows spore - Wide excision followed by electrocautery of base
- Itching - Pink or reddish in color - Discharge culture under LA/GA
- Nasal bleeding - Granular surface - Biopsy and histopathology - Thorough clearance followed by-
- Reddish polypoidal mass - Inj. Dapsone/ Inj. Amphotericin B/ Inj. Sodium
- Bleeds on touch
- Granular surface, sensitive and bleeds - Surface has a strawberry like appearance stibogluconate
on touch
 THROAT

Adenoid
Presented with- Causes- Treatment- Complications:
- Feeding difficulty - Repeated URTI Conservative: - ASOM
- Dribbling of saliva - Physiological enlargement - Nasal decongestant - OME
- Snoring, mouth breathing Investigations- - Treatment of associated disease e.g. sinusitis, tonsillitis - Persistence of CSOM
- Adenoid facies - X-ray nasopharynx lateral view - Antihistamine - Rhinitis
- Deafness - X-ray PNS OM view to exclude sinusitis and rhinitis - Antibiotic - Sinusitis
- Regular nasal breathing exercise - speech impairment
Surgical: Adenoidectomy - tonsillitis
Acute Tonsillitis
Presented with- Causes- Treatment- Complications:
- Sore throat - Streptococcus beta haemolyticus - Bed rest, - Chronic tonsillitis
- Difficulty in swallowing - Staphylococcus - Soft diet - Peritonsillar abscess
- Fever, malaise, earache - H. influenzae - Take plenty of fluids - Para pharyngeal abscess
- Tonsils are red and swollen with Investigations- - Analgesics - Cervical abscess
yellowish spot or white patches - Throat swab for C/S - Antimicrobials: Penicillin is drug of choice, alternatively - Acute otitis media
- Foetid breath - CBC with ESR Erythromycin - Rheumatic fever
- Furred tongue
- Enlarged tender regional lymph node
Chronic Tonsillitis
Presented with- Incidence- Investigations- Cardinal features-
- H/O persistent/repeated sore throat - Chronic parenchymatous tonsillitis: Children 4-15 year - Throat swab for C/S - Tonsils are enlarged & fibrotic
- Difficulty in swelling - Chronic follicular tonsillitis: Adults - CBC with ESR - Injected or congested anterior faucal pillar
- Irritating cough Treatment- - Inspissated pus may come out pressing
- Unpleasant taste & smell - Tonsillectomy under G/A anterior pillar
- Referred pain: Earache - Non-tender bilateral palpable enlarged
jugulo-digastric lymph node
Peritonsillar Abscess
Presented with- Aetiology- Treatment- Complications-
- Severe unilateral sore throat - Complications of acute tonsillitis - Hospitalization - Parapharyngeal Abscess
- Dysphagia, - Beta haemolytic streptococcus - IV fluid - Edema of larynx
- Fever (up to 104oF) - Mixed infections of aerobic and anaerobic - Suitable antibiotics - Septicemia
- Dribbling of saliva - Analgesics - Lung abscess
- Trismus Investigations- - Oral hygiene maintains - Aspiration Pneumonia
- Muffled & thickened voice - Contrast CT/MRI - Surgical: incision drainage under LA. Incision should be
- Needle aspiration and c/s over most bulging & fluctuating part of the abscess.
Position: Sitting posture

Presented with-
- Dysphagia & difficulty in breathing
- Stridor and croupy cough
- Fever
- Torticollis
- Bulge in post. Pharyngeal wall
Presented with-
- Slight dysphagia
- Sore throat & cough, Fever
- Smooth bulging on the posterior
pharyngeal wall in the midline
- Palpable painless cervical L. node
Presented with-
- History of initial chocking or gaging
- Pain & discomfort in RT or LT of
trachea
- Dysphagia
- Drooling of saliva
- Respiratory distress
- Substernal or epigastric pain
Presented with-
- Hoarseness of voice
- Cough, stridor
- Respiratory distress
- Neck swelling (palpable, immobile,
hard, fixed)
- Weight loss
Acute Retropharyngeal Abscess
Aetiology- Treatment- Complications:
- Result of suppuration of retropharyngeal LN secondary - Incision and drainage of abscess without anesthesia - Tonsillar abscess
to infection of adenoids, nasopharynx, Posterior nasal - Systemic antibiotics - Pharyngeal abscess
sinus - Tracheostomy - Lung abscess
- Penetrating injury of post pharyngeal wall by sharp - Septicemia
foreign bodies - Edema of larynx
- St. pneumonieae
Investigations-
- X-ray neck Lateral view:
Widening of paravertebral shadow and even presence of
gas.
Chronic Retropharyngeal Abscess
Aetiology- Investigations- Treatment-
- Tuberculous Infection - X-ray neck soft tissue lateral view - Incisional drainage of the abscess
- Common in child, also seen in adolescent & adult Shows caries of cervical spine - Anti-TB therapy
- Immobilization of neck by collar & cuff
- Orthopedic consultation to fix the spine
Foreign Body in Oesophagus
Common foreign bodies: Treatment- Complications:
Children: coins, plastic materials - Endoscopic removal under GA - Respiratory obstruction
Adult: meat bone, fish bone, dentures - Cervical esophagotomy - Perioesophageal cellulitis & abscess
Old age: meat bolus, dentures - Transthoracic esophagotomy - Perforation
Insane: blade, safety pin, needle - Ulceration & stricture
Investigations- - Tracheo-esophageal fistula
- Straight & lateral view x-ray neck & chest:
abnormal radio opaque shadow
- Barium swallow x- ray: radio lucent
- Endoscopic examination
Carcinoma Larynx
Causes- Investigations- Treatment-
- Tobacco and alcohol - Indirect laryngoscopy: cauliflower like growth Curative: Radiotherapy, Laryngectomy
- Asbestos exposure - Direct laryngoscopy; biopsy & histopathology Palliative: Radiotherapy, Analgesic
- Laryngeal keratosis, leukoplakia - X-ray chest & neck According to staging & site of involvement
- Environment pollution - Blood for routine & microscopic examination - Radiotherapy (Stage I & II)
- Radiation - Surgery (Stage III & IV)
- Genetic factor - Chemotherapy
- Voice rehabilitation

Presented with-
- Enlargement of thyroid gland
- Mass or lump in thyroid gland
Presented with-
- Non-tender, spherical, smooth,
clearly defined lump in neck
- Hoarseness of voice
- Dysphagia
- Anemia
- Poor health condition
- H/O weight loss
Thyroid Swelling (Goiter)
Causes- Investigations- Treatment-
- Iodine deficiency - Thyroid profile: Serum T3, T4, TSH level - Anti-thyroid drugs
- Enzyme deficiency - Isotope scan - Surgical incision: Thyroidectomy
- Presence of goitrogens in diet - USG of thyroid gland
- FNAC
- Biopsy & histopathology
Papillary Carcinoma of Thyroid
Aetiology- Investigations- Treatment-
- Age: Children & young adult For dx- - Total thyroidectomy with neck dissection +
- Sex: M : F = 1 : 4 - Radio-isotope scan thyroxine replacement
- FNAC of lump - Radio-iodine therapy
- Biopsy & histopathology (if FNAC is negative) - Treatment of metastasis
For surgery- Follow-up
- X-ray of neck PA & Lateral view To see the local recurrence & distant
- S. thyroglobulin level metastasis-
- S. Ca level - Annually isotope scan done
- Indirect laryngoscopy - Measurement of S. thyroglobulin
- CBC with ESR, Blood urea, S. creatinine, U/R/E, CXR
Prepared By-
PARTHA SAROTHI SINGHA
AMUMC-7