Download Otolaryngology

ENT
OSCE Review
by KP Ferraris
Outline
• 10-pt identification quiz
• Case presentations with quiz
– Case 1
– Case 2
– Case 3
• Other ENT symptoms
• Laundry list of must-know and common diagnoses
(For best resolution, view this as Slide Show.)
Outline
• 10-pt identification quiz
• Case presentations with quiz
– Case 1
– Case 2
– Case 3
• Other ENT symptoms
• Laundry list of must-know and common diagnoses
Identification Quiz
1.
Shown below is a Lateral X-Ray of the neck showing
the thumbprint sign. What is the most likely
diagnosis?
a.
b.
c.
d.
Retropharyngeal abscess
Epiglottitis
Acute Tonsillopharyngitis
Croup
Answer: b. Epiglottitis (double t in the first only). It is
characterized by fever, drooling, dysphagia,
odynophagia, noisy breathing, stridor
Identification Quiz
2.
Identify the lesion/diagnosis. The larger field is oral
mucosa.
Answer: Aphthous ulcer or Aphthous stomatitis. It is
an erosion of the mucosa caused by either trauma, hot
foods/liquid, or lack of hygiene.
Identification Quiz
3.
Give the complete diagnosis, with Grading.
Answer: Tonsillitis Grade III with Peritonsillar
Abscesses (Quinsy). The usual complaint is
odynophagia and dysphagia, with or without fever.
Identification Quiz
4.
What type of fracture is shown?
a.
b.
c.
d.
e.
Le Fort I
Le Fort II
Le Fort III
Tripod
Temporal
bone
Answer: b. Le Fort II fracture. In contradistinction to Le Fort
I which is only in the maxilla (upper jaw) and Le Fort III which
involves the inferolateral portion of the orbit (cheek).
Identification Quiz
5.
Identify this diagnostic test used to confirm Benign
Paroxysmal Positional Vertigo (BPPV).
Answer: Dix-Hallpike test. It is confirmatory for only one
pathology: BPPV, a disorder of the posterior semicircular canal. If
positive, where the head is turned to is the side of the lesion.
Identification Quiz
6.
Classify the cleft lip and palate using the Thallwitz
nomenclature.
Answer: L3 A3 H3 S3 H3 A3 L3 (Remember from RIGHT
to LEFT, and only one S). Mnemonic is “Lahshal.” This is
surgically corrected by Cheiloalveolorhinoplasty.
Identification Quiz
7.
Which is the most important part of the sinonasal
anatomy commonly blocked during Sinusitis?
Answer: Ostiomeatal Unit. It is the common drainage of
all sinuses EXCEPT 2: posterior ethmoid cells and the
sphenoid sinus.
Identification Quiz
8.
What is the most common etiologic agent (bacteria) of
Otitis Media?
Answer: Streptococcus pneumoniae. H. influenzae is
more common in pedia. Another agent is M. catarrhalis.
Identification Quiz
9.
Below is a picture from posterior rhinoscopy. It is the
potential site of growth for Nasopharyngeal
carcinoma.
a.
b.
c.
d.
Vallecula
Rosenmüller’s fossa
Pyriform sinus
Choana
Answer: b. Rosenmüller’s fossa. It is a pharyngeal recess
(bilateral) at the back of the nose (nasopharynx) near the torus
tobarius surrounding the entrance to the Eustachian tube.
Identification Quiz
10. Interpret the Audiogram below.
Answer: Sensorineural hearing loss, mild, AD. See
next slide for explanations. AD means right ear (cf. AS,
left ear)
Audiogram
Meaning
Right ear
Left ear
Air unmasked
O
X
Air masked
∆

Bone unmasked
<
>
Bone masked
[
]
Remember: Air (AC) uses
shapes and X, Bone (BC) uses
[ ] and greater-than less-than.
Audiogram
Conductive hearing
loss
Sensorineural hearing
loss
Mixed hearing loss
BC is normal while AC
is >25 dB.
In sensorineural, both AC
and BC are >25 dB. But BC
dipped in higher freq.
Similar to sensorineural,
both AC and BC are >25
dB in mixed. But both AC
and BC really dip together.
Result
Normal
Conductive hearing loss
Sensorineural hearing loss
Mixed hearing loss
AC
<25 dB
>25 dB
>25 dB
>25 dB
BC
<25 dB
<25 dB
>25 dB
>25 dB
Outline
• 10-pt identification quiz
• Case presentations with quiz
– Case 1.0, 1.1, 1.2, 1.3, 1.4
– Case 2
– Case 3
• Other ENT symptoms
• Laundry list of must-know and common diagnoses
Case 1.0
A.Y., a 19 year-old male complained of otalgia.
What questions about the history will you ask?
Hx: OPQRST of Pain, Colds? Allergies?
Rode airplane/diving/swimming? Discharge
(Otorrhea)? Fever? Hearing loss?
Dizziness? Headache?
What will you perform on P.E.?
Inspect for craniofacial anomalies, Otoscopy,
Anterior rhinoscopy, Posterior
rhinoscopy/Nasal endoscopy, Weber test,
Rinne test, Schwabach test (due to the
hearing loss) and complete HEENT exam
(because may be Referred only).
Case 1.0
Hx revealed:
2 years PTC: recurrent otorrhea
Sought consult, prescribed w/ unrecalled
meds (oral and topical drops), doctor said
that tympanic membrane was intact.
1 year PTC: otalgia and otorrhea
worsened; consult revealed perforated
tympanic membrane.
2 weeks PTC: low-grade fever, headache
localized to temporal bone, dizziness,
persistent otalgia and otorrhea
Case 1.0
You took your Welch Allyn and Otoscopy revealed:
How would you describe the otoscopic findings?
Review of Otoscopy
It is important to memorize the anatomic parts of the tympanic membrane to be able
to say where the perforation is, where hyperemia is, where the keratin debris
are, or where the serosanguinous fluid is coming out.
The cone of light reflex (from the reflection of the otoscope light) always points
anterior. So this is the RIGHT ear.
Case 1.0
How would you describe the otoscopic findings?
Perforation
at the pars flaccida,
30%
Serosanguinous fluid
behind the TM
(discoloration)
Hyperemia in the
Epitympanum
Case 1.0
A.Y., a 19 year-old male complained of otalgia.
What other diagnostic tests will you request?
Pure Tone Audiometry, Audiogram, and
Imaging: CT-scan or MRI?
MRI would be good for soft tissues but not
for this case.
CT would be better because it assesses
bony integrity which will confirm concomitant
complications such as:
Skull-base Osteomyelitis or Petrositis
Acute Mastoiditis
Coalescent Mastoiditis
Besides, CT will better aid future surgical
interventions.
Presence of erosion of the
labyrinth at the left ear
(axial cut).
Although a CT scan usually
cannot make a definitive
diagnosis regarding the
nature of any existing
temporal bone disease, the
presence of labyrinthine
erosion is highly-suggestive
of Cholesteatoma.
Opacification of the
mastoid antrum and
mastoid air cells at the left
ear (axial cut).
This finding is suggestive of
Coalescent Mastoiditis, and
other sequelae of worse
prognosis such as
subperiosteal abscess and
intracranial complications.
Case 1.0
You requested CT and findings revealed:
How would you describe the CT findings?
Case 1.0
Audiogram revealed:
Conductive hearing loss,
mild, both ears.
Average hearing level is
approximately 35 dB.
How would you interpret?
Review of Weber test
Normal
Unilateral
conductive hearing
loss
Unilateral
sensorineural
hearing loss
Lateralization
Midline, sound equally heard
Sound lateralizes to poor ear
Sound lateralizes to better ear
What results of the Weber test would you expect in a
patient with mild conductive hearing loss on the left
and normal right ear? Lateralize to right or left?
Review of Rinne test
Normal or
sensorinueral
hearing loss(+)
Unilateral
conductive hearing
loss (-)
Result
AC >BC (positive)
BC>AC (negative)
What results of the Rinne test would you expect in a
patient with mild conductive hearing loss on the
left? AC > BC or BC > AC?
Back to Case 1.0
What is the diagnosis?
Otitis Media
with Effusion
(OME)
Chronic Otitis Media
(COM) without
Cholesteatoma
COM with
Cholesteatoma;
Coalescent
Mastoiditis*; R/O
Labyrinthine Fistula**
2 years PTC: recurrent otorrhea
Sought consult, prescribed w/
unrecalled meds (oral and topical
drops), doctor said that tympanic
membrane was intact.
1 year PTC: otalgia and otorrhea
worsened; consult revealed
perforated tympanic membrane.
Correlate with Otoscopy.
2 weeks PTC: low-grade fever,
headache localized to temporal
bone, dizziness, persistent otalgia
and otorrhea; Correlate with
Otoscopy and CT findings.
*Acute Mastoiditis
already accompanies
COM without
Cholesteatoma but
Coalescent
Mastoiditis is the
one that causes fever
and CT-findings.
Furthermore COM
can be Suppurative
if the discharge is
purulent or pus-like.
**Labyrinthine
Fistula must be
ruled-out due to the
dizziness. If the
dizziness is
characterized to be
vertigo, then there is
inner ear
involvement, making
this a concomitant
diagnosis.
Case 1.0
A.Y., a 19 year-old male complained of otalgia.
The diagnosis of
Chronic Otitis Media with Cholesteatoma;
Coalescent Mastoiditis, left ear requires
further investigation as to its cause.
Did the patient have failed treatment from
previous ear infection (e.g. after swimming)?
Does the patient have craniofacial
abnormalities (e.g. cleft palate, deformed
ear) that make him prone to Eustachian tube
dysfunction and ear canal dysfunction
respectively?
Does the patient complain of “sneezing
everyday, especially upon waking up,” such
that it interferes with daily activities?
Case 1.1
You can have Cholesteatoma without having
Otitis Media! This diagnosis is:
Attic Retraction Cholesteatoma.
From trans:
CC: 5 year history of on/off right ear with gradual hearing loss. No otorrhea.
Figure below. Normally, extension of the blood vessels on the ear canal are travel in
a radial fashion towards the ear drum and then to the head of malleus (or umbo).
Recall that Cholesteatoma is skin/keratin debris that eroded portions of the ear.
Abnormal: what if a part of the eardrum gets sucked in  attic retraction
You will see an interruption in the path of the blood vessel. Then you
will see the blood vessel reappear.
The blood vessel “stops” in its path because it traversed a weak part –
the part that gets sucked in by negative pressure
A part of the eardrum gets sucked in but the rest of it remains in place.
Therefore, the eardum would look ballooned out.
The part of the eardrum sucked in is made of skin and this will keep on
producing new skin (cholesteatoma)  leads to invagination 
eventually eroding the ossicle and the promontory
Most likely diagnosis is
Acute Otitis Externa, R/O
concomitant Acute Otitis
Media.
Since otalgia is also a
characteristic of Otitis Media
(OM) and because the
tympanic membrane is not
seen, OM cannot be fully
ruled-out.
Because the patient has a
history of swimming, and
because the Otitis Externa
(OE) is diffuse, this is most
likely caused by
Pseudomonas aeruginosa.
In contrast to S. aureus
where it is more likely due to
ear manipulation and the
OE is circumscribed, not
diffuse.
Case 1.2
WHAT IF our patient A.Y., a 19 year-old
male, complained of otalgia, without
otorrhea. No other symptoms.
Hx revealed swimming in Montalban river 2 days
PTC.
Otoscopy revealed:
Here, external auditory
canal is narrowed, precluding visualization of
the tympanic membrane.
What is the most likely diagnosis?
Since this looks like infection, what is the most
likely etiologic agent?
Case 1.3
WHAT IF our patient A.Y., a 19 year-old
male, complained of otalgia, with otorrhea,
with other symptoms of difficulty breathing
in the nose and frequent sneezing.
Hx revealed 3 yrs PTC: recurrent bilateral watery
rhinorrhea associated with hyposmia,
frontal headache
1 yr PTC: symptoms progressed, now with total
nasal obstruction on the left, mucopurulent
nasal discharge bilateral and post-nasal drip,
anosmia, hyponasal speech and left sided
facial pain.
Otoscopy is the same as Case 1.0
Case 1.3
Anterior rhinoscopy of the
left nares: (+) smooth,
gelatinous, semi-translucent
and pale white mass arising
from the pink mucosa
What other P.E. will you do?
Anterior rhinoscopy to visualize the inferior
turbinate and meatus and the anterior
portion of the middle turbinate.
Anterior rhinoscopy revealed:
Anterior rhinoscopy of the
right nares: mucosal
edema, swollen and
hyperemic nasal septum and
middle turbinate; (+) of
obstructive mass,
visualization of which is
precluded by a suppurative
yellow discharge
Looks familiar…
Nose SGD! 
Case 1.3
What other diagnostic tests will you request?
CT-scan or MRI?
MRI would be good for soft tissues but not
for this case.
CT would be better. CT scan of the what?
What view?
a.
b.
c.
d.
Axial
Coronal
Waters
Transverse
a. Temporal bone
b. Sinuses
c. Orbit and facial bones
d. Nasopharynx
See next slide for answer.
Left: complete opacification of
the maxillary sinus and
Ostiomeatal unit (OMU); partial
opacification of the anterior
ethmoid cells with air-fluid level
Right: complete opacification
of the anterior ethmoid cells
and OMU; partial opacification
of the maxillary sinus with airfluid level
Overall: Homogeneity of
opacification; intact bony
structures with (–) bone
remodeling or thickening
Case 1.3
You requested CT (coronal view) of the sinuses and
findings revealed:
Diffuse mucosal thickening
whether partial or complete
suggests mucosal hypertrophy
from inflammation, retained
secretions and obstruction, as
well as polyposis.
Opacification of the OMU is
indicative of grave obstruction
because it will eventually
involve almost all of the
paranasal sinuses.
How would you describe the CT findings?
Case 1.3
RECAP:
A.Y., a 19 year-old male, complained of otalgia,
with otorrhea, with other symptoms of
difficulty breathing in the nose and
frequent sneezing.
What is the diagnosis?
The diagnosis is:
Chronic Rhinosinusitis (Pansinusitis);
Inflammatory Nasal Polyposis with
concomitant Chronic Otitis Media with
Cholesteatoma and Coalescent
Mastoiditis
Case 1.4
WHAT IF our patient A.Y., a 19 year-old
male, complained of otalgia, without
otorrhea. No other symptoms.
Hx revealed sensation of swelling “inside ear”
Otoscopy cannot be done
due to microtia and absence
of external meatus.
Case 1.4
You requested CT (coronal view) of the temporal
bone and findings revealed:
How would you describe the CT findings?
A big mass of skin has eroded the bone.
Case 1.4
RECAP:
A.Y., a 19 year-old male, complained of otalgia,
without otorrhea. No other symptoms.
Microtia and absence of external meatus.
What is the diagnosis?
The diagnosis is:
External Canal Cholesteatoma secondary
to Congenital Meatal Stenosis.
From trans:
•pain and swelling behind ear
•Granulation tissue present
•Ear with an abnormal pinna; 2 mm ear canal
•Grayish mass of soft tissue with some blood inside the ear canal
•In congenital meatal stenosis, the outer part of the ear canal is narrow but the inner
part is not as narrow. Since the canal’s skin is like a conveyor belt, the skin gets
dammed back inside because the outer opening is so narrow, causing skin extension
to the middle ear and possibly, to the bone. Pus may drain from the ear (posteriorly).
General Principles of
Treatment
For Otitis Externa:
Topical antibiotic drops: Ciprofloxacin,
Ofloxacin; but fluoroquinolones for
Pseudomonas
For Otomycosis:
Topical antifungal drops: Miconazole,
Ketoconazole
For Otitis Media:
Systemic antibiotics, esp. if with fever +/analgesics
For Impending Perforation of tympanic
membrane:
Myringotomy, and tube; antibiotics
For Cholesteatoma, with Mastoid involvement
and Perforation:
Surgery (Tympanoplasty, Mastoidectomy)
Outline
• 10-pt identification quiz
• Case presentations with quiz
– Case 1
– Case 2.0, 2.1, 2.2, 2.3, 2.4
– Case 3
• Other ENT symptoms
• Laundry list of must-know and common diagnoses
Case 2.0
O.T., a 39 year-old female complained of
hoarseness.
What questions about the history will you ask?
Hx: Quality of hoarseness? Duration of
hoarseness? Progressive? Pain? OPQRST
of Pain, Cough and colds? Sore throat?
Occupation?
What will you perform on P.E.?
Inspection of oral cavity, and complete
HEENT exam (because there might be
associated s/sx).
Case 2.0
Hx revealed:
1 week PTC: hoarseness, non-progressive;
no dysphagia, cough, colds; patient was
previously normal
Occupation: singer (alto); Noticed that
hoarseness worsened with reaching the high
notes of soprano
Case 2.0
O.T., a 39 year-old female complained of
hoarseness.
What diagnostic test will you request?
Best answer: Laryngoscopy, a.k.a.
Stroboscopy or Strobovideo laryngoscopy
Other tests could be:
•Objective voice assessment (not elaborated in
lecture)
•Laryngeal electromyography (not elaborated)
•High-resolution CT of the larynx
Imaging such as CT are not really of use in this
case.
However, imaging may be important:
• if the patient complains of dysphagia
• if the doctor is entertaining malignancy
Laryngoscopy revealed:
Case 2.0
What is the diagnosis?
Laryngoscopy revealed:
Subepithelial hemorrhage.
From trans:
•Often results from voice abuse or misuse
•Voice rest usually resolves hemorrhages, with restoration of normal
voice
•In rare cases, the hemorrhage organizes and fibroses, leading to
scarring
•In specially selected cases, surgical incision and drainage of the
hematoma may be done
Treatment:
•Absolute voice rest until the hemorrhage has resolved
(usually about 1 week)
•Relative voice rest until normal vascular and mucosal integrity
have been restored (usually about 6 weeks)
•Recurrent vocal fold hemorrhages are usually due to
weakness in a specific blood vessel, which may require
surgical cauterization of the blood vessel using a laser or
microscopic resection of the vessel
Case 2.1
WHAT IF our patient O.T., a 39 year-old
female, is a teacher; complained of nonprogressive hoarseness which started 6
months ago. Fatigable voice after 1-hour of
speaking.
Laryngoscopy revealed:
What is the diagnosis?
The diagnosis is:
Benign vocal cord nodules.
•Callous-like masses of the vocal folds caused by vocally abusive behavior
•Hoarseness, breathiness, loss of range and vocal fatigue
•Voice abuse should be suspected particularly in patients who report voice fatigue
associated with voice use, in those whose voices are worse at the end of a working day
or week, and in those who are chronically hoarse
•Confined to the superficial layer of the lamina propria
•Composed primarily of edematous tissue or collagenous fibers
•Vocal nodules are bilateral and fairly symmetrical
•mid membranous portion: area with most contact
•Treatment:
oVoice therapy 6-12 weeks
oIn rare cases, may need microsurgical excision
Bilateral, midline
protrusions
Case 2.2
WHAT IF our patient O.T., a 39 year-old
female, is a teacher; complained of nonprogressive hoarseness which was there for
as long as she can remember.
Laryngoscopy revealed:
What is the diagnosis?
The diagnosis is:
Submucosal cyst.
•May arise from a blocked mucus gland duct, but may also be congenital
•Often mistaken for nodules
•Often cause contact swelling to the contralateral cord
•Diagnosis:
o Fluid-filled appearance on strobovideolaryngoscopy
o Lined with thin squamous epithelium; Retention cysts contain mucus;
o Epidermoid cysts contain caseous material
o Located in the superficial layer of the lamina propria. In some cases, cysts are
attached to the vocal ligament.
•Treatment:
oVoice therapy does not resolve the cysts
oMicrosurgical exclusion
Unilateral,
midline
protrusion
Case 2.3
WHAT IF our patient O.T., a 39 year-old
female, is a teacher; smoker (5 pack-years);
complained of non-progressive hoarseness
for 1 month. She has a low, coarse, gruff
voice which makes her voice mistaken as a
male’s.
What is the diagnosis?
The diagnosis is:
Laryngoscopy revealed:
Reinke’s edema.
•Low, coarse, gruff voice
•Often associated with smoking, voice abuse, reflux, and hypothyroidism
•Diagnosis:
o "elephant ear" floppy vocal fold appearance
o the superficial layer of lamina propria (Reinke's space) becomes edematous
•Treatment:
oTreat underlying condition
oOften requires surgery, which is generally done one side at a time
Bilateral, fluidfilled protrusions
at the base
Case 2.4
WHAT IF our patient O.T., a 39 year-old
female, is a sales agent; smoker (20 packyears); complained of progressivelyLaryngoscopy revealed:
worsening hoarseness for 2 years. She has
Anterior
a low, coarse, gruff voice which makes her
voice mistaken as a male’s.
Relevant P.E. showed palpable
lymphadenopathy (non-tender) of the
Left
Right
submental and (right) submandibular
triangles, Level I, IIA, and IIB. Inspection of
the oral cavity revealed a 4x4cm painless
lump in the underside of the tongue.
Unilateral, hemorrhagic mass
What is the diagnosis?
(metal is an endotracheal tube)
The diagnosis is:
Squamous cell carcinoma of the larynx and floor of the mouth.
•May present as an exophytic, or infiltrative lesion
•Smoking, alcohol intake are risk factors
•Voice problems may be an early symptom of laryngeal cancer
•Can be treated with radiotherapy, surgery, chemotherapy, or a combination of the three
Outline
• 10-pt identification quiz
• Case presentations with quiz
– Case 1
– Case 2
– Case 3.0
• Other ENT symptoms
• Laundry list of must-know and common diagnoses
Case 3.0
B.L., a 22 year-old male sought consult for his unilateral neck
mass, right since 8 months ago.
Nb: This is based on a true patient during ENT ClinEx in Amang last Oct. 21,
2011; with slight modification only of the chief complaint and a PE result.
Case 3.0
O.T., a 22 year-old male sought consult for his
unilateral neck mass, right since 8 months
ago.
What questions about the history will you ask?
Hx: Progressive enlargement? Headaches?
Cough and colds? Sore throat? Mumps,
Parotitis, Otitis? Pain? Nasal obstruction?
Rhinorrhea? Epistaxis? Otalgia? Otorrhea?
Hearing loss? Tinnitus? Dysphagia?
Hoarseness? Trismus? Limitation of jaw
movement and mouth opening?
Occupation?
What will you perform on P.E.?
Complete HEENT exam including Cranial
nerve exam.
Case 3.0
O.T., a 22 year-old male sought consult for his
unilateral neck mass, right since 8 months
ago.
History revealed:
The patient claimed to be previously normal;
(–) infectious/inflammatory diseases such as mumps,
parotitis, otitis.
8 months PTC: first noticed a small lump, non-movable,
non-tender, at the right lateral neck (4x4cm), inferior to the
ear and posterior to the jaw.
7 months PTC: tinnitus, described as “offline of TV station,”
persisted until consult; “mabigat ang kanang tenga”
6 months PTC: neck mass swelled twice the size
5 months PTC: limitation in fully opening the mouth and
trismus at the right; diminished hearing at the right (40%)
4 months PTC: one episode of epistaxis, 5mL blood,
relieved by cold compress
3 months PTC: earache at the right
ROS: recurrent headaches; snoring
Case 3.0
O.T., a 22 year-old male sought consult for his
unilateral neck mass, right since 8 months
ago.
History revealed that the mass enlarged up to
the size shown below:
Review of the Relevant
Levels and Triangles
of the Neck
See next 3 slides!
Back to Case 3.0
O.T., a 22 year-old male sought consult for his
unilateral neck mass, right since 8 months ago.
P.E. revealed:
(–) weight loss; afebrile
Anterior rhinoscopy: essentially unremarkable – no polyps,
masses, septal deviation, and other lesions
Posterior rhinoscopy: (not done)
HEENT: normal-bulk masseter and temporalis muscles; nonenlarged and non-tender parotid gland; no facial
abnormalities; small lump, slightly-movable, non-tender, at
the left lateral neck (1x1.5cm), inferior to the ear and
posterior to the jaw (unnoticed by the patient); no palpable
lymph nodes
Cranial nerve exam: intact corneal reflex, intact sensory and
motor for V1, V2, V3 branches, intact motor functions for XI
and VII except for weakness of the platysma at the right
Weber test: lateralized to the right
Rinne test: BC > AC at the right, BC > AC as well at the left
Case 3.0
What is the meaning of this?
• Weber test: lateralized to the right
Which of the following are possible interpretations for
Weber?
a.
b.
c.
d.
e.
f.
There is conductive hearing loss on the right
There is conductive hearing loss on the left
There is sensorineural hearing loss on the left
There is sensorineural hearing loss on the right
A and C
B and D
Answer: e. A and C. Although both A and C are
possible interpretations for lateralization to the right,
the patient (case 3.0) might only have conductive
hearing loss on the right.
Case 3.0
What is the meaning of this?
• Rinne test: BC > AC at the right, BC > AC as well at the
left
Which of the following are possible interpretations for
Rinne?
a.
b.
c.
d.
e.
f.
There is conductive hearing loss on the right
There is conductive hearing loss on the left
The left either has sensorineural hearing loss or is normal
The right either has sensorineural hearing loss or is normal
A and B
C and D
Answer: e. A and B. In the case of the patient, he
notices the diminished hearing only on the left because
it is relatively weaker. Remember too that a positive
Rinne test (AC > BC) is NORMAL!
Case 3.0
With Tintin’s otoscope, Otoscopy revealed:
How would you describe the otoscopic findings?
Case 3.0
How would you describe the otoscopic findings?
Hyperemia in the
Pars flaccida
Serosanguinous
fluid behind the TM
(discoloration)
Intact tympanic
membrane, no
perforation; good
cone of light reflex
Case 3.0
O.T., a 22 year-old male sought consult for his
unilateral neck mass, right since 8 months
ago.
Further P.E. revealed:
Oral cavity: numerous dental caries; Grade I
Tonsillitis; pink mucosa; midline uvula; no atrophy,
fasciculations and other lesions for the tongue;
non-enlarged posterior pharyngeal follicles, no
other lesions noted; intact gag reflex
Case 3.0
O.T., a 22 year-old male sought consult for his
unilateral neck mass, right since 8 months
ago.
What diagnostic tests will you request?
All of the following are
generally useful for
evaluation EXCEPT:
a. CT
b. Chest X-ray
c. Ultrasound
d. FNAB
e. MRI
f. None of the above
Answer: f. None of the above
because all are useful; CT
and MRI are good choices for
whole Head & Neck
evaluation; CXR would be
useful for TB and ruling-out
some differentials; FNAB
would be useful for minimizing
the seeding if the mass were
malignant; and UTZ may
guide the FNAB, especially if
the mass has cystic
components.
Case 3.0
You requested CXR and readings by the radiologist found
Ghon lesions at the apical lung portions. An ENT in
Amang did a therapeutic trial by having the patient
undergo a 1-month treatment of Izoniazid, Rifampicin,
Ethambutol, and Pyrazinamide. The doctor suspected
that the neck mass is:
due to Tuberculosis presenting as TB Adenitis of
the cervival lymph nodes.
Nb: This is the actual course of action taken by the
ENT and corroborated by Dr. Lacanilao as an
appropriate initial management if TB is suspected.
However, after 1 month of compliant medication
use, the patient’s mass did not subside but actually
grew in size.
Case 3.0
You requested CT and findings are below:
Review of the Relevant
Radiologic Anatomy
of the Neck
See next 2 slides!
PMS – Pharyngeal Mucosal Space
PPS – Parapharyngeal Space
RPS – Retropharyngeal Space
PMS – Pharyngeal Mucosal Space
PPS – Parapharyngeal Space
RPS – Retropharyngeal Space
Case 3.0
How would you interpret the CT findings?
There is obliteration of the pharyngeal mucosal and
parapharyngeal spaces. There is a heterogeneous
mass noted on the posterior pharyngeal wall,
superior portion.
Case 3.0
You may also request MRI (although CT may suffice) and
findings are below:
Blue arrows point the pharyngeal mass;
White arrows point the lateral neck mass.
The neck mass has the same homogeneity as the
pharyngeal mass.
Case 3.0
O.T., a 22 year-old male sought consult for his
unilateral neck mass, right since 8 months
ago.
What is your next diagnostic step for workup?
After seeing the imaging
results, you choose to do
biopsy. Which are the next
courses of action?
a. Endoscopic biopsy of the
nasopharynx
b. Fine needle aspiration
biopsy (FNAB) of the neck
mass
c. Either A or B
d. Neither A or B
Answer: c. Either A or B
because the neck mass
and the mass in the
nasopharynx are
connected.
Case 3.0
Before doing the biopsy, Posterior rhinoscopy is
done. It revealed the picture below. Interpret.
There is obliteration of the
Rosenmüller’s fossa by a growing
space-occupying (mass) lesion.
Case 3.0
After all the revealed information from History, PE, Imaging,
your Primary impression, even without the biopsy
results yet, is:
Nasopharyngeal Carcinoma. This accounts for
the neck masses because pharyngeal tumors
metastasize early. In fact, a neck mass may
precede the demonstration of a mass in the
nasopharynx (by posterior rhinoscopy).
What are other differential diagnoses?
• Lymphoma (Non-Hodgkin’s).
• Lymphoma (Burkitt’s).
• 2nd Branchial Cleft Cyst with superimposed infection.
• Rhabdomyosarcoma.
Case 3.0
How can we rule-out the other DDx?
• Lymphoma (Non-Hodgkin’s and Burkitt’s) Lymphoma
(Burkitt’s) frequently present as supraclavicular neck
masses and a much faster growth in size (days or weeks).
They may also recede in size and grow back again
insiduously. Lymphomas are systemic cancers and
frequently begin as intrathoracic masses. These are not
evident in the patient.
• 2nd Branchial Cleft Cyst with superimposed infection;
although congenital, they may enlarge rapidly if with
superiposed infection. However, the patient denied having a
mass prior to the earliest mass presentation; and no fever
and constitutional symptoms can suggest superimposed
infection.
• Rhabdomyosarcoma; although more common in the
pediatric population, this presents as a growth of soft tissue
mass. However, this cannot account for other head & neck
manifestations.
General Principles of
Treatment
For Nasopharyngeal Carcinoma:
Radiotherapy
For Lymphoma:
Chemotherapy
For Branchial Cleft Cysts:
Surgery
Outline
• 10-pt identification quiz
• Case presentations with quiz
– Case 1
– Case 2
– Case 3
• Other ENT symptoms (and Review of the former shown)
• Laundry list of must-know and common diagnoses
ENT symptoms
• Hearing loss (conductive) suggests involvement of either the
external ear or middle ear, or both. Dx could be Otitis Externa or
Media, Perforated tympanic membrane, or Impacted cerumen.
Otomycosis is heralded by pruritus (itch).
• Hearing loss (sensorineural) suggests involvement of the
inner ear, frequently damage to the cilia and/or the auditory
nerve. This is different from mixed hearing loss (both
conductive and sensorineural) and also from central hearing
loss due to lesions in the auditory cortex.
• Tinnitus described as “ringing in the ears” is a very nonspecific symptom that can signify inner ear involvement as well.
It can accompany any other head & neck pathology and can be
in normal individuals.
• Otalgia or earache and Otorrhea or ear discharge can both be
from Otitis Externa or Otitis Media. Otorrhea can happen even in
an intact tympanic membrane, i.e., if due to Otitis Media with
Effusion (OME) or if due to a pus in the external canal. Otalgia
can happen in non-infectious cause such as in pressure changes
(e.g. riding an airplane). This condition, called Barotrauma, is
frequently accompanied by Hemotympanum, or blood inside the
tympanic membrane.
ENT symptoms
• Dizziness is a non-specific symptom that may not be an ENT
case. It must be further characterized.
TYPES
Lightheadedness
(lumulutang)
CAUSES
some drugs, metabolic processes
(hypothyroidism,
hyperglycemia,
hypoglycemia pregnancy)
Spinning
Induced by vestibular (ear)/ central
(umiikot, vertigo)
(brain: cerebellum and area of the
brain stem) problems, visual system
(but in actuality, the eyes are
affected by the changes in the ear
and not the reverse)
Feeling of fainting or cardiac (any cardiac condition, things
syncope
which decrease blood supply to the
(hinihimatay,
brain), neurovascular (related to the
mawawalan
ng blood supply to the brain)
malay)
Unsteadiness/
alcohol intake, neurologic,
Imbalance/
musculoskeletal, proprioceptive loss
dysequilibrium
(cause: lesions of the posterior
(nalulula/
parang column, Syphilis – tabes dorsalis,
laseng/ nawawalan peripheral neuropathy – diabetes)
ng
balanse/natutumba)
• Vertigo is connected with dizziness but is characterized by a
spinning sensation. It must be differentiated if central (Neuro
case) or peripheral (ENT case).
ENT symptoms
• Vertigo and its differentiation:
Table 1. Characteristics of Peripheral and Central
Vertigo
PERIPHERAL
CENTRAL
Vertigo
Nystagmus
Intermittent
Severe
Always present
Unidirectional
Never vertical
Constant
Less Severe
May be absent
Uni/Bidirectional
May be vertical
Associated
Findings:
Often present
Rarely present
Hearing
Absent
Typically present
loss/tinnitus
Intrinsic
brainstem
signs
Table 2. Differences in Nystagmus in Peripheral and
Central Vertigo
PERIPHERAL
CENTRAL
Direction
Any
Laterality
Horizontal or
horizontorotator
y (never vertical)
Bilateral
Latency
Duration
Intensity
Fatigability
Long (>10 sec)
Transient (<1 min)
Mild to severe
Fatigable
Short (<10 sec)
Sustained (>1 min)
Mild
Nonfatigable
Unilateral or
bilateral
Visual Fixation
Suppressed
NOT suppressed
(may be
Table 3. Dix-Hallpike Test in Peripheral and Central Vertigo
enhanced)
PERIPHERAL
CENTRAL
ENT symptoms
• Nasal Obstruction and Nasal Congestion go hand-in-hand in
that one can cause the other, creating a vicious cycle. For
example, Rhinosinusitis can predispose one to Polyps, although
the latter can also worsen the former’s symptoms.
• Nasal Discharge or Rhinorrhea may be as benign as allergy
or as worse as CSF Leak.
• Epistaxis or nosebleed is a symptom and not a disease. It can
be in normal individuals and can be due to a variety of reasons
such as friable blood vessels, and benign and malignant mass
lesions. For pedia, it may be a sign of Dengue.
• Sore throat is part of the symptom of Dysphonia or
Hoarseness, a symptom of laryngeal pathology. Most benign
lesions are usually non-progressive unless insult is continuous.
Dysphagia or difficulty swallowing and is often due to infectious
or inflammatory causes of the oropharynx and hypopharynx. It
could also be esophageal in origin. In contrast, Stridor, or
wheezing sound, is often due to tracheobronchial problems.
• Snoring can accompany Obesity and palatal abnormalities.
ENT symptoms
• Trismus is the inability to normally open the mouth
due to one of many causes. It may be due to
maxillofacial fractures.
• Most ENT symptoms suggest pathologies confined to
the head & neck, except for signs and symptoms
arising from the neck and nearby structures. Neck pain
can be due to infection in the neck but along with jaw
pain, is a frequent sign or referred pain due to
Myocardial Infarction. Neck masses can be from head
& neck primary but can also be metastases from
systemic cancers.
Outline
• 10-pt identification quiz
• Case presentations with quiz
– Case 1
– Case 2
– Case 3
• Other ENT symptoms (and Review of the former shown)
• Laundry list of must-know and common diagnoses
Other common ENT Dx
not mentioned previously
This list excludes most ear conditions as these have been extensively
mentioned elsewhere in the previous slides. Thyroid and Parathyroid
diseases will be touched on Endo.
• Acute Tonsillopharyngitis
• Acute Laryngitis
• Papilloma of the larynx
• Presbylaryngeus
• Laryngopharyngeal reflux
• Sulcus Vocalis
• Oral Candidiasis
• Retropharyngeal Abscess
• Foreign body in the nose, throat
• Laryngotracheobronchitis
• Laryngotracheal Stenosis
• Juvenile Angiofibroma
• Allergic Rhinitis
• Sialolithiasis
• Pleomorphic Adenoma
Other common ENT Dx
not mentioned previously
• Vestibular Schwannoma
• Presbycussis
• Menierre’s disease
• Viral Labyrinthitis
• Tympanosclerosis
• Rhinitis medicamentosa
• Atrophic Rhinitis
• Vasomotor Rhinitis
• Thyroglossal duct cyst
• Hemangioma
• Nasal bone fracture
• Mandibular fracture
• Tripod fracture
• Zygomatic arch fracture
Outline
• 10-pt identification quiz
• Case presentations with quiz
– Case 1
– Case 2
– Case 3
• Other ENT symptoms (and Review of the former shown)
• Laundry list of must-know and common diagnoses
GOOD LUCK!