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ENT PAST YEARS QUESTION ACCORDING TO TOPICSShort form = Sx- Symptom ;CP (clinical picture),Mx(management),Dx(diagnosis),Rx(treatment) ; Ix = investigation
Topic EAR
1. Basic Anatomy & Physiology of Ear
-causes of referred pain to ear**along any of the following nerves:1. trigeminal (V)
1) nose & sinuses: acute sinusitis (ant. group)2) teeth and gums:
i) impacted wisdom toothii) dental caries and abscesses
3) temporomandibular joint disfunction4) nasopharynx: post-adenoidectomy, nasopharyngeal carcinoma5) trigeminal neuralgia6) Floor of the mouth: ulcer or tumors7) trigeminal neuroma
5. C2 and C31) trauma to the cervical spine2) cervical spondylosis3) occipital neuralgia
etc...*3 neuralgias.
-referred otalgia by glossopharyngeal n (see previous question)
2. Audiology & vestibular evaluation
-give an account on tuning fork hearing test
3. Diaseas of external ear
-give an account on ear wash(see 3 questions below :) )
-complications of ear wash******
1. Vertigo, nausea, and vomiting - dt. caloric stimulation of inner ear (lat. semicircular canal)
2. Cough and syncope - dt. vasovagal attack3. More impaction of the wax plug or FB4. Traumatic rupture of tympanic membrane - there is sharp pain
and slight bleeding in the ear and the patient may feel water passing to his throat.
5. Trauma to the skin of the external canal - this also causes pain and bleeding from ear but the ear drum is intact.
6. External otitis - dt. contaminated instruments
-indications of ear wash**
wax plug foreign body except:
o vegetable foreign bodyo impacted FBo animated (insect)
scaly debris otomycosis ear discharge
-contraindications ear wash
dry perforation of tympanic membranne recent head trauma with suspected fracture base of skull history of previous tympanic membrane perforation/ head trauma acute inflammation impacted FB
-etiology & clinical picture of malignant otitis media
4. Acute otitis media
-etiology,Cp,Mx ASOM**
Dis organism CP Rx
ASOM
Moraxella Catarrhalis, H influenza, Strept Pneumonia
signs1. Occlusion: retracted congested memb (cart wheel)->c/o : fullness, earache, fever.2. Catarrhal OM: retracted memb, distorted/loss of cone of light, handle of malleus prominent, foreshortened, more horizontal, conductive HL-> ℅: increase ear ache, fever3. Suppuration OM: loss of landmarks, reduced mobility, absent cone of light, yellowish spot, mastoidism - ℅: severe throbbing pain, high fever4. Resolution (after rupture): relief of symptoms, central rounded perforation, mucopurulent odorless discharge ->mucopurulent odorless discharge, relieve fever, pain.
1. analgesics2. antibioticsBefore perforationwarm glyco-phenol preparationmyringotomy*After perforationcleaninglocal antibioticsculture and sensitivity
-indications of myringotomy1. in AOM before perforation:
1) adequate medical treatment but no improvement in 48 hrs2) severe otalgia and high fever3) complication from the start eg. facial palsy4) yellowish colour and bulging5) patient is immunocompromised or is a premature baby
2. in AOM after perforation: very tiny hole with inadequate drainage(kalau ada lagi sila tambah) * asal dah perforate pun nk myringotomy?
-types & Rx of tympanic membrane perforation
5. Chronic suppurative OM
-types & complication of cholesteatomatypes:
congenital acquired
o 1ryo 2ry
complications (same macam CSOM kan?)
cranialo mastoiditis, mastoid abscesso petrositiso labyrinthitiso VII paralysiso osteomyelitis temporal bone
tenderness over mastoid process over the tragus and on pulling the ear
otoscopy sagging of the post-sup wall leading to narrowing of the inner bony part of
narrowing of the outer cartilaginous part of the external
the external canal canal
deafness conductive hearing loss not relieved by insertion of speculum
conductive hearing loss relieved by insertion of speculum
postauricular groove
maintained (due to attachment to the periosteum)
flat
edema of the eyelids
upper if there is zygomatic abscess
lower only if present
culture and sensitivity testing
strept hemolyticus staph aureus
x-ray of mastoid
mastoiditis (haziness and opacity of air cells) or actual abscess cavity (mastoid abscess)
normal
-type of mastoidectomy
-enumerate complication of CSOM,give details about lateral sinus thrombophlebitis
-Rx of acute mastoiditis
7. Ear related facial n paralysis
-diagnostic feature of different level of facial palsy/how to define level of facial pasly**
-etiology/causes of facial palsy**
8. Hearing loss & tinnitus
-causes of conductive hearing loss****
1. Causes in external ear
a. Congenital e.g. congenital meatal atresiab. Acquired
i. Impacted wax (most common in adults)ii. FB
iii. Inflammatory: furunculosis, otomycosisiv. Neoplastic: exostosis
2. Causes in tympanic membrane
a. Stiffness: tympanosclerosis or fibrosis of TMb. Perforation
3. Causes in middle ear
a. Vacuum: ET dysfunction/occlusionb. Fluid: CSF, serum, mucus, pus, bloodc. Adhesionsd. Soft tissue
i. Tumors: glomus tumorii. Cholesteatoma
e. Ossicular pathologyf. Fixation: otosclerosisg. Disconnection incudo-stapedial or incudo-malleal joints
-causes of SNHL/perceptive deafness/inner ear hearing loss*****
Disease of inner ear & acoustic neuroma-Mx of meniere’s disease ****
-CP & invest to dx acoustic neuroma
-full account on meniere’s disease(pathology,CP,invest,Rx) **
Pathology
Accumulation endolymph causes distension and rupture of membranous labyrinth
This lead to leakage endolymph into perilymphatic spaces and results into suppresion neural elements of labyrinth
Membranous rupture responsible for recurrent episodic vertigo and hearing loss
Rupture heals symptoms subside
9. Middle ear effusion,glomus tumor,otosclerosis
-CP of secretory OM **
-Etiology & Mx of secretory OM
-Dx & Rx of secretory OM
-CP & Rx otosclerosis
10. Vertigo
-etiology & how to Dx vertigo **
-investigation in dizzy patient
Topic NOSE
1. Anatomy,physiology nose,choanal atreasia
-function of nose & paranasal sinusesNose : 1. airway2. air conditioning3. reflex 4. olfaction
Paranasal sinuses : 1.resonance voice 2.air conditioning 3.light wt skull 4.buffer head trauma 5.secretion for mucociliary blanket nose 6.thermal insulators
2. Allergy & nasal polypi
-types,CP,Mx of nasal polypi******Types1- Solitary (ACP)2- Multiple (diffuse nasal polyposis,middle meatal polyposis)CP1- Long history AR or VMR2- Symp (nasal obs x relieve compltely by VC,hyposmia)3- Signs (polyp-bilat,multiple,pale,soft gelatinous masses,smooth)(pale,edema mucosa)Mx1- cp2- Ix (CT-plan surgical Rx)3- Rx AR or VMR4- Drug: top steroid.oral antiH5- Surgery : bilat complete obs (simple polypectomy,endoscopic polypectomy w ethmoidectomy)
-Rx of antrochoanal polyp
o middle meatal antrostomyo sublabial antrostomy ‘ caldwell-luc approach’
-Dx & Rx allergic rhinitisDx1- Hx : FH , environment , occupation , sp habit , seasonal variants2- CP : Symp (sneezer,runner,blocker,hyposmia,itchy throat,irritant cough,itching,watery eyes) signs (pale.moist.edema mucosa,hyperT inf turbn8,polyp)(allergy salute,shiner,gap)3- Nasal smears : eosinophilia4- Bld exam : IgE,eosinophilia5- Skin test6- Nasal challenge test :spfc Ag to nasal mucosa7- RAST : circulating Ab for spcfc AgRx1- Avoidance : most important2- drug (top steroid,oral antiH,top antiH,top Na+ cromoG,oral steroid)3- hyposensitization : blocking Ab IgG4- surgery : better avoid,limited role ONLY relieve gross nasal obs or open significant obs drainage sinus
-give an account on diffuse nasal polyposis
3. Rhinitis,nasal obstruction
-causes of nasal obstructionBilateral:CC n TTNaSAL CAUSECongenital choanal atresiaRhinusitis ( common cold )Nasal polyp / nasal allergyTrauma = septal hematoma, foreign bodyTumour = SCC, inverted papillomaNASOPHARYNGEAL CAUSEsadenoidenasopharyngeal carcinomanasopharyngeal fibroma
Investigation1.Specific scoring system bout patency of the nasal airways2.Acoustic Rhinometry
4. External nose & nasal septum
-Dx & Rx of nasal septum deviation **
5. Epistaxis
-local Rx of epistaxis
1) Nose packed for 10min with cotton soaked in epinephrine and xylocaine.2)when the bleeding stop we’ll find the bleeding point and do cautery (chemical by silver nitrate, electrical, diathermy)2) anterior nasal packs ( gauze soaked with vasline and ab ointment left for 24h)3) post nasal pack ( epistaxis of nasopharyx origin - post adenoidectomy, angiofibroma, carcinoma)4)nasal balloooon-ant nasal
-causes of epistaxis(local & systemic)***
LOCAL GENERAL
a) Congenital – osler’s disease
a) Blood disease –hemophilia,purapura n leukaemia
b) Deviated septum b) Hypertension – COMMONEST in old age
c) Idiopathic – commonest c) Raised venous pressure –mitral stenosis / mediastinal syndrome
d) Inflammator y –rhinitis( atrophic , acute )
d) Drug – salicylate , anticoagulant
e)Traumatic – nose picking.FB,fracture
e) Hormonal -pregnancy
f) Tumour – malignant ,bleeding poolypus
f) Fever
g) High altitude
-systemic causes of epistaxis
-local causes of epistaxis**
-Mx of severe epistaxis***- Endoscopic cautery of sphenopalatine artery- CLipping [ maxillary artery / ant ethmoidal artery ]
-Mx of epistaxis***First aid measure:- Ask patient to incline forward and breath tru the mouth- squeezing the ala of the nose as it will compress the sphenopalatine artery thus will help to decrease bleeding / stop bleeding
- put ice compresses to the bridge of the nose will lead to reflex VC nasal mucosa- place nasal pack or nasal drop in the nose to induce VC
General Measure in the hospital:- check BP and other vital sign- apply anti shock measure- coagulant n other medication may be given
Local Measure:a) Anterior epistaxis- Nasal pack with vasocontrictor- cautery ( chemical cautery by silver nitrate ; galvanocautery ; coagulation diathermy )- Ant nasal pack with vaselin n Ab for 24-48H to guard against TSS and sinusiti.
b) Post epistaxis-post nasal pack with vaseline and aB-post nasal balloons
c) Superior epistaxis:-ant. nasal packing
if those measure can’t control the bleeding, proceed to:- Endoscopic cautery of sphenopalatine artery- clipping [ maxillary artery & ant. ethmoidal art )
6. Sinusitis
-indication maxillary sinus punctureDiagnostic: - To confirm present of infection in the sinus- Instillation of the radiopaque material to do radiologic examination- For culture and sensitivity procedure- Cytological examination
Theraputic:- Rx the subacute and chronic rhinosinusitis if not respond to medical rx.- fungcal sinusitis- barotaraumatic sinusisit
Rx:- Removing the predisposing factors- Medical treatment by antibiotic, decongestant, anti histamine, steroid- surgical is done in case of resistant medical rx ( proetz ; antral washout )
-CP acute sinusitisSymptoms :1- Paina) Maxillary sinus = below the eye, cheek , refer to the temporal and frontal and upper teeth region.b) Frontal sinus = above the eye , foreheadc) Ehtmoidal sinusitis = on the bridge of the nose, in the between of th eye, and refer to the parietal region.d) Sphenoid sinusitis = deep seated pain ; Vault.occipital.mastoid region and behind the eye as this sinus is posterior sinus. rigth?2- Nasal obs3- Nasal discharge n postnasal (mucopurulent/purulent/offensive odour)4- Fever malaise
-enumerate complications of tonsillectomy operation**Anasthetic Complication and local complication.
-indications for tonsillectomy*******EIGHT INDICATION:
a. Repeated att ac tonsilitis 7,55,333b. Repeated att with chrn valvular dis and febrile seizurec. 1 att quinzyd. Chrinc tnsilitis xrespond to med Rx causing obstructive
symptom(enumerate sdri)e. TB tonsilf. Beningn tumour tonsil eg fibromag. sUSPICIOUS malignant tonsilh. removal tonsil as part of other operation
-routine investigation before tonsillectomy operation1.Proper History taking.2.General examination
Local ENT ex3.Urine aanalysis,bld analysis.(enumerate sendiri)
-DD membranous tonsils**
1. GabHs-yg causing acute tonsillitis kita belajar ni2. Diphteria (must put first after acute tonsilitis,VERY IMPORTANT DDX,If remove membrane will bleed not like Gabhs)2. IM3. Scarlet fever4. Glandular Fever8. Angina Vincent 9. Agranulocytosis9. Acute leukemia8. Thrush7. Behcet
-discuss indications,contraindications & complications of tonsillectomy CONTRAINDICATION: 5 absolute,5 relative
Relative:1Acute tonsilits(tonsil tgh vascular!!) so Rx first because can cause severe bleedig and septicemia
2.Epidemic Polio3.Rheumatic Fever
4.DM5.ASTHMA
+- Cleft Palate (can cause icompetenet velopharyngeal isthmus,see complication*)
COMPLICATIONS. :anasthetic and operative(periop,i/m op,post op)ANASTHETHIC-cARdiac arrest-RESP arres-TOxicity-Intubation granuloma during ett (jgn lupa)
Operative 1)pERI:1.Primary HGE
2.mISHAPE,TRAUMA
2)IMMEDIATE POST OP:1.REACTIONARY HGE2.edema uvula(lupa nk bukak ligateion kat uvula)4.Chest infection5.DM,septicemia
6.Velopharyngeal incomp. (if has cleft plt)
3)LATE POST OP:1.Liabilitiy to catch infction,thats whyl;2.Secondary HGE (dt infection)
-Rx snoring& OSA ( YOU CAN DIVIDE INTO CONSERVATIVE,SIMPLE NASAL,SIMPLE PALATAL,SEVERE )
1.conservative treatment-ie.treat the risk factor[obsity-lose weight,alcohol-stop,smokin-stop]2.For SIMPLE nasal cause of snoring-medical treament-nasal appliances-nasal surgery3.FOR SIMPPLe palatal cause of snoring-UPPP-LAUP-Palatal stiffening operation4.Severe OSA-CPAP-TRACHEOSTOMY
-Rx snoring sahaja macam mana ye?
5. Pharyngeal & neck suppuration
-discuss acute retropharyngeal abscess***DEF: *Suppuration in btw post ph wall and prevetbral fascia.ETIO:-Child,supp. of Henle node.-Adult,need imunocompromised+ trauma eg foreign body
CP:-Fever(diff with chronic;no fever)-Dficult suckling and feeding-Neck rigidityso contraction is at the opposite site(diff with quinsy having spasm of sternomastoid!)-MIdline cystic sweeling UNILATERAL (because have bucopharyngeal and prevetbral fasscia adherence)
Ix-Xray lateral;1.Thickening prevet tissue more than 50% of vetebra2.Air in prevetebral soft tisue3. Normal CUvature of spinal REVERSAL.
Complication.Child may aspirate if rupture,cause death.Child may have laryngeal spasm or mediastinitis if spread.
Rx.No anasthesia,usually relieve after vertical incision,POsition- HEAD MUST LOWERED DOWN,MUST USE SUCTION TO AVOID ASPIRATION(see DANGEROUS complication!!)systemic antibiotic+++IF AIRWAY COMPROMISE=TRACHEOSTOMY
-CP & Rx of quinsy****
CP:-Symptom:General-HIGH fever,malaise,headache etcLocal-Sore throat with refred pain,odynophagia,halitosis,salivation.
Sign:-Diff exam dt trismus-Cx LN swelling
-Pain so spasm of sterno mastoid
when u examine;-uvula edematous then push to midline.-soft palate above and lateral swell-tonsil go medially and downward-salivation acccum and coated tongue-CAN SEE POINT OF SUPPURATION!
Treatment:(QUINSY U MUST DIVIDE Rx to PRE AND SUPP!)Local(pre suppurative)-bed restsoft diet,hydrationantibioticanalgesic
Post suppurative:-Incision and drainge;local anasthesia,intraorally(check 4 site for incision)-systemic antibitioc-Tonsillectomy after 1 month(after cure)
-complication of quinsy***
o Sudden rupture & inhalation of pus can lead to chest complications
o Extension laterally leading to parapharyngeal abscess or downwards leading to laryngeal edema & stridor
o Internal jugular vein thrombophlebitiso Pyemia & septicaemia (very rare)
-discuss quinsy(etiology,CP,Invest,Rx)same as above;ETIOLGY=USUALLY follow attack of acute tonsillitis dt GABHS
6. Neck swelling
7. Hypopharyngeal tumor
-post cricoid tumor (CP,Dx,Rx)**
SOALAN NI PARTICULARLY FOR POST CRICOID TUMOUR RIGHT?so CP:1.DysphagiA-gradual and progressive,to solid food 2.Pain and refrred otalgia3.Hoarseness of voice-infiltrate nerve,cricoarytenoid joint,muscle,or mass on vocal cord.4.Neck mass-thyroid infiltration,LN metatastatisze (post cricoid is to para tracheal LN),extrahypopharyngeal extension5.Hemoptysis6.Weight loss,malignant cachexia,anemia7.Halitosis-dt necrosis and extension to nasopharynx
Dx:--History--Clinical picture--Clinical examination;1.Neck inspection and palpation-Laryngeal box-tender,edema,broader-Neck mass(dt causes mention above)-Moure’s click absent(fix to vet column alreadY)
2.Indirect laryngoscope;(using mirror,rigid 90 laryngoscope,flexible nasopahrygolaryngoscope)-see pooling of saliva,cord mvmnt,mass on cord
3.Direct laryngoscope with esopharyngoscopy-For biopsy-For detection of second primary tumour***** very important to do esophagoscopy to check wether esophagous have extension of tumour or not.--Lab Ix;-liver fx,blood count,iron-Imaging;CT,MRI,Barium Swallow ****-Metastatic work up
TREATMENT:A..Curative1.SurgeryPrimary-For post cricoid!! Total Laryngopharyngectomy + total/partial esophagectomySecondary -Modified selective neck LN disection
Mx-diagnosis by: -CBC n blood sugar-ct scan from skull base to mediastinum-laryngoscopy visualising-nasopharynx,hypopharynx, larynx, esophagus,bronchial tree..take biopsy for any suspicious lesion
Rx;
unilateral recurrent laryngeal n paralysis--wait for 6m for nerve recovery-if no recovery--> medialisation of the cord:
o injection of teflon, autologous* fat ( autogenous or autologos ? )
o silastic insertion
bilateral recurrent laryngeal n paralysis-(refer to question below)
-etiology & CP of Vocal cord paralysis
-CP & Rx bilateral rec laryngeal n paralysis(recurrent laryngeal n paralysis= abductor paralysis=paramedian vocal cord)
cp: -stridor -normal voice but easily fatigueRx:1st- treat STRIDOR by tracheostomy(definitive line of treatment; emergency mx)2- wait 6m-1yr for nerve recovery, if no recovery we do operation to widen the glottis:
Conservative therapy-MLS- Open surgery:partial laryngectomyRadiotherapy
Total laryngectomyLPP ( Laryngeal preserve protocol )Postop radiotherapy
c/p
early
a. change of voiceb. hoarsenessc. otalgiad. FB sensatione. irritative coughf. sense of airway obstruction
(F,O,O, C,C) = “ Freedom Oof Ccreation”
-(fb sensation, Otalgia,Obstruction of airway, Cough(irritative type), Changes of voice & hoarseness)
late
a. hot potato voice (supraglottic tumor)b. lump in the neck (lymph node; ++ in supraglottic)c. stridor(biphasic)- (glottic extend to subglottic)d. dysphagiae. blood tinge sputumf. pain
advanced
1. weight loss2. fetor oris
(DD with hypopharyngeal tumor, these advanced symptoms occur early)
management early:
conservative-endoscopic removal(MLS/CO2 laser)
-open surgery-partial laryngectomy
radiotherapy
-clinical types,investigations,general Rx of Vocal cord cancer