Minimal Criteria ENT

Question 1

1. Symptoms and clinical features of diffuse otitis externa

Answer 1

Symptoms
 Earache;
 External part of the ear canal is painful (esp. tragus);
 Discharge, itching;
 Ear congestion, hearing loss;
 Fever is uncommon.
Clinical findings
 Swelling and hyperemia of the skin of the ear canal;
 Serous or purulent discharge;
 Accumulation of debris in the ear canal;
 Tympanic membrane appears to be normal.

Question 2

2. Symptoms and clinical features of acute otitis media (AOM) – suppurative form

Answer 2

Symptoms
 Earache;
 Hearing loss;
 Nasal discharge and congestion;
 Fever, malaise;
 If perforation is present: otorrhea
Clinical findings
 Ear canal appears to be normal;
 Hyperemia of tympanic membrane;
 Later in the course of the disease: marked bulging of the tympanic membrane,
subsequently spontaneous perforation can develop.

Question 3

3. Causes of acute hearing loss

Answer 3

-Conductive type:
 wax, foreign body;
 acute tubal occlusion, otitis media (OME/AOM);
 trauma (e.g. perforation of the tympanic membrane)
-Sensorineural type:
 Noise (acute) induced hearing loss;
 Viral infection;
 Vascular causes;
 Toxical damage (medication, chemicals);
 Traumas.

Question 4

4. What is to be done in case of acute sensorineural hearing loss?

Answer 4

In case of acute sensorineural hearing loss, immediate intravenous nootropic/vasodilatating therapy or steroid bolus treatment is necessary w/ hospitalization; meanwhile detailed investigation is required to be carried out to clarify the etiology. The earlier the treatment is started, the better the outcome is

Question 5

5. Recognition of hearing loss in childhood

Answer 5

 the newborn does not react to sounds;
 tone of crying is unusual;
 babbling period does not appear;
 visual orientation is dominant;
 speech development is delayed;
 tone, pitch, intensity, melody and rhythm of the speech is pathologic;
 articulation disorders;
 worse reading and writing skills

Question 6

6. Causes of ear pain

Answer 6

6. Causes of ear pain
   -Primary otalgia
    Otitis;
    Tumors of the ear;
   -Referred ear pain
    Tumors and inflammations of the Larynx, Pharynx, Tonsils, base of the Tongue;
    Dental inflammations, Temporomandibular joint syndrome, Neuralgic pain.

Question 7

7. Complications of acute otitis media (AOM)

Answer 7

-Extracranial
  >Intratemporal
 Acute mastoiditis;
 Zygomaticitis;
 Petrositis;
 Facial nerve palsy;
 Labyrinthitis;
  >Extratemporal
 Abscess: subperiosteal, preauricular, suboccipital, Bezold's abscess;
-Intracranial
 Extradural abscess;
 Sinus phlebitis - sinus thrombosis;
 Subdural abscess;
 Meningitis, encephalitis;
 Brain abscess;
-General: sepsis.

Question 8

8. Clinical features and symptoms of acute mastoiditis

Answer 8

8. Clinical features and symptoms of acute mastoiditis
    Associated w/, or following AOM;
    Pinna is pushed forward;
    The posterior wall of the external ear canal is swollen, seems to be lowered;
    Retroauricular pain, Erythema;
    Pulsating, severe pain;
    Pulsating otorrhea

Question 9

9. Causes of unilateral otitis media with effusion (OME) in adults and childhood.

Answer 9

Chronic dysfunction of the Eustachian tube (Adenoid vegetation or Nasopharyngeal tumor)
In adults, the possibility of a NP tumor must not be left out of consideration!

Question 10

10. How to diagnose vertigo caused by vestibular disorders

Answer 10

10. How to diagnose vertigo caused by vestibular disorders
    -Patient history:
     Type of vertigo (sensation of spinning or falling);
     Vegetative symptoms, nausea, vomiting.
    -Examination:
     deviation, tilting;
     spontaneous nystagmus and nystagmus provoked by head movements.

Question 11

11. Causes of peripherial facial palsy (list)

Answer 11

11. Causes of peripherial facial palsy (list)
     Bell’s palsy;
     Herpes zoster oticus;
     Other viral or bacterial infections (HSV, EBV, Lyme);
     Middle ear diseases (A/C infections, cholesteatoma, rarely tumors);
     Tumors of the pontocerebellar angle, vestibular schwannoma;
     Malignant tumors of parotid gland.
     Traumas: Cranial (pyramid bone fractures), Extratemporal

Question 12

12. Primary management of epistaxis/nosebleeding (at home/ambulance/by GP)

Answer 12

 The patient should lean forward with open mouth, firm digital pressure should be applied to both nasal alae for 10 minutes;
 Ephedrine/nasal drop/vasocontrictor solution-imbibed cotton or spongostan
should be applied in nasal cavity;
 Cold compress should be applied to the nape of the neck and to the nasal dorsum;
 Blood pressure-measurement, antihypertensive treatment if needed

Question 13

13. Management of epistaxis/nosebleeding (anterior, posterior) by ENT professionals

Answer 13

 Blood pressure-measurement, antihypertensive treatment - if needed;
 Visible bleeding source: chemical cauterization (trichloroacetate, silver nitrate) or
coagulation (bipolar electrocoagulation);
 Anterior nasal bleeding: anterior nasal packing;
 Posterior nose bleeding: posterior nasal packing (Bellocq tamponade), balloon catheter

Question 14

14. Management and complications of nasal folliculitis and furuncles

Answer 14

 Circumscript folliculitis: local therapy with antibiotic and steroid containing creams, vapor coverage;
 The patient should be told not to pick or squeeze the lesions;
 For furunculosis and/or phlegmonous reaction,
arenteral antibiotics should be administered, along with vapor coverage;
 The infection is usually caused by Staphylococcus aureus;
 Possible complications: Facial phlegmone, angular vein thrombophlebitis, cavernous sinus thrombosis.

Question 15

15. Types of rhinitis (list)

Answer 15

15. Types of rhinitis
     Common infections: Simple acute rhinitis, purulent rhinitis;
     Specific forms of Rhinitis: TB, syphilis, sarcoidosis;
     Allergic rhinitis
     Atrophic rhinitis (Ozena)
     Rhinitis sicca anterior.
     Other causes: idiopathic, vasomotoric, hormonal, drug-induced, rhinitis medicamentosa, occupational (caused by irritants) foodstuffs. (3 causes are required from the “other” group)

Question 16

16. Clinical features and management of angioedema (Quincke-edema)

Answer 16

Sx and Cf:
 urticaria, edema in the head and neck region;
 dysphagia, globus feeling or visible swelling in the throat, choking;
 in a severe form: anaphylaxis;
Treatment: antihistamines, steroids, adrenaline, maintaining free airways: cricothyrotomy/tracheotomy – if needed.

Question 17

17. Complications of paranasal sinus infections (list)

Answer 17

Extracranial complications
 Periorbital cellulitis;
 Subperiosteal abscess;
 Orbital phlegmone / abscess;
 Osteomyelitis;
 Sepsis;
Intracranial complications
 Meningitis;
 Epi/subdural or brain abscess, encephalitis;
 Cavernous sinus thrombosis

Question 18

18. Where does the patient localize the pain in cases of frontal, maxillary, ethmoidal or sphenoidal sinusitis?

Answer 18

 Frontal sinusitis – forehead;
 Maxillary sinusitis – face;
 Ethmoidal sinusitis –periorbitally, between the eyes;
 Sphenoid sinusitis – crown of the head, referring to the occipital area;
-All forms of sinusitis can cause diffuse Headache

Question 19

19. Causes of unilateral nasal obstruction and discharge in childhood and in adulthood

Answer 19

Childhood:
 foreign body;
 sinusitis;
 nasopharyngeal angiofibroma;
 Congenital malformation: choanal atresia, meningoencephalocele.
Adulthood:
 NP tumors;
 deviation of the nasal septum;
 hypertrophy of turbinates;
 TRAUMA and it’s late consequences;
 Dz => nasal cavity Obstruction (POLYP, B/M tumors);
 rhinosinusitis

Question 20

20. ENT diseases causing headache

Answer 20

1. Viral infection of the upper airways;
2. Nasal sinuses Inflammations (A/C);
3. Nasal sinuses Tumors (B/M);
4. Sinusitis&Otitis Cx: mastoiditis, meningitis, brain abscess, petrositis;
5. Cervical: cervical vertebra disorders, spondylosis, myalgia;
6. Neuralgias;
7. Pain of Temporomandibular joint

Question 21

21. Most frequent causes of dysphagia

Answer 21

dysphagia

1. GERD;
2. Globus feeling, psyhogenic disorders;
3. Inflammation in the mesoP, hypoP, L region;
4. Tumors in the mesoP, hypoP, L region;
5. Neuralgia (n. IX, n. X);
6. Sensorial/Motor inn. disorders: sensorial disorders in supraglottical region;
7. Foreign bodies in the hypoP and oesophagus;
8. Esophageal motility disorders, achalasia;
9. Diverticulum (e.g. Zenker);
10. Stenoses of hypoP and esophagus , ;

Question 22

22. Indications of tonsillectomy (absolute and relative)

Answer 22

Absolute indications:
 rheumatic fever;
 peritonsillar abscess;
 tonsillogenic sepsis.
Relative indications:
 chronic Tonsillitis;
 recurrent Tonsillitis;
 Tonsillogenic or posttonsillitis focal symptoms;
 marked hypertrophy of the Tonsils => mechanical obstruction;
 Tonsillar Tumor is suspected;
 OSAS or other obstructive sleep-related breathing
disorders;
 severe orofacial / dental disorders => narrow upper airways.

Question 23

23. Clinical features and symptoms of peritonsillar abscess

Answer 23

 Throat pain, referred ear pain;
 Difficulty in swallowing;
 Trismus, the speech is thick and indistinct;
 Oral fetor;
 Fever, insomnia, loss of appetite;
 Swelling, redness and protrusion of the tonsil, faucial arch, palate and uvula; the uvula is pushed towards the healthy side.

Question 24

24. Peritonsillar abscess – treatment

Answer 24

24. Peritonsillar abscess – treatment
     Drainage of the abscess - puncture, incision, daily opening of the abscess cavity;
     Tonsillectomy:
    -abscess-tonsillectomy;
    -tonsillectomy 6 weeks after recovery;
     Antibiotics, decreasing edema, analgesics,
    administration of fluids.

Question 25

25. Clinical features, symptoms and complications of para- and retropharyngeal abscesses

Answer 25

Sx: 
1. throat and neck pain, 
2. Foreign-body sensation, 
3. Fever, 
4. difficulty in Swallowing, 
5. trismus, 
6. torticollis, 
7. Swelling of the lateral or posterior pharyngeal wall, 
8. thick speech, 
9. laryngeal/oropharyngeal edema;
Cx:
1. oropharyngeal and laryngeal edema, 
2. septicemia, 
3. mediastinitis, 
4. choking.

Question 26

26. Pathogens of tonsillitis and pharyngitis, indication of antibiotic treatment

Answer 26

Pathogens:
- Viral (80-90%);
 adenovirus, rhinovirus;
 (EBV - infectious mononucleosis);
- Bacterial:
 Streptococcus pyogenes - follicular tonsillitis;
 Group C and G Streptococci;
 Mycoplasma, Chlamydia, Neisseria subspecies;
 (Pneumococci);
 (Haemophilus influenzae);
 (Moraxella catarrhalis);
 (Staphylococcus subspecies);
Antibiotics: bacterial infection - physical findings, laboratory findings (blood count, CRP, ESR, rapid bacteriological test), A/C infection, presence of immunosuppression.

Question 27

27. Precancerous lesions of the oral cavity and oropharynx

Answer 27

 Erythroplakia,
 Leukoplakia,
 Lichen planus
 Naevus
 Spongiosus albus mucosae

Question 28

28. Causes of chronic hoarseness (Why is it necessary to visit an ENT specialist after 3 weeks of hoarseness?)

Answer 28

1. A/C inflammations of the Larynx;
2. Benign Laryngeal lesions (cysts, granulation, Reinke edema, polyps, papillomatosis);
3. Malignant Laryngeal lesions;
4. Recurrent Laryngeal nerve paresis, (caused by: hypopharyngeal, thyroid gland, esophageal, pulmonary, mediastinal cancer, intracranial diseases);
5. GERD;
   It is exceptionally important to diagnose a malignant lesion as soon as we can

Question 29

29. Symptoms of laryngeal and hypopharyngeal cancers

Answer 29

Sx laryngeal + hypopharyngeal cancers: 
 Hoarseness;
 Dyspnea;
 Dysphagia;
 Referred ear pain;
 Hemoptoe;
 Globus feeling;
 Loss of body weight
 Neck lump.

Question 30

30. Swollen neck lymph nodes – causes:

Answer 30

• Non-specific inflammations (e.g. upper respiratory tract infections);
• Specific inflammations:
   Bacterial: TB, syphilis, cat scratch disease, tularemia,
   Protozoal: toxoplasmosis,
   Viral: HIV-infection,
   Non-infectious: sarcoidosis;
• Lymphomas;
• Metastases of head and neck cancers.

Question 31

31. Evaluation of neck lumps – diagnostic steps

Answer 31

1. Correct, accurate registration of patient history: e.g. duration of symptoms, upper
   respiratory tract infections, dysphagia, hoarseness;
2. Careful ENT examination – special attention should be paid to the examination of
   the neck: localization, consistency, sensibility of the lump, its relation to the
   surrounding structures;
3. Blood tests: inflammation markers, serology;
4. Imaging modalities: ultrasound, CT/MRI;
5. US guided Fine Needle Aspiration Biopsy;
6. For lymphadenomegaly, excision of the node is carried out only if the evaluation
   of the FNAB reveals lymphoma (or, if it is needed by the pathologist).

Question 32

32. Causes of dyspnea in the upper respiratory tract

Answer 32

1. URT infections (tonsillitis, epiglottitis, laryngitis);
2. Lumps in the URT: abscess, granulation tissue, malignancies;
3. Non-specific reactions of URT mucosa: allergy, Reinke edema, hereditary angioneurotic edema;
4. Foreign body;
5. Stenosis;
6. Recurrent laryngeal nerve palsy.

Question 33

33. Middle-aged, smoker patient presents with unilateral ear pain, but the examination of the ear does not reveal any disorders. What may be the cause, and what is obligatory to be examined?

Answer 33

Unilateral, referred ear pain is a typical finding in patients with hypopharyngeal (less commonly supraglottic and oropharyngeal) malignancies. This symptom and the tobacco use in the patient history make the examination of the oral cavity, oropharynx/hypopharynx, larynx and the neck obligatory.

Question 34

34. Management of choking patients – if intubation cannot be carried out

Answer 34

1. Cricothyrotomy – in the lack of time and appropriate tools: we find the cricothyroid ligament above the cricoid cartilage (using fingers), and after carrying
   out a transversal incision on the skin, we pierce the ligament with any instrument at hand, and insert a holed tool (e.g. outer tube of a pen).

2. Tracheotomy – After incising the skin and the platysma, we find (and if necessary - ligate) the isthmus of the thyroid gland, and - at the 2nd or 3rd tracheal cartilage - we make an incision on the anterior wall of trachea (in childhood) or remove a part of
the cartilage (in adults). We insert a tube/cannula in order to maintain the free airway.