Review Flashcards
List indications 5 and contraindications 3 of tonsillectomy
Indications:
1- Marked tonsillar hypertrophy causing obstructive sleep apnea
2- Recurrent acute tonsillitis
(7 times in one year, 5 times in two successive years or 3 times in three successive years)
3- Recurrent Peritonsillar abscess (Quinsy)
4- Suspected tumour,
5- Troublesome tonsillolith
Contraindications:
1- Bleeding tendency because of systemic disease
2- Current or recent infection
3- Uncontrolled systemic disease (hypertension, diabetes)
Give your management of corrosive esophagitis
Symptoms:
-Severe pain in mouth, tongue, pharynx
-Severe dysphagia & regurgitation
-Stridor due to laryngeal edema
Signs:
-White sloughs, edema
-Skin burns
-Shock & dehydration
Treatment:
1-Milk & egg white.
2-Management of shock & electrolyte imbalance
3-Tracheostomy if severe obstruction
4-Parentral antibiotics
5-Cortisone to decrease edema & fibrosis
6-Rubber naso-gastric tube is inserted in 1st few days to facilitate feeding & maintain the lumen
Differential diagnosis of a membrane over the tonsils
- Acute Follicular Tonsillitis: Caused by beta-hemolytic streptococci
- Bilateral, Yellowish, Limited to the tonsils, Loose, No bleeding upon removal - Diphtheriae: Caused by Corynebacterium Diphtheriae
- Unilateral, Exceeds tonsil, Dirty greyish, Bleeding upon removal and reform rapidly, Severe toxemia and tachycardia disproportionate to fever - Vincent’s Angina
- Caused by spirochetes and fusiform bacilli, Unilateral
- pharyngeal ulceration with deep punched out edges, covered by a dirty grayish pseudomembrane that extends beyond tonsils. - Infectious Mononucleosis: Caused by EBV
Oropharyngeal ulcerations with greyish-white pseudomembrane, and Generalized lymphadenopathy + splenomegaly
Give the clinical picture of Ludwig’s Angina
Caused by: Dental infections (70%), Penetrating injuries of the floor of mouth and Mandibular fractures.
- Usually young patient with poor dentition or diabetics.
- Unilateral neck pain and swelling that soon becomes bilateral.
- Increasing edema and brawny induration of floor of mouth thrusting of tongue against the palate with resultant respiratory embarrassment.
- Increasing fever, neck rigidity, trismus, and odynophagia.
- Some patients progress rapidly from onset of symptoms to respiratory obstruction in 24 hours.
Complications of peritonsillar abscess (Quinzy)
Sudden rupture and inhalation of pus causing chest infections.
Extension:
* Laterally causing Parapharyngeal abscess.
* Downwards leading to Laryngeal edema, stridor
- Pyemia and Septicemia.
Give the clinical picture of Peritonsillar abscess (Quinzy)
Symptoms:
General: High fever – headache – malaise.
Local:
Marked sore throat.
* Referred otalgia.
* Bad odoured breath
* Difficulty in mouth opening (Trismus).
* Marked dysphagia with dribbling of saliva.
Signs:
- Enlarged tender jugulo-digastric lymph nodes.
- Difficult oral exam due to trismus
- Soft palate swelling above and lateral to inflamed tonsil.
- Tonsil pushed downwards and medially.
- Uvula edematous and pushed to other side.
Give the clinical picture and treatment of acute tonsilitis
Caused by Group A beta-hemolytic streptococcus or viral infection
Symptoms:
- Fever, anorexia
- Sore throat
Signs:
- Congested tonsils with possible follicles of pus
-Tender large jugulodigastric lymph nodes
Treatment: analgesic and antipyretics and antibiotics usually amoxicillin group
Investigations of VC paralysis
(1) Radiology
- CT from skull base to mid thorax.
- According to suspicion: CT& MRI brain, barium swallow, or thyroid scan.
(2) Endoscopy: Panendoscopy + biopsies.
(3) Blood exam
Especially blood sugar.
Causes of vocal cord paralysis
(A) Peripheral causes
Surgical trauma: Thyroidectomy (most common) and Radical neck dissection. Esophageal surgery, Cardiovascular surgery, Vagus injury at skull base.
Neoplastic (important):
* Thyroid malignancy.
* Nasopharyngeal carcinoma
* Hypo pharyngeal malignancy
* Bronchogenic carcinoma
* Esophageal carcinoma.
* Malignant lymph nodes.
* Pharyngeal pouch
Non-surgical trauma: * Vagal schwannoma
* Neck trauma e.g., strangulation, open injuries.
* Cricothyroid joint dislocation.
* Fracture skull base.
Inflammatory: Infections herpes, influenza, and diphtheria.
* Diabetes Mellitus
* Malignant OE.
* Apical pulmonary T.B.
* Ascending polyneuritis.
Idiopathic: most probably viral infection.
Miscellaneous: Myasthenia gravis, rheumatoid arthritis, and SLE.
(B) Central causes (Bulbar palsy)
Discuss the treatment of laryngeal carcinoma
Treatment of Early Cancer Larynx (depending on TNM staging).
- Radiotherapy
- Transoral laser microsurgery
- Open surgery (partial laryngectomy)
* The choice of treatment depends on tumor primary site, extension, and patient’s lifestyle and preference.
Treatment of Advanced Cancer Larynx (depending on TNM staging)
* The golden standard of treatment is total laryngectomy and concurrent chemoradiation therapy.
- In lymph node metastases, the neck is treated by performing the appropriate type of neck dissection.
Postoperative rehabilitation of voice after total laryngectomy: esophageal speech or artificial larynx or creating tracheoesophageal fistula
Follow-up after treatment of cancer larynx is mandatory, every 3 months for the first year, every 4 months for the second year, every 6 months for the third to fifth year, then once a year after that.
Discuss the investigations for laryngeal carcinoma
- Routine laboratory tests to evaluate the patient’s medical condition
- CT scan: To assess tumor extension and lymph nodes involvement.
- Biopsy by direct laryngoscopy: To confirm the diagnosis.
- Metastatic work-up: Chest x-ray, brain CT scan, bone scan & abdomen ultrasound.
- PET CT may be required in the staging of more advanced cancers and for follow up of patients postoperatively or following chemotherapy or radiotherapy
Investigations and treatment of orbital cellulitis
- C.T. paranasal sinus axial & coronal cuts with contrast
- Visual acuity and fundus examination, documented by the ophthalmologist.
-Hospitalization
Medical: Massive broad-spectrum IV antibiotics
-Nasal wash and decongestant nasal drops.
-Daily monitoring of visual acuity.
Surgical decompression:
Indications for surgery:
1. Failure of any response to medical treatment for 48 hours.
2. Threat to vision, as documented by the ophthalmologist.
3. Formation of Subperiosteal or Orbital Abscess, as documented by the CT.
Type of Surgery:
* ESS: Complete ethmoidectomy, and abscess drainage.
Orbital Complications of Sinusitis
- Orbital Edema: Upper eye lid edema, the lower eye lid is NOT affected. NO pain, chemosis, proptosis, affection of vision
- Orbital Cellulitis: Eye pain, Chemosis, Proptosis and Opthalmoplegia. Diminution of vision that is reversible
- Subperiosteal Abscess: Throbbing pain, Chemosis, Lateral Proptosis and Ophthalmoplegia. Diminution of vision is more marked and reversible.
- Orbital Abscess: Throbbing severe pain, Chemosis, forward Proptosis and severe Ophthalmoplegia. Diminution of vision is Irreversible.
- Cavernous Sinus Thrombosis: Inflammatory process extends through the draining veins into the cavernous sinus, causing thromboses.
Discuss the etiology of this disease
-UMNL (Central)
1- Traumatic: head trauma
2- Inflammatory: meningitis-encephalitis- brain abscess
3- Vascular: hemorrhage- thrombosis- embolism
4- Neoplastic: brain tumours
5- Degenerative: multiple sclerosis
- LMNL
1-Pontine lesions: same as central causes
2-CPA lesions: Meningioma, Congenital cholesteatoma,
3-Cranial (temporal bone) lesions:
a-Idiopathic: Bell’s palsy
b-Traumatic:
-surgical: ear surgery
-accidental: fracture skull base.
c-Inflammatory: AOM, CSOM especially unsafe, Malignant otitis externa
d-Neoplastic: -glomus tumor, SCC of temporal bone
4-Extracranial (parotid) lesions: Traumatic: parotid surgery - parotid stab – parotid tumor
5-Miscellaneous: DM, Polyneuritis (Guillain – Barre Syndrome),
Investigations of this disease
Malignant otitis externa investigations:
1-Blood sugar for diabetes control, leukocyte count, ESR and CRP for diagnosis and follow up, and kidney function for monitoring side effects of antibiotics analgesics.
2-Culture and sensitivity of ear discharge
3-CT & MRI petrous: detect bone erosion and extension
4-bone scans as Technetium for diagnosis and Gallium for follow up
5-Biopsy from granulation tissue to exclude malignancy
Treatment of this disease
Treatment of malignant otitis externa
Hospitalization
1- Strict control of diabetes and other medical conditions
2- Systemic parenteral antibiotics (anti-pseudomonas)
3- Analgesics
4- Local daily ear cleaning by suction
5- Local antibiotic ear drops & ear packing using antibiotic cream
6- Local debridement of granulation tissue
8-Hyperbaric O2
Give the investigations needed for this disease
1- PTA: CHL.
2- Tympanometry: type B flat curve.
3- Plain x-ray nasopharynx lateral view to detect adenoids
4- CT scan of nasopharynx to detect masses of nasopharynx
Treatment of this disease
Medical: In children, a conservative approach with regular follow up is tried up to 3 months. Valsalva maneuver to open ET is recommended.
Surgical: Myringotomy, aspiration of effusion and insertion of ventilation tube (Grommet) is advised in:
- Effusion persists for more than 3 months
- Effusion is associated with other procedures such as adenoidectomy
Insertion of a permanent ventilation T tube is done in OME associated with persistent nasopharyngeal pathology, or cleft palate.
Enumerate the causes of CNS rhinorrhea
1- Traumatic:
a) Surgical: - Endoscopic sinus surgery (ESS)
b) Accidental: fracture base of anterior cranial fossa.
2- Inflammatory: syphilitic osteitis or osteomyelitis
3- Neoplastic: tumor eroding the roof of nose.
4- Congenital: defect in the cribriform plate.
5- Idiopathic
