Written Flashcards
Treatment of this
1-Local ear cleaning by dry mopping and suction.
2-Antifungal ear drops: Nystatin (antifungal) ear drops. Solution of 2% salicylic acid + 70% alcohol
3-Ear pack with antifungal cream if canal skin is swollen obstructing the meatus
4-Avoid water entry into ear.
Clinical picture and complications
Malignant otitis externa CP: Agonizing ear pain more at night (Nocturnal otalgia) and headache, with significant hearing loss.
Spread of infection may lead to 7th nerve palsy: commonest cranial nerve affected usually irreversible, lower 4 cranial nerve palsy, trigeminal facial pain & 6th nerve palsy, Parotid affection: pain and swelling
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
Clinical picture and etiology of this
Acute otitis media (suppurative stage) CP:
1- Acute onset of otalgia, fever, and CHL. Infants present with ear pulling, crying, restlessness and vomiting or diarrhea.
2- Examination reveals red bulging tympanic membrane OR otorrhea
- Causative organisms:
- Viral: rhinovirus, adenovirus, influenza virus.
- Bacterial: Streptococcus pneumoniae, Hemophilus influenza
- Route of infection: usually following upper respiratory tract infection where organisms reach the middle ear through the eustachian tube.
Investigations and treatment of this
No routine investigations are required except in: In complications CT is done and In cases of treatment failure Culture of the discharge is done
Analgesics.
Systemic antibiotics
- First choice is oral Amoxicillin.
- In case of treatment failure, Amoxicillin-clavulanic acid, or ceftriaxone.
- In case of penicillin allergy, Clarithromycin
Local (nasal) or systemic decongestants.
Surgical treatment e.g. myringotomy may be considered rarely in complicated AOM
Discuss the clinical picture and the investigations of this disease
Safe CSOM (suppurative otitis media) Cl/P: Tinnitus, CHL, history of intermittent profuse ODORLESS mucopurulent discharge. Examinations show central tympanic membrane perforation (rounded oval or kidney shaped) with regular margins
PTA: shows CHL
Culture and sensitivity of discharge
Discuss the treatment of the following disease
Safe CSOM (suppurative otitis media)
- Aural toilet by suctioning of ear discharge.
- Topical antibiotics.
- Systemic antibiotics may be used
Tympanoplasty. It includes myringoplasty with eradication of middle ear disease e.g. polyps, and/or ossiculoplasty (repair the ossicles)
Discuss the clinical picture of this disease
Squamous CSOM, unsafe CSOM, Cholesteatoma of ME
Symptoms:
▫ CHL and tinnitus.
▫ History of persistent, scanty, offensive, purulent ear discharge
. Signs:
▫ Discharge: Purulent (characteristic).
▫ Perforation: It may be attic (in pars flaccida) or marginal.
▫ Cholesteatoma may appear as a whitish mass in the attic.
▫ Granulation tissue or polyp may be present.
PTA shows CHL and CT scan.
Discuss the treatment of this disease
removal of cholesteatoma sac usually by modified radical mastoidectomy
▫ Reconstruction of hearing (Tympanoplasty) could be done at the same time (primary) or delayed (secondary) later, to ensure the absence of residual or recurrence of the disease before reconstruction.
▫ A long-term clinical follow-up is necessary to detect residual cholesteatomas and recurrences.
Discuss the clinical picture of this disease and investigations required
Mastoiditis: Profuse otorrhea (reservoir sign), sagging of posterosuperior meatal wall, tender mastoid bone
- Radiology is mandatory. CT of the temporal bones is diagnostic for mastoiditis. MRI should be performed if intracranial abscess formation or lateral sinus thrombophlebitis is suspected. MR venography demonstrates the degree of patency of the related venous sinuses.
- Audiogram.
- Cultures and sensitivity of the discharge to guide therapy.
- Lumbar puncture is indicated in suspected meningitis.
Enumerate the complications of cholesteatoma
- Cranial
* Mastoiditis
* Petrositis.
* Labyrinthitis
* Facial nerve paralysis - Intracranial
* Meningitis
* Extradural abscess
* Subdural empyema (brain abscess)
* Lateral/sigmoid sinus thrombosis
* Otitic hydrocephalus
Treatment of complications of otitis media
- Hospitalization
- Surgical drainage of the suppurative content and cleaning cholesteatoma entirely.
✓ Radical mastoidectomy is done in mastoiditis.
✓ Tracing the diseased cells to petrous apex is done in petrositis.
✓ Cholesteatoma eradication and facial canal exploration is done if facial paralysis complicating Cholesteatoma.
✓ Aspiration of brain abscess (with the aid of neurosurgeon)
- Antibiotics are adjuvant therapy given during disease according to culture exam
✓ Eye care and care of facial muscles
✓ Antiemetics and antivertiginous are given in labyrinthitis
✓ Anticoagulant are given in lateral sinus thrombosis
Give the symptoms and signs of this dease
Otitis media with effusion=secretory otitis media=Glue ear
Symptoms:
1- Conductive hearing loss (CHL) and tinnitus - may be unilateral (more in adults) or bilateral (more in children)
- in children (most common ear disease in children): the parents complain of decreased child attention.
- In adults: sensation of ear fullness
2- Bubbling sensation in ear.
3- History of recurrent AOM.
Signs:
a- Otoscopic examination: 1- Intact drum, dull grey color in mucoid OM and amber yellow in serous OM.
2- Air fluid level (hair line).
3- Air bubbles seen through a semi translucent membrane.
4- Retracted drum with foreshortened handle of malleus and disturbed cone of light
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.
Discuss the etiology of this disease
1- Bacterial or viral OM which increases viscosity of secretions
2- Eustachian tube obstruction &/or dysfunction:
- Adenoid enlargement.
- Nasopharyngeal tumours or swelling
- Cleft palate
- Recurrent rhinosinusitis or allergic nasal polypi
- Radiotherapy to head and neck tumours
3- Otitic barotrauma
Discuss the clinical picture of this disease
Symptoms:
* Inability to close the eye
* Deviation of the mouth to the healthy side
* Accumulation of food behind the cheek and drippling of saliva
+ Decreased lacrimation, disturbed hearing and Metallic taste
Signs:
* Inability to elevate the eyebrow.
* Loss of corrugations of forehead.
* Obliteration of nasolabial fold
* Drooping of the lower lip on affected side
* Facial asymmetry either on movement (partial palsy) or at rest (complete paralysis)
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),
Compare between UMNL and LMNL in facial nerve paralysis
Discuss the investigations needed for this disease
- To Identify the Cause: Imaging (CT temporal bone) and Hearing tests (PTA).
- To detect the level of the lesion e.g. Schirmer’s test, Stapedial reflex, taste test
- Electrophysiological tests: Electroneurography (ENOG) for diagnosis and Electromyography (EMG for follow up).
Give the treatment of Bell’s palsy
Primarily medical by immediate full dose of steroids (60mg/day) with gradual withdrawal.
- Reassurance, eye care (ointment and natural tears) and care of facial muscles (massage or physiotherapy to avoid disuse atrophy).
-Surgical nerve decompression is hardly needed nowadays.
Recovery is usual and spontaneous but may be incomplete
Give the treatment of traumatic palsy of facial nerve
-Immediate postoperative nerve paralysis is managed with immediate exploration and repair, while delayed palsy is usually relieved through loosening of surgical dressings and steroids
-Depending on the guide of the Electrophysiological tests, surgery as nerve repair can be done by: End to end anastomosis - Nerve graft - Cross facial anastomosis. In some cases, only surgical nerve decompression can be enough.
-Eye care (ointment and natural tears) and care of facial muscles (massage or physiotherapy to avoid disuse atrophy).
Discuss the clinical picture and investigations needed for otosclerosis
Most cases present bilateral gradual progressive conductive hearing loss. In most cases, Otoscopy shows a rather normal picture. More common in middle age women.
PTA shows CHL:
If the cochlea was also involved, the PTA will show MHL.
Rarely cochlea only is involved, the PTA will show pure SNHL.
Tympanometry shows type As curve
Give the treatment of otosclerosis
The conductive component of otosclerosis can be corrected surgically in the form of Stapedectomy and insertion of a synthetic piston
Amplification by Hearing Aid is an alternative.
Discuss the clinical picture and how to confirm diagnosis in Meniere’s disease (endolymphatic hydrops)
Recurrent attacks of vertigo, hearing loss, tinnitus, nausea and vomiting usually preceded by aural fullness before the onset of vertigo.
Confirm Diagnosis: At least 2 definitive episodes of vertigo of at least 20 minutes duration must have occurred to make the diagnosis. Attacks usually come in clusters
Discuss the investigations needed for Meniere’s disease (endolymphatic hydrops)
- PTA shows reversible low frequency hearing loss at the onset of the disease, later the condition progresses to high frequency loss.
- Caloric test shows hypoactive labyrinth.
The caloric test is done by introducing water into the ear canal on one side, both 7 degrees above and below the assumed body temperature. The water is stopped after 30 seconds, and nystagmus is observed, while the patient is distracted. - Electrocochleography (Ecog) is diagnostic.
Discuss the treatment of Meniere’s disease (endolymphatic hydrops)
o During the attack: Anti-vertigenous drugs.
o In Between the attacks:
* Conservative treatment: includes reassurance, a low salt diet and medications such as vasodilators , antihistaminic and diuretics.
- Intratympanic injection of steroids
- In case of progressive SNHL and vertigo: intratympanic gentamycin injection (Medical labyrinthectomy).
- In resistant cases with intractable vertigo despite of medical, treatment entails surgery as endolymphatic sac decompression, labyrinthectomy or vestibular nerve section relying on hearing level.
Discuss the indications and contra-indications of ear wash
o Wax causing deafness or difficulty in examining the drum.
o Foreign body if not impacted or vegetable.
o Fungal mass.
o Caloric test.
Contra-indications
o T.M. perforation.
o Vegetable foreign body or impacted foreign body.
o Bacterial otitis externa.
o Fistula between the middle and inner ears.
Enumerate the complications of ear wash
1- Trauma:
A-Ruptured drum: the patient feels sudden severe pain with dizziness and deafness. Patient may feel fluid in the nasopharynx.
B-Injury to external canal by: Nozzle of syringe, very hot fluid.
2- Infection: otitis externa.
3- Reflex Cough due to vagal stimulation.
4- Dizziness and vomiting if cold or hot water is used.
Discuss the causes of CHL
EAC causes of CHL:
* Congenital: anomalies e.g., meatal atresia
* Traumatic: foreign body
* Inflammatory: infections and acute inflammatory swelling as in large furuncle, diffuse acute otitis externa and malignant otitis externa
* Neoplastic: Benign and malignant tumors
* Miscellaneous: impacted wax, the most common cause of conductive deafness.
Tympanic membrane causes of CHL:
*Perforation of tympanic membrane either traumatic or infective
Middle ear causes of CHL:
* Congenital: anomalies.
* Traumatic: otitis barotrauma, hemotympanum and ossicular disruption
* Inflammatory: All types of otitis media (AOM, CSOM).and Eustachian tube dysfunction leading to retracted tympanic membrane or otitis media with effusion (OME)
*Neoplastic: Middle ear tumors.
*Otosclerosis.
Discuss the clinical picture and investigations of this disease
Bilateral choanal atresia
It presents with acute respiratory distress immediately after birth as newborns are obligate nasal breathers.
The classical picture is cycles of respiratory distress and cyanosis which are relieved by crying
CT nose and protective nasal splint
Treatment of this disease
Bilateral choanal atresia
The goal is first directed towards securing the airway.
o Oral airway is usually suitable to alleviate the distress as it temporarily bypasses the nasal obstruction.
o Improvement using oral airway may aid the diagnosis of bilateral choanal atresia.
Definitive treatment: surgical repair
o Endoscopic nasal repair.
o Trans-palatal approach can be used.
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
Investigations of CSF rhinorrhea
1- Biochemical analysis of discharge:
- Clear, Colorless and contains no mucus.
- Contains sugar more than 30 mg%.
- Contains B2 transferrin, which is diagnostic.
2- CT with intrathecal metrizamide: to detect the site of leakage.
3- MRI
4- Endoscopic examination of nose after intra-thecal dye injection to locate the defect.
Treatment of CSF
A) Conservative: most traumatic cases heal spontaneously
- Bed rest in semi-sitting position with the head-up.
- Avoid coughing, straining, blowing of nose, nasal medications
- Prophylactic antibiotics that cross blood brain barrier to prevent meningitis.
B) Surgical: covering the defect by graft or flap Non traumatic cases usually need surgical repair
Discuss the stages of Rhinoscleroma
Atrophic stage: characterized by foul smelling purulent nasal discharge and crusting.
Granulomatous stage: granulomatous nodules form in nasal mucosa usually starts at the mucocutaneous junction
Cicatricial stage: stenosis of nares, distortion of upper lip, adhesions in the nose and pharynx
-May extend to: Lacrimal sac > dacryoscleroma Pharynx > pharyngoscleroma Larynx > laryngoscleroma
Acute sinusitis investigations
Not required in uncomplicated cases
- X ray sinus view shows sinus opacity or fluid level.
- C.T. paranasal sinuses show the same finding and are more accurate. Required only in recurrent cases.
- Culture & sensitivity of the discharge.
Treatment of acute sinusitis
Medical:
- Symptomatic treatment: bed rest, worm fluids, worm fomentations, steam inhalation, saline nasal irrigation, analgesics, antipyretics, decongestant nasal drops, antihistamines, and mucolytics.
- Antibiotics are added if ABRS (acute bacterial rhinosinusitis) is suspected. Most guidelines recommend amoxicillin as first-line therapy.
- Treat the predisposing factor e.g. diabetes.
Surgical:
- The aim of surgery is to drain the sinus and to restore aeration. Functional Endoscopic Sinus Surgery (FESS)
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 Limitation of eye movement. 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.
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.
Types of fungal sinusitis
- Invasive
- Acute Invasive Fungal Sinusitis
- Chronic Invasive Fungal Sinusitis
- Chronic Invasive Granulomatous Fungal Sinusitis
- Non-invasive
- Allergic Fungal Sinusitis
- Fungal Ball (Mycetoma)
Investigations and treatment of nasal polyps
Investigations of Nasal polyps
CT scanning coronal cuts is the investigation of choice for assessing the extent of the disease.
Treatment of Nasal polyps
- All patients should have a trial of medical therapy first.
- Medical treatment consists mainly of topical and systemic corticosteroids
Surgical: - Surgical management is considered for patients who have failed to respond to maximal medical treatment and for those with complications.
- Functional endoscopic sinus surgery aims to improve sinus ventilation and drainage as well as removing polyps.
Enumerate causes of epistaxis
Local causes:
1. Idiopathic: this is diagnosed after exclusion of the all possible scenarios. It is the most common, about 90%, from little’s area.
2. Trauma: Foreign bodies, nasal picking, accidental or surgical trauma.
3. Inflammations: Any acute or chronic rhinitis.
4. Neoplastic: Nasal or nasopharyngeal benign or malignant tumours.
5. Irritants (e.g., cigarette smoke)
6. Medications (e.g., topical corticosteroids)
7. Septal deviation or perforation.
8. Vascular malformation
9. Environmental factors: Humidity, dryness, allergens.
Systemic causes:
1. Systemic hematologic, hepatic, renal, genetic, or cardiovascular diseases.
2. Long-term anticoagulation (aspirin, warfarin).
3. Hypertension.
4. Underlying coagulation disorder hemophilia, or thrombocytopenia.
Complications and treatment of septal hematoma
Septal abscess, organization, and septal thickening.
Treatment of Septal hematoma
1- Systemic antibiotics to prevent secondary infection.
2- Incision and evacuation: vertical incision on one side and horizontal on the other side to prevent septal perforation.
3- Anterior nasal packing to prevent recollection of the hematoma
Complications and treatment of septal abscess
Septal perforation, external deformity, cavernous sinus thrombosis.
Treatment of Septal abscess
1- Systemic antibiotics.
2- Incision and evacuation: vertical incision on one side and horizontal on the other side to prevent septal perforation.
3- Anterior nasal packing to prevent recollection.
Enumerate the causes of offensive nasal discharge
1- Atrophic rhinitis.
2- Nasal Granuloma.
3- Neglected foreign body.
4- Oroantral fistula.
5- Maxillary sinusitis especially of dental origin.
Discuss the investigations of allergic rhinitis
If there is diagnostic uncertainty, then allergy testing should be performed. These include skin prick test or measurement of specific IgE in the blood ( RAST test)
Discuss the treatment of allergic rhinitis
Allergen avoidance
Oral antihistamines: This relieves the symptoms of running, sneezing, and nasal and eye itching. They have little effect on nasal blockage.
Nasal irrigation with isotonic saline
Intranasal corticosteroids: It is the first-line treatment of patients with mild to moderate persistent symptoms. The most commonly reported adverse effects are irritation, epistaxis, stinging, burning, and nasal dryness.
Local nasal decongestants: Xylometazoline causes rapid decongestion, but prolonged use should be avoided.
Systemic corticosteroids: Oral steroids may occasionally be useful in patients with chronic severe symptoms: Prednisolone 20–40mg/day is normally sufficient
Leukotriene receptor antagonists
Immunotherapy is a method of inducing tolerance to an allergen. It involves repeated exposure of the patient to the allergen, usually with a gradual increase in allergen dose.
Surgical treatment: Surgery cannot cure allergy but can give relief of nasal blockage if other methods fail. - Reduction of submucosal tissue on the inferior turbinates that has developed
Compare the types of papillomas
Discuss the symptoms, etiology and treatment of laryngomalacia
Symptoms:
1.Inspiratory stridor; starts soon after birth, improves on lying in the prone position.
2. Normal cry i.e. no hoarseness of voice.
Signs:
Laryngoscopy: usually shows the characteristic omega shaped epiglottis. The supraglottis collapses inwards during inspiration.
Abnormally soft and flaccid cartilaginous framework. The ary-epiglottic folds are short and approximated ➔ narrow laryngeal inlet
Is mainly conservative as it improves spontaneously.
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
Discuss the treatment of laryngeal carcinoma
Treatment of Early Cancer Larynx (depending on TNM staging).
- Radiotherapy
- Transoral laser microsurgery
- Open surgery (partial laryngectomy or conservation laryngeal surgery).
* 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.
- Radiation therapy alone is used if patients are medically unfit for surgery.
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.
Give clinical picture and investigations needed for Subglottic stenosis
- It present with Biphasic stridor
- Almost always there is a history of prolonged ICU intubation, or manifestation of rhinoscleroma.
- Congenital types may pass unnoticed if the stenosis grade is mild
- Laryngoscopy show the stenosis grade
- CT scan sagittal or coronal cuts shows the stenotic part length
Discuss treatment of subglottic stenosis
- Tracheostomy if needed.
- Laser excision in short, small stenosis.
-excision of stenotic area with skin graft closure.
- Resection of the stenotic area with end-to-end anastomoses.
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)
Investigations of VC paralysis
Done if the cause is unknown
(1) Radiology
- CT from skull base to mid thorax.
- According to suspicion: CT& MRI brain, barium swallow, or thyroid scan.
(2) Endoscopy
Panendoscopy: nasopharyngoscopy, laryngoscopy, hypopharyngoscopy, oesphagoscopy & bronchoscopy + biopsies.
(3) Blood exam
Especially blood sugar.
Treatment of unilateral vocal cord paralysis
1- Most cases require no treatment: compensation or Spontaneous recovery occurs in 6 months
2- Treat the causes if possible.
3- Surgery is done if there are persistent symptoms after 6 months, it may be either: Injection of the paralyzed vocal cord either by synthetic material or fat to meet the healthy vocal cord
* Thyroplasty:
* Reinnervation of the RLN.
Treatment of bilateral vocal cord paralysis
1- In cases of severe stridor: tracheostomy.
2- In established cases: laryngeal widening procedure 6-12 months later.
Endoscopic arytenoidectomy, or posterior cordectomy, using CO2 laser, to provide space for respiration. This improves breathing but affects voice quality.
3- Reinnervation procedures are still under trials.
Enumerate causes of hoarseness of voice
- Acute laryngitis which (the most common cause)
- Voice abuse and misuse e.g. professional voice users
- Benign vocal cords lesion e.g. nodules, cyst and polyps
- Reinke’s edema.
- Vocal hemorrhage: sudden loss of voice after a yell
- Gastroesophageal Reflux (GERD)
- Specific inflammatory conditions
- Intubation granuloma
- Neoplastic lesions especially vocal cord carcinoma.
- Neurological lesion as unilateral vocal cord paralysis.
- Muscle tension dysphonia vocal cords are free from lesions and move normally, but aphonia occurs due to a psychological and neurological disorder.
Enumerate causes of stridor
1-Congenital: CONGENITAL LARYNGEAL WEB, LARYNGOMALACIA
2-Traumatic: FB, CORROSIVE or rough intubation.
Physical trauma: radiotherapy and thermal injury.
3-Inflammatory: ACUTE NON-SPECIFIC LARYNGITIS in infants and children, ACUTE LARYNGOTRACHEORONCHITIS in children, laryngeal diphtheria or Chronic specific laryngitis (granuloma)
4-Neoplastic: RECCURENT MULTIPLE LARYNGEAL PAPILLOMATOSIS and laryngeal carcinoma
5-Miscellaneous: LARYNGEAL SPASM, LARYNGEAL EDEMA, Bilateral vocal cords paralysis
6-Tracheal causes
Enumerate causes of stridor in children
Congenital laryngeal web and laryngomalacia
Foreign body and corrosives
Inflammatory: Acute nonspecific laryngitis in infants and children, acute laryngotracheobronchitis in children
Neoplastic: recurrent multiple laryngeal papillomatosis
Others: Laryngeal spasm, laryngeal edema
Enumerate the indications of tracheostomy
◦ Upper airway (mechanical) obstruction
◦ Stridor (if severe)
◦ Obstructive SA (if severe)
◦ Lower airway (secretory) obstruction
◦ Chronic aspiration
◦ Depression of cough reflex
◦ Prolonged coma
◦ Severe chest injury
◦ Paralysis of the respiratory muscles
Discuss the value of tracheostomy
- Facilitate suction
- Assist ventilation
◦Prophylactic: Before bloody major operation on the mouth, pharynx, larynx
Value: To avoid blood inhalation during surgery
If prolonged intubation is planned, to guard against occurrence of subglottic stenosis, and for better oral and pulmonary hygiene
Enumerate the complications of tracheostomy
1-Anesthetic complications local or general.
2- Apnea: When operation is done under local anasthesia
3- Bleeding
a-Primary: Anterior jugular vein injury, thyroid gland injury, innominate vein injury.
b-Reactionary: Slipped ligature, from previously ligated vein
c-Secondary: Due to infection (antibiotics & fresh blood).
4- Pneumothorax (most common)
5- Pneumomediastinum.
6- Crustation.
7- Delayed complications:
a) Subglottic stenosis: due to cricoid injury.
b) Tracheal stenosis: due to erosion by tube or infection.
c) Difficult extubation.
d) Tracheoesophageal fistula.
e) Tracheocutaneous fistula.
8- Emphysema (surgical): Air accumulation under skin.
9- Embolism (air embolism)
10- Injury
Thyroid gland → Hemorrhage.
Apex of pleura → pneumothorax.
Cricoid cartilage → subglottic stenosis.
Posterior tracheal wall → Tracheoesophageal fistula.
Big vessels → Hemorrhage.
RLN → V.F paralysis.
11- Infection
Wound infection.
Chest infection.
12- Tube complications:
a) Slipped tube: Due to low tracheostomy, wide stoma, short neck, or short tube. .
c) Blocked tube by dried secretions.
Discuss the contraindications of tracheostomy
NO ABSOLUTE CONTRAINDICATIONS, SINCE IT IS A LIFE SAVER
Clinical picture and treatment of adenoid
Symptoms:
- Bilateral nasal obstruction:
o Mouth breathing.
o Speech hyponasality
o Difficult suckling in infants
o Snoring. - Bilateral nasal discharge.
Signs:
Nasal endoscopy shows the hypertrophied adenoid
Treatment: adenoidectomy
Complications of adenoids
-Obstructive Sleep Apnea.
-Recurrent acute otitis media or otitis media with effusion
-Adenoid facies due to habitual mouth opening and underdevelopment of middle 1/3 of face.
* Pinched nostrils, Open dry mouth
* Short elevated upper lip
* Protruding central incisors.
* High arched palate.
* Receding mandible
* Idiot expressionless look.
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
Enumerate complications of acute tonsilitis
1-Suppuration: Peritonsillar abscess (Quinsy), Retropharyngeal abscess, Parapharyngeal Abscess
2-Immune complex disorders: Acute rheumatic fever and acute glomerulonephritis are due to immune complex formation following infection
Discuss the investigations and treatment of nasopharyngeal angiofibroma
- CT with contrast: hyperintense mass with forward bowing of posterior wall of maxilla, and widened sphenopalatine foramen.
- MRI, MRA
- Angiography: is diagnostic and used for preoperative embolization
-Biopsy should be avoided as to avoid extensive bleeding since the tumor is very vascular.
Treatment: Endoscopic excision after preoperative embolization is a treatment of choice. In recurrent or extensive cases, the tumor is excised using an external approach.
Discuss the investigations and treatment of nasopharyngeal carcinoma
- Biopsy is mandatory
- CT nasopharynx with contrast
- MRI
- Positron emission tomography (PET)
Treatment:
o Radiotherapy with or without Chemotherapy
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:
General: High temperature.
Local:
* 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.
Treatment of peritonsillar abscess (Quinzy)
-Antibiotics and analgesics in cellulitis stage.
-After abscess formation: (hectic fever and pulsating pain): Incision and drainage (Intraoral -under local or general anesthesia).
-Tonsillectomy in recurrent cases
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 Ludwig’s Angina
Caused by: Dental or periodontal 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.
Give the treatment of Ludwig’s angina
- Intensive I.V. antibiotic therapy.
- Early airway maintenance; tracheostomy must be ready.
- Rapid surgical intervention: Horizontal submental incision just above hyoid bone.
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
- Gingivitis & 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 symptoms, signs, complications and treatment 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
Complications:
* Shock, dehydration, electrolyte imbalance.
* Esophageal perforation.
* Esophageal stricture.
* Tracheo-esophageal fistula.
* Stridor.
* Chest infection.
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
Give the clinical picture, investigations and treatment of post corrosive stricture
Clinical picture:
1- Dysphagia reappears 2-3 weeks.
2- Dehydration & starvation.
3- Regurgitation & chest infection.
Investigations:
* Plain X ray neck & chest.
* Barium swallow: irregular narrow segment.
* Esophagoscopy
Treatment:
A) Permeable stricture: Regular dilatation via rigid Esophagoscopy.
B) Impermeable stricture (non dilatable)
1-Temporary gastrostomy
2-Resection of stricture & free jejunal loop re-anastomosis, or colon bypass.
3-Esophagogastrostomy or jejunostomy
4-Stents
Esophageal causes of dysphagia
A. Causes in the lumen: Foreign body.
B. Causes in the wall:
1. Congenital diseases: Congenital atresia or stenosis
2. Inflammatory: Acute ulcerations, chron’s disease,
3. Traumatic: Foreign body
4. Ingestion of corrosives.
5. Persistent vomiting
6. Reflux esophagitis
7. Plummer Vinson syndrome.
8. Neoplastic: benign and malignant tumors
9. Neurological: Paralytic: paralysis of the pharyngeal and esophageal muscles.
10. Pharyngeal pouch
11. Achalasia of the cardia
12. Diffuse esophageal spasm
C. Pressure on the esophagus from outside
In the cervical region (upper 1/3):
-Malignant thyroid tumor
-Huge multinodular goiter.
-Enlarged cervical lymph nodes e.g. metastasis /lymphoma.
In the thorax (middle 1/3)
-Mediastinal tumors.
-Pericardial effusion.
-Enlarged left atrium.
-Bronchogenic carcinoma.
-Aneurysm of the aorta.
In the abdomen (lower 1/3)
-Enlarged left lobe of liver
-Para-esophageal hiatus hernia
List indications and contraindications 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)
