ENT Final

Rhinosinusitis (Acute & Chronic)

• Acute Rhinosinusitis:
  • Most common cause overall: Viral (>90%), often Rhinovirus.
    • Viral typically presents with watery discharge, low-grade fever, and resolves spontaneously without antibiotics within 7-10 days.
    • Supportive treatment (decongestants, bed rest, painkillers) is key for viral RS.
  • Bacterial: Less common (0.5-2%), often secondary to viral infection.
    • Most common bacteria: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis.
    • Suggestive features: Symptoms > 7-10 days, worsening after initial improvement ("double sickening"), high fever, purulent discharge.
    • First-line antibiotic: Amoxicillin with clavulanic acid.
  • Imaging (X-ray, CT) is generally not needed for uncomplicated acute sinusitis diagnosis.
  • Sinus puncture is the gold standard for diagnosis but rarely performed.
  • Location-specific pain:
    • Maxillary: Jaw/dental pain.
    • Ethmoidal: Pain between the eyes / nasal bridge. (Common in younger children).
    • Frontal: Lower forehead pain.
    • Sphenoidal: Retro-orbital or vertex pain.

• Chronic Rhinosinusitis:
  • Symptoms include purulent discharge, nasal obstruction, facial pain/pressure, hyposmia. Lasts for 12 weeks or more. Nasal polyps (1/3 of chronic cases) is usually associated with aspirin intake or asthma patients (eosinophilic)
  • Diagnosis often involves CT scan and endoscopy.
  • Specific Infective Chronic Rhinosinusitis: Caused by TB, Syphilis, etc. (granulomatous). Diagnosis via biopsy/culture. Septal perforation site may indicate cause (anterior=TB, posterior=Syphilis).
  • Non-infective Chronic Rhinosinusitis (Atrophic Rhinitis):
    • Features: Wide nasal cavity, crusting, foul odor (ozaena), often with anosmia ("merciful anosmia").
    • More common in young females, tropical climates.
    • Associated organism: Klebsiella ozaenae.
    • Treatment: Nasal douching/lubricants to remove crusts, antibiotics. Surgery (narrowing/closure like Young's procedure) if medical treatment fails.
  • Non-infective Chronic Rhinosinusitis (Hypertrophic) → Non-allergic rhinitis (rhinitis medicamentosa, gustatory rhinitis, hormonal rhinitis, senile rhinitis, vasomotor)
  • Allergic rhinitis → IgE/Type 1 hypersensitivity, most sensitive test (gold standard) is nasal challenge test, most effective treatment is desensitization, most important is to avoid the allergen. Most common form of Chronic Rhinosinusitis

• Sinusitis Complications:
  • Most common: Orbital complications (especially from ethmoiditis due to thin lamina papyracea). Includes orbital cellulitis, subperiosteal abscess, orbital abscess.
  • Intracranial: Meningitis, abscesses (epidural, subdural, intracerebral), cavernous sinus thrombosis. Most common IC complication is subdural abscess related to frontal sinusitis
  • Bony: Osteomyelitis (e.g., Pott's puffy tumour of frontal bone).

Hearing Loss & Assessment

• Types of Hearing Loss:
  • Conductive Hearing Loss (CHL): Problem in external or middle ear.
    • Causes: Wax, Otitis Externa, Otitis Media (Acute/Serous), TM perforation, Otosclerosis, Cholesteatoma, Ossicular discontinuity, Congenital atresia.
    • Tuning Forks: Rinne negative (BC>AC), Weber lateralizes to the affected ear.
  • Sensorineural Hearing Loss (SNHL): Problem in cochlea or auditory nerve/pathway.
    • Causes: Presbycusis, Noise exposure, Ototoxicity (e.g., aminoglycosides), Meniere's disease, Viral infections (Mumps=most common acquired SNHL cause in children, Measles), Meningitis, Acoustic neuroma, Trauma, Genetic syndromes.
    • Tuning Forks: Rinne positive (AC>BC), Weber lateralizes away from the affected ear.
  • Mixed Hearing Loss: Both CHL and SNHL components.

• Presbycusis (Age-Related Hearing Loss):
  • Most common cause of SNHL in adults.
  • Characteristics: Bilateral, progressive, symmetric, high-frequency SNHL with a sloping audiogram pattern.
  • Often associated with tinnitus and difficulty hearing in noise.
  • Management: Hearing aids.

• Hearing Assessment:
  • Neonate Screening: Auditory Brainstem Response (ABR) is the investigation of choice. Otoacoustic Emissions (OAE) are also used (screening tool, affected by middle ear status).
  • Tuning Fork Tests (Weber & Rinne): Used to differentiate CHL and SNHL. Use 512 Hz fork ideally.
    • See interpretation under CHL/SNHL above.
  • Audiometry: Pure Tone Audiometry (PTA), Tympanometry (assesses middle ear pressure/compliance - Type A=Normal, Type B=Flat/Effusion, Type C=Negative Pressure/ETD).

• Pediatric Hearing Loss Risk Factors:
  • Family history, congenital infections (TORCH), meningitis, ototoxic drug exposure, hyperbilirubinemia, prematurity (<1500g), syndromes, craniofacial anomalies, head trauma, hypoxia.
  • History of Otitis Externa or Cesarean delivery are NOT risk factors.

Nasopharyngeal Carcinoma (NPC)

• Most common site of origin: Fossa of Rosenmüller.

• Presentation:
  • Most common presentation: Neck mass (cervical lymph node metastasis). Usually bilateral nodes.
  • Unilateral Otitis Media with Effusion (OME) in an adult is highly suspicious for NPC and must be ruled out. (Due to Eustachian tube obstruction).
  • Other symptoms: Nasal obstruction, epistaxis, hearing loss, tinnitus, otalgia, cranial nerve palsies (late).

• Associated with Epstein-Barr Virus (EBV), especially non-keratinizing types.

• Risk factors: Genetics (South-eastern Asia), environment (smoking, alcohol, pollution), EBV.

• Diagnosis: Examination under anesthesia with biopsy. FNA of neck nodes. CT/MRI for staging.

• Treatment: Primarily Radiotherapy +/- Chemotherapy. Surgery mainly for biopsy.

Tonsils & Adenoids (Including Tonsillitis & Tonsillectomy)

• Tonsillitis:
  • Most common cause: Viral (50-80%).
  • Most common bacterial cause: Group A Beta-Hemolytic Streptococcus (GABHS / S. pyogenes).
  • Acute Bacterial Tonsillitis Treatment: Penicillin or Amoxicillin.
  • Follicular Tonsillitis: Pus in crypts.
  • Membranous Tonsillitis DDx: Infectious Mononucleosis (EBV), Diphtheria, Scarlet Fever, Vincent's Angina.
    • Infectious Mononucleosis: Sore throat, exudate/membrane, significant cervical lymphadenopathy, hepatosplenomegaly, atypical lymphocytes. Avoid ampicillin (rash).
  • Peritonsillar Abscess (Quinsy): Collection of pus between tonsil capsule and pharyngeal wall. Features: Severe sore throat, dysphagia, trismus, muffled ("hot potato") voice, uvular deviation. Treatment: Incision & drainage or aspiration + antibiotics.
  • Tonsils primarily drain into the Level II lymph nodes, specifically the jugulodigastric group

• Tonsillectomy:
  • Absolute Indications: Obstructive Sleep Apnea (OSA), Suspected Malignancy, and Failure to Thrive.
  • Relative Indications: Recurrent acute tonsillitis (specific criteria: e.g., >7/yr, >5/yr x2yrs, >3/yr x3yrs), recurrent febrile convulsions, recurrent OME (if tonsils are focus), history of quinsy (especially 2nd episode), tonsillolithiasis.
  • Complications:
    • Bleeding: Primary (within 24 hrs) vs Secondary (usually ~1 week post-op, often due to infection).
    • Other: Pain, infection, dental damage, TMJ dislocation, injury to uvula/palate.

• Adenoids (Pharyngeal Tonsils):
  • Part of Waldeyer's ring, located in the nasopharynx. Composed of B-lymphocytes.
  • Produce IgA, IgG, IgM.
  • Size peaks at 6 yrs, then atrophies until 16 yrs.
  • Adenoiditis/Hypertrophy: Can cause nasal obstruction, snoring, mouth breathing, OME.

Neck Masses

• Congenital Neck Masses:
  • Most common overall: Thyroglossal duct cyst.
    • Midline, usually near hyoid bone.
    • Moves upward with swallowing and tongue protrusion.
    • Requires Sistrunk procedure for removal (includes central hyoid bone).
    • Must check thyroid function/scan pre-op as cyst may contain only thyroid tissue.
  • Branchial cleft cyst: Lateral neck mass, usually anterior border of sternocleidomastoid muscle. Most common is second arch cyst.
  • Dermoid cyst: Usually midline, firm/hard, non-tender, mobile side-to-side but not up/down. Contains ectodermal elements.
  • Lymphatic malformation (Cystic hygroma).

• Malignant Neck Masses:
  • Secondary (Metastatic) are most common overall (90%). Primary source often above clavicle (Nasopharynx, tonsil, base of tongue, larynx).
  • Primary Malignant: Lymphoma is most common primary neck malignancy, followed by Squamous Cell Carcinoma (SCC).

• Location Clues:
  • Midline: Thyroglossal duct cyst, Dermoid cyst, Thyroid pathology, Submental lymph node.
  • Lateral: Branchial cleft cyst, Lymph nodes (inflammatory/malignant), Salivary gland tumors, Carotid body tumor, etc.

Stridor & Airway Obstruction

• Stridor: High-pitched noise due to turbulent airflow through a narrowed airway.
  • Inspiratory: Supraglottic obstruction.
  • Expiratory: Intrathoracic/tracheal obstruction.
  • Biphasic: Glottic or Subglottic obstruction.

• Congenital Stridor Causes:
  • Most common cause in infants: Laryngomalacia.
    • Due to delayed cartilage development -> soft, floppy supraglottic structures (omega-shaped epiglottis, short aryepiglottic folds).
    • Inspiratory stridor, worse when supine/crying, relieved by prone position/head extension.
    • Usually benign, self-limiting (improves by 1 year). Observation for mild/moderate cases. Severe cases may need supraglottoplasty or tracheostomy.
  • Vocal cord paralysis: Can be unilateral (weak cry, hoarseness, biphasic stridor) or bilateral (aphonia, severe stridor, respiratory distress - may need tracheostomy). Can be congenital (birth trauma, Arnold-Chiari) or acquired.
  • Laryngeal web: Incomplete recanalization of larynx. Usually glottic. Causes biphasic stridor and weak cry.
  • Subglottic stenosis: Narrowing below vocal cords. Causes biphasic stridor.
  • Tracheomalacia.

• Acquired Stridor Causes:
  • Croup (Laryngotracheobronchitis): Viral (Parainfluenza common), affects subglottic area. Barking cough, inspiratory stridor, low-grade fever. Steeple sign on X-ray.
  • Epiglottitis: Bacterial (H. influenzae type B historically, now others too). Medical emergency. High fever, dysphagia, drooling, muffled voice, "tripod" position. Thumb sign on X-ray. (Note: This is ACQUIRED, not congenital).
  • Foreign body aspiration.
  • Laryngoedema, tumors, trauma.

Epistaxis

• Anterior Epistaxis:
  • Most common site: Kiesselbach's plexus (Little's area) on the anteroinferior septum (90% of cases).
  • Common in children/young adults.
  • Usually caused by trauma (nose picking), inflammation, dryness.
  • Vessels involved: Anterior Ethmoidal, Sphenopalatine, Greater Palatine, Superior Labial arteries. (Acronym: LEGS).
  • Management: Direct pressure, topical vasoconstrictors, cautery (silver nitrate/electrical), anterior packing.

• Posterior Epistaxis:
  • Less common (10%), more severe.
  • Common site: Woodruff's plexus (posterolateral wall). Primarily involves branches of the Sphenopalatine artery.
  • More common in elderly, often associated with hypertension or atherosclerosis.
  • Management: Requires posterior packing (e.g., Foley catheter, balloon packs), possible hospitalization, potential surgical ligation or embolization.

Otitis Media & Complications (Including CSOM & OME)

• Acute Otitis Media (AOM):
  • Infection of the middle ear.
  • Most common bacterial pathogens: S. pneumoniae, H. influenzae, M. catarrhalis.
  • Risk factors: Eustachian tube dysfunction (most common factor in children), young age, daycare, smoke exposure, bottle feeding, cleft palate.

• Otitis Media with Effusion (OME / Serous OM / Glue Ear):
  • Fluid in the middle ear without acute inflammation.
  • Most common cause of hearing loss in children. Peak age 2-5 years.
  • Can follow AOM or result from chronic Eustachian tube dysfunction.
  • Most common cause in children: Adenoid hypertrophy.
  • Unilateral OME in an adult raises suspicion for Nasopharyngeal Carcinoma.
  • Complications: Hearing loss, speech delay, recurrent AOM, TM retraction, cholesteatoma (rare).

• Chronic Suppurative Otitis Media (CSOM):
  • Persistent TM perforation with chronic middle ear inflammation and discharge (otorrhea) > 2 weeks (or 6 weeks).
  • Most common persistent symptom: Painless otorrhea.
  • Types:
    • Tubotympanic (Safe): Central perforation, mucoid discharge (often profuse), no cholesteatoma, rare complications.
    • Atticoantral (Unsafe): Marginal or attic perforation, purulent, foul-smelling discharge (often scanty), cholesteatoma often present, granulation/polyps common, high risk of complications.

• Otitis Media Complications:
  • Intratemporal: Mastoiditis, Petrositis (Gradenigo syndrome: Otorrhea, retro-orbital pain, CN VI palsy), Facial paralysis, Labyrinthitis.
  • Intracranial: Meningitis (most common IC complication), Brain abscess (temporal lobe/cerebellum), Epidural/Subdural abscess, Lateral sinus thrombosis.

Ear Anatomy & Physiology (Including Cranial Nerves & Referred Otalgia)

• External Ear Canal Innervation & Reflexes:
  • Vagus Nerve (CN X - Arnold's Branch): Innervates posterior/inferior canal wall. Stimulation can cause cough reflex (Arnold's reflex).
  • Trigeminal Nerve (CN V3 - Auriculotemporal Branch): Innervates anterior/superior canal wall.
  • Facial Nerve (CN VII): Minor contribution.
  • Glossopharyngeal Nerve (CN IX): Minor contribution.

• Referred Otalgia (Ear pain originating elsewhere):
  • Common pathways involve shared cranial nerve innervation:
    • CN V (Trigeminal): Dental issues, TMJ disorders, oral cavity lesions.
    • CN IX (Glossopharyngeal): Pharynx, tonsils, base of tongue pathology.
    • CN X (Vagus): Larynx, hypopharynx, esophagus pathology.
    • Cervical Nerves (C2, C3): Neck pathology (spinal/muscular).
  • Hypoglossal nerve (CN XII) is NOT typically associated with referred otalgia.

• Eustachian Tube: Connects middle ear to nasopharynx. Functions: Pressure equalization, drainage, protection. Dysfunction is key in OM pathogenesis.

Vertigo & Balance Disorders

• Vertigo: Illusion of movement (self or surroundings).

• Causes:
  • Peripheral (Inner ear/Vestibular nerve):
    • Benign Paroxysmal Positional Vertigo (BPPV): Most common cause overall. Short episodes triggered by head movements. Diagnosed with Dix-Hallpike maneuver. Treated with repositioning maneuvers (e.g., Epley).
    • Meniere's Disease: Triad of episodic vertigo, fluctuating SNHL, and tinnitus. Often preceded by aural fullness. Due to endolymphatic hydrops.
    • Vestibular Neuritis: Acute onset vertigo, nausea/vomiting, without hearing loss. Often follows viral illness. Labyrinthitis includes hearing loss.
    • Ototoxicity, trauma.
  • Central (Brainstem/Cerebellum): Stroke, Multiple Sclerosis, Tumors. Less common. Central nystagmus characteristics differ (non-fatiguing, vertical, direction-changing).

• Epidemiology: Vertigo is more common in the elderly (>60 years).

• Nystagmus:
  • Peripheral: Usually horizontal/rotatory, fatigable, suppressed by visual fixation.
  • Central: Can be vertical, non-fatigable, not suppressed by fixation.

Nasal Conditions (Polyps, Furunculosis, Foreign Body, Septal Hematoma)

• Nasal Polyps: Benign growths from nasal/sinus mucosa.
  • Ethmoidal Polyps: Most common type. Usually bilateral, multiple, arise from ethmoid sinuses. Associated with allergy, asthma, aspirin sensitivity (Samter's triad), cystic fibrosis. Treatment: Medical (steroids), surgical (FESS). High recurrence.
  • Antrochoanal Polyp (ACP): Less common. Arises from maxillary sinus, grows into choana/nasopharynx. Usually unilateral, single. More common in adolescents/young adults. Often associated with infection. Treatment: Surgical excision. Low recurrence. Benign.

• Nasal Furunculosis: Infection of a hair follicle in the nasal vestibule (lateral 1/3).
  • Usually Staphylococcus aureus.
  • Features: Severe localized pain, redness, swelling.
  • Treatment: Systemic anti-staphylococcal antibiotics (e.g., oral). Analgesics. Incision & drainage only if localized abscess forms.
  • Danger area: Risk of spread via valveless facial veins to cavernous sinus (Cavernous Sinus Thrombosis).

• Nasal Foreign Body:
  • Common in children.
  • Classic presentation: Unilateral, foul-smelling nasal discharge. May have epistaxis or obstruction.
  • Must be assumed in a child with these symptoms until proven otherwise. Removal required.

• Septal Hematoma:
  • Collection of blood between septal cartilage and perichondrium.
  • Usually result of nasal trauma.
  • Appearance: Bilateral (or unilateral) reddish/bluish, boggy swelling of septum.
  • Requires urgent incision and drainage followed by packing/sutures to prevent cartilage necrosis (saddle nose deformity) or septal abscess.

Otitis Externa (Including Otomycosis & Malignant OE)

• Acute Diffuse Otitis Externa ("Swimmer's Ear"):
  • Generalized inflammation of the external auditory canal (EAC) skin.
  • Most common bacterial cause: Pseudomonas aeruginosa. Staphylococcus aureus also common.
  • Risk factors: Water exposure, trauma (cotton buds), hearing aids, dermatologic conditions.
  • Symptoms: Ear pain (otalgia - often severe, worse on tragal pressure/pinna pull), itching, discharge, hearing loss (due to swelling/debris).
  • Treatment: Thorough aural toilet (cleaning), topical antibiotic +/- steroid drops (e.g., ciprofloxacin/dexamethasone), keep ear dry.

• Otomycosis (Fungal Otitis Externa):
  • Fungal infection of EAC skin.
  • Common organisms: Aspergillus (black/grey/yellowish dots/fluff), Candida (white, creamy patches).
  • Symptoms: Intense itching (pruritus) > pain, discharge, blockage feeling.
  • Treatment: Thorough aural toilet, topical antifungal drops (e.g., clotrimazole) for three weeks, keep ear dry. Acidifying drops may help.

• Malignant (Necrotizing) Otitis Externa:
  • Aggressive, potentially lethal osteomyelitis of the skull base, typically starting in EAC. NOT a malignancy.
  • Almost always caused by Pseudomonas aeruginosa.
  • Risk factors: Elderly, Diabetes Mellitus (uncontrolled), Immunocompromised state.
  • Symptoms: Severe, deep-seated, unrelenting otalgia (out of proportion to exam), persistent purulent otorrhea, headache.
  • Signs: Granulation tissue at the bony-cartilaginous junction of the EAC floor is characteristic. Cranial nerve palsies (especially CN VII) indicate advanced disease and poor prognosis.
  • Diagnosis: Clinical suspicion, CT/MRI (bone erosion), Technetium/Gallium scans (inflammation/follow-up).
  • Treatment: Long-term (weeks-months) systemic anti-pseudomonal antibiotics (often IV initially), strict glycemic control, local debridement.

Laryngeal Conditions (Including Vocal Cord Paralysis & Cancer)

• Vocal Cord Paralysis:
  • Due to damage to Recurrent Laryngeal Nerve (RLN) or Vagus nerve.
  • Causes: Malignancy (lung, thyroid, esophageal, laryngeal), Thyroid surgery (most common iatrogenic cause), trauma, neurological disease, viral infection, idiopathic.
  • Unilateral: Hoarseness, breathy voice, weak cough, possible aspiration.
  • Bilateral: Can cause airway obstruction (especially bilateral abductor paralysis). May require tracheostomy.

• Laryngeal Cancer:
  • Most common type: Squamous Cell Carcinoma (SCC).
  • Risk factors: Tobacco (primary risk factor), Alcohol (synergistic with tobacco), industrial exposure, radiation.
  • Location:
    • Glottic (Vocal cords): Most common site (60%). Presents early with Hoarseness. Good prognosis due to limited lymphatics. T2 involves both cords or extends slightly.
    • Supraglottic: Presents later with dysphagia, odynophagia, referred otalgia, muffled voice, neck mass (early LN mets).
    • Subglottic: Rare (1%). Presents late with stridor/airway obstruction.

• Laryngeal Trauma:
  • Can involve cartilage fracture, hematoma, mucosal tears.
  • Priority is to secure the airway.
  • Cartilage framework can fracture.

Ear Drum Conditions (Perforation, Bullous Myringitis, Tympanosclerosis)

• Tympanic Membrane (TM) Perforation:
  • Causes: Infection (AOM/CSOM), Trauma (direct blow, penetrating injury, barotrauma).
  • Symptoms: Pain (often sudden onset with trauma), hearing loss (conductive), bleeding, tinnitus, vertigo (if ossicles involved).
  • Dry traumatic perforations often heal spontaneously. Management: Keep ear dry. Antibiotics if infected. Myringoplasty if non-healing.

• Bullous Myringitis:
  • Inflammation of the TM with formation of vesicles (bullae).
  • Usually caused by viruses. Sometimes associated with Mycoplasma pneumoniae.
  • Symptoms: Sudden onset of severe ear pain. Hearing usually normal unless blebs rupture (bloody otorrhea).
  • Treatment: Analgesics. Topical antibiotics may prevent secondary infection. Incision of blebs usually unnecessary. Self-limiting.

• Tympanosclerosis:
  • Scarring (hyalinization, calcification) on the TM +/- middle ear structures. Appears as white patches/plaques.
  • Usually caused by previous infection or ventilation tube insertion.
  • Often asymptomatic and does not cause significant hearing loss unless ossicles are fixed.

Cholesteatoma

• Accumulation of keratinizing squamous epithelium in the middle ear or mastoid. Benign but locally destructive.

• Types: Congenital (rare), Acquired (Primary - retraction pocket; Secondary - through TM perforation).

• Associated with atticoantral (unsafe) CSOM and marginal/attic perforations.

• Appearance: White/pearly mass behind TM, often associated with foul-smelling discharge and conductive hearing loss.

• Can erode bone, leading to complications (ossicular erosion, facial paralysis, labyrinthine fistula, intracranial complications).

• Diagnosis: Otoscopy suggestive. CT scan essential to assess extent and bony erosion.

• Treatment: Surgical excision (Mastoidectomy).

Croup (Laryngotracheobronchitis)

• Viral infection (Parainfluenza most common) causing inflammation of larynx, trachea, bronchi.

• Affects mainly children 6 months - 2 years.

• Symptoms: Inspiratory stridor, Barking cough, Hoarseness, low-grade fever. Symptoms often worse at night.

• Diagnosis: Clinical. Lateral neck X-ray may show "Steeple sign" (subglottic narrowing).

• Treatment: Supportive (cool mist, fluids), Corticosteroids (oral/IM/nebulized), Nebulized epinephrine for moderate/severe stridor. Antibiotics generally NOT indicated.

Tinnitus

• Perception of sound in the absence of external acoustic stimulus.

• Types:
  • Subjective: Most common. Only heard by the patient. Causes numerous (hearing loss - presbycusis/noise, Meniere's, ototoxicity, trauma, TMJ, etc.).
  • Objective: Rare (<1%). Heard by both patient and examiner. Causes: Vascular (AVMs, glomus tumors, aneurysms), Muscular (palatal myoclonus, middle ear muscle spasms).

• Management: Treat underlying cause if identifiable, reassurance, masking devices, hearing aids (if HL present), tinnitus retraining therapy.