ENT

Cases

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 Index

Nose…………………….…………….……………………..3
Pharynx& hypopharynx…………..………....…………...13
Esophagus………………………………...…....………….22
Larynx……………………………………………..………25
Ear………………………………………………………....32

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Nose
NB:
Discharge - Watery:
*Viral: Bilateral & Acute
*Allergic: bilateral & chronic
*CSF: unilateral & increases on straining or leaning
forwards

- Mucoid:
*inflammatory

- Offensive: must be exclude fungal sinusitis before tt as if

bacterial or viral infection
*child: F:B , unilat
*Adult: dental origin
*old: malignancy

- Sanguineous:
*Inflammatory
*malignant old age & unilateral

Water & food - Palatal muscle paralysis

regurgitation - Palatal perforation
- Oro Antral fistula

1-A newborn with difficult breathing or suckling + bilateral nasal discharge & cyanosis.
Diagnosis Bilateral choanal atresia
symptoms -Bilateral Nasal obstruction
-Bilateral Nasal discharge
-Difficult suckling and cyanosis improve on crying.
signs -Rubber catheter and colored drops can't be passed from nose to
nasopharynx.
-Nasal endoscopy shows atresia.
investigation X-ray of skull in lat.view after applying lipiodol
CT: it differentiates bony from membranous atresia
treatment It's an emergency situation:
-saving airway after birth by maintaining the mouth open by:
Plastic oral airway or endotracheal intubation.
-Operations:
Trans-nasal endoscope or tans-palatal (not commonly used)
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2- A child with unilateral nasal obstruction + nasal offensive discharge.
Diagnosis Foreign body in the nose
Symptoms -unilateral nasal obstruction
-unilateral nasal offensive discharge
-Recurrent mild epistaxis
Signs -Ant. Rhinoscopy shows FB or discharge
-nasal endoscopy (sometimes) is needed
Treatment -Removal of the FB by hook or suction(preferred over forceps to
avoid backward slippage of F.B)
-if the child isn’t co-operative >> removal under general anesthesia
with cuffed ET tube

3- unilateral nasal regurgitation + offensive discharge or after dental extraction.

Diagnosis Oro-antral fistula
Symptoms -unilateral nasal regurgitation
-unilateral offensive nasal discharge (sinusitis)
-discharge though the fistula to the mouth
Signs -fistula is seen though the oral cavity
-a prop can be passed from mouth to the antrum (not preferred)
investigation CT shows the site of fistula + associated sinusitis
Treatment -Recent cases (1st 24 hrs.): small fistula > heals spontaneously, Lage
fistula > surgical closure + antibiotics
-old cases: radical antrum operation + surgical closure
-failed cases: dental operator
4- a patient unilateral watery nasal discharge.
Diagnosis CSF rhinorrhea
C/P -unilateral watery nasal discharge: which is clear, colorless, has salty
taste, doesn’t stiffen the tissue & increased by coughing, straining &
leaning forwards.
-headache: maybe dt. High or low CSF pr.
Investigation -Biochemical analysis of the discharge> CSF characterized by:
Clear, colorless & with no mucus.
Contains sugar more than 30 mg%
Contains B2 transferrin which is diagnostic
-CT with intrathecal metrizamide: can detect the site of leakage
-Intrathecal dye (flourescine): endoscopic Exam. Of nose after dye
injection to see the defect.

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Treatment -Conservative: most of cases heal spontaneously
Bed rest in a semi-sitting position
Avoid coughing, straining & blowing of the nose
Avoid nasal medications
Prophylactic ABs to prevent meningitis
-Surgical (if the conservation failed): covering the defect by graft or
flap. It's done by nasal endoscope (ESS)
5- A Female Patientwith bilateral nasal obstruction + crustations (±offensive).
Diagnosis Atrophic rhinitis
Symptoms -nasal obstruction
-nasal discharge (crusty, greenish black & offensive)
-anosmia (atrophy of olfactory mucosa)
-epistaxis on the removal of crust
Signs -atrophic dry nasal mucosa
-atrophic turbinates
-roomy nasal cavity
-crustations (greenish black, offensive & bleeding on removal)
Treatment -ttt of the cause
-Medical:
Alkaline nasal douche
Menthol paraffin oil (nasal drops)
25% glucose in glycerin (nasal pack)
K iodide (systemic) (to stimulate glandular secretion)
Mucolytics, Iron & vit. A, ABs
-Surgical (aim > narrowing of the nasal cavity till mucosa
regenerate):
Submucosal augmentation by bone or cartilage
Young's operation: closure of one side of the nose for 1 year the
open it & repeat it on the other side.

**Radiotherapy or after Surgery may be complicated by chronic atrophic rhinitis

6- A patient with bilateral nasal obstruction + crustations (±offensive) and on examination
showed mass(es).
Diagnosis Rhinoscleroma
Symptoms -atrophic stage: similar to atrophic rhinitis symptoms.
-active nodular stage: bilateral Nasal obstruction & bilateral Nasal
discharge (crusty). (mucoid discharge, ± dyspnea or stridor ±
epiphora)
-fibrotic stage: bilateral Nasal obstruction (internal fibrosis) &
deformity (external fibrosis).

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Signs -atrophic stage: similar to atrophic rhinitis signs.
-active nodular stage: (External: broad rubbery nose)
(Ant. Rhinoscopy: bilat.reddish masses covered by intact mucosa)
bilateral nasal masses mainly at the muco-cutaneous junction.
-fibrotic stage:
Nose: bilateral Nasal obstruction (internal fibrosis) & deformity.
Pharynx: shortening of soft palate->regurgitation
Larynx:s ubglottic stenosis->stridor
Investigation -biopsy: Mikulicz cells & Russel bodies in active stage.
-culture (not essentially).
Treatment -Medical:
Rifampicin 600 mg/day
Alkaline nasal douche
-Surgical: removal of the masses (better by the laser)
Reconstruction & Rhinoplasty

7- patient with recurrent attacks of acute rhinitis (common cold) then developed bilateral nasal
obstruction & bilateral mucoid discharge
Diagnosis Chronic hypertrophic rhinitis
Symptoms -bilateral nasal obstruction
-bilateral nasal mucoid discharge (ant. & post-nasal)
-frequent throat clearing
-hoarseness of voice
Signs -hypertrophied congested inferior turbinate which doesn’t shrink
with local vasoconstrictor.
Treatment -ttt of the cause
-medical: steroid nasal spray
-Surgical: reduction of inf. Turbinate by either:
Sub mucous diathermy – partial turbinectomy – laser turbinectomy

**Septal deviation may be presented by chronic hypertrophic rhinitis on the wide side
8- a diabetic patient developed acute bilateral nasal obstruction & discharge, with progressive
diminution of vision & proptosis.
Diagnosis Mucormycosis + intra-orbital & cerebral invasion
Symptoms -nasal obstruction
-headache
-orbital manifestations (proptosis, ophthalmoplegia & diminution of
vision)
-cerebral manifestations (cranial nerve paralysis)
Signs -nasal endoscopy shows black necrotic tissue with ulceration &
crusts.

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Investigation CT: shows extensive bone destruction with orbital and/or cerebral
invasion.
Treatment Combination of surgery (ESS) & antifungal (amphotericin-B) +
control of diabetes.

9- patient with uni or bilateral nasal obstruction & discharge ± epistaxis ± headache
Diagnosis Deviated septum
Symptoms -asymptomatic in mild cases
-nasal obstruction: Unilateral in C-shaped deviation – bilateral in S-
shaped deviation.
-nasal discharge: (ant. or post-nasal) due to either: sinusitis – contact
between med. & lat. wall.
-epistaxis: due to angulation of blood vessels.
-headache: due to either: contact between med. & lat. wall –
obstruction of frontal recess (vacuum headache) (irritation of ant.
ethmoidal nerve).
Signs -ant. Rhinoscopy shows the deviation
-nasal endoscopy may be needed to see posterior deviation.
Investigation CT: to show the associated sinusitis.
Treatment -Surgical correction by either:
Sub-mucous resection (SMR): removal of the deviated cartilage
(done after the age of 18 years).
Septoplasty: straightening of the septal cartilage (in children &
adolescents under 17 years should weighed very carefully as it can
damage the growth zone of the septum causing long-term
problems).
10- bilateral swelling or obstruction after nasal trauma.
Diagnosis Septal hematoma
Symptoms -history of trauma
-bilateral nasal obstruction
Signs -ant. Rhinoscopy >> bilateral swelling on both sides of the septum.
-syringe aspiration >> blood
Treatment -systemic ABs to prevent 2ry infection
-incision & evacuation
-ant. Nasal pack to prevent recollection
11- patient with bilateral nasal obstruction + throbbing pain ± purulent discharge
Diagnosis Septal abscess
Symptoms -general: fever, headache & malaise
-local:
Pain
Bilateral nasal obstruction
Purulent nasal discharge after rupture of the abscess
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Signs -ant. Rhinoscopy >> bilateral tender swelling on both sides
-syringe aspiration >> pus
Treatment -avoid squeeze the affected area > to prevent complications.
-systemic ABs
-incision & evacuation
-ant. Nasal pack to prevent recollection

12- Facial pain & headache ± nasal discharge after acute attack of common cold. Or change or
the watery discharge of common cold to mucopurulent.
Diagnosis Acute rhinosinusitis (caused by pneumococci->The commonest)
Symptoms -history of common cold
-general: fever, headache & malaise
-local: PODS
P: facial pain headache over the affected sinus
O: obstruction
D: discharge (mucopurulent)
S: Smell ( offensive in sinusitis of dental origin)

Signs -general: high temp. & rapid pulse

-local:
Inspection: edema
Palpation: tenderness over the affected sinus
Ant. Rhinoscopy & nasal endoscopy shows:
Congestion & edema of nasal mucosa – mucopurulent
discharge in: middle meatus > ant. Group sinusitis – sup. Meatus >
ethmoidal sinusitis – shpenoethmoidal recess > sphenoidal
sinusitis.
Post. Rhinoscopy: post-nasal discharge.
Investigation -X-ray: shows opacity or fluid level
-Culture & sensitivity of discharge
CT scan PNS & brain (requested in chronic, recurrent acute cases
or in case of suspected complication): mandatory as a pre-operative
investigation.
Treatment -Complete bed rest with plenty of warm fluids
-Medical:
Systemic ABs – analgesics, antipyretics – decongestant drops
(Xylometazoline) – steam inhalation – warm fomentation over the
affected sinus – ttt of PFs if present.
-Surgical:
Functional endoscopic sinus surgery (FESS). indicated in: failure
of medical ttt or complicated sinusitis.

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13- patient with history of: skin sepsis in dangerous Δ, sinusitis or orbital infection. Then
developed C/P of cavernous sinus thrombosis.
Diagnosis Cavernous sinus thrombosis
Symptoms and -general: fever, headache & malaise.
Signs -local: orbital manifestations
Ipsilateral-> Edema of upper eyelid, chemosis, proptosis,
ophthalmoplegia, diminution of vision > blindness,& papilledema
Contralateral->paralysis of 6th CN. The earliest sign

Investigation -CT with contrast

-MRV (magnetic resonance venography)
-CBC: leucocytosis
Treatment -Medical:
Hospitalization
Intravenous ABs that cross BBB
Anticoagulants (Heparin)
-Surgical:
ttt of infected sinuses after recovery
14- patient with recurrent attacks of sneezing, nasal itching (burning), rhinorrhea & nasal
obstruction
Diagnosis Allergic rhinitis
Symptoms -recurrent attacks of sneezing & itching + nasal obstruction
-rhinorrhea (bilateral watery discharge)
-other allergic manifestations may be present: as allergic
conjunctivitis, asthma or eczema.
Signs -in between attacks: the nasal mucosa appears normal
-during the attacks: the nasal mucosa may become edematous &
pale bluish + the turbinate may be enlarged
-nasal polypi may be present.
Investigation -nasal cytology > eosinophils
-nasal challenge test: inhalation of the antigen > allergic
manifestations
-skin prick test > +ve test (cental wheel surrounded by erythema)
-CT PNS -> to detect complications

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Treatment -Avoid exposure to the causative antigen
-Medical:
Antihistaminic (Loratidine or Fexofenadine)
Local decongestant drops (Xylometazoline)
Cortisone best line of tt: either local nasal spray (Beclomethasone)
or systemic (Dexamethasone)
Mast cell stabilizers (Ketotifen)
-Hypo-sensitization.
-Surgical: for obstruction
Reduction of enlarged inf. turbinates – Endoscopic sinus surgery
(ESS): ethmoidectomy with removal of polyps.

15- patient with unilateral nasal obstruction & mucoid discharge

Diagnosis Antro-choanal polyp
Symptoms unilateral nasal obstruction & mucoid/mucopurulent discharge
Signs -ant. Rhinoscopy shows single polyp, unilateral, soft ,pale greyish
and jelly like.
-post. Rhinoscopy shows the polyp in the nasopharynx passing
from the choana.
Investigation CT: diagnostic
Treatment -ESS & removal of polyp (standard ttt)
-radical antrum operation may be used in recurrent cases (old
procedure).
N.B. allergic polyps = bilateral, multiple with allergic criteria.

16- patient with unilateral nasal obstruction & discharge ± epistaxis. Examination reveals a
fleshy polypoidal mass.
Diagnosis Inverted papilloma
Symptoms unilateral nasal obstruction, discharge & sometimes epistaxis
Signs Unilateral nasal mass
Investigation -CT: shows site, size & extension
-Biopsy
Treatment -Medial maxillectomy with complete excision of the tumor either by
endoscopic (recent) or external lateral rhinotomy (old)

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 17- an old patient with unilateral nasal mass which bleeds on touch with offensive bloody
discharge± symptoms of local spread
Diagnosis Malignant maxillary tumor
Symptoms The presentation usually with local spread:
-Downwards: unilateral dental pain, loosening of teeth, and/or oro-
antral fistula.
-Upwards: proptosis, diplopia, ophthalmoplegia & diminution of
vision.
-Posterior: trismus (infiltration of pterygoids) & anesthesia
(infiltration of maxillary nerve).
-Anterior: facial pain, swelling & ulceration
-Medially: to nasal cavity > unilateral nasal obstruction, discharge &
epistaxis.
+ symptoms of lymphatic & blood spread.
Signs -Local examination:
Nasal: ant. Rhinoscopy shows unilateral mass which friable &
bleeds on touch in lat nasal wall.
Neck: to exclude lymph node metastasis
-General examination: to exclude distant metastasis.
Investigation -CT: shows site, size, extension & lymph node metastasis.
-MRI: to detect intra-cranial or intra-orbital extension.
-Biopsy: by nasal endoscopy under local anesthesia.
Treatment Combined ttt i.e. surgery & radiotherapy
-Curative: Surgery – post-operative radiotherapy – chemotherapy
may be used.
Palliative: analgesics – palliative surgery – palliative radio &
chemotherapy.
18- A pregnant female with paroxysmal attacks of sneezing + persistent nasal obstruction &
profuse discharge but no itching.
Diagnosis Vasomotor (hormonal) rhinitis
Symptoms -long standing persistent nasal obstruction & perfuse discharge.
-paroxysmal attack of sneezing.
-No itching
Signs -Congestion & edema of nasal turbinates.
-Hypertrophy is most marked in inf. turbinates.
Treatment -it’s often unsatisfactory.
-topical steroid as sprays.
-inf. Turbinectomy, laser turbinectomy or submucous diathermy for
management of inf. Turbinate hypertrophy.

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19- Patient with slowly growing painless swelling in forehead & headache on examination
eggshell crackling like sensation over frontal bone & proptosis. With history of trauma.
Diagnosis Mucocele in frontal sinus
Symptoms -slowly growing painless swelling under medial third
of superior orbital margin.
-headache & proptosis.
Signs -Mucocele at first hard then with bone thinning > eggshell
crackling.
-Fluctuation is found after complete resorption of bone.
-Proptosis is directed downward.
Investigation -CT is diagnostic.
Treatment -ESS
20- 15y patient with history of recurrent epistaxis. Examination reveals small polypoidal mass
at ant. border of septum.
Diagnosis Capillary hemangioma
Symptoms Recurrent epistaxis
Sign Small polypod mass at the ant. Border of the septum
Treatment Excision by knife of laser.

**Epistaxis is a symptom not a disease, but Because it's important to know management
of patient with epistaxis, we will discuss it

Investigation -coagulation profile

-CBC
-CT (if a tumor is suspected)
-Biopsy from a tumor (except angiofibroma)
Treatment First we should know the First aid measures position of the
patient: the patient kept in this position with pressure for 5-10 min
*Patient sits with his head slightly flexed forwards
*Pressure is applied by pinching the ant.cartilaginous part of the
nose between Thumb & index

-Mild:
Cauterization: if the bleeding point is seen
Nasal packing ant first  if failed to control  add post
-Sever: (control of bleeding & management of shock should be
done simultaneously):
Nasal packing
Surgery: maxillary a. ligation – ethmoidal a. ligation
Embolization: angiography is done to detect the bleeding vessels
-ttt of the cause if present.

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Pharynx
1- a child with mouth breathing, snoring & apathetic look ± conductive hearing
loss.
Diagnosis Adenoids
Symptoms -uni/Bilateral nasal obstruction > snoring & sleep apnea, difficult
suckling in infants, rhinolalia clausa & ant. Nasal discharge.
-Eustachian tube obstruction > conductive hearing loss.
-adenoid facies: open dry mouth, elevated upper lip, prominent
central incisors, narrow pinched nares & apathetic look.
-Recurrent infection > rhinitis, sinusitis, OM & pharyngitis.
-General effects: school retardation, nocturnal enuresis.
Signs -Adenoid facies.
-Ant. Rhinoscopy: narrow pinched nares with discharge.
-Post. Rhinoscopy: postnasal discharge (gummy egg white)& the
adenoid maybe seen
-Oral cavity: open dry mouth.
-Nasal endoscopy: can be done for co-operative child.
+ signs of OME
Investigation -For adenoids: Plain X-ray (lateral view on nasopharynx)
-Ear: Pure tone audiometry & tympanometry
-General investigations before operation
Treatment Adenoidectomy ± tonsillectomy if indicated.
2- patient with FAHM + dysphagia & sore throat. His palatine tonsils showed yellowish spots.
Diagnosis Acute tonsillitis
Symptoms -General: FAHM
-Local: dysphagia, sore throat, hot potato voice, foetor oris, referred
otalgia & rapid onset.
Signs -General: high temp. & high pulse.
-Local: tonsils show:
Congestion & edema in catarrhal tonsillitis.
Yellowish spots in follicular tonsillitis.
Hugely enlargement in parenchymatous tonsillitis.
LNs: enlarged, firm & tender.
Investigation In resistant cases:
-Throat swab for culture & sensitivity.
-CBC > leukocytosis.
-High ESR
Treatment -General: Complete bed rest, warm fluids,
systemic Abs:penicillin for 10 days, analgesic antipyretics.
-Local: antiseptic mouth gargle.
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 3- a child with low grade Fever AHM + dysphagia & sore throat. His pharynx showed
unilateral pseudomembrane.
Diagnosis Diphtheria
Symptoms -General: low grade fever, AHM (gradual onset)
-Local: sever dysphagia, sore throat & unilat. swelling in the neck.
Signs -General:
High temp. (not more than 38).
Rapid pulse (disproportionate to fever).
Toxemia.
-Local:
Pharynx shows pseudomembrane which is: unilateral, exceeds the
limit of the tonsils, dirty greyish in color, if removed > raw bleeding
surface area & it will reform rapidly.
Cervical LNs: hugely enlarged (bull’s neck).
Investigation -Throat swab for:
Direct smear: G +ve bacilli (Chinese letter appearance).
Culture on Loffler’s serum or Tellurite medium.
Treatment -Hospitalization & isolation.
-Antitoxic serum: 40000 – 100000 IU, IM or IV, given once the
diagnosis is suspected.
-ABs: penicillin or erythromycin.
-ttt of complications.
4- patient with fever, dysphagia, abdominal pain + enlarged LNs allover his body. CBC
showed monocytosis + Not responding to antibiotic treatment
Diagnosis Infectious mononucleosis
C/P -Febrile manifestations: FAHM. Fever doesn’t respond to ttt
-Anginose manifestations: dysphagia, sore throat & oropharyngeal
ulceration with pseudomembrane.
-Glandular manifestations: generalized lymphadenopathy ±
hepatosplenomegaly.
-in addition: palatal petichiae, skin rash (if ampicillin is
taken) > diagnostic phenomena
Investigation -CBC: monocytosis.
-Serological tests: Paul-Bunnel test or monospot test, if –ve > viral
capsid Ag is requested.
Treatment -Complete bed rest, plenty of warm fluids.
-ABs but avoid ampicillin.
-Analgesic antipyretics.
-Cortisone: if there is airway obstruction.
-Antiseptic mouth wash.

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5- FAHM, sever dysphagia with dripping of saliva & flexion of the neck to the diseased side.
Oropharyngeal exam. Showed swelling above & lateral to the tonsils.
Diagnosis Peritonsillar abscess (Quinsy)
Symptoms -General: FAHM
-Local: Dysphagia & odynophagia with dripping of saliva.
Neck pain behind the angle of mandible referred to the ear.
Trismus & torticollis to the diseased side.
Signs -General: High Temp. & rapid pulse.
-Local: Trismus, torticollis.
Oropharyngeal exam. > swelling above & lateral to the
tonsil pushing the tonsil downwards & medially & pushing the uvula
to the opposite side.
Neck exam. > Jugulodigastric LNs are enlarged, firm & tender.
Treatment -Before suppuration: treated as acute tonsillitis. (i.e. medical ttt).
-After suppuration: needs drainage + medical ttt.
a. incision & drainage: under local or general anesthesia, indication:
pus formation, site: most pointing point (if not seen > in the crypta
magna).
b. parenteral ABs & analgesic antipyretics.
c. tonsillectomy: this is to avoid recurrence, it’s done within 1 month
after drainage.
**Quinsy: Before drainage must be differentiate quinsy from Carotid aneurysm: in
carotid aneurysm there no toxemia , no trismus
6- FAHM, sever dysphagia with dripping of saliva & flexion of the neck to the diseased side.
Oropharyngeal exam. showed swelling lateral to pharyngeal wall.
Diagnosis Parapharyngeal abscess
Symptoms -General: FAHM
-Local: Dysphagia & odynophagia with dripping of saliva.
Neck pain behind the angle of mandible referred to the ear.
Trismus & torticollis to the diseased side.
Signs -General: High Temp. & rapid pulse.
-Local: diagnostic signs (Bec’s triad)
external swelling: at & under sternomastoid + skin: red, hot &
tender
internal swelling: in lat side of oropharynx > push the tonsil medial
trismus
Investigation -CT is diagnostic.
-Culture and sensitivity
Treatment -Hospitalization with parenteral ABs + analgesic antipyretics.
-Incision & drainage > indication: pus formation, site: external
incision along the ant. Border of sternomastoid.

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7- FAHM, dysphagia with dripping of saliva & flexion of neck forwards.
Diagnosis Retropharyngeal abscess
Symptoms -General: FAHM
-Local: Dysphagia & odynophagia with dripping of saliva.
Torticollis: flexion of neck forwards.
Nasal obstruction: collection of pus behind the nasopharynx.
Laryngeal obstruction: collection of pus behind the hypopharynx.
Signs -General: high Temp. & rapid pulse.
-Local: Torticollis, oropharyngeal exam. > swelling
in post. Pharyngeal wall to one side of mid-line limited by median
raphe.
Neck exam. > enlarged, firm, tender deep cervical LNs.
Investigation - X-ray lateral view neck: widening of prevertebral space with
normal vertebrae.
-CT is diagnostic.
-Culture and sensitivity.
Treatment -Hospitalization with parenteral ABs + analgesic antipyretics.
-incision & drainage > indication: pus formation, site:
internal incision (in the pharynx), vertical over the abscess with the
head low down.
8- FAHN with sever dysphagia with dripping of saliva & pain below the mandible ± dental
caries.
Diagnosis Ludwig's angina
Symptoms -General: FAHM
-Local: Severe dysphagia & odynophagia with dripping of saliva.
Neck pain below the mandible.
Change of voice & respiratory obstruction
Signs -General: high temp. & rapid pulse.
-Local: Oropharyngeal exam.
>swelling in the floor of the mouth pushing the tongue upwards &
backwards > protrusion of tongue
Neck exam. > swelling in the submandibular region, first it is
indurated, later on it becomes flactuant (on pus formation).
Trismus.
Treatment -Hospitalization with parenteral ABs + analgesic antipyretics.
-Saving the airway: tracheostomy in sever stridor.
-if cellulitis: injection AB
-Incision & drainage > indication: pus formation, site: transverse in the
submandibular region.

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9- patient with history of ABs abuse or low immunity + whitish pseudomembrane on the
tongue.
Diagnosis Moniliasis (oral thrush, candidiasis)
Symptoms *no fever
-Dysphagia & sore throat.
Signs -Milky whitish pseudomembrane.
Treatment -Stop ABs therapy.
-Antifungal: Nystatin.
10- FAHM, dysphagia & sore throat + bad oral hygiene.
Diagnosis Vincent's angina (trench mouth)
Symptoms -Sever pain without fever
-Foetor oris
-Local: Dysphagia & sore throat.
Signs
-Local: Pharynx shows pharyngeal ulceration with pseudomembrane
(unilateral, with deep irregular ulcer).
Cervical LNs: enlarged, firm & tender.
Treatment Local: H2O2 , gargle
Systemic: penicillin or erythromycin + metronidazole
11- a young boy with unilateral nasal obstruction & sever epistaxis + pink nasal mass that
bleeds on touch.
Diagnosis Angiofibroma
Symptoms -General: pallor (d.t. anemia), stunted growth, face shows >
proptosis, facial growth & frog-face deformity.
-Nasal: unilateral nasal obstruction, intermittent sever epistaxis &
unilateral nasal discharge.
-Aural: ET obstruction > conductive hearing loss.
Signs -Ant. Rhinoscopy > unilateral nasal mass (pinkish) which bleeds on
touch.
-Post. Rhinoscopy > lobulated pinkish mass.
N.B. digital palpation is contraindicated > sever bleeding.
Investigation -CT: to detect site, size & extension.
-Carotid angiography: to see feeding vessel, & to do preoperative
embolization.
-MRI or MRA (MR angiography): to detect intracranial extension.
N.B. biopsy is contraindicated > bleeding.
Treatment -Surgical: surgical excision with preoperative embolization.
Recently, excision can be done by nasal endoscopy (ESS).
-Hormonal: combination of estrogen + testosterone > it increases the
fibrosis & decrease the vascularity (not used nowadays).
-Radiotherapy: not used nowadays as it’s carcinogenic (used in
recurrent cases with intracranial extension).
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 12- an old male with a progressive diminution of hearing, swelling on his neck, blurred vision
& facial pain. Or old male with unilateral facial pain, unilateral palatal immobility & unilateral
conductive hearing loss.
Diagnosis Nasopharyngeal carcinoma
Symptoms #Primary tumor:
-Aural: Unilateral secretory OM d.t. obstruction of ET
Referred otalgia through 9th cranial nerve.
-Nasal: unilateral the bilateral obstruction, discharge & epistaxis.
#Local spread (neurological): cranial nerve palsies in this order >
5th : unilateral facia pain, numbness then loss of sensation.
Ocular (3rd , 4th ,6th ): squint, diplopia & ophthalmoplegia.
Lower 4 cranial nerves: compression by retropharyngeal LNs at
skull base.
#Lymphatic spread: upper deep cervical LNs may be felt.
#Blood spread: lung, brain, liver, bone (LBLB).
Signs -Local: Nasopharyngeal exam. with nasal endoscopy
Neck exam. For LNs.
-General exam. To exclude distant metastasis.
*Trotter’s triad (diagnostic for nasopharyngeal carcinoma) >
unilateral facial pain, unilateral palatal immobility & CHL.
Investigation -CT: to detect site, size, extension & retropharyngeal LNs
metastasis.
-MRI: to detect intracranial extension.
-Biopsy by nasal endoscopy (under local anesthesia).

-metastatic work up.

Treatment -Radiotherapy: to 1ry tumor & to neck (for LNs) in both sides.
-Surgery: has no place as a primary ttt, it’s done only (radical neck
dissection) for persistent or recurrent cases.
13- an old male with dysphagia for solids & weight loss + neck swelling.
Diagnosis Hypopharyngeal carcinoma
Symptoms -Primary tumor: Dysphagia, referred otalgia, chocking,
regurgitation & loss of weight.
-Local spread: to larynx > hoarseness of voice &/or stridor.
-Lymphatic spread: neck swelling & LNs enlargement.
Signs #Local: -Exam. of hypopharynx to see either the tumor mass or
froth collection in pyriform fossa or pos-cricoid area.
-Exam. of the neck: Moure's sign (absence of normal laryngeal
click), LNs enlargement.
#General: Cachexia (d.t. dysphagia).
Pallor & anemia (Plummer-vinson $ may be the cause).
Exclude distant metastasis.
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Investigation -X-ray lateral view neck: widening of prevertebral space in
postcricoid carcinoma.
-Barium swallow: to see the lower limit of the tumor.
-CT neck: to see site, size, extension & LNs metastasis.
-Hypopharyngoscopy: biopsy under general anesthesia.
-Metastatic work up.
Treatment #Curative ttt: combined surgery & radiotherapy.
-For primary tumor: total pharyngolaryngectomy ± esophagectomy
with post-operative radiotherapy.
-For LNs: radical neck dissection if LNs enlargement.
#palliative ttt: for extensive tumors fixed to vertebral column &/or
distant metastasis.
-Radiotherapy, chemotherapy, palliative surgery as tracheostomy,
analgesics & adequate IV feeding.
14- 50y old male patient 3y ago suffering from dysphagia, regurgitation of food & neck
swelling on the left side.
Diagnosis Pharyngeal pouch
Symptoms -Dysphagia, regurgitation of undigested food, neck swelling on the
left side.
Signs -Hypopharynx: indirect or flexible laryngoscopy shows froth in
pyriform fossa.
-Neck: swelling on the left side of the neck under sternomastoid
which is > cystic, compressible & increasing with coughing &
straining.
Investigation -Barium swallow: Retort shaped swelling.
-Hypopharyngoscopy: froth or undigested in the pyriform fossa, the
opening of the pouch may be seen.
Treatment #Endoscopic ttt:
-Repeated dilatation of cricopharyngeal sphincter if the pouch is
small.
-Endoscopic excision of the septum between pouch & esophagus by
diathermy or laser.
#Surgical ttt:
-Cricopharyngeal myotomy: to open the sphincter.
-Excision of the pouch (diverticulectomy) with cricopharyngeal
myotomy to prevent recurrence.

19
15- male with snoring, apnea, arousal & hypersomnia by day.
Diagnosis Obstructive sleep apnea (OSA)
Symptoms -Snoring, apnea & arousal.
-Hypersomnia by day.
-Moring headache & loss of concentration.
-Nocturnal enuresis, HTN & impotence.
Signs -General: obesity, short neck & HTN may be present
-Local: nasal, nasopharyngeal, oropharyngeal & hypopharyngeal
exam. to detect the cause of airway obstruction.
Investigation -Cephalometric study.(endoscopic examination, CT, Plain X-ray lat
view of the H&N) at the same size of the patient
-Flexible nasopharyngoscopy.
-Rhinomanometry.
-Polysomnography.
Treatment #Medical:
-Reduction of body weight.
-Avoid alcohol & sedatives.
-Antidepressant (protriptyline).
-Nasovent to open the nasal valve.
-Tongue retaining device.
-CPAP (Continuous Positive Airway Pressure).
#Surgical: according to the site of obstruction.
-Adenotonsillectomy.
-Nasal surgery: as SMR, turbinectomy or ESS.
-Palatal surgery: UPPP (Uveopalatopharyngoplasty) or LAUP (laser
assisted uveopalatoplasty).
-Midline glossectomy: in macroglossia.
-Mandibular advancement: in micrognathia.
-Tracheostomy: in severe cases with no other options.

20
Esophagus
Dysphagia:
 Food only: stenosis (Plummer Vinson syndrome)
 Fluid only: Achalasia
 Both: obstruction (Cancer)
1. 3y old boy presented with difficult swallowing & drooling
Diagnosis Foreign body in Esophagus
o Dysphagia
o Increase salivation
C/P
o Regurgitation
o Difficult respiration
o Plain X-ray (ant-post &lat)
Investigations o Barium swallow
o Esophagoscopy
o Esophagoscopy
o Esophagostomy (external cervical or
Treatment
transthoracic): if impacted FB or
complicated
Complications:
 Esophagitis: ulceration, rupture -> pressure necrosis
 Stricture
 Perforation: (If sharp FB) -> mediastinitis, mediastinal emphysema, pneumothorax,
empyema
 Tracheo-esophageal fistula

2. 20y old female, 3y ago suffering from attacks of vomiting & discomfort during
swallowing especially to fluids.
Diagnosis Achalasia of the cardia
*intermittent course with periods of remission
 Dysphagia more to fluids
 Regurgitation of undigested food (bad odor, free of
C/P
acids )
 Cough & choking
 Loss of weight ( may be absent, or late )
 X-ray barium swallow
 Esophagoscopy to confirm Diagnosis, exclude
Carcinoma, dilate sphincter
Investigations

21
 *medical *surgical
- assurance -repeated dilatation
Treatment - amyl-nitrate before meals -Heller’s cardiomyotomy
to relax the sphincter -Cardioplasty
-sedatives -esophago-gastrostomy
Complications:
 Aspiration pneumonia
 Malignant change: rare

3. 50y old male, smoker, 3 weeks ago suffering from vomiting & difficulty of
swallowing first to solids then become for both fluids & solids.
4. 45y old female, 7y ago suffering from difficulty of swallowing more to solids, 2 w ago
unable to swallow fluids too.
3. Cancer esophagus
Diagnosis
4. Cancer esophagus on top of Plummer Vinson syndrome
 Rapidly progressive dysphagia first to solids then to
fluids
 Regurgitation of undigested food may be mixed with
blood
 Hematemesis
C/P  Marked loss of weight, Cancer cachexia
 Pain late, retrosternal indicate spread to mediastinal
 Hoarseness of voice: affection of recurrent laryngeal n
 If bilat affection of recurrent laryngeal n: Respiratory
obstruction
 +signs &Symptoms of metastasis
o Barium swallow
o Esophagoscopy: assessment & biopsy
Investigations
o CT: extend
o Bronchoscopy
*inoperable: palliative ttt
- palliative irradiation
* operable: - intubation with soutter tube for
-surgery: esophagectomy feeding
Treatment
-irradiation: external or -chemotherapy
intestinal -pain killers
-tracheostomy: if resp
obstruction

22
Signs of inoperability:
o Direct spread to outside esophagus: recurrent laryngeal paralysis, spread to
bronchial tree or vertebrae post
o Distant metastasis to liver, lung
Site:
Male: lower third of esophagus
Female: upper third of esophagus

Plummer Vinson Syndrome: it’s a precancerous condition

o Dysphagia of long duration more to solids
o Anemia (iron & vit B12)
o Glossitis: smooth tongue, loss of papilledema,
C/P fissuring of angle of the mouth
o Achlorhydria
o Splenomegaly
o Spoon shaped brittle nails
o CBC
Investigations o Gastric secretion: Achlorhydria
o Endoscopy: confirm & take biopsy
o Correction of anemia &Vit deficiency
Treatment o Repeated dilatation
o Follow up for development of malignancy
Complications:
o Post cricoid Carcinoma
o Red flags:
*rapid progression of dysphagia
*the appearance of new symptoms due to infiltration: (throat pain, referred
earache, hoarseness of voice, respiratory distress)
*lump in the neck (LN metastasis)

23
Larynx

NB **Larynx in children: Smaller, easily collapsed, loose submucosal areola tissue, &
cough reflex & muscle co-ordination aren't yet well developed, so For these reasons
obstruction occurs rapidly & laryngitis in children should be taken seriously & handled
promptly to avoid serious complications.
*Stridor: Difficult noisy respiration due partial airway obstruction at the level of vocal
folds or below
*Stertor/Snoring: is a low pitched noisy breathing due to partial obstruction above the
level of vocal folds
*Dyspnea: Chest , lung problems
1- Female came to the hospital with her newborn complain of difficulty in
feeding, & breathing and not cry although her look as if being crying.
Diagnosis Congenital web
 Mild: Asymptomatic
 Moderate: dyspnea, stridor, change of voice ( during
C/P
exertion)
 Sever: Same moderate but at rest up to cyanosis
Investigations  Direct laryngoscopy
According to case, if
 Mild: no surgery
 Severe stridor: tracheostomy
Treatment
 Thin web: Excision by laser microlaryngosurgery
 Thick web: laryngofissure + put a keel to prevent
adhesions
 Stridor: biphasic, but mainly inspiratory + change of voice up to aphonia

2. 2w after delivery, female patient with her infant presented with difficult breathing
especially during sleep although he is crying normally
Diagnosis Laryngomalacia
 Stridor since birth, usually mild, increases during
C/P sleep & improve laid in prone position
 Cyanosis rare, may be present if infection occurs
 DL: elongated omega shaped epiglottitis, narrow
Investigations
laryngeal inlet
 Reassurance, self-limiting & spontaneously cured by
age of 1.5 y
Treatment
 In sever conditions: laser microlaryngosurgery
 If distressed: hospitalization, closely observation
 Inspiratory stridor + no change of voice (normal cry)

24
  Tracheostomy rarely needed

3. 3 months after delivery, female patient came with her infant suffering from
recurrent attacks of difficult breathing especially after common cold.
Diagnosis Congenital subglottic stenosis (mild case)
*mild stenosis:
*Severe stenosis
-no stridor at birth
C/P -stridor & dyspnea since birth
-stridor app after URT
-no change of voice
infection
Investigations DL
*mild:
*sever
- lumen widen as child
Treatment -tracheostomy
grows
-definitive ttt: LTR or partial CTR
-no surgical ttt
-biphasic stridor (or inspiratory) + no change of voice
- tracheostomy usually needed
-LTR: laryngotracheal reconstruction
-CTR: Crico- tracheal resection

4. 4y child present with sudden difficult breathing & bloody cough

5. 4y child presented with persistent fever, bloody cough unresponsive to treatment.

4.Foreign body inhalation

Diagnosis
5.Complicated FB inhalation (inflammatory sequelae)
 May be Asymptomatic (like case 5)
 Initial: Sudden onset of choking, cough, severe gagging
& Cyanosis
 Latent stage: symptom less or may be complain of
occasional cough &mild expectoration, unilateral localized
C/P
wheezes
 Manifest stage:
*mechanical obstruction: lung collapse, emphysema
*inflammatory: cough, expectoration, FAHM, hemoptysis,
dyspnea &Cyanosis
 Plain X-ray: postero-ant & lat view: we can see FB or
it’s effect (collapse, emphysema )

Investigations  Bronchoscopy: to confirm & remove FB

25
  Ensure patent airway
 Bronchoscopy: If failed : open thoracic surgery &
Treatment bronchotomy
 Post-operative ttt: AB, bronchodilator, expectorants &
physiotherapy

6. A child presented with FAHM & difficult breathing

Diagnosis Acute nonspecific laryngitis in children
 FAHM
 Dyspnea: passes rapidly to stridor
C/P
 Croupy cough
 Husky voice, crying tone is changed
Investigations  Fiber optic laryngoscopy
 Emergency: ABC
 Hospitalization if severe
Treatment  IV fluids
 Antibiotics: penicillin
 Steroids: very important to decrease edema
 Organism: usually viral superadded by 2ry bacterial infection (strept,
pneumococci)
 Fever: 38°C-39°C

7. A child with FAHM + difficult breathing & swallowing+ drooling saliva

Diagnosis Acute epiglottitis
 Severe sore throat
 Severe odynophagia: drooling
 Marked FAHM : Rapidly rising of fever
Symptoms
 Rapidly progressive Dyspnea & biphasic stridor within few
hours
 Muffled voice
 Fever 40°C
Signs  Child sets in bed leaning forward
 Marked respiratory distress
 By tongue depressor: rising up marked swollen congested
Examination
epiglottitis (sun rise sign)
Investigations  Pain x-ray lat view neck  Thumb sign
 Emergency: ABC
nd
 IV antibiotics: 2 generation cephalosporins
Treatment
 Steroid
 IV fluids
 Direct examination of the larynx by flexible laryngoscope is better avoided in severe
 cases > vagal stimulation

26
  Organism: Hemophilus influenza (bacteria)

8. 2y-old child few days later has a mild attack of common cold now he presented with
thick viscid secretion, hoarse cry, difficult breathing.
Diagnosis Acute laryngo-tracheo-bronchitis
 Starts by mild attack of common cold
 Slowly progressive dyspnea & stridor few days
Symptoms
 Hoarse cry, Croupy cough
 Expectoration of thick viscid sputum
 Fever 38-39°C
Signs
 Biphasic stridor
 Indirect laryngoscopy or flexible Laryngoscopy: congested
Examination
edema to us mucosa
 Emergency: ABC
 broad spectrum AB
Treatment  Mucolytic & steam inhalation
 Steroids
 IV fluids
 Organism: viral infection (parainfluenza, Coxsackie, RSV) usually followed by 2ry
bacterial infection

9. 40y-old female, 7 y ago suffering from bilat nasal obstruction & broadening nose, &
few months ago suffering from change of voice, cough, & difficult breathing
Diagnosis Laryngoscleroma follow rhinoscleroma
o Hoarseness of voice
o Cough & expectoration
Symptoms
o Stridor
o +nasal symptoms
Indirect laryngoscopy:
o Bilat. Symmetrical subglottic granulations
Examination
o Crustations
o Later: fibrosis producing subglottic web
o Plain X-ray lat view neck
Investigations
o Direct laryngoscopy &biopsy
o Severe stridor: tracheostomy
o AB: rifampicin, septrin + ampicillin, quinolones
Treatment o Surgical:
*new by laser
*old: repeated dilatation , laryngofissure
 Organism: klebsiella rhinoscleromatis

27
 10.40y old male, smoker for 15y, few days ago notice change in his voice
Diagnosis Leukoplakia
 Change of voice, Hoarseness
 By examination: indirect laryngoscopy: white patches on vocal
C/P
folds
 & vocal folds are freely mobile
 Stop smoking
Treatment  Microlaryngosurgery: stripping of the vocal folds & biopsy
 Careful prolonged follow up

11.40y old male, suffering from discomfort in throat several months ago but he didn’t
care, now he developed a new symptoms, muffled thickened voice, difficult breathing,
swelling in the neck
Diagnosis  Laryngeal carcinoma (mostly supraglottic)
 Later:
 Early: if
 Stridor
 Glottic: hoarseness of
 Sub/supraglottic: change of
voice
voice
 Supraglottic:
 Late:
Asymptomatic or
Symptoms  Dysphagia
discomfort un throat
 Pain
followed by muffled
 Referred otalgia
thickened voice
 Foetor Oris
 Subglottic: dyspnea
 Cough
with exertion
 Loss of weight/appetite
 External:
 Broadening of thyroid cartilage
 Tenderness: perichondritis
 Fixed larynx: extra laryngeal spread
 Absent click: post cricoid association /perichondritis
Examination
 Neck:
 LN
 Indirect laryngoscopy:
 Site & extension
 Mobility of VF
 General:
 Radiology: CT scan
Investigations  Endoscopy DL: extension & biopsy (Confirmatory)
 Metastatic work up: chest x-ray, abdominal ultrasound, bine
scan

28
  Curative: You should know in cancer
 Surgical larynx The chemotherapy
 Radiotherapy is not effective alone
Treatment  Combination of radio &
chemotherapy
 Rehabilitation
 Palliative
-Treatment according to TNM calcification system:
Early: T1,2: single modality surgical or radiotherapy
Late: T3,4: Double modality surgical + radiotherapy or radio + chemotherapy

12.40y old female presented with sudden onset of difficult breathing after
thyroidectomy
Diagnosis Bilateral RLN paralysis
 Stridor(sudden: post operative, gradual: malignancy or
aneurysm)
C/P  Dyspnea
 Voice not bad
 No aspiration
 Indirect laryngoscopy:
Examination  Fixed VF in middle line/ paramedian
 Head & neck examination: LN &thyroid
 Radiology
 X-ray skull, Chest
 CT skull, Chest
Investigations  Thyroid scan
 Lab:
 Syphilis, TB,….
 DL, nasopharyngoscopy, Esophagoscopy, Bronchoscopy
 Tracheostomy with speaking valve
 Tt of cause
Treatment  Follow up for spontaneous recovery for 6-12
 Surgical ttt
 Voice therapy &rehabilitation

13.Unilateral Vocal cord paralysis:

C/P:
 Dysphonia
 No stridor
 Aspiration sometimes occur if complete paralysis

29
 14.Bilateral Vocal cord paralysis:

C/P
 Aphonia
 No stridor
 Aspiration pneumonia main problem

NB: MAPL: minimal associated pathological lesions

Nodules Female , chronic abuse of voice
*treatment: voice therapy
Polyp, cyst, contact granuloma Surgical microlaryngosurgery
Reinke's edema Smoker, abuse of voice teacher , tt: Surgical

30
Ear
*Most common organism:
Furuncle Staph aureus
Diffuse otitis externa Staph / may be pseudomonas aeruginosa
Malignant otitis externa Pseudomonas aeruginosa
ASOM Strept pneumonae, H.influenza
CSOM Pseudomonas aeruginosa & proteus
species

1-A child delayed language development & HL

Diagnosis congenital meatal atresia
symptoms Hearing loss, delayed speech
signs closed meatus +/- auricular, ME, IE deformity
investigation CT Temporal and ABR
treatment Hearing aid-bilateral and cosmetic surgery -unilateral

2- 18year old purulent right ear discharge recurrent, fluctuating swelling

Diagnosis Right furuncle of external auditory canal
symptoms Sever throbbing pain: Increase on moving the jaw during
mastication, scanty, purulent discharge
signs tenderness on moving auricle or pressure on tragus
-obliteration of the auricular sulcus
treatment Instruct the patient not to manipulate the furuncle
Avoid predisposing factors
Local: Glycerin- Icthiol or antibiotic- Corticosteriod pack
Systemic: Analgesics & anti staph antibiotics

3-A boxer auricular swelling, painful swelling

Diagnosis Auricular hematoma
Clinical Cystic swelling, red & tender
picture
investigation If child coagulation profile
treatment -surgery:
•early->blood still fluid: aspiration
•late->clotting: wide skin incision
-pressure bandage
Prophylactic antibiotic

31
 5-23 female left ear itching, HL, whitish mass in EXT canal, pain
Diagnosis Left ear otomycosis complicated by bacterial infection
symptoms Itching, HL , pain
signs Whitish mass ->candida, back spots->Aspergillus Niger
yellowish ->Aspergillus flavus
treatment -Removal of fungal mass: suction or dry mopping
-antifungal ear drops /cream: nystatin, 2%salicylic acid in alcohol,
clotrimazole
-ear plugs or vasline

6-21 male SNHL, ROTATION, INABILITY to whistle, multiple painful vesicles in EXT canal
Diagnosis Herps zoster Oticus Ramasy hunt syndrome
symptoms Pain, vesicles ext. canal &auricle
signs LMNL of facial, 8th cranial nerve lesion > SNHL & vertigo.
treatment Analgesics, antiviral
7-56 diabetic male left purulent discharge 6month, sever pain, loss of left side corrugation,
inability to close left eye
Diagnosis Left malignant otitis externa complicated by LMNL paralysis facial
symptoms Acute otitis externa not respond to treatment, sever pain ,HL,
Discharge
+ facial nerve paralysis
signs Granulation tissue in ext. canal, LMNL facial
investigation LAB C&S > PESUDOMENOUS, Blood &urine > diabetes
RADIO CT Temporal, Radioisotope gallium &Tc99
Audio Audiometry > CHL OR MIXED
Treatment Systemic quinolone &3rd generation cephalosporin ..weeks
Local topical AG or quinolone ear drops, debridement of necrotic
tissue
Control of diabetes

8-1year old child fever, ear ache, intact reddish bulging TM, 2days deviation of angle of mouth
toward RT side
Diagnosis acute otitis media complicated by left LMNL facial nerve
symptoms -High fever, +/-convulsion& rigor
-vomiting &diarrhea
-rubbing the affected ear
signs Loss of luster & disturbed cone of light
investigation Lab C&S
Radio x ray mastoid, CT scan
Audio CHL
32
treatment MEDICAL rest, antibiotics, anti-inflammatory, decongestant nasal
drops.
SURGICAL Myringotomy …impeding rupture, complication
LMNL, child, high perforation

9- a 6 month high fever, convulsion, ear ache, neck rigidity

Diagnosis Acute otitis media complicated by meningitis
symptoms Headache, projectile vomiting, blurring vision, convulsion, neck
rigidity.
signs Neurological Kernig’s sign, Brudzikski's sign, fundus, otoscopic
examination
investigation Lab C&S, lumber puncture
Radio CT Temporal, X ray mastoid
Audiogram
treatment Antibiotic 3rd generation cephalosporin, rifampicin, metronidazole
(cross blood brain barrier)
Lasix, mannitol (decrease ICT)
Treatment of AOM

10- 6 child pain in both ear after common cold, fever, stopped treatment but the child not
respond to her mother sound
Diagnosis Un resolved AOM complicated by otitis media with effusion
Symptoms Of AOM + HL, Tinnitus
signs -TM Intact, slightly congested, decrease mobility , retracted , fluid
level (hair line ), air bubbles
-CHL
Investigation Audio audiometry CHL, TYMPANOTOMETERY > TYPE B
FLAT

Treatment PROPHYLACTIC > treatment of AOM

Curative > antibiotics, mucolytics, steroids
Auto inflation Valsalva, chewing
Surgical if adenoids, myringotomy, grommete tube or T Tube

11- 5year fever, ear ache, 2days painful tender post auricle swelling, RT congested TM.
Diagnosis AOM COMPLICATED BY MASTOID ABCESS
Symptoms AOM>FAHM (more sever), sever throbbing pain, profuse offensive
discharge, hearing loss & tinnitus, swelling behind the ear or in front
of ear

33
Signs -high fever ,tenderness, redness & edema over mastoid tip &post
border
-preserved post auricular sulcus
-mucopurulent/purulent rapidly accumulates-->+ve reservoir sign
-CHL
•pathognomonic sign->Sagging: swelling the posterosuperior part of
the bony external auditory canal

Investigations Lab C&S

Radio X-ray mastoid, CT TEMPORAL
Audio CHL
Treatment Rest, ANTIBOITICS, analgesics, anti-inflammatory
Myringotomy, cortical mastoidectomy

12- 10y child suffering from Rt mucopurulent for 4yearr + dizziness, nausea, nystagmus, fever,
crying, headache ,neck retraction
Diagnosis Rt chronic supp OM Complicated by supp labyrinthitis then
meningitis
Symptoms HL, discharge, vertigo, SNHL, VOMITING, BLURRING OF
VISION, photophobia, restlessness, diplopia
Signs CSOM
Marginal perforation, polyp
Meningitis Kernig’s sign, Brudzikski's sign
Investigations Lumbar puncture, CT temporal, x-ray mastoid
Treatment ABS cross BBB, Analgesics ,repeated lumbar puncture,
dehydrating agent
Treatment of CSOM

13- a 9y old child with scanty offensive discharge, followed by headache, fever, vomiting,
difficulty going up and down, weakness in left arm, leg, comatosed
Diagnosis Rt cholesteatoma complicated by Rt temporal lobe abscess
Symptoms -of cholesteatoma: Hearing loss, offensive scanty otorrhea
-complication-temporal lobe abscess: Headache.
Signs Rt attic antral perforation, aphasia, uncinate fits, contra lateral
hemianopia
Investigations C&S abscess aspiration, CBC, X-ray mastoid, CT temporal,
Audiogram, fundus
Treatment ABS, abscess aspiration or excision, treatment of Cholesteatoma

34
 14- a 30 year old female, bilateral HL Following delivery, marked in quite place, negative
tuning fork
Diagnosis Bilateral otosclerosis
Symptoms HL, tinnitus, vertigo, paracusis wilicii
Signs Intact, mobile TM, +ve Schwartz sign
Investigations Audiometry> CHL
tympanometry> type As
Stapedius reflex
CT scan
Treatment Stapedectomy, hearing aid
Na fluoride therapy->SNHL
15- 20 year old male after car accident complained with inability to close his Rt eye, dribbling
of saliva, Rt hearing loss, clear fluid in Rt ear
Diagnosis Longitudinal fracture of temporal bone complicated by right lower
motor neuron facial paralysis, CSF otorrhea
CP -CHL
-CSF otorrhea
-perforation of TM
-Facial never paralysis-20%: usually partial & delayed
Investigations CT scan
schirmer's test, electroneurography
Audiogram
Treatment Facial nerve > care of eye, surgical exploration and repair if 90%
degeneration
CSF > semi setting position, avoid straining ,close observation of
patient
Treatment of hearing loss

16- 35 year old female SUDDEN ATTACK O bleeding from RT ear, pulsating tinnitus
…change of voice
Diagnosis RT ear glomus tumor complicated by vagus paralysis
Symptoms -pulsating tinnitus: the most frequent complain & the earliest
manifestation of glomus Tympanicum
-Jugular Foramen syndrome (lX,X,Xl)-->usually the earliest
manifestation of glomus jugular: Hoarseness of voice &
aspiration
-10% -secrete catecholamines
-HL & bleeding -perforate TM
Signs Reddish mass behind intact TM (pulsating, blanch on pneumatic
otoscope)
Bleeding polypoidal mass in EOC
Tuning fork early CHL then SNHL
35
Investigations SERUM catecholamines, urine VMA,
CT &MRI on both ear
Angiography (diagnostic)
Audiogram, Tympanogram
No biopsy -as sever bleeding may occur
Treatment -surgical excision after Embolization of feeding artery
-radiotherapy

17-40 year-old male tinnitus and progressive left HL ..SWAYING during walking ,change in
voice ,inability to close left eye ,deviation of angle of mouth
Diagnosis Left acoustic neuroma (neurological phase)
Clinical pic -paralysis of cranial nerves V,lX,X,Xl,Xll
-cerebellar manifestations
-SOL in post cranial fossa-> Headache, vomiting & blurring
vision
Investigations CT & MRI (most accurate & most diagnostic)
Audiometry, ABR, SPEECH DISCRIMINATION, ENG
Treatment Surgical excision

18-patient unable to open his eye & his mouth deviated to the opposite side.
Diagnosis Bell's palsy
C/P LMNL (symptoms & signs) of sudden onset, partial or complete.
-pain behind the ear (hours before paralysis).
-red chorda tympani (rare): seen through the drum

Investigations -Radiological: CT, MRI

-Audiological: PTA
-Leveling investigation: Schirmer’s test, taste sensation, stapedial
reflex.
-Electrophysiological tests: nerve excitability test (NET),
electroneurography (ENOG), electromyography (EMG).
Treatment -General: reassurance, care of the eye, care of facial muscle.
-Medical: steroids> decreased gradually.
-Surgical: decompression of facial nerve by deroofing of facial
canal.

36
9- patient suffers from acute onset of sever vertigo with nausea without hearing problems.
Diagnosis Vestibular neuritis
C/P Acute onset of vertigo associated with nausea & vomiting without
hearing problems.
The condition lasts few days to few weeks.
Treatment -Antivertigo drugs.
-Steroids.
-Vestibular exercise.

20- sudden onset of vertigo &nystagmus for few seconds.

Diagnosis Benign paroxysmal positional vertigo
C/P Sudden onset of vertigo & nystagmus for few seconds without
hearing problems.
+ve Dix-Hallpike test
Investigations
Treatment -Repositioning of the debris to the utricle by Epley maneuver.
-Obliteration of the post. SCC or singular nerve neurectomy.

21- 50y old patient with recurrent attacks of vertigo, deafness & tinnitus.
Diagnosis Meniere's disease (endolymphatic hydrops)
C/P -vertigo: lasts for few mins to few hours, the patient is normal in
between the attacks, associated with nausea, vomiting &
nystagmus.
-deafness: SNHL (low tone)
-tinnitus
Investigations #audiological: PTA, Glycerol test is +ve,
electrotrococheagraphy.
#vestibular: Caloric test

Treatment #medical ttt:

-during the attack: complete bed rest, antivertigo drugs,
antiemetics.
-in between the attacks: salt restriction, diuretics (frusemide),
vasodilator (betahistidine), streptomycin (medical
lanrynthectomy): in toxic doses (in bilateral sever SNHL).
#Surgical ttt:
-if hearing is bad > intratympanic injection of aminoglycoside or
surgical labyrinthectomy.
-if haering is good > endolymphatic sac decompression, if failed
> vestibular neurectomy.
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