ENT Collections ..

Final Edition
- All these collections are based on Dr. Mosaad’s Book & extra notes from Lectures & Sections
- These collection don’t cover the whole subjects
- in these collections we try to Put a whole subject in one page to make it easy for studying & memorizing
by finding the correlations and differences between them
- A lot of people help us to produce these collections & we are appreciate for everyone for that .. “ ”
- This summary is not official and may contain some wrongs ..
so, Please check it before adopt in the study .. & In case of wrongs, please let us know to correct it

がんばってね！ - Semoga Berjaya

 EAR Collections ..
01- ENT table(1) Ear1- External Auditory Canal
02- ENT table(2) Ear2- Physiology of Ear
03- ENT diag.(1) Ear3- Middle Ear Cavity
04- ENT table(3) Ear4- Diseases of the AURICLE
05- ENT table(4) Ear5- Otitis Externa (OE)
06- ENT diag.(2) Ear6- Quinolones in ttt of Malignant OE
07- ENT diag.(3) Ear7- Otitis Media scheme
08- ENT table(5) Ear8- Acute Otitis Media
09- ENT table(6) Ear9- Chronic Non-Suppurative O.M.
10- ENT diag.(4) Ear10- Chronic Non-Suppurative O.M.
11- ENT table(7) Ear11- Chronic Suppurative Otitis Media (C.O.S.M.)
12- ENT table(8) Ear12- Cranial Complications of Suppurative O.M.
13- ENT comp.(1) Ear13- Otosclerosis & Meniere’s Disease
14- ENT comp.(2) Ear14- Longitudinal & Transverse Fracture
15- ENT table(9) Ear15- Ear Operations
16- ENT diag.(5) Ear16- Ear Discharge
17- ENT diag.(6) Ear17- Tender Ear
18- ENT table(10) Ear18- Ear Cases scheme
19- ENT table(11) Ear19- Distinctive Term in Ear
 External Auditory Canal (E.A.C.) .. 24mm
Outer Cartilaginous ⅓
- continuous with the Cartilage of Auricle
- lined by: Thick Skin ..
- containing: Hair Follicles & Glands ‘Sebaceous & Ceruminous’
 Localized Otitis Externa (  )
- direction: UPwards, BACKwards, Medially
Medial Bony ⅔
- part of Temporal bone
- lined by: Thin Skin ..
NO Hair Follicles, Glands ‘Sebaceous & Ceruminous’ 01- ENT table(1) Ear1- External Auditory Canal
 Localized Otitis Externa (  )
- direction: DOWNwards, FORwards, Medially
* has 2 Constrictions:
- at the bony-cartilaginous junction
- 5 mm from drum (Isthmus)
* contain Tympanic Sulcus in its medial end
‘in ὠ Tympanic Annulus of the Drum is lodge’

Physiology of Ear
 Collection of sound
Auricle
External Ear  Localization of sound
External Auditory Canal (E.A.C.)  Conduction of sound
 Conduction of sound
‘drum  ossicles  oval window’
 Amplification of sound, about 20 times .. by 2 factors :
- area ratio ‘drum 17:1 oval window’ 02- ENT table(2) Ear2- Physiology of Ear
- lever action of ossicular chain
Meddle Ear Cavity
# Impedance Matching Mechanism : The Amplification of Sound
Middle Ear about 20 times in M.E. to compensates the Decreases in Sound
when it Transmitted to the Fluid of Inner Ear
# Phase Difference : Preventing  inner ear pressure
( when the oval window becomes In, the round window will be Out )
 Ventilation : equalization of the pressure in both side of the drum
Eustachian Tube
 Drainage of the middle ear secretion
Cochlear Part  Hearing : Concerned with Perception of sound
Inner Ear  Equilibrium : - Utricle & Saccule  Linear Acceleration
Vestibular Part - Semi-Circular Canals (SCC)  Angular Acceleration
  Roof :
- Temporal Lobe of Brain

- Tegmen Tympani

 Posterior Wall :  Anterior Wall :

Middle Ear Cavity - Canal of Tensor Tympani ms.
- Aditus Ad Antrum
- The Pyramid : contain Stapedius ms - Eustachian Tube
 Contains :
- Vertical Part of Facial Nerve - Carotid Canal
- AIR
- 3 Ossicles ] Malleus, Incus & Stapes [
- 2 Ms. ] Tensor Tympani  supplied by Trigeminal N. ‘5th N.’
& Stapedius  supplied by Facial N. ‘7th N.’[
- 2 N. ] Chorda Tympani ‘of 7th N.’ & Tympanic Plexus ‘of 9th N. [

 Lateral Wall :
 Floor :  Medial Wall :
- Plate of Bone - Transverse Part of Facial Nerve
Drum - Oval Window  closed by Foot of Stapes
Bone - Jugular Bulb - Promontory
* some times Dehiscent  High Jugular Bulb, - Sinus Tympani
Pulsatile Tinnitus - Round Window  closed by 2ry Tympanic membrane
- Process Cochleariformis

03- ENT diag.(1) Ear3- Middle Ear Cavity

 Diseases of the AURICLE
Congenital Traumatic Inflammatory Neoplastic
st nd
(the auricle develops from 6 Tubercles ‘from 1 & 2 Branchial Arches’)
N.B. Congenital Diseases may be Uni-lateral or Bi-lateral
2- Defect in
1- Defect in the Size 3- Accessory 4- Pre-Auricle
the Shape 1- Haematoma 2- Lacerations 3- Frost Bite Perichondritis Benign Malignant
Auricle Cyst & Fistula
Anotia Microtia Macrotia Bat Ear
No Small Large (Protruding Small Cartilage at the root of Collection of Blood Necrosis of Inflammation of the Perichondrium of  Skin :  Skin :
Auricle Auricle Auricle or Lop Ear) covered with Skin the helix, between Perichondrium part of auricle the Cartilage of auricle Papilloma - Squamous cell
Def. > 40° in the line of presented with & Cartilage due to Sever or Naevus carcinoma (SCC)
Tragus to Angle Cyst Swelling, Coldness
of Mouth Repeated Blunt Truma as Punch Sharp Trauma Sever 1- Infected Haematoma  Cartilage : - Basal-cell
Aetiology Infection & (Boxer’s Ear) Coldness 2- Infected Surgical Wound Chondroma carcinoma
Discharge 3- Furuncle ‘if squeezed’ (Rodent Ulcer)
Cystic Swelling (Painful Loss of Auricle : Swollen, Red, Hot & Tender
Clinical Picture but NOT Tender) Sensation
Necrosis & Infection of Necrosis of Cartilage, followed by Fibrosis
Cartilage   Cauliflower Ear
Complications Perichondritis &
Cauliflower Ear
Surgical - Antibiotics - Antibiotic : Local + Systemic
Plastic Surgery before school age if it’s Large - Aspirate & Evacuation - Analgesics
Treatment with Application of Tight - Incision & Drainage with Debridement
Bandage (removal of necrosis cartilage)

04- ENT table(3) Ear4- Diseases of the AURICLE

 Otitis Externa (OE) .. [ Inflammation of External Auditory Canal (EAC) ]

Viral OE Bacterial OE
Fungal OE
Malignant OE
Herpes Simplex OE Herpes Zoster OE Bollous Myringitis Localized OE (Furuncle) Diffuse OE
(Skull Base Osteomyelitis)
Staphylococcal infection of Hair Follicle ‘in the Diffuse Inflammation of Sever infection starts in the EAC &
Def. : Viral infection of EAC Fungal infection of EAC
Outer ⅓ of EAC’ EAC Spread to involve Skull Base
Causative
Staphylococcal infection Pseudomonas Aureginosa
Organism
Aetiology :

occur due to Spread of Aspergillus Niger - Diabetes - Scratch of EAC - Diabetes

Herpes Simplex Virus Varicella Zoster Virus “Low General Resistance” - Swimming in infected “Low General Resistance”
Infection .. after +
Predisposing (HSV) (VZV) swimming pool
Common Cold Candida Albicans
Factors : N.B. Frunculosis is Multiple & Recurrent in - Sweating if excessive
Diabetics - Seborrhea
- Sugar (Diabetic)
- Fever - characterized by Bullae - Itching in EAC - Pain ( on Mastication)
filled ὠ Serous Fluid & - Deafness ‘if EAC is - Discharge (Scanty & Purulent)
Symptoms :
Clinical Picture :

- characterized by - characterized by may be Blood in the Obstructed’ - Deafness ‘if EAC is Obstructed’ Deeply Seated Pain
Vesicles Painful Vesicles Outer Layer of Drum
discharge also Cheesy Malignant OE as Diffuse OE but .. pain  Sever & Prolonged
- Fungal Mass like a Wet - Tenderness (on pulling the auricle or pressure on the tragus)
News Paper (White Mass - Internal Swelling in EAC, ὠ is Reddish (in Outer ⅓)
Signs : & Black Spots) - External Swelling (Enlarged Pre- & Post-auricular Lymph Nodes)
Malignant OE as Diffuse OE with Granulations in the Floor of EAC
at the Bony-Cartilaginous Junctions
- Blood Sugar in recurrent cases - Blood Sugar for Diabetic - Culture & Sensitivity
‘if recurrent’ - Fasting Blood Sugar
- C.T. Scan
Investigation : - Culture & Sensitivity of - Gallium & Technetium Scan
Discharge ‘if resistant’ - Biopsy from the granulations 
to exclude Tumor
- Analgesics for pain - Local Cleaning of EAC : - General : Antibiotics + Analgesics - Hospitalization
- Antibiotics : Local & Suction or Ear Wash - Local : & Control of Diabetes
Systemic ‘to prevent 2ry - Antifungal Ear Drops as :  Local Cleaning of EAC (NEVER by Ear Wash)
infection’  Nystatin ear drops  Packing EAC with Cream containing Antibiotic + Steroid - Antibiotics : Systemic Quinolones,
 2% Salicylic Acid  10% Glycerin Icthyol ear drops (Glycerin is  8% Aluminium Acetate as Ciprofloxacin
Treatment : (Keratolytic) + Alcohol 70% Hygroscopic, while Icthyol is Counter Irritant) Packing (Astringent)
(Fungicidal) ear drops  Incision & Drainage - Ear Drops : Ciprofloxacin
- Packing of EAC W ‘if a localized abscess has formed’
Antifungal Cream on a - Surgical Debridement
Piece of Gauze ‘if resistant’ N.B. Avoid squeezing of a furuncle “lead to ‘sometimes needed’
N.B. Ramasy-Hunt Syndrome (RHS) : Perichondritis”
It’s a Herpes Zoster Oticus .. # Extension of Malignant OE : due to Osteomyelitis
characterized by : - Facial Palsy ‘compressed at Stylomastoid Foramen’
- Otalgia (pain) - Vesicles - Parotid Swelling
th
- Facial Paralysis (7 ) - SNHL & Vertigo - Lower 4 Cranial Nerves Palsy ‘compressed at Jugular Foramen’
th
(8 ) 9th N. Glossopharyngeal nerve, 10th N. Vagus nerve,
Treatment : Oral or I.V. 11th N. Accessory nerve, 12th N. Hypoglossal nerve
Quinolones - Trigeminal Facial Pain ‘if it extend to Petrous Apex’
- Analgesics for pain Perfusion to Both Bone & Soft Tissue
are good for ttt of Malignant OE
- Acyclovir : Local & Systemic Minimal Hepatotoxic & Nephrotoxic ‘good in long course’

05- ENT table(4) Ear5- Otitis Externa (OE) 06- ENT diag.(2) Ear6- Quinolones in ttt of Malignant OE
 Otitis Media (O.M.)

Acute O.M. Chronic O.M.

Non-Suppurative Suppurative
C.S.O.M.

in Adults in Children Secretory Otitis Media Adhesive Otitis Safe CSOM Unsafe CSOM
(S.O.M.) Media ( Tubo-tympanic ( Attico-antral
‘see 08- ENT table(5) Ear8’ (Glue Ear or Mucosal CSOM ) or Bony CSOM
or Middle Ear Effusion ) or Cholesteatoma )

‘see 09- ENT table(6) Ear9’ ‘see 11- ENT table(7) Ear11’

07- ENT diag.(3) Ear7- Otitis Media scheme

 Acute Otitis Media (A.O.M.)
A.O.M. in Adults A.O.M. in Infants & Children
Def. Acute Inflammation of Mucosal Lining of Middle Ear Cleft
Causative Organism 1- Streptococcus pneumoniae 2- Haemophilus influenzae 3- Moraxella catarrhalis
1- Eustachian Tube : 2- External Auditory Canal : 3- Blood Spread : rare  Predisposing Factors :
In case of Perforated Drum 1- Eustachian Tube  “Shorter, Wider &
* Extension of infection : More Horizontal in children”
- Nose : Rhinitis of Common Cold, Influenza & Exanthemata * the most common factor
Aetiology

- Sinuses : Sinusitis 2- Adenoid  ET Obstruction & Infection

- Nasopharynx : Adenoid 3- Respiratory Tract Infection (Common
Route of Infection Cold & Exanthemata)  more common in
* Passage of infected material : children
- Vomitus 4- Teething   Immunity
- Infected Milk 5- Regurgitation of Milk & Vomitus :
- Infected Water # Milk :
- Nasal Packing Artificial Fed baby is MORE liable than
3- Suppurative O.M. Breast Fed Liable to be
1- Tubal (ET) Catarrh 2- Catarrhal O.M. 4- Perforation 5- Recovery Contaminated
(ASOM)
Flat Position No Antibodies
Pathology Oedema & Congestion of E.T.  Oedema & Congestion of M.E. Accumulation of Pus in Necrosis of the drum  Healing of drum &
( Immunity)
Obstruction of E.T.  -ve Pressure in M.E. mucosa M.E. Perforation  Discharge Resolution of # Vomitus :
 Retraction of Drum pathological changes in Gastero-Enteritis, may pass through ET
- Deafness - Deafness - Deafness - Deafness Recovery may occur - Fever & Rigors ‘the heat regulating
- Tinnitus - Tinnitus - Tinnitus - Tinnitus at any stage if center is Not Fully Developed in infants’
Symptoms

- General - Pain - Pain ‘throbbing’ - Pain (less) adequate treatment - Vomiting & Diarrhea ‘may be
- Fever - Fever (less) is given Mis-diagnosed as Gastero-Enteritis’
- Discharge - The Child Cries & Doesn’t Sleep
Clinical Picture

- Pulling the ear

- Local
- Movement of the head from side to side
 Retracted Drum : Congested Drum ‘mainly at Bulging Drum  Discharge : Drum of children is Thick & Resist bulging,
- Prominent Lateral Process Periphery & The Handle’ Mucopurulent & Pulsating so the Only sign may be Absence of Cone
- Shortened Handel of Malleus Perforation : of Light or Congestion
- Otoscopy Antero-Inferior ‘near ET opening’
Signs

- Disturbed or Absent Cone of Light

- Exaggerated Anterior & Posterior  M.E .mucosa :
Malleolar Folds Congested & Oedematous
- Limited Mobility on Siegalization
- Tuning Fork Test CHL
 Systemic Antibiotic  Systemic Antibiotic
General
 Analgesic Antipyretics  Analgesic Antipyretics
 Decongestion Nasal Drops  Glycerin Phenol Warm Ear  Myringotomy  Myringotomy  Decongestion Nasal Drops as
as Xylometazoline Drops; Xylometazoline
Treatment

- Glycerin  Hygroscopic  Repeated Cleaning  Glycerin Phenol Warm Ear Drops

- Phenol  Local Anaesthetic by Suction or Dry Mopping  Myringotomy :
Local - Warm  ++ Vascularity N.B. NO Ear Wash may be needed early ‘if medical ttt Failed
‘according to the stage'
for 48 H.’ to avoid complication
 Local Antibiotic Ear Drops * it’s done in Postero-Inferior part of
drum (for Safety & Gravity), followed by
Suction & Antibiotic Ear Drops

08- ENT table(5) Ear8- Acute Otitis Media

 Chronic Non-Suppurative O.M.
Glue Ear or Middle Ear Effusion
Secretory O.M.
Adhesive O.M.
Serous Mucoid
Retraction of the drum, ὠ become in contact with the
Def. Accumulation of non-purulent effusion behind an intact drum
promontory (Atelectasis) with adhesion of M.E. Structure
Characters -ve Pressure in M.E.  Transudation of fluid from blood vs. Active Secretion by Mucosal Glands of M.E.
1- Eustachian Tube Obstruction : by Adenoid, Infection, Tumor or Otitic Barotrauma 1- Long Standing ET Obstruction
2- Acute Otitis Media : If Acute, Recurrent with Inadequate treatment 2- it may follow Secretory O.M.
3- Viral Infection 3- it may follow Healed C.S.O.M.
Aetiology 4- Cleft Palate (deficient Palatal ms.)
Old Male + Uni-lateral Secretory O.M.
5- Tumor in the Naso-pharynx : (old age, unilateral)
 should examine for Naso-Pharyngeal Carcinoma
6- Radiotherapy to H&N
7- Allergy of M.E. Mucosa
1- Deafness & Tinnitus : may be Uni-lateral or Bi-lateral (in Adenoid) Deafness & Tinnitus
* usually the child presented ὠ school retardation
Symptoms 2- Bubbling Sensation in the ear : usually in Adults
# NO PUS  NO PAIN
 Retracted Drum :
Clinical Picture

- Intact Drum, with Drum Color :

 Amber Yellow color (in Serous) Dull Gray color (in Mucoid) - Prominent Lateral Process
- Shortened Handel of Malleus
- Otoscopy
Signs

- there may be Fluid Level (Hair Line)
- there may be Bubbles
- Tuning Fork Test
- PTA  CHL
Investigations - Tympanometry  Type B (Flat Curve)
- X-ray lateral view Naso-pharynx for Adenoid
( For 3 Months .. after 3 Times of treatment .. then Surgical )
 Treatment of Cause: infection or adenoid
 Systemic Antibiotic  prevent recurrent infection
Medical  Steroids ‘withdrawal method’  anti-allergic
 Mucolytics  dissolve mucoid
Treatment
- Disturbed or Absent Cone of Light
- Exaggerated Anterior & Posterior Malleolar Folds
- Limited Mobility on Siegalization
CHL
- PTA  CHL
- Tympanometry  Type C
- Prophylactic : treat the cause
- Curative : Cartilage Tympanoplasty or Hearing Aid
Treatment According to Cause ..
- if Tumor in the Naso-pharynx  Radiotherapy
- if Cleft Palate  Surgical Repair

 Decongestant Nasal Drops  open ET - if Adenoid  Adenoidectomy

 Valsalva Maneuver & Chewing Gum  open ET
( if Medical treatment Failed )
Myringotomy & Insertion of Ventilation Tube
with Adenoidectomy if there is adenoid
Surgical - Incision: Antero-Superior part of the drum (as it’s the least migratory area  Delay tube extraction)
# Types of Ventilation Tube :
- Grommet’s Tubes : Temporary Tubes, as spontaneous extrusion occurs within 6 months
- T-tube : Permanent tube, preferred in Adults

09- ENT table(6) Ear9- Chronic Non-Suppurative O.M.

Retracted Drum
Chronic Non-Suppurative O.M.
No Perforation
No Discharge

10- ENT diag.(4) Ear10- Chronic Non-Suppurative O.M.

 Chronic Suppurative Otitis Media (C.O.S.M.)
[ Chronic inflammation of muco-periosteal lining of M.E. cleft characterized by perforation & discharge ‘persistent or intermittent’ ]
Un-Safe C.O.S.M.
(Attico-antral or Bony C.O.S.M. or Cholesteatoma)
Safe C.O.S.M.
Acquired Cholesteatoma
(Tubo-tympanic or Mucosal C.O.S.M.)
Congenital Cholesteatoma (Epidermoid) 2ry Acquired
1ry Acquired Cholesteatoma
Cholesteatoma
Sac of keratinized stratified Squamous epithelium (skin) called matrix filled ὠ keratinous material (± cholesterol)
Def. Chronic non-specific inflammation of the muco-periosteal lining of the M.E. cleft & it erodes the bone by osteolytic enzymes or 2ry ‘anaerobic’ infection
* Cholesteatoma : the name is Wrong as : - Cholest : Not necessarily contain cholesterol - Oma : Not a tumor
Characters - affects mucosa of M.E. cleft - Complications : Less - Erosion of bone - Complications : More
A.O.M.  C.S.O.M. .. due to : # Site : 1ry means Not preceded by O.M. 2ry means preceded by
1-  Treatment .. due to : - Petrous Apex * Retraction Pocket Theory : O.M.
- Infective antibiotics - Cerebello Pontian Angle (CPA) Prolonged ET Obstruction (2ry to safe C.S.O.M.)
- Short course of antibiotic - Middle Ear  -ve Pressure in M.E. * Metaplasia Theory :
- Inadequate drainage # Clinical Presented by :  Invagination of part of the drum Sq. Metaplasia of M.E.
Aetiology 2-  Virulence of organism - Trigeminal Facial Pain forming retraction pocket (the mucosa by chronic
3-  Resistance of patient if present in Petrous Apex weakest part is the Pars Flaccid ‘No irritation
- Facial Tics then Paralysis + SNHL + Vertigo fibrous layer’ or Postero-Superior * Migration Theory :
if present in CPA part of the drum) .. the pocket will Migration of the
- CHL if present in M.E. be filled with keratin forming epithelium of E.A.C. to
N.B. : the drum in Intact cholesteatoma M.E. through perforation
- Deafness + Tinnitus - Deafness + Tinnitus
Symptoms - Intermittent Discharge - Persistent Discharge
- Discharge Perfuse, Muco-purulent, Odorless Scanty, Purulent, Offensive & may contain epithelial debris
Central in Pars Tensa Marginal or Attic in Pars Flaccida
- Perforation
Clinical Picture

(there is rim of the drum all round the perforation & Not reach the annulus) (Not surrounded by rim of drum all round the perforation & reach the annulus)
May be either : May show Granulation or Polyp, ὠ are more frequent in unsafe C.O.S.M.
- Thin, Pale & Dry : if inactive
- Otoscopy
Signs

- M.E. Mucosa - Oedematous & Congested : if active infection

- Granulations : Sessile Reddish tissue, ὠ bleed on touch
- Polyp : Pedunculated, Oedematous mucosa passing through perforation
Retraction Pocket may be seen in Postero-Superior Part in early stages of cholesteatoma (during formation)
- Others
Cholesteatoma itself may be seen as Whitish Epithelial Mass
- Tuning Fork Test CHL CHL .. except if there is erosion of inner ear (labyrinthitis)  Mixed HL
- PTA  CHL - PTA  CHL or Mixed HL ‘if there is labyrinthitis’
- Culture & Sensitivity of discharge - Culture & Sensitivity of discharge # Sequalae of Cholesteatoma :
- X-ray Mastoid (Schüller View): shows - X-ray Mastoid (Schüller View): shows 1- Expansion :
 state of mastoid (aeration)  state of mastoid (aeration) due to repeated infection & formation of keratin
Investigations
 level of dura  level of dura 2- Bone Erosion : of
 position of sigmoid sinus  position of sigmoid sinus
- Mastoid .. lead to Natural Cavity
 Bone Erosion
- Ossicles .. lead to Hearing Loss
- C.T. : if complication were suspected
N.B. The Commonest Part to be eroded in C.O.S.M. is the
- General - Systemic Antibiotic (given according to culture & sensitivity )
Long Process of Incus ‘as it is Slender & Less Vascular’
Medical

- Local Antibiotic Ear Drops

- Local 3- Mastoid Sclerosis : it becomes less cellular
No
Treatment

- Aural Toilet by Suction or Dry Mopping

- Prevention of Re-infection
Surgical
- Avoid Wetting of the ear ‘keep it dry’ 4- Complications may occur
- Control any upper resp. infection as common cold
Tympanoplasty with or without Cortical mastoidectomy The Treatment is Surgical ONLY
 if there is discharge : Tympanoplasty + Cortical mastoidectomy The Classic Treatment is Radical Mastoidectomy
 if there is NO discharge(Dry ear) : Tympanoplasty ONLY either canal wall up (closed) Technique or Canal wall down (open) Tichnique

11- ENT table(7) Ear11- Chronic Suppurative Otitis Media

(C.O.S.M.)
 Cranial Complications of Suppurative O.M.
Acute Mastoiditis Labyrinthitis Petrositis Facial Paralysis .. due to OM
Acute Inflammation of Mastoid Antrum & Air Cells with Destruction of Inflammation of the Air Cells in the
Def. their Bony Partitions (Septa)
Inflammation of Inner Ear (Bony & Membranous Labyrinth)
Petrous Apex ‘present in 30%’
Facial Paralysis due to O.M. (LMNL)

 Destruction of Bony Partitions between Mastoid Air Cells  Large 1- Localized Labyrinthitis = Circumscribed Localized Labyrinthitis :  Predisposing Factor :  Aetiology :
Cavity Filled with Pus Cholesteatoma  Bone Erosion  Fistula Complications to O.M. in Diabetic  ASOM with Dehiscent Facial Bony Canal
 Extension of infection under the Peri-osteum : * the commonest site for fistula is Lat. SCC patient  CSOM with Cholesteatoma eroding the
1- Post-auricular (Mastoid) Abscess : Lateral extension from Antrum 2- Diffuse Labyrinthitis : Facial Canal
Pathology

2- Sagging of Postero-superior Meatal Wall : Anterior extension  Serous Labyrinthitis :

[ Diagnostic Sign ] Serous Fluid in inner ear (No Pus)
3- Zygomatic Abscess : Lateral extension from Zygomatic Air Cells  Suppurative Labyrinthitis :
4- Bezold’s Abscess : Inferior extension along the Sternomastoid ms. Pus in inner ear  Destruction of Neuro-epithelium  Permanent SNHL
sheath
5- Citteli’s Abscess : Inferior extension along the Digastric ms. sheath N.B. Suppurative Labyrinthitis may lead to Meningitis by Spread through
 Rupture of Peri-osteum & Fistula Formation Internal Auditory Canal .. indicated by Fever, Headache & Neck Rigidity
 Symptoms : - Deafness + Tinnitus + Discharge + - Deafness + Tinnitus + Discharge +

- Facial Pain (5th n. affection) “also called Trigeminal Facial Pain”

 General : Fever, Headache, Malaise & Anorexia 1- Localized Labyrinthitis : L.M.N. Facial Paralysis
 Local : - it may be Asymptomatic ‘if small’ Acute onset  ASOM
- Deafness + Tinnitus + Discharge - Intermittent Vertigo withOUT Nausea or Vomiting & Gradual onset  CSOM (Partial or
- Pain : Post-auricular ‘become Throbbing on abscess formation’ - Nystagmus ‘Rapid Phase Towards the Diseases Ear’ (irritative) Complete)
- Swelling : in abscess formation - Positive Fistula Sign : Vertigo + Nystagmus .. on
 Sign :  Pressure on the tragus   EAC Pressure by Siegalization
 General :  Temp. (Fever) &  Pulse (Tachycardia)  Manipulation of Aural Polyp
 Local : N.B. the test may be –ve even in the presence of a fistula (False –ve test) .. if :
Clinical Picture

 Ear Examination : by Otoscopy  the fistula is Closed by Cholesteatoma  the fistula is Very Small
- Discharge : Profuse & Recollect Rapidly after suction  Inadequate Sealing of EAC during Siegalization  Dead Ear

- Diplopia & Squint (6th n. affection)

(it’s called Reservoir Sign) [ Diagnostic Sign ] 2- Diffuse Labyrinthitis :
Diagnosis

- Sagging of Postero-superior Meatal Wall [Diagnostic Sign ]  Serous Labyrinthitis :

- Perforated Drum ‘may be Intact & Congested in infants’ - Continuous Vertigo with Nausea or Vomiting
 Mastoid Examination : - Nystagmus ‘Rapid Phase Towards the Diseases Ear’ (irritative)

 Gradenigo’s Triad :
- Swelling : either - Reversible SNHL
* Post-auricular  Pushing the auricle Downwards & Forwards  Suppurative Labyrinthitis :
As Serous Labyrinthitis  but

* Zygomatic  Above & in Front of auricle at root of Zygomatic process
* Bezold’s  in Upper Lateral part of the neck ‘rare’
* Citteli’s  in Sub-mandibular Region ‘rare’
- Tenderness : over the Antrum (marked by Cymba Concha), Tip of
Mastoid & Posterior Border (as these are the Most Superficial Air Cells)
- PTA  CHL
Invest.
- Discharging Ear
- More Sever
- Nystagmus Towards the Normal Ear (Paralytic)
- Irreversible SNHL
N.B. Differentiate between Serous & Suppurative Labyrinthitis  Retrograde
If SNHL improved with treatment  Serous .. if NOT  Suppurative
- PTA  Mixed HL (CHL + SNHL) in diffuse labyrinthitis

- Culture & Sensitivity of discharge

- X-ray Mastoid  Clouding (Opacity) of Mastoid Air Cells - Tests to detect the level of paralysis
- Ct  to Detect the Mastoiditis & to Exclude other complications & to Detect the Petrositis
- Hospitalization + & Control of Diabetes
Medical

- Systemic Antibiotics ‘according to culture & sensitivity ’ - Systemic Antibiotics ‘those Cross BBB’ : Chloramphenicol or Cefuruxim - Systemic Antibiotics ‘according to - Steroid  Anti-Oedematous to
- Analgesic Antipyretic - Sedative : Diazepam culture & sensitivity ’ Decompress the nerve
- Frequent Suction of Discharge & Local Antibiotic Ear Drops - Anti-vertigo Drugs : Dramamine
Treatment

- Anti-emetics as Chlorpromazine
- Cortical Mastoidectomy : - Radical Mastoidectomy .. with - Radical Mastoidectomy & - in AOM  Myringotomy
if medical treatment Failed ‘for 48 Hs.’ .. or  in Fistula : Removal of Cholesteatoma & Covering the fistula with Drainage of Infected Air Cells - in Cholesteatoma Radical
Surgery

if there is Abscess .. or Temporalis Fascia Graft Mastoidectomy

if Associated with other complications  in Suppurative Labyrinthitis : Labyrinthectomy
* also Myringotomy is needed in Children
N.B. Serous Labyrinthitis  improved with Medical treatment

12- ENT table(8) Ear12- Cranial Complications of Suppurative

O.M.
 Otosclerosis Meniere’s Disease
Hereditary localized disease of the Oticus Capsule characterized by Replacement of normal Distension of the membranous labyrinth with endolymph, characterized by recurrent attack of Vertigo, Deafness & Tinnitus
Def. compact bone by spongy bone (Otospongiosis) of increased cellularity, vascularity & thickness
Site of disease Middle Ear Inner Ear
1- Stapedial Type : around footplate of the stapes  Fixation (Ankylosis) of footplate & CHL
Types 2- Cochlear Type : (rare) in the cochlea  SNHL & Vertigo
3- Mixed Type : Both
Unknown Unknown
but may be Hereditary or Hormonal but may be : Autoimmune, Viral infection, Allergy, Salt & Water Retention & Sympathetic Overtone (Autonomic)
Causes & it’s due to :   excessive formation of endolymph ‘by stria vascularis’
  lack of its drainage ‘by endolymphatic sac’
more common in Females more common in Males
Incidence usually Bi-lateral disease usually Uni-lateral disease
in Middle Age around age of 50
 Deafness  Vertigo “lasts few minutes to few hours” .. 30 min.-5 hours
- usually bi-lateral - in between the attacks, the patient is Normal
Clinical Picture

Symptoms - associated with Paracusis Willicii Phenomenon (Hearing is Better in Noisy Places) - associated with Nausea, Vomiting & Nystagmus
 Tinnitus  Deafness
 Vertigo “rare” .. in Cochlear & Mixed Otosclerosis  Tinnitus
- Otoscopy : Normal Drum .. but “rare the drum may be  Flamingo-red in color - Otoscopy : Normal Drum
[Schwartz's sign]
Signs - Tuning Fork Test : - Stapedial type  CHL - Tuning Fork Test : SNHL .. associated with Hypersensitivity to load sound (+ve Recruitment)
- Cochlear type  SNHL
- Both  Mixed Hearing Loss MHL
- PTA : CHL, SNHL, Mixed HL - PTA : fluctuant SNHL, low tone
- Electro-Cochleography : Audiological
- Tympanometry : As Curve - Glycerol Test : +ve ,, hearing will be Better after intake of glycerol “Diuretics”
Investigations - Caloric Test, Rotational Test or Electric Test :
- Acoustic (Stapedial) Reflex : No response Vestibular
Hypofunction ‘because some of cells were degenerated by difference of Pressure in meniere’s ear

- CT Scan : to exclude tumor & may show narrow vestibular aqueduct Radiological

 The Main Line of ttt

Sodium Fluoride (Toxic, Expensive & Life Long)  during the attack :  In between attacks :
.. used if :  Complete Bed Rest  Psychological Reassurance
- the operation is Contra-indicated  Sedatives as Diazepam  Salt & Water Restriction
- SNHL (Cochlear type)  Anti-emetics as Chlorpromazine  Diuretics as Frusemide (Lasix)
Medical  Anti-histamine
- +ve Schwartz type ( Vascularity)
Treatment

 Vasodilator as Betahistadine
*Hearing Aid : in Sever SNHL  Anti-vertigo drugs as Dramamine
 Streptomycin in Toxic Doses as Medical Labyrinthectomy in Bi-lateral Sever SNHL
N.B. there is NO treatment if there is Air-Bone Gap less than 20 dB
Stapedectomy is the ttt of Choice if medical ttt Failure
(Removal of Stapes & Replacement with Teflon Piston or Wire & Fat) - if Hearing is Bad  Surgical Labyrinthectomy
Surgical - if Hearing is Good  Endolymphatic Sac Decompression
“if Failed”  Vestibular Neuroectomy
“if Failed”  Intratympanic Gentamicin

13- ENT comp.(1) Ear13- Otosclerosis & Meniere’s Disease

 Fracture Base of the Skull (Temporal Bone)
Longitudinal Fracture Transverse Fracture
More Common 80% Less Common 20%
Incidence Less Dangerous More Dangerous
Site of the trauma Side of the head Back of the head
Aetiology

Passing Perpendicular to the Longitudinal Axis of

Fracture Line Passing Along the Longitudinal Axis of Petrous bone
Petrous bone
Laceration of Roof of E.A.C. Inner Ear
Structures Affected Rupture of the Drum Facial Canal “Paralysis”
Dislocation of Ossicles
Rare 20% Common 50%
Partial & Delayed Complete & Immediate
- Facial Paralysis
Clinical Picture

due to : due to :
Compression of the nerve by Oedema or Haematoma Injury (Cut) of the nerve
- Otoscopy Rupture of the drum & Laceration of the E.A.C. Reddish or Bluish Drum  Heamo-Tympanum
CHL SNHL
- Tuning Fork Test due to : Rupture of the Drum & Dislocation of Ossicles due to : Injury of the Inner Ear
- Hemo-tympanum :
- Others - Laceration  Bleeding per ear
Bleeding in Middle Ear with Intact Drum
- CT  to detect Fracture (Bone)
Investigations - MRI  to exclude Brain Injury (Soft Tissue)
- Hospitalization under Complete Aseptic Condition
- Systemic Antibiotics : those cross BBB to prevent infection
- Steroids : to  Brain Oedema
Treatment - Surgical Management :  of Brain Injury .. by Neuro-surgeon Never Give Ear Drops
 of Ruptured Drum .. by Myringo-plasty
 of Dislocated Ossicles .. by Ossiculo-plasty
 of Facial Nerve Injury

14- ENT comp.(2) Ear14- Longitudinal & Transverse Fracture

 Ear Operations
Myringotomy Cortical Mastoidectomy Radical Mastoidectomy Tympanoplasty Stapedectomy
Removal of All Mastoid Air Cells & All
Middle Ear Contents Except the Stapes Eradication of Middle Ear Disease Removal of the Stapes
Def. Incision of the drum Removal of All Mastoid Air Cells
Mastoid & Middle Ear  Single Large & Reconstruction of Conductive Hearing Mechanism Superstructure & Replace it
Cavity
1- ASOM  for Drainage 1- Acute Mastoiditis .. if there is : 1- Cholesteatoma ‘if extensive’ 1- CSOM ‘Safe Type’ Stapedial Otosclerosis
If there is : - Failed medical treatment for 48 Hs. 2- Cholesteatoma with Complications 2- Congenital Middle Ear Anomalies causing CHL with Air-Bone Gap
- Bulging drum + Failure of Medical ttt - Associated with other Complications 3- Tumour of Middle Ear : Carcinoma – 3- Traumatic Rupture of drum  Myringoplasty than 20 dB
- Small or High up perforation - Mastoid Abscess ‘any type’ Glomus 4- Traumatic Dislocation of the Ossicle  Ossiculoplasty
- Failure of medical treatment after 48 Hs. 4- T.B. Otitis Media
Indications ‘especially in Children’ 2- Part of another operation : N.B. Cortical Mastoidectomy should be Combined
- Complications as Facial paralysis or Mastoiditis - Radical Mastoidectomy with Tympanoplasty if there is Ear Discharge
2- Otitis Barotrauma  for Drainage - Tympanoplasty
3- Secretory Otitis Media with Insertion of Ventilation (CSOM Safe)
Tube  for Ventilation
After Failure of medical treatment
Children  General
Anaesth. Adults  Local or General
General General General or Local General or Local

in ASOM  Postero-inferior quadrant Post-auricular

Incision in SOM  Antero-superior quadrant * take care in children
Post-auricular Post-auricular End-aural or Per-meatal
 Advantages in ASOM : - Removal of Mastoid Cortex, then Opening of - Cortical Mastoidectomy - Eradication : Removal of Polyps & Granulation Tissue - Removal of the Stapes
- to Relief Pain the Antrum (through Mc Ewen’s triangle - Removal of All Middle Ear Contents .. - Reconstruction : of Superstructure (Head +
Technique

- surgical incision Heals Better than pathological “Suprameatal triangle”) & Removal of Mastoid Except the Stapes  Drum  Myringoplasty : Cruara)
perforation air cells - Removal of the posterior Wall of External The graft may be : - Partial Removal or Making a
Procedure

Canal (bony part) by : 1- Temporalis Fascia Hole in the Footplate

N.B. Mc Ewen’s triangle : is surgical landmark  Removal of the Bridge 2- Perichondrium ‘from Tragus’ - Restoration of Conductive
for Mastoid Antrum ‘upper part of post. wall’  Ossicles  Ossiculoplasty : Hearing Mech. by the use of
 Superior : Supra-meatal Crest  Lowering of the Facial Ridge The graft may be : Teflon Piston or Fat and Wire
 Anterior : Postero-superior meatal wall ‘lower part of post. wall’ 1- Cartilage ‘from Tragus or Septum’
 Posterior : Tangential line to posterior meatal - Obliteration of ET 2- Bone ‘from Mastoid or patient own ossicles’
wall - Meatoplasty : Widening of the External 3- Prosthesis : either Total Ossicular Replacement Prosthesis
Auditory Meatus (cartilaginous part) (TORP) or Partial Ossicular Replacement Prosthesis (PORP)
1- Injury to : 1- Injury to : 1- Injury to : 1- SNHL + Vertigo ‘due to
- Incudo-Stapedial Joint - Dura of Middle Cranial Fossa - Dura of Middle Cranial Fossa Perilymph Fistula’
- High Jugular Bulb - Sigmoid Sinus - Sigmoid Sinus 2- CHL : due to Slipping of
- Facial Nerve - Facial Nerve prosthesis
Complications 2- Persistent Perforation - Lateral Semicircular Canal - Lateral Semicircular Canal 3- Injury to :
3- TympanoSclerosis 2- Persistent Mastoid Fistula - Chorda Tympani
2- Persistent Mastoid Fistula 3- Mastoid Cavity Problems : as Persistent - Dehiscent Facial Nerve
Discharge & Wax Accumulation
4- Recurrent Cholesteatoma

N.B. Modified Radical Mastoidectomy (attico-antrostomy) :  Contraindications of Stapedectomy :

The same as radical but with Removal of Unhealthy tissue & Preservation of Healthy tissue (ossicles or part of drum) 1- Children .. ‘Otosclerosis is active’
N.B. there are 2 lines of treatment for cholesteatoma : 2- SNHL
1- Canal Wall Up (Closed) Technique : 3- Schwartz Sign +ve
 Def. : Combined Approach Tympanoplasty 4- Old Age
Remove cholesteatoma from Middle Ear though EAC & from Antrum ‘through Cortical Mastoidectomy’ .. and may open Facial Canal 5- Only Hearing Ear .. (Hearing Aids is preferred)
 Advantages : Preservation of Posterior Meatal Wall of EAC 6- Meniere’s Disease
 Disadvantages : High incidence of residual or recurrent cholesteatoma .. So, 2nd look operation is usually carried out after 6 months 7- Medical Contraindications (however Local Anaesthesia may be used)
2- Canal Wall Down (Open) Technique : 8- Pregnancy : Pregnancy Hormones Activate Otosclerosis
 Def. : Removal of Cholesteatoma through Antrum & ME with Removal of Posterior Meatal Wall (All or Part of it) to Facilitate
Eradication of the disease
 Advantages : Low Incidence of recurrent or residual cholesteatoma
 Disadvantages : No Preservation of Posterior Meatal Wall  Difficult Reconstruction of Hearing
 Types :  Atticotomy : in Localized Attic Cholesteatoma 15- ENT table(9) Ear15- Ear Operations
 Modified Radical Mastoidectomy : in Localized Attico-antral Cholesteatoma [Atico-Antrostomy]
 Radical Mastoidectomy : in Extensive Cholesteatoma or if there is Complicated CSOM
 Ear Discharge :

Otitis Externa [Localized, Diffuse & Malignant]

Purulent & Scanty Discharge  Localized OE (Furuncle) : Scanty, Purulent & Cheesy
Unsafe CSOM (Cholesteatoma)

Acute Otitis Media ‘in Perforation’

Muco-Purulent Discharge  Diffuse OE : Scanty & Purulent
Safe CSOM

Safe CSOM
Profuse Discharge  Malignant OE (Skull Base Osteomyelitis) : Scanty & Purulent
Acute Mastoiditis “Reservoir Sign”

Acute Otitis Media ‘in Perforation’

Pulsating Discharge  Acute Otitis Media (A.O.M.) ‘in Perforation’ : Mucopurulent & Pulsating
Extra-dural Abscess
Acute Exacerbation of CSOM
 Safe C.O.S.M. (Tubo-tympanic or Mucosal C.O.S.M.) : [Intermittent] Profuse, Muco-purulent & Odorless
Intermittent Discharge Safe CSOM

Persistent Discharge Unsafe CSOM (Cholesteatoma)

 Un-Safe C.O.S.M. (Attico-antral or Bony C.O.S.M. or Cholesteatoma) : [Persistent] Scanty, Purulent & Offensive may contain epithelial debris
Odourless Discharge Safe CSOM

Offensive Discharge Unsafe CSOM (Cholesteatoma)  Acute Mastoiditis : Profuse & Recollect Rapidly after suction

may contain Epithelial Debris Unsafe CSOM (Cholesteatoma)

 Extra-dural Abscess : Pulsating Discharge
Recollect Rapidly after suction Acute Mastoiditis “Reservoir Sign”

Cheesy Discharge Localized O.E. (Furuncle)

 Glomus Tumour : Pulsating Tinnitus
Perilymph Fistula
Watery Discharge Fracture Base of Skull ‘Longitudinal’
Tumours

F.B. in E.A.C. (Injurious)

Rupture of the Drum
Fracture Base of Skull
‘Longitudinal’
Bloody Discharge Bullous Myringitis
Perichondritis of the Cartilage of Auricle
C.S.O.M. with Granulation Localized O.E.(Furuncle)
Glomus Tumour
Tender Ear .. occurs in Diffuse O.E.
Sq. Cell Carcinoma
Malignant O.E. (Skull Base Osteo-myelitis)

Acute Mastoiditis

17- ENT diag.(6) Ear17- Tender Ear

16- ENT diag.(5) Ear16- Ear Discharge

  Ear Cases scheme :
Congenital
- Meatal Atresia [Deafness, Closed Meatus]
- Congenital Cholesteatoma [Facial Paralysis + SNHL + Vertigo if present in CPA] .. [Trigeminal Facial Pain if present in Petrous Apex] .. [CHL if present in M.E.] ..
 Intact Drum  Discharge : Persistent, Scanty, Purulent, Offensive & may contain epithelial debris
- Congenital Stapedial Fixation [CHL, Normal Drum, As Curve in Tympanometry]
- Alport’s Syndrome [SNHL + Nephritis] - Pendred’s Syndrome [SNHL + Goiter]
- Usher’s Syndrome [SNHL + Retinitis Pigmentosa] - Cleft Palate  Secretory O.M. [Nasal Regurgitation, Rhinolalia Operta]
Children
- F.B. [History of FB insertion, Uni-lateral CHL]
- Adenoid  Secretory O.M. [Snoring, Mouth Breathing]
- Acute Otitis Media [Fever, Night Crying & No Sleep, Vomiting & Diarrhea] .. may due to Common Cold or Adenoid
Adults
CHL
- F.B. [History of FB insertion, Uni-lateral CHL, Mentally Retarded]
- Localized OE (Furuncle) [Diabetes, Pain ( on Mastication), Tenderness (on pulling the auricle or pressure on the tragus), External Swelling (Enlarged Pre- & Post-auricular Lymph Nodes), Discharge Scanty, Purulent & Cheesy]
- Diffuse OE [Diabetes, Scratch, Swimming, Pain ( on Mastication), Tenderness (on pulling the auricle or pressure on the tragus), External Swelling (Enlarged Pre- & Post-auricular Lymph Nodes), Discharge Scanty & Purulent]
- Malignant OE [Diabetes, Deeply Seated Pain, Granulations in the Floor of EAC at the Bony-Cartilaginous Junctions, Facial Palsy, Parotid Swelling, Chocking, Hoarseness, Shoulder Drop, Tongue Paralysis, Discharge Scanty & Purulent]
- Fungal OE [Swimming, Itching, Deafness, Fungal Mass like a Wet News Paper]
- Acute Otitis Media (A.O.M.) [Notice on the Drum to detect the stage]
- Stapedial Otosclerosis [Normal Drum, ♀ Middle Age, usually Bi-lateral, As Curve in Tympanometry, Hearing is Better in Noisy Places]
- Glomus Tumour [Pulsatile Tinnitus, Facial Palsy, Chocking, Hoarseness, Shoulder Drop, Tongue Paralysis, Sun Rising Appearance ὠ Blanch on Siegalization]
- Osteogenesis Imperfecta [Blue Sclera, Multiple Fracture]
- Traumatic Rupture of the Drum [History of Trauma, Central Perforation in Drum, Whistling Sound on Blowing of the Nose]
- Longitudinal Fracture of Temporal Bone[History of Falling from Height, Rupture of the Drum, Bleeding]
- Otitic Barotrauma [Flying, Sensation of Air Fullness]
SNHL
- Acoustic Neuroma [Uni-lateral SNHL, Facial Palsy, Chocking, Hoarseness, Shoulder Drop, Tongue Paralysis, Loss of Corneal Reflex]
N.B. Differentiate between Serous & Suppurative Labyrinthitis  Retrograde .. If SNHL improved with treatment  Serous .. if NOT  Suppurative
- Meniere’s Disease [♂around age of 50, usually Uni-lateral, Vertigo “lasts few minutes to few hours” .. 30 min.-5 hours]
- Cochlear Otosclerosis [Normal Drum, ♀ Middle Age, usually Bi-lateral, As Curve in Tympanometry, Hearing is Better in Noisy Places]
Vertigo
- Benign Paroxysmal Positional Vertigo (BPPV) [Sudden Onset, Short Duration, occurs when the patient takes Certain Positions]
C.S.O.M. “Prolonged Period of Discharge” ± Complication
Safe C.O.S.M. (Tubo-tympanic or Mucosal C.O.S.M.)  Discharge: Intermittent, Perfuse, Muco-purulent, Odorless, Central Perforation .. On top of Acute
Un-Safe C.O.S.M. (Attico-antral or Bony C.O.S.M. or Cholesteatoma)  Discharge: Persistent, Scanty, Purulent, Offensive & may contain epithelial debris, Marginal Perforation
- Acute Mastoiditis [Post-auricular (Mastoid) Abscess, Sagging of Postero-superior Meatal Wall, Swelling around Mastoid area, Post-auricular Pain, Discharge : Profuse & Recollect Rapidly after suction]
- Labyrinthitis [Deafness + Tinnitus + Discharge +
Intermittent Vertigo + irritative Nystagmus + Positive Fistula Sign  Localized Labyrinthitis (Labyrinthine Fistula)
Continuous Vertigo with Nausea or Vomiting + irritative Nystagmus + Reversible SNHL  Serous Labyrinthitis
Continuous Vertigo with Nausea or Vomiting + Paralytic Nystagmus + Irreversible SNHL  Suppurative Labyrinthitis]
N.B. Suppurative Labyrinthitis may lead to Meningitis by Spread through Internal Auditory Canal .. indicated by Fever, Headache & Neck Rigidity
- Meningitis [Neck Rigidity, Fever, +ve Kernig’s Sign, +ve Brudzinski’s Sign]
- Lateral Sinus Thrombophlebitis [Intermittent Fever, Pallor, Tender Cord like structure along the side of the neck, Oedema & Tenderness over the Posterior Border of Mastoid Process, Proptosis, Ophthalmoplegia, Oedema of the Eye Lids]
- Petrositis [Diabetes, Ear Discharge, Diplopia & Squint, Facial Pain]
- Extra-dural Abscess [Pulsating Ear Discharge]
- Temporal Abscess [Aphasia, Contra-lateral Hemiplegia, Contra-lateral Hemianopia, Contra-lateral Hemianaesthesia]
- Cerebellar Abscess [Ataxia ’Staggered Gait - +ve Rombergism’, Muscle Inco-ordination, Nystagmus, Staccato Speech]
- Sq. Cell Carcinoma of M.E. [Long Standing CSON with Change of the characters; Pain - Bleeding - Facial Palsy -  Hearing Loss, Smoking, Reddish Mass ὠ Bleeds on Touch, CT is Recommended]

18- ENT table(10) Ear18- Ear Cases scheme

 Distinctive Term in Ear :

 Fallopian Canal : Bony Canal in the Temporal Bone for Facial Nerve
 Organ of Corti : Sensory Organ of Cochlea .. for Hearing
 Macula : Sensory Organ of Utricle & Saccule .. for Linear Equilibrium
 Crista Ampullaris : Sensory Organ of Semi-Circular Canals (SCC) .. for Linear Equilibrium
 Impedance Matching Mechanism : The Amplification of Sound about 20 times in M.E. to compensates the Decreases in Sound when it Transmitted to the Fluid of Inner Ear
 Phase Difference : when the oval window becomes In, the round window will be Out  Preventing  inner ear pressure
 Bat Ear : Protruding or Lop Ear > 40° degree
 Boxer’s Ear : = Haematoma in the Auricle
 Swimmer’s Ear : = Fungal O.E. : Otomycosis
 Wet News Paper : in Fungal O.E. : Otomycosis
 Exostosis : Osteoma of E.A.C. .. More Common in Divers
 Necrotizing O.M. : Occurs in Exanthemata leading to Total Necrosis of the drum
 Bezold’s Abscess : Inferior extension of Mastoiditis Abscess along the Sternomastoid ms. sheath
 Citteli’s Abscess : Inferior extension Mastoiditis Abscess along the Digastric ms. sheath
 Reservoir Sign : Diagnostic Sign for Acute Mastoiditis in ὠ Discharge Recollect Rapidly after suction
 Sagging of Postero-superior Meatal Wall : Diagnostic Sign for Acute Mastoiditis due to Anterior extension
 Positive Fistula Sign : for Labyrinthitis N.B. the test may be –ve even in the presence of a fistula (False –ve test) .. if :
Vertigo + Nystagmus .. on  Pressure on the tragus  the fistula is Closed by Cholesteatoma  the fistula is Very Small
  EAC Pressure by Siegalization  Inadequate Sealing of EAC during Siegalization  Dead Ear
 Manipulation of Aural Polyp
 Griesenger’s Sign : for Lateral Sinus Thrombophlebitis .. It’s Oedema & Tenderness over the Posterior Border of Mastoid Process (Extension to Mastoid Emissary Vein)
 Positive Tobey-Ayer’s Test : for Lateral Sinus Thrombophlebitis
Lumbar Puncture Needle Connected to Pressure Manometer, then Pressure on IJV of Diseased Side (Thrombosed)  No Elevation of CSF Pressure .. while Pressure on IJV of Normal Side 
Elevation of CSF Pressure
 Kernig’s Sign : for Meningitis
The patient is asked to Lie in Supine Position with Hip & Knee Flexed   do Extension
 Brudzinski’s Sign : for Meningitis .. Flexion of the Neck will be Accompanied with Reflex Flexion of Hip & Knee
 Paracusis Willicii Phenomenon : [Hearing is Better in Noisy Places] .. occurs in Otosclerosis
 Schwartz Sign : for Otosclerosis in Active Stage
the Drum may be Flamingo-red in color
 Osteogenesis Imperfecta : CHL, Blue Sclera & Multiple Fracture
 Glycerol Test : for Meniere’s Disease .. Glycerol is Diuretic  Hearing will be Better after intake of glycerol
 Hemotympanum : in Otitic Barotrauma .. Bleeding inside the Middle Ear
 Brown’s Sign : for Glomus Tumour .. Sun Riding Appearance ὠ Blanch on Siegalization
 Gamma Knife : for Acoustic Neuroma .. Stereotactic Radiosurgery in Small Tumour
 NeuroPraxia : Just Compression of the Nerve (Reversible Conduction Block) .. Weakness Not Paralysis
 AxonoTemesis : Interruption of the Axon with Still Intact Endo-Neurium
 NeuroTemesis : Interruption of the Axon & Endo-Neurium
 Guillain–Barré syndrome (GBS) : Ascending Poly-Neuritis .. leads to Facial Nerve Paralysis
 Melkersson–Rosenthal syndrome : is a rare neurological disorder characterized by 4 F : Facio-Labial Oedema, Fissured Tongue, Facial Palsy (Recurrent) & Familial
 Commonest Site to be Injured : 2nd Genu .. when Facial n. turns downwards above the Oval Window
 BPPV : = Benign Paroxysmal Positional Vertigo .. Vertigo of Sudden Onset & Short Duration about 30 sec. when the patient takes Certain Position .. No Cochlear Affection
 Vestibular Neuritis : Acute Onset of Vertigo due to Functional Failure of the Vestibular Nerve .. No Cochlear Affection
 Acoustic (Stapedial) Reflex : Stimulation of Hearing by High Sound  Contraction of Stapedius & Stiffness of the Drum .. ὠ is measured
 Alport’s Syndrome : SNHL + Nephritis
 Usher’s Syndrome : SNHL + Retinitis Pigmentosa (RP)
 Pendred’s Syndrome : SNHL + Goiter
 Mondini’s Disease : The Cochlea is Single Turn
 Moro’s Reflex : The Child Respond to Loud Sound by Jerky Movement of the Body .. for assessment of Hearing in Children

19- ENT table(11) Ear19- Distinctive Term in Ear

 NOSE Collections
..
20- ENT table(12) Nose1- Para-nasal Sinuses & Opens in .. & Lymphatic Drainage
21- ENT diag.(7) Nose2- Inflammations of the Nose scheme
22- ENT table(13) Nose3- Inflammations of the Nose; In Skin of Vestibule
23- ENT table(14) Nose4- Inflammations of the Nose; In Mucosa; Acute Rhinitis
24- ENT table(15) Nose5- Inflammations of the Nose; In Mucosa; Chronic Rhinitis
25- ENT table(16) Nose6- Inflammations of the Nose; In Mucosa; Chronic Rhinitis; Fungal Infection
26- ENT table(17) Nose7- Septal Diseases of the Nasal Septum
27- ENT table(18) Nose8- Acute Sinusitis & Chronic Sinusitis
28- ENT comp.(3) Nose9- Clinical Picture of Acute Sinusitis
29- ENT diag.(8) Nose10- Uni-lateral Offensive Nasal Discharge
30- ENT table(19) Nose11- Distinctive Term in Nose
 Para-nasal Sinuses Opens in .. Lymphatic Drainage

Sphenoid Sinus Spheno-Ethmoidal Recess

Posterior Group Retro-pharyngeal LNs
Posterior Ethmoidal Sinus Superior Meatus

Frontal Sinus Anterior Part Upper Deep Cervical LNs

Anterior Group Anterior Ethmoidal Sinus Middle Part Middle Meatus Sub-mandibular LNs

Maxillary Sinus Posterior Part

20- ENT table(12) Nose1- Para-nasal Sinuses & Opens in .. & Lymphatic Drainage
 Inflammations of the Nose

in Skin of Vestibule In Mucosa

Furunculosis Vestibulitis Acute Rhinitis Chronic Rhinitis

[Localized] [Diffuse]
Specific Non-Specific Specific Non-Specific
‘see 22- ENT table(13) Nose3’ (Granuloma)

Diphtheria Common Influenza Exanthemata Scleroma Lupus Syphilis Leprosy Fungal Atrophic Hypertrophic
Cold Infection Rhinitis Rhinitis

‘see 23- ENT table(14) Nose4’

Mycetoma Indolent Form Allergic Fungal Sinusitis Mucor-mycosis (Invasive)

‘see 24- ENT table(15) Nose5’

21- ENT diag.(7) Nose2- Inflammations of the Nose scheme

 Inflammatory Diseases of the Nose
In Skin of Vestibule :
Furunculosis [Localized] Vestibulitis [Diffuse]
Def. : Staphylococcal infection of Hair Follicles ‘in the Vestibule’ Diffuse Inflammation of the skin of vestibule
 Scratch  Secondary to Nasal Discharge of Common Cold
Causes :  Diabetes
- Symptoms :  Diffuse Redness & Excoriation of the skin on
 Pain & Swelling of Nose nostril
Clinical Picture :  Purulent Discharge ‘if Ruptured’
- Signs :
Red, Hot, Tender Nodule in the vestibule
 Septal Abscess
 Cavernous Sinus Thrombosis
Complications :
N.B. Avoid Squeezing of Furuncle, to Avoid Cavernous Sinus Thrombosis
(Dangerous ▲)
- General : Systemic Antibiotic + Analgesics
Medical
Treatment - Local : Antibiotic Cream
Surgical Incision & Drainage if there’s Pus 

22- ENT table(13) Nose3- Inflammations of the Nose; In Skin of Vestibule

 Inflammatory Diseases of the Nose
In Mucosa :
Acute Rhinitis
Specific
Nasal Diphtheria
- usually 2ry to Faucial (Pharyngeal ) diphtheria
- it causes Uni-lateral Pseudomembrane  Uni-lateral Nasal Obstruction & Serosanguinous (Serous + Blood) Discharge
Non-Specific
Common Cold (Coryza)
- caused by Rhinoviruses ‘more than 100 types’
- Mode of Transmission : Droplet Infection
- Incubation Period : 1-3 days
- Predisposing Factors :  Over- Crowdedness
 Low Immunity
 Exposure to Temperature Changes
1- Stage of Vasoconstrictor :  General : Bony Aches
 Local : Dryness, Burning Sensation in the nose & Sneezing
2- Stage of Vasodilatation :  General : Fever, Headache & Malaise
Clinical Picture :

 Local : - Bi-lateral Nasal Obstruction 23- ENT table(14) Nose4- Inflammations of the Nose; In Mucosa; Acute Rhinitis
Symptoms : - Bi-lateral Watery Nasal Discharge
3- Stage of 2ry Bacterial Infection :  General :  Fever, Headache, Malaise & Anorexia
 Local : - Bi-lateral Nasal Obstruction
- Bi-lateral Mucopurulent Nasal Discharge
4- Stage of Recovery : in about 3 days “withOUT 2ry infection”
Signs Congested Nasal Mucosa ὠ Watery or Mucopurulent Discharge ‘if there is 2ry infection’
- Infection of surrounding structure :
Complications : as Sinusitis, Otitis Media, Pharyngitis, Laryngitis, Bronchitis & Pneumonia
- Anosmia, ὠ may be Permanent [Viral Peripheral Neuritis]
- Avoid Predisposing Factors
Prophylaxis :
- Vaccination is of NO value
Treatment :

- Complete Bed Rest & Plenty of Warm Fluids

- Antibiotics  Prevent 2ry infections
Curative : - Analgesic & Antipyretics
- Anti-histaminic
- Vitamin C  Support the Cilia
Influenza
similar to common cold  .. except :
- caused by Influenza Virus ‘type A, B & C’
- Clinical Picture : More Sever
- Complications : More Common
- Vaccination : can be done
Rhinitis of Exanthemata
as Influenza  ( but with Skin Rash ) .. as Measles
 Inflammatory Diseases of the Nose
In Mucosa :
Chronic Rhinitis
Specific Non-Specific
 Granuloma of Nose : +
Fungal Infection Chronic Hypertrophic Rhinitis Chronic Atrophic Rhinitis
Chronic Specific Inflammation characterized by Formation of Macrophage & Giant Cells
‘see 25- ENT table(16) Nose6’
Rhinoscleroma Chronic non-specific rhinitis with
Chronic non-specific rhinitis with Atrophy of Nasal
- The Commonest Granuloma in Egypt - Endemic in certain areas as Sharkia govern rate in Egypt Def. : Hypertrophy of Nasal Mucosa especially
Mucosa (&it’s Contents) & it’s Bony Turbinates
- Mode of Transmission : of the turbinates “inf. turb.”
- caused by Klebsiella rhinoscleromatis
- More Common in Females ♀ (starts 15-25 Years) Unknown ‘slightly infective .. needs Long Time of Contact’  Repeated Acute Rhinitis (Common  1ry : [Bi-lateral & More in Females ♀.. of
a. Atrophic Stage : b. Active Nodular ( Hypertrophic) Stage : c. Fibrotic Stage : Cold) Unknown cause] .. may be due to
 Persistence of the predisposing  Deficiency of Iron & Vit. A
as Atrophic Rhinitis  [Diagnostic Stage]characterized by Formation of Fibrous Tissue Formation
Pathology

factors as Smoking or Pollution  Autoimmune Disease

Atrophy of Mucous
Membrane, Blood Vs., Nerves,
Glands & Bony Turbinate
as Atrophic Rhinitis 
Clinical
Picture
Inflammatory Cells especially : (Collagen Bundle & Fibroblasts)  Allergic Rhinitis  Hormonal (Oestrogen)
 Russell Bodies : Degenerated Bright Red Plasma Cells  Autonomic Imbalance (Symp. Over Activity)
 Mikulicz Cells : Large Vacuolated Foamy Cells Causes :
 Bacillus ozaenae infection
‘Macrophage engulfing organism’  2ry : [Destruction of Nasal Mucosa] .. due to
 Symptoms : - Internal Fibrosis  Bi-lateral Nasal  Granuloma
- Bi-lateral Nasal Obstruction Obstruction  Operations as Turbinectomy ‘if Total’

- Bi-lateral Crusty Nasal Discharge - External Fibrosis  Deformity  Irradiations

 Signs : Bi-lateral Nasal Masses ..  Deviated Septum ‘in Wider Side’
mainly at Muco-Cutaneous Junction - Bi-lateral Nasal Obstruction - Loss of Sensation of Air Passage  Atrophy of
 Biopsy  Mikulicz Cells & Russell Bodies in Active Stage - Bi-lateral Mucoid Nasal Discharge Nerve Endings ‘subjective or obstructive’  Nasal
Invest.

Symptoms :
 Culture : after mincing of the tissue (Ant- & Post-nasal Discharge) Obstruction ‘even with the roomy nose’
 Electron Microscopic Examination - Nasal Discharge : Crusty, Greenish Black &

Clinical Picture :
1- Extension : 2- Fibrosis 3- Malignant Transformation : if treated by Radiotherapy Offensive (but NOT perceived by patient )
- Anosmia
Complicat.

- Subcutaneous  Ulceration + Fibrosis

- Lacrimal Sac  Dacryo Scleroma - Epistaxis on removal of crusts
- Pharynx  Pharyngo-scleroma Hypertrophied Inferior Turbinate, Dose - Atrophy Dry Nasal Mucosa
- Larynx  Laryngo-scleroma ‘subglottic area’ NOT Shrink with Local Vasoconstrictor - Atrophic Turbinates

Signs :
- Rifampicin : 600 mg/day [#Side Effects : Hepatotoxic & Red Discoloration of Urine] - Roomy Nasal Cavity
Treatment

Medical : - Streptomycin : 1 gm/day for 40 days [#Side Effects : Ototoxic & Nephrotoxic] - Crustations ὠ is Greenish Black, Offensive with
- Alkaline Nasal Douche  Dissolve Crusts Bleeding on removal
Removal of the masses ‘better by Laser’ 1: Treatment of the cause
Surgical :
N.B. Radiotherapy .. NOT used nowadays as it is CARCINOGENIC & the condition is Benign Steroid Nasal Spray  Alkaline Nasal Douche  Dissolve Crusts
 Menthol Paraffin Oil (Nasal Drops)   Offensive
Lupus Syphilis Leprosy
Odour (Foetor)
- caused by attenuated T.B. bacilli - caused by Treponema pallidum - caused by Mycobacterium leprae

- Site : Anterior Part of Nasal Septum
(Cartilaginous Part)
at Muco-Cutaneous Junction
Medical :
 25% Glucose in glycerin (Nasal Pack)  
- Types : - Site : Anterior Part of Nasal Septum Proteolytic Organisms
 Acquired :  Primary (Chancre) : ‘rare’ Nodule  Potassium Iodide (Systemic)  Stimulates Gland
 Secondary (Mucous Patches) : Rhinitis Secretion

- causing Apple-Jelly Nodule ..
ὠ Ulcerate  Perforation in
Cartilaginous Septum
- Treatment : 1- Anti-tuberculous :
Rifampicin
 3- Surgical Correction of Deformity
 Tertiary : Gumma
 Congenital :  Early : as 2ry syphilis
 Late : as 3ry syphilis
 Gumma :- Site : Posterior Bony Septum (it’s a disease of
Bl. Vs. .. as Bone is Vascular while Cartilage is Avascular)
 causing Perforation in this part  Saddle Nose
 it may cause Perforation of Hard Palate
- Treatment : 1- Anti-syphilitic :
Penicillin
2- Alkaline Nasal Douche
24- ENT table(15) Nose5- Inflammations of the Nose; In Mucosa; Chronic Rhinitis
Treatment :
[Reduction of Inferior Turbinate] by
either ..
 Sub Mucous Diathermy
Surgical :  Partial Turbinectomy
 Laser Turbinectomy
- Treatment : 1- Anti-lepromatous :
Dapson -Rifampicin
 3- Atrophy of the Nasal Glands  Diminished Nasal Secretions  Formation of Crusts
 Oestrogen (Local)  Stimulates Gland Secretion
 Mucolytics  Iron & Vit. A  Antibiotic
[Narrowing of Nasal Cavity till the Mucosa
Regeneration]
 Sub-mucosal Augmentation by Bone or Cartilage
 Young’s Operation: Closure of one side if the nose
for 1 year then open it & operate on the other
 Pathology of Chronic Atrophic Rhinitis :
1- End-arteritis or Per-arteritis of the Nasal Terminal Arterioles  Ischemia
2- Atrophy of the Nasal Epith. with Destruction of Cilia  Stasis of Nasal Secretions
4- Atrophy of the Nerve  Anosmia & Dullness of the Sensation of the Air
5- Atrophy of the Bony Turbinates  Wide (ROOMY) Nasal Cavity
6- Proteolytic Organism as Klebsiella ozaenae  2ry Infection
 Putrefaction of the Crusts  Production of the Foul Odour .. Called OZAENE
 Fungal Infection
Occur in patient with Low Immunity as Diabetics
1- Mycetoma 3- Allergic Fungal Sinusitis 4- Mucor-mycosis (Invasive)
Mass within the sinus ‘localized’ - caused by Aspergillus - it’s Fatal Disease, occur with Uncontrolled Diabetes
2- Indolent Form - Characterized by : - Sites :
Bone Expansion – Calcification – Greenish Discharge  Nose  Bloody Blackish Discharge
Affect Mucosa
- causes Polyps ‘usually Uni-lateral’  Orbit  Proptosis, Ophthalmoplegia, Chemosis & Diminution of vision
 Cerebral  Nerve Palsies
- Treatment : 1- Anti-allergic : Cortisone - Treatment : 1- Hospitalization & Control of Diabetes
2- Anti-fungal : Fluconazole 2- Anti-fungal : Amphotericin-B ‘Hepatotoxic & Nephrotoxic’
3- Surgical Removal of polyps by ESS 3- Surgical Debridement

25- ENT table(16) Nose6- Inflammations of the Nose; In Mucosa; Chronic Rhinitis; Fungal Infection
 Septal Diseases of the Nasal Septum
Deviated Septum Septal Haematoma Septal Abscess Septal Perforation
The Septum is rarely in Mid-line .. Collection of Blood between Muco- Collection of Pus between Muco-
Def. : it may be Deviated to Rt to Lt or to Both Sides Perichondrium & Cartilage of Septum Perichondrium & Cartilage of Septum
1- Developmental Usually Traumatic - Infected Haematoma 1- Traumatic :
2- Traumatic - Surgical : after SMR or Septo-plasty - Infected Surgical Wound - Surgical :
- Accidental : associated with Fracture Nose - Furuncle  after SMR or Septo-plasty ‘More in SMR’
 Pathology :  Cauterization if done Bi-laterally in the Same Line
 Simple Deviation : - Accidental :
obstruction of One Side  C-Shaped  Nasal Picking  Localized Perichondritis
obstruction of Both Side  S-Shaped  Penetrating Injury
 Deviation with Spur : 2- Inflammatory :
Causes : Sharp Angulations at Bony-Cartilaginous Junction - Acute  Septal Abscess
 Deviation with Dislocation : - Chronic :
Displacement of Septum from Columella  Lupus  Cartilaginous (Anterior)
 Leprosy  Cartilaginous (Anterior)
 Syphilis  Bony (Posterior)
3- Neoplastic : Malignant Tumour
4- Toxic :
Cocaine Addiction  Ischemia ‘Sever VasoConst.’
1- Asymptomatic .. in Mild Cases - History of Trauma  General : - it may be Asymptomatic
2- Nasal Obstruction [ Commonest Symptom ] - Bi-lateral Nasal Obstruction Headache, Malaise & Anorexia - Epistaxis & Crusty Discharge
- Uni-lateral in C-Shaped - Whistling Sound during respiration
Symptoms :

- Bi-lateral in S-Shaped  Local :

3- Nasal Discharge ‘Ant. & Post-nasal’ .. - Pain become Throbbing on abscess
Clinical Picture :

due to contact of medial wall (septum) & lateral wall or sinusitis formation
4- Epistaxis : due to Angulations of Blood Vessels [Spur] - Bi-lateral Nasal Obstruction
5- Headache .. due to : - Purulent Nasal Discharge .. after Rupture
- Sinusitis of the abscess
- Contact between medial & lateral wall
- Vacuum Headache (Obstruction of sinus opening)
- Anterior Rhinoscopy : - Anterior Rhinoscopy : - Anterior Rhinoscopy :
the septum will be seen Bi-lateral Fluctuant Swelling on Both Sides of Bi-lateral Fluctuant Tender Swelling on
Signs :

Septum Both Sides of Septum

- Nasal Endoscopy :
Sometimes, Posterior Deviation will be seen - Aspiration  Blood - Aspiration  Pus
1- Obstruction of sinus opening  Recurrent (Chronic) Sinusitis Septal Abscess .. with its Complications  1- Cavernous Sinus Thrombosis
2- Obstruction of Eustachian Tube  Recurrent (Chronic) Otitis Media 2- Necrosis of Septal Cartilage 
Complications : 3- Mouth Breathing  Recurrent Pharyngitis Perforation of Septum & Supratip
4- 2ry Atrophic Rhinitis Depression “Deformity”
or Compensatory Hypertrophy of Turbinates in Wider Side
Investigation : X-ray & CT .. to show associated sinusitis
Surgical Correction .. by either 1- Systemic Antibiotic  Prevent 2ry Infection - Medical :
 Sub-Mucous Resection (SMR) : after the age of 18 Years 2- Incision & Evacuation : Vertical Incision on One Side & Horizontal on Other .. to Avoid  Repeated Alkaline Nasal Douche
 Septo-plasty : at Any age Septal Perforation  Closure of the perforation by Obturator
3- Anterior Nasal Pack  Prevent Re-collection (Button Like)
Treatment : - Surgical :
 Closure of the perforation by Temporalis Graft or
Mucosal Flap from the surrounding area
(Poor Bl. Supply  No good results)

26- ENT table(17) Nose7- Septal Diseases of the Nasal Septum

 Acute Sinusitis Chronic Sinusitis
Acute Inflammation of the Mucosal lining f the Sinuses .. usually associated with Rhinitis  so, it’s called Rhino-sinusitis Chronic Inflammation of the Muco-Periosteal lining f the Sinuses .. with Irreversible Pathological Changes
Def.
* one or more of the sinuses may be affected
1- Streptococcus pneumoniae 2- Haemophilus influenzae 3- Moraxella catarrhalis Acute Sinusitis  Chronic Sinusitis .. due to :
C.O.
N.B. Sinusitis of Dental Origin  Anaerobic Infection  Offensive Discharge 1-  Treatment .. due to :
* General  Low Resistance & Overcrowdness - Infective antibiotics
P.F.
* Local  Deviated Septum & Allergic Rhinitis & Adenoid (Obstruction of Sinus Ostium) - Short course of antibiotic
1- Nasal : “Most Common” * Passage of infected material : * Extension of infection : - Inadequate drainage
Aetiology

Route of Infection

- FB in nose Starts by Viral Infection 2-  Virulence of organism

- Nasal Packing (Rhinitis) as common cold .. 3-  Resistance of patient
- Naso-gasteric Tube then 2ry Bacterial Infection 4- Gastro-Esophageal Reflux Disease (GERD)
2- Dental : - Infected Water
Dental Caries or Oro-antral Fistula  Maxillary Sinusitis
3- External :
Fracture Maxilla reaching to the sinus ‘rare’
1- Catarrhal Sinusitis : Congestion & Oedema of Mucosa  Obstruction of Sinus Drainage (Viral) .. Serous Fluid Oedema & Congestion of Mucosa  Loss of Cilia with Sub-mucosal Pathological Changes either Atrophic or
Pathology 2- Suppurative Sinusitis : Accumulation of Pus within the sinuses (Bacterial) Hypertrophic
N.B. the region of OMC is key area of Sinuses .. if Obstructed  Infection of Ant. Group of Sinuses
[History of Common Cold] is usually present - History of Recurrent Acute Attack
 General : Fever, Headache, Malaise & Anorexia .. * Fever is more in Children & if there is Complications - Nasal Obstruction (Uni-lateral or Bi-lateral)
Symptoms

 Local : - Mucopurulent Nasal Discharge (Uni-lateral or Bi-lateral) .. Ant. & Post-Nasal

- Nasal Obstruction (Uni-lateral or Bi-lateral) - Facial Pain & Headache : - its site Over the Affected Sinus
- Mucopurulent Nasal Discharge (Uni-lateral or Bi-lateral) .. Ant. & Post-Nasal - Increased by Coughing, Straining & Leaning Forwards
Clinical Picture

- Facial Pain & Headache : - its site Over the Affected Sinus - More Sever in the Morning
- Increased by Coughing, Straining & Leaning Forwards - Symptoms of Septic Focus
- More Sever in the Morning - Symptoms of Descending Infection
 General : High Temperature & Rapid Pulse “as any acute inflammation” - Palpation : Tenderness on Deep Pressure over the affected sinus
 Local : - Anterior Rhinoscopy & Nasal Endoscopy : - Congestion & Oedema of Nasal Mucosa
- Inspection : Oedema & Redness (Occur Only with Complications) - Mucopurulent Discharge .. in the Opening of affected sinus
Signs

- Palpation : Tenderness over the affected sinus N.B. Nasal Polypi may be seen in Chronic Ethmoidal Sinusitis
- Anterior Rhinoscopy & Nasal Endoscopy : - Congestion & Oedema of Nasal Mucosa - Posterior Rhinoscopy : Post-Nasal Mucopurulent Discharge
- Mucopurulent Discharge .. in the Opening of affected sinus
- Posterior Rhinoscopy : Post-Nasal Mucopurulent Discharge N.B. Nasal Endoscopy .. is Important to Detect the cause of chronicity
- X-ray (Sinus View) : show Opacity or Fluid Level As Acute Sinusitis
- Culture & Sensitivity of Discharge but CT is Mandatory as a Pre-Operative investigation
Investig. - CT ‘in recurrent cases’ .. to detect the predisposing factors to detect any anatomical abnormality such as Low Cribriform Plate, Dehiscent Carotid or Optic Nerve
N.B. Trans-illumination (Not used nowadays) : shows opacity of affected frontal or maxillary sinuses
 General :  Local : - Systemic Antibiotics
Medical

- Complete Bed Rest with Plenty of Warm Fluids - Decongestant Nasal Drops as Xylometazoline - Analgesic
- Systemic Antibiotics - Steam Inhalation - Mucolytics
- Analgesic – Antipyretics - Warm Fomentations over the affected sinus - Decongestant Nasal Drops as Xylometazoline (but don’t use it for Long Time  Rhinitis Medicamentosa)
- Mucolytics - Treatment of the Predisposing Factors
* Indications :
- Failure of Medical Treatment
Treatment

- Complicated Sinusitis
Nowadays FESS (Functional Endoscopic Sinus Surgery) : Is the standard Surgical Treatment for Recurrent Sinusitis .. in which the Diseased Mucosa is Removed while the Healthy Mucosa is Preserved with Restoration of Sinus Opening
Surgical

# Old Procedures : [All these procedures became Obsolete & were Replaced by FESS] # Old Procedures : [All these procedures became Obsolete & were Replaced by FESS]
- Maxillary Sinusitis  Antral Puncture and Lavage - Maxillary Sinusitis  - Repeated Antral Puncture and Lavage
- Frontal Sinusitis  Trephine Operation ‘through the Floor & Placement of Tube’ - Intra-Nasal Inferior Antrostomy
- Ethmoidal Sinusitis  External Ethmoidectomy - Cald-well Luc (Radical Antrum) Operation : removal of antral mucosa
- Sphenoidal Sinusitis  External Spheno-ethmoidectomy - Frontal Sinusitis  Osteoplastic Flap Operation in which the sinus is obliterated by fat
- Ethmoidal Sinusitis  External Ethmoidectomy
- Sphenoidal Sinusitis  External Spheno-ethmoidectomy

* See also 28- ENT comp.(3) Nose9- Clinical Picture of Acute Sinusitis 27- ENT table(18) Nose8- Acute Sinusitis & Chronic Sinusitis
 Acute Maxillary Sinusitis Acute Frontal Sinusitis Acute Ethmoidal Sinusitis Acute Sphenoidal Sinusitis
 Facial Pain :  Facial Pain :  Facial Pain :  Facial Pain :
- over the Cheek - over the Forehead (-ve Pressure in the sinus  Vacuum Headache) - over the Inner Canthus  Anterior Ethmoidal Sinusitis - Retro-Orbital
- referred to the Teeth & Ear [Trigeminal 5th n.] - Retro-Orbital  Posterior Ethmoidal Sinusitis
Symptoms :

N.B. the pain has Characteristic Periodicity - referred to the Occipital Region
starts in the morning
  by mid-day
  gradually by end of day

- History of Dental Problems may be present

- Anaerobic Infection  Offensive Nasal Discharge
- Palpation : - Palpation : - Palpation :
Tenderness over the Cheek Tenderness over the Forehead & Floor of Sinus Tenderness over the Inner Canthus  Anterior Ethmoidal Sinusitis
Signs :

- Anterior Rhinoscopy & Nasal Endoscopy : - Anterior Rhinoscopy & Nasal Endoscopy : - Anterior Rhinoscopy & Nasal Endoscopy : - Anterior Rhinoscopy & Nasal Endoscopy :
Discharge in Posterior Part of Middle Meatus Discharge in Anterior Part of Middle Meatus - Discharge in Middle Part of Middle Meatus  Anterior Ethmoidal Sinusitis - Discharge in Spheno-Ethmoidal Recess
- Discharge in Superior Meatus  Posterior Ethmoidal Sinusitis
- Oral Examination may show Dental Problem
N.B. there is No Palpation for Posterior Ethmoidal Sinusitis or Acute Sphenoidal Sinusitis “behind the eye”

N.B. Complications are Common with Ethmoiditis in Children .. due to : 1- Thin Lamina Paparycea ‘sometimes dehiscent’
2-  Immunity

N.B. Infection usually starts in Ethmoiod then Spread to other sinuses

28- ENT comp.(3) Nose9- Clinical Picture of Acute Sinusitis

Foreign Body (FB) in Nose

Uni-lateral Offensive Nasal Discharge
Oro-Antral Fistula
Acute Sinusitis “Uni-lateral or Bi-lateral”

29- ENT diag.(8) Nose10- Uni-lateral Offensive Nasal Discharge

 Distinctive Term in Nose :

 Vomer : Separate Bone .. Postero-inferior

 The Largest Turbinate : Inferior Turbinate
 The Smallest Turbinate : Superior Turbinate
 Bulla Ethmoidalis : Rounded Projection; The Largest of the Anterior Ethmoidal Air Cells
 Hiatus Semilunaris : Semilunar Groove Below the Bulla
 Uncinate Process : Shelf of Bone Medial to the Bulla
 Ostio-Meatal Complex (OMC) : The area of Drainage of Anterior Group of Sinuses .. present between Lamina Paparycea Laterally & Middle Turbinate Medially
 Nasal Valve : The Narrowest Part at the Junction of Lower & Upper Lateral Cartilages (Anterior End of Inferior Turbinates)
 Ground Lamella : Separate between Anterior & Posterior Ethmoid Sinuses
 Muco-Ciliary Clearance (Mucous Blanket) : Ciliated Mucosa that Protect the Air-way Structure
 McGovern Nipple : for Choanal Atresia
to Maintain the Mouth Opened
 Walsham’s Forceps : for Nasal Bone Reduction
 Asch’s Forceps : for Septum Reduction
 B2 Transferrin : for CSF Rhinorrhoea
ὠ is Diagnostic as B2 Only in CSF
 Dose NOT Shrink with Local Vasoconstrictor : Chronic Hypertrophic Rhinitis
 The Commonest Granuloma in Egypt : Rhinoscleroma .. also, Laryngoscleroma
 Muco-Cutaneous Junction : Site of Lesion in Rhinoscleroma & Lupus
 Apple-Jelly Nodule : for Lupus
ὠ Ulcerate  Perforation in Cartilaginous Septum
 Saddle Nose : in Gumma (3ry Syphilis)
 Cocaine Addiction :  Ischemia .. lead to Septal Perforation
 CT  is Mandatory as a Pre-Operative Investigation : for Chronic Sinusitis & Allergic (Ethmoidal) Polyps
to Detect Any Anatomical Abnormality such as Cribriform Plate, Dehiscent Carotid or Optic Nerve
 Pott’s Puffy Tumour : = Sub-Periosteal Abscess
Tender Fluctuant Swelling of the Forehead
 +ve Family History : in Allergic Rhinitis
 Vasomotor Rhinitis (Intrinsic Rhinitis) : Non-Allergic Perennial Rhinitis due to Disturbance of Autonomic Nerve Supply of the Nose (Parasympathetic Part)
 Schniederian Membrane : in Inverted Papilloma
The Junction between St. Sq. Epith. & Resp. Epith. In Lateral Wall of the Nose
 Egg-shell Crackling Sensation on Palpation : for Adamantinoma
 Soap Bubble Appearance in X-ray : for Osteoclastoma
 Albright Syndrome : for Fibrous Dysplasia
more in Females ♀ with Uni-lateral Polyostotic fibrous dysplasia, Skin Pigmentation & Endocrinal Manifestations as Precocious Puberty
 Ground Glass Appearance in X-ray : for Fibrous Dysplasia
 Little's area (Kiesselbach’s Plexus) : region in the Antero-Inferior part of the Nasal Septum, where 4 arteries anastomose to form a Vascular Plexus [The Commonest Site of Epistaxis]
The arteries are :
- Anterior Ethmoidal Artery (from the Ophthalmic Artery of ICA)
- Sphenopalatine Artery (from the Maxillary Artery of ECA)
- Greater palatine Artery (from the Maxillary Artery of ECA)
- Superior Labial Artery (from the Facial Artery of ECA)
 The Commonest Cause of Facial Pain : Dental Caries
 Trigeminal Neuralgia : Paroxysmal Attacks of Pain along distribution of Trigeminal Nerve
 Glossopharyngeal Neuralgia : Paroxysmal Attacks of Pain along distribution of Glossopharyngeal Nerve
 Cacosmia : Sensation of Bad Smell
 Parosmia : Perverted Sense of Smell

30- ENT table(19) Nose11- Distinctive Term in Nose

 Pharynx Collections ..
31- ENT diag.(9) Pharynx1- Inflammations of the Pharynx scheme
32- ENT table(20) Pharynx2- Inflammations of Lymphoid Tissues
33- ENT table(21) Pharynx3- Acute Inflammations of the Pharynx; Blood Diseases
34- ENT table(22) Pharynx4- Acute Inflammations of the Pharynx; Specific Inflammations
35- ENT table(23) Pharynx5- Pharyngeal Suppurations
36- ENT table(24) Pharynx6- Tumours of the Pharynx
37- ENT table(25) Pharynx7- Distinctive Term in Pharynx
 Inflammations of the Pharynx

Acute Inflammations Chronic Inflammations Inflammations of Lymphoid Tissues

Non-Specific Specific Pharyngitis Blood Diseases Non-Specific Pharyngitis Specific Pharyngitis Adenoid Tonsillitis
Pharyngitis
‘see 32- ENT table(20) Pharynx2’

Diphtheria Vincent’s Moniliasis Agranulocytosis Leukaemia Infectious Scleroma T.B. Syphilis

Angina Mononucleosis

‘see 34- ENT table(22) Pharynx4’ ‘see 33- ENT table(21) Pharynx3’

31- ENT diag.(9) Pharynx1- Inflammations of the Pharynx scheme

 Inflammations of Lymphoid Tissues
Adenoid Tonsillitis
The COMMONEST NASO-PHARYNGEAL SWELLING Acute Tonsillitis Chronic Tonsillitis
Def. Hypertrophy of Lymphoid Tissue of Naso-pharynx .. Sufficient to Produce Symptoms Acute Inflammation of Lymphoid Tonsillar Tissues Chronic Inflammation of Lymphoid Tonsillar Tissues
- Repeated Upper Respiratory Tract Infection - Upper Respiratory Tract Infection - Recurrent Acute Attacks
- Low General Resistance - Persistence of the predisposing factors e.g. Smoking
Causes * Age : Childhood period * Causative Organism :
may starts by Viral infection then 2ry Bacterial infection
Thw Commonest Organism  Beta-hemolytic Streptococci
1- Acute Catarrhal Tonsillitis : Oedema & Congestion of Mucosa of tonsils 1- Atrophic
(NO Pus) 2- Hypertrophic
Types 2- Acute Follicular Tonsillitis : PUS within the crypts appear as Yellowish
Spots on the surface
3- Acute Parenchymatous Tonsillitis : Highly Enlarged Tonsils
1- Effects of Hypertrophy : 2- Affects of Recurrent Infection :  General : Fever, Headache, Malaise & Anorexia  General : Manifestations of Septic Focus
- Bi-lateral Nasal Obstruction : -Rhinitis & Sinusitis
 Snoring & Sleep Apnea - Otitis Media  Local :  Local :
 Difficult Suckling in Infants - Pharyngitis, Laryngitis & Bronchitis - Dysphagia, Sore Throat -  Recurrent Acute Attacks
 Rhinolalia Clausa (± Referred Otalgia ‘via Glossopharyngeal Jacobson') - Referred Otalgia ‘via Glossopharyngeal Jacobson
 Anterior Nasal Discharge 3- General Effects : - Hot Potato Voice - Foetor Oris
Symptoms

- Eustachian Tube Obstruction : - Deafness + Interrupted Sleep  School - Foetor Oris - Enlarged Tonsils .. lead to :  Dysphagia
 Recurrent AOM or Secretory OM  CHL Retardation  Snoring & Sleep Apnea
- Adenoid Facies : - ++ Wake-Up Threshold  Nocturnal Enuresis  Hot Potato Voice
 Open Dry Mouth - Sleep Apnea
Clinical Picture

 Septic Focus :
 Elevated Upper Lip  Def. : Chronic Bacteraemia or Toxaemia caused by Chronic Inflammations
 Promient Central Incisors  Examples : Chronic Tonsillitis, Chronic Sinusitis, Chronic Cholecystitis, Chronic Salpingitis
 High Arched Palate  Clinical Picture :
 Receding Lower Jaw
1- Kidney  Glomerulo-nephritis 2- Low Grade Fever 3- Anaemia 4- Myalgia & Arthralgia
 Narrow Pinched Anterior Nares
5- Heart  Rheumatic Fever 6- Lung  Bronchi-ectasis 7- Skin  Dermatitis 8- Eye  Irido-cyclitis
 Apathetic Look
- Adenoid Facies   General :  Temp. &  Pulse  Local :
- Anterior Rhinoscopy :  Tonsils .. shows :
Narrow Pinched Anterior Nares + Discharge  Local : - Congestion Anterior Pillars
- Posterior Rhinoscopy :  Tonsils .. shows : - Size  Asymmetrical Enlargement
Signs

Post-nasal Discharge + Adenoid .. may be seen - Congestion & Oedema  Catarrhal Tonsillitis - Shape  Irregular
N.B. the diff. between Adenoid & Tumour is the Adenoid has Furrows - Yellowish Spots  Follicular Tonsillitis - Squeezing  Oozing Pus
- Oral Cavity  Open Dry Mouth - Hugely Enlargement  Parenchymatous Tonsillitis - Probing  Indurated (Firm)
- Digital palpation ‘Not done nowadays’ : Adenoid .. may be felt  Lymph Nodes .. shows :  Lymph Nodes .. shows :
Enlarged, Firm & Tender (Jugulodigastric LNs) Enlarged, Firm & Tender (Jugulodigastric LNs)
- Plane X-ray (Soft Tissue Lateral View on Nasopharynx)  Narrowing of Air Column * (in Resistant Cases) -  Erythrocyte Sedimentation Rate (E.S.R.)
- Throat Swab .. for Culture & Sensitivity -  Anti-Streptolysin O (A.S.O.) titre
Investigations - C.B.C.  Leucocytes ‘Normal =up to 200 tod’s units’
-  Erythrocyte Sedimentation Rate (E.S.R.)
 General :  Local :
- Rheumatic Fever - Pharyngeal Suppurations
Complications - Glomerulonephritis - Extension of Infections
- Chronicity
- Adenoidectomy [Medical ttt] [Surgery ttt]
(± Tonsillectomy .. if indicated)  General :  Local : Tonsillectomy
Treatment - Complete Bed Rest + Warm Fluid - Antiseptic Mouth Gargle
- Systemic Antibiotics
- Analgesic Antipyretics

32- ENT table(20) Pharynx2- Inflammations of Lymphoid Tissues

 Acute Inflammations of the Pharynx
Blood Diseases
Infectious Mononucleosis
Agranulocytosis Leukaemia
(Glandular Fever) , (Kissing Disease)
* Def. : * Def. : * Causative Organism : Epstein Barr Virus
Bone Marrow Depression   Granulocytes Neoplastic Proliferation of Leukocytic Precursors in Bone
(Neutrophils) i.e. Leukopenia < 1000/cc Marrow  Leucocytosis (Blast Cells) + Thrombocytopenia
Aetiology * Cause : ( Platelets) + Anaemia ( RBCs)
May be Idiopathic or due to Antibiotic as
Chloramphenicol, Cytotoxic Drugs or Irradiation
 General :  General :  Febrile Manifestations :
Recurrent Infections - Recurrent Infections (Blast Cells) Fever, Headache & Malaise
- Bleeding Tendency ( Platelets)  Anginose Manifestation :
Clinical Picture

- Pallor ( RBCs) Dysphagia & Sore Throat

- Generalized Lymphadenopathy ± HepatoSplenoMegaly Oropharyngeal Ulcerations, with Pseudomembrane
 Glandular Manifestation :
Generalized Lymphadenopathy ± HepatoSplenoMegaly
 Local :  Local : # can be FATAL due to Rupture of Spleen
- Dysphagia & Sore Throat - Dysphagia & Sore Throat
- Oropharyngeal Ulcerations, with Pseudomembrane, - Oropharyngeal Ulcerations, with Pseudomembrane In addition :
surrounded by Little Inflammatory Reactions 1- Palatal Petechiae
(Leukopenia) 2- if Ampicillin is taken  Skin Rash
- C.B.C.  Leukopenia - C.B.C.  Leukocytosis + Anaemia + Thrombocytopenia - C.B.C.  Monocytosis
Investigation - Sternal Puncture - Sternal Puncture - Serological Tests : Paul-Bunnel Test or Monospot Test
1- Stop the Causative Drug  General :
2- Hospitalization, Isolation & Antibiotics to Prevent 1- Hospitalization, Isolation & Antibiotics to Prevent any - Complete Bed Rest + Warm Fluid
any Infection Infection - Systemic Antibiotics but Avoid Ampicillin 
Treatment 3- Fresh Blood Transfusion (Platelet & Igs) 2- Fresh Blood Transfusion - Analgesic Antipyretics
4- Bone Marrow Transplantation .. may be needed 3- Chemotherapy : Leukeran (Cytotoxic Drug)  Local :
- if there is Airway Obstruction  Cortisone
- Antiseptic Mouth Wash

33- ENT table(21) Pharynx3- Acute Inflammations of the Pharynx; Blood Diseases
 Acute Inflammations of the Pharynx
Specific Inflammations
Diphtheria Vincent’s Angina (Trench Mouth) Moniliasis
* Causative Organism : * Types : * Pathology : * Causative Organism : * Causative Organism :
Corynebacterium diphtheriae 1- Pharyngeal (Faucial) diphtheria : The organism Remains in the Pharynx .. Borrelia vincenti & Fusiform bacilli Candida Albicans (Fungus)
* Mode of Transmission : the Commonest Producing Powerful Exotoxin ὠ has : * Predisposing Factor : * Predisposing Factor :
Droplet infection - Local Effects : Bad Oral Hygiene - Prolonged Antibiotic Therapy
Aetiology
* Age : 2-5 Years 2- Laryngeal : 2ry to Faucial diphtheria Necrosis of tissues & Pseudomembrane Formation (Super-Infection)
* Incubation Period :
2-5 Days 3- Nasal : 2ry to Faucial diphtheria - Systemic Effects : -  Immunity :
Fixation to Cardiac & Neural Tissues Diabetes, AIDS, Chronic Diseases ….
 General : Low Grade Fever, Headache, Malaise & Anorexia  General : Fever, Headache, Malaise & Anorexia No Fever
Symptoms Dysphagia & Sore Throat
 Local : Sever Dysphagia ‘due to Necrosis’ & Sore Throat  Local : Dysphagia & Sore Throat
 General : -  Temp. (Not more than 38°) -  Pulse (Disproportionate to fever) - Toxaemia (Pallor)  General :  Temp. &  Pulse Milky Whitish Pseudomembrane
Clinical Picture

 Local :
 Pharynx .. shows Pseudomembrane ὠ is : - Uni-lateral  Cervical Lymph Nodes .. shows :  Local :
- Exceeds the limit of tonsil Hugely Enlarged (Bull’s Neck)  Pharynx .. shows :
Signs - Dirty Grayish in Color Pharyngeal Ulceration with Pseudomembrane
- Offensive in Odour (Uni-lateral, Deep Irregular)
- Deeply Adherent
- if Removed  Raw Bleeding Surface  Sub-mandibular Lymph Nodes .. shows :
- it will Reform Rapidly Enlarged, Firm & Tender
Throat Swab for : - Direct Smear : G +ve bacilli (Chinese Letter Appearance) Swab for Direct Smear & Culture
Investigation
- Culture on Loffler’s Serum or Tellurite Medium
1- Hospitalization & Isolation as Acute Tonsillitis ttt - Stop the Antibiotic Therapy
2- Anti-toxic Serum :  Dose : 40.000 – 100.000 IU ‘according to Extension of Pseudomembrane’, - Anti-Fungal : Nystatin
IM or IV (Double this dose in Sever Cases)  General :
 Given Once the diagnosis was Suspected - Complete Bed Rest + Warm Fluid
 Pre-test should be carried out (0.05 ml Injected Intra-Dermal  Erythematous Wheel in +ve Cases) - Systemic Antibiotics
 In Hypersensitivity : use Sheep’s Serum (Not Hoarse Serum), or Hypo-sensitization and Cortisone & Anti-Histaminic - Analgesic Antipyretics
Treatment 3- Antibiotics : Penicillin or Erythromycin
4- Treatment of Complications :  Laryngeal Paralysis  Tracheostomy  Local :
 Palatal, Pharyngeal & Oesophageal Paralysis  Naso-gasteric Tube - Antiseptic Mouth Gargle
 Respiratory Paralysis  Artificial Respiration
# Prophylaxis : 1- Acute Follicular Tonsillitis :
1- Active Immunization : DPT (Compulsory), given at 2, 4, 6 Months, then Booster Dose at 18 Months, 2nd Booster Dose at School Age
2- Passive Immunization : Small Dose Anti-toxic Serum (for Contactants) Acute Follicular Tonsillitis Diphtheria
# Complication : - Onset Acute Insidious
1- Cardio-Vascular : Heart Failure .. my be Early due to Toxic Myocarditis or Late due to Vagal Neuritis - Temperature May be High LOW GRADE FEVER
2- Neurological : - Palatal Paralysis .. the 1st  Nasal Regurgitation - Pulse Proportionate to Fever Dis-Proportionate to Fever
- Ocular Paralysis : Intrinsic  Loss of Accommodation - Face Flushed Toxic (Pale)
Extrinsic  Diplopia & squint - Toxaemia No or Mild Sever
- Laryngeal Paralysis  Laryngeal Obstruction (Stridor & Hoarseness) - Pseudomembrane Bi-lateral, Yellowish, Limited to Uni-lateral, Dirty Grayish,
# Others
- Pharyngeal & Oesophageal Obstruction  Dysphagia Tonsils & Loose Exceeds the limit of tonsil &
- Respiratory Paralysis  Respiratory Failure Deeply Adherent
3- Respiratory : - Laryngeal Obstruction .. by Pseudomembrane - Throat Swab β-Hemolytic Streptococci Corynebacterium diphtheriae
- Respiratory Infection : Bronchopneumonia, Abscess 2- Vincent’s Angina  Pseudomembrane (Uni-lateral, Irregular & Removed Easily leaving Ulcer)
- Respiratory Paralysis  Respiratory Failure 3- Moniliasis  Milky Whitish Pseudomembrane
4- Renal : - Glomerulo-Nephritis  Alpuminuria 4- Agranulocytosis  surrounded by Little Inflammatory Reactions (CBC: Leukopenia)
N.B. Don’t Forget to write the Differential Diagnosis for Diphtheria from All Diseases causing Membranes on the Pharynx 5- Leukaemia  (CBC: Leukocytosis)
6- Infectious Mononucleosis  Bi-lateral Ulcer & +ve Monospot Test

34- ENT table(22) Pharynx4- Acute Inflammations of the Pharynx; Specific Inflammations
 Pharyngeal Suppurations .. Infections of the Spaces around the pharynx
Retro-Pharyngeal Abscess
Peri-Tonsillar Abscess (Quinsy) Para-Pharyngeal Abscess Chronic Ludwig’s Angina
Acute
(Cold Abscess, Pott’s Disease)
Collection of Pus in the Peri-Tonsillar Space Collection of Pus in the Para-Pharyngeal Space Collection of Pus T.B. with Collection of Caseous Collection of Pus
 Peri-Tonsillar Space : in the Retro-Pharyngeal Space Material Behind the Pre- in the Sub-Mandibular Space
Def.
present between Capsule of the Tonsil ὠ Atrophies by age of 5 years Vertebral Fascia * usually develops in  Immunity
& Its Bed (Sup. Constrictor) at its upper pole e.g. in Diabetics
Acute Tonsillitis .. infection starts in the Crypta Magna, then pass - Peri-Tonsillar Abscess Suppuration in Lymph Gland of - Dental Infection, in most cases
Causes to the Peri-Tonsillar Space - Acute Tonsillitis Henle.. due to Infection in Nose, - Sub-Mandibular Sialadenitis
- After Tonsillectomy Pharynx or Tonsils
General Fever, Headache, Malaise & Anorexia  General :
1- Dysphagia & Odynophagia with Dribbling of Saliva 1, 2, 3 & 4 .. as before + 1, 2, & 3 .. as before + - T.B. Toxemia : 1 & 2 .. as before +
Symptoms

2- Neck Pain ‘Behind the Angle of Mandible’ .. referred to the Ear - Neck Swelling in the Upper Lateral Part of - Nasal Obstruction : Collection of  Loss of Weight - but Neck Pain : Below the
Local 3- Torticollis Neck ‘Jugulodigastric LNs’ Pus Behind Naso-pharynx  Loss of Appetite Mandible
4- Trismus - Laryngeal Obstruction : Collection  Nigh Fever
of Pus Behind Hypo-pharynx  Night Sweating
- Pulmonary T.B. :
Clinical Picture

General -  Temp. &  Pulse

1- Torticollis : Flexion of Neck to the Diseases Side 1 & 2 .. as before + 1.. as before + Cough & Hemoptysis - Internal Swelling : in the Floor
2- Trismus : Inability to Open the Jaw - Internal Swelling : swelling Lateral to the - Internal Swelling : in the of the Mouth .. Pushing the
3- Oropharyngeal Examination : Swelling Above & Lateral to Tonsil & Pushing the Tonsil Medially Posterior Pharyngeal Wall to One  Local : Tongue Above & Backwards
Tonsil Pushing the Tonsil Downwards and Medially & Pushing the - External Swelling : Below & Behind the Side of Mid-line Limited by Median - Dysphagia & Odynophagia with  can lead to Asphyxia
Signs

Uvula to Opposite Side Angle of the Mandible deep to the Anterior Raphe Dribbling of Saliva - External Swelling :
Local - Internal Swelling : in the Mid-
- Jugulodigastric LNs  Enlarged, Firm & Tender Border of Sternomastoid - External Swelling : Enlarged, Firm in the Sub-Mandibular Region
line of Posterior Pharyngeal Wall .. First  its Indurated
 Beck’s Triad = Para-Pharyngeal Abscess & Tender Upper Deep Cervical LNs
- External Tenderness & Neck
- Internal Swelling (Hard & Brawny),
Rigidity : Over the Cervical Spines
- External Swelling Later on  become Fluctuant
 General : - Trismus (on Pus Formation)
NO Investigations - Complete Bed Rest + Warm Fluid - CT is Diagnostic - X-ray Lateral View Neck   As before .. but Destroyed - Blood Sugar 
- Systemic Antibiotics Widening of Pre-Vertebral Space Vertebrae
Investigations - Analgesic Antipyretics with Normal Vertebrae + Investigations for T.B. : as
 Local : - CT is Diagnostic Chest X-ray & Sputum Analysis
1- Laryngeal Oedema - Antiseptic Mouth Gargle 1 & 2 .. as before + 1 & 2 .. as before
Complications 2- Pyaemia & Septicaemia - Thrombosis of IJV
3- Extension  Para-Pharyngeal Abscess - Rupture of Carotid Artery
1- Before Suppuration (in Cellulitis) : as Acute Tonsillitis ttt 1- Hospitalization with Parenteral Antibiotics + 1.. as before + + Anti-Tuberculous Treatment : 1.. as before +
2- After Suppuration (Pus Formation) : Analgesics Antipyretics  Incision & Drainage : as Rifampicin  Saving the Airway 
 Indicated by : - Fever become Hectic - Pain become Throbbing  Incision & Drainage : - Under General Anaesthesia  Incision & Drainage : Tracheostomy in Sever Stridor
- Pitting Oedema - Aspiration brings Pus - Under General Anaesthesia  Indicated by : Pus Formation - Site of Incision :  Incision & Drainage :
 Incision & Drainage :  Indicated by : Pus Formation - Site of Incision : [External Incision] .. along the  Indicated by : Pus Formation
- Under Local or General Anaesthesia - Site of Incision : [External Incision] .. along [Internal Incision] in the Pharynx, Posterior Border of - Site of Incision : [External
- the knife must be Guarded  to Avoid Deep Injury the Anterior Border of Sternomastoid ms. Vertical Over the Abscess with the Sternomastoid ms. Incision] .. Transverse in the Sub-
- Site of Incision : [Internal Incision] .. either in :  Para-Pharyngeal Space : Head Low Down (Trendelenburg Mandibular Region
 Most Pointing Point  Crypta Magna present on either Side of the Pharynx .. position)
Treatment  Mid-Point of Transverse Line Drawn from Base of Uvula to the extends from Skull Base to the Hyoid Bone using Suction Apparatus & Cuffed
Last Upper Molar - Laterally : Ramus of Mandible & Deep Loop Endotracheal Intubation  to
 ½ cm Lateral to Meeting Point between Transverse Line from of Parotid Gland and its Fascia Avoid Aspiration of Pus
Base of Uvula & Vertical Line along the Anterior Pillar - Medially :
 Parenteral Antibiotics + Analgesic Antipyretics Anterior  Bucco-Pharyngeal Fascia  Retro-Pharyngeal Space :
 Tonsillectomy : Posterior  Pre-Vertebral Fascia Present Posterior to the Pharynx  Mandibular Space :
- within one month from drainage  to Avoid Recurrence  Contents : - Carotid Sheath & its Contents between Bucco-Pharyngeal Fascia & Pre-Vertebral Fascia from the Floor of Mouth Above
- sometimes quinsy-tonsillectomy (Incision of Abscess + Removal - Deep Cervical LNs along IJV to the Deep Fascia of the Sub-
of Tonsils) .. especially if the quinsy is Posteriorly Located - Sympathetic Chain Mandibular Region Below
- Last 4 Cranial Nerves

35- ENT table(23) Pharynx5- Pharyngeal Suppurations

 Tumours of the Pharynx
Naso-Pharynx Oro-Pharynx Hypo-Pharynx
Benign Malignant
Malignant Tumours Malignant Tumours
Juvenile Naso-Pharyngeal Angiofibroma Naso-Pharyngeal Carcinoma
Age 12 Years with Spontaneous Regression at Sexual Maturity Old .. Above 60 Years
 Race : More in Chinese People
Sex Exclusively in Males ♂ ‘Young Boy’ More in Males ♂
Unknown .. but may be : - Genetic : related to Human Leukocyte Antigen (HLA) - Plummer-Vinson Syndrome  leads to Post-Cricoid Carcinoma
- Benign Tumour of the Peri-osteum of Skull Base - Epstein Barr Virus Infection
Predisposing Factors - Hamartoma of Vascular Erectile Tissue ‘Tumour Marker Ab against EBV’ - Alcohol
- Paraganglioma of Maxillary Artery - Smoking
- Hormonal Disturb.   of the Peri-osteum of Skull Base - Irradiation
- Firm, Lobulated, Pinkish Tumour  Shape : Ulcer (in Carcinoma), Cauliflower Mass (in Lymphoma) or Nodular Infiltrative
- Gross .. has NO True Capsule [Pseudo-Capsule]  Site : Fossa of Rosen Muller ‘COMMONEST SITE’  Site : Tonsil & Base of the  Site : Pyriform Fossa (50%), Post-Circoid (40%) & Posterior Pharyngeal Wall (10%)
Tongue ‘COMMONEST SITE’
- Angio = Vascular Space withOUT Musculosa ‘Thin Walled’ - Sq. Cell Carcinoma ‘COMMONEST’ - Sq. Cell Carcinoma - Sq. Cell Carcinoma
- Microscopic Silent Areas in the Head & Neck :
- Fibroma = Collagen Bundles & Fibroblasts or Lymphoma
Pathology

- Def. : Areas that may leads to Lymph

- Feeding Vessel : Mainly from Maxillary Artery  Direct  to the surrounding structure
Node Metastasis (Neck Swelling) before
 Differential Diagnosis : Unilateral Nasal Mass  Lymphatic Spread  to Retro-Pharyngeal LNs then  Lymphatic Spread  Lymphatic Spread  to Upper & Lower Deep Cervical LNs giving Symptoms related to the Affected
1- Antro-Choanal Polyp  Teen Age, Unilateral & NO Epistaxis to Upper Deep Cervical LNs * Post-Circoid is Mid-line Structure give Bi-lateral Nodal Metastasis
- Spread 2- Angiofibroma  ONLY in Males ♂ & SEVER Epistaxis
Area
3- Tumour  Males Above 50
N.B. Naso-Pharynx is Mid-line Structure, * Post-Circoid also, give Superior Mediastinal LNs (Bad Prognosis) 1- Fossa of Rosen-Muller (Naso-Pharynx)
N.B. Young Boy with Uni-lateral Nasal Obstruction & Epistaxis  Angiofibroma so Bi-lateral Nodal Metastasis is Common * Pyriform Fossa is One of the Silent Areas 2- Pyriform Foss (Hypo-Pharynx)
until proved otherwise  Blood Spread  Lung, Liver, Bone & Brain 3- Floor of Mouth
Either Spontaneous Regression (Rare) at Sexual Maturity - Bad as Naso-Pharynx is a Silent Area & Mid-line According to the Stage of the - Bad & the 5 Year Survival Rate = 30% 4- Supra-glottic Area of Larynx
- Prognosis 5- Tonsil
or Extension to the Surrounding Structures Tumour
6- Tongue Base
 General : it's Vascular Tumour & Vs. are Thin Walled  Aural Manifestations :  Symptoms :  Symptoms :  Signs :
recurrent A.O.M.)
- Eustachian Tube Obstruction  CHL (S.O.M. or
 Aural :
7- Thyroid
- Excessive Epistaxis  Anaemia  Pallor - Eustachian Tube Obstruction - Dysphagia - Dysphagia ‘Progressive’  General :
- Sleep Apnea  No Deep Sleep  Stunted  Uni-lateral Secretory Otitis Media - Pain in Oro-Pharynx .. Pyriform Fossa is Silent Area  No - Underweight (Cachexia)
Growth - Referred Pain in the ear through 9th Nerve referred to the Ipsi-lateral Dysphagia - Pallor & Anaemia
- Face Shows : - Proptosis ‘One Eye Only’  Nasal Manifestations : Ear - Pain.. referred to the Ipsi-lateral Ear - Signs of Distant Metastasis
- Facial Swelling - Nasal Obstruction ‘Uni- or Bi-lateral’ - Symptoms of LNs - Hoarseness of Voice
- Frog-Face Deformity - Nasal Discharge ‘Uni- or Bi-lateral’ Metastasis : Neck Swelling - Stridor  Local :
Clinical Picture

 Nasal : - Epistaxis - Chocking - Examination of Hypo-Pharynx (Behind the Larynx) : by

 Symptoms :  Nodal Manifestations : - Symptoms of Blood - Regurgitation Indirect Laryngoscopy .. to see either the Tumour Mass or
- Uni-lateral Nasal Obstruction - Upper Deep Cervical LNs .. may be felt Metastasis - Cough, Expectoration Froth Collection in Pyriform Fossa or Post-Circoid Area
- Intermittent Epistaxis - Incidence of Metastasis = 70%  Signs : & may be Hemoptysis - Examination of the Neck :
- Uni-lateral Nasal Discharge  Neurological Manifestations : - Oro-Pharyngeal - Neck Swelling : LNs Enlargement  Moure’s Sign : Friction of the Cricoid Cartilage to Vertebrae
 Signs : - Cranial Nerve Palsies .. in this order of freq. Examination  Ulcer or - Loss of Weight ‘Progressive’ showing Absent Click in Post-Cricoid Carcinoma
- Anterior Rhinoscopy  Uni-lateral Nasal Mass  5th  Uni-lateral Facial Pain, Numbness Mass - Symptoms of Distant Metastasis  Masses in the Neck : LNs Enlargement
ὠ Bleeds on Touch then Loss of Sensation - Neck Examination  for
rd th th
- Posterior Rhinoscopy  Lobulated Pink Mass  Ocular (3 , 4 & 6 ) LNs Metastasis
- Digital Palpation  CONTRA-INDICATED  Squint, Diplopia & Ophthalmoplegia - General Examination  for
‘Except in the Operation Theatre,  Lower 4 Cranial Nerves .. Distant Metastasis
usually NOT needed’ Compression by Retro-Pharyngeal LNs at Skull Base
- Ct  to show Site, Degree & Extension of the Tumour.. & LNs Metastasis
 Trotter’s Triad [Diagnostic for Naso-Pharyngeal Carcinoma] :
- MRI  to detect Intra-cranial Extension - X-ray Lateral View Neck  Widening of Pre-Vertebral Space in Post-Cricoid Carcinoma
- Uni-lateral Facial Pain (Trigeminal Nerve)
- MRA (Angiography)  - Barium Swallow  to see Lower Limit of the Tumour
Investigations - Carotid Angiography  to see Feeding Vessel & to do
- Uni-lateral Palatal Immobility
- Direct Laryngoscopy
“due to Fixation of ms. & NOT to Nerve Paralysis”
Preoperative Embolization - Metastatic Work-up
- Uni-lateral Conductive Deafness
N.B. Biopsy is CONTRA-INDICATED & NOT needed - Biopsy
 Surgical :  Radiotherapy : to 1ry Tumour & to Neck ‘for LNs’ in Both Sides  Curative Treatment :  Palliative Treatment: for Extensive
Surgical Excision with Preoperative Embolization  Surgical : NOT done ..  Surgical : COMMANDO Combined Surgery & Radiotherapy Tumours FIXED to Vertebral Column
 Hormonal : Except ‘After Failure of Radiotherapy’ Operation ‘in Failure of - for 1ry Tumour  Total Pharyngeal Laryngectomy ± and/or with Distant Metastasis
Treatment

Combination of Oestrogen + Testosterone   Fibrous in Radical Neck Dissection (RND) Radiotherapy’ Oesophagectomy .. - Radiotherapy
Tissue +  Vascularity for Persistent or Recurrent LNs (COMbined Neck Dissection, followed by Post-Operative Radiotherapy - Chemotherapy
 Radiotherapy : NOT done nowadays as it’s MANDibulectomy & - for LNs ‘if there is LNs Enlargement’  RND - Surgery as Tracheostomy for respiration
CARCINOGENIC .. Except in Recurrent Cases with Intra- Oropharyngeal Resection)  Re-Construction After Total Pharyngo-Laryngoectomy : & Gastrostomy for feeding
cranial Extension by one of .. - Stomach Pull-up (the BEST) - Pain Killers (Analgesics)
- Def. : Benign, Highly Vascular, Locally Aggressive Tumour of Naso-Pharynx - Free Radial Forearm Flap - Adequate Feeding
- Origin : Spheno-Palatine Foramen

36- ENT table(24) Pharynx6- Tumours of the Pharynx

 Distinctive Term in Pharynx :

 The Commonest Site for Naso-Pharyngeal Carcinoma : Fossa of Rosen Müller

 Pyriform Fossa : - Laterally : Thyroid Cartilage & Thyrohyoid Membrane
- Medially : Cricoid Cartilage & Aryepiglottic Fold
 Waldeyer’s Ring : It’s a ring of Lymphoid Tissue Present in the Sub-Epithelial Connective Tissues in the Upper Part of Aerodigestive Tract
- it has NO Afferent Lymphatic Vessels & has Only Efferent Lymphatic Vessels (Direct Contact with the Organism) .. as Peyer's patches of Insistent
it’s Drained in Retro-Pharyngeal LNs then to Upper Deep Cervical LNs
it consists of :
[Naso-Pharyngeal Lymphoid Tissue, Tubal Tonsil around the ET, Palatine Tonsils in Oro-Pharynx, Lingual Tonsils at the Base of the Tongue & Lymphoid Follicles in Post. Pharyngeal Wall]
 Paul-Bunnel Test or Monospot Test : for Infectious Mononucleosis
 Paterson – Brown Kelly Disease : = Plummer – Vinson’s Syndrome
It’s Chronic Pharyngo-Oesophagitis
 Koilonychia : = Spooning of Nails .. in Plummer – Vinson’s Syndrome
 Dyspeptic (Aphthous Ulcers) : The Exact cause is Unknown
Multiple, Small, Painful, Recurrent & Yellowish Ulcers associated with GIT Troubles
 Pemphigus : Bullae .. Rupture  Ulcers
Biopsy  Intra-Epithelial Lesion + Acantholysis
 Pemphigoid : Bullae .. Rupture  Ulcers
Biopsy  Sub-Epithelial Lesion + NO Acantholysis
 Behcet’s Diseases : Oro-Pharyngeal Ulceration & Genital Ulceration & Irido-Cyclitis
 Herpangina : Caused by Coxsakie Virus
ὠ is Acute Viral Stomatitis
 Trendlenberg’s Position : for Acute Retro-Pharyngeal Abscess
the body is laid flat on the back (supine position) with the feet higher than the head by 15-30 degrees (Head Low Down)
 Zenker’s Diverticulum : = Pharyngeal Pouch
Herniation of Pharyngeal Mucosa through Killian’s Dehiscence
 Killian’s Dehiscence : Site of Pharyngeal Pouch
The Space between Transverse Crico-Pharyngeus & Oblique Thyro-Phryngeous
 Frog-Face Deformity : in Juvenile Naso-Pharyngeal Angiofibroma
Proptosis + Facial Swelling
 Commando Operation : for Oro-Pharynx Malignant Tumours
‘in Failure of Radiotherapy’ (COMbined Neck Dissection, MANDibulectomy & Oropharyngeal Resection)
 Moure’s Sign : for Hypo-Pharynx Malignant Tumours
Friction of the Cricoid Cartilage to Vertebrae showing Absent Click in Post-Cricoid Carcinoma
 Müller’s Manoeuvre : for Snoring & Sleep Apnea
Suction of the Air-way after Closure of Nose & Mouth with the Naso-Pharyngo-Scope Introduce to Detect the Most Collapsed Area
 Davis-Boyle Mouth Gag : for Tonsillectomy
to Maintain the Mouth Opened
 Rat-Tail Appearance in Barium Swallow : in Cancer Oesophagus
 Parrot’s Beak Appearance in Barium Swallow : in Achalasia of the Cardia
 Soutter’s Tube : for Cancer Oesophagus
Radiotherapy treatment .. containing Radioactive Material
 Heller’s Operation : for Achalasia of the Cardia
Cardiomyotomy
 Dysphagia Lusoria : Compression of the Oesophagus by Vascular Loop as Double Aortic Arch [Congenital Anomaly]
 Velopharyngeal Incompetence : Failure of the Palate to be Elevated & Close the Naso-Pharynx  Escape of Air during Speech [Rhinolalia Operta] & Fluids during Swallowing [Nasal Regurgitation]

37- ENT table(25) Pharynx7- Distinctive Term in Pharynx

 Larynx Collections ..
38- ENT diag.(10) Larynx1- Inflammations of the Larynx scheme
39- ENT table(26) Larynx2- Acute Laryngeal Inflammations
40- ENT table(27) Larynx3- Chronic Laryngeal Inflammations
41- ENT table(28) Larynx4- TNM Classification of Cancer Larynx
42- ENT diag.(11) Larynx5- Case Larynx; VC Paralysis
43- ENT comp.(4) Larynx6- Single Papilloma & Multiple Papillomatosis
44- ENT table(29) Larynx7- Distinctive Term in Larynx
 Inflammations of the Larynx

Acute Inflammations Chronic Inflammations

Specific Non-Specific Non-Specific Specific

Granuloma Atrophic Hyper-Trophic

Diphtheria Laryngitis Epiglottitis Laryngo Tracheo-Bronchitis Scleroma Syphilis T.B. Leprosy Fungal Diffuse Localized

‘see 39- ENT table(26) Larynx2’ Singer’s Nodes Polyp Leukoplakia

‘see 40- ENT table(27) Larynx3’

38- ENT diag.(10) Larynx1- Inflammations of the Larynx scheme

 Acute Laryngeal Inflammations
Specific Non-Specific
Acute Non-Specific Laryngitis Acute Epiglottitis Acute Laryngo Tracheo-
Laryngeal Diphtheria
In Adults In Children (Supra-glottitis) Bronchitis
Inflammation of the mucosa of the Acute Inflammation of Laryngeal &
Def. : Acute Inflammation of Laryngeal Mucosa
Epiglottis Lower Respiratory Mucosa
usually Secondary to Pharyngeal (Faucial) usually associated with Upper Respiratory * it’s More Dangerous than Adults .. causing Stridor in usually associated with Upper usually associated with Upper
Diphtheria Infection (as Common Cold or Exanthemata) Children due to : Respiratory Infection (as Common Respiratory Infection (as Common
Causes :

- Organisms : starts by Viral - Larynx  Small ‘easy Obstruction’ Cold or Exanthemata) Cold or Exanthemata)
then 2ry Bacterial Infection - Larynx  Funnel-Shaped with Very Narrow Subglottic Area - Organisms : Haemophilus influenza - Organisms : usually Viral
- Predisposing Factors : ‘easy Obstruction’ * More in Children * More in Children
 Local : Abuse of Voice & Smoking - Sub-mucosa  Loose ‘easy Oedema’
 General : Low General Resistance & Pollution - Laryngeal Cartilage  Softer ‘easy Collapse’
- Hoarseness  General :
- Stridor - Constitutional Symptoms ‘group of symptoms that can affect many different systems of the body’ e.g. Weight loss, Fevers, Fatigue, and Malaise
Symptoms :

 Local :  Local :  Local :

- Hoarseness  Main Symptom in Adults - Hoarseness - Stridor
- Stridor  Main Symptom in Children (Hot Potato ‘Muffled’ Voice) - Hoarseness
Clinical Picture :

- Stridor ‘Inspiratory’ - Cough & Expectoration

- Dysphagia & Odynophagia
- Dirty Grayish Membrane over the Laryngeal - Diffuse Congestion and Oedema of VC & Laryngeal Mucosa especially Subglottic Area in Children - Severely Congested & Oedematous Sub-glottic Oedema & Congested
Inlet Epiglottis Laryngeal Mucosa
Signs :

# Investigations : As Faucial Diphtheria

Throat Swab for :
- Direct Smear : G +ve bacilli (Chinese Letter
Appearance)
- Culture on Loffler’s Serum or Tellurite Medium
1- Saving the Air-way .. by Endo-tracheal  General :  Hospitalization +
Treatment :

Intubation, or [ Tracheostomy in Sever Stridor ] - Complete Bed Rest + Plenty of Warm Fluids
2- Anti-Toxic Serum - Systemic Antibiotics + Analgesics
3- Systemic Antibiotic  Local :
- Complete Voice Rest
- Steam Inhalation with Tincture Benzoin
- Systemic Antibiotics by Injection
- Steroids   Oedema
- Supplying O2 Inhalation
- Steam Inhalation with Tincture Benzoin
- Saving the Air-way .. by Endo-tracheal Intubation, or [ Tracheostomy in Sever Stridor ]

39- ENT table(26) Larynx2- Acute Laryngeal Inflammations

 Chronic Laryngeal Inflammations
Non-Specific
Chronic Atrophic Chronic Localized Hypertrophic Laryngitis
Chronic Diffuse Hypertrophic Laryngitis
Laryngitis Vocal Cord Nodules (Singer’s Nodes) Laryngeal Polyp Leukoplakia
Chronic Diffuse Inflammation  Grossly :
Def. Localized Area of VC Hyperplasia Polypoid Mucosa on the VC
with Hypertrophy of Laryngeal Mucosa - Raised White Patch above the surface epith.
usually associated with - Repeated Acute Attack Voice Abuse  Sub-epithelial Hematoma  Voice Abuse  Microscopically :
Atrophic Rhinitis - Persistence of the Predisposing Factors Organization - Hyperplasia, Hyperkeratosis & Acanthosis ..
Cause
- Laryngeal Mucosa  Pale, (Smoking, Voice Abuse, ….) but the basement membrane is Intact
Dry & Covered with Crusts *it’s a Precancerous Lesion
- Hoarseness - Hoarseness - Hoarseness - Hoarseness - Hoarseness
Symp.
Clinical Picture

- Stridor - Irritative Cough

Signs
- Potassium Iodide
- Direct Laryngoscopy  to
Treatment Remove the Crusts
- In-direct Laryngoscopy  Bi-lateral Diffuse - Bi-lateral Small Nodules at the Junction between - Sessile or Pedunculated Uni-lateral as a gross picture 
Symmetrical Thickening & Congestion of VC Anterior ⅓ & Posterior ⅔ Polyp ὠ may be
Grayish [Oedematous Polyp]
N.B. Reinke’s Oedema : is Oedema of the Sub- Reddish [Vascular Polyp]
epithelial Space of the VC Whitish [Fibrotic Polyp]
- Avoid the Predisposing Factors - Complete Voice Rest - Complete Voice Rest
- Steam Inhalation with Tincture Benzoin - if the Nodules are Small  Speech Therapy - Micro-LaryngoSurgery (MLS) - Micro-LaryngoSurgery (MLS)
- Micro-LaryngoSurgery (MLS) - Micro-LaryngoSurgery (MLS) with Removal of Polyp with Removal of Lesion
with Stripping of VC ‘either Conventional or Laser’ with Removal of Nodules ‘either Conventional or Laser’ ‘either Conventional or Laser’ ‘either Conventional or Laser’
Followed by Speech Therapy Followed by Speech Therapy Followed by Speech Therapy Followed by Carful Follow-up

Specific [Granuloma] .. Chronic Specific Inflammation characterized by Formation of Macrophages

Laryngo-Scleroma T.B. Laryngitis Syphilis Leprosy
Caused by .. Klebsiella rhinoscleromatis Mycobacterium T.B. Treponema pallidum - Caused by : Mycobacterium leprae
- usually 2ry to Rhinoscleroma - usually 2ry to Pulmonary T.B. - Site : Anterior Part of Larynx
Aetiology - It’s the COMMONEST ENT Granuloma in EGYPT Fungal Infection
- Sub-glottic area (Junctional area between St. Sq. epith. & Resp. epith.) - Posterior Part of the Larynx - Gamma affects Anterior Part of Occur in patients with Low Immunity
Site
it starts as Bi-lateral Nodules then Masses then Web (Inter-arytenoid) Larynx as Diabetics, Prolonged Antibiotic Therapy or AIDS
- Stridor ‘Biphasic’ - Hoarseness - Hoarseness  Moniliasis
- Hoarseness ‘Not Marked’ - Stridor - Stridor - Caused by : Candida albicans
- Crusty Expectoration - Pain referred to the ear - NO Pain - usually associated with Aerodigestive moniliasis
Clinical Picture

‘via Arnold’s of Vaus’ - Characterized by Milky Whitish Membrane

Symp. - Pulmonary T.B.  Cough, Hemoptysis - Treatment : Anti-Fungal as Nystatin
- T.B. Toxemia :
 Night Fever & Night Sweating  Aspergillosis
 Loss of Weight & Loss of Appetite  Actinomycosis
- In-direct Laryngoscopy  Sub-glottic Masses or Web - In-direct Laryngoscopy  - In-direct Laryngoscopy   Perichondritis of the Larynx :
Signs T.B. Granulation Syphilitic Granulation - Def. : Inflammation of the Perichondrium of the Laryngeal Cartilage
in Posterior Part of Larynx in Anterior Part of Larynx - Causes :  Traumatic : Mechanical, Chemical or Physical
 Inflammatory : T.B., Syphilis or Leprosy
Complications Perichondritis  Necrosis of Cartilage  Laryngeal Stenosis  Neoplastic : Cancer Larynx invading Laryngeal Cartilage
- X-ray  Narrow Air Column - Clinical Picture :
 Symptoms : - General : Fever, Headache & Malaise
Investigation - Ct  to show Site, Degree & Length of Stenosis
- Local : Stridor, Hoarseness, Pain in the Neck referred to Eat & Dysphagia
- Direct Laryngoscopy & Biopsy  Russel Bodies & Mikulicz Cells in Active Stage  Signs : - Inspection  Broadening of Larynx
 Medical Treatment : - Tracheostomy.. in Sever Stridor - Tracheostomy.. in Sever Stridor - Palpation  Tenderness
- Rifampicin : 600 mg/day [#Side Effects : Hepatotoxic & Red Discoloration of Urine] + Anti-Tuberculous Treatment : + Anti-Syphilitic Treatment : - Indirect Laryngoscopy  Congested Oedematous Laryngeal Mucosa
- Complications : Necrosis of the Cartilage & Fibrosis  Stenosis
- Streptomycin : 1 gm/day for 40 days [#Side Effects : Ototoxic & Nephrotoxic] as Rifampicin - Isoniazid as Penicillin - Treatment :
Treatment  Surgical Treatment :  Medical : Systemic Parenteral Antibiotics + Analgesic Antipyretics
- Tracheostomy (Low) .. in Sever Stridor  Surgical : - Tracheostomy (Low) .. in Sever Stridor
- Micro-LaryngoSurgery (MLS) & Excision of the Web by Laser - Incision & Drainage of Pus with Removal of Necrosed Cartilage
- Laryngo-Fissure with Removal of Web & Covering the area by Skin Graft - Laryngectomy .. if there is Extensive Necrosis

40- ENT table(27) Larynx3- Chronic Laryngeal Inflammations

 TNM Classification of Cancer Larynx N Staging of Cancer Larynx
T  1ry Tumour
Tis : Carcinoma in Situ
T1 : Tumour Limited to One Area (Supra-, Sub- or Glottic) with Mobile Vocal Cords
T2 : Tumour Extended to More than One Area with Mobile Vocal Cords Palpation
T3 : Tumour Limited to Larynx with Fixed Vocal Cords
T4 : Tumour Extended to Laryngeal Cartilage and/or Extra Laryngeal Spread
N  Lymph Node
No : No Palpable Lymph Nodes
N1 : Single, Ipsi-lateral, 3 cm or Less in diameter If NOT Palpable
N2 : a: Single, Ipsi-lateral, 3-6 cm in diameter If Palpable
b: Multiple, Ipsi-lateral, Non More than 6 cm in diameter
c: Contra-Lateral or Bi-lateral, Non More than 6 cm in diameter
N3 : Node(s) More than 6 cm in diameter
N0
M  Metastasis
Mo : No Distant Metastasis < 6 cm
> 6 cm
N1 : there’s Distant Metastasis

Look to Site
N3

Contra-Lateral or Bi-lateral
Ipsi-lateral
Mostafa Shawky MS

N2 c Look to No. of LNs

Multiple
Single

41- ENT table(28) Larynx4- TNM Classification of Cancer Larynx

N2 b Look to Diameter

≤ 3 cm
3-6 cm

N1 N2 a
 Case Larynx
Vocal Cord Paralysis

Rt. Lt.
you should see the VC & Notice the Mobility of the VC & Determine the Side of Lesion ‘if there’s Lesion’

If there is NO Lesion in VC

The doctor ask patient to Say “AHHH”, then Notice the Movement of the Palate

 Intra-Cranial : If NOT Moved If Moved  Cranial :

- Traumatic : Head Trauma or Car Accident So, it’s SUPRA-Palatal Lesion to Vagus So, it’s INFRA-Palatal Lesion to Vagus - Neoplastic : Carcinoma of the Naso-Pharynx
- Inflammatory : Meningitis or Encephalitis  either in Skull Base or Intra-Cranial  VC Paralysis  Extra-Cranial :
- Neoplastic : Brain Tumour  detected by MRI  in the Neck : - Thyroid Operations (Rt. is More Liable)
- Vascular : Thrombosis, Hemorrhage or Embolism - Cancer Thyroid
- Degenerative : Multiple Sclerosis (MS) - Malignant Lymph Nodes
Rt. Lt.
 Cranial : - Neck Injury
- Thyroid - Chest
- Traumatic : Fracture Base - Cancer Oesophagus
- Apical Lung - Thyroid
- Inflammatory : Malignant Otitis Externa  in the Chest (for Lt. Only) : - Bronchogenic Carcinoma
- Cardiothoracic Operations

If everything is NORMAL

Idiopathic 25%

42- ENT diag.(11) Larynx5- Case Larynx; VC Paralysis

 Multiple Papillomatosis
Single Papilloma
Juvenile Multiple Papillomatosis or Recurrent Respiratory Papillomatosis
Age Adults Children
Sex More in Males ♂
Unknown .. but may be :
- Autoimmune
Causes - Viral (Human Papilloma Virus 6, 11)
- Hormonal Disturbance (Estrogen Deficiency)
 Site : Arises at VC [mainly Glottic]  Site : affecting Any Part of Larynx even Trachea & Bronchi & around the Tracheostomy Opening
Gross Picture
Pathology

Whitish, Warty or Keratotic, Sessile or Pedunculated Multiple Warty Growth, Sessile

Papilloma = Vascular Connective Tissue Core covered by Hyperplastic St. Sq. Epith.  Papilloma but Multiple
Microscopic Picture

- Hoarseness - Stridor
Clinical Picture

Symptoms - if Large  Stridor ‘rare’ - Hoarseness

as gross picture .. seen by In-direct Laryngoscopy as gross picture .. seen by In-direct Laryngoscopy or Flexible Laryngoscopy

Signs

- if there is Sever Stridor  Tracheostomy

- Micro-LaryngoSurgery (MLS) & Removal ‘either Conventional or Laser’ - Micro-LaryngoSurgery (MLS) & Removal ‘either Conventional or Laser’ [the Best ttt]
Treatment - Anti-Viral : Interferon
- Hormonal : Estrogen
Prognosis - Malignant Transformation = 5% [Pre-Cancerous] - Recurrent .. but Spontaneous Regression at Puberty

43- ENT comp.(4) Larynx6- Single Papilloma & Multiple Papillomatosis

 Distinctive Term in Larynx :

 The Only Complete Ring in Respiratory System : Cricoid Cartilage

 Stroposcopy : viewing the Vocal Cord by Flexible Laryngoscopy with Intermittent Flashes of Light Coinciding with Vocal Cord Vibration to see the Mucosal Waves
 Heimlich Maneuver : for Foreign Body (FB) Inhalation
Sudden Compression of the Upper Abdomen & Xiphi-Sternum is done in the Initial Stage of FB Inhalation to Extrude it
 Reinke’s Oedema : Oedema of the Sub-Epithelial Space of the VC
 The Commonest Granuloma in Egypt : Laryngoscleroma .. also, Rhinoscleroma
 The ONLY Abductor ms. of VC [ms. of the Life] : Posterior Crico-arytenoid
 Wagner & Grossman Theory : - Injury of Vagus  Cadaveric Position .. All Muscles’ are Paralyzed
- Injury of RLN  Para-median Position .. as the Crico-thyroid has some Adductor Action & it’s Supplied by SLN
 Tucker’s Operation : for Vocal Cord Paralysis
Re-innervation Procedure in Uni-lateral VC Paralysis “Bi-lateral”
 Woodman’s Operation : for Vocal Cord Paralysis
Arytenoidectomy + Cordopexy ‘Fixation’
 Laryngismus Stridulus : = Laryngeal Spasm (Ca+2 Deficiency in Tetany) .. leads to Stridor

44- ENT table(29) Larynx7- Distinctive Term in Larynx

 Miscellaneous Collections ..
45- ENT table(30) Miscellaneous1- Foreign Body (FB) in ENT
46- ENT table(31) Miscellaneous2- ENT Disease Associated with EYE PROBLEMS
47- ENT table(32) Miscellaneous3- Diseases related to Specific Gender
48- ENT diag.(12) Miscellaneous4- Diabetes
49- ENT diag.(13) Miscellaneous5- Triads in ENT
50- ENT diag.(14) Miscellaneous6- Combined Treatment in ENT
51- ENT table(33) Miscellaneous7- Investigations Collection
52- ENT diag.(15) Miscellaneous8- caused by .. Dental Problems
53- ENT diag.(16) Miscellaneous9- Systemic Antibiotics those ‘Cross Blood Brain Barrier’ .. used in
54- ENT table(34) Miscellaneous10- T.B., Syphilis, Leprosy .. in Nose & Larynx
55- ENT diag.(17) Miscellaneous11- Re-gressive Dysphagia
56- ENT table(35) Miscellaneous12- Diseases Caused by Organisms
57- ENT diag.(18) Miscellaneous13- Pallor Patient
58- ENT diag.(19) Miscellaneous14- Pre-Cancerous Lesions
59- ENT diag.(20) Miscellaneous15- Steroids .. used in ttt of
 Foreign Body (FB) in ENT
in Ear in Nose
Type of Patient : Child or Mentally Retarded Adult
 Animate : Flies - Vegetable as Beans & Seeds
Type of FB :  In-animate : - Vegetable as Beans & Seeds - Non-Vegetable as Beads, Cotton & Paper
- Non-Vegetable as Beads, Cotton & Paper
- History of FB Insertion - Symptoms :
- Irritation & Noise ‘in Animate FB’  Uni-lateral Nasal Obstruction
- Closure of E.A.C.  CHL  growth of Anaerobic Bacteria  Uni-lateral Offensive Nasal Discharge
Clinical Picture : N.B. FB Should be Suspected in any Child with Uni-lateral Nasal Obstruction & Offensive Discharge
- Signs :
 Anterior Rhinoscopy  shows FB or Discharge
 Nasal Endoscopy ‘Sometimes’ is needed
- Injury  to E.A.C. or Drum - Nasal :  Early  Infections (Rhinitis & Sinusitis)
Complications : - Infection  to E.A.C. [Otitis Externa]  Late  Stone Formation (Rhinolith)
or Middle Ear ‘if the drum Ruptured’ [Otitis Media] - Pulmonary : FB Inhalation & Respiratory Obstruction
 Animate FB  Killed 1st by Oil Drops .. then Ear Wash  if the Child is Cooperative  Removal by Forceps, Hook or Suction
 In-animate : - Vegetable  Removed by Hook or Suction  if the Child is NOT Cooperative  Removal under General Anaesthesia with Cuffed Endo-tracheal Intubation
Treatment : (NEVER use Ear Wash, as it Swells with water) (to Prevent FB Inhalation during the procedure)
- Non-Vegetable  Removed by Ear Wash, Hook or Suction
N.B. if the Child NOT Cooperative  you should use General Anaesthesia
in Oesophagus in Larynx
Type of Patient : - Coins  in Children More Common in Children
- Fish or Meat Bone  in Adults  Exogenous FB : - Vegetable as Water Melon Seeds & Beans
- Denture  in Old Age - Non-Vegetable as Pins & Beads
- Razors or Pins  in Prisoners & Mentally Retarded Patients  Endogenous FB: - Vomitus or Blood
Type of FB :  Site of Impaction :
- Below the Crico-Pharyngeal Sphincter .. at the Upper End of the Oesophagus
- at the Sites of Constrictions
- Dysphagia  Initial Stage :
- Regurgitation - a history of Attacks of Coughing, Chocking, Dyspnea & Cyanosis in Young Child is Suspicious of FB Inhalation
- ‘Retro-Sternal’ Pain  Latent Stage:
N.B. a Coin may be Remain Latent for Weeks or even Months Period with NO Symptoms ..
- Vegetable FB  soon causes Acute Vegetal Bronchitis as “Allergic Reaction” to the Vegetable Oil
- Metallic FB  may Remain Latent for Longer Period
 Manifest Stage:
Clinical Picture : - FB in Rt. Bronchus .. causing
Complete Obstruction or Partial Valvular Obstruction
The patient presented with Dyspnea +
 Complete Obstruction  leads to Lung Collapse :  Partial Valvular Obstruction  leads to Emphysema :
 Percussion  Dullness  Percussion  Hyper-Resonance
 Shift of Mediastinal  to Same Side  Shift of Mediastinal  to Opposite Side
 Auscultation  No Air Entry  Auscultation  Diminished Air Entry
- Plain X-ray  to show Radio-Opaque FB - X-ray .. may show :  Radio-Opaque FB
- Barium Swallow  to show Radio-Lucent FB  Collapse
Investigations : - Oesophagoscopy  Emphysema
- Bronchoscopy : is Diagnostic to see FB
- Oesophagoscopy & Removal - Removal by Bronchoscopy under Special Technique of Anaesthesia
( Because the Air-way is Shared between Anaesthetics & Otolaryngoscopy
Treatment : or Because the Air-way is Occupy by the Endo-tracheal Tube with No Possibility to Accommodate the Bronchoscope Beside)
N.B. Heimlich Maneuver :
Sudden Compression of the Upper Abdomen & Xiphi-Sternum is done in the Initial Stage of FB Inhalation to Extrude it

45- ENT table(30) Miscellaneous1- Foreign Body (FB) in ENT

 ENT Disease Associated with EYE PROBLEMS ..
In the EAR
- Petrositis  Diplopia & Squint
- Labyrinthitis  Nystagmus
- Lateral Sinus Thrombo-Phlebitis Proptosis, Chemosis, Ophthalmoplegia, Diminution of Vision & Oedema of Eye Lid
- Temporal Lobe Abscess  Homonymous Hemianopia
- Cerebral Abscess  Nystagmus
- Meningitis  Blurring of Vision ( I.C.T.) & Photophobia (Meningeal Irritation)
- Acoustic Neuroma  Loss of Corneal Reflex & Nystagmus
46- ENT table(31) Miscellaneous2- ENT Disease Associated with EYE
In the NOSE PROBLEMS
- Mucor-mycosis (Invasive)  Proptosis, Ophthalmoplegia, Chemosis & Diminution of vision
- ORBITAL COMPLICATIONS OF SINUSITIS (see page 75 & 76 in Dr. Mosaad’s Book)
- Osteoma  Proptosis
- Fibrous Dysplasia  Proptosis
- Malignant Tumours of Nose  (Local Spread Up-wards) Proptosis, Diplopia, Ophthalmoplegia & Diminution of Vision
- Mucocele  Proptosis (Down-wards & Laterally in Frontal Mucocele & Laterally in Ethmoidal Mucocele)
In the Pharynx
- Diphtheria  Ocular Paralysis .. [Intrinsic .. Loss of Accommodation // Extrinsic .. Diplopia & Squint]
- Naso-Pharyngeal Carcinoma  Squint, Diplopia & Ophthalmoplegia

Diseases related to Specific Gender

Male ♂  Age Female ♀  Age
 in Ear - Meniere’s Diseases (Endolymphatic Hydrops) Old , above 50 Y - Otosclerosis Middle Age
Malignant Tumours in the Nose Old , above 60 Y - Chronic Atrophic Rhinitis
 in Nose - Rhinoscleroma starts 15-25 Years
- Fibrous Dysplasia *Albright Syndrome Teen-agers
- Juvenile Naso-Pharyngeal Angiofibroma around 12 Years - Plummer – Vinson’s Syndrome
- Naso-Pharyngeal Carcinoma Old , above 60 Y, < Chinese - Achalasia of the Cardia Middle Age, Neurotic
 in Pharynx & Oesophagus - Oro- Pharynx Malignant Tumour Old , above 60 Y
- Hypo- Pharynx Malignant Tumour Old , above 60 Y
- Cancer Oesophagus Old
- Single Papilloma Adults
 in Larynx - Juvenile Multiple Papillomatosis Children
- Cancer Larynx Old , above 40 Y

47- ENT table(32) Miscellaneous3- Diseases related to Specific Gender

 EAR Diseases :
- Localized O.E.(Furuncle)
- Diffuse O.E.
- Malignant O.E. (Skull Base Osteo-myelitis)
- Petrositis
Nose Diseases :
- Furunculosis
- Fungal Infection : 1- Mycetoma
2- Indolent Form
Diabetes
3- Allergic Fungal Sinusitis
4- Mucor-mycosis (Invasive)
Pharynx Diseases :
- Moniliasis
Larynx Diseases :
- Fungal Infection : 1- Moniliasis
2- Aspergillosis
3- Actinomycosis

48- ENT diag.(12) Miscellaneous4- Diabetes

 Gradenigo’s Triad  Petrositis

- Discharging Ear
- Diplopia & Squint (6th n. affection)
- Facial Pain (5th n. affection) “also called Trigeminal Facial Pain”
Triads
in ENT  Beck’s Triad  Para-Pharyngeal Abscess
- Internal Swelling : swelling Lateral to the Tonsil & Pushing the Tonsil Medially
- External Swelling : Below & Behind the Angle of the Mandible deep to the Anterior Border of Sternomastoid
- Trismus

 Trotter’s Triad  Naso-Pharyngeal Carcinoma

- Uni-lateral Facial Pain (Trigeminal Nerve)
- Uni-lateral Palatal Immobility “due to Fixation of ms. & NOT to Nerve Paralysis”
- Uni-lateral Conductive Deafness

48- ENT diag.(13) Miscellaneous5- Triads in ENT

 Malignant Tumour in the Nose : [Surgery & Radiotherapy]
 Curative : - Surgery
- Post-Operative Radiotherapy
Combined Treatment - Chemotherapy .. may be used
in ENT  Palliative : -Pain Killers (Analgesics)
- Palliative Surgery
- Palliative Radiotherapy & Chemotherapy
N.B. Palliative Treatment is Indicated in Extensive Tumours with Intra-cranial Extension or Distant Metastasis

# Curative Treatment :
1- for 1ry Tumour :
 Surgery - in Localized Tumour Involving Medial Wall Medial Maxillectomy .. through Moure’s Lateral Rhinotomy
- in Localized Tumour Involving Inferior Wall Palatal Resection .. through Sub-Labial Incision
- in Large Tumour Involving the Whole Maxilla Total Maxillectomy .. through Weber-Ferguson Incision
- if Involves the Orbit or its Peri-osteum  Orbital Exenteration
- if it Reaches to the Roof of the Nose Cranio-Facial Resection
Cancer Larynx (according to stage) : [Surgery & Radiotherapy]
 Post-Operative Radiotherapy
 Curative : - Surgery
- Radiotherapy
2- for Lymph Nodes (LNs)  Radical Neck Dissection ‘if there’s LNs Enlargement’
 Palliative : - Pain Killers (Analgesics)
- Surgery as Tracheostomy for respiration
Malignant Tumour in Hypo-Pharynx : [Surgery & Radiotherapy]
& Gastrostomy for feeding
 Curative : - Surgery
- Radiotherapy
- Post-Operative Radiotherapy
N.B. Palliative Treatment is for Extensive Tumours FIXED to Vertebral Column and/or with Distant Metastasis
 Palliative : - Radiotherapy
- Chemotherapy
# Curative Treatment :
- Surgery as Tracheostomy for respiration
1- for 1ry Tumour :
& Gastrostomy for feeding
 Glottic Tis :  Surgery : Micro-LaryngoSurgery (MLS) with Conventional Removal OR Laser (Surgery is BETTER) - Pain Killers (Analgesics)
OR Radiotherapy - Adequate Feeding
T1 :  Surgery : Laser Excision OR Laryngo-Fissure & Cordectomy N.B. Palliative Treatment is for Extensive Tumours FIXED to Vertebral Column and/or with Distant Metastasis
OR Radiotherapy (Voice is BETTER)
T2 :  Surgery : Partial Laryngectomy # Curative Treatment :
OR Radiotherapy
1- for 1ry Tumour :
T3, T4 :  Surgery : Total Laryngectomy AND Radiotherapy
 Supra-Glottic T1, T2 :  Surgery : Partial Laryngectomy OR Radiotherapy  Surgery - Total Pharyngo Laryngectomy ± Oesophagectomy
T3, T4 :  Surgery : Total Laryngectomy AND Radiotherapy  Post-Operative Radiotherapy
 Sub-Glottic
 Surgery : Total Laryngectomy AND Radiotherapy
 Trans-Glottic 2- for Lymph Nodes (LNs)  Radical Neck Dissection ‘if there’s LNs Enlargement’

2- for Lymph Nodes (LNs)  Radical Neck Dissection ‘if Palpable’  Re-Construction After Total Pharyngo-Laryngoectomy : by one of .. - Stomach Pull-up (the BEST)
 Selective Neck Dissection or Radiotherapy .. esp. in Supra-Glottic Carcinoma ‘if NOT Palpable’ - Free Radial Forearm Flap

Sq. Cell Carcinoma of M.E. Radical Mastoidectomy + Radical Neck Dissection ‘if LNs Enlargement + Radiotherapy

N.B. Cancer Oesophagus may need Combined Treatment in Operable Cases

50- ENT diag.(14) Miscellaneous6- Combined Treatment in ENT

 - Meatal Atresia - Labyrinthitis - Fracture Base of the Skull (Temporal Bone)
- Malignant OE (Skull Base Osteomyelitis) - Lateral Sinus Thrombo-Phlebitis - Glomus Tumour (Chemodectoma – Paraganglioma)
- Un-Safe C.O.S.M. (Attico-antral or Bony C.O.S.M. – Cholesteatoma) - Extra-dural Abscess - Squamous Cell Carcinoma of Middle Ear
 in Ear
- Acute Mastoiditis - Brain Abscess - Acoustic Neuroma (Vestibular Schwannoma)
- Facial Nerve Paralysis & Bell’s Palsy - Meningitis - Traumatic Facial Nerve Paralysis
- Petrositis - Meniere’s Disease (Endolymphatic Hydrops)
- Choanal Atresia - Antro-Choanal Polyp - Inverted Papilloma (Schniederian or Transitional Cell Papilloma)
CT - Oro-Antral Fistula - Osteomyelitis of Frontal Bone - Malignant Tumour of the Nose
- CSF Rhinorrhoea - Cavernous Sinus Thrombosis - Dentigerous Odontogenic Cysts
 in Nose
- Acute Sinusitis - Adamantinoma - Dental Odontogenic Cysts
- Allergic (Ethmoidal) Polyps - Fibrous Dysplasia - Muco-cele
- Chronic Sinusitis
- Para-Pharyngeal Abscess - Chronic Retro-Pharyngeal Abscess - Naso-Pharyngeal Carcinoma - Hypo-Pharynx Malignant Tumours
 in Pharynx & Oesophagus
- Acute Retro-Pharyngeal Abscess - Juvenile Naso-Pharyngeal Angiofibroma - Oro-Pharynx Malignant Tumours - The Occult Primary
 in Larynx - Laryngeal Trauma - Laryngo-Scleroma - Vocal Cord Paralysis - Laryngeal Stenosis - Cancer Larynx
- Un-Safe C.O.S.M. (Attico-antral or Bony C.O.S.M. – Cholesteatoma) - Secretory O.M.
 in Ear
- Safe C.O.S.M. (Tubo-tympanic or Mucosal C.O.S.M.) - Acute Mastoiditis
- Choanal Atresia - Oro-Antral Fistula - Chronic Sinusitis - Adamantinoma - Fibrous Dysplasia - Dental Odontogenic Cysts
 in Nose - Fracture Nasal Bones - Acute Sinusitis - Antro-Choanal Polyp - Osteoclastoma - Dentigerous Odontogenic Cysts - Muco-cele
X-ray - Osteoma
- Adenoid - Acute Retro-Pharyngeal Abscess - Hypo-Pharynx Malignant Tumours - Foreign Body (FB) in Oesophagus
 in Pharynx & Oesophagus
- Plummer – Vinson’s Syndrome - Chronic Retro-Pharyngeal Abscess - The Occult Primary
 in Larynx - Foreign Body (FB) in Larynx - Laryngeal Stenosis - Laryngo-Scleroma
 X-ray used for Metastatic Work-up in Lung
- Lateral Sinus Thrombo-Phlebitis - Facial Nerve Paralysis & Bell’s Palsy - Fracture Base of the Skull (Temporal Bone) - Acoustic Neuroma (Vestibular Schwannoma)
 in Ear
MRI - Squamous Cell Carcinoma of Middle Ear - Brain Abscess - Glomus Tumour (Chemodectoma – Paraganglioma)
&  in Nose - Cavernous Sinus Thrombosis - Malignant Tumour of the Nose
MRA  in Pharynx & Oesophagus - Juvenile Naso-Pharyngeal Angiofibroma - Oro-Pharynx Malignant Tumours - Naso-Pharyngeal Carcinoma
 in Larynx
 in Ear
 in Nose
Barium - Plummer – Vinson’s Syndrome - The Occult Primary - Achalasia of the Cardia
Swallow  in Pharynx & Oesophagus - Pharyngeal Pouch (Zenker’s Diverticulum) - Foreign Body (FB) in Oesophagus
- Hypo-Pharynx Malignant Tumours - Corrosive Oesophagitis ‘Chronic Stage’
 in Larynx - Vocal Cord Paralysis

Gallium & Technetium Scan used ONLY in ..  Malignant OE (Skull Base Osteomyelitis)
+ve Tobey-Ayer’s Test used ONLY in ..  Lateral Sinus Thrombo-Phlebitis
Pan-Endoscopy used ONLY in ..  The Occult Primary & Vocal Cord Paralysis
Polysomnography used ONLY in ..  Sleep Apnea

51- ENT table(33) Miscellaneous7- Investigations Collection


caused by .. Dental Problems
EAR Diseases :
- Dental Caries + Impacted Wisdom Tooth  Referred Pain to the Ear
- TMJ Arthritis + Impacted Wisdom Tooth  Tinnitus without deafness
Nose Diseases :
- Dental Extraction (2nd Premolar or 1st Molar)  Oro-Antral Fistula
- Dental Caries + Oro-Antral Fistula  Maxillary Sinusitis
- Dental Caries or Peri-Apical Abscess  Headache & Facial Pain
Pharynx Diseases :
- Mal-directed Tooth  Traumatic Ulcers ‘Mechanical’
- Dental Infection  Ludwig’s Angina
- Dental Caries  Foetor Oris (Halitosis)

52- ENT diag.(15) Miscellaneous8- caused by .. Dental Problems

EAR Diseases :
- Labyrinthitis :  Chloramphenicol or Cefuroxime
- Brain Abscess :  Sulphonamide I.V. drips
 Chloramphenicol I.V. or I.M.
 3rd ot 4th Generation Cephalosporin I.V. or I.M.
 Metronidazole I.V. drips
Systemic Antibiotics those ‘Cross Blood Brain Barrier’ .. used in
- Meningitis :  same as Brain Abscess 
- Fracture Base of the Skull
- Trauma to the Inner Ear
Nose Diseases :
- CSF Rhinorrhoea : to prevent Meningitis
- Cavernous Sinus Thrombosis : I.V.

53- ENT diag.(16) Miscellaneous9- Systemic Antibiotics those ‘Cross Blood Brain Barrier’ .. used in

(Lupus), (T.B.) Syphilis Leprosy

in Nose Lupus  in Anterior Part of Nasal Septum in Posterior Part of Nasal Septum in Anterior Part of Nasal Septum
in Larynx T.B.  in Posterior Part of Larynx in Anterior Part of Larynx in Anterior Part of Larynx

54- ENT table(34) Miscellaneous10- T.B., Syphilis, Leprosy .. in Nose & Larynx
 All Dysphagia are Pro-gressive
Starts for Solids than Fluids

EXCEPT
Achalasia of the Cardia
Re-gressive Dysphagia
More for Fluids than Solids Bi-lateral Pharyngeal Paralysis

55- ENT diag.(17) Miscellaneous11- Re-gressive Dysphagia

Diseases Caused by Organisms ..

Bacterial Viral Fungal
- Staphylococcal  Localized O.E. (Furuncle) - Herpes Simplex Virus  Herpes Simplex - Aspergillus Niger + Candida Albicans  O.E. Otomycosis
- Diffuse O.E. - Herpes Zoster Virus  Herpes Zoster & Ramsay-Hunt Syndrome
in Ear

- Pseudomonas Aureginosa  Malignant O.E. (Skull Base Osteomyelitis) - Bollous Myringitis

- Streptococcus pneumoniae & Haemophilus influenzae & Moraxella catarrhalis  Acute Otitis Media (A.O.M.)
- Gram +ve (Staph., Strept.) + Gram –ve (Pseudomonas, Proteus) + Anaerobes (Bacteroides)  Brain Abscess
- Staphylococcal  Furunculosis - Rhinoviruses ‘more than 100 types’  Common Cold (Coryza) - Mycetoma
- Vestibulitis - Influenza Virus ‘type A, B & C’  Influenza - Indolent Form
- Corynebacterium diphtheriae Nasal Diphtheria (2ry to Pharyngeal Diphtheria) - Aspergillus  Allergic Fungal Sinusitis
in Nose

- Klebsiella ozaenae  Chronic Atrophic Rhinitis - Mucor-mycosis (Invasive)

- Klebsiella rhinoscleromatis  Rhinoscleroma
- attenuated T.B. bacilli  Lupus
- Treponema pallidum  Syphilis
- Mycobacterium leprae  Leprosy
- Streptococcus pneumoniae & Haemophilus influenzae & Moraxella catarrhalis  Acute Sinusitis
- Beta-hemolytic Streptococci  Tonsillitis - Epstein Barr Virus  Infectious Mononucleosis - Candida Albicans  Moniliasis
- Corynebacterium diphtheriae Pharyngeal Diphtheria - Epstein Barr Virus  PF for Naso-Pharyngeal Carcinoma
in Pharynx

- Borrelia vincenti & Fusiform bacilli Vincent’s Angina (Trench Mouth) - Herpes Simplex Virus  Acute Inflammatory Stomatitis
- Klebsiella rhinoscleromatis  Pharyngoscleroma (2ry to Rhinoscleroma) - Herpes Zoster Virus  Acute Inflammatory Stomatitis
- mycobacterium T.B.  T.B. (2ry to Pulmonary T.B.) - Coxsakie Virus (Herpangina) Acute Inflammatory Stomatitis
- Treponema pallidum  Syphilis
- mycobacterium T.B.  Chronic Retro-Pharyngeal Abscess (Cold Abscess, Pott’s Disease)
- Corynebacterium diphtheriae Laryngeal Diphtheria (2ry to Pharyngeal Diphtheria) - Acute Laryngo Tracheo-Bronchitis - Candida Albicans  Moniliasis
Haemophilus influenzae  Acute Epiglottitis (Supra-glottitis) - Human Papilloma Virus  Juvenile Multiple Papillomatosis - Aspergillosis
in Larynx

- Klebsiella ozaenae  Chronic Atrophic Laryngitis (2ry to Atrophic Rhinitis) - Actinomycosis

- Klebsiella rhinoscleromatis  Laryngoscleroma (2ry to Rhinoscleroma)
- mycobacterium T.B.  T.B. Laryngitis (2ry to Pulmonary T.B.)
- Treponema pallidum  Syphilis
- Mycobacterium leprae  Leprosy

56- ENT table(35) Miscellaneous12- Diseases Caused by Organisms

 EAR Diseases :
- Lateral Sinus Thrombophlebitis
Pallor Patient
Pharynx Diseases :
- Plummer – Vinson’s Syndrome
- Juvenile Naso-Pharyngeal Angiofibroma
- Hypo- Pharynx Malignant Tumour

57- ENT diag.(18) Miscellaneous13- Pallor Patient

Pharynx Diseases :
- Plummer – Vinson’s Syndrome
Pre-Cancerous Lesions
Larynx Diseases :
- Leukoplakia
- Single Papilloma

58- ENT diag.(19) Miscellaneous14- Pre-Cancerous

Lesions

EAR Diseases :
- Localized O.E.
- Diffuse O.E.
- Secretory Otitis Media
- Brain Abscess
- Meningitis
- Fracture Base of the Skull
- Idiopathic Facial Paralysis (Bell’s Palsy)
Steroids .. used in ttt of - Traumatic Facial Paralysis
Nose Diseases :
- Orbital Complications of Sinusitis
‘if there is Diminution of Vision’
- Allergic Rhinitis
Pharynx Diseases :
- Corrosive Oesophagitis ‘Acute Stage’
Larynx Diseases :
- Laryngeal Trauma
- Acute Non-Specific Laryngitis
- Laryngeal Oedema

59- ENT diag.(20) Miscellaneous15- Steroids .. used in ttt of