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2 Short Cut of ENT i

3 Publishing-in-support-of, EDUCREATION PUBLISHING RZ 94, Sector - 6, Dwarka, New Delhi Shubham Vihar, Mangla, Bilaspur, Chhattisgarh Website: Copyright, Authors All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form by any means, electronic, mechanical, magnetic, optical, chemical, manual, photocopying, recording or otherwise, without the prior written consent of its writer. ISBN: Price: ` The opinions/ contents expressed in this book are solely of the authors and do not represent the opinions/ standings/ thoughts of Educreation or the Editors. The book is released by using the services of self-publishing house. Printed in India ii

4 SHORT CUT of ENT MS Ansari EDUCREATION PUBLISHING (Since 2011) iii

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6 How to Study this Book? Everyone studies but everyone don t gets expected result, because it requires smart study. Smart study gives better result with less efforts. SHORT CUT is designed taking care of rule (Pareto principle). This rule indicates that effort to be done is as low as 20% to get up to 80% result. It applies in all aspects when it comes to smart management. Here I give you refined 20% extract of subject in this book, so that you can score up to 80%. This book contains Important Questions with their answers that are frequently asked in exams. Book covers all the points that need to be pondered in last minute study before the exam. Book will maximally benefit you if used after reading the text from standard book for complete understanding. v

7 Index Sr. Content Page 1. EAR 1 2. NOSE LARYNX & PHARYNX 78 vi

8 Short Cut - of ENT EAR LONG QUESTIONS- 1) Acute Mastoiditis aetiology, clinical features & management. Inflammation of mucosal lining of antrum and mastoid air cell system is an invariable accompaniment of acute otitis media and forms a part of it Aetiology- Children are affected more; usually accompanies or follows acute suppurative otitis media; Betahaemolytic streptococcus is the more causative organism. Clinical features- Symptomsi. Pain behind ear- persistence of pain, increase its intensity or recurrence of pain (acute otitis media) ii. Fever- persistence or recurrence of fever in a case of acute otitis media iii. Ear discharge- Profuse and increases in purulence. Any persistence of discharge beyond 3 weeks, in a case of acute otitis media, point to Mastoiditis. Signi. Mastoid tenderness (important sign) ii. Ear discharge- Mucopurulent or purulent discharge, often pulsatile (light-house effect). iii. Sagging of posterosuperior meatal wall. iv. Perforation of TM. v. Swelling over the mastoid. vi. Hearing loss. vii. General finding- Patient appears ill and toxic with low grade fever, (children, high fever with rise in pulse rate). Management- Investigationi. Blood count- polymorphonuclear leukocytosis. ii. Erythrocyte sedimentation rateraised. iii. X-ray mastoid- clouding of air cells, bony partitions b/w air cells become indistinct, but the sinus plate is seen as a distinct outline. Later stage, cavity may be seen in mastoid. Differential Diagnosisi. Suppuration of mastoid lymph nodes ii. Furunculosis of meatus. iii. Infected sebaceous cyst. Treatmenti. Hospitalization of the patient. ii. Antibiotics- start with amoxicillin or ampicillin (in the absence of culture and sensitivity). For anaerobic organisms (often present), chloramphenicol or metronidazole is added. Specific antimicrobial is started on the receipt of sensitivity report. iii. Myringotomy- when pus is under tension. iv. Cortical mastoidectomy- indicated when there is a. Subperiosteal abscess. b. Sagging of posteriosuperior meatal wall. 1

9 MS Ansari c. Positive reservoir sign, i.e. meatus immediately fills with pus after it has been mopped out. d. No change in condition of patient or it worsens. e. Complications, e.g. facial paralysis, labyrinthitis, intracranial complication, etc. 2) Acute otitis media (ASOM) - aetiology, clinical features, management & complication. It is acute inflammation of middle ear by pyogenic organisms. Aetiology- more common in infants and children of lower socioeconomic gp. Follows viral infection of URT, but soon the pyogenic organism invade the middle ear. Route of infection- via eustachian tube, external ear and blood-borne. Predisposing factors- recurrent attack of common cold, URI, infections of tonsils and adenoids, chronic rhinitis and sinusitis, tumours of nasopharynx, packing of nose or nasopharynx for epistaxis and Cleft palate. Clinical featuresi. Stage of tubal occlusion- Symptoms- Deafness and earache (not marked), no fever Sign- TM is retracted, Tuning for tests show conductive deafness. ii. Stage of presuppuration- Symptoms- marker earache (throbbing nature, disturbed sleep), Deafness and tinnitus also present (complained by adult), high degree of fever and restless (in child) Sign- congestion of pars tensa, leash of blood vessels appear along the handle of malleus and at the periphery of TM (cart-wheel appearance) iii. Stage of suppuration- Symptoms- earache become excruciating, deafness increases. Child run fever of May accompanied by vomiting and convulsions. Signs- TM appears red and bulging with loss of landmarks, A yellow spot may be seen on the TM where rupture is imminent. X-ray of mastoid clouding of air cells (exudate). iv. Stage of resolution- Symptoms- with evacuation of pus, earache is relieved, fever comes down and child feels better. Signs- External auditory canal may contains blood-tinged discharge (which later become Mucopurulent) v. Stage of complication- May lead to a. acute mastoiditis b. subperiosteal abscess. c. facial paralysis d. labyrinthitis e. Petrositis f. extradural abscess g. meningitis h. brain abscess or lateral sinus thrombophlebitis. Treatmenti. Antibacterial therapy- S. pneumoniae and H. influenzae (most common) ampicillin (50 mg/kg/day in four divided dose) and amoxicillin (40 mg/kg/day in three divided dose). 2

10 Those allergic to penicillin- cefaclor, co-trimoxazole or erythromycin. β-lactamase-producing H. influenzae or M. catarrhalis amoxicillin clavulanate, Augmentin, cefuroxime axetil or cefixime may be used. Antibacterial therapy must be continued for a min. of 10 days. ii. Decongestant nasal drops- Ephedrine nose drops (1% in adults and 0.5% in children) or oxymetazoline (Nasivion) or xylometazoline (Otrivin). iii. Oral nasal decongestants- Pseudoephedrine (Sudafed) 30mg twice daily or a combination of decongestant and antihistamine (Triominic). iv. Analgesics and antipyretics- Paracetamol v. Ear toilet vi. Dry local heat- relieve pain vii. Myringotomy- indicated when a. drum is bulging and there is acute pain b. incomplete resolution despite antibiotics (drum remains full with persistent conductive deafness) c. there is persistent effusion beyond 12 weeks. 3) Chronic otitis media (CSOM) - aetiology, clinical features, management & complication. CSOM is a long standing infection of a part or whole of the middle ear cleft characterized by ear discharge and a permanent perforation. Types- 1. Tubotympanic; 2. Atticoantral 1. Tubotympanic Aetiology- Short Cut - of ENT i. It is sequelae of acute otitis media ii. Ascending infection via eustachian tube iii. Persistent mucoid otorrhea. C/Fi. Ear discharge- nonoffensive, mucoid or Mucopurulent, constant or intermittent. ii. Hearing loss- conductive type; severity varies but rarely exceed 50dB. Paradoxical effect i.e. hears better in the presence of discharge than the ear dry.( round window shielding effect). In long standing cases cochlea may suffer damage due to absorptions of toxins from the oval and round windows and hearing loss becomes mixed type. iii. Perforation- Always central (lie anterior, posterior or inferior to the handle of malleus). iv. Middle ear mucosa- seen when the perforation is large. Normally, pale pink or moist; when inflamed it looks red, oedematous and swollen. Management- Investigationsi. Examination under microscopeprovide useful information regarding presence of granulations, in-growth of squamous ep. From the edges of perforation, status of ossicular chain, Tympanosclerosis and adhesion. ii. Audiogram- degree of HL and its type. iii. Culture and sensitivity of ear discharge. iv. Mastoid X-ray/CT scan temporal bone- Mastoid is usually sclerotic but may be pneumatized with clouding of air cells. 3

11 MS Ansari Treatmenti. Aural toilet ii. Ear drop- Antibiotic ear drops containing neomycin, polymyxin, chloromycetin or gentamicin are used three or four times a day. Combined with steroids for local antiinflammatory effect. Acid ph helps to eliminate pseudomonas infection (irrigation with 1.5% acetic acid). iii. Systemic antibiotics- for acute exacerbation of chronically infected ear. iv. Precautions- keep water out of the ear, hard nose blowing should be avoided. v. Treatment of contributory cause vi. Surgical treatment- Aural polyp or granulations, if present, should be removed before local treatment with antibiotics. An aural polyp should never be avulsed. vii. Reconstructive surgery- Once ear is dry, myringoplasty with or without ossicular reconstruction can be done to restore hearing. 2. Atticoantral type- Is also called unsafe or dangerous type. Aetiology- Same as cholesteatoma C/F- Symptomsi. Ear discharge- usually scanty, but always foul-smelling due to bone destruction. ii. Hearing loss- HL is mostly conductive but sensorineural element may be added. Cholesteatoma hearer. iii. Bleeding- from granulations or the polyp when cleaning the ear. Signsi. Perforation- either attic or posterosuperior marginal type ii. Retraction pocket- An invagination of TM is seen in the attic or posterosuperior area of pars tensa. Stage - a. Stage I- TM is retracted but does not contact the incus b. Stage II- TM is retracted deep and contact the incus; middle ear mucosa is not affected. c. Stage III- also called middle ear atelectasis. Middle ear is totally or partially obliterated but middle ear mucosa is intact. d. Stage IV- also called adhesion otitis media.tm is very thin and wraps the promontory and ossicles. There is no middle ear space; mucosa lining of the middle ear is absent and TM gets adherent to the promontory. iii. Cholesteatoma- Pearly white flakes of cholesteatoma can be sucked form the retraction pockets. Management- Investigationi. Examination under microscopereveal presence of Cholesteatoma, its site and extent, evidence of bone destruction, granulation, condition of ossicles and pockets of discharge. ii. Tuning fork tests and audiogramessential for preoperative assessment, to confirm the degree and type of HL. iii. X-ray mastoid/ct scan temporal bone- indicate extent of bone destruction and degree of mastoid pneumatization. iv. Culture and sensitivity of ear discharge. 4

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