ENT CASES

(1)

A 24 year old male patient presented because of severe pain in the throat and the left ear that increased with swallowing of sudden onset and 2 days duration. He gave a history of sore throat and fever a few days prior to the condition. On examination, the patient looked very ill and has a thickened voice. The temperature was 39.5 C and the pulse 110/minute. The patient had fetor of the breath and was unable to open his mouth. There was marked edema of the palate concealing the left tonsil that was found injected. There was a painful hot swelling located below the left angle of the mandible. The left tympanic membrane was normal

Diagnosis & reasons

Acute tonsillitis (sore throat and fever) complicated by peritonsillar abscess {quinzy} (severe throat pain referred to the left ear, very ill, thickened voice, fever, fetor, unable to open his mouth, edema of the palate, painful hot swelling at the angle of the mandible)

Explain the following manifestations

Pain in the left ear: refeered earache along Jackobsen’s tympanic branch (that supplies the middle ear) of the glossopharyngeal nerve (that supplies the palatine tonsil)

Thickened voice: due to palatal edema

Fetor of the breath: severe dysphagia leading to inability to swallow saliva together with the presence of an abscess in the oropharynx

Unable to open his mouth: trismus due to irritation of the medial pterygoid muscle by the pus under tension in the peritonsillar abscess

Left tonsil injected: markedly congested due to severe inflammatory process

Hot swelling below the left angle of the mandible: jugulodigastric lymph adenitis

Normal tympanic membrane: there is no acute otitis media pain in the ea is referred from the throat

Further examination &/or investigations

• Complete blood picture lecocytosis

• CT scan

Treatment

Medical treatment: antibiotics, analgesics, antipyretics and antiinflammatory drugs

Surgical drainage of the quinzy (pus pointing, palatal edema, throbbing pain, pitting edema)

Tonsillectomy after 2-3 weeks

(2)

A 5 year old boy was referred to an ENT specialist because of mouth breathing and impairment of hearing of 2 years duration. His mother reported that her child has almost constant mucoid nasal discharge that sometimes changes to a mucopurulent one and he snores during his sleep. On examination, the child has nasal speech and obvious mouth breathing. Examination of the ears showed retracted tympanic membranes. Tympanograms were flat type B.

Diagnosis & reasons

Adenoid enlargement (mouth breathing, nasal discharge, snoring, nasal speech) complicated by bilateral otitis media with effusion (impairement of hearing, retracted tympanic membranes type B tympanograms)

Explain the following manifestations

Mucoid nasal discharge that can change to be mucopurulent: adenoid enlargement may be complicated by ethmoiditis causing the mucopurulent nasal discharge

Snoring: due to bilateral nasal obstruction during his sleep can progress to respiratory obstruction during his sleep (sleep apnea)

Nasal speech: rhinolalia clausa due to nasal obstruction were the letter m is pronounced as b

Type B tympanograms: due to presence of fluid behind the intact retracted tympanic membrane leading to no vibrations of the drum

Further examination &/or investigations

• Other symptoms and signs: adenoid face, stunted growth, poor scholastic achievement, nocturnal enuresis,……

• X-ray lateral view skull: soft tissue shadow in the nasopharynx causing narrowing of the nasopharyngeal airway

• Audiogram: air bone gap indicating conductive hearing loss

Treatment

Adenoidectomy

Bilateral ventillation tube (grommet) insertion in the tympanic membranes

(3)

A male patient 49 year old presented with the complaint of enlargement of the upper deep cervical lymph nodes on both sides of the neck of 6 months duration. The nodes appeared first on the right side later on the other side. The patient gave a history of decreased hearing in the right ear that was intermittent but later became permanent. Recently he developed diminution of hearing in his left ear, nasal regurge, nasal intonation of voice and recurrent mild nosebleeds.

Diagnosis & reasons

Nasopharyngeal carcinoma with lymph node metastasis (early appearance of lymph node metastasis as the nasopharynx is one of the silent areas of the head and neck – occult primary sites; decreased hearing due to eustachian tube affection)

Explain the following manifestations

Bilateral enlargement of upper deep cervical lymph nodes: the nasopharynx may send metastasis to both sides because it is present in the center of the head and neck

Decreased hearing in the right ear: due to eustachian tube destruction by the malignant tumor causing right otitis media with effusion and a retracted tympanic membrane leading to a conductive hearing loss

Nasal regurge: due to palatal paralysis

Nasal intonation of voice: due to nasal obstruction and palatal paralysis it is a combined rhinolalia clausa and aperta

Further examination &/or investigations

• CT scan

• Nasopharyngoscopy and biopsy

• Audiogram and tympanogram

• General investigations

Treatment

Radiotherapy for the primary nasopharyngeal carcinoma

Radical neck dissection for residual lymph node metstasis after treatment with radiotherapy

Chemotherapy in certain selected cases according to histopathological finding of biopsy

Palliative treatment for terminal cases

(4)

A 40 year old female began to experience difficulty in swallowing for the last 3 years. This difficulty in swallowing was to all kinds of food and the condition showed variation in the degree of dysphagia and was associated with a sense of obstruction at the root of the neck. For the last 2 months, she developed rapidly progressive difficulty in swallowing even to fluids together with a change in her voice. Recently she noticed a firm non-tender swelling in the right upper neck.

Diagnosis & reasons

Plummer – Vinson disease (dysphagia of intermittent nature for 3 years to all kinds of food) leading to hypopharyngeal or esophageal malignancy ( progression of dysphagia in the last 2 months, change of voice, appearance of neck swelling indicating lymph node metastasis)

Explain the following manifestations

Sense of obstruction at the root of the neck: the level of obstruction in Plummer Vinson disease is due to the presence of pharyngeal and esophageal webs of fibrous tissue in the lower pharynx and upper esophagus

Change of voice: due to malignant involvement of the recurrent laryngeal nerve leading to vocal fold paralysis

Firm non tender swelling in the right upper neck: lymph node metastasis in the right upper deep cervical lymph node

Further examination &/or investigations

• Indirect laryngoscopy: tumor is seen in the hypopharynx with overlying froth

• Direct laryngoscopy and biopsy

• X-ray lateral view neck showing a wide prevertebral space displacing the airway anteriorly

• CT scan to show extent of the tumor especially lower extent

• Barium swallow

• General investigations to assess the general condition of the patient

Treatment

Surgical excision by total laryngopharyngectomy and radical neck dissection of metastatic lymph nodes

Radiotherapy

Chemotherapy

Palliative treatmet

Type of treatment depends on general condition of patient, age of patient, extent of tumor and its histopathological type

(5)

4 hours following an adenotonsillectomy for a 6 year old the pulse was 110/min, blood pressure 100/70, respiration 20/min and the child vomited 250 cc of a dark fluid. 2 hours later he vomited another 150 cc of the same dark fluid, the pulse became 130/min, the blood pressure became 80/50. The respiration rate remained 20/min.

Diagnosis & reasons

Post-tonsillectomy reactionary hemorrhage (rising pulse, lowering of blood pressure, vomiting of altered blood, 4 hours following an adenotonsillectomy)

Explain the following manifestations

Pulse is 110/min then rises to 130/min: a continuous rising pulse is due to tacchycardia as a compensation for the blood loss

Vomiting of dark fluid: altered blood (acid hematin when blood is changed by stomach HCL)

Further examination &/or investigations

• Examination of the throat site of bleeding may be from the tonsil bed or from the adenoid bed

• Rapid assessment of hemoglobin

Treatment

Antishock measures (fluid and blood transfusion, steroids, coagulants)

Surgical hemostasis under general anesthesia

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