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Thread: ENT cases

  1. #1
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    Default ENT cases

    Here i'll add ENT cases.. Just press the "Thanks button" if you like the post..Do not reply, your post will be deleted.. Dnt spam this thread, so that i can make it a continuous quiz and answer format..

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    Case 1


    A 10 year old child was having a right mucopurulent otorhea for the last 4 years. A week ago he became dizzy with a whirling sensation, nausea, vomiting and nystagmus to the opposite side; his deafness became complete and his temperature was normal. Three days later he became feverish, irritable and continuously crying apparently from severe headache. Also he had some neck retraction. The child was not managed properly and died by the end of the week.

    [hide]
    Diagnosis & reasons


    Right chronic suppurative otitis media (mucopurulent otorhea of 4 years duration) complicated by suppurative labyrinthitis (dizziness, nausea and vomiting with nystagmus to the opposite side and complete loss of hearing) and then complicated by meningitis (fever, severe headache and neck retraction).

    Explain the following manifestations

    Whirling sensation: vertigo due to inner ear inflammation
    Nystagmus to the opposite side: suppurative labyrinthitis leading to fast phase of eye movement to the opposite ear and slow phase to the diseased ear nystagmus direction is called according to the fast phase. In serous labyrinthitis with no inner ear cell destruction the direction of nystagmus is toward the diseased ear.
    Severe headache: increased intracranial pressure due to meningitis
    Neck retraction: due to meningeal inflammation

    Further examination &/or investigations
    • Otologic examination possible finding of a marginal perforation of atticoantral CSOM (cholesteatoma)
    • Audiogram to reveal SNHL in the affected ear
    • Kernig's and Brudzinski's signs
    • Fundus examination to show papilledema
    • Lumbar puncture: turbid high pressure CSF with pus rich in proteins
    • Complete blood picture

    Treatment


    Antibiotics that cross the blood brain barrier
    Analgesics
    Repeated lumbar puncture to drain infected CSF and to relieve symptoms and to inject antibiotics
    Treaetment of the underlying otitis media appropriately according to its type
    [/hide]
    Last edited by Asrafee; 12-06-2006 at 06:15 AM.

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    Case 2

    A 50 year old male patient complained of right earache of 2 days duration. The pain was especially severe on chewing food and during speech. There was also marked edema of the right side of the face. On examination, pressure on the tragus was painful; and there was a small red swelling arising from the anterior external auditory meatal wall. Rinne test was positive in the right ear. The patient gave a history of 2 previous similar attacks in the same ear during the last six months but less severe.
    Answer
    [hide]
    Diagnosis & reasons


    Recurrent furunculosis of the right external auditory canal (pain in the ear with movements of the temporomandibular joint or pressure on the tragus, edema of the face and a small red swelling in the anterior wall of the external auditory canal)


    Explain the following manifestations

    Severe pain on chewing food: movements of the temporomandibular joint lead to movements of the cartilaginous external auditory canal that is lined by skin containing hair follicles from which the furuncle arises.
    Edema of the right side of the face: extension of the inflammatory edema to the face in severe cases
    Rinne positive: means normal hearing and NO conductive hearing loss because when air conduction is better than bone conduction it is called Rinne positive
    Previous similar attacks: recurrence the most probable cause is Diabetes mellitus


    Further examination &/or investigations

    • Otoscopic examination of the tympanic membrane if possible
    • Blood glucose analysis to discover diabetes


    Treatment
    Antibiotics
    Analgesics
    Never incise or excise for fear of perichondritis
    Local antibiotic or glycerine icthyol ointment
    Proper control of diabetes if discovered[/hide]

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    Case 3

    A 10 year old child complained of a right mucopurulent otorhea for the last 2 years. He suddenly became feverish and this was associated with diminution of the ear discharge. There was also tenderness on pressure behind the auricle. The retroauricular sulcus was preserved. There was no retroauricular fluctuation.
    [hide]
    Diagnosis & reasons

    Right chronic suppurative otitis media (mucopurulent discharge of 2 years duration) complicated by mastoiditis (fever with decreased ear discharge, tenderness behind the auricle with preservation of retroauricular sulcus; it is not an abscess because there is no retroauricular fluctuation).

    Explain the following manifestations

    Diminution of ear discharge: reservoir sign dischrge decreases but is still there and whenever discharge decreases fever and other constitutional symptoms increase in intensity
    Tenderness behind the auricle: due to inflammation of the bone of the mastoid process and its overlying periosteum
    Retroauricular sulcus preserve: as the inflammatory process is subperioteal
    No retroauricular fluctuation: it is mastoiditis and so is not a mastoid abscess yet

    Further examination &/or investigations


    • Otoscopic examination of the ear possible finding of a cholesteatoma
    • Look for the rest of the manifestations of mastoiditis as sagging of the posterosuperior wall of the bony external auditory canal
    • CT scan of the ear to show opacity in the mastoid bone
    • Complete blood picture

    Treatment

    Medical treatment in the form of antibiotics and
    Drainage of the ear through myringotomy and
    Mastoidectomy is essential to remove all disease from the ear
    [/hide]
    Last edited by Asrafee; 12-06-2006 at 06:17 AM.

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    Case 4
    A 9 year old child has been complaining of right continuous offensive ear discharge for the last 3 years. A month ago he began to suffer from headache, fever and some vomiting for which he received symptomatic treatment. The patient’s condition was stable for a while, then after 2 weeks he started to suffer from severe headache and drowsiness. The patient also noticed difficulty going up and down the stairs. A week later, he developed weakness in the left arm and left leg, and became markedly drowsy. He became comatose the next day
    [hide]
    Diagnosis

    Right atticoantral (cholesteatoma) chronic suppurative otitis media (continuous offensive ear discharge for 3 years) complicated by right temporal lobe abscess (manifestations of increased intracranial tension with weakness in the opposite side of the body on the left arm and leg)


    Explain the following manifestations

    Initial headache fever and vomiting: indicates the initial stage of a brain abscess formation in the stage of encephalitis
    Stable condition of 2 weeks: latent phase of brain abscess with decreased symptoms
    Severe headache and vomiting after 2 weeks: manifestations of a formed brain abscess leading to increased intracranial tension
    Difficulty going up and down the stairs: due to hemipareisis (weakness) in the opposite left leg to the diseased ear
    Comatose: final stage of brain abscess


    Further examination &/or investigations


    • Otoscopic examination of the ear
    • CT scan with contrast to locate the brain abscess
    • Complete blood picture to show leucocytosis very good to know prognosis with treatment
    • Fundus examination to show papilledema


    Treatment

    Antibiotics that cross the blood brain barrier
    Drainage or excision of the brain abscess neurosurgically
    Tympanomastoidectomy to remove the cholesteatoma from the ear
    Avoid lumbar puncture as it might lead to conization of the brainstem and death[/hide]

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    Case 5:

    A 6 year old child developed severe pain in both ears together with a rise of temperature (39 C) following an attack of common cold. The child received medical treatment that lead to drop of his temperature and subsidence of pain; so the physician stopped the treatment. However, the mother noticed that her child did not respond to her except when she raised her voice. This decreased response remained as such for the last 2 weeks after the occurrence of the primary condition.


    [hide]Diagnosis & reasons

    Common cold leading to bilateral acute suppurative otitis media (fever and earache) complicated by nonresolved acute otitis media or otitis media with effusion (only symptom is a hearing loss)


    Explain the following manifestations

    Ear condition following common cold: due to extension of infection along eustachian tube
    Decreased response to sound: fluid due to non resolved acute otitis media behind the drum leads to decreased vibration of the tympanic membrane


    Further examination &/or investigations


    • Otoscopic examination will reveal in the primary condition a congested maybe bulging tympanic membrane and in the secondary condition a retracted drum showing afluid level with loss of lustre
    • Audiogram will show an air bone gap indicating a conductive hearing loss
    • Tympanogram will show either a type C (negative peak) or a type B (flat) curves
    • X-ray of the nasopharynx might reveal an underlying adenoid enlargement specially if the condition is recurrent


    Treatment

    Continue antibiotic treatment until hearing returns to normal
    May combine treatment with antihistamines, corticosteroids and mucolytics
    Insertion of ventillation tubes (grommet) in the drum if condition persistent or recurrent
    Usage of tubes relies on tympanometry findings if the curve is type B flat curve
    Adenoidectomy is required if there is an enlarged adenoid obstructing the eustachian tube[/hide]

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    Case 6:

    A 3 year old boy presented to the ENT specialist because of an inability to close the right eye and deviation of the angle of the mouth to the left side upon crying of 2 days duration. His mother reported that he had severe pain in the right ear 5 days prior to his present condition. She also added that his earache improved on antibiotic therapy.

    [hide]Diagnosis & reasons


    Right acute suppurative otitis media (earache that improved with antibiotics of 2 days duration) complicated by right lower motor neuron facial paralysis (inability to close the right eye and deviation of the angle of the mouth to the left side)


    Explain the following manifestations

    Inability to close the right eye: paralysis of the orbicularis occuli muscle supplied by the facial
    Deviation of the angle of the mouth to the left: muscles of the orbicularis oris of the left non paralysed side pull the mouth to the left side
    Onset of paralysis 5 days only after the original condition: due to pressure of the inflammatory exudate in the middle ear on a dehiscent (exposed) facial nerve


    Further examination &/or investigations


    • Otoscopic examination may show a congested bulging tympanic membrane
    • Examination of the rest of the facial nerve to diagnose the proper level of paralysis
    • Electroneuronography of the facial nerve to estimate the degree of damage
    • Audiogram and tympanogram


    Treatment

    Urgent myringotomy to drain the middle ear and allow for facial nerve recovery
    Antibiotics for acute suppurative otitis media preferabley according to culture and antibiotic sensitivity


    Care of the eye during period of paralysis by eye drops, ointment and covering of the eye[/hide]

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    Case 7:

    A 30 year old female complained of bilateral hearing loss more on the right side following the delivery of her first child; hearing loss was marked in quiet places but hearing improved in a noisy environment. Both tympanic membranes showed a normal appearance. Rinne tuning fork test was negative.

    [hide]Diagnosis & reasons


    Bilateral otosclerosis (hearing loss related to pregnancy, more marked in quiet environment, normal tympanic membranes, Rinne tunning fork test negative that is bone conduction better than air conduction indicating conductive hearing loss)


    Explain the following manifestations


    Hearing loss marked in quiet places: patient has conductive hearing loss in noisy environment the speaker usually raises his voice and so patient hears better (paracusis Wilsii)
    Normal appearance of both tympanic membranes: this is the common finding in rare cases a reddish tympanic memebrane may be present called Schwartze's sign (flamingo red appearance)
    Rinne tunning fork test negative: that is bone conduction better than air conduction indicating conductive hearing loss


    Further examination &/or investigations

    • Other symptoms (tinnitus, sensorineural hearing loss, vertigo)
    • Audiogram shows either air bone gap indicating conductive hearing loss or low bone curve indicating sensorineural hearing loss or both indicating mixed hearing loss
    • Tympanogram usually shows type As with stunted type curve
    • CT scan may show decreased density of the bone around the inner ear (otospongiotic focus) indicating activity of the disease


    Treatment

    Stapedectomy (the best) if hearing loss is conductive or mixed
    Hearing aid if patient refuses surgery or has pure sensorineural hearing loss
    Medical treatment to stop progression of the disease (fluoride therapy) if disease is extensive
    Avoid contraceptive pills and preganacy in order to limit the disease[/hide]

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    Case 8:

    After a car accident a young male complained of inability to close the right eye and deviation of the angle of the mouth to the left side together with dribbling of saliva from the right angle of the mouth. There was also a right hearing loss and a blood clot was found in the right external auditory canal. 3 days later a clear fluid appeared in the right ear that increased in amount on straining. A day later the patient was drowsy and developed fever and neck stiffness.
    [hide]Diagnosis & reasons

    Longitudinal fracture of the right temporal bone (accident, blood in external auditory canal and hearing loss) complicated by right lower motor neuron facial paralysis ( inability to close the right eye and deviation of the angle of the mouth to the left side) and complicated by CSF otorhea (clear fluid in the right external auditory canal that increased with straining) and later complicated by meningitis (drowzy, fever and neck stiffness)


    Explain the following manifestations

    Dribbling of saliva from angle of mouth: due to facial nerve paralysis leading to inability to coapte the lips so angle of mouth is open and droops downwards with escape of saliva outwards
    Hearing loss: most probably due to longitudinal fracture causing tympanic membrane perforation and auditory ossicular disrruption leading to conductive hearing loss also the blood clot may cause obstruction of the external auditory canal leading to conductive hearing loss
    Clear fluid increases with straining: CSF otorhea as CSF pressure increases with straining causing increase in the otorhea
    Neck stiffness: due to meningeal irritation and inflammation


    Further examination &/or investigations


    • CT scan to diagnose the fracture and study its extent
    • Topognostic testa for the facial nerve as (Shirmer's, stapedius reflex,….) to know the level of paralysis
    • Electroneuronography: to study the electrophysiologic status of the facial nerve
    • Audiogram: to know the type of hearing loss
    • Examination of fluid dripping from the ear
    • Lumbar puncture: increased pressure of turbid pus containing CSF



    Treatment

    Treatment of meningitis: antibiotics, lower CSF pressure by repeated lumbar puncture, diuretics and mannitol 10%

    Treatment of CSF otorhea: semisitting position, avoid straining, diuretics and close observation of the patient regarding fever and neck stiffness for the development of meningitis

    Treatment of facial nerve paralysis: care of the eye, surgical exploration and repair if electroneuronography reveals 90% degeneration of the affected nerve within one week of the onset of paralysis
    Treatment of hearing loss: tympanoplasty if the hearing loss or tympanic membrane perforation persists for more than 6-8 weeks[/hide]

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    Case 9:

    A 28 year old male has been complaining of hearing loss in the left ear for the last 6 years. The hearing loss was progressive in nature and accompanied by tinnitus. During the last 6 months there was swaying during walking to the left side, a change in his voice and an inability to close the left eye with deviation of the angle of the mouth to the right side. Otologic examination showed no abnormality. The corneal reflex was lost in the left eye.
    [hide]Diagnosis & reasons

    Left acoustic neuroma (progressive history of hearing loss over 6 years followed by imbalance due to cerebellar manifestations and developing neurological manifestations)


    Explain the following manifestations

    Hearing loss of 6 years duration: pressure of the tumor on the eighth nerve responsible for hearing and balance
    Swaying during walking to the left side: cerebellar attaxia alaways to wards the side of the lesion due to weakness (hypotonia) of the muscles on the same side of the lesion
    Change of voice: intracranial vagus paralysis leading to vocal fold paralysis
    Inability to close the eye: left lower motor neuron paralysis as the facial nerve accompanies the vestibulocochlear nerve in the internal auditory canal
    Absent sorneal reflex in the left eye: due to facial or trigeminal paralysis with trigeminal paralysis the contralateral reflex is lost as well as the patient can not feel in the affected left cornea


    Further examination &/or investigations


    • MRI of the internal auditory canals, cerebellopontine angles and inner ears
    • CT scan if MRI is not available
    • Audiological evaluation especially auditory brainstem response
    • Electrophysiological tests for the facial nerve


    Treatment


    Excision of the neuroma

    In old patients another option is the gamma knife (directed radiotherapy) to limit growth of the tumor
    In young patients with small tumors that do not produce new symptoms other than hearing loss it is advised to follow up the case with MRI on a 6-12 month basis as most of the tumors do not grow and so do not require surgery or gamma knife[/hide]

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    Case 10:

    A 35 year old female suddenly complained of an attack of bleeding from her right ear (otorrhagia). An ENT specialist packed the ear and after removal of the pack found an aural polyp. The patient also complained of pulsatile tinnitus in the right ear of 2 years duration and a change in her voice of 2 months duration. On laryngeal examination there was right vocal fold paralysis, the vocal fold was found in the abduction position. No lymph node enlargement was found in the neck.
    [hide]Diagnosis & reasons

    Right glomus jugulaire tumor (blleding from the ear, pulsatile tinnitus and neurological manifestations of the jugular foramen syndrome)


    Explain the following manifestations


    Aural polyp: this is not an inflammatory polyp it is extension of the tumor mass in the external auditory canal when touched by any instrument will cause severe bleeding
    Pulsatile tinnitus: the sound heard by the patient is that of the blood flowing in the very vascular tumor mass the sound disappears when the jugular vein in the neck is compressed or when there is a sensorineural hearing loss in the ear
    Abduction position of the vocal fold: due to a complete vagus paralysis paralysing all muscles of the right hemilarynx and so the vocal fold rests in the cadaveric abduction position
    No lymph node enlargement: glomus is a benign tumor there is no lymph node metastasis


    Further examination &/or investigations


    • CT scan with contrast to know the extent of the tumor
    • MRI and MR angiography (MRA)
    • Angiography to know the feeding vessels of the tumor
    • Examination of the entire body for a possible associated chromafffin tissue tumors as phaechromocytoma especially in aptients that are hypertensive


    Treatment


    Excision of the tumor via the infratemporal approach according to its extent[/hide]

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