Thread: ENT cases (no 20-30)

Case 21: A 3 year old child was referred to an ENT specialist because of cough, difficulty of respiration and temperature 39.5 C of few hours duration. The child was admitted to hospital for observation and medical treatment. 6 hours later, the physician decided an immediate tracheostomy. After the surgery the child was relieved from the respiratory distress for 24 hours then he became dyspnic again. The physician carried out a minor procedure that was necessary to relieve the child from the dyspnea. Few days later the tracheostomy tube was removed and the child discharged from the hospital.


[HIDE]CASE 21



Diagnosis & reasons


Acute laryngotracheobronchitis – CROUP (dyspnea relieved by tracheostomy placed for a few days only, cough and fever) complicated by an obstruction of the tracheostomy tube by secretions (relieved after cleaning the tube)



Explain the following manifestations


Cough: common with croup due to the presence of tracheal and broncjial imflammation and secretions
Temperature 39.5 C: temperature in croup is varaiable may be mild or severe according to the virus causing the condition
Observation and medical treatment: the main observation is that of the degree of respiratory distress and tacchcyardia to detect early heart failure. Medical treat is mainly steroids and humidification of respired air, mucolytics and expectorants to facilitate getting rid of the secretions in the bronchi and trachea.
Minor procedure: clearnace of the tracheostomy tube from accumulated secretions.



Further examination &/or investigations


• Pulse rate
• Cyanosis
• Chest x-ray to differentiate from foreign body inhalation



Treatment


Steroids
Mucolytics
Expectorants
Antibiotics
Humidified oxygen inhalation
Treatment of heart failure[/HIDE]

Case 22: A 45 year old male who is a heavy smoker complained of change in his voice of 3 years duration in the form of hoarseness. During the last 3 months his voice became very hoarse and he developed mild respiratory distress. Later he became severely distressed and required a surgical procedure to relieve the distress. On examination there were bilateral firm non-tender upper neck swellings

[HIDE]CASE 22


Diagnosis & reasons


Leukoplakia of the vocal folds (hoarseness of 3 years duration) leading to vocal fold carcinoma (glottic carcinoma increased hoarseness, respiratory distress relieved by tracheostomy) with bilateral lymph node metastasis (firm non-tender upper neck swellings)



Explain the following manifestations


Hoarseness: the presence of lesions whether leukoplakia or carcinoma on the vocal fold will limit its vibration capability causing hoarseness
Bilateral firm non-tender swellings in the upper neck: lymph node metastasis not common with vocal fold carcinoma but may occur when the tumor spreads to the neighboring supraglottis or subglottis
Surgical procedure: tracheostomy to bypass the glottic lesion causing respiratory obstruction



Further examination &/or investigations


• Other symptoms: cough and hemoptsys
• Indirect laryngoscopy: visualize the lesion and vocal fold paralysis
• Laryngeal stroboscopy: to examine the vocal fold movement very useful with small vocal fold carcinoma lesions
• Direct laryngoscopy and biopsy
• CT scan and MRI
• Chest X-ray


Treatment


Laser excision of the lesion
Laryngofissure and cordectomy
Laryngectomy ( partial or total)
Radiotherapy for small cordal lesions
Chemotherapy and palliative treatment for terminal cases[/HIDE]

Case 23: A 40 year old female had repeated attacks of chest infection not improving by medical treatment. The patient was admitted for investigation of her condition in a hospital. A chest x-ray revealed basal lung infection. During her hospital stay it was noticed that she suffered from chest tightness and choking following meals. The ward nurse noticed that the patient refuses fluid diet and prefers solid bulky food.


[HIDE]CASE 23


Diagnosis & reasons


Cardiac achalasia (basal chest infection due to aspiration, choking following meals and dysphagia more to fluids)



Explain the following manifestations


Chest infection not improving by medical treatment: because of continuous aspiration the original condition of cardiac achalasia must be treated first and the chest infection will improve subsequently
Basal lung infection by X-ray: with aspiration by gravity the basal lung is always affected
Patient refuses fluid diet and prefers solid food: solid food creates a better stimulation by rubbing against the esophageal wall and so the cardiac sphincter opens while fluids need to accumulate in the esophagus before causing a sufficient stimulus




Further examination &/or investigations



• X-ray barium swallow esophagus shows a large dilatation of the esophagus and a stenosis at the level of the cardiac sphincter
• Esophagoscope
• CT scan with barium swallow
• Chest X-ray

Treatment

Heller's operation
Esophagoscopic dilatation[/HIDE]

Case 24: A 4 year old child was referred to an ENT specialist by a pediatrician because of repeated attacks of severe chest infection (three in number) during the last month that usually resolved by antibiotics, expectorants and mucolytics, but the last attack did not resolve. On examination the lower right lobe of the lung showed no air entry and a lot of wheezes all over the chest by auscultation. A chest x-ray revealed an opacified lower right lobe. Temperature 38 C, pulse 120/min and respiration rate 35/min.


[HIDE]CASE 24



Diagnosis & reasons


Foreign body inhalation in the right lung most probably a vegetable seed as a peanut (attacks of chest infection, no air entry and opacified lower right lobe of the lung, fever tachycardia and dyspnea 35/min normal reting respiratory rate in a child should not exceed 18/min



Explain the following manifestations


Last attack of chest infection did not resolve: the chemical bronchopneumonia caused by the vegetable seed has reached a severity that it could not be controlled by the medical treatment always suspect a foreign body inhalation in a non-responsive chest infection in a child
Wheezes all over the chest: although the foreign body is in the right lung the site of decreased air entry and an opacified lobe by X-ray but the chemical effect of the fatty acids in the vegetable seed is all over the lung causing marked dyspnea and tachypnea as well
Pulse 120/min: respiratory failure is also accompanied by tachycardia which might lead to heart failure



Further examination &/or investigations



• Proper history
• Tracheobronchoscopy



Treatment


Tracheobronchoscopy and removal of the foreign body followed by
Antibiotics
Steroids
Expectorants[/HIDE]

Case 25: A 3 year old child suddenly complained of a sore throat and enlarged left upper deep cervical lymph node. Later he suffered from marked body weakness and mild respiratory distress that progressively became severe. Oropharyngeal examination revealed a grayish membrane on the left tonsil, soft palate and posterior pharyngeal wall. 2 days later he developed nasal regurge. His temperature was 38 C and pulse 150/min.


[HIDE]CASE 25



Diagnosis & reasons


Diphtheria (sore throat, enlarged upper deep cervical lymph node, marked weakness, respiratory distress, extension of the membrane outside the tonsil, low grade fever with marked tachycardia)



Explain the following manifestations


Enlarged upper deep cervical lymph node: markedly enlarged (Bull's Neck) common in diphtheria in the early stages of the disease
Respiratory distress: could be because of heart failure caused by marked toxemia or due to extension of the diphtheritic membrane to the larynx
Grayish membrane: due to tissue necrosis
Extension of the membrane outside the surface of the tonsil: diphtheria is a disease of the mucous membrane not only of the tonsil
Pulse 150/min: toxemia causing heart failure leading to a rapid pulse



Further examination &/or investigations


• Swab from the membrane
• Bacteriological diagnosis


TReatment


Start treatment immediately do not wait for a definite bacteriological diagnosis
Antitoxin serum 20,000 – 100,000 units daily until the membrane disappears
Bacteriological swabs until the organism disappears from the throat
Antibiotics
Treatment of heart failure if present
Tracheostomy for respiratory distress or even marked heart failure to decrease the effort of breathing by decreasing the respiratory dead space
Passive and active immunization of the contacts of the patient[/HIDE]

Case 26: A 45 year old male patient presented to the ENT emergency room with severe incapacitating dizziness of 5 days duration. The dizziness was continuous with no periods of rest and was accompanied by hearing loss and tinnitus in the right ear. He was admitted to hospital and medical treatment was started. The patient gave a history of right ear offensive continuous discharge of seven years duration. On examination there was right beating nystagmus. Otoscopic examination of the right ear showed a marginal attic perforation with a discharge rich with epithelial flakes, the edge of the perforation showed granulation tissue. The left ear was normal. On the next day the patient’s condition became worse despite the medical treatment, he developed a mild fever of 38.5 C and the nystagmus became directed to the left ear. 2 days later the temperature became higher 40 C, the patient became irritable, but later became drowsy. On examination at this stage there was marked neck rigidity.



[HIDE]CASE 26


Diagnosis & reasons

Right chronic suppurative otitis media – cholesteatoma (seven years of offensive continuous ear discharge, marginal attic perforation with epithelial flakes, edge of the perforation shows granualtion tissue) complicated by serous labyrinthitis (severe incapacitating dizziness, hearing loss and tinnitus, right beating nystagmus) followed by suppurative labyrinthitis (worsening of the condition despite medical treatment, mid fever 38 and left beating nystagmus) and finally complicated by meningitis (very high fever 40, irritability and drowsiness, marked neck ridgidity)


Explain the following manifestations

Incapacitating dizziness: meaning vertigo due to serous labyrinthitis with irritation of the vestibular part of the inner ear
Hearing loss: due to labyrinthitis is sensorineural hearing loss
Right beating nystagmus: due to irritation of the vestibular endorgan with the slow phase away from the diseased ear and the fast phase towards the diseased ear
Offensive continuous ear discharge: cholesteatoma causes continuous ear discharge that is offensive because of the presence of anerobic organisms and because of bone destruction and erosion
Nystagmus became directed to the left ear: indicating that serous labyrinthitis is now suppurative with destruction of the vestibular endorgan
Drowsy: means a decrease in the level of conciousness that which occurs with meningitis and intracranial complications



Further examination &/or investigations


• CT scan
• Audiogram
• Lumbar puncture


Treatment


Treatment of meningitis: antibiotics, lower intracranial tension
Treatment of cholesteatoma: tympanomastoidectomy
Labyrinthitis will subside after removing the causing cholesteatoma (no need to carry out labyrinthectomy as this will spread more the infection)[/HIDE]

Case 27: The mother of a 3 year old child complained that her child had a fever 5 days ago. 2 days following that he developed severe right sided earache that kept the child continuously crying. A day later she noticed that his mouth was deviated to the left side and he was unable to close the right eye


[HIDE]CASE 27


Diagnosis & reasons


Right acute suppurative otitis media (fever of short duration, right sided earache) 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) the cause is dehiscence of the fallopian canal in the middel ear so the pus under tension of acute suppurative otitis media causes inflammation and pressure on the facial nerve


Explain the following manifestations


Severe right earache: due to psu formation in the suppurative phase of acute suppurative otitis media leading to pressure and bulging of the tympanic membrane
Unable to close the right eye: due to lower motor neuron facial nerve paralysis leading to paralysis of the orbicularis occuli responsible for the firm closure of the eye lids


Further examination &/or investigations



• Otoscopic examination: will most probably show a congested bulging tympanic membrane
• Audiogram and tympanogram will show an air bone gap of conductive hearing loss and a flat tympanogram type B
• Culture and antibiotic sensitivity of the ear discharge obtained after performing myringotomy


Treatment


Urgent myringotomy to relieve pressure on the facial nerve
Antibiotics according to culture and antibiotic sensitivity
Steroids to relieve edema due to inflammation of the facial nerve
Care of the eye by drops ointment and closure to prevent possible corneal ulceration[/HIDE]

Case 28: A 30 year old female patient developed a sudden attack of fever and rigors. She was admitted to the fever hospital and properly investigated and received an antibiotic. On the fifth day after her admission a blood culture was requested and the result was negative for bacteria. The patient improved and was discharged from hospital; but 2 weeks later the condition recurred with a very high fever and there was a tender swelling in the right side of the neck. An otologic consultation was obtained as the patient mentioned that she had a right chronic offensive otorhea for the last 5 years. The otologist found an aural polyp with purulent ear discharge. A laboratory workup showed Hb%= 7gm% WBC count 23,000/cc.


[HIDE]CASE 28


Diagnosis & reasons


Right chronic suppurative otitis media – cholesteatoma (chronic offensive otorhea of 5 years duration, an aural polyp) complcated by lateral sinus thrombophlebitis (fever and rigors, tender lymphadenitis in the right upper deep cervical lymph nodes, marked anemia and leucocytosis)


Explain the following manifestations


Fever and rigors: due to spread of infection to the bloodstream
Negative blood culture: as the patient is receiving antibiotics
Tender swelling in the right upper neck: could be due to lymphadenitis caused by extending thrombophlebitis in the internal jugular vein or due to the inflammation of the veins wall
Aural polyp: an indication of chronic ear inflammation especially by cholesteatoma
Hb% 7gm%: marked anemia as the organism in the blood releases hemolysing causing hemolysis of the RBCs – it is one of the cardinal signs of thrombophlebitis



Further examination &/or investigations


• CT scan of the ear
• MRI and MR venography to diagnose thrombophlebitis
• Blood culture after stopping antibiotics for 48 hours
• Bloof film to exlude malaria
• Leucocytic count and hemoglobin to follow up the case


Treatment


Intravenous antibiotics
Anticoagulants to limit spread of the thrombus
Tympanomastoidectomy for the cholesteatoma[/HIDE]

Case 29: An 18 year old male patient presented to the ENT clinic with an offensive continuous right ear discharge of 2 years duration for which he received antibiotic ear drops, but with no improvement of his condition. A month ago a swelling appeared behind the right ear. The swelling was red, hot, tender and was accompanied by deep seated pain and a fever 39 C . The swelling was incised by a surgeon and pus released after which the temperature dropped to 37.5 C but the pus continued draining from the incision and the incision did not heal since then.


[HIDE]CASE 29



Diagnosis & reasons


Right chronic suppurative otitis media – cholesteatoma (continuous offensive otorhea, no improvement with antibiotic ear drops) complicated by mastoiditis and a mastoid abscess (swelling red hot tender, deep seated pain and fever followed by a mastoid fistula (incision made by surgeon, no healing of the incision)



Explain the following manifestations


Red hot tender swelling: criteria of an abscess that originated from the mastoid diagnostic when it is fluctuant
Incision did not heal: as the cause of the mastoid abscess is mastoiditis in the bone of the mastoid the wound will never heal unless the underlying mastoiditis is treated by mastoidectomy to clear the bone of the mastoid from the infected bone tissue



Further examination &/or investigations


• Other criteria of mastoiditis as: sagging of the posterosuperior extenal auditory canal wall, reservoir sign, tenderness all over the mastoid especially at the tip, preservation of the retroauricular sulcus
• X-ray shows hazziness of the mastoid bone air cells indicating an inflammation of the bone partitions between the air spaces
• CT scan to show the underlying cholesteatoma and its extensions
• Audiogram


Treatment


Tympanomasoidectomy to remove the underlying causative cholesteatoma
Antibiotics[/HIDE]

Case 30: A 35 year old male patient had been complaining of a right continuous offensive otorhea for the last 10 years. One month ago he had a very high fever and became drowsy. This condition lasted for 5 days, after which the fever dropped and the drowsiness disappeared. The patient kept complaining of a mild non continuous headache. One week ago the patient felt that he could not go up and down the stairs easily. Neurological examination revealed right side body weakness in the upper and lower limbs. There was also nystagmus and a difficulty on grasping objects by the right hand. Temperature was 36 C, pulse 80/min. The patient was slightly disoriented to his surrounding and was slow in his responses.

[HIDE]CASE 30


Diagnosis & reasons

Right chronic suppurative otitis media – cholesteatoma (continuous otorhea of 10 years duration) complicated by a cerebellar abscess (headache, imbalance, weakness on the same side of the body right, nystagmus, difficulty grasping objects by the right hand, temperature 36 C, disorientation ans slow responses)


Explain the following manifestations


Original high fever and drowsiness: encephalitic stage of brain abscess
Mild non-continuous headache: latent quiescent stage of the brain abscess
Could not go up and down the stairs: imbalance and due to hypotonia on the right side (same side) of the body
Difficulty in grasping objects: incoordication of cerebellar attaxia
Disorientation and slow responses: end stage of brain abscess stage of stupor


Further examination &/or investigations


• Examination of cerebellar function: finger nose test, knee heel test, dysdidokokinesia
• CT scan with contrast for the brain and the ear
• MRI
• Fundus examination may show papilledema
• Blood picture especially leucocytic count for follow up and prognosis


Treatment


Antibiotics that cross the blood brain barrier
Avoid lumbar puncture as it might lead to conization of the medulla oblongata and death
Drainage of the abscess or excision neurosurgically
Tympanomastoidectomy for the cholesteatoma[/HIDE]