Thread: ENT Cases[no36-40]

Case 36: A 40 year old male presented to the ENT clinic with a swelling in the right upper neck of 2 months duration. The swelling was non-tender, firm and progressively increased in size. After a complete ENT examination there was a right conductive hearing loss and a retracted tympanic membrane. Also, there was right vocal fold paralysis and on swallowing there was also some nasal regurge. The patient gave a history of an offensive sanguineous post nasal discharge.


[HIDE]CASE 36



Diagnosis & reasons



Nasopharyngeal carcinoma with right upper deep cervical lymph node metastasis (early presentation by right upper deep cervical lymph node metastasis, right conductive hearing loss, right retracted tympanic membrane, offensive sanguineous post nasal discharge)



Explain the following manifestations



Right conductive hearing loss and retracted tympanic membrane: due to nasopharyngeal carcinoma destroying the nasopharyngeal orifice of the eustachian tube causing poor aeration of the middle ear causing otitis media with effusion
Right vocal fold paralysis: due to involvement of the vagus nerve by the nasopharyngeal carcinoma as the nerve passes just lateral the nasopharyngeal wall
Nasal regurge: paralysis of the vagus high up in the neck close to the skull base leads to paralysis of its pharyngeal branch that supplies the palate this palatal paralysis causes nasal regurge



Further examination &/or investigations


• CT scan to see the extent of the malignancy and lymph node metastasis
• Nasopharyngoscopy and biopsy
• Audiogram and tympanogram


Treatment


Radiotherapy for the primary tumor and the metastsis
Radical neck dissection for the residual metastatic lymph nodes after radiotherapy
Myringotomy and T-tube insertion of the right tympanic membrane to relieve otitis media with effusion[/HIDE]

Case 37: A 50 year old female has been complaining of dysphagia for 3 years. The dysphagia was towards solids and stationary in nature. 2 months ago the dysphagia progressed to become absolute, there was a change of voice and some respiratory distress. On examination there was a firm swelling in the neck that was not tender

[HIDE]CASE 37


Diagnosis & reasons

Plummer Vinson disease (dyspahgia towards solids stationary in nature for 3 years) complicated by hypopharyngeal carcinoma (progression of dysphagia in the last two months to become absolute) with lymph node metastasis (firm non-tender swelling in the neck)



Explain the following manifestations


Dysphagia of 3 years duration: due to Plummer Vinson disease that causes inflammation and fibrosis of the hypopharyngeal and esophageal walls leading to the formation of webs that cause dysphagia
Progression of dysphagia: Plummer Vinson disease is premalignant progression of dysphagia means development of malignancy
Change of voice and respiratory distress: means involvement of the larynx or the recurrent laryngeal nerves by the malignancy


Further examination &/or investigations


• Indirect laryngoscopy: froth in the region of the hypopharynx, a mass may be seen in the post cricoid, posterior pharyngeal wall or the pyriform fossa and may be laryngeal involvement
• Direct hypopharyngoscopy and biopsy
• CT scan
• Barium swallow
• General investigation for the patients condition


Treatment

Total laryngopharyngectomy if the patient's general condition permits with radical neck dissection for the lymph node metastasis
Radiotherapy for inoperable cases
Chemotherapy
Palliative treatment for terminal cases[/HIDE]

Case 38: A 25 year old male presented to the ENT emergency room with severe right side throat pain, inability to swallow, accompanied by right earache of 2 days duration. The patient was unable to open his mouth and was feverish 40 C. On examination there was a tender swelling at the angle of the mandible. The patient gave a history of sore throat and fever 39 C during the last week.

[HIDE]CASE 38



Diagnosis & reasons


Acute tonsillitis (history of sore throat and fever) complicated by right peritonsillar abscess – quinzy (right sided throat pain, inability to swallow and to open the mouth, fever 40 C)



Explain the following manifestations


Right sided throat pain: due to the collection of pus in the peritonsillar pain that causes immense throbbing pain
Inability to swallow: marked dysphagia accompanying the quinzy that may lead to drooling of saliva from the mouth
Right earache: refered pain along the glossopharyngeal nerve (Jackobsen's nerve)
Unable to open the mouth: trismus caused by spasm of the medial pterygoid muscle present lateral to the peritonsillar abscess
Tender swelling at the angle of the mandible: inflammed jugulodigastric lymphadenitis



Further examination &/or investigations

• Complete blood picture with leucocytic count


Treatment

Drainage of the quinzy
Antibiotic therapy for the quinzy and acute tonsillitis
Tonsillectomy after 2-3 weeks is an absolute indication[/HIDE]

Case 39: A 3 year old child suddenly developed respiratory distress fever 38 C and biphasic stridor. In the ENT emergency room an immediate surgical procedure was done after which there was complete relief of the respiratory distress and the child received the necessary medical treatment. On the next morning the respiratory distress recurred and the attending physician carried out an immediate minor interference that relieved the distress immediately. 2 days later the child was discharged from hospital in a healthy condition

[HIDE]CASE 39



Diagnosis & reasons


Acute laryngitis (respiratory distress, biphasic sridor, fever, complete relief by tracheostomy)



Explain the following manifestations



Biphasic stridor: means stridor in both inspiration and expiration caused by lesions in the larynx and the trachea if the condition is accompanied by cough it is acute laryngotracheobronchitis – croup
Surgical procedure: is tracheostomy to relieve the respiratory distress
Necessary medical treatment: in such a condition it is mainly steroids to relive the laryngeal edema
Recurrence of respiratory distress after tracheostomy: due to tube obstruction by viscid secretions



Further examination &/or investigations



• Close observation of the patient
• Examine the heart condition as respiratory distress in children is commonly accompanied by heart failure
• Chest X-ray



Treatment

Close observation of the patient in intensive care unit
Oxygenation by humidified oxygen
Steroids
Mucolytics
Antibiotics to prevent secondary infection[/HIDE]

Case 40: A 60 year old heavy smoker has been complaining of hoarseness of voice for 3 years. Lately he noticed worsening of his voice and a mild respiratory distress on exertion. There was also cough and some blood tinged sputum. On laryngeal examination a whitish irregular mass was found on the right vocal fold that was found also paralysed


[HIDE]CASE 40


Diagnosis & reasons


Right glottic (laryngeal) carcinoma (hoarseness of voice that is worse, mild respiratory distress, cough and blood tinged sputum, whitish irregular mass and the vocal fold is paralysed) the condition followed the original precancerous condition of leucoplakia (hoarseness of voice of 3 years duration in a heavy smoker)


Explain the following manifestations


Mild respiratory distress on exertion: due to the presence of the glottic cancer that may cause narrowing of the laryngeal lumen
Blood tinged sputum: carcinoma of the vocal fold may lead to destruction of the fine blood vessels on the vocal fold leading to some bleeding
Whitish irreguar mass: white because of hyperkeratosis of the non keratinized vocal fold epithelium due to malignancy irregular because of the fungating mass
Vocal fold paralysis: indicates spread of the malignant lesion to involve either the nerve, muscle supply of the right vocal fold that is a deep invasion of the vocal fold, also vocal fold fixation may occur if the cricoarytenoid joint is involved


Further examination &/or investigations


• Direct laryngoscopy and biopsy
• CT scan
• Chest X-ray
• General investigations


Treatment

Surgical: total laryngectomy (because ther is a fixed vocal fold) achieves very good results
Radiotherapy
Palliative treatment if the condition is terminal[/HIDE]