ent osce review by kp ferraris. outline 10-pt identification quiz case presentations with quiz –...

ENTOSCE Review

by KP Ferraris

Outline• 10-pt identification quiz• Case presentations with quiz

– Case 1– Case 2– Case 3

• Other ENT symptoms• Laundry list of must-know and common diagnoses

(For best resolution, view this as Slide Show.)

Identification Quiz1. Shown below is a Lateral X-Ray of the neck showing

the thumbprint sign. What is the most likely diagnosis?

a. Retropharyngeal abscessb. Epiglottitisc. Acute Tonsillopharyngitisd. Croup

Answer: b. Epiglottitis (double t in the first only). It is characterized by fever, drooling, dysphagia, odynophagia, noisy breathing, stridor

Identification Quiz2. Identify the lesion/diagnosis. The larger field is oral

mucosa.

Answer: Aphthous ulcer or Aphthous stomatitis. It is an erosion of the mucosa caused by either trauma, hot foods/liquid, or lack of hygiene.

Identification Quiz3. Give the complete diagnosis, with Grading.

Answer: Tonsillitis Grade III with Peritonsillar Abscesses (Quinsy). The usual complaint is odynophagia and dysphagia, with or without fever.

Identification Quiz4. What type of fracture is shown?

a. Le Fort Ib. Le Fort IIc. Le Fort IIId. Tripode. Temporal

bone

Answer: b. Le Fort II fracture. In contradistinction to Le Fort I which is only in the maxilla (upper jaw) and Le Fort III which involves the inferolateral portion of the orbit (cheek).

Identification Quiz5. Identify this diagnostic test used to confirm Benign

Paroxysmal Positional Vertigo (BPPV).

Answer: Dix-Hallpike test. It is confirmatory for only one pathology: BPPV, a disorder of the posterior semicircular canal. If positive, where the head is turned to is the side of the lesion.

Identification Quiz6. Classify the cleft lip and palate using the Thallwitz

nomenclature.

Answer: L3 A3 H3 S3 H3 A3 L3 (Remember from RIGHT to LEFT, and only one S). Mnemonic is “Lahshal.” This is surgically corrected by Cheiloalveolorhinoplasty.

Identification Quiz7. Which is the most important part of the sinonasal

anatomy commonly blocked during Sinusitis?

Answer: Ostiomeatal Unit. It is the common drainage of all sinuses EXCEPT 2: posterior ethmoid cells and the sphenoid sinus.

Identification Quiz8. What is the most common etiologic agent (bacteria)

of Otitis Media?

Answer: Streptococcus pneumoniae. H. influenzae is more common in pedia. Another agent is M. catarrhalis.

Identification Quiz9. Below is a picture from posterior rhinoscopy. It is the

potential site of growth for Nasopharyngeal carcinoma.

a. Valleculab. Rosenmüller’s fossac. Pyriform sinusd. Choana

Answer: b. Rosenmüller’s fossa. It is a pharyngeal recess (bilateral) at the back of the nose (nasopharynx) near the torus tobarius surrounding the entrance to the Eustachian tube.

Identification Quiz10. Interpret the Audiogram below.

Answer: Sensorineural hearing loss, mild, AD. See next slide for explanations. AD means right ear (cf. AS, left ear)

Audiogram

Meaning Right ear Left ear

Air unmasked O X

Air masked ∆

Bone unmasked < >

Bone masked [ ]

Remember: Air (AC) uses shapes and X, Bone (BC) uses [ ] and greater-than less-than.

Audiogram

Conductive hearing loss

BC is normal while AC is >25 dB.

Sensorineural hearing loss

In sensorineural, both AC and BC are >25 dB. But BC dipped in higher freq.

Result AC BCNormal <25 dB <25 dBConductive hearing loss >25 dB <25 dBSensorineural hearing loss >25 dB >25 dBMixed hearing loss >25 dB >25 dB

Mixed hearing loss

Similar to sensorineural, both AC and BC are >25 dB in mixed. But both AC and BC really dip together.


– Case 1.0, 1.1, 1.2, 1.3, 1.4– Case 2– Case 3


Case 1.0A.Y., a 19 year-old male complained of otalgia.

What questions about the history will you ask?

What will you perform on P.E.?

Hx: OPQRST of Pain, Colds? Allergies? Rode airplane/diving/swimming? Discharge (Otorrhea)? Fever? Hearing loss? Dizziness? Headache?

Inspect for craniofacial anomalies, Otoscopy, Anterior rhinoscopy, Posterior rhinoscopy/Nasal endoscopy, Weber test, Rinne test, Schwabach test (due to the hearing loss) and complete HEENT exam (because may be Referred only).

Case 1.0Hx revealed:

2 years PTC: recurrent otorrheaSought consult, prescribed w/ unrecalled meds (oral and topical drops), doctor said that tympanic membrane was intact.

1 year PTC: otalgia and otorrhea worsened; consult revealed perforated tympanic membrane.

2 weeks PTC: low-grade fever, headache localized to temporal bone, dizziness, persistent otalgia and otorrhea

Case 1.0You took your Welch Allyn and Otoscopy revealed:

How would you describe the otoscopic findings?

Review of Otoscopy

It is important to memorize the anatomic parts of the tympanic membrane to be able to say where the perforation is, where hyperemia is, where the keratin debris are, or where the serosanguinous fluid is coming out.

The cone of light reflex (from the reflection of the otoscope light) always points anterior. So this is the RIGHT ear.

Case 1.0How would you describe the otoscopic findings?

Perforationat the pars flaccida, 30%

Serosanguinous fluid behind the TM (discoloration)

Hyperemia in the Epitympanum


What other diagnostic tests will you request?Pure Tone Audiometry, Audiogram, and Imaging: CT-scan or MRI?

MRI would be good for soft tissues but not for this case.CT would be better because it assesses bony integrity which will confirm concomitant complications such as:

Skull-base Osteomyelitis or PetrositisAcute MastoiditisCoalescent Mastoiditis

Besides, CT will better aid future surgical interventions.

Case 1.0You requested CT and findings revealed:

How would you describe the CT findings?

Presence of erosion of the labyrinth at the left ear (axial cut).Although a CT scan usually cannot make a definitive diagnosis regarding the nature of any existing temporal bone disease, the presence of labyrinthine erosion is highly-suggestive of Cholesteatoma.

Opacification of the mastoid antrum and mastoid air cells at the left ear (axial cut).This finding is suggestive of Coalescent Mastoiditis, and other sequelae of worse prognosis such as subperiosteal abscess and intracranial complications.

Case 1.0Audiogram revealed:

How would you interpret?

Conductive hearing loss, mild, both ears.

Average hearing level is approximately 35 dB.

Review of Weber test

What results of the Weber test would you expect in a patient with mild conductive hearing loss on the left and normal right ear? Lateralize to right or left?

LateralizationNormal Midline, sound equally heardUnilateral conductive hearing loss

Sound lateralizes to poor ear

Unilateral sensorineural hearing loss

Sound lateralizes to better ear

Review of Rinne test

What results of the Rinne test would you expect in a patient with mild conductive hearing loss on the left? AC > BC or BC > AC?

ResultNormal or sensorinueral hearing loss(+)

AC >BC (positive)

Unilateral conductive hearing loss (-)

BC>AC (negative)

What is the diagnosis?2 years PTC: recurrent otorrheaSought consult, prescribed w/ unrecalled meds (oral and topical drops), doctor said that tympanic membrane was intact.

1 year PTC: otalgia and otorrhea worsened; consult revealed perforated tympanic membrane. Correlate with Otoscopy.

2 weeks PTC: low-grade fever, headache localized to temporal bone, dizziness, persistent otalgia and otorrhea; Correlate with Otoscopy and CT findings.

Otitis Media with Effusion (OME)

Chronic Otitis Media (COM) without Cholesteatoma

COM with Cholesteatoma; Coalescent Mastoiditis*; R/O Labyrinthine Fistula**

*Acute Mastoiditis already accompanies COM without Cholesteatoma but Coalescent Mastoiditis is the one that causes fever and CT-findings. Furthermore COM can be Suppurative if the discharge is purulent or pus-like.

**Labyrinthine Fistula must be ruled-out due to the dizziness. If the dizziness is characterized to be vertigo, then there is inner ear involvement, making this a concomitant diagnosis.

Back to Case 1.0


The diagnosis ofChronic Otitis Media with Cholesteatoma; Coalescent Mastoiditis, left ear requires further investigation as to its cause.

Did the patient have failed treatment from previous ear infection (e.g. after swimming)?

Does the patient have craniofacial abnormalities (e.g. cleft palate, deformed ear) that make him prone to Eustachian tube dysfunction and ear canal dysfunction respectively?

Does the patient complain of “sneezing everyday, especially upon waking up,” such that it interferes with daily activities?

Case 1.1You can have Cholesteatoma without having

Otitis Media! This diagnosis is: Attic Retraction Cholesteatoma.

From trans:CC: 5 year history of on/off right ear with gradual hearing loss. No otorrhea.Figure below. Normally, extension of the blood vessels on the ear canal are travel in a radial fashion towards the ear drum and then to the head of malleus (or umbo).

Recall that Cholesteatoma is skin/keratin debris that eroded portions of the ear.

Abnormal: what if a part of the eardrum gets sucked in attic retraction You will see an interruption in the path of the blood vessel. Then you will see the blood vessel reappear.The blood vessel “stops” in its path because it traversed a weak part – the part that gets sucked in by negative pressureA part of the eardrum gets sucked in but the rest of it remains in place. Therefore, the eardum would look ballooned out.The part of the eardrum sucked in is made of skin and this will keep on producing new skin (cholesteatoma) leads to invagination eventually eroding the ossicle and the promontory

Case 1.2WHAT IF our patient A.Y., a 19 year-old male,

complained of otalgia, without otorrhea. No other symptoms.

Hx revealed swimming in Montalban river 2 days PTC.Otoscopy revealed:Here, external auditorycanal is narrowed, pre-cluding visualization ofthe tympanic membrane.

What is the most likely diagnosis?Since this looks like infection, what is the most likely etiologic

agent?

Most likely diagnosis is Acute Otitis Externa, R/O concomitant Acute Otitis Media.Since otalgia is also a characteristic of Otitis Media (OM) and because the tympanic membrane is not seen, OM cannot be fully ruled-out.

Because the patient has a history of swimming, and because the Otitis Externa (OE) is diffuse, this is most likely caused by Pseudomonas aeruginosa.In contrast to S. aureus where it is more likely due to ear manipulation and the OE is circumscribed, not diffuse.

Case 1.3WHAT IF our patient A.Y., a 19 year-old male,

complained of otalgia, with otorrhea, with other symptoms of difficulty breathing in the nose and frequent sneezing.

Hx revealed 3 yrs PTC: recurrent bilateral watery rhinorrhea associated with hyposmia, frontal headache

1 yr PTC: symptoms progressed, now with total nasal obstruction on the left, mucopurulent nasal discharge bilateral and post-nasal drip, anosmia, hyponasal speech and left sided facial pain.

Otoscopy is the same as Case 1.0

Case 1.3What other P.E. will you do?

Anterior rhinoscopy to visualize the inferior turbinate and meatus and the anterior portion of the middle turbinate.

Anterior rhinoscopy revealed:

Looks familiar… Nose SGD!

Anterior rhinoscopy of the left nares: (+) smooth, gelatinous, semi-translucent and pale white mass arising from the pink mucosa

Anterior rhinoscopy of the right nares: mucosal edema, swollen and hyperemic nasal septum and middle turbinate; (+) of obstructive mass, visualization of which is precluded by a suppurative yellow discharge

Case 1.3What other diagnostic tests will you request?

CT-scan or MRI?

MRI would be good for soft tissues but not for this case.CT would be better. CT scan of the what? What view?

a.Axial a. Temporal boneb.Coronal b. Sinusesc.Watersc. Orbit and facial bonesd.Transverse d. Nasopharynx

See next slide for answer.

Case 1.3You requested CT (coronal view) of the sinuses and findings revealed:

How would you describe the CT findings?

Left: complete opacification of the maxillary sinus and Ostiomeatal unit (OMU); partial opacification of the anterior ethmoid cells with air-fluid levelRight: complete opacification of the anterior ethmoid cells and OMU; partial opacification of the maxillary sinus with air-fluid levelOverall: Homogeneity of opacification; intact bony structures with (–) bone remodeling or thickening

Diffuse mucosal thickening whether partial or complete suggests mucosal hypertrophy from inflammation, retained secretions and obstruction, as well as polyposis. Opacification of the OMU is indicative of grave obstruction because it will eventually involve almost all of the paranasal sinuses.

Case 1.3RECAP:A.Y., a 19 year-old male, complained of otalgia, with otorrhea, with other

symptoms of difficulty breathing in the nose and frequent sneezing.

What is the diagnosis?

The diagnosis is:

Chronic Rhinosinusitis (Pansinusitis); Inflammatory Nasal Polyposis with concomitant Chronic Otitis Media with Cholesteatoma and Coalescent Mastoiditis

Case 1.4WHAT IF our patient A.Y., a 19 year-old

male, complained of otalgia, without otorrhea. No other symptoms.

Hx revealed sensation of swelling “inside ear”Otoscopy cannot be donedue to microtia and absenceof external meatus.

Case 1.4You requested CT (coronal view) of the temporal bone and findings revealed:

How would you describe the CT findings?A big mass of skin has eroded the bone.

Case 1.4RECAP:A.Y., a 19 year-old male, complained of otalgia, without otorrhea. No

other symptoms. Microtia and absence of external meatus.

What is the diagnosis?The diagnosis is:

External Canal Cholesteatoma secondary to Congenital Meatal Stenosis.

From trans:•pain and swelling behind ear •Granulation tissue present•Ear with an abnormal pinna; 2 mm ear canal•Grayish mass of soft tissue with some blood inside the ear canal•In congenital meatal stenosis, the outer part of the ear canal is narrow but the inner part is not as narrow. Since the canal’s skin is like a conveyor belt, the skin gets dammed back inside because the outer opening is so narrow, causing skin extension to the middle ear and possibly, to the bone. Pus may drain from the ear (posteriorly).

General Principles of Treatment

For Otitis Externa:Topical antibiotic drops: Ciprofloxacin, Ofloxacin; but fluoroquinolones for Pseudomonas

For Otomycosis:

Topical antifungal drops: Miconazole, Ketoconazole

For Otitis Media:Systemic antibiotics, esp. if with fever +/- analgesics

For Impending Perforation of tympanic membrane:Myringotomy, and tube; antibiotics

For Cholesteatoma, with Mastoid involvement and Perforation:Surgery (Tympanoplasty, Mastoidectomy)


– Case 1– Case 2.0, 2.1, 2.2, 2.3, 2.4– Case 3


Case 2.0O.T., a 39 year-old female complained of

hoarseness.

What questions about the history will you ask?


Hx: Quality of hoarseness? Duration of hoarseness? Progressive? Pain? OPQRST of Pain, Cough and colds? Sore throat? Occupation?

Inspection of oral cavity, and complete HEENT exam (because there might be associated s/sx).

Case 2.0Hx revealed:

1 week PTC: hoarseness, non-progressive; no dysphagia, cough, colds; patient was previously normalOccupation: singer (alto); Noticed that hoarseness worsened with reaching the high notes of soprano

Case 2.0O.T., a 39 year-old female complained of

hoarseness.

What diagnostic test will you request?Best answer: Laryngoscopy, a.k.a. Stroboscopy or Strobovideo laryngoscopy

Other tests could be:•Objective voice assessment (not elaborated in lecture)•Laryngeal electromyography (not elaborated)•High-resolution CT of the larynx

Imaging such as CT are not really of use in this case.However, imaging may be important:• if the patient complains of dysphagia• if the doctor is entertaining malignancy

Laryngoscopy revealed:

Case 2.0

What is the diagnosis?

Subepithelial hemorrhage.

From trans:•Often results from voice abuse or misuse•Voice rest usually resolves hemorrhages, with restoration of normal voice•In rare cases, the hemorrhage organizes and fibroses, leading to scarring•In specially selected cases, surgical incision and drainage of the hematoma may be done Treatment:

•Absolute voice rest until the hemorrhage has resolved (usually about 1 week) •Relative voice rest until normal vascular and mucosal integrity have been restored (usually about 6 weeks)•Recurrent vocal fold hemorrhages are usually due to weakness in a specific blood vessel, which may require surgical cauterization of the blood vessel using a laser or microscopic resection of the vessel


Case 2.1

Laryngoscopy revealed:WHAT IF our patient O.T., a 39 year-old

female, is a teacher; complained of non-progressive hoarseness which started 6 months ago. Fatigable voice after 1-hour of speaking.

Bilateral, midline protrusions


Benign vocal cord nodules.•Callous-like masses of the vocal folds caused by vocally abusive behavior•Hoarseness, breathiness, loss of range and vocal fatigue•Voice abuse should be suspected particularly in patients who report voice fatigue associated with voice use, in those whose voices are worse at the end of a working day or week, and in those who are chronically hoarse•Confined to the superficial layer of the lamina propria•Composed primarily of edematous tissue or collagenous fibers•Vocal nodules are bilateral and fairly symmetrical•mid membranous portion: area with most contact•Treatment:

oVoice therapy 6-12 weeksoIn rare cases, may need microsurgical excision

Case 2.2

Laryngoscopy revealed:WHAT IF our patient O.T., a 39 year-old

female, is a teacher; complained of non-progressive hoarseness which was there for as long as she can remember.

Unilateral, midline protrusion


Submucosal cyst.•May arise from a blocked mucus gland duct, but may also be congenital•Often mistaken for nodules•Often cause contact swelling to the contralateral cord•Diagnosis:

o Fluid-filled appearance on strobovideolaryngoscopy o Lined with thin squamous epithelium; Retention cysts contain mucus;o Epidermoid cysts contain caseous materialo Located in the superficial layer of the lamina propria. In some cases, cysts are attached to the vocal ligament.

•Treatment: oVoice therapy does not resolve the cystsoMicrosurgical exclusion

Case 2.3


WHAT IF our patient O.T., a 39 year-old female, is a teacher; smoker (5 pack-years); complained of non-progressive hoarseness for 1 month. She has a low, coarse, gruff voice which makes her voice mistaken as a male’s.

Bilateral, fluid-filled protrusions at the base


Reinke’s edema.•Low, coarse, gruff voice•Often associated with smoking, voice abuse, reflux, and hypothyroidism •Diagnosis:

o "elephant ear" floppy vocal fold appearanceo the superficial layer of lamina propria (Reinke's space) becomes edematous

•Treatment: oTreat underlying conditionoOften requires surgery, which is generally done one side at a time

Case 2.4


WHAT IF our patient O.T., a 39 year-old female, is a sales agent; smoker (20 pack-years); complained of progressively-worsening hoarseness for 2 years. She has a low, coarse, gruff voice which makes her voice mistaken as a male’s.

Relevant P.E. showed palpable lymphadenopathy (non-tender) of the submental and (right) submandibular triangles, Level I, IIA, and IIB. Inspection of the oral cavity revealed a 4x4cm painless lump in the underside of the tongue.

Unilateral, hemorrhagic mass (metal is an endotracheal tube)


Squamous cell carcinoma of the larynx and floor of the mouth.•May present as an exophytic, or infiltrative lesion•Smoking, alcohol intake are risk factors•Voice problems may be an early symptom of laryngeal cancer•Can be treated with radiotherapy, surgery, chemotherapy, or a combination of the three

Anterior

RightLeft


– Case 1– Case 2– Case 3.0


Case 3.0B.L., a 22 year-old male sought consult for his unilateral neck

mass, right since 8 months ago.Nb: This is based on a true patient during ENT ClinEx in Amang last Oct. 21,

2011; with slight modification only of the chief complaint and a PE result.

Case 3.0O.T., a 22 year-old male sought consult for his

unilateral neck mass, right since 8 months ago.What questions about the history will you ask?


Hx: Progressive enlargement? Headaches? Cough and colds? Sore throat? Mumps, Parotitis, Otitis? Pain? Nasal obstruction? Rhinorrhea? Epistaxis? Otalgia? Otorrhea? Hearing loss? Tinnitus? Dysphagia? Hoarseness? Trismus? Limitation of jaw movement and mouth opening? Occupation?

Complete HEENT exam including Cranial nerve exam.


unilateral neck mass, right since 8 months ago.

History revealed:The patient claimed to be previously normal;(–) infectious/inflammatory diseases such as mumps, parotitis, otitis.8 months PTC: first noticed a small lump, non-movable, non-tender, at the right lateral neck (4x4cm), inferior to the ear and posterior to the jaw.7 months PTC: tinnitus, described as “offline of TV station,” persisted until consult; “mabigat ang kanang tenga”6 months PTC: neck mass swelled twice the size5 months PTC: limitation in fully opening the mouth and trismus at the right; diminished hearing at the right (40%)4 months PTC: one episode of epistaxis, 5mL blood, relieved by cold compress3 months PTC: earache at the rightROS: recurrent headaches; snoring



History revealed that the mass enlarged up to the size shown below:

Review of the Relevant

Levels and Trianglesof the Neck

See next 3 slides!

Back to Case 3.0O.T., a 22 year-old male sought consult for his


P.E. revealed:(–) weight loss; afebrileAnterior rhinoscopy: essentially unremarkable – no polyps, masses, septal deviation, and other lesions Posterior rhinoscopy: (not done)HEENT: normal-bulk masseter and temporalis muscles; non-enlarged and non-tender parotid gland; no facial abnormalities; small lump, slightly-movable, non-tender, at the left lateral neck (1x1.5cm), inferior to the ear and posterior to the jaw (unnoticed by the patient); no palpable lymph nodesCranial nerve exam: intact corneal reflex, intact sensory and motor for V1, V2, V3 branches, intact motor functions for XI and VII except for weakness of the platysma at the rightWeber test: lateralized to the rightRinne test: BC > AC at the right, BC > AC as well at the left

Case 3.0What is the meaning of this?• Weber test: lateralized to the rightWhich of the following are possible interpretations for

Weber?

Answer: e. A and C. Although both A and C are possible interpretations for lateralization to the right, the patient (case 3.0) might only have conductive hearing loss on the right.

a. There is conductive hearing loss on the rightb. There is conductive hearing loss on the leftc. There is sensorineural hearing loss on the leftd. There is sensorineural hearing loss on the righte. A and Cf. B and D

Case 3.0What is the meaning of this?• Rinne test: BC > AC at the right, BC > AC as well at the

leftWhich of the following are possible interpretations for

Rinne?

Answer: e. A and B. In the case of the patient, he notices the diminished hearing only on the left because it is relatively weaker. Remember too that a positive Rinne test (AC > BC) is NORMAL!

a. There is conductive hearing loss on the rightb. There is conductive hearing loss on the leftc. The left either has sensorineural hearing loss or is normald. The right either has sensorineural hearing loss or is normale. A and Bf. C and D

Case 3.0With Tintin’s otoscope, Otoscopy revealed:

How would you describe the otoscopic findings?

Case 3.0How would you describe the otoscopic findings?

Hyperemia in the Pars flaccida

Serosanguinous fluid behind the TM (discoloration)

Intact tympanic membrane, no perforation; good cone of light reflex



Further P.E. revealed:

Oral cavity: numerous dental caries; Grade I Tonsillitis; pink mucosa; midline uvula; no atrophy, fasciculations and other lesions for the tongue; non-enlarged posterior pharyngeal follicles, no other lesions noted; intact gag reflex



What diagnostic tests will you request?

All of the following are generally useful for evaluation EXCEPT:a.CTb.Chest X-rayc.Ultrasoundd.FNABe.MRIf.None of the above

Answer: f. None of the above because all are useful; CT and MRI are good choices for whole Head & Neck evaluation; CXR would be useful for TB and ruling-out some differentials; FNAB would be useful for minimizing the seeding if the mass were malignant; and UTZ may guide the FNAB, especially if the mass has cystic components.

Case 3.0You requested CXR and readings by the radiologist found

Ghon lesions at the apical lung portions. An ENT in Amang did a therapeutic trial by having the patient undergo a 1-month treatment of Izoniazid, Rifampicin, Ethambutol, and Pyrazinamide. The doctor suspected that the neck mass is:

due to Tuberculosis presenting as TB Adenitis of the cervival lymph nodes.

Nb: This is the actual course of action taken by the ENT and corroborated by Dr. Lacanilao as an appropriate initial management if TB is suspected.

However, after 1 month of compliant medication use, the patient’s mass did not subside but actually grew in size.

Case 3.0You requested CT and findings are below:

Review of the Relevant

Radiologic Anatomyof the Neck

See next 2 slides!

PMS – Pharyngeal Mucosal SpacePPS – Parapharyngeal SpaceRPS – Retropharyngeal Space

Case 3.0How would you interpret the CT findings?

There is obliteration of the pharyngeal mucosal and parapharyngeal spaces. There is a heterogeneous

mass noted on the posterior pharyngeal wall, superior portion.

Case 3.0You may also request MRI (although CT may suffice) and

findings are below:

Blue arrows point the pharyngeal mass;White arrows point the lateral neck mass.The neck mass has the same homogeneity as the pharyngeal mass.



What is your next diagnostic step for workup?

After seeing the imaging results, you choose to do biopsy. Which are the next courses of action?a.Endoscopic biopsy of the nasopharynxb.Fine needle aspiration biopsy (FNAB) of the neck massc.Either A or Bd.Neither A or B

Answer: c. Either A or B because the neck mass and the mass in the nasopharynx are connected.

Case 3.0Before doing the biopsy, Posterior rhinoscopy is

done. It revealed the picture below. Interpret.

There is obliteration of the Rosenmüller’s fossa by a growing space-occupying (mass) lesion.

Case 3.0After all the revealed information from History, PE, Imaging,

your Primary impression, even without the biopsy results yet, is:

Nasopharyngeal Carcinoma. This accounts for the neck masses because pharyngeal tumors metastasize early. In fact, a neck mass may precede the demonstration of a mass in the nasopharynx (by posterior rhinoscopy).

What are other differential diagnoses?

• Lymphoma (Non-Hodgkin’s).• Lymphoma (Burkitt’s).• 2nd Branchial Cleft Cyst with superimposed infection.• Rhabdomyosarcoma.

Case 3.0How can we rule-out the other DDx?

• Lymphoma (Non-Hodgkin’s and Burkitt’s) Lymphoma (Burkitt’s) frequently present as supraclavicular neck masses and a much faster growth in size (days or weeks). They may also recede in size and grow back again insiduously. Lymphomas are systemic cancers and frequently begin as intrathoracic masses. These are not evident in the patient.• 2nd Branchial Cleft Cyst with superimposed infection; although congenital, they may enlarge rapidly if with superiposed infection. However, the patient denied having a mass prior to the earliest mass presentation; and no fever and constitutional symptoms can suggest superimposed infection.• Rhabdomyosarcoma; although more common in the pediatric population, this presents as a growth of soft tissue mass. However, this cannot account for other head & neck manifestations.

General Principles of Treatment

For Nasopharyngeal Carcinoma:Radiotherapy

For Lymphoma:

Chemotherapy

For Branchial Cleft Cysts:

Surgery



• Other ENT symptoms (and Review of the former shown)• Laundry list of must-know and common diagnoses

ENT symptoms• Hearing loss (conductive) suggests involvement of either the external ear or middle ear, or both. Dx could be Otitis Externa or Media, Perforated tympanic membrane, or Impacted cerumen. Otomycosis is heralded by pruritus (itch).• Hearing loss (sensorineural) suggests involvement of the inner ear, frequently damage to the cilia and/or the auditory nerve. This is different from mixed hearing loss (both conductive and sensorineural) and also from central hearing loss due to lesions in the auditory cortex.• Tinnitus described as “ringing in the ears” is a very non-specific symptom that can signify inner ear involvement as well. It can accompany any other head & neck pathology and can be in normal individuals.• Otalgia or earache and Otorrhea or ear discharge can both be from Otitis Externa or Otitis Media. Otorrhea can happen even in an intact tympanic membrane, i.e., if due to Otitis Media with Effusion (OME) or if due to a pus in the external canal. Otalgia can happen in non-infectious cause such as in pressure changes (e.g. riding an airplane). This condition, called Barotrauma, is frequently accompanied by Hemotympanum, or blood inside the tympanic membrane.

ENT symptoms• Dizziness is a non-specific symptom that may not be an ENT case. It must be further characterized.

TYPES CAUSESLightheadedness (lumulutang)

some drugs, metabolic processes (hypothyroidism, hyperglycemia, hypoglycemia pregnancy)

Spinning (umiikot, vertigo)

Induced by vestibular (ear)/ central (brain: cerebellum and area of the brain stem) problems, visual system (but in actuality, the eyes are affected by the changes in the ear and not the reverse)

Feeling of fainting or syncope (hinihimatay, mawawalan ng malay)

cardiac (any cardiac condition, things which decrease blood supply to the brain), neurovascular (related to the blood supply to the brain)

Unsteadiness/ Imbalance/ dysequilibrium (nalulula/ parang laseng/ nawawalan ng balanse/natutumba)

alcohol intake, neurologic, musculoskeletal, proprioceptive loss (cause: lesions of the posterior column, Syphilis – tabes dorsalis, peripheral neuropathy – diabetes)

• Vertigo is connected with dizziness but is characterized by a spinning sensation. It must be differentiated if central (Neuro case) or peripheral (ENT case).

ENT symptoms• Vertigo and its differentiation:

Table 1. Characteristics of Peripheral and Central VertigoPERIPHERAL CENTRAL

Vertigo IntermittentSevere

ConstantLess Severe

Nystagmus Always presentUnidirectionalNever vertical

May be absentUni/BidirectionalMay be vertical

Associated Findings:Hearing loss/tinnitusIntrinsic brainstem signs

Often presentAbsent

Rarely presentTypically present

Table 2. Differences in Nystagmus in Peripheral and Central Vertigo

PERIPHERAL CENTRAL

Direction Horizontal or horizontorotatory

(never vertical)

Any

Laterality Bilateral Unilateral or bilateral

Visual Fixation Suppressed NOT suppressed (may be

enhanced)

Table 3. Dix-Hallpike Test in Peripheral and Central VertigoPERIPHERAL CENTRAL

Latency Long (>10 sec) Short (<10 sec)Duration Transient (<1 min) Sustained (>1 min)Intensity Mild to severe Mild Fatigability Fatigable Nonfatigable

ENT symptoms• Nasal Obstruction and Nasal Congestion go hand-in-hand in that one can cause the other, creating a vicious cycle. For example, Rhinosinusitis can predispose one to Polyps, although the latter can also worsen the former’s symptoms.• Nasal Discharge or Rhinorrhea may be as benign as allergy or as worse as CSF Leak.• Epistaxis or nosebleed is a symptom and not a disease. It can be in normal individuals and can be due to a variety of reasons such as friable blood vessels, and benign and malignant mass lesions. For pedia, it may be a sign of Dengue.• Sore throat is part of the symptom of Dysphonia or Hoarseness, a symptom of laryngeal pathology. Most benign lesions are usually non-progressive unless insult is continuous. Dysphagia or difficulty swallowing and is often due to infectious or inflammatory causes of the oropharynx and hypopharynx. It could also be esophageal in origin. In contrast, Stridor, or wheezing sound, is often due to tracheobronchial problems.• Snoring can accompany Obesity and palatal abnormalities.

ENT symptoms

• Trismus is the inability to normally open the mouth due to one of many causes. It may be due to maxillofacial fractures.• Most ENT symptoms suggest pathologies confined to the head & neck, except for signs and symptoms arising from the neck and nearby structures. Neck pain can be due to infection in the neck but along with jaw pain, is a frequent sign or referred pain due to Myocardial Infarction. Neck masses can be from head & neck primary but can also be metastases from systemic cancers.

Other common ENT Dx

not mentioned previouslyThis list excludes most ear conditions as these have been extensively mentioned elsewhere in the previous slides. Thyroid and Parathyroid diseases will be touched on Endo.

• Acute Tonsillopharyngitis• Acute Laryngitis• Papilloma of the larynx• Presbylaryngeus• Laryngopharyngeal reflux• Sulcus Vocalis• Oral Candidiasis• Retropharyngeal Abscess• Foreign body in the nose, throat• Laryngotracheobronchitis• Laryngotracheal Stenosis• Juvenile Angiofibroma• Allergic Rhinitis• Sialolithiasis• Pleomorphic Adenoma

Other common ENT Dx

not mentioned previously• Vestibular Schwannoma• Presbycussis• Menierre’s disease• Viral Labyrinthitis• Tympanosclerosis• Rhinitis medicamentosa• Atrophic Rhinitis• Vasomotor Rhinitis• Thyroglossal duct cyst• Hemangioma• Nasal bone fracture• Mandibular fracture• Tripod fracture• Zygomatic arch fracture




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