Transcript Clinical cases in ENT

CLINICAL
CASES IN
ENT
AND PICTURE QUIZ
CASE 1
A 36-year-old woman presents with recurrent episodes of
right-sided tinnitus, hearing loss and vertigo. Episodes
typically last between 10-30 minutes. He also describes a
'full' sensation in his right ear. Otoscopy is unremarkable and
the cranial nerve examination is normal.
Diagnosis?
Meniere's disease
More common in middle-aged adults
Triad of Recurrent episodes of vertigo, tinnitus and hearing
loss (which type?)
Episodes last minutes to hours
What other features can be seen?
Nystagmus and positive Romberg test
Management of acute attacks?
Bed rest, vestibular sedatives (Diazepam), Prochlorperazine
for N&V
Prevention of attacks?
Betahistine,? Salt restriction
Let’s say this patient had absent corneal relfex on
examination. Would your differential diagnosis change?
Acoustic neuroma
CASE 2
A 31-year-old man presents with bilateral
hearing loss and tinnitus. There is a family
history of similar problems. Examination of
the tympanic membranes:
Diagnosis?
Otosclerosis
What is otosclerosis?
•Autosomal dominant.
•Replacement of normal bone by vascular spongy bone.
Onset is usually at 20-40 years
•conductive deafness
•tinnitus
•tympanic membrane - 10% of patients may have a 'flamingo
tinge', caused by hyperaemia
•positive family history
CASE 3
Which one of these is the correct
technique to stop epistaxis?
Picture A- So-called ‘Hippocratic
technique’
Where do most nose bleeds come from?
Little’s area in the anterior inferior part of
the nasal septum.
TYPES OF EPISTAXIS
1) ANTERIOR: Most common site

Known as little’s area (Kiesselbach’s plexus)

Nose picking & Infection
2) POSTERIOR:

Known as Woodruff’s plexus

hypertension +/- anticoagulants
3) Lateral wall/Nasal mucosa/Postnasal space
Local Causes:

Trauma, Infection, Foreign body, Previous surgery

Tumors: Rare Juvenile Nasopharyngeal Angiofibroma -> recurrent
unilat. Epistaxis.

Illicit drug use: Cocaine/septal perforation
Systemic Causes:

Hypertension

Hepatic disease

Blood Dyscrasias

Endometriosis patient will give history of cyclical epistaxis
Genetic:
Osler-weber-Rendu syndrome ( Hereditary Haemorrhagic telangiectasia)

Autosomal Dominant

elements
Vascular malformation where vessel walls lack contractile

Affect respiratory and GI systems
Medication:
Aspirin, warfarin, heparin, NSAIDS
Management of epistaxis?
1) ABC- make sure the patient is adequately
resuscitated
2) Identify the source of bleeding
3) Apply local anaesthetic and vasoconstrictor to
nasal mucosa. (Do not use vasoconstrictors if
the patient is hypertensive)
4) If bleeding point can be identified, cauterise
(either chemical with silver nitrate or electrocautery)
5) If no source can be identified or cautery has
failed: Anterior packing
6) If cannot be localized anteriorly or controlled
with anterior packing: Posterior packing
7) Arterial embolisation or arterial ligation
When to admit the patient?
If bleeding continues
Nasal pack (don’t forget Ab cover)
Posterior bleed
Elderly, frail
When sending home, patient education and Naseptin (Avoid
with nut allergy!)
CASES 4-8
1) 24 year old primary school teacher. Gradual onset of voice
change, worse at the end of day.
Vocal nodules
2) 62 year old smoker; 3 month history of sudden onset change in
voice. Has a cough. Had one episode of hemoptysis.
Left vocal cord paralysis
3) 42 year old female publican; smokes 20 cigarettes a day. Enjoys
curry twice a week. Takes Gaviscon. Noticed her voice has become
deeper over last 9 months. Was upset when she was mistaken for a
man on the phone during a dating agency interview.
Reinke’s oedema
4) 30-year old lead singer in a famous rock band. Felt a sharp pain
at the level of larynx during the last concert. Was unable to finish
the concert.
Vocal fold hemorrhagic polyp
CASE 9
2 year old
child is
presenting
with fever and
otalgia.
1) What is the diagnosis?
Acute otitis media
2) Most common pathogens?
50% Viral; Bacterial:
o
Streptococcus pneumoniae
o
Haemophilus influenzae
o
Moraxella catarrhalis
3) Management?
Most likely spontaneous rupture and
resolution + management of symptoms.
4) Most serious possible complication?
Brain abscess
6 months later, mom is concerned about his hearing and
delayed speech. You can see from the notes he had 2 other
episodes of otitis media since last time.
Glue ear (Otitis media with effusion)
CASE 10
This is the right
ear of a 28-yearold man with
recurrent ear
discharge.
What is the diagnosis?
Cholesteatoma
Main features:
foul smelling discharge
hearing loss
Other features are determined by local invasion:
vertigo
facial nerve palsy
cerebellopontine angle syndrome
Management:
Refer to ENT for consideration of surgical removal
PICTURE QUIZ
RHINOPHYMA
Reinke’s
oedema
(Gross
oedema of the
vocal folds)
This patient is
presenting with
renal failure and
nose deformity.
WEGENER’S
GRANULOMATOSIS
CAULIFLOWER
EARUNTREATED
AURICULAR
HEMATOMA
QUINSY
(PERITONSILLAR
ABSCESS)
THANK YOU!
ANY QUESTIONS?