NAME: DAKHARA SAGARBHAI VINUBHAI

GROUP: C
CLERK: BCCM

ENT QUIZ

Case 1: AR, 8 year-old, boy came in at the ENT-OPD complaining of otalgia 5/10 on

pain scale accompanied by intermittent fever of 38°C and tinnitus from right ear for 2
weeks duration. He had history of colds 2 weeks PTC but has now subsided. Physical
examination showed AD: bulging hyperemic tympanic membrane. With displaced
cone of light. AS: intact tympanic membrane, no discharge, good cone of light.

1. List 3 differential diagnosis for the patient. Enumerate the signs and symptoms
in the case

Differentials Rule in Rule out

ACUTE OTITIS MEDIA Most Common in Children Decrease hearing
Hx of upper respiratory infection
Fever,Otalgia,Tinnitus
Bulging and hyperemic TM
ACUTE MASTOIDITIS Otalgia, fever, bulging tympanic Discharge from the ear
membrane,
BULLOUS Hearing loss, fluid draining from ear, Inner ear infection
MYRINGITIS Tugging or pulling ear, , Loss of balance,
Otorrhea Good night sleep
Fever
Fluid draining in ear

2. What are the stages of otitis media? On the case above, what stage of otitis
media is the patient experiencing?

There are 6 Stages of otitis media as follows

1. Hyperemia
2. Exudation
3. Suppuration
4. coalescence and mastoiditis
5. Stage of complication
6. Stage of resolution
The patient is experiencing stage 1 hyperemia of otitis media.

3. What is the primary tool in the diagnosis of middle ear effusion? Explain.

The primary tool in the diagnosis of middle ear effusion is Pneumatic otoscopy.

Pneumatic otoscopy will readily detect the presence of perforation of the

tympanic membrane or fluid in the middle ear. The principle is that of increasing
and decreasing air pressure within the external ear canal while visualizing the
movement of the TM in response to the pressure changes. If a perforation is
present, the TM will have no movements. Movements will be abnormal in the
presence of fluid.

4. What is the 1st line treatment for this patient? Explain the mechanism of
action.?
The 1st line treatment for the patient is to prescribe Amoxicillin 20-40mg/kg/d in
3 doses.

The mechanism of action

Amoxicillin competitively inhibits penicillin-binding protein 1 and
other high molecular weight penicillin binding proteins.
Penicillin bind proteins are responsible for glycosyltransferase and transpeptidase
reactions that lead to cross-linking of D-alanine and D-aspartic acid in bacterial
cell walls.Without the action of penicillin binding proteins, bacteria up regulate
autolytic enzymes and are unable to build and repair the cell wall, leading to
bactericidal action.

5. What management options can you give to this patient when he complains of

worsening symptoms or failure to respond to medications? Explain.

If Px failed to respond to initial antibiotic therapy and then reassess the Px after
48-72 hr and shift to ceftriaxone or Co-amoxiclav because there might be still
presence of infection and if still failure respond we can perform
MYRINGOTOMY.Myringotomy is incising the drum to remove the pus.

CASE 2
VN, 27 year old, female complained of recurrent rhinorrhea accompanied by nasal
itchiness and hyposmia occurring for more than 4 days per week for one month
duration. Patient does not have difficulty sleeping and has no problems at school.
On anterior rhinoscopy, bilateral boggy reddish turbinates with minimal watery
nasal discharge.

Salient features
27 year old, female Recurrent rhinorrhea Nasal itchiness Hyposmia (-)
difficulty of sleeping (-) problem at school B/L boggy reddish turbinates Minimal
watery nasal discharge.

6. What is the diagnosis of the patient? Enumerate the signs and symptoms in
the case.
Diagnosis of the px is allergic rhinitis.
Recurrent rhinorrhea,Nasal itchiness,Hyposmia,difficulty of sleeping B/L boggy
reddish turbinates,Minimal watery nasal discharge are the signs and symptoms.

7. Enumerate the ARIA Classification in a table. Based on the ARIA classification,

the patient is classified as having what symptoms?

INTERMITTEN SYMPTOMS PRESISTENT SYMPTOMS

- <4 days per week - > 4 days / week
- Or <4 weeks - And > 4 weeks

MILD MODERATE – SEVERE ONE or

- Normal sleep MORE
- Normal daily activities, - Abnormal sleep
sports, leisure - Impairment of daily
- Normal works and school activities, sports, leisure
- No troublesome - Problem caused of works
symptoms or school
- Troublesome symptoms

8. What are the most common aeroallergens found in the Philippines?

house dust mites, cockroach, mold spore, cat dander, kapok, dog dander, grass
pollens, weed pollens, acacia pollen.

9. What is the best initial pharmacologic treatment for the patient? Explain the
mechanism of action?

The best initial pharmacological treatment is topical nasal steroids Intranasal

steroids which helps to reduce the influx of inflammatory cells into the nasal
mucosa in response to allergic stimuli and reduces the release of inflammatory
mediators and the development of nasal hyper responsiveness.

10.What is an effective treatment of allergic rhinitis that may prevent the

development of new allergen sensitizations and reduce the risk for future
development of asthma in patients with allergic rhinitis?

Allergen specific immunotherapy

CASE 3
KP, 21 year old, male, complained of dysphagia to both solids and liquids. He had
fever of 39 °C. He claimed that he had been having 3 episodes per year of
recurrent tonsillitis for the past 3 years. On PE, there is noted peritonsillar
swelling, right.

11. What are the most common organisms that can cause the infection?
Group A beta hemolytic streptococcus (GABHS).

12. What is the 1st line antibiotic to be given to this patient? Explain the
mechanism of action
Penicillin is 1st line antibiotic to be given to the px. They act by binding to specific
penicillin-binding proteins (PBPs) located inside the bacterial cell wall,
G inhibits the third and last stage of bacterial cell wall synthesis.
Cell lysis is then mediated by bacterial cell wall autolytic enzymes such as
autolysis.

13.What are the absolute indications for a patient to undergo tonsillectomy?

1.Recurrent episode of acute tonsillitis a-3 episodes/yr for 3 consecutive yr b-5
episodes/yr for 2 consecutive yr c-7 episodes/yr for single yr
2. febrile seizures due to fever in tonsillitis
3. chronic tonsillitis
4. peritonsillar abscess
5. obstructive sleep apnea and dysphagia due to hypertrophied tonsil.
6.unilateral enlargement of tonsils with suspected malignancy

14.Explain the Paradise the criteria for tonsillectomy.

CASE 4 A 2-year-old male came in with a chief complaint of 2 episodes of vomiting of

previously ingested food after a witnessed episode of ingestion of a one-peso coin. He
was brought to the emergency with no cough, no further episodes of vomiting, and no
difficulty breathing.

15. What is your initial impression?

Esophageal Foreign body ingestion

16. What diagnostic procedure would you request?

Radiological examination (X ray) PA and Lateral airway film and PA & lateral chest
films including the abdomen.

17. What are the different phases of foreign body ingestion?

Symptoms associated with the ingestion of foreign bodies occur in three stages.
In the 1st stage of initial symptoms, there is a violent paroxysm of coughing or
gagging. This occurs when the foreign body is 1st swallowed.
The 2nd stage is a symptomless interval. The foreign body has lodged, and
symptoms are no longer produced. This stage may last only a moment or two.
The 3rd stage consists of the symptoms produced by complications. There may be
discomfort, dysphagia, obstruction or perforation of the esophagus with resultant
mediastinitis.

18. What are the different constrictions of the esophagus?

Cervical constriction
- Thoracic constriction,Abdominal constriction

19.Which constriction is the most common site where foreign bodies lodge?
Cervical constriction

20. What is the gold standard procedure for this patient?

Esophagospy is considered as gold standard procedure for foreign body removal.

LABEL THE LEVELS OF THE CERVICAL LYMPH NODES AND ENUMERATE

THEIR BORDERS
LEVEL OF CERVICAL LYMPH NODES AND ITS BORDERS
IA – Submental lymph node
It contains one or two lymph glands, the submental lymph nodes (three or four in
number) and Submental veins and commencement of anterior jugular veins.

IB – Submandibular lypmh node

It contains contains the submandibular gland, superficial to which is the anterior
facial vein, while imbedded in the gland is the facial artery and its glandular
branches.

II - Upper jugular nodes (Sub digastric nodes) - around the upper third of the
internal jugular vein and adjacent accessory nerve. The upper boundary is the
base of the skull and the lower boundary is the inferior border of the hyoid bone.
The anterior/medial boundary is the stylohyoid muscle and the posterior/lateral
one is the posterior border of the sternocleidomastoid muscle.

IIA – Beneath the gland, on the surface of the Mylohyoideus, are the
submentalartery and the mylohyoid artery and nerve.
IIB – Carotid Triangle It contains superior thyroid artery, lingual artery, facial
artery, occipital artery, internal jugular vein, lingual vein, superior thyroid vein.

III – Muscular Triangle It contains descending filaments from the Ana cervicalis;
behind the sheath are the inferior thyroid artery, the recurrent nerve, and the
sympathetic trunk; and on its medial side, the esophagus, the trachea, the thyroid
gland, and the lower part of the larynx.

IV – lower deep cervical VA – Occipital Triangle It contains cutaneous nerves of

cervical plexus and the external jugular vein and platysma muscle. A chain of
lymph glands is also found running along the posterior border of the
Sternocleidomastoideus, from the mastoid process to the root of the neck.

V - Posterior triangle lymph nodes

VA – Above the horizontal plane formed by the inferior border of the anterior
cricoid arch, including the spinal accessory nodes.

VB – Lymph nodes below this plane, including the transverse cervical nodes and
supraclavicular nodes

VI – Anterior compartment nodes –

Pretracheal, paratracheal, precricoid (Delphian) and perithyroid nodes, including
those on the recurrent laryngeal nerve.