Low & Wong ENT Short Cases Record

ENT Short Cases Records & OSCE Questions

Low Qin Jian, Wong Weng Loon
1
st
edition



Low & Wong ENT Short Cases Record


ENT Topics

1. Nasopharyngeal Carcinoma

OSCE Questions

1. Thudichums nasal speculum
2. Tracheostomy
3. Trachea dilator
4. Metal tongue depressor
5. Tuning fork




Publish Date : 11
th
April, 2012

Low & Wong ENT Short Cases Record

Nasopharyngeal Carcinoma (NPC)
Sir, my patient is a middle age Kadazan gentleman. He appears to be cachexic.
On inspection, there is a well demarcated erythematous area over the right neck. Otherwise, there is no
mass seen, no scars, dilated veins noted.
On palpation, I can appreciate a _x_ cm (SIZE) lump over SITE. The lump is not tender. It is
immobile but not attached to the surrounding structures. There is __ cervical lymph nodes.
Cranial nerves examination : There are no diplopia or ophthalmoplegia. Weber and Rinne test reveal
__ sided conductive hearing loss.
To complete my examination, I would like to examine for distant metastasis to the liver, lungs and
bone.
In summary, my patient who appears cachexic and has a right sided lump with cervical
lymphadenopathy, ipsilateral conductive hearing loss, and a radiotherapy burn mark suggestive of
nasopharygeal carcinoma (NPC).

Questions
What are the differential diagnoses of lateral neck swelling?
* Lymph node
* Parotid swelling
* Submandibular salivary gland
* Branchial cyst
* Carotid body tumor
* Carotid aneurysm
* Cystic hygroma




Low & Wong ENT Short Cases Record

What are the etiologies for NPC?
Genetic - Chinese, Kadazandusuns, HLA-A2 and HLA-Bsin2
Viral - Epstein Barr Virus (EBV)
Environmental - Diet (salted fish, nitrosamine), smoking, air pollution.
What is the commonest site of origin for NPC?
Fossa of Rosenmuller (lateral nasopharynx), herniation of mucsa through lateral gap at sinus of
Morgagni.

What are the clinical presentations of NPC?
Nasal : Epistaxis, nasal congestion, blood stain nasal discharge
Otologic : Otitis media, conductive hearing loss, tinnitus
Ophthalmoneurologic : Cranial nerve palsies - CN III, V, VI, and VII (para-cavernous
sinus tumor invasion), squint, diplopia.
Cervical lymph nodes metastasis
Distant metastasis : Bone, lung, liver
What is your initial investigation?
Endoscopically guided biopsy of the primary tumor.
Magnetic resonance imaging (MRI) of the nasopharynx, skull base & neck for assessing
locoregional disease extent.



Low & Wong ENT Short Cases Record

Is there a role of monitoring EBV DNA titer in NPC?
I will like to obtaining pretreatment plasma EBV DNA levels for its prognostic significance, although
at this time, there is no clear indication for serial measurement of plasma EBV DNA levels for
assessing treatment response or in monitoring for recurrence.
What are the modalities of treatment available?
Early disease(stage 1) : Radiotherapy
Intermediate (stage 2) : Radiotherapy
Advanced (stage 3+4) : Chemoradiotherapy
How do we manage this condition?
Radiotherapy is the mainstay of treatment. Surgical treatment is not recommended due to anatomical
constraints in the nasopharynx. Combination therapy with chemotherapy seems beneficial for late
stage disease.
What is the prognosis of nasopharyngeal carcinoma?
When radiotherapy is used alone, survival rates range from 40-50%. Use of combination radiation
therapy and chemotherapy allows long-term survival rates of 55-80%.
What is the staging of NPC
TNM
T0 : no evidence of primary tumour
T1 : condince to nasopharynx, or extends to orppharynx or nasal cavity without parapharyngeal
T2 :parapharygeal extension
T3 :involve bony structure of skull base/ paranasal sinuses
T4 :tumour with intracranial extension and / involvement of CN, hypopharynx, orbit, extend to
infra temporal fossa.

N0 : no regional lymph node metastasis
N1 : unilateral, 6cm or less in diameter, above supraclavicular fossa /unilateral or bilateral
retropharyngeal lymph node, 6cm or less in diameter
N2 : bilateral, 6cm or less in diameter, above supraclavicular fossa
N3 :lymph node >6 cm or to supraclavicular fossa.

M0 : no metastasis
M1 : metastasis



Low & Wong ENT Short Cases Record



Low & Wong ENT Short Cases Record



Low & Wong ENT Short Cases Record













Low & Wong ENT Short Cases Record

OSCE Question 1

1. What is the name of the instrument above?
Thudichums nasal speculum
2. What are the uses of this instrument?
In anterior rhinoscopy, Foreign body removal from the nose, Peroperatively, for nasal packing,
In septal surgeries (septoplasty and SMR) while making the incision.
3. How to hold this instrument?


First, hold the instrument at its bend with your thumb and index finger.
Then, place your middle and ring fingers either side of the limbs of the speculum. Bringing
these fingers close to each other will also bring the flanges of the speculum close together.
Insert the instrument into the nostril in this position. Moving your middle and ring fingers apart
will widen the flanges of the speculum, opening up the nasal cavity in the process.
4. What are the structures seen with this instrument?
Nasal septum, Lateral wall of the nose including the turbinates and the meati, Floor of the nasal
cavity.


Low & Wong ENT Short Cases Record

OSCE Question 2

1. What are the functions of tracheostomy?
Alternative pathway for breathing.
Improves alveolar ventilation
Protects airway
Permits removal of tracheobronchial secretions
Intermittent positive pressure respiration (IPPR)
To administer anaesthesia
2. What are the indications of tracheostomy?
3 main indications are respiratory obstruction (infection, trauma, neoplasm, foreign body larynx,
larynx oedema), retained secretions, respiratory insufficiency (chronic lung disease).
3. What are types of tracheostomy?
Emergency and elective (Temporarily or permanent) tracheostomy.
4. What are the possible complications during tracheostomy procedure?
Immediate (Hemorrhage, apnoea, pneumothorax, injury to recurrent laryngeal nerve and
innominate vesel, aspiration); Intermediate (Reactionary bleeding, displacement/block tube,
subcutaneous emphysema, tracheobronchitis, local wound infection and granuloma,); Late
(Hemorrhage, laryngeal/trachea stenosis).
5. What are the structures to be divided before the trachea can be reached:
Skin, Subcutaneous tissue, Strap muscles, Isthmus of the thyroid, Pretracheal fascia

6. What are the types of tracheostomy tubes?
Cuffed, uncuffed and fenestrated.

Low & Wong ENT Short Cases Record


Cuffed tracheostomy tube
Cuff tracheostomy tube is used in immediately post-op to prevent dislodgement of tube, in
cases with unsure indications, for ventilation purposes (Upper airway obstruction, assisted
ventilation, frequent tracheal toilet, prevent aspiration), or in preventive upper head & neck
surgery.
Uncuffed tracheostomy tube

For children who are not ventilator dependant, the tracheostomy tube should allow some
airflow around the tube to avoid damage to the tracheal wall and to permit speech. Usually 3-6
days post op, plain tube is used.

Fenestrated tracheostomy tube.
Fenestrated tubes have an opening in the tube that permits speech through the upper airway
when the external opening is blocked, even if the tube is too big to allow airflow around the
outer cannula. Fenestrated tubes are not recommended for small children, because they can
obstruct the opening with granulation tissue. The opening of the hole must be at a correct angle
to prevent problems. Also, in an emergency, a solid inner cannula must be inserted in order to
ventilate the child through the trachea.

Low & Wong ENT Short Cases Record

OSCE Question 3

1. What is the instrument above?
Tracheal dilator
2. What are the uses of this instrument?
It is basically used to widen the tracheal opening while inserting a tracheostomy tube
Peroperatively during tracheostomy
During a tube change
It is especially useful should the tube accidentally come off in the early post op period, when
the track is still not well formed.
3. What is the difference between an artery forceps and a trachea dilator?
It looks like a pair of regular artery forceps except that :
Its tip is bent at almost right angles to the rest of the instrument.
There is no lock or clasp.
The tip is smooth and rounded unlike the sharp, dissecting tip of the artery forceps.

Trachea dilator Artery forceps







Low & Wong ENT Short Cases Record

OSCE Question 4

1. What is the instrument shown above?
Metal tongue depressor.
2. What are the indications for use?
Depress tongue to visualize oropharynx.
Cold spatula test for airway patency.

OSCE Question 5

1. What is this instrument?
Tuning fork.
2. What are the types of hearing loss?
Sensorineural, involving the inner ear, cochlea, or the auditory nerve.
Conductive, involving any cause that in some way limits the amount of external sound from
gaining access to the inner ear. Examples include cerumen impaction, middle ear fluid, or
ossicular chain fixation (lack of movement of the small bones of the ear).
Mixed loss, which is a combination of conductive and sensorineural hearing loss.
3. What are the usual frequency of tuning fork and their indications?
512-256 Hz tuning fork Weber/Rinne test.
125 Hz tuning fork Vibration test in neurological examination.

Low & Wong ENT Short Cases Record


4. Draw a normal left and right tympanic membrane with labels.

5. What are the interpretations of the tympanograms below?


Low & Wong ENT Short Cases Record