ENT OSCE - Solved

Station 01: CT SCAN of Para-nasal Sinuses

 Structures can be seen:
 Anomalies can be seen: Polyp, Mass, Foreign Body, Sinusitis
 Views/Angels of CT for Paranasal Sinuses: Coronal View, Axial View, Lateral
View/Sagittal View
Station 02: Pleomorphic Adenoma of Parotid Gland

 D/D: Warthin Tumor, Pleomorphic Adenoma, Oxyphil Adenoma, Squamous Cell Carcinoma of
Parotid Gland
 Diagnosis: Pleomorphic Adenoma
 Investigation to be performed: FNAC, CT/MRI
 Treatment: Superficial Parotidectomy
 Complications of Treatment: Nerve Dysfunction, Frey’s Syndrome, Numbness, Facial
Asymmetry, Necrosis near Incision, Reappearance of Tumor

Station 03: OTOSCOPE

 Identify: Otoscope
 Used for: Ear Examination – Gives view of Tympanic Membrane
and Ear Canal
 Structures seen with it: Tympanic Membrane/Ear Drum – Cone
of Light, Posterior Malleal Fold, Lateral Process of Malleus,
Anterior Malleal Fold
 Pathologies can seen with it: Discharge, Tympanic Membrane
Bulging, Tympanic Membrane Retraction, Tympanic Membrane
Perforation, Cerumen, Foreign Body, Exostoses
 What is Serous Otitis Media? : Accumulation of non-purulent
fluid in Middle Ear Cleft
 What age group it involves? : School Going Children
 Why it happens? : Malfunction of Eustachian Tube, Allergy,
Viral Infection
 What will you see on otoscope in it? : Dull opaque tympanic
membrane with loss of light reflex. Thin leash of blood vessels
may also be seen along the handle of malleus.
 What color of tympanic membrane you will see in it? : Tympanic Membrane may appear
yellow, blueish or grey in color.
  How will you treat it? : Medical Treatment includes decongestants, anti-allergic, antibiotics,
Middle Ear Aeration. Surgical Treatment includes Myringotomy and Aspiration of Fluid,
Grommet Insertion, Surgical Treatment of Causative Factor
 What is Grommet? : Grommet is a tube surgically inserted to provide continued aeration of
middle ear.

Station 04: Nose Examination

 Check Broadcast Msg, Link is provided for Examinations

Station 05: Perform Posterior

Rhinoscopy
 Technique. Patient sits facing the examiner,
opens his mouth and breathes quietly from
the mouth. The examiner depresses the
tongue with a tongue depressor and
introduces posterior rhinoscopic mirror, which
has been warmed and tested on the back of
hand. The mirror is held like a pen and carried
behind the soft palate. Without touching it on
the posterior third of tongue to avoid gag
reflex, light from the head mirror is focussed
on the rhinoscopic mirror which further
illuminates the part to be examined. Patient’s relaxation is important so that soft palate does
not contract.
Station 06: Anterior Rhinoscopy
 Name the Instrument: Thudicum Nasal
Speculum
 In Which Surgery it is used? : Submucous
Resection of Nasal Septum (SMR)
 What are the indications for SMR or
Septoplasty? : Deviated Nasal Septum,
Recurrent Epistaxis, To Correct External Nose
Deformity
 What is little’s Area? : It is a vascular area in
anterioinferior part of nasal septum, where
anastomosis of arteries is present (Kiesselbach’s Plexus). Commonest site for epistaxis.
 What arteries anastomose here? : Anterior ethmoidal, sphenopalatine, greater palatine and
septal branch of superior labial arteries and their corresponding veins form an anastomosis
here.

Station 07: Tracheostomy

 Identify: Tracheostomy Tube for
Tracheostomy
 What is Tracheostomy? : Tracheostomy is
making an opening in anterior wall of trachea
for ventilation or removing secretions.
 Types of Tracheomstomy: Emergency
Tracheostomy, Elective Tracheostomy,
Permanent Tracheostomy, Percutaneous
Dilation tracheostomy and Mini
Tracheostomy
 Indications: Respiratory obstructions,
Respiratory Insufficiency, Retained Secretions
 Complications: Hemorrhage, Aponea, Tube Blockage, Injury to reccurent laryngeal nerve,
Laryngeal Stenosis, Tracheal Stenosis, Tracheo-esophageal Fistula

Station 08: Thyroid Nodule

 D/D: Colloid Nodule, Adenoma,
Thyroid Cyst, Carcinoma,
Regeneration Nodule
 Investigations to do: Fine Needle
Aspiration Cytology (FNAC), Thyroid
Function Test, Ultrasound
 Treatment: Thyroidectomy
 What are the complications of its
surgery? : Hematoma, Airway
Obstruction, Injury to recurrent
 laryngeal nerve, Injury to Superior Laryngeal Nerve, Infection, Pneumothorax, Hypothyroidism,
Hypocalcemia.

Station 09: Peri-tonsillar Abscess (Quinsy)

 D/D: Para-Pharyngeal Abscess, Neoplasm of Tonsil,
Retro-Pharyngeal Abscess, Peri-Tonsillar Abscess
 Diagnosis: Peri-Tonsillar Abscess or Quinsy
 Clinical Features: Pain usually unilateral,
Odynophagia, Hot Potato Voice (Thick and Muffled
Voice), Foul Breathe, Trismus
 Treatment: Hospitalization, IV Fluids, Antibiotics,
Analgesics, Oral Hygiene, Incision and Drainage.

Station 10: Adenoidectomy

 Identify: St. Clair Thompson adenoid
curette
 Used for: Used in adenoidectomy
 Indications: Adenoid Hypertrophy,
Recurrent Rhino-sinusitis, Chronic
Otitis Media with effusion associated
to Adenoid Hypertrophy, Dental
Malocclusion
 Contraindications: Cleft Palate,
Hemorrhagic Diathesis, Acute
Infection of Upper Respiratory Tract
 Complications of Adenoidectomy: Hemorrhage, Injury to Eustachian Tube opening, Injury to
pharyngeal musculature, Nasopharyngeal Stenosis, Recurrence

Station 11: Nasal Gauge – Killian’s nasal gouge (bayonet-shaped)

 Name the Instrument: Nasal Gauge – Killian’s nasal gouge (bayonet-shaped)

 Used for: Used for removal of septal spurs or bony crests and ridges in SMR operation
 Name the Surgery: Submucous Resection of Nasal Septum (SMR)
 Difference b/w Septoplasty and SMR:
Septoplasty SMR
 Type of Procedure Conservative Destructive
Age Any Age Adults (>17 Years)
Mucoperichondrial One Side Both Sides
Flap
Risk of Tearing Low High
Flap
Risk of Septal Low High
Perforation
Contraindications Acute Nasal or Sinus Infection, Bleeding Age Below 17, Acute
Diatheses, Untreated Diabetes and Attack of Respiratory
Hypertension Infection, Bleeding
Diatheses, Untreated
Diabetes and Hypertension
 Complications: Bleeding, Septal Hematoma, Septal Abscess, Perforation, Depression of Bridge,
Toxic Shock Syndrome, Persistence of Deviation

Station 12: Case of Mastoiditis

 Diagnose: Mastoiditis
 Clinical Findings for Diagnosis:
Symptoms – Pain Behind the Ear, Fever, Ear Discharge
Signs – Mastoid Tenderness, Sagging of Posteriosuperior Meatal Wall, Perforation of
Tympanic Membrane, Swelling over the mastoid, Conductive Hearing loss
 Treatment: Hospitalization, Antibiotics, Myringotomy, Cortical Mastoidectomy if Indicated

Station 13: Aphthous Ulcer Case

 Diagnosis: Aphthous Ulcer
 Risk Factors: Nutritional Deficiency, Viral or Bacterial Infection, Food Allergies, Hormonal
Changes, Stress
 Treatment: Topical Application of Steroids and cauterization with 10% Silver nitrate. Local Pain
can be relieved with Lignocaine Viscous.

Station 14: Tonsillectomy

 Identify: Eve’s Tonsillar Snare
 Uses: Used for tonsillectomy. After the tonsil has been dissected till its lower pole, snare is
passed round the tonsil to
engage the pedicle and
then firmly closed. It
crushes and cuts the
pedicle thereby
minimizing bleeding. Wire
used in snare is number
25 SWG.
 Indications for Tonsillectomy:
 Absolute Indications: Recurrent Infection of Throat, Peritonsillar Abscess, Tonsillitis,
Suspicious of Malignancy, Hypertrophy of Tonsils
Relative Indications: Unresponsive Diptheria Carriers, Chronic Tonsillitis, Streptococcal
Carriers, Recurrent Streptococcal Tonsillitis
 Contraindications: Hb less than 10g, Acute infection of Upper Respiratory Tract, Under 3 year
age, Cleft Palate, Bleeding Disorder, Menses, Uncontrolled Systemic Disease

Station 15: Case of Angiofibroma

 Diagnosis: Angiofibroma – Tumor of Adolescent Males, thought to be testosterone related
 Clinical Findings:
Profuse, Recurrent, Spontaneous Epistaxis
Nasal Obstruction
Otitis Media with Effusion due to Eustachian tube blockage
Proptosis
Broadening of nasal bridge
Mass in Nasopharynx
 Investigations: CT Scan of Nose and Paranasal Sinuses, both Coronal and Axial, Four Vessel
Angiography
 Treatment: Surgical Removal of Angiofibroma

Station 16: Mastoidectomy

 Identify: Mastoid Retractor
 Used for: Used in mastoidectomy
to retract soft tissues after incision
and elevation of flaps. It is self-
retaining and haemostatic.
 Define Mastoidectomy: A Surgical
Procedure to remove diseased
mastoid air cells when medical
treatment is not effective.
 Types of Mastoidectomy:
Cortical: A Canal wall up
mastoidectomy which is an exenteration of all accessible mastoid air cells preserving the
posterior meatal wall.
Modified Radical: A canal wall down mastoidectomy in which the attic and mastoid are
exteriorized into the external auditory canal by removal of the posterior meatal and
lateral attic walls. Tympanic membrane remnant, functioning ossicles and the reversible
mucosa and function of the Eustachian tube are preserved and reconstructed.
Radical: A canal wall down mastoidectomy in which the tympanic membrane and
ossicles are not reconstructed, thus exteriorizing the middle ear and the mastoid.

Station 17: Indirect Laryngoscopy

 Identify: Laryngeal Mirror, used to perform Indirect Laryngoscopy
  What is Laryngoscopy? : An endoscopic procedure to get close view of larynx and other
surrounding structures.
 Perform Indirect Laryngoscopy: Patient is seated opposite the examiner. He should sit erect
with the head and chest leaning slightly towards the examiner. He is asked to protrude his
tongue which is wrapped in gauze and held by the examiner between the thumb and middle
finger. Index finger is used to keep the upper lip or moustache out of the way. Gauze piece is
used to get a firm grip of the tongue and to protect it against injury by the lower incisors.
Laryngeal mirror (size 4–6) which has been warmed and tested on the back of hand is
introduced into the mouth and held firmly against the uvula and soft palate. Light is focused on
the laryngeal mirror and patient is asked to
breathe quietly. To see movements of the
cords, patient is asked to take deep
inspiration (abduction of cords), say “Aa”
(adduction of cords) and “Eee” (for
adduction and tension). Movements of
both the cords are compared.
 Indications: Dysphonia, Hoarseness,
Foreign body sensation, Dysphagia
 Structures seen on indirect laryngoscopy:
Epiglottis, arytenoid, Ring of trachea, vocal
cord, subglottis, pyriform fossa, ventricular
fold, Base of tongue, vallecular.

Station 18: Throat Instruments

 Identify: Boyle-Davis mouth gag
 Uses: Used for opening the mouth and retracting the
tongue anteriorly.
 Indication: used for palate surgery, tonsillectomy, surgery
of soft palate, pharyngoplasty adenoidectomy, excision of
angiofibroma.
 Identify: Doyen’s mouth gag
 Uses: Used to keep the mouth open for intraoral surgery
when retraction of the tongue is not required or
desirable. Mostly used for tongue surgery.
 Identify: Jenning’s mouth gag
Station 19: Laryngeal Papilloma
 Diagnosis: Laryngeal Papillomatosis
(Juvenile Laryngeal Papillomatosis for
being more specific)
 Findings: Glistering white lumpy
irregular growth, pedunculated or
sessile, bleed easily
 Investigation: Direct Laryngoscope
 Etiology: Viral – Human Papilloma Virus
 Age group: Infants and Young Children
 Give 4 Treatment Options: Interferon
Alpha 2, 13-cis-retinoic acid, CO2 Laser,
Endoscopic removal with cup forceps

Station 20: Aphthous Ulcer

 Diagnosis: Aphthous Ulcer
 Risk Factor: Autoimmune, Vitamin Deficiencies,
Young age
 What time it takes to heal? : 2 weeks
 Treatment: Self-limiting, Sometimes topical steroids

Station 21: Squamous Cell Carcinoma of Lip –

This is picture of 50 years old male patient,
chronic smoker having lesion at lip.
 What is your probable diagnosis? : Squamous Cell Carcinoma
 Who will you confirm your diagnosis? : Biopsy
(Histopathology)
 What investigations you will advise to stage the disease? : CT
Scan head and neck with contrast

Station 22: Thudicum nasal Speculum

 Identify: Thudicum Nasal Sepculum
 To be Hold in: Left Hand
 Used for: to examine anterior nasal cavity (Anterior
Rhinoscopy)
 Structure seen: Nasal Vestibule, Nasal Septum, Inferior and
Middle Turbinate and floor of nasal cavity
Station 23: A 29 years old female patient
complaint of bilateral impairment of
hearing for the past 5 years. Examination
of tympanic membrane was normal and
tympanometry shows:
 What type of Graph? : Type As tympanogram
 Pathology causing this type of tympanogram:
Otosclerosis
 Treatment of Otosclerosis: Stapedotomy

Station 24: Tympanogram

 What Type of Tympanogram is this? : Type C
 What pathology causing it? : Eustachian tube blockage (Negative
pressure in middle ear)

Station 25: Carcinoma of Tongue

 Finding: Ulcer on Left lateral border of tongue –
Squamous Cell Carcinoma of Tongue
 Clinical Features: Pain at lesion site, Ipsilateral Earache,
Lump in mouth, Dysphagia, Unable to protrude the
tongue
 Investigations: Biopsy, MRI
 Treatment: Surgery (Wide Local Excision) + Neck
Dissection
 Rehab: Obturator Prosthesis

Station 26: Vocal Polyp

 Identify: Polypoidal swelling at right vocal cord
 Diagnosis: Vocal Polyp
 Clinical Features: Hoarseness, difficulty in speech,
cough, sometime difficulty in breathing
 Treatment: Micro-Laryngeal Excision
Station 27: X-Ray PNS
 What X-Ray is this? : X Ray PNS
water’s view
 What are the findings in this x-ray
marked with arrow? : Mucosal
Thickening in Right Maxillary Sinus
 How will you manage this
patient? : Antibiotics,
Antihistamine, nasal
decongestants, anti-
inflammatory/anti-pyretic drugs
 How many sinuses are visualized?
: Maxillary Sinus, Frontal Sinus,
Sphenoid Sinus

Station 28: Case of CSOM

 Possible Diagnosis: Chronic Suppurative Otitis Media
 Types:
Tubo-Tympanic : Without Cholesteatoma (Central Perforation)
Attico-Antral : With Cholesteatoma (Marginal Perforation)
 Clinical Features:
Tubo-Tympanic: Mucopurulent Ear Discharge, Conductive Hearing Loss, Central
Perforation, Pale Polyp, Edematous and Swelled Middle Ear Mucose
Attico-Antral : Marginal perforation, retraction pocket, foul smelling discharge, Fleshy
Polyp, Hearing Loss (Conductive or Mixed)
 Treatment:
Medical Management: Aural Toilet, Ear Drops, Systemic Antibiotics, Keep Ears Dry
Surgical Management: Tympanoplasty, Maryngioplasty, Cortical Mastoidectomy,
Radical Mastoidectomy, Modified Radical Mastoidectomy.

Station 29: Case of Polyp

 DDx: Hypertrophied turbinate, Inverted Papilloma, Angiofibroma, Malignant Tumor
 Two Types: Ethmoidal and Antro-Coanal
 Ethmoidal:
Age: Common in adults
Laterality: Bilateral
Origin: Ethmoidal Sinus, Middle Turbinate, Middle Meatus
Etiology: Chronic Rhinosinusitis, Asthma, Aspirin intolerance, cystic fibrosis, Allergic
Fungal sinusitis
Investigation: CT Scan
Medical Treatment: Antihistamines, Steroids
Surgical Treatment: Polypectomy, Ethmoidectomy, Endoscopic Sinus Surgery
 Antro-Coanal Polyp
 Age: Common in Children
Laterality: Unilateral
Origin: Maxillary Sinus near the ostium
Etiology: Infections
Investigation: X-ray Lateral View, Posterior
Rhinoscopy
Treatment: Endoscopic Sinus Surgery, Caldwell-Luc
Operation

Station 30: Microscope from ENT OPD

 Identify: ENT Microscope (Electron Microscope)
 What can be seen with it? : Tympanic Membrane, External
Auditory Canal, Foreign Body, Ossicles, Middle Ear
 What are the other methods to see membrane? : Otoscope,
Endoscopy, Ear Speculum
 Normal Components of Membrane: Cone of Light, Umbo,
Lateral Head of Malleus, Pars Flaccida, Pars Tensa, Malleal
Folds

Station 31: Coin in Esophagus

 What you see? : Foreign Body in Esophagus
 Where is this foregin body? : At the level of thoracic Inlet –
C6 Cricopharynx
 Clinical Features: Discomfort or Pain, Dysphagia, Drooling of
Saliva, Respiratory Distress
 Complications: Respiratory Obstruction, Strictures,
Ulceration, Perioesophageal Cellulitis/Abscess
 How will you remove it? : Endoscopic Removal
 What other procedure if it is not deep? : Hypo-pharyngeal
speculum resembling direct laryngoscope

Station 32: Tilley’s Dressing Forceps

 Identify: Tilley’s Dressing Forceps
 Used for: Used for nasal packing, ear dressing, removal of
foreign bodies from the nose.
 Difference b/w Septoplasty and SMR:
 Septoplasty SMR
Type of Procedure Conservative Destructive
Age Any Age Adults (>17 Years)
Mucoperichondrial One Side Both Sides
Flap
Risk of Tearing Low High
Flap
Risk of Septal Low High
Perforation
Contraindications Acute Nasal or Sinus Infection, Bleeding Age Below 17, Acute
Diatheses, Untreated Diabetes and Attack of Respiratory
Hypertension Infection, Bleeding
Diatheses, Untreated
Diabetes and Hypertension
 Complications: Bleeding, Septal Hematoma, Septal Abscess, Perforation, Depression of Bridge,
Toxic Shock Syndrome, Persistence of Deviation

Station 33: Myringotome

 Identify: Myringotome
 Used for: Used to make incison on tympanic membrane (Myringotomy)
 Indications: Acute Suppurative Otitis Media, Serous Otitis Media, Aero-Otitis Media, Atelectatic
Ear
 Disadvantage/Complications: Injury to Stapes, Injury to jugular bulb, Middle Ear Infection
 Contraindication: Intra-tympanic Glomus Tumor

Station 34: Acute Epiglottitis Case

 Diagnosis: Acute Epiglottitis
 X-Ray Manifestation: Thumb’s Sign
 Causative Organism: H Influenza
 Differential Diagnosis: Laryngitis, Edema of Larynx, Acute
Laryngeo-tracheal Bronchitis, Foreign Body Aspiration
 Clinical Findings: Sore throat, Dysphagia, Dyspnoea, Stridor,
Fever
  Examination: Indirect Laryngoscopy will show edema and congestion of supraglottic structures,
Lateral View of X-ray will show thumb’s sign.
 Treatment: Hospitalization, Antibiotics, Steroids, Adequate Hydration
 Is tracheostomy required? : Yes, only in case of respiratory obstruction

Station 35: Case of Laryngeal Polyp – 30 year old smoker with history of
hoarseness, pedunculated mass on larynx
 Diagnosis: Laryngeal Polyp
 Causes: Allergy, Smoking, Vocal Abuse, Sudden shouting
 Clinical Features: Hoarseness, Dyspnoea, Stridor, Intermittent Chocking, diplophonia
 Investigation: Direct Laryngoscopy
 Treatment: Surgical Excision

Station 36: Adenoid

 Identify: adenoid mass obstructing the
nasopharyngeal airway
 Structures can be seen: Cervical Spine,
Adenoids, Teeth, Skull
 Pathology: Adenoid Hypertrophy
 Where are adenoids? : At the junction of the
roof and posterior wall of the nasopharynx.
 Function of Adenoids: Normally, in children, it
forms a soft mound in the roof and posterior
wall of the nasopharynx, just above and behind
the uvula. It provides immunity and form
antibodies.
 Cause of adenoidal hypertrophy: Allergy,
Recurrent Attacks of Rhinitis, Sinusitis and
chronic tonsillitis.
 Treatment: Decongestants Nasal Drops,
Antihistamine, Adenoidectomy – Removal of
Adenoids
 Indication for Adenoidectomy: Adenoid
hypertrophy causing snoring, mouth breathing,
sleep apnoea syndrome or speech
abnormalities
 Complications of Adenoidectomy: Hemorrhage, Injury to Eustachian tube opening, Injury to
pharyngeal musculature and vertebrae, Nasopharyngeal stenosis
 At what age adenoids regress: Completely regress by age 20, while atrophy starts at puberty
 Features of Adenoid Facies: An elongated face with dull expression, open mouth, prominent
and crowded upper teeth, hitched up upper lip and highly arched Hard Palate. Nose gives a
pinched in appearance.
 Parts of Pharynx: Nasopharynx, Oropharynx, Hypopharynx/Laryngopharynx
 Parts of Hypopharynx: Pyriform Sinus (Fossa), Posterior Pharyngeal Wall, Post-cricoid Region
Station 37: Ludwig’s Angina Case – Person with fever and mass in
submandibular area and dental infection
 Possible Diagnosis: Ludwig’s Angina
 Etiology: Dental Infections (80%), Submandibular Sialadenitis, injury to oral mucosa, fracture of
mandible
 Organisms Involved: Mixed Infection of Aerobes and Anaerobes (Alpha-hemolytic streptococci,
Staphylococci, Bacteriods)
 Investigations: Physical Examination, Blood Complete Picture
 Treatment: Systemic Antibiotics, Incision and Drainage & Tracheostomy if there is airway
obstruction.

Station 38: Impedance Audiometry

 Define: This is audiometry impedance, it
measures compliance of tympanic membrane
with a microphone reflects sound.
 Types of tympanogram:
A—Normal
As—Reduced compliance at ambient
pressure (otosclerosis). ‘s’ stands for
shallow tympanogram but remember for
stiffness.
Ad—Increased compliance at ambient
pressure (ossicular discontinuity). ‘d’
stands for deep tympanogram.
Remember disruption of ossicular chain.
B—Flat or dome-shaped (fluid in middle ear).
C—Maximum compliance at pressures more than −200 mm H2O (negative pressure in
middle ear), e.g. eustachian tube obstruction or early stage of otitis media with effusion.
 Type of Audiometry:
Subjective: Pure Tone Audiometry, Speech Audiometry
Objective: Impedance Audiometry, Brain Evoked Response Audiometry (BERA)
 Define BERA: elicit brainstem responses to auditory stimulation by clicks or tone bursts. It is a
noninvasive technique to find the integrity of central auditory pathways. Done in Children

Station 39: Audiometry Graph showing conductive deafness

 What is this? : Pure tone audiometry
 Which type of hearing loss it is showing? : Conductive Hearing loss
 Causes of Conductive hearing loss: Impacted wax, big foreign body,otomycosis, boil, tumor,
otitis media, trauma, otosclerosis, tympnosclerosis, ear drum perforation, dislocation of ear
ossicles.
  Causes of sensorineural deafness: Congenital causes, genetic, labyrinthitis, perilymph fistula,
trauma to inner ear or cochlear nerve, blast injury, meniere’s disease, acoustic neuroma,
presbyacusis, ototoxicity.
 Cause of Mixed Deafness: Otosclerosis
 Last Resort for Patient with conductive deafness: Hearing Aid

Station 40: Septal Hematoma Case – Child with history of trauma, after 4
hours he presents with nasal obstruction and pain
 Diagnosis: Septal Hematoma
 Treatment: Incision and Drainage, Systemic Antibodies and Nasal Packing
 Complication if left untreated: Permanent thickened septum, secondary infection causing
septal abscess, Necrosis of cartilage, Depression of nasal dorsum.

Station 41: Case of a man presenting with dysphagia, can’t swallow

saliva, high grade fever and there is grey white membrane over the
tonsils.
 Diagnosis: Faucal Diphtheria
 Organism causing this disease: Gram-positive bacillus, C. diphtheriae.
 Treatment: Diphtheria Antitoxin, Antibiotics (Benzyl Penicillin or Erythromycin)
 Complications: Myocarditis, Cardiac Arrhythmia, acute circulatory failure, Paralysis of soft
palate, paralysis of diaphragm and paralysis of ocular muscles

Station 42: Diffuse Midline Swelling of Neck

 Differential Diagnosis:

 Investigations: Sonogram, Ultrasound, CT, MRI, Fine Needle Aspiration

 What will you if thyroid cancer is suspected? : FNAC, Ultrasound, CT, MRI, Thyroid Scan,
Thyroid Function Test
Station 43: Septal Hematoma Case
with Bilateral Red Nasal Swelling
and History of trauma 1 day back
 Findings: Smooth rounded swelling in both
nasal fossae
 Probable Diagnosis: Septal Hematoma
 Treatment: : Incision and Drainage,
Systemic Antibodies and Nasal Packing
 Complication if left untreated: Permanent
thickened septum, secondary infection
causing septal abscess, Necrosis of
cartilage, Depression of nasal dorsum.

Station 44: Laminated Picture of Enlarged Thyroid

 Possible Diagnosis: Goiter
 Differential Diagnosis: Iodine Deficiency, Goiter, Multinodular Goiter, Grave’s Disease, Thyroid
Adenoma
 Initial Test: Ultrasound
 Confirmatory Test: FNAC
 Other Investigations: Thyroid Function Test, Thyroid Scan, Antibody Test, Biopsy

Station 45: Endotracheal tube

 Identify: Endotracheal Tube
 Define: is an emergency procedure that is often performed on people who are unconscious or
can’t breathe on their own. Given through mouth mostly but can be given through nose
 Indication: To open airway to give oxygen, medication or anesthesia, For Mechanical
Ventilation, Suction in case of meconium aspiration,
Angioneuritc Edema
 Complications: Mechanical Trauma to Tongue, Teeth, Palate,
Pharynx and Larynx, Pneumothorax, Pressure Necrosis,
Vasovagal Reflex
 Types:
Cuffed E.Tube: For >8 Year , When Inflated maintain
E.Tube in proper position
Uncuffed E.Tube: For < 8 year, Narrow Subglottic area
prevents E.Tube form slipping
 3 Ends:
Proximal: Connects to Ventilator
Central: Vocal Cord Opening
 Distal: Prevents Complete blockage of E.Tube in case of secretions

Station 46: Myringotomy and Serous Otitis Media

 Myringotomy: Incision in tympanic membrane to drain fluid from middle ear.
 Serous Otitis Media: Accumulation of non-purulent fluid in Middle Ear Cleft
 Cause: Malfunction of Eustachian Tube, Allergy, Viral Infection
 DDx: Cholesteatoma, Otitis Externa, Acute Sinusitis
 Clinical Findings: Hearing Impairment, Defective or Delayed Speech, Mild Earache
Otoscope Findings: Dull opaque tympanic membrane with loss of light reflex. Thin leash
of blood vessels may also be seen along the handle of malleus.
Conductive Hearing loss on tuning fork test
 Treatment: Treat the underlying cause, Surgical Treatment – Myringotomy, Grommet Insertion

Station 47: Direct Laryngoscope

 Identify: Direct Laryngoscope
 Indication:
Diagnostic indications: 1.When indirect laryngoscopy is not possible (in infants and
young children), 2.When indirect laryngoscopy has not
been successful as in excessive gag reflex or over
hanging epiglottis obscuring a part of complete view of
larynx, 3.To examine base of tongue , valecullae, lower
part of pyriform fossa , infra hyoid epiglottis , anterior
commissure , ventricles and subglottic region, 4.To take
a biopsy and to find the extent of growth
Therapeutic indications: 1.Removal of benign lesions of
larynx (papilloma, fibroma, vocal nodule, polyp cyst),
2.Removal of foreign bodies from larynx and
hypopharynx, 3.Dilation of laryngeal strictures
 Contraindications: Disease or Injury to Cervical Spine,
Respiratory Obstruction, Cardiac decompensation, Recent
coronary occlusion
 Complications: Upper Airway trauma, Dental Trauma,
Aspiration

Station 48: Deviated Nasal Septum – X-ray PNS

Water’s View
 Normal Structures can be seen:
 Pathology: Deviated Nasal Septum
 Treatment of DNS: Treatment is indicated only when it produces mechanical nasal obstruction
Septoplasty SMR
Type of Procedure Conservative Destructive
Age Any Age Adults (>17 Years)
 Mucoperichondrial One Side Both Sides
Flap
Risk of Tearing Low High
Flap
Risk of Septal Low High
Perforation
Contraindications Acute Nasal or Sinus Infection, Bleeding Age Below 17, Acute
Diatheses, Untreated Diabetes and Attack of Respiratory
Hypertension Infection, Bleeding
Diatheses, Untreated
Diabetes and Hypertension
 Complications of Treatment: Bleeding, Septal Hematoma, Septal Abscess, Perforation,
Depression of Bridge, Toxic Shock Syndrome, Persistence of Deviation
 Which one is preferred now a days? : Septoplasty

Station 49: Barium Swallow

 Name the Investigation: Barium Swallow
 Purpose to do this investigation: To identify the abnormalities in Upper GI
Tract
 Findings of this X-ray: Cardiac achalasia (megaoesophagus). There is a
failure of lower oesophageal sphincter to relax with dilatation of
oesophagus due to stasis of food.
 Causes of Dysphagia: Esophageal Lumen Obstruction, Achalasia,
Scleroderma, Diffuse esophageal spasm, Hiatus Hernia, Hypopharyngeal
diverticulum, Thyroid Enlargement

Station 50: Pure Tone Audiogram

 Type of Hearing Loss: Conductive
 Causes of Conductive Hearing Loss: Congenital Atresia, Impacted wax, big
foreign body, otomycosis, boil, tumor, otitis
media, trauma, otosclerosis, tympnosclerosis,
ear drum perforation, dislocation of ear
ossicles.
 Name the Procedure for External Auditory
Canal Atresia:
 Types of Tympanoplasty:
Type I tympanoplasty is called
myringoplasty, and only involves the
restoration of the perforated eardrum
by grafting.
Type II tympanoplasty is used for
tympanic membrane perforations with
erosion of the malleus. It involves
 grafting onto the incus or the remains of the malleus.
Type III tympanoplasty is indicated for destruction of two ossicles, with the stapes still
intact and mobile. It involves placing a graft onto the stapes, and providing protection
for the assembly.
Type IV tympanoplasty is used for ossicular destruction, which includes all or part of the
stapes arch. It involves placing a graft onto or around a mobile stapes footplate.
Type V tympanoplasty is used when the footplate of the stapes is fixed.

Station 51: Observe the Graph of 68 year old and answer the questions
 Name of Investigation: Pure tone
audiometry/audiogram
 These 2 lines show: Continuous line shows the
threshold of hearing of air conduction in that air
while dashed line shows the threshold for bone
conduction in that ear.
 Findings in the graph: Both Bone conduction and Air
Conduction lines are below normal hearing
threshold, which is more marked in the higher
frequencies than lower frequencies. There is no
significant air-bone gap. There is sensorineural
hearing loss more marked in higher frequencies
 Diagnosis: The findings are consistent with high
frequency sensorineural hearing loss. The most
probable cause is presbycusis or senile deafness.
 Treatment Options: Reassurance, Hearing Aid, Auditory Rehab, Lip Reading

Station 52: Bronchoscopy

 Identify: Bronchoscope
 Type of Bronchoscopy:
Rigid and Flexible Fibroptic
 Indication:
Diagnostic: To find
out the cause for
wheezing,
haemoptysis or
unexplained cough
persisting for more
than 4 weeks.
Collection of
bronchial
secretions for
culture and sensitivity tests, acid fast bacilli, fungus and malignant cells.
Therapeutic: Removal of Foreign Bodies or Retained secretions/mucus plug.
  Complications: Injury to teeth and lips, Hemorrhage from biopsy side, Hypoxia, Cardiac Arrest,
Laryngeal edema

Station 53: Observe the graph and answer the questions

 Name of Investigation: Pure Tone Audiometry
 Write the meaning of two lines in the graph:
Continuous line shows the threshold of hearing of air
conduction in that air while dashed line shows the
threshold for bone conduction in that ear.
 Describe the findings of this graph: Both the air
conduction and bone conduction lines are showing
normal hearing threshold i.e. up to 25 DB. There is no
significant air gap. The hearing of this person is within
normal limits.
 Outline the classification of deafness according to its
severity:
Normal Hearing: Up to 25 dB
Mild deafness: 26 – 40 dB
Moderate Deafness: 41 – 55dB
Moderately Severe Deafness: 56 – 70dB
Severe Deafness: 71-90 dB
Profound deafness: >91dB

Station 54: Observe the graph and answer the questions

 Name of Investigation: Pure Tone Audiometry
 Describe the findings of this graph:
Air conduction line is much below the normal
threshold up to 60 dB in the lower frequencies
and up to 35 dB in the higher frequencies
Bone conduction line is in normal hearing
threshold except in 2000 Hz which is a dip,
known as Carhart’s notch.
There is conductive deafness more in the lower
frequencies.
 What is the diagnosis in this patient: Findings are
typical of Otosclerosis
 Enlist the treatment options in this case:
Medical Treatment: Fluoride therapy in active and cochlear Otosclerosis.
Surgical Treatment: Stapedotomy or Stapedectomy with insertion of prosthesis/piston
Hearing Aid and Rehab: In cases where surgery is not possible.
Station 55: Case of Branchial Cyst
 Diagnosis: Branchial Cyst
 Theories of origin: Branchial apparatus theory , cervical sinus theory , thymopharyngeal theory ,
inclusion theory
 Complications: Fistula Formation, Sinus Formation
 Treatment: Surgical Excision

Station 56: Case of Female 15 Year old, history of fever, Unilateral

Obstruction and Discharge, now presents with headache and epistaxis
 Probable Diagnosis: Rhinolith
 Investigations: Plan X-ray Nose Lateral View
 Confirmatory Investigations: Clinical Examination, Water’s View X-ray
 Treatment: removed under general anaesthesia. Most of them can be removed through
anterior nares. Large ones need to be broken into pieces before removal. Some particularly hard
and irregular ones require lateral rhinotomy.
 Complications: Fistula Formation, Septal Perforation

Station 57: Case of a patient have pinna swelling after the trauma
 Diagnosis: Hematoma Formation after the trauma
 Mechanism of Hematoma Formation: Blunt trauma causes the vessels in the perichondrium to
be ruptured. Extravasated blood may clot and the organize resulting in a typical deformity called
cauliflower ear.
 Complications: Perichondritis, Necrosis
 Treatment: Treatment is aspiration of the haematoma under strict aseptic precautions and a
pressure dressing. When aspiration fails, incision and drainage should be done and pressure
applied by dental rolls tied with through and through sutures. All cases should receive
prophylactic antibiotics.

Station 58: Perform Indirect Laryngoscopy

 Method: Patient is seated opposite the examiner. He should sit erect with the head and chest
leaning slightly towards the examiner. He is asked to protrude his tongue which is wrapped in
gauze and held by the examiner between the thumb and middle finger. Index finger is used to
keep the upper lip or moustache out of the way. Gauze piece is used to get a firm grip of the
tongue and to protect it against injury by the lower incisors. Laryngeal mirror (size 4–6) which
has been warmed and tested on the back of hand is introduced into the mouth and held firmly
against the uvula and soft palate. Light is focused on the laryngeal mirror and patient is asked to
breathe quietly. To see movements of the cords, patient is asked to take deep inspiration
(abduction of cords), say “Aa” (adduction of cords) and “Eee” (for adduction and tension).
Movements of both the cords are compared.
 Indications: Dysphonia, Hoarseness, Foreign body sensation, Dysphagia
  Structures seen on indirect laryngoscopy: Epiglottis, arytenoid, Ring of trachea, vocal cord,
subglottis, pyriform fossa, ventricular fold, Base of tongue, vallecular.
 Can we see structures of hypopharynx through indirect laryngoscope? : No as these structures
of hidden structures of larynx which can be visualized by direct laryngoscope.
 Causes of Hoarseness: Acute laryngitis, tuberculosis of larynx, papilloma, haemangioma,
chondroma, glottic carcinoma, contact ulcer, foreign bodies, intubation, paralysis of recurrent or
superior laryngeal nerve, arthritis, laryngeal web, laryngeocele.
 Which carcinoma of larynx can cause hoarseness? : the glottic ca of larynx (hoarseness is the
major complain) and then the supraglottic (as hoarseness is this lesions late feature)

Station 59: Case of a patient with complaint of painful pussy ear

discharge and has fever. On examination
these were the findings
 What findings can you see in this picture? : A
Large Boil in external Auditory canal
 Diagnosis: Boil or Furuncle
 Pathogenesis: A furuncle is a staphylococcal
infection of the hair follicle. As the hair are
confined only to the cartilaginous part of the
meatus, furuncle is seen only in this part of meatus.
Usually single, the furuncles may be multiple.
 Treatment: In early cases without abscess:
systemic antibiotics, analgesics, and local heat, an
ear pack of 10% icthamol glycerin provides
splintage and reduces pain. With abscess
formation: incision and drainage.

Station 60: A School teacher presented with complain of hoarseness. On

examination there were two nodular swelling over her both vocal cords.
 Diagnosis: Vocal Nodules
 Causes: They are the result of vocal trauma when
person speaks in unnatural low tones for prolonged
periods or at high intensities.
 Treatment: Early cases of vocal nodules can be
treated conservatively by educating the patient in
proper use of voice. Surgery is required for large
nodules or nodules of long standing in adults. They
are excised with precision under operating
microscope.
Station 61: On Otoscopy of male adult there
was foul smelling creamy debris in the ear
canal and a marginal perforation in
posterior-superior quadrant of ear drum was
seen.
 Probable Diagnosis: Chronic Suppurative Otitis Media –
Atico-antral type
 Investigations: Pus for Culture and Sensitivity, Pure tone
audiogram, Plain X-ray Mastoid (Law’s View), CT Scan of
Temporal Bone and Brain.
 Treatment Options: Radical Mastoidectomy, Modified Radical Mastoidectomy, Cortical
Mastoidectomy and Tympanoplasty.

Station 62: A swimming champion

presented with complain of itching in
the ear. On Otoscopy, a wet bloating
paper like mass along with some
filamentous structures seen.
 Diagnosis: Otomycosis
 Mention the most common organism causing
this disease: Aspergillus is the most common
cause.
 Investigation: Fungal Smear
 Treatment: Ear Toilet, Anti-fungal, Keep Ear
Dry.

Station 63: Grommet

 Name the device seen in this picture:
Grommet
 Mention any two conditions while this
device neede: Acute Suppurative Otitis
media and Aero-otitis media