ENT — Distinction Level Answers
Questions 1 to 4 | All questions attempted | Two-column A4 format
Q1. 45-year-old male with decreased hearing, ear discharge history, large central perforation, inactive mucosal disease and mixed hearing loss
Diagnosis
  • Inactive mucosal type chronic suppurative otitis media (safe COM)
  • Right ear has a large central perforation with dry/inactive middle-ear mucosal disease
  • Audiometry showing 50 dB mixed hearing loss suggests conductive loss from perforation and possible associated sensorineural component / ossicular involvement
Diagnostic protocol
  • Detailed history
    • duration and nature of discharge
    • ear pain, fever, headache, vertigo, tinnitus
    • previous treatment and recurrence
    • hearing loss pattern
    • nasal allergy, sinus disease, recurrent upper respiratory infection
  • Examination
    • otoscopy / otoendoscopy
    • size, site and edge of perforation
    • condition of middle ear mucosa
    • presence or absence of granulations, polyp, cholesteatoma or discharge
  • Hearing assessment
    • tuning fork tests: Rinne, Weber, absolute bone conduction
    • pure tone audiometry to quantify hearing loss and type
    • tympanometry if required
  • Assessment of Eustachian tube and nasopharynx before surgery
  • Culture and sensitivity of discharge only if active infection is present
  • HRCT temporal bone if cholesteatoma, complications or ossicular erosion are suspected, or before complex surgery
Treatment protocol
  • Medical treatment first
    • keep ear dry
    • avoid water entry and ear picking
    • aural toilet if any residual discharge
    • topical antibiotic ear drops if infection persists
    • treat associated nasal / nasopharyngeal pathology
  • Definitive treatment in dry inactive mucosal COM is surgery
  • Tympanoplasty is indicated to close the perforation and restore hearing
  • If ossicular discontinuity is present, ossiculoplasty may be required
  • If ear is dry and mucosa healthy, Type I tympanoplasty / myringoplasty is usually appropriate
  • Hearing aid can be advised if patient is not fit for surgery or has persistent mixed loss
  • Postoperative follow-up is essential for graft take and hearing improvement
Memory hook: Dry central perforation = safe CSOM; treat infection if present, then close the drum by tympanoplasty and assess ossicles and ET function.
Q2. Male after total thyroidectomy developing change in voice and stridor
Likely cause
  • Recurrent laryngeal nerve palsy, especially bilateral if stridor is present
  • Other possible causes after thyroidectomy:
    • laryngeal edema
    • postoperative neck hematoma
    • tracheomalacia
    • hypocalcaemia causing laryngospasm
    • superior laryngeal nerve injury causing voice change
  • Voice change may occur with unilateral RLN or SLN injury, but stridor strongly suggests airway compromise, often bilateral RLN palsy or compressive hematoma
Management
  • Immediate assessment of airway and oxygen saturation
  • Look for neck swelling / hematoma; if present, open wound urgently if airway compromise is suspected
  • Flexible laryngoscopy to assess vocal cord movement
  • If bilateral vocal cord palsy with stridor, secure airway:
    • intubation if feasible
    • emergency tracheostomy if required
  • Keep patient monitored in a high-dependency setting
  • Correct hypocalcaemia if present
  • Manage laryngeal edema with steroids / nebulization as indicated
  • Voice therapy or further laryngeal rehabilitation later, depending on cause and prognosis
Nerve supply of larynx
  • The larynx is supplied by branches of the vagus nerve (X).
  • Superior laryngeal nerve divides into:
    • Internal branch: sensory supply to mucosa above vocal cords up to epiglottis; afferent limb of cough reflex
    • External branch: motor supply to cricothyroid muscle
  • Recurrent laryngeal nerve:
    • motor supply to all intrinsic muscles of larynx except cricothyroid
    • sensory supply to mucosa below vocal cords
  • Clinical relevance:
    • injury to external SLN → weak voice, loss of pitch / vocal fatigue
    • injury to RLN → hoarseness, aspiration, and if bilateral, stridor / airway obstruction
Memory hook: RLN moves the cords; SLN controls pitch. After thyroidectomy, stridor means airway danger until proved otherwise.
Q3. 46-year-old female after flying with aural fullness, decreased hearing and autophony
Diagnosis
  • Barotitis media / aerotitis media due to Eustachian tube dysfunction
  • Flying causes rapid atmospheric pressure change; if ET does not open properly, pressure cannot equalize between nasopharynx and middle ear
  • This leads to aural fullness, hearing reduction and sometimes autophony
Likely management
  • During acute episode:
    • reassure and advise swallowing / yawning / Valsalva if possible
    • nasal decongestant if mucosal edema is present
    • analgesics if pain
  • If there is middle-ear effusion or significant dysfunction:
    • treat nasal / ET cause such as allergy, URTI or rhinitis
    • decongestants and antihistamines when indicated
    • autoinflation exercises may help
  • If persistent effusion or repeated barotrauma:
    • myringotomy ± grommet if needed
    • ENT review for chronic ET dysfunction
  • Advise preventive measures for future flights if prone to symptoms:
    • avoid flying with active cold / severe congestion when possible
    • use pressure-equalizing measures during ascent/descent
Eustachian tube patency tests
  • 1. Valsalva test:
    • Patient takes deep breath, closes mouth, pinches nose and blows gently
    • Positive test: patient hears crackling / ear pop and drum may move outward
    • Assesses active opening of ET
  • 2. Toynbee test:
    • Patient pinches nose and swallows
    • Positive test: sensation of ear click or movement of tympanic membrane
    • Useful for ET opening during swallowing
  • 3. Politzer test:
    • Air is forced into one nostril while patient swallows or pronounces certain words
    • If ET is patent, air enters middle ear and patient hears a click
    • Also called Politzerization
  • 4. Catheter test:
    • ET is cannulated through the nose and air is passed directly into the tube
    • Used less commonly, but it is a more direct test of patency
  • 5. Tympanometric / impedance methods:
    • objective assessment in selected cases
    • help document middle-ear pressure changes and ET function
Memory hook: After flying, pressure mismatch causes barotitis; ET patency is checked by Valsalva, Toynbee, Politzer and catheter tests.
Q4. Describe briefly
a) Lateral sinus thrombosis
  • Serious intracranial complication of chronic otitis media / mastoiditis
  • Usually due to infection spreading to the sigmoid (lateral) sinus
  • Features:
    • high swinging fever
    • picket-fence fever pattern
    • headache
    • ear discharge
    • tenderness over mastoid or Griesinger sign
    • papilloedema may occur
  • Diagnosis: clinical suspicion, imaging (CT / MR venography), blood cultures
  • Treatment: intravenous antibiotics, mastoid surgery / source control, management of thrombus and complications
b) Nasal bone fractures
  • Common facial fracture, usually due to direct trauma
  • Features: pain, swelling, deformity, epistaxis, crepitus, nasal obstruction
  • Examination: look for septal hematoma, nasal deviation and associated facial injury
  • Imaging: usually clinical diagnosis; CT if complex facial injury suspected
  • Treatment:
    • closed reduction after swelling subsides
    • septal hematoma must be drained urgently
    • open reduction if severe or associated with other facial fractures
c) Vocal cord polyps
  • Benign phonotraumatic lesions of the true vocal cord
  • Usually unilateral, pedunculated or sessile, often due to voice abuse, smoking or irritation
  • Symptoms: hoarseness, vocal fatigue, breathy voice, reduced pitch range
  • Management:
    • voice rest and speech therapy
    • remove causative factors
    • microlaryngoscopic excision if persistent / large / atypical
d) Osteomeatal complex
  • Functional anatomical unit in the middle meatus where drainage of frontal, anterior ethmoid and maxillary sinuses occurs
  • Components: uncinate process, ethmoid infundibulum, hiatus semilunaris, bulla ethmoidalis, middle meatus
  • Blockage leads to impaired ventilation and drainage of paranasal sinuses
  • Important in pathogenesis of chronic rhinosinusitis
e) Choanal atresia
  • Congenital blockage of posterior nasal choanae
  • Can be unilateral or bilateral; bilateral in neonates causes respiratory distress because newborns are obligate nasal breathers
  • Symptoms: nasal obstruction, cyclical cyanosis, feeding difficulty, failure to thrive, unilateral discharge if unilateral
  • Diagnosis: inability to pass catheter, endoscopy, CT scan
  • Treatment: surgical repair / transnasal endoscopic choanoplasty with stenting as indicated
f) Fistula test
  • Clinical test to detect labyrinthine fistula, commonly associated with cholesteatoma
  • Performed by pressing and releasing tragus or by applying pressure in the external canal
  • Positive test: vertigo, nystagmus or dizziness due to pressure transmission to the labyrinth
  • Suggests erosion of bony labyrinth, classically lateral semicircular canal fistula
g) Ranula
  • Mucous extravasation cyst of the sublingual gland, seen as a swelling in the floor of mouth
  • Looks bluish, translucent and cystic
  • Types: simple ranula and plunging ranula
  • Symptoms: painless floor-of-mouth swelling, difficulty in speech / swallowing if large
  • Treatment: marsupialization or excision of cyst with sublingual gland in recurrent cases
h) Adenoid facies
  • Characteristic facial appearance due to chronic adenoid hypertrophy and mouth breathing
  • Features:
    • open mouth posture
    • long face
    • high-arched palate
    • crowded teeth / dental malocclusion
    • pinched nose / narrow nostrils
    • dull expression
  • Represents chronic upper airway obstruction in children
Memory hook: Lateral sinus thrombosis gives picket-fence fever; nasal fracture needs septal hematoma check; OM complex is the sinus drainage gateway; choanal atresia blocks the back of nose; fistula test provokes vertigo; ranula is a floor-of-mouth mucous cyst; adenoid facies is the mouth-breathing face.
Q1. 35-year-old male with progressive unilateral nasal obstruction, epistaxis and facial swelling
1) Differential diagnosis
  • Sinonasal malignancy — most important consideration in a middle-aged adult with unilateral nasal obstruction, epistaxis and facial swelling.
  • Inverted papilloma
  • Antrochoanal / ethmoidal polyp
  • Juvenile nasopharyngeal angiofibroma is less likely because age is not typical, but should be kept in mind if bleeding is prominent.
  • Fungal sinus disease / fungal mass
  • Benign or malignant salivary / maxillary / nasal cavity tumours
  • Rhinosporidiosis in endemic settings
  • Granulomatous disease with mass lesion
2) Clinical evaluation
  • History:
    • duration and progression of nasal obstruction
    • unilateral or bilateral symptoms
    • epistaxis, blood-stained discharge
    • facial pain / swelling, dental symptoms, loosening of teeth
    • anosmia, headache, diplopia, epiphora
    • weight loss, anorexia, neck swelling
    • risk factors such as smoking, occupational exposure and previous sinus disease
  • Examination:
    • general examination for pallor, facial asymmetry, cachexia, cervical nodes
    • anterior rhinoscopy / nasal endoscopy
    • look for mass, ulceration, bleeding point, septal deviation, crusting, pus, polypoid lesion
    • palpation of facial swelling, maxilla, orbit and palate
    • ocular examination for proptosis, restriction of movements or visual impairment
    • oral cavity and pharyngeal examination for extension
3) Diagnostic work-up
  • Nasal endoscopy to define the lesion, site of origin and bleeding tendency
  • CT scan of nose and paranasal sinuses to assess extent, bone erosion and sinus involvement
  • MRI when soft tissue spread, orbit, skull base or intracranial extension is suspected
  • Biopsy for histopathology, except when a highly vascular lesion such as JNA is suspected, where biopsy may be dangerous
  • FNAC / biopsy of neck node if cervical lymphadenopathy is present
  • Baseline investigations: CBC, coagulation profile, blood sugar, renal function
  • Staging work-up if malignancy is confirmed
4) Treatment
  • If malignancy:
    • surgery depending on site and stage
    • radiotherapy / chemoradiation as indicated
    • neck management if nodal disease is present
    • rehabilitation and follow-up
  • If inverted papilloma: complete endoscopic / open excision with attachment clearance and follow-up for recurrence
  • If polyp disease: medical therapy and FESS if persistent / recurrent
  • If fungal disease: medical / surgical treatment as appropriate
  • Supportive measures for epistaxis, infection and obstruction
Memory hook: In an adult with unilateral obstruction + epistaxis + facial swelling, think tumour first; endoscopy, CT/MRI and biopsy decide the diagnosis and stage.
Q2. Child with fever, inspiratory stridor and drooling of saliva — acute stridor in children
1) Differential diagnosis of acute stridor
  • Acute epiglottitis — classic with fever, toxic look, drooling, dysphagia and stridor
  • Croup (laryngotracheobronchitis)
  • Foreign body airway obstruction
  • Bacterial tracheitis
  • Retropharyngeal abscess / peritonsillar abscess
  • Laryngeal edema / allergy / anaphylaxis
  • Laryngomalacia in infants
  • Diptheritic laryngitis in unvaccinated child
2) Immediate management of acute stridor
  • Do not agitate the child; keep the child sitting up with parent present.
  • Assess airway, breathing, circulation and pulse oximetry immediately.
  • Give humidified oxygen if tolerated.
  • Call ENT, anesthetist and pediatric team early.
  • Prepare for definitive airway control if respiratory distress is severe.
  • Do not attempt forceful throat examination in suspected epiglottitis.
  • IV access only if the child can tolerate; otherwise stabilize first.
  • Broad-spectrum IV antibiotics if epiglottitis or bacterial infection is suspected.
  • Monitoring in a controlled setting / ICU if required.
3) Disease-specific management of epiglottitis
  • Secure airway in operation theatre if needed, usually by experienced anesthetist / ENT surgeon.
  • After airway is secured, start IV third-generation cephalosporin or suitable antibiotic.
  • Maintain hydration and monitor for complications.
4) Role of tracheostomy
  • Tracheostomy is a life-saving surgical airway when upper airway obstruction cannot be safely managed by intubation or when prolonged airway protection is required.
  • In children, it is reserved for:
    • failed intubation
    • massive upper airway obstruction
    • certain laryngeal / tracheal lesions
    • prolonged ventilation needs
  • It bypasses the obstructed supraglottic or glottic airway.
5) Complications of tracheostomy
  • Immediate: hemorrhage, pneumothorax, false passage, subcutaneous emphysema, tube displacement, airway loss
  • Early: blockage by secretions, infection, bleeding, tube obstruction, decannulation
  • Late: tracheal stenosis, tracheomalacia, tracheo-esophageal fistula, granulation tissue, persistent tracheocutaneous fistula, scar
  • Accidental decannulation can be catastrophic, especially in a young child.
Memory hook: Fever + drooling + stridor = epiglottitis until proven otherwise; tracheostomy is the rescue airway when intubation fails or obstruction is severe.
Q3. Diabetic patient with severe otalgia, foul-smelling ear discharge and granulation tissue in external auditory canal
1) Diagnosis
  • Malignant otitis externa / necrotizing otitis externa
  • Usually due to Pseudomonas aeruginosa
  • Seen mainly in elderly diabetics and immunocompromised patients
2) Differential diagnoses
  • Simple bacterial otitis externa
  • Otomycosis
  • Chronic suppurative otitis media with polyp
  • External auditory canal carcinoma
  • Granulation due to foreign body / trauma
  • Skull base osteomyelitis of other cause
3) Investigations
  • Blood sugar and glycemic control assessment
  • ESR / CRP — usually raised and useful for follow-up
  • Ear swab culture and sensitivity
  • CT temporal bone to detect bony erosion
  • MRI if soft tissue spread, skull base or intracranial extension is suspected
  • Radionuclide / bone scan may help in diagnosis and monitoring in selected cases
  • Biopsy of granulation tissue if carcinoma or fungal disease is suspected
4) Management
  • Strict control of diabetes is essential.
  • Prolonged antipseudomonal antibiotics:
    • IV ceftazidime / piperacillin-tazobactam / ciprofloxacin according to severity and sensitivity
    • step-down oral therapy if appropriate
  • Aural toilet and local cleaning
  • Pain control and supportive care
  • Treat complications and monitor ESR / CRP and symptoms
  • Surgery is limited; debridement only when needed for necrotic tissue / abscess / diagnostic biopsy
5) Complications
  • Skull base osteomyelitis
  • Cranial nerve palsies, especially VII, IX, X, XI, XII
  • Meningitis / intracranial spread
  • Persistent pain, discharge and chronic infection
  • Death in advanced untreated disease
Memory hook: In a diabetic with severe ear pain and granulation, think malignant otitis externa and treat aggressively with antipseudomonal antibiotics plus glucose control.
Q4. Short notes
Clinical features, diagnosis and treatment of cholesteatoma
  • Clinical features:
    • foul-smelling ear discharge
    • conductive hearing loss
    • attic or marginal perforation
    • retraction pocket with keratin debris
    • aural polyp / granulations
    • vertigo or facial weakness in advanced disease
  • Diagnosis:
    • history and otoscopy / otoendoscopy
    • tuning fork tests and pure tone audiometry
    • HRCT temporal bone to define extent and complications
  • Treatment:
    • aural toilet and control infection
    • surgery — mastoidectomy / canal wall up or canal wall down procedure according to extent
    • ossiculoplasty if hearing reconstruction is possible
    • long-term follow-up for recurrence
Complications of sinusitis with clinical presentation
  • Orbital: periorbital edema, painful eye movements, proptosis, diplopia, reduced vision, ophthalmoplegia
  • Intracranial: headache, fever, vomiting, altered sensorium, seizures, meningitis, brain abscess, extradural / subdural abscess, cavernous sinus thrombosis
  • Bony: frontal osteomyelitis (Pott’s puffy tumour), swelling over forehead
  • Presentation depends on spread from paranasal sinuses to orbit, bone or brain
Enumerate causes of epistaxis. Discuss emergency management.
  • Causes:
    • local trauma / nose picking
    • septal deviation / spur
    • inflammation / rhinitis / sinusitis
    • foreign body
    • dryness / crusting
    • tumours
    • hypertension, bleeding disorders, anticoagulants
    • hereditary hemorrhagic telangiectasia
  • Emergency management:
    • sit forward, pinch soft part of nose for 10–15 minutes
    • apply cold compress
    • check airway, BP and pulse
    • topical vasoconstrictor / local anesthetic if required
    • identify bleeding point and cauterize if visible
    • anterior packing if needed; posterior packing if posterior bleed
    • correct coagulopathy and admit severe cases
Complications of tonsillectomy
  • Primary hemorrhage — within first 24 hours
  • Secondary hemorrhage — usually around 5th to 10th day
  • Pain and reduced oral intake
  • Dehydration
  • Airway obstruction / laryngospasm
  • Infection
  • Injury to teeth, soft palate or lips
  • Anesthetic complications
  • Rare late complications: velopharyngeal insufficiency, taste disturbance
Clinical features and management of peritonsillar abscess (Quinsy)
  • Clinical features:
    • severe unilateral sore throat
    • fever, malaise
    • muffled “hot potato” voice
    • trismus
    • odynophagia / dysphagia
    • uvula pushed to opposite side
    • bulging of soft palate and anterior tonsillar pillar
    • drooling may be present
  • Management:
    • airway assessment
    • needle aspiration or incision and drainage
    • IV / oral antibiotics covering streptococci and anaerobes
    • analgesics, fluids and hydration
    • quinsy tonsillectomy in selected recurrent or unresponsive cases
Differential diagnosis and evaluation of a painless neck swelling in Level II
  • Level II neck corresponds to upper jugular chain lymph nodes.
  • Differential diagnosis:
    • reactive / inflammatory lymphadenopathy
    • tuberculous lymphadenitis
    • metastatic node from oral cavity, oropharynx, larynx, thyroid or nasopharynx
    • lymphoma
    • branchial cyst
    • salivary gland lesions or paraganglioma when appropriate
  • Evaluation:
    • history of duration, pain, fever, weight loss, dental / throat symptoms
    • full head and neck examination including oral cavity, nasopharynx, larynx, tonsil and thyroid
    • examination for other lymph nodes and organomegaly
    • ultrasound neck
    • FNAC as first-line tissue diagnosis
    • CT / MRI / endoscopic evaluation if primary site is suspected
    • biopsy if FNAC is inconclusive and lymphoma is suspected
Memory hook: Sinusitis can spread to orbit, bone and brain; epistaxis is first compressed then packed; tonsillectomy bleeds early or late; quinsy causes trismus and uvular deviation; level II neck swellings are usually lymph nodes needing FNAC.
Q1. Fungal Sinusitis — Etiology, Classification, Clinical Features, Complications & Management
Etiology
  • Common organisms: Aspergillus, Mucor, Rhizopus
  • Predisposing factors:
    • Diabetes mellitus (especially ketoacidosis)
    • Immunocompromised state (HIV, chemotherapy, steroids)
    • Prolonged antibiotic use
    • Chronic sinusitis
Classification
  • Non-invasive
    • Allergic fungal rhinosinusitis
    • Fungal ball (mycetoma)
  • Invasive
    • Acute fulminant (mucormycosis)
    • Chronic invasive
    • Granulomatous invasive
Clinical Features
  • Nasal obstruction, headache, facial pain
  • Nasal discharge (often thick or blackish)
  • Anosmia
  • Allergic type → nasal polyps, allergic mucin
  • Invasive → facial swelling, necrosis, orbital involvement, cranial nerve palsy
Complications
  • Orbital cellulitis, proptosis
  • Cavernous sinus thrombosis
  • Brain abscess, meningitis
  • Bone destruction
Principles of Management
  • Early diagnosis and aggressive treatment
  • Non-invasive: FESS + steroids (AFRS)
  • Invasive:
    • Urgent surgical debridement
    • IV antifungals (Amphotericin B)
    • Control underlying disease (diabetes)
Hook: Black discharge + diabetes = think mucormycosis → emergency!
Q2. Carcinoma Larynx — Risk factors, Clinical Features, Investigations, Staging & Management
Risk Factors
  • Smoking (most important)
  • Alcohol
  • HPV infection
  • Occupational exposure (dust, chemicals)
Clinical Features (Site-wise)
  • Supraglottic: dysphagia, neck nodes early
  • Glottic: hoarseness (early symptom)
  • Subglottic: late dyspnea, stridor
Investigations
  • Laryngoscopy (direct/indirect)
  • Biopsy — confirm diagnosis
  • CT/MRI — extent
  • Chest X-ray — metastasis
Staging (TNM)
  • T — tumor size/extent
  • N — nodal involvement
  • M — metastasis
Management
  • Early stage → radiotherapy / conservation surgery
  • Advanced → total laryngectomy + radiotherapy
  • Chemotherapy in selected cases
  • Rehabilitation (speech therapy)
Hook: Hoarseness >3 weeks = rule out laryngeal cancer
Q3. Otosclerosis — Clinical Features & Management
Clinical Features
  • Progressive conductive hearing loss
  • Paracusis Willisii (better hearing in noise)
  • Tinnitus
  • Normal TM or Schwartz sign (reddish hue)
Management
  • Hearing aid (mild cases)
  • Surgery:
    • Stapedectomy
    • Stapedotomy (preferred)
  • Fluoride therapy (rarely used)
Hook: Young female + conductive loss + normal TM = Otosclerosis
Q4. Deviated Nasal Septum (DNS)
Clinical Features
  • Nasal obstruction
  • Headache
  • Epistaxis
  • Sinusitis
Management
  • Medical → decongestants
  • Surgical:
    • Septoplasty (preferred)
    • SMR (rare now)
Hook: DNS causes obstruction + sinusitis → treat by septoplasty
Q5. Foreign Body Airway
Clinical Features
  • Sudden choking
  • Cough, wheeze
  • Stridor (upper airway)
  • Unilateral decreased air entry
Management
  • Emergency:
    • Heimlich maneuver
    • Back blows (infants)
  • Definitive → Rigid bronchoscopy
Hook: Sudden cough + choking = FB airway until proven otherwise
Q6. Nasal Polyps
Clinical Features
  • Bilateral nasal obstruction
  • Anosmia
  • Watery discharge
  • Pale, glistening mass
Management
  • Medical → steroids
  • Surgical → FESS
Hook: Pale + insensitive mass = polyp (not tumor)
Q7. Tonsillectomy — Indications & Complications
Indications
  • Recurrent tonsillitis
  • Peritonsillar abscess
  • Obstructive sleep apnea
Complications
  • Primary hemorrhage
  • Secondary hemorrhage
  • Pain, infection
Hook: Day 7 bleed = secondary hemorrhage
Q8. Complications of Tracheostomy
Immediate
  • Hemorrhage
  • Pneumothorax
  • False passage
Late
  • Tracheal stenosis
  • Tracheoesophageal fistula
  • Infection
Hook: Tracheostomy → early airway problems, late stenosis