Ultimate ENT Exam Guide

Lecture 1: Sinonasal Tumours

  • Exophytic Papilloma: Arises from nasal septum/vestibule, associated with Human Papillomavirus (HPV) types 6 and 11.
  • Osteomas: Most common benign (~1%). Frontal sinus most common (57%, usually silent). Gardner syndrome (Autosomal Dominant): multiple osteomas, colonic polyposis.
  • Fibrous Dysplasia: Ground glass appearance on CT scan, 80% monostotic (1 bone).
  • Inverted (Transitional Cell) Papilloma: Originates from lateral wall of the nose. Intact basement membrane. High MCQ yield: ~10% malignant transformation. Requires thorough removal. Recurrence rates: Endoscopic (12%) vs Open approach (20%).
  • Juvenile Nasopharyngeal Angiofibroma (JNA): Exclusively males (7-19 years). Originates at sphenopalatine foramen. Presents with unilateral obstruction & epistaxis. CT shows bowing of posterior maxillary wall. Avoid preoperative biopsy due to bleeding risk; preoperative angiogram and embolization (24h preop) is needed. Medical Tx includes Flutamide (testosterone receptor blocker).
  • Schwannoma: Positive S-100 protein staining.
  • Squamous Cell Carcinoma (SCC): Most common malignancy. Maxillary sinus (60-70%) > Nasal cavity.
  • Risk Factors: Hardwood dust (strongly linked to Adenocarcinoma), Toxin exposure (nickel, chromium), Snuff, HPV.
  • Ohngren Line: Tumours posterior or superior to this line have a poorer prognosis.
  • Other Malignancies: Adenoid cystic carcinoma, Mucoepidermoid carcinoma, Esthesioneuroblastoma (Olfactory Neuroblastoma). Lymphoma has a <60% 5-year survival.
  • Metastasis: Most are primary. If metastasis occurs: Renal cell carcinoma (>50%) > Lung > Breast.
  • Clinical Signs: Infra-orbital anaesthesia, persistent oroantral fistula, trismus, proptosis.
  • Imaging: MRI distinguishes tumors from retained secretions/sinusitis.
  • Staging highlights: T1: Limited to mucosa/one subsite. T2: Bone erosion (except posterior wall of maxilla). T3: Invades posterior wall, orbit floor, cribriform plate. T4b: Invades orbital apex, dura, brain, cranial nerves (except Maxillary Nerve V2).
  • Exposure to Hardwood dust is specifically linked to Adenocarcinoma of the sinuses.
  • Exclusively Males with severe epistaxis + nasal mass = Juvenile Nasopharyngeal Angiofibroma. NEVER BIOPSY! Treat medically with Flutamide.
  • 10% malignant transformation is the hallmark of Inverted Papilloma. Endoscopic removal has a better recurrence rate (12%) than open surgery.
  • Most common benign tumor is Osteoma (usually Frontal sinus). Most common malignant is Squamous Cell Carcinoma (SCC).
  • Ohngren's Line divides the maxillary sinus; tumors Posterior/Superior to it have a worse prognosis.

Lecture 2: Traumatic Conditions of the Nose & Sinuses

  • Nasal Foreign Bodies (NFBs): Commonly located anterior to the middle turbinate. Classic presentation: Unilateral foul-smelling, blood-stained nasal discharge in a child. Right naris affected twice as often (due to right-handedness).
  • Removal: Best with wax hook or Eustachian tube catheter passed above the object and pulled anteriorly. Clumsy attempts can push it leading to lung collapse/aspiration or meningitis.
  • Nasal Fractures: Most commonly fractured bones of the face.
    • Class 1: Vertical (Chevallet fracture), depressed distal bone.
    • Class 2: Horizontal (Jarjavay fracture), involves perpendicular plate of ethmoid.
    • Class 3: Severe, involves ethmoid labyrinth, telecanthus (widening space between eyes).
  • Timing for Closed Reduction (CR): Window 1 is 2 to 3 hours before edema. Window 2 is 5 to 10 days after injury.
  • Deviated Nasal Septum: Can cause Sluder’s neuralgia (contact point headache between spur and middle turbinate). Types include Septal deviation, Spurs, and Dislocation.
  • Nasal Septal Hematoma: Blood collection between cartilage and perichondrium. Red, soft swelling. Must incise and drain to prevent septal abscess, septal perforation, or saddle nose deformity.
  • Septal Perforation: Causes whistling sound during respiration. Most common cause: Previous nasal surgery. Medical Tx: Vaseline/lubrication. Surgical Tx: Septal Buttons for small/medium holes, flap repair for large.
  • Le Fort Fractures:
    • Le Fort I: Floor of nose, lower 1/3 maxilla, palate.
    • Le Fort II: Across nasal bones, medial orbit, infra-orbital foramen.
    • Le Fort III: Across orbital floor into lateral orbit, zygoma moves during palate palpation.
  • Cerebrospinal Fluid (CSF) Rhinorrhoea: Clear fluid, halo sign on pillow, headache relieved by laying supine. Confirmed by Beta-2 transferrin (or beta-trace protein). Locate defect via CT/MRI. Tx Rule: Avoid nasal packing (prevents meningitis). If persists >4 weeks: Lumboperitoneal shunt or craniotomy.
  • Unilateral foul-smelling discharge in a child = Nasal Foreign Body until proven otherwise. DO NOT use clumsy forceps, use a wax hook passed above the object.
  • Red, boggy septal swelling post-trauma = Septal Hematoma. Needs urgent incision & drainage to prevent cartilage necrosis.
  • Beta-2 transferrin is the highly specific marker for confirming Cerebrospinal Fluid (CSF) leak. Never use nasal packing for a CSF leak!
  • A whistling sound while breathing strongly suggests a Nasal Septal Perforation. Treat small ones with Septal Buttons.
  • If the zygoma moves during palate palpation, it indicates a severe Le Fort III fracture.

Lecture 3: Epistaxis

  • Kiesselbach’s plexus (Little's Area): Anteroinferior septum. Most common site (90% of epistaxis). Anastomosis of 4 arteries: Anterior ethmoidal, Sphenopalatine, Greater palatine, Superior labial. Note: Ophthalmic artery gives rise to anterior/posterior ethmoidal arteries.
  • Woodruff area: Posterior-inferior lateral wall. Common site for severe posterior epistaxis.
  • Systemic Causes: Hypertension, Coagulopathies, NSAIDs, Hereditary Hemorrhagic Telangiectasia (HHT / Osler-Weber-Rendu syndrome). 85% are idiopathic.
  • Bimodal Age Distribution: (2-10 years) and (50-80 years).
  • Primary rule: Hemodynamic stability takes priority over history.
  • Prevention: Instruct patients to avoid strenuous activities, hot/spicy environments, and excessive nose blowing.
  • Stepwise approach: 1. Manual pressure (5-10 mins).
    2. Cauterization (Chemical via Silver Nitrate/Trichloroacetic acid, or Electrocautery).
    3. Anterior packing (prevent toxic shock with oral/topical antibiotics). Complications: Synechia, rhinosinusitis, scarring of ala.
    4. Posterior packing (Use 12/14 French Foley catheter / Storz Epistaxis Catheter). Complications: Hypoventilation, toxic shock syndrome, sudden death, Eustachian tube dysfunction.
    5. Arterial Ligation: Closer to the bleeding site is better.
    6. Embolization: Effective for External Carotid Artery (ECA) system. Complications of Embolization (MCQ!): Facial nerve palsy, blindness, skin necrosis, stroke.
  • The absolute first step in a patient with severe epistaxis is securing Hemodynamic stability (ABC).
  • 90% of all nosebleeds are anterior, originating from Kiesselbach’s Plexus.
  • Arterial embolization for severe epistaxis carries severe risks including Blindness and Facial Paralysis.
  • When performing Arterial Ligation, the rule is: The closer the ligation is to the bleeding site, the more effective it is.
  • Always prescribe antibiotics with nasal packing to prevent Toxic Shock Syndrome.

Lecture 4: Anatomy & Physiology of the Mouth

  • Divisions: Vestibule (between lips/cheeks and teeth) and Oral Cavity Proper (within teeth to oropharynx).
  • Lips & Cheeks Muscles: Composed of skeletal muscles (Orbicularis oris, Buccinator).
  • Mastication Muscles: Include the Masseter, Temporalis, and Pterygoid muscles.
  • Teeth: Adults have 32 permanent teeth, children have 20 primary teeth.
  • Tongue Innervation (High Yield MCQ!):
    • Motor: Hypoglossal nerve (Cranial Nerve XII).
    • Sensory (Anterior 2/3): Trigeminal nerve (Cranial Nerve V3).
    • Sensory (Posterior 1/3): Glossopharyngeal nerve (Cranial Nerve IX).
    • Taste (Anterior 2/3): Facial nerve (Cranial Nerve VII).
    • Taste (Posterior 1/3): Glossopharyngeal nerve (Cranial Nerve IX).
  • Palate: Hard palate (anterior roof, maxillary/palatine bones), Soft palate (posterior, part of oropharynx).
  • Salivary Glands: Major glands (Parotid, Submandibular, Sublingual). Secretion contains Amylase and Lipase.
  • Salivation: ~1-1.5 L/day. Parasympathetic = watery, enzyme-rich. Sympathetic = thicker saliva.
  • Taste: 5 primary tastes (Sweet, sour, salty, bitter, umami). Transmitted via CN VII, IX, X.
  • Swallowing: Oral phase (Voluntary), Pharyngeal phase (Involuntary, epiglottis closes), Esophageal phase (Involuntary).
  • The Glossopharyngeal nerve (CN IX) is unique because it supplies BOTH sensory and taste to the Posterior 1/3 of the tongue.
  • All motor function to the tongue is supplied by the Hypoglossal nerve (CN XII).
  • The muscles of mastication include the Masseter, Temporalis, and Pterygoid muscles.
  • Parasympathetic stimulation produces watery saliva, while Sympathetic produces thick saliva.
  • Children have 20 primary teeth, whereas adults have 32 permanent teeth.

Lecture 5: Diseases of the Mouth

  • Herpetic Stomatitis (HSV-1): Multiple painful vesicles, cold sores. Tx: Acyclovir.
  • Hand, Foot, and Mouth Disease: Coxsackievirus A16, Enterovirus 71. Vesicular rash on hands/feet + oral ulcers.
  • Acute Necrotizing Ulcerative Gingivitis (ANUG / Vincent’s Angina): Fusobacterium and Treponema. Punched-out ulcerated interdental papillae, foul odor. Tx: Metronidazole.
  • Ludwig’s Angina: Polymicrobial. Bilateral submandibular swelling, significant airway obstruction risk. Tx: IV Antibiotics, surgical drainage.
  • Oral Candidiasis (Thrush): Candida albicans (Opportunistic). White curd-like plaques that CAN be scraped off. Diagnosis via KOH preparation / culture. Tx: Topical Nystatin, Fluconazole for severe cases.
  • Traumatic Ulcers: Caused by biting or ill-fitting dentures. Tx: Remove the cause.
  • Xerostomia (Dry Mouth): Causes include Sjögren’s syndrome, meds, radiation. Tx: Hydration, saliva substitutes, Pilocarpine.
  • Aphthous Ulcers (Canker Sores): Round, shallow ulcers with a yellow base and red halo.
  • Oral Lichen Planus: Autoimmune. White, lacy patches (reticular) or erosive. Tx: Topical steroids, immunosuppressants.
  • Pemphigus Vulgaris: Autoimmune blistering. Fragile blisters, Positive Nikolsky’s sign. Diagnosis via Direct immunofluorescence.
  • Oral Leukoplakia: White patches that CANNOT be scraped off. Precancerous potential.
  • Squamous Cell Carcinoma (SCC): Most common oral cancer. Non-healing ulcers with induration. Associated with tobacco, alcohol, Human Papillomavirus (HPV).
  • If a white oral patch CAN be scraped off, it is Oral Candidiasis. If it CANNOT be scraped off, it is Oral Leukoplakia (Precancerous).
  • A patient with severe bilateral submandibular swelling has Ludwig's Angina. The immediate concern is Airway Obstruction.
  • Positive Nikolsky’s Sign (skin sloughing with pressure) and Direct immunofluorescence are classic for Pemphigus Vulgaris.
  • For severe cases of Xerostomia (Dry Mouth), the specific medical treatment is Pilocarpine.
  • Coxsackievirus A16 is the classic cause of Hand, Foot, and Mouth Disease.

Lecture 6: Anatomy & Physiology of the Pharynx

  • 12 cm muscular tube. Extends from skull base to 6th cervical vertebra (C6).
  • Divisions: 1. Nasopharynx (Skull base to soft palate).
    2. Oropharynx (Soft palate to upper border of epiglottis).
    3. Laryngopharynx / Hypopharynx (Epiglottis to lower cricoid cartilage).
  • Muscles: Circular Constrictors (Superior, Middle, Inferior) to propel food. Longitudinal Elevators (Stylopharyngeus, Palatopharyngeus, Salpingopharyngeus).
  • Arterial Supply: Branches of the External Carotid Artery (ascending pharyngeal, facial, maxillary) and Subclavian Artery (inferior thyroid).
  • Lymphatic Drainage: Deep cervical, retropharyngeal, and Jugulodigastric nodes.
  • Motor Nerve Supply: Vagus nerve (CN X) via pharyngeal plexus, EXCEPT Stylopharyngeus which is supplied by the Glossopharyngeal nerve (CN IX).
  • Sensory Supply: Nasopharynx = CN V2 (Maxillary). Oropharynx = CN IX. Laryngopharynx = CN X.
  • Waldeyer’s Ring (Lymphoid tissue): 1. Pharyngeal tonsil (Adenoid). 2. Palatine tonsils. 3. Lingual tonsil. 4. Tubal tonsils. 5. Lateral pharyngeal bands.
  • The Vagus Nerve (CN X) provides motor supply to ALL pharyngeal muscles EXCEPT the Stylopharyngeus (supplied by CN IX).
  • The Nasopharynx gets its sensory supply from the Maxillary nerve (CN V2).
  • Waldeyer’s Ring is the collection of lymphoid tissues including Adenoids, Palatine, Lingual, and Tubal tonsils.
  • The Pharynx ends and the Esophagus begins at the level of the C6 vertebra.
  • The principal lymphatic drainage for the pharynx includes the Jugulodigastric nodes.

Lecture 7: Anatomy & Physiology of the Larynx

  • Unpaired Cartilages: Thyroid (largest, Adam's apple), Cricoid (the ONLY complete ring), Epiglottis (leaf-shaped).
  • Paired Cartilages: Arytenoids (pyramid-shaped, control vocal cord tension/position), Corniculate, Cuneiform.
  • Important Membranes: Cricothyroid ligament (site for emergency cricothyrotomy), Quadrangular membrane (forms false cords), Conus elasticus (forms true cords).
  • Intrinsic Muscles:
    • Posterior cricoarytenoid: The ONLY abductor (opens vocal cords).
    • Lateral cricoarytenoid: Adductor.
    • Cricothyroid: Tenses the vocal cords.
  • Extrinsic Muscles: Suprahyoid (elevate larynx e.g., mylohyoid, digastric). Infrahyoid (depress larynx e.g., sternothyroid, sternohyoid).
  • Vessels: Superior Laryngeal Artery (from Superior Thyroid) and Inferior Laryngeal Artery (from Inferior Thyroid). Superior thyroid vein drains to Internal Jugular Vein, Inferior thyroid vein drains to brachiocephalic vein.
  • Nerve Supply (High Yield!):
    • External branch of Superior Laryngeal Nerve (SLN): Motor to Cricothyroid ONLY.
    • Recurrent Laryngeal Nerve (RLN): Motor to ALL other intrinsic muscles. Sensory below vocal cords.
    • Internal branch of SLN: Sensory above vocal cords.
  • The Posterior Cricoarytenoid is the most important respiratory muscle because it is the ONLY abductor (opener) of the vocal cords.
  • The Cricoid is the only complete cartilaginous ring in the entire respiratory tract.
  • The External branch of the Superior Laryngeal Nerve (SLN) supplies ONLY the Cricothyroid muscle.
  • The Recurrent Laryngeal Nerve (RLN) supplies ALL intrinsic muscles EXCEPT the Cricothyroid.
  • A child's airway is most narrow at the Subglottis, making them highly prone to obstruction (Croup).

Lecture 8: Inflammations of the Pharynx

  • Acute Pharyngitis: Sudden onset. Most common cause is Viral (70-90%) (Rhinovirus, Adenovirus, Influenza, Epstein-Barr Virus).
  • Most important bacterial cause is Group A beta-hemolytic Streptococcus (GABHS). Other bacteria: Corynebacterium diphtheriae, Neisseria gonorrhoeae.
  • Bacterial presentation: Fever, Tonsillar exudates, Cervical lymphadenopathy. Viral presentation: associated with rhinorrhea, cough, hoarseness.
  • Diagnosis: Rapid Antigen Detection Test (RADT) for Streptococcus. Monospot test for Epstein-Barr Virus.
  • Treatment: Penicillin or Amoxicillin ONLY if Streptococcus is confirmed.
  • Chronic Pharyngitis: Persistent irritation (> weeks). Causes: GERD, smoking, chronic mouth breathing. Mucosa shows epithelial hyperplasia, fibrosis, mucosal dryness, and glandular hypertrophy.
  • The vast majority (70-90%) of Acute Pharyngitis cases are Viral, meaning antibiotics are generally useless.
  • If a patient has Tonsillar exudates and cervical lymphadenopathy, suspect GABHS (Streptococcus). Treat with Penicillin/Amoxicillin.
  • Use the Rapid Antigen Detection Test (RADT) to quickly confirm a Strep throat infection.
  • Use the Monospot test if you suspect Epstein-Barr Virus (EBV / Infectious Mononucleosis).
  • Chronic Pharyngitis is non-infectious; always evaluate for GERD or smoking.

Lecture 9: Diseases of the Tonsils & Adenoids

  • Acute Tonsillitis: Viral or Bacterial (S. pyogenes). Avoid Amoxicillin in suspected EBV (infectious mononucleosis) to prevent severe rash.
  • Peritonsillar Abscess (Quinsy): Spreads beyond tonsil. Uvular deviation AWAY from affected side, trismus, "hot potato voice". Tx: Needle aspiration/drainage + IV antibiotics.
  • Tonsillectomy Indications: Recurrent infections (≥ 7 episodes/1 yr, ≥ 5/yr for 2 yrs, ≥ 3/yr for 3 yrs), OSA, recurrent Quinsy, asymmetric enlargement (rule out malignancy/lymphoma).
  • Surgical Techniques: Cold Knife Dissection, Electrocautery, Coblation (radiofrequency with saline), and Harmonic Scalpel (ultrasonic vibration).
  • Post-op complication: Secondary hemorrhage occurs 5-10 days post-op.
  • Adenoids (Pharyngeal tonsil) are located in the Nasopharynx.
  • Chronic Adenoiditis/Hypertrophy: Causes mouth breathing, snoring, Secretory Otitis Media (due to Eustachian tube dysfunction).
  • Adenoidectomy Indications: OSA, persistent secretory otitis media, chronic rhinosinusitis.
  • Adenoidectomy Techniques: Curettage, Suction Diathermy, and Coblation Adenoidectomy (plasma-mediated ablation).
  • Contraindications for Tonsillectomy/Adenoidectomy: Uncontrolled bleeding disorders, acute infection, Cleft palate (risk of velopharyngeal insufficiency).
  • Uvula deviating AWAY from a swollen, painful tonsil + Trismus = Peritonsillar Abscess (Quinsy).
  • Never give Amoxicillin for tonsillitis if you suspect EBV (Mononucleosis), it will cause a maculopapular rash!
  • Coblation and Harmonic Scalpel are modern tonsillectomy techniques minimizing thermal damage.
  • Cleft Palate is an absolute contraindication for Adenoidectomy due to the risk of velopharyngeal insufficiency.
  • Secondary Hemorrhage after tonsillectomy typically occurs 5 to 10 days post-operatively.

Lecture 10: Airway Obstruction & Tracheostomy

  • Types of Stridor:
    • Inspiratory = Supraglottic obstruction.
    • Biphasic = Glottic/Subglottic obstruction.
    • Expiratory = Tracheal obstruction.
  • Causes: Congenital (Laryngomalacia), Infectious (Epiglottitis, Croup, Diphtheria, Ludwig angina), Traumatic (Burns, Inhalational injuries), Allergic (Anaphylaxis).
  • Radiology MCQ Gold: Thumb sign on neck X-ray = Acute Epiglottitis. Steeple sign = Croup (Laryngotracheobronchitis).
  • Emergency Medical Tx: Heliox (Helium-Oxygen reduces airway resistance), Nebulized epinephrine (for Croup), Corticosteroids.
  • Definition: Surgical opening created in the trachea to establish an airway. Can be Surgical (in OR, requires anterior neck incision) or Percutaneous (bedside using dilators, preferred in ICU).
  • Indications: Airway obstruction, Prolonged Mechanical Ventilation (>14 days) in ICU, neuromuscular disorders (Myasthenia Gravis, stroke) preventing secretion clearance, failed intubation.
  • Procedure: Tracheal opening is created between 2nd and 4th tracheal rings.
  • Complications: Early (Bleeding, Pneumothorax, tracheoesophageal fistula), Late (Tracheal stenosis, granuloma, tracheomalacia).
  • Post-op care: Humidified oxygen to prevent dryness, regular suctioning.
  • Inspiratory Stridor ALWAYS means the obstruction is high up (Supraglottic).
  • A lateral neck X-ray showing a Thumb Sign is diagnostic for Acute Epiglottitis.
  • Percutaneous Tracheostomy is the preferred method for ICU patients needing bedside intervention.
  • Tracheostomy is indicated if a patient needs Prolonged Mechanical Ventilation for more than 14 days.
  • A standard Tracheostomy is performed between the 2nd and 4th tracheal rings.

Lecture 11: Hoarseness

  • Timing: Acute (< 2 weeks) vs Chronic (> 2 weeks). *Persistent hoarseness >2 weeks in a smoker requires ruling out malignancy via laryngoscopy.*
  • Neurological Causes: Recurrent Laryngeal Nerve (RLN) palsy (due to thyroid surgery, tumors, stroke), Parkinson's, Multiple Sclerosis, Myasthenia Gravis.
  • Structural Causes: Vocal cord nodules (vocal abuse), Polyps, Laryngeal Papillomatosis (Human Papillomavirus - HPV), Laryngeal Carcinoma.
  • Traumatic Causes: Intubation injury, Chemical/thermal burns.
  • Systemic & Psychogenic: Hypothyroidism (myxedema of vocal cords), Rheumatoid arthritis (cricoarytenoid joint fixation), GERD. Psychogenic Causes: Functional dysphonia, Conversion disorder.
  • Diagnosis: Indirect/Flexible Laryngoscopy. CT/MRI for malignancy/nerve involvement. Stroboscopy evaluates vocal cord vibration. Laryngeal EMG for neuromuscular disorders.
  • Treatment: Voice rest, hydration, PPIs for GERD. Microlaryngoscopy for polyps/nodules. Laryngeal framework surgery for vocal cord paralysis. Voice Therapy for vocal rehabilitation.
  • Any smoker with Hoarseness lasting more than 2 weeks MUST have a laryngoscopy to rule out Laryngeal Carcinoma.
  • Hypothyroidism causes hoarseness through myxedema (fluid accumulation) in the vocal cords.
  • Rheumatoid Arthritis can cause hoarseness by attacking and fixing the Cricoarytenoid joint.
  • Stroboscopy is the specific tool used to properly evaluate the fine vibrations of the vocal cords.
  • Laryngeal Papillomatosis is a structural cause of hoarseness caused by Human Papillomavirus (HPV).

Lecture 12: Laryngeal Carcinoma

  • 95% are Squamous Cell Carcinomas (SCC). Risk factors: Tobacco, Alcohol, HPV, GERD. Peak age 60-70. Male:Female 4:1.
  • Pathological Progression: Dysplasia → Carcinoma in situ → Invasive Carcinoma.
  • Glottic Tumors: Most common. Early symptom: Persistent hoarseness / Dysphonia. Has the best prognosis due to early detection.
  • Supraglottic Tumors: Presents with sore throat, dysphagia, odynophagia, and referred otalgia. High rate of neck node metastasis.
  • Subglottic Tumors: Rare. Present late with dyspnea and stridor.
  • Diagnosis: PET scan used for staging and distant metastasis. Biopsy assesses perineural/vascular invasion. Staging via TNM Classification.
  • Early-Stage (T1-T2): Radiotherapy or endoscopic laser excision. Goal: Voice preservation. Survival rate 80-90%.
  • Advanced-Stage (T3-T4): Chemoradiotherapy (for organ preservation) or Total Laryngectomy (for extensive tumors with airway obstruction). Total laryngectomy results in permanent tracheostomy and loss of normal voice. Survival rate drops to 30-50%.
  • Squamous Cell Carcinoma (SCC) represents 95% of all Laryngeal Carcinomas.
  • Glottic tumors have the BEST prognosis because the vocal cords lack lymphatics and hoarseness forces early detection.
  • Referred Otalgia (ear pain) with a normal ear exam strongly suggests a Supraglottic or Pharyngeal tumor.
  • PET-CT is highly specific in laryngeal cancer for assessing staging and distant metastases.
  • Total Laryngectomy inevitably leaves the patient with a permanent tracheostomy.

Lecture 13: Malignant Tumors of the Pharynx

  • Nasopharyngeal Carcinoma (NPC): Strongly linked to Epstein-Barr Virus (EBV), Chinese/North African descent, and consumption of Salted fish/Nitrosamines.
    • Presents with nasal obstruction, unilateral serous otitis media (Eustachian tube block), and cranial nerve palsies (CN VI diplopia, CN V facial pain). First sign often Neck Mass (cervical metastasis).
    • Diagnosis: EBV serology and plasma DNA analysis.
    • Tx: Radiation Therapy (highly radiosensitive). Surgery has limited role.
  • Oropharyngeal Carcinoma: Increasing incidence due to Human Papillomavirus (HPV-16/18). HPV-positive tumors have a better prognosis than HPV-negative tumors. Presents with unilateral tonsillar enlargement and ulceration. Diagnosis: p16 immunohistochemistry for HPV testing.
  • Laryngopharyngeal (Hypopharyngeal) Carcinoma: Linked to tobacco/alcohol, GERD, and nutritional deficiency. Presents with progressive dysphagia and referred otalgia (via CN IX). Has the worst prognosis among pharyngeal cancers due to late presentation. Treatment: Total laryngopharyngectomy. Chemotherapy includes targeted therapy like Cetuximab for EGFR-positive tumors.
  • An adult presenting with Unilateral Serous Otitis Media MUST be checked for Nasopharyngeal Carcinoma (NPC).
  • NPC is fundamentally linked to Epstein-Barr Virus (EBV) and is diagnosed via EBV serology/plasma DNA.
  • Oropharyngeal cancer incidence is rising due to HPV. Diagnosis of HPV is confirmed specifically using the p16 immunohistochemistry test.
  • Hypopharyngeal Carcinoma has the WORST prognosis. Treatment for EGFR-positive variants involves Cetuximab.
  • Cervical Lymph Node metastasis (a Neck Mass) is frequently the very first symptom noticed in NPC.

Lecture 14: Dysphagia

  • Oropharyngeal Dysphagia: Difficulty initiating swallow. Sensation of coughing/choking/nasal regurgitation. Causes: Neurological (Stroke, Myasthenia Gravis, Parkinson's, Multiple Sclerosis), Structural (Zenker’s diverticulum, tumors, pharyngeal stenosis).
  • Esophageal Dysphagia: Food sticking in chest. Causes: Mechanical (Strictures, esophageal cancer), Motility (Achalasia, Scleroderma, Diffuse Esophageal Spasm), GERD (leads to strictures).
  • Complications: Aspiration pneumonia, Malnutrition, and Dehydration.
  • Imaging: Videofluoroscopic Swallow Study (VFSS) evaluates swallowing mechanics. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) assesses pharyngeal function. Barium Swallow detects structural esophageal abnormalities. Esophagogastroduodenoscopy (EGD) directly detects esophageal pathology. Manometry for motility disorders.
  • Medical Tx: Dietary modification (thickened fluids, soft diet), Speech/swallow therapy, Prokinetics for motility disorders, PPIs.
  • Procedural Tx: Dilation for strictures, Botulinum Toxin Injection for Achalasia, Surgical removal for Zenker's Diverticulum.
  • Difficulty INITIATING a swallow with coughing/choking = Oropharyngeal Dysphagia (mostly neurological).
  • Food sticking in the CHEST after swallowing = Esophageal Dysphagia (mostly mechanical/motility).
  • The gold standard test to evaluate Swallowing Mechanics in real-time is the Videofluoroscopic Swallow Study (VFSS).
  • If a patient has Achalasia (a motility disorder), Botulinum Toxin Injection is a key procedural treatment.
  • Esophagogastroduodenoscopy (EGD) is vital for directly visualizing and detecting internal esophageal pathology like tumors.

Lecture 15: Otolaryngologic Symptoms of Systemic Diseases

  • Diabetes Mellitus (DM): Causes SNHL and severe Malignant Otitis Externa (Pseudomonas).
  • Hypothyroidism: Macroglossia, hoarseness (myxedema of vocal cords), impaired olfaction.
  • Hyperthyroidism: Vocal cord paralysis (thyroid compresses RLN).
  • Rheumatoid Arthritis (RA): Cricoarytenoid joint arthritis causing hoarseness and stridor, conductive hearing loss (ossicular joint).
  • Sjögren’s Syndrome: Severe Xerostomia (dry mouth), leading to oral candidiasis and dental caries. Dry nose.
  • Systemic Lupus Erythematosus (SLE): Immune-mediated inner ear damage (SNHL), vocal cord paralysis.
  • Leukemia: Gingival hyperplasia, spontaneous mucosal bleeding, leukemic infiltration of cochlea (SNHL).
  • Anemia: Glossitis (smooth tongue), burning sensation in the mouth, pallor, fatigue-related dysphonia.
  • Tuberculosis (TB): Tuberculous laryngitis, chronic otitis media with caseating granulomas.
  • Syphilis: Otosyphilis causes sudden Sensorineural Hearing Loss (SNHL) and Meniere-like vertigo.
  • HIV/AIDS: Kaposi’s sarcoma, oral candidiasis, viral neuropathy SNHL.
  • Wegener’s Granulomatosis (Granulomatosis with Polyangiitis): Nasal septal perforation causing Saddle nose deformity.
  • Sarcoidosis: Causes SNHL (granulomatous cochlea) and Granulomatous laryngitis.
  • Gastroesophageal Reflux Disease (GERD): Chronic laryngitis, Globus sensation (feeling of a lump in the throat).
  • Inflammatory Bowel Disease (IBD): Aphthous ulcers, mucosal swelling.
  • A diabetic patient with severe, deep ear pain likely has Malignant Otitis Externa (caused by Pseudomonas).
  • A patient with a Saddle Nose Deformity and septal perforation without trauma likely has Wegener’s Granulomatosis.
  • Rheumatoid Arthritis (RA) is the systemic disease most likely to cause Cricoarytenoid Joint arthritis and hoarseness.
  • Sjögren’s Syndrome causes extreme Xerostomia (dry mouth), heavily predisposing the patient to Oral Candidiasis.
  • Sarcoidosis presents with SNHL and specifically causes Granulomatous Laryngitis leading to hoarseness.

⚖️ Ultimate Comparisons (High Yield)

Feature Children Adults
Position Higher (C2-C4) Lower (C3-C6)
Shape More funnel-shaped Cylindrical
Epiglottis Omega-shaped, more floppy Leaf-shaped, firmer
Subglottic Space Narrower (more prone to obstruction) Wider and more rigid
Cartilage Softer and more flexible Harder and more ossified
Feature Anterior Epistaxis Posterior Epistaxis
Location (Plexus) Kiesselbach’s plexus (Little's Area) Woodruff area
Frequency Most common (90%) Less common
Severity Usually mild / self-limiting More severe, harder to control
Demographic Common in children/young adults Common in older adults (Hypertension)
Feature Oral Candidiasis (Thrush) Oral Leukoplakia
Etiology Fungal (Candida albicans) Chronic irritation (Tobacco, Alcohol, Human Papillomavirus)
Scraping test CAN be scraped off CANNOT be scraped off
Diagnosis KOH Preparation Biopsy
Malignant Potential Benign opportunistic infection Precancerous
Feature Oropharyngeal Dysphagia Esophageal Dysphagia
Primary Issue Difficulty initiating swallowing Sensation of food sticking in the chest
Associated Symptoms Coughing, choking, nasal regurgitation Acid reflux (GERD), stricture sensation
Common Causes Neurological (Stroke, Parkinson's), Zenker's Mechanical (Stricture, Cancer), Motility (Achalasia)
Best Diagnostic Test Videofluoroscopic Swallow Study (VFSS) Barium Swallow or Esophagogastroduodenoscopy
Feature Inverted (Transitional Cell) Papilloma Juvenile Nasopharyngeal Angiofibroma
Origin Site Lateral wall of the nose Sphenopalatine foramen
Key Demographics Peak 5th to 6th decade, M:F (2-5:1) Exclusively males (7 to 19 years)
Hallmark Danger ~10% Malignant transformation (to SCC) High vascularity; Preoperative biopsy is contraindicated
Medical Treatment Surgery only Flutamide (testosterone receptor blocker)
Feature Glottic Carcinoma (True Vocal Cords) Supraglottic Carcinoma
Frequency Most common laryngeal tumor Second most common
Early Symptoms Persistent Hoarseness / Dysphonia Sore throat, dysphagia, Referred Otalgia
Lymphatic Spread Very rare early on (sparse lymphatics) High rate of neck node metastasis
Prognosis Best prognosis (detected early) Worse (presents later)
Feature Surgical Tracheostomy Percutaneous Tracheostomy
Location of Procedure Operating Room (OR) Bedside (ICU)
Technique Direct incision in the anterior neck Uses Dilators over a guidewire
Invasiveness More invasive Less invasive
Preferred Setting Complicated airways, emergency neck trauma ICU settings for prolonged mechanical ventilation
Feature Group A beta-hemolytic Streptococcus (GABHS) Epstein-Barr Virus (EBV / Mononucleosis)
Type of Pathogen Bacterial Viral
Classic Clinical Sign Fever, Tonsillar exudates, Cervical lymphadenopathy Sore throat, widespread lymphadenopathy, profound fatigue
Specific Diagnostic Test Rapid Antigen Detection Test (RADT) Monospot test
Antibiotic Implication Treat with Penicillin / Amoxicillin AVOID Amoxicillin (Causes severe maculopapular rash)
Feature Osteoma Fibrous Dysplasia
Frequency & Peak Age Most common benign tumor (~1%), 5th to 6th decade Usually diagnosed in childhood (<20 years)
Most Common Location Frontal Sinus (57%) Maxilla or Mandible (painless swelling)
Radiological Finding (CT) Dense, opaque bone mass Ground glass appearance
Associated Syndrome Gardner Syndrome (multiple osteomas, colon polyps) Mostly Monostotic (80% involves 1 bone)