University of Sulaimany
College of Medicine
5th stage
A collection of important Questions on :
Clinical E.N.T
Prepared by :
Dr. Soran Mohammad Gharib
( 2008 – 2009 )
Clinical E.N.T
Some common instruments which are used in clinical E.N.T :
• Auriscope (otoscop ):
Used for :
1.illumination
2.magnification
3.straightening
4.instrumination
5.pneumatic auriscope
6.visualization
7.anterior
8.application of drugs.
9.as a tourch light to see oral cavity.
• Tunning fork :
Used for :
1.Rinne test
2.Weber test.
• Eustachian catheter :
Used for : Eustachian tube catheterization.
• Postnasal mirror :
Used for :
Visualization and indirect posterior rhinosopy.
• aural speculum :
Used for :
1. instrumination
2. visualization
3. straightening
4. dilatation.
• Head mirror :
Used for illumination.
• Aural syringe :
Used for washing of auditory canal.
• Crocodile forceps :
Used for
1.Removing foreign body
2.Removing wax
• Laryngeal mirror :
Used for
1.indirect laryngoscopy
2.examination of hypopharynx
3.examination of some parts of oropharynx which is not seen by nacked eye.
• Thudichum's nasal speculum :
Used for visualization of external nose.
• Jobson aural (horne ear) probe :
Cerated end :
Used for : holding local anesthesia , drying and mopping(wiping) .
Ring end :
Used for: Removing of foreign body
Differentiating between polyp and turbinate as
polyp is painless but turbinate is painful.
• Nasal snare :
Used for cutting of polyp surgically
• Politzer bag :
Used for politzeration (inflation) of Eustachian tube and middle ear .
• Trochear and canulla :
Used for maxillary sinus washing .
• Antral Trochear and canulla :
Used for : 1.Antral washing
2.theraputic for drainage of pus in sinusitis.
3.diagnostic for cytology and biochemistry.
• Tyllydressing forceps :
Used for anterior packing of nose
• Siegle's pneumatic speculum :
Used for observing movement (motion) of tympanic membrane .
• Nasal speculum :
Used for visualization of external ear
☺ Some important Questions :-
Q.1/ Why we don’t make general anesthesia for postnasal pack ?
Because of :
1. Risk of inhalation.
2. most of anesthetic drugs are hepatotoxic.
3. hypovolemia.
Q.2 / Functions of intrinsic laryngeal muscle ?
1.Abductor of vocal cord.
2.Adductor of vocal cord
3.Tensor of vocal cord
4.Opner of vocal cord .
Q.3/ What are the Phases of swallowing?
1. Oral phase → voluntary
2. Pharyngeal phase → involuntary
3. Oesophageal phase → involuntary.
Q.4 / Pneuminization : is the assessment of mobility of tympanic membrane.
-If tympanic membrane is moveable it means tympanic membrane is intact.
-If tympanic membrane is not moveable; it means air enters through
perforation (tympanic membrane is not intact ) .
Q.5/ What are the lymph node groups in the neck and head ?
1.submental
2.submandibular
3.preauricular
4.post auricular
5.upper,middle,lower deep cervical
6.supra clavicular
7.pre trocheal.
Inflammatory or neoplastic enlargement implies that :
1.there is primary disease within the nodes.
2.they have become involved secondary to pathology in the head and neck.
3.occasionally they may become involved due to pathology below the clavicle.
Q.6/ Positions of the patient ?
1. Adult : the head away from the wall (20 cm) for free movement of the head.
2. Child : need assistant .
3. Comatous patient or fractured neck: the patient should be lay down in bed.
4. Neonate : supine.
Q.7/ What are the extrinsic muscle of the tongue ?
1.Genulossus
2.Styloglossus Responsible for movement of the tongue supplied by
3.Palato glossus vagus nerve .
4.Hyoglossus
Q.8/ What are the intrinsic muscle of the tongue ?
1.Longitudinal
2.Transverse Responsible for shape of the tongue .
3.Vertical
Q.9/ Enumerate the para nasal sinuses ?
1. Maxillary air sinus
2. Frontal sinus
3. Ethmoid cells
4. Sphenoidal sinus .
Q.10/ Examination of Eustachian tube ?
A) Direct :
1. inspection of Eustachian tube through nasopharynx.
2. inspection of Eustachian tube through tympanic membrane when
perforated.
B) Indirect :
1.Valsava maneuver
2.Tympanometery
3.Eustachian tube catheterization .
4.Politzer bag → politzeration .
Q.11/ Audiology :
Sound is an audible band of mechanical wave spectrum .
( 20 – 20 000 Hz ) → human can hear .
Frquency cycle / min
More cycle →high frequency like female sound.
Less cycle → low frequency like male sound .
Conduction apparatus are :-
1.External ear
2.Tympanic membrane
3.Eustachian tube
4.Ossicular chain
5.Labyrinthin fluid .
Perceptive apparatus are :
1.Organ of corti
2.Cochlear nerve
3.Central connection .
Types of deafness are :
1.Conductive deafness like wax in external meatus .
2.Sensori neural deafness like genetic.
3.Mixed deafness .
Q.12 / Why do tinnitus become worse at night ?
Because: 1.Audible ground disappers
2.sound become more clear .
Q.13/ Hearing aid
Application of :
1. hearing loss (sound)
2. tinnitus (audible sound) .
Q.14/ How phonation occurs?
Phonation occurs with movement of vocal folds in midline. This produces a
rise in subglottic pressure which , with controlled exhalation , causes the vocal
cord to vibration .
Q.15/What prevent food and liquid from entering the lower respiratory tract?
1.Tha action of the false cords.
2.The sphincter action of the aryepiglotic folds and epiglottis.
Q.16/What are the causes of change in volume of voice ?
1.Changes in the volume of voice are caused alteration in subglottic pressure.
2.Alteration in pitch are due to modification of length and tension within vocal
cords .
Q.17/ Define Halitosis ?
Halitosis (offensive smell) is one of the symptom of mouth and throat
disease , it is usually associated with dental caries and gingivitis , but may be
caused by tonsillar infection or para nasal sinus infection with a purulent
postnasal drip.
Q.18/ Odynophagia and dysphagia :
Odynophagia means pain in swallowing .
Dysphagia means difficulty ( not necessary pain ) in swallowing.
Q.19/Comparision between two forms of chronic supporative otitis media?
Safe Unsafe
1.Discharge thin,intermittent,copious, thick, continous,
inoffensive scanty, offective
2.Defect Pars tensa , Pars flaccida ,
central marginal
3.Commplication nil Brain abscess, meningitis
extradural abscess .
4.Surgery patient may Surgery must be done ,
choose tympanoplasty mastiodectomy .
5.Deafness Conductive Conductive,
may be sensorineural .
The Nose :
• Examination
• nose bleed
• inflammation
• foreign body
• nasal allergy
• deviated nasal septum
• nasal injury
• sinuses and sinusitis
• vasomotor rhinitis
• nasal polypi
• Functions of nose :
1.olfaction
2.respiration
3.tonation to speech
4.nasal reflex : sneezing reflex part of protective mechanism of nose
5.lysosome enzyme : immunologic function
6.air conditioning
♣ Epistaxis ( nose bleed )
Causes :
Local effects :
1.Idiopathic (unknown ) , common in children
2.Trauma, injury, fracture of nose.
3.Inflammatory rhinitis
4.Tumor
A/ Benign tumor : like; juvenile nasopharyngeal
angiopharyngeoma.
B/ Congenital tumor : like; hemangeoma
C/ Malignant tumor : like; adenocarcinoma.
Systemic effects :
1.Atherosclerosis of median size artery .
2.Blood disorders like; leukemia, hemophilia.
3.Infection : like; malaria, typhoid.
4.Metabolic disorders : like; DM , hypothyroidism , hyperthyroidism, uremia 5.
Drugs :like; anticoagulant .
6.Venous hypertension , right ventricular failure .
Management :
1.Docter should be alone with patient .
2.Both doctor and patient put on gown .
3.Good suction , good illumination and kidney dish are available .
4.Doctor put pressure over the nostril for 10 minutes , patient should open
mouth and head lower down to come blood.
5.Bleeding evident point to cotterization.
Cottery : Chemical ( silver nitrate )
Electrical ( glavanocottery )
Electrical is better than chemical, because material goes deep.
Degree of blood loss :-
1.Mild blood loss ( up to 10 % )
no problem in children you should be aware and you should give fluid .
2.Moderate blood loss ( over 10 % and below 25% )
you can replace with blood and fluid .
3.Severe blood loss ( up to 30 % ) you should replace with blood and fluid .
♣ Foreign body in the nose :
Children insert a wide range of objects into the nose .
Clinical features :
1.nasal obstruction
2.foul unilateral or bilateral nasal discharge
Treatment:
Many will need referral to an ENT clinic , where good illumination of
examination of nose and appropriate instrumentation are available.
In cooperative patient and firmly restrained children foreign body can be
removed without general anesthesia but sometimes may be needed.
Q.20/ Acute viral inflammation of nose ?
1.common cold 2.influenza.
Clinical features:
1.blockage
2.discharge
3.sneezing
Q.21/Nasal allergy :
For the purpose of management , can be divided into two types :-
1.Acute paroxysmal allergy
2.Perrenial allergy
1) Acute paroxysmal allergy:
Acute episode of allergic nasal symptoms include :
1.blockage
2.watery nasal discharge
3.sneezing
It occurs when contact with specific allergians like feather,pollen,fur…etc.
Sign includes the nasal mucosa is edematous and has a blue/purple color.
Treatment :1.Anti histamine
2.A steroid nasal spray
3.Disodium cromoglycate that stabilizes the mast cell.
2) Perrenial allergy : In this case the patient complains of persistant allergic
nasal symptoms for the year. Perrenial allergy is less severe and dramatic than
those of acute paroxysmal allergy.
Symptoms:
1.perrenial obstruction.
2.discharge of nose
3.sneezing.
Sign includes the nasal mucosa is edematous and has a blue/violent color.
Tretment:
1.Anti histamine
2.low dose steroid nasal spray
3.Disodium cromoglycate is of great help in paroxysmal nasal allergy and
asthma but in limited role in perennial cases.
If conservative treatment fails ;the patient needs surgery .
Q.22/Nasal polyp appears to be a manifestation of nasal allergy :
Symptoms:
1.nasal obstruction
2.watery nasal discharge
3.polypi rarely causes bleeding.
Sign: the pale oedematus polypi in both side of the nose.
Treatment: it can be removed by local or general anesthesia by using a nasal
snare and a variety of forceps.
Q.23/ Symptoms of nasal disease?
1.nasal obstruction
2.nasal discharge(rhinorrhea)
3.sinus pain
4.sneezing and cough
5.disturbance of smell.
Q.24/Facial nerve examination ?
1.blow the cheeks .
2.whistle to examine the muscle of expression .
3.show the teeth to make any facial palsy more apparent.
4.inspection of mouth angle for deviation to the normal side, inability to
close eyes on the paralyzed side.
5.examine taste sensation in the anterior two-third of the tongue.
Q.25/What are the causes of facial nerve paralysis?
1.Trauma: -ear surgery
-parotid surgery
-fracture of the temporal bone
-external wounds.
2.Inflammation: - herpes zoster oticus , Bell's palsy.
3.Tumor + acoustic neuroma.
• Evidence of facial nerve destruction can be obtained by a study of its
branches :
1.greater superfacial petrosal nerve → decreased lacrimation
2.chorda tympani→ decreased taste sensation in the anterior two-third
of the tongue tested by electrogustatometer.
3.nerve to stepedius → abnormal stapedial reflex.
The Throat :
• Functions of the Larynx :
1.protection of air passage
2.phonation
3.respiration
4.fixation of chest
5.sphenictric action
• Position of the examiner :-
3 Positions :-
1.Sitting position : same gender , infront of the patient , best and easy .
2.Sitting position : versus gender , bedside the patient , little bit difficult .
3.Standing position .
Anatomy of the throat : the regions that comprise the throat include :
1/ The oral cavity
2/ The pharynx ( oropharynx , nasopharynx , hypopharynx )
3/ The larynx
4/ The major salivary gland.
The oral cavity includes : the ant. 2/3 of the tongue , the lips , hard palate , teeth,
alveoli of the maxilla and the mandible .
The pharynx stretches from the base of the skull to the cricopharyngeal below.
The larynx consists of 3 compartments :-
1/ The glottis
2/ The supraglottis
3/ The subglottis
The prime function of the larynx is to protect the upper airway,
Voice production is a secondary function that has evolved with time .
The major salivary glands of clinical importance are : parotid and
submandibular glands.
The parotids produce serous secretion , the mandibular secretion is more
seromucinous .
The parotid ducts open in the mouth opposite to the second upper molar teeth,
the sub mandibular ducts open into the floor of the mouth adjacent to the
frenulum of the tongue .
Lymph nodes in the head and neck provide a barrier against the spread of
diseases .
Examination of the throat :-
- With practice it is possible to inspect all of the oral cavity, the larynx and
the pharynx .
- First check the lips, teeth, gums, the floor of the mouth and the opening of
the submandibular and parotid ducts .
- A tongue depresser is then introduced so that its tip lies at junction the
posterior and middle thirds of the dorsum of the tongue .
- The more distant portions of the pharynx can be seen by a laryngeal mirror
or fibro-optic laryngoscope
- For indirect laryngoscopy the patient is asked to remove any dentures and
to protrude the tongue .
- The soft palate is displaced upwards and backwards by the mirror and by
instructing the patient to say " aah " or " eee " , the larynx is elevated
towards the examining mirror and examined .
Special investigations :
1.Pure tone audiometry
2.Speech audiometry
3.Impedance audiology
4.Evoked response audiomettry
5.Electrocochliography
6.Caloric testing .
♦ Tonsillitis :
Clinical feature :
1.sore throat
2.fever
3.headache
4.dysphagia.
Acute tonsillitis :
Causes :
1.Group A streptococci
2.Staph
3.Virus → change to secondary bacterial infection .
Treatment :
1.drainage of pus
2.Antibiotic
3.Analgesia
4.soft warm diet .
Complications of Tonsillitis :-
Local complications :
1.Chronic (lower degree of symptoms but persistent )
2.Mesntric lymph adenitis .
3.Suppuration ( pus formation )
Treatment :-
1.drainage of pus
2.Antibiotic
3.Analgesia
4.soft warm diet .
Systemic complications :
1.Glomeruonephritis
2.Septecemia
3.Rheumatic fever .
Chronic Tonsillitis :
Clinical features : 1.no fever
2.low degree of painful swallowing
3.bad odour
4.recurrent acute infection .
Treatment :
Medical treatment :
1.Antibiotics
2.Analgesia
If no improved : Surgical treatment ( Tonsillectomy )
Indications of Tonsillectomy :-
1.failure of medical treatment
2.Quinsy ( peretonsillar abscess )
3.Big tonsil
4.Recurrent acute tonsillitis.
5.Tumor (lymphoma)
6.Bleeding .
.♦ Adenoid :
Lymphoid tissue in the roof and posterior wall of nasopharynx .
Hypertrophy of lymphatic tissue in children because of using it to get immunity
Some have over hypertrophy leads to obstruction .
- nasal obstruction if infected leads to rhinitis .
- if adenoid infected through Eustachian tube leads to otitis media ,
pharyngitis, bronchitis .
- mouth bleeding .
Treatment of adenoid hypertrophy ;
1.Antibiotics
2.Analgesia
3.Decongestent of nose
4.Adenoidectomy .
Symptoms of throat disease :-
1.Pain
2.Dysphagia
3.Dysphonia(hoarseness)
4.Stridor(noisy breathing)
5. A lump in the neck .
• Sore throat :
Causes :
1.bacterial pharyngitis
2.viral pharyngitis
3. acute tonsillitis
4.Quinsy is an abscess adjacent to the tonsil.
5.dry throat from mouth breathing .
6.the commonest cause in the oral cavity is the carious teeth and periodontal di
7.Thrush
8.Glandular fever
.
• Stridor is a noisy breathing associated with upper airway obstruction .
Etiology of stridor :
In neonate :
1.Congenital cysts and tumors
2.laryngomalacia
3. subglottic stenosis.
In child :
1.acute laryngitis
2.foreign body
3.epiglottitis( supraglottitis )
4.laryngotracheobronchitis.
In adult :
1.acute laryngitis
2.epiglottitis( supraglottitis )
3.laryngeal trauma
4.laryngeal carcinoma.
• Dysphonia : Causes of dysphonia :
A) Organic :
1. Inflammatory : infective laryngitis
2. neoplasia: carcinoma
3. neurological : thyroidectomy 4. systemic : hypothyroidism
B) Non – organic :
1.habitual dysphonia : oedema , nodules .
2.psychogenic : musculoskeletal tension, ventricular dysphonia.
• Dysphagia :
Any lesion that interrupts the normal sequence of coordinated muscular activity
that is necessary for swallowing may cause dysphagia.
Causes of dysphagia :
1.neuromascular : motor neuron disease .
2.intrinsic lesions : oesophageal stricture.
3.extrensic lesions : thyroid enlargement .
4.systemic : scleroderma .
5.psychosomatic: globus pharynges .
• A Lump in the neck :
Causes of neck lump by age :
A) Less than 20 years
1.inflammatory :
2.congenital : midline dermoid, thyroglossal and branchial cysts
3.lymphoma.
B) 20-40 years :
1.salivary gland pathology : like infection
2.thyroid pathology : goiter
3.chronic infection : T.B
C) Greater than 40 years :
1.primary malignancy : lymphoma
2.secondary malignancy .
Q/ What are the symptoms of ear disease ?
1.aural pain ( otalgia ) .
2.discharge ( otorrhea ) + bloody discharge ( otorrhagia ) .
3.hearing loss ( deafness ) .
4.sensation of sound in absence of an appropriate auditory stimulus (Tinnitus)
5.sensation of abnormal movement (vertigo) .
• Otalgia :-
Causes of otalgia :
A)Otological causes :
1.acute otitis externa
2.malignant otitis externa
3.acute otitis media
4.furunculosis.
B)Non-otological causes :
1.tonsillitis
2.dental disease
3.temporomandibular joint pathology
4.cervical spine disease
• Otorrhea :-
Classification of otorrhea according to site and aetiology :
1.watery (serous) → - CSF leak
- eczema of external meatus
2.purulent → acute otitis externa
Furunculosis
3.mixed → chronic tubotympanic suppurative otitis media.
4.mucopurulent → acute otitis media , trauma
5.
• Hearing loss ( Deafness ) :
Causes of deafness :-
A) Conductive ( trauma ,F.B ,wax ,congenital ,carcinoma )
1.Trauma to the drum or ossiccular chain.
2.wax or foreign body in the external meatus
3.chronic suppuration (tubotympanic , attico-antral )
4.congenital atresia of the external meatus or congenital ossicular fixation.
5.carcinoma of the middle ear.
B) Sensorineural ( trauma + infection )
1.genetic
2.perinatal: jaundice
3.prenatal : rubella
4.infective : measles , meningitis , mumps
5.trauma : head injury , surgery, noise.
Rinne test Weber test
Normal Air conduction is better than bone Sound waves travel
conduction through the bone equally
to both cochlea.
Conductive Bone conduction is better than air Louder in deaf ear
deafness conduction
Sensorineural Air conduction is better than bone Louder in good ear
deafness conduction
Tunning fork is placed on the bone Tunning fork is placed on
of mastoid process and is putting the forehead of the
near the ear. patient .
• Vertigo : Causes of vertigo :
1.with motion : motion sickness
2.with drug induced :
Vestibule toxic drugs
* quinine
* anti hypertensive
* gentamycin
3. after trauma : post-traumatic vertigo
4.with systemic disorders :
* panic attacks and anxiety
* cardiac dysrrhythmia
* syncope
5.with deafness and tinnitus :
* acoustic neuroma
* menere's disease
6.with ear discharge :
* middle ear disease
Prepared by : Dr.Soran Mhamad Ghareb
Special thanks to my dear friend :
Dr.Soran Mhamad Gharib
for helping medical students by his works to simplify the subjects and
collection of important questions and thanks for his great sense of
responsibility. which surely students will get benefit from his works .
♦ In the series of his works for ( 5th stage ) medical school students for
this year (2008-2009) are:-
• Clinical E.N.T
• Clinical Orthopedics
• Clinical Gynecology
• Clinical Psychiatry
• Clinical Ophthalmology
• Clinical Radiology ( CD )
• History taking and examination in neurology
• The most important subjects for theory examination .
Also available :
• Introduction to ECG reading .
• 25 cases in clinical pediatrics with their answer .
• Common abdominal signs and findings .
• Guide for rapid management in surgical casuality .
And collection of all questions of previous years ( mid-year and final theory
examination ) for (4th , 5th and 6th stages ) .
* All darkness of world can't hide the light of a candle.
* No matter how long the night is, the day is sure come.
* A friend in need is a friend indeed.