NB:ENT OSCE Orientation Slides 2023 in

the contents or bookmarks ==> (27 Slides)

1/ rt ear , the tympanic memb. Showing tympano sclerotic patch in the postro
inferior & postro anterior quadrents it also showing dry central small perforation
in the antro superior part with With rounded and regular edge , middle ear
mucosa white , pale not congested

1 quadrant = small
2 Quadrant = medium sized
3 quadrant = large
4 quadrent = sub total
4 + pars flacida = total

2/ 3 ossicles : mallues – incus – stapes

2 muscles : tensor tympanai – stapedius
2 nerves : chorda tympanai – tympanic plexus
Air

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Rt or Lt ?-Rt ear
Describe? -ant. perforation include antrosuperior and antroinferior compartments ,small to medium size
Diadnosis? - CSOM without Cholesteatoma
Investigations?
1-PTA (Pure tone audiometry): CHL
2-Culture and sensitivity of discharge.
3- CT: If complications were suspected.
4-nasophareangeal endoscopy: adinoid
TTT?
- Surgical treatment:
Tympanoplasty with or without cortical mastoidectomy.
Tympanoplasty should be combined with cortical mastoidectomy if there is ear discharge (i.e. failure of
medical treatment to control the infection).
But if the ear is dry Tympanoplasty without codical mastoidectomy (Myringoplasty).

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1/ RT ear otoscope showing small – dry – central perforation in the antro superior
quadrant with rounded and regular edges , middle ear cavity is pale without signs
of congestion , the tympanic memb also showing whitish patch extending from
postro inf quadrant to antro inf quadrant most probably tympanosclerosis

2/
General measures :
Avoid witting the ear
Avoid swimming
Prevention of upper resp inf
Medical ttt :
AB if infection suspected
NSAID
Suction if there is secretion
Surgical :
Tympanoplasty

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Rt or Lt ?
-Rt ear
Describe?
-post. perforation include postsuperior and postinferior compartments ,
medium size
-White TYMPANOSCLEROSIS patches seen through the drum in
anterior half
Diadnosis? - TYMPANOSCLEROSIS
Investigations?
1-PTA (Pure tone audiometry): CHL
2-Culture and sensitivity of discharge.
TTT?
Ttt of perforation (conservative and tympanoblasty)
1- CONSERVATIVE
1- keep it dry & 2- recurrent dry and sucction 3- antibiotics local and
sstematic
2- SURGERY
Tympanoblasty
1- removal of ear disease & 2- reconstruction of conductive hearing
3- closure of TM by graft
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Tympanosclerosis has no ttt mainly
SILENT AREAS IN THE HEAD AND NECK
Areas that may lead to lymph node metastasis (neck
swelling = lump) before giving symptoms related to this
area (areas rich in lymphatic):
FTS
1-Fossa of Rosen-Muller (Nasopharynx).
2-Pyriform Fossa (Hypopharynx).
3-Floor of mouth.
4-Tonsilolingual sulcus.
5-Tongue base.
6-Tonsil

Rt or Lt ?-Lt ear
Describe? --Intact opaque dull retracted drum (its colour may be amber yellow in
serous type or gray in mucoid type). - There may be fluid level (hair line).
Diadnosis? - SECRETORY OTITIS MEDIA due to nasophareangeal ca.
Investigations?
1-PTA (Pure tone audiometry): CHL
2-Tympanometry: type B (flat curve)
3-Nasophareangeal endoscopy: for nasophareangeal ca.
TREATMENT?
# Medical:
a. Treatment of the cause: nasophareangeal ca.
b. Systemic Antibiotics to prevent recurrent infection.
c, Steroids: withdrawal method. d. Mucolytics: to dissolve mucoid secretion.
e. Decongestant nasal drops to open ET. f. Valsalva maneuver and
chewing gum to open ET.
# Surgical: if medical treatment failed.
Myringotomy and insertion of ventilation tube
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1/ Nasopharyngeal carcinoma
2/ B curve
3/ Rinne test , lymph node examination , nasal endoscopy

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Rt or Lt ?-Rt ear
Describe? -post. perforation include posto-superior compartment ,small size
Diadnosis? - CSOM with Cholesteatoma
Investigations?
1-PTA (Pure tone audiometry): CHL
2-Culture and sensitivity of discharge.
3- CT: If complications were suspected.
TTT?
The treatment is surgical.
The classic treatment is radical mastoidectomy
N.B.: There are 2 lines for treatment of cholesteatoma: which are
A. Canal wall up (closed) Technique.
B. Canal wall down (open) Technique.
complications?
1- CRANIAL (in the bone of the cranium): 1-Mastoiditis. 2-Labyrinthitis.
3-Petrositis. 4- Facial paralysis.
2- INTRA CRANIAL:
1-Extradural abscess. 2-Subdural abscess. 3-Meningitis.
4- Brain abscess. 5- Lateral sinus thrombophlebitis. 6- Otitic
hydrocephalus.
3-EXTRA CRANIAL:
1- Diffuse otitis externa: secondary to discharge.
2-Jugular vein thrombosis
3-Bezold's abscess
4- Citteli's abscess Scanned by CamScanner
1/ chronic suppurative otitis media with cholesteatoma
2/
1- mastoiditis
2- labyrinthitis
3- facial palsy
4- extradural abscess
5- subdural abscess
6- meningitis
7- brain abscess
8- lateral sinus thrombosis

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Rt or Lt ?-Lt ear

Describe? -Fungal mass like a wet news paper (white mass and black spots)

Diadnosis? - FUNGAL OE : OTOMYCOSIS

AETIOTOGY:
Aspergillus Niger + Candida albicans.

TTT?
TREATMENT:
1-Local cleaning of EAC: suction or ear wash.
2-Antifungal ear drops
3- Packing of EAC with antifungal cream on a piece of gauze (if resistant)
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1/ otomycosis
2/
Suction & ear wash
Antifungal ear drops ( salicylic acid + alcohol) , nystatin
In resistant cases packing with antifungal cream

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Rt or Lt ?
-Lt ear
Describe?
There may be only absence of cone of light or congestion as the drum of children is
thick and resist bulging
Diadnosis? - ACUTE OTITIS MEDIA (AOM)
AETIOLOGY:
Causative organism: 3
Strept. Pneumoniae+ Hemophilus influenzae + Moraxella catarrhalis
ARTER
1-ADENOID: causes ET obstruction and infection.
2-RESPIRATORY tract viral infection: common cold and exanthemata are more
common in children.
3-TEETHING: it decreases the immunity of infants.
4-EUSTACHIAN tube: shorter, wider and more horizontal in children.
5-REGURGITATION of milk or vomitus:
TTT?
General: (a) Systemic antibiotics. (b) Analgesic antipyretic.
Local:
-Decongestant nasal drops as 0xylometazoline to open ET.
•Glycerin phenol warm ear drops.
•Myringotomy: may be needed early for pus drainage (If medical treatment failed
for 48 h ) Followed by suction and antibiotic ear drops. Scanned by CamScanner
1/ Acute otitis media
2/ Strept. Pneumonia – Hemophilus infiluenza – Moraxella catarrhalis
3/ ARTER cause the Eustachian tube is shorter wider and more
horizontally in children making upper Resp inf more susceptible to
reach middle ear – Teething decrease the immunity of children –
Regurgitation of milk or vomits – if Adenoid enlarged causing ET
obstruction & infection – common cold is more common in children

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1/ otitis media with effusion
2/ type B curve
3/ ARTER cause the Eustachian tube is shorter wider and more
horizontally in children making upper Resp inf more susceptible to
reach middle ear – Teething decrease the immunity of children –
Regurgitation of milk or vomits – if Adenoid enlarged causing ET
obstruction & infection – common cold is more common in children

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1/ conductive hearing loss
2/ -ve
3/
1- acute otitis media
2- chronic otitis media
3- cholesteatoma
4- glomus tumor
5- traumatic rapture of the drum
6- adhesive OM
7- otosclerosis

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1/sensory neural hearing loss
2/ +ve
3/ hearing aid

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1/ Ramsay hunt syndrome ( herpes zoster oticus)
2/ general measures
Care of the eye ( eye drops , eye ointment at night , sunglasses )
Care of facial muscles ( massage , physiotherapy , facial exercise)
Control diabetes
Medical ttt
Acyclovir systemic
Steroid systemic large dose under hospitalization
Anti anxiety for vertigo
NSAID : for pain

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1/ malignant otitis externa
2/ diabetes
3/pseudomonas aeruginosa

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1/ facial palsy in the RT part of the face most probably bells palsy
2/
Psychological reassurance
Care of the eye ( eye drops , eye ointment at night , sunglasses )
Care of facial muscles ( massage , physiotherapy , facial exercise)
Steroids in large dose
Surgical intervention by nerve deroofing if degeneration more than 90% in 2
weeks

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1/ facial palsy in the RT part of the face most probably bells palsy
2/
1- Psychological reassurance
2- Care of the eye ( eye drops , eye ointment at night , sunglasses )
3- Care of facial muscles ( massage , physiotherapy , facial exercise)
4- Steroids in large dose
5- Surgical intervention by nerve deroofing if degeneration more than 90% in
2 weeks
3/ frontalis – orbicularis oculi – orbicularis oris – buccinator – platysma muscle

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1/ preauricular sinus
2/ medical tt : AB + Nsaids until the inf subside
drainage & removal definitive tt
3/ Auricotemporal nerve from trigeminal N
Auricular branch from vagus
Great auricular nerve

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1/ auricular hematoma
2/ AB for infection NSAid for pain
Drainage

3/ auricotemporal N
Auricular branch of vagus
Great auricular nerve

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1/ grommet tube insertion
2/ otitis media with effusion
3/ ARTER cause the Eustachian tube is shorter wider and more horizontally in
children making upper Resp inf more susceptible to reach middle ear – Teething
decrease the immunity of children – Regurgitation of milk or vomits – if Adenoid
enlarged causing ET obstruction & infection – common cold is more common in
children

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1/ cholesteatoma
2/ pure tone audiometry
Ct
Culture & sensitivity of discharge
3/ mastoidectomy wall up or down
4/ extradural abscess
Subdural abscess
Labyrinthitis
Mastoiditis
Meningitis
Brain abscess

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 1/ mastoiditis
2/ drainage mastoidectomy if necessary , AB , NSAID , General mesures etc..

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1/Acute suppurative otitis media
2/ strept coccus pneumonia
Hemophilius infiluenza
Moraxella catarrhalis
3/ ARTER cause the Eustachian tube is shorter wider and more horizontally in
children making upper Resp inf more susceptible to reach middle ear – Teething
decrease the immunity of children – Regurgitation of milk or vomits – if Adenoid
enlarged causing ET obstruction & infection – common cold is more common in
children

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A-ORBITAL COMPLICATIONS: is the commonest
1-Orbital oedema.
2-Orbital cellulitis.
3-Extra-periosteal abscess.
4-Sub-periosteal abscess.
5-Cavernous sinus thrombosis.
B-CRANIAL COMPLICATIONS:
1- Osteomyelitis (frontal, rarely maxillary).
2-Fistula (after rupture of sub-periosteal abscess).
C-INTRACRANIAL COMPLICATIONS:
1-Extradural abscess.
2-Subdural abscess.
3-Meningitis,
4-Brain abscess (frontal lobe).
5-Cavernous sinus thrombosis.
D- OTHERS:
1-Descending infections: Recurrent otitis media, pharyngitis, laryngitis and
bronchitis.
2-Mucocele: if the sinus ostium is obstructed. Scanned by CamScanner
1/ Acute Rhinosinusitis 3/ TREATMENT:
2/ orbital complication: a)Medical:
1-Complete bed rest with plenty of
1. Orbital edema warm fluids in acute cases.
2. Orbital cellulitis 2-Systemic antibiotics according to
3. Orbital abscess culture and sensitivity.
4. Cavernous sinus thrombosis 3-Analgesic, antipyretics for pain
Cranial complications and headache.
1. Osteomyelitis 4-Decongestant nasal drops
2. Intra cranial 5- Steam inhalation.
6-Warm fomentations over the
Extradural abscess
affected sinus.
1. Subdural abscess
7- Treatment of predisposing factor
2. Meningitis
(if present)
3. Brain abscess
b) Surgical: FESS Indications: Failure
Others of medical treatment. + Complicated
Otitis media , pharyngitis , bronchitis sinusitis.
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1/ trauma
Hypertension
Idiopathic
Angiofibroma
Liver cell failure
Hemophilia
2/ cauterization
Nasal packing
Surgery ( maxillary artery ligation) or ethmoidal according to the source
Emobilization

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1/ placed in sitting position , head fixed forward , pinched the nostril . ice packing
over the nose , nasal decongestant
If persistent nasal packing ant or post
2/ hypertension
3/ traumatic
Acute rhinitis , chronic rhinitis
Angiofibroma
Hypertension
Idiopathic
Liver failure , hemophilia
2ndry due to anticoagulant

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Left Nasal cavity
ALLERGIC RHINITIS and Nasal septum devation

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Right Nasal cavity

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1/ Nasopharynx
2/ 1 = fossa of rosenmiller , 2 = eustachian tube opening
3/ epistaxis , conuctive hearing loss , otitis media , dysphagia due to palatal palsy ,
nasal obstruction

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1/ Allergic rhinitis
2/ Avoid exposure to the irritant if known
Antihistaminic tablet
Nasal steroid spray
Mast cell stabilizer
Steroid systemically if unresponsive
Hyposensitization
Surgical
ESS if polyps , reduction of in turbinate

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1/ septal deviation on the rt side
2/Adenoid / nasopharyngeal mass / Allergic rhinitis / hypertrophic rhinitis /
angiofibroma / nasal polyposis / choanal atresia
3/ septoplasty

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SEPTAL HAEMATOMA
Collection of blood between mucoperichondrium and cartilage
of septum.
CAUSES: Usually traumatic
Surgical trauma: after SMR or Septoplasty.+ Accidental
trauma: associated with fracture nose.
CLINICAL PICTURE
Symptoms: - History of trauma. - Bilateral nasal obstruction.
Signs: Anterior rhinoscopy bilateral both sides of septum. +
Syringe aspiration blood.
COMPLICATIONS: Secondary infection leads to septal
complications.
TREATMENT:
1-Systemic antibiotics to prevent 2ry infection.
2-Incision and evacuation: vertical incision on one side and
horizontal on the other, to avoid septal
perforation.
3-Anterior nasal pack to prevent recollection. Scanned by CamScanner
1/ septal hematoma
2/ medical : AB systemic
Incision & evacuation - ant nasal packing to prevent recollection
3/ 2ndry infection – septal abscess – cavernous sinus thrombosis – necrosis of
septal cartilage – perforation of septum

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1/ Ant rhinoscopy
2/ nasal septum deviation toward the lt side
3/ Adenoid , allergic rhinosinusitis , rhinosinusitis , hypertrophic inf turbinate ,
chronic rhinitis choanal atresia

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1/ foreign body
2/ x ray , ct , nasal endoscopy
3/ removal of foreign body by nasal endoscope

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1/ Anterior rhinoscopy
2/
1- rt nasal septum
2- inferior turbinate
3- middle turbinate
3/ Ant & post Ethmoidal arteries
Sphenopalatine artery
Superior labial from facial
Greater palatine from maxillary
Venous drainage
Cavernous sinus through ophthalmic vein
Nerve supply :
Sensory : maxillary nerve
Olfactory : olfactory nerve
Autonomic ( sympathetic = deep petrosal /// parasympathetic = greater
superficial petrosal nerve

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1/ chronic rhinitis with bilateral nasal polyposis
2/ septal hematoma , Allergic rhinitis , septal abscess , adenoid , angiofibroma
mallergic polyp
3/ medical : steroid or anti histamine , AB for infection
Surgery : FESS (functional endoscopic sinus surgery)

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1/Littles Area
2/ Ant ethmoidal A
Sphenopalatine artery
Sup labial
Greater palatine
3/ sitting position head tilted forward pinching the nose , ice packing , nasa
decongestant
If failed nasal packing ant or post

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1/ littles area
2/ placed in sitting position , head fixed forword , pinched the nostril . ice packing
over the nose , nasal decongestant
If persistent nasal packing ant or post
3/ cautery

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1/ Acute rhinosinusitis complicated with preseptal cellulitis
2/ cavernous sinus thrombosis
Extradural abscess
Subdural abscess
Brain abscess
Meningitis
Otitis media
Secretory otitis media
Chronic otitis media
Osteomyelitis

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1/ Adenoid hypertrophy
2/ nasal endoscope , xray , ct
3/ open dry mouth
Elevated upper lip
Prominent central incisors
High arched palate
Receding lower jaw
Apathetic look
Narrow pinched ant nares
4/ adenoidectomy +- tonsillectomy

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1/ acute follicular tonsilitis
2/ group A beta hemolytic streptococcus pyogenes
3/ diphtheria
Vincent angina
Epstein bar virus (infectious mononeocleosis)
Moniliasis
Agranulocytosis
4/ sleep disorder breathing (obstructive sleep apnea)
Dysphagia
Chronicity ( recurrent more than 5 times in 1 year witnessed by physician or
recorded)
Trauma or foreign body
5/ complications of tonsilictomy
Pain
Primary & secondary post tonsillectomy bleeding
wound Infection
Incomplete removal
Respiratory infection

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What is the name of the procedure this man underwent ?
tracheostomy
Mention 2 complications.
-Complications: SHIRIF
1) Shock: anaphylactic shock from local anaesthesia,
2) Haemorrhage: it may be
a.Primary: - b.Reactionary: - c.Secondary:
3) Injury: to
-Cricoid cartilage (above): leads to porichondritis necrosis ==>stenosis
(subglottic).
-Apex of pleura (below): leads to pneumothorax.
-Vessels of neck (lateral): leads to haemorrhage.
-Oesophagus (posterior): leads to tracheo-oesopheal fistula
4) Respiratory complications: ASPO
-Apnea:
-Surgical emphysemapening (stoma).
-Pneumothorax: air in the pleural sac (injury to its apex).
-Obstruction: due to either Normal lung -Obstruction of the tube: usually by dried
mucus.
5) Infection: either
-Wound infection (local sepsis)
-Respiratory infection
6) Fistula: The opening remains without healing after removal of tracheostomy
tube.

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1/ tracheostomy
2/
1- Prolonged intubation
2- Fractures in face
3- Subglottic hemangioma
4- Bilateral vocal cord paralysis
5- Laryngeal stenosis
6- failed to intubate
7- malignant cancer larynx
3/
1- hemorrhage
2- damage to tracheal structure
3- aspiration
4- air embolism
5- tracheoesophageal fistula
6- infection
7- death

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1-Rt false cord
2-Lt true cord
3-Lt Ary-epiglottic fold
4- ant. commisure
5- Lt pyriform fossa
6-Rt Arytenoid Area

NERVE SUPPLY: Via vagus nerve by 2 branches

a. Superior laryngeal nerve (SLN):
- Motor to cricothyroid muscle (via External branch).
- Sensory to mucosa above VC (via Internal branch).
b. Recurrent laryngeal nerve (RLN):
- Motor to all laryngeal muscles except cricothyroid.
- Sensory to mucosa below VC.
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 Indirect laryngoscopy
1/
1. Rt False vocal cord
2. Lt true vocal cord
3. Lt Ary-epiglottic fold
4. Anterior commissure
5. Lt pyriform fossa
6. Rt Vocal process of the arytenoid

2/ Posterior cricoarytenoid

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1/ indirect laryngoscope showing whitish mass extended along the rt vocal cold (
leukoplakia)
2/ smocking – alcohol – GERD
3/ biopsy / excision by microlaryngosurgury & follow up

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LARYNGOMALACIA
Abnormal softening of the larynx that collapse during inspiration.
It is the commonest congenital anomaly of the larynx. It is the
commonest cause of stridor in neonates.

• CLINICAL PICTURE:
Symptoms:
- Stridor: Inspiratory only, increased by upper respiratory infection.
Also, increased on supine position and
become much better on prone
position
-No hoarseness: as the larynx is normal during expiration with no
vocal cords affection.
Signs: Flexible laryngoscopy or direct laryngoscopy show collapse of
larynx during inspiration but it opens
normally during the
expiration.

TREATMENT:
-No treatment as the condition improves spontaneously by the age of
18-24 months, but avoid upper
respiratory infection.
-Tracheostomy: in severe stridor, with excision of redundant mucosa
by Laser (MLS).
N.B. Endotracheal intubation may be used in emergency for relief of
stridor (instead of tracheostomy). Scanned by CamScanner
1/ laryngomalacia
2/ no treatment required as the condition improve over time ( prevention of
upper resp. tract infection )
If the infant show severe symptoms ( episodic cyanosis while feeding ,
recurrent aspiration pneumonia failure to thrive ) surgical intervention =
tracheostomy emergency , supraglottoplasty

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1/ direct laryngoscopy
2/ laryngeal polyp in the rt true vocal cord at the junction between ant 1/3 & post
2/3
3/ complete voice rest - removal of polyp by micro laryngosurgery – phono
therapy , stop smocking

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1/ Rt vocal cord mass in the anterior 2/3 of vocal cord with surface leukoplakia
2/ smocking – alcohol – GERD
3/ biopsy
Definitive ttt removal by micro laryngosurgery & follow up

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 1/ direct laryngoscope showing mass in the ant 2/3 of rt vocal cold
2/ smocking – alcohol – Gerd – radiation
3/ biopsy

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1/ indirect laryngoscope
2/ bilateral singer nodule at the junction between ant 1/3 & post 2/3
3/ complete voice rest
Phono therapy
Phonomicrosurgery ( microlarngosurgery)

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1/ thyroglossal cyst
2/ thyroglossal duct
3/ thyroid
Dermoid cyst
Lipoma
Tracheal lymph node
Submental lymph node
Sub hyoid bursa

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