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*AR, NOSE & THROAT

by
Prof Dr Hassan Wahba
Professor of OtoRhinoLaryngology
Faculty of Medicine Ain Shams University
Case 1

A 10 year old child was having a right mucopurulent otorhea for

the last 4 years. A week ago he became dizzy with a whirling

sensation, nausea, vomiting and nystagmus to the opposite side;

his deafness became complete and his temperature was normal.

Three days later he became feverish, irritable and continuously

crying apparently from severe headache. Also he had some neck

retraction. The child was not managed properly and died by the

end of the week.

Diagnosis &
reasons
Case 2:
A 50 year old male patient complained of right earache of 2 days
duration. The pain was especially severe on chewing food and

during speech. There was also marked edema of the right side of

the face. On examination, pressure on the tragus was painful;

and there was a small red swelling arising from the anterior

external auditory meatal wall. Rinne test was positive in the

right ear. The patient gave a history of 2 previous similar attacks

in the same ear during the last six months but less severe.

CASE 2
Case 3:
A 10 year old child complained of a right mucopurulent otorhea
for the last 2 years. He suddenly became feverish and this was

associated with diminution of the ear discharge. There was also

tenderness on pressure behind the auricle. The retroauricular

sulcus was preserved. There was no retroauricular fluctuation.

CASE 3
Case 4:
A 9 year old child has been complaining of right continuous

offensive ear discharge for the last 3 years. A month ago he

began to suffer from headache, fever and some vomiting for

which he received symptomatic treatment. The patient's

condition was stable for a while, then after 2 weeks he started to

suffer from severe headache and drowsiness. The patient also

noticed difficulty going up and down the stairs. A week later, he

developed weakness in the left arm and left leg, and became

markedly drowsy. He became comatose the next day.

CASE 4
 brainstem and death

Case 5:
A 6 year old child developed severe pain in both ears together
with a rise of temperature (39 C) following an attack of common

cold. The child received medical treatment that lead to drop of

his temperature and subsidence of pain; so the physician

stopped the treatment. However, the mother noticed that her

child did not respond to her except when she raised her voice.

Thi s decreased response remained as such for the last 2 weeks

after the occurrence of the primary condition.

CASE 5
Case 6:

A 3 year old boy presented to the ENT specialist because of an

inability to close the right eye and deviation of the angle of the
mouth to the left side upon crying of 2 days duration. His

mother reported that he had severe pain in the right ear 5 days

prior to his present condition. She also added that his earache

improved on antibiotic therapy.

CASE 6
Case 7:

A 30 year old female complained of bilateral hearing loss more

on the right side following the delivery of her first child; hearing

loss was marked in quiet places but hearing improved in a noisy

environment. Both tympanic membranes showed a normal

appearance. Rinne tuning fork test was negative

CASE 7
Case 8:

After a car accident a young male complained of inability to

close the right eye and deviation of the angle of the mouth to the

left side together with dribbling of saliva from the right angle of

the mouth. There was also a right hearing loss and a blood clot

was found in the right external auditory canal. 3 days later a clear

fluid appeared in the right ear that increased in amount on

straining. A day later the patient was drowsy and developed

fever and neck stiffness.

CASE 8
 CSF
Treatment Treatment of meningitis: antibiotics, lower CSF pressure by repeated
lumbar puncture, diuretics and mannitol 10%
Treatment of CSF otorhea: semisitting position, avoid straining,
diuretics and close observation of the patient regarding fever and neck
stiffness for the development of meningitis
Treatment of facial nerve paralysis: care of the eye, surgical
exploration and repair if electroneuronography reveals 90%
degeneration of the affected nerve within one week of the onset of
paralysis
Treatment of hearing loss: tympanoplasty if the hearing loss or
tympanic membrane perforation persists for more than 6-8 weeks

Case 9:

A 28 year old male has been complaining of hearing loss in the

left ear for the last 6 years. The hearing loss was progressive in

nature and accompanied by tinnitus. During the last 6 months

there was swaying during walking to the left side, a change in his

voice and an inability to close the left eye with deviation of the

angle of the mouth to the right side. Otologic examination

showed no abnormality. The corneal reflex was lost in the left

eye.

CASE 9
Diagnosis & Left acousticneuroma (progressive history of hearing loss over 6
reasons years followed by imbalance due to cerebellar manifestations and
developing neurological manifestations)
Explain the Hearing loss of 6 years duration: pressure of the tumor on the eighth
following nerve responsible for hearing and balance
Swaying during walking to the left side: cerebellar attaxia alaways
manifestations
towards the side of the lesion due to weakness (hypotonia) of the
muscles on the same side of the lesion
Change of voice: intracranial vagus paralysis leading to vocal fold
paralysis
Inability to close the eye: left lower motor neuron paralysis as the
facial nerve accompanies the vestibulocochlear nerve in the internal
auditory canal
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manifestations
n
 w
Explain the

following

manifestations
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CASE 16
 n
ears showed retracted tympanic membranes. Tympanograms
were flat type B.

CASE 17
CASE 18
 Y^

CASE 19
CASE 20
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Explain the

following

manifestations
 Yi

Explain the
following
manifestations
Y1
 TV

diagnosis
Antitoxin serum 20,000 - 100,000 units daily until the membrane
disappears
Bacteriological swabs until the organism disappears from the throat
Antibiotics
Treatment of heart failure if present

Tracheostomy for respiratory distress or even marked heart failure to

decrease the effort of breathing by decreasing the respiratory dead
space
Passive and active immunization of the contacts of the patient

Case 26:
A 45 year old male patient presented to the ENT emergency

room with severe incapacitating dizziness of 5 days duration.

The dizziness was continuous with no periods of rest and was

accompanied by hearing loss and tinnitus in the right ear. He
was admitted to hospital and medical treatment was started.

The patient gave a history of right ear offensive continuous

discharge of seven years duration. On examination there was

right beating nystagmus. Otoscopic examination of the right ear

showed a marginal attic perforation with a discharge rich with

epithelial flakes, the edge of the perforation showed granulation

tissue. The left ear was normal. On the next day the patient's

condition became worse despite the medical treatment, he

developed a mild fever of 38.5 C and the nystagmus became

directed to the left ear. 2 days later the temperature became

higher 40 C, the patient became irritable, but later became

drowsy. On examination at this stage there was marked neck

rigidity.
 YA

CASE 26
 Y1

Case 27:
The mother of a 3 year old child complained that her child had a
fever 5 days ago. 2 days following that he developed severe right

sided earache that kept the child continuously crying. A day

later she noticed that his mouth was deviated to the left side and
he was unable to close the right eye.

CASE 27
Case 28:
A 30 year old female patient developed a sudden attack of fever
and rigors. She was admitted to the fever hospital and properly

investigated and received an antibiotic. On the fifth day after

her admission a blood culture was requested and the result was

negative for bacteria. The patient improved and was discharged

from hospital; but 2 weeks later the condition recurred with a

very high fever and there was a tender swelling in the right side

of the neck. An otologic consultation was obtained as the

patient mentioned that she had a right chronic offensive otorhea

for the last 5 years. The otologist found an aural polyp with

purulent ear discharge. A laboratory workup showed Hb%=

7gm% WBC count 23,000/cc.
CASE 28
 n
Treatment Intravenous antibiotics
Anticoagulants to limit spread of the thrombus
Tympanomastoidectomy for the cholesteatoma

Case 29:
An 18 year old male patient presented to the ENT clinic with an
offensive continuous right ear discharge of 2 years duration for

which he received antibiotic ear drops, but with no

improvement of his condition. A month ago a swelling appeared
behind the right ear. The swelling was red, hot, tender and was

accompanied by deep seated pain and a fever 39 C . The swelling

was incised by a surgeon and pus released after which the

temperature dropped to 37.5 C but the pus continued draining

from the incision and the incision did not heal since then.

CASE 29
 rv

Treatment Tympanomasoidectomy to remove the underlying causative

cholesteatoma
Antibiotics

Case 30:
A 35 year old male patient had been complaining of a right

continuous offensive otorhea for the last 10 years. One month

ago he had a very high fever and became drowsy. This condition

lasted for 5 days, after which the fever dropped and the

drowsiness disappeared. The patient kept complaining of a mild

non continuous headache. One week ago the patient felt that he
could not go up and down the stairs easily. Neurological

examination revealed right side body weakness in the upper and

lower limbs. There was also nystagmus and a difficulty on

grasping objects by the right hand. Temperature was 36 C, pulse

80/min. The patient was slightly disoriented to his surrounding

and was slow in his responses.

CASE 30
 rr

examination test, dysdidokokinesia

&/or CT scan with contrast for the brain and the ear
investigations MRI
Fundus examination may show papilledema
Blood picture especially leucocytic count for follow up and
prognosis
Treatment Antibiotics that cross the blood brain barrier
Avoid lumbar puncture as it might lead to conization of the medulla
oblongata and death
Drainage of the abscess or excision neurosurgically
Tympanomastoidectomy for the cholesteatoma

Case 31:
A 25 year old female is complaining of bilateral nasal

obstruction of 5 years duration. She gave a history of attacks of

sneezing, lacrimation and watery nasal discharge that may be

clear or yellowish green. On examination her nasal cavities were
blocked by smooth glistening pedunculated nasal masses with a

clear nasal discharge.

CASE 31
 n
Treatment Remove nasal polypi by endoscopic nasal surgery
Treatment of allergy by avoidance of the cause of allergy,
hyposensitization
Treatment of allergy by medical treatment: steroids, local
steroids, antihistamines
Avoid non-steroidal antiinflammatory drugs as aspirin in all
forms as it leads to the exacerbation of allergy and leads to the
formation of nasal polypi (aspirin triade)

Case 32:
A 50 year old male complained of a swelling in the upper right
side of the neck of 2 months duration. The swelling was firm

and non-tender and progressively increasing in size. The patient

mentioned that he has been suffering from right side offensive

blood stained nasal discharge of 6 months duration. Now he has

diplopia, right side nasal obstruction and looseness of the teeth

of the right side of the upper jaw.

CASE 32
 r°

Treatment Surgical radical maxillectomy to remove the maxilla and the

metastatic lymph nodes
Radiotherapy for selected cases
Chemotherapy
Palliative management for inoperable cases

Case 33:
A 30 year old female had a common cold 6 weeks ago. Thi s was
followed by right forehead pain, upper eyelid edema and a
temperature of 38.5 C. Later her fever rose to 40.5 C, the lid

edema increased and she started to complain of double vision.

On examination the eye showed a downward and lateral

proptosis. She now presented to the emergency room with

decreased level of consciousness and marked neck rigidity.

CASE 33
 ri

Case 34:
A 25 year old farmer has been complaining of nasal obstruction,
greenish nasal discharge and nasal deformity of one year

duration. On examination the nose was broad and contained a

lobulated firm mass that may bleed on touch. Also, there was a

hard swelling below the medial canthus of the right eye. One
week ago, he noticed a change in his voice that was followed by
respiratory distress. On examination there was marked stridor

and laryngeal examination showed a subglottic laryngeal web.

CASE 34
 rv

Treatment Medical treatment with Rifampscin

Surgical treatment in the form of tracheostomy to relieve
respiratory obstruction
Laser excision of the subglottic web
Removal of the mass in the lacrimal sac and
dacrocystorhinostomy

Case 35:
Following a common cold a 30 year old male started to

complain of left forehead pain and edema of the upper eyelid.

One week later, his general condition became worse, there was a
fever 40 C and rigors. On examination there was right eye

proptosis with conjunctival chemosis and paralysis of eye

movement. Also, there was a small red, hot tender swelling in

the vestibule of the right nasal cavity.

CASE 35
 rA

Treatment Intravenous antibiotics

Anticoagulants
Treatment of the underlying cause furuncle by antibiotic
ointment and drainage as it has already caused cavernous sinus
thrombosis so there is no fear of such a complication
Treatment of frontal sinusitis

Case 36:
A 40 year old male presented to the ENT clinic with a swelling
in the right upper neck of 2 months duration. The swelling was

non-tender, firm and progressively increased in size. After a

complete ENT examination there was a right conductive

hearing loss and a retracted tympanic membrane. Also, there

was right vocal fold paralysis and on swallowing there was also

some nasal regurge. The patient gave a history of an offensive

sanguineous post nasal discharge.

CASE 36
 ri

Treatment Radiotherapy for the primary tumor and the metastsis

Radical neck dissection for the residual metastatic lymph nodes
after radiotherapy
Myringotomy and T-tube insertion of the right tympanic
membrane to relieve otitis media with effusion

Case 37:
A 50 year old female has been complaining of dysphagia for 3

years. The dysphagia was towards solids and stationary in

nature. 2 months ago the dysphagia progressed to become

absolute, there was a change of voice and some respiratory

distress. On examination there was a firm swelling in the neck

that was not tender.

CASE 37
Treatment Total laryngopharyngectomy if the patient's general condition
permits with radical neck dissection for the lymph node metastasis
Radiotherapy for inoperable cases
Chemotherapy
Palliative treatment for terminal cases

Case 38:
A 25 year old male presented to the ENT emergency room with
severe right side throat pain, inability to swallow, accompanied

by right earache of 2 days duration. The patient was unable to

open his mouth and was feverish 40 C. On examination there

was a tender swelling at the angle of the mandible. The patient

gave a history of sore throat and fever 39 C during the last week.

CASE 38
 i\

Case 39:
A 3 year old child suddenly developed respiratory distress fever
38 C and biphasic stridor. In the ENT emergency room an

immediate surgical procedure was done after which there was

complete relief of the respiratory distress and the child received

the necessary medical treatment. On the next morning the

respiratory distress recurred and the attending physician carried

out an immediate minor interference that relieved the distress

immediately. 2 days later the child was discharged from hospital

in a healthy condition.

CASE 39
 iY

Case 40:
A 60 year old heavy smoker has been complaining of hoarseness
of voice for 3 years. Lately he noticed worsening of his voice and

a mild respiratory distress on exertion. There was also cough and

some blood tinged sputum. On laryngeal examination a whitish

irregular mass was found on the right vocal fold that was found

also paralysed.

CASE 40
 tr

Case 41:
A 70 year old male had loosening of the upper left molar tooth
which was extracted followed by loosening of the next 2 teeth.

Healing was very slow at the site of extraction and was attributed

to his old age. One month later, the patient on blowing his nose
noticed left side offensive nasal discharge. He also noticed that

his left nasal cavity was slightly obstructed. He now presented

with a swelling of the left upper neck that was explained by his

dentist as an inflammatory lymph node, but it did not disappear

by medical treatment.

CASE 41
 a

Case 42:
A 60 year old female patient has been complaining of left

earache of 3 months duration. One month ago a swelling

appeared in the left side of the neck that progressively increased

in size. 2 days ago she complained of change of her voice

together with dysphagia. On indirect laryngoscopy there was

froth in the region behind the larynx.

CASE 42
 to

Case 43:
A 60 year old male patient complained of bilateral hearing loss.
The patient underwent a minor procedure in an ENT clinic

followed immediately by return of his hearing. 2 days later he

complained of severe pain in both ears more on the right side.

The pain increased on talking and eating and was slightly

relieved by analgesics. 2 days later a tender non-fluctuant well

circumscribed swelling appeared behind the right auricle.

CASE 43
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Case 44:
A 50 year old female has been complaining for 10 years of a right
forehead headache and intermittent nasal discharge. 2 months

ago she noticed a swelling above and medial to the right eye.

This was followed by double vision. When she sought medical

advice she noticed that nasal discharge had completely stopped.

She received medical treatment with no improvement. She was

admitted to hospital with a very high fever 40 C, neck rigidity

and impaired level of consciousness and continuous forcible

vomiting. Vision is blurred.

CASE 44
 iV

Treatment Antibiotics that cross the blood brain barrier

Brain dehydrating measure as diuretics, mannitol 10%
Corticosteroids
After cure from meningitis excision of the mucopyocele
surgically through external approach

Case 45:
A 50 year old female underwent surgery to remove a swelling in
the neck that moved up and down with deglutition. Following

surgery she started to complain of a very weak voice and choking

especially when drinking fluids. 2 weeks later the condition

improved and a month later she had no symptoms.

CASE 45
 iA

Case 46:
A 10 year old child was taken to the emergency room
complaining of left frontal headache and a mild orbital swelling.

He had a severe common cold a week before. On examination he

was feverish 38 C with left proptosis and decrease in extreme left
lateral gaze. No chemosis and visual acuity 6/6 in both eyes. The
patient was admitted and antibiotics started; WBC count

20,000. On the following day, the patient's condition became

worse, fever became 39.5 C, the eye swelling increased, still

there was no chemosis, visual acuity 6/9 in the left eye and there

was marked photophobia.

CASE 46
 il

Case 47:
A 65 year old male patient had a swelling polypoid in nature in
the left nasal cavity, diagnosed by many physicians as a

unilateral nasal polyp. He also complained of left decreased

hearing and tinnitus. One week ago, a very small swelling

appeared in the neck on the left side. The swelling was not

tender and firm.

CASE 47
Case 48:
A 35 year old male patient has been complaining of left

continuous offensive otorhea that was purulent in nature for the

last 10 years. Recently he suffered from deep seated pain behind

the left eye with diplopia. Ear examination revealed a marginal

pars flaccida (attic) perforation filled with keratin and

surrounded by granulations.

CASE 48
 o)

Case 49:
A 16 year old boy was struck in the left temporal region during a
motor car accident. He was hospitalized for observation because
of altered state of consciousness that subsequently cleared. On
examination of his ears there was a serosanguineous otorhea

from the left ear. Otologic consultation by a specialist was

obtained on the third day and additional findings included

lateralized Weber test to the left ear and Rinne negative test also
in the left ear. Under sterile conditions ear examination showed

a laceration in the posterosuperior wall of the external auditory

canal with a tympanic membrane perforation. A small amount

of the serosanguineous fluid was present. Facial nerve function

was normal. A few days later the patient became feverish 39.8 C,
irritable with a change in his level of consciousness.

CASE 49
Diagnosis & Longitudinal fracture of the left temporal bone (trauma to the left

reasons temporal region,bloody ear dischage, conductive hearing loss by

Weber and Rinne test, perforation of the tympanic membrane,
laceration of the posterosuperior wall of the external auditory
canal) with CSF otorhea (serosanguineous aotorhea) complicated
by meningitis (fever 39.8 C, irritable, change in the level of
conciousness)
Explain the Serosanguineous otorhea: means a clear fluid that is blood
following tinged, this is CSF as the condition is later complicated by

manifestations meningitis - to prove that it is CSF it increases by straining and

laboratory tests for levels of glucose and proteins
Lateralized Weber test to the left and Rinne test negative:
means bone conduction is better than air conduction and so the
patient is suffering from conductive hearing loss
Irritable patient: indicating meningeal inflammation which in
its early stages is accompanied by some encephalitic

inflammation leading to irritability

Further
examination
&/or
investigations
°r
 °t

Further
examination
&/or
investigations
was characterized by rigors and tender enlarged right upper

deep cervical lymph nodes.

CASE 53
Case 54:
A 25 year old male patient complained of sore throat fever and
bilateral earache of 3 days duration. He then developed very

high fever 40 C, severe left earache, inability to open the mouth,

drooling of saliva and a minimal difficulty in respiration. He

underwent a minor surgical intervention with relief of all

symptoms except the sore throat.

CASE 54
Case 55:
A 60 year old female had a severe attack of epistaxis blood came
from both nostrils. She received the proper management and the

bleeding stopped. After removal of the nasal packs, she had

severe frontal headache on the left side accompanied by rise in

her temperature and a small amount of an offensive nasal

discharge. 2 days later the temperature became higher 40 C,

there was impaired consciousness, vomiting, blurring of vision

and some neck retraction and backache.

CASE 55
 °1

Treatment of the underlying cause for epistaxis commonly

systemic hypertension

Case 56:
A 40 year old female was having an offensive purulent ear

discharge from the right ear for the last 5 years. Recently, she

started to suffer from dizziness on sudden change of head

position only. This was described as a momentary feeling of

rotation following head movement. Otologic examination

revealed a right posterosuperior marginal perforation with a

scanty offensive discharge. Rinne test positive and Weber

centralized.

CASE 56
Treatment Tympanomastoidectomy to remove cholesteatoma and seal the
lateral canal fistula

Case 57:
A 7 year old boy was seen by an ophthalmologist for headache
that has been present for the last few months. Headache was
maximum between the eyes. However, there was no occular

cause for such a headache. The child was referred to an ENT

specialist who noticed nasal intonation of voice and bilateral

nasal obstruction. The mother reported that her child snores

during his sleep and has repeated attacks of chest infection.

CASE 57
 n

Case 58:
A 20 year old female complained of severe sore throat of 20 days
duration. On examination she showed the presence of ulcers and
dirty membranous lesions in the oropharynx and the oral cavity.

She gave a history of having typhoid fever 2 weeks prior to the

present condition for which she received antibiotic therapy and

was still receiving injections of that antibiotic.

CASE 58
 1Y

Case 59:
A 17 year old male complained of severe epistaxis and was

packed to control bleeding. Finally a posterior nasal pack was

applied with difficulty and after its removal the bleeding

recurred again in a more severe manner. He also complained of

nasal obstruction more on the right side together with decreased

hearing in the right ear. One month later he developed

proptosis of the right eye with no limitation of movement and

no affection of vision. There was no swelling in the neck.

CASE 59
 ir

Case 60:
A 50 year old male patient suffered from a stroke and was

comatose. He was admitted to hospital where he was intubated

and artificially ventilated. He recovered 25 days later and was

discharged from hospital. Upon discharge he only suffered from

right body weakness, a change of his voice and some dysphagia.

CASE 60
 It

but was rapidly corrected by a minor interference by the

pediatric interne. 2 days later the child's condition improved

remarkably and was discharged from hospital in a healthy

condition.

CASE 61
Case 62:

A 70 year old male suddenly complained of absolute dysphagia.

The barium swallow requested showed arrest of the barium at

the midesophagus. Esophagoscopy revealed the presence of a

foreign body (piece of meat) that was removed and the patient
was discharged from hospital after he could swallow again. One
month later he developed jaundice and was readmitted for

investigation. During his second hospital stay he started to have

attacks of hemoptsys.

CASE 62
Case 63:
A 5 year old boy developed change of his voice that was followed
by stridor. The stridor was severe enough to necessitate a

tracheostomy. 2 years later the tracheostomy site was not fit for

respiration, another tracheostomy was done at a lower level. A

reddish tissue that was polypoid in nature filled the

tracheostomes. The child died a year later when his

tracheostomy tube became obstructed at home.

CASE 63
Case 64:
A 40 year old female is complaining of attacks of lacrimation

and watery nasal discharge accompanied by sneezing. She had a

severe attack one spring morning that was accompanied by

respiratory difficulty and she was admitted to hospital. She

received the proper treatment and her condition improved. On

examination she had bilateral nasal obstruction by bluish

pedunculated masses that were covered by a clear mucous

discharge.

CASE 64
Case 65:
Following a meal a female patient aged 31 complained of severe

pain in the right ear together with localized pain in the right side

of the neck during swallowing. This pain was relieved by

analgesics and local mouth gurgles containing a local anesthetic,

but the pain reappeared after the effect of the drugs was over.

CASE 65
 11

CASE 66
Case 67:
A 25 year old male complains of right nasal obstruction and

right tenderness of the cheek of 2 years duration. Lately he

developed gagging especially on lying on his back together with

a purulent post nasal discharge. He underwent surgery and his

condition improved but recurred again after one year.

CASE 67
 v^

Case 68:
A 20 year old had a submucous resection operation for a

deviated nasal septum. The next day he had edema of the eyelids
of both eyes. Temperature 38 C and rigors. 2 days later he

developed conjunctival chemosis and blurred vision and an

inability to see sideways.

CASE 68
 VY

CASE 69
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Case 72:

A 4 year old child experienced marked loss of weight due to

dysphagia together with choking during feeding after a house

accident that occurred 18 months ago. The child was admitted

to hospital for investigation. The barium swallow showed a very

long esophageal stricture in the middle and lower thirds of the

esophagus.

CASE 72
patient developed a flexion of the neck deformity, severe

painful dysphagia and a swelling in the neck on the right side

that was cross fluctuating with another oropharyngeal swelling.

CASE 73
CASE 74
CASE 75
 VI

CASE 76
CASE 77
 A^

was associated with hearing loss. Ear examination showed an

aural polyp and a purulent discharge.

CASE 78
 AY

CASE 79
 Ar

CASE 80
 At

CASE 81
Explain the
following
manifestations
CASE 84
weight. Examination of the neck revealed bilateral mobile hard

upper deep cervical lymph nodes. The laryngeal click is absent.

CASE 85
 A1

Case 86:

A 30 year old female suddenly noticed a heaviness in the right

side of the face accompanied by a burning sensation of the right

eye when she washed her face. There was accumulation of food

in the right vestibule of the mouth. All food had a metallic taste.

The patient could not tolerate loud sounds. She received the

proper care and treatment and after one month there was

marked improvement of her condition. There was no fever all

through her illness and both tympanic membranes were normal.

There was no hearing impairment.

CASE 86
Diagnosis & Right lower motor neuron facial paralysis - Bell's palsy (sudden
reasons onset and marked improvement of her condition after one
month)
Explain the Heaviness in the right side of the face: due to paralysis of the
following facial muscles the face tissue feels heavy and drops downwards

manifestations by gravity
Burning sensation of the eye when washing the face: the eye
isexposed as the eyelids are unable to close completely and so
water and soap cause a burning sensation in the eye when
washed
Accumulation of food in the right vestibule of the mouth: due
to paralysis of the buccinator muscles that pushes food into the
oral cavity during mastication so when paralyzed food simply is

not pushed into the oral cavity and accumulates outside the teeth
in the oral vestibule
Metallic taste: due to paralysis of the chorda tympani nerve so
food is felt by the trigeminal nerve (lingual nerve) only and this
gives the metallic taste
Could not tolerate loud sounds: due to paralysis of the
stapedius muscle that contracts and holds back the stapes if loud
sound is exposed to the ear - absent acoustic reflex
Marked improvement of her condition: usually cases of Bell's
palsy especially in the young age improve greatly and in a short
period of time
Further
examination
&/or
investigations
<n
 1Y

Treatment Antishock measures (fluid transfusion, blood transfusion, steroids,

controlled sedation)
Stop the bleeding (anterior or posterior nasal pack if failed arterial

ligation or endoscopic control of bleedin

Control systemic hypertension in the future to prevent a recurrent
episode of epistaxis
Correction of any post hemorrhagic anemia by iron therapy

Case 89:
A female patient 18 years old sought medical advice because of

inability to close her right eye of 3 days duration. She gave a

history of longstanding scanty bad smelling discharge from her

right ear. On examination, a right attic perforation was found.
CASE 89
 ir

Case 90:
A male patient 25 years old asked for medical advice because of
intense headache together with discharge from the right ear.

The ear discharge was scanty, foul smelling and of five years

duration. Headache started six weeks ago, increased in the last

two weeks and became associated with vomiting, vertigo and

blurring of the vision. On examination, the patient was found

not alert, having abnormal gait with tendency to fall to the right

side. Temperature was 36 C and the pulse rate was 60/min.

Examination of the ears revealed right attic perforation and

tuning fork testing showed a right conductive hearing loss.

CASE 90
Diagnosis & Right chronic suppurative otitis media - cholesteatoma (scanty
reasons foul smelling five year duration ear discharge, right attic
perforation) complicated by right cerebellar abscess (headache,
vomiting, blurring of vision, vertigo, abnormal gait and tendency
to fall to the right)

Explain the Intense headache: due to increased intracranial tension

following Vomiting: due to increased intracranial tension and pressure on
manifestations the chemoreceptor trigger zone
Vertigo: damage of the vestibular centers in the cerebellum and
is usually accompanied by nystagmus

Blurring of vision: due to increased intracranial tension and

papilledema of the optic disc
Patient was not alert: the brain abscess causing some stupor -
disturbed level of conciousness
Abnormal gait: due to imbalance and incoordinated body
movements
Tendency to fall to the right: due to hypotonia and weakness of
the muscles on the right side of the body the same side as the
cerebellar abscess
Temperature 36 C: commonly a brain abscess is accompanied
by subnormal temperature due to affection of the heat regulatory
center
It
 1°

CASE 91
 11

membranes. Tuning fork testing demonstrated bilateral

negative Rinne test and Weber test lateralized to the right ear.

CASE 92
 IV

Case 93:
A 10 year old child presented to the outpatient ENT clinic

because of severe headache of 5 days duration which did not

respond to the usual analgesics. His mother reported that her

son had his right ear discharging for the last 2 years. On
examination, the child's general health was bad, he was irritable

and his temperature was 39 C, pulse 100/min and there was

marked neck stiffness. Examination of the right ear revealed

fetid aural discharge from an attic perforation.

CASE 93
 1A

Case 94:
A male patient 32 years old was referred from a Neurosurgeon

for otological evaluation. The patient had a motor car accident 2

days before. He gave a history of loss of consciousness for a few

minutes together with bleeding from the right ear. The patient

stated that he could not move the right side of his face since the

recovery of consciousness. On examination, blood clots were

found in the right external auditory meatus, ecchymosis of the

right tympanic membrane and a central posterior perforation

with irregular edges could be seen. Tuning fork examination

revealed Rinne test was negative in the right ear and positive in

the left ear. Weber test was lateralized to the right ear. The
patient could not close the right eye or move the right angle of

his mouth.

CASE 94
11
Treatment Conservative treatment (avoid water in the ear, avoid blowing
the nose forcibly) usually most perforations heal spontaneously
in 3-4 weeks time
Myringoplasty if perforation persists after 6 weeks time

Case 96:
A male child 3 years old presented to the emergency room of the
hospital at 3 am because of severe respiratory distress of one

hour duration. His mother stated that her child was awakened

from sleep by cough, hoarse voice and respiratory distress. On

examination, temperature 39 C, pulse rate 110/min and the

respiratory rate was 30/min. The child had stridor more

manifest during inspiration, he had working ala nasi and

supraclavicular recession. However, he was not cyanosed.

CASE 96
Diagnosis & Acute laryngotracheobronchitis - croup (sudden onset of marked
reasons respiratory distress with biphasic stridor more marked with
inspiration with cough)
Explain the Cough: due to inflammation of the larynx trachea and bronchi
following there is increased viscid mucous secretions in the airway causing

manifestations cough
Hoarse voice: due to subglottic edema extending to the
undersurface of the true vocal folds leading to change of voice
Temperature 39 C: usually temperature is lower than that but it

may be elevated as in this case according to the type of the

organism causing the condition
Pule rate 110/min: indicating affection of the heart by heart
failure
Stridor more manifest during inspiration: stridor means a
sound produced due to respiration against partial airway
obstruction it is more manifest during inspiration as the main
power of breathing occurs during inspiration against the
subglottic edema in the airway
Working ala nasi and recession of the supraclavicular areas:
is an indication of forcible breathing against an obstructed
airway due to the negative pressure created inside the chest cage
\ \
\ -Y
 \ -r

Explain the
following
manifestations
 \ -i

CASE 99
 ) .0

Case 100:
A 35 year old male patient has been complaining over the last 10
years of attacks of incapacitating vertigo, tinnitus and decreased

hearing. During the attack there was a sense of aural fullness,

the patient described it as if his ear is about to explode. In

between the attacks that usually occur once or twice a week the

patient feels fine or may have a minor sense of imbalance. The

patient also reported that his hearing ability is decreasing over

the years. Examination of the ears showed bilateral normal

tympanic membranes and some non- occluding earwax.

CASE 100
\ -1