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A 2 year old boy with Acute Otitis Media – Case Presentation

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ENT emergency

Jul 24, 2014

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ENT emergency. Dr . Fatima alzahraa haj oubid Damascus hospital. Management of Emergent Airway Epistaxis A uricular Hematoma ENT Foreign bodies trauma facial cervical. Causes of a Difficult Airway . Trauma ( Midface , Mandible , Neck ) Bleeding into airway Caustic ingestion

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ENT emergency Dr . Fatima alzahraahajoubid Damascus hospital

Management of Emergent Airway • Epistaxis • Auricular Hematoma • ENT Foreign bodies • trauma facial cervical

Causes of a Difficult Airway Trauma ( Midface , Mandible , Neck ) Bleeding into airway Caustic ingestion Thermal burns Foreign Body inflammation infection Deep Neck Space Abscess Ludwig’s angina

Causes of a Difficult Airway Trismus Anaphylaxis Angioedema Previous head and neck surgery Vocal cord paralysis Macroglossia Anatomic/congenital factors

LEMON Airway Assessment Look Evaluate Mallampati classification Obstruction Neck mobility

Our Aim Maintain patent airway Secure airway Prevent aspiration Adequate and effective ventilation Further resuscitation

Clear the Airway Clear the airway – oropharyngeal cavity of: Any secretions Any blood Vomitus Loose dentures Any foreign body obstructing the airway

Open the Airway Jaw thrust Head tilt–chin lift

Bag Mask Ventilation Key—ventilation volume: “enough to produce obvious chest rise” 1-Persondifficult, less effective 2-Personeasier, more effective

Bag Mask Ventilation Sellick’s Maneuver Cricoid Pressure – to prevent regurgitation and aspiration

Oropharyngeal Airway

Nasopharyngeal Airway

Endotracheal Intubation Endotracheal tube is passed into trachea of patient through oral or nasal route to ensure the patent airway and adequate ventilation Achieves all the goals of airway management Rapid, Simple, Safe and Non-surgical Maintains patent airway Protect lungs from aspiration Leak free ventilation Remains GOLD STANDARD of airway management

Laryngeal Mask Airway

Blunt Neck Trauma and Laryngotracheal Injury Strangulation Cervical Spine Injuries in BNT Vascular Injuries in BNT Penetrating neck injuries

Zones of the Neck This actually applies to penetrating trauma but is useful to review when discussing neck anatomy. Zone I: thoracic inlet to cricoid cartilage Zone II: cricoid cartilage to the angle of mandible Zone III: angle of the mandible to skull base to

Anatomy: Facial planes • Hematomas, air tracks • Bullet, metal tracks • Carotid space: Carotid, IJV, CN X • Retropharyngeal space: behind pharynx, anterior to prevertebral muscles • Perivertebral space: muscles & soft tissue around vertebrae Bleeding that displaces prevertebral muscles anteriorly is associated with vertebral body fractures. Retropharyngeal carotid artery important for presurgical planning Esophageal injury can track air into RP, prevertebral space Missed esophageal injuries can present as retropharyngeal abscess, mediastinitis, sepsis www.medscape.com

Morbidity: Vascular injury • Major Signs • Active bleeding • Unstable/hypotension • Expanding hematoma • Pulsatile swelling • Bruit, thrill • Unilateral CNS deficit • Pulse deficit • Minor Signs • Parasthesias • Nonexpanding hematoma • C spine or skull base fractures in MVAs

Morbidity: Esophageal Injury • Odynophagia, dysphagia, hematemesis • Airway injury  25% have esophageal injury • Transcervical trajectory • Saliva in wound, subcutaneous emphysema • Prevertebral air on lateral neckX ray Kietdumrongwong P & Hemachudha T 2005 Kietdumrongwong P & Hemachudha T. Pneumomediastinum as initial presentation of paralytic rabies: A case reportBMC Infectious Diseases 2005, 5:92.

Morbidity: Airway Injury • More common in blunt trauma • 5-15% PNI will have laryngotracheal trauma • Hoarseness, stridor, hemoptysis, difficulty breathing, pain • Air leak in wound, difficult airway  surgery!!! • Majority airways managed by rapid sequence intubation (RSI) at scene or ED • Eggen JT et al. Airway management, penetrating neck trauma. J Emerg Med 1993: 11: 31-5. • Mandavia DP et al. Emergency airway management in penetrating neck injury. Ann Emerg Med 2000; 35: 221-5. • Shearer VE et al. Airway management for patients with penetrating neck trauma: a retrospective study. Anasth Analg 1993; 77: 1135-8. • Mandavia et al • Shearer et al

Morbidity: Airway Injury Baisakhiya N et al 2009 Baisakhiya N et al. Laryngotracheal Trauma . The Internet Journal of Otorhinolaryngology. 2009 Volume 9 Number 1 CT shows right thyroid cartilage fracture & air escape suggesting tracheal tear. Extensive subQ air. Patient managed with tracheostomy, reduction of fracture + fixation with 4-0 prolene. Tracheal partially excised with primary repair of trachea.

Auricular Hematoma accumulation of blood in the subperichondrial space, secondary to blunt trauma . This creates a barrier for diffusion between the cartilage and the perichondrialvascularity, leading to necrosis of the cartilage .

Auricular Hematoma

Nasal trauma Nasal fracture is the most common of head and neck fractures . the amount of force required to create a fracture of the nasal structure is small, possibly as little as 25 pounds of pressure .

Nasal trauma Evaluation : New deformity of the nose , often with epistaxis. Facial swelling and black eyes . X ray to exclude other bony facial fracture , And to document nasal fracture . Looking for septal hematoma .

Nasal trauma Timing of repair : Within 1 - 3 hours of the time of injury before significant edema has developed . However, patients rarely present this early and often require reevaluation within 3 -7 days to allow for extensive facial edema to subside.

Nasal trauma Anesthesia Local : for adults , cooperative patient . General : For children , uncoopetrative patient . Reduction Closed : safe , easy and reasonable cosmetic and functional results . Open :usually reserved for cases in which either a prior closed reduction has failed or malunion has occurred .

epistaxis common problem , affects most of us at sometimes . It is usually mild and self-limiting . The anterior part ( little area ) of the nasal septum is the most frequent site for bleeding , because of rich blood supply .

Causes of epistaxis Local causes : Nose picking . Trauma . Infection . Tumor . Idiopathic . Systemic causes : Hypertension . Anti coagulant drug . NSAIDs . Coagulopathy ( haemophilia , leukaemia ). Hereditary haemorrhagictelangiectasia .

treatment First aid : Lean forward . Pinch the fleshy part of the nose for 10 minutes . Put an icepack on the nasal bridge . Suck an ice cube . Assess blood loss . Take the pulse and blood presure . Gain intravenous access .

Anterior nasal packing

posterior nasal packing

Foreign Body Aspiration

Aspiration in young children • Lack of molar teeth • Poorer mastication • Tendency to put things in mouth • Playing with things in mouth • Immature protective laryngeal reflexes

Symptoms and Physical findings • Cough • Dyspnea • Wheezing • Stridor • Cyanosis • Decreased breath sounds • Tachypnea • Rhonchi • Somnolence

ENT Foreign bodies Signs Foreign bodies in the ear : Pain . deafness . unilateral discharge . deafness .

ENT Foreign bodies Signs Foreign bodies in the nose Unilateral foul smelling discharge . Unilateral nasal obstruction . Epistaxis.

ENT Foreign bodies Signs Foreign bodies in the throat : Acute onset of symptoms Drooling Dysphagia tenderness in the neck . Pricking sensation on every swallow .

management Insects may be drowned with olive oil . Pull foreign bodies by suction . Grasping with crocodile forceps . Refer to general anesethea if : Failed attempt . Uncooperative child . Suspected trauma to the drum .

Pull foreign bodies by suction

right-angled hook is passed beyond the object

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ENT manifestations of tuberculosis: an important aspect of ENT practice

Shilpam sharma.

1 Department of ENT, Vardhaman Mahaveer Medical College and Safdarjung Hospital, New Delhi, India,

Amit Kumar Rana

2 Department of Otorhinolaryngology and Head Neck Surgery, SRMS Institute of Medical Sciences, Bareilly (UP), India

Tuberculosis involving organs other than the lungs is termed as 'extra pulmonary tuberculosis'. Tuberculosis (TB) remains a worldwide public health problem despite the fact that the causative organism was discovered more than 100 years ago. The present study was conducted to assess different manifestations of tuberculosis affecting the ear, nose and throat (ENT) in patients attending the outpatient department in a total of 520 cases of tuberculosis. One hundred and eight cases were of extra pulmonary tuberculosis. Sixty nine cases had the manifestations of TB in the ENT region. These included patients with tuberculous cervical lymphadenopathy (91.35), laryngeal TB (4.3%), tuberculous otitis media (1.4%), nasal TB (1.4%) and oral tuberculosis (1.4%). Extra pulmonary tuberculosis constitutes about 15-20% of all tuberculosis cases as per WHO survey and it is 20.6% in the present study.

Introduction

Tuberculosis (TB) is a chronic granulomatous, infectious and communicable disease caused by Mycobacterium tuberculosis [ 1 ]. Tuberculosis usually attacks the lungs but can also affect other parts of the body. Tuberculosis involving organs other than the lungs is termed as 'extra pulmonary tuberculosis'. Tuberculosis remains a worldwide public health problem despite the fact that the causative organism was discovered more than 100 years ago and highly effective drugs are available for preventing and curing the disease. According to the estimates, there are 15-20 million cases of infectious tuberculosis in the world. Globally in 2012 an estimated 8.6 million people developed tuberculosis and 1.3 million died from the disease [ 2 ]. This pool of tuberculosis is maintained by the occurrence of 7.25 million new cases annually [ 3 ]. Out of the extra pulmonary manifestations of tuberculosis, ear, nose and throat manifestations are mainly in the form of cervical lymphadenopathy, otitis media, laryngitis, pharyngitis and nasal TB [ 4 ]. The present study was conducted to assess different manifestations of tuberculosis affecting the ear, nose and throat in patients attending the outpatient department of a tertiary care hospital in Western Uttar Pradesh.

This prospective study was conducted in Department of Otorhinolaryngology and Head Neck Surgery of a tertiary care center of Uttar Pradesh, India. All cases diagnosed with extra pulmonary tuberculosis in ear, nose and throat region of all age group attending ENT OPD and willing to be part of study were included in study. A written consent was obtained from patients. The study was conducted after taking permission from the institutional ethics committee. The time period of this study was January 2018 to December 2019. A detailed ENT history was obtained from all the patients in order to assess the involvement of the ear, nose and throat. Details regarding demographic data and presenting complaints. Emphasis was placed especially on symptoms like chronic ear discharge, hemoptysis, change in voice, chronic cough, persistent neck swellings, fever and weight loss. Relevant past and family history of tuberculosis was also obtained. General, systemic and complete ENT examination was carried out. All the patients were subjected to X-ray chest posteroanterior (PA) view. Radiological examination of the soft tissue neck cervical spine and X-ray Schuler´s view for mastoid were carried out. Endoscopic examination including otoendoscopy, diagnostic nasal endoscopy and direct laryngoscopy was performed wherever indicated. Ultrasound neck and fine needle aspiration cytology (FNAC) was performed on all suspected neck swellings. Investigations also included culture and sensitivity and AFB staining of the sputum, pus from discharging sinuses, laryngeal secretions and ear discharge. Direct laryngoscopic and lymph node biopsy was done if required for suspected laryngeal lesions. All data were collected, tabulated and analyzed.

A total of 520 cases of tuberculosis diagnosed in our institute during the period of review, 108 cases were of extra pulmonary tuberculosis (EPTB) either in isolation or associated with concomitant pulmonary tuberculosis (PTB). Of the 108 patients with EPTB, 69 cases had the manifestations of TB in the ENT region. These included patients with tuberculous cervical lymphadenopathy, laryngeal TB, tuberculous otitis media (TBOM), nasal TB and oral tuberculosis ( Table 1 ).

nature of lesion

Tubercular lymphadenitis: the commonest presentation of extra-pulmonary tuberculosis in ENT region was cervical tuberculous lymphadenopathy. There were 35 males and 28 females. The commonest age group affected was the third decade of life and patients came with complaint of neck swelling. There were other complaints like cough with expectoration (22 cases), fever (18 cases) and discharging sinus (1 case) ( Figure 1 ). There were multiple matted lymph nodes in 60 cases and single lymph node in 3 cases. Bilateral lymph node involvement was noted in 39 cases. In majority of the cases lymph nodes in the anterior triangle were involved. The next common group of lymph nodes involved were the posterior triangle. The diagnosis was confirmed by USG neck and FNAC of the neck nodes. FNAC diagnosis was in the form of granulomatous lymphadenopathy or chronic lymphadenitis consistent with the findings of tuberculosis. Thirty three patients had pulmonary tuberculosis too. The patients were started on category I anti tuberculous treatment (ATT) according to Revised National Tuberculosis Control Programme (RNTCP) for 6 months. They were kept on monthly follow up till the completion of treatment and as per requirements after that. In 55 cases the swelling subsided by the end of the treatment course. In 8 patients the swelling remained of same size in spite of taking full treatment ( Figure 1 ).

tuberculous sinus in neck

Tubercular otitis media: out of total 108 cases of extra pulmonary tuberculosis, one case was identified as having tubercular otitis media. The presenting symptoms were persistent ear discharge not responding to antibiotics, severe to profound hearing loss disproportionate to hearing loss and facial palsy. The complaint of the patient was recurrent ear discharge, profound hearing loss with infra nuclear facial palsy. On examination, large tympanic membrane perforation was seen with multiple pale granulations in middle ear. On culture and sensitivity of discharge, Mycobacterium tuberculosis were seen. The patient underwent modified radical mastoidectomy and the granulation tissue was sent for histopathological examination and diagnosis of tubercular otitis media was made. The patient was put on antitubercular treatment.

Laryngeal tuberculosis: the common presenting symptoms of laryngeal tuberculosis were hoarseness and odynophagia, along with constitutional symptoms of tuberculosis. Total 3 cases were diagnosed to have laryngeal tuberculosis. The patients presented with cough with expectoration and hoarseness. On laryngeal examination polypoidal changes were seen in interaytenoid region along with mouse nibbled epiglottis in 1 case and congestion was seen in the vocal cords in 2 cases. Stripping was done and specimen was sent for histopathology examination. Diagnosis of laryngeal tuberculosis was made. Patient was started on antitubercular treatment. All these patients were sputum positive, however typical signs of laryngeal tuberculosis were not seen.

Nasal tuberculosis: nasal obstruction and blood stained nasal discharge are the most common presenting symptom of nasal tuberculosis. One case of nasal tuberculosis was reported during the study period. The patient complained of persistent nasal discharge and nasal obstruction. On examination a pale polypoidal mass was seen in the left nasal cavity. The patient underwent functional endoscopic sinus surgery and the mass was removed which was then sent for histopathological examination which confirmed the diagnosis of nasal tuberculosis. The patient was put on ATT and got relieved of symptoms. This case was secondary to pulmonary tuberculosis, though cases of primary tuberculosis have also been reported.

Oral tuberculosis: patient came with the chief complaint of difficulty in opening mouth and gradually increasing painless ulcer on the buccal mucosa ( Figure 2 ). On clinical examination crusts were present on angle of mouth with an ulcer with well-defined rolled up margins. The base was indurated, granular and non tender and did not bleed on touch. Oral hygiene was poor. The blood investigations were within normal limits except erythrocyte sedimentation rate (ESR) which was 45mm. X-ray chest revealed ill-defined opacities in both upper zones suggestive of pulmonary Koch´s. Sputum for AFB was negative. The patient underwent biopsy under local anesthesia. Histopathological report revealed squamous epithelium with features of hyperplasia. Subepithelial tissue showed granulomatous pathology consisting of epitheloid cells and multinucleated Langhan´s type of giant cells and areas of caseation ( Figure 3 ). Acid fast bacilli were identified on Ziehl-Neelsen´s staining. Features were suggestive of tuberculous pathology. Patient was treated as a new case of TB and DOTS category 1 regimen was started. Significant improvement was seen within 15 days of starting the treatment, in the form of decrease in the size and erythema of the ulcer ( Figure 3 ).

tuberculous ulcer

A) before treatment of the tuberculous ulcer; B) after treatment

Tuberculosis is a global disease and it is estimated that extrapulmonary tuberculosis constitutes 15 to 20 per cent of tuberculosis cases in general practice among HIV-negative adults in India [ 5 ]. In our study 520 cases of tuberculosis were evaluated out of which 108 cases were of extra pulmonary type. In our study cervical TB lymphadenitis accounted for 95.5% of cases of extra pulmonary tuberculosis in the ENT region. In the present study the pattern of lymph node involvement showed multiple lymph node group involvement in 96% of the cases and the lymph nodes of the posterior triangle were the most common lymph node involved (78%). This corresponds to the findings in the study of Bayazit Ya et al . [ 6 ]. FNAC was the diagnostic investigation for the lymph node tuberculosis except in 2 cases in which lymph node biopsy was done. FNAC confirmed the diagnosis in most of the cases which is in accordance with the study by Chakravorty S et al . [ 7 ]. Tubercular otitis media is a rare manifestation of tuberculosis [ 8 ]. It accounted for 1.5% of EPTB case in the present study. In our study, the case with tubercular otitis media had a finding of recurrent ear discharge, not responding to usual antibiotics, hearing loss with infranuclear facial palsy. On examination, a large tympanic membrane perforation was seen.

On culture and sensitivity of discharge, Mycobacterium tuberculosis were seen. The classical multiple perforations were not noted. Histopathology report (HPE) of diseased tissue from the ear is the surest way to confirm the diagnosis of TBOM. This has also been reported by other studies [ 8 , 9 ]. Dysphonia is the commonest presenting complaint with pain also being a prominent feature in laryngeal TB [ 4 , 10 , 11 ]. Our patients complained of hoarseness. It is believed that the recent resurgence in reported cases of LTB is due to increase in HIV cases [ 10 - 12 ]. There was one case in our study. A direct laryngoscopy is necessary not only to confirm diagnosis and rule out malignancy but also to take tissue for HPE [ 10 , 11 ]. Nasal TB is a very rare entity even in countries with high disease load [ 12 ]. We had only one case over a period of study. Our patient was a 21 year old female. The complaint of blood stained nasal discharge reported by our case was also noted by Dixit et al . [ 13 ]. The case in the present study had nasal mass with sinus involvement. However, the commonest feature of nasal tuberculosis is septal involvement with perforation resulting in external nasal deformity. A high index of suspicion is the only key especially since there can be varied differential diagnosis [ 14 ].

The typical lesion of oral TB is an irregular, superficial or deep, painful ulcer which tends to increase slowly in size. It is frequently found in areas of trauma and may be mistaken clinically for a simple traumatic ulcer or even carcinoma. The present case there was an irregular, superficial painless ulcer. It appears most likely that the organisms are carried in the sputum and enter the mucosal tissue through a break in the surface, or hematogenous route, deposited in the submucosa and subsequently proliferate and ulcerate the overlying mucosa. In the present case the patient was sputum negative hence the route of infection appears to be hematogenous in nature. The patient had poor oral hygiene which could also facilitate the infective process. It is suggested that when granulomatous inflammation is confirmed by tissue biopsy, TB should also be one of the differential diagnosis, especially in countries that still have higher TB incidence [ 15 ]. According to WHO global tuberculosis report 2013 diagnosis of extra pulmonary tuberculosis should be based on one culture-positive specimen, or histological or strong clinical evidence consistent with active extra pulmonary disease, followed by a decision by a clinician to treat with a full course of anti-TB chemotherapy. A patient in whom both pulmonary and extra pulmonary TB has been diagnosed should be classified as a pulmonary case [ 2 ].

Extra pulmonary tuberculosis constitutes about 15-20% of all tuberculosis cases as per WHO survey and it is 20.6% in the present study. Although incidence of tuberculosis is on the decline in developed countries, but still pulmonary and extra pulmonary tuberculosis cases do exist. Even when ENT manifestations of tuberculosis have reduced due to health awareness, early detection and treatment, yet tuberculosis should be considered as a differential diagnosis in case of chronic lymphadenopathy, chronic discharging ears, hoarseness, nasal masses with blood stained discharge and other chronic long standing ENT diseases. Changing patterns of presentations of laryngeal, aural and nasal tuberculosis was observed in these cases.

What is known about this topic

• Tuberculosis has reemerged as a disease in the last two decades;
• Now extra-pulmonary manifestations have taken the center stage in tubercular presentations;
• Most commonly, cervical lymphadenopathy is the presenting complaint in patients.

What this study adds

• Our study highlights more common extra pulmonary presentations in Indian scenario which is endemic to tuberculosis;
• Our study emphasizes on reporting oral tuberculosis as an important finding not commonly seen elsewhere;
• In ENT practice, a recurrent otitis media not responding to medical or surgical management should arise suspicion of tubercular otitis media and a trial of anti- tubercular treatment gives good response.

Cite this article: Shilpam Sharma et al. ENT manifestations of tuberculosis: an important aspect of ENT practice. Pan African Medical Journal. 2020;36(295). 10.11604/pamj.2020.36.295.24823

Competing interests

The authors declare no competing interests.

Authors' contributions

Shilpam Sharma: preparation of manuscript; Amit Kumar Rana: conceptualization and data maintenance and proof reading. All the authors have read and agreed to the final manuscript.

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25 Important Cases in Ear, Nose & Throat

25 Important Cases in EAR, NOSE & THROAT

ENT is a clinical subject intensive case preparation and scenario diagnosis to be expert it. Here presented are 25 important cases in Ear, Nose & Throat. For downloading PDFs file, go to the bottom of the page.

A 10 year old child was having a right mucopurulent otorrhea 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.

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.

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.

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.

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. This decreased response remained as such for the last 2 weeks after the occurrence of the primary condition.

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.

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.

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.

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.

A 35 year old female suddenly complained of an attack of bleeding from her right ear (otorrhagia). An ENT specialist packed the ear and after removal of the pack found an aural polyp. The patient also complained of pulsatile tinnitus in the right ear of 2 years duration and a change in her voice of 2 months duration. On laryngeal examination there was right vocal fold paralysis, the vocal fold was found in the abduction position. No lymph node enlargement was found in the neck.

A 30 year old female has been suffering from seasonal nasal obstruction for the last few years. A watery nasal discharge and attacks of sneezing accompanied this nasal obstruction. 2 weeks ago she had an attack of common cold, she refused to have medical treatment and 2 days later she began to develop pain over the forehead and a mild fever. She did not receive any treatment and so recently developed severe headache with a high fever (40 C) and became severely irritable and could not withstand light. On examination there was marked neck and back stiffness.

A 25 year old patient had been complaining from severe acute rhinitis. On the fifth day he started to get severe headache, mild fever and marked pain over the left forehead. The patient did not receive any treatment and on the tenth day started to get repeated rigors and became severely ill. On examining the patient the following signs were detected:

• A large red tender swelling in the right nasal vestibule.
• Marked edema of both upper and lower right eye lids.
• Chemosis of the conjunctive in the right eye.
• Forward proptosis of the right eyeball.

An 18 year old male patient complained of dull aching pain over the forehead for the last 3 years. This pain increased in the morning and decreased in the afternoons, together with intermittent nasal discharge. 10 days ago the pain became very severe with complete nasal obstruction and fever 38 C the patient did not receive the proper treatment and by the tenth day became drowsy with some mental behavioral changes, also there was vomiting and blurred vision.

A 52 year old male started to develop right sided progressively increasing nasal obstruction 6 months ago. This was followed by blood tinged nasal discharge from the right side as well. Due to looseness of the right second upper premolar tooth, the patient consulted a dentist who advised extraction, this resulted in an oroantral fistula. On examination there was a firm tender swelling in the right upper neck.

A 40 year old female has been complaining of nasal troubles of a long duration in the form of bilateral nasal obstruction, anosmia and nasal crustation. 2 months ago she developed mild stridor that necessitated a tracheostomy later on. She received medical treatment for her condition, but 1 month later developed severe to profound hearing loss that necessitated the use of a hearing aid.

A 24 year old male patient presented because of severe pain in the throat and the left ear that increased with swallowing of sudden onset and 2 days duration. He gave a history of sore throat and fever a few days prior to the condition. On examination, the patient looked very ill and has a thickened voice. The temperature was 39.5 C and the pulse 110/minute. The patient had fetor of the breath and was unable to open his mouth. There was marked edema of the palate concealing the left tonsil that was found injected. There was a painful hot swelling located below the left angle of the mandible. The left tympanic membrane was normal.

A 5 year old boy was referred to an ENT specialist because of mouth breathing and impairment of hearing of 2 years duration. His mother reported that her child has almost constant mucoid nasal discharge that sometimes changes to a mucopurulent one and he snores during his sleep. On examination, the child has nasal speech and obvious mouth breathing. Examination of the ears showed retracted tympanic membranes. Tympanograms were flat type B.

A male patient 49 year old presented with the complaint of enlargement of the upper deep cervical lymph nodes on both sides of the neck of 6 months duration. The nodes appeared first on the right side later on the other side. The patient gave a history of decreased hearing in the right ear that was intermittent but later became permanent. Recently he developed diminution of hearing in his left ear, nasal regurge, nasal intonation of voice and recurrent mild nosebleeds.

A 40 year old female began to experience difficulty in swallowing for the last 3 years. This difficulty in swallowing was to all kinds of food and the condition showed variation in the degree of dysphagia and was associated with a sense of obstruction at the root of the neck. For the last 2 months, she developed rapidly progressive difficulty in swallowing even to fluids together with a change in her voice. Recently she noticed a firm non-tender swelling in the right upper neck.

4 hours following an adenotonsillectomy for a 6 year old the pulse was 110/min, blood pressure 100/70, respiration 20/min and the child vomited 250 cc of a dark fluid. 2 hours later he vomited another 150 cc of the same dark fluid, the pulse became 130/min, the blood pressure became 80/50. The respiration rate remained 20/min.

A 3 year old child was referred to an ENT specialist because of cough, difficulty of respiration and temperature 39.5 C of few hours duration. The child was admitted to hospital for observation and medical treatment. 6 hours later, the physician decided an immediate tracheostomy. After the surgery the child was relieved from the respiratory distress for 24 hours then he became dyspnic again. The physician carried out a minor procedure that was necessary to relieve the child from the dyspnea. Few days later the tracheostomy tube was removed and the child discharged from the hospital.

A 45 year old male who is a heavy smoker complained of change in his voice of 3 years duration in the form of hoarseness. During the last 3 months his voice became very hoarse and he developed mild respiratory distress. Later he became severely distressed and required a surgical procedure to relieve the distress. On examination there were bilateral firm non-tender upper neck swellings.

A 40 year old female had repeated attacks of chest infection not improving by medical treatment. The patient was admitted for investigation of her condition in a hospital. A chest x-ray revealed basal lung infection. During her hospital stay it was noticed that she suffered from chest tightness and choking following meals. The ward nurse noticed that the patient refuses fluid diet and prefers solid bulky food.

A 4 year old child was referred to an ENT specialist by a pediatrician because of repeated attacks of severe chest infection (three in number) during the last month that usually resolved by antibiotics, expectorants and mucolytics, but the last attack did not resolve. On examination the lower right lobe of the lung showed no air entry and a lot of wheezes all over the chest by auscultation. A chest x-ray revealed an opacified lower right lobe. Temperature 38 C, pulse 120/min and respiration rate 35/min.

A 3 year old child suddenly complained of a sore throat and enlarged left upper deep cervical lymph node. Later he suffered from marked body weakness and mild respiratory distress that progressively became severe. Oropharyngeal examination revealed a grayish membrane on the left tonsil, soft palate and posterior pharyngeal wall. 2 days later he developed nasal regurge. His temperature was 38 C and pulse 150/min.

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