Long Cases-2

DR MUNTASIR MAHBUB
DEPT OF ENT & HNS
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N
LONG CASES rE
si
ta
IN OTOLARYNGOLOGY
un
rM
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SUPRAGLOTTIC CARCINOMA
Chief Complaints
• Alteration of voice for – 6 months
• Difficulty in swallowing for – 4 months
• Swelling in Right side of Upper neck for – 3 months
• Pain in Right ear for – 2 month
• Respiratory distress for – 15 days.
History of Present Illness
• According to the statement of patient he was reasonably well about 6 months back.
T
• Voice Change – Then he noticed alteration in the quality of voice – which was becoming progressively muffled in nature.
• The change of voice was insidious in onset.
• Had a progressive & unremitting course, with gradual deterioration.
N
• It was associated with throat discomfort & occasional pain
• Dysphagia – Patient also complained about occasional difficulty in swallowing for – 4 months.
• It was more on swallowing solids, than liquids, but was progressively increasing in severity.
• It was not associated with any regurgitation of food.
rE
• Neck Swelling – Patient also complained about a swelling in Right side of upper neck for last – 3 months.
• Initially it was smaller, but was progressively increasing in size.
• Not associated with any pain.
• Earache – Patient has been suffering from Pain in Right ear for last – 2 months.
• It was dull aching & constant in nature.
•
•
•
si
Not associated with hearing loss or ear discharge.
Temporarily relieved by taking analgesics
Respiratory Distress – Patient complained about respiratory distress for last – 15 days.
• Insidious in onset & progressive in nature.
ta
• Was associated with noisy breathing.
• It was aggravated by strenuous work & relieved by rest.
• Patient gave No H/O – Fever, Cough, Weight loss, Hemoptysis, Night Sweats.
• Patient is – Non-diabetic & Normotensive.
• With these complaints, patient got admitted in NIENT for better management.
un
History of Past Illness

• Nothing contributory.
• There was no history of – Major illnesses & operation.
• Patient never suffered from – PTB, COPD, Bronchial asthma.
rM
Personal History
• Patient is a chronic heavy smoker, & used to smoke 20 sticks a day for last 20 years.
• He didn't give any history of – Alcohol intake or Betel nut chewing.
Family History
• Patient has 3 brothers & 2 sisters. None is suffering from similar illness.
D
Occupational History
• Patient is a Farmer by occupation.
Socioeconomic History
• Comes from a low socio-economic background.
Medical History
Drug/Immunization History
• Patient took some drugs for his condition, but couldn't mention their names.
• Patient is partially Immunized.
General Examination
• Appearance – Ill looking. Body–built – Average. Cooperation – Co-operative. Decubitus – On choice
• Anaemia – Present. Jaundice – Absent. Cyanosis – Absent
• Clubbing – Absent. Koilonychia – Absent. Leukonychia – Absent.
• Edema – Absent. Dehydration – Absent
• Pulse – 76/min
• Blood pressure – 130/90 mmHg
• Temperature – Normal
• Respiratory rate – 14/min
Local Examination
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External Laryngeal Examination
Temperature Normal
Tenderness Absent
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Laryngeal Contour Normal
Laryngeal Crepitus Present
Tracheal Position Central
Indirect Laryngoscopic Examination
rE
There's an ulcero-proliferative growth in Right aryepiglottic fold
Extension of Growth Extending laterally to the medial wall of Right piriform fossa
Extending downwards towards the glottis
Area free from tumor Epiglottis, Lt AE fold, arytenoids – are free of tumor
Right Vocal cord fixed.

Vocal cord mobility
Airway adequacy
si Left vocal cord – mobility normal.
Airway is inadequate.
Examination of Neck
• Location – There is a swelling in the Right upper part of the neck
ta
• Extension – Extending superiorly from the angle of mandible, to inferiorly upto hyoid bone
• Size – 2cm x 1cm in size

• Shape – Globular in shape
• Surface – Smooth
un
• Margin – Well defined

• Overlying Skin – Not fixed
• Tenderness – Absent
• Consistency – Firm to Hard
• Fixity & Mobility – Not fixed with overlying skin or underlying structures. Moves from side to side, not above downwards.
rM
• Relation to SCM – Lies deep to SCM
Other ENT Exam

• Oral Cavity & Oropharynx – Normal. Tonsil & Tongue base palpation revealed normal findings.
• Nose & Ear – Normal
Systemic Examination
Cardiovascular System
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• Apex Beat – Present in 5th ICS in MCL

• Heart Sounds – Present (S1 & S2)
• Peripheral pulses – Present
Respiratory System
• Inspection – Chest movement normal & Symmetrical
• Palpation – Chest expansion normal
• Percussion – Note resonant
• Auscultation – Breath sound vesicular & normal
Alimentary System
• NAD
Nervous system
• NAD
SUPRAGLOTTIC CARCINOMA– Salient Features
• Mr. Iskandar, 50 years of age, Male, farmer, smoker, Hailing from Barisal,
• Presented with, Alteration of voice for last 6 months – which was insidious in onset & progressive in nature & had a muffled quality.
• He also complained about, Difficulty in swallowing for 4 months – which was more on solid than liquids & gradually increased in severity.
• The patient complained about, a Swelling in upper neck for last 3 months – which was not associated with pain & progressively increased in size.
• He also has, Pain in Right ear for 2 months – which was not associated with any hearing loss or ear discharge.
• Patient is suffering from, Respiratory distress for last 15 days - which has become difficult to bear & is associated with breathing noise.
• Patient is a smoker, taking 20 sticks per day for last 20 years.
T
On General examination
• Patient is ill looking, body build average. There is no anemia, Jaundice, Cyanosis, Clubbing, Koilo–Leukonychia, Edema, Dehydration
• Pulse – 76/min. Blood pressure – 130/90 mmHg. Temperature – Normal. Respiratory rate – 14/min
N
On Local examination
• Laryngeal contour appears normal, Laryngeal crepitus present, Trachea centrally placed.
• Non-tender & temperature normal.
rE
On Indirect Laryngoscopy
• There's an ulcero-proliferative growth in Right aryepiglottic fold
Extending laterally to the medial wall of Right piriform fossa & downwards towards the vocal folds
Epiglottis, Lt AE fold, arytenoids – are free of tumor
• Right Vocal cord fixed. Left vocal cord – mobility normal.

•
si
On neck Examination
• There is a swelling in the Right upper part of neck, below the angle of mandible
ta
• Size 2cm x 1cm, Shape globular, Surface smooth, Margin well defined
• Consistency firm, Not fixed with overlying skin or underlying structures.
• Carotid pulsation – present in normal location. No other LNs palpable.
un
Other examinations
• Examination of Ear, Nose, Oral cavity, Oropharynx – reveals no abnormality.
• Systemic examination – reveals normal findings.
• So my diagnosis is – Supraglottic carcinoma with Neck Metastases (T3N1Mx)

rM
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GLOTTIC CARCINOMA
Chief Complaints
• Change of voice for – 3 months
• Respiratory distress for – 1 month.
• Voice Change – Then he noticed change in the quality of his voice.

• There was progressive, unremitting deterioration of voice.
T
• Voice was hoarse, rough & breathy.
• It was associated with throat discomfort & occasional pain during speaking.
• Respiratory Distress – Patient complained about respiratory distress for last – 1 month.
Was mild initially & later increased in severity.
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•
• Associated with noisy breathing for last 15 days.
• It was aggravated by strenuous work & relieved by rest.
Patient is – Non-diabetic & Normotensive.
rE
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•
si
Patient never suffered from – PTB, COPD, Bronchial asthma.
Personal History
ta
Family History
un
Medical History
rM
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General Examination
Local Examination
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Temperature Normal
Tenderness Absent
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rE
There's an ulcero-proliferative growth in Right true vocal cord
Extension of Growth Extending anteriorly & laterally to involve the Left true vocal cord
Extending superiorly towards the Right false cord & AE fold.
Area free from tumor Epiglottis, Lt AE fold, arytenoids – are free of tumor
Right Vocal cord fixed.

Vocal cord mobility
Airway adequacy
si Left vocal cord – mobility normal.
Examination of Neck
• No palpable cervical lymphadenopathy
ta
Other ENT Exam
un
• Apex Beat – Present in 5th ICS in MCL
• Heart Sounds – Present (S1 & S2)
• Peripheral pulses – Present all.
Respiratory System
• Inspection – Chest movement normal & Symmetrical
rM
• Palpation – Chest expansion normal

• Percussion – Note resonant
• Auscultation – Breath sound vesicular & normal
Alimentary System
• NAD
Nervous system
D
• NAD
GLOTTIC CARCINOMA – Salient Features
• Presented with, Change of voice for last 4 months – which was progressive in nature & had a hoarse, rough, breathy quality.
• Patient is suffering from, Respiratory distress for last 1 month - aggravated by strenuous work & slightly relieved by rest.
T
• There's an ulcero-proliferative growth in Right True vocal cord
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Extending to the anterior part of left vocal cord
Superiorly to involve the Right False cords & AE fold
rE
• Airway is inadequate.
On neck Examination
• No Cervical LNs palpable.
Other examinations
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•
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Systemic examination – reveals normal findings.
So my diagnosis is – Carcinoma Glottis (T3N0Mx)

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rM
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HYPOPHARYNGEAL CARCINOMA (PF)
Chief Complaints
• Difficulty in swallowing for – 8 months
• Alteration of voice for – 4 months
• Pain in Right ear for – 1 month
T
• Dysphagia – Then he noticed occasional difficulty in swallowing.
• Which was more on swallowing solids, than liquids, but was progressively increasing in severity.
Neck Swelling – Patient also complained about a swelling in Right side of upper neck for last – 6 months.
N
•
• Voice Change – Patient complained about alteration in the quality of voice – which was becoming muffled in nature.
The change of voice was insidious in onset.
rE
•
• Had a progressive & unremitting course, with gradual deterioration.
• It was associated with throat discomfort & occasional pain
• Earache – Patient has been suffering from Pain in Right ear for last – 2 months.
• It was dull aching & constant in nature.
• Not associated with hearing loss or ear discharge. Temporarily relieved by taking analgesics
•
•
•
si
Patient gave No H/O – Fever, Cough, Weight loss, Hemoptysis, Night Sweats.
With these complaints, patient got admitted in NIENT for better management.
ta
un
Personal History
Family History
rM
Medical History
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General Examination
Local Examination
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Temperature Normal
Tenderness Absent
rE
There's an ulcero-proliferative swelling in Right piriform fossa – involving the floor, medial wall & lateral wall.
Extension of Growth
Extends medially to Right AE fold & involves the supraglottis.
Area free from tumor
Vocal cord mobility

si Epiglottis, Lt AE fold, arytenoids, Lateral/Posterior pharyngeal wall – are free of tumor
Right Vocal cord – fixed.

Left vocal cord – mobility normal.
ta
Airway adequacy Airway is inadequate.
Examination of Neck
un

rM
• Fixity & Mobility – Not fixed with overlying skin or underlying structures. Moves from side to side, not above downwards. (May be fixed)
D
Other ENT Exam

Respiratory System
Alimentary System No Abnormality detected
Nervous system
HYPOPHARYNGEAL CARCINOMA (PF) – Salient Features
• He also has, Pain in Right ear for 1 month – which was not associated with any hearing loss or ear discharge.
T
N
rE
• There's an ulcero-proliferative swelling in Right piriform fossa – involving the floor, medial wall & lateral wall.
• Extends medially to Right AE fold & involves the supraglottis.
• Epiglottis, Lt AE fold, arytenoids, Lateral/Posterior pharyngeal wall – are free of tumor
• Right Vocal cord – fixed. Left vocal cord – mobility normal. Airway is inadequate.
On neck Examination
si
ta
Other examinations
un

• So my diagnosis is – Hypopharyngeal carcinoma with Neck Metastases (T3N1Mx)

rM
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CARCINOMA TONGUE/BUCCAL MUCOSA
Chief Complaints
• Ulceration in Right side of Tongue – for 4 months.
• Swelling in Right side of Upper neck – for 2 months
• Ulceration in mouth – Then he noticed an ulceration in the lateral border of tongue – on the right side.
• It was slowly increasing in size – Initially was painless, later became painful.
T
• Pain was dull aching type – was aggravated by tongue movement.
• It was associated with excessive salivation, restriction of tongue movement & Difficulty in swallowing.
• Neck Swelling – Patient also complained about a swelling in Right side of upper neck – for 2 months.
Initially it was smaller, but was progressively increasing in size.
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• Patient gave No H/O – Difficulty in speech or mouth opening.

• There was no – Fever, Cough, Weight loss, Hemoptysis, Night Sweats.
rE
•

•
si
Patient never suffered from – PTB, COPD, Bronchial asthma.
Personal History
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• He didn't give any history of – Alcohol intake. But has a habit of Betel nut chewing.
Family History
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Medical History
rM
General Examination
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Local Examination
Ulcer exam
Inspection
• Location – Right Lateral margin of tongue, starting 2–3 cm behind the tip of tongue
• Extension – Extends inferiorly to the Floor of mouth, posteriorly towards the tongue base.
• Size – 4 cm X 2 cm
• Margin – Irregular
• Floor – Necrotic slough present in floor.
Palpation
• Edge – Everted
• Base – Indurated
• Tenderness – Tender
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• Fixity – Fixed with underlying tongue muscles
• Extension – There was no extension through midline
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Oral Cavity Examination
Inspection
• Oral hygiene – Poor, Halitosis present
• Trismus – Mouth opening normal
rE
• Tongue movement – Normal
• Teeth – Stained with betel quid
• Gingivolabial sulcus – Normal
• Buccal mucosa – Normal
Palpation
• Teeth – No loose teeth or tenderness in teeth
•
si
Tongue base – Palpation revealed no abnormality
Examination of Neck
• There is a swelling in the Right upper part of the neck

ta
• Extension – Below the lower border of mandible & in the submandibular region. Extending inferiorly upto hyoid bone

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• Overlying Skin – Not fixed. No scar mark.
• Consistency – Hard
• Fixity & Mobility – Not fixed with overlying skin, but fixed with underlying structures.
rM
Other Exam
ENT Exam
• Nose (AR, PR) – Normal
• Ear – Normal
• Indirect Laryngoscopy – Normal Findings.
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Respiratory System
Nervous system
CARCINOMA TONGUE – Salient Features
• Mr. Iskandar, 50 years of age, Male, farmer, smoker, Hailing from Barisal, Presented with,
• Tongue ulceration – Ulceration on the lateral margin of tongue on right side for 4 months.
• The ulcer was initially painless, later became painful.
• Pain was Dull aching type & aggravated by tongue movement. Caused difficulty in swallowing.
• Neck Swelling – Patient complained about, a Swelling in upper neck for 3 months – which was not associated with pain & progressively increased in size.
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• Oral hygiene was poor & there was halitosis. Teeth were stained with betel quid.
• An ulcerative lesion was seen on Right lateral margin of tongue.
• The ulcer measured about 4cm X 2cm in size.
rE
• Starting from 3 cm behind the tip, posteriorly to base of tongue. Extended to Floor of mouth.
• On palpation, the ulcer was tender & indurated, but didn't cross midline.
• Lower gum was free from ulcer. Rest of oral cavity appeared normal.
On neck Examination
• There is a swelling in the Right upper part of neck, below the lower border of mandible, in submandibular region, extending inferiorly to hyoid bone.
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Size 3cm x 2cm, Shape globular, Surface smooth, Margin well defined
Consistency Hard, Not fixed with overlying skin or underlying structures.
No other LNs palpable.
ta
Other examinations
un
• So my diagnosis is – Carcinoma Tongue with Neck Metastases (Level 1B) (T4N1Mx)

rM
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CARCINOMA PAROTID
Chief Complaints
• Swelling below & infront of Right ear – for 6 months
• Weakness of Right side of face – for 2 months
• Parotid Swelling – Then he noticed a swelling in front & below of his Right ear.
• It was initially small & progressively increased in size.
T
• It was not associated with pain & there was no alteration of size related to intake of food.
• There was no difficulty in mouth opening.
• There was no aggravating or relieving factor.
Facial Weakness – Patient also complained weakness of Right side of face – for 2 months.
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•
• There was incomplete closure of Right eye & mouth deviated to Left side during smiling.
With these complaints, patient got admitted in NIENT/BSMMU for better management.
rE
•

Personal History
si
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• There was no history of Radiation exposure.
Family History
un
Medical History
rM
General Examination

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Local Examination
Examination of Parotid Swelling

• Finding – There is a swelling
• Location – In front & below the Right ear
• Extension – Extending superiorly to the level of tragus & inferiorly & Posteriorly to upper border of SCM.

• Overlying Skin – Not fixed. No scar mark, discoloration, Venous engorgement or Congenital abnormality.
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N
• Relation to Masseter – Lies superficial to Masseter (Becomes more prominent on clenching).
Examination of Oral Cavity & Oropharynx
rE
Inspection
• Lip, Gum, Vestibule, FOM, Palate, Buccal mucosa – Normal

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•
si
Teeth – Stained with betel quid
Parotid Duct Opening – Located lateral to Upper 2nd molar, normal in appearance..
• Lateral Pharyngeal wall – No bulging or swelling.
ta
Palpation
• Teeth – No loose teeth or tenderness in teeth
• Tongue base – Palpation revealed no abnormality
• Parotid duct – No stone was present. Mucoid fluid comes out on pressing parotid
• Others – Deep lobe parotid was not palpable. Tonsil & Tongue base palpation revealed normal findings.
un
Examination of Facial Nerve

• Eye Closure – Incomplete in Right side
• Angle of Mouth – Deviated to Left side on smiling.
Other Examinations
rM
ENT Exam
• TM joint examination – No tenderness, Movement normal.
• Neck Node examination – No enlarged node.
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Respiratory System
Nervous system
CARCINOMA PAROTID – Salient Features
• Presented with, a Swelling in front & below of Right ear – for 6 months. It was painless, & progressively increasing in size.
• There was no alteration of size related to food intake & no difficulty in opening mouth.
• The patient also complained about, weakness of Right side of face – for 2 months. Which was progressive in nature
• Making patient unable to close Right eye & there was deviation of Right Angle of mouth towards left during smiling.
• There was no History of – Dry mouth, Difficulty in chewing or swallowing.
T
N
On Local Examination
• There is a swelling in front & below of Right ear,
• Extending anteriorly towards cheek, superiorly towards tragus & below towards the upper part of SCM.
rE
• Consistency Hard, Not fixed with overlying skin, but fixed with underlying structures.
• TM joint – was non-tender & mobility was normal.
On examination of Oral cavity

• There was no swelling of lateral pharyngeal wall & opening of parotid duct was normal.
• Watery discharge comes out when pressing the parotid from outside.
•
si
Rest of oral cavity was normal in appearance.
On Examination of Facial Nerve

• Palsy involving multiple terminal branches was found.
ta
Other examinations
• Examination of Ear, Nose, Neck nodes – reveals no abnormality.
un
• So my diagnosis is – Carcinoma Parotid with Facial Nerve Palsy (T4N0Mx)

rM
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THYROID CANCER WITH NECK METASTASES
Chief Complaints
• Swelling in front of the neck – for 2 years
• Swelling in Right lower neck– for 6 months
• According to the statement of patient he was reasonably well about 2 years back.
• Thyroid swelling – Then she noticed a swelling in front of the neck, mostly to right side
• Which was initially smaller, and gradually enlarged in size.
T
• It was not associated with – Pain, Dysphagia, Voice change or Respiratory distress.
• Neck Swelling – Patient also complained about a swelling in Right side of upper neck for last – 6 months.
Not associated with any pain.
N
•
• Patient gave No H/O – Weight Loss/Gain, Intolerance to Heat/Cold, Diarrhea/Constipation, Palpitation.
rE
•

• There was no history of – Major illnesses & operation. No History of Radiation exposure.
Personal History
si
ta
Family History
un
Medical History
rM
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General Examination
• Pulse – 76/min, Blood pressure – 130/90 mmHg, Temperature – Normal. Respiratory rate – 14/min
Local Examination
Examination of Thyroid Gland

• Location – There is a swelling in the Anterior part of the neck, mostly to right side → Moved up & down with deglutition.
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Overlying Skin – Not fixed. No scar mark, No change in color, No visible pulsation.
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•
• Consistency – Firm
rE
• Fixity & Mobility – Not fixed with overlying skin or surrounding structures. Moves up & down with deglutition.
• Tracheal Position – Centrally placed.
• Get Below the swelling – Possible.
• Pemberton sign – Negative

• Barry's Sign – Carotid pulsation present in normal position.
• Kocher’s sign – Negative
Signs of Thyro-toxicity
•
si
Eye Signs – Absent (Von Graefe's, Dalrymple, Mobius, Stellwag, Joffroy’s)
• Palm of Hand – Not warm or moist.
ta
• Tremor – No tremor present.
Examination of Neck Nodes

• Location – There is a swelling in the Right Lower part of the neck
un

• Overlying Skin – Not fixed. Moves from side to side.
rM
• Fixity & Mobility – Not fixed with overlying skin or underlying structures. Moves from side to side, not above downwards.
Other Exams
ENT Exam
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• Indirect Laryngoscopy – Both vocal cords are mobile & met in midline during phonation.
Respiratory System
Nervous system
THYROID CANCER – Salient Features
• Mr. Iskandar, 50 years of age, Male, farmer, smoker, non-diabetic, normotensive, Hailing from Barisal, Was admitted with the complaints of –
• Swelling in front of the neck for 2 years – which moved up & down with deglutition. Progressively increased in size, Not associated with pain or voice change.
• Patient also complained about another swelling for last 6 months, on the Right side of lower neck.
• Which was gradually increasing in size & not associated with pain.
• There was no history of palpitation, change of weight, heat or cold intolerance, change in bowel habit or radiation exposure.
• Patient is normal looking, body build average. There is no anemia, Jaundice, Cyanosis, Clubbing, Koilo–Leukonychia, Edema, Dehydration
T
On Neck examination
N
• There was a swelling in the Anterior part of the neck, mostly on Right side, which moved up & down with deglutition.
• Consistency firm, Not fixed with overlying skin.
• Temperature normal, Tenderness absent.
rE
• There was another swelling – in Right side of lower neck, which didn't move on deglutition.
•
si
Revealed normal findings.
Other examinations
Examination of Ear, Nose, Oral cavity, Oropharynx – reveals no abnormality.
ta
•
• So my diagnosis is – Thyroid carcinoma with Neck Metastases (T2N1bMx)

un
rM
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SINONASAL CARCINOMA
Chief Complaints
• Blood stained nasal discharge – 9 months
• Right sided nasal obstruction – 6 months
• Swelling of Right cheek – 3 months
• Protrusion of Right Eyeball – 1 month
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• Blood Stained Nasal Discharge – Then he noticed blood stained discharge from Right nostril (for 9 months)
• Which was intermittent in nature & scanty in amount.
• It was associated with local discomfort & occasional pain
Nasal Obstruction – Patient also complained about – Right sided progressive nasal obstruction for 6 months
N
•
• Initially it was incomplete & gradually became complete.
• Cheek Swelling – He also complained about Right sided cheek swelling for last – 3 months.
• It was gradually increasing in size & associated with dull aching pain – Which relieved temporarily by taking medications.
rE
• Protrusion of Eyeball – Patient noticed Protrusion of Right eyeball for last 1 month.
• There was no impairment of vision or pain in the eye.
• But patient complained of continuous watering from that eye.
• Patient gave No H/O – Trismus, Fever, Cough, Weight loss, Hemoptysis, Night Sweats. He complains of mild headache.

si
ta
• There was no history of – Major illnesses & operation or Radiation exposure.
Personal History
un
Family History
• Patient is a Farmer/Carpenter by occupation.
rM
Medical History
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General Examination
ENT Examination
Examination of Nose & PNS
• Inspection
− External appearance of Nose: Normal. Skin color is normal. No scar mark or ulceration
− There's a swelling in the right cheek, below Right eye.
• Palpation
− Bridge of Nose – Non-tender
− Mass over Right Cheek
o Tenderness – Present. Temperature – Normal
o Size – 3cm X 3cm. Shape – Globular. Surface – Irregular. Margin – Ill defined. Consistency – Firm
o Fixity – Fixed with underlying structures, but overlying skin free.
• Nasal Patency & Olfaction
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− Right Nostril – Obstructed with impairment of smell sensation
− Left Nostril – Patent, with intact sense of smell.
• Anterior Rhinoscopy
N
− Right sided nasal cavity is full of discharge
− After clearing the discharge, a red fleshy mass was seen – Non-tender, Bleeds on touch, Attached to lateral wall of nose.
− Septum is deviated to left side
− Left Nasal cavity is normal.
rE
• Posterior Rhinoscopy
− No abnormality detected
Examination of Oral Cavity
Inspection
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•
•
si
Trismus – Mouth opening normal
Tongue movement – Normal
Lip, Gum, Vestibule, FOM, Buccal mucosa – Normal
• Gingivolabial sulcus – Swelling in Right gingivobuccal sulcus, no ulceration over the swelling.
ta
• Palate – Swelling over hard palate on Right side
• Teeth – No loss of teeth.
Palpation
• Gingivolabial sulcus & Palate – Swelling over these region is non-tender.
un
• Teeth – Loosening of 1st incisor & 1st premolar teeth.

• Others – Deep lobe parotid was not palpable. Tonsil & Tongue base palpation revealed normal findings.
Examination of Eyes
• Position – Proptosis of Right Eye
• Visual Acuity – Normal
• Color Vision – Normal
• Field of Vision – Normal
rM
• Movement of Eyeball – Restricted on Medial & Inferior gaze.
Examination of Cranial Nerves

• CN 1 – Olfaction absent on Right side.
• CN 2 – Vision normal
• CN 3–6 – Movement impaired on Medial & Inferior gaze.
• CN 5 – Impairment of sensation over the right cheek area.
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Examination of Neck
• No palpable cervical LNs. Trachea centrally placed.
Examination of Ear
• Normal
Respiratory System
Nervous system
SINONASAL CARCINOMA – Salient Features
• Mr. Iskandar, 50 years of age, Male, Muslim carpenter, smoker, Hailing from Bhola, Barisal, was admitted to NIENT, with the complaints of –
• Blood stained nasal discharge for 9 months – which intermittent in nature & scanty in amount.
• He also complained of, Right sided Nasal Obstruction for 7 months, which was initially incomplete & later became complete.
• Patient also noticed a Swelling in Right cheek for 3 months, which was gradually increasing in size & associated with dull aching pain.
• Patient complained about Protrusion of Right Eyeball for 2 months
• It was not associated with impairment of vision, but caused impaired eye movement in downward & medial direction
T
On Examination of Nose & PNS
• Right Nostril – was Obstructed with impairment of smell sensation
N
• Right sided nasal cavity is full of discharge
• After clearing the discharge, a red fleshy mass was seen – Non-tender, Bleeds on touch, Attached to lateral wall of nose.
• Septum is deviated to left side
• Left Nasal cavity is normal. Patent, with intact sense of smell.
rE
• There is a swelling over the Right Cheek.
• Size 3cm x 3cm, Shape globular, Surface smooth, Margin well defined. Temperature normal, Tenderness present.
• Consistency firm, Not fixed with overlying skin, But fixed with underlying structures.
• Infraorbital Margin – Blunt & Irregular
• Loss of Sensation – over the swelling in the
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si
On Examination of Oral Cavity
Swelling in Right gingivobuccal sulcus & Right side of hard palate.
Non-tender & no ulceration over the swelling
• There was Loosening of 1st incisor & 1st premolar teeth but No loss of teeth.
ta
On Examination of Eyes
• There was proptosis of Right eye, with impairment of movement downwards & medially.
• There was no impairment of vision.
Other examinations
• Examination of Ear & Neck – reveals no abnormality.
un
• So my diagnosis is – Sinonasal carcinoma (T3N0Mx)

rM
D
ACTIVE SQUAMOUS COM
Chief Complaints
• Discharge from Right ear – for 10 years
• Impairment of hearing in Right ear – for 5 years.
• Ear Discharge – Then he noticed discharge from Right ear.

• Scanty in amount, Foul smelling, Thick & Purulent in nature – was not associated with pain.
• Deafness – Patient also complained about – Right sided progressive hearing loss for 5 years.
T
• Hearing loss was insidious in onset, Progressive in nature.
• Not associated with any relieving or aggravating factors.
• Patient gave No H/O – Otalgia, Headache, Vertigo, Tinnitus, Fever

N
•

rE
• There was no history of – Major illnesses & operation or Radiation exposure.
Personal History
si
Family History
• Patient is a Farmer/Carpenter by occupation.
ta
Medical History
un
rM
D
General Examination
ENT Examination
T
Examination of EAR
• Inspection
− Preauricular, Postauricular region & Pinna – Normal in appearance
Overlying skin normal, No scar, No congenital anomaly.
N
−
• Palpation
− Preauricular, Postauricular region & Conchal Bowl – Non tender.
• EAC examination with Speculum
rE
• Otoscopy
− Discharge in deep meatus – Thick, Purulent, (Scanty, Foul smelling/Profuse, Non foul smelling), Not blood stained.
− After mopping – TM was visualized.
− There was a central perforation in Par Tensa – oval in shape, regular margin.
− Middle ear mucosa was seen to be edematous & congested, partially filled with pus.
−
−
si
Whitish Flakes of Keratin was seen in Postero-superior part of TM, exuding out of a Retraction pocket.
Rest of TM was dull & retracted, with loss of Light reflex.
• Tuning Fork Test

ta
− Rinne: Negative in Right Ear.
− Weber: Lateralized to Right ear.
− ABC: Equal to examiner.
• Facial Nerve Test

un
− Facial Nerve Intact.
• Fistula Test
− Negative
Other ENT Examination
Examination of Oral cavity & Oropharynx

− Normal
rM
Examination of Nose & Nasopharynx

− Normal
Examination of Neck
− No palpable cervical LNs. Trachea centrally placed.
D
Respiratory System
Nervous system
ACTIVE SQUAMOUS COM – Salient Features
• Mr. Iskandar, 35 years of age, Male, Muslim Farmer, Hailing from Bhola, Barisal, was admitted to NIENT, with the complaints of –
• Discharge from Right Ear for 10 years – which was Scanty in amount, Foul smelling, Thick & Purulent in nature – was not associated with pain.
• He also complained of, Hearing impairment in Right ear for 5 years – which was insidious in onset, Progressive in nature.
On Examination of Ears
• Preauricular, Postauricular region & Pinna – Normal in appearance & Non tender.
• Otoscopy revealed – foul smelling scanty discharge in EAC.
T
• After mopping – TM was visualized.
• Whitish Flakes of Keratin was seen in Postero-superior part of TM, exuding out of a Retraction pocket.
• Rest of TM was dull & retracted, with loss of Light reflex.
Examination of Oral Cavity, Nose, PNS, Nasopharynx & Neck
N
• Revealed no abnormality.
Systemic examination
• Reveals normal findings.
rE
• So my diagnosis is – Active Squamous COM (Right)
si
ta
un
rM
D
PARAPHARYNGEAL MASS
Chief Complaints
• Swelling in Right upper part of neck – for 2 years.
• Difficulty in swallowing – for 6 months.
• Change of voice – for 2 months.
• Snoring – for 2 months
T
• Neck Swelling – Then he noticed a swelling in upper part of right side of neck, which was insidious in onset & Progressively increased in size.
• It was initially small & progressively increased in size.
• It was not associated with pain & there was no alteration of size related to intake of food.
• There was no difficulty in mouth opening.
N
• There was no aggravating or relieving factor.
• Dysphagia – Patient also complained about difficulty in swallowing for – 6 months.

• It was more on swallowing solids, than liquids, but was progressively increasing in severity.
rE
• Snoring – Patient also complained about – Snoring for last 2 months.
• Patient gave No H/O – Trismus, Regurgitation, Tinnitus, Fever, Cough, Weight loss, Hemoptysis, Night Sweats.
• With these complaints, patient got admitted in NIENT/BSMMU for better management.

•
•
Nothing contributory.
si
There was no history of – Major illnesses & operation.
ta
Personal History
• There was no history of Radiation exposure.
Family History
un
rM
Medical History
D
General Examination
Local Examination
Examination of Parotid Swelling

• Finding – There is a swelling
T
• Location – In front & below the Right ear
• Extension – Extending superiorly to the level of tragus & inferiorly & Posteriorly to upper border of SCM.
N
• Overlying Skin – Not fixed. No scar mark, discoloration, Venous engorgement or Congenital abnormality.
rE
• Relation to Masseter – Lies superficial to Masseter (Becomes more prominent on clenching).
si
Inspection
ta
• Lip, Gum, Vestibule, FOM, Buccal mucosa – Normal

un
• Teeth – Normal
• Parotid Duct Opening – Located lateral to Upper 2nd molar, normal in appearance..
• Lateral Pharyngeal wall – Bulging of Right lateral pharyngeal wall, with medial displacement of soft palate & tonsils.
Palpation
• Tonsils & Tongue base – Swelling of Right tonsil was not tender.
• Parotid duct – No stone was present. Serous fluid comes out on pressing parotid
rM
Other Examinations
ENT Exam
• Nose – Anterior /Posterior Rhinoscopy revealed no abnormality.
• Ear – Otoscopy revealed no abnormality.
D
• TM joint examination – No tenderness, Movement normal.

• Neck Node examination – No enlarged node.
• Cranial Nerves examination – Normal.
Respiratory System
Nervous system
PARAPHARYNGEAL MASS – Salient Features
• Presented with, a Swelling in Right upper part of neck – for 2 years. It was painless, & progressively increasing in size.
• The patient also complained about difficulty in swallowing for – 6 months
• Which was more on swallowing solids, than liquids, but was progressively increasing in severity. It was not associated with any regurgitation of food
• Patient also complained about – Snoring for last 2 months
T
N
rE
•
si
There was swelling of lateral pharyngeal wall pushing soft palate & tonsils medially.
• Opening of parotid duct was normal. Watery discharge comes out when pressing the parotid from outside.
• Rest of oral cavity was normal in appearance.
ta
Other examinations
• Examination of Ear, Nose, Neck nodes & Cranial nerves – reveals no abnormality.
un
• So my diagnosis is – Parapharyngeal Mass (Most probably Pleomorphic adenoma of Deep Lobe of Parotid)
rM
D
CARCINOMA OF UNKNOWN PRIMARY
Chief Complaints
• Voice Change – Then he noticed alteration a swelling in Right side of upper neck
T
• Patient gave No H/O – Nasal bleeding, Dysphagia, Dyspnea, Change of voice, Fever, Cough, Weight loss, Hemoptysis, or Night Sweats.
N
• There was no history of – Major illnesses, operation or Radiation exposure.
rE
Personal History
Family History
•
si
Patient has 3 brothers & 2 sisters. None is suffering from similar illness.

ta
Medical History
un
rM
D
General Examination
Local Examination
Examination of Neck
T
Margin – Well defined
N
•
rE
• Fixity & Mobility – Not fixed with overlying skin. But fixed with underlying structures.

• Normal. Tonsil & Tongue base palpation revealed normal findings.
•
•
si
Examination of Nose & Nasopharynx
Anterior Rhinoscopy – Normal
Posterior Rhinoscopy – Normal
Examination of Ear
ta
• Normal
Examination of Larynx & Hypopharynx

• Position of Trachea – Central
• Laryngeal Contour – Normal
• Laryngeal Tenderness – Absent
un
• Laryngeal Crepitus – Present

• Indirect laryngoscopy – Vocal cord mobility normal. Airway is inadequate
Respiratory System – Percussion, Auscultation – Normal.

rM
Nervous system
D
CARCINOMA OF UNKNOWN PRIMARY – Salient Features
T
• Temperature – Normal, Tenderness – Absent
• Consistency firm, Not fixed with overlying skin, but fixed with underlying structures.
N
• Carotid pulsation – present in normal location.
• No other LNs palpable.
rE
Other ENT examinations
• Examination of Oral Cavity & Oropharynx Nose & Ear – Revealed normal findings.
• Palpation of Tonsils & Tongue base – revealed no abnormality.
• On Indirect Laryngoscopy – Vocal cord mobility normal. Airway is inadequate
•
•
si
Reveals normal findings.
So my diagnosis is – Carcinoma of Unknown Primary (T3N1Mx)

ta
un
rM
D
Supraglottic Carcinoma– Salient Features
• He also has, Pain in Right ear for 2 months – which was not associated with any hearing loss or ear discharge.
• Patient is suffering from, Respiratory distress for last 15 days - which has become difficult to bear & is associated with breathing noise.
T
N
rE
• There's an ulcero-proliferative growth in Right aryepiglottic fold
Extending laterally to the medial wall of Right piriform fossa & downwards towards the vocal folds

•
si
On neck Examination
ta
un
Other examinations

rM
D
Glottic Carcinoma – Salient Features
• Presented with, Change of voice for last 4 months – which was progressive in nature & had a hoarse, rough, breathy quality.
• Patient is suffering from, Respiratory distress for last 1 month - aggravated by strenuous work & slightly relieved by rest.
Laryngeal contour appears normal, Laryngeal crepitus present, Trachea centrally placed.
T
•
• There's an ulcero-proliferative growth in Right True vocal cord
N
Extending to the anterior part of left vocal cord
Superiorly to involve the Right False cords & AE fold
rE
• Airway is inadequate.
On neck Examination
• No Cervical LNs palpable.
Other examinations
•
•
si
Systemic examination – reveals normal findings.
So my diagnosis is – Carcinoma Glottis (T3N0Mx)

ta
un
rM
D
Hypopharyngeal Carcinoma (Pf) – Salient Features
• He also has, Pain in Right ear for 1 month – which was not associated with any hearing loss or ear discharge.
Patient is ill looking, body build average. There is no anemia, Jaundice, Cyanosis, Clubbing, Koilo–Leukonychia, Edema, Dehydration
T
•
N
• There's an ulcero-proliferative swelling in Right piriform fossa – involving the floor, medial wall & lateral wall.
rE
• Extends medially to Right AE fold & involves the supraglottis.
• Epiglottis, Lt AE fold, arytenoids, Lateral/Posterior pharyngeal wall – are free of tumor
• Right Vocal cord – fixed. Left vocal cord – mobility normal. Airway is inadequate.
On neck Examination
•
•
si
There is a swelling in the Right upper part of neck, below the angle of mandible
Carotid pulsation – present in normal location. No other LNs palpable.
ta
•
Other examinations
un

rM
D
Carcinoma Tongue – Salient Features
• Mr. Iskandar, 50 years of age, Male, farmer, smoker, Hailing from Barisal, Presented with,
• Tongue ulceration – Ulceration on the lateral margin of tongue on right side for 4 months.
• The ulcer was initially painless, later became painful.
• Pain was Dull aching type & aggravated by tongue movement. Caused difficulty in swallowing.
• Neck Swelling – Patient complained about, a Swelling in upper neck for 3 months – which was not associated with pain & progressively increased in size.
T
N
• Oral hygiene was poor & there was halitosis. Teeth were stained with betel quid.
• An ulcerative lesion was seen on Right lateral margin of tongue.
The ulcer measured about 4cm X 2cm in size.
rE
•
• Starting from 3 cm behind the tip, posteriorly to base of tongue. Extended to Floor of mouth.
• On palpation, the ulcer was tender & indurated, but didn't cross midline.
• Lower gum was free from ulcer. Rest of oral cavity appeared normal.
On neck Examination
•
•
•
si
There is a swelling in the Right upper part of neck, below the lower border of mandible, in submandibular region, extending inferiorly to hyoid bone.
Consistency Hard, Not fixed with overlying skin or underlying structures.
ta
Other examinations
un
• So my diagnosis is – Carcinoma Tongue with Neck Metastases (Level 1B) (T4N1Mx)

rM
D
Carcinoma Parotid – Salient Features
• Presented with, a Swelling in front & below of Right ear – for 6 months. It was painless, & progressively increasing in size.
• The patient also complained about, weakness of Right side of face – for 2 months. Which was progressive in nature
• Making patient unable to close Right eye & there was deviation of Right Angle of mouth towards left during smiling.
T
N
rE

• There was no swelling of lateral pharyngeal wall & opening of parotid duct was normal.
•
•
si
Watery discharge comes out when pressing the parotid from outside.
On Examination of Facial Nerve

• Palsy involving multiple terminal branches was found.
ta
Other examinations
• Examination of Ear, Nose, Neck nodes – reveals no abnormality.
un
• So my diagnosis is – Carcinoma Parotid with Facial Nerve Palsy (T4N0Mx)

rM
D
Thyroid Cancer – Salient Features
• Mr. Iskandar, 50 years of age, Male, farmer, smoker, non-diabetic, normotensive, Hailing from Barisal, Was admitted with the complaints of –
• Swelling in front of the neck for 2 years – which moved up & down with deglutition. Progressively increased in size, Not associated with pain or voice change.
• Patient also complained about another swelling for last 6 months, on the Right side of lower neck.
• Which was gradually increasing in size & not associated with pain.
• There was no history of palpitation, change of weight, heat or cold intolerance, change in bowel habit or radiation exposure.
T
On Neck examination
N
• There was a swelling in the Anterior part of the neck, mostly on Right side, which moved up & down with deglutition.
rE
• There was another swelling – in Right side of lower neck, which didn't move on deglutition.
si
• Revealed normal findings.
Other examinations
ta
• So my diagnosis is – Thyroid carcinoma with Neck Metastases (T2N1bMx)

un
rM
D
Sinonasal Carcinoma – Salient Features
• Mr. Iskandar, 50 years of age, Male, Muslim carpenter, smoker, Hailing from Bhola, Barisal, was admitted to NIENT, with the complaints of –
• Blood stained nasal discharge for 9 months – which intermittent in nature & scanty in amount.
• He also complained of, Right sided Nasal Obstruction for 7 months, which was initially incomplete & later became complete.
• Patient also noticed a Swelling in Right cheek for 3 months, which was gradually increasing in size & associated with dull aching pain.
• Patient complained about Protrusion of Right Eyeball for 2 months
• It was not associated with impairment of vision, but caused impaired eye movement in downward & medial direction
T
On Examination of Nose & PNS
• Right Nostril – was Obstructed with impairment of smell sensation
N
• Right sided nasal cavity is full of discharge
• After clearing the discharge, a red fleshy mass was seen – Non-tender, Bleeds on touch, Attached to lateral wall of nose.
• Septum is deviated to left side
• Left Nasal cavity is normal. Patent, with intact sense of smell.
rE
• There is a swelling over the Right Cheek.
• Size 3cm x 3cm, Shape globular, Surface smooth, Margin well defined. Temperature normal, Tenderness present.
• Consistency firm, Not fixed with overlying skin, But fixed with underlying structures.
• Infraorbital Margin – Blunt & Irregular
• Loss of Sensation – over the swelling in the
•
•
si
On Examination of Oral Cavity
Swelling in Right gingivobuccal sulcus & Right side of hard palate.
Non-tender & no ulceration over the swelling
• There was Loosening of 1st incisor & 1st premolar teeth but No loss of teeth.
ta
On Examination of Eyes
• There was proptosis of Right eye, with impairment of movement downwards & medially.
• There was no impairment of vision.
Other examinations
Examination of Ear & Neck – reveals no abnormality.
un
•
• So my diagnosis is – Sinonasal carcinoma (T3N0Mx)

rM
D
Active Squamous Com – Salient Features
• Mr. Iskandar, 35 years of age, Male, Muslim Farmer, Hailing from Bhola, Barisal, was admitted to NIENT, with the complaints of –
• Discharge from Right Ear for 10 years – which was Scanty in amount, Foul smelling, Thick & Purulent in nature – was not associated with pain.
• He also complained of, Hearing impairment in Right ear for 5 years – which was insidious in onset, Progressive in nature.
On Examination of Ears
• Preauricular, Postauricular region & Pinna – Normal in appearance & Non tender.
• Otoscopy revealed – foul smelling scanty discharge in EAC.
T
• After mopping – TM was visualized.
• Whitish Flakes of Keratin was seen in Postero-superior part of TM, exuding out of a Retraction pocket.
• Rest of TM was dull & retracted, with loss of Light reflex.
N
Examination of Oral Cavity, Nose, PNS, Nasopharynx & Neck
• Revealed no abnormality.
• Reveals normal findings.
rE
• So my diagnosis is – Active Squamous COM (Right)
si
ta
un
rM
D
Parapharyngeal Mass – Salient Features
• Presented with, a Swelling in Right upper part of neck – for 2 years. It was painless, & progressively increasing in size.
• The patient also complained about difficulty in swallowing for – 6 months
• Which was more on swallowing solids, than liquids, but was progressively increasing in severity. It was not associated with any regurgitation of food
Patient also complained about – Snoring for last 2 months
T
•
N
rE
TM joint – was non-tender & mobility was normal.

•
si
• There was swelling of lateral pharyngeal wall pushing soft palate & tonsils medially.
• Opening of parotid duct was normal. Watery discharge comes out when pressing the parotid from outside.
ta
•
Other examinations
• Examination of Ear, Nose, Neck nodes & Cranial nerves – reveals no abnormality.
un
• So my diagnosis is – Parapharyngeal Mass (Most probably Pleomorphic adenoma of Deep Lobe of Parotid)
rM
D
Carcinoma Of Unknown Primary – Salient Features
T
• Temperature – Normal, Tenderness – Absent
• Consistency firm, Not fixed with overlying skin, but fixed with underlying structures.
N
• Carotid pulsation – present in normal location.
rE
Other ENT examinations
• Examination of Oral Cavity & Oropharynx Nose & Ear – Revealed normal findings.
• Palpation of Tonsils & Tongue base – revealed no abnormality.
• On Indirect Laryngoscopy – Vocal cord mobility normal. Airway is inadequate
•
•
si
Reveals normal findings.
So my diagnosis is – Carcinoma of Unknown Primary (T3N1Mx)

ta
un
rM
D

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DR MUNTASIR MAHBUB

DEPT OF ENT & HNS

History of Present Illness

History of Past Illness

• Appearance – Ill looking. Body–built – Average. Cooperation – Co-operative. Decubitus – On choice

• Anaemia – Present. Jaundice – Absent. Cyanosis – Absent

• Clubbing – Absent. Koilonychia – Absent. Leukonychia – Absent.

• Edema – Absent. Dehydration – Absent

Indirect Laryngoscopic Examination

Right Vocal cord fixed.

• Size – 2cm x 1cm in size

• Margin – Well defined

• Relation to SCM – Lies deep to SCM

Other ENT Exam

• Apex Beat – Present in 5th ICS in MCL

• Patient is a smoker, taking 20 sticks per day for last 20 years.

• Right Vocal cord fixed. Left vocal cord – mobility normal.

• So my diagnosis is – Supraglottic carcinoma with Neck Metastases (T3N1Mx)

History of Present Illness

• Voice Change – Then he noticed change in the quality of his voice.

History of Past Illness

• Patient is a Farmer by occupation.

• Appearance – Ill looking. Body–built – Average. Cooperation – Co-operative. Decubitus – On choice

• Anaemia – Present. Jaundice – Absent. Cyanosis – Absent

• Clubbing – Absent. Koilonychia – Absent. Leukonychia – Absent.

• Edema – Absent. Dehydration – Absent

Indirect Laryngoscopic Examination

Right Vocal cord fixed.

• Palpation – Chest expansion normal

• Patient is a smoker, taking 20 sticks per day for last 20 years.

• Right Vocal cord fixed. Left vocal cord – mobility normal.

So my diagnosis is – Carcinoma Glottis (T3N0Mx)

History of Present Illness

• Appearance – Ill looking. Body–built – Average. Cooperation – Co-operative. Decubitus – On choice

• Anaemia – Present. Jaundice – Absent. Cyanosis – Absent

• Clubbing – Absent. Koilonychia – Absent. Leukonychia – Absent.

• Edema – Absent. Dehydration – Absent

Indirect Laryngoscopic Examination

Area free from tumor

Vocal cord mobility

Right Vocal cord – fixed.

• Size – 2cm x 1cm in size

Other ENT Exam

Alimentary System No Abnormality detected

• Patient is a smoker, taking 20 sticks per day for last 20 years.

• Epiglottis, Lt AE fold, arytenoids, Lateral/Posterior pharyngeal wall – are free of tumor

• Examination of Ear, Nose, Oral cavity, Oropharynx – reveals no abnormality.

• So my diagnosis is – Hypopharyngeal carcinoma with Neck Metastases (T3N1Mx)

History of Present Illness

• Patient gave No H/O – Difficulty in speech or mouth opening.

History of Past Illness

• Patient is a Farmer by occupation.

• Appearance – Ill looking. Body–built – Average. Cooperation – Co-operative. Decubitus – On choice

• Anaemia – Present. Jaundice – Absent. Cyanosis – Absent

• Clubbing – Absent. Koilonychia – Absent. Leukonychia – Absent.

• Edema – Absent. Dehydration – Absent

• There is a swelling in the Right upper part of the neck