ENT

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De La Salle Health Sciences Institute

De La Salle University Medical Center

College of Medicine

Department of Otorhinolaryngology-Head and

Neck Surgery

OPD CLINICAL CASE

DISCUSSION

August 16-22, 2011

Bryan Paul G. Ramirez

Junior Intern

Dr. Brendan R. Ferrolino

Preceptor

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De La Salle University Medical Center De La Salle University Medical Center

College of Medicine College of Medicine

Department of Otorhinolaryngology – Head and Neck

Department of Otorhinolaryngology – Head and Neck SurgerySurgery SUBMITTED

SUBMITTED BY: BY: JI JI BRYAN BRYAN PAUL PAUL RAMIREZRAMIREZ PRECEPTOR:

PRECEPTOR: DR. DR. BRENDAN BRENDAN R. R. FERROLINOFERROLINO

OPD CLINICAL CASE

OPD CLINICAL CASE DISCUSSION (AUGUST 16-22, 2011)DISCUSSION (AUGUST 16-22, 2011)

1. Miranda, Jian Khurt 6 mo./M 1. Miranda, Jian Khurt 6 mo./M

This is the case of J.M, 6 months old male who came in for follow up and was last This is the case of J.M, 6 months old male who came in for follow up and was last seen Aug. 12, 2011, with a

seen Aug. 12, 2011, with a chief complaint of Right Lateral Neck Mass, beneath the post-chief complaint of Right Lateral Neck Mass, beneath the post-auricular area.

auricular area.

4 months prior to

4 months prior to consult, the mother noticed bluish-purple patch beneath theconsult, the mother noticed bluish-purple patch beneath the patient’s right posterior auricu

patient’s right posterior auricular area around the size of 1 lar area around the size of 1 peso coin. There were no earpeso coin. There were no ear discharge

discharge, fever, bleeding, cough , fever, bleeding, cough and colds. The and colds. The patient was seen and examined by patient was seen and examined by ENTENT OPD last 7/14/2011 and

OPD last 7/14/2011 and was diagnosed with reactive lymphadenitis r/o hemangioma. He waswas diagnosed with reactive lymphadenitis r/o hemangioma. He was prescribed with Clindamycin 75/5ml 1.25 ml q6 x 7 d. However there was no decrease in size prescribed with Clindamycin 75/5ml 1.25 ml q6 x 7 d. However there was no decrease in size noted. On physical examination, there was a

noted. On physical examination, there was a 3x3 cm 3x3 cm tender, non-movable, hard, bluishtender, non-movable, hard, bluish purple lateral neck mass below the preauricular area. On otoscopy, there were cerumen on purple lateral neck mass below the preauricular area. On otoscopy, there were cerumen on both Eustachian tubes. Otherwise, the other ENT

both Eustachian tubes. Otherwise, the other ENT findings were normal.findings were normal. The patient was diagnosed to have

The patient was diagnosed to have HemangiomaHemangiomaand was referred to a tumor clinic.and was referred to a tumor clinic. Hemangiomas are proliferat

Hemangiomas are proliferative lesions as compared to ive lesions as compared to AV malformations which are vesselAV malformations which are vessel malformations

malformations. Visible lesion on . Visible lesion on the face or the face or neck may signify presence of neck may signify presence of another internalanother internal hemangioma such as in

hemangioma such as in the oral cavity, larynx or the oral cavity, larynx or pharynx. Hemangiomapharynx. Hemangiomas are sometimess are sometimes associated with certain syndromes such as Sturge-Weber or posterior fossa lesion

associated with certain syndromes such as Sturge-Weber or posterior fossa lesion in thein the brain, arterial lesio

brain, arterial lesions in the neck or ns in the neck or in the face, cardiac or coarctation problems and eyein the face, cardiac or coarctation problems and eye abnormalitie

abnormalities. Superficially located lesions appear flat and reddish in s. Superficially located lesions appear flat and reddish in color. Deep lesions arecolor. Deep lesions are bluish. Compound lesions such as in this case is both

bluish. Compound lesions such as in this case is both deep and superficial and may appeardeep and superficial and may appear purple. Cavernous hemangioma

purple. Cavernous hemangiomas are compressible, globular, bright red s are compressible, globular, bright red or deep purpleor deep purple involving deep structures. This is the most likely clinical type of hemangioma in this patient. involving deep structures. This is the most likely clinical type of hemangioma in this patient. Capillary hemang

Capillary hemangiomas on iomas on the other hand the other hand are plaque-like lesions, slightly elevated and moreare plaque-like lesions, slightly elevated and more superficia

superficial. Port-wine stains are capillary type, flat l. Port-wine stains are capillary type, flat and mostly in and mostly in the dermis. Strawberrythe dermis. Strawberry marks are capillary type with cavernous component.

marks are capillary type with cavernous component.

Hemangiomas are usually just observed since they may

Hemangiomas are usually just observed since they may involute in time. Indicationsinvolute in time. Indications for treatment may include involvement of

for treatment may include involvement of vital organs, recurrent bleeding, ulceration,vital organs, recurrent bleeding, ulceration, crusting or infection and rapid growth and deformity. CT scan is

crusting or infection and rapid growth and deformity. CT scan is usually warrausually warranted but MRInted but MRI may be needed for deep and large lesions. For small areas not involving the

may be needed for deep and large lesions. For small areas not involving the face,face, intralesion

intralesional injection with steroids may al injection with steroids may be done with be done with or without liquid or without liquid nitrogen cryosurgerynitrogen cryosurgery also with pulsed dye

also with pulsed dye laser. Larger hemangiomas require oral steroids. For lesions that arelaser. Larger hemangiomas require oral steroids. For lesions that are life-threaten

life-threatening or ing or non-responsnon-responsive to ive to steroids Alpha-interfesteroids Alpha-interferon may ron may be warranted. Carefulbe warranted. Careful surgical excision may be the last resort which can be very bloody since hemangioma is a surgical excision may be the last resort which can be very bloody since hemangioma is a vascular lesion.

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2. Fernandez, Nancy Contreras 43/F 2. Fernandez, Nancy Contreras 43/F

This is the case of

This is the case of N.F. 43, female who sought consult for tinnitus of N.F. 43, female who sought consult for tinnitus of the left ear. 3the left ear. 3 months prior to consult patient noticed sudden onset of

months prior to consult patient noticed sudden onset of ringing sensatiringing sensation on on on the left earthe left ear associated with dizziness, hearing difficulty and

associated with dizziness, hearing difficulty and occasional headachesoccasional headaches. Otherwise there . Otherwise there is nois no associated ear discha

associated ear discharge, cough or colds. 2 rge, cough or colds. 2 months prior to consult patient consulted in amonths prior to consult patient consulted in a private clinic and was prescribed with Polynerve Vitamins. However, patient noticed

private clinic and was prescribed with Polynerve Vitamins. However, patient noticed persistence of symptoms. On otoscopy both ET are patent with

persistence of symptoms. On otoscopy both ET are patent with scanty cerumen and intactscanty cerumen and intact TM. Tuning fork test was done

TM. Tuning fork test was done with the following results:with the following results:

Weber’s: Lateraliza

Weber’s: Lateralization on tion on R earR ear

Rinne’s: AC>BC R ear; BC>AC L ear Rinne’s: AC>BC R ear; BC>AC L ear Schwabach’s

Schwabach’s: : (+)(+)

The patient was diagnosed with

The patient was diagnosed with Sensorineural Hearing Loss, T/C Meniere’sSensorineural Hearing Loss, T/C Meniere’s andand was advised for PTA, ST and tympanometry. In Sensory Hearing Loss, the pathology may was advised for PTA, ST and tympanometry. In Sensory Hearing Loss, the pathology may involve the inner and outer hair cells of the

involve the inner and outer hair cells of the Cochlea, hence the transmitted sound wavesCochlea, hence the transmitted sound waves does not stimulate those structures. HL is usually severe to profound and more

does not stimulate those structures. HL is usually severe to profound and more so in highso in high frequency sound

frequency sounds (4,000-8,000 kHz). s (4,000-8,000 kHz). The clarity of speeThe clarity of speech sound is usually disch sound is usually distorted. Thetorted. The hearing is worse in

hearing is worse in the presence of background noise hence the presence of background noise hence understandunderstanding speech ising speech is impaired. Etiology may include

impaired. Etiology may include congenital aplasias of the congenital aplasias of the cochlea, presbyacusicochlea, presbyacusis, perilymphs, perilymph fistula, noise-in

fistula, noise-induced, infection or ototoxic drugs such duced, infection or ototoxic drugs such as quinine, aminogas quinine, aminoglycosides orlycosides or aspirin or Meniere’s disease. In Neural Hearing loss, the pathology

aspirin or Meniere’s disease. In Neural Hearing loss, the pathology is in the is in the spiral ganglionspiral ganglion and CN VIII.

and CN VIII. There is impaired nerve impulse transmission even if There is impaired nerve impulse transmission even if the cochlea is stimulated.the cochlea is stimulated. There is poorer speech discrimination as compared with

There is poorer speech discrimination as compared with sensory hearing loss. It issensory hearing loss. It is associated with very severe hearing loss and tinnitus. The

associated with very severe hearing loss and tinnitus. The etiology may be etiology may be an acoustican acoustic neuroma or vestibular schwann

neuroma or vestibular schwannoma. In this case, the oma. In this case, the etiology of the SNHL is considered toetiology of the SNHL is considered to be Meniere’s disease.

be Meniere’s disease.

Meniere’s disease involves a triad of vertigo, fluctuating hearing loss

Meniere’s disease involves a triad of vertigo, fluctuating hearing loss and tinnitus alland tinnitus all of which are present in this patient. It usually occurs in

of which are present in this patient. It usually occurs in the 3the 3rdrd _{or 4}_{or 4}thth_{decade of life (the}_{decade of life (the}

patient is 43 years old)

patient is 43 years old) It is secondary to distention or increaseIt is secondary to distention or increased volume of endolymphaticd volume of endolymphatic system. There is remission and relapses and

system. There is remission and relapses and with bilateral involvement in 30% of with bilateral involvement in 30% of cases. Incases. In treating Meniere’s

treating Meniere’s, the goal is to , the goal is to increase the circulatincrease the circulation in the ion in the inner ear to decrease theinner ear to decrease the pressure of the lymphatic system. Betahistine HCL

pressure of the lymphatic system. Betahistine HCL may be given as may be given as prophylaxis. Diureticprophylaxis. Diureticss such as Hydrochlorthiazides and Azetazolamide may be given to

such as Hydrochlorthiazides and Azetazolamide may be given to reduce the distention.reduce the distention. Intratympani

Intratympanic gentamycin may be c gentamycin may be injected. Methotrexainjected. Methotrexate may te may be given as be given as immunologicimmunologic treatment.

treatment.

3. Nario, Dennis Asis 25/M 3. Nario, Dennis Asis 25/M

This is the case of

This is the case of D.N. 25 year old male who consulted for D.N. 25 year old male who consulted for a 10 year history of a 10 year history of enlarged tonsils. There is no

enlarged tonsils. There is no pain, dysphagia, odynophagia, difficulty sleeping or apnea. Hepain, dysphagia, odynophagia, difficulty sleeping or apnea. He has tonsillitis 3x/year in 2 years. On inspection of the oral cavity and pharynx, there are has tonsillitis 3x/year in 2 years. On inspection of the oral cavity and pharynx, there are enlarged tonsils, Grade 3. There is no hyperaemia or exudates noted. He was diagnosed enlarged tonsils, Grade 3. There is no hyperaemia or exudates noted. He was diagnosed with

with Chronic Hypertrophic TonsillitisChronic Hypertrophic Tonsillitis..

Human tonsil tissue includes the pair of tonsils at the

Human tonsil tissue includes the pair of tonsils at the back of the mouth, theback of the mouth, the adenoids behind the nose and a final area of

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tonsillitis or infection may become difficult to treat using only antibiotics. Surgery to remove tonsillitis or infection may become difficult to treat using only antibiotics. Surgery to remove the tonsils is sometimes required, especially if a

the tonsils is sometimes required, especially if a condition known as hypertrophic tonsilscondition known as hypertrophic tonsils develops. The term hypertrophic tonsils, also referred to

develops. The term hypertrophic tonsils, also referred to as tonsillar hypertrophy, describesas tonsillar hypertrophy, describes tonsils that are so enlarged that they may obstruct breathing. It can be

tonsils that are so enlarged that they may obstruct breathing. It can be most bothersome atmost bothersome at night when trying to sleep. The condition can also

night when trying to sleep. The condition can also cause difficulty swallowcause difficulty swallowing. All of whiching. All of which are not present in this patient.

are not present in this patient. Most cases of hypertrophic tonsils also involMost cases of hypertrophic tonsils also involve enlargedve enlarged adenoids. The combination of swollen tissue can lead to more than breathing problems. In adenoids. The combination of swollen tissue can lead to more than breathing problems. In fact, ear infections, sinus infections, oral and mental

fact, ear infections, sinus infections, oral and mental maldevelopmenmaldevelopment, and eustachiant, and eustachian (auditory) tube blockages can also occur.

(auditory) tube blockages can also occur.

Biopsies of hypertrophic tonsils that have

Biopsies of hypertrophic tonsils that have been surgically removed often show signsbeen surgically removed often show signs of bacterial pathogens. Hypertrophic tonsils contain significantly higher amounts of microbes of bacterial pathogens. Hypertrophic tonsils contain significantly higher amounts of microbes than that of healthy tonsils. This pathogenic bacterium has been found to

than that of healthy tonsils. This pathogenic bacterium has been found to collect in thecollect in the crypts of hypertrophic tonsils, causing infection and

crypts of hypertrophic tonsils, causing infection and excessive inflammaexcessive inflammation. A tion. A diagnosis of diagnosis of hypertrophic tonsils is often visually based. They are very pronounced and tend to bulge out hypertrophic tonsils is often visually based. They are very pronounced and tend to bulge out towards the front of the

towards the front of the mouth. The tonsils are often so large that mouth. The tonsils are often so large that they touch one another---they touch one another---often termed

often termed "kissing tonsils." Chronic infections, breathing problems and "kissing tonsils." Chronic infections, breathing problems and maldevelopmenmaldevelopmentsts are also taken into consideration along with other symptoms that may develop. Chronic are also taken into consideration along with other symptoms that may develop. Chronic halitosis, weight loss, decreased appetite and fatigue are also considered in

halitosis, weight loss, decreased appetite and fatigue are also considered in a diagnosis of a diagnosis of hypertrophic tonsils.

hypertrophic tonsils.

Hypertrophic tonsils generally warrant surgical intervention. When enlarged tonsils or Hypertrophic tonsils generally warrant surgical intervention. When enlarged tonsils or adenoids interfere with sleeping by causing snoring or

adenoids interfere with sleeping by causing snoring or severe sleep apnea, surgery is oftensevere sleep apnea, surgery is often recommended. Surgery is also recommended when swallowing difficulties occur or dental recommended. Surgery is also recommended when swallowing difficulties occur or dental problems are involved.

problems are involved.

4. Cabahug, Nissa Yvonne 10/F 4. Cabahug, Nissa Yvonne 10/F

This is the case of

This is the case of N.C. 10 year old female who sought consult for N.C. 10 year old female who sought consult for ear pain. 2 daysear pain. 2 days PTC, patient noted pain on both

PTC, patient noted pain on both ears with decreased hearingears with decreased hearing. There were no noted. There were no noted discharge

discharge, cough , cough or colds. Otoscopic findings revealed impacted cerumen on or colds. Otoscopic findings revealed impacted cerumen on right ear andright ear and some on the left

some on the left ear. The visualized portion of the left TM is ear. The visualized portion of the left TM is intact. The patient is diagnosedintact. The patient is diagnosed with

with Retained Cerumen, AS; Impacted Cerumen, ADRetained Cerumen, AS; Impacted Cerumen, AD and was prescribed withand was prescribed with Paraceta

Paracetamol Tablet 250mg 1 mol Tablet 250mg 1 Tab every 4 hours as necessary for pain. Aural flushing wasTab every 4 hours as necessary for pain. Aural flushing was done. The patient was advised to come back after one

done. The patient was advised to come back after one week if pain persists.week if pain persists.

Ear wax, also known as cerumen, is the result of

Ear wax, also known as cerumen, is the result of mixing skins cells of the outer earmixing skins cells of the outer ear canal with glandular secretions that protect the ear

canal with glandular secretions that protect the ear against infections by cleaning andagainst infections by cleaning and trapping dirt in the ear canal. The amount of

trapping dirt in the ear canal. The amount of ear wax produced varies by individual. Someear wax produced varies by individual. Some individual

individuals produce very s produce very little wax; others overproduce ear wax to little wax; others overproduce ear wax to the point that the point that blockageblockage may occur. Cerumen normally works itself out of the ear; however, there are situations when may occur. Cerumen normally works itself out of the ear; however, there are situations when ear was begins to plug up

ear was begins to plug up the outer ear canal. When ear wax blocks the ear canal so that itthe outer ear canal. When ear wax blocks the ear canal so that it begins to cause problems, it

begins to cause problems, it results in impacted ear wax, or results in impacted ear wax, or cerumen impaction. Impactedcerumen impaction. Impacted ear wax is a common phenomenon. It

ear wax is a common phenomenon. It is most likely caused when an individual cleans theis most likely caused when an individual cleans the outer ear with a cotton-tipped applicator, which ends up pushing the wax down so

outer ear with a cotton-tipped applicator, which ends up pushing the wax down so much thatmuch that it plugs the outer ear canal. This condition is

it plugs the outer ear canal. This condition is also prevalent among the population who wearalso prevalent among the population who wear hearing aids. Individuals who have impacted ear wax often

hearing aids. Individuals who have impacted ear wax often complain about hearing loss,complain about hearing loss, pain in the ear, tinnitus, cough, vertigo, or itching of

pain in the ear, tinnitus, cough, vertigo, or itching of the ear. Cerumen accumulation canthe ear. Cerumen accumulation can occur if there is an overproduction of ear wax in

occur if there is an overproduction of ear wax in response to infections or loud noises. Anresponse to infections or loud noises. An individual with an abnormally shaped ear canal may

individual with an abnormally shaped ear canal may also encounter ear wax build-up. It also encounter ear wax build-up. It maymay be removed by flushing after softening the ear wax with oil-based agents such as mineral be removed by flushing after softening the ear wax with oil-based agents such as mineral oil. Docusate sodium may also be used to

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5. Felonia, Renato Esrellado 31/M 5. Felonia, Renato Esrellado 31/M

This is the case of

This is the case of RF 31 year-old male who presented with ear pain, AS. 4 RF 31 year-old male who presented with ear pain, AS. 4 days PTC,days PTC, patient had rhinorrhea. 3 days PTC, he experienced ear fullness, AS and decreased hearing. patient had rhinorrhea. 3 days PTC, he experienced ear fullness, AS and decreased hearing. No itchiness was noted. On otoscopy, the left ET

No itchiness was noted. On otoscopy, the left ET is hyperaemic with scanty cerumen. Theis hyperaemic with scanty cerumen. The left TM is intact and also

left TM is intact and also hyperaemic and bulging. Weberhyperaemic and bulging. Weber’s test does not ’s test does not lateralizlateralize ande and Rinne’s test revealed AC>BC. The patient was diagnosed with

Rinne’s test revealed AC>BC. The patient was diagnosed with Acute Otitis Media, ASAcute Otitis Media, AS andand was prescribed with Amoxicill

was prescribed with Amoxicillin 500mg/cap, 1 cap q8 in 500mg/cap, 1 cap q8 x 7 days and Mefenamic acidx 7 days and Mefenamic acid 500mg/cap, 1 cap q6.

500mg/cap, 1 cap q6.

The middle ear cleft connects middle ear with nasopharynx and is lined by columnar The middle ear cleft connects middle ear with nasopharynx and is lined by columnar ciliated secretor

ciliated secretory epithelium. It is normally closed and opens on y epithelium. It is normally closed and opens on contraction of Tensor Velicontraction of Tensor Veli Palatini muscle. The Eustach

Palatini muscle. The Eustachian tube is the ian tube is the key to normal middle ear function. In infants thekey to normal middle ear function. In infants the ET is shorter and horizontally oriented, prone to reflux from nasopharynx and has poor TVP ET is shorter and horizontally oriented, prone to reflux from nasopharynx and has poor TVP function. In adults, the ET is longer and

function. In adults, the ET is longer and angulated at 45angulated at 45oo_{and drains better than an}_{and drains better than an infant’s.}_infant’s.

The ET functions

The ET functions to drain middle to drain middle ear secretions via mucociliary clearanear secretions via mucociliary clearance of ce of respiratrespiratoryory epithelium. It also protects the

epithelium. It also protects the middle ear from nasopharyngeal secretions and soundmiddle ear from nasopharyngeal secretions and sound pressure chang

pressure changes thru the action es thru the action of the TVP. Its of the TVP. Its most important function is that it ventilatesmost important function is that it ventilates the middle ear for optimum hearing.

the middle ear for optimum hearing.

Otitis media is the inflammation of the middle ear. Based on

Otitis media is the inflammation of the middle ear. Based on duration it is classifiedduration it is classified as acute (<3 weeks), subacute ( 3 weeks-3months) and chronic (>3 months). In

as acute (<3 weeks), subacute ( 3 weeks-3months) and chronic (>3 months). In this casethis case the inflammation occurred in 3 days hence it is classified as acute otitis media. Factors that the inflammation occurred in 3 days hence it is classified as acute otitis media. Factors that contribute to the pathogenesis of Otitis Medi

contribute to the pathogenesis of Otitis Media include infection a include infection (URTI which is most likely(URTI which is most likely the etiology in

the etiology in this case), ET dysfunction, immunologic status, allergy, environment andthis case), ET dysfunction, immunologic status, allergy, environment and social factors. In this case, the URTI caused mucosal congestion. The ET may be

social factors. In this case, the URTI caused mucosal congestion. The ET may be dysfunctional too causing persistent negative middle ear pressure. The ET

dysfunctional too causing persistent negative middle ear pressure. The ET suddenly openedsuddenly opened causing insufflations of nasopharynx secretions. The

causing insufflations of nasopharynx secretions. The secretions may have caused bacterialsecretions may have caused bacterial inoculation in the middle ear hence there is inflammation leading to otitis media. The

inoculation in the middle ear hence there is inflammation leading to otitis media. The microbiology of OM includes

microbiology of OM includes S. Pneumonia, H. S. Pneumonia, H. Influenza, Moraxella catarrhaInfluenza, Moraxella catarrhalislis and others.and others. Diagnosis of otitis media is

Diagnosis of otitis media is usually made with clinical history and otoscopic usually made with clinical history and otoscopic findings.findings. Pnuematic otoscopy, audiometry and tympanometry may also be

Pnuematic otoscopy, audiometry and tympanometry may also be done. Management of done. Management of AOM includes antimicrobial agents for 7-14 days.

AOM includes antimicrobial agents for 7-14 days. If symptomatic failure occurs, change of If symptomatic failure occurs, change of antimicrobi

antimicrobial agents, examination for other al agents, examination for other foci or tympanocentesis or foci or tympanocentesis or myringotomy may bemyringotomy may be performed. After 7-14 days, re-examination may be done,

performed. After 7-14 days, re-examination may be done, if no if no effusion is appreciated,effusion is appreciated, periodic follow up may be done. If

periodic follow up may be done. If there is effusion change of antimicrobial agent/s isthere is effusion change of antimicrobial agent/s is warrante

warranted. If effusion occurs >3 d. If effusion occurs >3 months, myringotomy with tympanostomy tube is done.months, myringotomy with tympanostomy tube is done.

6. Ante, Teresita Flores 52/F 6. Ante, Teresita Flores 52/F

This is the case of

This is the case of TA 52 year-old female who came in for TA 52 year-old female who came in for follow-up and wasfollow-up and was previously diagnosed with nasal polyposis. 13 years PTC

previously diagnosed with nasal polyposis. 13 years PTC patient had anosmia and consultedpatient had anosmia and consulted at PGH and was diagnosed with

at PGH and was diagnosed with nasal polypsnasal polyps. Patient had recurrent rhinorrhea and nasal. Patient had recurrent rhinorrhea and nasal congestion. At present the patient is asymptomatic and is awaiting schedule of FESS. On congestion. At present the patient is asymptomatic and is awaiting schedule of FESS. On anterior rhinoscopy there is a grade I whitish mass near the right middle turbinate, and a anterior rhinoscopy there is a grade I whitish mass near the right middle turbinate, and a grade II pale, whitish boggy mass at the left

grade II pale, whitish boggy mass at the left middle turbinate.middle turbinate.

Nasal polyps are polypoidal masses arising mainly from

Nasal polyps are polypoidal masses arising mainly from the mucous membranes of the mucous membranes of the nose and

the nose and paranasaparanasal sinuses. They l sinuses. They are overgrowths of the mucosa are overgrowths of the mucosa that frequentlythat frequently accompany allergic rhinitis. They are freely movable and nontender. Nasal polyps are accompany allergic rhinitis. They are freely movable and nontender. Nasal polyps are usually classified into

usually classified into antrochoanalantrochoanal polyps andpolyps and ethmoidalethmoidal polyps. Antrochoanal polyps arisepolyps. Antrochoanal polyps arise from the

from the maxillary sinusesmaxillary sinuses and are the much less common, ethmoidal polyps arise fromand are the much less common, ethmoidal polyps arise from the

the ethmoidal sinuses.ethmoidal sinuses. AntrochoanaAntrochoanal polyps l polyps are usually single and are usually single and unilateral whereasunilateral whereas ethmoidal polyps are multiple and

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block,

block, sinusitissinusitis,, anosmiaanosmia (loss of smell), and (loss of smell), and secondarysecondary infectioninfection leading toleading to headacheheadache.. Despite removal by surgery, nasal polyps are found to reoccur in about 70% of

Despite removal by surgery, nasal polyps are found to reoccur in about 70% of cases. Sinuscases. Sinus surgery require

surgery requires great amount of s great amount of precision as this involves risk of damage to orbit matter.precision as this involves risk of damage to orbit matter. The tendency to

The tendency to manifest multiple polyps is referred to manifest multiple polyps is referred to as “polyposis”.as “polyposis”. The

The pathogenesispathogenesisof nasal polyps is unknown. Nasal polyps are most commonlyof nasal polyps is unknown. Nasal polyps are most commonly thought to be caused by

thought to be caused by allergy and rarely byallergy and rarely by cystic fibrosiscystic fibrosis although a significant numberalthough a significant number are associated with non-allergic adult

are associated with non-allergic adult asthmaasthma or no respiratory or allergic trigger that can beor no respiratory or allergic trigger that can be demonstrated. These polyps have no relationship with colonic

demonstrated. These polyps have no relationship with colonic or uterine polyps. Irregularor uterine polyps. Irregular unilatera

unilateral polyps l polyps particularparticularly associated with ly associated with pain or pain or bleeding will require urgentbleeding will require urgent investigatio

investigation as n as they may represent an intranasal tumour. There are they may represent an intranasal tumour. There are various diseasesvarious diseases associated with polyp formation: Chronic

associated with polyp formation: Chronic rhinosinusitisrhinosinusitis,, Asthma,Asthma, Aspirin intoleranceAspirin intolerance,, CysticCystic fibrosis

fibrosis,, Kartagener's syndromeKartagener's syndrome,, Young's syndrome Young's syndrome,, Churg-strauss syndromeChurg-strauss syndrome aandnd Nasal

Nasal mastocytosismastocytosis. Exposure to some forms of . Exposure to some forms of chromiumchromium can cause nasal polyps andcan cause nasal polyps and associated diseases. They are also linked to

associated diseases. They are also linked to salicylate sensitivitysalicylate sensitivity.. Nasal polyps are most often treated with

Nasal polyps are most often treated with steroidssteroids or topical, but can also be or topical, but can also be treatedtreated with surgical methods. Pre-post

with surgical methods. Pre-post surgery,surgery, sinus rinsessinus rinses with a warm water (240 ml / 8 oz)with a warm water (240 ml / 8 oz) mixed with a small amount (teaspoon) of

mixed with a small amount (teaspoon) of saltssalts ((sodium chloridesodium chloride && sodium bicarbonatesodium bicarbonate) can) can be very helpful to clear the

be very helpful to clear the sinusessinuses. This method can be . This method can be also used as a preventative measurealso used as a preventative measure to discourage the polyps from growing back and should be

to discourage the polyps from growing back and should be used in combination with a nasalused in combination with a nasal steroid. The removal of nasal polyps via surgery lasts approximately 45 minutes to 1 hour. steroid. The removal of nasal polyps via surgery lasts approximately 45 minutes to 1 hour. The surgery can be done under general or local

The surgery can be done under general or local anaesthesiaanaesthesia, and the polyps are removed, and the polyps are removed using

usingendoscopic surgeryendoscopic surgery. Recovery from this type of surgery is anywhere from 1 . Recovery from this type of surgery is anywhere from 1 to 3 weeks.to 3 weeks.

7. Violanda, Brenda Gucilatar 40/F 7. Violanda, Brenda Gucilatar 40/F

This is the case of

This is the case of BV a 40 year-old female who came in BV a 40 year-old female who came in for follow-up with UTZ resultsfor follow-up with UTZ results showing enlarged nodular thyoid. 2 years

showing enlarged nodular thyoid. 2 years PTC, patient had dysphagia and odynophagia. OnPTC, patient had dysphagia and odynophagia. On PE, there is a palpable thyroid with no cervical lymphadenopathy. TSH, FT3, FT4 were

PE, there is a palpable thyroid with no cervical lymphadenopathy. TSH, FT3, FT4 were requested but showed normal values. She

requested but showed normal values. She was diagnosed withwas diagnosed with Nodular Nontoxic goiterNodular Nontoxic goiter.. She was started with levothyroxine 5 mcg. 1 tab. BID

She was started with levothyroxine 5 mcg. 1 tab. BID x 14 days.x 14 days.

Thyroid Gland has two pear-shaped lobes, isthmus (which connects the left and right Thyroid Gland has two pear-shaped lobes, isthmus (which connects the left and right lobes), and a pyramidal lobe

lobes), and a pyramidal lobe (may present as a (may present as a superior extension of the embryologicalsuperior extension of the embryological thyroid duct). A nontoxic

thyroid duct). A nontoxic goitergoiter is a diffuse or nodular enlargement of theis a diffuse or nodular enlargement of the thyroid glandthyroid gland thatthat does not result from an

does not result from an inflammatorinflammatory or neoplastic process and is not y or neoplastic process and is not associated withassociated with abnormal

abnormal thyroid functionthyroid function. The histopathology varies with etiology and age of the . The histopathology varies with etiology and age of the goiter.goiter. Initially, uniform follicular epithelial hyperplasia (diffuse goiter) is

Initially, uniform follicular epithelial hyperplasia (diffuse goiter) is present, with an present, with an increaseincrease in thyroid mass. As

in thyroid mass. As the disorder persists, the thyroid architecture loses uniformity, with thethe disorder persists, the thyroid architecture loses uniformity, with the development of areas of

development of areas of involution and fibrosis interspersed with areas of focal involution and fibrosis interspersed with areas of focal hyperplasiahyperplasia.. This process results in multiple

This process results in multiple nodulesnodules (multinodula(multinodular goiter). r goiter). On nuclear scintigraphy, someOn nuclear scintigraphy, some nodules are hot, with high isotope uptake (autonomous) or cold,

nodules are hot, with high isotope uptake (autonomous) or cold, with low isotope uptake,with low isotope uptake, compared with the normal thyroid tissue (as demonstrated in the images below). The compared with the normal thyroid tissue (as demonstrated in the images below). The development of nodules correlates with the

development of nodules correlates with the development of functional autonomy anddevelopment of functional autonomy and reduction in thyroid-stimulating hormone (TSH) levels. Clinically, the natural history of reduction in thyroid-stimulating hormone (TSH) levels. Clinically, the natural history of aa nontoxic goiter is growth,

nontoxic goiter is growth, nodule production, and functional autonomy (resultingnodule production, and functional autonomy (resulting in

in thyrotoxicosisthyrotoxicosis in a minority of patients). The overall risk of in a minority of patients). The overall risk of malignancmalignancy is the y is the same in asame in a patient with a nodular goiter as with a solitary nodule.

patient with a nodular goiter as with a solitary nodule.

The thyroid gland usually grows outward because of its location anterior to the The thyroid gland usually grows outward because of its location anterior to the trachea. Occasion

trachea. Occasionally, the thyroid wraps around ally, the thyroid wraps around and compresses the trachea and/orand compresses the trachea and/or esophagus or extends inferiorly into the

esophagus or extends inferiorly into the anterior mediastinuanterior mediastinum. Determining whether them. Determining whether the goiter has been present for many years and whether a change has occurred in the

goiter has been present for many years and whether a change has occurred in the recentrecent past is important. Recent or accelerated growth of a discrete nodule or thyroid lobe should past is important. Recent or accelerated growth of a discrete nodule or thyroid lobe should

(7)

raise the suspicion

raise the suspicion of malignancy.Goiterof malignancy.Goiters associated with s associated with unilateraunilateral adenopathy should l adenopathy should raiseraise the suspicion of

the suspicion of malignancymalignancy. Goiters rarely are painful or . Goiters rarely are painful or grow quickly unless recentgrow quickly unless recent hemorrhage into a nodule has

hemorrhage into a nodule has occurred.occurred.

Tracheal compression is generally asymptomatic until

Tracheal compression is generally asymptomatic until critical narrowing hascritical narrowing has occurred. Patients develop a dry cough,

occurred. Patients develop a dry cough, dyspnea, and stridor, especially with exertion. Indyspnea, and stridor, especially with exertion. In patients with intrathoracic goiter, the dyspnea and stridor may

patients with intrathoracic goiter, the dyspnea and stridor may be nocturnal or be nocturnal or positional (ie,positional (ie, occurring when the patient's arms are

occurring when the patient's arms are raised) when the thoracic outlet is raised) when the thoracic outlet is narrowed.narrowed. Hemorrhag

Hemorrhage into a e into a nodule or cyst or development of nodule or cyst or development of bronchitis may acutely worsen thebronchitis may acutely worsen the respirator

respiratory symptoms in y symptoms in a patient with tracheal narrowing. The esophagus is a patient with tracheal narrowing. The esophagus is more posteriormore posterior in the neck, and a goiter

in the neck, and a goiter occasionalloccasionally extends posteriorly and causes solid food and pilly extends posteriorly and causes solid food and pill dysphagia. Compress

dysphagia. Compression of ion of the recurrent laryngeal nerve by a goiter the recurrent laryngeal nerve by a goiter or invasion by a or invasion by a thyroidthyroid malignancy results in vocal cord dysfunction and

malignancy results in vocal cord dysfunction and may cause hoarseness. The superiormay cause hoarseness. The superior laryngeal nerve control

laryngeal nerve controls the pitch of s the pitch of the voice. An expanding goiter may cause a change inthe voice. An expanding goiter may cause a change in the character of the

the character of the voice, especially in individuals who use their voice voice, especially in individuals who use their voice extensively (eg, inextensively (eg, in certain occupations

certain occupations). Compression of the venous outflow through ). Compression of the venous outflow through the thoracic inlet by athe thoracic inlet by a mediastina

mediastinal goiter results in l goiter results in facial plethora and dilated neck and facial plethora and dilated neck and upper thoracic veins.upper thoracic veins.

9. Raposon, Virgilio Requejo 65/M 9. Raposon, Virgilio Requejo 65/M

This is the case of

This is the case of VR 65 year old male who VR 65 year old male who came in for follow-up with a chief came in for follow-up with a chief complaint of hoarseness for 2

complaint of hoarseness for 2 weeks. There is throat itchiness and weeks. There is throat itchiness and non-productive cough,non-productive cough, with no dysphagia or odynophagia. On indirect laryngoscopy, the TVCs are mobile. The FVC with no dysphagia or odynophagia. On indirect laryngoscopy, the TVCs are mobile. The FVC is mobile and

is mobile and swollen. There is no swollen. There is no subglottic masses, the arythenoids are nonedematous;subglottic masses, the arythenoids are nonedematous; the epiglottis is nonhyperemic and nonedematous. There is no pooling in the

the epiglottis is nonhyperemic and nonedematous. There is no pooling in the pyriform. Shepyriform. She was diagnosed with

was diagnosed with Chronic LaryngitisChronic Laryngitis..

More common in

More common in males than females, chronic laryngitis is aggravated by:males than females, chronic laryngitis is aggravated by: habitualhabitual shouting;

shouting; faulty voice production coupled with excessive vocal use faulty voice production coupled with excessive vocal use seen in teachers, actors,seen in teachers, actors, singers; smoking; spirit drinking;

singers; smoking; spirit drinking; andand chronic upper airway infection, such as sinusitis. Thechronic upper airway infection, such as sinusitis. The voice is hoarse and fatigues easily. There may be discomfort and a tendency to

voice is hoarse and fatigues easily. There may be discomfort and a tendency to clear theclear the throat constantly. Examina

throat constantly. Examination shows the cords to tion shows the cords to be thickened and pink and thebe thickened and pink and the

surrounding mucosa is often red and dry. Treatment is often ineffective. The voice should be surrounding mucosa is often red and dry. Treatment is often ineffective. The voice should be rested as far as

rested as far as possible, any upper airway sepsis dealt with and possible, any upper airway sepsis dealt with and steam inhalations given tosteam inhalations given to humidify the larynx. Voice therapy may be helpful in cases of faulty voice production and humidify the larynx. Voice therapy may be helpful in cases of faulty voice production and referral to a singing teacher is

referral to a singing teacher is of value to of value to professional or amateur singers.professional or amateur singers.

10. Garcia, Rowelyn 14/F 10. Garcia, Rowelyn 14/F

This is the case of

This is the case of RG 14 year old female diagnosed withRG 14 year old female diagnosed with Conductive Hearing LossConductive Hearing Loss,, and was advis

and was advised for PTA, ST and tympanomed for PTA, ST and tympanometry. etry. In CHL, the pathology lieIn CHL, the pathology lies in the externals in the external ear canal, ear drum (tympanic membrane), ossicles or middle

ear canal, ear drum (tympanic membrane), ossicles or middle ear. Because of the ear. Because of the pathology,pathology, impaired conduction of sound

impaired conduction of sound occur; hence, there is decreased intensity of occur; hence, there is decreased intensity of sound reachingsound reaching the cochlea. Unlike SNHL, there is no distortion of sound

the cochlea. Unlike SNHL, there is no distortion of sound hence understandhence understanding speech is noing speech is no problem with adequate intensity. Person

problem with adequate intensity. Persons with CHL tends to s with CHL tends to speak softly because they hearspeak softly because they hear the speech louder (bone>air conduction), hence they

(8)

that they are speaking loudly. Hearing loss is mild to moderate around 30-40 dB.

that they are speaking loudly. Hearing loss is mild to moderate around 30-40 dB. The mostThe most common etiology is

common etiology is Impacted cerumen and other foreign bodies. Other Impacted cerumen and other foreign bodies. Other possible etiologypossible etiology include: ear canal atresia, otitis externa/media, otosclerosis, ear canal tumors, and

include: ear canal atresia, otitis externa/media, otosclerosis, ear canal tumors, and myringitis. Diagnos

myringitis. Diagnosis of CHL is of CHL includes otoscopic findings of the ear canal and ear drum;includes otoscopic findings of the ear canal and ear drum; Weber’s test that lateralizes to the affected ear; a negative Rinne test (bone>air

Weber’s test that lateralizes to the affected ear; a negative Rinne test (bone>air

conduction); a higher air conduction threshold on PTA. Treatment is directed at the specific conduction); a higher air conduction threshold on PTA. Treatment is directed at the specific etiology. For instance, in cases of impacted cerumen, the cerumen is flushed out; or in

etiology. For instance, in cases of impacted cerumen, the cerumen is flushed out; or in AOM,AOM, the infection is relieved by

the infection is relieved by antimicrobiaantimicrobial agents.l agents.

12. Panelo, Arnold 42/M 12. Panelo, Arnold 42/M

This is the case of

This is the case of AP, 42 year old male who AP, 42 year old male who consulted for nasal obstruction and wasconsulted for nasal obstruction and was diagnosed with

diagnosed with New growth, Right nasal conchaNew growth, Right nasal concha. . The causes The causes of Nasal Obof Nasal Obstruction maystruction may be structural, such as congenital deformities, deformities from trauma or

be structural, such as congenital deformities, deformities from trauma or infection,infection, neoplastic masses or polyps, or

neoplastic masses or polyps, or foreign bodies. It may foreign bodies. It may also be systemic: physiologically italso be systemic: physiologically it can be because of the nasal cycle or the

can be because of the nasal cycle or the position or temperature; pathologicaposition or temperature; pathologically, it can belly, it can be rhinosinusi

rhinosinusitis, atrophic rhinitis, metabolic tis, atrophic rhinitis, metabolic or endocrine or or endocrine or specific chronic rhinitis.specific chronic rhinitis. In this patient a new growth was

In this patient a new growth was appreciaappreciated at the right ted at the right nasal concha, which cannasal concha, which can either be a polyp

either be a polyp or malignant neoplasm. Nasal polyps are polypoidal masses arising mainlyor malignant neoplasm. Nasal polyps are polypoidal masses arising mainly from the mucous membranes of the

from the mucous membranes of the nose and paranasal sinusesnose and paranasal sinuses. They are overgrowths of . They are overgrowths of the mucosa that frequently accompany allergic rhinitis. They are

the mucosa that frequently accompany allergic rhinitis. They are freely movable andfreely movable and nontender. Nasal polyps are

nontender. Nasal polyps are usually classified intousually classified into antrochoanalantrochoanal polypspolyps and

and ethmoidalethmoidal polyps. Antrochoanal polyps arise from thepolyps. Antrochoanal polyps arise from the maxillary sinusesmaxillary sinuses and are theand are the much less common, ethmoidal polyps arise from the

much less common, ethmoidal polyps arise from the ethmoidal sinusesethmoidal sinuses. Antrochoanal polyps. Antrochoanal polyps are usually single and unilateral whereas ethmoidal polyps are multiple and

are usually single and unilateral whereas ethmoidal polyps are multiple and bilateralbilateral.. Symptoms of polyps include nasal block,

Symptoms of polyps include nasal block, sinusitissinusitis,, anosmiaanosmia (loss of smell), and secondary(loss of smell), and secondary infection

infection leading toleading to headacheheadache. Despite removal by surgery, nasal polyps are found to. Despite removal by surgery, nasal polyps are found to reoccur in about 70% of

reoccur in about 70% of cases. Sinus surgery requicases. Sinus surgery requires great amount of precision as thisres great amount of precision as this involves risk of damage to orbit matter. The tendency to

involves risk of damage to orbit matter. The tendency to manifest multiple polyps is referredmanifest multiple polyps is referred to as

to as “polyposis”“polyposis”.. The