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Third (Final) M.B.B.S. Degree Examination (August 2006) question paper with
solutions
Dr T Balasubramanian
I. Write Essay:
1. Describe the clinical features, diagnosis and management of cancer oesophagus. (15 marks)
a.Difficulty in swallowing
b. Painful swallowing.
Usually dysphagia is the most common symptom. Initially dysphagia is pronounced for solid
food. Fluids and semisolid diet are better tolerated.
c. These patients manifest with excessive loss of weight which could be due to:
Difficulty in swallowing
Reduced appetite due to malignancy.
d. Heart burns – These patients characteristically complain of burning pain in the midline of the
chest. This type of pain progressively gets worse and is made still worse by the act of swallowing.
e. Voice change – This is usually due to involvement of recurrent laryngeal nerves causing paralysis
of vocal folds. Right recurrent laryngeal nerve is commonly involved in these patients. During
early stages these patients may have varying degrees of aspiration. Sometimes aspiration may be
severe enough to cause aspiration pneumonitis.
f. Disruption of peristalsis – The sheer bulk of tumor present intraluminally within the oesophagus
may cause disruption of normal peristalsis. This could cause nausea, vomiting and food
regurgitation.
g. Haematemesis – If the tumor is friable it can cause intraluminal bleeding leading on to
hematemesis.
h. Compression symptoms – Increasing bulk of oesophageal mass can cause compression of local
structures. It can cause compression to trachea leading on to upper airway obstruction. Another
area of compression is at the level of superior vena cava causing superior vena caval syndrome.
Erosion of trachea may lead to troublesome tracheo oesophageal fistula.
Diagnosis:
Radiology:
Barium swallow / meal can reveal occlusal mass in the oesophagus.
CT scan imaging will reveal the extent of the lesion, compression to adjacent structures if any.
Metastatic lesions can also be identified by performing CT scan.
PET scans can be used to identify and ascertain whether the lesion is active and metabolically
active.
Upper GI endoscopy:
This is the standard in the diagnosis of oesophageal cancer. It helps in identifying the exact
location of the lesion, biopsying the lesion. The location of the tumor is generally measured from
the incisor.
Histopathology:
This offers the final diagnosis. Adenocarcinoma is common in the lower oesophagus while
squamous cell carcinoma is prevalent in the upper third of oesophagus.
Management:
The ideal management modality is determined by:
Chemotherapy is reserved for advanced lesions. It also depends on the histological type of the
tumor. The drugs used include:
Cisplatin
5-flurouracil.
3. Discuss the etiology, clinical features, management and complications of acute frontal sinusitis.
(2+3+3+2)
Introduction:
Acute frontal sinusitis is defined as inflammation of mucosal lining of frontal sinus and it’s out
flow tract of less than 3 weeks duration. The incidence of acute frontal sinusitis is considerably
lower when compared with that of maxillary sinusitis in adults and ethmoidal sinusitis in
children. Early diagnosis and management of acute frontal sinusitis will go a long way in preventing
development of complications.
Incidence:
Acute sinusitis commonly affects 20% of population. Acute frontal sinusitis affects about 4% of
these individuals. Acute frontal sinusitis commonly affects adolescent males and young men. The
age predilection is due to the fact that frontal sinuses become vascular and enlarge rapidly during 7
– 15 years of life. Male predilection largely remains unexplained.
Etiopathogenesis:
Acute frontal sinusitis is commonly preceded by viral infections of upper respiratory
tract. Rhino virus has been commonly implicated. Other viruses like corona virus, respiratory
syncitial virus and Para influenza viruses have been implicated. Viral infections up regulate
inflammatory cytokines like IL6, IL8, Tumor necrosis factor ά, histamine and bradykinin. These
A series of accessory ethmoidal cells line the frontal sinus outflow tract. These cells receive
various names according to their position in relation to the sinus outflow tract. These cells include:
1. The agger nasi cell
2. Frontal intersinus septal cells
3. Suprabullar cells
4. Frontal / infundibular cells
Bent and Khun classified frontal infundibular cells based on their proximity to agger nasi cell.
Diagnosis:
Acute frontal sinusitis is a clinical diagnosis depending on the duration of symptoms, i.e. lasting
for less than 4 weeks. CT scans may show false positive results.
1. Pain / tenderness over frontal sinus (tenderness can be elicited by applying pressure in the
floor of the frontal sinus.
2. Head ache showing classic periodicity (More during early morning hours and gets better as
the day progresses). This is due to the gravitational effects of frontal sinus drainage.
3. Nasal obstruction
4. Purulent rhinorrhoea
5. Fever
6. Hyposmia / anosmia
Unless complications are suspected imaging is not a must in the diagnosis of acute frontal sinusitis.
Aims of treatment:
1. High fever
2. Photophobia
3. Neck pain
4. Neck stiffness
5. Severe headache
6. Altered mental status
Osteomyelitis is one of the complications of acute frontal sinusitis. This is caused by direct
extension of infection or by thrombophlebitis involving the diploic veins. In patients with
osteomyelitis of anterior table of frontal bone may lead to formation of subperiosteal abscess which
present as swelling over the forehead. This is also known as the “Pott’s puffy tumor”.
Surgery is indicated in recalcitrant cases. It includes frontal sinus trephening and endoscopic
decompression.
II – Type II frontal cell (a series of air cells above agger nasi but below the orbital roof)
III – Type III frontal cell (this cell extends into the frontal sinus but is contiguous with agger nasi
cell)
Diagnosis:
Acute frontal sinusitis is a clinical diagnosis depending on the duration of symptoms, i.e. lasting
Pain / tenderness over frontal sinus (tenderness can be elicited by applying pressure in the floor of
the frontal sinus.
Head ache showing classic periodicity (More during early morning hours and gets better as the day
progresses). This is due to the gravitational effects of frontal sinus drainage.
Nasal obstruction
Purulent rhinorrhoea
Fever
Hyposmia / anosmia
Unless complications are suspected imaging is not a must in the diagnosis of acute frontal sinusitis.
Aims of treatment:
Meningitis is one of the important intracranial complications of acute frontal sinusitis. Signs and
symptoms of meningitis include:
High fever
Photophobia
Neck pain
Osteomyelitis is one of the complications of acute frontal sinusitis. This is caused by direct
extension of infection or by thrombophlebitis involving the diploic veins. In patients with
osteomyelitis of anterior table of frontal bone may lead to formation of subperiosteal abscess which
present as swelling over the forehead. This is also known as the “Pott’s puffy tumor”.
Surgery is indicated in recalcitrant cases. It includes frontal sinus trephening and endoscopic
decompression.
Epidemiology:
The typical patient with malignant otitis externa is an elderly diabetic, with males outnumbering
females by twice the number. This could be due to the possibility of males being more prone to
secrete wax which are more acidic in nature. Malignant otitis externa is very rare in children; if
present it will be associated with malnutrition or HIV infection.
Pathophysiology:
Treatment:
b. Cerumen:
This is also known as ear wax. This is a yellowish waxy substance secreted in the external auditory
canal of humans. It protects the skin lining of the external auditory canal from excessive moisture.
It also protects the external canal from bacteria, fungi and insects.
Humans are known to secrete two types of cerumen:
1. Soft and moist
2. Firm and dry
Persons secreting soft and moist type of ear wax have no problem due to its accumulation. It can
easily be extruded by the normal cleansing mechanism of the external auditory canal. This
difference in wax secretion has been traced to alterations in C11 gene. Persons secreting frim and
dry wax are more prone for impaction of cerumen. Impaction of cerumen causes conductive
hearing loss.
Cerumen is usually produced in the outer third of the cartilagenous portion of the external auditory
canal. It is composed of:
1. Viscous secretions from sebaceous glands
2. Less viscous secretions from modified apocrine sweat glands
3. Shed layers of skin
Cerumen has been found to have bacterostatic effect. Excessive occlusion of the external canal due
to accumulation of cerumen and desquamated epithelial cells associated with migration defect of
the lining epithelium can cause keratosis obturans. This is a painful condition which needs to be
treated by removing the mass under anesthesia.
Removal of cerumen can be performed using probes / curettes if the consistency is soft. If cerumen
is excessively soft then cotton buds can be used for removal.
Firm cerumen should be lubricated by using ceruminolytics / liquid paraffin to soften it up before
attempted removal.
Aural syringing is one of the painless way of removing accumulated cerumen.
c. Septoplasty:
Incision: Freer's Hemitransfixation incision is used to gain access to the nasal septum. This incision
is sited 2 mm posterior to the caudal edge of cartilagenous septum.
Anterior tunnel is created between the cartilage and the perichondrium. This anterior tunnel is
created on both sides. Sometimes to gain adequate exposure to nasal septum, inferior tunnels need
to be created.
In making the inferior tunnels, there is a posterior and anterior approach. The posterior approach is
also known as the maxilla - premaxilla approach.
Correction of septal pathology: If the deviation of the septum is caused by excessive tension to the
septal cartilage, it can be corrected by removing an inferior cartilagenous strip. Dislocations due to
fractures can be corrected intraseptally by mobilizing or resection of parts of nasal septum.
Removal of septal pathology: Severe deformities involving the nasal septum may rarely require
complete removal of septal cartilage. The resected area is reconstructed using the cartilagenous
elements removed from the septum.
Indications for resection include duplications, spines, crests and convexities present in the septum.
All the cartilagenous material removed should be saved for reconstruction. The parts of nasal
septum that are straight are preserved to support the dorsum, tip and columella of the nose.
Reshaping cartilage and bone: Reshaping of nasal septal cartilage should be done with as little
trauma as possible, with maximum preservation of straight portions of nasal septum. Cartilage does
not heal. Fractures and defects of the septal cartilage will be filled with connective tissue.
Retraction of connective tissue can alter a good surgical result during the course of healing process.
The dynamics of healing process of septal cartilage should be clearly understood before embarking
on this step.
Reconstruction of nasal septum: The patients septal cartilage is the most ideal one for nasal septal
reconstruction. Other materials like ear cartilage or rib cartilage should be used only as a second
choice. Use of septal cartilages from tissue bank can be avoided if possible due to the risk of
infections. A strong strip of cartilage under the cartilagenous dorsum of the nose should prevent the
formation of saddle nose. Tip projection is preserved by placing a strip of cartilage in the caudal
part of nasal septum. This step will also prevent columella retraction in these patients. Small bits of
cartilage pieces can be used to fill up a defect in the cartilagenous septum to prevent retraction of
nasal soft tissues due to scar formation.
Stabilizing the septum after surgery: This can be achieved by judicious use of splints, sutures and
by packing the nasal cavity with roller gauze. This not only helps to stabilize the septum, but also
Otogenic brain abscess always develop in the temporal lobe or the cerebellum of the same side of
the infected ear. Temporal lobe abscess is twice as common as cerebellar abscess. In children nearly
25% of brain abscesses are otogenic in nature, whereas in adults who are more prone to chronic ear
infections the percentage rises to 50%. The routes of spread of infection has already been discussed
above, the commonest being the direct extension through the eroded tegment plate. Although dura is
highly resistant to infection, local pachymeningitis may be followed by thrombophlebitis
penetrating the cerebral cortex, sometimes the infection could extent via the Virchow - Robin spaces
in to the cerebral white matter. Cerebellar abscess is usually preceded by thrombosis of lateral sinus.
Abscess in the cerebellum may involve the lateral lobe of the cerebellum, and it may be adherent to
the lateral sinus or to a patch of dura underneath the Trautmann's triangle.