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Annual 2003Q.No.2Write short note on causes of (L) recurrent NERVE PALSYAns!

These are

a. Carcinoma of bronchusb. Carcinoma of the cervical and thoracic esophagusc. Carcinoma of thyroid glandd. Operative trauma from throidectomy, radical neck dissection, pharyngeal

pouch removal, cricopharyngeal myotomy, ligation of patent ductus andother cardiac and pulmonary surgery.

e. Mediastinal nodes or tumours, e.g. Hodgkin’s diseasef. Any enlargement of the left atrium, e.g. mitral stenosisg. eripheral neuritish. Aortic aneurysm

OTH!" CA#$!$ MA% &!

a. High vagal lesionsb. $ystemic causes i.e. 'iabetes, syphilis, diphtheria, typhoid, streptococcal orviral infections, lead poisoning

c. (diopathic Pa"e #$# Lo"an %urner&s EN% an' PA E

2 $ *hin"raAnnual 200+

Q.N,.3-o ill /ou in esti"ate a 1ft/ /ears ol' an ho resents ithhoarseness of oiceAns!

4n esti"ations!#. -istor/ . Mode of onset and duration of illness, patient)s occupation,habits and associated complaints are important and *ould often help toelucidate the cause. Any hoarseness persisting for more than three *eeksdeserves e+amination of laryn+. Malignancy should be e+cluded in patientsabove - years. 2. 4n'irect lar/n"osco /. Many of the local laryngeal causes can bediagnosed .3. E5a ination of nec67 chest7 car'io ascular an' neurolo"icals/ste *ould help to nd cause for laryngeal paralysis.+. La8orator/ in esti"ations an' ra'iolo"ical e5a ination should be

done as perdictates of the cause suspected on clinical e+amination.9. *irect lar/n"osco / an' icrolar/n"osco / help in detailede+amination, biopsy of the lesions and assessment of the mobility ofcricoarytenoid /oints.:. ;ronchosco / an' oeso ha"osco / may be re0uired in cases ofparalytic lesions of the cord to e+clude malignancy.Reference *hin"ra Pa"e 2$ + th e'ition

Su le entar/ 200+

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1.2O.'iscuss indications and complications of tracheostomy3

Annual 2009Q.N,.:

A

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Wa"ner an' ross an theor/A high lesion of the vagus nerve *ill leave the paraly>ed cord

further from the midline ? aramedian@ than the paralysis of therecurrent laryngeal nerve.

PA E #$0 L, AN %@RNER7 PA E 2 *-4N RA

Annual 200:Q.N,.a) What are Vocal No'ules8) i e the etiolo"/ an' clinical features of this con'ition.c) What is its re entionAns!

a) Vocal No'ules! They appear symmetrically on the free edge of vocal cord, at the

/unction of anterior one third, *ith the posterior t*o thirds, as this isthe area of ma+imum vibration of the cord and thus sub/ect to

ma+imum trauma. Their si>e varies from that of pin head to half a pea.8) Etiolo"/! They are the result of vocal trauma *hen person speaks inunnatural lo* tones for prolonged periods or at high intensities.

They mostly a;ect teachers, actors, vendors or pop singers. Theyare also seen in school going children *ho are too assertive andtalkative.>linical

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● 9ateral soft tissue ray of neck may sho* s*ollen epiglottis ?thumb sign@.c) Anti8iotic!

Ampicillin or third generation cephalosporin are e;ective.') Air a/!● (ntubation or tracheostomy.●

&ronchoscopy.● O+ygen (nhalation.

PA E 2$ *-4N RAAnnual 200$

Q.N,.##A ale 90 /ears of a"e resente' ith -oarseness of oice for :

onths. 4t is ro"ressi e. ,n in'irect lar/n"osco / there is a asson the ri"ht ocal cor' hich e5ten's su ra"loticall/ across the

entricle of the lar/n5. %he ri"ht he ilar/n5 is 15e'. %here is nonec6 no'es an' no e i'ence of 'istant etastasis.

a) What is ro8a8le 'ia"nosis

8) -o ill /ou con1r /our 'ia"nosis an' sta"e the 'iseasec) -o ill /ou ana"e the atientAns!

a) *ia"nosis!Carcinoma of laryn+

8) >on1r ation of *ia"nosis!#) History2) (ndirect laryngoscopy● Appearance of lesion● Bocal cord mobility● !+tend of disease

3) E5a ination of nec6 To nd out e+tra laryngeal spread of disease

+) Ra'io"ra h/Chest ray, soft tissue lateral vie* neck, contrast laryngogram

9) >% scan:) *irect lar/n"osco /?) =icrolar/n"osco /$) ;io s/

S%A E T D2 - M-

c) =ana"e ent!See Q.N,.:

PA E 30$ 30 *-4N RAAnnual 200

Q.N,.#2A 3 /ear ol' 1t 8o/ starte' ha in" sore throat hich 'e elo e' into'/s ha"ia uic6l/. 4ns irator/ stri'or ith 'roolin" of sali afollo e' soon. %he chil' loo6s terri1e' an' feels co forta8le onl/ insittin" an' leanin" for ar' osition.

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a) What is the ro8a8le 'ia"nosis8) -o ill /ou secure the air a/ in this atientc) Na e three other con'itions hich can easil/ i ic this clinical

ictureAns!

a) See Q.N,.#08) See Q.N,.#0c) 9aryngomalacia

"etrophyrangeal abscess9aryngeal *eb

Pa"e 2$ *hin"raQ.N,.#3A ?0 /ears ol' an7 s o6er is suBerin" fro hoarseness of oice forlast 2 /ears. Recentl/ he 'e elo e' nois/ 8reathin" an' at ti ess ells of res irator/ 'istress. ;ut for last 2 'a/s res irator/ 'istress

as ersistent co ellin" the fa il/ to see6 e'ical a' ice in

acci'ent an' e er"enc/ 'e art ent.a) What ill 8e /our i e'iate action8) -o ill /ou e5ecute /our actionc) What co lications can occur 'urin" the rocessC roce'ure') -o ill /ou ana"e the atient further

Ans!a) Tracheostomy8) Proce'ure!● A vertical incision is made in the midline of neck, e+tending from cricoid

cartilage to /ust above the sternal notch. This is the most favored incisionand can be used in emergency and elective procedures. (t gives rapid access

*ith minimum of bleeding and tissue dissection. A transverse incision, 6 cmlong, made < ngers) breadth above the sternal notch can be used in electiveprocedures. (t has the advantage of a cosmetically better scar.

● After incision, tissues are dissected in the midline. 'ilated veins are eitherdisplaced or ligated.

● $trap muscles are separated in the midline and retracted laterally.● Thyroid isthmus is displaced up*ards or divided bet*een the clamps, and

suture ligated.● A fe* drops of 7 lignocaine are in/ected into the trachea to suppress the

cough *hen trachea is incised.● Trachea is +ed *ith a hook and opened *ith a vertical incision in the region

of Drd and th or Drd and e is inserted and secured by tapes ?seepage -E for di;erent types and si>e of tracheostomy tubes@.

● $kin incision should not be sutured or packed tightly as it may lead todevelopment of subcutaneous emphysema.

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● :au>e dressing is placed bet*een the skin and Fange of the tube around thestoma.

c) See Q.N,.+') See Q.N,.: Treatment of Carcinoma laryn+.

Pa"es 3#?D3#$ 'hin"ra.

Annual 20#0Q.N,.#+A 2 /ear ol' 8a8/ 8o/ is ha in" a fe er of #0#

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a) See Q.N,.+8) %reat ent!

'epends upon situation hemorrhage can be treated by electrocauteri>ing the bleeding vessel. $urgeon should take care *hile puttingtube so that it does not cause any damage to surrounding tissues.

ost op caring steps should be follo*ed strictly.

Q.N,.#:a) What is the etiolo"/ of carcino a lar/n58) What is the treat entANS

a) Etiolo"/!&oth to8acco an' alcohol are *ell established risk factors inlaryngeal cancer. Cigarette smoke contains ben>opyrene and otherhydrocarbons *hich are carcinogenic in man. Combination of alcoholand smoking increases the risk 86 folds compared to each factor alone

?< D folds@. revious ra'iation to neck for benign lesions or laryngealpapilloma may induce laryngeal carcinoma. Iapanese and "ussian*orkers have reported cases of familial laryngeal malignancyincriminating "enetic factors . ,ccu ational e5 osure to asbestos,mustard gas and other chemical or petroleum products has also beenrelated to the genesis of laryngeal cancer but *ithout conclusiveevidence.

8) See Q.N,.: PA E 30? *-4N RA

Annual 20##Q.N,.#?

A 2 /ear ol' chil' resente' in e'iatric e er"enc/ roo ithse ere 4ns irator/ stri'or for the last 2+ hours in the onth of*ece 8er.

a) i e 3 li6el/ causes of stri'or8) i e 3 a/s of securin" his air a/c) i e ra'iolo"ical in esti"ation ith ositi e 1n'in"s in each

'ia"nosis

Ans!a) >auses!● (nspiratory stridor is often produced in obstructive lesions of supraglottis or

pharyn+, e.g. laryngomalacia or retropharyngeal abscess.● !+piratory stridor is produced in lesions of thoracic trachea, primary and

secondary bronchi, e.g. bronchial foreign body, tracheal stenosis.● &iphasic stridor is seen in lesions of glottis, subglottis and cervical trachea,

e.g. laryngeal papillomas, vocal cord paralysis and subglottis stenosis.8) Wa/s ,f Securin" Air a/!● 'irect 9aryngoscopy● :eneral anesthesia follo*ed by &ronchoscopy

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● Microlaryngoscopy● Tracheostomy in some typesc) Ra'iolo"ical 4n esti"ations!● ray of chest and soft tissue neck both in anteroposterior and lateral vie*s.● Jluoroscopy to see chest movements both during inspiration and e+piration.● Tomography of chest for Mediastinal mass.● Oesophagogram *ith lipoidal for atresia of oesophagus, tracheobronchial

stula or aberrant vessels.● Angiography, if aberrant vessels are suspected.● eroradiography is useful to sho* soft tissue lesions in the neck.● CT scan.

Pa"e 2 :D2 ? *hin"ra7 Pa"e 3$2 Lo"an %urnerQ.N,.#$Enu erate >o lications of tracheosto /Ans!See Q.N,.+

Q.no.#A +0 /ear ol' la'/ teacher7 =arrie'7 has 9 chil'ren an' co lains ofhoarseness for last : onths.

a) Enu erate + causes of -oarseness of oice8) -o ill /ou treat ocal no'ules

Ans!a) >auses!

4nFa ationAcute

>hronic

Acute laryngitis usually follo*ing

cold, inFuen>a, e+anthematous fever,laryngo tracheo bronchitis,diphtheria.

8@S eci1c . Tuberculosis, syphilis, scleroma,fungal infections.

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trauma ?blunt and sharp@, foreignbodies, intubation

Paral/sis aralysis of recurrent, superiorlaryngeal or both nerves

ae') %reat ent!● -os italiGation . !ssential because of the danger of respiratory obstruction.● Anti8iotics . Ampicillin or third generation cephalosporin are e;ective

against H. inFuen>ae and are given by arenteral route ?(.M. or (.B.@ *ithout*aiting for results of throat s*ab and blood culture.

● Steroi's . Hydrocortisone or de+amethasone is given in appropriate doses(.M. or (.B. They relieve oedema and may obviate need for tracheostomy.

● A'e uate h/'ration . atient may re0uire parenteral Fuids.● -u i'i1cation an' o5/"en . atient may re0uire mist tent or a croupette.● 4ntu8ation or tracheosto / may be re0uired for respiratory obstruction.

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Pa"e 2$ D2 0 *-4N RAQ.N,.2#What is osto erati e nursin" care of tracheosto / atientAns!P,S% ,P N@RS4N

8. >onstant su er ision . After tracheostomy,constant supervision of the patient for bleeding, displacement orblocking of tube and removal of secretions is essential. A nurse orpatient)s relative should be in attendance. atient is given a bell ora paper pad and a pencil to communicate.

er or keeping a boiling kettle in the room.▪ ?b@ (f crusting occurs, a fe* drops of normal or hypotonic saline or "inger)s

lactate are instilled into the trachea every < D hours to loosen crusts. Amucolytic agent such as acetylcysteine solution can be instilled to li0uefytenacious secretions or to loosen the crusts.

. >are of tracheosto / tu8e . (nner cannula shouldbe removed and cleaned as and *hen indicated for the rst D days.Outer tube, unless blocked or displaced, should not be removed forD days to allo* a track to be formed *hen tube placement *ill

become easy. After D days, outer tube can be removed andcleaned every day.

Pa"e 3#$ 'hin"ra.Annual 20#2

Q.N,.2#a) Enu erate + >auses of stri'or in a + /ear

ol' chil' ho is not fe8rile8) What are clinical features of

LARYN ,=ALA>4AANS

a) >auses!● apillomatosis● (n/ury● Joreign body● 9aryngeal edema● Adenotonsillar hypertrophy8) Lar/n"o alacia!

(t is characteri>ed by e+cessive Faccidity of supraglotticlaryn+ *hich is sucked in during inspiration producing stridor and

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a) What 'o /ou sus ect in this case an' hat are 'iBerentossi8ilities

8) -o 'o /ou in esti"ate this casec) -o ill /ou ana"e this case (Annual 20#3)

Ans!

A) This is a case of voice strain also kno*n as honasthenia.,ther ossi8ilities are 8@ (nFammation like acute or chronic laryngitis, inFuen>a, laryngo tracheo

bronchitis, atrophic laryngitiso lications!

A) 4 e'iate (at the ti e of o eration)8@ Hemorrhage.

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Ans!a) Vocal no'ule See Q.N,. An' Q.N,.#8) Patholo"/!

athologically, trauma to the vocal cord in the form of vocal abuse ormisuse causes oedema and haemorrhage in the submucosal space.

This undergoes hyalini>ation and brosis. The overlying epithelium alsoundergoes hyperplasia forming a nodule. (n early stages, the nodulesappear soft, reddish and edematous s*ellings but later become grayishor *hite in color.

c) See Q.N,. an' Q.N,.#Annual 20#+

Q.N,.2?A ?0 /ears ol' ale ith carcino a of lar/n5 an' stri'or for last 2

onths is 8rou"ht to e er"enc/ 'e art ent. An ur"ent%racheosto / is carrie' out an' hen trachea is o ene' an'tracheosto / tu8e is lace' in the trachea it is o8ser e' that

atient is not 8reathin".a) What has ha ene' to the atient8) What is cause of this con'itionc) -o ill /ou ana"e this atient

Ans!a@ Apnoeab@ This follo*s opening of trachea in a patient *ho had prolonged respiratory

obstruction. This is due to sudden *ashing out of CO< *hich *as acting as arespiratory stimulus.

c@ . Treatment is to administer 67 CO< in o+ygen or assisted ventilation.Reference Q.N,.29(c)

Q.N,.2$A 2 /ear ol' 8o/ hile la/in" ith his to/s 'e elo e' su''encho6in". -e is c/anose' an' has intense 4ns irator/ stri'or hen8rou"ht to e er"enc/ roo . -o ill /ou ana"e hiAns!=ana"e ent!Lar/n"eal forei"n 8o'/!

A large bolus of food obstructed above the cords may make the patienttotally aphonic, unable to cry for help. He may die of asphy+ia unlessimmediate rst aid measures are taken. The measures consist of poundingon the back, turning the patient upside do*n and follo*ing Heimlich

maneuver. These measures should not be done if patient is only partiallyobstructed, for fear of causing total obstruction.

-ei lichJs aneu er . $tand behind the person, and place your armsaround his lo*er chest and give four abdominal thrusts. The residual air inthe lungs may dislodge the foreign body providing some air*ay.

Cricothyrotomy or emergency tracheostomy should be done ifHeimlich)s maneuver fails. Once acute respiratory emergency is over, foreign

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body can be removed by direct laryngoscopy or by laryngo ssure, if foundimpacted.%racheal an' 8ronchial forei"n 8o'ies!

These can be removed by bronchoscopy *ith full preparation andunder general anesthesia. !mergency removal of these foreign bodies is not

indicated unless there is air*ay obstruction or they are of the vegetablenature ?e.g. seeds@ and likely to s*ell up.

=etho's to re o e tracheo8ronchial forei"n 8o'/!● Conventional rigid bronchoscopy.● "igid bronchoscopy *ith telescopic aid.● &ronchoscopy *ith C arm Fuoroscopy.● #se of 'ormia basket or Jogarty)s balloon for rounded ob/ects.● Tracheostomy rst and then bronchoscopy through the tracheostome.● Thoracotomy and bronchotomy for peripheral foreign bodies.● Jle+ible bre optic bronchoscopy in selected adult patients.

Pa"e 323 *hin"ra :th

E'ition.Q.No.2A : /ear ol' chil' resents ith hi"h "ra'e fe er7 '/s ha"ia an'stri'or. ,n e5a ination he is sittin" an' leanin" for ar' ith'ri88lin" of sali a. -e is loo6in" to5ic. -e has ha' histor/ of Futhree 'a/s a"o.

a) What is ost ro8a8le 'ia"nosis8) i e its 'iBerential 'ia"nosisc) -o ill /ou ana"e it Enu erate four ste s of ana"e ent

ANSSee Q.N,.#07 #2 an' 20

Su le entar/ 20#+Q.N,.30A ale 90 /ears of a"e resents ith hoarseness of oice for t o

onths hich is ro"ressi e. Patient is s o6er for 30 /ears. 4n'irectlar/n"osco / sho s a ass on the ri"ht ocal cor' hich is o8ile.%here is no si"ni1cant e5tension of the ass. %here are no nec6no'es.

a) What is ost ro8a8le 'ia"nosis8) -o ill /ou ro e /our 'ia"nosisc) What are the treat ent o tions

Ans!See Q.N,.3 an' Q.N,.: