Iraqi Board ENT cheat sheet

Chronic suppurative otitis media (CSOM): persistent (>3 months) middle-ear inflammation with tympanic membrane perforation and otorrhoea; divided into mucosal (safe) and squamous (cholesteatoma, unsafe) types.

Cholesteatoma: keratinising squamous epithelium in the middle ear or mastoid; retraction-pocket or attic type is most common; treated surgically (tympanomastoidectomy), because antibiotics alone do not eliminate it.

Cholesteatoma complications: ossicular erosion (incus long process most often), facial nerve palsy, labyrinthine fistula, sigmoid sinus thrombosis, intracranial abscess.

Conductive hearing loss: air-bone gap with normal bone conduction; sensorineural loss: air and bone thresholds equal, with no gap. Mixed loss: both a gap and depressed bone thresholds.

Rinne test: normal = air > bone (positive); conductive loss = bone > air (negative) in that ear. Weber lateralises to the conductive or the worse sensorineural ear.

Tuning fork tests: 512 Hz is the standard frequency; Rinne and Weber are screening only and are confirmed by pure-tone audiometry.

Benign paroxysmal positional vertigo: brief (<1 minute) positional vertigo with torsional upbeating nystagmus on Dix-Hallpike; posterior canal is most common; treated with Epley canalith repositioning.

Vestibular neuronitis: acute prolonged vertigo without hearing loss; labyrinthitis adds hearing loss; both are usually viral and treated with short-course vestibular suppressants plus early vestibular rehabilitation.

Facial nerve: lower motor neuron lesion = whole ipsilateral face, with loss of forehead wrinkling; upper motor neuron lesion spares the forehead. Bell's palsy is idiopathic LMN palsy; treat with corticosteroids within 72 hours.

Chronic rhinosinusitis (CRS): ≥12 weeks of two or more of nasal obstruction, discharge, facial pain/pressure, and hyposmia, plus endoscopic or CT evidence of mucosal inflammation.

CRS phenotypes: CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP); CRSwNP is associated with asthma, aspirin-exacerbated respiratory disease, and type 2 inflammation.

First-line CRS therapy: prolonged topical intranasal corticosteroids with saline irrigation; oral steroids are short-course for severe polyposis; antibiotics are reserved for documented acute bacterial exacerbations.

Functional endoscopic sinus surgery (FESS): indicated when maximal medical therapy fails; the middle meatus and ostiomeatal complex are opened; the frontal recess, sphenoid, and posterior ethmoid cells are addressed as needed.

FESS complications: orbital entry or haematoma (lamina papyracea), CSF leak (cribriform or fovea ethmoidalis), internal carotid injury (sphenoid lateral wall), and synechiae.

Allergic rhinitis: IgE-mediated; intranasal corticosteroids are the most effective single agent for all symptoms, with oral second-generation antihistamines as adjuncts; allergen immunotherapy is disease-modifying.

Epistaxis: most arise from Kiesselbach's plexus on the anterior septum; first-line treatment is direct pressure for 10–15 minutes plus topical vasoconstrictor and cautery; posterior bleeding needs packing or sphenopalatine artery ligation.

Nasal polyps: grey, oedematous, insensitive to touch; unilateral polyp in an adult requires biopsy or imaging to exclude inverted papilloma or malignancy.

Laryngeal cancer: glottic tumours present early with hoarseness and have the best prognosis (rich lymphatic drainage is poor at the glottis); supraglottic tumours present late with nodal spread because of rich bilateral lymphatics.

Laryngeal cancer staging: T1 = confined to one subsite with normal vocal fold mobility; T2 = impaired mobility or extension; T3 = vocal fold fixation or cartilage invasion; T4 = invasion beyond the larynx.

Oral cavity cancer: the tongue and floor of mouth are the most common sites; the neck should be treated electively at ≥2 mm depth of invasion (or high-risk features); margins of ≥5 mm are the goal.

Thyroid nodules: fine-needle aspiration cytology is the first-line investigation; papillary carcinoma spreads via lymphatics and is iodine-avid; follicular carcinoma spreads haematogenously and needs histology for diagnosis.

Thyroid surgery risks: recurrent laryngeal nerve injury (hoarseness) and hypocalcaemia from parathyroid injury; bilateral RLN injury causes airway obstruction requiring immediate re-intubation or tracheostomy.

Salivary gland tumours: the parotid is the most common site, and pleomorphic adenoma is the most common benign tumour; the facial nerve runs through the parotid and must be preserved unless directly invaded.

Neck masses by age: congenital (branchial cleft cyst, thyroglossal duct cyst) in children; neoplastic or inflammatory in adults; a supraclavicular node suggests infraclavicular malignancy.

Reconstruction ladder: primary closure, then skin graft, then local flap, then regional (e.g., pectoralis major) flap, then free tissue transfer; free flaps are needed for large defects and irradiated fields.

Benign vocal fold lesions: vocal fold nodules are bilateral and at the junction of the anterior and middle thirds; polyps are usually unilateral; both are linked to phonotrauma and are treated with voice therapy first.

Dysphonia red flags: progressive hoarseness >3 weeks, smoking history, stridor, dysphagia, or a visible lesion require laryngoscopy to exclude malignancy.

Vocal fold paralysis: unilateral causes a breathy voice and diplophonia; bilateral paralysis causes stridor and airway compromise; check the entire recurrent laryngeal nerve course (thyroid, mediastinum, skull base).

Airway stenosis: classify as supraglottic, glottic, or subglottic/tracheal; subglottic stenosis is often post-intubation or autoimmune (granulomatosis with polyangiitis); treatment is dilation, laser, or resection with anastomosis.

Tracheostomy: indications are prolonged ventilation, upper airway obstruction, and airway protection; early complications include bleeding and tube misplacement; late complications include stenosis and tracheocutaneous fistula.

Swallowing disorders: dysphagia after stroke is assessed with a bedside swallow screen, then videofluoroscopy or FEES; aspiration risk is highest with liquids and with silent aspiration.

Laryngomalacia: the most common cause of stridor in infants; inspiratory stridor worse when supine and on feeding, improves with age, and supraglottoplasty is reserved for severe cases.

Acute otitis media: otalgia plus a bulging, opaque, or erythematous tympanic membrane; Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the common pathogens; amoxicillin is first-line.

Otitis media with effusion: fluid without acute infection, often after AOM; watchful waiting for 3 months, then ventilation tubes if bilateral hearing loss or speech delay.

Adenotonsillar disease: tonsillectomy is indicated for recurrent throat infection (≥7 episodes in 1 year, ≥5/year for 2 years, or ≥3/year for 3 years) or obstructive sleep apnoea.

Paediatric obstructive sleep apnoea: adenotonsillectomy is first-line; screen for obesity, Down syndrome, and craniofacial anomalies; severe OSA or comorbidity may need post-operative monitoring.

Congenital neck masses: thyroglossal duct cyst moves with tongue protrusion (Sistrunk procedure); branchial cleft cyst is lateral; dermoid cyst is midline and does not move.

Paediatric airway: laryngomalacia is the most common cause of stridor in infants; croup (barking cough, steeple sign) and epiglottitis (drooling, tripod posture) must be distinguished clinically.

Foreign body aspiration: sudden choking in a toddler with unilateral wheeze; chest X-ray may be normal; rigid bronchoscopy is diagnostic and therapeutic.

Rhinoplasty: the keystone area and the internal nasal valve are critical; dorsal reduction risks an inverted-V deformity and middle vault collapse; spreader grafts prevent this.

Nasal valve collapse: the internal valve angle is normally 10–15 degrees; a Cottle manoeuvre that improves breathing predicts benefit from valve surgery.

Facial trauma: Le Fort I, II, and III fractures are classified by level; a mandible fracture is assessed for occlusion and the inferior alveolar nerve; zygomatic complex fractures affect the orbital floor and cheek projection.

Nasal bone fracture: the most common facial fracture; reduce within 7–10 days before fibrous union; assess for septal haematoma, which needs immediate drainage to prevent saddle deformity.

Scar revision: wait for scar maturation (6–12 months); techniques include Z-plasty (lengthens), W-plasty (breaks a line), and geometric broken-line closure.

Local flaps: advancement, rotation, transposition, and interpolation; the nasolabial flap is used for nasal ala defects; the paramedian forehead flap is used for larger nasal defects.

Skin grafts: split-thickness grafts survive by plasmatic imbibition, then inosculation, then revascularisation; full-thickness grafts contract less and give better colour match.

Airway emergency: stridor is inspiratory in upper airway obstruction, expiratory in lower airway obstruction, and biphasic in fixed lesions; the first priority is to secure the airway.

Peritonsillar abscess: unilateral sore throat, trismus, and a displaced uvula; treat with needle aspiration or incision and drainage plus antibiotics; a 'hot potato' voice is typical.

Deep neck space infections: the retropharyngeal space (children, from upper respiratory infection) and the parapharyngeal space (dental source) are common; CT with contrast is the imaging of choice; airway and drainage are priorities.

Ludwig's angina: bilateral submandibular and sublingual cellulitis from a dental source; it threatens the airway and requires urgent airway management plus drainage of involved spaces.

Foreign bodies: nasal foreign body (unilateral foul discharge) is removed with a hook or forceps; button batteries in the nose or oesophagus are emergencies and must be removed urgently.

Epistaxis emergency: posterior bleeding may not respond to anterior packing; use posterior packing or balloon, then sphenopalatine artery ligation or embolisation; watch for bradycardia from the oculocardiac reflex.

Caustic ingestion: do not induce vomiting; assess the airway; endoscopy within 24–48 hours grades injury; steroids are not routinely recommended.

Pure-tone audiometry: normal hearing is ≤25 dB HL; conductive loss has an air-bone gap; sensorineural loss has equal air and bone thresholds; the audiogram plots frequency (Hz) against hearing level (dB).

Speech audiometry: the speech reception threshold should agree with the pure-tone average within 10 dB; rollover suggests retrocochlear pathology.

Tympanometry: type A = normal middle-ear pressure; type B = effusion or perforation; type C = negative pressure from eustachian tube dysfunction; the normal peak is around 0 daPa.

Otoacoustic emissions: present in normal cochlear outer hair cells; absent in sensorineural loss >25–30 dB; used for newborn screening and to detect cochlear (not retrocochlear) pathology.

Auditory brainstem response: used for newborn hearing screening, threshold estimation, and detecting retrocochlear lesions; the interpeak latency I–V is prolonged in acoustic neuroma.

Vestibular testing: caloric testing assesses the horizontal semicircular canal; a reduced response indicates unilateral weakness; the head impulse test is a bedside test of the vestibulo-ocular reflex.

Hearing rehabilitation: hearing aids for mild-to-severe loss; cochlear implants for severe-to-profound bilateral sensorineural loss with limited benefit from aids; the earlier the implantation in children, the better the language outcome.

Anatomy: the middle ear ossicles are the malleus, incus, and stapes; the stapes footplate sits in the oval window; the round window provides pressure release; the chorda tympani carries taste from the anterior two-thirds of the tongue.

Larynx: the vagus nerve gives the superior laryngeal nerve (external branch = cricothyroid, pitch; internal branch = sensation above the vocal folds) and the recurrent laryngeal nerve (all other intrinsic muscles).

The recurrent laryngeal nerve loops around the subclavian artery on the right and the aortic arch on the left; the left is longer and more vulnerable to mediastinal disease.

Microbiology: the most common organisms in acute otitis media are S. pneumoniae, H. influenzae, and M. catarrhalis; in CSOM, Pseudomonas aeruginosa and Staphylococcus aureus predominate.

Pharmacology: aminoglycosides are ototoxic (cochlear and vestibular); loop diuretics are ototoxic; aspirin causes reversible tinnitus; intratympanic gentamicin is used for intractable Ménière's disease.

Immunology: IgE-mediated type I hypersensitivity underlies allergic rhinitis; eosinophils and type 2 cytokines (IL-4, IL-5, IL-13) drive CRSwNP; biologics target IgE or IL-4/IL-13 receptors.

Pathology: squamous cell carcinoma is the most common malignancy of the head and neck; risk factors are tobacco and alcohol; HPV-related oropharyngeal cancer has a better prognosis.