ENT Pathology
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Direct answer
Recurrent epistaxis in an adolescent boy, a neck node in an adult from an endemic region, hoarseness in a smoker — ENT pathology for FMGE clusters around a handful of recurring entities: nasopharyngeal carcinoma, an EBV-associated non-keratinising tumour that presents as a cervical node mass; juvenile nasopharyngeal angiofibroma, the bleeding tumour of adolescent boys in which biopsy is contraindicated; laryngeal carcinoma, where the glottic site presents earliest through hoarseness; cholesteatoma, a keratinising epidermoid cyst of the middle ear that erodes bone; and otosclerosis, the stapes-fixing bone disease of young adults. Squamous cell carcinoma underlies most head-and-neck malignancy, and tobacco, alcohol and betel quid remain its drivers in Indian patients.
What you must remember
- Nasopharyngeal carcinoma: WHO non-keratinising (undifferentiated) type is EBV-associated, presents with a neck node, nasal obstruction or epistaxis and otitis media from Eustachian blockage; it is radiosensitive, and serum EBV DNA tracks disease.
- Juvenile nasopharyngeal angiofibroma: adolescent males, posterior nasal mass with recurrent epistaxis and obstruction; biopsy is contraindicated because of haemorrhage — diagnosis is angiographic and treatment embolisation plus surgical excision.
- Sinonasal neighbours: inverted (Schneiderian) papilloma is unilateral, locally recurrent and carries malignant potential; occupational wood-dust exposure links to intestinal-type sinonasal adenocarcinoma.
- Laryngeal carcinoma: glottic cancers present early with persistent hoarseness and metastasise late (sparse lymphatics); supraglottic and subglottic sites present later with node disease; smoking is the driver.
- Vocal cord lesions: singer's nodules are bilateral, at the junction of the anterior and middle thirds, from voice abuse; a polyp is usually unilateral and haemorrhagic.
- Middle ear disease: cholesteatoma is keratinising stratified squamous epithelium in the middle ear — bone erosion threatens facial nerve and labyrinth, and chronic suppurative otitis media is the substrate; malignant otitis externa is Pseudomonas osteomyelitis of the skull base in elderly diabetics.
- Otosclerosis: abnormal bone around the oval window fixing the stapes footplate, conductive deafness in young adults with a positive family history; no history of otorrhoea — the point that separates it from chronic otitis media.
A teenager who will not stop bleeding
A 15-year-old boy attends the emergency department for the third time in two months with brisk epistaxis and increasing nasal obstruction; anterior rhinoscopy suggests a mass in the posterior nasal cavity. The correct next step is imaging, not biopsy: contrast CT and MRI with angiography show a vascular tumour extending through the sphenopalatine foramen — juvenile nasopharyngeal angiofibroma. Biopsy here is famously contraindicated because these tumours can bleed catastrophically; the pathway is preoperative embolisation followed by endoscopic excision, with recurrence risk related to residual invasion. Contrast the adult with painless unilateral nasal obstruction and a fleshy mass: that lesion should be biopsied, because inverted papilloma and carcinoma enter precisely there. Same anatomical corridor, opposite rules about tissue diagnosis — the ENT question most reliably tested.
Where students slip
The site-deafness logic of laryngeal cancer is inverted by candidates: hoarseness appears early in glottic cancer (vocal cord mobility is disturbed early) while supraglottic disease whispers until a neck node appears. Cholesteatoma gets dismissed as a tumour or as "chronic discharge" — it is a keratinising epidermoid in situ whose bone erosion causes the feared complications, which is why scanty, foul, persistent discharge with hearing loss demands examination. Finally, otosclerosis presents with conductive loss and a family history but no discharge; mixing it up with otitis media wastes the discriminating clue.
Frequently asked questions
Why is biopsy contraindicated in juvenile nasopharyngeal angiofibroma?
Because these vascular tumours can bleed torrentially; diagnosis rests on imaging and angiography, with embolisation-assisted excision as treatment.
What is the association of nasopharyngeal carcinoma?
Epstein-Barr virus with the non-keratinising WHO type, typically presenting as a cervical lymph node in an adult from an endemic region.
Which laryngeal cancer presents earliest and why?
Glottic carcinoma, because even a small cord lesion disturbs vibration and phonation, producing persistent hoarseness while curative options remain wide.
What is a cholesteatoma?
A keratinising stratified squamous epidermoid within the middle ear, erosive toward ossicles, facial nerve and labyrinth, arising on chronic otitis media.
What causes conductive deafness in otosclerosis?
Fusion of the stapes footplate by otospongiotic bone at the oval window, in a young adult with a positive family history and no history of otorrhoea.