EN2.6 | ENT Investigation Selection — Summary & Reflection

KEY TAKEAWAYS

ENT investigation selection principles: (1) clinical examination precedes investigation; (2) never biopsy JNA or glomus tumour — diagnose by contrast CT/MRI; (3) FNAC is first-line for all neck and parotid masses — not open biopsy. Radiological modalities: X-ray (Waters' view for PNS — mucosal thickening, air-fluid level; Schuller's for mastoid — superseded); CT temporal bone (HRCT — mandatory before mastoidectomy, shows ossicular erosion and cholesteatoma extent); CT PNS (coronal — gold standard for FESS); CT neck with contrast (staging, lymph node necrosis); MRI IAM with gadolinium (acoustic neuroma — unilateral SNHL without cause); MRI soft tissue neck (NPC, parapharyngeal). Microbiological: ear swab deep from fresh discharge (aerobic + anaerobic + fungal); throat swab from tonsillar surface. Histological: FNAC for neck/parotid masses (adequate specimen = 3–4 passes, smear fixed + air-dried); laryngeal biopsy under GA (suspension laryngoscopy). Functional: PTA for hearing loss type and severity; tympanometry for middle ear status (Type B + normal volume = OME; Type B + large volume = TM perforation).

REFLECT

Think about a patient you have seen with a neck swelling in any posting — medicine, surgery, or ENT. What investigation was ordered first? Was it FNAC, or was it an excision biopsy, or was it imaging without tissue? Reflecting on real cases is the fastest way to internalise investigation selection principles, because you remember the context and the outcome. As you go through your clinical postings, make it a practice to ask yourself — before the senior orders anything — 'what would I order, and why?' Then compare your reasoning with what is actually ordered and discuss the difference with your supervisor. This simple habit of prospective reasoning is how investigation selection skill is built.