Head & Neck, ENT Flashcards

Question

Function preservation Mx for HnN tumours

Answer 1

* *1) Vision** - eye shield during RT - chloramphenicol ointment for dry eyes - tarsorrhaphy * *2) Airway** - tracheostomy **3) Taste... :(** * *4) Swallowing** - anastomosis - speech therapist * *5) Speech** - voice prosthesis - speech therapy

Answer 2

**1) Oral cavity proper**: space medial or posterior to teeth **2) Vestibule**: space between teeth and cheek * *3) Oropharynx:** - behind the glossopalatine arch (anterior pillars)

Answer 3

* *_External carotid artery branches:_** - Lingual artery - Facial artery - Maxillary artery

Answer 4

- Sensation: V2, V3 - Muscle of mastication: V3 - Tongue: XII (except Palatoglossus which is pharyngeal plexus) - Taste: VII (chorda tympani)

Answer 5

Get gloves, penlight, tongue depressor: **0) General Examination** * *1) Ask patient to "AHH" open mouth, stick out tongue** - note hoarseness of voice - note trismus, ankyloglossia * *2) Inspection of oral cavity** - palate (roof) - buccal mucosa (sides) - floor of mouth (below tongue) - vestibule using 2-prong technique - tonsils - anterior & posterior fallucial pillars - oropharynx - "comment on alveolar & gum health" - "to complete by looking @ tongue base using indirect mirror" * *3) Inspection of tongue** - lateral border - frenulum & inferior aspect - look for movement * *4) Palpation** - try scraping white lesions - characterise the mass - BIMANUAL PALPATION * *5) Neck exam, Cranial Nerve exam** - for LN, facial nerve involvement

Answer 6

1) Leukoplakia 2) Lichem planus 3) Candidiasis, secondary syphilis, EBV hairy leukoplakia 4) Linea Alba 5) Leukoedema 6) Papilloma 7) Verrucous carcinoma, Squamous cell carcinoma 8) Geographic tongue 9) Hairy tongue

Answer 7

* *1) Oral candidiasis** - white, easily scrapped off white plagues - shows hyphae in Gram stain * *2) 2° syphilis** - Snail track * *3) EBV** - hairy leukoplakia

Answer 8

White colour due to scattering of the light through an altered epithelial surface

Answer 9

Leukoplakia - White patch firmly attached to oral mucosa which cannot be rubbed off - Precancerous; 5% undergo malignant change

Answer 10

**_Lichen Planus_** - Common chronic inflammation of oral mucosa (usually buccal mucosa) - T cell mediated auto-immune - "Wickham’s striae" (white striae around the lesion) - Skin manifestations: pruritic papules on flexor surface - Low malignant potential

Answer 11

* *_Oral candidiasis_** - Creamy-white - elevated, removable plaques _**Risk factors:** Local_ - poor oral hygiene, xerostomia, dentures _Systemic_ - immunocompromised: steroids, antibiotics, radiation, HIV, haematological malignancy, neutropenia

Answer 12

* *_Linea Alba_** - Normal linear elevation of the buccal mucosa extending from the corner of the mouth to the 3rd molars *_at the occlusal line_*

Answer 13

* *_Leukoedema_** - Normal anatomic variant of the oral mucosa - Bilateral, involves most of the buccal mucosa (rarely the lips and tongues) - If streched, will become red again - Increased thickness of epithelium and intracellular edema of prickle cell

Answer 14

* *1) Papilloma** - Exophytic, painless - fingerlike projections forming cauliflower pattern - usually solitary * *2) Verrucous Carcinoma** - Exophytic - Low-grade variant of SCC - HPV related * *3) Squamous cell carcinoma** - Early SCC looks like leukoplakia - 6 Ss

Answer 15

Red due to thin epithelium, inflammation, dilatation of blood vessels, increased number of blood vessels, extravasation of blood: 1) Trauma 2) Infection (Stomatitis, Glossitis) 3) Lupus erythomatosus, Reactive arthritis (Reiter’s syndrome) 4) Erythroplakia (pre-malignant) 5) Hereditary hemorrhagic telangiectasia

Answer 16

- Red, non-specific, well-demarcated patch that cannot be classified under any other disease - 15 times increased risk of SCC - 90% CIS or SCC at time of diagnosis

Answer 17

1) Malignant melanoma 2) Lentigo 3) Pigmented naevi 4) Black hairy tongue 5) Smoker's melanosis 6) Amalgam tattoo (from adj dental fillings) 7) Peutz-Jeghers syndrome 8) Addison disease

Answer 18

ABCDE A - Asymmetrical Shape B - Border is irregular C - Color is variegated D - Diameter \>6mm E - Evolution

Answer 19

**1) Traumatic ulcers** (Sharp tooth, dentures etc) * *2) Aphthous ulcer** (major, minor, herpetiform) - SLE - Reiters syndrome * *3) SqCC** - Everted, irregular edge with dirty floor - Indurated base - Painless at first, then painful with nerve infiltrated **4) Infective ulcers**

Answer 20

- HSV - Herpangina by Coxsackie virus - TB - Syphilis – 1°, 2°, 3°

Answer 21

Benign vs Malignant: _MALIGNANT:_ **★ 1) SqCC, verrucous carcinoma ★ 2) Minor salivary gland adenocarcinoma 3) lymphoma 4) melanoma 5) Kaposi sarcoma** _BENIGN:_ * *1) Fibroma** - hard nodule * *2) Ranula** - At Floor of mouth - soft pseudocyst filled with saliva - Due to Blocked sublingual duct * *3) Lipoma** - Soft mass * *4) Torus palatini** - at the hard palate - Boney hard - normal anatomical variation

Answer 22

(actually same as H&N with additional Ix\*) * *1) Incisional biopsy** - for oral lesions that persist for \>3 weeks * *2) USG, FNAC** - for enlarged LN **3) Pan-endoscopy ± biopsy** to look for SYNCHRONOUS tumours - flexible rhinoscopy - flexible laryngoscopy - OGD - bronchoscopy **4\*) Orthopantomogram** (look for bone erosion) * *5) CT, MRI of H&N** - T, N staging - look for boney erosion in skull base, orbit * *6) PET/CT, Bone scan** - for distant & bone met

Answer 23

* *Environement factor** 1) Smoking 2) Spirits, alcohol 3) Sharp teeth 4) Betel nut chewing (嚼檳榔 in TW) 5) Previous H&N RT **Patient factor** 1) Male Sex (M:F = 4:1) 2) Dental Sepsis 3) Syphilis, HPV 4) GERD 5) Primary H&N tumour (synchronous tumours) 6) Family history \_\_\_\_\_\_\_\_ think about 6S of oral cancer: - smoking, spirits, sex, syphilia HPV, sharp teeth, sepsis dental

Answer 24

- erythroplakia - leukoplakia - erythroleukoplakia - proliferative verrucous leukoplakia

Answer 25

* *1) Tongue** (most common) - lateral margin, middle third * *2) Lips** - lower half * *3) Floor of mouth** - anteriorly below tongue **4) Buccal mucosa** **5) Alveolus & gingiva** **6) Hard palate**

Answer 26

Ulcer edge, because: - can compare with normal tissue - easier to suture for haemostasis

Answer 27

* *1) Resection of the tumour** with adequate margins - partial glossectomy if T1 (\<2cm) - hemiglossectomy if T2 (2-4cm) - total glossectomy (might need concommitant laryngectomy due to aspiration risk) * *2) Adequate neck dissection** - Selective neck dissection of _I-IV_ (classically is I-III i.e. supraomohyoid neck dissection but can skip metastasis to level IV) * *3) Reconstruction** - ALT flap **4) Adjuvant RT**

Answer 28

Tonsillar ulcer can be due to: * *1) Infective** - acute tonsillitis - diptheria - infectious mononucleosis * *2) Neoplasm** - orophayngeal SCC - lymphoma - salivary gland tumour * *3) Blood disease** - agranulocytosis - leukaemia * *4) Others** - apthous ulcer - Bechets disease - AIDS

Answer 29

**Roof**: oral surface of soft palate & uvula **Lateral**: anterior & posterior pillars (glossopalatine arch & pharyngopalatine arch), palatine tonsils **Anterior**: posterior third of tongue & vallecula **Posterior**: level of hard palate to aryepiglottic fold

Answer 30

- Tonsils 50% - Tongue base 25% - Soft palate 10% - Posterior wall 5%

Answer 31

**_6Ss:_** 1) Smoking 2) Spirits, alcohol 3) Sharp teeth 4) Male Sex (M:F = 4:1) 5) Dental Sepsis 6) Syphilis, HPV 7) Betel Nut chewing (嚼檳榔 in TW)

Answer 32

* *1) Symptoms** - local ulcer, pain - sore throat, muffled hot potato speech - trismus - dysphagia, odynophagia - constitutional symptoms - cervical lymphadenopathy * *2) Risk factors** - 6Ss (Smoking, spirits, sharp teeth, male sex, dental sepsis, syphilis, HPV, betel nut) * *3) Other primary cancer** (VERY IMPORTANT) - 30% synchronous primary - 1.5% yearly cummulative risk of metachronous tumour

Answer 33

(actually same as H&N with additional Ix\*) **1\*) EUA (examation under anaes), biopsy, tonsillectomy** * *2) USG, FNAC** - for enlarged LN **3) Pan-endoscopy ± biopsy** to look for SYNCHRONOUS tumours - flexible rhinoscopy - flexible laryngoscopy - OGD - bronchoscopy * *4) CT, MRI of H&N** - T, N staging - look for boney erosion in skull base, orbit * *5) CXR, PET/CT, Bone scan** - for distant & bone met

Answer 34

**1) Resection** * *2) Lymph node clearance** - Level II-IV (lateral selective neck dissection) **3) Reconstruction** _- Soft palate, tonsillar fossa_: radial forearm free flap _- Extensive palatomaxillary defects_: prosthesis or vascularized bone-containing free flaps **4) Chemo-RT**

Answer 35

i.e. from the laryngopharynx (Level of hyoid to lower border of cricoid): - 60% **Piriform fossa** - 30% **Postcricoid** - 10% **Posterior pharyngeal wall**

Answer 36

- Smoking - Alcohol - Male predominance (exp in Postcricoid CA, more female than male) - Irradiation for thyroid disease - Plummer Vinson syndrome (aka Paterson-Kelly-Brown syndrome)

Answer 37

- Dysphagia - Sore throat - Hoarseness - Otalgia - LN 30% occult metastases - Loss of laryngeal crepitus

Answer 38

* *1) Surgical resection** - Partial pharyngectomy - Circumferential pharyngectomy + reconstruction - Total pharyngo- laryngo- esophagectomy (PLO) with gastric pull up * *2) Lymph node clearance** - Level II-IV (lateral selective neck dissection) * *3) Reconstruction** - free flap (jejunal graft) - regional flap (pectoralis major) - (gastric pull-up for PLO) **4) RT**

Answer 39

**1) Hyoid bone** * *2) Cartilages** i) Cricoid cartilage ii) Thyroid cartilage iii) Epiglottis iv) Arytenoids v) Corniculate cartilage vi) Cuneiform cartilage * *3) Ligaments** - thyrohyoid ligament - crico-thyroid ligament - vestibular, vocal ligament

Answer 40

* *1) Recurrent Laryngeal Nerve** - supplies all intrinsic muscles of larynx (except cricothyroid) * *2) External** branch of **Sup Laryngeal Nerve** - supplies cricothyroid muscle (tenses vocal cord) * *3) Internal** branch of **Sup Laryngeal Nerve** - sensation of vestibule

Answer 41

**1) Organic** * *2) Functional** - e.g. muscle tensional dysphonia * *3) Psychiatric** - Conversion disorder

Answer 42

aka Singer’s nodules * *Presentation:** - dysphonia, Breathy voice - at junction of anterior and middle 1/3 of vocal folds - always comes _in pairs_ (bilateral & symmetrical), as chronic vocal trauma from vocalisation should symmetrically affect both sides of vocal folds * *Pathogenesis:** - Chronic vocal trauma (voice misuse) lead to local edema - local edema causes fibrosis & nodules

Answer 43

Speech therapy +/- excision

Answer 44

* *Pathogenesis** - Acute vocal trauma creates haemorrhagic cyst - becomes polyp * *Presentation:** - Dysphonia with breathy voice - Unilateral protrusion * *Management:** - Excision

Answer 45

**1) Idiopathic** **2) Brainstem lesion** * *3) Recurrent laryngeal nerve palsy** - CA thyroid, CA esophagus, CA lung - Ortner syndrome in aortic stenosis * *4) Aryteno-cricoid joint pathology:** - intubation causing dislocation - RA - cancer infiltration * *5) Iatrogenic** - intubation - H&N surgery - thyroid, esophageal, cardiothoracic surgery

Answer 46

* *1) Endoscopy** - distinguish whether it is unilateral or bilateral - if bilateral, whether in open or closed position * *2) Assess airway adequacy and aspiration** - bilateral open position -\> aspiration risk - bilateral close position -\> airway obstruction * *3) Rule out organic cause** - CT/ MRI brain - CT thorax * *4a) For unilateral:** - Vocal therapy - Injection laryngoplasty (temporary) - Medialization thyroplasty * *4b) For bilateral** - Tracheostomy for airway protection

Answer 47

* *Onset, pattern** - acute or chronic - recurrent? - acute vocal trauma e.g. screaming? * *Occupation, vocal demand** - singer? teacher? * *Risk factors** - smoking? - GERD? - hypothyroidism? - neurological disorders? * *Medical & Surgical Hx** - CA mediastinum? - H&N surgery? * *Red flags for CA larynx** - Bleeding - Dyspnoea - Dysphagia - Constitutional symptoms

Answer 48

**1) Cervical lymphadenopathy** **2) Inspection of larynx** _a) indirect laryngoscopy_ (DO NOT use direct layngoscopy which is for intubation) _b) Trans-nasal Flexible laryngoscopy_ - less gag reflex - inferior image quality _c) Trans-oral Rigid laryngoscopy with Stroboscopy_ - Gag reflex - better image quality - Allows stroboscopy to detect subtle vocal cord lesions

Answer 49

1) Glottic 60% 2) Supraglottic 30% 3) Infraglottic 10%

Answer 50

Depends on site: * _Glottic:_* * *1) Dysphonia, hoarseness of voice** - progressive (\>2 wks) - non-resolving (\>4 wks) * _Supraglottic:_* * *2) Sore throat 3) Odynophagia, dysphagia 4) Referred otalgia** * _Subglottic_* * *5) Stridor, dyspnoea from airway obstruction** * _Others:_* * *6) Haemoptysis** 7) Cervical lymph node metastasis 8) Constitutional symptoms

Answer 51

1) Smoking 2) Alcohol 3) Radiation 4) Synchronous H&N cancer 5) Chronic laryngitis 6) GERD 7) Family history HIV??

Answer 52

(actually same as H&N with additional Ix\*) * *1\*) Flexible indirect laryngoscopy; microlaryngoscopy + Biopsy** - assess extent of tumour - histological diagnosis * *2) USG, FNAC** - for enlarged LN **3) Pan-endoscopy ± biopsy** to look for SYNCHRONOUS tumours - flexible rhinoscopy - flexible laryngoscopy - OGD - bronchoscopy * *4) CT, MRI of H&N** - T, N staging - look for boney erosion in skull base, orbit * *5) CXR, PET/CT, Bone scan, blood ALP** - for distant & bone met \_\_\_\_ All of the above are for TNM stageing: T = Local tumour stage (Endoscopy, CT/MRI) N = Regional lymph node (USG neck + FNA) M = Distant metastasis (CXR, Blood test, PET)

Answer 53

**Requires biopsy:** - Leukoplakia - Erythroplakia - Mass (CA larynx)

Answer 54

_Early stage (T1-T2)_ * *1) Radiotherapy**, or * *2) Endolaryngeal laser surgery** (preserve voice) * *3) Partial laryngectomy** (rarely) - e.g. vertical hemilaryngectomy; supraglottic laryngectomy _Late stage:_ * *1) Resection** - total laryngectomy * *2) Lymph node management** - modified radical neck dissection (or II-IV if possible) * *3) Reconstruction** - terminal tracheostomy + voice prosthesis **4) Adjuvant radiotherapy and chemotherapy**

Answer 55

**1) Esophageal speech** + no prosthesis, no cost - difficult to learn, difficult to understand - Fragmented speech, hard to speak after eating **2) Tracheo-esophageal speech** (valve prosthesis e.g. Provox) + good tone & understanding - costly, unclean - complication e.g. swallowing **3) Pneumatic device** + tone is acceptable, cheap - conspicuous **4) Electrolarynx** + one-off cost, easy to learn - monotonal robotic voice - need battery

Answer 56

**General**: bleeding, SSI, etc * *Specific**: 1) pharyngo-cutaneous fistula 2) tracheostomal stenosis (from radiation, infection) 3) Neo-pharyngeal stricture (thus dysphagia) 4) Hypothyroidism ± Hypoparathyroidism

Answer 57

1) Non-differentiated carcinoma (95%) 2) Non-keratinising carcinoma 3) Keratising SqCC

Answer 58

* *Site: _Fossa of Rosenmuller_** of nasopharynx - clinically obscure area - thus clinically silent until widespread metastases occur * *Metastasis:** 1) Local spread to parapharyngeal space - \> base of skull - \> cranium via foramina 2) Distal spread - \> usually by lymphatics to H&N lymph nodes - \> may be hemat spread to organs

Answer 59

* *1) Genetics**: - Cantonese - Combination of HLA-A2 & BW-46 * *2) Infection**: - EBV +ve * *3) Diet**: - High nitrosamine e.g. Salted fish, preserved food

Answer 60

**0) Constitutional symptoms** ``` _Primary symptoms (ENT!)_ **1) Ear**: conductive hearing loss, recurrent OME, tinnitus ``` **2) Nose**: obstruction, epistaxis, postnasal drip **3) Throat**: sorethroat * *4) Headache and facial pains** - trigeminal nerve compression (test for corneal reflex) - usu temporal headache * *5) CN palsy** (2-6, 9-12) - sphenoid sinus above nasopharynx, above that is cavernous sinus - optic chiasm is also close _LN met, distant met:_ * *6) Neck LN** - level 2-4 (more common contralat; can be bilat)

Answer 61

Conductive hearing loss due to: - Obstruction of the eustachian tube

Answer 62

* *1) EBV testing** - EBV DNA titre - EBV VCA-IgA has the highest sensitivity - EBV EA-IgA has the highest specificity **2) Flexible nasal endoscopy + biopsy** **3) US + FNAC** of neck LN **4) CT, MRI H&N** 5) CXR, PET for met

Answer 63

**1) Radiotherapy** (best for undifferentiated carcinoma, SCC least) **+) Adjuvant chemotherapy** * _if relapsed:_* 2) Surgical management i.e. **Nasopharyngectomy** - maxillary swing classically - now have endoscopic methods

Answer 64

_Routine follow up with plasma EBV DNA_ - High recurrence in first 2 year and after 10 years -\> use plasma EBV DNA to determine relapse - Monitor for RT complications e.g. sarcomas, xerostomia, hypopituitarism

Answer 65

_Symptoms:_ 1) Gross disfigurement 2) Pain 3) Malocclusion 4) Drooling _Signs:_ 1) Trismus 2) Fragment mobility 3) Gingival laceration 4) Haematoma in floor of mouth

Answer 66

1) Malunion 2) Non-union 3) Osteomyelitis 4) TMJ ankylosis

Answer 67

They are usually multiple site This is because the mandible forms an anatomic ring, thus \>95% of mandible fractures have more than one fracture site

Answer 68

For mid-face fracture: _Le Fort I_ - transverse maxillary fracture, above dental apices - also traverses the pterygoid plate - thus palate necomes mobile, but nasal complex is stable _Le Fort II_ - fracture through frontal process of maxilla - through the orbital floor and pterygoid plate - thus midface is mobile _Le Fort III_ - fracture through the nasofrontal suture and fronto-zygomatic sutures - thus complete craniofacial separation

Answer 69

i. e. **zygomatico-maxillary complex fracture**, involving 3 fractures: 1) Zygomatic arch fracture 2) Floor of orbit fracture (including maxillary sinus) 3) Lateral orbital rim and wall fracture

Answer 70

After facial trauma or deceleration injury: **1) Loss of cheek projection, increased width of face** * *2) Loss of sensation over cheek and upper lip** - due to infra-orbital nerve injury (passes through orbital floor) **3) Facial bruising, swelling** * *4) Impingement** - impingement of the temporalis muscle -\> trismus - impingement of extra-orbital muscles -\> diplopia

Answer 71

* *Etiology:** - Trauma at birth - Trauma (e.g. fighting) - Unequal growth of nasal septum * *Presentation & PE:** - Unilateral nasal obstruction - nose speculum can see deviation, sometimes even septal spur (sharp bone growth from severe trauma, see pic) - If severe, the deviation can be observed directly * *Management:** - Septoplasty/SMR (submucous resection of septum)

Answer 72

Septal haematoma Because septal haematoma will cause **pressure-induced septal necrosis**, and ultimately **saddle nose deformity** if unmanaged This is because nasal septum & cartilage receive its nutrient from the nasal perichondrium. In septal hematoma, the two are separated, and septal necrosis will occur, causing deformity.

Answer 73

* *Presentation:** - bilateral nasal obstruction after nose trauma - blood stain * *Management:** - Urgent drainage

Answer 74

_MAJOR GLANDS:_ **1) 2 parotids** **2) 2 submanidbular** **3) 2 sublingual** _MINOR GLANDS:_ - Hundreds - Oral cavity, tongue base, larynx, NP

Answer 75

The parotid gland are bounded by: * Superiorly – Zygomatic arch. * Inferiorly – Inferior border of the mandible. * Anteriorly – Masseter muscle. * Posteriorly – External ear and sternocleidomastoid. Inferiorly it wraps around the angle of the mandible. Its posterior border runs up behind the ramus of the mandible over the mastoid process. _Position:_ - 80% overlies Masseter & Mandible - 20% is retromandibular

Answer 76

Superficial lobe & deep lobe, which is divided by: * *Anatomically** - Facial Nerve (anatomically) * *Radiologically:** - an imaginary line from mandible to mastoid - the retromandibular vein might be used as surrogate of facial nerve (which cannot be visualised in MRI)

Answer 77

_Superficial to deep:_ * *1) Facial nerve & 5 branches (Tarzan big mac)** - temporal - zygomatic - buccal - marginal mandibular - cervical **2) Retromandibular vein** * *3) External carotid artery** - gives of last 2 branches: maxillary artery and superficial temporal artery (both supplies the parotid gland) **4) Parotid lymph nodes**

Answer 78

Facial nerve leaves stylomastoid foramen to enter Parotid gland, in which in forms bifurcates & further branches at the pes anserinus "*TARZAN BIG MAC*": * *1) Temporal-zygomatic** - temporal (e.g. frontalis) - zygomatic (obicularis oculi) * *2) Cervical-facial** - Buccal (Orbicularis oris, buccinator) - Marginal mandibular (Depressor anguli) - Cervical (Platysma)

Answer 79

**1) In Submandibular Triangle, i.e. superior to the digastrics** * *2) Gland wraps around the mylohyoid** - superficial lobe (larger) palpable between body of mandible and mylohyoid - smaller deep lobe **3) Superficially covered by platysma**

Answer 80

* *_Wharton's duct (5cm):_** - arises from medial surface of deep gland of submandibular gland - lies between mylohyoid and hypoglossus - opens into the oral cavity via Wharton's duct on either side of the lingual frenulum.

Answer 81

* *Sublingual glands location:** - at FOM, between Mandible & Genioglossus - separated from base of tongue by submandibular duct and lingual nerve - bilateral gland merge to form horseshow around lingual frenulum **Drainge**: It drains directly into the buccal floor * *Characteristics:** - No capsule - Basically a collection of many small glands, thus sialogram is impossible

Answer 82

Skin incision is made: - around 3–4 cm below the mandible - in order to avoid the marginal mandibular branch of facial nerve - Note that the hypoglossal (CN XII) and lingual nerves are at risk during deeper dissection.

Answer 83

Differentiate between infection (& inflammation), & neoplasm, & others * *_A. INFECTION, INFLAMMATION_** - Acute parotitis (S aureus) - Viral sialadenitis (in childhood) - Chronic sialoadenitis - Sialolithiasis - Sjogren’s syndrome * *_B. NEOPLASTIC_** (usu unilateral) - pleomorphic adenoma - Warthin’s tumour - Mucoepidermoid carcinoma - Adenoid cystic carcinoma - Acinic cell carcinoma - Adenocarcinoma - Malignant mixed tumour (e.g. Carcinoma ex-pleomorphic adenoma, Carcinosarcoma) - Squamous cell carcinoma - Lymphoepithelial carcinoma (Undifferentiated carcinoma) * *_C. OTHERS_** - Bulimia nervosa - Alcoholism (sialadenosis) - DM - Drugs e.g. Phenytoin - Cysts, lymphoepithelial cysts (e.g. HIV, post-transplant) _D) Mimics_ - Pseudoparotidemegaly i.e. masseter hypertrophy caused by bruxism - Skin lesions e.g. lipoma, sebaceous cyst - Denal infection

Answer 84

**1) Pseudo-parotidemegaly**, i.e. masseter hypertrophy from bruxism * *2) Systematic disease** - Bulimia nervosa - Alcoholic cirrhosis (sialadenosis) - DM - Sjogren's syndrome **3) Warthin tumour (10% is bilateral)** **4) Benign lymphoepithelial cysts** (e.g. in HIV)

Answer 85

* *_Parotid Gland Swelling:_** 1) Masseter hypertrophy (e.g. due to bruxism) 2) Enlarged cervical LN (Upper level II) - have to differentiate by imaging 3) Lipoma or other overlying skin / subcutaneous lesions - subcutaneous in nature 4) Vascular malformation * *_Submandibular Gland Swelling_** 1) Enlarged submandibular lymph node 2) Oral cavity mass (e.g. FOM Cancer) with direct extension to submandibular space

Answer 86

* *1) Is it Painful?** - if pain, more likely inflammation (not necessarily) - most salivary gland neoplasm are painless mass - can still be high grade mucoepidermoid tumour, adenoid cystic carcinoma, adenocarcinoma (i.e. the aggressive ones) * *2) Is the pain associated with meal?** - if yes, more likely infection or inflamation * *3) Swelling** - acute onset or insidious onset? - does it swell after meals? (if yes, more likely infection) **4) Presence of symptoms of acute infection** (fever, tenderness, pus)

Answer 87

* *1) Inspection** - scars? esp BEHIND EAR!! - Facial nerve palsy - Swelling unilateral or bilareral? Symmetrical? - Intraoral inspection of (Stensen's duct, Wharton's duct, FOM swelling, any pus in the duct openings?) * *2) Palpation** - Confirm lesion not arising from the skin (rule out e.g. lipoma) - Palpate the ducts (for stones, to express pus) **3) Complete H&N ENT examination** **4) Facial nerve examination** **5) Palpation of neck lymph nodes** **6) Endoscopy of the upper aerodigestive tract**

Answer 88

**1) XR or sialogram** for sialolithiasis * *2) Ultrasound** - Confirm mass from parotid or submandibular gland (differentiate from neck LN) - Good for stones, dilated ducts * *3) CT scan/ CT sialogram** - good for inflammatory disease * *4) MRI** - Best soft tissue differentiation - True multi-plane - Better for tumour, accurate delineation of extent of invasion - Differentiate other pathologies, e.g facial nerve schwannoma * *±5) FNAC** (21 gauge or smaller) - still performed for better patient prepare - inaccurate & cannot note histology - not for sole decision making * *6) Biopsy** - mainly excisional biopsy (i.e. Parotidectomy, submandibulectomy) - incisional biopsy easily cause spillage - core biopsy (Trucut) is not enough

Answer 89

* *Causes:** i) poor dental hygiene, with spread of bacteria via duct to gland -\> may become parotid abscess ii) mumps infection * *Presentation:** - Tender swelling of parotid gland - Pus from Stenson's duct opening * *Management:** - Rehydration - IV antibiotics

Answer 90

Commonly presented in children due to viral infection: * *1) Mumps** - used to be common, now protected by vaccination **2) Coxsackievirus** **3) CMV** **4) Influenza**

Answer 91

Commonly presented in old age * *Presentation**: 1) Mild pain, worsen after meal 2) Recurrent parotid or submandibular swelling after meal * *Etiology:** 1) Destruction of gland tissue from ascending duct infection related to dehydration and debilitation e.g in old age with thicker saliva 2) Secondary to ductal obstruction e.g. Stones (submandibular duct most likely) 3) Autoimmune (i.e. Sjogren)

Answer 92

**1) Hydration** **2) Sialogogues, massage, heat, hydration, antibiotics** during acute attacks * *3) Remove stones** - Spontaneous passage with assistance of massage - Exploration of submandibular duct (transoral removal of stone with marsupialization or sialotomy) - Sialoendoscopy * *4) Excision of the gland** - if stone is near hilum or refractory disease

Answer 93

- Serological test to r/o Sjogren syndrome (Anti-Ro SS-A; Anti-La SS-B, ANA, RF) - Sialogram - USG to r/o stones

Answer 94

* *Presentation:** - Recurrent chronic sialoadenitis (i.e. swelling esp after meal, pain esp after meal) - usually in teenagers or young adults * *Complication:** - chronic sialoadenitis - ductal ectasia - duct strictures * *Treatment:** - Spontaneous passage with assistance of massage - If near duct orifice, transoral removal of stone with sialotomy +/- marsupialization - If near hilum, gland excision

Answer 95

- 80% in submandibular gland, 20% in parotid - Usually only 1 stone - Most submandibular stones are radio-opaque - Most parotid stones are radiolucent

Answer 96

1) More female, 30-40yo 2) keratoconjunctivitis sicca, xerostomia 3) Injected cornea,conjunctivitis 4) Diffuse, tender enlargement of parotid and submandibular glands (Chronic sialoadenitis) 5) Features of associated autoimmune diseases - fatigue, fever - e.g. SLE

Answer 97

**1) Schirmer's test** **2) Raised ESR & CRP** * *3) Serology** - ANA, RF - Anti-Ro (SS-A), Anti-La (SS-B) - should also check for ds-DNA antibody, Anti-CCP (or ACPA) to look for secondary Sjogren's * *4) Biopsy of sub-labial minor salivary glands** - Gland destruction with lymphocytes infiltration

Answer 98

1) Rapid growth and pain 2) Irregular surface, craggy 3) Tethering to skin and underlying muscles 4) Facial nerve palsy (suggestive of invasion)

Answer 99

* *1) Parotid** - most common site (80% overall) - mostly benign (80% benign) - mostly pleomorphic adenoma (80% of benign is PA) * *2) Submandibular** - 15% overall - 50% benign * *3) Sublingual/ Minor** - 5% overall; - 40% benign

Answer 100

"Prince of Wales :) got MAAACS love" * *Benign**: - Pleomorphic adenoma - Warthin's Tumour * *Malignant**: - Mucoepidermoid carcinoma - Adenoid cystic carcinoma - Acinar cell carcinoma - Adenocarcinoma - Carcinoma ex-pleomorphic adenoma - Squamous cell carcinoma - Lymphoepithelial carcinoma (undifferentiated carcinoma)

Answer 101

Influenced by site, stage, grade, histological subtype: * *1) Surgical Excision** - Complete local excision - Radical excision for carcinoma ex-pleomorphic adenoma & SqCC * *2) Control of invasions** - Neck dissection for nodal metastasis (mucoepidermoid cancinoma, adenocarcinoma, carcinoma ex-pleomorphic adenoma) - Extended neck dissection for SqCC - Facial nerve sacrifice? (in Adenoid cystic carcinoma, due to tendency for perineural invasion) * *3) Post-operative Radiotherapy** - for high grade mucoepidermoid carcinoma, Adenoid cystic carcinoma, Acinic cell carcinoma, Carcinoma ex-pleomorphic adenoma, SqCC, Undifferentiated carcinoma aka lymphoepithelial carcinoma)

Answer 102

* *Presentation:** - Slow-growing, painless mass * *Site:** 1) 80% of Parotid tumours: mostly in superficial lobe, most in tail of gland 2) 50% of submandibular tumours 3) 45% of Minor salivary gland: lateral palate, submucosal mass 4) 6% of sublingual tumors * *Complication:** - Malignant degeneration risk in long term (e.g. Carcinoma ex-pleomorphic adenoma)

Answer 103

* *1) Complete surgical excision** - Parotidectomy with facial nerve preservation - Submandibular gland excision - Wide local excision of minor salivary gland * *2) Avoid enucleation and tumor spillage** - if ruptured, cancer cells might be spread all over, causing seeding * *3) Radiotherapy** - for recurrent tumour - prevention of recurrence in case of spillage

Answer 104

aka Papillary Cystadenoma Lymphhmatosum * *Presentation:** - Old male - Soft cystic mass - slow-growing, painless mass - Commonly parotid gland (10% bilateral); tail of parotid

Answer 105

Most common salivary gland cancer Commonly seen in women from 30-80 * *Presentation:** - Mostly parotid gland - _Low-grade_: slow growing, painless mass - _High-grade_: rapidly enlarging, +/- pain - Ulcerates in later stage

Answer 106

2nd most common salivary gland malignancy, in both sex around 50s **Site**: common in submandibular, sublingual and minor salivary glands * *Presentation:** - enlarging mass - Tendency of perineural spread (facial nerve), thus pain, paresthesias, facial weakness/ paralysis - Common distant metastasis to lungs

Answer 107

Commonly parotid gland, more common in women: * *Presentation**: - Solitary, slow-growing, often painless mass - Bilateral parotid disease in 3%

Answer 108

Rare; affects parotid glands or minor salivary gland; more common in women from 50-80 **Presentation:** – Enlarging salivary gland mass – _Aggressive_, 25% with pain or facial weakness

Answer 109

* *1) Carcinoma ex-pleomorphic adenoma** - Carcinoma developing in the epithelial component of preexisting pleomorphic adenoma * *2) Carcinosarcoma** - Mixture of carcinomatous and sarcomatous components * *3) Metastatic mixed tumor** - Metastatic deposits of otherwise typical pleomorphic adenoma

Answer 110

* *_Presentation:_** 1) Longstanding painless (usu parotid) mass i.e. pleomorphic adenoma, that undergoes *_sudden enlargement_* 2) Poorly circumscribed, Infiltrative 3) Hemorrhage and necrosis

Answer 111

Consider Squamous cell carcinoma of salivary gland, after ruling out: 1) High-grade mucoepidermoid carcinoma 2) Metastatic SCC to intraglandular nodes, usually from scalp SCC 3) Direct extension of skin SCC

Answer 112

- Common in eskima (eskimoma) & Chinese - EBV related, histology identical to NPC (i.e. undifferentiated): - Always try to rule out it being a metastasis from NPC

Answer 113

_A. Local diseases around the face_ 1) Skin - cellulitis (subcutaneous inflamm) - erysipelas (cuticular lymphangitis) - Facial Shingles 2) Sinus: acute or chronic sinusitis 3) Dental infections 4) Temporomandibular joint problems _B. Referred pain_ 5) NPC _C. Neurogenic pain_ 6) Trigeminal neuralgia 7) Post-herpetic neuralgia 8) Migraine 9) Cluster headache (retroorbital pain)

Answer 114

* *1) Panendoscopy** - bronchoscopy & esophagoscopy * *2) Plain X-rays** - paranasal sinus - orthopantomography of upper & lower jaw * *3) CT / MRI scanning** - sinuses - cerebellopontine angle - brain

Answer 115

* *1) Somatic motor** for Facial musles - consider the five branches * *2) Special sensory** - taste to anterior 2/3 of tongue, via chorda tympani * *3) Secretomotor** - via sphenopalatine ganglion to lacrimal glands and nose (greater petrosal nerve) - via submandibular ganglion to submandibular and sublingual gland (chorda tympani)

Answer 116

1) Starts from facial nucleus in **pons** 2) Goes through **facial canal** in the temporal bone 3) goes to **geniculate ganglion** - **greater petrosal nerve** branches out; via **sphenopalatine ganglion** to supply lacrimal glands 4) Further branches - motor branch to **stapedius** - **chorda tympani** to tongue taste; as well as via **submandibular ganglion** to submandibular glands 5) Emerges from the **stylomastoid foramen** 6) Pierce the **parotid gland**, and bifrucates to: _a) Temporal-zygomatic_ - temporal (e.g. frontalis) - zygomatic (obicularis oculi) _b) Cervical-facial_ - Buccal (Orbicularis oris, buccinator) - Marginal mandibular (Depressor anguli) - Cervical (Platysma)

Answer 117

* *1) Supranuclear** (UMN lesion) - usu stroke - upper face spared * *2) Lesion in the facial nucleus** (LMN lesion) - usu stroke, tumour, demyelinating disease * *3) Tumour in internal acoustic meatus**, or cerebropontine angle - CP angle meningioma - acoustic neuroma (rarely facial palsy due to slow growth) **4) Temporal bone fracture** * *5) Middle ear** - AOM, CSOM, cholesteatoma - Bell's palsy (idiopathic swelling in facial canal) - Ramsay Hunt Syndrome - Middle ear tumour * *6) Beyond stylomastoid foramen** - Facial trauma (usu affect 1 branch) - Parotid tumour - Metastatic intraparotid lymph node * *7) Others** - Facial nerve schwannoma - Iatrogenic from surgery

Answer 118

* *1) Upper face spared** - UMN lesion (thus lesion above facial nucleus) * *2) Decrease in lacrimation and affects ipslateral taste** - proximal to geniculate ganglion * *3) Preserved lacrimation** - distal to geniculate ganglion * *4) hyperacusis present** - proximal to stylomastoid foramen (stapedial reflex affected) * *5) Only facial movments affected, normal stapedial reflex** - dital to stylomastoid foramen

Answer 119

1) Cranial nerve examination - especially facial nerve (but also try the other nerves) 2) External ear & middle ear exam 3) Parotid gland & intra-oral examination 4) Neck palpation 5) House & Brackmann facial paralysis grading system

Answer 120

**1) MRI brain** – for suspected intracranial lesion **2) MRI temporal bone** – if middle ear pathology is suspected **3) CT temporal bone** – temporal bone trauma **4) MRI/CT parotid and USG FNA** – if parotid lesion is suspected * *5) Electrophysiological testing** - electromyography (Determines the activity of the muscle itself) - Electroneurography

Answer 121

* *Pathogenesis** - idiopathic - Now identified as a herpes reactivation neuritis - Nerve swollen in the facial nerve canal causing neuropraxia **Diagnosis**: Diagnosis by exclusion

Answer 122

* *1) Prednisolone** for 7-14 days - reduce swelling - use if not contraindicated (e.g. DM, TB) **2) Acylcovir or famciclovir** for 5 days * *3) Eye protection and eye drops** - prevention of dry eyes from lack of blinking * *4) Facial nerve physiotherapy** - maintain muscle tone and hasten recovery - prevent facial muscle dysuse atrophy 5) Rule out other cause if no improvement

Answer 123

– Traumatic cause – Middle ear infection – Iatrogenic injury (middle ear or parotid surgery)

Answer 124

**_A. Skin_** * *_B. Bone_** - Nasal bones - Nasal part of frontal bone - Frontal process of maxilla * *_C. Cartilage_** - upper & lower lateral * *_D. Muscles_** 1) Nasalis - transverse (compress nostril) - alar (opens nostril) 2) Procerus - pulls eyebrows down 3) Depressor septi nasi - pulls nose down

Answer 125

* *Roof:** - Cribiform plate (part of ethmoid bone) **Medial Wall:** Nasal septum which is partly cartilaginous (ant) & partly boney (post) - Septal cartilage - Vomer - penpendicular plate of ethmoid bone * *Lateral wall:** - Superior, middle and inferior nasal conchae/ turbinates - Superior, middle and inferior nasal meatus below the turbinates * *Floor:** - Palatine process of maxilla - Horizontal plate of palatine bone

Answer 126

From both external & internal carotid artery: * *Artery (MFO) motherfucko:** 1) maxillary artery =\> sphenopalatine/ nasopalatine artery 2) facial artery =\> alar and nasal branches 3) ophthalmic artery =\> anterior and posterior ethmoidal artery * *Venous drainage PIFO piperfucko** 1) Pterygoid venous plexus 2) infraorbital vein 3) facial vein 4) ophthalmic vein

Answer 127

Rupture of superficial mucosal vessels: - Kiesselbach's plexus (if anterior, which is most common 90%) - Sphenopalatine artery (if posterior, which is more serious)

Answer 128

**1) Direct pressure** * *2) Packing** - anterior nasal packing with gauze strips - posterior packing with Foley catheter - packs must be removed in less than 5 days * *3) Ligation or embolisation** - of sphenopalatine artery (if posterior) or ethmoidal artery (if anterior)

Answer 129

Toxic shock syndrome - due to exotoxin released from Staph aureus

Answer 130

- Common benign tumour - Malignant potential (may turn into SCC in 1~2 decades) * *Presentation:** - Unilateral nasal obstruction * *Diagnosis:** - Histology (definitive) - MRI (Convoluted Cerebriform Pattern) * *Management:** - Need complete removal

Answer 131

- Male in puberty (due to Vascular malformation) - Unilateral nasal obstruction (looks like an "unilateral polyp") - Profuse, recurrent unilateral epistaxis

Answer 132

Air filled extension of nasal cavity in: **1) frontal** * *2) ethmoid** - divided by middle turbinate into anterior & posterior * *3) sphenoid** - require Lateral X-ray for visualisation **4) maxilla**

Answer 133

**For resonance of voice and drainage** \_\_\_\_\_ Drained by Osteomeatal Unit (OMU) **1) Frontal**: Middle meatus via infundibulum **2) Ethmoid**: Middle meatus via infundibulum (anterior); middle meatus on bulla ethmoidalis (middle); superior meatus (posterior) **3) Sphenoid**: Sphenoethmoidal recess **4) Maxillary**: Middle meatus via hiatus semilunaris

Answer 134

* *_PE:_** 1) Nasal speculum (inspection) 2) Mist Test aka Nasal Airflow Patency Test (using the metal tongue depressor) 3) Rigid endoscopy (rhinoscopy) * *_Ix:_** * *1) CT** (for extent of disease, bone erosion) **2) MRI** (for soft tissue invasion e.g. eye, brain) * *3) Tests for allergy** (for type I hypersentivity, i.e. allergic rhinitis) - Blood test for Antigen specific IgE - Skin prick test **4) Histology of mass** **+ Resch)** Rhinomanometry (calculates nasal airway resistance by measuring nasal flow and pressure) **+ Resch)** Acoustic rhinometry (sends sound pulse into nose & measures reflected sound)

Answer 135

* *_Ear disease_** 1) Otitis externa, furunculosis 2) Foreign body in ear 3) Herpes zoster external ear (Ramsay Hunt syndrome) 4) Erysipelas or other skin lesions of external ear 5) AOM 6) CSOM 7) Carcinoma of ear canal/middle ear 8) Cerebropontine angle tumour * *_Referred Pain_** 1) Dental problems 2) Temporo-mandibular joint syndrome 3) Pharyngitis, tonsillitis, peritonsillar abscess 4) Parotitis (mumps, bacterial) 5) CA nasopharynx, oropharynx, hypopharynx, larynx 6) Cervical spondylosis C1,2,3

Answer 136

* *1) Exudation in infection** - Otitis Externa - Chronic Suppurative Otitis Media - Late stage of Acute otitis Media (i.e. with perforation) * *2) CSF otorrhoea** - Trauma, Skull base fracture * *3) Blood** - Trauma - Barotrauma - Tumours

Answer 137

_1) Hearing_ * *normal**: external ear disease e.g. otitis externa (rarely, might have temporary conductive hearing loss) * *hearing loss**: middle ear disease _2) Otalgia?_ painful: infection or neoplasm (note possibility of referred pain) _3) Nature of ear discharge_ - blood? infection? CSF?

Answer 138

**_Definition_** aka Swimmer’s ear; an inflammation of the outer ear and external ear canal (EAC) skin * *_Presentation:_** * *1) Otalgia** - directly related to the severity - DIAGNOSTIC: worsened by pushing the tragus **2) Otorrhoea** **3) Pruritus** * *4) Usually no hearing loss** - might (though rarely) present with temporary conductive hearing loss

Answer 139

_A. Anatomical predisposition/ blockade_ * *1) Narrow ear canal** (e.g. congenital meatal stenosis or post-traumatic) * *2) Cerumen impaction 3) Foreign bodies, hearing aids, ear plugs** _B. High humidity of ear canal:_ * *4) Swimming, shower, watersports** (high humidity) * *5) Summer** _C. Skin lesions, immunosuppression:_ * *6) Scratching and abrasion, post-RT 7) Skin disease e.g. Eczema 8) DM**

Answer 140

* *_Bacterial_** - Pseudomonas aeruginosa (most common!!!) - Strep epidermidis - Staphylococcus aureus * *_Viral_** - Varicella Zoster Virus (Ramsay Hunt Syndrome) * *_Fungal_** - Candida albicans and Aspergillus spp. - Usually due to overuse of topical antibiotics (e.g. in a patient with CSOM, or bacterial EOM)

Answer 141

_A. Non-pharmacological:_ * *1) Local cleansing** - remove wax/foreign body - suction clearance - dry mopping **2) Keep away from moisture** esp NO swimming! _B. Pharmacological therapy_ * *1) Local antibiotic eardrops** against skin flora i) Choramphenicol 5% otic drops, 2-3 drops in affected ear, 3 times daily for 1 week ii) Ofloxacin 0.3% otic drops, 10 drops in affected ear, 1 time daily for 1 week **2) Paracetamol** for pain relief

Answer 142

A localised abscess (boil) in the external auditory canal (EAC); a form of otitis externa - very painful

Answer 143

* *1) Systemic antibiotics** - e.g.cloxacillin against staphylococcus * *2) Symptomatic treatment** - Analgesics for pain relief **3) Drainage** seldom required

Answer 144

* *1) Conductive Hearing Loss** (CDHL) - Outer ear, middle ear * *2) Sensorineural Hearing Loss** (SNHL) - Inner ear, auditory nerve, central nervous system **3) Mixed Hearing Loss** (CDHL + SNHL)

Answer 145

_**A. CONDUCTIVE** _{EAC pathology}_ **1) Cerumen impaction, foreign body** 2) EAC stenosis 3) Otitis externa 4) Tumour 5) Exostosis, osteoma _{ME pathology} 6) CSOM, cholesteatoma **7) OME (Look out for NPC!!!) 7) Otosclerosis 8) Temporal bone fracture** 9) Haemotympanum * *_B. SENSORINEURAL_** * *1) Presbyacusis 2) Ototoxicity 3) Transverse temporal bone fracture 4) Meniere’s disease 5) Ramsay hunt syndrome, syphilis 6) Hypothyroidism 7) Acoustic neuroma**

Answer 146

_Rule of 3_ ## Footnote **- 30dB or more SNHL** **- over 3 contiguous frequency** **- within 3 days**

Answer 147

**_An otological emergencyt!!!_** * *1) Steroid** - Systemic or intratympanic - Strong & immediate **2) Stop any possible ototoxic drugs** **3) Perform MRI** to rule out acoustic neuroma

Answer 148

* *Pathogenesis:** - Ascending infection of middle ear from the Eustachian tube. Usually in children. * *Pathogens:** * _1) Viral_* - RSV * _2) Bacterial_* - Strep.pneumoniae - H. influenzae - Moraxella catarrhalis

Answer 149

**1) Otalgia** (unilateral) **2) Conductive deafness** * *3) Constitutional symptoms** - fever * *4) Otorrhoea** - only when eardrum perforated (late stage)

Answer 150

* *1) Oral antibiotics** - Amoxiclav - erythromycin - 1 week to 10 days * *2) Supportive treatment** - Analgesics for pain relief * *3) M&G** - myringotomy and grommet insertion (occasionally) - to relieve middle ear pressure

Answer 151

* *1) Infection** - acute otitis media (late stage) - CSOM * *2) Trauma** - direct mechanical - oatrogenic (e.g. Myrinectomy Grommet) - barotrauma - Blast injury

Answer 152

Chronic or intermittent otorrhoea through a persistent perforated TM

Answer 153

* *1) Otalgia** - chronic * *2) Hearing loss** - conductive or mixed * *3) Chronic or recurrent Otorrhoea** - *_Persistent, non-healing eardrum perforation_* **4) Vertigo** **5) Constitutional symptoms**

Answer 154

* *1) Otoscopy** - for diagnosis * *2) Assess for active infection** - Ear mopping - Ear swab x bacterial culture - Broad spectrum antibiotic eardrops (might not be a good idea due to potential sudden hearing loss) * *3) Pure tone audiogram** (PTA) - for both ears

Answer 155

* *Bacterial:** - Staphylococcus aureus - Pseudomonas aeruginosa - Escherichia coli - Bacteroides fragilis - Tuberculosis (rarely) * *Fungal:** - Candidiasis - Aspergillosis

Answer 156

Depends on the site: * *1) Central perforation** - i.e. tubotympanic - "safe" perforation * *2) Marginal, or attic perforation** - i.e. atticoantral - "unsafe" perforation

Answer 157

i.e. Attico-antral perforation: * *1) Cholesteatoma** - Keratinizing squamous epithelium can be pushed back from EAC into middle ear via the marginal perforation * *2) Extracranial Complications** - facial nerve paralysis - ossicular chain erosion - Labyrinthitis (causing sudden hearing loss) - Lateral semicircular canal fistula (cause vertigo) - subcutaneous/subperiosteal abscess * *3) Intracranial Complications** - Meningitis, Brain abscess (usu temporal lobe, cerebellum) - extradural abscess, subdural abscess - Sigmoid sinus thrombophelbitis (posterior to mastoid) - otitic hydrocephalus

Answer 158

_Safe CSOM:_ **1) Hearing aid** **2)** **Tympanoplasty** to manage perforation **3) Antibiotics eardrops** (? beware: SHL) **4) Aural toilet, ear ventilation** **5) Avoid water sports, swimming** _Unsafe CSOM:_ **1) Screen for complications** * *2) Mastoidectomy** (removal of mastoid, middle ear cavity, EAC walls) - eradicate infection - prevent complication - not to improve hearing **3) Aural toilet, ear ventilation** **4) Avoid water sports, swimming**

Answer 159

Most of the topical antibiotics currently used are also **ototoxic, esp aminoglycosides** Therefore, Sudden hearing loss (SHL) if long term antibiotic ear drops in CSOM / perforated ear drum patients; because antibiotics going into the middle and inner ear through the TM defect.

Answer 160

* *Definition**: - _Sterile_ effusion in middle ear for \> 3months - the presence of middle ear fluid for 6 weeks or more from the initial acute otitis media - No perforation - otitis media in inactive (no active inflammation)

Answer 161

Once the eustachian tube is blocked, air is continuously drew in by the vasculatures (very much like the lungs), creating a space of negative pressure in the middle ear. As a result, transudation of interstitial fluid -\> forming the collection of **Sterile effusion** in middle ear

Answer 162

Basically causes of blockade of Eustachian tube: * *Congenital** - Cleft palate - Down’s syndrome - Craniofacial abnormality - Mucociliary dysfunction (e.g. Kartegener's) - IgG deficiency * *Acquired** - URTI - AOM - Nasal polyp - NP mass (e.g. NPC)

Answer 163

**1) Conductive Hearing loss** **2) Otalgia** * *3) Speech delay, articulation problem** - in children

Answer 164

**1) Otoscopy** **2) Tympanometry** **3) Pure tone audiometry** (PTA) conductive hearing loss

Answer 165

1) Myringotomy + Grommet insertion 2) Do not swim

Answer 166

**- Autosomal dominant, with incomplete penetrance** **- Focal osseous dysplasia of bone derived from otic capsule:** i) Abnormal bone absorption & deposition ii) Fibrous replacement & sclerosis

Answer 167

Usu during pregnancy, around 20-30yo, present with: **1) Bilateral conductive hearing loss** (80%) **2) Tinnitus** **3) Vertigo** **4) 50% Family Hx**

Answer 168

**1) Conservative** **2) Hearing aid** **3) Stapedectomy**

Answer 169

**- Benign paroxysmal positional vertigo** - Functional vertigo - Central-vestibular vertigo - Vestibular migraine **- Meniere’s disease** - Vestibular neuronitis

Answer 170

* *1) Symptom** - confirm it is vertigo (cf. LOC, postural instability, nausea) - ideally bystander interview * *2) Time course** - episodic vs acute sustained vs chronic sustained * *3) Trigerring factors** - loud noise? light? specific postures? URTI? Trauma? Ototoxic drugs? * *4) Associated symptoms** - headache? photophobia? Hearing loss?

Answer 171

**1) Neurological examination, muscle power examination** * *2) Romberg test** - if single leg is okay \>5s, then _Somatoform dizziness_ - if Romberg failed, but HINTS & neurological exam normal, then motor weakness * *3) HINTS (for stroke!)** - Head Impulse (if abnormal, peripheral vertigo) - Nystagmus - Test of Skew (alternating cover uncover test; if abnoraml, then central vertigo) * *4) Hallpike’s test** - diagnostic for BPPV

Answer 172

* *_1) CT/MRI Brain & Brainstem_** - if suspects central causes * *_2) Audiological Test_** (to confirm peripheral cause) - Electronystagmography (using caloric reflex test or rotary chair) - Posturography

Answer 173

Due to **canalolithiasis or cupulolithiasis**: BPPV is caused by presence of particulate/debris from from saccule/utricle affecting semicircular canal endolymph flow. It can be _spontaneous_ or caused by _head trauma_ Usually lodged in posterior semiciruclar canal, bending the Posterior canal stereocilia

Answer 174

* *1) Vertigo** - recurrent, last for about 3wk - associated with a SPECIFIC position - cause wakes in sleep ## Footnote **2) No hearing symptoms**

Answer 175

**_Diagnosis:_** Hallpike manoevre * *_Management:_** * *1) Reassurance & General measures** - stop driving - prop up or 2 high pillows - Don’t sleep on side of bad ear - Keep head vertical **2) Epley manoevre** **3) Cawthorne-Cooksey exercises** * *4) Surgery** (not performed in HK) - Posterior ampullary nerve section - Posterior canal obliteration

Answer 176

i.e. idiopathic endolymphatic hydrops (more common in women): _Triad of:_ * *1) tinnitus 2) Vertigo** * *3) Progressive deafness** (esp low tone on audiometry) **+/-) aural fullness +/-) each attack about a few hours**

Answer 177

* *_1) Long term:_** - Sodium restriction - Thiazide diuretics (not loop as it causes vertigo too) - Meniett Device - _Betahistine_ - _Intratympanic gentamicin injection_ (Medical labyrinthectomy) * *_2) Anti-vertigo & anti-nausea for attack_** - Betahistine - Antihistamine (promethazine for vomit prevention) - Anticholinergics antiemetic (Hyoscine) - diazepam - Phenothiazines? **_3) Hearing aid for deafness_** * *_4) Occasionally surgery_** - endolymph sac decompression - Vestibular neurectomy - Labyrinthectomy

Answer 178

- Dyspnea - Feeding difficulties - Choking, aspiration - Coughing - Voice change (noisy breathing, hoarseness, weak cry, not crying) - Stridor - Stertor

Answer 179

- Croup (laryngotracheobronchitis) - Acute Epiglottitis - Retropharyngeal abscess - Recurrent respiratory papillomatosis - Foreign body (e.g. food, toy) - Anaphylaxis - Trauma - OSA - adenotonsillar hypertrophy

Answer 180

- Tumours (pharyngeal tumours) - Infection - Trauma - Foreign body (e.g. fish bone) - Anaphylaxis - OSA (e.g. obesity) - Vocal cord palsy

Answer 181

Young children of 3 months to 3 yo * *Signs:** - Fever, preceded by URTI - Biphasic Stridor - Barking cough, Tripod position - Recurrent croup is associated with subglottic stenosis or subglottic hemangioma **XR neck**: subglottic swelling - hourglass or _steeple sign_ **Nasopharyngeal aspirated (NPA)** - viral antigens

Answer 182

Caused mainly by viral infection: * Parainfluenza virus * Influenza virus type A * Respiratory syncitial virus * Mycoplasma pneumoniae

Answer 183

* *0) ABC, Close observation, 10% admitted** - O2 therapy - intubation needed for repeated adrenaline * *1) PO/IM dexamathasone 2) nebulised budesonide 3) Nebulised adrenaline** (1:1000) Must rule out underlying subglottic stenosis or hemangioma if recurrent croup

Answer 184

Children 2-6 yo: * *Presentation:** - Fever - Severe sore throat, rapidly worsening - Inspiratory stridor - Stertor, Hot potato voice - Dysphonia, Drooling, not crying - Tripod position **_Ix are NOT indicated, but:_ Laryngoscopy**: cherry red epiglottis **XR neck**: thumb sign **Blood culture**: HIB

Answer 185

Mainly **H. influenzae type B** but can be: • Beta-hemolytic streptococcus • Pneumococcus • Staphylococcus

Answer 186

1) **DO NOT** attempt for throat exam (esp laryngoscopy), blood taking or IV access: **2) Diagnosis by history** 3) Immediately OT for **airway protection** - Inform senior pedi, ENT and anaesthetist * *- Gaseous induction followed by intubation** * *4) Antibiotics: IV Augmentin & Ceftaxime (Claforan)** - also take blood for blood culture **5) Prophylactic Rifampicin** for close contacts

Answer 187

1) Rifampicin 2) Prophylaxis HIB vaccination

Answer 188

All causes upper airway obstruction: * *1) Peritonsillar abscess (Quinsy)** - fever, stridor, sore throat, dysphagia, drooling - _Unilateral Peritonsillar swelling_, _medial tonsil deviation_, _deviation of uvula_ - _Trismus_ * *2) Submandibular and sublingual** abscess (Ludwig's agina) - fever, stridor, sore throat, dysphagia, drooling - Stertor, hot potato speech, trismus - _Board like floor swelling_ (Tender swelling at submental) - _Superior, posterior displacement of tongue_ - _Dental root abscess_ 50-90% * *3) Parapharyngeal abscess** - Commonest deep neck infection in adults - fever, stridor, sore throat, dysphagia - note neck stiffness, _jaw angle swelling_ - _Great pain & trismus_ (if ant); _great dyspnoea_ (if post) - often Tonsillitis or Dental origin * *4) Retropharyngeal abscess** - Commonest deep neck infection _in children \< 4yo_ - _mimic croup_, with fever, stridor, dysphagia, drooling - Note neck stiffness & hyperextension - _Hx of URTI_ - _XR neck_: increase retropharyngeal space

Answer 189

* *1) Peritonsillar abscess (Quinsy)** - Airway protection - Incision and drainage (trans-oral) - Antibiotics with penicillin G + metronidazole - Analgesics - Consider elective tonsillectomy * *2) Submandibular & submental abscess (Ludwig's angina)** - Airway protection (intubation) - Antibiotics by penicillin G + metronidazole - Soft tissue decompression - Dental assessment * *3) Paraphayngeal abscess** - Airway protection (tracheostomy) - Transcervical drainage - CT/MRI (assess extent), blood culture, pus culture - Antibiotics * *4) Retropharngral abscess** - Airway protection - Drainage - Antibiotics

Answer 190

* *1) Jugular vein thrombophlebitis** aka **Lemierre syndrome** - spiked fevers, rigors, swollen cervical lymph nodes, and a swollen, tender or painful neck - abdominal pain, diarrhea, nausea and vomiting - Pulmonary involvement - Septic shock ## Footnote **2) Carotid artery erosion**

Answer 191

Paratonsillar abscess, i.e.: Collection of pus **between tonsillar capsule & superior constrictor**

Answer 192

In peritonsillar abscess, most commonly **GAS (strep pyogenes)** Can also be mixed oropharyngeal organisms: - anaerobes - viridans streptococcus - Bacteroides, peptostreptococcus

Answer 193

Infection begins in the floor of the mouth, leading to rapidly spreading indurated cellulitis, without abscess formation, involving the **submandibular and sublingual spaces** on both sides.

Answer 194

**Pathogen:** Polymicrobial, but mainly: - streptococcus - anaerobes * *Source:** - Mostly dental source

Answer 195

- Airway protection (intubation) - IV Antibiotics by penicillin G + metronidazole - Soft tissue decompression - Dental assessment

Answer 196

* *1) Infective** - laryngitis, pharyngitis, tonsilitis, acute epiglottitis - pertonsillar abscess (quinsy) - croup - Infective mononucleosis - diptheria * *2) Neoplastic** - Orophayngeal tumour - hypopharyngeal tumour **3) Allergy** **4) Gastric Reflux** * *5) Inflammatory** - e.g. post radiotherapy

Answer 197

May persists for 1-3 months * *1) Prodromal period 4-5 days 2) Malaise, headache** Local **3) Sorethroat (pharyngitis) _4) Membranous tonsillitis_ (Inflammed tonsils, membranous slough, juicy-looking) 5) Petechiae on soft palate -\>) can lead to upper airway obstruction** * *_6) Lymphadenopathy_ 7) Palpebral conjunctivitis, puffy eyelids** Complications: * *_8) Hepato splenomegaly_ 9) Sepsis 10) Rubelliform rash with amoxicillin, ampicillin**

Answer 198

* *1) CBC** - Raised WBC - mononuclear cells - decreased platelet count * *2) Peripheral Blood Smear** - atypical lymphocytes **3) LFT** - deranged LFT - increased clotting time * *4) Positive monospot test** - detection of heterophile antibodies * *5) Serology** - Seroconversion of IgM to IgG to EBV antigens

Answer 199

_Supportive treatment only:_ * *1) Bed Rest 2) Fluid replacement 3) Avoid ampicillin & amoxicillin**(due to rubelliform rash in children with EBV) * *4) Observe airway, Manage complications** - corticosteroid if airway compromised - consider penicillin if GAS cultured from tonsils

Answer 200

_Symptoms_: - Fever - Sore throat - Odynophagia, dysphagia, trismus _Oral cavity:_ - Red Hyperaemic swollen tonsils (**Always Bilateral**), with whitish spots (i.e. exudates, pus) - Red hyperaemic throat - Swollen uvula - Grey furry tongue - Otalgia _Systemic:_ - fever - Cervical lymphadenopathy - abdomimal pain, vomiting

Answer 201

_LOCAL:_ **1) Upper airway obstruction** * *2) Abscess formation** - peritonsillar abscess (quinsy) - parapharyngeal abscess - retropharyngeal abscess **3) AOM** _GENERAL:_ * *1) Septicaemia 2) Acute rheumatic fever 3) Acute glomerulonephritis 4) Meningitis**

Answer 202

* *1) Virus (mainly)** - Enterovirus - Respiratory viruses e.g. Influenza ABC, Parainfluenza 1-4, adenovirus, rhinovirus, respiratory syncytial virus, metapneumovirus, coronavirus **2) Bacteria** _- Strep pyogenes_ - strep pneumoniae, H influenzae - anaerobic * *3) Others:** - Corynebacterium diptheria - Candida - Syphilis - TB

Answer 203

* *Ix:** - Throat swab for culture * *General measures:** - Bed rest - Fluid replacement, IV line * *Medical therapy:** - Penicillin, Erythromycin - Analgesics * *Surgery:** - Tonsillectomy if chronic & complicated (see "Indications for Tonsillectomy")

Answer 204

* *_ABSOLUTE indicators_** 1) Enlarged tonsils causing upper airway obstruction, severe dysphagia, sleep disorders, cardiopulmonary complication 2) Peritonsillar abscess unresponsive to medical treatment & drainage 3) Tonsillitis resulting in febrile convulsion 4) Tonsils requiring biopsy to define tissue pathology (e.g. unilateral swelling of tonsils) * *_RELATIVE indicators_** 5) 3 or more tonsillitis per year 6) Halitosis 7) Recurrent tonsillitis in streptococcal carrier not responsive to antibiotics 8) Unilateral tonsil hypertrophy that is presumed to be neoplastic

Answer 205

**1) Bleeding tendency** **2) Acute infection within 2 weeks** **3) Uncontrolled medical illness** * *4) Body Weight \< 15kg** - as the tonsillectomy may lead to significant proportion of bleeding - relative contraindication: usually still perform but with monitor in pediatric ICU

Answer 206

* *Intra-operative:** 1) Uncontrolled bleeding 2) Injury to teeth 3) Injury to posterior pharyngeal wall 4) TMJ dislocation (jaw dislocation) 5) Atlantoaxial subluxation e.g. Down’s syndrome

Answer 207

* *Immediate (within 24 hours post-op)** 1) Reactionary haemorrhage 2) Aspiration 3) shock 4) bronchospasm * *Early** 1) Secondary haemorrhage D5-10 (due to infection) 2) Peritonsillar, parapharyngeal abscess 3) Pulmonary complication, pneumonia 4) Poor intake * *Late:** 1) Scarring of soft palate 2) Voice change 3) Recurrent infection (tonsil remnant)

Answer 208

^{An immediate complication post-op of tonseillectomy:} * *1) Resuscitation** - ABC, may need intubation if airway compromise - BP, capillary refill - Fluid resuscitation - 2 large bore IV access, ensure T&S * *2) Inspect wound -\> haemostasis procedure** - if minor bleed: pack with adrenaline gauze, cauterisation, antibiotics - if major bleed: haemostasis under GA, may need rapid sequence induction

Answer 209

1) Frequent swallowing, gurgling sound in throat, vomiting 2) fresh blood in mouth 3) Pale skin, Cold periphery, poor capillary return 4) Restlessness 5) Tachycardia, orthostatic hypotension, Shock

Head & Neck, ENT Flashcards

(233 cards)