23 Jan 24 Ent

Question 1

CSF rhinorrhea etiology

Answer 1

➡️ accidental trauma (most common)
Fracture of skull base (cribriform plate , temporal bone.

➡️ surgical trauma. (eg sinus surgery)
➡️ non traumatic. (eg elevated ICP)

Question 2

CSF rhinorrhea CF

Answer 2

UL watery rhinorrhea with salty or metallic taste

Can have instant as well as delayed presentation after trauma.

Possible complication meningitis

Question 3

How to evaluate for CSF rhinorrhea

Answer 3

➡️ test for CSF specific proteins (beta 2 trasferrin, beta trace protein)
➡️ imaging (with intrathecal contrast)
➡️ endoscopy (intrathecal fluorescein dye)

Question 4

Management if CSF rhinorrhea

Answer 4

▶️ inpatient bed rest , head of bed elevation , avoidance of straining

▶️ freq neurologic evaluation bcz of risk of meningitis due to nasal flora contamination if CSF

▶️ lumbar drain placement

▶️ surgical repair

Question 5

Bisphosphonate related osteonecrosis Of Jaw RF

Answer 5

High dose parenteral bisphonates
Dental procedures (extractions , implants)
Area of exposed necrotic bone after tooth extraction is classic

Concurrent glucocorticoid use
Concurrent or prev malignancy

Question 6

Bisphosphonate related ON of jaw cause

Answer 6

Impaired bone healing

Question 7

CF of osteonecrosis of jaw

Answer 7

Chronic indolent symptoms
Mild pain , swelling
Exposed bone , loosening if teeth , pathologic fractures

Question 8

Ttt of ON of jaw

Answer 8

Oral hygiene
Antibacterial rinses
Antibiotics and debridement as needed.

Question 9

Epiglottitis pt with resp failure CF

Answer 9

Tripod positioning
Drooling
hoarseness

Question 10

How to manage epiglottitis patient with resp failure

Answer 10

Bag valve mask ventilation with 100% O2 to keep saturation > 88%

If BVM ventilation does not cause adequate oxygenation
ETT using video laryngoscope

If Single attempt of ETT fails
Cricothyrotomy(surgical airway)

➡️multiple attempts at ETT with video laryngoscope is not recommended as it would delay adequate oxygenation in a hypoxic pt.
If intubation without video Laryngoscope fails then 2nd attempt is done with a video laryngoscope.

Question 11

Parotid gland tumor and signs of malignancy

Answer 11

Cranial nerve involvement
5th nerve (facial numbness)
7th nerve (facial droop)

Do Cranial nerve exam in all patients with parotid mass

Question 12

Perilymphatic fistula

Answer 12

Complication of head injury or barotrauma causing leakage of endolymph from semicircular canals and cochlea into surrounding tissues

Question 13

CF of perilymphatic fistula

Answer 13

Progressive SNHL
Episodic vertigo with Nystagmus triggered by pressure changes ;

     Valsalva 
     Elevator ride (causing inc pressure in endolymph) 

Clinical test ;
Tullio phenomenon : a loud clap near pts ear and observing nystagmus

Question 14

Ttt of perilymphatic fistula

Answer 14

Limit activities that inc ear pressure
ENT referral

Question 15

Why do we supplement levothyroxine in pts after total thyroidectomy

Answer 15

😡 to replace thyroid hormone
😡 to supress pituitary release of TSH
(Prevents cancer recurrence )

Question 16

Indication of Thyroid cancer recurrence after total thyroidectomy

Answer 16

Measure serum THyroglobulin levels
(Precursor to active thyroid hormone T3 and T4 formed by healthy and cancerous thyroid tissue. Rising levels after total thyroidectomy and radioactive iodine ttt means TG coming from reccurent tumor)

🚑 TG is formed by papillary and follicular cancer but not medullary cancer which doesnt produce thyroid hormone.

Question 17

Medullary thyroid cancer Epidemiology

Answer 17

Neuroendocrine malignancy
Arises from calcitonin secreting Parafollicular C cells

Mostly Sporadic
25% due to RET mutations (MEN 2)

Pt can have MTC being RET negative

Question 18

MTC tumor markers

Answer 18

Serum calcitonin
CEA

Question 19

Ulcerated tonsil in a pt with smoking

Answer 19

Oropharyngeal SCC

RF for Oropharyngeal SCC
   Age >40
   Smoker 
   Alcohol
   Immunicomp status 

🧇 tonsilloliths are not known risk factor
But manipulation for stone removel can be mistaken for ulcerated neoplasm.

Question 20

Sialoadenosis RF

Answer 20

Non tender beningn enlargement of parotids

Cause : overaccumulation of secretory granules in
Alcoholics
Bulimics
Malnutrition
Liver dx and diabetics (due to fatty infltration)

Vs Cancer: Cancer is unilateral with a palpable distinct mass

Question 21

Pregnant Pt with thyroid nodule and USG findings of malignancy

Answer 21

Do FNA biopsy (safe in pregnancy)

If thyroidectomy is need it can be delayed until delivery.
For aggressive cancer do surgery in second trimester.

Question 22

Thyroid nodules workup

Answer 22

Nodule > 1cm with high risk features
Do FNA

Nodule >2cm do FNA for all
Except cystic

High risk features :

microcalcifications , irregular margins, internal vascularity

Question 23

Post op pt has expanding neck mass ballotable neck swelling

Answer 23

Do immediate wound exploration and drain hematoma promptly to avoid potential upper airway obstruction.

Question 24

Peritonsillar abscess CF

Answer 24

Acute bacterial infection between tonsil and pharyngeal muscles.

CF:
Fever dysphagia throat pain
Muffled voice
UL swelling of soft palate
Uvular deviation
Trismus ( involvement of pterygoids)
Cervical LAD

Question 25

Untreated PTA compications

Answer 25

Airway obstruction
Spread of infection to parapharyngeal space which may lead to involvement of carotid sheath.