4 General Oto

Question 1

1 Define sensitivity. (▶Fig. 4.1)

Answer 1

The ability of the test to identify correctly those patients with the disease TP/(TP+FN)

Question 2

2 Define specificity.

Answer 2

The ability of the test to identify correctly those patients without the disease TN/(TN+FP)

Question 3

3 Is high sensitivity or high specificity most important for a screening test?

Answer 3

Sensitivity

Question 4

4 Define a type 1 error.

Answer 4

The chance of testing positive among those without the condition; false-positive rate = 1 specificity.

Question 5

5 Define a type 2 error.

Answer 5

The chance of testing negative among those with the condition; false negative rate = 1-sensitivity.

Question 6

6 Define positive predictive value.

Answer 6

The chance of having the condition among those that test positive TP/(TP+FP)

Question 7

7 Define negative predictive value.

Answer 7

The chance of not having the condition among those that test negative TN/(TN+FN)

Question 8

8 A cervical spine X-ray revealing a greater than 5- mm widening of the predentate space (between the anterior surface of the dens and the posterior surface of the C1 tubercle) is worrisome for what traumatic injury?

Answer 8

Atlantoaxial dissociation

Question 9

9 Conventional radiography of the facial bones and neck has been largely replaced by computed tomography (CT). What traditional views were used to view the following:

• Frontal, maxillary, and sphenoid sinus
• Frontal sinuses, posterior ethmoid air cells, orbital floors
• Maxillary sinuses, anterior ethmoid air cells, orbital floors
• Sphenoid sinuses, anterior and posterior walls of the frontal sinuses
• Soft tissue of the neck

Answer 9

• Lateral view (5 degrees off true lateral)
• Caldwell view (15 degrees off caudal angulation)
• Waters view (neck in 33 degrees of extension)
• Submentovertex view (anteroposterior [AP] projection, head in 90 degrees of extension)
• AP and lateral views

Question 10

10 In a stable pediatric patient with stridor, what radiography is appropriate?

Answer 10

AP and lateral neck films to evaluate for retropharyngeal abscess, croup, epiglottitis, and radiopaque foreign body

Question 11

11 What are the most common findings on chest radiography in a patient with a witnessed foreign body aspiration and clinical signs suggestive of aspiration?

Answer 11

Mediastinal shift, unilateral hyperinflation, atelectasis, and a foreign object if radiopaque

Question 12

12 Although they have been largely replaced by CT scan, radiographs of the temporal bone are occasionally necessary. Name the following views:

• Lateral view of the mastoid with 30 degrees of cephalocaudad angulation
• View of the petrous apex with patient facing the film, head slightly flexed and turned 45 degrees opposite the film
• Comparison of both mastoid bones and petrous pyramids via AP view with a 30-degree tilt

Answer 12

• Schüller view
• Stenvers view
• Towne view

Question 13

13 Why is a CT scan typically a more appropriate imaging study in evaluating patients with a potential deep neck space infection instead of magnetic resonance imaging (MRI)?

Answer 13

Although MRI provides better soft tissue definition, it is expensive and requires a lengthy scan time compared with CT and therefore may necessitate sedation of a child or a distressed patient and increase the likelihood of airway compromise.

Question 14

14 On T1-weighted MRI, contrast-enhancing tumors may be hidden by surrounding fat. What technique can be used to achieve better visualization of the tumor?

Answer 14

Fat suppression

Question 15

15 Describe the T1-weighted appearance of water and fat on MRI.

Answer 15

Low intensity and high intensity, respectively

Question 16

16 What are some of the contraindications to MRI use?

Answer 16

Electromagnetic force can cause serious malfunction to cardiac pacemakers and cochlear implants (although new techniques have been developed that allow cochlear implant recipients the ability to have MRI studies). Some older vascular clips and ossicular prostheses contain paramagnetic components, and unless these are known to be MRI compatible, another modality should be used.

Question 17

17 What does SUV stand for in regard to positron emission tomography (PET) imaging?

Answer 17

Standardized uptake value, which provides a semiquantitative index of radio tracer uptake

Question 18

18 What does the presence of an echogenic (fatty) hilum typically indicate during ultrasound examination of the neck?

Answer 18

Benign disease. Normal lymph nodes have an echogenic hilum, whereas it is reported that there is an absent hilum in 96 of metastatic lymph nodes.

Question 19

19 Can the location of normal parathyroid glands be identified on ultrasound examination of the thyroid and neck?

Answer 19

Normal parathyroid glands are not usually visible because of their small size and similar echo texture to adjacent thyroid tissue.

Question 20

20 What is acoustic shadowing in ultrasound imaging?

Answer 20

Diminished sound or loss of sound posterior to a strongly reflecting or attenuating structure

Question 21

21 Review the differences between first-generation and second-generation antihistamines.

Answer 21

Compared with first-generation antihistamines, second-generation medications generally have a longer duration of action, have less central nervous system (CNS) penetration, and are less sedating.

Question 22

22 Review contraindications to glucocorticoid steroid use.

Answer 22

Psychosis, severe diabetes, peptic ulcer disease, congestive heart failure, severe hypertension, systemic tuberculosis, osteoporosis

Question 23

23 Describe the features of ototoxicity associated with salicylate use.

Answer 23

Reversible sensorineural hearing loss and tinnitus, hypothesized to result from disruption of oxidative phosphorylation. Its use does not produce histologic changes.

Question 24

24 What severe neurologic side effect is associated with intramuscular administration of prochlorperazine?

Answer 24

Extrapyramidal side effects including focal dystonia

Question 25

25 List the different amide and ester local anesthetics.

Answer 25

Amides have two "i's," whereas esters only have one "i" in their generic name. Examples of esters include benzocaine, cocaine, and tetracaine. Examples of amides include bupivacaine, lidocaine, and mepivacaine. Esters are more likely to cause an allergic reaction

Question 26

26 What topical anesthetic reversibly binds to and inactivates sodium channels, thus inhibiting excitation of nerve endings and causing vasoconstriction?

Answer 26

Cocaine

Question 27

27 What is the maximum dose of lidocaine hydrochloride?

Answer 27

4 to 5 mg/kg, maximum total dose of 300mg

Question 28

28 What medication can be given to reverse the effects of local injectable epinephrine?

Answer 28

Local infusion of 1.5 to 5mg of phentolamine

Question 29

29 What is the mechanism of action for β-lactam antibiotics?

Answer 29

Binds to DD-transpeptidase (also called penicillin-binding protein) and inhibits the formation of peptidoglycan crosslinks in the bacterial cell wall

Question 30

30 What is the mechanism for acquiring penicillin resistance?

Answer 30

Enzymatic deactivation of penicillin G through β-lactamases and altered penicillin binding proteins

Question 31

31 What is the mechanism of action of aminoglycosides?

Answer 31

They irreversibly bind to the 30S ribosome and freeze the 30S initiation complex. Additionally, they cause misreading of the mRNA code (bactericidal).

Question 32

A mutation in which a gene may lead to increased aminoglycoside toxicity even at low doses?

Answer 32

Mitochondrial 12S ribosomal RNA gene

Question 33

33 What are the earliest signs of aminoglycoside ototoxicity?

Answer 33

Tinnitus, high-frequency hearing loss, and dizziness

Question 34

34 What is the mechanism of action of macrolides?

Answer 34

They inhibit translocation of the peptidyl tRNA from the A to the P site on the ribosome by binding to the 50S ribosomal RNA (bacteriostatic).

Question 35

35 What is the treatment of Clostridium difficile colitis?

Answer 35

IV or oral (PO) metronidazole or PO vancomycin

Question 36

36 What are the most common antibiotics that have been implicated in the development of C. difficile colitis?

Answer 36

Second- and third-generation cephalosporins, ampicillin/ amoxicillin, and clindamycin

Question 37

37 A child develops gray staining of the teeth with a prominent horizontal line across the upper and lower teeth after being prescribed an antibiotic. Which antibiotic was most likely prescribed?

Answer 37

Tetracycline

Question 38

38 What is the mechanism of action of aspirin?

Answer 38

Irreversible acetylation of serine 529 of cyclooxygenase (COX) 1. Rapid onset of action if dose is 160mg or greater. The effects of use last for the lifetime of the platelet, which is 7 to 10 days.

Question 39

39 What is the mechanism of action of thienopyradines (e.g., clopidogrel bisulfate)?

Answer 39

Irreversible inhibition of the **cysteine residue of the P2Y12 platelet receptor.** Onset of action is rapid if patient is given a loading dose, and the effects last for the lifetime of the platelet (7 to 10 days).

Question 40

40 What drug can be given to reverse the antiplatelet effects of nonsteroidal anti-inflammatory drugs (NSAIDs)?

Answer 40

Desmopressin acetate (DDAVP)

Question 41

41 In the event of significant bleeding following administration of heparin, what medication should be considered?

Answer 41

Protamine. Give 1mg for every 100 units of heparin, and closely monitor activated partial thromboplastin time (aPTT).

Question 42

42 What is the mechanism of action of warfarin?

Answer 42

It is a vitamin K antagonist that inhibits the production of vitamin K-dependent clotting factors.

Question 43

43 Describe the mechanism of malignant hyperthermia.

Answer 43

It is caused by a combination of a volatile inhalational anesthetic (commonly halothane) and the short-acting paralytic succinylcholine. An abnormal ryanodine receptor causes overwhelming amounts of calcium to be released from the sarcoplasmic reticulum of skeletal muscle, thereby initiating prolonged and intense muscle contraction.

Question 44

44 What is the initial treatment for malignant hyperthermia?

Answer 44

Stop the anesthetic, give dantrolene (which prevents the release of calcium from endoplasmic reticulum), increase oxygen, and initiate cooling measures including ice packs.

Question 45

45 What are the physical examination findings of cardiac tamponade?

Answer 45

Tachycardia, paradoxical pulse with respirations, hypotension, jugular vein distension, muffled cardiac sounds, decreased QRS amplitude on electrocardiogram (ECG)

Question 46

46 What are the four basic classifications of shock?

Answer 46

* Hypovolemic shock: Loss of blood volume * Obstructive shock: Decreased circulation resulting from external or intrinsic compression * Septic shock: Related to vascular dilation * Cardiogenic shock: Impaired perfusion from lack of sufficient cardiac output

Question 47

47 What is the formula describing the rate of fluid maintenance for the pediatric patient?

Answer 47

The 4:2:1 rule = 4 mL/kg hourly for the first 10 kg, adding 2 mL/kg per hour for the second 10 kg, and adding 1 mL/kg per hour for each kilogram over 20 kg

Question 48

48 What is the formula used to calculate the rate of fluid resuscitation of a burn victim?

Answer 48

The Parkland formula: Fluid for the first 24 hours (milliliter) = 4 x patient weight (kg) x % body surface area involved; the first half is given over 8 hours, the second half over the remaining 16 hours. Rule of 9's for determining percentage of burned: 9% = head, each arm; 18% = chest, back, each leg

Question 49

49 What preoperative condition is associated with immunosuppression, poor wound healing, decreased basal metabolic rate, longer hospitalization, and an increased mortality rate?

Answer 49

Preoperative malnutrition

Question 50

50 Why should gastric residuals be checked every 4 hours in a patient receiving enteral nutrition via tube feeds?

Answer 50

Regurgitation and aspiration are risks of tube feeding

Question 51

51 What is involved in the refeeding syndrome that is observed in severely malnourished patients following initiation of feeds?

Answer 51

Malnourishment leads to hypoinsulinemia and electrolyte abnormalities including intracellular hypophosphatemia. Within 4 to 5 days of reinitiation of carbohydrate metabolism and subsequently increased insulin production, patients can develop severe hypophosphatemia.

Question 52

52 You are rounding on a patient who underwent major surgery for polytrauma and required 20 units of packed red blood cells. The patient is complaining of perioral numbness and tingling. What is the likely diagnosis and treatment?

Answer 52

Citrate toxicity with subsequent hypocalcemia. Treat with calcium gluconate. This should be given for symptomatic patients only.

Question 53

53 What medications can be given as pretreatment to prevent mild hypersensitivity and nonhemolytic febrile reactions in a patient receiving blood transfusion with a history of mild reactions?

Answer 53

Acetaminophen and antihistamines such as diphenhydramine

Question 54

54 What complications may be encountered in a patient who has received massive intraoperative transfusions?

Answer 54

Volume overload, hyperplasia or hypokalemia, hyperammonemia, acidosis, thrombocytopenia, coagulation factor depletion, coagulopathy, hypothermia, transfusion related acute lung injury, and citrate toxicity

Question 55

55 What is transfusion-related acute lung injury?

Answer 55

Acute respiratory distress and noncardiogenic pulmonary edema that develops during or within 6 hours of blood transfusion. Treatment includes supportive measures, often including mechanical ventilation, high-inspired oxygen, and positive end expiratory pressures.

Question 56

56 Mechanical ventilation is most commonly delivered via positive-pressure ventilation (PPV). What are the two most common subtypes of PPV that focus on the transition from inspiration to expiration?

Answer 56

● Volume control: A set volume is delivered per breath ● Pressure control: A set pressure is delivered per breath

Question 57

57 What common rule can be used to select the tidal volume and rate for a patient on assist control mechanical ventilation?

Answer 57

12–12 rule: 12 mL/kg of lean body mass delivered 12 times a minute. It is useful for patients without preexisting lung disease. It must be adjusted for patients with known chronic obstructive pulmonary disease (COPD), etc.

Question 58

58 What technique can be used in mechanical ventilation to maintain a patient's airway pressure above atmospheric pressure at the end of expiration?

Answer 58

Positive end expiratory pressure (PEEP)

Question 59

59 What is the difference in the 1-second forced expiratory volume FEV1 to vital capacity (FVC) ratio in COPD compared with that in restricted lung disease?

Answer 59

In COPD, the FEV1/FVC ratio decreases, whereas the ratio is preserved or increased in restrictive lung disease.

Question 60

60 Describe the difference between the two types of postobstructive pulmonary edema.

Answer 60

● Type 1. Follows an acute severe cause of upper airway obstruction (epiglottitis, laryngospasm, strangulation) and usually manifests within 1 hour of the event ● Type 2. Follows relief from a chronic obstruction (obstructive sleep apnea (OSA), choanal stenosis, subglottic stenosis) and usually manifests within 6 hours of reversing the obstruction

Question 61

61 What is the treatment of postobstructive pulmonary edema?

Answer 61

Oxygen and supportive care in mild cases and PEEP in more severe cases. Diuretic therapy can be instituted, although the benefit is not clear.

Question 62

62 What is the most common cause of fever in the immediate postoperative period?

Answer 62

Within the first 48 hours of surgery, fever is likely due to an inflammatory reaction to surgical insult or reaction to medication or blood product given intraoperatively. It is unlikely to be infectious. Evaluate for possible source of infection, but prophylactic antibiotics are not indicated. Patient may be treated with antipyretic and monitor for change in clinical status.

Question 63

63 In the acute postoperative setting, how can the mnemonic "Wind, Water, Walk, Wound, Wonder Drugs, What did you do?" help in the evaluation of a febrile patient?

Answer 63

● Wind: Pneumonia? Aspiration? Atelectasis? ● Water: Urinary tract infection? ● Walk: Thrombophlebitis? Deep venous thrombosis? Pulmonary embolus? ● Wound: Surgical-site infection? ● Wonder drugs: Drug reaction (β-lactam antibiotic? Sulfa antibiotic?) ● What did we do? Catheter-related infection? IV site infection?

Question 64

64 What is eosinophilic granuloma?

Answer 64

Eosinophilic granuloma is the most common form of Langerhans cell histiocytosis and is characterized by the formation of solitary or multiple discrete nodules within bones.

Question 65

65 What is Hand-Schüller-Christian disease?

Answer 65

It is multifocal Langerhans cell histiocytosis with bone “granulomas,” associated with the triad of exophthalmos, lytic skull lesions, and diabetes inspidus.

Question 66

66 True or false. Most patients with Langerhans cell histiocytosis have multisystem disease.

Answer 66

False. Approximately two-thirds of patients have disease involving one site.

Question 67

67 What is Letterer-Siwe disease?

Answer 67

Systemic Langerhans cell histiocytosis is the rarest (~ 10% of cases) and the most severe form of disease. Initial symptoms often include generalized skin eruption, anemia, and hepatosplenomegaly.

Question 68

68 Extranodal natural killer cell (NK)/T-cell lymphoma, nasal type, is commonly associated with which virus?

Answer 68

Epstein-Barr virus

Question 69

69 How is extranodal NK/T-cell lymphoma, nasaltype, commonly treated?

Answer 69

Chemotherapy (CHOP: cyclophosphamide, doxorubicin, vincristine, prednisone) in conjunction with radiotherapy

Question 70

70 Compared with other types of lymphoma involving the head and neck, what is the prognosis for extranodal NK/T-cell lymphoma, nasal type?

Answer 70

Much poorer

Question 71

71 What is the most common laryngeal manifestation of Wegener granulomatosis?

Answer 71

Subglottic stenosis

Question 72

72 What is the most common otologic manifestation of Wegener granulomatosis?

Answer 72

Serous otitis media

Question 73

73 What histopathologic findings are seen in Wegener disease?

Answer 73

Necrotizing granulomas and arteritis involving small vessels

Question 74

74 What laboratory test is used to diagnose and follow Wegener disease?

Answer 74

Antineutrophil cytoplasmic antibody (C-ANCA). Test will be positive in more than 90% of cases.

Question 75

75 What histopathological findings are seen in sarcoidosis?

Answer 75

Noncaseating granulomas

Question 76

76 What condition is characterized by uveitis, parotid swelling, fever, and facial nerve palsy?

Answer 76

Heerfordt syndrome (uveoparotid fever), a manifestation of sarcoidosis

Question 77

77 What is the most common site of laryngeal involvement of sarcoidosis?

Answer 77

Supraglottis

Question 78

78 What is the most common head and neck manifestation of sarcoidosis?

Answer 78

Cervical lymphadenopathy

Question 79

79 Describe a common presentation for pyogenic granuloma.

Answer 79

Less than 1-cm lobular red or purple lesion that develops on the gingiva or nasal mucosa that is friable and prone to bleeding. It occurs more commonly in women and is associated with trauma and pregnancy.

Question 80

80 Describe the treatment of pyogenic granuloma.

Answer 80

Lesions frequently resolve spontaneously when associated with pregnancy. If frequent bleeding or cosmesis is a concern, conservative cauterization or excision can be pursued.

Question 81

81 Describe the natural history of untreated necrotizing sialometaplasia.

Answer 81

Spontaneous resolution over weeks to months

Question 82

82 How does blastomycosis typically manifest?

Answer 82

A common triad includes cutaneous disease, pulmonary involvement, and constitutional symptoms. Skin lesions may involve the face with verrucous growth and scarring. Oropharyngeal and laryngeal involvement are rare.

Question 83

83 Describe the clinical manifestations of coccidiomycosis.

Answer 83

It is the cause of "valley fever." Most patients have an influenza-like illness that includes malaise, fever, myalgia, arthralgia, and cough. Initial symptoms are pulmonary, mucocutaneous involvement with maculopapular rash, cervical lymphadenopathy, and/or meningeal involvement.

Question 84

84 Where is Coccidioides immitis endemic?

Answer 84

Desert Southwest including New Mexico, Nevada, California, Texas, Utah, and northern Mexico

Question 85

85 Histoplasmosis most commonly occurs in which geographic location?

Answer 85

The Ohio, Missouri, and Mississippi River valleys

Question 86

86 Describe the head and neck manifestations of disseminated histoplasmosis.

Answer 86

Granulomatous lesions involving the lips, gingiva, tongue, larynx, and pharynx manifesting with painful ulcers containing heaped edges

Question 87

87 What is the most common site of laryngeal involvement of histoplasmosis?

Answer 87

Supraglottis

Question 88

88 How is histoplasmosis diagnosed?

Answer 88

Histoplasma antibody latex agglutination test, fungal stains, blood or urine antigens using enzyme-linked immunosorbent assay or polymerase chain reaction (PCR), or histoplasma skin test

Question 89

89 What pathogen is responsible for the development of rhinosporidiosis?

Answer 89

The parasite Rhinosporidium seeberi

Question 90

90 What are the common head and neck clinical manifestations of rhinosporidiosis?

Answer 90

Fleshy, friable strawberry-like lesions most commonly involving the inferior turbinate, oropharynx, conjunctiva, and perineum

Question 91

91 What is the treatment for rhinosporidiosis?

Answer 91

Wide local excision or prolonged dapsone therapy

Question 92

92 What is the causative organism in syphilis?

Answer 92

The spirochete Treponema pallidum

Question 93

93 What is the treatment of syphilis?

Answer 93

Penicillin G benzathine

Question 94

94 Describe the presentation of primary syphilis.

Answer 94

A painless ulcer (chancre) at the site of transmission demonstrating a rolled edge and punched-out base is present after 3 to 6 weeks at the site of exposure.

Question 95

95 Describe the presentation of secondary syphilis.

Answer 95

Secondary syphilis is characterized by systemic spread of disease with manifestations including fever, myalgias, arthralgias, and lymphadenopathy. A mucocutaneous rash often develops including the oral mucosa and the palms and soles. Finally, condyloma lata and patchy alopecia may develop.

Question 96

96 What are the three categories of tertiary syphilis?

Answer 96

The three categories are gummatous syphilis, cardiovascular syphilis, and neurosyphilis.

Question 97

97 Describe the findings of congenital syphilis.

Answer 97

"Snuffles" with sinonasal drainage, saddle nose, saber shins, Hutchinson teeth, and mulberry molars

Question 98

98 Describe the Argyll-Robertson pupil.

Answer 98

A pupil that does not react to light but does constrict during accommodation. Associated with syphilis

Question 99

99 Describe the manifestation of otosyphillis.

Answer 99

Otosyphilis is associated with either congenital or tertiary acquired syphilis and manifests with sensorineural hearing loss beginning in the high frequencies, fluctuating tinnitus, and vertigo.

Question 100

100 What is the Hennebert sign?

Answer 100

Rotary nystagmus when positive or negative pressure is applied to the tympanic membrane

Question 101

101 Describe the Jarisch-Herxheimer reaction.

Answer 101

After treatment of syphilis, dying spirochetes may trigger a cytokine cascade that manifests with myalgias, fever, headache, and tachycardia.

Question 102

102 What tests are commonly used for syphilis screening?

Answer 102

Venereal Disease Research Laboratory (VDRL), rapid plasma reagin (RPR) test

Question 103

103 What confirmatory test should be ordered after a positive or equivocal screening test for syphilis?

Answer 103

FTA-ABS

Question 104

104 What is the most common cause of subacute pediatric cervical lymphadenopathy?

Answer 104

Atypical Mycobacterium, most commonly M. avium-intracellulare, M. haemophilum, and M. scrofulaceum

Question 105

105 How is brucellosis transmitted?

Answer 105

It is transmitted from contaminated meat or dairy products or via direct contact through broken skin.

Question 106

106 What are the clinical manifestations of cat-scratch disease?

Answer 106

The primary lesion develops as an erythematous, nonpruritic pustule 1 week affter inoculation. Lymphadenitis of the axilla, neck, and inguinal region commonly develops 2 to 4 weeks after exposure. Suppuration with acute tenderness and fever frequently occurs. Lymphadenopathy usually resolves over 2 weeks but may persist for up to 2 years.

Question 107

107 What are the pathogens associated with leprosy (Hansen disease)?

Answer 107

Mycobacterium leprae and Mycobacterium lepromatosis

Question 108

108 What is the treatment for Hansen disease?

Answer 108

Dapsone

Question 109

109 What pathogen is responsible for the development of rhinoscleroma?

Answer 109

Klebsiella rhinoscleromatis

Question 110

110 What histologic findings are strongly suggestive of the diagnosis of rhinoscleroma?

Answer 110

Russell bodies (immunoglobulin containing inclusions in plasma cells), pseudoepitheliomatous hyperplasia, Mikulicz cells (foamy histiocytes containing Klebsiella)

Question 111

111 What is the treatment for rhinoscleroma?

Answer 111

Tetracycline or ciprofloxacin

Question 112

112 What tests are helpful in diagnosing systemic lupus erythematosus?

Answer 112

Antinuclear antibody (ANA), anti-Sm, anti-DNA, anti-ribonuclear protein (anti-RNP), and anticardiolipin antibody

Question 113

113 What are the typical clinical manifestations of a patient with mixed connective tissue disease?

Answer 113

1. Raynaud phenomenon 2. Arthralgias 3. Inflammatory myopathy 4. Lymphadenitis 5. Skin or mucosal lesions 6. Serositis

Question 114

114 What is the definition of mixed connective tissue disease?

Answer 114

Mixed connective tissue disease is characterized by a combination of overlapping features of systemic lupus erythematous, scleroderma, and polymyositis. Patients may manifest Raynaud phenomenon, arthralgias, inflammatory myopathy, lymphadenitis, skin or mucosal lesions, and serositis.

Question 115

115 Which joints in the head and neck are most commonly affected by rheumatoid arthritis (RA)?

Answer 115

RA can affect any diarthrodial joint, including the temporomandibular, cricoarytenoid, and ossicular joints.

Question 116

116 What does the acronym CREST stand for?

Answer 116

Calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasias. CREST syndrome is a limited cutaneous form of systemic scleroderma.

Question 117

117 What are the histologic findings in a minor salivary gland lip biopsy performed in a patient with Sjogren disease?

Answer 117

Focal lymphocytic infiltrate with atrophic acini

Question 118

118 What head and neck sites are commonly affected by relapsing polychondritis?

Answer 118

Ear, nasal septum, and larynx

Question 119

119 What is the most common head and neck manifestation of relapsing polychondritis?

Answer 119

Episodic auricular chondritis, presenting with erythema and pain of the pinna with sparing of the fatty lobule. Eventually presents in ~ 90% of patients

Question 120

120 What are common symptoms of giant cell arteritis?

Answer 120

Headache (predominantly temporal region), jaw claudication (~ 50% patients), vision loss or visual disturbance, fatigue, general malaise, fever, anorexia, weight loss, night sweats, and tongue pain

Question 121

121 What histologic finding on temporal artery biopsy is suspicious for giant cell arteritis?

Answer 121

Inflammatory infiltrates in at least the adventitia and media, with elastic lamina fragmentation

Question 122

122 What imaging study may be useful in the diagnosis of giant cell arteritis?

Answer 122

Duplex ultrasound. High-resolution MRI has been reported to have very similar diagnostic power, but more data are needed before it can be recommended as a diagnostic tool.

Question 123

123 What is the classic triad of Wegener granulomatosis?

Answer 123

Granulomas of the respiratory tract, progressive glomerulonephritis, and necrotizing vasculitis of small to mediumsized arteries and veins

Question 124

124 What condition is characterized by uveitis, oral aphthous ulcers, and genital ulcers?

Answer 124

Behçet disease

Question 125

125 What are the two primary fascia networks of the neck? (▶Fig. 4.2)

Answer 125

Superficial cervical fascia and the deep cervical fascia

Question 126

126 Describe the anatomy of the superficial cervical fascia.

Answer 126

It lies just deep to the dermis and superficial to the deep cervical fascia. It extends from the zygoma to the clavicle and envelops the platysma and muscles of facial expression.

Question 127

127 Describe the anatomy of the deep cervical fascia.

Answer 127

It is composed of the superficial (investing), middle (visceral and muscular), and deep (prevertebral and alar) layer. The carotid sheath fascia is created by all three layers of the deep cervical fascia.

Question 128

128 Describe the anatomy of the superficial (investing) layer of the deep cervical fascia.

Answer 128

It surrounds the neck and inserts superiorly at the nuchal ridge, mastoid, zygoma, and mandible and inferiorly at the clavicles, sternum, scapula, and acromion. It envelops the sternocleidomastoid muscle, trapezius, muscles of mastication, submandibular glands, and parotid gland. Inferiorly, its manubrial insertion splits to form the suprasternal space of Burns.

Question 129

129 Describe the anatomy of the middle (visceral and muscular) layer of the deep cervical fascia.

Answer 129

It extends superior to the cranial base and inferiorly to the upper mediastinum. It is subdivided into the muscular and visceral layers. The muscular division surrounds the infrahyoid strap muscles; the visceral portion surrounds the pharyngeal constrictors, esophagus, trachea, and thyroid and creates the buccopharyngeal fascia. Both divisions contribute to the carotid sheath.

Question 130

130 Describe the anatomy of the deep (prevertebral and alar) layer of the deep cervical fascia.

Answer 130

It is subdivided into the alar and prevertebral fascia. Both extend superiorly from the cranial base, but the alar fascia fuses with the middle cervical fascia and extends into the upper mediastinum, and the prevertebral fascia extends to the level of the coccyx. The alar fascia and prevertebral fascia fuse at the vertebral transverse processes and after joining, envelop the paraspinous muscles.

Question 131

131 Describe the anatomy of the suprasternal space (space of Burns).

Answer 131

The inferior insertion of the superficial (investing) fascia splits just above the manubrium attaching anterior to the manubrium and posteriorly to the interclavicular ligament. This small potential space contains a portion of the anterior jugular veins, and the sternal heads of the sternocleidomastoid muscle.

Question 132

132 Define the boundaries of the buccal space.

Answer 132

The buccal space is created by the buccinator muscle medially; the superficial layer of the deep cervical fascia and the muscles of facial expression laterally and anteriorly; and the muscles of mastication, mandible, and parotid gland posteriorly. It primarily contains adipose tissue (buccal fat pad), minor salivary glands, accessory parotid tissue, and facial/buccal arteries, veins, and lymphatics. The buccal fat pad is pierced by the parotid duct as it courses to the buccinator and eventually enters the mouth opposite the second upper molar.

Question 133

133 Define the mechanism of spread of infection (or tumor) to and from the buccal space.

Answer 133

It permits spread between the mouth, parotid space, and masticator space from deficient fascial compartmentalization along the superior, inferior, and posterior limits.

Question 134

134 Define the boundaries of the carotid space.

Answer 134

The carotid sheath contains the carotid artery, internal jugular vein, vagus nerve, and jugular lymphatic chain. All three divisions of the deep cervical fascia form the carotid sheath. It extends from the skull base to the mediastinum; anteriorly lies the sternocleidomastoid muscle, posteriorly the prevertebral space, and medially the visceral compartment.

Question 135

135 Review the risk factors for carotid blowout.

Answer 135

Radiation, salivary fistula, malnutrition, hypothyroidism, Tincision over the great vessels, radical neck dissection

Question 136

136 Define the boundaries of the danger space.

Answer 136

The danger space is a potential space that rests between the alar fascia and the prevertebral fascia. Infections in this area can communicate with the thorax (mediastinum) to the level of the diaphragm.

Question 137

137 Define the boundaries of the masticator space.

Answer 137

The masticator space is created from the superficial layer of the deep cervical fascia surrounding the masseter laterally and the pterygoid muscles medially. It contains masseter muscle, pterygoid muscles, inferior tendon of the temporalis muscle, ramus, and posterior body of the mandible, internal maxillary artery, and the inferior alveolar neurovascular bundle.

Question 138

138 Define the boundaries of the parapharyngeal space. (▶Fig. 4.3)

Answer 138

It is shaped as an inverted pyramid with the base at the cranial base and the apex at the hyoid bone. Anteriorly, it is bound by the pterygomandibular raphe, posteriorly be the prevertebral fascia, medially by the superior pharyngeal constrictor, and laterally by the parotid, mandible, and lateral pterygoid.

Question 139

139 How is the parapharyngeal space commonly divided?

Answer 139

Prestyloid and poststyloid compartments are divided by the tensor-vascular-styloid fascia connecting the tensor veli palatini and the styloid process.

Question 140

140 What structures are contained within the prestyloid space?

Answer 140

Fat, lymph nodes, minor salivary gland tissue, internal maxillary artery, and the inferior alveolar, auriculotemporal and lingual nerves

Question 141

141 What structures are contained within the poststyloid space?

Answer 141

Carotid artery, internal jugular vein, cranial nerves 9 through 12, and the superior sympathetic chain

Question 142

142 What is the syndrome that follows the parapharyngeal space or parotid surgery that causes pain with the onset of eating?

Answer 142

First-bite syndrome

Question 143

143 Define the boundaries of the parotid space.

Answer 143

It is created by the superficial layer of deep cervical fascia as it surrounds the mandible and parotid gland and contains the parotid gland and parotid lymph nodes, the facial nerve, posterior facial vein, and facial artery.

Question 144

144 Describe the mechanism of infection or tumor spread from the parotid space to the parapharyngeal space.

Answer 144

The superomedial parotid space fascia is deficient, allowing for direct spread into the parapharyngeal space via the stylomandibular tunnel.

Question 145

145 Define the boundaries of the peritonsillar space.

Answer 145

It is bound by the palatine tonsil medially and the superior pharyngeal constrictor, palatoglossus, and palatopharyngeus medially, superiorly, inferiorly, anteriorly, and posteriorly. It contains loose areolar tissue and minor salivary glands.

Question 146

146 Define the boundaries of the prevertebral space.

Answer 146

It extends from the skull base to the coccyx and is bordered anteriorly by the prevertebral fascia, posteriorly by vertebral bodies, and laterally by the transverse processes of vertebrae.

Question 147

147 Describe the sequential layers and spaces (superficial to deep) of the posterior pharyngeal wall.

Answer 147

Mucosa, pharyngeal constrictor, buccopharyngeal fascia, retropharyngeal space, alar fascia, danger space, prevertebral fascia, prevertebral space

Question 148

148 Define the boundaries of the sublingual space.

Answer 148

* Contains the sublingual gland, Wharton duct, and lingual and hypoglossal nerves * Boundaries * Superiorly: mucosa of FOM * Laterally: mandible * Inferiorly: mylohyoid * Medially: genioglossus * Anteriorly: mandible.

Question 149

149 What are the two divisions of the submandibular space?

Answer 149

It is subdivided into the sublingual and submaxillary spaces, which are separated by the mylohyoid. These two spaces communicate at approximately the second molar.

Question 150

150 Define the boundaries of the submaxillary (submylohyoid) space.

Answer 150

It contains the submandibular gland and is bound superiorly and medially by the mylohyoid muscle, inferiorly and posteriorly by the digastric muscle, and laterally and anteriorly by the superficial layer of the deep cervical fascia and mandible.

Question 151

151 Define the boundaries of the infratemporal fossa. (▶Fig. 4.4)

Answer 151

● Located inferior and medial to the zygomatic arch ● Anterior: Posterolateral portion of maxillary sinus ● Lateral: Ramus of the mandible ● Medial: Lateral pterygoid plate ● Superior: Greater wing of the sphenoid bone ● Inferior: Medial pterygoid muscle ● Posterior: Articular tubercle of the temporal bone, glenoid fossa

Question 152

152 Describe the branches of the three segments of the internal maxillary artery. (▶Fig. 4.5)

Answer 152

● First (lateral) portion: Deep auricular artery, anterior tympanic artery, middle meningeal artery, inferior alveolar artery, accessory meningeal artery ● Second (middle) portion: Masseteric artery, pterygoid branches, anterior and posterior deep temporal arteries, buccal artery ● Third (medial) portion: Sphenopalatine artery (terminal branch), descending palatine artery, infraorbital artery, artery of the vidian canal, anterior, middle, and posterior superior alveolar artery

Question 153

153 Define the boundaries of the pterygopalatine fossa.

Answer 153

● Located medial to the infratemporal fossa ● Anterior: Posteromedial portion of maxillary sinus ● Lateral: Pterygomaxillary fissure and infratemporal fossa ● Medial: Perpendicular plate of the palatine bone ● Superior: Body of the sphenoid bone ● Inferior: Pterygopalatine canal ● Posterior: Root of the pterygoid plates

Question 154

154 Name the foramina communicating with the pterygopalatine fossa.

Answer 154

● Anterior: Inferior orbital fissure ● Lateral: Pterygomaxillary fissure ● Medial: Sphenopalatine foramen ● Interior: Greater palatine canal ● Posterior: Vidian canal, foramen rotundum

Question 155

155 What important structure may be encountered if the vidian canal is followed posteriorly?

Answer 155

The second genu of the internal carotid artery

Question 156

156 Define the boundaries of the temporal fossa.

Answer 156

It is located between the superficial layer of the temporalis fascia and the periosteum of the squamosal portion of the temporal bone and is subdivided into the superficial and deep layer by the temporalis muscle. It contains the internal maxillary artery and inferior alveolar nerve.

Question 157

157 During submandibular gland excision, the marginal mandibular nerve cannot be readily identified. What strategy can be used to decrease the risk of marginal mandibular nerve injury?

Answer 157

The common facial vein can be identified low, ligated, and divided and then reflected superiorly because the marginal mandibular nerve rests superficial to the common facial vein and facial artery in the region of the mandibular notch.

Question 158

158 Describe the location and course of the hypoglossal and lingual nerves in the region of the submandibular gland.

Answer 158

It is located deep to the digastric muscle and mylohyoid and superficial to the hypoglossus muscle. The lingual nerve is located cephalad to the hypoglossal nerve.

Question 159

159 What landmarks can be used for identification of the accessory nerve during level 2 neck dissection?

Answer 159

Transverse process of C1, anterolateral to the internal jugular vein, two fingerbreadths below the mastoid tip, or just as it runs posterior to the sternocleidomastoid 1 to 2cm above the Erb point

Question 160

160 Describe the location of the phrenic nerve and superior sympathetic chain.

Answer 160

It is located anterior to the anterior scalene muscle. The phrenic nerve runs lateral to the sympathetic chain.

Question 161

161 The hypoglossal nerve is "pinned" by what artery as it descends behind the digastric muscle?

Answer 161

The occipital artery

Question 162

162 Describe five methods or landmarks for identifying the facial nerve during parotidectomy.

Answer 162

The tragal pointer, tympanomastoid suture line, level of the digastric groove (posterior digastric muscle), retrograde from marginal mandibular nerve at mandibular notch, anterograde from the vertical segment of the mastoid

Question 163

163 During deep-lobe parotidectomy, what arteries must be divided for en bloc removal?

Answer 163

External carotid artery, superficial temporal artery, internal maxillary artery

Question 164

164 Which cervical rootlets contribute to the ansa cervicalis?

Answer 164

C1, C2, and C3

Question 165

165 Which deep neck spaces involve the entire length of the neck?

Answer 165

Four: the retropharyngeal, danger, prevertebral, and carotid spaces

Question 166

166 Describe the parasympathetic innervation to the parotid gland.

Answer 166

Inferior salivatory nucleus → cranial nerve IX (Jacobson nerve) → lesser superficial petrosal nerve → otic ganglion → auriculotemporal nerve (V3) → parotid gland

Question 167

167 Describe the parasympathetic innervation to the submandibular gland and sublingual glands.

Answer 167

Superior salivatory nucleus → nervus intermedius → cranial nerve VII → chorda tympani → lingual nerve → submandibular ganglion → submandibular gland

Question 168

168 Describe the parasympathetic innervation to the lacrimal gland.

Answer 168

Superior salivatory nucleus → greater superficial petrosal nerve → vidian nerve → sphenopalatine ganglion → lacrimal branch V1 → lacrimal gland

Question 169

169 Describe the condition of benign symmetric lipomatosis (location, sex, comorbidities).

Answer 169

* Diffuse lipomatosis of the head, neck, shoulders, and proximal upper extremities. * M\>F * Hx alcoholism and diabetes.

Question 170

170 True or False. Most liposarcomas develop from a preexisting benign lipoma.

Answer 170

False. Most liposarcomas develop *de novo*.

Question 171

171 What is the most common type of monomorphic adenoma?

Answer 171

Basal cell adenoma

Question 172

172 What is the most common paraganglioma of the head and neck? (▶Fig. 4.6)

Answer 172

Carotid body tumor, which develops within the adventitia of the carotid bifurcation and are of neural crest origin

Question 173

173 Describe the Lyre sign. (▶Fig. 4.7)

Answer 173

● Splaying of the internal carotid artery and the external carotid artery at the carotid bifurcation ● Seen with carotid body tumors ● Glomus vagale and sympathetic chain paragangliomas on the other hand displace the carotid system anteriorly.

Question 174

174 What percentage of head and neck paragangliomas are functional?

Answer 174

Less than 3%

Question 175

175 What cellular pattern is characteristically seen in paragangliomas?

Answer 175

**Cells of Zellballen**: alveolar-like clumps of tumor cells are surrounded by a network of thin-walled capillaries. Thick bands of collagenous tissue divide the tumor. Five to 20 epithelial cells compose a nest or group of cells.

Question 176

176 What percentage of head and neck paragangliomas are malignant?

Answer 176

**Less than 10%.** Malignancy determined by **the presence of lymph node metastasis**, not by cellular atypia or local invasion.

Question 177

177 Familial paraganglioma syndromes are caused by a mutation in genes that encode for what enzyme?

Answer 177

Succinate dehydrogenase

Question 178

178 True or false. Neural fascicles can be more easily spared during resection of a schwannoma compared with a neurofibroma.

Answer 178

True

Question 179

179 What is the most common poststyloid parapharyngeal space tumor?

Answer 179

Schwannoma of the vagus or sympathetic chain

Question 180

180 Which benign salivary gland tumors have pronounced fluorodeoxyglucose (FDG) uptake on PET imaging?

Answer 180

Oncocytoma, and Warthin tumor. Both tumors are composed of large eosinophilic granular cells containing high mitochondrial concentrations.

Question 181

181 What is the most common type of tumor to arise within the prestyloid parapharyngeal space?

Answer 181

Benign salivary gland tumors

Question 182

182 Describe the MRI findings of pleomorphic adenoma.

Answer 182

Well-circumscribed mass with low intensity on T1- and hyperintensity on T2-weighted sequences. Frequently demonstrates homogeneous gadolinium uptake

Question 183

183 What is the most common prestyloid parapharyngeal space tumor?

Answer 183

Pleomorphic adenoma is the most common overall. Mucoepidermoid carcinoma is the most common malignancy.

Question 184

184 What are the main access routes to the parapharyngeal space?

Answer 184

Cervical, submandibular/cervical, cervical parotid, cervical parotid with mandibular osteotomy, transoral (not recommended)

Question 185

185 When should a mandibulotomy be considered for parapharyngeal space tumors?

Answer 185

● Tumors \> 5 cm ● Tumors with extensive skull base disease ● Extensive invasion

Question 186

186 What are laryngoceles?

Answer 186

Air-filled dilations of the laryngeal ventricle that may be congenital or acquired

Question 187

187 Describe the three types of laryngoceles.

Answer 187

● Internal: Connects the ventricle with the paraglottic space, false cord, and aryepiglottic fold ● External: Ventricular dilation extends through the thyrohyoid membrane to the lateral neck. ● Combined: Both internal and external extension

Question 188

188 What are plunging ranulas, and how do they differ from nonplunging ranulas?

Answer 188

Plunging ranulas form from obstructed sublingual gland ducts leading to the formation of an epithelial-lined retention cyst. A plunging ranula requires that the cyst extend through the mylohyoid, most commonly to the submandibular space.

Question 189

189 Review the characteristic signs and symptoms of Kawasaki (lymphomucocutaneous) disease.

Answer 189

Fever for more than 5 days with at least four of the following five findings: ● Bilateral nonsuppurative conjunctivitis ● One or more changes of the mucous membranes of the upper respiratory tract, including pharyngeal injection, fissured or erythematous lips, and "strawberry" tongue ● One or more changes of the extremities, including peripheral erythema or edema and periungual and generalized desquamation ● Polymorphous rash ● Cervical lymphadenopathy \> 1.5cm in diameter (usually unilateral)

Question 190

190 Describe the cardiac complications associated with Kawasaki disease.

Answer 190

Coronary artery aneurysms occur in up to 25% of untreated patients. Death may occur secondary to coronary artery thrombosis or aneurysm rupture. An ECG and echocardiogram should be obtained in all patients suspected of having Kawasaki disease.

Question 191

191 Describe the clinical manifestation of Kikuchi- Fujimoto disease.

Answer 191

A benign, self-limiting necrotizing lymphadenitis that most commonly affects young Japanese women. Initial symptoms may include malaise, fever, fatigue, arthralgias, weight loss, and hepatosplenomegaly.

Question 192

192 Describe Castleman disease.

Answer 192

Castleman disease is a rare lymphoproliferative disorder that can manifest with localized or multicentric disease. It is commonly associated with human immunodeficiency virus (HIV) and human herpes virus (HSV) 8.

Question 193

193 What is the most common cause of deep neck space infections in the adult population?

Answer 193

Odontogenic infection

Question 194

194 What is the most common cause of deep neck space infections within the pediatric population?

Answer 194

Tonsillitis

Question 195

195 Describe the head and neck manifestations of Actinomyces israelii infection?

Answer 195

Development of a "lumpy jaw" and multiple painless, red or bluish raised, firm lesions containing multiple draining sinus tracts

Question 196

196 Describe the histologic appearance of Actinomyces israelii?

Answer 196

Gram-positive, non–acid-fast, anaerobic bacilli demonstrating a filamentous fungal-like growth pattern and "sulfur granule" formation

Question 197

197 What are the most common sites of the head and neck to develop Mycobacterium infections?

Answer 197

Anterior superior cervical region near the submandibular space, followed by the posterior cervical, middle cervical, and supraclavicular regions. Atypical mycobacterial infection is sometimes found in the preauricular region

Question 198

198 What is the most common manifestation for atypical Mycobacterium infections involving the neck?

Answer 198

Persistent firm painless cervical adenopathy with overlying violaceous skin discoloration

Question 199

199 What is the current recommended management of atypical Mycobacterium infections involving the neck?

Answer 199

Persistent lesions are best managed by surgical excision or incision and curettage. Common antibiotic choices include clarithromycin, ethambutol, isoniazid, and rifampin, depending on the species.

Question 200

200 What tests should be ordered for patients with suspected mycobacterial infections involving the head and neck?

Answer 200

PPD, chest plain film, cultures (Ziehl-Neelson stain, Lowenstein-Jensen medium), nucleic acid probes, and PCR

Question 201

201 Are PPD tests usually positive in patients with atypical mycobacterial infections of the head and neck?

Answer 201

No. PPD tests are generally negative or weakly reactive.

Question 202

202 Why are mycobacteria called acid-fast bacteria?

Answer 202

Once they are colorized with a red dye, they cannot be decolorized with acid solutions.

Question 203

203 What is the most common head and neck manifestation of tuberculosis?

Answer 203

Cervical lymphadenopathy

Question 204

204 What is the treatment of cervical lymphadenopathy associated with tuberculosis?

Answer 204

Isoniazid, rifampin, ethambutol, and pyrazinamide

Question 205

205 What pathogen is associated with cat-scratch disease?

Answer 205

Bartonella henselae

Question 206

206 Name the three types of Langerhans cell histiocytosis.

Answer 206

● Eosinophilic granuloma ● Hand-Schüller-Christian (disseminated chronic) ● Letterer-Siwe (disseminated acute)

Question 207

207 What condition manifests with the triad of osteolytic skull lesions, exophthalmos, and diabetes insipidus?

Answer 207

Hand-Schüller-Christian disease (disseminated chronic)

Question 208

208 Which type of Langerhans cell histiocytosis is associated with early in life onset and a rapidly progressive course?

Answer 208

Letterer-Siwe (disseminated acute)

Question 209

What is Lemierre syndrome?

Answer 209

Septic thrombophlebitis of the neck that most commonly results from Fusobacterium necrophorum. It often begins with pharyngitis progressing to lymphadenopathy, fevers, chills, and rigors. Septic emboli may involve the lung, brain, spleen, and liver, among other sites.

Question 210

What is the most common cause of pediatric cervical lymphadenopathy?

Answer 210

Reactive lymphadenopathy from viral infection

Question 211

What is the most common cause(s) of pediatric suppurative lymphadenopathy?

Answer 211

Group A Streptococcus and Staphylococcus aureus

Question 212

What is the test of choice for primary syphilis?

Answer 212

The **FTA-ABS test** evaluates for the presence of **treponemal antibodies**. The test is **positive in 90% of patients who seek therapy for primary syphilis** and remains positive for life. NOT A SCREENING TEST.

Question 213

213 What are the symptoms of meningeal neurosyphilis?

Answer 213

Headache, nuchal rigidity, nausea, and vomiting. Cranial nerve involvement is seen in 40% of patients resulting in hearing loss, facial paralysis, and visual disturbances.

Question 214

214 What constitutes the Hutchinson triad of congenital syphilis?

Answer 214

Small notched teeth, deafness, and interstitial keratitis

Question 215

215 What test is most useful in establishing the diagnosis of neurosyphilis?

Answer 215

Reactive cerebrospinal fluid (CSF) VDRL and a CSF white blood cell count of 20 cells/μL or greater

Question 216

216 What is the definition of otosyphilis?

Answer 216

The presence of a positive FTA-ABS in the setting of unexplained sensorineural hearing loss

Question 217

217 What are the causes of syphilis-associated hoarseness?

Answer 217

Laryngeal chancres, mucous membrane manifestations of secondary syphilis involving the upper aerodigestive tract, and gummata of the larynx may directly cause hoarseness. Long-term syphilis may result in infraglottic stenosis, adhesions between vocal folds or arytenoid fixation. Neurosyphilis may result in recurrent laryngeal nerve paresis.

Question 218

218 Describe the common initial symptoms of toxoplasmosis.

Answer 218

1. Fever 2. Malaise 3. Pharyngitis 4. Myalgias 5. Cervical lymphadenopathy occurring in the most patients

Question 219

219 What are the pathogen, vector, and carrier responsible for the development of tularemia?

Answer 219

Francisella tularensis, Amblyomma americanum (lone star tick), rabbits, and wild rodents, respectively

Question 220

220 What are the early symptoms of tularemia infection?

Answer 220

Fever, headache, chills, myalgia, photophobia, diminished visual acuity, and lymphadenopathy

Question 221

221 What are the possible side effects of amphotericin B?

Answer 221

Nephrotoxicity, anemia, fever, chills, nausea, and vomiting

Question 222

222 What is the mechanism of action of the "azole" antifungal medications?

Answer 222

Fungistatic. All azoles work by inhibiting a cytochrome P- 450–dependent enzyme that is required to convert lanosterol to ergosterol.

Question 223

223 What are the five recognized forms of fungal sinusitis?

Answer 223

● Acute fulminant invasive fungal sinusitis ● Chronic invasive fungal sinusitis ● Granulomatous invasive fungal sinusitis ● Fungus ball ● Allergic fungal rhinosinusitis

Question 224

224 What is the most common causative organism in chronic invasive fungal sinusitis?

Answer 224

Aspergillus fumigatus

Question 225

225 Describe the condition of HIV lymphadenopathy.

Answer 225

Diffuse lymphadenopathy (\> 2 cm) involving two or more extrainguinal sites for longer than 3 months. Two thirds of patients infected with HIV will develop this syndrome shortly after seroconversion.

Question 226

226 What are the anatomical boundaries of the deep neck space involved in Ludwig angina?

Answer 226

The submandibular space is bound superiorly by the mucosa of the floor of mouth, laterally and anteriorly by the mandible, and inferiorly by the superficial layer of the deep cervical fascia. It contains two divisions (sublingual and submaxillary), separated by the mylohyoid muscle.

Question 227

227 How do submandibular infections spread to other deep neck space compartments?

Answer 227

Communication between potential spaces exists at the buccopharyngeal gap, which connects the submandibular and lateral pharyngeal spaces.

Question 228

228 Why is there a lack of trismus in patients suffering from Ludwig angina?

Answer 228

Trismus develops from irritation of the masticatory muscles (masseter and pterygoids), which insert into the mandibular ramus. The submandibular space is not contiguous with these muscles.

Question 229

229 What is the mechanism of airway compromise in patients with Ludwig angina?

Answer 229

Increased swelling in the bilateral submandibular space pushes the tongue superiorly and posteriorly, thereby causing progressive airway obstruction.

Question 230

230 What is the best management of the airway in a patient with a progressive infection of the submandibular space with increasing airway compromise?

Answer 230

Awake intubation or tracheostomy

Question 231

231 What is the most common causative organism in necrotizing soft tissue infections?

Answer 231

Group A streptococcus

Question 232

232 What are the clinical characteristics of necrotizing fasciitis?

Answer 232

Tense edema, pain disproportionate to examination, skin discoloration, bullae, necrosis, and crepitus

Question 233

233 What is the treatment of necrotizing fasciitis?

Answer 233

Incision and drainage are inadequate. Necrotic tissue must be debrided and the wound left open with packing. Broadspectrum antibiotics should be administered, and the patient should be monitored in an intensive care unit setting. Hyperbaric oxygen may provide additional benefit.

Question 234

234 Describe the clinical presentation of infectious mononucleosis.

Answer 234

Fever, fatigue, generalized lymphadenopathy, splenomegaly, and exudative pharyngitis with adenotonsillar hypertrophy

Question 235

235 Define the following terms: ● Ageusia ● Hypogeusia ● Dysgeusia

Answer 235

● Ageusia: Inability to taste ● Hypogeusia: Diminished ability to taste ● Dysgeusia: Distorted sense of taste

Question 236

236 Describe the taste innervation of each of the following upper aerodigestive locations: * Anterior two-thirds of the tongue * The posterior two-thirds of the tongue * The circumvallate papillae * Pharynx * Epiglottis

Answer 236

* Chordae tympani of facial nerve * Glossopharyngeal nerve * Glossopharyngeal nerve * Glossopharyngeal and vagus * Superior laryngeal branch of vagus

Question 237

237 What is the most common cause of perceived taste dysfunction?

Answer 237

Olfactory dysfunction

Question 238

238 What tastes and odors are detected by the trigeminal nerve?

Answer 238

Spice and ammonia

Question 239

239 What is a Burton line?

Answer 239

A dark blue stippled line across the upper gingiva indicative of lead poisoning

Question 240

240 Oral cavity nevi most commonly occur where?

Answer 240

On the palate and gingiva

Question 241

241 Describe Peutz-Jeghers syndrome.

Answer 241

Autosomal dominant disorder characterized by intestinal hamartomatous polyps and mucocutaneous melanocytic macules involving the lips and buccal mucosa. It is associated with an increased risk of developing GI, pulmonary, and reproductive track malignancies.

Question 242

242 What is the most common intraoral pigmented lesion?

Answer 242

Amalgam tattoo resulting from amalgam implantation from prior dental work

Question 243

243 Review the risk factors for mucosal melanoma.

Answer 243

There are no known environmental risk factors. Smoking, chemical exposure, and sun exposure do not appear to be linked with an increased risk. A small subset may arise from junctional nevi.

Question 244

244 Which common medications are associated with gingival hyperplasia?

Answer 244

Phenytoin, calcium channel blockers, and cyclosporine

Question 245

245 Name several conditions associated with pseudoepitheliomatous hyperplasia.

Answer 245

1. Rhinoscleroma 2. Granular cell tumor 3. Blastomycosis 4. Syphilis 5. Necrotizing sialometaplasia

Question 246

246 What benign process is often clinically and histologically mistaken for squamous cell carcinoma of the hard palate?

Answer 246

Necrotizing sialometaplasia

Question 247

247 Describe the important features of granular cell tumors of the head and neck.

Answer 247

Most commonly involve the tongue, palate and less commonly the larynx. They are sessile gray colored lesions that are of probable neurogenic origin; they stain strongly with s100 and histologically may be mistaken for squamous cell carcinoma since they exhibit pseudoepitheliomatous hyperplasia.

Question 248

248 Describe the common oral manifestations of Crohn disease.

Answer 248

Generalized mucosal swelling, cobblestoning of the buccal mucosa and gingiva, aphthous stomatitis, and angular cheilitis

Question 249

249 Describe the common oral manifestations of Sjogren disease.

Answer 249

Changes largely result from xerostomia, including difficulty in swallowing and eating, disturbances in taste and speech, dental caries, cobblestoning of the tongue, and increased risk of oral candidiasis.

Question 250

250 What is the most common oral manifestation of amyloidosis?

Answer 250

Macroglossia, occurring in 20% of patients

Question 251

251 What are the histologic findings with amyloidosis?

Answer 251

Apple-green birefringence, Congo red stain

Question 252

252 What is the most common intraoral malignancy associated with HIV?

Answer 252

Kaposi sarcoma

Question 253

253 Review the conditions associated with the development of hairy leukoplakia.

Answer 253

Immunocompromised states such as HIV/AIDS and prior organ transplantation. Hairy leukoplakia is associated with Epstein-Barr virus.

Question 254

254 What is the natural history of primary herpetic gingivostomatitis?

Answer 254

Mean duration of: ● Fever: 4.4 ± 2.4 days ● Oral lesions: 12 ± 3.4 days ● Extraoral lesions: 12 ± 3.9 days ● Dysphagia to food: 9.1 ± 3 days ● Dysphagia to liquid: 7.1 ± 2.5 days ● Viral shedding: 7.1 ± 2.5 days

Question 255

255 What is the most common presentation of a primary HSV infection in the pediatric population?

Answer 255

Herpetic gingivostomatitis

Question 256

256 General prodromal symptoms associated with primary herpetic gingivostomatitis include what?

Answer 256

General malaise, fever, anorexia, irritability, and headache

Question 257

257 What are primary and secondary clinical findings associated with primary herpetic gingivostomatitis?

Answer 257

● Primary: Painful pinhead vesicles that rupture to form ulcerative lesions, which are irregular and covered by a yellow gray membrane ● Secondary: Submandibular lymphadenitis, halitosis, and dehydration from refusal to take in adequate oral hydration

Question 258

258 What tests can be used to definitively diagnose an HSV-1 viral infection?

Answer 258

PCR, viral culture, serology, immunofluorescence. Note: Tzanck smear is not helpful for delineating HSV-1 from HSV-2.

Question 259

259 What are potential complications of herpetic gingivostomatitis?

Answer 259

Dehydration, herpetic whitlow, herpetic keratitis, secondary bacterial infection, esophagitis, epiglottitis, pneumonitis, encephalitis, eczema herpeticum

Question 260

260 What are the three most common antiviral agents used to treat herpetic gingivostomatitis, and what is their mechanism of action?

Answer 260

Acyclovir, valacyclovir, famciclovir. Metabolized by viral enzymes to form metabolites that interfere with DNA synthesis and cause cell death. It works best if initiated within 72 hours.

Question 261

261 What benefit does valacylcovir offer compared with acyclovir for the treatment of herpetic gingivostomatitis?

Answer 261

The dosing is twice a day compared with three to five times per day; however, it is more expensive.

Question 262

262 What is the generally accepted window of opportunity for prescribing oral acyclovir for effective treatment of primary herpetic gingivostomatitis?

Answer 262

Three days. This therapy has been shown to decrease the duration of the lesions (intraoral and extraoral), fever, dysphagia/odynophagia, and viral shedding.

Question 263

263 Recurrent oral HSV-1 infections can be associated with what important complications?

Answer 263

● Disfiguring lesions ● Erythema multiforme ● Aseptic meningitis ● Eczema herpeticum

Question 264

264 What noncontagious acute gingivitis is caused by an overgrowth of common bacterial species, including Prevotella intermedia, α-hemolytic streptococci, Actinomyces, or spirochetes, among others?

Answer 264

Acute necrotizing ulcerative gingivitis (trench mouth)

Question 265

265 In a patient with acute necrotizing gingivostomatitis, if the disease progresses beyond the gingiva to include other mucosal surfaces, what is this condition called?

Answer 265

Noma (cancrum oris)

Question 266

266 What are common risk factors for development of acute necrotizing ulcerative gingivitis?

Answer 266

Stress, immune incompetence (i.e., HIV infection), poor nutrition, poor oral hygiene, alcohol or tobacco use. This is not a contagious disease.

Question 267

267 What are common examination findings seen in **acute necrotizing ulcerative gingivitis** ("trench mouth")?

Answer 267

* Lymphadenopathy * Halitosis * Mucosal edema/ulceration/inflammation, with or without a pseudomembrane

Question 268

268 What is the treatment for acute necrotizing ulcerative gingivitis?

Answer 268

* Analgesia (NSAID, narcotics, viscous lidocaine, etc.) * Antibacterial (clindamycin, penicillin, or erythromycin) * Oral hygiene (chlorhexidine 0.12% mouth rinse, brushing, flossing, etc.) * Dental consultation for debridement and definitive periodontal therapy * Management of underlying immunocompromised status is important if present

Question 269

269 What is the most common oral manifestation of HIV infection?

Answer 269

Oral candidiasis

Question 270

270 What are the common forms of oral candidiasis?

Answer 270

* Pseudomembranous candidiasis (thrush) * Erythematous (atrophic) candidiasis * Angular cheilitis (perlèche) * Hyperplastic candidiasis

Question 271

271 What in-office diagnostic test can you perform to confirm the diagnosis of oral candidiasis?

Answer 271

**Scraping** of erosive lesion followed b**y potassium hydroxide (KOH) preparation** and looking for **_budding yeast with or without pseudohyphae_**

Question 272

272 Review the initial treatment options for oral candidiasis.

Answer 272

Topical antifungal lozenges or solutions for 7–14 days: Clotrimazole troches, nystatin suspension, or nystatin pastilles

Question 273

273 What can you offer as treatment for moderate to severe oral candidiasis or for patients who do not respond to topical therapy for oral candidiasis?

Answer 273

Oral fluconazole for 7 to 14 days

Question 274

274 When is daily suppressive management with antifungals indicated for oral candidiasis?

Answer 274

Suppressive management Is usually **unnecessary** (even for HIV-positive patients). Treating active infections and managing the underlying immunocompromised status are recommended. When indicated (usually assisted by ID Consult), management usually includes fluconazole, three times a week.

Question 275

275 The esophagus, an embryologic foregut derivative, undergoes what important process during **week 8 to 10** of life?

Answer 275

Recanalization of the esophageal lumen

Question 276

276 Describe the muscular arrangement of the esophagus.

Answer 276

* Outer longitudinal fibers, inner circular fibers * Superior thier skeletal, middle third mixed, inferior third smooth

Question 277

277 What are three physiologic areas of narrowing within the esophagus?

Answer 277

* Upper esophageal sphincter (cricopharyngeus muscle, C6, narrowest segment) * Crossed by **aorta** and **left main bronchus** in mid chest * Lower esophageal sphincter (passes through diaphragm)

Question 278

278 What is the blood supply to the esophagus?

Answer 278

Arterial * Segmental blood supply, extensive submucosal anastomosis * Upper esophageal sphincter and cervical esophagus: Inferior thyroid artery * Thoracic esophagus: Paired esophageal arteries (terminal branches of bronchial arteries * Lower esophageal sphincter: Left gastric artery and left phrenic artery Venous * Neck: Inferior thyroid veins * Mediastinum: Azygous and hemiazygous veins * Abdomen: Left gastric vein

Question 279

279 What is the innervation of the esophagus?

Answer 279

* Sympathetic innervation from T6-T10 bilaterally * Greater and often lesser splanchnic nerves * Branches from the celiac plexus Note: The vagal nerves form a plexus along the distal esophagus and then reform two distinct nerves on passage through the diaphragm.

Question 280

280 The upper, mid, and lower third of the esophagus drain into which nodal basin(s)?

Answer 280

* Upper third = Paratracheal and internal jugular lymph nodes * Middle third = Mediastinal nodes * Lower third = Gastrohepatic and celiac axis lymph nodes

Question 281

281 What is the normal epithelial lining of the esophagus?

Answer 281

Nonkeratinizing stratified squamous epithelium

Question 282

282 What are the four layers of the esophageal wall?

Answer 282

* Mucosa * Submucosa * Muscularis propria * Adventitia

Question 283

283 What key surgical landmarks must be kept in mind when operating on the esophagus in the neck?

Answer 283

* It lies slightly left of midline. * Anterior: Trachea, thyroid lobe, and anterolaterally the recurrent laryngeal nerves bilaterally in the tracheoesophageal groove * Posterior: Vertebral column and longus colli muscles * Lateral: Thoracic duct on the left

Question 284

284 What key surgical landmarks are relevant when dilating an esophageal stricture in the mediastinum?

Answer 284

* Superior mediastinum: Slightly left of midline * Posterior: Vertebral column, thoracic duct (not in direct contact, to left) * Anterior: Trachea, left mainstem bronchus, aortic arch * Left lateral: Descending aorta, left parietal pleura (direct contact) * Right lateral: Vena azygos * Inferior mediastinum: Returns to midline * Posterior: Vertebral column; inferiorly, the aorta moves posterior to the esophagus and esophagus. * Anterior: Pericardium * Left lateral: Parietal pleura (direct contact) * Right lateral: Parietal pleura (direct contact)

Question 285

285 At what thoracic level is the esophageal hiatus?

Answer 285

T10

Question 286

286 How many centimeters are the incisor teeth from the **cricopharyngeus**, **aortic arch**, **left mainstem bronchus,** and **lower esophageal sphincter and diaphragm** in an average adult?

Answer 286

* 15cm * 25cm * 40cm

Question 287

287 What two types of peristalsis propel food through the esophagus?

Answer 287

* Primary peristalsis: Triggered by swallowing * Secondary peristalsis: Triggered by esophageal dilation

Question 288

288 What are the functional muscular components of the upper esophageal sphincter?

Answer 288

The **cricopharyngeus muscle**, **thyropharyngeus**, and the **proximal cervical esophagus** Note: Many muscles contribute to the function of the upper esophageal sphincter (e.g., movement of the larynx, infrahyoid musculature, etc.).

Question 289

289 What is the innervation of the upper esophageal sphincter?

Answer 289

At rest, the upper esophageal sphincter is contracted, and during oropharyngoesophageal events (swallowing, belching, emesis), the sphincter relaxes. The major tone effect stems from contraction of the cricopharyngeus, which is modulated by **cranial nerve X**. Afferent information is primarily transmitted via cranial nerve IX.

Question 290

290 What is the innervation of the lower esophageal sphincter?

Answer 290

At rest, the lower esophageal sphincter is contracting as a result of neurotransmitter and hormonal influences. Swallow-induced relaxation occurs about 1 to 2 seconds after the bolus is swallowed. The vagal efferent motor neurons inhibit neurons within the **myenteric plexus**, which results in a decrease in the of the baseline tone.

Question 291

291 What anatomical relationship augments the function of the lower esophageal sphincter?

Answer 291

Diaphragmatic crura

Question 292

292 What are the four main protective mechanisms against esophageal reflux?

Answer 292

1. Upper esophageal sphincter: Tonically closed 2. Lower esophageal sphincter: Tonically closed 3. Esophageal acid clearance: Peristalsis, gravity 4. Epithelial resistance: Mucous layer, aqueous layer, cell membrane, and intracellular junctions

Question 293

293 When should esophagoscopy be considered after **caustic** ingestion?

Answer 293

**Within the first 24 hours** because the risk for perforation and complications may be greater at 2 to 3 days after injury

Question 294

294 What endoscopic findings suggest an increased risk of stricture formation after caustic ingestion?

Answer 294

**Circumferential erythema** with exudate and perforation

Question 295

295 Most esophageal foreign-body impactions occur at what level in the esophagus?

Answer 295

Cervical esophagus, just **below the cricopharyngeus muscle**

Question 296

296 Describe Boerhaave syndrome.

Answer 296

Elevated intraabdominal pressure results in a **transmural** tear within the distal esophageal wall after vomiting. This commonly occurs in the **posterolateral wall of the distal esophagus.**

Question 297

297 Describe Mallory-Weiss syndrome.

Answer 297

**Incomplete** tear of the esophageal wall involving the esophageal mucosa and **submucosal arteries,** often associated with retching

Question 298

298 What does the **Hamman sign** indicate?

Answer 298

* Pneumomediastinum or pneumopericardium, often from tracheobronchial injury or Boerhaave syndrome * Demonstrated by a **crunching sound that is synchronous with heartbeat**

Question 299

299 What type of imaging study should be used In a patient with a suspected esophageal perforation?

Answer 299

Gastrografin swallow study

Question 300

300 Why should patients with findings concerning for esophageal diverticulum, complex stricture, or achalasia undergo esophageal barium swallow instead of initial endoscopy?

Answer 300

Barium swallow is sensitive for these findings, and these conditions are associated with **a higher risk for esophageal perforation with endoscopy use**.

Question 301

301 Is the barium swallow examination always performed using liquid barium?

Answer 301

No. It can be performed with barium tablets or barium-coated food objects, such as a marshmallow or bread, to identify more subtle lesions.

Question 302

302 What is esophageal impedance testing?

Answer 302

This test is performed by a catheter measuring multichannel intraluminal impedance, which measures the difference in resistance when a bolus (mucosa, gas, liquid, solid) passes the detecting channels on the device. It can be used in combination with manometry or pH monitoring and can identify **directionality of bolus movement**.

Question 303

303 What are the indications for esophageal impedance testing?

Answer 303

1. Esophageal dysphasia 2. Noncardiac chest pain 3. Heartburn or regurgitation 4. Preoperative evaluation for antireflux surgery 5. Identification of the lower esophageal sphincter before pH catheter placement

Question 304

304 In a patient for whom twice-daily proton pump inhibitor (PPI) therapy has failed and who has a normal EGD, what test can be performed to confirm GERD?

Answer 304

Ambulatory esophageal pH monitoring, which may also be performed to assess adequacy of treatment

Question 305

305 What are the two available methods of ambulatory pH monitoring?

Answer 305

Ambulatory pH monitoring entails 24- to 48-hour monitoring of reflux events and clinical symptoms while eating an unrestricted diet with the patient off antacid medication for at least 7 days. It can be performed via **a transnasal catheter positioned 5 cm above the lower esophageal sphincter** or **a capsule attached to mucosa 6 cm proximal to the Z-line**

Question 306

306 What main outcome measure is used when evaluating the results of ambulatory pH monitoring?

Answer 306

**Percentage of time the intraesophageal pH is \<4**, to distinguish physiologic from pathologic reflux

Question 307

307 What endoscopic test allows for evaluation of the oropharynx, esophagus, stomach, and upper duodenum?

Answer 307

EGD

Question 308

308 What test is often recommended as the initial test for GERD because it provides diagnostic (both visual and histologic via biopsy) and possibly therapeutic options to allow stratification of disease?

Answer 308

EGD

Question 309

309 Describe three methods for esophageal endoscopy.

Answer 309

* **Rigid transoral esophagoscopy** performed with the patient under general anesthesia * **Flexible transoral esophagoscopy** performed with the patient under conscious sedation * **Flexible transnasal esophagoscopy (TNE)** performed with the patient under local and/or conscious sedation

Question 310

310 What benefit does endoscopy offer as the first step in evaluating a patient with esophageal dysphagia?

Answer 310

Endoscopy can provide visual evaluation and pathologic tissue samples and can also intervene and provide therapeutic benefit.

Question 311

311 What diagnostic test evaluates both the **intraluminal pressures** and **coordination of the upper esophageal sphincter, esophageal body, and lower esophageal sphincter**?

Answer 311

Esophageal manometry

Question 312

312 In a patient with dysphagia, noncardiac chest pain, or a possible esophageal motility disorder, what diagnostic test should be considered?

Answer 312

Esophageal manometry

Question 313

313 In a patient with dysphagia, how can you differentiate oropharyngeal from esophageal dysphagia based on symptoms?

Answer 313

* Esophageal dysphagia: Food gets stuck after the swallow is completed because of structural or neuromuscular pathology; the problem is in the esophageal body or lower esophageal sphincter. * Oropharyngeal dysphagia: Difficult to **complete** swallow; disorders involve the oropharynx, hypopharynx, and upper esophageal sphincter.

Question 314

314 How does the differential diagnosis change if a patient with esophageal dysphagia complains of symptoms with **solids only** versus both solids and liquids?

Answer 314

**Mechanical obstruction** usually causes difficulty with solids (but it may progress to involve liquids later on). Motility disorders commonly result in concurrent solid and liquid dysphagia.

Question 315

315 What are the most common diagnoses in a patient with solid-food esophageal dysphagia?

Answer 315

* Esophageal ring (intermittent) * Peptic stricture (progressive) * Malignancy (progressive)

Question 316

316 What is the most common cause of acute esophageal dysphagia?

Answer 316

Food impaction (meat); results in saliva expectoration

Question 317

317 What disease process is characterized by decreased or absent lower esophageal sphincter relaxation and decreased or absent esophageal peristalsis?

Answer 317

Achalasia (Greek: "does not relax")

Question 318

318 Eagle syndrome is associated with what anatomical abnormality?

Answer 318

Elongated styloid process (about \> 3 cm) and/or ossification or calcification of part or all the stylohyoid ligament. This syndrome was described in 1937 by Dr. Wyatt Eagle.

Question 319

319 Dysphagia lusoria is associated with what anatomical anomaly?

Answer 319

Aberrant right subclavian artery

Question 320

320 What histopathologic findings support the diagnosis of achalasia?

Answer 320

**Decrease in total ganglion cells** within the **myenteric plexus**, the presence of T cell, eosinophil, and mast cell infiltration, and increased neural fibrosis

Question 321

321 What is the general age group most commonly affected by achalasia?

Answer 321

20 to 60 years

Question 322

322 What are the primary complaints associated with loss of lower esophageal sphincter relaxation and esophageal aperistalsis (achalasia)?

Answer 322

Solid and liquid dysphagia, weight loss, chronic cough, chest pain, hiccups, regurgitation, heartburn, and globus

Question 323

323 What three associations are often included in triple A syndrome (**Allgrove syndrome**), which is most commonly found in children?

Answer 323

* Achalasia * Adrenal insufficiency * Alacrima

Question 324

324 What infectious disease can lead to clinical manifestations of achalasia?

Answer 324

Chagas disease

Question 325

325 What management strategy can be used to reverse or stop the progression of achalasia?

Answer 325

None. The goal of management is to decrease lower esophageal sphincter tone and manage reflux.

Question 326

326 What is first-line therapy for patients with severe achalasia?

Answer 326

**Surgical dilation** or **myotomy** unless the patient is a poor operative candidate

Question 327

327 What medical options are available for patients with achalasia?

Answer 327

**Nitrates** and **calcium channel blockers** with the goal of decreasing lower esophageal sphincter tone

Question 328

328 What surgical interventions are available for achalasia?

Answer 328

Good operative candidates may undergo **pneumatic dilation** or **myotomy**. Poor operative candidates may undergo dilation with a **bougie** or **botulinum toxin injection**.

Question 329

329 What pathogen is associated with Chagas disease?

Answer 329

Parasite *Trypanosoma cruzi*

Question 330

330 What is the vector for Trypanosoma cruzi?

Answer 330

Reduviid bugs

Question 331

331 Describe the esophageal manifestations of Chagas disease?

Answer 331

* Megaesophagus with dilation and muscular hypertrophy * Reduction in the number of neurons in the myenteric plexus

Question 332

332 What is the most common condition associated with chronic Chagas disease?

Answer 332

* Cardiomyopathy * Arrhythmias * Conduction blocks

Question 333

333 What are the clinical manifestations of scleroderma?

Answer 333

Skin tightening, hyperpigmentation, and hypopigmentation of skin, sclerodactyly, Raynaud phenomenon, GERD, arthralgias, myalgias, Sicca syndrome, and dysphagia

Question 334

334 How common is esophageal involvement in patients with scleroderma?

Answer 334

**90%**; 50% experience significant symptoms

Question 335

335 The progressive fibrosis and atrophy within the smooth muscle of the esophagus associated with scleroderma manifest with what classic finding on esophageal manometry and barium esophagram?

Answer 335

* Manometry: Progressive loss of esophageal body peristalsis in distal two-thirds and decreased lower esophageal sphincter pressure * Barium esophagram: Dilated esophagus, patulous gastroesophageal (GE) junction, and uninhibited reflux events into the distal esophagus

Question 336

336 What are common complications noted in patients with scleroderma and GERD?

Answer 336

Barrett esophagus, esophagitis, and strictures

Question 337

337 What laboratory test is most sensitive and specific for dermatomyositis?

Answer 337

Creatine kinase

Question 338

338 How is dermatomyositis commonly treated?

Answer 338

**Systemic steroid therapy** and potentially immunosuppressive and cytotoxic therapy, including **methotrexate**, **azathioprine**, and **cyclophosphamide**

Question 339

339 Describe the potential head and neck manifestations of dermatomyositis.

Answer 339

Heliotrope discoloration of upper eyelids, malar rash, dysphonia, dysphagia, scaly scalp, and hair loss

Question 340

340 What part of the aerodigestive tract is affected by polymyositis?

Answer 340

Hypopharynx and upper third of the esophagus

Question 341

341 What is the cause of diffuse esophageal spasm?

Answer 341

Neural and muscular defects triggered by reflux events, stress, extreme temperature variability in food or drink, carbonation, or particular smells

Question 342

342 What symptoms are associated with diffuse esophageal spasm?

Answer 342

Intermittent esophageal dysphagia, noncardiac chest pain, reflux/heartburn

Question 343

343 What are the classic esophageal manometric findings in patients with diffuse esophageal spasms?

Answer 343

**\>2 uncoordinated contractions during 10 consecutive swallows**, aperistalsis in more than 30% of wet swallows, and a fifth of contractions being simultaneous

Question 344

344 What is the test(s) of choice to evaluate for cricopharyngeal dysfunction?

Answer 344

Videofluoroscopic swallow with esophagram

Question 345

345 What are the theories behind the relationship between cricopharyngeal dysfunction and dysphagia?

Answer 345

The cricopharyngeus is normally under tonic contraction but fails to relax with swallow. There is a lack of coordination between cricopharyngeus relaxation and the propulsion of food.

Question 346

346 Describe the relative contraindications to cricopharyngeal myotomy.

Answer 346

* Advanced GERD * Progressive neurologic conditions such as bulbar palsy * Known proximal esophageal cancer * Hx radiation to the neck

Question 347

347 What is the proposed cause of epiphrenic esophageal diverticula?

Answer 347

Pulsion effect created superior to the cardioesophageal junction

Question 348

348 What is the proposed cause of traction esophageal diverticula?

Answer 348

Traction effect caused by inflammation associated with cervical adenopathy or adjacent fibrotic tissue

Question 349

349 Between what muscles does a Zenker diverticulum herniate? (▶Fig. 4.8)

Answer 349

Between the **inferior pharyngeal constrictors** and the **cricopharyngeus** (Killian triangle)

Question 350

350 Which side does a Zenker diverticulum most commonly involve and why?

Answer 350

It involves the **left** neck **~90%** of the time and results from the convexity of the cervical esophagus to the left side and a more laterally positioned carotid artery on the left side, creating a space for the sac to protrude.

Question 351

351 Define the Killian-Jamieson area.

Answer 351

Dehiscence between the **oblique** and **transverse** fibers of the **_cricopharyngeus muscle_**

Question 352

352 Define the Laimer triangle.

Answer 352

Dehiscence between the cricopharyngeus muscles and the proximal esophageal muscles

Question 353

353 What nonmalignant complication of GERD can manifest with progressive esophageal dysphagia starting with solid-food dysphagia and progressing to both solid and liquid dysphagia?

Answer 353

Peptic stricture

Question 354

354 Describe the risk factors for developing a peptic stricture.

Answer 354

* Older age * Male * Long history of reflux symptoms * GERD * Scleroderma * Zollinger-Ellison syndrome * Nasogastric tube placement * Hx of surgical management for achalasia (Heller myotomy)

Question 355

355 What is a Schatzki ring?

Answer 355

Smooth, thin (\< 4mm) web of mucosa and submucosa at the squamocolumnar junction, marking the proximal margin of a hiatal hernia

Question 356

356 Describe the characteristics of a muscular esophageal ring.

Answer 356

Hypertrophic musculature within the esophageal body typically located within 2 cm of the GE junction

Question 357

357 What disease processes increase the likelihood of developing an esophageal ring?

Answer 357

GERD and eosinophilic esophagitis

Question 358

358 What is an esophageal web?

Answer 358

Thin mucosal fold covered in squamous epithelium that extends into the esophageal lumen, most commonly in the anterior cervical esophagus

Question 359

359 What is the most common cause of an esophageal web?

Answer 359

Most often, it is idiopathic and asymptomatic.

Question 360

360 What are common risk factors for the formation of an esophageal web?

Answer 360

Chronic GERD or iron deficiency associated with Plummer-Vinson syndrome.

Question 361

361 Describe the clinical features of Plummer-Vinson syndrome.

Answer 361

Triad of **dysphagia**, **iron-deficiency anemia**, and **esophageal webs**. Additionally associated with atrophic glossitis and squamous cell carcinoma of the oral cavity, esophagus, and hypopharynx

Question 362

362 What are common initial symptoms of GERD?

Answer 362

**Heartburn 30 minutes to 2 hours after eating and regurgitation.** Symptoms worsen with lying down or bending over. Less common symptoms include chest pain, chronic cough, laryngitis, asthma, and dental caries. Patients may complain of odynophagia and dysphagia in addition to belching.

Question 363

363 What symptoms are worrisome for a more sinister diagnosis than isolated GERD?

Answer 363

Dysphagia, odynophagia, choking, weight loss, chest pain, upper GI bleed, and no or poor response to an empiric trial of antacids. If these symptoms are present, or if a patient does not improve on empiric therapy, endoscopy should be considered.

Question 364

364 Why is an initial empiric trial of antacid therapy a reasonable first step in a patient with symptoms suggestive of GERD?

Answer 364

It is noninvasive, cost-effective, and in most cases diagnostic and therapeutic.

Question 365

365 What technique offers the best evaluation of a patient's esophageal mucosa?

Answer 365

Endoscopic esophagoscopy

Question 366

366 What is commonly seen on esophagoscopy in a patient with reflux esophagitis?

Answer 366

Erosions or ulcerations at the squamocolumnar junction (Z line)

Question 367

367 To determine the severity of acid reflux, demonstrate reflux in a patient with normal endoscopic findings, or to evaluate response to therapy, a 24- hour pH probe test may be performed. What is the primary limitation of this test?

Answer 367

A fourth of patients with erosive esophagitis and a third of patients with nonerosive esophagitis will have normal results.

Question 368

368 When discussing lifestyle modifications for the management of GERD, what foods should be avoided?

Answer 368

Fatty foods, chocolate, coffee, excess alcohol, colas, red wine, orange juice, large meals, peppermint, basically anything that increases pH or decreases sphincter tone

Question 369

369 Beyond dietary considerations, what lifestyle modifications should be considered to improve mild GERD?

Answer 369

Elevate the head of bed while sleeping, avoid eating right before sleep, exercise regularly, and lose weight.

Question 370

370 Which histamine 2 (H2) blocker is the most effective for treating GERD, and what is the dose dependent relationship between symptoms and therapy?

Answer 370

When adjusted for potency, no H2 blocker has been shown to be stronger or more effective than another. There is not a dose-dependent relationship. If a patient is treated with 6 weeks of standard therapy and does not respond, it is time to look to additional intervention.

Question 371

371 In a patient diagnosed with erosive reflux disease, what medical management is indicated?

Answer 371

PPI therapy

Question 372

372 Is there any difference in treatment outcome for GERD when comparing once-daily proton pump inhibitor therapy with more frequent dosing regimens?

Answer 372

Yes. More frequent dosing schedules (twice a day) have been shown to result in a significant improvement in gastric pH and provide a longer duration of effect.

Question 373

373 After discontinuing a PPI for GERD, in what time frame do most patients who have recurrence begin to experience relapsing symptoms?

Answer 373

Three months

Question 374

374 What risks are associated with chronic suppressive PPI therapy for reflux disease?

Answer 374

Potentially **decreased bone density**, infections, and electrolyte abnormalities

Question 375

375 In a patient with long-standing esophageal reflux disease, the endoscopist identified specialized intestinal metaplasia or metaplastic cuboidal epithelium extending proximally to the natural squamocolumnar junction. What disease process is most likely associated with this finding?

Answer 375

Barrett esophagus

Question 376

376 To classify peptic esophagitis on endoscopy and decrease interobserver variability, several classification systems have been devised. The Los Angeles classification system is most commonly used. Describe the different grades involved in this system.

Answer 376

Los Angeles Classification * Grade A: One or more mucosal break, each ≤ 5mm long * Grade B: One or more mucosal break \> 5mm long, without continuity between the tops of adjacent mucosal folds * Grade C: One or more mucosa breaks continuous between the tops of adjacent mucosal folds; not circumferential * Grade D: Circumferential mucosal break Note: Historically the Savory-Miller grading system was the most prevalent; however, because of variable definitions, it is not as commonly used today.

Question 377

377 During endoscopy for erosive esophagitis, what is the strongest predictor of Barrett esophagitis on examination?

Answer 377

The length of the columnar appearing epithelium segment extending from the GE junction (long segment \> 3 cm, short segment \< 3 cm). Specialized intestinal metaplasia is required on pathology to confirm the diagnosis.

Question 378

378 What is the most feared complication of Barrett esophagus?

Answer 378

Esophageal adenocarcinoma. Annual incidence ranges between 0.12 and 0.5% in patients with Barrett esophagus.

Question 379

379 With Barrett esophagus, how often should a patient with (1) no evidence of dysplasia, (2) lowgrade dysplasia, and (3) high-grade dysplasia without eradication therapy be examined endoscopically?

Answer 379

1. Every 3 to 5 years 2. Every 6 to 12 months 3. Every 3 months

Question 380

380 What three management strategies are available for patients with Barrett esophagus?

Answer 380

Controversy regarding optimal management is ongoing. Options include the following: * Management of GERD * Surveillance via serial endoscopy * Attempt to eradicate dysplasia

Question 381

381 What endoscopic options are available for dysplasia eradication in patients with Barrett esophagus?

Answer 381

* Radiofrequency ablation * Photodynamic therapy * Endoscopic mucosal resection (recommended for patients with dysplasia and a visible mucosal irregularity to evaluate for T stage)

Question 382

382 Provide several reasons why the prognosis for esophageal cancer is poor.

Answer 382

It often manifests late in the disease, and the esophagus is **without an outer serosal layer**, which may lead to early spread.

Question 383

383 Describe the Müller maneuver.

Answer 383

Endoscopic evaluation during **maximal inspiration, against a closed nose and mouth**, at various levels in an attempt to identify anatomical regions of obstruction

Question 384

384 What is the Epworth sleepiness scale?

Answer 384

A commonly used, statistically validated questionnaire for daytime sleepiness. A score of 0 to 5 is supernormal, 5 to 10 is normal, **10 to 15 is sleepy**, 15 to 20 is very sleepy, \> 20 is dangerously sleepy.

Question 385

385 What is upper airway resistance syndrome (UARS)?

Answer 385

UARS is characterized by excessive daytime somnolence but normal sleep studies. Esophageal pressure monitoring shows abnormally increased negative intrathoracic pressures leading to increased work of breathing and sleep arousals. UARS is associated with crescendo snoring. In contrast to OSA, UARS is seen as frequently in women as in men, occurs in nonobese patients, and is more common in young adults than in elderly adults.

Question 386

386 What cephalometric findings are associated with OSA?

Answer 386

The skull base appears to be shorter. The sagittal dimension of both jaws is smaller and in a more retrognathic position. The height of the lower face is increased, as the mandible tends to be rotated posteriorly. The chin and tongue are retruded, the soft palate is elongated, and the upper airway space is narrowed.

Question 387

387 What is the definition of OSA?

Answer 387

OSA is a sleep disorder characterized by periodic complete or partial upper airway obstruction during sleep, causing intermittent apneas, hypopnea, or both despite ongoing respiratory effort. There is no universally accepted definition, but it is usually defined as a **respiratory disturbance index (RDI) of 5 or greater**. Measurements of the severity of OSA are based on the RDI, the severity of oxygen desaturation, and the level of daytime sleepiness.

Question 388

388 What medical therapies exist for treatment of OSA?

Answer 388

* Weight control, CPAP (continuous positive airway pressure), and oral appliances * Medical conditions such as acromegaly and hypothyroidism should be ruled out. * Medications or substances such as alcohol, sedative hypnotics, narcotics, anesthetics, and sedating antihistamines should be avoided.

Question 389

389 What are potential complications or sequelae of Uvulopalatopharyngoplasty (UPPP)?

Answer 389

Persistent snoring or OSA, bleeding, nasopharyngeal regurgitation of liquids, oropharyngeal dryness, oropharyngeal dysphagia, and pharyngeal stenosis

Question 390

390 What does the Friedman staging system assess?

Answer 390

This staging system is used as a clinical predictor of which patients may have successful improvement of their OSA after UPPP surgery.

Question 391

391 What is the most common surgical treatment of children with OSA?

Answer 391

Adenotonsillectomy. Less commonly, lingual tonsillectomy may be performed.

Question 392

392 What craniofacial syndromes are closely associated with snoring and sleep apnea?

Answer 392

* Achondroplasia * Pierre Robin syndrome * Treacher-Collins syndrome * Crouzon disease * Down syndrome * Prader-Willi syndrome * Apert syndrome

Question 393

393 What is the mechanism of radiofrequency tissue volume reduction used for the treatment of snoring?

Answer 393

Inserting electrodes and applying thermal energy will create a definable “thermal lesion” that over time will be replaced by stiff fibrotic tissue with reduced vibratory capacity.

Question 394

394 Describe **tongue base and hyoid bone suspension** procedures for treatment of OSA.

Answer 394

A screw, with two sutures attached, is drilled into the lingual cortex of the mandibular symphysis. The two sutures are then submucosally secured to the tongue base or wrapped around the hyoid and tied under tension.