Chapter 10 - ENT Flashcards
3 general etiologies of neck masses? Compare the timing of presentation.
Congenital - seen in young people, typically present for years before they become symptomatic (usually infected) and medical help is sought
Inflammatory - typically days or weeks, resolution within a few weeks (drained or resolved)
Neoplastic - several months of relentless growth
Presentation of thyroglossal duct cyst?
Located on the midline at the level of the hyoid bone, seems to be somehow connected to the tongue (pulling at the tongue retracts the mass)
Typically 1-2cm in diameter
Management of thyroglossal duct cyst?
Some insist that the location of the normal thyroid should be ascertained by radionuclide scan
Surgical removal of the cyst, middle segment of the hyoid bone, and the track that leads to to the base of the tongue
Presentation of branchial cleft cysts?
Occur along the anterior edge of the SCM, anywhere from the front of the tragus to the base of the neck
Several cm in diameter
Sometimes have a little opening and blind tract in the skin overlying them
Presentation of cystic hygroma?
Base of the neck
Large mushy ill-defined mass that occupies the supraclavicular area
Seems to extend deeper into the chest (often do extend to the mediastinum)
Management of cystic hygroma?
CT scan to determine depth of extension
Surgical removal
Management of a recently discovered enlarged lymph node?
Most are benign and therefore an expensive work-up should not be undertaken right away
Complete H&P followed by follow-up in 3-4 weeks
If still there, begin work-up
Persistent enlarged lymph nodes (week or months) could still be inflammatory, but ___ has to be ruled out.
Neoplasia
Presentation of lymphoma?
Typically young people
Often have multiple enlarged nodes (in the neck and elsewhere)
Low-grade fever and night sweats
Work-up and Rx of lymphoma?
FNA can be done, but usually a node has to be removed for pathologic study to determine specific type
Chemo
Metastatic tumor to supraclavicular nodes invariably come from what tumors?
Below the clavicles (not from head/neck) -> lung or intra-abdominal
Presentation of squamous cell carcinoma of the mucosae of the head and neck?
Old men who smoke, drink, and have rotten teeth; patients with AIDS
First manifestation is often metastatic node in the neck (typically to the jugular chain)
Persistent hoarseness, persistent painless ulcer in the floor of the mouth, persistent unilateral earache
Dx work-up of suspected squamous cell carcinoma of the mucosae of the head and neck?
Triple endoscopy to look for the primary tumor/tumors
Biopsy of the primary/primaries
CT scan demonstrates extent
FNA of node may be done, but open biopsy of the neck mass should never be performed - this will eventually interfere with surgical approach
Rx squamous cell carcinoma of the mucosae of the head/neck?
Resection, radical neck dissection, often radiotherapy and platinum-based chemo
Presentation of acoustic nerve neuroma?
Adult with sensory hearing loss in one ear but not the other (and who does not engage in sport shooting that would subject one ear to more noise than the other)
Dx acoustic nerve neuroma?
MRI
Presentation of facial nerve tumors?
Gradual unilateral facial nerve paralysis affecting both the forehead and the lower face
(paralysis of sudden onset suggests Bell’s palsy)
Dx facial nerve tumor?
Gadolinium-enhanced MRI
Presentation of parotid tumors?
Visible and palpable in front of the ears or around the angle of the mandible
Most are pleomorphic adenomas, which are benign but have potential for malignant degeneration; no pain or facial nerve paralysis
If hard mass with pain or paralysis -> parotid cancer
Dx and Rx parotid tumors?
FNA may be done
Open biopsy is absolutely contraindicated
Formal superficial parotidectomy (or superficial and deep if deep to the facial nerve) is the appropriate way to excise and thereby biopsy tumors (prevents recurrence and spares the facial nerve). Enucleation alone leads to recurrence.
In malignant tumors, the nerve is sacrificed and a raft done
Main cause of unilateral ENT problems in toddlers?
Foreign bodies
Presentation of foreign body in toddler?
2-year old with unilateral earache/rhinorrhea/wheezing in ear canal/nose/bronchus
Rx foreign body in toddler?
Appropriate endoscopy under anesthesia for extraction
What is Ludwig angina?
Abscess of the floor of the mouth, often the result of a bad tooth infection
Usual abscess findings present - concerning because of the threat to the airway
Rx Ludwig angina?
I/D
Intubation and tracheostomy may be needed
Presentation and management of Bell’s palsy?
Sudden paralysis of the facial nerve for no apparent reason
Although not an emergency per se, current practice includes the use of antiviral medications - prompt and early administration. Steroids are also typically prescribed.
Presentation of cavernous sinus thrombosis?
Diplopia (paralysis of extrinsic eye muscles), along with facial pain and high fever, in a patient suffering from frontal or ethmoid sinusitis
Dx and Rx cavernous sinus thrombosis?
Rare but serious emergency (30% mortality) that requries hospitalization
Dx - MRI
Rx - early and aggressive IV antibiotic administration for a minimum of 3-4 weeks with penicillinase-resistant penicillin + 3rd or 4th gen cephalosporin
Surgical drain the responsible paranasal sinus
Cause and management of epistaxis in children?
Nosepicking
Bleeding comes from the anterior septum, phenylephrine spray and local pressure controls the problem
DDx - epistaxis in an 18-year old?
Cocaine abuse (with septal perforation) Juvenile nasopharyngeal angiofibroma
Management of epistaxis 2/2 cocaine abuse?
Posterior packing
Management of juvenile nasopharyngeal angiofribroma?
Mandatory surgical resection (benign tumor, but it eats away at nearby structures)
Management of epistaxis and in the elderly and hypertensive?
Can be copious and life-threatening; BP has to be controlled, posterior packing, sometimes surgical ligation of feeding vessels
DDx - dizziness + management?
Inner ear disease - vertigo (room spinning) -> promethazine or diazepam
Central problem - unsteady, but room is stable -> neuro work-up
Presentation and Rx of Meniere disease?
Vertigo, tinnitus, hearing loss
Rx diuretics
