Chapter 10 - ENT

Question 1

3 general etiologies of neck masses? Compare the timing of presentation.

Answer 1

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

Question 2

Presentation of thyroglossal duct cyst?

Answer 2

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

Question 3

Management of thyroglossal duct cyst?

Answer 3

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

Question 4

Presentation of branchial cleft cysts?

Answer 4

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

Question 5

Presentation of cystic hygroma?

Answer 5

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)

Question 6

Management of cystic hygroma?

Answer 6

CT scan to determine depth of extension

Surgical removal

Question 7

Management of a recently discovered enlarged lymph node?

Answer 7

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

Question 8

Persistent enlarged lymph nodes (week or months) could still be inflammatory, but ___ has to be ruled out.

Answer 8

Neoplasia

Question 9

Presentation of lymphoma?

Answer 9

Typically young people
Often have multiple enlarged nodes (in the neck and elsewhere)
Low-grade fever and night sweats

Question 10

Work-up and Rx of lymphoma?

Answer 10

FNA can be done, but usually a node has to be removed for pathologic study to determine specific type

Chemo

Question 11

Metastatic tumor to supraclavicular nodes invariably come from what tumors?

Answer 11

Below the clavicles (not from head/neck) -> lung or intra-abdominal

Question 12

Presentation of squamous cell carcinoma of the mucosae of the head and neck?

Answer 12

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

Question 13

Dx work-up of suspected squamous cell carcinoma of the mucosae of the head and neck?

Answer 13

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

Question 14

Rx squamous cell carcinoma of the mucosae of the head/neck?

Answer 14

Resection, radical neck dissection, often radiotherapy and platinum-based chemo

Question 15

Presentation of acoustic nerve neuroma?

Answer 15

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)

Question 16

Dx acoustic nerve neuroma?

Answer 16

MRI

Question 17

Presentation of facial nerve tumors?

Answer 17

Gradual unilateral facial nerve paralysis affecting both the forehead and the lower face

(paralysis of sudden onset suggests Bell’s palsy)

Question 18

Dx facial nerve tumor?

Answer 18

Gadolinium-enhanced MRI

Question 19

Presentation of parotid tumors?

Answer 19

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

Question 20

Dx and Rx parotid tumors?

Answer 20

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

Question 21

Main cause of unilateral ENT problems in toddlers?

Answer 21

Foreign bodies

Question 22

Presentation of foreign body in toddler?

Answer 22

2-year old with unilateral earache/rhinorrhea/wheezing in ear canal/nose/bronchus

Question 23

Rx foreign body in toddler?

Answer 23

Appropriate endoscopy under anesthesia for extraction

Question 24

What is Ludwig angina?

Answer 24

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

Question 25

Rx Ludwig angina?

Answer 25

I/D

Intubation and tracheostomy may be needed

Question 26

Presentation and management of Bell’s palsy?

Answer 26

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.

Question 27

Presentation of cavernous sinus thrombosis?

Answer 27

Diplopia (paralysis of extrinsic eye muscles), along with facial pain and high fever, in a patient suffering from frontal or ethmoid sinusitis

Question 28

Dx and Rx cavernous sinus thrombosis?

Answer 28

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

Question 29

Cause and management of epistaxis in children?

Answer 29

Nosepicking

Bleeding comes from the anterior septum, phenylephrine spray and local pressure controls the problem

Question 30

DDx - epistaxis in an 18-year old?

Answer 30

Cocaine abuse (with septal perforation)
Juvenile nasopharyngeal angiofibroma

Question 31

Management of epistaxis 2/2 cocaine abuse?

Answer 31

Posterior packing

Question 32

Management of juvenile nasopharyngeal angiofribroma?

Answer 32

Mandatory surgical resection (benign tumor, but it eats away at nearby structures)

Question 33

Management of epistaxis and in the elderly and hypertensive?

Answer 33

Can be copious and life-threatening; BP has to be controlled, posterior packing, sometimes surgical ligation of feeding vessels

Question 34

DDx - dizziness + management?

Answer 34

Inner ear disease - vertigo (room spinning) -> promethazine or diazepam

Central problem - unsteady, but room is stable -> neuro work-up

Question 35

Presentation and Rx of Meniere disease?

Answer 35

Vertigo, tinnitus, hearing loss

Rx diuretics