Clin med ENT Flashcards
1
Q
The inner portion of the ______ is thin, the dermis is in direct contact with the periosteum
A
External auditory canal
2
Q
What should you always include in your PE of otalgia or otorrhea, aside from head and neck?
A
Heart and lungs
3
Q
4 causes of cerumen impaction
A
- Obstruction due to ear canal disease
- Narrowing of the ear canal
- Failure of epithelial migration
- Overproduction
4
Q
Cerumen impaction more prevalent in what demographic?
A
Older adults (1 in 3)
5
Q
How can a reflex cough in cerumen impaction be explained?
A
Vagus stimulation of the area near the TM
6
Q
Clinical presentation of cerumen impaction (2)
A
Asymptomatic
Hearing loss, otalgia, fullness, itchiness, reflex cough, tinnitus
7
Q
Frontline treatment for cerumen impaction
A
- Cerumenolytic agents (debrox,mineral oil, colace drops)
- Irrigation
- Manual removal
8
Q
What is the name of the tool that can be used to remove foreign bodies?
A
Katz-Extractor
9
Q
Inflammation of the external auditory canal or auricle
A
Otitis externa (swimmers ear)
10
Q
3 causes of OE
A
- Infectious
- Allergic
- Dermatologic
11
Q
What is the most common etiology of OE?
A
Bacterial (98%)
12
Q
What are two pathogens responsible for OE?
A
S. aureus
Pseudomonas
13
Q
Main clinical features/ distinction of OE
A
- FAST onset
- Pain
14
Q
What should you do in your PE to test for OE?
A
Palpation of the tragus and auricle (could indicate OE if painful)
Otoscopic exam
15
Q
The otoscopic exam for suspected OE is critical to distinguish between OE and
A
OM with perforation
16
Q
Frontline treatment for OE
A
Topical ABx (active acid,quinolone,sulfamonides,Aminoglycosides)
17
Q
Second line treatment for OE
A
Topical corticosteroids
18
Q
3rd line treatment for OE
A
Oral ABx only if severe
19
Q
2 complications of OE
A
Chronic OE
Malignant OE
20
Q
Most common pathogen of malignant OE
A
Pseudomonas (95%)
21
Q
Most common cause of chronic OE?
A
Allergies or inflammatory dermatologic conditions
22
Q
Chronic OE is OE lasting more than __________ months
A
3
23
Q
“Severe otalgia and otorrhea (not responsive to topical treatment)”
“Nocturnal pain, extending to TMJ”
A
Malignant OE
24
Q
What imaging should be done for malignant OE?
A
CT/MRI
25
Tx for malignant OE
IV ABx
Cirpofloxacin (can consider pip-tazo or cefepime)
26
Most common ear neoplasia type
SCC
27
“Failure of the functional valve of the Eustachian tube to open and/or close properly”
Eustachian Tube Dysfunction
28
Functions of the Eustachian tube (3)
1. Equalize pressure
2. Protect middle ear from pathogens
of oropharynx
3. Clearance of middle ear secretions
29
What is the most important factor in the pathogenesis of middle ear infections?
ETD
30
The #1 clinical feature of ETD is
Recurrent OM
31
Infection or inflammation of the middle ear marked by the presence of middle ear fluid
Acute OM
32
AOM found overwhelmingly in what population?
Pediatrics
33
Causative pathogens for AOM
Strep pneumo
H. influenza
RSV, influenza, rhinoviruses
34
Clinical features of AOM
Otalgia, unilateral, fever may/may not be present, often preceded by URI or exacerbation of allergic rhinitis
35
Otoscopic findings for AOM
Bulging, erythematous TM, or opacified. Purulence if perforated
36
What can pneumatic otoscopy be used to do?
Test for AOM (TM membrane movement limited could indicate inner ear pressure/infection)
37
Frontline ABx for pediatric AOM?
Amoxicillin
Augmentin if failed
38
Frontline ABx for adult AOM?
Augmentin
39
PCN allergic alternative for AOM
Cephalosporin, doxycycline, Azithromycin
40
Observation criteria for AOM
1. Healthy children
2. Ages 6-24 months
3. Unilateral, non severe pain
4. Age >24 mo with non severe pain, unilateral or bilateral
41
Otitis media with effusion (OME): infected or not infected
Not infected (“Serous OM”)
42
When to refer OME to ENT
If symptoms persist beyond 3 months or anytime there is a language or speech delay/ sig hearing loss
43
Most common cause of ruptured TM
OM
44
Key clinical distinction of ruptured TM
Pain RESOLVES with rupture
45
Frontline treatment for ruptured TM
Oral ABx (amoxicillin or augmentin)
46
Clinical hallmark of chronic OM
Purulent discharge
47
Most common cause of chronic OM
acute OM and ETD
48
Treatment for chronic OM
1. ENT
2. surgical repair (TM tubes)
49
Clinical hallmarks of mastoiditis
1. Post auricular pain
2. Fever
3. Otalgia
50
What causes mastoiditis?
Bacteria invading the bone
51
Frontline Tx for mastoiditis
IV ABx directed at S. Pneumo, H. Influenza, S. Pyogenes)
52
Myringotomy
Incision into the tympanic membrane
53
Highest demographic of having TM tubes
Children attending daycare, DD and ASD, craniofacial abnormalities
54
Why has TM tube placement declined since 2000?
Pneumococcal and H. flu vaccines
55
4 indications of TM tube placement
1. Long term ventilation of the middle ear space
2. Control conductive hearing loss
3. Reduce risk of recurrent AOM
4. Prevent cholesteatoma due to TM retraction
56
Why are oral ABx not needed with TM tubes?
Topicals will work to get to the site of infection through TM opening
57
“Keratinized mass in the middle ear or mastoid, may occur as a lesion due to ETD or TM perforation”
Cholesteatoma
58
How do cholesteatomas develop?
Prolonged exposure to negative middle ear pressure ———inflammation——— Keratinized debris collects
59
This type of hearing loss results from external or middle ear dysfunction
Conductive
60
This type of hearing loss results from deterioration of the cochlea (inner ear)
Sensorineural
61
What type of hearing loss is most common?
Sensorineural
62
Common causes of conductive hearing loss
Infections
Cerumen
TM perforation
63
Common causes of sensorineural hearing loss
Presbycusis (age related)
Meniere disease
Noise exposure
64
Normal Weber test findings
Vibrations heard equally on both sides
No lateralization.
65
In the Weber test with someone with conductive hearing loss, the sound will lateralize to which side?
Defected ear
66
In the Weber test with someone with sensorineural hearing loss, the sound will lateralize to which side?
Normal ear
67
Rinne test used to test for which type of hearing loss?
Conductive
68
Normal Rinne test findings
AC > BC
69
AC > BC (diminished) Rinne finding indicates
Sensorineural hearing loss
70
Acoustic neuroma, also known as
Vestibular schwannoma
71
Where do vestibular schwannomas commonly arise?
Vestibular portion of CN8
72
Clinical presentation of acoustic neuroma
Hearing loss
Tinnitus
Unsteady gait
Vertigo uncommon
Facial numbness/paralysis (compression of CN 5 or CN 7)
73
Test of choice for acoustic neuroma
MRI
74
Tx for acoustic neuroma
Surgical resection
Radiation
Observation
75
When would observation be the treatment of choice of acoustic neuroma?
Elderly population, slow growing
76
What causes tinnitus? (2)
1. Sensorineural hearing loss with resulting dysfunction within the auditory system
-Ototoxic meds
-Presbycusis
-Otosclerosis
-acoustic neuroma
2. Vascular disorders (venous hums)
77
Gold standard for assessing vascular tinnitus?
CTA or MRI
78
When you plug your nose and bear down, what is happening inside your ear?
ET opening, increasing middle ear pressure to match the pressure outside the ear
79
Etiologies for barotrauma
Flying
Blast injury
Diving
80
Most common clinical features of barotrauma
Pain/pressure
Hearing loss
Bleeding into TM
Vertigo/Tinnitus = more emergent
81
Tx for barotrauma
Prevention (oral decongestants, swallowing, ear plugs)
Surgical repair
Emergent ENT referral
ABx - only in TM perf
Analgesia
82
Auricular hematoma, AKA
Cauliflower ear
83
Tx for auricular hematoma
Needle aspiration
I&D
ABx - cover skin pathogens
Follow-up
84
What size/presentation of auricular hematoma necessitates needle aspiration?
<2 cm or present <24 hrs
85
ABx for auricular hematoma
Doxycycline, Bactrim
86
Medical term that describes the sensation of whirling and loss of balance, associated with looking down from a great height, or caused by disease affecting inner nerve or vestibular nerve
Vertigo
87
Sensation of impending fall or of the need to obtain assistance for proper locomotion
Disequilibrium
88
T/F Vertigo is a diagnosis
False, symptom
89
T/F: Syncope and near syncope are not dizziness or vertigo
True
90
Vertigo is divided into what two causes
Peripheral or central
91
What structure in the inner ear detects angular movement
Semicircular canals
92
What structure of the inner ear detects linear motion
Otolith organs
93
80% of all vertigo is
Peripheral
94
Common etiologies of peripheral vertigo
Benign paroxysmal positional vertigo (BPPV)
Vestibular neuritis
Meniere disease
95
Etiologies of central vertigo
Vestibular migraine
Brainstem ischemia (bad)
Cerebellar infarct/hemorrhage (bad)
96
Nystagmus direction in central vertigo
Any direction
97
Nystagmus direction in peripheral vertigo
Horizontal, unilateral
98
Neurologic signs in peripheral vertigo
Absent
99
Postural instability in central vertigo
Severe, falls
100
Postural instability in peripheral vertigo
Mild
101
Tinnitus, hearing loss in central vertigo
Absent
102
Tinnitus, hearing loss in peripheral vertigo
May be present
103
Pathophysiology of BPPV
Canalithiasis causes inappropriate endolymph motion in the semicircular canals, resulting in sensory mismatch and sensation of spinning with head movement
104
Clinical hallmarks of BPPV
Provoked by head movement
Typically no other Neurologic complaints
Hearing loss absent
105
Dix-hllpike maneuver used to provoke what
Nystagmus, indicative of BPPV
106
Treatment for BPPV
Epley maneuver
Meds: antihistamines - Meclisine (Bonine) frontline
Benzodiazepines (caution in elderly)
107
Vestibular neuritis, AKA
Labyrinthitis
108
Pathophysiology of Labyrinthitis
Inflammation of CN 8
109
Clinical features of Labyrinthitis
Rapid onset
Severe vertigo
Associated N/V
110
PE findings in Labyrinthitis
Horizontal, unilateral nystagmus fixed with visual fixation
Positive head thrust test
111
What is a more severe differential for Labyrinthitis
Vascular event affecting cerebellum or brainstem
112
What factors should move you towards a central cause of vertigo
1. Nystagmus NOT suppressed with visual fixation
2. Nystagmus can be vertical or change direction
3. Typically patient cannot walk or stand
4. Constant symptoms
5. Consider in patients with other risk factors
113
Treatment for Labyrinthitis
Corticosteroids - prednisone taper after 10 days
Antihistamines - meclisine 25-50 mg q8h or diphenhydramine 25 mg q4-q6h
114
Meniere disease triad
Episodic vertigo, tinnitus, hearing loss
115
Tx for Meniere disease
Chronic condition - receive symptoms
Lifestyle adjustments - diet
Medical management
Vestibular rehab
Interventional tx - ENT
116
Medical tx for Meniere disease
Diuretics
Antiemetics
Anxiolytics
Antihistamines
TCAs
(“Vestibular suppressants”)
117
Ebselen (gluthione peroxidase mimetic)
In phase 3 clinical trial, medication strictly for Meniere disease, 2023 expected
118
Most common viral etiologies of Pharyngitis
Rhinovirus
Coronavirus
Flu
Adenovirus
HSV
Cocksackie virus
EBV
CMV
119
Most common age group for beta hemolytic strep
5-15 yo
120
What pathogen accounts for 15-20% bacterial pharyngitis
S. aureus
121
Pharyngitis route of spread
Droplet exposure
122
Coryza symptoms (runny nose, scratchy throat) is suggestive of what viral etiology
Rhinovirus/coronavirus
123
Fever, fatigue, “shaggy” exudate, generalized adenopathy, splenomegaly suggestive of what viral etiology
EBV/CMV
124
Fever, myalgias, headache, cough suggestive of what viral etiology
Flu
125
Conjunctivitis suggestive of what viral etiology
Adenovirus
126
Exudate, vesicles & ulcers on palate suggestive of what viral etiology
HSV
127
Vesicles on soft palate/uvula rupture to what ulcers, HFM suggestive of what viral etiology
Cocksackie
128
Yellow-green exudate, dysuria suggestive of what etiology
Gonnococcal
129
Name the four centor criteria
Fever
Tonsillar exudate
Tender cervical lymphadenopathy
No URI/cough symptoms
130
“Other” pharyngitis criteria/findings
Scarlatiniform rash, strawberry tongue
131
Centor criteria is best for negative or positive predictive value
Negative (RULE-out disease)
132
Dx of pharyngitis
Rapid antigen test and/or throat culture
133
What % of children are carriers of strep A
20
134
Tx for viral pharyngitis
Supportive care (pain meds, gargling)
135
Tx for bacterial pharyngitis
Penicillin (VK PO or G IM) 1st line
Alternatives:
Amoxicillin, cephalosporin, Clindamycin, Azithromycin
136
Typical abx treatment course length for bacterial pharyngitis
10 days
137
How many of the centor criteria should be present to justify strep test
3-4
138
Negative predictive value of <3 centor criteria
<80%
139
Positive predictive value of 3-4 centor criteria
40-60%
140
Complications of strep throat
Rheumatic fever
Glomerulonephritis
Peritonsillar/retropharyngeal abscess
141
What is a pediatric complication of strep throat
PANDAS
142
PANDAS
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections
143
Viral illness could take how many days to resolve?
10 days
144
Strep patients are still contagious in the first ______ hours on ABX
24
145
1/3 of mononucleosis cases have
Strep
146
What is the importance of ABX choice with suspected strep
Careful of potential for EBV and amoxicillin reaction
147
Name the tonsillectomy criteria (3 options)
7+ episodes of sore throat in last year
OR
at least 5 episodes in each of the previous two years
OR
at least 3 episodes in each of the previous 3 years
148
“episode” defined as sore throat plus one of the following
Temp >100.9
Cervical adenopathy
Tonsillar exudate
Positive group A B hemolytic strep culture
149
Peritonsillar abscess, AKA
quinsy
150
Trismus, deviation of soft palate/uvula, “hot potato” voice suggestive of
Peritonsillar abscess
151
Work up for peritonsillar abscess
Ultrasound, CT, manual exam, labs
152
Tx for peritonsillar abscess
Aspiration and/or I&D
IV amp-sulbactam or clinda
Pain meds
Steroids?
153
Most common age and gender for retropharyngeal abscess
Boys > girls
Ages 3-4 most common
154
Causative pathogens for retropharyngeal abscess
Strep
Staph
H. flu
Klebsiella
155
Fever, drooling, stiff neck (torticoillis), toxic looking, stridor, bulging of pharynx suggestive of
Retropharyngeal abscess
156
Workup for Retropharyngeal abscess
Soft tissue neck X-ray
Labs and CT is most likely Dx
157
Tx for Retropharyngeal abscess
IV ABx (amp-sulbactam or clinda +/- Vanco)
I&D possible
158
Complications of Retropharyngeal abscess
Airway obstruction
Rupture leading to pneumonia
Thrombophlebitis of IJV or erosion into carotid sheath (Lemierre syndrome ~also associated with Ludwigs angina)
159
Deep tissue infection into the submandibular space secondary to poor dentition
Ludwig’s Angina
160
Pathogens associated with Ludwig’s angina
Staph
Strep
Bacteroides
Fusobacterium
161
Submittal and or sublingual swelling, drooling, fever suggestive of
Ludwig’s angina
162
Workup for Ludwig’s angina
CT or ultrasound for cellulitis vs. abscess
163
Treatment for Ludwig’s angina
IV ABx
Surgical I&D
Dental F/U
164
Complications of Ludwig’s angina
Lemierre syndrome
Airway compromise
165
Dysphonia
Abnormal voice quality
166
Important laryngeal structures
Tongue base
Epiglottis
Vocal cords/trachea
167
Laryngitis, vocal cord polyp, myasthenia gravis, vocal cord paralysis, stroke, GERD, croup:
Painful or painless?
Painless (generally)
168
Tonsillitis, peritonsillar abscess, Retropharyngeal abscess, Ludwig angina, Epiglottitis, foreign body, GERD, croup: painful or painless?
Painful
169
Hoarseness could indicate what pathology
Laryngitis
GERD
Lesion
170
Breathy voice could indicate what pathology
Vocal cord paralysis or mass
171
Harsh/rough voice could indicate what pathology
Laryngitis, Mass
172
Stridor could indicate what pathologies
Croup
Foreign body
Anaphylaxis
Laryngomalacia
173
Muffled voice could indicate what pathology
Retropharyngeal abscess
Epiglottitis
Ludwig’s angina
174
Hot potato voice indicate what pathology
Peritonsillar abscess
175
Gender and age patient that Epiglottitis typically effects
Males > females
Child 3-6 years old
Adults > 85 years old (increasing incidence)
176
Current most common pathogen responsible for Epiglottitis
Beta hemolytic group A strep
177
Fever and irritability, severe sore throat accompanied by drooling and dysphonia, cough or difficulty breathing indicative of
Epiglottitis
178
Epiglottitis usually fast or slow progression
Fast
179
DDx for dysphagia, dysphonia, and fever
Pharyngitis
Peritonsillar abscess
Ludwigs angina
Retropharyngeal abscess
Soft tissue neck infection
Croup
Tracheitis
Mono
180
Tripod position, toxic appearing, mouth open, neck extended, drooling, cervical adenopathy, retractions indicative of
Epiglottitis
181
Avoid _______ if airway compromised
Tongue depressor
182
First thing you’ll do for Epiglottitis
AIRWAY (intubation if compromised)
183
Workup for Epiglottitis
Soft tissue neck X-ray (“thumbprint sign”, “vallecula sign”)
Direct laryngoscopy in OR
184
Tx for Epiglottitis
Intubation
IV access
CBC, BMP, cultures
ABx: ceftriaxone (rocephin) 100 mg/kg/day IV x7 days
(Clindamycin or Vanco if PCN allergic)
Dexamethasone 4-10 mg/day (meds 0.6mg/kg)
IV floods, analgesics, antipyretics, extubate after 2-3 days
185
Etiologies of laryngitis
Viral
Bacterial (staph, strep, or candida/fungal)
Excessive voice use
Environmental allergies
Irritant inhalation
186
History for laryngitis
Recent URI or voice overuse
187
Reinkes edema
Fluid in the vocal cords secondary to smoking and overuse
188
Laryngitis caused by paralysis of the cords often involves what nerve and how can it be damaged?
Superior or recurrent laryngeal nerve
Cause: surgery, intubation, trauma, masses, stroke, MS, ALS
189
Tx for laryngitis
Strict voice rest, cool mist humidification, smoking cessation, hydration
NSAIDs
Antihistamines
190
Laryngotracheitis, AKA
Croup
191
Age and gender of patient usually affected by croup
Male 1.5 x more likely
6-36 months old
192
Causative agent for croup
Parainfluenza (common)
193
Barking cough, Stridor, agitation, rhinorrhea and fevers, nasal flaring, retractions, lack of rhonchi/wheezing indicative of
Croup
194
What is suggestive of more severe disease, inspiratory or expiratory Stridor?
Expiratory
195
Workup for croup
Mostly clinical
Soft tissue neck x-ray
Labs: RSV, flu and/or CBC if diagnosis is uncertain
196
Tx for croup
Dexamethasone 0.6 mg/kg PO or IM x 1 dose FRONTLINE
Racemic epinephrine nebulizer followed by 2 hrs observation
197
What can’t you diagnose infants with?
Sinusitis (sinuses filled with fluid until age 1)
198
Ostiomeatal complex
The drainage pathway for the paranasal sinuses
199
Name a few congenital nose abnormalities
Atresia
Deviation of the septum
200
Name a couple acquired nose abnormalities
Nasla polyps
Foreign bodies
Nasal septal disorders
Tumors
201
The presence of one or more of the following:
Rhinorrhea, sneezing, nasal congestion, nasal itching
Rhinitis
202
Disorder affecting both nasal passages and paranasal sinuses overlapping but distinct symptoms from rhinitis
Rhinosinusitis
203
Atopic triad
Atopic dermatitis, allergic rhinitis, asthma
204
Allergic rhinitis more common in what population
Children
205
Is there an increasing or decreasing sensitivity to allergen over time
Increased sensitivity (lower threshold)
206
Allergic shiners
Dark circles under eyes
207
Allergic salute
Transverse nasal crease
208
Lines or folds below lower eyelids, AKA
Concomitant allergic conjunctivitis
209
PE findings for allergic rhinitis
Nasal mucosa - pale, blueish hue
Edema of turbinates
Clear rhinorrhea
Cobblestoning of posterior pharynx
TM retraction or presence of serous fluid behind TM
210
When _______ coated cells encounter an allergy again, they become _______, leading to release of inflammatory mediators which leads to s/s of allergy
IgE
Activated
211
Mast cells are mostly in the
Tissue
212
Basophils are in the
Blood
213
When is allergy skin testing or in vitro testing for allergen specific IgE indicated?
If no improvement with treatment including removal of allergens
214
Frontline pharmacotherapy for mild or episodic allergic rhinitis
Oral antihistamine (certrizine, fexofenadine,loratadine)
215
Second line pharmacotherapy for mild or episodic allergic rhinitis
Nasal spray antihistamine (azelastine/astelin)
216
Third line pharmacotherapy for mild or episodic allergic rhinitis
INGC (fluticasone, mometasone, triamcinolone)
217
Frontline for mod severe or persistent allergic rhinitis
INGC
218
Other Tx for allergic rhinitis
Montelukast (Singulair) leukotriene inhibitor
Systemic glucocorticoids
219
Two types of non allergic rhinitis
Vasomotor rhinitis
Gustatory rhinitis
220
Intermittent nasal congestion and rhinorrhea with an exaggerated response to irritants (cold/dry air, pollution, etc)
Vasomotor rhinitis
221
Episodic, watery rhinorrhea triggered by hot/spicy food (vaguely mediated)
Gustatory rhinitis
222
Rhinitis medicamentosa
Rebound nasal congestion commonly associated with overuse of over-the-counter nasal decongestants (AFRIN)
223
Viral sinusitis, AKA
the common cold
224
What percentage of rhinosinusitis is bacterial?
2%
225
How long do viral symptoms usually last
7-10 days
226
How long do bacterial symptoms last
>10-14 days
227
Workup for infectious rhinosinusitis
Thorough history
PE (HEENT, cardiopulmonary)
228
Frontline Tx for infectious rhinosinusitis in immunocompetent patients
Observation and symptomatic care
-oral analgesics, INGC, intranasal saline, intranasal decongestant, oral antihistamines, oral expectorants
229
Frontline Tx for infectious rhinosinusitis in immunocompromised or symptoms worsening >7-10 days
ABx
230
Most common pathogens for infectious rhinosinusitis
Strep. pneumo
H. influenza
S. aureus (lower prevalence)
231
Frontline ABx choice for infectious rhinosinusitis
Augmentin
Doxycycline (if PCN allergic)
Fluoroquinolone (levofloxacin) as second line
NOT CIPRO
232
Higher resistance rates seen in what ABx
Macrolides and Bactrim
233
Complications of infectious rhinosinusitis
Orbital cellulitis (whole orbit)
Preseptal cellulitis (just eyelid)
Intracranial abscesses
Meningitis
234
How should orbital cellulitis be treated
IV ABx with admission
Ophthalmology referral
235
Inflammatory disorder of the paranasal sinuses and lining of the nasal passages lasting >12 weeks
Chronic rhinosinusitis
236
Clinical manifestations of chronic rhinosinusitis
Anterior and or posterior nasal mucopurulent drainage
Nasal obstruction/congestion
Facial pain, pressure, fullness
Reduction or loss of smell in children
237
Gold standard for diagnosing chronic rhinosinusitis
CT facial/sinus
238
Tx for chronic rhinosinusitis
Intranasal saline (not alone)
Intranasal steroids
239
Indications for sinus intervention
1. Failure of medical treatment
2. Restoration of patency
3. Debunking of severe polyposis
4. Bony erosion or invasion into sinus cavities
240
Important patient education tip for neti pot
Purchase or make saline solution, don’t just use any water
241
Nasal polyps associated with
Sinusitis
Allergies
Recurring infection
Drug sensitivity
Immune disorders
242
Symptoms of nasal polyps
Nasal airway obstruction or congestion
Thick nasal discharge
Anosmia
Recurrent/chronic sinusitis
243
Tx for nasal polyps
INGC (fluticasone, budesonide,mometasone)
244
90% of anterior epistaxis occur from what blood vessel
Kisselbach’s plexus (nasal septum)
245
Most posterior epistaxis occur from what blood vessel
Sphenopalatine artery
246
Initial evaluation in ED for epistaxis
Airway, breathing, circulation
247
What is really important to know/find out for your patient with epistaxis?
Predisposition for bleeding - anticoagulant use (Coumadin)
248
Pretreatment for epistaxis
1. Blow nose to remove all clots
2. Oxymetazoline (Vasoconstriction)
3. Tamponade at septum x10 minutes
249
Tx for epistaxis
1. Conservative (pretreatment)
2. Cautery
3. Chemical
4. Electrical
250
Nasal packing types to treat Anterior nosebleed
Nasal tampons
Gauze packing
Thrombogenic foams
Rapid rhino (ant and post)
251
Nasal packing types to treat POSTERIOR nosebleed
Epistat double ballon catheter
Foley Catheter
252
Who places a Foley catheter or epistat for control of posterior nosebleed
ENT
253
ABx tx for epistaxis
Prophylaxis (to prevent toxic shock syndrome)
Augmentin
254
Clinical manifestation of foreign body (nose)
History
Mucopurulent nasal discharge
Mouth breathing
255
X-ray of foreign body only if suspicious of
Button or magnet
256
Tx of foreign body (nose)
Postive pressure (parent to mouth, child blowing)
Instrumentation (Katz-extractor)
257
Most common age group for nasal trauma
16-20 yo
258
Complications of nasal trauma
Dislocation
Septal hematoma
Nasal fractures
259
Periorbital ecchymosis in the absence of other orbital findings indicative of
Nasal fracture
260
External nasal deformity, epistaxis, edema, ecchymosis suggestive of
Septal injury
261
How much saliva is produced on average per day
1-1.5 L/day
262
Role of saliva
Digestion, pH balance, and hygiene
263
98% of saliva is
Water
264
Other 2% of saliva is
Electrolytes (calcium, phosphorus)
Digestive enzymes (salivary amylase)
Antimicrobial factors (IgA, peroxidase) and mucin (glycoprotein)
265
Functions of saliva
Keeps mucous membranes moist
Lubrication of food (bolus)
Starts starch digestion
Natural mouth wash
Essential for taste sensation
266
What % of digestion of starch is done in the mouth
30%
267
Salivary stones
Sialolithiasis
268
Inflammation of the salivary glands
Sialadenitis
269
Dry mouth
Xerostomia
270
Xerostomia occurs when salivary flow is <_________%
50
271
Most common etiology of Xerostomia
Chronic use of anticholinergic medications
272
Other etiologies of Xerostomia
Radiation to oropharynx
Autoimmune disorders (Sjorgen’s syndrome)
Chronic disease (DM, eating disorders)
Social habits (tobacco/cannabis, chronic ETOH use)
273
Medication causing disease is known as
Iatrogenic
274
Name the anticholinergic agents that cause Xerostomia
Tricyclic antidepressants (amitriptyline)
SSRIs (Zoloft)
Diuretics (lasix)
Antihistamines (Benadryl)
Antihypertensive medications (calcium channel blockers)
Anticholinergic drugs for urinary incontinence (detrol)
Antispasmodics (lomotile)
275
Tx for xerostomia
Change or eliminate medication
Promote gum chewing
Encourage oral hydration
OTC saliva substitutes
Cholinergic agonist (pilocarpine hydrochloride)
276
Side effects of pilocarpine hydrochloride
Excessive sweating
277
“Cavities filled with mucus arising from the salivary glands/ducts due to damage to ducts and extravasation of mucin into surround tissue”
Mucocele/Ranula
278
What is more common, mucocele or ranula
Mucocele
279
Mucoceles occur in the _________
Minor salivary glands
280
Ranulas occur in the floor of the mouth arising from the _________
Sublingual gland
281
2 types of ranulas
Oral
Cervical AKA “plunging”
282
Chronic lip biting (lip trauma) most likely to cause
Mucocele
283
Improper drainage of sublingual glands or acquired after oral trauma
Ranula
284
Painless, mobile, dome shaped fluctuate lesion may appear as bluish-clear fluid filled cysts
Mucocele/Ranula
285
Where do mucocele commonly occur
Lower lip
286
Tx for mucoele/Ranula
Surgical removal
Self-resolving
287
80-90% of salivary stones occur in which gland
Submandibular gland (Wharton’s duct)
288
6-20% of salivary stones occur in which gland
Parotid gland
289
1-2% of salivary gland stones
Sublingual
290
Etiology of sialolithiasis
Idiopathic
291
Hallmark clinical presentation of sialolithiasis
Swelling, pain and erythema of the face/neck that is worse with meals
Pain and swelling may lesson a few hours after eating
292
Risk factors for sialolithiasis
Dehydration
Anticholinergic meds
Trauma to duct
Smoking
293
Purulent drainage should or should not be expressed in sialolithiasis
Not
294
Can reproduce symptoms of sialolithiasis with
Sialagogues
295
What is a great sialagogue?
Sour hard candy
296
Workup for sialolithiasis
Typically clinical
X-ray, U/C, CT
Sialography (not utilized in practice)
297
Frontline Tx for sialolithiasis
Conservative treatment
(Sialagogues, hydration)
298
Only time you prescribe ABx for sialolithiasis
If bacterial coinfection (sialadentis)
299
Complications of sialolithiasis
Acute bacterial sialadentis
300
Etiologies for acute sialadentis
Bacterial
Viral
Salivary stones
301
Sudden enlargement and pain of salivary glands
Acute sialadentis
302
Less painful gland enlargement/pain, present for weeks or months
Chronic sialadentis
303
Etiologies for chronic sialadentis
Tumor
Structure of duct
Immune mediated conditions (Sjorgen’s syndrome)
304
Sjorgen syndrome (SS)
Autoimmune process that results in dry eyes, dry mouth, and gradual salivary gland swelling
305
Acute bacterial sialadenitis, AKA
Acute purulent sialadenitis or suppurative sialadenitis
306
Acute bacterial sialadenitis most commonly occurs in which gland
Parotid
307
Who are most effected by acute bacterial sialadenitis
Older adults, elderly and medically compromised (chronic illness)
308
Most common pathogen for acute bacterial sialadenitis
Staph aureus
(Strep pneumonia and strep viridians, anaerobic oral bacteria)
309
Risk factors for acute bacterial sialadenitis
Increasing age
Chronic illness
Post-op/intubated
Trauma to duct
History of stones
Anticholinergic meds
Poor oral hygiene (periodontitis)
310
Acute bacterial sialadenitis
Sudden onset unilateral enlargement more commonly than bilateral movement
Fever and/or chills; may have adenopathy
Purulent drainage from duct may be expressed (bad taste in mouth)
311
Diagnosis of acute bacterial sialadenitis
Clinical
Culture purulent discharge
Labs (leukocytosis)
Imaging if you suspect abscess or obstruction
312
Tx for acute bacterial sialadenitis should include
IV ABx (cover S. aureus until cultures return)
-Ex. Nafcillin 1gm Q4-6 hr with clinical improvement transition to oral regimen based on cultures, 10-14 course
Supportive
-(hydration/good oral care)
-NSAIDS
-Sialagogues
-Chlorhexidine
313
If symptoms of acute bacterial sialadenitis don’t improve with treatment, pt will require
ENT referral
-Possible surgical intervention
314
Viral sialadenitis most commonly occurs in what gland
Parotid
315
Most common etiology of viral sialadenitis
Mumps virus (paramyxovirus)
316
Least common viral etiology of sialadenitis
EBV
Parainfluenza
Influenza A
317
Acute, self limited, systemic viral illness characterized by swelling of one or more salivary glands
MUMPS (viral sialadenitis)
318
Clinical presentation of mumps (viral sialadenitis)
Short prodrome (low grade temp, malaise, HA, anorexia, ear pain)
Salivary enlargement that is sudden and painful 48 hrs after prodrome
Parotid most common
No purulent drainage from duct
319
Mumps work up
Clinical
-serologies (IgG and IgM)
-RT-PCr buccal swab (detects viral RNA)
320
Tx for mumps
Symptomatic (Tylenol, warm compresses, fluids)
Prevention (MMR vaccine or MMRV)
321
80-85% of salivary gland tumors occur in what gland
Parotid
322
Most common histological type of benign salivary gland tumor
Pleomorphic adenoma
323
Two most common types of malignant salivary gland tumors
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
324
Mean age for malignant salivary tumors
50-60 years
325
Risk factors for salivary gland tumors
Radiation exposure
Occupational/environmental
326
Facial nerve involvement = higher correlation with
Malignancy
327
Benign tumors grow over _______ to _______
Months to years
328
Malignant tumors grow over _________
Weeks (rapid)
329
Red flags signs and symptoms for salivary tumors
Nerve involvement (facial palsy or decreased sensation)
Fixed adenopathy
Facial pain +/-
Weight loss (advanced)
330
What are you doing to confirm diagnosis of salivary gland neoplasm
Biopsy
(FNA or ultrasound guided core needle biopsy)
331
Low grade tx
Surgery alone
332
High grade Tx
Surgery followed by radiation
333
Unresectable or relapse treatment
Radiation alone or radiation + chemotherapy
334
What scan is used for cancer staging?
PET or CT
335
Role of the primary care clinician with oral health
Education
Screening/risk assessment
Promotion
Oral exam/fluoride varnish
Referral/collaboration
336
Oral health =
systemic health
337
The most chronic disease of childhood is
Dental caries
338
Dental caries are _____x more common than asthma
5
339
How many deaths per hour are a result of oral cancer?
1.1
340
Outer protective layer of the tooth (very hard)
Enamel
341
Middle layer, most abundant dental tissue
Dentin
342
Composed of nerves and blood vessels that exit the tooth via the apices
Pulp
343
_______ connects alveolar bone via the periodontal ligament
Root
344
Primary dentition = __________ teeth
20
345
How many incisors? (primary)
8
346
How many canines? (Primary)
4
347
How many molars? (primary)
8
348
Rarely need to be concerning about lack of tooth eruption unless evidence of
Underlying syndrome
Developmental issues
or no teeth have erupted by 18 months
349
How many adult teeth
32
350
How many incisors are there (adult)?
8
351
How many canines are there? (Adult)
4
352
How many premolars are there (adult)?
8
353
How many molars are there (adult)?
12
354
Yellowish tint of teeth represents what component of tooth
Dentin
355
Age related changes to teeth
Dark staining
Worn incised edges/yellowing
356
Three categories of oral disease risk factors
Individual (history, medications/xerostomia etc)
Behavioral (alcohol, tobacco, lack of dental care)
Environmental (non-fluoridated community water, poor access to care)
357
Name meds that can cause gingival hyperplasia
Anticonvulsants (est phenytoin)
Methotrexate
Cyclosporine
Calcium channel blockers
358
Name meds that can cause dental erosion
Progesterone
Nitrates
Beta blockers
Calcium channel blockers
359
Name med that can cause osteonecrosis
Biphosphonates
360
T/F: Xerostomia can induce caries
True
361
Most common cause of xerostomia
Polypharmacy (anticholinergic)
362
Effects of cannabis use
Dental caries
Increased oral infections
Xerostomia
Periodontal disease
Dysplastic changes/premalignant oral lesions
363
Tx for substance use disorders (oral health)
Oral surgery referral and behavioral health interventions
364
Untreated oral infection can spread and cause:
Intraoral abscess
Sinusitis
Facial cellulitis
Bacteremia and sepsis
Brain abscesses
Airway compromise
Aspiration PNA
365
untreated oral infection can spread, AKA
direct bacterial extension
366
_________ is a major mechanism for link between oral disease and several systemic diseases
Inflammation
367
Strong __________ link between periodontal disease and DM
Bi-directional (both ways)
368
What is the association between DM and periodontal disease thought to be due to?
Poor glycemic control
369
What is the association between CVD and periodontal disease thought to be due to?
Inflammatory cytokines implicated in atherogenesis
370
What is the association between rheumatoid arthritis and periodontitis thought to be due to?
Bacteria produces toxins/autoantibodies that trigger hypercitrullination in neutrophils
371
A periodontal infection could be a reservoir for ____________, which causes a host response and possible preterm labor
gram negative anaerobes
372
Why is oral health important for peri/post menopausal women?
Incidence of periodontitis increases after menopause
373
Strengthens enamel and can prevent progression of early caries and slow enamel destruction
Fluoride varnish
374
________ % caries reduction with fluoride varnish
30-35%
375
3 types of patients in need of care coordination with other providers
Medically complex patients
Require ABx prophylaxis
Taking anticoagulation
376
Most patients (do/do not) require ABx prophylaxis
Do Not
377
What patients require ABx prophylaxis?
Prosthetic heart valves
Prior hx of endocarditis
CHD/unrepaired defects
Post-transplant
378
ABx of choice and dose for dental procedure prophylaxis
Amoxicillin
Adults 2g; children 50 mg/kg orally 1 hr before procedure or up to 2 hours after
379
PCN allergic alternative for dental procedure prophylaxis
Cephalexin or cefadroxil
Azithromycin or clarithromycin
Doxycycline
380
What ABx do we not use for dental prophylaxis?
Clindamycin
381
Common bacteria causing dental caries
Mutans streptococci and lactobacilli
382
Risk factor for adult caries
Family history
High bacterial counts
Low socioeconomic status
Poor oral hygiene
383
Etiology for root caries
Gingival recession causes roots to become
384
S/s of gingivitis
Tenderness
Gum swelling
Halitosis
Erythema
Bleeding gums
385
Etiologies for gingivitis
Plaque buildup
Changes in hormones (pregnancy, puberty,diabetes)
Oral foreign bodies (popcorn kernels)
386
Etiologies for gingival hyperplasia
Poor oral hygiene
Drug induced
Systemic disease underlying(leukemia)
387
ANUG, aka
acute necrotizing ulcerative gingivitis
Vincent’s angina
“Trench mouth”
388
ANUG
Plaque-associated, non contagious infection of the gums causing painful, bleeding gums and ulcers
389
Acute onset halitosis, severe oral pain, blunting of interdental papilla, ulcerative necrotic slough of gingiva indicative of
ANUG
390
Tx for ANUG
ABX
-Metronidazole 500 mg PO TID
-Augmentin 875 mg PO BID or 500 mg PO TID
-Clindamycin 450 mg PO TID
Debridement
Antimicrobial rinses (Chlorohexidine BID x 2 weeks)
391
Leading cause of adult tooth loss
Periodontitis
392
Tx for periodontitis
Effective brushing and flossing
Lifestyle change
Dental referral for deep root scaling
393
_____% of adults >65 y/o are completely edentulous
25
394
>65 y/o have an average of _______ remaining teeth
18
395
Negative impacts of tooth loss
Difficulty eating
Inadequate nutritional intake
Dissatisfaction with facial appearance
396
Deep infection of the tooth support structures
Periodontal abscess
397
Tx for periodontal abscess
Analgesics
ABx if indicated
Dental referral
398
Osteonecrosis of the jaw caused by
Biphosphonate therapy
399
ABx that can be used to treat oral infections
Penicillin VK
Amoxicillin
Augmentin
400
PCN allergic ABx option for oral infections
Clindamycin
401
ABx choice for severe oral infections
Broad spectrum
Ampicillin-sulbactam
Cefotaxime
Ceftizoxime
Pip-tazo
Imipenem-cilastatin
402
Etiologies for dental erosion
Bulimia
GERD
Methamphetamine use
Acidic drinks
Medication effects
403
Aphthous stomatitis, aka
Canker sore
404
Discrete round to oval ulcers with an erythematous rim and yellowish exudate
Aphthous stomatitis
405
Most common locations of aphthous stomatitis
Buccal and labial mucosa, ventral tongue
406
Three clinical forms of aphthous stomatitis
Minor <7 mm (common)
Major >7 mm
Herpetiform 1-2 mm in clusters
407
Herpes labilais, aka
Cold sore
408
Etiology for herpes labialis
Reactivation of latent HSV-1
409
Consider ________ antiviral prescription for recurrent herpes labialis
Prophylactic
410
Cocksackie A virus part of what family
Enterovirus
411
Most common serotypes of Cocksackie A virus are
HFMD and Herpangina
412
Clinical syndrome characterized by oral enanthes and rash on hands and feet
HFMD
413
Clinical syndrome characterized by fever and painful papulovesiculo-ulcerative oral enathem
Herpangina
414
Tx for cocksackie A virus
Supportive
415
75% of HFMD have both
Enanthem and exanthem
416
Which presents with an abrupt, high fever: HFMD or Herpangina?
Herpangina
417
Rapidly growing tumor like mass in response to local irritation
Pyogenic granuloma
418
Erythematous, non painful, smooth or lobulated mass
Pyogenic granuloma
419
Geographic tongue: normal or abnormal
Normal variant
420
Migratory inflammatory filiform papillae atrophy
Geographic tongue
421
Elongation and hypertrophy of filiform papillae
Hairy tongue
422
Benign bony protuberances arising from cortical plate
Bony Tori
423
Surgical removal of bony Tori only indicated if
Affects oral function
Interferes with denture fabrication
Subject to recurrent trauma or ulceration
424
Most common form of oral candidiasis
Pseudomembranous
425
Pseudomembranous candidiasis, aka
thrush
426
Testing for thrush
Gram stain or KOH prep from scrapings
427
Subtypes of candidiasis
Angular cheilitis
Median rhomboid glossitis
Erythematous candidiasis
428
Candidiasis treatment
Nystatin swish swallow
Clotrimazole
Fluconazole (if topical agent fails or immunocompromised, other risks)
429
Tx for lichen planus
Asymptomatic = none
Topical corticosteroids
430
What locations in the mouth are the highest risk sites for malignancy
Tongue and mouth floor
431
Leukoplakia/erythroplakia are
Premalignant
432
All unexplained white lesions in mouth >________weeks should be referred for biopsy and evaluation
3
433
90% of oral cancers are
SCC
434
______% of oral cancers are advanced at the time of detection
60
435
Risk factors for oral cancer
Alcohol and tobacco
HPV
436
BRCA gene is a
“Tumor suppressor”; mutation here can cause increase risk of cancer
437
The three main drivers of cancer
Proto-oncogenes
Tumor suppressor genes
DNA repair genes
438
“Gas pedal of the car”
Control the regulation of cell growth
Proto-oncogenes
439
Regulate apoptosis/identify gene damage
Tumor suppressor genes
440
__________ are mutated proto-oncogenes
Oncogenes
441
Angiogenesis
Formation of new blood vessels that feeds the growing tumor
442
Head and neck cancer account for _______% of cancer cases in the US
3
443
Most head/neck cancers are this type
SCC
444
Main risk factors for head/neck cancers
Tobacco
ETOH
Viral (HPV/EBV)
Betel nut
Male gender
Occupational
High nitrate/salt diet
445
HPV related cancer increasingly recognized in head and neck cancers, particularly at ___________
Base of tongue and tonsils
446
What strain of HPV is most concerning for cancer
HPV-16
447
Carcinogenic HPV infections that persist beyond ________ months increase likelihood of precancerous or cancerous lesion
12
448
S/s of head/neck cancer
Oral nonhealing ulcer >3 weeks
Painless neck mass
Trismus
Changes in vocal quality
Numbness/CN deficits
449
Early stages of head/neck cancer patients are often________
Asymptomatic
450
Confirmatory testing for suspected malignancy
FNA (biopsy)
451
The “T” in TNM staging system refers to
Size and extent of the primary tumor
452
The “N” in the TNM staging system refers to
the number/location of lymph nodes that are found to be disease positive
453
The “M” in the TNM staging system refers to
Whether the cancer has metastasized to distant organs
454
TNM staging varies depending on
The primary tumor site
455
3 major factors to consider in the treatment approach to head and neck cancer
-Primary site of disease
-Stage of disease
-Patient comorbidities/goals wishes and performance status
456
The ECOG measures
Performance status
457
ECOG of 0 indicates
Fully active; no performance restrictions
458
ECOG of 1 indicates
Strenuous physical activity restricted; fully ambulatory and able to carry out light work
459
ECOG of 2 indicates
Capable of all self-care but unable to carry out any work activities.
Up and about >50% of waking hours
460
ECOG of 3 indicates
Capable of only limited self-care;
Confined to bed or chair >50% of waking hours
461
ECOG of 4 indicates
Completely disabled; cannot carry out any self-care; totally confined to bed or chair
462
Tx for stage 1 or 2
Single modality tx
(Surgery or radiation alone)
463
Tx stage 3-4
Multi-modality treatment
464
Common sites for Mets
Lung, liver, bone
465
Prognosis for head/neck cancer in the first 2 years
20-30%
466
Locally advanced head/neck cancer would be evident by which clinical sign
Local lymphadenopathy
467
Side effects of chemotherapy
Infections
Neuropathy
Electrolyte imbalance
N/V
Rash or allergic reaction
468
Side effects of radiation
Taste dysfunction
Infection
Xerostomia
Soft tissue necrosis
Osteonecrosis
469
Side effects of surgical interventions for head and neck cancer
Neuropathy
Disfigurement
Effects on speech
One way breaths (stoma)
Dysphagia
470
________% of cancer pt have pain during and post treatment which is not adequately controlled
40-85%
471
Most common locations for oral cancer
Lateral aspects of tongue
Floor of the mouth
472
Average age of oral cancer
63 year old
473
Males or females more prevalent oral cancer
Male (2:1)
474
90% of oral cancer are
SCC
475
Risk factors for oral cancer
Tobacco
ETOH
Betel nut
Sunlight exposure/artificial sunlight
476
Most common symptom of oral cancer
Non-healing ulcer/lesion >3 weeks (biopsy)
477
RULE acronym
Red
Ulcerated
Lump
Especially in combination
478
Erythroplakia/leukoplakia has a higher rate of malignant transformation
Erythroplakia
479
Dysarthria
Change in speech
480
Lymphadenopathy in which lymph nodes could show up oral cancer
Cervical chains
Submandibular
Submental
481
Prognosis of lip cancer:better or worse
Best
482
Most affected paranasal sinus
Maxillary
483
Age most affected by paranasal sinus/nasal cavity cancer
>55 yrs
484
Risk factors for paranasal sinus/nasal cavity cancer
Tobacco
Occupational exposure (woodworking, carpentry,metal plating)
485
S/s of paranasal sinus/nasal cavity cancer
Persistent blocked sinuses
Sinus headache
Epistaxis
Lump/mass
Nasal obstruction
Swelling around eyes/blurry vision
486
Prognosis for paranasal sinus/nasal cavity cancer
Poor cure rates <50% because delay in care
487
Nasopharyngeal cancer more common in what endemic areas
Asia and southern China
488
Risk factors for nasopharyngeal cancer
EBV
High salt diet
Asian ancestry
ETOH and tobacco lower prevalence
489
Most common #1 symptom of nasopharyngeal cancer
Neck mass
(Spreads to nodes early)
490
Other symptoms of nasopharyngeal cancer
Otalgia
Hearing loss
Recurrent serous otitis
491
With nasopharyngeal cancer, high viral loads of EBV correlates with
Poorer outcomes
492
Mainstay of treatment for nasopharyngeal cancer
Radiation
493
Age and gender most affected by oropharyngeal cancer
Males (3:1)
40-70 years of age
494
Risk factors for oropharyngeal cancer
HPV (particularly HPV-16)
Tobacco
ETOH
495
S/s of oropharynx carcinoma
Persistent sore throat
Lump in mouth or throat
Mass in neck
Dysphagia
Odynophagia
496
What improves prognosis by 30-50% in oropharyngeal cancer?
+ HPV status
497
Most common site of hypopharynx cancer
Pyriform sinus
498
Other sites of hypopharynx cancer
Post cricoid area
Inferoposterior pharyngeal wall
499
Age prevalence of carcinoma of hypopharynx
>50 yrs
500
What is concerning about carcinoma of the hypopharynx
Aggressive early local spread to lymph nodes
High risk of distant metastatic disease
501
50% initial symptom of carcinoma the hypopharynx
Enlarged lymph node or lump in neck
502
Other symptoms of carcinoma of the hypopharynx
Persistent sore throat
“Something caught in throat”
Dysphagia
Airway obstruction, difficulty breathing, noisy breathing
503
_____% of patients (hypopharyngeal carcinoma) have stage 3 diesease by the the time of diagnosis
50
504
Treatment goal for carcinoma of the hypopharynx
Organ preservation
505
Advanced stage 3-4 hypopharynx carcinoma tx
Resection + post radiation
Or
Concurrent chemo/radiation
506
Supraglottic, glottic, subglottic cancer:
Which is most favorable? Least favorable?
Glottic: most favorable
Subglottic: least favorable
507
Risk factors for carcinoma of larynx
Tobacco
ETOH
HPV
508
Most common symptom of carcinoma of larynx
Hoarse voice
(New, persistent >2 weeks)
509
4 goals of Tx of carcinoma of larynx
1. Cure
2. Preservation of swallowing
3. Preservation of useful voice
4. Avoidance of permanent tracheostoma
