csv-export (4)

Question 1

rhinosinusitis
diagnostic criteria
major symptoms (6)
minor symptoms (5)

Answer 1

inflammation/infection of nose and sinuses
2 major or 1 major and 2 minor criteria

major: facial pain/pressure, nasal obstruction/congestion, hyposmia (dec smell), nasal drainage, fever (acute), purulence on nasal exam
minor: headache, fatigue, dental pain, cough, ear pain/pressure

Question 2

acute sinusitis duration
subacute?
chronic?
recurrent acute?

Answer 2

acute: 4 weeks
subacute: 4 wks?12 wks
chronic: 12+ weeks
recurrent acute: 4+ episodes per year

Question 3

aute rhinosinusitis

Answer 3

ostium gets inflamed, impairs your drainage and ventilation, can lead to secondary bacterial infection
most common: viral (rhinovirus, coronavirus, influenza, respiratory syncytial virus, parainfluenza)

bacterial: secondary?? 7?10 days after
strep pneumo, haemophilis influenza, moraxella cararhalis

Question 4

how do you diagnose acute rhinosinusitis?

Answer 4

clinical dx and physical
NOT CT, x ray, MRI
(sinus culture can be appropriate)

Question 5

tx of acute rhinosinusitis

Answer 5

self limited? symptomatic management
if symptoms persist, treat with 10?14 days of antibiotics (amoxicillin?clauvunate, doxy or fluoroquinolone)
intranasal steroid can be used to reduce time/symptoms
saline irrigations, nasal decongestants

Question 6

complications of rhinosinusitis

Answer 6

cross orbit or anterior cranial fossa or by hematologic spread

orbital cellulitis or abscess, meningitis, subdural absecess, etc

Question 7

chronic rhinosinusitis

how is it classified?

Answer 7

12+ weeks
considered more of an inflammatory disorder than infectious
(can be assoc w/ cystic fibrosis, autoimmune disorders)
classified as with or without nasal polyposis

Question 8

what is gold standard for dx of chronic rhinosinusitis?

Answer 8

computed tomography
symptom?based dx can be unreliable
sinus all the time” headache and facial pressure, stopped up..”

Question 9

predisposing factors for chronic rhinosinusitis?

Answer 9

systemic (allergic rhinitis, immunodeficiency, genetic?? CF, ciliary dyskinesia)
local (anatomic obstruciton, GE reflux, mucociliary dysfunction)
microorganisms (viral infxn from daycare, fungi, resistant bacteria, bioflims)
pollutants (cigarrette)
meds (inappropriate use of decongestant)

Question 10

tx for chronic rhinosinusitis

Answer 10

allergen avoidance, saline, AB for 3?6 wks, surgery
to attenuate inflammation; steroids, immunotherapy, antiluekotrienes, macrolides

saline irrigation: inc. mucociliary flow rates, give vasoconstricitve effect (adding baking soda leads to thinning of mucus)

mucolytics (guaifenesin?? high doses show desired effect but also emesis and abd pain)

Question 11

are antihistamines effective in CRS?

Answer 11

ineffefective in relieving nasal congestion
first generation: have Ach effects?? drowsiness, drying of seretions
2nd gen: no anticholinergic effects?? higher affinity to histamine receptors (zyrtec, claritin, allegra)

Question 12

corticosteroids

contraindications?

Answer 12

stabalize mast cells, block formation of inflammatory mediators, inhibit chemotaxis of inflammatory cells
short courses: manage nasal mucosal congestion in allergic patients

contraindications: diabetes, PUD, glaucoma, severe HTN, advances osteoporosis

Question 13

topical corticosteroids

adverse effects

Answer 13

improve patency of ostiomeatal complex (reduces mucosal swelling)
inhibits immediate and late phase rxns to antigenic stimulation (after 7 days tx)
will improve 90% of allergic rhinitis!

adverse effects: nasal irritation, mucosal bleeding (give saline to lessen effects)

Question 14

antibiotics in CRS

Answer 14

based on culture results
s aureus, anaerobes, gram neg, psuedomonas aeruginosa?? different than acute!
first line: amoxicillin?clavulunate or cephalosporin
second line: qinolones (ciprofloxacin, levofloxacin)
broad spectrum antibiotic for up to 3 wks (symptoms improve within 3?5 days, resolution of symp within 7?10, +another week to diminish mucosal edema)

if there is rapid recurrence after prior tx, add 3?6 wk course of once daily phrophylactic ab

Question 15

malignant sinonasal/extradural tumors

Answer 15

esthesioneuroblastoma, squamous cell carcinoma, sinonasal undiff carcinoma, adenocarcinoma, sarcoma

Question 16

benign sinonasal/exradural tumors

Answer 16

juvenile nasopharyngeal angiofibroma
bone neoplasms
inverting papilloma
schwannoma

Question 17

symptom of sinonasal tumor

Answer 17

nosebleeds, sinonasal discharge, sinus pain, visual changes, excessive tearing, neck nodes (atypical symptoms)

Question 18

when do you do surgery for chronis rhinosinusitis?

Answer 18

after you have exhausted medical options

you want to restore sinus ventilation

Question 19

pharyngitis

Answer 19

inflammation of pharynx

sore throat””

Question 20

bacterial pharyngitis

Answer 20

5?10% adults, 30?40% children
symptoms: severe sore throat, odynophagia, cervical lymphadenopathy, fevers, chills, malaise, HA, neck stiffness, anorexia
physical exam: big, purulent tonsils

group A beta hemolytic strep pyogenes most common!

Question 21

tx of bacterial pharyngitis

Answer 21

patients are contagious
prompt AB tx: penicillin or amoxicillin for 10 days
macrolide or clindamycin if allergic to penicillin

Question 22

viral pharyngitis

Answer 22

most common cause of pharyngitis in adults
rhinovirus, coronavirus, parainfluenzae, influenza A, B, C
HIV, adenovirus, HSV

Question 23

what causes infectious mononucleosis?

Answer 23

epstein barr virus (double stranded DNA)
latent in B lymphocytes, intermittently replicating in oropharyngeal epithelial cells to enable transmission through saliva
incubates for 3?7 wks?? malaise, fevers, chills, then sore throat, fever, lymphadenopathy, anorexia
70?90% test positive on monospot test

complicatioN: secondary bacterial infxn, upper airway obstruction, meningitis, splenic rupture

Question 24

tx for mono

Answer 24

supportive care, rest, antiypretics, analgesics, avoid contact sports
antivirals are NOT helpful, abs only helpful for secondary bact. ifxn
no ampicillin/amoxicillin?? maculopapular rash
steroids for impending upper airway obstruction, severe hemolytic anemia, severe thrombocytopenia, persistant severe disease

Question 25

peritonsillar abscess

Answer 25

associated with trismus (lock jaw), hot potato voice (muffled), drooling tx: I&D, IV ab

Question 26

retropharyngeal abscess symptoms? cause?

Answer 26

goes from base of skull to mediastinum?? behind buccopharyngeal fascia, in front of prevertebral fascia symptoms: sore throat, fever, neck stiffness, odynophagia (pain w/ swallowing), SOB polymicrobial aerobic: beta hemolytic stretococci and staph aureus anaerobic: bacteroides, veillonella gram neg: haemophilus parainfluenza, bartonella henselae complications: airway obstruction, jugular venous thrombosis, necrotizing fascitis, sepsis

Question 27

ludwigs angina symptoms? cause? tx?

Answer 27

inflammation and cellulitis of submandibular space spreading from sublingual space to fascial planes airway obstruction can occur if floor of mouth becomes indurated and tongue is forced upward and backward source: dental origin symptoms: drooling, trismus (lockjaw), pain, dysphagia, submandibular mass, dyspnea life threatening condition: airway control by tracheotomy?? IV ab, I&D mixed flora, aerobes, anaerobes (strep, staph, bacteroides)

Question 28

pt comes in with severe sore throat, odynophagia, cervical lymphaedenopathy, fevers. what do they have?

Answer 28

bacterial pharyngitis

Question 29

pt comes in with sore throat, odynophagia, cervical lymphadenopathy, trismus, drooling, hot potato voice, fevers. what do they have?

Answer 29

peritonsillar abscess

Question 30

pt comes in with drooling, trismus, pain, dysphagia, submandibular mass, dyspnea. what do they have?

Answer 30

ludwigs angina

Question 31

pt comes in with sore throat, fever, neck stiffness, odynophagia, SOB. what do they have?

Answer 31

retroperitoneal abscess

Question 32

contributors to vocal production

Answer 32

generator: lungs oscillator: larynx: tone and pitch restonator: pharynx/sinuses? ?shape, resonate, articulate sound into individual voice

Question 33

what should you do if you have 2 weeks of hoarsness? what other symptoms accompany?

Answer 33

refer to otolaryngologist accompanied by otalgia (ear pain), dysphagia, difficulty breathing dysphonia >2 weeks suggests possibility of other diagnosis besides acute viral laryngitis

Question 34

cause of hoarsness

Answer 34

neuro injury: recurrent laryngeal nerve injury iatrogenic injury, neoplasm, viral, idiopathic alterations of vocal cord lining?? non lesion (gerd, sinus disease/allergic rhinitis, dehydration) lesion

Question 35

where are lesions that cause hoarseness?

Answer 35

in the superficial layers of the vocal fold (superficial lamina propria and epithelial cover) nodules, polyps, cysts, hemorrhage, carcinoma

Question 36

cause of most benign vocal fold lesions?

Answer 36

phonotrauma

Question 37

recurrent respiratory papillomatosis

Answer 37

exophytic ariway lesions that may involve entire aerodigestive tract most common benign neoplasm of larynx in children HPV 6 and 11?? benign childhood disease: linked to mom's genital HPV adult onset?? oral?genital contact gardasil: 6, 11, 16, 18

Question 38

what is most common cause of unilateral vocal cord paralysis?

Answer 38

iatrogenic | then neosplasm then idiopathic

Question 39

what is most common cause of vocal cord lesions?

Answer 39

phonotrauma

Question 40

laryngeal carcinoma what type is it? cause? cure rates?

Answer 40

>90% is squamous cell carcinoma smoking is largest risk factor, EtOH has synergistic effect good cure rate for early stage disease (inactivated p16/Rb), p53 mutation, EFGR overexpression, infection with HPV (inactivates p53 and Rb) 4:1 male predilection, common among socioeconomic class

Question 41

if you are a younger patient with head and neck cancer, what is suspected agent?

Answer 41

HPV (inactivates p53 and Rb)

Question 42

molecular progression to cancer

Answer 42

normal mucosa ??> hyperplasia ?> dysplasia ?> carcinoma in situ ?> carcinoma

Question 43

work up for cancer

Answer 43

CT neck or MRI chest xray or chest CT PET/CT used more often now direct laryngoscopy, bronchoscopy, esophagoscopy

Question 44

how do you treat early stage cancer (I or II)?

Answer 44

single modality therapy | surgery or radiation?? 85?95% local control rate

Question 45

tx advanced stage cancer (II or IV)

Answer 45

combined modality therapy (primary surgery followed by raidiation) concurrent chemo if it recurs, do CRT or RT with surgery

Question 46

complications of radiation

Answer 46

high energy rays, 6?7 wks dialy skin changes, mucositis, odynophagia, laryngeal edema, xerostomia, stricture and fibrosis, radionecrosis, hypothryoidism

Question 47

chemo

Answer 47

cisplatin chemo thought to sensitize cells to radiation n/v, loss of appetite, fatigue, neuropathy, susceptible to infxn

Question 48

total layrngectomy

Answer 48

take out entire voice box

Question 49

different voice rehabs

Answer 49

electrolarynx (voice box?? external device) pure esophageal speech (force bolus thorugh cricopharyngeus, air bolus regurgitated and vibrates to produce sound) tracheoesophageal speech?? diversion of exhaled air into pharynx by way of surgically constructed tracheoesophageal fistula?? segment above fistula vibrates, producing neovoice

Question 50

what is a neck mass in an adult? | what should you suspect in a smoker with prolonged hoarseness?

Answer 50

cancer

Question 51

epiglottitis

Answer 51

tripod stance, stridor (high pitch sound on expiration and inspiration) thumb sign on X ray more common in children bacteria: haemophilus influenza type B, steptococcus species tx: secure airway, flexible fiberoptic nasotracheal intubation, tracheotomy, cricothryotomy AIRWAY EMERGENCY! anesthesia and ENT should be notified immediately?? dont waste time imaging, mainipulating pt avoid agitating patient

Question 52

stridor | what does stridor indicate?

Answer 52

high pitch breathing from turbulent airflow through larynx or trachea caused by narrowing or osbruction can be inspiratory, expiratory, biphasic stridor indicates upper airway obstruction

Question 53

croup cause? symptoms? tx?

Answer 53

common primarily pediatric viral respiratory illness 15% childrne 6 mo? 6 yrs barking cough, stridor, hoarseness, difficulty breathing usually viral?parainfluenza, influenza, measles, adenovirus, RSV swelling from inflammation leads to airway narrowing mostly managed as outpatient, recover with no issues steroids, nebulized racemic epinephrine, cool mist (soothes inflamed mucosa)

Question 54

other causes of stridor in kids

Answer 54

``` most common: laryngomalacia vocal cord paralysis laryngeal web layrngeal atresia subglottic stenosis subglottic hemangioma recurrent respiratory papillomatosis ```

Question 55

laryngomalacia | tx?

Answer 55

congenital abnorm of laryngeal cartilage, usually leads to collapse and inspiratory stridor

Question 56

laryngeal atresia

Answer 56

incomplete or complete (may be stillbirth) from failed recanalization of layrnx and trachea can be diagnosed prenatally in ultrasound requires immediate tracheostomy

Question 57

management of bilateral vocal cord paralysis

Answer 57

static conservative: botox, lateralization static destructive: cordotomy, partial vs total artenoidectomy dynamic: arytenoid abduction, reinnervation, laryngeal pacing

Question 58

subglottic stenosis

Answer 58

congenital or acquired iatrogenic injuries is most common often it has an insidious onset and early manifestations are mistaken for asthma, bronchitis

Question 59

which disorders can be misdiagnosed as asthma or bronchitis?

Answer 59

bilateral vocal cord paralysis, glottic, and subglottic stenosis ?? progressive, have protracted couse

Question 60

muscles of mastication which ones open jaw? which ones close jaw? which nerve are they innervated by?

Answer 60

masseter, temporalis, medial pterygoid close jaw lateral pterygoid abducts jaw all innervated by CN V, mandibular branch V3

Question 61

oral cavity cancer

Answer 61

largely preventable and easy to detect early >90% squamous cell carcinoma common in devleoping world?? sri lanka, pakistan, india, bangladesh it common cancer tobacco, alcohol, betel, dna repair gene defects, immune defects are risk factors

Question 62

how do you treat oral cavity cancer?

Answer 62

multimodality therapy indicated primarily for advanced stage tumors clear advaced XRT locoregional control if: positive margins, perineural or lymphovascular invasion, >1 positive lymph node, nodes with extracapsular extension use chemo for radiosensitivity usually surgery _ adjuvant therapy

Question 63

oropharyngeal cancer? what causes it? what do you do upon dx? how is it managed?

Answer 63

older patients: tobacco and alcohol younger patients: HPV biopsy and stage CT, CXR radiation +/? chemo, surgery

Question 64

seqeulae of chemo

Answer 64

mucositis, stomatitis, dysphagia, permanent salivary gland dysfunction, smell and taste alteration, oral microbial infxn (reactivation of HSV, VZV, C albicans)

Question 65

sjoren syndrome

Answer 65

systemic autoimmune disorder associated with inflammation of epithelial tissues most common medical disorder associated with xerostomia and salivary dysfunction primary: salivary and lacrimal gland disorder secondary: autoimmune diseases such as RA, SLE, scleroderma

Question 66

what is sjogrens syndrome associated with? hallmark of SS? symptoms?

Answer 66

increased incidence of non?hodgkins lymphoma hallmark of SS: predominantly T cell infiltrates in exocrine tissues autoantibodies anti?Ro and anti?La and rheumatoid factor symptoms: cracked lips, dessicated oral tissues, fungal infxn, difficulty speaking without fluids, xerostomia and keratoconjuctivitis sicca

Question 67

dx test for sjogrens syndrome

Answer 67

schirmers test: measures production of tears lip/salivary gland biopsy lab eval tx is not curative

Question 68

what is oral hairy luekoplakia associated wtih?

Answer 68

immunosuppression (HIV) along lateral tongue margins bilaterally, corrugated, shaggy surfaces white patch or plaque?? can be dysplasia, carcinoma in situ, or invasive carcinoma requires biopsy

Question 69

between leukoplakia and erythroplakia, which has higher malignant potential?

Answer 69

erythroplakia

Question 70

what are factors for oral candidiasis?

Answer 70

common opportunistic infection | factors include smoking, foreign bodies, diabetes, immunosuppression

Question 71

linchen planus

Answer 71

common T cell mediated disease that is treated with topical steroids

Question 72

xtraesophageal reflux

Answer 72

lack of classic heartburn and regurgitation symptoms hoarseness, throat clearing, cough, dysphagia, increased phlegm, globus sensation can lead to pharyngeal and laryngeal edema, ulceration, granulomas, leukoplakia

Question 73

zenkers diverticulum what is killians triangle? symptoms of zenkers?

Answer 73

caused by incomplete relaxation of the UES killians triangle?? weakness between inferior constrictor and cricopharyngeus dysphagia, regurgitation of undigested food, bad breath, cough, aspiration pneumonia

Question 74

what are 3 areas of narrowing in esophagus where foreign bodies can be stuck? which ingestion is an emergency?

Answer 74

UES, aorta, LES | disc battery ingestion is an emergency?? esophageal perforation can occur in 6 hours

Question 75

management of foreign body ingestion

Answer 75

urgent removal?? drooling, unable to handle secretions, sharp objects emergent removal?? batteries (But if in stomach, safe)?? if not it can cause necrosis 80% of coins at LES will pass in 24?48 hrs

Question 76

what does acidic ingestion do?

Answer 76

coagulation necrosis?? forms an eschar/coagulum stomach affected (toilet bowl cleaners, battery fluid, rust removal products)

Question 77

what do alkaline substances do (drain cleaners, oven cleaners, dishwasher detergent, hair relaxers )?

Answer 77

liquefactive necrosis severe injury in minutes, granulation at 2 weeks, stricture tissue edema to oral cavity, oropharynx, hypopharynx

Question 78

what are worrisome symptoms after ingestion?

Answer 78

dyspnea, dysphagia, odynphagia, chest pain, N/V, pain hoarseness, stridor/resp distress, tachy, oropharyngeal burns, drooling, subcutaneous air, peritonitis, fever, chest pain/abd pain

Question 79

how do you manage pts after ingestion?

Answer 79

``` identify product do not induce emesis or neutralize secure airway chest and abd films?? look for free air endoscopy in 12?48 hr in symptomatic pt place NGT to serve as stent for 6 weeks steroids/ab? ```

Question 80

how much saliva is produced a day? from which glands (and which proportions?)

Answer 80

1.5 L submandibular glands?? 70% (basal flow) parotid glands?? 25% (stimulated flow) sublingual and minor salivary glands?? 5%

Question 81

parotid glands where odes the parotic (stensens) duct go? which nerve splits the parotid gland into deep and superficial lobes?

Answer 81

transverses the masseter and buccinator muscles, enters oral mucosa at level of 2nd maxillary molar facial nerve

Question 82

what duct is associated with submandibular glands? | where does it terminate?

Answer 82

submandibular duct (whartons duct) emerges from deep lobe, terminates as an elevated papilla just lateral to the frenulum of the tongue

Question 83

sublingual glands?? covered only by __

Answer 83

oral mucosa?? lies along distal half of the submandibular duct superficially drained series of ductules?? open either into the SM duct or directly into the floor of the mouth

Question 84

what is the parotid gland innervated by?

Answer 84

preganglionic PS fibers originate in inferior salivatory nucleus, travel via CN 9 and jacobsens nerve in teh middle ear, exti middle eary via lesser superfiical petrosal nerve (otic ganlion) postganglionic fibers travel via the auriculotemporal nerve (branch of V3)

Question 85

submandibular & sublingual gland innervations

Answer 85

preganglionic PS fibers originate in superior salivatory nucleus travel via CN VII and the chorda tympani through the middle ear exit via the petrotympanic fissure and travel with the lingual nerve to the submandibular ganglion postganglionic fibers travel onto SM and SL glands

Question 86

what predominates in the parotid gland? the submandibular gland?

Answer 86

parotid: serous acini predominate SB: serous and mucinous acini abundant contractile myoepithelial cells surround acini, help to drain saliva

Question 87

how is salivary flow broken down between glands?

Answer 87

parotid gland: 25% of daily salivary flow, serous SM: 70%, serous and mucinous sublingual: 5%, mucinous during stimulated flow, contribution of parotid and submandibular glands are reversed controlled by ANS (parasymp)

Question 88

what are salivary functions?

Answer 88

lubricate food, facilitate swallowing, protect teeth, deliver secretory IgA, lysozyme, peroxidase to the oral cavityho

Question 89

what is sialolithiasis? | how do patients with sialolothiasis present?

Answer 89

formation of calculi in ductal system of salivary glands most common form of inflammation 80?90 in submand gland postprandial pain, recurrent swelling in submandibular gland not related to serum Ca or Ph

Question 90

what is sialorrhea? what is it from? | how is chronic sialorrhea treated?

Answer 90

increase in salivary flow (drooling?? results from disturbance in oral phase of swallowing, assoc with poor synchronization of lip closure) can be related to cerebral palsy conservatively with meds and/or botox (can also be surgically treated after 6 mo of conservative managment and after 6 yo)

Question 91

what is most common benign salivary gland tumor?

Answer 91

pleomorphic adenoma architectural pleomorphism slow growing, painless, firm, single, mobile FNA: sensitivity of 90% treatment: resection?? parotidectomy?? its recurrent, so may need to take out whole thing including CN7!

Question 92

what is most common malignant salivary gland tumor?

Answer 92

mucoepdermoid carcinoma

Question 93

wharthin tumor (papillary cystadenoma lymphomatosum)

Answer 93

benign tumor associated with smoking | cystic spaces w/ germinal centers

Question 94

adenoid cystic carcinoma

Answer 94

most common malignancy of submandibular gland | slow growing, distant mets