Daily Questions Flashcards
After taking a split thickness skin graft from the
postauricular skin you ask for Monsel’s solution to
obtain hemostasis. Unfortunately, they do not have
it available in the operating room and the nurse
asks what the solution is made of so he can look
for it in the storage center. What is Monsel’s made
of?
A) Resorcinol, salicylic acid, lactic acid, and ethanol
B) Glycolic Acid 10% C) Glycolic Acid 70% D)
Trichloroacetic 50% E) Ferric Subsulfate
c
E: Monsel’s solution is a hemostatic agent made of ferric subsulfate that works well on split thickness skin graft donor sites although it can cause discoloration of the skin if left on to long. Resorcinol, salicylic acid, lactic acid and ethanol make up Jessner’s solution which is used for light and medium chemical peels. Glycolic acid can be used for light and medium chemical peels at 10% and 70% respectively. Trichloroacetic (TCA) is similarly used for chemical peels. - See Wikipedia “Ferric subsulfate solution”
A 14 year old male is brought to the clinic for
evaluation of hearing loss. He has bilateral
symmetrical sensorineural hearing loss which has
been stable on audiogram for several years. He
denies vestibular symptoms. He endorses
worsening vision which has progressed over the
last 2 years as well. His exam and a CT temporal
bone are unremarkable. A mutation in which of the
following genes is responsible for this patients
condition?
A) EYA1 B) TCOF1 C) USH2A D) SCL26A E)
GJB2
C; This patient’s presentation is consistent with Usher’s syndrome. These patients typically have moderate to profound hearing loss, may or may not have vestibular symptoms and develop vision loss in the 1st or 2nd decade of life. While Usher’s syndrome can be caused by a multitude of genetic mutations, the most common one is USH2A. Mutations in EYA1 causes branchio-oto-renal syndrome. TCOF1 is associated with treacher collins syndrome. SCL26A mutations lead to pendred/enlarged vestibular aqueduct. GJB2 mutations causes deficiencies in connexin 22 proteins and
sensorineural hearing loss. - See Wikipedia “Usher Syndrome”
Which of the following is true regarding the
submandibular gland?
A) Produces 70% of unstimulated saliva B)
Produces thinner saliva relative to the parotid gland
C) Receives parasympathetic innervation via the
glossopharyngeal nerve D) Produces 50% of all
salivary gland calculi E) Are the first salivary glands
to be formed during embryogenesis
A; The submandibular gland produces the majority of saliva in the unstimulated state. Upon eating, saliva production from the parotid gland increases significantly bringing the submandibular glands total share of production down to ~ 50%. The submandibular gland
produces thicker, more viscous saliva compared with the parotid gland, receives parasympathetic innervation from the facial (via the chorda tympani), produces 80% of all salivary calculi and is formed later than the parotid gland during embryogenesis. - See Wikipedia
“Submandibular Gland”
How many openings are there from the
semicircular canals into the vestibule?
A) 2 B) 3 C) 4 D) 5 E) 6
D; There are three semicircular canals and each has both an ampulated and nonampulated end. However, the posterior and superior canals share a common crus which opens into the vestibule. Therefore the 5 openings into the vestibule are the ampulated ends
of all 3 canals, the nonampulated end of the lateral canal and the common crus of the posterior and superior canal, for a total of 5 openings into the vestibule. - See Wikipedia “Semicircular Canals”
Which of the following is true regarding pediatric
subglottic stenosis?
A) The subglottis in the pediatric population is
prone to injury as it is the narrowest portion of the
airway, the subglottic mucosa is dense preventing
significant edema to develop and the stratified
squamous epithelium is particularly delicate B)
Coexistence of gastric reflux disease and need for
repeated intubations are the most important factors
in the development of acquired subglottic stenosis
C) Premature infants develop subglottic stenosis
much faster (within days) compared with older
children or adults D) The endotracheal tube should
be small enough to allow a cuff leak at 20 cm water
pressure E) 65% of acquired pediatric subglottic
stenosis is secondary to intubation
D; In order to prevent subglottic stenosis in the pediatric population management of the pressure exerted on the tracheal wall is critical. Excessive cuff pressure or a endotracheal tube that is too large will exert significant pressure on the airway walls damaging the delicate pseudostratified columnar mucosa and leading to significant airway edema. This can lead to scarring and ultimately stenosis. To help prevent this, the pressure should be light enough to allow for a cuff leak at 20 cm water. The subglottis is the narrowest portion of the airway in children but the mucosa is loose and allows significant edema and the mucosa is pseudostratified columnar, not stratified squamous cells. While reflux and repeated intubations are risk factors, duration of intubation and size of the endotracheal tube are the most important factors that affect the development of subglottic stenosis. Premature infants can tolerate several weeks of intubation without developing stenosis. 90% of acquired pediatric subglottic stenosis is due to intubation, not 65%.
- See Cummings 6th ed pg 3160
What percentage drop in systolic blood pressure
(BP) is expected upon induction of anesthesia
using propofol?
A) No drop in BP B) 5-20% drop in BP C) 20-30%
drop in BP D) 40-50% drop in BP E) More than
50% drop in BP in most patients.
C; Propofol causes a drop in arterial blood pressure of ~ 20-30%. Additional side effects include local pain on injection, apnea, airway obstruction and oxygen desaturation. Advantage includes rapid hypnosis which can be achieved in ~ 40 seconds. -See KJ Lee 10th
ed pg 839.
What is the function of the internal branch of the
superior laryngeal nerve?
A) Sensory innervation to the mucosa inferior to the
true vocal cords B) Sensory innervation to mucosa
superior to the true vocal cords C) Motor
innervation to the cricothyroid muscle D) Motor
innervation to the posterior cricoarytenoid muscle
E) Motor innervation to the thyroarytenoid muscle
B; The internal branch of the superior laryngeal nerve provides sensation to the distal pharynx superior to the true vocal cords. Damage to this nerve can increase risk of aspiration. The external branch of the superior laryngeal nerve provides motor sensation to the cricothyroid. The recurrent laryngeal nerve provides sensation below the true vocal cords and innervates the cricoarytenoid and thyroarytenoid muscles. -See KJ Lee 10th ed pg 577.
What is the mode of inheritance for Fanconi
Anemia Syndrome?
A) Autosomal Dominant B) Autosomal Recessive
C) X-linked Dominant D) X-linked Recessive E)
Mitochondrial Inheritance
B; Fanconi Anemia Syndrome is characterized by absent/deformed thumbs accompanied by other malformations involving the heart and kidneys, increased skin pigmentation, mental retardation,
pancytopenia and conductive hearing loss. Death due to leukemia usually occurs within the first 2 years of life. -See KJ Lee 10th ed pg
135.
What is the full range of human hearing?
A) 20-12,000 Hz B) 20-20,000 Hz C) 100-12,000
Hz D) 100 - 20,000 Hz E) 5 - 18,000 Hz
B; Although most audiograms only test hearing between 250-8,000 Hz, the full range of human hearing is 20-20,000 Hz. Speech sounds are mostly contained within 250 - 6,000 Hz. -See KJ Lee 10th ed pg
24.
80% of accidental tracheostomy decannulation
occur in patients with what risk factor?
A) Decreased nurse:patient ratio B) BMI 30+ C)
Altered Mental Status D) Increased secretions
B; Obesity is a major risk factor for complications related to tracheostomy. It is often considered a contraindication to percutaneous tracheostomy. 15% of obese patients will experience complications related to tracheostomy compared to 8% of nonobese
patients. -See Cummings 6th ed pg 99.
Korner’s septum is a remnant of what structure?
A) Tympanomastoid suture B) Tympanosquamous
suture C) Tympanoparietal suture D) Petromastoid
suture E) Petrosquamous suture
E; Korner’s septum (which must be opened to expose the mastoid antrum) is a remnant of the petrosquamous suture. -See Cummings 6th ed pg 2191
Which facial muscle is responsible for “bunny
lines”?
A) Frontalis B) Depressor Supercilli C) Corrugator
D) Procerus E) Nasalis
E; Frontalis can create horizontal forehead wrinkles whereas the corrugators (and to some degree depressor supercilii) create vertical wrinkles in the glabella. Both procerus and nasalis contribute to
“bunny lines” however nasalis is the dominant contributor and should be targeted with botulinum toxin to address this cosmetic issue. - Becker-Wegerich, P., Rauch, L. and Ruzicka, T. (2001), Botulinum toxin A in the therapy of mimic facial lines. Clinical and Experimental
Dermatology, 26: 619–630.
This structure forms a fibrous sling stretching below
the eyeball and blends with the cheek ligaments as
well as the medial/lateral horns of the levator
palpebrae superioris aponeurosis. Name that
structure.
A) Lockwood Ligament B) Whitnall Ligament C)
Tarsal Plate D) Medial Canthal Tendon E) Lateral
Canthal Tendon
A; The ligament of Lockwood is a suspensory ligament that is located underneath the eyeball and acts as a sling. It attaches to the cheek ligaments as well as the medial and lateral horns of the aponeurosis of the levator muscle. Whitnall ligament suspends the levator palpebrae superioris muscle and extends from its attachment to the trochlea over to the lateral orbital tubercle (Whitnall tubercle). The tarsal plates are plates of dense connective tissue that provide structure to the eyelids. The medial and lateral canthal tendons attach the tarsus to the bony structures of the orbit. -See KJ Lee 10th ed pg 896.
An 8 y/o male presents with left orbital pain,
swelling and double vision. The patient’s mother
states he had a cold for the past two weeks and
“gross stuff” coming out of his nose. A CT scan is
ordered and a small fluid collection underneath the
periosteum is found along the medial floor of the
left orbit. Despite the patient’s diplopia his vision is
intact and he has no other significant findings on
neurologic exam. What is the most appropriate
Chandler’s classification for this patient?
A) Group I B) Group II C) Group III D) Group IV E)
Group V
C; The patient’s CT scan indicates a subperiosteal abscess which is categorized as Group III. Group I = Periorbital edema (can treat w/ oral antibiotics and close observation) Group II = Periorbital cellulitis Group III = Subperiosteal abscess Group IV = Orbital abscess Group
V = Cavernous sinus thrombosis. -See KJ Lee 10th ed pg 987.
A 58 y/o female patient presents to your clinic for
evaluation of the aging face. You offer her an
endoscopic brow lift to treat her brow ptosis and
dynamic rhytids of the forehead. What is the best
landmark used intraoperatively to alert the surgeon
that they are close to the temporal branch of the
facial nerve?
A) Deep layer of the deep temporal fascia B)
Superficial layer of the deep temporal fascia C)
Zygomaticotemporal vein D) Superficial temporal
artery E) Supraorbital neurovascular bundle
C; The zygomaticotemporal vein (aka sentinel vein) has been shown to be a consistent landmark used to locate the temporal branch of the facial nerve in the endoscopic brow lift procedure. This structure
should be considered a marker that the surgeon is entering nerve territory and caution should be taken. When performing a Gillies procedure the plane used is deep to the superficial layer of the deep temporal fascia in order to protect the facial nerve (which is above
this) but an endoscopic brow lift dissection is performed directly on the skull so these structure do not come into play. The supraorbital neurovascular bundle is not a reliable landmark to use in order to locate the facial nerve.-Trinei, Filippo A., Janek Januszkiewicz, and
Foad Nahai. “The Sentinel Vein: An Important Reference Point for Surgery in the Temporal Region.” Plastic and Reconstructive Surgery
101.1 (1998): 27-32.
A 47 y/o F presents to your clinic with nasal
congestion, sinus pressure and thick nasal
discharge. She has not responded to medical
management so a CT scan is ordered which shows
complete opacification of a single sinus. On your
review of the scan there is a single, well
circumscribed radiodense mass similar to the
surrounding bone which appears to be obstructing
the affected sinus. Given the nature of these
masses, what is the most likely sinus affected in
this patient?
A) Ethmoid B) Frontal C) Maxillary D) Sphenoid E)
Unable to determine from the information provided
B; The description of the mass is consistent with an osteoma. These are benign lesions, however they can cause obstruction of sinus outflow tracts. They are most commonly found in the frontal sinus. The ethmoids are the second most common location followed by the
maxillary sinuses. -See KJ Lee 10th ed pg 672
Elective neck dissection is indicated for patients
with clinically and radiographically N0 necks if their
risk of micrometastases is - - - ?
A) 5% B) 10% C) 15% D) 20% E) All patients
should undergo elective neck dissection
D; It is generally accepted that if a patient’s risk of occult metastasis is 20% or greater, elective neck dissection should be performed. The rate of occult mets is estimated based on the patient’s primary site
and tumor staging. -See KJ Lee 10th ed pg 699
Which of the following is not a cause of
angioedema?
A) Food Allergy B) Lisinopril C) C1 Esterase
Deficiency D) Idiopathic E) All of the above are
causes of angioedema
E; Angioedema can be caused by hypersensitivity reactions, ACE inhibitors (of which lisinopril is one), and genetic causes such as C1 esterase deficiency. Most cases of angioedema however are idiopathic. Angioedema should be managed w/ epinephrine,
benadryl, steroids and above all protection of the airway. Intubation or tracheostomy may be required. -See KJ Lee 10th ed pg 518
Your junior resident cuts his hand while practicing
emergency tracheotomies on a plastic model. One
week later you see him in the halls and he tells you
that his cut has fully healed. Trying to turn this into
a teaching moment you ask him what the tensile
strength of his wound is compared to his preinjury
state. He answers correctly by saying - - - ?
A) 1% B) 10% C)30% D) 50%
B; The wound tensile strength at 1 week after injury is ~ 10%. This occurs during the proliferative phase (24hrs - 6 wks). By 10 weeks the tensile strength is up to 80%. -See KJ Lee 10th ed pg 765-766
—- cancer is more likely to present at an early
stage, whereas — cancer tends to present at more
advanced stages. —- cancer is quite rare.
A) Supraglottic - Subglottic - Glottic B) Supraglottic
- Glottic - Subglottic C) Glottic - Subglottic -
Supraglottic D) Glottic - Supraglottic - Subglottic
D; Because even small masses can cause changes in the vibratory pattern of the vocal cords, even small glottic cancers tend to cause symptoms and therefore present at an early stage. Additionally, the glottis is relatively devoid of lymphatics and does not metastasize as easily making presentation without regional mets more common. In contrast, supraglottic tumors do not cause symptoms until they are significantly larger and have a rich network of lymphatics making regional metastasis more common at presentation. Subglottic
malignancy is rare. -See Lalwani 3rd ed pg 458-460
The stapedius tendon attaches to what structure?
A) Ponticulus B) Subiculum C) Pyramidal process
D) Cochleariform process E) Neck of the malleus
C; The stapedius is the smallest muscle in the human body. It spans from the pyramidal process to the neck of the stapes and is innervated by CN VII. The tensor tympani makes a sharp turn at the cochleariform process and attaches to the neck of the malleus. It is
innervated by CN V. The ponticulus and subiculum are not attachment points for any middle ear muscles. -See KJ Lee 10th ed pg 13
A 68 y/o male presents to your clinic with
complaints of persistent daytime fatigue. He has a
BMI of 31, hypertension and headaches that are
worse in the morning. His wife tells him that he
snores loudly and sometimes stops breathing at
night. You order a sleep study. During a sleep
study, what is the definition of apnea?
A) Cessation of airflow B) Cessation of airflow for
>5 seconds C) Cessation of airflow for >5 seconds
with oxygen desaturation to < 95% D) Cessation of
airflow for >10 seconds E) Cessation of airflow for
>10 seconds with oxygen desaturation to < 95%
D; Apnea is defined as cessation of airflow for greater than 10 seconds. While blood oxygen saturation is also measured, apnea can occur with or without a decrease in blood oxygen saturation. Hypopnea is more difficult to define but is either a reduction in airflow of 50% for 10 seconds or longer, or is a reduction in airflow greater
than 30% lasting at least 10 seconds and associated with at least a 4% decrease in blood oxygen levels. -See KJ Lee 10th ed pg 247
A friend of yours is worried about developing sea
sickness on an upcoming fishing trip. You
recommend he take some Meclizine with him to
treat any potential nausea. Meclizine is what kind
of medication?
A) Cholinergic Agonist B) First Generation
Antihistamine C) Second Generation Antihistamine
D) Third Generation Antihistamine E) Dopamine
Agonist
B; Meclizine (aka Antivert/Bonine) is a first generation antihistamine (H1 receptor antagonist), dopamine antagonist and has anticholinergic properties. -https://en.wikipedia.org/wiki/Meclizine
All of the following are true with regards to saliva
except … ?
A) High in sodium and low in potassium B) Parotid
secretions are less viscous than submandibular
gland secretions C) Contains IgA D) ~ 1 liter is
secreted per day E) Most abundant protein is
alpha-amylase
A; Saliva is low in sodium and high in potassium. The other answer choices are all true. Saliva is made in the acinus and modified in the salivary duct. It also contains lysozymes, leukotaxins and opsonins.
-See KJ Lee 10th ed pg 491-492
What is the first line antibiotic of choice for acute otitis media?
A) Cefpodoxime 10 mg/kg/d B) Augmentin 90
mg/kg/d C) Cefuroxime 30 mg/kg/d D) Amoxicillin
90 mg/kg/d E) Ceftriaxone 50 mg/kg/d
D; Amoxicillin is the recommended 1st line antibiotic for AOM, the rest are all second line. Amoxicillin should be given for 10 days in children under 5 and 5-7 days in children older than 6. Use a second line antibiotic if there is no clinical improvement within 3 days. Note
that all of the choices are oral antibiotics except for Ceftriaxone which is given as a single IM injection.-See KJ Lee 10th ed pg 311-312
What is the incidence of pneumothorax after tracheostomy?
A) less than 0.1% B) 1.1% C) 4.3% D) 8.2%
C; Pneumothorax is an uncommon intraoperative complication of tracheostomy, but can be caused by direct injury to the pleura or rupture of an alveolar bleb. The incidence has been reported to be as high as 4.3% but rarely is intervention required. Clinically the rate
is much lower so there is no need to obtain routine screening chest x rays postop.
-See Cummings 6th ed pg 100-101
The anterior ethmoid artery enters the nose — mm
posterior to the orbital rim and the posterior
ethmoid artery enters the nose —mm posterior to
the anterior ethmoid artery.
A) 24mm; 12mm B) 12mm; 24mm C) 12mm; 6mm
D) 6mm; 12mm E) 12mm; 12mm
A; Use the 24-12-6 rule. The anterior ethmoid artery is 24mm posterior to the orbital rim/lacrimal crest, the posterior ethmoid is 12 mm posterior to the anterior ethmoid artery and the optic nerve is 6 mm posterior to the posterior ethmoid artery. These relationships are crucial when approaching the orbital floor or ligating these vessels to
control epistaxis. -http://emedicine.medscape.com/article/835021-
overview
A 3 year old male is brought to your clinic with
findings of new onset bilateral hearing loss. An
audiogram demonstrates bilateral moderate to
severe sensorineural hearing loss. On history the
mother states she had some type of infection while
she was pregnant but can’t remember what it was
called. A full workup including imaging and genetic
testing are unrevealing. You conclude that the
patient suffered the most common infection
associated with congenital hearing loss. Which of
the following is true about this disease?
A) Over 90% of patients are asymptomatic at birth
B) Is potentially treatable with penicillin C) Patients
are also likely to suffer from cataracts D) Exposure
to cats is a risk factor for this disease
A; Cytomegalovirus is the most common infection to cause
congenital hearing loss and the vast majority of patients are asymptomatic at birth. Hearing loss is often delayed and may not be diagnosed for several years. Syphilis is the only infectious cause of hearing loss that is potentially treatable with antibiotics. Patients with congenital rubella can suffer from cataracts in addition to hearing loss. Exposure to cats is a risk factor for toxoplasmosis. -See KJ
Lee 10th ed pg 815-816
A 63 y/o M undergoes a partial glossectomy with
radial forearm free flap reconstruction of the defect.
Due to concerns for airway obstruction a
tracheostomy is placed at the time of the
procedure. Post-op the patient becomes lost to
follow up for several months. Six months after the
procedure the patient presents to your clinic asking
for his tracheostomy to be removed. How likely is it
that he will have a persistent tracheocutaneous
fistula after decannulation?
A) 5% B) 20% C) 50% D) 70% E) 90%
D; Patients who have a tracheostomy tube for over 4 months have a 70% chance of developing a tracheocutaneous fistula. This is due to epithelialization of the tracheostomy tract. Bjork flaps and prior radiation exposure are also risk factor for tracheocutaneous fistula. - See Cummings 6th ed pg 101.
What is the superior border of the conus elasticus?
A) Superior border of cricoid cartilage B) Inferior
border of cricoid cartilage C) Vocal ligament D)
Vallecula E) Tip of epiglottis
C; The conus elasticus (aka cricovocal membrane or triangular membrane) extends from the superior border of the cricoid inferiorly up to the deep surface of the apex of the thyroid cartilage and the vocal process of the arytenoid. Its superior free edge is the vocal
ligament. -See KJ Lee 10th ed pg 530
The left recurrent laryngeal nerve loops around — , the right
recurrent laryngeal nerve loops around — , after which both run
in — .
A) Ligamentum arteriosum, subclavian artery, the
tracheoesophageal groove B) Aorta, subclavian
artery, the tracheoesophageal groove C)
Subclavian artery, Ligamentum arteriosum, the
tracheoesophageal groove D) Ligamentum
arteriosum, subclavian artery, posterior to the
esophagus E) Subclavian artery, ligamentum
arteriosum, posterior to the esophagus
A; The left RLN loops around the ligamentum arteriosum and has a relatively vertical course. The right RLN wraps around the subclavian artery and enters the neck more laterally creating a more obtusely angulated course. Both nerves ultimately run within the tracheoesophageal groove on their way to innervating the larynx. -
See KJ Lee 10th ed pg 577-579
Describe the changes in tissue composition that
occur during the maturation stage of wound
healing.
A) Type III collagen is replaced by type I B) Type III
collagen is replaced by type II C) Type II collagen is
replaced by type I D) Type II collagen is replaced
by type III E) Type I collagen is replaced by type III
A; The maturation phase of wound healing occurs between 2 weeks and 18 months and involves replacement of type III collagen with type I collagen which makes the scar softer and smaller. The wound
reaches its maximal strength (80% of its preinjury strength) during this phase. -See KJ Lee 10th ed pg 766
Which immunoglobulin is a dimer and is the most
common immunoglobulin in saliva?
A) IgG B) IgM C) IgA D) IgD E) IgE
C; IgA is present in salivary secretions and exists as a dimer. IgG is involved in secondary immune responses and is the only Ig class that crosses the placenta. IgM is primarily associated with early immune responses and exists as a pentamer. IgD is found on circulating B cells. Of all immunoglobulins, the body has the least amount of IgE which is involved in type I hypersensitivity reactions (anaphylaxis) as well as atopy. -See KJ Lee 10th ed pg 452-453
What muscle is the sole abductor of the vocal
cords?
A) Interarytenoid B) Thyroarytenoid C) Cricothyroid
D) Lateral Cricoarytenoid E) Posterior
Cricoarytenoid
E; The posterior cricoarytenoid is the only abductor of the larynx. The cricothyroid is the only laryngeal muscle innervated by the external branch of the superior laryngeal nerve. The interarytenoid is the only unpaired muscle in the larynx. -See KJ Lee 10th ed pg 531-
532
Cleft lips are caused by the failure to fuse of what
two embryologic structures?
A) Maxillary prominence and the lateral palatine
process B) Medial nasal prominence and the
maxillary prominence C) Maxillary prominence and
the lateral palatine process D) Medial nasal
prominence and lateral nasal prominence
B; The lateral lip is created by fusion of the medial nasal prominence to the maxillary prominence. This failure to fuse can also create a cleft in the primary palate. Failure of the maxillary prominence to fuse with the lateral palatine process results in a cleft of the secondary palate. Risk factors for clefts include pregestational
maternal diabetes, fetal alcohol and tobacco exposure, folic acid deficiencies, retinoic acid derivatives and anticonvulsant medications.
-See KJ Lee 10th ed pg 285-287
A 4 y/o male is brought to the emergency room with
significant right ear pain. Otoscopy reveals a
bulging, erythematous tympanic membrane and the
diagnosis of acute otitis media is made. The
parents ask your recommendation on whether or
not they should give their son antibiotics. You
inform them that he has a —% change of
improvement within 3 days without any intervention
and a —% chance of improvement if they start
antibiotics immediately.
A) 50% ; 50% B) 50% ; 80% C) 80% ; 80% D) 80%
; 92% E) 92% ; 80%
D; 80% of children with AOM will show clinical improvement within 3 days with no intervention. That rate goes up to 92% if antibiotics are started immediately. However, this should be weighed against the 30% of children who will develop a rash and 80% of children who will develop diarrhea with antibiotics.-See KJ Lee 10th ed pg 311
A 3 y/o F presents to the ED with drooling and
stridor which developed over the past few hours.
Vital signs demonstrate an elevated respiratory rate
and fever to 103. A lateral neck x-ray
demonstrates a “thumbprint sign” and the patient is
taken emergently to the operating room where the
patient is safely intubated. Once the patient is
stable you question the parents about the child’s
vaccination history and they state that she is up to
date on all her vaccinations. Given the most
common cause of epiglottitis, what is the most
likely immunoglobulin which is deficient in this
child?
A) IgG1 B) IgG2 C) IgA1 D) IgA2 E) IgM
B; The most common cause of epiglottitis in children is Haemophilus influenzae, however the incidence of epiglottitis has decreased significantly since vaccination against this bacteria was introduced. While IgA is the immunoglobulin most represented in the mucosa,
failure to mount an immune response after vaccination represents a failure of the IgG antibody as this is the immunoglobulin stimulated by vaccines. The most common IgG deficiency in children is IgG2.
- Oxelius, Aurivillius, Carlsson and Musil (1999), Serum Gm Allotype Development During Childhood. Scandinavian Journal of Immunology, 50: 440–446.
A 52 y/o M with PMH of poorly controlled diabetes
presents to the ED with pain and swelling of his left
cheek and neck. On history he states that he has
had some tooth pain for several months and that
within the last day he developed this pain and
swelling. On exam he has diffuse erythema of the
left face and neck w/ an “orange-peel” appearance
and subcutaneous crepitus. He has a fever of
103.2 and a LRINEC score of 7 is calculated.
Which of the following is the most likely cause of
this patient’s infection?
A) Clostridium perfringens B) Pseudomonas C)
Klebsiella D) Strep Pyogenes E) Bacteroides
D; This patient has classic signs and symptoms of necrotizing fasciitis. In the head and neck, dental infections are the most common cause and patients who are immunocompromised have an elevated risk. The infection should be treated aggressively with broad spectrum antibiotics, ICU level of care and surgical
exploration/debridement. Although all of the bacteria listed can cause necrotizing fasciitis, Strep pyogenes and Staph Aureus are the most common causes. The LRINEC score can be used to help make the diagnosis and consists of six blood test: CRP, WBC, Hg, Na, Cr
and glucose.
-See KJ Lee 10th ed pg 573 and -Wong, Chin-Ho, Lay- Wai Khin, Kien-Seng Heng, Kok-Chai Tan, and Cheng-Ooi Low. “The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) Score: A Tool for Distinguishing Necrotizing Fasciitis from Other Soft Tissue
Infections*.” Critical Care Medicine 32.7 (2004): 1535-541.
Which immunoglobulin can cross the placenta and
is involved in secondary immune responses?
A) IgG B) IgM C) IgA D) IgD E) IgE
A; IgG is involved in secondary immune responses and is the only Ig class that crosses the placenta. IgA is present in salivary secretions and exists as a dimer. IgM is primarily associated with early immune responses and exists as a pentamer. IgD is found on circulating B cells. Of all immunoglobulins, the body has the least amount of IgE which is involved in type I hypersensitivity reactions (anaphylaxis) as well as atopy.
-See KJ Lee 10th ed pg 452-453
A 59 y/o female presents to your clinic requesting a
chemical peel. On exam she demonstrates signs
of severe photoaging. Using Baker’s phenol you
perform a deep chemical peel. To what layer does
this chemical peel penetrate?
A) Stratum Granulosum B) Stratum Basale C)
Papillary Dermis D) Reticular Dermis E)
Subcutaneous Tissue
D; Deep chemical peels penetrate down to the reticular dermis. This is a thick layer made of compact collagen. Care must be taken with deep chemical peels as damage to this layer results in permanent scarring. Medium depth peels reach the papillary dermis or the
superficial reticular dermis. Superficial peels remove the epidermis (of which both the stratum granulosum and stratum basale are sublayers of) and some of the superficial papillary dermis.
-See KJ Lee 10th ed pg 756
A 44 y/o female with diabetes presents to the
emergency room two days after undergoing
endoscopic sinus surgery with a complaint of
continuous clear nasal discharge. She states that
she taste a salty taste in the back of her throat but
otherwise feels well. Because she was placed on a
postop course of prednisone she has had difficulty
managing her blood sugar level and her serum
glucose is found to be 315. To confirm the
suspected diagnosis you collect some of the clear
rhinorrhea and test its glucose level. If your
diagnosis is correct what level of glucose would
you expect?
A) 10 mg/dL B) 80 mg/dL C) 200 mg/dl D) 300
mg/dL E) 400 mg/dL
C; This patient presents with symptoms and history concerning for postoperative cerebrospinal fluid(CSF) leak. While B2 transferrin is the best test to confirm a CSF leak it can take several days for these test results to return. Glucose testing is a fast way to differentiate CSF rhinorrhea from other nasal discharge. CSF fluid is expected to
have 60-70% of the serum glucose level present whereas normal nasal discharge has very low levels of glucose. Normal CSF glucose levels are 40-80 mg/dL but it would be higher in this patient given her elevated serum glucose.
-https://en.wikipedia.org/wiki/CSF_glucose
An 8 year old male presents to the ED with fever,
odynophagia, muffled voice and PO intolerance.
On exam his uvula is deviated to the right and he
has 3cm trismus. After appropriate treatment he is
able to tolerate PO intake and he is discharged
home on oral antibiotics. What is the chance that
he will have a recurrence of his disease process?
A) <1% B) 7% C) 22% D) 48% E) 74%
B; The patient presents with classic symptoms of peritonsillar abscess (PTA). Appropriate treatment involves needle aspiration and/or incision and drainage. Once the patient can tolerate PO they are usually prescribed systemic antibiotics (clindamycin) for 10 days.
16% of adults and 7% of children will have a recurrence of their PTA. If a patient has a recurrence of their PTA they should be offered a delayed tonsillectomy as they are at significantly increased risk of a
third episode.
-KJ Lee 10th ed pg 571
You take a 13 y/o female to the OR to treat her
recurrent respiratory papillomatosis. This is her
19th trip to the operating room. The procedure
goes well however postoperatively she has some
shortness of breath. A CXR is obtained which
demonstrates abdominal distention and a
pneumothorax. What is the the most likely cause
of this patient’s complication?
A) Use of the Co2 laser B) Use of the Argon laser
C) Use of jet ventilation D) Sudden opening of
previously chronic obstruction E) None of the above
C; Jet ventilation is commonly used during treatment of recurrent respiratory papillomatosis (RRP) because it allows better visualization and access to the airway. Complications include abdominal distention, subcutaneous emphysema, pneumomediastinum, pneumothorax and hypoventilation. Although
in theory a pneumothorax could be caused by iatrogenic trauma to the tracheal/laryngeal wall, this is not common and would not cause abdominal distention. Sudden opening of a previously chronic obstruction can lead to pulmonary edema but not pneumothorax.
-KJ Lee 10th ed pg 1003
A 42 y/o male with a BMI of 31 and a neck circumference
of 19 inches presents to your clinic with symptoms of
snoring, hypersomnolence, early morning headaches
and hypertension. You send him for a polysomnography
and correctly make the diagnosis of sleep apnea. During what stage of sleep is he least likely to suffer from apnea events?
A) Stage 1 B) Stage 2 C) Stage 3 D) Rapid Eye
Movement sleep E) Apnea is equally prevalent in all
stages
C; While respiratory events including apneas and hypopneas occur in all stages of sleep, they are least likely to occur during stage 3 sleep. Apneas that occur during REM tend to be associated with lower
oxygen desaturations.
-See KJ Lee 10th ed pg 417
What is the lateral border of the anatomic space
that spans from the glottis to the inferior border of
the cricoid cartilage?
A) Conus elasticus B) Broyles’ tendon C)
Quadrangular membrane D) Vocal ligament E)
Piriform sinus
A; The space that spans from the glottis to the inferior border of the cricoid is the subglottis and its lateral border is the conus elasticus (in addition to the cricoid). The conus elasticus attaches to the superior border of the cricoid inferiorly. Superior it attaches to both the deep surface of the apex of the thyroid cartilage and the vocal process of the arytenoid and forms the median cricothyroid ligament. Its superior free edge forms the vocal ligament.
-See KJ Lee 10th ed pg 530-531
Which structures are best visualized on a Water’s
view xray?
A) Frontal sinus B) Maxillary sinus C) Sphenoid
sinus D) Posterior ethmoid sinuses
B; A Waters’ view xray is taken at a 45° angle to the orbitomeatal line and best shows the maxillary sinuses, although it also can help evaluate the anterior ethmoids and orbital floor. Other plain films views of the sinuses include the Lateral view (frontal, maxillary and
sphenoid sinus), Caldwell view (Frontal sinuses and posterior ethmoid cells) and Submentovertex view (sphenoid and anterior/posterior walls of frontal sinuses).
- Williams, John W., Leroy Roberts, Bruce Distell, and David L. Simel. “Diagnosing Sinusitis by X-ray.” J Gen Intern Med Journal of General Internal Medicine 7.5
(1992) : 481-85.
Which of the following is false regarding
nasopharyngeal carcinoma?
A) HPV+ tumors have a improved 5 year survival
rate B) WHO Type III is the most common subtype
in North America C) A diet high in salted fish is a
risk factor D) 87% of patients have palpable nodal
disease at presentation E) 20% of patients are
under the age of 30
A; Unlike in the oropharynx where p16/HPV+ tumors are correlated with better outcomes, HPV+ nasopharyngeal carcinomas (NPC) are associated with poorer outcomes. Epstein Barr Virus (EBV) is a double stranded DNA virus found in the vast majority of patients with NPC.
-Stenmark, Matthew H., “Nonendemic HPV-Positive
Nasopharyngeal Carcinoma: Association With Poor Prognosis.” and KJ Lee 10th ed pg 716-719
A 39 y/o F presents to your office with complaints
of vocal fatigue which has progressively become
worse over the last few months. She states that by
the end of the day she is barely able to speak,
however her voice is strong again after a full night’s
sleep. She has also noticed some double vision
and decreased exercise tolerance. On exam she
has mild bilateral upper lid ptosis. No abnormalities
are found on flexible laryngoscopy. You order the
proper test to confirm the suspected diagnosis.
What additional testing should be performed in this
patient given her diagnosis?
A) CT chest B) CT neck w/ contrast C) CT neck w/o
contrast D) MRI brain E) Chlamydia screening
A; This patient presents with symptoms concerning for myasthenia gravis which is caused by antibodies blocking the postsynaptic endplates of the neuromuscular junction. Symptoms include voice fatigue, double vision, ptosis, oropharyngeal muscle weakness, head drop, limb weakness. These symptoms tend to be worse later in the day or after activity. Diagnosis can be made with a tensilon (edrophonium chloride) test. CT scan of the chest is indicated in all of myasthenia patients to rule out tumors of the thymus which are present in 10-15% of patients.
-See KJ Lee 10th ed pg 883
You are called to consult on a neonatal patient to
evaluate the patient for a weak cry and concerns
for aspiration. The child has never been intubated
but does have a nasogastric feeding tube in place.
On exam the child has a weak breathy cry but no
other significant findings. Vitals are stable and the
child does not appear to be in any distress. When
performing flexible laryngoscopy on this child what
is the most likely finding?
A) Vocal cord nodule B) Bilateral vocal cord
paralysis C) Right vocal cord paralysis D) Left vocal
cord paralysis
D; Because the course of the left recurrent laryngeal nerve is longer (passing under the ligamentum arteriosum) there is a higher chance that this patient’s vocal cord paralysis is on the left side compared to
the right given the otherwise unexplained etiology. Bilateral vocal cord paralysis is unlikely given that the patient has no evidence of respiratory distress. Vocal cord nodules are unlikely to cause a breathy voice and would not contribute significantly to aspiration.
-Lalwani 3rd ed pg 476
A 48 y/o female presents to your clinic requesting a
chemical peel. On exam she demonstrates signs
of mild pigment changes and actinic damage.
Using Jessner’s solution you perform a superficial
chemical peel. To what layer does this chemical
peel penetrate?
A) Stratum Corneum B) Superficial Papillary Dermis
C) Deep Papillary Dermis D) Superficial Reticular
Dermis E) Deep Reticular Dermis
B; Superficial chemical peels penetrate past the epidermis (including the stratum corneum) and penetrate to the superficial papillary dermis. Deep chemical peels penetrate down to the reticular dermis. Medium depth peels reach the papillary dermis or the superficial
reticular dermis.
-See KJ Lee 10th ed pg 756
A 5 y/o male is brought to your clinic by his mother
for evaluation of left sided ear pain. You make the
diagnosis of acute otitis media (AOM), discuss the
use of antibiotics with the parents (they decide not
to use them) and the child is sent home. On follow
up 1 week later the patient’s pain has improved and
he has no middle ear effusion. Unfortunately, 2
months later the patient returns with the same
presentation. The mother asks you if there is
anything you can do to prevent this from happening
again. How many episodes of AOM must the
patient have before you would offer an
adenoidectomy?
A) 3 or more episodes in a 6 month period B) 4 or
more episodes in a 12 month period C) 3 episodes
in a 6 month period despite tympanostomy tubes D)
4 or more episodes in a 12 month period despite
tympanostomy tubes E) Adenoidectomy is not
indicated
E; A 2009 Cochrane review demonstrated no benefit to
adenoidectomy in decreasing the number of episodes of AOM. Adenoidectomy should only be offered to patients with otitis media with effusion in an effort to help resolution of a persistent effusion, however this is not routine and should be performed on an individual
basis.
-Aardweg. “Adenoidectomy for Recurrent or Chronic Nasal Symptoms and Middle Ear Disease in Children up to 18 Years of Age.” Protocols Cochrane Database of Systematic Reviews (2009).
Which of the following is not a subsite of the
hypopharynx?
A) Postcricoid region B) Posterior pharyngeal wall
C) Pyriform sinus D) Valleculae E) All of the above
are subsites of the hypopharynx
D; The subsites of the hypopharynx are the “3 Ps”: postcricoid region, posterior pharyngeal wall and pyriform sinus. The valleculae is a subunit of the oropharynx. Other subunits of the oropharynx include the soft palate/uvula, base of tongue, pharyngoepiglottic/glossoepiglottic folds, palatine arch, and oropharyngeal walls.
-See KJ Lee 10th ed pg 506
A 49 y/o female presents to your clinic 6 months
s/p total thyroidectomy with complaints of voice
changes. On further clarification she states that
she is able to speak normally but cannot hit the
high notes while singing in her church choir the
way that she used to. Which of the following would
support the most likely diagnosis?
A) Furstenberg sign B) Gutman sign C) Brown sign
D) Hitzelberger sign E) Griesinger sign
B; This patient most likely has superior laryngeal nerve paralysis given that her voice changes are limited to singing (otherwise recurrent laryngeal nerve damage would be suspected). Gutman sign is when lateral pressure over the thyroid cartilage causes decreased voice pitch whereas anterior pressure causes increased
voice pitch which is indicative of superior laryngeal nerve paralysis. In a normal individuals the opposite is true.
-See KJ Lee 10th ed pg 255
Which of the following is false regarding glomus
tumors?
A) Glomus tumors are the most common neoplasm
affecting the middle ear B) Metastatic change
occurs in 3-4% of tumors C) Fisch type D tumors
extend to the infralabyrinthine region D)
Glasscock/Jackson Type B glomus tympanicums
completely fill the middle ear space E) There is a 5:
1 F>M ratio
C; Fisch Type C tumors extend to the infralabyrinthine region, Type D tumors have less than 2 cm diameter and intracranial extension.
- See KJ Lee 10th ed pg 186
Which of the following are found within the foramen
lacerum?
A) Nodes of Krause B) Greater petrosal nerve C)
External carotid artery D) Middle meningeal artery
E) Labyrinthine artery
B; Contents of the foramen lacerum include the internal carotid artery (not external), deep petrosal nerve, greater petrosal nerve (aka superficial petrosal nerve), terminal branch of the ascending pharyngeal artery and emissary veins. Nodes of Krause are found in the posterior jugular foramen. The middle meningeal artery is found in foramen spinosum. The labyrinthine artery is found in the internal auditory canal.
- See KJ Lee 10th ed pg 954
A 39 y/o male presents to your clinic with an
asymmetric audiogram. An MRI reveals a left side
2.1 cm cerebellopontine angle lesion which is
isointense on T1, slightly hyperintense on T2 and
enhances with contrast. There is a similar 1.1 cm
lesion on the right side. What is the protein most
commonly associated with this patient’s disease
process?
A) GJB2 B) P53 C) Merlin D) RET E) None of the
above
C; The patient has bilateral acoustic neuromas (characteristically isointense on T1, hyperintense on T2 and enhances w/ contrast). This is pathognomonic for neurofibromatosis type 2 which is caused by deletions in the NF2 gene which codes for the tumor suppressor
protein Merlin. As a side fact, Merlin is an acronym for “Moesin- Ezrin-Radixin-Like Protein”.
-See Lalwani 3rd ed pg 715
A 62 y/o male with a 50 pack year history of
smoking presents with voice changes and is found
to have a vocal cord mass. A biopsy is obtained in
the clinic and the report indicates squamous cell
carcinoma (SCC). However, upon review by the
tumor board, including a senior pathologist, the
patient’s mass is felt to be benign. Which of the
following is most likely to be the diagnosis for this
patient?
A) Recurrent respiratory papilloma B)
Pseudoepitheliomatous hyperplasia C)
Mucoepidermoid D) Vocal cord polyp E) Reinke’s
edema
B; Pseudoepitheliomatous hyperplasia is a benign condition which demonstrates overgrowth of squamous epithelium on histology and can be confused for SCC. Mucoepidermoid carcinoma can also mimic SCC however it is not a benign condition. RRP, vocal cord polyp and Reinke’s are all benign conditions but are unlikely to be
confused for SCC. Necrotizing sialometaplasia is another benign condition that can be confused for SCC, however it is extremely rare in the larynx.
-Cummings 6th ed pg 1612
A 41 y/o female presents to your clinic with an large
neck mass. On exam her thyroid appears enlarged
and is symmetric, firm and nontender to palpation.
On review of her prior labs her primary care
provider had ordered, she is found to be euthyroid.
What additional lab work would most likely confirm
the suspected diagnosis?
A) Thyroglobulin B) Calcitonin C) Anti-TPO
antibodies D) TSH stimulating antibodies
C; The patient presents with symptoms most consistent w/ Hashimoto’s thyroiditis. It is most common in females age 30-50 and most patients are euthyroid. Presentation is usually a painless, firm, enlarged goiter. FNA will reveal lymphocytic infiltration with germinal
center formation, Hurthle cell metaplasia, fibrosis and follicular acinar atrophy. 70-90% of patients will have elevated thyroid peroxidase antibodies.
-See KJ Lee 10th ed pg 586
While performing a coronal approach for a
forehead lift you notice that the supraorbital
foramen is not complete and is instead a
supraorbital notch with an incomplete ring of bone.
What percentage of patients will have a
supraorbital notch instead of a true foramen?
A) 6% B) 27% C) 83% D) 98%
C; Per Fallucco 2012, 83% of patients will have a supraorbital notch instead of a foramen. It should be noted that these notches still have a fascial band holding the contents of the notch in place in the
majority of specimens. -Fallucco “The Anatomical Morphology of the Supraorbital Notch.”
Plastic and Reconstructive Surgery 130.6
(2012): 1227-233.
A 33 y/o male presents with sudden onset right
sided facial weakness. On exam he has facial
symmetry at rest but an obvious asymmetry when
he smiles. He is unable to completely close his eye.
What is the patient’s House-Brackmann score?
A) 1 B) II C) III D) IV E) V F) VI
D; I = normal facial function II = slight weakness and/or slight synkinesis but normal tone and symmetry at rest. III = obvious asymmetry with noticeable synkinesis, contracture or hemifacial spasm. There is normal symmetry and tone at rest and complete eye
closure with effort. IV = obvious asymmetry but normal tone and symmetry at rest with incomplete eye closure V = barely perceptible motion with asymmetry at rest VI = no movement
-See KJ Lee 10th ed pg 198
A 53 y/o female with recurrent headaches is
referred to your clinic after her primary care doctor
ordered an MRI brain as part of her workup. You
review her scan which demonstrates a small left
sided petrous apex lesion which is hyperintense on
T1 and T2. There is no appreciable enhancement
on T1 with contrast and T2 hyperintensity does not
change with fat saturation. What is the most likely
diagnosis?
A) Cholesteatoma B) Cholesterol Granuloma C)
Mucocele D) Retained Secretions
B; This is likely an incidental finding and not related to her
headaches. Although cholesterol granulomas can cause symptoms
as they expand and impinge upon other structures, they are often
asymptomatic. Cholesterol granulomas have very distinct MRI
findings. They do not enhance with contrast and demonstrate
hyperintensity on both T1 and T2. -Cummings 6th ed pg 2093
A 61 y/o male presents to clinic with severe right
sided ear pain. He states he noticed a firm lesion
on his ear which has become increasingly painful
over the past several weeks. Usually he sleeps on
his right side but because of the pain he has
switched to his left. On exam there is a firm, round
nodule on the right helical rim ~ 4mm in diameter
which is exquisitely tender to palpation. The
patient has no hx of smoking and minimal history of
sun exposure. What is the most likely diagnosis?
A) Squamous Cell Carcinoma B) Basal Cell
Carcinoma C) Winkler Disease D) Villaret
Syndrome E) Vail Syndrome
C;
This is a classic presentation for Winkler disease (i.e.
Chondrodermatitis Nodularis Helicis) which is a benign condition often mistaken for a neoplastic process on exam. The key to differentiating it from neoplasm is that these lesions are very painful, whereas skin cancer usually is not. Treatment involves complete
excision of the nodule.
Villaret Syndrome is jugular foramen syndrome with the addition of Horner syndrome. Vail syndrome is unilateral, nocturnal, vidian neuralgia associated with sinusitis.
-See KJ Lee 251-252
A 62 y/o male patient with a history of papillary
thyroid cancer s/p total thyroidectomy and
radioactive iodine ablation 1 year ago presents for
routine followup. He states he is doing well and
denies any new symptoms. His exam is
unrevealing. You order blood work which tests the
level of a substance which may indicate recurrent
cancer. Where is this substance normally stored?
A) Pituitary Gland B) Bone Marrow C) Parafollicular
Cells D) Follicular Cells E) Colloid
E; Thyroglobulin is used to monitor for recurrence of well
differentiated thyroid cancer after total thyroidectomy and radioactive
iodine ablation. Levels above 10 mg/dL are concerning for recurrent
disease. Thyroglobulin is made by follicular cells but then secreted
into the follicular lumen in the form of colloid. It is important to test for
anti-thyroglobulin antibodies at the same time, as elevated levels of
these antibodies invalidate the use of thyroglobulin as a tumor
marker. - See KJ Lee 10th ed pg 581.
Which of the following bones does not form part of the
medial wall of the orbit?
A) Palatine B) Maxilla C) Ethmoid D) Lacrimal E)
Sphenoid
A; The medial wall of the orbit is made up of the lacrimal bone,
sphenoid, lamina papyracea (of the ethmoid bone) and the frontal
process of the maxilla. The palatine bone contributes to the orbit as
part of the orbital floor. The frontal bone and zygoma also contribute
to the structure of the orbit. -See KJ Lee 10th ed pg 895
A 55 y/o male undergoes a partial mandibulectomy
for oral squamous cell carcinoma. As part of the
reconstruction, a superiorly based
sternocleidomastoid flap is used. What is the blood
supply for this flap?
A) Posterior Auricular Artery B) Occipital Artery C)
Superior Thyroid Artery D) Suprascapular Artery E)
None of the above
B; The blood supply of the sternocleidomastoid is made up of the
occipital artery (upper third), branches of the superior thyroid artery
(middle third) and branches of the thyrocervical trunk which gives off
the suprascapular artery (lower third). For a superiorly based flap the
corresponding vessel is the occipital artery. -See KJ Lee 10th ed pg
731.
A 33 y/o male with a history of three sets of
tympanostomy tubes as a child presents with right
sided hearing loss. Audiogram reveals a significant
conductive hearing loss and you decide to order
imaging. An MRI reveals a middle ear mass that is
hypointense on T1, hyperintense on T2 and
demonstrates rim enhancement with contrast. You
take the patient to surgery and remove the mass. 6
months later you obtain a repeat MRI to look for
residual disease. What is the sensitivity of using
MRI to detect residual disease?
A) 22% B) 54% C) 73% D) 91% E) 99%
D; The patient presents with classic symptoms and MRI findings
consistent with a cholesteatoma (hypointense T1, hyperintense T2
with rim enhancement). Although the question used an MRI to test
your knowledge, be aware that a noncontrast CT scan is the initial
imaging modality of choice for cholesteatoma workup. Canal wall up
mastoidectomy would be an appropriate surgical intervention for this
patient depending on the the extent of their disease and patient
preference. MRI scans can be used to followup these patients and
evaluate for residual/recurrent disease and carries a sensitivity of
91% and specificity of 96%. -See Cummings 6th ed Pg 2088-2093
A 40 y/o female is presented at tumor board. On
review of her imaging she is found to have a 5cm
thyroid nodule with extension into the strap
muscles as well as bilateral abnormally enlarged
lymph nodes the largest being 4 cm on each
side. On fine needle aspiration papillary thyroid
carcinoma was confirmed. A chest x ray
demonstrates a 3 cm mass which is hyperintense
on a thyroid uptake scan. What is the stage of this
patient’s thyroid cancer?
A) Stage I B) Stage II C) Stage III D) Stage IV
B; For well differentiated thyroid cancer, patients under the age of 45
have a much better prognosis than those older than 45 and therefore
can only be stage I or II. Stage II is for patients with distant
metastasis, and Stage I is for those without. The size of their primary
lesion and the location/size of their regional metastasis are irrelevant
to their staging. -See KJ Lee 10th ed pg 640.
A 33 y/o male presents to your clinic with
complaints that food gets stuck in his throat with
each meal. He denies hemoptysis, voice changes
or significant weight loss. His exam, including
flexible laryngoscopy, is unrevealing. An
esophagram is ordered which demonstrates a
“bird’s beak” esophagus. What is the etiology of
this condition?
A) Degeneration of Auerbach plexus B) Repetitive
nonperistaltic esophageal contractions C) Lower
esophageal sphincter relaxation D) Weakness of
the posterior esophageal wall E) Esophageal scar
tissue
A; This patient presents with classic symptoms of achalasia. This
disorder is characterized by failure of the lower esophageal sphincter
to relax and lack of peristalsis which leads to the class “bird’s beak”
appearance on esophagram. The underlying etiology is idiopathic
degeneration of Auerbach plexus (aka myenteric plexus) which
provides innervation to the muscular layer of the digestive tract.
Treatment options include calcium channel blockers and botox
injections into the lower esophageal sphincter however Heller
myotomy (aka lower esophageal sphincter myotomy) is the definitive
treatment method. -See KJ Lee 10th ed pg 524
A 26 y/o female presents with acute onset right
sided facial paralysis. She tells you that this has
happened to her several times in the past. On
exam she has a House-Brackmann grade III
weakness of her right face with edema of the facial
soft tissues and fissuring of the tongue. What is
the most likely diagnosis?
A) Ramsay Hunt Syndrome B) Melkersson-
Rosenthal Syndrome C) Heerfordt Disease D)
Lyme Disease E) Mobius Syndrome
B; Melkersson-Rosenthal syndrome is associated with recurrent
facial palsy, chronic/recurrent facial edema and fissuring of the
tongue. Patients tend to be in their 20s. The etiology of this
syndrome is unknown. Ramsay Hunt is facial paralysis due to
herpes zoster and presents with vesicular eruptions on the ear.
Heerfordt disease (aka uveoparotid fever) is a rare form of
sarcoidosis which can cause bilateral facial nerve paralysis, parotid
swelling and uveitis. Lyme disease is caused by borrelia burgdorferi
and is associated with erythema migrans. 10% of lyme disease
patients will have facial nerve palsy and bilateral involvement is not
uncommon. Almost 100% of patients will have a full recovery.
Mobius syndrome is a form of congenital facial paralysis which
presents with bilateral facial paralysis and unilateral or bilateral
abducens palsy. -See KJ Lee 10th ed pg 215
Cranial nerve IX exits the skull via what bony
opening?
A) Posterolateral Jugular Foramen B) Anteromedial
Jugular Foramen C) Anteromedial Foramen
Lacerum D) Posterolateral Foramen Lacerum E)
Foramen Spinosum
B; The jugular foramen is divided into anteromedial and
posterolateral segments called the par nervosa and par vasculara
respectively. CNs IX, X, XI and the inferior petrosal sinus pass
through par nervosa whereas the internal jugular vein and posterior
meningeal artery pass through the par vasculara. -See KJ Lee 10th
ed pg 235
A 39 y/o female presents to your clinic with left
sided hearing loss and pulsatile tinnitus. She
denies any other complaints and states that her
symptoms were insidious in onset. She has no
significant family history. On exam a left sided
middle ear mass is visualized on the promontory.
There is a positive Brown sign. Weber lateralizes
to the left with a negative Rinne on that side as
well. You decide to get a CT scan to better
delineate the mass. Given the most likely
diagnosis, what percentage of patients will have
multicentric disease?A) 1% B) 10% C) 25 D) 50% E) 80%
B; This patient has the classic presentation for a glomus tympanicum. These tumors are most common in caucasian females and present with pulsatile tinnitus and conductive hearing loss. They are often found on the promontory. Brown sign is blanching of the middle ear
mass on pneumatic otoscopy which is strongly suggestive of a glomus tumor. 10% of glomus tumors are multicentric so it is
important to evaluate the patient with imaging for potential additional
masses. -See KJ Lee 10th ed pg 681-683
A 35 y/o male presents for evaluation of an
incidentally discovered left thyroid nodule. On
ultrasound it measures 1.4 cm in largest dimension
and appears well circumscribed. No abnormal
appearing lateral neck nodes are found. To your
surprise the fine needle aspiration comes back
showing anaplastic thyroid cancer. What is the
stage of this patient’s thyroid cancer?A) Stage I B) Stage II C) Stage III D) Stage IV
D; All patients with anaplastic thyroid cancer are considered stage IV
due to the extremely poor prognosis. Tumor size, regional and
distant metastasis or irrelevant to their staging. -See KJ Lee 10th ed
pg 640
A 61 y/o male presents to your clinic after an MRI
for neck pain revealed multiple abnormal cervical
lymph nodes and thyroid nodules. You confirm
these findings on ultrasound and offer him a fine
needle aspiration (FNA). The patient is terribly
afraid of needles and only agrees to undergo an
FNA on a single site. Which of the following should
be biopsied to provide the most information?
A) A left sided 1.9 cm spongiform thyroid nodule B)
A 1.8cm right level IV node with a kidney bean
shape and echogenic hilum C) A 1.8cm left level III
lymph node with microcalcifications, round shape
and increased echogenicity D) A right sided 2.1 cm
solid hypoechoic nodule with irregular borders E) A
left sided 1.9 cm hypoechoic nodule which is taller
than it is wide
C; While both D and E likely represent well differentiated thyroid
carcinoma if an FNA is performed at these sites it does not provide
information as to regional metastasis and a second FNA will be
required for the suspicious cervical nodes. If you perform an FNA on
the suspicious lymph node (larger than 1 cm, microcalcifications,
abnormal round shape and increased echogenicity) and it is positive
for thyroid cancer then you know the patient has regional spread and
you can treat him appropriately. Spongiform thyroid nodules are
categorized as “very low suspicion” in the 2015 ATA thyroid nodule
guidelines. -See 2015 ATA Thyroid Nodule Guidelines
A 52 y/o male with a history of poorly controlled
diabetes presents with right sided otalgia. He
states that he has been taking vicodin for the pain
but that it hasn’t helped. On exam there is some
purulent otorrhea and granulation tissue present in
the EAC. You take a culture and admit the patient
for treatment. Which imaging study is best for
tracking the response to treatment in this patient?
A) MRI of the Skull Base B) Technetium
Radioisotope Scan C) CT Temporal Bone with
Contrast D) CT Temporal Bone Noncontrast E)
Gallium Scan
E; This patient presents with signs and symptoms of malignant otitis
externa. A noncontrast CT temporal bone scan can be used to
make/confirm the initial diagnosis as can an MRI of the skull base or
a technetium radioisotope scan. These scans are not great at
monitoring treatment however. It should be noted that once a
technetium scan becomes positive it will remain so indefinitely.
Gallium scans are best for detecting inflammatory response and a
reduction in uptake correlates with clinical improvement therefore
making them useful to track treatment response. -See KJ Lee 10th
ed pg 207-208
A 39 y/o female presents to your clinic with a right
sided parotid mass which she states has been
slowly growing over the past few years. The mass
is firm but mobile and does not cause her any pain.
She has no other significant medical history and
does not smoke. A fine needle aspiration does not
reveal any malignant cells. Given the most likely
diagnosis, what are the chances of eventual
malignant transformation if the patient decides not
to pursue any treatment.A)1%> B) 10% C) 25% D) 50% E) 75% F) >90%
C; The most common benign salivary gland neoplasm is pleomorphic
adenoma (benign mixed tumor), which most commonly presents in
the parotid gland. The rate of transformation to carcinoma ex-
pleomorphic adenoma is ~ 25%. -See KJ Lee 10th ed pg 501
A 32 y/o male presents to your clinic with
complaints of right sided hearing loss and vertigo
while lifting weights. The patient states this started
6 months ago after he suffered a concussion during
a car accident. On exam he demonstrates vertical
nystagmus during pneumatic otoscopy. An
audiogram demonstrates right sided low frequency
conductive hearing loss with an elevated bone
threshold. What scan should be ordered to confirm
the diagnosis?
A) CT in the plane of Ohngren B) CT in the plane of
Stenver C) CT in the plane of Frankfurt D) MRI T1
with contrast E) MRI T2 with contrast F) MRI
Diffusion Weighted Imaging
B; This patient has a presentation most consistent with superior
semicircular canal dehiscence. The most appropriate imaging
modality to order is a CT scan in the planes of Poschel and Stenver
as they transect the superior canal and allow the dehiscence to be
seen. The line of Ohngren connects the medial canthus of the eye to
the angle of the mandible and helps with prognostication of midface
tumors. The Frankfurt horizontal plane connects the inferior orbital
rim and the superior ear canal and helps define standard anatomic
positioning. MRI is not an appropriate scan to detect superior canal
dehiscence. -See KJ Lee 10th ed pg 355
Which of the following is the statistical definition of
“Power”?
A) Probability that the null hypothesis will be
rejected if it is indeed false B) Results observed in a
study, experiment, or test that are no different from
what might have occurred because of chance alone
C) Probability of making a type 1 error D) A zone of
compatibility within the data, which indicates a
range of values considered plausible for the
population from which the study sample was
selected
A; Factors that affect a study’s power include the statistical
significance criteria, the magnitude of the effect in the population and
the sample size used. B refers to the null hypothesis, C refers to the
P value, and D refers to the confidence interval. -See Cummings 6th
ed pg 16
An 11 month old male is brought to your clinic for
evaluation of his hearing. The mother states that
she is concerned because he doesn’t startle when
he is exposed to loud noises. The patient’s
delivery was without complications and he is
otherwise meeting his developmental milestones.
There is no family history of hearing loss and your
physical exam is unremarkable. What type of
hearing test is most appropriate for this patient?
A) Standard Audiometry B) Play Audiometry C)
Behavior Observation Audiometry D) Visual
Response Audiometry
D; For children less than 6 months, behavior observation audiometry is preferred (in addition to ABR and OAE). For children 6 months to 3 years (as in our patient) visual response audiometry is preferred. Play audiometry can be used in children 3-6 years and conventional audiometry can usually be achieved in children over the age of 6. - See KJ Lee 10th ed pg 51-53
After drilling out a facial recess and identifying the
round window niche you perform a cochleostomy
and prepare to insert a cochlear implant electrode
array. What space will the electrode array enter?
A) Saccule B) Scala Media C) Scala Vestibuli D)
Scala Tympani
D; Cochlear implants are inserted into the scala tympani which can
be accessed via the round window or adjacent cochleostomy. The
scala vestibuli can be accessed via the vestibule through the oval
window (although this will likely cause a sensorineural hearing
loss). The scala media cannot be accessed surgically without
causing significant damage to the inner ear and is located between
the scala vestibuli and scala tympani. The saccule detects linear
acceleration and is not involved in hearing. -See KJ Lee 10th ed pg
157-158.
Which of the following bones of the skull is an
endochondral bone, not a membranous bone?
A) Frontal B) Ethmoid C) Zygoma D) Vomer E)
Lacrimal
B; Endochondral bones of the skull include the petrous, occipital,
ethmoid, mastoid and sphenoid bones. The remaining bones are all
membranous. During the ossification of endochondral bone cartilage
is present as an intermediary whereas this is not the case in
membranous bone. -See KJ Lee 10th ed pg 955.
A 48 y/o female presents with right sided pulsatile
tinnitus and an audiogram demonstrating a right
sided conductive hearing loss. On exam a reddish
mass is seen behind the TM which blanches during
pneumatic otoscopy. The rest of the exam is
unremarkable. After obtaining a CT scan to
confirm your diagnosis you take the patient to the
operating room for treatment. Which nerve gives
rise to this disease process? Which cranial nerve
is it a branch from?
A) Arnold’s Nerve; CN X B) Arnold’s Nerve; CN IX
C) Jacobson’s nerve; CN IX D) Jacobson’s nerve;
CN X E) Auriculotemporal nerve; CN V3
C; The patient presents with findings consistent with a glomus
tympanicum. These tumors arise from Jacobson’s nerve (aka
Tympanic nerve) which is branch of the glossopharyngeal nerve (CN
IX). Arnold’s nerve is also known as the auricular branch of the
vagus nerve (CN X) and it provides sensation to the ear canal, tragus
and auricle. The auriculotemporal nerve is a branch of the
mandibular branch of the trigeminal nerve (CN V3) and provides
sensation to the ear canal, tympanic membrane and auricle. It also
carries parasympathetic fibers to the parotid gland. -See KJ Lee 10th
ed pg 4
A 29 y/o male presents to clinic with voice changes.
He states that for the past 6 months he has
increased difficulty speaking which comes and
goes but is present enough to be disruptive to his
work performance. He does not have difficulty with
whispering or singing but notes frequent voice
breaks while speaking. On exam his voice sounds
strained but not breathy and he has particular
difficulty with words beginning in vowels. Flexible
laryngoscopy was largely unrevealing. Given the
most likely diagnosis what is the most effective
treatment modality?
A) Berke procedure B) Recurrent laryngeal nerve
transection C) Speech therapy D) Botox injection of
the thyroarytenoid E) Botox injection of the
posterior cricoarytenoid
D; This patient’s presentation is consistent with adductor spasmodic
dysphonia. Classic symptoms include strained voice with frequent
voice breaks and difficulty with words beginning in vowels. The
NIDCD established four diagnostic criteria for spasmodic dysphonia
including: 1) Increased effort with speaking 2) difficulty fluctuates
over time 3) Symptoms last more than 3 months 4) At least one
nonspeaking task is normal (laugh, whisper, sing, yawn, shout, cry)
Botox injections of the thyroarytenoid muscle is currently the most
effective management option. The Berke procedure involves
transection of the adductor branches of the recurrent nerve with
reinnervation using ansa cervicalis. Recurrent nerve transection was
previously used however this often leads to significant breathiness
and symptoms will often return within 3 years. Speech therapy is not
effective in patients with spasmodic dysphonia. Botox injections of
the posterior cricoarytenoid is used in patients with abductor
spasmodic dysphonia which is much less common and presents with
breathy voice and voice breaks during plosive sounds. -See KJ Lee 10th ed pg 543-544
A 62 y/o male with advanced glottis squamous cell
carcinoma presents to clinic for evaluation. It is
decided that the patient requires a total
laryngectomy with free flap coverage of the wound
bed. The patient has been losing weight for
several months due to dysphagia and aspiration
however 10 days ago he received a gtube and has
been able to receive adequate nutrition during this
time. Which of the following lab values is most
likely to be abnormal in this patient?
A) Prealbumin B) Albumin C) Transferrin D) Serum
Glucose E) None of the above are likely to be
abnormal
B; Albumin is a good marker for patients’ long term nutritional status
and has a half life of 20 days. Values less than 3.0 g/dL are
associated with increased morbidity. Prealbumin and transferrin are
both markers for a patient’s nutritional status but they have short half
lifes (2 and 10 days respectively) and are therefore more likely to be
normal in this patient who has been receiving adequate nutrition for
the past 10 days. Glucose is not a commonly used marker to
evaluate for malnutrition and would be expected to be normal in this
patient who is currently receiving adequate nutrition. -See KJ Lee
10th ed pg 921 - 922
A 42 y/o male presents with an incidental finding of a left
sided neck mass found on CT neck obtained during a
trauma workup two weeks ago. On the CT scan a “Lyre
sign” is appreciated. An MRI is then obtained to further
delineate this mass. What characteristic finding is
expected on the patient’s MRI scan?
A) Microcalcifications B) No enhancement with
contrast C) Thumbprint sign D) “Salt and Pepper”
on T1 E) Cystic component
D; The “Lyre sign” refers to the splaying of the internal and external
carotid artery that is caused by a carotid body tumor. This splaying
resembles the classic Greek instrument of the Lyre. These tumors
are paragangliomas and as such also demonstrate the classic “salt
and pepper” appearance caused by areas of slow flow (salt) and flow
voids (pepper). -Baser, Husniye, Baris Ayhan, Meryem Ilkay Eren
Karanis, Salih Baser, Deniz Karasoy, Kemal Kalkan, and Samil Ecirli.
“A Carotid Body Tumor Mimicking a Thyroid Nodule: A Case Report.”
Endocrine Abstracts EJEA (2014).
Which of the following nerves is not involved in the
parasympathetic innervation of the parotid gland?
A) Trigeminal Nerve B) Less Superficial Petrosal
Nerve C) Nervus Intermedius D) Jacobson’s Nerve
C; The pathway for parasympathetic innervation of the parotid gland
is as follows: Inferior salivary nucleus –> Jacobson’s nerve (CN IX)
–> Lesser superficial petrosal nerve –> Auriculotemporal nerve (V3)
–> Parotid gland. The nervus intermedius carries parasympathetic
fibers from the Superior salivary nucleus to the chorda tympani which
eventually innervates the submandibular and sublingual glands, but
not the parotid gland. -See KJ Lee 10th ed pg 488-489
A 53 y/o male presents to your clinic with
complaints of heartburn. He states his symptoms
are worse at night after having a big meal and is
associated with significant belching. You refer him
for endoscopic esophagoscopy which reveals 2
mucosal breaks which bridge the tops of the
esophageal folds involving 50% of the
circumference of the mucosal lining. How would
this finding be classified?
A) Lahey Stage 2 B) Los Angeles Grade C C)
Brombart Stage 3 D) Morton Stage 1 E) Van
Overbeek Stage 3
B; Erosive esophagitis is most commonly classified using the Los
Angeles classification scheme which is divided into 4 categories:
Grade A: >1 isolated mucosal breaks <5 mm long Grade B: > 1
isolated mucosal breaks >5 mm long Grade C: > 1 mucosal breaks
bridging the tops of folds but involving <75% of the circumference
Grade D: > 1 mucosal breaks bridging the tops of folds and involving
>75% of the circumference. The remaining answer choices are all
various classification schemes used to categorize Zenker’s
diverticulum. -See Cummings 6th ed pg 1008
Using your first paycheck as an attending
physician, you buy a porsche and speed out of the
dealership. As you accelerate to get up to speed
on the freeway, which vestibular organ detects the
acceleration?
A) Utricle B) Saccule C) Superior Semicircular
Canal D) Lateral Semicircular Canal E) Posterior
Semicircular Canal
A; The utricle detects linear acceleration (accelerating in a car)
whereas the saccule detects vertical acceleration (descending in an
elevator). The semicircular canals detect rotational acceleration. -
See KJ Lee 10th ed pg 83
An 18 y/o male presents to the trauma bay after
sustaining significant blunt trauma to the head. On
exam he is noted to have complete left sided facial
nerve paralysis. Which type of temporal bone
fracture is the most common cause of facial nerve
injuries? What is the most common cause of
posttraumatic vertigo?
A) Longitudinal; Labyrinthine Concussion B)
Longitudinal; BPPV C) Transverse; Labyrinthine
Concussion D) Transverse; BPPV E) Transverse;
Endolymphatic Hydrops
A; While transverse temporal bone fractures are more likely to cause
a facial nerve injury, there are far more longitudinal fractures and
therefore they are the most common cause of facial nerve injuries.
Labyrinthine concussion is a more common cause of posttraumatic
vertigo than BPPV. -See KJ Lee 10th ed pg 264-265
What is the location of the sphenopalatine
foramen?
A) Anterior to the crista ethmoidalis B) Posterior to
the crista ethmoidalis C) Posterior to the superior
attachment of the middle turbinate D) Anterior to
the inferior attachment of the middle turbinate E)
Anterior to the inferior attachment of the middle
turbinate
B; The sphenopalatine foramen can be located directly behind the
crista ethmoidalis in the majority of individuals. This is useful when
performing a sphenopalatine artery ligation to control epistaxis. It
should also be kept in mind that the artery branches medial to the
crista in almost all patients, with some patients having up to 10
individual branches. -See KJ Lee 10th ed pg 407 and Bolger “The
Role of the Crista Ethmoidalis in Endoscopic Sphenopalatine Artery
Ligation” American Journal of Rhinology
During a neck dissection a large artery is cut
accidentally and immediate ligation is required.
After the field is cleared of blood you realize that
the artery that was ligated was the fourth artery to
branch off the external carotid. Which of the
following is a branch of that artery?
A) Superior labial artery B) Superior laryngeal
artery C) Sublingual artery D) Middle temporal
artery
A; The fourth branch off the external carotid is the facial artery. Use
the mnemonic “Some Attendings Like Freaking Out Potential Med
Students” (Superior thyroid, ascending pharyngeal, lingual, facial,
occipital, posterior auricular, internal maxillary, superficial temporal).
The superior labial artery is a branch off the facial. The superior
laryngeal is a branch from superior thyroid, the sublingual is a branch
off of lingual and the middle temporal is a branch off of superficial
temporal. -See KJ Lee 10th ed 958-959.
Which of the sinus cavities is present at birth?
A) Maxillary and Ethmoids B) Maxillary and
Sphenoids C) Sphenoids and Frontals D) Ethmoids
and Frontals E) Sphenoids and Ethmoids
A 1 year old child is brought to your clinic for
A; The maxillary sinus develops out of a furrow in the lateral nasal
wall at ~ the 65th day of development and the ethmoid sinuses
develop in the second trimester. These are the only two sinuses you
are born with. The sphenoid sinuses are not present until ~ 2 years
of age and the frontals do not appear until the age of 7. -See KJ Lee
10th ed pg 783-784
A 1 year old child is brought to your clinic for
hearing loss. On review of his medical record the
patient was recently diagnosed with Fanconi’s
Anemia. The parents are considering having a
second child. What is the chance that a second
child will also have Fanconi’s Anemia?
A) 1:130,000 B) 25% C) 50% D) 100% if the child is
a male E) 100% regardless of gender
B; Fanconi’s Anemia is a rare congenital disorder characterized by
spontaneous bleeding, decreased platelets, bone marrow
megakaryocytes and anomalies of the inner, middle and external ear.
Approximately 1:130,000 children are born with this disorder. It is
autosomal recessive and therefore the chances that a second child
has this disorder is 25%. -See KJ Lee 10th ed pg 229-230.
A 37 y/o male presents with swelling of both
pinnas. He states that his ears are tender and
become inflamed for 1-2 weeks every so often. He
denies any otorrhea, tinnitus or vertigo but has a
small amount of otorrhea and muffled hearing. On
exam he is breathing comfortably and in no acute
distress but has impressive erythema and edema
of both auricles with severe tenderness to
palpation. You draw labs which reveal a normal
white blood cell count but an erythrocyte
sedimentation rate of 64. Given the most likely
diagnosis, what are the chances that this patient’s
disease will eventually progress to cause airway
symptoms?A) <1% B) 20% C) 50% D) 80% E) >95%
C;
This patient’s presentation is most consistent with relapsing polychondritis. This disorder is characterized by recurring inflammation of cartilaginous structures including the auricles, septum and airway. Symptoms develop rapidly and resolve after 1-2 weeks. Inflammatory markers such as ESR and CRP are often significantly elevated and treatment consists of oral steroids and immune modulating agents. ~ 50% of patients will develop progressive destruction of the airway cartilages which result in airway symptoms.
-See KJ Lee 10th ed pg 549
A 62 y/o female presents to the clinic with edema,
pruritis and clear discharge from her right ear. She
is prescribed some ear drops and sent home,
however, three days later she returns saying the
ear drops only made things worse. On exam she
has increased erythema and edema of the canal
with extension to the conchal bowl and ear lobe but
sparing the portion of the pinna superior to the
external ear canal. What ototopical medication was
she most likely prescribed?
A) Polysporin B) Acetic Acid C) Ofloxacin D)
Cortisporin E) Ciprodex
D; Cortisporin contains hydrocortisone, polymyxin B and neomycin
which is a common cause of contact dermatitis. The other ototopical
medications listed can cause allergic reactions but are less likely to
do so. Ciprodex contains ciprofloxacin and dexamethasone.
Polysporin contains polymyxin and lidocaine. -Epstein E. Allergy to Dermatologic Agents. JAMA. 1966;198(5):517-520.
A 62 y/o male presents with a left sided neck mass.
Imaging reveals a parapharyngeal space mass in
the prestyloid space. The patient is very hesitant to
undergo surgery and wants to know what would
happen if he elects observation. Which of the
following prestyloid structures is at risk if the mass
continues to grow?
A) Spinal accessory nerve B) Vagus nerve C)
Internal jugular vein D) Cervical sympathetic chain
E) Lingual nerve
E; All of the structures listed are poststyloid structures except for the
lingual nerve. In general, poststyloid masses are more concerning
given the importance of the structures in that region. Prestyloid:
Internal maxillary artery, inferior alveolar nerve, lingual nerve,
auriculotemporal nerve Poststyloid: Carotid artery, internal jugular
vein, CN IX, X, XI, XII, cervical sympathetic chain. -See KJ Lee 10th
ed pg 491 and 963.
A 73 y/o male with a history of diabetes and
hypertension presents to the emergency
department with severe left sided ear pain. On
exam he has moderate edema and erythema of the
EAC skin and a small amount of granulation tissue
present. You decide to order a nuclear imaging
study given the patient’s history and degree of pain.
If the scan is positive what is the most likely
organism responsible for this patient’s infection?
A) Pseudomonas B) Staph Aureus C) Staph
Epidermidis D) Aspergillus E) Candida
A; This patient demonstrates a classic presentation of malignant otitis
externa (MOE). They have a history of diabetes, pain out of
proportion to exam and granulation tissue (which is usually present at
the bony/cartilaginous junction). A technetium scan is the most
appropriate scan for initial diagnosis although CT temporal bones are
sometime ordered as well. Gallium scans and ESR can be used to
monitor response to treatment. The most common organism to
cause MOE is Pseudomonas (98% of cases) and the patient should
be treated with ciprofloxacin with a 3rd/4th generation cephalosporin
for at least 6 weeks. -See KJ Lee 10th ed pg 207-208
A 36 y/o male is referred for evaluation of his
sinuses. The patient endorses constant
headaches for the past 2-3 months as well as some
vision changes but denies nasal discharge or
obstruction. On exam his nasal passages are clear
but you notice a left sided abducens nerve palsy.
Given his abnormal exam you order a CT scan
which reveals a midline clival lesion which is well
circumscribed with some abnormal internal
calcifications, enhancement with contrast and a
positive “thumb sign”. Given the most likely
diagnosis, what is likely to be found on histology
upon resection of the lesion?
A) Antoni A Pattern B) Antoni B Pattern C)
Physaliferous Cells D) Psammoma Bodies E)
Orphan Annie Eye Nuclear Inclusions F) Zellballen
C; This patient presents with symptoms and imaging consistent with
a chordoma. These tumors, which develop from notochord
remnants, often present in the midline clivus and are locally
aggressive with involvement of Dorello’s canal and CN VI being
common. Surgical resection is the standard treatment but 5 year
survival is only ~ 50%. On imaging, projection of the mass
posteriorly such that it indents the pons is called a “thumb sign” and
is characteristic of these lesions. On histology cells with small round
nuclei and abundant vacuolated cytoplasm (physaliferous cells) are
seen. Antoni A and B patterns are present in vestibular
schwannomas. Psammoma bodies and orphan Annie eye nuclear
inclusions are seen in papillary thyroid carcinoma. Zellballen are
characteristic of paragangliomas. -See KJ Lee 10th ed pg 685-686
A 24 y/o female presents for workup of a thyroid
nodule. She denies any hyper or hypothyroid
symptoms and has no history of radiation
exposure, however multiple members of her family
have undergone thyroidectomies for both
cancerous and noncancerous lesions. On exam the
patient has multiple small masses of her skin and
oral mucosa but she states they have been
biopsied and she was told they are benign. What
is the most likely diagnosis?
A) Cogan syndrome B) Von Recklinghausen
disease C) Cowden disease D) Pendred syndrome
E) Rosai-Dorfman disease
C; This patient presents with a family history of goiter, multiple skin
masses (hamartomas) and concern for thyroid cancer which is
consistent with Cowden syndrome. Cowden syndrome (aka Multiple
Hamartoma Syndrome) is an autosomal dominant disorder caused
by mutations of phosphatase and tensin homolog (PTEN) gene. It is
important to make this diagnosis as these patients are at increased
risk of multiple malignancies including thyroid, colon, breast and renal
cancer. 89% of these patients will develop some form of cancer
during their lifetime. Cogan Syndrome = interstitial keratitis and
Meniere’s like symptoms likely related to periarteritis nodosa. Von
Recklinghausen disease = NF1, Multiple neurofibromas and cafe au
lait spots Pendred Syndrome = Congenital sensorineural hearing
loss and euthyroid goiter Rosai-Dorfman = Benign
lymphadenopathy which is often self limiting -See KJ Lee 10th ed pg
227 and 1056.
A 33 y/o female presents to your clinic for
evaluation of a nasopharyngeal mass. The patient
states she had an MRI performed for neck pain and
an abnormal mass was found in the back of her
nose. She occasionally experiences postnasal drip
but otherwise denies nasal obstruction, nasal
discharge, loss of sense of smell, fevers, voice
changes or weight loss. She has no significant
past medical history, social history or family history.
On review of the MRI there is a well circumscribed
1 cm lesion in the midline nasopharynx which is
bright on T2 and does not enhance with contrast.
On flexible nasal endoscopy there is a smooth
submucosal mass in the nasopharynx. What is the
most likely diagnosis?
A) Epstein Nodule B) Pyogenic Granuloma C)
Fibrous Dysplasia D) Thornwaldt’s Cyst E)
Osteoma
D; The most likely diagnosis is a Thornwaldt’s Cyst. These are
benign masses in the midline nasopharynx that represent a remnant
of the notochord. They can sometimes cause symptoms such as
neck pain, eustachian tube dysfunction and postnasal drip however
they are commonly asymptomatic and noticed incidentally on
imaging. If they are symptomatic they can be marsupialized,
otherwise no intervention is indicated. -See KJ Lee 10th ed pg 404
A 49 y/o female presents to the clinic with right
sided nasal congestion and occasional epistaxis.
On exam a necrotic appearing lesion of her inferior
turbinate is identified. A biopsy is obtained which
returns demonstrating mucosal melanoma with a
depth of 2mm and no ulcerations. Imaging is
obtained which does not reveal any bony erosion
or evidence of nodal/distant mets. What is the
TNM classification and staging for this patient?
A) T2aN0M0 - Stage Ia B) T2bN0M0 - Stage Ib C)
T2aN0M0 - Stage IIa D) T3N0M0 - Stage III E)
T3N0M0 - Stage IVa
D; Mucosal melanoma has a much worse prognosis than cutaneous
melanoma and is therefore staged differently. T stage begins at T3 if
it is limited to mucosa and does not involve any underlying structures.
Unlike cutaneous melanoma, depth does not matter (and often is not
reported). Lesions that involve cartilage or bone are considered T4a
and those that are locally advanced involving skull base, brain, dura,
cranial nerves, etc. are T4b. See staging below: T3N0 = Stage III
T4aNx = Stage IVa T4bNx = StageIVb M1 = Stage IVc If this was a
cutaneous melanoma the correct staging would be T2a (1-2mm
thickness w/o ulceration)N0M0 - Stage Ib. - See KJ Lee 10th ed pg
650.
A 44 y/o female with a past medical history of
diabetes presents with left ear pruritus, mild pain
and foul smelling discharge. She states that her
symptoms started three weeks ago. Initially she
had more pain and less itching, but this improved
after a course of ear drops from her primary care
provider. Once finishing the ear drops her current
symptoms began. On exam there is white fluffy
material in the external canal and weber lateralizes
to the left. What percentage of otitis externa is
caused by the class of organisms responsible for
this patient’s infection?A) 2% B) 24% C) 57% D) 73% E) 98%
A; This patient’s presentation is most consistent with fungal otitis
externa. This can commonly occur after a course of topical
antibiotics and classically has more pruritus than bacterial otitis
externa. Fungal elements are often visualized in the external canal
on exam. 2% (or less) of acute otitis externa is caused by fungus. -
See KJ Lee 10th ed pg 935.
A 44 y/o female with a history of Grave’s disease
refractory to medical management is taken to the
operating room for a thyroidectomy. The surgery is
completed without complication, however in the
postoperative recovery unit the patient develops
tachycardia to 130s and hyperthermia to 103.
Which of the following medications should not be
given immediately?
A) Propylthiouracil B) Methimazole C) Propranolol
D) Iodine E) Corticosteroids
D;
Tachycardia and hyperthermia in a patient with poorly controlled graves and an acute insult such as thyroid surgery is concerning for thyroid storm. Treatment of thyroid storm involves all of the listed medications however iodine should not be given until 1 hour after propylthiouracil and methimazole. Propylthiouracil and propranolol blocks T4 conversion to T3. Methimazole prevents new thyroid hormone synthesis. Corticosteroids are used as prophylaxis against adrenal insufficiency.
-See Bahn “Management Guidelines of the
ATA and AACE” pg 607.
A 28 y/o male presents to the trauma bay with a
facial laceration. You offer him a repair and explain
that you will use some local anesthetic agents to
numb the area. He states that several years ago
he went to the dentist and developed a rash after
they injected local anesthesia. Which of the
following agents should you use to minimize the
potential for an allergic reaction?
A) Lidocaine B) Cocaine C) Novocaine D)
Benzocaine E) They are all equally as likely to
cause an allergic reaction
A; Local anesthetic agents can be divided into esters and amides.
Esters more commonly cause allergies and it is recommended that if
a patient has a history of allergic reactions to one class of anesthesia
that the opposite class be used. Lidocaine is the only amide
anesthetic agent listed. Given the fact that previously this patient
most likely had a reaction to an ester medication, an amide such as
Lidocaine is the best answer choice. Remember that all amide
anesthetic agents have two “i”s in their names. -See KJ Lee 10th ed
pg 830-831
The recurrent laryngeal nerve enters the larynx
directly underneath which muscle?
A) Cricothyroid B) Posterior Cricoarytenoid C)
Inferior Constrictor D) Superior Constrictor E)
Cricopharyngeus
C; The recurrent laryngeal nerve (RLN) travels in the
tracheoesophageal groove as it moves superiorly entering the larynx
just posterior to the cricothyroid joint. Prior to entering the larynx it
dives underneath the inferior constrictor muscle. The RLN innervates
the inferior constrictor muscle and all the intrinsic muscles of the
larynx except the cricothyroid muscle. -See KJ Lee 10th ed Pg 577-
578
