ENT/Otolaryngology and Head & Neck Surgery Flashcards
What is the significance of a left supraclavicular enlarged lymph node?
Virchow’s Node
- Indicates an abdominal malignancy
What is the significance of an enlarged right lymph node?
May indicate malignancy of:
- Mediastinum
- Lungs
- Esophagus
What is the significance of an enlarged occipital and/or posterior auricular lymph node?
Rubella
How does one tell the right and left ear apart from an otoscopy picture?
- Cone of light
>> Right: 5 o’clock
>> Left: 7 o’clock - Handle of malleus
>> Right: pointing anteriorly
>> Left: pointing posteriorly
NB: Front of card – Left. Back of card – Right.
Describe drainage sites and origins of the nasal cavity.
- Sphenoethmoidal sinus – Sphenoid sinuses
- Superior meatus – Posterior ethmoid sinuses
- Middle meatus – Frontal, Maxillary and Anterior ethmoid sinuses
- Inferior meatus – Nasolacrimal ducts
Define the superior and inferior boundaries of the different parts of the pharynx.
- Nasopharynx: skull base to soft palate
- Oropharynx: soft palate to hyoid bone
- Hypo/Laryngopharynx: hyoid bone to inferior cricoid cartilage
True nystagmus and vertigo caused by a peripheral lesion will never last longer than a couple of weeks because of compensation.
Central lesions do NOT compensate, hence nystagmus and vertigo will persist.
What are the four strap muscles of the neck?
- Thyrohyoid
- Sternothyroid
- Sternohyoid
- Omohyoid
Lung malignancy is the most common cause of extralaryngeal vocal cord paralysis.
What are the possible causes/differential diagnoses for hoarseness of voice?
- *Infectious**
- Acute laryngitis
- Chronic laryngitis
- Laryngotracheobronchitis (Croup)
- *Trauma**
- External laryngeal trauma
- Endoscopy
- Endotracheal intubation – intubation granuloma
- *Inflammatory**
- Vocal nodules/polyps
- Smoking/Chronic EtOH intake
- GERD
Neoplasms
- Benign
>> Papilloma – HPV infection
>> Minor salivary gland tumours
>> Retention cysts
- Malignant
>> SSC (e.g. of the thyroid)
Neurological
- Central
>> Cerebral Vascular Accident (CVA)
>> Multiple Sclerosis (MS)
>> Head injury
>> Skull base tumours
>> Arnold-Chiari Malformation
- Peripheral
>> Unilateral: lung malignancy
>> Bilateral: surgery/forceps delivery
- Neuromuscular
>> Myasthenia gravis (MG)
- Iatrogenic
>> Thyroid surgery
>> Parathyroid surgery
>> Carotid endarterectomy
>> PDA ligation
Systemic
- Endocrine
>> Hypothyroidism
>> Virilization
- Connective tissue disease
>> Rheumatoid arthritis (RA)
>> Systemic lupus arthritis (SLE)
- *Functional**
- Psychogenic/hysterical hoarseness
- *Congenital**
- Laryngeal web
- Laryngeal atresia
- Laryngomalacia
If hoarseness persists for >2 weeks in a smoker, laryngoscopy must be done to rule out malignancy.
What is the definition of acute VS. chronic laryngitis?
Acute: of inflammatory changes in the laryngeal mucosa
Chronic: >2 weeks of inflammatory changes in the laryngeal mucosa
What are the possible causes of acute laryngitis?
- Viral: adenovirus, influenza
- Bacteria: Group A Streptococcus
- Mechanical strain >> submucosal hemorrhage >> vocal cord edema >> hoarseness
- Environemntal: toxic fume inhalation
What are the possible causes of chronic laryngitis?
- Recurrent acute laryngitis
- Chronic irritants
- Chronic alcohol use
- Chronic voice strain
- Chronic rinosinusitis with postnasal drip
- Esophageal disorders
>> GERD
>> Zenker’s diverticulum
>> Hiatus hernia - Systemic disorders
>> Hypothyroidism
>> Addison’s disease
>> Allergy
NB: MUST rule out malignancy!
What are the differences between vocal nodules and vocal polyps?
- *Polyps**
- Unilateral and asymmetric
- Acute onset
- May resolve spontaneously
- Usually acute!
- Tx: surgical excision if persistent or in presence of risk factors for laryngeal cancer
Nodules
- Bilateral
- Chronic onset
- Chronic course
- Can be acute or chronic on onset
>> Early nodules: submucosal hemorrhage
>> Mature nodules: hyalinization with long-term voice abuse
- Tx: surgical excision if refractory (rarely indicated)
Vocal polyps are structural manifestations of vocal cord irritation.
Vocal polyps are more common in the anterior 1/3rd of the vocal cords.
Vocal nodules are more common at the junction between the anterior 1/3rd and posterior 2/3rd of the vocal cords – this is the point of MAXIMAL VIBRATION.
What are the possible causes of vocal cord palsy?
- *- Lung malignancy
- Thyroid surgery
- Idiopathic: DM, Vasculitis etc.**
- (Peri)Mediastinal/Midline pathologies
>> Tuberculosis
>> CA esophagus
>> CA hypopharynx
>> CA thyroid
>> Aortic aneurysms - Other iatrogenic causes
>> Parathyroid surgery
>> Carotid endarterectomy
>> Cervical esophagus mobilization in CA esophagus
>> PDA ligation in children - *Possible causes for BILATERLAL_ _vocal cord palsy**
- Total thyroidectomy
- Recurrent (bilateral) strokes
- Irradiation (usually as treatment for NPC)
What infection is associated with benign laryngeal papillomas?
HPV types 6 and 11
What infection is associated with CA larynx?
HPV-16, HPV-18
What is the age of onset of benign laryngeal papillomas?
Biphasic
- Juvenile onset – birth to puberty
>> Also known as “recurrent respiratory papillomatosis”
>> Vertical transmission of HPV infection from mother to child
>> Usually regresses in teenagehood - Adult onset
>> Acquired HPV infection
>> Does NOT regress
How does RRP or laryngeal papillomas present?
- Hoarseness
- Airway obstruction
- NB: Can seed into the tracheobronchial tree
How do we manage RRP/laryngeal papillomas?
Physical Examination: direct laryngoscopy
Investigations: biopsy for the first 2 times to look out for dysplastic changes – these lesions may undergo malignant transformation (3-5%)
- *Treatment**
- Repeated debulking by microdebridement or CO2 laser
- Intralesional antiviral (cidofovir)
- Interferon treatment slows the progress only
- HPV vaccine may prevent or encourage regression in juvenile types
NB: these papillomas are highly resistant to complete removal
What is the most common laryngeal tumour in childhood?
Benign laryngeal papillomas/Recurrent respiratory papillomatosis
What is the most common histological type of laryngeal carcinoma?
Squamous cell carcinoma (Almost 99%)
Other types include:
- Myosarcoma
- Adenocystic carcinoma (minor salivary glands)
What are the three possible sites of laryngeal carcinoma, and how will they present respectively?
- *Supraglottis** (30-35%)
- Boundaries: tip of epiglottis to the middle of the ventricle
- Globus sensation, blood-stained sputum (easily misdx as TB), and palpable lymph nodes
- Usually presents late
- *Glottis** (60-65%)
- Boundaries: middle of the ventricle to the inferior surface of true cords
- Hoarseness of voice
- Usually presents early >> good prognosis
- *Infraglottis/Subglottis** (1%)
- Boundaries: inferior surface of true cords to the inferior cricoid border
- Stridor
- Can be quite acute in presentation
Laryngeal carcinoma takes up 45% of all H&N cancers.
What are the known risk factors for laryngeal carcinoma?
- Male gender (M:F 10:1)
- Smoking
- Alcohol consumption – especially for supraglottic cancers
- HPV-16 infection is strongly associated with the risk of laryngeal squamous cell cancers (Li et al., 2013)
How do we manage CA larynx?
Depends on TMN staging
Investigations: Laryngoscopy with biopsy; CT/MRI
Treatment:
- Radiotherapy
- Surgery: total laryngectomy +/- (modified) radical neck dissection
- Chemoirradiation: usually for T3 tumours when patient wants to conserve the larynx
- Vocal rehabilitation
>> Electrolarynx
>> Pneumatic device
>> Tracheo-esophageal fistula
>> Esophageal speech
NB: survival is similar between surgery and chemoirradiation for T3 tumours – however, note that the long-term side effects of external irradiation can also be very debilitating when the patient survives the disease
How is the prognosis of CA larynx?
T4 lesions with adjuvant radiotherapy: >40%
Early lesions: >90% with radiation
How do we stage carcinoma of the larynx?
T-staging
T1: limited to one subsite and normal cord mobility
T2: more than one subsite and impaired cord mobility, BUT NO FIXATION
T3: limited to larynx with cord fixation
T4: extension into tissues beyond larynx
>> NB: subsites of larynx include supraglottis, glottis and subglottis
N-staging
N0: no regional nodal metastases
N1: single ipsilateral node <= 3cm
N2a: single ipsilateral node 3-6cm
N2b: multiple ipsilateral nodes <6cm
N2c: bilateral nodal metastases or contralateral nodal metastases <6cm
N3: any nodal metastases >6cm
M-staging
M0: no evidence of metastases
M1: distant metastases present
Name the common ototoxic drugs (5 groups).
- Aminoglycosides: neomycin, streptomycin, gentamicin
- Loop diuretics: furosemide, bumetanide
- Antineoplastics: cisplatin
- Salicylates
- Quinine
What are the possible causes of dizziness?
True Vertigo
- Peripheral (Vestibular) Causes
>> Benign Paroxysmal Positional Vertigo (BPPV)
>> Meniere’s disease
>> Labyrinthitis
>> Vestibular neuronitis
>> Recurrent vestibulopathy
>> Cholesteatoma
>> Perilymph fistula
>> Autoimmune inner ear disease
>> Drug ototoxicity
>> Temporal bone fractures
>> Superior semicircular canal dehiscence
- Central Causes
>> Migrainous Vertigo
>> Multiple Sclerosis
>> Cerebrovascular Disorders
:: Vertebrobasilar Insufficiency
:: Transient Ischemic Attacks
:: Wallenburg’s Syndrome
:: Cerebellar infarction
>> Tumours
:: Cerebellopontine angle
:: Posterior fossa
>> Inflammation
:: Meningitis
:: Cerebellar abscess
>> Trauma
:: Cerebellar contusions
>> Toxins
Non-Vertiginous
- Organic causes
>> Cardiac causes
:: Arrhythmia
:: Aortic stenosis
>> Orthostatic hypotension
>> Vasovagal attacks
>> Anemia
- Functional
>> Depression
>> Anxiety
>> Phobia
What are the possible causes of hearing loss?
- *Conductive Hearing Loss**
- External ear
- Middle ear
- Inner ear
- *Sensorineural Hearing Loss**
- Congenital
- Acquired
What are the common presenting symptoms and signs of vertebrobasilar insufficiency?
The 5Ds
- Drop attacks
- Dizziness
- Diplopia
- Dysarthria
- Dysphagia
What does panendoscopy include?
- Microlaryngoscopy
- Esophagoscopy (OGD)
- Pharyngoscopy
- Rigid bronchoscopy
+/- Tonsillectomy (microprimary in the tonsils)
What are the possible causes of otalgia?
External Ear
- Infection
>> Otitis externa
>> Herples simplex/zoster
>> Auricular cellulitis
>> External canal abscess
- Trauma
>> Burns
>> Hematoma
>> Laceration
>> Frostbite
- Others
>> Neoplasms of the external ear canal
>> Foreign body
>> Cerumen impaction
Middle Ear/Inner Ear
- Infection
>> Acute otitis media
>> Otitis media with effusion
>> Mastoiditis
>> Myringitis
>> Skull base infections
- Trauma
>> Traumatic perforation
>> Barotrauma
- Others
>> Neoplasms
>> Wegener’s
>> Cholesteatoma
Referred Pain
- Infection
>> Tonsilitis
>> Tracheitis
>> Ramsay-Hunt Syndrome
- Trauma
>> Thyroiditis
>> Cervical arthritis
- Others
>> TMJ Syndrome
>> Trismus
>> Dental problems
>> Glossopharyngeal neuralgia
>> Carcinoma/Neoplasms of the oral cavity/pharynx/larynx
Which tuning fork is used for audiological tuning fork tests?
512Hz
Describe the PTA.
A mild rising sensorineural hearing loss in the right ear
Typical of Meniere’s disease
Describe the PTA.
Moderate-severe conductive hearing loss with the Carhart’s notch present at the 2000Hz interval
Typical of otosclerosis
Describe the PTA.
High-frequency sensorineural hearing loss with the greatest HL at the 4000-6000Hz region with some recovery at 8000Hz
Typical of noise-induced hearing loss
Describe the PTA
Bilateral symmetrical high frequency sensorineural hearing loss with no rebound
Typical of presbycusis
How are the Brandt-Daroff exercises performed?
- Sit upright on bed
- Lie down on the side within 1-2s, with the head looking up at a 45 degree angle
- Remain in this position for 30s or until the dizziness subsides
- Return to upright position for 30s
- Repeat steps 2 and 3 on the other side.
>> Repeat cycle 5 times for one set. Repeat 3 sets per day for 14 days.
How is the Epley Maneuvre performed?
- Dix-Hallpike position: hold for 1-2 minutes
- Rotate patient’s head for 90 degrees to the opposite direction so that the opposite ear faces the ground, while maintaing the neck at 30 degrees extension – remain in the position for 1-2 minutes
- Keeping the head nad neck fixed, the patient rolls onto the shoulder, rotating the head another 90 degrees so he/she is now looking downwards at a 45 degree angle. – remain in the position for 1-2 minutes
- Patient is slowly brought up to an upright sitting posture, while maintaining a 45 degree rotation of the head
- Remain in the sitting position for up to 30 seconds
