ENT Staging Systems Flashcards
ANOMALOUS FACIAL NERVE IN THE MIDDLE EAR (Rohrt & Lorenzen)
- Facial nerve partially obliterates stapes footplate
- Bifurcation of VII
- VII rests on footplate with deformed stapes or oval window
- VII rests on promontory
Anomalies often in association with stapes fixation Stapes may be normal even in association with VII bifurcation
SIGNS OF OPTIC NEUROPATHY (5)
- Visual acuity
- Snellen chart vs finger counting vs hand movement (light perception only) - Pupils
- RAPD (bilateral dilation of pupils) - Colours
- Ishihara chart, check for red desaturation - Fields
- Subjective brightness
- Compare torch brightness between the 2 sides AcuityBrightnessColorDilation(RAPD)Fields
SPHENOID APPROACHES
Approaches:
Transnasal
Transethmoid
Transseptal
Trans-pterygoid root (violates SPA, PPF)
Wilson Grading for Pituitary Adenomas (Based on Extrasellar Extension)
STAGE
DESCRIPTION
0
No suprasellar extension
A
Extension into suprasellar cistern only
B
Extension into anterior recess of third ventricle
C
Obliteration of anterior recess and deformation of floor of third ventricle
D
Intradural extension into ACF/MCF/PCF
E
Extradural invasion into cavernous sinus
pl 147 105
THYROID N STAGING
N0 = no regional LN metastasis
N1a = Level VI nodes
N1b = Metastasis in other unilateral, bilateral or contralateral LNs
Thyroid staging is weighted towards primary site
- Lateral neck disease does not significantly alter prognosis
THYROGLOSSAL DUCT CYST
- Lingual 2%
- Suprahyoid 24%
- Thyrohyoid 61%
- Suprasternal 13%
TNM CANCER STAGING Not NPx Not p16+ OroP SCC
1 = 1
2 = 2
3 = 3 or N1
4a = 4a or N2
4b = 4b or N3
4c = M1
INVERTED PAPILLOMA (Krouse)
Developed by Krouse, Laryngoscope 2000:
- Confined to nasal cavity
- Ethmoids, OMU, medial wall maxillary sinus
- Anterior/lateral/superior/inferior/posterior walls maxillary sinus, frontal, sphenoid
- Extrasinus or any tumour associated with malignancy
Initial paper suggested endoscopic approach for T1/T2/selected T3
- Now routinely resect T3 and T4 with endoscopic approach
Recurrence rate directly related to extent of surgery
FRIEDMAN STAGING
dont forget BMI
Oral Cavity SCC T Staging AJCC 8th ed
T1 tumour <2cm and DOI < = 5mm
T2 Tumour < 2cm and DOI >5 - < =10mm OR 2-4cm and DOI < = 10mm
T3 Tumour >4cm or DOI > 10mm
T4a (oral cavity) Tumour invades adjacent structures- through cortical bone, into deep extrinsic muscles of tongue (genioglossus, hyoglossus, palatoglossus, styloglossus), maxillary sinus, skin of face
T4a (lip)- tumour invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face
T4b Tumour invades masticator space, pterygoid plates, skull base or encases carotid
4,4,4 check Front: cohesive or non cohesive? whats this?
ANGLE CLASSIFICATION OF MALOCCLUSION
Assesses relationship between: 1 is to 1
- Upper 1st molar tooth- mesiobuccal cusp (1st cusp): top molar is more posterior
- Lower 1st molar- mesiobuccal groove
Class I:
Maxillary cusp sits within the mandibular groove
- Normal arrangement
Class II:
Maxillary cusp sits in front of mandibular groove — retrognathia
Class III:
Maxillary cusp sits behind mandibular groove — prognathia
FITZPATRICK SKIN CLASSIFICATION
III: sometimes, gradual
STOMAL RECURRENCE (Sisson, 1976)
- Superior 1/2 of stoma without oesophageal involvement
- Superior 1/2 of stoma with oeseophageal extension
- Inferior 1/2 of stoma with direct extension to mediastinum
- Extension laterally and often below clavicles
Survival:
I/II = 45% at 2 years
III/IV = 9% at 2 years
- Aggressive Rx of III/IV usually not indicated
- Risks of surgery: great vessel injury, hypocalcaemia, fistula formation, mediastinitis
Risk factors:
- Advanced T stage — invasion of thyroid gland
- Advanced N stage — paratracheal node involvement
- Pre-op tracheostomy
- Subglottic involvement — failure to obtain clear margin
- Failure to complete PORT
Nasopharynx SCC T Staging
T1
Tumor confined to the nasopharynx or extends to oropharynx and/or nasal cavity
T2
Tumor extends to soft tissues of parapharyngeal space; muscle involvement such as MP, LP, PV muscles (new classification)
T3
Tumor involves bony structures of the base of skull and/or paranasal sinuses
T4
Tumor with intracranial extension and/or involvement of cranial nerves, infratemporal fossa, hypopharynx, orbit, or masticator space (5) air, soft tissue, bone, intracranial/orbit
FRONTAL MUCOCELE
Type 1: limited to frontal sinus (+/- orbital extension)
Type 2: Frontoethmoidal mucocele (+/- orbital extension)
Type 3: erosion of posterior wall
A. minimal or no intracranial extension
B. major intracranial extension
Type 4: erosion of anterior wall
Type 5: erosion of both posterior and anterior walls A. minimal or no intracranial extension
B. major intracranial extension
80% present with some degree of proptosis
REFLUX SYMPTOM INDEX 9 questions
RSI>13 strongly correlates with LPR on dual-probe pH study
Hoarseness, throat clearing, PND, cough x 2, dysphagia, heartburn, globus, aspiration
FUJITA CLASSIFICATION
Type 2 subdivided- A = predominantly palate, B = predominantly tongue
1 retropalatal collapse
2 both
3 retrolingual
MAXILLARY SINUS SCC T STAGING
- Sinus mucosa, no bony destruction
- Bony erosion — HP and middle meatus
- Excludes post wall and PPF - Post wall max sinus, PPF, subcutaneous tissues, ethmoid sinus, floor/med wall orbit (3 for E)
4a. Ant orbit, skin of cheek, ITF, pterygoid plates, frontal/sphenoid sinus, cribriform plate
4b. Orbital apex, dura, brain, MCF, CNs (except V2), NPx, clivus (same as ethmoid/nasal cavity SCC 7)
“4a for frontal”
CHOLESTEROL GRANULOMA
- Confined to one area of mastoid or middle ear system 2. Involves entire middle ear cleft
OLFACTORY ESTHESIONEUROBLASTOMA (Hyams histologic grading)
Graded I-IV
I = well-differentiated, relatively indolent
IV = undifferentiated, extremely aggressive
Homer Wright (pseudorosettes) present in Grade I and II (photo)
- Grouping of cells in a circumferential fashion around neurofibrillary matrix but without basement membrane
Flexner-Wintersteiner (true rosettes) present in Grade III and IV
- Cells align in a glandular fashion around spaces lined by distinct cell membranes
page 112 in Wenig
Major Salivary Gland T Staging
T1- Tumour <2cm in greatest dimension without extraparenchymal spread
T2- Tumour is 2-4cm without extraparenchymal spread
T3- Tumour >4cm and/or has extraparenchymal spread
T4a- Tumour invades skin, mandible, EAC and/or VII
T4b- Tumour invades skull base and/or pterygoid plates and/or encases carotid
*Extraparenchymal extension is clinical or macroscopic evidence of invasion of soft tissues.
T3 and above: N0: SND
EWALD’S LAWS/ ALEXANDER’S LAWS
EWALD’S LAWS:
1st- direction of nystagmus in plane of affected canal
2nd- Lateral canal- ampullopetal flow (towards ampulla) produces greater response
3rd- Vertical canals- ampullofugal flow (away from ampulla) produces greater response
ALEXANDER’S LAWS: degrees of nystagmus
1st- looking in direction of fast phase
2nd- present looking straight ahead
3rd- present looking in all directions
CUTANEOUS SCC T Staging N Staging as for mucosal sites (7th vs 8th edition change?)
T1 < 2cm and < 2 high-risk factors
T2 > 2cm or > 2 high-risk factors
T3 Invasion of maxilla, mandible, orbit, temporal bone (bone)
T4 Skeletal invasion (axial/appendicular) or perineural invasion of skull base
(AJCC 8th Edition: removed the risk factors)
High risk factors:
- Depth/invasion
- >2mm thickness
- Clark level > IV
- Perineural invasion - Anatomic location
- Primary site ear
- Primary site hair-bearing lip - Differentiation
- Poorly differentiated or undifferentiated
RT-INDUCED MALIGNANCY Diagnostic criteria
Cahan 1948:
- Within the treatment field
- Significant latency period
- Different type of cancer to the original
Controversial area- patients with one cancer are at increased risk of another due to lifestyle and genetic factors
Benefits of RT outweigh the risks of induced malignancy — shouldn’t be a factor in deciding Rx
- Maybe in those < 40 — avoid RT
Types of cancer:
- Sarcoma — long lead-time (i.e. 40 years)
- Lymphoma/Leukaemia
- Carcinoma (incl cutaneous SCC)
- (Thyroid PTC)
Congenital Ossicular Anomalies (Cremer)
- Isolated congenital stapes fixation 30.6%
- Footplate fixation
- Superstructure fixation - Stapes ankylosis assoc with another congenital ossicular anomaly 38.2%
- Incus/malleus deformation or aplasia of LPI
- Bony fixations of malleus and/or incus - Congenital anomaly of OC but mobile stapes footplate
- OC Discontinuity 15.3%
- Epitympanic fixation 6.3%
- Tympanic fixation 6.9% - Congenital aplasia/severe dysplasia of OW/RW
- Aplasia 2.1%
- Dysplasia 0.7%
Stapes fixation and nothing else
Stapes fixation and something else
Something else but not stapes fixation
Aplasia of OW/RW
Data from Cremer’s series of 144 operated ears (modified by Tos)
PERINEURAL INVASION in SCC Panizza review article. Williams et al - role in prognosis - signs/sx - investigation
Important in prognosis:
- Incidental perineural invasion has a 80-90% LRC 5yr
- Clinical perineural spread has 25-40% LRC 5yr
Signs / Sx
- Often cutaneous / high sun exposure areas
- V & VII MC affected
- Formication an early sign of PNS in V
- Slowly progressive facial palsy
Investigation
MRI - MR neurography detects extent of disease in 83%
- Inc intensity or enlargement of nerves
- Obliteration of fat in foramina
- Denervation change in supplied muscle (V3 / VII) - muscle hyper enhancement with gad
CT will detect late - bone erosion, foraminal widening, sclerosis
AUSTIN CLASSIFICATION FOR OCR
malleus more important than stapes superstructure ? malleus absent represents worse disease
75-50-25
Only A is a PORP, everyone else is a TORP
NASAL FRACTURE CLASSIFICATION Ondik et al, Arch Facial Plastic Surgery 2009 Read scott brown
(Nasal bones, septum dev?, septum fractured?, septum dislocated?)
- Simple straight
- Without midline deviation - Simple deviated
- With midline deviation - Comminuted nasal bones
- B/L nasal bone comminution + deviated septum
- Septum does not interfere with bony reduction - Severely deviated nasal and septal fractures
- Severe deviation of nasal midline
- Severe septal fracture or septal dislocation
- Comminution of nasal bones/septum may interfere with # reduction - Complex nasal and septal fractures
- Severe injuries, including
- Soft tissue trauma
- Acute saddling
- Open compound injury
- Avulsion of tissue
Management of nasal bone #:
- some controversy regarding closed vs open reduction (CR vs OR)
- Up to 50% will have residual deformity after CR
Management based on stage: see 4th facet
1, 2: closed reduction
3: not impacted — CR, impacted — modified OR with osteotomies
4: less severe — modified OR with osteotomies, more severe — acute open nasal/septal repair
5: acute open nasal/septal repair
Persistent deformity — septorhinoplasty (delayed)
LARYNGEAL WEB Cohen Airway occlusion, web character, function Severity classification
thickness, SG extension, cord visibility
1 and 2: endoscopic laser, CO2, cold steel, serial balloon dilatation, keel
3 and 4: LTR : anterior cricoid split and cartilage graft + stent
Supraglottis SCC T Staging
T1: Tumor limited to one subsite* of supraglottis with normal vocal cord mobility
T2: Tumor invades mucosa of more than one adjacent subsite* of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx
T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic tissues or paraglottic space
T4a: Tumor invades through the thyroid cartilage, and/or extends into soft tissues of the neck, thyroid, and/or esophagus
T4b: invades prevertebral fascia, encases carotid artery, superior mediastinum
*Subsites include the following:
- ventricular bands (false cords)
- arytenoids
- suprahyoid epiglottis
- infrahyoid epiglottis
- aryepiglottic folds (laryngeal aspect)
HODGKIN’S DISEASE Ann Arbor Staging
Staging guides treatment and prognosis
I: single LN region OR single extra-lymphatic site
II: 2 or more LN sites, same side of diaphragm OR Localised extra-lymphatic involvement + 1 nodal group
III: LNs on both sides of diaphragm may be accompanied by involvement of extralymphatic site or spleen or both
IV: disseminated involvement of one or more extra lymphatic organs with/without LN enlargement
Each Stage subdivided to A and B based on constitutional symptoms:
- Fever, drenching night sweats, unintentional weight loss of 10% within last 6 months
NEW TNM STAGE P16+ OROPHARYNX SCC NEW N STAGE P16- OROPHARYNX SCC
cT and pT (same)
T1 < 2cm
T2 2-4cm
T3 > 4cm or goes to lingual surface of epiglottis
T4 medial pterygoid, hard palate, mandible, larynx, extrinsic tongue muscles and beyond
(difference is no Tis and no T4b)
Clinical N
N0 no nodes
N1 iplateral 1 or more nodes < 6cm
N2 contralateral or bilateral nodes all < 6
N3 any node > 6cm
Pathological N (difference in outcome)
N0 no nodes
N1 < = 4 + nodes
N2 > 4 + nodes
so 2 stages cTNM and pTNM for p16 + only p16 - New N staging (for all new N staging of all subsites)
same as previous but include ENE (extranodal extension)
Clinical stage
N1 and N2 no ENE
N3a > 6 no ENE
N3b any node size and number but clinically overt + ENE
Essentially: P16 +
Stage I: T0-T2, N1
Stage II: T0-T3 N2
Stage III: T0-T4 N3
Stage IV: M1
CURACAO CRITERIA FOR HHT
Designated in 2000
FIVE criteria:
- Spontaneous, recurrent epistaxis
- Mucocutaneous telangiectasia
- Visceral involvement
- Family history
- Genetic testing. Confirms diagnosis
3 = Definite
2 = Suspected
1 = Unlikely
Congenital Cholesteatoma Diagnostic Criteria (Levenson)
- White mass medial to normal TM
- Normal pars flaccida and tensa
- No history of otorrhea or perforations
- No prior otologic procedures
- Prior bouts of otitis media not grounds for exclusion
CHARGE DIAGNOSTIC CRITERIA (Pagon)
Need 4 out of 6 criteria (at least 1 major):
MAJOR:
- Choanal atresia
- Coloboma (ocular- chorioretinal)
MINOR:
- Heart defects
- Genital anomalies
- Retardation of growth
- Ear abnormalities
1st BRANCHIAL ARCH CYSTS Work
Work Type 1: PPP: parallel to EAC, preauricular, purely ectodermal
- Ectodermal
- Doesn’t communicate with EAC
- Runs parallel to EAC. Involves parotid tissue, superior to VII
- cyst lined with squamous epithelium, no adnexa
- usually present as preauricular swellings
Work Type 2:
- Ectoderm and mesoderm
- Cartilage + skin adnexa (hair follicles, sebaceous glands, sweat glands)
- Duplication anomaly of membranous and cartilagenous EAC (EAC and Pinna)
- More intimately assoc with VII (may run through main trunk)
- Myringeal band
- floor of hypotympanum to umbo
- Pathognomonic
- MRI will demonstrate its tract
- pre, infra, post auricular, parotid swelling, posterior or inferior to angle of mandible, ant to SCM but always above hyoid bone
- cyst sinus or fistula anywhere from EAC to submandibular region
8-10% of all branchial arch anomalies Cysts twice as common as sinuses/fistulae
Esthesioneuroblastoma (Dulguerov)
T1 = Involving nasal cavity and/or sinuses (= Kadish 1 and 2)
- Excludes sphenoid and most superior ethmoid cells
T2 = Involving nasal cavity and/or sinuses with extension to or erosion of cribriform plate
- Includes sphenoid
T3 = Extending into orbit or protruding into ACF without dural invasion (K3ish)
T4 = Involving brain (K3ish)
N0 = No cervical LN metastases
N1 = Any form of cervical lymph node metastasis
M0 = No metastasis
M1 = Distant metastases
NEUROFIBROMATOSIS TYPE 1 CRITERIA
Any 2 of the following: 7
>6 cafe au lait spots (>5mm in prepubertal, >15mm in post-pubertal)
> 2 neurofibromas of any type or one plexiform neurofibroma
Axillary or inguinal freckling
Optic glioma
>2 Lisch nodules of the iris
Distinctive osseous lesion- sphenoid wing dysplasia or pseudoarthrosis
1st degree relative diagnosed with NF1
ENDOLYMPHATIC SAC TUMOURS Bambadikis
pre-op embolisation
post-op radio surgery
PARS TENSA RETRACTION (Sade)
- Minimally retracted TM
- Retracted onto incus
- Retracted onto promontory (atelectatic, not adhesive)
- Adhesive otitis
ENDOSCOPIC CORDECTOMY
- Subepithelial cordectomy- epithelium and SLP
- Subligamental cordectomy- epithelium, SLP and vocal ligament
- Transmuscular cordectomy- proceeds through vocalis muscle
- Total cordectomy- vocal process to anterior commissure
- Extended cordectomy
a. Encompasses contralateral VC and anterior commissure
b. Includes the arytenoids
c. Includes the subglottis
d. Includes the ventricle - Encompasses anterior commissure and anterior part of both vocal folds
MCADAM CRITERIA RELAPSING POLYCHONDRITIS EEENT and a Leg
- Recurrent chondritis of both auricles
- Non-erosive, seronegative polyarthritis
- Chondritis of nasal cartilages
- Ocular inflammation incl conjunctivitis, keratitis, scleritis/episcleritis and/or uveitis
- Chondritis of respiratory tract incl laryngeal/tracheal
- Cochlear and/or vestibular damage manifested by sensorineural HL, tinnitus +/- vertigo
(EE2NT and a Leg: eye, 2 ears, 1 nose, 1 throat)
Using the criteria: Damiani and Levine
- >3 criteria- histologic confirmation not necessary
- >1 criteria + histologic confirmation
- 2 or more separate anatomic locations with response to steroids
LATERAL CANAL FISTULA Dornhoffer
I: erosion of bony labyrinth, intact endosteum
II: open perilymphatic space:
IIa: undisturbed perlymph,
IIB: disturbed perilymph
III: open PL space, distubance of membranous labyrinth
RECURRENT RESPIRATORY PAPILLOMATOSIS (Derkay)
Anatomic Score:
Each site scored with
- Surface lesion
- Raised lesion
- Bulky lesion
Anatomic sites:
Epiglottis (lingual/laryngeal), AE fold (L/R), False cords (L/R), True VCs (L/R), Arytenoids (L/R), Ant comm, post comm, subglottis (8)
Trachea- upper 1/3, middle 1/3, lower 1/3, bronchi (L/R), tracheostomy stoma (5)
Other- nose,palate, pharynx, oesophagus, lungs, other (6)
Functional score: 2 2 3 4
- Voice - 0=normal, 1=abnormal, 2=aphonic
- Stridor - 0=absent, 1=present with activity, 2=present at rest
- Urgency of surgery - 0=scheduled, 1=elective, 2=urgent, 3=emergent
- Level of respiratory distress - 0=none, 1=mild, 2=moderate, 3=severe, 4=extreme
Factors significantly associated with repeated interventions:
- Anatomic score > 20
- Stridor with activity vs no stridor
- Urgency of surgery
THYROPLASTY (Isshiki)
Type 1: Medialisation
Type 2: Lateralisation
- Vertical midline cartilage incision through thyroid lamina
- Anterior lateralization of both vocal folds
- Used for Adductor spasmodic dysphonia (alternative to Botox- permanent, doesn’t require repeat injection, voice is breathy)
Type 3: Shortening cord (relax — lower pitch)
- Limited indications. Female-to-male transexuals
- Vocal fold atrophy/scarring/stiffening
Type 4: Elongating cord (tension — increase pitch)
- Cricothyroid approximation (mimics action of cricothyroid muscle). 2 sutures on each side
- Primarily in SLN palsy or male-to-female transexual patients
NEW TNM STAGE P16+ OROPHARYNX SCC
cT and pT (same)
T1 < 2cm
T2 2-4cm
T3 > 4cm or goes to lingual surface of epiglottis
T4 medial pterygoid, hard palate, mandible, larynx, extrinsic tongue muscles and beyond
(difference is no Tis and no T4b)
Clinical N
N0 no nodes
N1 iplateral 1 or more nodes < 6cm
N2 contralateral or bilateral nodes all < 6
N3 any node > 6cm
Pathological N (difference in outcome)
N0 no nodes
N1 < = 4 + nodes
N2 > 4 + nodes
so 2 stages cTNM and pTNM for p16 + only
REINKE’S OEDEMA (Savic)
- Marginal edge oedema
- Obvious sessile swelling, thrown over vocalis muscle during speech
- Large bag-like swelling, filled with fluid
- Partially obstructing lesion, medial borders in contact along most of length
NECK STAGING IN CUTANEOUS SCC - TNM - O’Brien P/N - N1S3 - ITEM
TNM N staging
N1- single node <3cm
N2a- single ipsilateral node 3-6cm
N2b- multiple ipsilateral nodes <6cm
N2c- bilateral or contralateral nodes <6cm
N3- any node >6cm
O’Brien P/N staging
P0- no parotid disease
P1- node <3cm
P2- node 3-6cm or mutliple nodes
P3- node>6cm or involvement- VII/skull base
N0- no nodes
N1- single ipsilateral node <3cm
N2- ipsilateral node >3cm, multiple nodes, contralateral nodes
Demonstrates independent effect of parotid nodes
P3 or N1/2 disease assoc with reduced survival N1S3
- Single node <3cm
- Multiple nodes <3cm or single node >3cm
- Multiple nodes >3cm
NOTE: incorporates parotid as one of the neck sub sites
Demonstrates predictive value for LR control, disease-specific survival, overall survival
ITEM
I= Immunosuppression
T= Treatment
E= Extranodal spread
M= Margins
Only allows post-operative staging
MICROTIA (Marx)
- Slightly smaller ear with majority of structures still present
- Greater deficiency of ear structures (absent helix/lobule)
- Very small auricular tag present (‘peanut’ deformity)
- Anotia
Note Weerda classification:
3 stages, similar to Marx I-III but includes anotia in III
COCHLEAR OTOSCLEROSIS (Shambaugh) S: Schwartz, stapedial reflex biphasic H: history (family) A: audiogram x 2, age B (C): CT scan
7 Diagnostic criteria for cochlear otosclerosis:
- Positive Schwartz sign in either ear
- Family history of otosclerosis
- Unilateral conductive HL typical of otosclerosis with bilateral SNHL
- Audiogram- flat or ‘cookie-bite’ pattern (of bone conduction)with excellent discrimination
- Progressive pure cochlear loss at usual age for otosclerosis onset
- CT scan showing typical demineralisation
- Stapedial reflex demonstrating biphasic “on-off effect” seen before stapedial fixation
Epidemiology:
- Pure cochlear otosclerosis thought to be very rare
Pathogenesis:
Involvement of the cochlea endosteum with an otosclerotic focus
- Progression — atrophy of spiral ligament and stria vascularis — inability to maintain the endolymphatic potential — hair cell loss
Imaging:
CT scan- distinctive pericochlear hypodense double ring appearance = demineralization of bone around the cochlea
Management:
Medical:
- Fluoride- start dose = 60mg, taper to maintenance of 20mg if show a clinical response
- Reduces bone resorption by inhibiting proteolytic enzymes, converts spongiotic lesions to sclerotic (inactive)
- Bisphosphonates- inihibit osteoclast activation
Hearing aid
Surgical
- CI if not aidable hearing (good candidates as preserved discrimination) — increased risk of cochlear ossification and VII stimulation
2ND BRANCHIAL ARCH CYSTS Bailey
Classification of 2nd arch cysts:
Type 1- superficial at border of SCM
Type 2- between SCM and IJV
Type 3- in the carotid bifurcation
Type 4- in the pharyngeal wall
Type II are most common
PHARYNGEAL POUCH
van Overbeek:
Small <1 vertebral body
- CP myotomy Moderate 1-3 vertebral bodies
- Endoscopic stapling
Large >3 vertebral bodies
- External approach CP myotomy + pouch excision/inversion/pexy
Morton and Bailey: (like a T stage)
Small <2cm
Medium 2-4cm
Large >4cm
Management as per van Overbeek
FESS SURGICAL FIELD GRADING (Boezaart)
0 - No bleeding (cadaveric conditions)
1- Slight bleeding — no suctioning required
2- Slight bleeding — occ frequent suctioning
3- Slight bleeding — frequent suctioning required. Bleeding threatens surgical field a few seconds after suction is removed
4- Moderate bleeding — frequent suctioning required, bleeding threatens surgical field directly after suction is removed
5- Severe bleeding — constant suctioning required. Blood appears faster than can be removed by suction - Surgical field severely threatened and surgery usually not possible
PITUITARY TUMOURS (Hardy and Somma)
Grade 1 and 2- confined to pituitary fossa
Grade 3- localised invasion and destruction of the sella
Grade 4- more extensive invasion and extension beyond the sella
Then use the Wilson grading system for extra-sellar extension
NECK DISSECTION
Neck Dissection Classification Update Arch OHNS 2002
Comprehensive ND: dissects Levels I-V
- Radical ND
- I-V + sacrificing XI, IJV, SCM - Modified Radical ND
- Type I- spares XI
- Type II- spares XI and IJV
- Type III- spares XI, IJV and SCM - Extended ND
- Skin, Carotid, XII, levator scapulae
- Additional LN groups- retropharyngeal, post-auricular, occipital
Selective ND: sparing LN groups
- Now classified based on levels dissected
- Previously- supraomohyoid, lateral, posterolateral, central
- Extended SND: take non-nodal structures in addition to limited nodal levels
TYMPANOSCLEROSIS
Stages:
- Confined to TM without hearing loss
- Confined to TM with hearing loss
- Involves middle ear without hearing loss
- Involves middle ear with hearing loss
- TM and middle ear without hearing loss
- TM and middle ear with hearing loss
MERKEL CELL CARCINOMA TNM STAGING
T stage: (unique)
T1- <2cm
T2- 2-5cm
T3- >5cm
T4- deep structures- bone, muscle, fascia, cartilage
N stage:
N1a- microscopic metastasis
N1b- macroscopic metastasis
N2- in transit metastasis (i.e. between primary and regional nodes or distal to primary site)
M stage: (same as melanoma)
M1a- skin, subcutaneous, non-regional lymph nodes
M1b- Lung
M1c- other sites
Staging:
I = Any T1, N0 (subdivide to A and B based on pathologic vs clinical nodal staging)
IIA = T2-T3, N0
IIB - T4 N0
IIIA = Any T N1a (A and B based on microscopic vs macroscopic nodes)
IIIB - Any T N1b N2
IV = Any M1 (no subgroups)
Simplified:
Local (N0)
I = T1
II = T2 3 4
Regional (N+) III = all N+
Mets IV = M
ORBITAL COMPLICATIONS OF SINUSITIS (Chandler/Wormald)
Chandler:
- Pre-septal cellulitis
- Orbital cellulitis
- Subperiosteal (extraconal) abscess
- Orbital (intraconal) abscess
- Cavernous sinus thrombosis
- Bilateral eye signs, obtundation
Wormald:
- Pre-septal- cellulitis vs abscess
- Subperiosteal- cellulitis vs abscess
- Orbital- cellulitis vs abscess
Advantages of Wormald classification:
- Indicates progression of disease
- Guides management- cellulitis vs abscess
- Recognises CST as an intracranial complication 24% with an orbital complication have a co-existent intracranial complication subperiosteal abscess: lenticular shaped
Ear Barotrauma (Teed)
- No visible damage, normal ear
- Congestion around the umbo
- Congestion of entire TM
- Hemorrhage into the middle ear
- Extensive middle ear hemorrhage with blood bubbles visible behind TM; TM may rupture
- Entire middle ear is filled with dark (deoxygenated) blood
MANDIBULAR FRACTURES
condylar most common
PARS FLACCIDA RETRACTION (Tos) scutal erosion starts at III
- Dimpled pars flaccida, not adherent to malleus
- Adherent to neck of malleus
- Part of retraction out of view, minimal scutal erosion
- Definite erosion of scutum, full extent uncertain
SPHENOID/PITUITARY PNEUMATISATION
TRADITIONAL ONE: FOR RHOTONS CLASSIFICATION, SEE OTHER CARD
Conchal: not pneumatised at all, < 5%
Pre-sellar: pneumatised to anterior sellar
Post-sellar: pneumatised beyond anterior sellar, most common 80-90%
LE FORT FACIAL FRACTURES
I: lateral nasal wall - pyriform aperture - alveolar ridge - pterygoid plates
II: frontonasal suture — lacrimal bone - orbital rim - zygomaticomaxillary suture - pterygoid plates
III: frontonasal suture - medial orbital wall - inferior orbital fissure - lateral orbital wall - zygomaticofontal suture - zygomaticotemporal suture Increased risk of CSF rhinorrhea with Le Fort III
LARYNGEAL CHONDRONECROSIS Chandler
Symptoms: about hoarseness and dryness and effects Signs: about oedema and VC mobility
Grade IV: airway obs: trachy; ffff
MALIGNANT OTITIS EXTERNA Dx criteria - modified Levenson (mod by Axon and Moffat)
- Severe otalgia
- Otitis externa refractory to usual treatments
- CT evidence of disease involvement outside EAC Usually, though not essentially:
- Diabetes mellitus
- Psuedomonas culture
The less stringent criteria for 4 and 5 represent the modification by Axon and Moffat of Levenson’s original criteria
Olfactory Esthesioneuroblastoma (Kadish)
STAGE
EXTENT OF TUMOUR
A Limited to nasal cavity
B Nasal cavity and paranasal sinuses
C Beyond nasal cavity and sinuses
D Tumour with mets to cervical nodes or distant mets
N Staging for Nasopharynx
N1 Unilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa*
N2 Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa*
N3 Metastasis in a lymph node(s) >6 cm and/or to supraclavicular fossa (new classification 8th ed, merge N3a and N3b)
N3a Greater than 6 cm in dimension
N3b Extension to the supraclavicular fossa
Ho Staging: (location)
N1- nodes above skin creases at laryngeal cartilage
N2- nodes below larynx, but above supraclavicular fossa
N3- supraclavicular fossa
PERINEURAL INVASION in SCC Panizza review article. Williams et al - definition - pathogenesis
PNI broadly divided into:
- Small nerve or Incidental (No symptoms) - Dx by pathologist
- Large nerve or Named nerve or Clinical (symptoms - paraestheaia / palsy) - Dx clinically
** small nerve <0.1mm, large >0.1mm
Pathogenesis: Cutaneous SCC and BCC mainly
Skin cancer gains access to the perineural space of a peripheral nerve = PNI (perineurium is thin or absent in the subcutis) —> incidental or small nerve invasion.
Tumor then spreads along the perineural space of the nerve away from the original tumor mass = perineural spread (PNS)
—> Cinical deficit manifesting as paresthesia (V) or a palsy (VII).
—> Clinical or large nerve spread (worse prognosis)
PERINEURAL INVASION Panizza review article. Williams et al
PNI broadly divided into:
- Small nerve
- Clinical, large nerve or named nerve
Zones of PNI:
- To skull base foramina
- V1 = SOF - V2 = FR - V3 = FO - VII = SMF - To primary ganglion
- V = Gasserian - VII = Geniculate 3. Cisterns/brainstem Likely non-existence of skip lesions (pathologic evaluation of 50 specimens at PA Hospital Brisbane) Slowly progressive neural deficits suggest malignant aetiology
ETHMOID/NASAL CAVITY SCC T STAGING
- One subsite with/without bony erosion
- 2 subsites or extending to adjacent region of nasoethmoidal complex with/without bony erosion
- Med wall/floor orbit, max sinus, palate, cribriform plate (4) (walls)
4a. Ant orbit, skin of cheek, pterygoid plates, frontal/sphenoid sinus, minimal ACF extension (5) (past the walls)
4b. Orbital apex, dura, brain, MCF, CNs (except V2), NPx, clivus (7)
Subsites of the nasoethmoidal complex:
Nasal cavity
- Septum
- Floor
- LNW
- Vestibule
Ethmoid
- Left
- Right
Inverted Papilloma (Cannady)
- Nasal cavity, ethmoids, medial wall of maxillary sinus
- Ant/lat/sup/inf maxillary sinus, frontal, sphenoid
- Extranasal/extrasinus extension, or any tumour associated with malignancy
Prognosis based on Cannady staging:
- 3% recurrence
- 20% recurrence
- 35% recurrence
Essentially combines Krouse 1 and 2 to a single stage.
POSTERIOR GLOTTIC STENOSIS (Bogdasarian & Olsen, modified by Irving)
- Vocal process adhesion
- Posterior commissure or interarytenoid scar
- Congenital/acquired unilateral CAJ fixation +/- interarytenoid scar
- Congenital/acquired bilateral CAJ fixation +/- interarytenoid scar
Scarring/web results in limited abduction but normal adduction
— Normal voice
CAJ fixation impairs both abduction and adduction
— Dysphonia and airway compromise
Aetiology:
- Congenital
- Acquired- more common, results from intubation trauma
Management:
- Web/scar- can manage with watchful waiting
- Avoid arytenoidectomy- assoc with aspiration, voice difficulty, impairs future treatment options
- Posterior cartilage grafting (ant + post cricoidotomy) procedure of choice
McCaffrey staging Adult Subglottic Stenosis Size and Location of stenosis
- Subglottis or trachea <1cm in length
- Isolated to Subglottis and >1cm in length
- Subglottis/tracheal lesions not involving glottis
- Involving glottis (w VC fixation and paralysis)
LYMPHATIC MALFORMATIONS de Serres Arch OHNS
Predicts: Surgical success, risk of complications, success of sclerosant
HYOID 20 , 40 70 80 100
Infra better than supra, unilateral then bilateral
THYROID CANCER PROGNOSTIC SYSTEMS Low Risk tumours: <4cm, female, <45 years, intrathyroid
AGES (Mayo):
- Age
- grade
- Extrathyroid spread
- Size
AMES (Lahey):
- Age
- metastatic disease
- Extrathyroid spread
- Size
MACIS:
- Metastatic disease
- Age
- Completeness of excision
- Extrathyroid invasion
- Tumour size
TNM Staging:
- Widely used but doesn’t include several important prognostic variables
Stratify tumours:
- Low risk: <45, tumours < 4cm, no extrathyroid spread, well differentiated histo, absence of mets
- Mortality almost zero, recurrence <10% — nodal mets
- Lobectomy may be sufficient - Intermediate: young patients wih unfavourable tumours OR older patients with favourable tumours
- High risk: >45, >4cm, extrathyroid spread, poorly diff, distant mets at presentation
- Mortality up to 50%, Recurrence 30% — distant mets or locally invasive
- Total thyroidectomy (incl approp surgical excision of invasive disease) + CND + SND + RAI
RHABDOMYOSARCOMA Modified TNM staging (pre-op staging for IRS trials)
stage 1 mostly site
stage 2: A and N0 (stage 2 and 3 difference is just size and N1)
stage 3: B, N whatever
stage 4 M1
CUTANEOUS MELANOMA M Staging
M0: no detectable evidence of distant metastasis
M1a: metastasis to skin, subcutaneous or distant lymph nodes
M1b: metastasis to lung
M1c: all other visceral sites or any site combined with elevated LDH
- The mechanism of elevated LDH is unknown/non-specific
STAGES OF AOM HESC
hesc suppuration = infection c for CSOM
PATHOLOGIC GRADING OF THYROID FNA
Thy3f = follicular (15-30% malig), Thy3a = atypia (5-15% malignancy)
COMBINED NASOPHARYNX STAGING 8th ed: removed IVC
I = T1N0
II = T2N0, T1-2N1(max 2 N1)
III = T3N0-1, T1-3N2 (max 3 N2)
IVA = T4N0-3
IVB = (M1 is the new stage)
(compared to the other SCCs, the nodes are not as severe, so go up on the nodes by 1: T2 N1 = stage 2) (1234, 0123): neck is not as bad as others
ALEXANDER’S LAWS
1st degree = only visible on gaze deviation in direction of fast phase
2nd degree = present in primary gaze
3rd degree = visible when eyes deviated to side opposite to fast phase
BRANCHIOGENIC SCC DIAGNOSTIC CRITERIA
- Carcinoma demonstrated arising in the wall of a branchial cyst
- Tumour should occur in a line running from a point just anterior to the tragus along the anterior border of SCM to the clavicle
- Histology should be compatible with an origin from tissue found in the branchial vestiges
- No evidence of high risk HPV should be identified in the tumour tissue
- Suggests cystic metastasis from oropharynx - No other primary should become evident within a five-year follow-up period (unknown primary)
Branchiogenic carcinoma is a rare entity in which carcinoma arises from within the branchial system
- Any diagnosis of branchiogenic carcinoma should be viewed with skepticism
MENIERE’S DISEASE STAGING AAO-HNS 1995
Uses 4-tone PTA (0.5, 1, 2, 4kHz): Initial hearing level
I = <25dB
II = 26-40
III = 41-70
IV = > 71
CHURG-STRAUSS DIAGNOSTIC CRITERIA
Need 4 out of 6:
- Asthma
- Eosinophilia in serum or tissue (>10% of total WCC)
- Pulmonary infiltrates
- Mononeuritis multiplex or migratory polyarthritis
- Nasal polyposis/sinusitis
- Vasculitis 4/6 criteria — 85% specificity WG and CSS overlap in 2: chest (infiltrates) and sinuses!
Malignant Otitis Externa- Clinicopathologic staging
- Clinical evidence of MOE with negative Tc-99 scan
- Soft tissue infection beyond EAC with positive Tc-99 scan
- As above with CN palsies
a. Single vs
b. Multiple - Intracranial complication
- Meningitis, empyema, sinus thrombosis, brain abscess
GRISEL’S SYNDROME
Non-traumatic subluxation of the atlantoaxial joint caused by inflammation of the adjacent tissues.
0: torticollis
1: deformity/fixation, not a subluxation
2: 1 LP 3-5mm
3: anterior bilateral > 5mm
4: posterior
PERINEURAL INVASION in SCC Panizza review article. Williams et al - Zones of PNI in major cranial nerves (skull base) (ganglia)
Zones of PNI:
- Peripheral to skull base foramina - V1 = SOF - V2 = FR - V3 = FO - VII = SMF
- To primary ganglion - V = Gasserian - VII = Geniculate
- Cisterns/brainstem Likely non-existence of skip lesions (pathologic evaluation of 50 specimens at PA Hospital Brisbane) Slowly progressive neural deficits suggest malignant aetiology
Hypopharynx SCC T Staging
T1 Tumor limited to 1 subsite of hypopharynx < 2 cm
T2 Tumor invades more than 1 subsite of hypopharynx or an adjacent site, or 2 - 4 cm in greatest diameter without fixation of hemilarynx
T3 > 4 cm in greatest dimension or with fixation of hemilarynx
T4a Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophagus, or central compartment soft tissue 5
T4b Tumor invades prevertebral fascia, encases carotid artery, or involves mediastinal structures
EPWORTH SLEEPINESS SCALE
8 questions scored 0-3 for each.
Total score = 24 ESS > 12 = definitive OSA, ESS 10-12 = borderline, ESS <8 = normal Very high ESS e.g. 23/24 — consider other Dx such as narcolepsy
Subjective self assessment of degree of sleepiness
MENIERE’S DISEASE AAO-HNS Dx criteria (Modified 2015)
HL- 0.25, 0.5, 1kHz >15dB worse than other side or higher than the average 1, 2, 3kHz thresholds (i.e low freq SNHL) See MD facet in summary cards for new criteria: Definitive or probable
CUTANEOUS MELANOMA T Staging
T1: <1.0mm
a. without ulceration, mitosis <1/mm2
b. with ulceration or mitosis >1/mm2
T2: 1.01-2.0mm
a. without ulceration
b. with ulceration
T3: 2.01mm-4.0mm
a. without ulceration
b. with ulceration
T4: >4.0mm
a. without ulceration
b. with ulceration (same as breslow thickness scale)
Presence of ulceration upstages the tumour by one T stage in terms of prognosis - 10% reduction in 5 year survival
Risk of regional metastatic disease: T2 = 10% T3 = 30% T4 = 40% Need to image neck in T3 and above: if + then dissect the neck, no need for SLNB
Aural Atresia Repair (Jahrsdohfer)
Grading system of candidacy for atresiaplasty
Auricle appearance
Mastoid pneumatization
VII course
Width middle ear cleft
Malleus-incus complex
Incudostapedial continuity
Stapes (2 points)
Oval window patent
Round window patent
Total 10 points
>8 = 80% success
How to remember:
1 nerve- VII
2 windows- OW, RW patency
3 spaces- EAC (auricle appearance), ME width, mastoid pneumatisation
4 ossicles- malleus-incus complex, IS continuity, stapes (2 points)
REFLUX FINDING SCORE 8 questions, highest score 26 aim for RFI < 5
Oedema is the halmark of LPR 8: 5 have 4 scores, 3 have 2 scores
Aural Atresia Repair (De La Cruz)
Ears with minor malformations are better surgical candidates, good possibility of servicable hearing
Major: poor surgical candidates and best treated with a BAHA space window and ossicle (stapes) nerve and ossicle inner ear
WEGENER’S DIAGNOSTIC CRITERIA
American College of Rheumatology (1990) Diagnosis requires 2 out of 4:
- Nasal/oral inflammation
- Abnormal CXR
- Urinary sediment
- Granulomatous inflammation on biopsy
KARTUSCH MIDDLE EAR RISK INDEX COOMPPS
Used to predict success of ME reconstruction procedures
- Otorrhea (Bellucci classification) 1-3
- TM perforation (present/absent = 1 or 0)
- Ossicular status (Austin) M+S+ = 1, M+S- = 2, M-S+ = 3, M-S- = 4, Ossicular head fixation = 2, stapes fixation = 3
- Cholesteatoma (present/absent = 1 or 0)
- Middle ear status (effusion or granular, present/absent = 1 or 0)
- Smoking (yes/no = 1 or 0)
- Prior surgery (staged, revision vs none = 1, 2 or 0)
COOMPPS
Highest score: 13 0 – best prognosis 2 - mild risk 5 – moderate risk 7 – severe risk 12– worse prognosis Lower the MERI the higher the chance of success
Congenital Cholesteatoma Staging (Potsic)
Limited to one quadrant 40%
Involving multiple quadrants without ossicular involvement 14%
Ossicular involvement without mastoid extension 23%
Mastoid involvement 23%
Related to risk of residual disease after excision and poorer hearing outcome - IV —
67% recurrence
OMOM
RHABDOMYOSARCOMA Intergroup Surgical-Pathologic staging
Surgical-Pathologic staging: Guides Rx in the Intergroup Trials
- Complete local resection, clear margins, no nodal disease
- Tumour grossly removed: a) microscopically involved, b) grossly resected regional nodes, c) both
- Grossly residual disease locally (incl after biopsy only)
- Distant mets at presentation
LARYNGOMALACIA Olney et al Laryngoscope 1999
3 Types:
- Redundant arytenoid mucosa prolapses into airway 58%
- Shortened AE folds 15%
- Posterior displacement of epiglottis 12%
Combination of sites in 15%
Direction of collapse:
1 = anterior
2 = lateral
3 = posterior
Guides Rx: 1, 2 — supraglottoplasty 3 — epiglottopexy
POST-TONSILLECTOMY HAEMORRHAGE
LABYRINTHITIS OSSIFICANS
A sequelae of an acute infection
Other causes - temporal bone trauma, vasc obstruction of labyrinthine artery, autoimmune IE dse, leukaemia, otosclerosis, other temporal bone malignancies (CIINT)
3 stages of disease:
- Obliteration of RW niche
- Obstruction limited to inferior segment
- Upper segment obstruction
S. pneumo — severe ossification (exotoxoin mediated) H. flu — less severe ossification (endotoxin mediated — responds well to steroids)
ALLERGIC FUNGAL SINUSITIS (Bent and Kuhn)
Criteria established in 1994:
- Nasal polyposis
- Fungal allergy — Type 1 Hypersensitivity
- CT findings are characteristic - Unilateral, can have bone erosion, double densities on ST windows (Magnesium)
- Eosinophilic mucus — non-invasive hyphae
- Fungal culture/histology
Associated features:
- Unilateral predominance
- Asthma
- Radiographic bone destruction
- Charcot-Leyden crystals
- Serum eosinophilia
SEVERELY DISEASED MAXILLARY SINUS (Wormald)
Grading;
- Normal/slightly oedematous mucosa
- Oedematous mucosa with small polyps, no significant eosinophilic mucus - Reversible disease
- Extensive polyps and tenacious mucus - Non-reversible disease
Guidelines for surgical management:
- Uncinectomy alone and visualise ostium
- Antrostomy to 1x1cm — clearance of sinus, aeration 3. CFT with complete clearance of polyps and creation of large antrostomy (+/- mega-antrostomy)
WULLSTEIN TYMPANOPLASTY
type 2 and 3: you lose the ossicular and canternary lever 4 and 5 lose both plus hydraulic
Hearing result in tympanoplasty Type 1: 0 db Type 2-3: 2.5 db Type 4-5: 27.5 db
Outcomes: Type 1-3: Good is < 15, sufficient 16-30, insufficient > 30db Type 4 and 5: Good < 30, insufficient > 30 dB
Sunderland classification nerve injuries
Seddon initially described 3 stages of nerve injury:
- Neuropraxia: reversible blockage of nerve impulse transmission (nerve intact)
- Axonotmesis- blockage of axolasmic flow. Endoneural tubes preserved, Wallerian degenration occurs
- Neurotmesis- total transection of the nerve Wallerian degeneration occurs over 3-4 days thus distal nerve excitability will be maintained
Sunderland classification:
- Anatomically intact with conduction blockade (neuropraxia) - Recover completely (HB 1)
- Transects axons but maintains intact endoneurium (axonotmesis) - Usually resolve without residual deficits (HB II)
- Transects axons and endoneurium but maintains intact perineurium (neurotmesis) - Aberrant regeneration can occur resulting in weakness and synkinesis in some (HB III-IV)
- Transect entire nerve trunk but maintains intact epineural sheath (neurotmesis) - High incidence of residual weakness, synkinesis, hyperkinesis (HB V)
- Complete transection of entire nerve trunk and epineurium (neurotmesis) - Poor likelihood of spontaneous recovery (HB VI)
Grade 1-3 can be caused by inflammation (HSV, VZV) Grade 4-5- traumatic, iatrogenic, neoplastic
Synkinesis develops in Grade III-V Involuntary movements whilst trying to perform a voluntary movement (esp mass movement)
STAGES OF MASTOIDITIS similar to AOM H E N C E
Mastoiditis can present in the following 5 stages and may be arrested at any point:
- Hyperemia of the mucosal lining of the mastoid air cells — blocks the aditus and disrupts aeration
- Mucous membane thickens and impaired ciliary function prevents drainage - Transudation and exudation of fluid and/or pus within the cells
- Necrosis of bone by loss of vascularity of the septae - Venous stasis, localized acidosis and decalcification of bony septa
- Cell wall loss with coalescence into abscess cavities - Osteoclastic activity softens and decalcifies bony partitions
- Extension of the inflammatory process to contiguous areas
- Direct extension through bone
- Phlebitis/periphlebitis
Contiguous areas: - Bezold’s = neck deep to SCM - Luc’s = zygomatic arch - Citelli’s = posterior belly of digastric Coalescence = osteoClasts
RHABDOMYOSARCOMA Modified TNM staging (pre-op staging for IRS trials)
Classification/Staging:
COMPLEX Parameningeal must be macroscopically cleared at least to be considered low risk
—> however this is usually not considered possible in the paranasal sinuses
—> HENCE parameningeal usually intermediate
A. TNM Staging based on IRS study IV LOCATION
- Any H&N excluding parameningeal
- Non H&N or parameningeal, <5cm (Size A) and N0 3. Non H&N or parameningeal, >5cm (Size B) and/or N1 4. M1
B. Grouping based on disease volume following biopsy or surgery depending on initial management MARGINS/METS I. Complete local resection, clear margins, no nodal disease ‘R0N0’ II. a) Resected but microscopically involved, no nodes ‘R1N0’ b) complete resection but involved regional nodes ‘R0N1’ nodes resected c) both ie. ‘R1N1’ nodes resected III. Grossly residual disease locally (incl after biopsy only) i.e. ‘R2’ IV. Distant mets at presentation C. Prognosticate Low risk tumours must be embryonal Excellent/Low risk (>85% 5 year survival) -Stage I & Group I, II or III (orbit) OR Stage II & Group I (ie. small nasal, completely excised) Very good/low risk (70-85%) -Stage II & Group II OR Stage III & Group I or II (ie. small or large nasal +/- regional nodes, macroscopic clearance / only microscopic disease now remains) Good/Intermediate risk (50-70%) - unresected parameningeal Poor/High risk <30%) - any M+
Mucosal Melanoma (Ballantyne)
STAGE
EXTENT OF TUMOUR
I Confined to primary site
II Primary site with regional nodal metastasis
III Systemic metastasis
OSTEORADIONECROSIS Schwartz & Kagan
Staging system based on clinical features
I = superficial cortical bone necrosis and small ulceration II = cortical and underlying medullary bone necrosis
- IIa = small ulceration, IIb = orocutaneous fistula
III = full thickness bone involvement (incl inferior border) - IIIa = small ulceration, IIIb = orocutaneous fistula
No clearly universal staging system Multiple other staging systems: Epstein: I = resolving, II = chronic persistent, III = progressive Marx: response to HBO
SJOGREN’S DIAGNOSTIC CRITERIA
- Ocular Sx- dry eyes>3months, gravel feeling, tear substitutes
- Oral Sx- dry mouth > 3 months, rec/persistent saliva gland enlargement, drinking to aid swallowing
- Ocular signs- Schirmer’s test <5mm in 5min, other ocular dye score (Rose Bengal)
- Histopathology- focal lymphocytic sialadenitis >1 lymphocytic foci/4mm2 gland tissue
- Salivary gland involvement- unstim flow <1.5mL/15min, sialography- diffuse sialectasis, scintigraphy
- Autoantibodies- Anti-Ro (SSA), Anti-La (SSB) Primary disease- 4/6 criteria (or 3/4 objective criteria 3/4/5/6) Secondary disease- assoc syndrome with either 1 or 2 and 2 of 3-6 Exclusion- H&N irradiation, Hep C, AIDS, Lymphoma, Sarcoidosis, GvH disease 1 and 2 are subjective 3-6 are objective
RTOG MUCOSITIS GRADING - aetiology - risk - managment
Aetiology:
Chemotherapy risks- 5-FU, Doxorubixin, Methotrexate
Radiotherapy risks - dose, fraction size, volume of tissue irradiated
Combination therapy increases risk >90% of patients will get mucositis
Risk of Grade 3 mucositis
41% of H&N patients receiving CRT, 21% of patients receiving RT alone
Management:
Good oral hygiene, dietary modification, topical adhesive anaesthetics
Rx secondary infection (e.g. Candida)
Analgesia - opioid patches
BEHCET’S DISEASE DIAGNOSTIC CRITERIA
Recurrent oral ulceration (3 times in 12 months) GESP And two of the following: - Recurrent genital ulceration - Eye lesions- ant/post uveitis, retinal vasculitis - Skin lesions- erythema nodosum, acneiform nodules - Pathergy — minor trauma leads to development of skin lesions/ulcers Sensitivity 85%, Specificity 96%
THYROID T STAGING
T1a = <1cm, limited to thyroid gland
T1b = 1-2cm, limited to thyroid gland
T2 = 2-4cm, limited to thyroid gland
T3 = >4cm and limited to gland or any tumour with minimal extrathyroid spread- sternothyroid muscle/perithyroid soft tissues
T4a = Beyond thyroid capsule invading: subcutaneous soft tissues, larynx, trachea, oesophagus, RLN
T4b = Invades prevertebral fascia, mediastinal vessels, encases carotid
Mucosal Melanoma AJCC TNM Staging
Aggressive behaviour of even small tumours with high recurrence rates — all tumours T3 or T4:
T-staging:
T3: mucosal disease
T4a: involving deep soft tissue, cartilage, bone, overlying skin
T4b: involving brain, dura, skull base, lower CNs (IX, X, XI, XII), masticator space, carotid, mediastinal structures
N-staging:
N0: no regional LN metastasis
N1: regional lymph node metastasis present
Staging:
Stage 3 = T3N0M0
Stage 4a = T4aN0M0 or T3/T4aN1M0
Stage 4b = T4b any N
Stage 4c = any M1 2/3 in sinonasal cavity 1/4 oral cavity Rest sporadic in other sites
EAC SCC (Modified Pittsburg 2015% Clinics 2015 Updated Pittsburgh staging all N+, T4 now stage IV Clinics 2015 (Ohio State) guide management- I LTBR or Rads; II LTBR + Rads; III S/TTTBR + Rads; IV Palliation or S/TTTBR + Rads
- Limited to EAC without erosion/evidence of soft tissue involvement
- Limited to EAC bone erosion (not full thickness) or limited (<0.5cm) soft tissue involvement
- Full thickness EAC bone erosion, limited soft tissue involvement (<0.5cm), extension to ME/mastoid 4. Soft tissue extension (>0.5cm- TMJ, styloid process, VII palsy), dura, cochlea, med wall ME, carotid canal, jugular foramen, petrous apex, facial nerve paralysis (6) After Arriaga, 1990
Staging:
Is a MODIFIED Pittsburgh staging system
- Facial nerve weakness now T4
- Any N+ is now Stage IV
- Recognises that although rare (5-15%), nodal disease is an ominous sign.
- Neck dissection does not seem to affect survival rate - Majority of deaths are local failure rather than regional/distant spread
Neurofibromatosis Type 2 Diagnostic Criteria (Manchester)
CONFIRMED NF2:
- Bilateral VS OR 2. FHx of NF2 PLUS - Unilateral VS < 30 years OR
- 2 of glioma, schwannoma, meningioma, posterior lenticular opacities
PROBABLE NF2:
- Unilateral VS PLUS
- 1 or more of glioma, schwannoma, meningioma, posterior lenticular opacities - Multiple meningiomas PLUS
- Unilateral VS < 30 years OR
- 1 or more of glioma, schwannoma, posterior lenticular opacities
ergo: you almost always need a VS (except for FH NF2 + 2 of glioma, schwannoma, meningioma, PLO)
GARDNER-ROBERTSON SCALE Acoustic Neuroma
AAO-HNS Committee on hearing and equilibrium guidelines for the eval of hearing presevation in AN 1995 Predicts hearing preservation in patients who undergo surgery / radiosurgery for AN
Can also be used as a scale before and after surgery
RTOG MUCOSITIS GRADING - definition - RTOG grades
Definition: The inflammatory response of the oral-pharyngeal mucosa resulting from systemic chemotherapy or from radiotherapy that includes oral-pharyngeal mucosa within the radiation field
Destruction of rapidly dividing cells or the oral-pharyngeal mucosal epithelium and the secondary release of inflammatory mediators- TNF-a, IL-1b
- Radiation-induced loss of cells in the basal layer
RTOG grades of acute mucositis
- Erythema of mucosa, may experience mild pain not requiring analgesics
- Patchy mucositis (ulcerations) which may produce an inflammatory serosanginous discharge, may experience moderate pain requiring alangesia
- Confluent fibrinous mucositis, may include severe pain requiring opiod analgesics. Bleeding with minor trauma
- Ulceration, haemorrhage or necrosis
- Death resulting from mucositis
CLEFT PALATE
Multiple systems proposed, non universally accepted LAHSHAL — mark each segment c = complete, i = incomplete, x = no cleft
LARYNGEAL WEB Benjamin ABCD: Anatomy is Benjamin, and Cohen is Degree (Extent and Function) ABCDEF Anatomic classification
4 degrees of laryngeal atresia according to their anatomic localisation:
- Glottic
- Subglottic
- Interarytenoid fixation
- Supraglottic
Can be used concurrently with Cohen’s ‘degree’ classification
BENIGN INTRACRANIAL HYPERTENSION Diagnostic Criteria (Dandy)
Dandy criteria:
- Symptoms and signs of raised ICP
- No localising neurologic signs (except VI palsy)
- ICP >25cmH2O
- No cytologic or chemical abnormalities in CSF
- Normal symmetrical ventricles
- Patient is awake and alert
Pathogenesis:
- Possibly resistance to absorption of CSF across arachnoid villi
Signs and Symptoms: (1 ear, 2 balance, 2 eyes, 2 HA)
- Pulsatile tinnitus
- Balance disturbance
- Headaches- worse in am
- Visual disturbance
- Diplopia
- Nausea, dizziness
- Retrobulbar pain
Investigations: .
- MRI
- LP
Management: preserve optic nerve function
- Medical: weight control, diuretics (Acetazolamide), steroids
- Surgical: CSF diversion (VP shunt), optic nerve sheath fenestration
Juvenile Nasal Angiofibroma Staging (Radkowski)
Stage I
IA- limited to nasal cavity
IB- nose and sinuses
Stage II
IIA- minimal extension to PPF
IIB- occupying PPF
IIC- into ITF (or posterior to pterygoid plates, towards foramen lacerum)
- More difficult excision due to invasion of a muscular bed
Stage III
IIIA- skull base erosion (isolated IC extension)
IIIB- intracranial extension (extensive) +/- cavernous sinus invasion
System is based on the Sessions criteria (1991)
- Stage I same as Radkowski
- Stage IIC- add posterior to pterygoid plates
- Stage III- subdivided to A and B
Prior criteria was Chandler (1984)- based on nasopharyngeal carcinoma staging
- JNA is a benign lesion with predictable patterns of spread (unlike NPC)
CUTANEOUS MELANOMA Combined Staging
Localised Disease: N0
- Stage I
- Ia = T1a
- Ib = T1b, T2a
- Stage II
- IIa = T2b, T3a
- IIb = T3b, T4a
- IIc = T4b Regional Disease:
- Stage III
- IIIa- non-ulcerated primary tumour and 1-3 microscopic nodes
- IIIb- non-ulcerated primary and 1-3 macroscopic nodes OR ulcerated primary and microscopic nodes OR non-ulcerated primary and intralymphatic metastasis
- IIIc- ulcerated primary and macroscopic nodes OR ulcerated primary and intralymphatic metastasis OR N3 disease Distant Disease:
- Stage IV- presence of distant metastatic disease OR:
IIIa: a primary and N1a N2a (AAA)
IIIb: a primary and N1bN2bN2c (ABC) b primary and N1aN2a (BAA)
IIIc: b primary and N1bN2bN2c (BBC) N3
Austin-Kartush classification: ossicular status
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SCHAEFER-FUHRMAN Laryngeal Trauma
- Minor endolaryngeal haematomas/lacerations without detectable fracture
- Oedema, haematoma, minor mucosal disruption without exposed cartilage
- Varying degrees of airway compromise, non-displaced fractures - Massive oedema, large mucosal lacerations, exposed cartilage, displaced fractures, VC immobility
- Same as 3 but more severe
- Disruption of anterior larynx, unstable fractures, >2 fracture lines, severe mucosal injury - Complete laryngotracheal separation
Classification helps to guide management:
1 and 2- probably don’t require tracheostomy
3-5- probably do require tracheostomy (Himani asked me this)
4: require likely a stent
5: likely RLN stretched or injured, may need reanastomosis
SINONASAL SARCOIDOSIS (Krespi)
Grades sinonasal symptoms and their suggested treatment:
I- mild, reversible disease without paranasal sinus involvement
- Saline douche, INCS
- 50% went on to develop Stage 2 disease
II- moderate, potentially reversible disease with sinus involvement
- Intralesional steroids — 90% improvement. 10% progress to Stage III
III- severe, irreversible disease
- Systemic and intralesional steroids
SPHENOID PNEUMATISATION - Traditional - 2nd system
AXIAL PLANE (Traditional)
Agenesis of the sinus is said to occur in 0.7% of individuals A small rudimentary conchal sinus confined to the anterior part of the sphenoid is found in <5%
A pre-sellar sinus extends as far as the anterior bony wall of the pituitary fossa in 11-28%.
A sellar sinus that extends posterior to the pituitary fossa is found in the rest (~80-90%)
CORONAL PLANE (Rhoton 2010)
Body type (A) Lesser wing type (B, extends above optic n. into clinoid)
Lateral type -Greater wing (C) -Pterygoid process (D) -Combined (E) most common
Neck N Staging AJCC 8th ed with OPSCC nodes brian sullivan and hwang: current opinion get the article: ICONS study Different N staging for p16 status
clinical p16 + Oropharyngeal SCC Neck nodes (like nasopharyngeal SCC now except no Supraclavs)
N1: single or multiple ipsilateral < = 6 cm
N2: bilateral or contralateral single or multiple nodes < = 6cm
N3: any node > 6cm
pathological (p) p16 + OPSCC
N1 < = 4 nodes +
N2 > 4 nodes +
Overall stage for P16 + OPSCC
stage 1: T0-2N1M0
stage II: T0-3N2 M0
stage III: any T4 any N3 M0
stage IV M1 (234, 123)
MIGRAINE-ASSOCIATED VERTIGO Neuhauser and Lempert
Similar to Menieres disease Definite vestibular migraine:
- At least 2 attacks of vestibular vertigo
- Current/previous Hx of migraine with/without aura Dx by ICHD criteria
- Concomitant migrainous Sx during at least 2 vertigo attacks - H/A, photophobia, phono phobia, aura
- Other causes ruled out by appropriate investigations
Probable vestibular migraine:
- At least 2 attacks of vestibular vertigo One of:
- Current/previous Hx of migraine with/without aura Dx by ICHD criteria OR
- Concomitant migrainous Sx during at least 2 vertigo attacks - H/A, photophobia, phono phobia, aura
- Other causes ruled out by appropriate investigations
LARYNGEAL CLEFT (Benjamin-Inglis)
- To level of cords,
- Below cords into cricoid,
- Cervical trachea,
- Thoracic trachea Niall Jefferson paper 3mm type 1 cleft
SPITE FACTORS FOR OSSICULOPLASTY SUCCESS
Surgical: (P)
- Complexity of surgery
- Scutum + TM need repair
Prosthetic: (O)
- Absence of malleus and/or incus (Austin classification) - Presenting 50dB A-B gap
Infection: (O)
- Chronic otorrhea — greatest adverse effect
- Chronic myringitis (indicates tissue vitality problem)
Tissue: (M)
- Poor general condition- age <5 or >70, poor general health
- Meatoplasty required
- Poor mucosa
Eustachian tube: (M)
- Effusion present
- Severely retracted TM
Most patients have 1-2 factors - Each factor reduces success by 10%
Most significant factors: - Unremitting otorrhea - Damaged/diseased mucosa - Presence of MEE
SKULL BASE HEIGHT (Keros)
Length of the lateral lamella of the cribriform plate
- Thinnest bone in the anterior skull base
Type 1: 1-3mm - Ethmoid roof almost same plane as cribriform plate
Type 2: 4-7mm
Type 3: >7mm
- Ethmoid roof significantly higher than cribriform plate — instrumentation can penetrate the thin and vulnerable lateral lamella
Glottis SCC T Staging T3, T4a T4b same as supra and subglottis
Glottis
▪T1: Tumor limited to vocal cord(s) (may involve anterior or posterior commissure) with normal mobility
- T1a: Tumor limited to one vocal cord
- T1b: Tumor involves both vocal cords
▪ T2: Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility
▪ T3: Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of thyroid cartilage
▪ T4a: Tumor invades through outer cortex of thyroid cartilage and/or to other tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic tongue muscles, strap muscles, thyroid, oesophagus)
▪ T4b: Tumour encases carotid, invades prevertebral fascia, invades mediastinal structures
ANAPLASTIC THYROID T STAGING Straight T4
T4A = intrathyroidal disease
T4B = gross extrathyroidal spread
Oropharynx SCC T Staging p16(-) AJCC 8th ed
p 16 - OPSCC
T1 Tumour < 2cm in greatest dimension
T2 Tumour > 2cm but not more than 4 cm
T3 Tumour >4cm in greatest dimension or lingual surface of epiglottis
T4a Tumour invades larynx, deep/extrinsic muscle of tongue, medial pterygoid, hard palate, mandible (shares 2 with OCSCC) 5
T4b Tumour invades lateral pterygoid, pterygoid plates, lateral nasopharynx, skull base, carotid (shares 3 with OCSCC) 5
P16 + OPSCC: the same except
No Tis ( because of non aggressive pattern of p16+ and no distinct basement membrane in Waldeyers ring )
T4a = T4
T4b has been removed, because its been found that T4a and b in P16+ has no survival difference
Jugulo-Tympanic Glomus Tumours (Fisch)
A touching air ·
Confined to the middle ear space
B touching bone ·
Confined to middle ear, hypotympanum and mastoid
C touching carotid ·
C1- jugular bulb/carotid foramen involvement, not invading carotid ·
C2- invasion of vertical portion of ICA (petrous part) · C3- invasion of horizontal portion of ICA (petrous part·
C4- invasion to foramen lacerum and cavernous sinus
D touching dura ·
D1 <2cm (displacement of the PCF dura for e) · D2 >2cm, e = extradural, i = intradural · D3 unresectable intracranial extension
(e.g De1, De2 vs Di1, Di2, Di3)
De1, De2: Di1: < 2cm intradural, does not involve pontomedullary brainstem
Di2: > 2cm intradural; attached to pontomedullary structures: needs second stage neurosurgical procedure
Di3: unresectable
ENCEPHALOCELE
- Occipital - Cervico-occipital - Low occipital = involves foramen magnum - High occipital = above intact rim of foramen magnum
- Sincipital (25%) assoc with face/anterior skull base - Interfrontal - Frontoethmoidal - Nasofrontal - Nasoethmoid - Naso-orbital
- Basal - Midline - Transethmoid - Sphenoethmoid - Transsphenoid - Lateral - Spheno-orbital - Spheno-maxillary
Subglottis SCC T Staging
T1: Tumor limited to the subglottis
T2: Tumor extends to vocal cord(s) with normal or impaired mobility
T3: Tumor limited to larynx with vocal cord fixation
T4a: Tumor invades through cricoid or thyroid cartilage and/or extends to other tissues beyond the larynx (e.g., trachea, soft tissues of neck, including thyroid, oesophagus)
T4b: invades prevertebral space, encases carotid artery or invades mediastinal structures T4a and b same as hypopharynx
CUTANEOUS MELANOMA N Staging numbers
N1: 1 node
a. micrometastasis — diagnosed after SNB and completion neck dissection
b. macrometastasis — clinically detectable
N2: 2-3 nodes
a. micrometastasis
b. macrometastasis
c. in transit met/satellite without metastatic nodes
N3: > 4 nodes, matted nodes, in transit metastasis with metastatic node Intralymphatic metastases: considerable risk of additional LR and distant metastasis - Small but distinct group of melanoma Satellite: visible cutaneous/subcutaneous metastasis occurring within 2cm of the primary melanoma Microsatellite: microscopic/discontinuous cutaneous/subcutaneous metastasis found on pathologic examination In transit: clinically evident cutaneous/subcutaneous metastasis > 2cm from primary melanoma Micrometastasis: only after elective ND or Sentinel LNB Macrometastasis: clinically detectable node + on FNA or ND
FRONTAL SINUS OSTEOMA Chiu AJR 2005
Grade 1: appropriate for endoscopic approach - Tumour medial to lamina papyracea - Attachment- posterior-inferior along frontal recess - Lesion <75% of AP diameter of frontal recess
Grade 2: limits of endo approach- may benefit from frontal trephine - Tumour medial to lamina papyracea - Attachment- posterior-inferior along frontal recess - Lesion >75% of AP diameter of frontal recess
Grade 3: - Tumour lateral to lamina papyracea - Attachment- anterior or superior within frontal sinus
Grade 4: - Tumour fills entire frontal sinus Grades tumours based on 3 factors:
- Size in relation to size of frontal recess
- Point of attachment
- Location in relation to a virtual sagittal plane through lamina papyracea Related to ability to remove endoscopically
External approach for Grade 3/4 bicoronal flap, ext frontoethmoidectomy - Too large for frontal recess (may take many hours of drilling endoscopically) - Located lateral in frontal sinus - More accurate/safe removal of posterior table attachment (prevent a CSF leak)
Endoscopic options for large osteomas: - Lothrop procedure
Neck N Staging AJCC 8th ed with OPSCC nodes brian sullivan and hwang: current opinion get the article: ICONS study N staging (not broken down by subtype)
Regional lymph nodes (N)
▪ NX: Regional lymph nodes cannot be assessed
▪ N0: No regional lymph node metastasis
▪ N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
▪ N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
- N2a: Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension
- N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
- N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
▪ N3: Metastasis in a lymph node more than 6 cm in greatest dimension For OPSCC cTNM
p16 - N stage: same except all are ENE (extranodal spread -) and only N3b is ENE (+) For overall stage of p16 - OPSCC: same as others
CUTANEOUS MELANOMA Clsrk levels
Clarks
I epidermis
II papillary dermis but not entire thickness
III entire thickness of papillary dermis
IV reticular dermis
V subcutaneous fat
Jugulotympanic Glomus Tumours (Glasscock-Jackson)
Tympanic:
- Limited to promontory
- Fills middle ear space
- Middle ear and mastoid
- Through TM to EAC
Jugular:
- Jugular bulb, middle ear, mastoid
- Under IAC
- Petrous apex
- Beyond petrous apex into clivus, ITF - II-IV may have intracranial extension
GRAVES ORBITOPATHY
Graves Orbitopathy: NOSPECS
- No sign or symptoms
- Only signs limited to upper lid retraction and stare +/- lid lag
- Soft tissue involvement (conjunctiva/lid oedema, conjunctival injection)
- Proptosis
- EOM involvement (usually diplopia)
- Corneal involvement (due to lagphthalmos)
- Sight loss (optic nerve involvement)
COCHLEOVESTIBULAR MALFORMATIONS
Classification of membranous and osseous labyrinth malformations:
- Complete labyrinthine aplasia (Michel)
- Cochlear anomalies- aplasia, hypoplasia, incomplete partition (mondini), common cavity)
- Labyrinthine anomalies- SCC aplasia (CHARGE, SCC hypoplasia
- Aqueduct anomalies- EVA, ECA
- IAC anomalies- narrow, wide
- VIII anomalies- aplasia, hypoplasia
Timing of developmental arrest:
3/40- Michel
4/40- Common cavity (cochlea and vestibule are confluent)
5/40- Cochlear aplasia
6/40- Cochlear hypoplasia
7/40- Incomplete partition (>50% of CV anomalies)
End of 8/40- membranous labyrinth is formed. Osseous lab forms around it (complete by 26/40)
20% of congenital SNHL demonstrate a radiologic abnormality (may be multiple)
- Cochlea 76%
- SCC- 39%
- EVA- 32%
Anomalous VII in 16% of dysplastic ears
Increased risk of CSF leak or perilymph gusher
NECK TRAUMA LEVELS
Zone I- sternal notch-cricoid. Occult injuries. Thoracic injuries incl vascular. Often require sternotomy to control Zone II- cricoid-angle of mandible. 75% of penetrating neck wounds Zone III- angle of mandible-BOS. CN deficits + vascular injury. Difficult access (ant dislocation of TMJ)
COMBINED THYROID STAGING
Age < 45 years:
I M0
II M1
Age > 45 years: (similar to others)
I = T1N0
II = T2N0
III = T3N0, T1-3N1A (nodes)
IVA = T4aN0-1A, T1-4AN1B
IVB = T4B
IVC = M1
10 year cancer specific mortality (2, 15, 30, 60%)
I: 1.7%
II: 15.8%
III: 30%
IV: 60.9%
MTC: (same as above except T3N0 is stage II or moved up a spot)
I = T1N0
II = T2-3N0
III = T1-3N1A
IVA = T4AN0-1A, T1-4AN1B
IVB = T4B
IVC = M1
Anaplastic: IVA = T4A any N M0 IVB = T4B any N M0 IVC = M1
