ENT Staging Systems Flashcards

Question

Congenital Ossicular Anomalies (Cremer)

Answer 1

1. Isolated congenital stapes fixation 30.6% - Footplate fixation - Superstructure fixation 2. Stapes ankylosis assoc with another congenital ossicular anomaly 38.2% - Incus/malleus deformation or aplasia of LPI - Bony fixations of malleus and/or incus 3. Congenital anomaly of OC but mobile stapes footplate - OC Discontinuity 15.3% - Epitympanic fixation 6.3% - Tympanic fixation 6.9% 4. 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)

Answer 2

**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

Answer 3

malleus more important than stapes superstructure ? malleus absent represents worse disease 75-50-25 Only A is a PORP, everyone else is a TORP

Answer 4

(Nasal bones, septum dev?, septum fractured?, septum dislocated?) 1. Simple straight - Without midline deviation 2. Simple deviated - With midline deviation 3. Comminuted nasal bones - B/L nasal bone comminution + deviated septum - Septum does not interfere with bony reduction 4. 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 5. 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)

Answer 5

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

Answer 6

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)

Answer 7

**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

Answer 8

**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

Answer 9

Designated in 2000 **FIVE criteria:** 1. Spontaneous, recurrent epistaxis 2. Mucocutaneous telangiectasia 3. Visceral involvement 4. Family history 5. Genetic testing. Confirms diagnosis 3 = Definite 2 = Suspected 1 = Unlikely

Answer 10

1. White mass medial to normal TM 2. Normal pars flaccida and tensa 3. No history of otorrhea or perforations 4. No prior otologic procedures 5. Prior bouts of otitis media not grounds for exclusion

Answer 11

Need 4 out of 6 criteria (at least 1 major): **MAJOR**: 1. Choanal atresia 2. Coloboma (ocular- chorioretinal) **MINOR**: 3. Heart defects 4. Genital anomalies 5. Retardation of growth 6. Ear abnormalities

Answer 12

**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

Answer 13

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

Answer 14

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

Answer 15

pre-op embolisation post-op radio surgery

Answer 16

1. Minimally retracted TM 2. Retracted onto incus 3. Retracted onto promontory (atelectatic, not adhesive) 4. Adhesive otitis

Answer 17

1. Subepithelial cordectomy- epithelium and SLP 2. Subligamental cordectomy- epithelium, SLP and vocal ligament 3. Transmuscular cordectomy- proceeds through vocalis muscle 4. Total cordectomy- vocal process to anterior commissure 5. Extended cordectomy a. Encompasses contralateral VC and anterior commissure b. Includes the arytenoids c. Includes the subglottis d. Includes the ventricle 6. Encompasses anterior commissure and anterior part of both vocal folds

Answer 18

1. Recurrent chondritis of both auricles 2. Non-erosive, seronegative polyarthritis 3. Chondritis of nasal cartilages 4. Ocular inflammation incl conjunctivitis, keratitis, scleritis/episcleritis and/or uveitis 5. Chondritis of respiratory tract incl laryngeal/tracheal 6. 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

Answer 19

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

Answer 20

**Anatomic Score:** Each site scored with 1. Surface lesion 2. Raised lesion 3. 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** 1. Voice - 0=normal, 1=abnormal, 2=aphonic 2. Stridor - 0=absent, 1=present with activity, 2=present at rest 3. Urgency of surgery - 0=scheduled, 1=elective, 2=urgent, 3=emergent 4. Level of respiratory distress - 0=none, 1=mild, 2=moderate, 3=severe, 4=extreme Factors significantly associated with repeated interventions: 1. Anatomic score \> 20 2. Stridor with activity vs no stridor 3. Urgency of surgery

Answer 21

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

Answer 22

**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

Answer 23

1. Marginal edge oedema 2. Obvious sessile swelling, thrown over vocalis muscle during speech 3. Large bag-like swelling, filled with fluid 4. Partially obstructing lesion, medial borders in contact along most of length

Answer 24

**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 1. Single node \<3cm 2. Multiple nodes \<3cm or single node \>3cm 3. 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

Answer 25

1. Slightly smaller ear with majority of structures still present 2. Greater deficiency of ear structures (absent helix/lobule) 3. Very small auricular tag present ('peanut' deformity) 4. Anotia **Note Weerda classification:** 3 stages, similar to Marx I-III but includes anotia in III

Answer 26

**7 Diagnostic criteria for cochlear otosclerosis:** 1. Positive Schwartz sign in either ear 2. Family history of otosclerosis 3. Unilateral conductive HL typical of otosclerosis with bilateral SNHL 4. Audiogram- flat or 'cookie-bite' pattern (of bone conduction)with excellent discrimination 5. Progressive pure cochlear loss at usual age for otosclerosis onset 6. CT scan showing typical demineralisation 7. 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

Answer 27

**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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

**Neck Dissection Classification Update Arch OHNS 2002** Comprehensive ND: dissects Levels I-V 1. Radical ND - I-V + sacrificing XI, IJV, SCM 2. Modified Radical ND - Type I- spares XI - Type II- spares XI and IJV - Type III- spares XI, IJV and SCM 3. 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

Answer 32

**Stages**: 1. Confined to TM without hearing loss 2. Confined to TM with hearing loss 3. Involves middle ear without hearing loss 4. Involves middle ear with hearing loss 5. TM and middle ear without hearing loss 6. TM and middle ear with hearing loss

Answer 33

**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

Answer 34

**Chandler**: 1. Pre-septal cellulitis 2. Orbital cellulitis 3. Subperiosteal (extraconal) abscess 4. Orbital (intraconal) abscess 5. Cavernous sinus thrombosis - Bilateral eye signs, obtundation **Wormald**: 1. Pre-septal- cellulitis vs abscess 2. Subperiosteal- cellulitis vs abscess 3. 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

Answer 35

0. No visible damage, normal ear 1. Congestion around the umbo 2. Congestion of entire TM 3. Hemorrhage into the middle ear 4. Extensive middle ear hemorrhage with blood bubbles visible behind TM; TM may rupture 5. Entire middle ear is filled with dark (deoxygenated) blood

Answer 36

condylar most common

Answer 37

1. Dimpled pars flaccida, not adherent to malleus 2. Adherent to neck of malleus 3. Part of retraction out of view, minimal scutal erosion 4. Definite erosion of scutum, full extent uncertain

Answer 38

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%

Answer 39

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

Answer 40

**Symptoms**: about hoarseness and dryness and effects **Signs**: about oedema and VC mobility **Grade** IV: airway obs: trachy; ffff

Answer 41

1. Severe otalgia 2. Otitis externa refractory to usual treatments 3. CT evidence of disease involvement outside EAC Usually, though not essentially: 4. Diabetes mellitus 5. Psuedomonas culture The less stringent criteria for 4 and 5 represent the modification by Axon and Moffat of Levenson's original criteria

Answer 42

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

Answer 43

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

Answer 44

PNI broadly divided into: 1. Small nerve or Incidental (No symptoms) - Dx by pathologist 2. 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)

Answer 45

**PNI broadly divided into:** 1. Small nerve 2. Clinical, large nerve or named nerve **Zones of PNI:** 1. To skull base foramina - V1 = SOF - V2 = FR - V3 = FO - VII = SMF 2. 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

Answer 46

1. One subsite with/without bony erosion 2. 2 subsites or extending to adjacent region of nasoethmoidal complex with/without bony erosion 3. 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

Answer 47

1. Nasal cavity, ethmoids, medial wall of maxillary sinus 2. Ant/lat/sup/inf maxillary sinus, frontal, sphenoid 3. Extranasal/extrasinus extension, or any tumour associated with malignancy **Prognosis based on Cannady staging**: 1. 3% recurrence 2. 20% recurrence 3. 35% recurrence Essentially combines Krouse 1 and 2 to a single stage.

Answer 48

1. Vocal process adhesion 2. Posterior commissure or interarytenoid scar 3. Congenital/acquired unilateral CAJ fixation +/- interarytenoid scar 4. 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

Answer 49

1. Subglottis or trachea \<1cm in length 2. Isolated to Subglottis and \>1cm in length 3. Subglottis/tracheal lesions not involving glottis 4. Involving glottis (w VC fixation and paralysis)

Answer 50

**Predicts**: Surgical success, risk of complications, success of sclerosant HYOID 20 , 40 70 80 100 Infra better than supra, unilateral then bilateral

Answer 51

**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:** 1. 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 2. Intermediate: young patients wih unfavourable tumours OR older patients with favourable tumours 3. 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

Answer 52

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

Answer 53

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

Answer 54

hesc suppuration = infection c for CSOM

Answer 55

Thy3f = follicular (15-30% malig), Thy3a = atypia (5-15% malignancy)

Answer 56

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

Answer 57

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

Answer 58

1. Carcinoma demonstrated arising in the wall of a branchial cyst 2. Tumour should occur in a line running from a point just anterior to the tragus along the anterior border of SCM to the clavicle 3. Histology should be compatible with an origin from tissue found in the branchial vestiges 4. No evidence of high risk HPV should be identified in the tumour tissue - Suggests cystic metastasis from oropharynx 5. 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

Answer 59

Uses 4-tone PTA (0.5, 1, 2, 4kHz): Initial hearing level I = \<25dB II = 26-40 III = 41-70 IV = \> 71

Answer 60

**Need 4 out of 6:** 1. Asthma 2. Eosinophilia in serum or tissue (\>10% of total WCC) 3. Pulmonary infiltrates 4. Mononeuritis multiplex or migratory polyarthritis 5. Nasal polyposis/sinusitis 6. Vasculitis 4/6 criteria --- 85% specificity WG and CSS overlap in 2: chest (infiltrates) and sinuses!

Answer 61

1. Clinical evidence of MOE with negative Tc-99 scan 2. Soft tissue infection beyond EAC with positive Tc-99 scan 3. As above with CN palsies a. Single vs b. Multiple 4. Intracranial complication - Meningitis, empyema, sinus thrombosis, brain abscess

Answer 62

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

Answer 63

**Zones of PNI:** 1. Peripheral to skull base foramina - V1 = SOF - V2 = FR - V3 = FO - VII = SMF 2. 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

Answer 64

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

Answer 65

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

Answer 66

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

Answer 67

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

Answer 68

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)

Answer 69

Oedema is the halmark of LPR 8: 5 have 4 scores, 3 have 2 scores

Answer 70

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

Answer 71

**American College of Rheumatology (1990) Diagnosis requires 2 out of 4:** - Nasal/oral inflammation - Abnormal CXR - Urinary sediment - Granulomatous inflammation on biopsy

Answer 72

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

Answer 73

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

Answer 74

Surgical-Pathologic staging: Guides Rx in the Intergroup Trials 1. Complete local resection, clear margins, no nodal disease 2. Tumour grossly removed: a) microscopically involved, b) grossly resected regional nodes, c) both 3. Grossly residual disease locally (incl after biopsy only) 4. Distant mets at presentation

Answer 75

**3 Types:** 1. Redundant arytenoid mucosa prolapses into airway 58% 2. Shortened AE folds 15% 3. 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

Answer 76

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:** 1. Obliteration of RW niche 2. Obstruction limited to inferior segment 3. Upper segment obstruction S. pneumo --- severe ossification (exotoxoin mediated) H. flu --- less severe ossification (endotoxin mediated --- responds well to steroids)

Answer 77

**Criteria established in 1994:** 1. Nasal polyposis 2. Fungal allergy --- Type 1 Hypersensitivity 3. CT findings are characteristic - Unilateral, can have bone erosion, double densities on ST windows (Magnesium) 4. Eosinophilic mucus --- non-invasive hyphae 5. Fungal culture/histology **Associated features:** 1. Unilateral predominance 2. Asthma 3. Radiographic bone destruction 4. Charcot-Leyden crystals 5. Serum eosinophilia

Answer 78

**Grading**; 1. Normal/slightly oedematous mucosa 2. Oedematous mucosa with small polyps, no significant eosinophilic mucus - Reversible disease 3. Extensive polyps and tenacious mucus - Non-reversible disease **Guidelines for surgical management:** 1. Uncinectomy alone and visualise ostium 2. Antrostomy to 1x1cm --- clearance of sinus, aeration 3. CFT with complete clearance of polyps and creation of large antrostomy (+/- mega-antrostomy)

Answer 79

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

Answer 80

**Seddon initially described 3 stages of nerve injury:** 1. Neuropraxia: reversible blockage of nerve impulse transmission (nerve intact) 2. Axonotmesis- blockage of axolasmic flow. Endoneural tubes preserved, Wallerian degenration occurs 3. Neurotmesis- total transection of the nerve Wallerian degeneration occurs over 3-4 days thus distal nerve excitability will be maintained **Sunderland classification:** 1. Anatomically intact with conduction blockade (neuropraxia) - Recover completely (HB 1) 2. Transects axons but maintains intact endoneurium (axonotmesis) - Usually resolve without residual deficits (HB II) 3. Transects axons and endoneurium but maintains intact perineurium (neurotmesis) - Aberrant regeneration can occur resulting in weakness and synkinesis in some (HB III-IV) 4. Transect entire nerve trunk but maintains intact epineural sheath (neurotmesis) - High incidence of residual weakness, synkinesis, hyperkinesis (HB V) 5. 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)

Answer 81

**Mastoiditis can present in the following 5 stages and may be arrested at any point:** 1. 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 2. Transudation and exudation of fluid and/or pus within the cells 3. Necrosis of bone by loss of vascularity of the septae - Venous stasis, localized acidosis and decalcification of bony septa 4. Cell wall loss with coalescence into abscess cavities - Osteoclastic activity softens and decalcifies bony partitions 5. 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

Answer 82

**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 1. Any H&N excluding parameningeal 2. 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+

Answer 83

STAGE EXTENT OF TUMOUR I Confined to primary site II Primary site with regional nodal metastasis III Systemic metastasis

Answer 84

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

Answer 85

1. Ocular Sx- dry eyes\>3months, gravel feeling, tear substitutes 2. Oral Sx- dry mouth \> 3 months, rec/persistent saliva gland enlargement, drinking to aid swallowing 3. Ocular signs- Schirmer's test \<5mm in 5min, other ocular dye score (Rose Bengal) 4. Histopathology- focal lymphocytic sialadenitis \>1 lymphocytic foci/4mm2 gland tissue 5. Salivary gland involvement- unstim flow \<1.5mL/15min, sialography- diffuse sialectasis, scintigraphy 6. 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

Answer 86

**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

Answer 87

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%

Answer 88

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

Answer 89

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

Answer 90

**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

Answer 91

CONFIRMED NF2: 1. Bilateral VS OR 2. FHx of NF2 PLUS - Unilateral VS \< 30 years OR - 2 of glioma, schwannoma, meningioma, posterior lenticular opacities PROBABLE NF2: 1. Unilateral VS PLUS - 1 or more of glioma, schwannoma, meningioma, posterior lenticular opacities 2. 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)

Answer 92

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

Answer 93

**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** 1. Erythema of mucosa, may experience mild pain not requiring analgesics 2. Patchy mucositis (ulcerations) which may produce an inflammatory serosanginous discharge, may experience moderate pain requiring alangesia 3. Confluent fibrinous mucositis, may include severe pain requiring opiod analgesics. Bleeding with minor trauma 4. Ulceration, haemorrhage or necrosis 5. Death resulting from mucositis

Answer 94

Multiple systems proposed, non universally accepted LAHSHAL --- mark each segment c = complete, i = incomplete, x = no cleft

Answer 95

**4 degrees of laryngeal atresia according to their anatomic localisation:** 1. Glottic 2. Subglottic 3. Interarytenoid fixation 4. Supraglottic Can be used concurrently with Cohen's 'degree' classification

Answer 96

**Dandy criteria:** 1. Symptoms and signs of raised ICP 2. No localising neurologic signs (except VI palsy) 3. ICP \>25cmH2O 4. No cytologic or chemical abnormalities in CSF 5. Normal symmetrical ventricles 6. 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

Answer 97

**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)

Answer 98

**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

Answer 99

1. Minor endolaryngeal haematomas/lacerations without detectable fracture 2. Oedema, haematoma, minor mucosal disruption without exposed cartilage - Varying degrees of airway compromise, non-displaced fractures 3. Massive oedema, large mucosal lacerations, exposed cartilage, displaced fractures, VC immobility 4. Same as 3 but more severe - Disruption of anterior larynx, unstable fractures, \>2 fracture lines, severe mucosal injury 5. 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

Answer 100

**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

Answer 101

**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

Answer 102

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)

Answer 103

**Similar to Menieres disease Definite vestibular migraine:** 1. At least 2 attacks of vestibular vertigo 2. Current/previous Hx of migraine with/without aura Dx by ICHD criteria 3. Concomitant migrainous Sx during at least 2 vertigo attacks - H/A, photophobia, phono phobia, aura 4. Other causes ruled out by appropriate investigations **Probable vestibular migraine**: 1. At least 2 attacks of vestibular vertigo One of: 2. Current/previous Hx of migraine with/without aura Dx by ICHD criteria OR 3. Concomitant migrainous Sx during at least 2 vertigo attacks - H/A, photophobia, phono phobia, aura 4. Other causes ruled out by appropriate investigations

Answer 104

1. To level of cords, 2. Below cords into cricoid, 3. Cervical trachea, 4. Thoracic trachea Niall Jefferson paper 3mm type 1 cleft

Answer 105

**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

Answer 106

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

Answer 107

**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

Answer 108

T4A = intrathyroidal disease T4B = gross extrathyroidal spread

Answer 109

**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

Answer 110

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

Answer 111

1. **Occipital** - Cervico-occipital - Low occipital = involves foramen magnum - High occipital = above intact rim of foramen magnum 2. **Sincipital** (25%) assoc with face/anterior skull base - Interfrontal - Frontoethmoidal - Nasofrontal - Nasoethmoid - Naso-orbital 3. **Basal** - Midline - Transethmoid - Sphenoethmoid - Transsphenoid - Lateral - Spheno-orbital - Spheno-maxillary

Answer 112

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

Answer 113

**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

Answer 114

**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: 1. Size in relation to size of frontal recess 2. Point of attachment 3. 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

Answer 115

**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

Answer 116

**Clarks** I epidermis II papillary dermis but not entire thickness III entire thickness of papillary dermis IV reticular dermis V subcutaneous fat

Answer 117

**Tympanic**: 1. Limited to promontory 2. Fills middle ear space 3. Middle ear and mastoid 4. Through TM to EAC **Jugular**: 1. Jugular bulb, middle ear, mastoid 2. Under IAC 3. Petrous apex 4. Beyond petrous apex into clivus, ITF - II-IV may have intracranial extension

Answer 118

**Graves Orbitopathy:** NOSPECS 0. No sign or symptoms 1. Only signs limited to upper lid retraction and stare +/- lid lag 2. Soft tissue involvement (conjunctiva/lid oedema, conjunctival injection) 3. Proptosis 4. EOM involvement (usually diplopia) 5. Corneal involvement (due to lagphthalmos) 6. Sight loss (optic nerve involvement)

Answer 119

**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

Answer 120

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)

Answer 121

**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