ENT2 Flashcards
what afferent pupillary defect look like
what does it mean
thee affected pupil doesn’t constrict symetrically when a light is moved from one eye to the other
what will the swinging flashlight test look like
the consensual pupillary reflex will be diminshed in the good eye when the light is shined in the affected eye
causes of afferent pupillary defect
retinal detachment (total)
optic nerve damage
causes of acute vision loss
macular disease
retinal detachments
vein occlusions
arterial onclusions
vitreous hemorrhage
optic nerve trauma
“functional vision loss”
SS macular degeneration
metamorphosia
central scotoma
metamorphosia
a symptom of macular degeneration where a grid of straightlines will appear wavy and some parts of the grid will look black
central scotoma
a symptom of macular degeneration where the middle part of the visual field looks black
why is afferent pupillary defect diagnostically valuable
because you can assess the function of the afferent and efferent nerves in both eyes from one
what would cause a bitempral visual field defect
lesion at the optic chiasma
how would a lesion in the optic tract behind the optic chiasm manifest
contralateral homogogenous hemianopsia (vision lost on the nasal ipsilateral and the temporal contralateral side)
T/F macular degeneration is painless
true
blood under the retina is indicative of what
macular degeneration
intact confrontational visual fields with poor vision is indicative of what
central scotoma from macular degeneration
VEGF inhibition
vascular enthothelial growth factor inhibition, treatment for macular degeneration
what causes macular degeneration
vascular overgrowth in the retinal pigmented epithelium precipitated by an defect
symptoms of retinal detachment
new floaters
flashing lights (photopsia)
visual field loss
what causes retinal detachment
tears that allow the vitreous humor to escape the posterior chamber and flow behind the retina
what is the goal of the scleral buckle
to fix retinal detachment by indenting the posterior eye to remove traction on the retina from the vitreous
vitrectomy
scope operation that fixes retinal detachment by draining the vitreous from behind the retina then putting an air bubble in the vitreous chamber to tamp down the retina
pneumatic retinopexy
repair of a retinal tear on the superior portion of the retina tha tuses are an air bubble in teh vitreous chamber to tamp down the tear why whe pigemented retinal cells pump out eh vitreous
branch retinal occulsion
ischemia in the retina related to HTN caused by a blockage int he retinal veins that releases VEGF`
central RVO
central retinal vein occulsion that can cause blindness of varying severity with no real treatment
caused by compression around teh optic nerve
Branch retinal artery occusion
blockage of the artery associated with carotid/cardiac dieases
may be considered emergent
hollenhort plaque
a piece of cholesterol or calcium from the carotid or heart valves that has lodged in a retinal artery
correlated with high risk of stroke
in central retinal artery occulsion, why would the fovea be red
causes
treatment
because the fovea doesn’t get much blood from the arteries of the eye
thrombosis, embolism
usually untreatable
ciloretinal artery
a branch of the retinal artery that has left the optic nerve and found a different way into the retina
SS optic neuritis
gender bias
imaging
MS
pain with eye movement
APD
usually makes a complete recovery
more young women
MRI is advisable
describe ischemic optic neuropathy
usually optic nerve swelling
usually irrerverislbe
artheritic or non arteritic, both usually in the eldery
describe arteritic ION
elderly women
related to PMR (tender scalp, headache, fever, jaw pain)
can progress to giant cell arteritis
treatment for arteritic ION
stat esr, CRP
immediate referral
start high dose steroids
schedule biopsy
describe non arteritic ION
No GCA symptoms
small disc cup
other involved 25-50%
might be related to nocturnal hypotension
what is one tool that can help localize the location of a stroke
central visual field defect
patient presents with a trauma that lacerates the retina
what might be sequela from this
some visual field lost from retinal artery occlusion
signs of background diabetic retinopathy
dot/blot hemorrhages
hard exudate
cotton wool spots
intraretinal microvascular abnormalities
what causes vision loss in background diabetic retinopathy
macular edema
what is the treatment of diabetic macular edema
advantages
focal laser
painless, mild side effects, reduces severe vision loss by half
pars plana
the area of the eye that can be incised without damaging other structures to allow access to the vitreous and retina
T/F presence of a fovea reflex indicates diabetic macular edema
false, it indicates good retainal health
what do cotton wool spots indicate in terms of progression in diabetic retinal edema
very davanced disease
what is the goal of laser treatment of diabetic edema
but
it coagulate microaneurysms
only 1 in 7 will regain vision
future treatments of DME
surgery
steroids
VEGF inhibitor
oral meds
proliferative diabetic retinopathy
neovascularization of the retina that causes the secretion of VEGF and infiltration of the vitreous
factors that are cocerning for proliferative diabetic retinopathy
can cause true blindness, esp in DM I
important to look for uncontrolled DMI as teens
treatments for PDR
laser
surgery
VEGF injections/steroids
PDR laser treatment
considerations
a more extensive laser treatment
more extensive, treats peripheral retina, can be painful, reduces side/night vision
pars plana vitrectomy
surgical removal of part of the vitreous
diabetic screening for retinal health
DM I, yearly dilated exams starting a puberty or within 5 years of diagnosis
DM II, at diagnosis and yearly after
Gestational: in the first trimester, each trimester as indicated
talking points for patients about diabetic eye disease
most damage is assymptomatic
control is of the ut must importance
encourage them to take charge
DMII can be managed with diet and exercise
T/F HTN is a direct cause of vision loss
false, it can cause many eye issues indirectly
how does HTN affect the eye
worsens DR
vein/artery occlusions
aneurysyms
optic nerve issues
macular degeneration
HTN related signs of poor retinal health
arterial narrowing
AV nicking
exudate
optic nerve swelling
common cause of blindness related to HIV
CMV retinitis
patient presents with hard exudate but no DM or HTN
what might be the cause
hyper lipidemia
retinal side effect of plaquenil
screening
toxicity that can cause bullseye maculopathy
need to have eye exam yearly
T.F maculopathy from plaquenil is reversible
false
structures of the outer ear
auricle and ear canal
strucutres of the middle ear
tympanic membrane, ossicles, middle ear space
structures of the inner ear
cochlea, semicircular canal, internal auditory canals
types of hearing loss
conductive, sensorineural, mixed
what will cause conductive hearing loss
dysfunction of the EAC, TM, or ossicles
what will cause sensorineural hearing loss
dysfunction of the cochlea or neural components of the auditory system
what are the weber and rinne tests used for
to differentiate between senory and conductive hearing loss
what will happen during the weber test if there is CHL
SNHL
normal
CH - sound lateralizes to the bad ear
SNHL - sound lateralizes to the good ear
normal hearing - sound hear equally in both ears
what will happen in a rinne test with normal hearing
CHL
SNHL
air condicution will be better than bone
bone conduction will be equal or better than air
ac conduction will be better than bone
typical causes of conductive hearing loss in the outer ear
wax
otitis externa
trauma
exostosis
osteoma
squamous cell carcinoma
middle ear causes of conductive hearing loss
otitis media
cholesteatoma
otosclerosis
TM perforation
Eustachian tube issue
middle ear barotrauma
causes of SNHL
prebycusis
ototoxic drugs
meniere disease
acoustic neuroma
MS
autoimmune
auricular hematoma
presentation
treatment
complications
tender, fluctuant collection of blood floowling a blunt trauma
drainage, pressure to keep the hematoma from forming, ABx
infection, recurrance, hematoma, cauliflower ear
consideration of treatment for cerumen impaction
treat symptomatic patients
keep in mind you don’t know what is behind the wax
sometimes a patient cannot adequately express their symptoms
what age is most likely to present with a foreign body in the EAC
6
treatment for EAC foreign object
presentation
what types of objects require immediate action
hearing loss, otalgia, otorrhea
penetrating foreign bodies, batteries, live insects
what should be used to kill life insects in the ear
ethanol, mineral oil, lidocaine
common causes for otitis externa
what bacteria are the most common vectors in otitis externa
infection, allergy, dermatological reasons
pseudmonas and staphylococcus
ramsay huny syndrome (herpes zoster oticus)
definition
presentation
an otologic complication of the herpes zoster virus
ipsilateral face paralysis, ear pain, vesicles in the auditoy canal and auricle
clinical presentation of otitis externa
otalgia, itching, ear fullness, possible hearing loss
tenderness at the tragus or pinna
diffuse ear canal edema, erythema
purulent otorrhea
treatment for otitis externa
are ABx always nessasry
Aural toliet
topical therapy with steroids
analgesics
no ABx unless there is an extenstion out side the ear canal or comorbities that raise concern (diabetes, immune deficiency
Eustachian tube dysfunction
etiology
presentation
commonly associated with edema of the URT (viral URI or allegery)
earfullness, popping or cracking when swallowing, mild to moderate hearing loss, retraction or decreased mobility on pneumatic otoscopt
typical presentation of an Overly patent eustachian tube (a.k.a. patulous eustachian tube)
treatment
autophony (exaggerated ability to hear ones breathing and voice)
directed at treating an underlying condition
typical cause of barotrauma
usually flying or scuba diving, in conjuction with an ET dysfunction that prevents equalization
barotrauma
presentation
prevention
referral?
ear pressure, hearing loss, otalgia, tinnitus
avoid activities that might cause injury
if there is SNHL or dizziness, but most will heal on their own
medical prevention of barotrauma
decongestants, antihistamines
causative factors for TM perforation
barotrauma, foreign body injury, infection
what determines the presentaion of hearing loss with TM perforation
depends on the size and location of the perforation
treatment of TM perforation
treat causative factor
most heal on their own, refere for surgical correction
mastoiditis defined
presentation
common complication of acute otitis media that is associated with mastoid bone destruction
fever, post auricular erythema/tenderness, ear proptosis, acute otitis media on otoscopy
how does mastoiditis present on CT scan
loss of mastoid air cells and local bone destruction
treatment of mastoiditis
IV ABx directed against staph pneumo, h flu, strep pyo
myringotomy (incsion of the TM to drain fluid)
mastoid ectome if medical therapy fails
otosclerosis
process in which the stapes loses mobility by excessive bone growth at the oval window
presentation of otosclerosis
treatment
slowly progressive conductive hearing loss that is usually bilateral and assymetric
tinnitus, SNHL
refer to ENT for hearing amplification or surgery
two categories of causes leading to vertigo
peripheral (benign paroxsysmal positional vertigo)
central (MS)
DDx for tinnitus
SNHL (most common)
neuro
ototoxic meds
infection
metabolic disorders
autoimmune
vascular disorders
DDx for tinnitus: neurologic
MS, Tumor
DDx for tinnitus: ototoxic meds
aminoglycosides, cisplatin, aspirin, loop diuretics
DDx for tinnitus; infection
rubella, neurosyphylis, lymdisease
DDx for tinnitus: metabolic disorders
thyroid, chronic renal failure
DDx for tinnitus: autoimmune
RA, SLE
DDx for tinnitus
when to suspect a vascular cause
lab studies?
when the tinnitus is pulsatile
contrast CT, MRI, and angiography
benign paroxysmal positional vertigo etiology
most commonly associated with calcium debris of the posterior semicircular canal (canalthiasis)
benign paroxysmal positional vertigo presentation
recurrent episodes of vertigo lasting one minute or less provoked by sudden head movement
positive dix hallpike manuver with characteristic nystagmus
benign paroxysmal positional vertigo treatment
particle reposition with the epley manuver
labyrinthitis etiology
unknown, maybe viral infection
labyrinthitis presentation
vertigo lasting for several days to a week accompanied by hearing loss
labyrinthitis treatment
vestibular suppressants
anti emetics
corticosteroids
T/F labyrinthtis will recover completely with with time
false, patients my have sporadic vertigo and might never regain hearing
meniere disease etiology
possible fluid in the ear due to abnormal ion homeostasis
meniere disease presentation
episodic vertigo
SNHL that fluctuates and typically affects lower frequencies
tinnitis
aural fullness
meniere disease acute treatment
vestivbular suppressants and antiemetics
meniere disease long term therapy
avoid triggers (high salt, caffiene, alcohol, stress)
diuretics with lifestyle control is ineffective
vestibular rehab with hearingaids
hall mark presentaton of prebycusis
other symptoms
progressive, systemic loss of hearing over many years (SNHL)
tinnitus, vertigo
Presbycusis treatment
hearing aids
assistive listening devices
cochlear implants if hearing aids are ineffective
Vestibular schwannoma (acoustic neuroma) defined
Schwann cell-derived tumors-commonly originating from the vestibular potion of cranial nerve VIII
Vestibular schwannoma (acoustic neuroma) presentation
diagnostic studies
treatment
unilateral SNHL accompanied by tinnitus
MRI is the standard for diagnosis
surgery, radiation, observation
common cold etiology
rhinovirus
Common Cold presentation
rhinitis, congestion, sore throat, cough, sometimes conjunctivitis
typically NOT fever
common cold treatment
symptomatic therapy
Acute rhinosinusitis (ARS) defined
inflammation of the nasal passages and paranasal sinuses lasting up to four weeks combined with purulent nasal discharge, nasal obstruction, sinus pain and pressure
Acute rhinosinusitis (ARS) common cause
viral etiology along with URI or common cold
Acute rhinosinusitis (ARS) presentation
drainage, clogged nose, sinus pain or pressure, fever, fatigue, cough, ear pressure
Acute bacterial rhinosinusitis (ABRS) must fit one of what three presentations
acute rhinosinusitis lasting for 10 days after the onset of URI
acute rhinosinusitis worsening within 10 days after initial improvement
onset of sever symptoms of signs of high fever (+102F), purulent discharge or facial pain, lasting for at least 3-4 days at the beginning of illness
Acute bacterial rhinosinusitis (ABRS) treatment
ABx (amoxicillin or augmentin)
NSAIDs and tylenol
intranasal saline irrigation
intranasal corticosteroids
when would augmentin be prescribed for treatment of Acute bacterial rhinosinusitis (ABRS)
what if they are cilin allegeric
likely ABx resistance (ABx use in the last month)
moderate to severe infection
presence of comorbidities (Diabetes)
use doxyclyclin
Acute bacterial rhinosinusitis (ABRS) complications
orbital cellulitis and abcess
osteomyelitis
intracranial extension
cavernous sinus thrombosis
Recurrent acute rhinosinusitis defined
4+ episodes of acute bacterial rhinosinusitis per year without signs or symptoms of rhinosinusitis between episodes
chronic rhinosinusitis defined
12 weeks or more with
mucopurulent drainage, nasal obstruction, facial pain/pressure, decreased sense of smell AND inflammation documented
chronic rhinosinusitis ways to document inflammation
purulent mucus and edema in the middle meatus or anterior ethmoid
polyps in the nasal cavity or middle meatus
radiographs showing inflamation of the sinuses
classifications of allergic rhinitis
temporal pattern (seasonal)
perennial
episodic
determined by frequency and severity of symptoms
Allergic rhinitis clinical presentation
paroxysms of sneezing, rhinorrhea, nasal itching, obstruction
post nasal drip, cough, fatigue
Allergic rhinitis diagnosis
HP consistent with allegic cause
nasal congestion, rhinorrhea, itchy nose, sneezing
Allergic rhinitis treatment
intranasal glucocorticoids
oral antihistamines
antihistamine sprays
decongestant/antihistamine combo
intranasal cromolyn sodium
montelukast
immunotherapy
Allergic rhinitis treatment with Intranasal glucocorticoids
onset of action
continuous vs intermittent use?
adverse drug reactions
3-5 to 36 hours after first dose
continuous is better than intermittent
headache, throat irriation, epistaxis, nasal dryness
Allergic rhinitis treatment with oral antihistamines
issues with first generation (benedryl)
issues with second (claritin)
lots of side effects (drowsiness)
cause less sedation and useful with patients who need relief from intermittent symptoms
Allergic rhinitis treatment with Oral antihistamine/decongestant combinations
why use them?
adverse drug reactions
nonsedating antihistamines combined with pseduoephedrine provide better relief than antihistamine alone
limit us, include HTN, insomnia, irritability, headache
Intranasal cromolyn sodium
how effective of a treatment is it for allergic rhinitis
mast cell stabilizer that inhibits mast cell degranulation
frequently less effective than intranasal glucocorticoids or 2nd gen antihistamine
montelukast
how it it used in treating allergic rhinitis
selective leukotriene receptor antagonist, less effecive than intranasal glucocorticoids
sometimes used for people with allegies and asthma or nasal polyps
when is immunotherapy used in allergic rhinitis
typically for refractory or severe cases
nasal polyps
pale, edematous, mucosa covered masses that form in the nasal cavity or paranasal sinuses
conditions related to nasal polyps in adults
in kids
chronic sinusitis, ashtma, aspirin sensitivty
cystic fibrosis
samters triad
asthma, aspirin sensitivity, nasal poyps
first line treatment for nasal polyps
intranasal corticosteroids
anterior nose bleeds most typically comes from what
posterior comes from what
up to 90% area of kiesselbach’s plexus
originate most cmmonly from the posterolateral branches of the sphenopalatine artery
epistaxis etiology
trauma
neoplasm
hereditary hemorrhagic telangectasia (osler-weber-rendu)
wegeners
coagulopathy
blood thiners
infection
epistaxis diagnosis
HP with airway and CV assessment
work up for anemia and coagulopathy
labs for severe epistaxsis
CBC for anemia and thrombocytosis
coagulation (PT, INR, PTT)
blood type
epistaxis treatment
ABC’s
conservative (squeeze your nose, bend at the waist
2 sprays of oxymetazoline
chemical or electrocautery for anteriot nose bleed
if the bleeding stops and no source is visualized, observe for recurrance
if epistaxis doesn’t stop with convervative measures
if that doesn;t work then what
if that doesn’t work then what
nasal packing with ABx
ENT consult, pack the oppostive nasal cavity
consider posterior source
unilateral purulent discharge in a young patient suggests what
a foreign body of organic nature
T/F inorganic foreing bodies cause more severe symptoms
false, they are typically assymptomatic
nasal foreign body dx
history or visualized foreign body
when is urgent removeal for a nasal foreign body required
treatment
when to refer
button batteries or paired magnets
positive pressure or direct instrumentation
when the object is posteriorly located, impacted, or penetrating
leukoplakia often indicates what
how often will it progress to carcinoma
when should it be biopsied
hyperkeratosis from chronic infection
1-20% within 10 yrs
indurated or enlarged lesions
erythroplakia
is this more or less indicative of malignancy compared to leukoplakia
red mucosal plaques
more likely to be malignant, should be biopsied
atrophoic glossitis
causes
inflammation of the tonhe that makes the tongue look glossy
iron, b12, folic acid deficient
low protein diet
infection
sjogrens
celiac
what is the most common of periodontal disease
it is a precursor to what
how can it be reversed
gingivits
periodontitis
can be reversed withgood dental hygiene
periodonitis
gingival inflammation that leads to loss of connective tissue and alvolar bone that causes tooth loss
sialadenitis bacterial cause
viral
infection of the salivary glands cuased by staph, strep, h flu though to be caused by retrograde contamination from the oral cavity
mumps
Acute suppurative sialadenitis presentation
pain and swelling of the affected gland
induration, edema, tenderness
possible expression of pus
Acute suppurative sialadenitis treatment
correct predisposing factors
warm compress
sour lozenges
ABx (augmentin)
parotiditis usuallly needs IV Abx
Sialolithiasis
salivary stones, presents with pain and swelling exacerbated by eating
can be imaged if suspected but PE doesn’t reveal an obvious probelm
Sialolithiasis treatment
hydration, warm compress, treat underlying infection
refer if treatment is ineffective or have severe symtpoms
what is considered head and neck cancer
what type of cell is usually effected
generally cancer of the upper aerodigestive tract
usually squamous cells
what is the primary risk factor for head and neck cancer
tobacco use
what does a head and neck oncologist do
management of cerival lymph nodes, salivary glands, thyroid malignancy, otologic maliganancy, paranasal sinus malignancy, cranial base malignancy
diagnostic categories of neck masses
inflammatory
congenital
neiplastic
traumatic
inflammatory neck masses
lymphadenopathy, abscess
congenital neck masses
thyroglossal duct cyst, brachial cleft cyst, dermoid, laryngocele, thymic masses
neoplastic neck masses
benign (paraganglioma, schwannoma, hemangioma, lipoma)
malignant (lymphoma, sailvary, thyroid)
metastatic
DDx of lymphadenopathic neck masses
infection (bacterial, abscess)
caseating granuloma
reactive
sarcoidosis
History clues that can help Dx a neck mass
congenital (age, duration)
inflammatory (infection, pain, fever)
neoplastic (rapid growth, associated symptoms, risk factors, location)
what percent of neck masses in kids are benign vs malignant
what about adults
80% benign, 20% malignany
8-% maliganant, 20% benign
DDx of a +2cm inflammatory neck mass in children
atypical TB, lymphadenitis
DDx of a +2cm congenital neck mass in kids
brachial cleft cyst, thyroglossal duct cyst
DDx of a +2cm neoplastic neck mass in kids
lymphoma, thyroid, sacroma
DDx of +2cm neoplastic neck mass in an adult
SCCA, thyroid, salivary gland, lymphoma
DDx of +2cm inflammatory neck mass in an adult
HIV, TB
DDx of +2cm congenital neck mass in an adult
branchial cleft cyst, thyroglossal duct cyst
what are lymph node stages used for in head and neck surgery
certain primary cancers are know to spread to certain lymph nodes so those nodes can be targeted and removed
describe a brachial cleft cyst
- Lateral neck
- Increase in size with URI
- Second cleft most common
- First associated with parotid
- Third may be associated with thyroiditis
describe thyroglossal duct remnants
- Midline
- Move with swallowing, tongue protrusion
types of imaging used for neck masses
US
CT
MRI
PET
nuc med
midline head and neck cancers
thyroglossal duct cyst
level I lymph nodes
dermoids
thyroid masses
level IV pathology
indications for removal of a substernal goiter
airway obstruction or dysphagia
how is a substernal goiter removed
transcerivcally, sometimes by sternotomy
types of thyroid carcinoma
- Papillary
- Follicular
- Medullary
- Anaplastic
- Lymphoma
- Metastatic (melanoma, renal and others rarely)
what type of thyroid cancer has the best prognosis
papillary, it also is the most common
treatment for thyroid carcinoma
most require total thyroid
radioactive iodine
synthyroid
occasionally external beam
T/F there are many things that can present as a cyst, so it is important to not assume things are a cystic
true
what must be done when lymphoma is suspected
fine needle biopsy to exclude carcinoma
types of carotid body tumor
chemodectoma
paraganglioma
lyre sign
a splayed appearance of the internal and external carotids indicative of carotid body tumor
best treatment for carotid body tumor
surgical removal, but conservative can be used in ellderly patient
what percent of parotid cancers are benign
what percent of submandubular cancer are benign
80% parotid
50% submandibular
T/F sublingula tumors are rare
true
ranula
a mucocele found on the floor of the mouth
what type of cancerous cells are found in parotid tumors
are they primary or mets
squamous cell carcinoma.
usually mets from a cutaneous lesion, but rarely is a primary lesion
pleiomorphic adenoma
a benign tumor of the parotid gland that can convert into a more serious issue if allowed to grown
risks of a deep lobe tumor in the parotid gland
more likely to have a facial nerve insult that causes facial paralysis
T/F squamous cell parotid tumors require nothing post op
false, they need aggressive surgical managment and post operative radiation
vascular lesions associated with head and neck surgery
hemangioma, lymphangioma, vascular malformations
what type of neck masses are most common in children
young adults
adults
inflammatory
congenital or inflammatory
neoplasia
T/F fine needle biopsy is a last resort for aneck mass
false, open biopsy is a last resort
types of head and neck neoplasia
- Carcinoma
- Salivary Gland
- Lymphoma
- Thyroid
- Carotid Body
- Sarcoma
- Melanoma
the unknown primary
cancer in a cervical node with no detectable primary tumor
usually a squamous, undifferentiated tumor
how does HPV cause metastatic head and neck cancer
HPV causes occult tonsil cancer or base of tongue cancer
virus dies, but the tumor still grows
nasopharyngeal carcinoma is related to what virus
epstein bar
common presentation of unknown primary cancer
painless unilateral mass, typically in a non smoking white male
T/F HPV positve oropharyngeal cancers have a worse prognosis than those who have cancer realted to tobacco
false, HPV has a better prognosis
History for unknow primary cancer
- Risk Factors
- Prior Malignancy
- Prior Surgery (including skin or neck)
- Head and Neck Symptoms
- Oromandibular and Dental
- Dysphagia/Odynophagia/Voice complaints
- Epistaxis, Nasal Congestion/obstruction
- Otalgia, Hearing Loss
- Weight Loss
- Fever, Chills, Sweats
clinical presentation of oral cavity cancer
non-healing ulcer, dysarthria, bleeding, pain, loose teeth
clinical presentation of oropharyngeal cancer
referred otalgia, trismus, throat pain, dysphagia, odynophagia
clinical presentation of nasopharyngeal cancer
epistaxis, nasal obstruction, unlateral hearing loss, SOm, Neck mass, cranial nerve palse
why is nasopharyngeal cancer unique
EBV is the carcinogen
what is the treatment for nasopharyngel carcinoma
chemo
clinical presentation of cancer below the pharynx
dysphagia, odynophagia, hoarseness, otalgia, neck mass, sore throat
clinical presentation of laryngeal cancer
muffled voice, hoarseness, sore throat, otaligia, airway obstruction
clinical presentation is tongue cancer
leukoplakia
erythroplasia
mass
ulceration
ill fitting dentures
pain
otalgia
neck mass
what happens during panendoscopy
- Palpation of the base of tongue facilitated
- Evaluation of the pyriform sinuses
- Biopsy of inaccessible regions
- Telescopic Mapping
- Screening for multiple primaries
indications for biopsy of a neck mass
- Progressively enlarging nodes
- Single, asymmetric nodal mass
- Persistent nodal mass, Esp. if no prior signs of infection
- Active infection not responding to conventional antibiotics with routine cultures indeterminate
what is the use of fine needle aspiriation
- Differentiates benign from malignant
- Carcinoma vs. Lymphoid
- Avoids open biopsy
- Standard work-up for thyroid nodule
- Can be used for culture
classic radical neck dissection removes what
internal jugular
SCM
CN XI
modified neck dissection spares what
Type I
Type II
Type III
Type I CN XI
type II IJV and XI
Type III IVJ, SCM, XI
Unusual Presentations of Head and Neck Cancer and Sinonasal and Skull Base Tumors
- Trismus
- Proptosis (unilateral)
- Cheek swelling
- Facial numbness
- Facial Pain
- Intermittent epistaxis
- Facial nerve paralysis
- Nasal obstruction
Lip-Splitting Incisions
Straight
Curved around mental sulcus and chin
“Z” and “V”
Stepped approaches
function of the vocal chords
phonation
airway patency
valsalva
what is the larynx suspended from
the hyoid bone
what is the only complete ring of cartilage in the larynx
the cricoid cartilage, below the thyroid cartilage
accumulation of mucous around teh cricoid cartilage may cause what
stenosis
where is the arytenoid cartilage
on the upper border of the posterior cricoid cartilage
whatis the function of the arytenoid cartilage
allow for attachment of intrinsic muscles of the neck that perfrom complex movements of the larynx
diseases that cause fibrosis or fixation of teh cricoarytenoid cartilage
RA, trauma
describe the composition and location of the true vocal cords
bands of msucle, ligaments, mucosa that run from the arytenoids posterior to the midline of the thyroid cartilage posterior
where are the false vocal cords
what separates them from the true vocal cords
above the true vocal cords
the laryngeal ventricle, that contains mucous producing glands that produce lubrication for the true vocal cords
subdivisions of the larynx
supraglottis, glottis, subglottis
structures in the supraglottis
structures above the true vocal cords
epiglottis, false vocal cords, arytenoglottal folds, arytenoids
location and structures in the glottis of the larynx
true vocal cords and the area adjecent extending 1 cm below
location and structures of the subglottis
the region of the larynx extending from the inferior edge of the glottis down to the inferior edge of the cricoid cartilage
what CN innervates the laryngopharynx
the vagus
describe the course of the reccurrent laryngeal nerve
on the left it passes under the aortic arch, on the right it passes under the subclavian, then it reenters the ekc at the thoracic inlet
what nerve innervates all the intrinsic muscles of the larynx
the reccurrent laryngeal nerve
problems assocaited with laryngeal dysfunction
hoarseness (often with weakness, fatigue, strained voice)
stridor
when should hoarseness be refered to ENT
when there are no URI symptoms, lasts more than 2 weeks
accompanied by risk factors for head and neck cancer, severe cough, hemoptysis, unlateral ear or throat pain, dysphagia, unexplained weight loss
typical causes of hoarseness
acute/chronic laryngitis
benign vocla cord lesion
maliganacy
neuro dysfunction
systemic condition
how long does acute laryngitis last
what is it usually associared with
3 weeks (self-limiting)
usually a URI (rhinorrhea, cough, sore throat) or acute vocal strain
typical vectors that can cause acute laryngitis
treatment
M cat, H flue, strep pneumo
usually resolves with conservative treatment
ABx not needed
sterds can be given if there is a pressing need to use their voice
chronic laryngitis
laryngitis that lasts longer than 3 weeks
factors associatd with chronic laryngitis
referral?
inhaled irritants (smoke, GERD, alcohol)
yes, requires laryngoscopy
laryngopharyngeal reflux
retrograde movemnt of gastric contents into the laryngopharnyx
Laryngopharyngeal Reflux symptoms
–dysphonia/hoarseness
–globus pharyngeus
–mild dysphagia
–chronic cough
–nonproductive throat clearing
globus
feeling like there is something in the throat
T/F most people are aware of Laryngopharyngeal Reflux and easy to diagnose
false, they are often assymptomatic so all other conditions must be ruled out then confirmed with laryngoscopy
treatment for Laryngopharyngeal Reflux
full strength PPI for 3 months
Laryngopharyngeal Reflux reccomendation
avoid foods that strip mucous from the esophagus (coffee, tea, peppermit(
avoid acidic foods
no smoking
eat smaller meals
avoid exercise for 2 hours after eating
what causes Unilateral Vocal Cord Paralysis
unilateral RLN injury from malignancy, iatrogenic injury, ET tubes, trauma, degenerative disorders
Unilateral Vocal Cord Paralysis signs
weak, breathy voice
risk for aspiration
Bilateral Vocal Cord Paralysis caauses what
why
stridor
beccause the non functrional vocal cords cause glottal stenosis
T/F Bilateral Vocal Cord Paralysis leaves the voice intact but has impaired respiratory function ranging from moderate stridor to respiratory distress
treu
causes of Bilateral Vocal Cord Paralysis
iatrogenic
ALS, diabetic neuropathy, myasthenia gravis, organophosphate pesticide toxicity, stroke, head injury
Laryngeal Growths are manifestations fo what
irritation caused by smoking, reflux, muscle tension, trauma
T/F Laryngeal Growths tend to be bilateral
false, they tend to be unilateral with a contralateral friction lesion, though some “screamer nodes” can occur that are bilateral
epiglottis
Infectious epiglottitis is a cellulitis of the epiglottis and adjacent tissues that can result from bacteremia and/or direct invasion of the epithelial layer by the pathogen
what is the major risk of epiglottis
infection that will cause swelling and eventually result in airway obstruction
what is the most common cause of epiglottis in kids
H flu, but also associated with strep, staph, mrsa
what is the most common cause of epiglottis in adults
viruses, but can be bacterial, fungal, or a combination
epiglottis in immunocompromised hosts can be caused by wha
pseudomonas aeruginosa or candida
clinical findings associated with epiglottis in kids
respiratory distress (stridor, tachypnea, tripod breathing)
sore throat
dysphasia
muffled voice
retractions
management and treatment of epiglottis
intubation
epiglottal culture
ABx
T/F pediatric epiglottitis can be confirmed with a through oral exam
false, adults can be examined but children can gag and completely close their glottis
thumb sign
a radiographic sign of epiglottis where it is so inflammed it looks like a thumb in the neck
