General ENT Flashcards
1
Q
Tracheotomy v Tracheostomy
A
tracheOTomy: temporary airway or the actual surgical procedure
tracheoOSTomy: permanent or semi-permanent tracheo-cutaneous fistula
2
Q
Indications for Tracheostomy
A
-Acute or chronic obstruction
(foreign body, laryngeal paralysis, cancer, trauma, craniofacial abnormalities, subglotic stenosis)
-prolonged intubation (to prevent tracheal stenosis).
-improved pulm toilet
-Prevent aspiration
- severe osa
3
Q
Equipment needed for trach
A
Bovie, sens, tracheal dilatory, 15 blade scapel, Debakey’s, tracheal retractors, peanut, Army-Navy retractor, 2-0 silk sutures, cuffed tracheostomy tube or endotracheal tube, 10cc syringe, Mayo scissors
4
Q
Relative CI for Trachs
A
- High PEEP and vent support preventing safe transport or preventing pt from safely tolerating apnea during exchange of the ET tube for the trach appliance
- Bleeding d/o’s
- Anatomy (see other card)
5
Q
Anatomy RF for higher risk tracheostomy
A
♣ Body habitus
♣ Down syndrome (antlanto-occipital instability, prevents neck extension)
♣ Cervical spine fusions (prevent neck extension)
♣ High riding innominate at suprasternal notch
♣ High pressor requirements preventing adequate sedation during procedure 2/2 hypotension
6
Q
Trachea anatomy, general
A
¬ 16-20 hyaline cartilaginous rings connected by fibromuscular membrane
¬ Start: Cricoid cartilage ~6th Cervical vertebra; End: Carina
¬ 10-13cm
¬ Runs superoanterior to inferoposterior
¬ Posterior trachea separated by eso by thin layer of connective tissue “party wall”
7
Q
Trachea vasculature
A
¬ Superior trachea: Inf thyroid aa. branches
¬ Inferior: Bronchial aa. +3rd intercostal
¬ Inf. Thyroid venous plexus
8
Q
Trach Complications: Intraop
A
♣ Hemorrhage/damage to great vessels ♣ PTX ♣ Pneumomediastinum ♣ Damage to party wall/tracheoesophageal fistula ♣ SC emphysema ♣ RLN injury ♣ Airway fire ♣ Cardiopulmonary arrest ♣ Post-obstruction pulm edema CHF Extravasation of fluid into alveoli in response to reduced PEEP
9
Q
Trach Complications: Immediate post-op
A
♣ Obstruction ♣ Displaced tube ♣ Hemorrhage ♣ Wound infection ♣ SC emphysema
10
Q
Trach complications: Delayed
A
♣ Stenosis/tracheomalacia
♣ Granuloma formation
♣ TEF
♣ Tracheoinnominate fistula
11
Q
4 cardinal symp of CRS
A
- Ant/Post nasal mucopurulent drainage
- Nasal obstruction/blockage/congestion
- Facial pain/pressure/fullness
- Anosmia/hyponosmia (Cough in kids)
12
Q
Samter’s Triad
A
- Asthma
- Nasal polyps
- NSAID sensitivity
13
Q
Nasal obstruction DDX
A
- allergic rhinitis,
- chronic nonallergic (idiopathic) rhinitis,
- rhinitis -associated with medication use (rhinitis medicamentosa)
- secondary atrophic rhinitis (ie, “empty nose syndrome”)
14
Q
Maxillary Sinus Hypoplasia Types
A
I: normal uncinate process, a well-defined infundibular passage, and mild sinus hypoplasia 7%
II: absence or hypoplasia of the uncinate process, an ill-defined infundibular passage, and soft-tissue density opacification of a significantly hypoplastic sinus. 3%
III: absence of the uncinate process and a profoundly hypoplastic, cleft-like sinus. 0.5%
15
Q
CRS warning signs
A
Ocular symp: Diplopia, proptosis, Ophthalmoplegia Periorbital edema Fever>102 Severe headache/meningeal signs Significant/recurrent epistaxis
16
Q
Types of CRS
A
- w/ Nasal polyposis
- w/o nasal polyposis (most common)
- allergic fungal (more common in south)
17
Q
CRS time duration
A
> 12 weeks
18
Q
ABRS vs ARS
A
ABRS >10d or if symptoms beginning to improve and then worsen
19
Q
Sinus disease: evaluation history
A
4 cardinal symp duration Exacerbating conditions prior tx prior imaging prior surgery exposure to environmental allergies
20
Q
Exacerbating conditions of CRS
A
- Allergic rhinitis
- Environmental irritants
- Immunodeficiencies
- Mucociliary clearance (CF; PCD)
- Recurrent URIs
- GPA, churg-strauss, sarcoid
- Anatomic abnormality
- Iatrogenic
21
Q
Demonstration of mucosal disease
A
requirement of CRS dx
- purulent mucus/edema
- polyp
- radiographic imaging demonstrating mucosal thickening or opacifications of sinus
22
Q
Nasal endoscopy normally can visualize what:
A
In virgin nose
sphenoethmoidal recess,
sphenoid and posterior ethmoid ostia,
and middle meatus
23
Q
Haller air cells
A
Infraorbital ethmoidal air cells
Clinically significant when: infected–> extension into orbit
Narrowing of ostiomeatal complex–> maxillary obstruction
Inadvertent entry into orbit during FESS
24
Q
Agger Nasi air cells
A
Most anterior ethmoidal air cells
Lie anterolat and inf to frontoethmoidal recess
Anterior above attachment of middle turb
25
Basal Lamellae
Divides ethmoidal air cells into anterior and posterior groups w/ different drainage patterns
26
Ant ethmoid drainage
Hiatus semilunaris and middle meatus
27
Post ethmoid drainage
Sphenoethmoidal recess
28
Nasolacrimal duct empties where?
Into the inferior meatus
29
Ostiomeatal complex
Uncinate process
Hiatus semilunaris
Ethmoid bulla
Ostium of maxillary sinus
Located in middle meatus
30
Samter's triad sensitivity
NSAID sensitivity results in large spectrum of symp
Mild--> congestion
Severe: wheezing/coughing even anaphylaxis
31
Samter Triad Pathophys
Anomaly of archidonic acid metabolism
Increased leukotrienes
COX-1 blockage stops anti-inflam proteins like prostaglandins
32
Surgical mgmt of chronic maxillary sinusitis
Endoscopic uncinectomy w/ or w/o max antrostomy
Caldwell-Luc procedure
Inferior antrostomy
33
Tx differences in CRS w/ and w/o nasal polyps
In CRS w/ polyps--> relieve obstruction w/ intranasal and/or systemic glucocorticoids
34
Common pathogens of ABRS
S. pneumo
H. influ
M. catarrhalis
35
Hiatus semilunaris
Crescent groove in lateral wall.
Inf to ethmoidal bulla
Location where frontal, maxillary and ant ethmoid sinuses drain
Bounded inferiorly and anteriorly by uncinate process of ethmoid
36
Uncinate process
Ethmoid bone, outcropping just anterior to hiatus semilunaris and where the frontal, ant eth and max drain
37
House-Brackman grading
Originally used for Bell's palsy
I: normal
VI: completely paralyzed
38
House Brackman grade II
Slight weakness, slight synkinesis
At rest: normal tone/symmetry
Eyelid closes
Mouth: slight asymmetry
39
House Brackman grade III
Obvious but not disfiguiring difference
Noticeable (not severe) synkinesis, contracture, or hemifacial spasm
At rest: normal tone/symmetry
Eye: complete closure w/ effort
Mouth: Slightly weak w/ max effort
Forehead: slight to moderate movement
40
House Brackman grade IV
Mod-severe dysfx
At rest: normal tone/symmetry
No forehead
**Eye: Incomplete clsoure**
Mouth: Asym w/ max effort
41
House Brackman grade V
Severe
At rest: asymmetry
Barely perceptible motion
42
Best House brackman grade post-nerve graft
Grade III
| takes 4-6 months to see
43
Silent sinus syndrome
can be 2/2 Maxillary hypoplasia
Infraorbit bone destruction leading to enophthalmosis
44
Acute suppurative sialadenitis pathophys and organisms
bacterial infxn
causes: salivary stasis, reduced flow, obsruction, xerostomia
S. aureus**, anaerobes, S. pneumo, E. coli, H. influ
45
Acute suppurative sialadenitis: presentation
Acute swelling, pain, tenderness of gland. Gland massage may result in pus. Gland may be firm.
Fevers, chills, trismus, even dysphagia
MC in parotid gland
46
Acute suppurative sialadenitis: TX
Massage, hot compresses, sialogogues,
Antibiotics: IV nafcillin+ clinda or flagyl as in patient. Can substitute nafcillin for vanc
If no improvement in 2 days consider imaging for possible abscess requiring surgical drainage (modified blair incision)
47
Acute suppurative sialadenitis complications
massive swelling of neck
respiratory obstruction
septicemia
Parapharyngeal space infection w/ potential for Lemierre's syndrome (septic jugular thrombophlebitis)
48
Viral causes of sialadenitis
CMB, EBV, coxsackie, echovirus, HIV
Often bl instead of unilateral
No pus
Less toxic appearing
Symptomatic treatment
49
Mycobacterial Sialadenitis
```
Granulomatous
Rare, seen more in adults
♣ MC in parotid w/ primary TB
♣ MC in Submandibular w/ Disseminated TB
♣ Looks like neoplasm on imaging
♣ Can mimic Acute suppurative sialadenitis
♣ TX: like TB infection
```
50
Mycobacterial infection of cervical LNs
```
Non-TB mycobacteria
• Common in soil, water, food
• MC in kids <5 yo
• Fail Abx therapy
• Violaceous hue characteristic
• FNA has risk of fistula formation and cultures often negative
• TX: Clarithromycin
```
51
Bartonella in Sialadenitis
♣ Cat scratch disease
♣ Local infection of scratch followed 1-2 weeks later by LAD
• LAD can progress over 1-2 weeks and last 2-3 months
• Watch for abscess
TX: OBs unless severe. Rifampin, erythromycin, gentamycin, Cipro all options
52
Sarcoidosis and salivary gland involvement
6-30% have parotid involvement
swelling can last for years but eventually resolves on its own
- sub category Heerfordt syndrome
53
Heerfordt syndrome characteristics
Uveitis
Parotid enlargement
Facial paralysis
-Corticosteroids effective acutely, esp for facial paralysis
54
Sjogren's: general features
♣ Xerostomia, dry eyes, salivary gland enlargement
♣ ~1million people in US dx w/ 2-4x affected. Male:Female 9:1
♣ B- and T- cell mediated damaging exocrine glands
• Histo: focal dense lymphocytic infiltration. T cells dominate
• 44x higher risk of lymphoma
55
Primary vs secondary Sjogrens
♣ 1’ affects exocrine glands alone
| ♣ 2’ has superimposed autoimmune d/o
56
Sjogren's treatment
♣ Tx: symptomatic w/ sialogogues and prevention of dental problems
• Sialologues
♦ Lemon juice
♦ Pilocarpine (muscarinic-cholinergic agonist)
♦ Cevimeline
• Artificial saliva
• Fluoride tx
57
Sjogren's Dx
SSA/Ro, SSB/La. La antibody much more specific
These are not always positive
Other tests for dx
Schirmer's tear test
Salivary flow rate
Lip biopsy of minor salivary gland looking for lymphocytic invasion
58
Chronic Sialadenitis: features
♣ Parotid MC involved
♣ Destroys the duct
♣ Symp often exacerbated by eating
Precipitating events: stasis, obstruction, decreased flow
59
Chronic sialadenitis: Presentation
• Recurrent painful swelling of gland(s)
• Asymmetric, firm, occasionally tender glands
• Gland massage typically reveals decreased output
Saliva Consistency may be more tenacious
Worsen with eating
60
Chronic sialadenitis: TX
```
• Treat cause if possible
• Symptomatically
• Abx during acute flares
• If these fail
♦ Papillary dilation +/- sialodochoplasty
♦ Steroid injection
♦ Dilation of ductal strictures
♦ Ductal ligation to promote gland atrophy
♦ Surgical excision
♦ Sialoendoscopy
```
61
Juvenile Recurrent Parotitis features
¬ 2nd MC salivary gland disorder in kids
¬ Recurrent, nonobstructive, nonsuppurative swelling of unilateral or BL parotid glands
¬ Seen in infancy-12 y/o, most cases stop after puberty
¬ Flare ups require
♣ Intense antibiotics, analgesics and hospital admissions
♣ Unpredictable disease pattern
Idiopathic
62
Imaging of salivary duct/gland
```
♣ US is excellent for stones
♣ Sialography
♣ CT
♣ MRI sialography
♣ Stones <2mm may be missed
```
63
Sialolithiasis features
¬ Calcium carbonate and phosphate+organic cellular debris, glycoproteins
♣ 80% submandibular
• Thought to be bc of more alkaline sliva w/ more Ca and Phos and mucous
• Ducti s also longer
♣ Single stone 75% of the time
♣ Multiple gland involvement 3%
¬ Gout is the only systemic dz known to cause salivary gland calculi
64
Sialolithiasis presentation
¬ Presentation
♣ Like acute suppurative sialadenitis
♣ Recurrent swelling+pain
♣ Not essential for dx, may be incidental
♣ Complications
• Sialadenitis, ductal ectasia, stricture
65
Sialolithiasis treatment
¬ TX:
♣ Depends on location, size, shape
♣ Conservative, sialogogues, gland massage (best for <2mm)
♣ Transoral stone removal, salivary gland excision
♣ Lithotripsy
Sialoendoscopy
66
Sialoendoscopy indications
♣ Mechanical
• Relieve obstruction to salivary flow (strictures and stones)
♣ Nonmechanical
• Dx+TX of inflammatory d/o’s like JRP, autoimmune sialadenitis and radioiodine induced sialadenitis
67
Sialoendoscopy algorithm of stone management based on size and location of stone
¬ Marchal et al. w/ algorithm for stone mgmt.
♣ <4mm submandibular and <3mm parotid can be managed endoscopically
♣ 5-6mm stones, use laser lithotripsy and endoscopic stone removal
♣ >6mm hybrid endoscopic/intraoral
68
Congenital salivary cysts
♣ Dermoid
♣ First branchial cleft cysts
• Type I: duplications of EAC, ectodermal
• Type II: ecto+mesoderm from 1st and 2nd branchial arch
• Both have tracts intimately a/w facial nerve
• Excise during quiet time in order to cure
69
Acquired salivary cyst causes
HIV, trauma, neoplasm, calculi, obstructions
Mucoceles (including ranulas)
Mucous retention cysts (actually have epithelium)
70
Ranulas
¬ mucocele from sublingual gland
♣ From ruptured acini after obstruction or ruptured salivary duct
♣ Cystic swelling in floor of mouth superficial to mylohyoid
• Can also extend into neck along the deep lobe of the submandibular gland
71
Radiation induced salivary gland damage
```
♣ Common after H&N cancer radiation
♣ Parotids more susceptible
♣ 20-30Gy dose can cause xerostomia
• Lipid peroxidation of glandular tissue
♣ Increased risk of pleomorphic adenomas and malignant neoplasms
```
72
Radioactive Iodine-Induced Sialadentis
♣ MC complication of I-131 RAI
• 10-60%
♣ Na-I transporter in salivary tissues concentrates I-131 to 30-40x the level in the plasma
♣ Parotids>submandivular
♣ Dose dependant side effective
♣ Sialoendoscopy mediated irrigation provides symptom relief
73
Trauma to salivary glands
¬ Suspect when: Penetrating injury to anterior border of masseter
¬ Inspect and look for duct
♣ If difficult, take probe through stenson’s duct
¬ TX: End-to-end anastomosis over polyurethane catheter or salivary duct stent w/ 6-0 suture
♣ Leave catheter in place for 2 weeks
¬ If salivary cutaneous fistula develops
♣ Aspirate and apply pressure dressing
♣ 1-2 weeks resolution
♣ Persistent fistula raises suspicion for obstruction. Do sialography
¬ Thoroughly eval facial nerve function
74
Sialoadenosis
```
¬ on-inflamm, nonneoplastic enlargement of salivary gland
♣ Malnutrition
♣ Alcoholic cirrhosis
♣ Celiac dz
♣ Uremia
```
75
Thyroid Embryology
ϖ Thyroid embryology and anatomy
¬ Medial 1st and 2nd pharyngeal pouches (endoderm)
¬ Lateral portion 4th and 5th pharyngeal pouches
¬ Starts at foramen cecum and descends to pretrachea from 4-7weeks gestation
♣ Remnants of this the duct TGDCs
76
Thyroid Histology
♣ Parafollicular C cells
• Ectodermal neural crest cells
• Secrete calcitonin
• Majority located deep within upper 1/3 of lateral lobe (MC location of medullary thyroid carcinoma)
♣ Follicular cells
• Secrete T3, T4
• Stimulated by TSH released from anterior pituitary
Transport and metabolize Thyroglobulin found in the colloid
77
Thyroglobulin
♣ T1/2 = 65hours
♣ Should be 0 after thyroidectomy (may take a month to decrease)
♣ Used mainly as tumor marker for recurrence of PTC or FTC
78
Thyroglobulin antibodies
♣ Cause falsely low levels of thyroglobulin
| ♣ Should concomitantely test for TgAbs when getting Tg
79
Lingual Thyroids
♣ Caused by failure of thyroid to descend. @foramen cecum
♣ 70% of pts w/ lingual thyroids don’t have any thyroid tissue in the neck
♣ Always eval thyroid fx prior to removal of lingual thyroid
80
Thyroid cancer RFs
♣ Ionizing radiation to H&N during childhood
♣ Family history
♣ Gardner syndrome and Peutz-Jeghers a/w PTC
♣ Cowden dz a/w FTC
♣ MEN IIA or IIB a/w MTC
81
Molecular basis of Thyroid cancer
BRAF
RAS
RET/PTC
PPARgamma
82
BRAF mutations in Thyroid cancer
♣ BRAF
• V600E found in 70-80% of tall cell variants and 60% of PTC
♦ Strongly correlated with aggressive features
♦ Specific for PTC
83
RAS mutation in thyroid cancer
• Found in FTC, PTC, and follicular adenoma
• 45% of FTCs
• 10% of PTCs
♦ Almost always a follicular variant
84
RET/PTC mutation in Thyroid cancer
* MC seen in post-radiation
| * 20% of papillary cancners
85
Evaluation of Thyroid nodules
H&P
TSH/Imaging
FNAB
86
H&P Findings indicating increased risk for thyroid malignancy
• Nodules>4cm, lateral cervical LAD, VC immobility, fixed nodule
87
Thyroid incidentalomas vs palpable nodules
risk of malignancy the same
88
TSH levels during workup
Low--> Get T3/T4
| Normal/High--> FNAB
89
Thyroid imaging types
• US
• Radionuclide thyroid scan
♦ Limited role, use if TSH low. Need to determine functional status of nodule. Hot vs cold
♦ Hyperfunctioning nodule obviates need for FNA biopsy
• CT, MRI, PET/CT
♦ Not great for intrathyroid nodules
♦ Excellent ways to evaluate the mediastinal extension or to assess trachea, eso, and/or extrathyroid invasion.
♦ CT w/ contrast will delay post-op RAI by about 3 months
90
Thyroid FNAB
♣ Procedure of choice to eval thyroid nodule
♣ Indications
• Nodule w/ high risk hx if it is >5mm, has microcalcifications, or any abnormal LNs
• >1cm and solid
• >1.5cm with any suspicious US features
• >2.cm with spongiform nodules or mixed nodules
♣ Benign or malignant follicular neoplasms cannot be dx on cytology alone due to capsular or angiolymphatic invasion need to make the diagnosis
91
Thyroid Bethesda FNAB grading system
* 1. Nondx or unsatisfactory (1-4%)
* 2. Benign (0-3%)
* 3. FLUS (5-15%)
* 4. Follicular neoplasm or suspicious for one (15-30%)
* 5. Suspicious for malignancy (60-75%)
* 6. Malignancy (97-99%)
92
Thyroid neoplasm types
```
Thyroid adenoma
PTC
FTC
Anaplastic
Medullary
Lymphomas
Hurthle cell carcinoma
```
93
Thyroid Adenomas
♣ Benign
♣ Encapsulated
♣ Arising from thyroid follicular cells, multinodular goiter, or in thyroiditis
♣ Usually asymptomatic, but pain can be from spontaneous bleeding
♣ Types
• Follicular adenoma MC
• Oncocytic (hurthle cells) adenomas
• Hyalinizing trabecular adenoma
• Nodular adenomatous goiter
♣ Benign FNABs warrant follow up due to False negative rate =5%
94
PTC
```
♣ MC
♣ 2x in woman athan men
♣ Hallmarks: Psammoma bodies w/ calcifications, papillary architecture, nuclear grooves, pseudo-inclusions, micronucleoli
♣ Subtypes
• PT microcarcinoma
• Follicular variant
• Encapsulated variant
• Diffuse sclerosing variant
• More aggressive subtypes
♦ Tall cell
♦ Columnar cell
♣ 35% of patients have cervical LNs involved
```
95
FTC
♣ More aggressive than PTC
♣ More prevalent in iodine deficient regions
♣ Types
• Minimally invasinve
• Widely invasive
♣ DX based on capsular invasion and lymphvascular invasion
• Cannnot make diagnosis based on FNA or frozen sections
Higher rate of distant metastasis at presentation (lung and bones)
96
Hurthle cell carcinomas
♣ Oncocytic is uncommon and is a subtype of FTC
♣ 2x more common in males
♣ Hurthle cell=Large follicular epithelial cell w/ dense eosinophilic cytoplasm
♣ Has the highest rate of distant metastasis compared to PTC and FTC (34%)
97
Anaplastic
♣ 1-3% of primary thyroid malignancy
♣ most aggressive
♣ 5th and 6th decade
♣ many a/w preexisting PTC/Follicular or goiter
♣ P/w rapid growing neck mass w/ airway obstruction or dysphagia
• Usually fixed
98
Medullary
```
♣ Arises from calcitonin secreting parafollicular C cells
♣ Neural crest in origin
♣ 4% of thyroid malignancies
♣ Cervical LN involvement common at presentation
♣ A/w the MEN’s
• MEN IIA
♦ MTC
♦ Pheochromocytomas
♦ Primary hyperparathyroidism
• MEN IIB
♦ MTC
♦ Pheochromocytomas
♦ Musculoskeletal abnormalities (maranoid)
♦ Neuromas of lips, conjunctiva, tongue
RET mutations
```
99
Thyroid lymphomas
♣ <5%
♣ Can arise from preexisting hashimoto thyroiditis
♣ Majority tho are non-hodgkin B cell lymphomas
♣ Presents similar to anaplastic carcinoma
♣ Rapid response to chemo (CHOP) +/- rads
♣ Non surgical
100
Thyroid TNM staging: T
* T1 <2cm
* T2 2-4cm
* T3 >4cm but limited to thyroid
* T4a extends beyond thyroid, invading subq osft tissues, larynx, trachea, eso, RLN
* T4b very advanced dz- invades prevertebral fascia, carotid, mediastinum
101
Thyroid TNM Staging: N
* N1 Regional LN mets
* N1a Mets to level 6
* N1b mets to level I, II, III, IV, or V
102
Thyroid Pre-Op evaluation
¬ Always check VC movement
¬ CT scan to assess tracheoesophageal invasion
¬ Hyperthyroid pts need medical mgmt. to avoid intraop and postop complications
¬ Pts w/ MDC need to be checked for pheochromocytomas
103
RLN anatomy R vs L
¬ R side- loops around R subclavian artery
| ¬ L side- loops around ductus arteriosus and follow a more medial course running along the tracheoesophageal groove
104
Places to ID the RLN
♣ Laryngeal entry point (cricothyroid joint)
♣ Lateral approach
♣ Midpole level
♣ Inferior approach- RLN found in the triangle:
• Trachea medially
• Inf pole superiorly
• Carotid sheath laterally
♣ Relationship to parathyroids
• Superior parathyroids are immediately posterior and lateral to entry point of RLN
105
Thyroid complications
Post-op hematomas
RLN injury
SLN injury
Hypocalcemia
106
Thyroid Post-op hematomas
♣ Can lead to life threatening airway obstruction
♣ Urgently open wound to evacuate hematoma
♣ Take back to OR
107
Thyroid RLN injury
♣ Transient injury not uncommon
♣ Permanent paralysis 1%
♣ Increased risk w/ reoperation and central neck dissection
♣ Symptomatic pts should be managed by VC medicalization including VC injection or thyroplasty
108
Thyroid post-op hypocalcemia
♣ Transient post-op is MC complication from thyroid surgery (25%)
♣ Permanent hypoparathyroidism .4-13% of cases
109
RAI
¬ Recommended for pts with distant mets, T4 and T3s over 45y/o
¬ Requires TSH stimulation (>30mU/L) to increase iodine uptake by thyroid cancer cells
♣ Withdraw thyroid hormone
♣ Thyrogen stimulation
¬ Low iodine diet and avoid iodine exposure (amiodarone, IV contrast) prior to RAI
110
RAI Side effects
♣ Dose dependent acute sialadenitis
♣ Taste disturbance, short term
♣ Nausea
♣ Epiphora 2/2 nasolacrimal duct obstruction
♣ BM suppression
♣ Over time, a low risk of leukemia and secondary malignancies
111
Cervical Fascia Layers
Skin
Superficial
Deep: Investing, pretracheal, prevertebral
112
Cervical Fascia Layers: Superficial contains what?
* Platysma, External and Anterior jugular veins
| * Continues superiorly into the SMAS
113
Cervical Fascia Layers: Deep investing contains what?
* SCM and Trap
* Parotid and SMG
* Stylomandibular ligament
114
Cervical Fascia Layers: Deep pretracheal contains what?
* continuous with buccopharngeal fascia
* Extends from hyoid to aortic arch
* Muscular portion encloses infrahyoid muscles
* Visceral encloses thyroid and parathyroid
115
Cervical Fascia Layers: Deep prevertebral contains what?
Thick, covering of pre vertebral muscles (scalene, longus colli and wapitis)
116
Cervical Fascia Layers: Retropharyngeal space
* potential space b/t pre vertebral and visceral middle fascias
* Extends from skull base to mediastinum
* Alar space “Danger space”
* Easily spreads infection
117
Cervical Fascia Layers: carotid sheath
formed by all three deep cervical fascias
| Contains IJ, CCA, vagus
118
Parapharyngeal space overview
* Mostly fat filled space, but is surrounded by important spaces
* Identifying the direction of displacement of PPS is key in determining origin of mass
119
Parapharyngeal space displacement and the coinciding mass
* Pharyngeal mucosal mass pushes PPS lateral
* Masticator space mass pushes it posteriorly
* Parotid space lesions pushes it medially
* Carotid space lesions push it anteriorly
* Lateral retropharyngeal space mass pushes it anterolaterally
120
True Parapharyngeal space mass lesion DDX
(very few really, vast majority are 2/2 to spaces surrounding it)
* Congenital
* Atypical 2nd branchial clef cyst, lymphatic or venous malformations
* Inflam
* Large ranula
* Infection
* PTA
* Benign
* Lipoma, mixed (pleomorphic adenoma
* Malignant
* SCCa spreading from nasa or oropharynx
121
Thyoid masses on CT. What to look for
* Eval for malignancy
* Features: Spotty calcifications, local invasiveness, thyroid capsule intact, lymphadenopathy
* Assess degree of tracheal deviation and compression
* Mild v. mod v severe
122
Eagle's Syndrome: overview and treatment
* Elongated styloid or calcified stylohyoid ligament
* Causes recurrent sharp throat pain, often with swallowing (CN IX irritation)
* Styloid should be palpable intraorally
* TX: analgesics, antidepressants, anticonvulsants,
* Local anesthesia injection
* intraoral styloidectomy preferred over extra oral
123
Eagle Syndrome Imaging
* CT best for imaging, 3-D recon ideal
* >30mm styloid process abnormal (4% of population will have it and how they measure it varies)
* Look for distance from styloid to tonsil-air interface (Kent, Rath, snyderman paper)
124
MRI: T1
CSF color?
Fat?
CSF dark
| Fat bright
125
MRI: T2
CSF color?
Fat?
Flair sequence utility?
CSF bright
T2 FLAIR= good for edema, blood products (Extra axial collections)
CSF dark
126
MRI: DWI good for?
| Restricted DWI and masses associated with this
diffusion weighted imaging, good for strokes and hypo cellular tumors restrict (medulloblastoma, lymphoma, high grade glial tumors)
Restricted==> bright on DWI and dark on ADC
127
Ludwig's Angina: S/S, organisms, tx
Bilateral infxn of the submandibular, sublingual and submental spaces.
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B/L lower facial edema
Raised FoM
Posterior displacement of tongue
Dysphagia+odynophagia
Airway compromise
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Usually secondary to dental infection
Usually mixed infection from GAS/Staph/Bacteroides
TX: antibiotics, airway mgmt, I&D
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Lemierre's Syndrome: Overall, organism, Imaging, TX
Jugular thrombophlebitis with septic emboli usually to the lungs 2/2 throat infection (PTAs classically in kids). Can easily disseminate from jugular vein causing sepsis
Usually from Fusobacterium
Imaging: CT w/ con best, get CT chest
TX: IV unasyn, flagyl, 3rd gen cephalosporins, may require I&D or even sacrifice of IJ for persistent infection
Unknown if anticoagulation good or bad
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Incidence of OSA in population: men? women?
Men: 9%, middle-aged
Women: 3%
from Wisconsin sleep cohort
Only getting worse
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Sleep disordered breathing
Encompasses: primary snoring (no OSA), upper airway resistance, OSA
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OSA Definition: hypopnea and apnea definition?
Repetitive episodes of airway obstruction consistent with Hyponeas or Apneas. Respiratory effort must be made (unlike central sleep apnea)
Hypopneas- partial obstruction w/ hypoxia and brief sleep arousal
Apneas- complete obstruction for at least 10sec a/w hypoxia and brief arousal
OSA MC in stage 2 or REM sleep
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Medical consequences of untreated OSA
- HTN (increased sympathetic tone from chronic hypoxia)
- CV disease- independent mortality risk w/ stroke, MI, death, arrhythymias
- CVA- increased ICP, decreased cerebral perfusion
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Epworth sleepiness scale: overall
Validated measure of DAYTIME SOMNOLENCE not specific for OSA
<7 normal, >10 problematic
Berlin scale is more specific but more difficult to use
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Physical exam for OSA by anatomy: Nose. DDX
if blocked can cause mouth breathing which can drop the tongue and push the hyoid back
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DDX:
Deviated septum
Turbinate hypertrophy
Nasal polyposis
Concha bullosa
Adenoid tissue
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135
Physical exam for OSA by anatomy: Oral cavity. DDX
- Scalloping of tongue can indicate macroglossia
- Jaw occlusion can be a sign of retrognathia (tongue will be relatively posteriorly positioned)
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DDX:
Size and position of tongue
Scalloping of tongue edges
mandibular or palatal tori
Occlusive status and jaw position
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136
Physical exam for OSA by anatomy: Oropharynx. DDX
Relationship b/t tonsils, tongue and palate can be assessed by Friedman staging
Tonsil size and position
soft palate thickness and position
Uvular size, wrinkles, thickness, position
Medialized lateral pharyngeal walls
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Friedman vs Mallampati
Friedman: tonsil and palate relationship
Friedman--> tongues is not protruded and remains in a neutral position w/ mouth open
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Physical exam for OSA by anatomy: Hypopharynx. DDX
Use FFL
- Mueller maneuver: mouth is closed and nose pinched and patient inhales both sitting and lying down. Poor inter-rater reliability
End-expiration maneuver: (time of most collapse in respiratory cycle). More reproducible and more valid
Assess size and position of tongue base relative to epiglottis, lingual tonsil hypertrophy
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Physical exam for OSA by anatomy: Supraglottis. DDX
Epiglottic shape,
position relative to posterior pharyngeal wall,
size and position of tongue base relative to epiglottis
140
Drug-Induced Sleep Endoscopy (DISE)
Midazolam or propofol induction of sleep
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Asseses VOTE
V: Velum
O: Oropharynx lateral walls
T: Tongue base
E: Epiglottis
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CI: very severe OSA and morbid obesity
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DISE relative indications
- Where clinical findings do not match sleep study outcomes
- failure of primary surgery
- prior to major surgical intervention
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Types of sleep study I-IV
I: PSG: hospital based.
-AHI<15 mild; AHI 15-30 moderate; AHI >30 severe
able to distinguish central vs obstructive
also can allow immediate CPAP therapy and titration
Gold std
II: Patient's home PSG, no technician present. high incidence of lost data
III: Ambulatory sleep study, test of the future. At home but better results and data more easily saved
IV: home oximetry
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Nonsurgical TX for OSA
Behavioral changes: decrease etoh, sedatives, weight reduction (bariatric surgery), positional therapy
CPAP: gold std. need at least 4 hrs/5nights a week but nonadherence an issue
Oral appliance therapy: prevents oropharyngeal or hypopharyngeal collapse
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Surgical TX for OSA: Nasal obstruction
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Septoplasty;
Functional septorhinoplasty for nasal valve surgery
Turbinate surgery
Polypectomy
Endoscopic adenoidectomy
Removal obstructive concha bullosa
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Nose technically does not collapse but can improve perception of sleep quality, decrease daytime symptoms, and improve CPAP compliance
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Surgical TX for OSA: Oropharyngeal obstruction
Usually main area of collapse
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Tonsillectomy
UPPP
Uvulopalatal flap
Expansion sphincteroplasty
Transpalatal advancement pharyngoplasty
Cautery-assisted palate stiffening operation
Soft palate implants
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146
Uvulopalatopharyngoplasty UPPP overview
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Started by Fujita in 1981
Very effective (85%) in pts with Friedman II-IV and palate I-II. Otherwise only 50% effective
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Not appropriate when tongue base collapse is strongly suspected
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Uvulopalatal Flap (UPF)
Variant of UPPP
Adv: muscle is left intact
CI: if palate is overly thick, pts can feel the resulting flap leading to gagging
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Expansion Sphincteroplasty
For pts with narrowed lateral dimension compared to anteroposterior
Thick palatopharyngeus muscles which are then divided
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Transpalatal Advancement
Excessively lengthy hard palates
| Posterior edge of hard palate is trimmed and soft palate is advanced
150
Surgical TX for OSA: Hypopharyngeal/Supraglottic obstruction
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Radiofrequency ablation of tongue base
Lingual tonsillectomy
Hyoid suspension
Midline glossectomy
Supraglottoplasty
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Surgical TX for OSA: Osseus surgery
Genioglossus advancement
| Maxillomandibular advancement: LeFort+BSSO
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Surgical TX for OSA: Trach
Definitive cure for OSA
| Very rarely performed
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Defining Successful Treatment of OSA
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Decrease in AHI less than <50%
Decrease in AHI to less than 20
Improved witnessed apneas
Improved daytime symptoms
Improved comorbidities
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