General ENT Flashcards
Sensitivity
The ability of a test to identify correctly those patients with the disease
Specificity
The ability of a test to identify correctly those patients without the disease
Is high sensitivity or specificity most important for a screening test?
Sensitivity
Type I error
The chance of testing positive among those without the condition; false positive rate = 1-specificity
Type II error
The chance of testing negative among those with the condition; false negative rate = 1-sensitivity
Positive predictive value
The chance of having the condition among those that test positive
Negative predictive value
The chance of not having the condition among those that test negative
A cervical spine X ray revealing a greater than 5mm widening of the predentate space (between the anterior surface of the dens and the posterior surface of the C1 tubercle) is worrisome for what traumatic injury?
Atlantoaxial dissociation
Traditional xray view for facial bones and neck (largely now replaced by CT)
- Lateral view (5 degrees of true lateral) - frontal, maxillary and sphenoid sinus
- Caldwell view (15 degrees off caudal angulation) - frontal sinuses, posterior ethmoid air cells, orbital floor
- Waters view (neck in 33 degree extension) - maxillary sinuses, anterior ethmoid air cells, orbital floor
- Submentovertex view (AP projection, head in 90 degrees of extension) - sphenoid sinuses, anterior and posterior wall of frontal sinuses
- AP and lateral views - soft tissues of the neck
Schuller view
lateral xray view of the mastoid with 30 degrees of cephalocaudad angulation
Stenvers view
Xray view of the petrous apex with patient facing the film, head slightly flexed and turned 45 degrees opposite the film
Towne view
Xray comparison of both mastoid bone and petrous pyramids via AP view with 30 degree tilt
T1 weighted appearance of water and fat on MRI
Low intensity and high intensity respectively
What does the presence of an echogenic (fatty) hilum typically indicate during US of the neck?
Benign disease. Normal lymph nodes have a fatty hilum whereas an absent hilum is often seen with metastic lymph nodes
Differences between first and second generation antihistamines
Compared with first generation, second generation meds generally have a longer duration of action, less CNS penetration and are less sedating.
Contraindications to glucocorticoid steroid use
Psychosis, severe diabetes, peptic ulcer disease, congestive heart failure, severe hypertension, systemic TB, osteoporosis
What severe neurologic side effect is associated with intramuscular administration of prochlorperazine (used for nausea and vomiting and schizophrenia)?
Extrapyramidal side effects including focal dystonia
Maximum dose of lidocaine
4-5mg/kg without epi 7mg/kg with epi, maximum total dose of 300mg
What medication can be given to reverse the effects of local injectable epinephrine?
Local infusion of 1.5-5mg of phentolamine
What is the mechanism of action for Beta lactam antibiotics
Binds to DD transpeptidase and inhibits the formation of peptidoglycan cross links in the bacterial cell wall.
What is the mechanism of action of aminoglycosides?
They irreversible bind to the 30S ribosome and freeze the 30S initiation complex. Additionally, they cause misreading of the mRNA code (bactericidal)
A mutation in which a gene may lead to increased aminoglycoside toxicity even at low doses?
Mitochondrial 12S ribosomal RNA gene
Mechanism of action of macrolides
They inhibit translocation of the peptidyl tRNA from the A to the P site on the ribosome by binding to the 50S ribosomal RNA (bacteriostatic)
Most common antibiotics that have been implicated in the development of C. diff
Second and third generation cephalosporins, ampicillin/amoxicillin, and clindamycin
A child develops gray staining of the teeth with a prominent horizontal line across the upper and lower teeth after being prescribed an antibiotic. Which antibiotic was most likely prescribed?
Tetracyclin
Mechanism of action of aspirin
Irreversible acetylation of COX1. Effects last for the lifetime of the platelet which is 7-10days.
What drug can be given to reverse the antiplatelet effects of nonsteroidal anti-inflammatory drugs?
Desmopressin acetate (DDAVP)
In the event of significant bleeding following administration of heparin, what medication should be considered?
Protamine
Mechanism of action of warfarin
It is a vitamin K antagonist that inhibits the production of vitamin K dependent clotting factors
Mechanism of malignant hyperthermia?
An abnormal ryanodine receptor causes overwhelming amounts of calcium to be released from the sarcoplasmic reticulum of skeletal muscle thereby initiating prolonged and intense muscle contraction.
Initial treatment for malignant hyperthermia
Stop anesthetic, give dantrolene, increase O2, initiate cooling measures
Physical exam findings of cardiac tamponade
tachycardia, paradoxical pulse with respirations, hypotension, jugular vein distension, muffled cardiac sounds, decreased QRS amplitude on ECG
What complications may be encountered in a patient who has received massive intraoperative transfusions?
volume overload, hyperplasia or hypokalemia, hyperamonemia, acidosis, thrombocytopenia, coagulation factor depletion, coagulopathy, hypothermia, transfusion related acute lung injury, citrate toxicity (which causes hypocalcemia)
What common rule can be used to select the tidal volume and rate for a patient on assist control mechanical ventilation?
12-12 rule. 12ml/kg of lean body mass delivered 12 times a minute. Needs to be adjusted for lung disease (COPD)
What is the difference in the FEV1/FVC ratio in COPD vs restrictive lung disease
FEV1/FVC is decreased in COPD and increased or preserved in restrictive lung disease
Treatment of post obstructive pulmonary edema
Oxygen, supportive care, PEEP. Diuretic therapy can be instituted although benefit is unclear.
Ddx of the febrile patient after surgery
Wind: pneumonia, aspiration, atelectasis Water: UTI Walk: DVT, PE, Wound: surgical site infection Wonder drugs: drug reaction
What is eosinophilic granuloma?
Eosinophilic granuloma is the most common form of Langerhans cell histiocytosis and is characterized by the formation of solitary or multiple discrete nodules within bones.
Hand Schuller Christian disease
Multifocal Langerhans cell histiocytosis with bone “granulomas” associated with the triad of exophthalmos, lytic skull lesions, and diabetes insipidus
Letterer Siwe disease
Systemic Langerhans cell histiocytosis. Initial symptoms often include generalized skin eruption, anemia, and hepatosplenomegaly
Extranodal natural killer cell (NK)/T cell lymphoma is commonly associated with which virus?
EBV
Most common laryngeal manifestation of GPA?
Subglottic stenosis
Most common otologic manifestation of GPA?
Serous otitis media
What histopathologic findings are seen in GPA?
Necrotizing granulomas and arteritis involving small vessels
What lab test is used to diagnose GPA?
C-ANCA (will be + in more than 90% of cases)
What histopathologic finding is seen in sarcoidosis?
Noncaseating granulomas
Most common site of laryngeal involvement in sarcoidosis?
Supraglottis
What is the most common head and neck manifestation of sarcoidosis?
Cervical lymphadenopathy
Describe the natural history of untreated necrotizing sialometaplasia
Spontaneous resolution over weeks to months
Where is coccidioides immitis endemic?
Desert southwest including New Mexima, Nevada, California, Texas, Utah, and northern Mexico
Histoplasmosis most commonly occurs in which geographic location?
The Ohio, Missouri and Mississippi river valleys
Describe head and neck manifestations of disseminated histoplasmosis
Granulomatous lesions involving the lips, gingiva, tongue and larynx, pharynx manifesting with painful ulcers containing heaped edges
What are the common head and neck clinical manifestations of rhinosporidiosis?
Fleshy, friable strawberry like lesions most commonly involving the inferior turbinate, oropharynx, conjunctiva and perineum
What is the treatment for rhinosporidiosis?
Wide local excison or prolonged dapsone therapy
Presentation of primary syphilis
Painless ulcer (chancre) at the site of transmission demonstrating a rolled edge and punched out base present after 3-6 weeks at site of exposure
Presentation of secondary syphilis
Systemic spread of disease with manifestations including fever, myalgias, arthralgias, lymphadenopathy. Mucocutaneous rash often develops including the oral mucosa and the palms and soles. Condyloma lata and patchy alopecia may develop.
What are the three categories of tertiary syphillis?
Gummatous syphilis, cardiovascular syphilis, neuosyphilis
Argyll Robertson pupil
A pupil that does not react to light but does constrict during accommodation. Associated with syphilis.
Manifestation of otosyphilis
Associated with either congenital or tertiary acquired syphilis and manifests with high frequency SNHL, fluctuating tinnitus, vertigo
Jarisch Herxheimer reaction
After treatment of syphilis, dying spirochetes may trigger a cytokine cascade that manifests with myalgias, fever, headache and tachycardia
What tests are commonly used for syphilis screening?
VDRL and RPR
What confirmatory test should be ordered after a positive or equivocal screening test for syphilis?
FTA-ABS
What is the most common cause of subacute pediatric cervical lymphadenopathy?
Atypical mycobacterium
How is brucellosis transmitted?
From contaminated meat or dairy products or via direct contact through broken skin
Clinical manifestations of cat scratch disease
Primary lesion develops into an erythematous non-pruritic pustule 1 week after inoculation. Lymphadenitis of the axilla, neck and inguinal region commonly develops 2-4 weeks after exposure. Suppuration with acute tenderness and fever. Lymphadenopathy usually resolved over 2 weeks but may persist for up to 2 years.
What pathogen is responsible for development of rhinoscleroma?
Klebsiella rhinoscleromatis
What histologic findings are strongly suggestive of rhinoscleroma?
Russell bodies (immunoglobulin containing includions in plasma cells), pseudoepitheliomatous hyperplasia, Mikulicz cells (foamy histiocytes containing Klebsiella)
What is the treatment of rhinoscleroma?
Tetracycline or ciprofloxacin
What tests are helpful in diagnosing systemic lupus erythematosus?
ANA, anti-Sm, anti-DNA, anti ribonuclear protein (anti-RNP, anticardiolipin antibody
Which joints in the head and neck are most commonly affected by RA?
TMJ, Cricoarytenoid and ossicular joints
What does CREST stand for?
Calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangectasias
- CREST is a limited cutaneous form of systemic scleroderma
What are the histologic findings in a minor salivary gland lip biopsy performed in a patient for Sjogrens?
Focal lymphocytic infiltrate with atrophic acini
What is the most common head and neck manifestation of relapsing polychondritis?
Episodic auricular chondritis, presenting with erythema and pain of the pinna with sparing of the fatty lobule.
What histologic finding on temporal artery biopsy is suspicious for giant cell arteritis?
Inflammatory infiltrates in at least the adventitia and media with elastic lamina fragmentation.
Classic triad of GPA
Granulomas of the respiratory tract, progressive glomerulonephritis, necrotizing vasculitis of small to medial sized arteries and veins
What condition is characterized by uveitis, oral aphthous ulcers and genital ulcers?
Behcet disease
What are the two primary fascia networks of the neck?
Superficial cervical fascia and the deep cervical fascia
Describe the anatomy of the superficial cervical fascia?
It lies just deep to the dermis and superficial to the deep cervical fascia. It extends from the zygoma to the clavicle and envelops the platysma and mscles of facial expression.
Describe the anatomy of the deep cervical fascia?
It is composed of the superficial (investing), middle (visceral and muscular), and deep (prevertebral and alar) layer. The carotid sheath fascia is created by all three layers of the deep cervical fascia.
Describe the anatomy of the superficial (investing) layer of the deep cervical fascia?
It surrounds the neck and inserts superiorly at the nuchal ridge, mastoid, zygoma, and mandible and inferiorly at the clavicles, sternum, scapula, and acromion. It envelops the SCM, trapezius, muscles of mastication, submandibular gland and parotid gland. Inferiorly, its manubrial insertion splits to form the suprasternal space of Burns
Describe the anatomy of the middle (visceral and muscular) layer of the deep cervical fascia?
It extends superior to the cranial base and inferiorly to the mediastinum. It is subdivided into muscular and visceral layers. Muscular division surrounds the infrahyoid strap muscles. The visceral portion surrounds the pharyngeal constrictors, esophagus, trachea, and thyroids and creates the buccopharyngeal fascia. Both divisions contribute to the carotid sheath.
Describe the anatomy of the deep (prevertebral and alar) layer of the deep cervical fascia.
Both alar and prevertebral fascia extend superiorly to the cranial base the alar fascia fuses with the middle cervical fascia and extends into the upper mediastinum, and the prevertebral fascia extends to the level of the coccyx. The alar fascia and prevertebral fascia fuse at the vertebral transverse processes and after joining envelop the paraspoinous muscles.
Describe the boundaries of the buccal space
Created by the buccinator muscle medially; the superficial layer of the deep cervical fascia and the muscles of facial expression laterally and anteriorly; and the muscles of mastication, mandible and parotid gland posteriorly. Primarily contains adipose (buccal fat pad), minor salivary glands, accessory parotid tissue and facial/buccal arteries, veins and lymphatics.
Define the mechanism of spread of infection (or tumor) to and from the buccal space.
It permits spread between the mouth, parotid space and masticator space from deficient fascial compartmentalization along the superior, inferior and posterior limits.
Boundaries of the carotid space
It extends from the skull base to the mediastinum; anteriorly lies the sternocleidomastoid muscle, posteriorly the prevertebral space, and medially the visceral compartment.
Boundaries of the danger space
A potential space that rests between the alar fascia and the prevertebral fascia. Infections in this area can communicate with the thorax (mediastinum) to the level of the diaphragm
Boundaries of the masticator space
Created from the superficial layer of the deep cervical fascia surrounding the masseter laterally and the pterygoid muscles medially. Contains masseter muscle, pterygoid muscles, inferior tendon of the temporalis muscle, ramus, and posterior body of the mandible, internal maxillary artery and the inferior alveolar neurovascular bundle.
Boundaries of the parapharyngeal space
It is shaped as an inverted pyramid with the base at the cranial base and the apex at the hyoid bone. Anteriorly, it is bound by the pterygomandibular raphe, posteriorly by the prevertebral fascia, medially by the superior pharyngeal constrictor and laterally by the parotid, mandible and lateral pterygoid.
How is the parapharngeal space commonly dividied?
Prestyloid and poststyloid compartments are divided by tensor-vascular-styloid fascia connecting the tensor veli palatine and the styloid process
What structures are contained in the prestyloid space?
Fat, lymph nodes, minor salivary gland tissue, internal maxillary artery, and the inferior alveolar, ariculotemporal and lingual nerves
What structures are contained within the poststyloid space?
Carotid artery, internal jugual vein, cranial nerves 9-12 and the superior sympathetic chain
Boundaries of the parotid space
Created by the superficial layer of deep cervical fascia as it surrounds the mandible and parotid gland and containus the partid gland and parotid lymph nodes, the facial nerve, posterior facial vein and facial artery.
Describe the mechanism of infection or tumor spread from the parotid space to the parapharyngeal space
The superiomedial parotid space fascia is deficient, allowing for direct spread into the parapharyngeal space via the stylomandibular tunnel
Define the boundaries of the peritonsiallar space
Bound by the palatine tonsil medially and superior pharyngeal constrictor, palatoglossus and palatopharyngeus medially, superiorly, inferiorly, anteriorly and posteriorly. It contains loose areolar tissue and minor salivary glands.
Define the boundaries of the prevertebral space
It extends from the skull base tot he coccyx and is bordered anteriorly by the prevertebral fascia, posteriorly by the vertebral bodies and laterally by the transverse processes of vertebrae
Describe the sequential layers and spaces (superficial to deep) of the posterior pharyngeal wall
Mucosa, pharyngeal constrictor, buccopharyngeal fascia, retropharygneal space, alar fascia, danger space, prevertebral fascia, prevertebral space
Define the boundaries of the sublingual space
Contains the sublingual gland, Wharton duct, lingual and hypoglossal nerves and is bound superiorly by the mucosa of the floor of mouhth, laterally by the mandible, inferiorly by the mylohyoid, medially by the genioglossus, anteriorly by the mandible
What are the two divisions of the submandibular space?
Subdivided into the sublingual and submaxillary spaces which are separated by the mylohyoid. These two spaces communicate at the second molar.
Define the boundaries of the submaxillary space
Contains the submandibular gland and is bounded superiorly and medially by the mylohyoid muscle, inferiorly and posteriorly by the digastric muscle, and laterally and anteriorly by the superficial layer of the deep cervical fascia and mandible.
Define the boundaries of the infratemporal fossa
- Located inferior and medial to the zygomatic arch
- Anterior: posteriolateral portion of maxillary sinus
- Lateral: ramus of mandible
- Medial: lateral pterygoid plate
- Superior: greater wing of sphenoid
- Inferior: medial pterygoid muscle
- Posterior: articular tubercle of the temporal bone, glenoid fossa
Describe the branches of the three segments of the internal maxillary artery
- First: lateral portion - deep auricular artery, anterior tympanic artery, middle meningeal artery, inferior alveolar artery, accessory meningeal artery
- Second: middle portion - masseteric artery, pterygoid branches, anterior and posterior deep temporal arteries, buccal artery
- Third: medial portion - sphenopalatine artery (terminal branch), descending palatine artery, infraorbital artery, artery of the vidian canal, anterior, middle and posterior superior alveolar artery
Define the boundaries of the pterygopalatine fossa
- Located medial to the infratemporal fossa
- Anterior: posteriomedial portion of the maxillary sinus
- Lateral: pterygomaxillary fissure and infratemporal fossa
- Medial: perpendicular plate of the palatine bone
- Superior: body of the sphenoid bone
- Inferior: pterygopalatine canal
- Posterior: root of pterygoid plates
Name the foramina communicating with the pterygopalatine fossa
Anterior: inferior orbital fissure Lateral: pterygomaxillary fissure Medial: Sphenopalatine foramen Inferior: greater palatine canal Posterior: vidian canal, foramen rotundum
What important structure may be encountered if the vidian canal is followed posteriorly?
The second genu of the internal carotid artery
Define the boundaries of the temporal fossa?
It is located between the superficial layer of the temporalis fascia and the periosteum of the squamosal portion of the temporal bone and is subdivided into the superficial and deep layer by the temporalis muscle. It contains the internal maxillary artery and inferior alveolar nerve.
Describe the location and course of the hypoglossal and lingual nerves in the region of the submandibular gland?
Hypoglossal is located deep to the digastric muscle and mylohyoid and superficial to the hyoglossus muscle. Lingual is located cephalad to the hypoglossal nerve.
What landmarks can be used for identification of the accessory nerve during level 2 neck dissection?
Transverse process of C1, anterolateral to the internal jugular vein, two fingerbreadths below the mastoid tip, or just as it runs posterior to the SCM 1-2cm above Erb point.
Describe the location of the phrenic nerve and superior sympathetic chain
It is located anterior to the anterior scalene muscle. The phrenic nerve runs lateral to the sympathetic chain.
The hypoglossal nerve is “pinned” by what artery as it descends behind the digastric muscle?
The occipital artery
During deep lobe parotidectomy what arteries must be divided for en bloc removal?
External carotid artery, superficial temporal artery, internal maxillary artery
Which cervical rootlets contribue to the ansa cervicalis?
C1, C2, C3
Which deep neck spaces involve the entire length of the neck?
The retropharyngeal, danger, prevertebral and carotid spaces
Describe the parasympathetic innervation to the parotid gland
Inferior salivary nucleus -> cranial nerve IX (Jacobson nerve) -> lesser superficial petrosal nerve - otic ganglion -> auriculotemporal nerve (V3) -> parotid gland
Describe the parasympathetic innervation to the submandibular and sublingual glands
Superior salivary nucleus -> nervus intermedius -> cranial nerve VII -> chorda tympani -> lingual nerve -> submandibular ganglion -> submandibular ganglion
Describe the parasympathetic innervation to the lacrimal gland
Superior salivary nucleus -> greater superficial petrosal nerve -> vidian nerve -> sphenopalatine ganglion -> lacrimal branch V1 -> lacrimal gland
Benign symmetric lipomatosis
Condition involves diffuse lipomatosis of the head, neck, shoulders, and proximal upper extremities. More common in men. Patients often have a history of alcoholism and diabetes
Most common type of monomorphic adenoma?
Basal cell adenoma
Most common paraganglioma of the head and neck?
Carotid body tumor (develops within the adeventitia of the carotid bifurcation and are of neural crest origin)
- Lyre sign: splaying of the internal and external carotid arteries at the carotid bifucation
What % of head and neck paragangliomas are function?
Less than 3%
What cellular pattern is characteristically seen in paragangliomas?
Cells of Zellballen. Alveolar like clumps of tumor cells are surrounded by a network of thin walled capillaries. Thick bands of collagenous tissue divide the tumor. 5-20 epithelial cells compose a nest or group of cells.
What % of H&N paragangliomas are malignant?
<10%
Familial paraganglioma syndromes are causes by a mutation in genes that encode for what enzyme?
Succinate dehydrogenase
Most common poststyloid parapharyngeal space tumor/
Schwannoma of the vagus or sympathetic chain
Which benign salivary gland tumors have pronounced FDG uptake on PET
oncocytoma and Warthin tumor. Both are composed of large eosinophilic granular cells containing high mitochondrial concentrations.
Most common type of tumor to arise within the prestyloid parapharyngeal space
Benign salivary gland tumors
MRI finding of pleomorphic adenoma
Well circumscribed mass with low intensity on T1 and hyperintensity on T2. Frequently demonstrates homogenous gadolinium uptake.
Most common prestyloid parapharyngeal space tumor?
Pleomorphic adenoma most common overall. Mucoepidermoid carcinoma most common malignancy.
Main access rounes to the parapharyngeal space?
Cervical, submandibular/cervical, cervical parotid, cervical parotid with mandibular osteotomy, transoral (not recommended)
When should a mandibulotomy be considered for a parapharyngeal space tumor?
- Tumors > 5cm, tumors with extensive skull base disease, extensive invasion
Laryngocele
Air filled dilations of the laryngeal ventricle that may be congenital or acquired
Three types of laryngoceles
- Internal: connects the ventricle with the paraglottic space, false cord and AE fold
- External: ventricular dilation extends through the thyrohyoid membrane to the lateral neck
- Combined
Castelman disease
A rare lymphoproliferative disorder that can manifest with localized multicentric disease. Commonly associated with HIV and HSV8
Kikuchi Fujimoto disease
A benign, self limiting necrotizing lymphadenitis that most commonly affects young Japanese women. Symptoms include malaise, fever, fatigue, arthralgias, weight loss and hepatosplenomegaly
Most common cause of deep neck space infections in adults
Odontogenic infection
Most common cause of deep neck space infections in children
Tonsillitis
Head and neck manifestations of Actinomyces israelli infection?
Development of a lumpy jaw with multiple painless, red or bluish raised, firm lesions containing multiple draining sinus tracts.
Histologic appearance of Actinomyces israelii?
Gram positive, non acid fast, anaerobic bacilli demonstrating a filamentous fungal like growth pattern and “sulfur granule” formation
Most common sites of H&N to develop mycobacterium infections
Anterior superior cervical region near submandibular space, followed by posterior cervical, middle cervical and supraclavicular regions.
Mons common manifestation of atypical mycobacterium?
Persistent firm painless cervical adenopathy with overlying violaceous skin discoloration
What is current recommended management of atypical mycobacterium infections?
Persistent lesions are best managed by surgical excision or incision and curettage. Common antibiotic choices include clarithromycin, ethambutol, isoniazid, rifampin.
Tests to order for patients with suspected mycobacterial infection?
PPD (generally negative or weakly reactive with atypical mycobacterium), chest plain film, cultures, nucleic acid probes, PCR
Why are mycobacteria called acid fast bacteria?
Once they are colorized with a red dye they cannot be decolorized with acidic solutions.
Most common H&N manifestation of TB?
Cervical lymphadenopathy
Treatment of cervical lymphadenopathy associated with TB?
rifampin, isoniazid, ethambutol, pyrazinamide
What pathogen is associated with cat scratch disease?
Bartonella henselae
Three types of Langerhans cell histiocytosis
- Eosinophilic granuloma
- Hand Schuller Christian (disseminated chronic)
- Letterer Siwe (disseminated acute)
What condition manifests with triad of osteolytic skull lesions, exophthalmos, and DI?
Hand Schuller Christian disease
Which type of Langerhans cell histiocytosis is associated with early in life onset and rapidly progressive course?
Letterer Siwe
Lemierre syndrome
Septic thrombophlebitis of the neck that most commonly results from Fusobacterium necrophorum. Often begins with pharyngitis progressing to lymphadenopathy, fevers, chills and rigors. Septic emboli may involve the lung, brain, spleen, and liver among other sites.
Most common cause of pediatric cervical lymphadenopathy?
Reactive from viral infection
Most common causes of pediatric suppurative lymphadenopathy?
Group A strep, staph aureus
Test of choice for primary syphilis
FTA-ABS test evaluates for the presence of treponemal antibodies. The test is positive in 90% of patients who seek therapy for primary syphilis and remains positive for life.
What constitutes the Hutchinson triad of congenital syphilis?
Small notched teeth, deafness, interstitial keratitis
What test is most useful in establishing the diagnosis of neurosyphilis?
Reactive CSF VDRL and a CSF WBC of 20 cells/microL or greater
Definition of otosyphilis
The presence of positive FTA ABS in the setting of unexplained SNHL
Common initial symptoms of toxoplasmosis
Fever, malaise, pharyngitis, myalgias, cervical lymphadenopathy
Pathogen, vector and carrier responsible for development of tularemia?
Francisella rularensis, Amblyomma americanum (lone star stick), rabbits, and wild rodents
Early symptoms of tularemia infection
Fever, headache, chills, myalgia, photophobia, diminished visual acuity, lymphadenopathy
Possible side effects of amphotericin B
Nephrotoxicity, anemia, fever, chills, nausea, vomiting
Mechanism of action of the “azole” antifungal medications
Fungistatic. All azoles work by inhibiting cytochrome P450 dependent enzyme that is required to convert lanosterol to ergosterol
Most common causative organism in chronic invasive fungal sinusitis
Aspergillus fumigatus
HIV lymphadenopathy
Diffuse lymphadenopathy (>2cm) involving two or more extrainguinal sites for longer than 3 months. 2/3 of patients with HIV will develop this
How do submandibular infections spread to other deep neck space compartments?
Communication between potential spaces exist at the buccopharyngeal gap, which connects the submandibular and lateral pharyngeal spaces
Why is there a lack of trismus in patients with Ludwig’s angina?
Trismus develops from irritation of the masticatory muscles (masseter and pterygoids) which insert into the mandibular ramus. The submandibular space is not contiguous with these muscles.
What is the mechanism of airway compromise in Ludwig’s patients?
Increased swelling in the bilateral submandibular space pushes the tongue superiorly and posteriorly causing airway obstruction.
Most common causative organism in necrotizing soft tissue infections?
Group A strep
Clinical characteristics of necrotizing fasciitis
Tense edema, pain disproportionate to examination, skin discoloration, bullae, necrosis, crepitus
Clinical presentation of mononucleosis
Fever, fatigue, generalized lymphadenopathy, splenomegaly, exudative pharyngitis with adenotonsillar hypertrophy
Define the following terms:
- Ageusia
- Hypogeusia
- Dysgeusia
- Ageusia: inability to taste
- Hypogeusia: diminished ability to taste
- Dysgeusia: distorted sense of taste
Describe the taste innervation of the upper aerodigestive tract
- Anterior 2/3 of the tongue: chordae tympani of CN VII
- Posterior 2/3 of tongue: CN IX
- Circumvallate papillae: CND IX
- Pharynx: CN IX and X
- Epiglottis: Superior laryngeal branch of vagus
Most common cause of perceived taste dysfunction
Olfactory dysfunction
What tastes and odors are detected by the trigeminal nerve?
Spice and ammonia
What is a Burton line?
A dark blue stippled line across the upper gingiva indicative of lead poisoning
Oral cavity nevi most commonly occur where?
Palate and gingiva
Describe Peutz Jegers syndrome
Autosomal dominant disorder characterized by intestinal hamartomatous polyp and mucocutaneous melanocytic macules involving the lips and buccal mucosa. Associated with increased risk of developing GI, pulmonary and reproductive tract malignancies.
Most common intraoral pigmented lesions?
Amalgam tattoo resulting from amalgam implantation from prior dental work
Risk factors for mucosal melanoma
No known environmental risk factors
Which common medications are associated with gingival hyperplasia?
Phenytoin, calcium channel blockers, cyclosporine
Name several conditions associated with pseudoepitheliomatous hyperplasia
Rinoscleroma, granular cell tumor, blastomycosis, syphilis, necrotizing sialometaplasia
What benign process is often clinically and histologically mistaken for SCC of the hard palate?
Necrotizing sialometaplasia
Describe the important features of granular cell tumors of the head and neck
Most commonly involve the tongue, palate and less commonly the larynx. They are sessile gray colored lesions that are of probable neurogenic origin. Stain strongly with s100 and histologically may be mistaken for SCC since they exhibit pseudoepitheliomatous hyperplasia.
Common oral manifestations of Chron disease
Generalized mucosal swelling, cobblestoning of the buccal mucosa and gingiva, aphthous stomatitis and angular chelitis
Common oral manifestations of Sjogren disease
Changes largely result from xerostomia including difficulty swallowing and eating, disturbances in taste and speech, dental caries, cobblestoning of the tongue and increased risk of oral candidiasis
Most common oral manifestation of amyloidosis
Macroglossia (20% of patients)
Histologic findings with amyloidosis
Apple green birefringence, Congo red stain
Most common intraoral malignancy associated with HIV?
Kaposi sarcoma
Conditions associated with development of hairy leukoplakia?
Immunocompromised states (HIV, organ transplant). Associated with EBV
Most common presentation of a primary HSV infection in pediatric population?
Herpetic gingivostomatitis
What tests can be used to definitively diagnose an HSV-1 viral infection?
PCR, viral culture, serology, immunofluorescence. Tzank smear is not helpful for delineating HSV-1 from HSV-2.
Recurrent oral HSV-1 infections can be associated with what important complications?
- Disfiguring lesions
- Erythema multiforme
- Aseptic meningitis
- Eczema herpeticum
What noncontagious acute gingivitis is caused by an overgrowth of common bacterial species including Prevotella intermedia, alpha hemolytic strep, Actinomyces or spitochetes among others?
Acute necrotizing ulcerative gingivitis (trench mouth)
If a patient with acute necrotizing ulcerative gingivostomatitis, if the disease progresses beyond the gingiva to include other mucosal surfaces what is the condition called?
Noma (cancrum oris)
Common risk factors for developing acute necrotizing ulcerative gingivitis
Stress, immune compromised, poor nutrition, poor oral hygiene, alcohol tobaco
Common exam findings seen in trench mouth
Lymphadenopathy, halitosis, mucosal edema/ulceration/inflammation with or without pseudomembrane
Treatment for trench mouth
- Analgesia
- Antibiotics (clindamycin, penicillin or erythromycin)
- Oral hygiene (chlorhexidine)
- Dental consult for debridement and definitive periodontal therapy
- Management of underlying immunocompromised state if present
Most common oral manifestation of HIV infection?
Oral candidiasis
Common forms of oral candidiasis
- Pseudomebranous candidiasis (thrush)
- Erythematous (atrophic) candidiasis
- Angular chelitis (perleche)
- Hyperplastic candidiasis
What in office test can be done to confirm the diagnosis of oral candidiasis?
Scarping of erosive lesion followed by KOH preparation looking for budding yeast with or without pseudohyphae
Initial tx options for oral candidiasis
Topical antifungal lozenges or solutions for 7-14 days. Clotrimazole troches, nystatin suspension or nystatin pastilles. Can try fluconazole orally for patients who do not respond to topical therapy
The esophagus undergoes what important process during week 8-10 of life?
Recanalization of esophageal lumen
Describe the muscular arrangement of the esophagus
- Outer longitudinal fibers, inner circular fibers
- Inferior third smooth muscle, middle third mixed, superior third skeletal muscle
Three physiologic areas of narrowing within the esophagus
- Upper esophageal sphincter (cricopharyngeus muscle, C6 narrowest segment)
- Crossed by aorta and left main bronchus in mid chest
- Lower esophageal sphincter (passes through diaphragm)
Blood supply to esophagus
Arterial:
- Segmental blood supply, extensive submucosal anastamosis
- UES and cervical esophagus - inferior thyroid artery
- Thoracic esophagus - paired esophageal arteries (terminal branches of bronchial arteries)
-LES - left gastric artery and left phrenic artery
Venous:
- Neck: inferior thyroid veins
- Mediastinum: azygus and hemiazygous veins
- Abdomen: left gastric vein
Innervation of the esophagus
- Sympathetic innervation from T6-T10 bilaterally
- Greater and often lesser splanchnic nerves
- Branches from the celiac plexus
The upper, mid and lower third of esophagus drain into which nodal basins?
- Upper third: paratracheal and internal jugular
- Middle third: mediastinal
- Lower third: gastrohepatic and celiac axis
Normal epithelial lining of esophagus
Nonkeratinizing stratified squamous epithelium
Four layers of the esophageal wall
- Mucosa
- Submucosa
- Muscularis propria
- Adventitia
At what thoracic level is the esophageal hiatus?
T10
What two types of peristalsis propel food through the esophagus?
- Primary: triggered by swallowing
- Secondary: triggered by esophageal dilation
What are the functional muscular components of the UES?
The cricopharyngeus muscle, thyropharyngeus and proximal cervical esophagus
What are the four main protective mechanisms against esophageal refulx?
- UES: tonically closed
- LES: tonically closed
- Esophageal acid clearance: peristalsis, gravity
- Epithelial resistance: mucous layer, aqueous layer, cell membrane and intracellular junctions
When should esophagoscopy be considered after caustic ingestion?
Within the first 24 hours because risk for perforation and complications may be greater at 2-3 days after injury
What endoscopic findings suggest an increased risk of stricture formation after caustic ingestion?
Circumferential erythema with exudate and perforation
Most esophageal foreign body impactions occur at what level in the esophagus?
Cervical esophagus just below cricopharyngeus muscle
Boerhaave syndrome
Elevated intraabdominal pressure results in a transmural tear within the distal esophageal wall after vomiting. Commonly occurs in posteriolateral wall of distal esophagus
Mallory Weiss syndrome
Incomplete tear of esophageal wall involving the esophageal mucosa and submucosal arteries, often associated with retching
What does the Hamman sign indicate?
Pneumomediastinum or pneumopericardium often from tracheobronchial injury or Boerhaave syndrome
- Demonstrated by a crunching sound that is synchronous with the heartbeat
What type of imaging study should be used in a patient with suspected esophageal perforation?
Gastrografin swallow study
What main outcome is used when evaluating the results of ambulatory pH monitoring?
% of time the intraesophageal pH is <4 to distinguish physiologic from pathologic reflux
Esophageal manometry
Diagnostic test that evaluates both the intraluminal pressures and coordination of the UES, esophageal body and lower esophageal sphincter. Should be considered in patients with dysphagia, noncardiac chest pain, possible esophageal motility disorders
How does the differential dx change if a patient with esophageal dysphagia complains of symptoms with solids vs symptoms with solids and liquids?
Mechanical obstruction usually causes difficulty with solids (but may progress to involve liquids latera on). Motility disorders commonly result in concurrent solids and liquid dysphagia
Most common diagnoses in a patient with solid food dysphagia?
- Esophageal ring
- Peptic stricture
- Malignancy
Eagle syndrome
Elongated styloid process (> 3cm) and or ossification/calcification of part or all the stylohyoid ligament
Dysphagia lusoria is associated with what anatomical anomaly?
Aberrant right subclavian artery
What histopathologic findings support the diagnosis of achalasia?
Decrease in total ganglion cells within the myenteric plexus, the presence of T cell, eosinophil, and mas cell infiltration, and increased neural fibrosis
Triple A syndrome (Allgrove syndrome)
- Achalasia
- Adrenal insufficiency
- Alacrima
What infectious disease can lead to clinical manifestations of achalasia?
Chagas disease (associated with the parasite trypanosoma cruzi. Vector is reduviid bugs). Esophageal manifestations include megaesophagus with dilation and muscular hypertrophy, Reduction in the number of neurons in the myenteric plexus.
What medical options are available for patients with achalasia?
Nitrates and calcium channel blockers with the goal of decreasing lower esophageal sphincter tone.
Eagle syndrome
Elongated styloid process (about > 3 cm) and or ossification or calcification of part of all of the styloid ligament
Dysphagia lusoria is associated with what anatomical anomaly?
Aberrant right subclavian artery
What histopathologic finding supports the diagnosis of achalasia
Decrease in total ganglion cells within the myenteric plexus, the presence of T cells, eosinophils and mas cell infiltration and increased neural fibrosis
General age group affected by achalasia
20-60 years
Primary complaints associated with achalasia
Solid and liquid dysphagia, weight loss, chronic cough, chest pain, hiccups, regurgitation, heartburn, globus
Trip A syndrome (Allgrove syndrome)
- Achalasia
- Adrenal insufficiency
- Alacrima
Most commonly found in children
What infectious disease can lead to clinical manifestations of achalasia?
Chagas disease
First line therapy for severe achalasia
Surgical dilation or myotomy
Medical options for achalasia
Nitrates and calcium channel blockers with goal of decreasing lower esophageal sphincter tone
What pathogen is associated with Chagas disease
Parasite trypanosoma cruzi
Vector: reduviid bugs
Esophageal manifestations of Chagas disease?
Megaesophagus with dilation and muscular hypertrophy
Reduction in number of neurons in the myenteric plexus
Most common conditions associated with chronic Chagas disease
- Cardiomyopathy
- Arrhythmias
- Conduction blocks
Clinical manifestations of scleroderma
Skin tightening, hyperpigmentation or hypopigmentation, sclerodactyly (claw hand), Raynauds, GERD arthralgias, myalgias, Sicca syndrome (aka Sjogrens), dysphagia
How common is esophageal involvement in Scleroderma
90%, 50% will have significant symptoms
What lab test is most sensitive and specific for dermatomyositis
Creatine kinase
How is dermatomyositis treated
Systemic steroids or immunosuppressives
Potential head and neck manifestations of dermatomyositis
Heliotrope discoloration of upper eyelids, malar rash, dysphonia, dysphagia, scaly scalp, hair loss
What part of the aerodigestive tract is affected by polymyositis?
hypopharynx and upper third of esophagua
What is the test of choice to evaluate for cricopharyngeal dysfunction?
Videofluoroscopic swallow with esophagram
Theories behind relationship between CP dysfunction and dysphagia
- CP is normally under tonic contraction but fails to relax with swallow
- There is a lack of coordination between CP relaxation and propulsion of food
Relative contraindications to CP myotomy
- Advanced GERD
- Progressive neurologic conditions
- History of radiation to the neck
Between what muscles does a Zenker’s diverticulum herniate
- Inferior constrictor and cricopharyngeus (Killian triangle)
Which side does a Zenker’s diverticulum most commonly involve and why?
Left neck (90%) due to convexity of cervical esophagus to the left side and more laterally positioned carotid artery on the left creating a space for the sac to protrude
Killian Jamieson area
Dehiscence between the oblique and transverse fibers of the CP muscle
Laimer triangle
Dehiscence between the CP muscles and the proximal esophageal muscles
Risk factors of developing peptic structure
Older age, male, long history of reflux symptoms and GERD, scleroderma, Zollinger ellison syndrome, nasogastric tube placement, history of surgical management for achalasia (heller myotomy)
Schatzki ring
Smooth, thin (<4mm) web of mucosa and submucosa at the squamocolumnar junction, marking the proximal margin of a hiatal hernia
Esophageal web
A thin mucosal fold covered in squamous epithelium that extends into the esophageal lumen, most commonly in the anterior cervical esophagus
Clinical features of plummer vinson syndrome
triad of dysphagia, iron deficiency anemia, esophageal webs
Associated with atrophic glossitis and SCC of the oral cavity, esophagus and hypopharynx
What is commonly seen on esophagoscopy in a patient with reflux esophagitis?
Erosions or ulcerations at the squamocolumnar junction (Z line)
What is the primary limitation of a 24 hour pH probe?
1/4 of patients with erosive esophagitis and 1/3 of patients with nonerosive esophagitis will have normal results
Which H2 blocker is the most effective for GERD
No H2 blocker is more effective than another. If treated for 6 weeks with no response then time to look to additional intervention
What medical management is indicated for erosive reflux disease
PPI
After discontinuing a PPI for GERD in what time frame to most patients who have recurrence begin to experience symptoms?
3 months
What risks are associated with chronic suppressive PPI therapy for reflux disease?
Potentially decreased bone density, infections and electrolyte abnormalities
Los Angeles Classification of peptic esophagitis
Grade A: one or more mucosal breaks < 5mm long
Grade B; one more more mucosal breaks > 5mm long without continuity between the tops of the adjacent mucosal folds
Grade C: one more more mucosal breaks continuous between the tops of the adjacent mucosal folds
Grade D: circumferential mucosal break
Most feared complication of Barrett esophagus?
Esophageal adenocarcinoma
Management strategies for Barrett esophagus
- Management of GERD
- Photodynamic therapy
- Endoscopic mucosal resection
4 parasympathetic ganglia in the head and neck
- Otic: located inferior to the foramen ovale. Parasympathetic fibers for parotid gland travel through.
- Submandibular: located near posterior edge of mylohyoid just over hypoglossus and superior to deep portion of submandibular gland. Preganglionic parasympathetic fibers travel in chorda which is traveling with lingual nerve, synapse and then go to submandibular and sublingual glands
- sphenopalatine or pterygopalatine: preganglionic fibers of GSPN synapse here and travel to lacrimal glands and seromucinous glands in nose
- Ciliary: located in posterior orbit. Fibers that have synapsed here innervate sphincter pupilae (cause miosis) and ciliary muscle (causes accommodation by making lense more convex)
Blood supply to the tonsil
- Dorsal lingual (branch of lingual)
- Ascending pharyngeal (branch of ECA)
- Ascending palatine (branch of facial)
- Tonsillar branch of facial
- Descending palatine and greater palatine (branch of internal maxillary)
