Hals

Question 1

Supraglottic structures:

Answer 1

Epiglottis, false vocal cords, aryepiglottic folds, arytenoid cartilages and ventricles

Question 2

Glottic structures

Answer 2

True vocal cords, anterior and posterior commissures

Question 3

Subglottic structures

Answer 3

Between lower border of vocal cords and 1st tracheal ring

Question 4

How many tonsils to we have?

Answer 4

6. (1xpharyngeal, 2x tubal, 2x palatine, 1x lingual)

Question 5

Waldeyer’s tonsillar ring is?

Answer 5

An annular arrangement of lymphoid tissue in larynx

Question 6

Parapharyngeal space(PS) is:

Answer 6

A level of nasopharynx, lateral to tonsils. (Connects posteriorly to retropharyngeal space where 0,5% of all H&N tumors occur, 80% of them are benign)

Question 7

What can you find in Parapharyngeal space (PS)?

Answer 7

Pterygoid plexus, one branch of the trigeminal nerve, carotid arteries, jugular vein and cranial nerves XI-XII.

Question 8

Tumors of the Parapharyngeal space - origin and symptoms

Answer 8

Most tumors of this space is of salivary origin. Symptoms:

1. Neck mass
2. Dysphagia
3. Pharyngeal mass
4. Medial displacement of oropharyngeal wall without erythema
5. Hoarseness
6. Parotid mass
7. Otalgia
8. Tinnitus
9. Hearing loss
10. Trismus(Very common sign)

Differential diagnosis: Paratonsillar absecces

Contraindication: fine needle biopsy due to all the big vessels going there.

Question 9

Acute Tonsilitis - causes

Answer 9

Bacterial (Tender lymph nodes, sudden onset, fever) - S.pyogenes most common. Viral (runny nose, cough). The Centor/Mclsaac’s scale may help you decide pathogen when in doubt.

Question 10

Acute Tonsillitis - Treatment

Answer 10

Penicillin for 10 days, recurrent? clindamycin/augmentin

Question 11

Acute Tonsillitis - complication

Answer 11

Peritonsillar abscess.

Question 12

Acute Tonsillitis - Symptoms

Answer 12

Sore throat, dysphagia, fever, potato-voice. On physical: 1 side protrude and cause deviation of uvula. Can’t see anterior fold.

Question 13

Laryngitis - causes

Answer 13

Infectious (Rhinovirus, RSV, adenovirus) vs non-infectious.

Question 14

Laryngitis - Predisposition

Answer 14

Smoking, psychological stress, physical stress

Question 15

Laryngitis - Pediatric concerns

Answer 15

They lack a firm cartilaginous skeleton, thus it may easily collapse, glottic aperture is relatively smaller, mucosa swells rapidly, and have stridors as presenting symptom.

Question 16

Laryngitis - Differential diagnosis

Answer 16

Reinke’s edema (virus, pediatric disease), diphteria, acute epiglottis

Question 17

Chronic Laryngitis(7-13d)

Answer 17

Mucosa thick, infiltrative plasma cells plus one other cell line (didnt get which?)

Question 18

Throat Cancer - origin

Answer 18

Most of them are laryngeal cancer and 80-95% of them are of SCC origin.

Question 19

Throat Cancer - Supraglottic

Answer 19

40% epiglottis most common location. Symptoms: Dysphagia, pain in neck. Most patients present in stage IV(36%) and V(34%) & fast lymph node metastases. 5 year survival: 51%.

Question 20

Throat Cancer - Glottic

Answer 20

59%, most commonly on vocal cords. Symptoms: hoarseness. Most patients present in stage I, and a long time to metastasize. 5 year survival: 81%

Question 21

Throat Cancer - Subglottic

Answer 21

1%. Symptoms: very mild symptoms for a long time = change in melody of voice which is hard to recognize(singers might). Late symptom of dyspnea. Often present with lymph node spread. 5 year survival: 77%.

Question 22

Throat cancer - Risk factors

Answer 22

smoking and alcohol (synergism), age, HPV type 16 and 18, GERD, exposure to occupational toxins.

Question 23

Throat cancer - general symptoms

Answer 23

Dyspnea, aspiration, hoarseness, blood in the sputum, cachexia, otalgia

Question 24

Throat cancer - work up

Answer 24

Biopsy under general anesthesia, direct laryngoscopy, bronchoscopy, esophageal US, CT/MRI or X-ray to find severity and spread.

Question 25

Throat cancer - Metastases

Answer 25

Nr 1: 2nd space - behind angle of mandible. Posterior scalp, ear, nasopharynx, thyroid, breast, esophagus

Question 26

Throat cancer - by TNM system

Answer 26

N3 = lymph node more than 6cm in diameter (yes cm)

Question 27

Throat cancer - Treatment

Answer 27

Depend on local invasion. Moveable vocal cords: radiotherapy/partial laryngectomy. Fixated vocal cords: Partial laryngectomy. Local invasion and LN spread: total laryngectomy.
(Hemilaryngectomy - vertical - Removal of part of front of larynx) (Supraglottic laryngectomy - horizontal - removes top of larynx above vocal cords). 3 to 4 laryngectomy (horizontal + vertical)

Question 28

Traceotomy and - stomy

Answer 28

Tracheotomy is creation of the opening of trachea. This can be reversed. Tracheostomy is creating the permanent hole in trachea (after total laryngectomy).

Question 29

Indications for tracheotomy

Answer 29

Mechanical upper airway obstruction(e.g.) tumor. 
Access lower tracheobronhial tree to provide pulmonary hygiene. 
Difficult intubation (usually done as elective procedure under general anesthesia while being intubated.

Question 30

Contraindications for tracheotomy

Answer 30

No absolute one. Relative: coagulation defect, skin/subcutaneous tissue infection.

Question 31

Emergency tracheotomy

Answer 31

30min procedure should be done in 30 sec “Cricothyrotomy”

1. Vertical incision under local anesthesiaI(vertical give decreased bleeding). Watch out for isthmus of thyroid.
2. Deepen the incision
3. Identify by exposing trachea
4. Cut/stabb trachea
5. Once you get tube in(might also be a large gauge needle if emergency) suck out blood from the trachea.

Question 32

Tracheotomy - complications

Answer 32

Intubate esophagus, bleeding, cardiovascular instability, injury to recurrent laryngeal nerve, poor choice of tracheotomy tube -> dyspnea. Post-op: bleeding and infection.

Question 33

Tonsillectomy

Answer 33

Indications: recurrent acute tonsillitis - 7times/1year, local complications - local vs central, airway obstruction(apnea), suspected malignancy.
- Tonsillectomy = full removal, tonsillotomy = partial. When child is < 10 year old.

Question 34

Adenoidectomy

Answer 34

Child might have a myotonic face - breathe through mouth all of the time. Indications: otologic, rhinologic, orthodontic (when breathing through mouth, the teeth and jaw will not develop properly)