Head And Neck Surgery Flashcards
A 34 year old lady presents with a long standing offensive discharge from the ear and on examination is noted to have a reduction in her hearing of 40 decibels compared to the opposite side. What is the most likely cause?
Otosclerosis Acute otitis media Cholesteatoma Long standing perforation of the pars tensa Otitis externa
Cholesteatoma
The combination of long history, offensive discharge and hearing loss is strongly suggestive of cholesteatoma
A dentist treating a woman with rheumatoid arthritis for recurrent episodes of dental sepsis notices that both parotid and submandibular glands are symmetrically enlarged. What is the most likely diagnosis?
Sjogren's syndrome Mikulicz's syndrome Alcoholism Liver cirrhosis Metastatic cancer
Sjogren’s is associated with autoimmune disorders. Mikulicz’s is similar but there is no sicca or arthritis.
A 29 year old man has had a sore throat for the past 5 days. Over the past 24 hours he has noticed increasingly severe throbbing pain in the region of his right tonsil. He is pyrexial and on examination he is noted to have a swelling of this area. What is the most likely cause?
Tonsillar cancer Lymphoma Quinsy Glandular fever Common cold
Unilateral swelling and fever is usually indicative of quinsy. Surgical drainage usually produces prompt resolution of symptoms
A 42 year old singer is admitted for a thyroidectomy. Post operatively she is only able to make a gargling noise. Her voice sounds breathy. What is the most likely explanation?
Bilateral inferior laryngeal nerve injury Unilateral inferior laryngeal nerve injury Unilateral superior laryngeal nerve injury Bilateral superior laryngeal nerve injury Lacunar infarct
Unilateral inferior laryngeal nerve injury
This patient has diplophonia which causes a gargling sound. This is associated with dysphagia. This can also be caused by a vagus nerve lesion, but the recurrent laryngeal nerve is more at risk of damage. In bilateral injury, the airway is at risk and therefore this takes precedence.
A 53 year old man presents with a mass lesion slightly inferior to the tragus of his right ear. An FNA and USS are performed and a 2cm pleomorphic adenoma is diagnosed. What is the most appropriate course of action?
USS guided core biopsy Radical parotidectomy Superficial parotidectomy Discharge MRI scanning of the region
Superficial parotidectomy
Pleomorphic adenomas a usually benign tumours. However, they will enlarge over time and a proportion can undergo malignant transformation. Therefore, all pleomorphic adenomas are excised and a superficial parotidectomy is generally the procedure of choice. The facial nerve is preserved. More recently, there has been a move towards partial superficial parotidectomy. However, complete resection of the lesion is still mandatory
A child is brought to casualty complaining of a headache and a sensation of pressure between the eyes. On examination, she is febrile with a smooth swelling overlying the superomedial aspect of the right eye. The eye is uncomfortable and there is a purulent discharge from the inner canthus. What is the most likely cause?
Maxillary sinusitis Ethmoidal sinusitis Nasal polyps Ethmoid sinus cancer Maxillary sinus cancer
Ethmoidal sinusitis
Ethmoidal sinusitis may spread to the periorbital tissues resulting in periorbital cellulitis. The superomedial distribution makes a maxillary sinusitis less likely.
An 8 year old boy presents with a lump in his neck. On examination, he is found to have a lump in the midline of the neck immediately below the hyoid which moves on tongue protrusion. What is the most likely diagnosis?
Benign lymphadenopathy Malignant lymphadenopathy Thyroglossal cyst Branchial cyst Dermoid cyst
Thyroglossal cyst
Both dermoid and thyroglossal cysts are often located in the midline. Dermoid cysts are usually found above the hyoid and do not move on swallowing. Thyroglossal cysts lie below the hyoid and move on tongue protrusion
An 18 year old boy presents with pancreatitis. He has bilateral painful parotid enlargement. What is the most likely underlying cause?
Sialectasis Bacterial parotitis Viral parotitis Mucoepidermoid carcinoma Sjogren's syndrome
Viral parotitis
In a young adult with parotid swelling and pancreatitis/orchitis/reduced hearing/meningoencephalitis suspect mumps.
A 14 year old boy presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice peticheal haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly. What is the most likely cause?
Oral candidiasis Infection with Streptococcus pyogenes Infection with Rickettsia rickettsii Infection with Epstein Barr virus Infection with Staphylococcus aureus
Infection with Epstein Barr virus
A combination of pharyngitis and tonsillitis is often seen in glandular fever. Antibiotics containing penicillin may produce a rash when given in this situation, leading to a mistaken label of allergy. Infection with candidiasis can occur in individuals with systemic illness of which splenomegaly may be a feature.
A 70 year old lady presents with a painless neck lump. There is a mass noted beneath the sternocleidomastoid muscle. There is a long history and somewhat unkindly her husband remarked on her rather noticeable halitosis. What is the most likely explanation?
Branchial cyst Branchial fistula Pharyngeal pouch Thyroglossal cyst Dental caries
Pharyngeal pouch
Usual history of regurgitation of undigested food or coughing at night. Associated with halitosis and throat infections.
A 21 year old man presents with a unilateral facial nerve palsy after being hit on the head. On examination, he has a right sided facial nerve palsy and a watery discharge from his nose. What is the most likely cause?
Pleomorphic adenoma Cerebrovascular accident Occipital bone fracture Petrous temporal fracture Sarcoidosis
Petrous temporal fracture
Nasal discharge of clear fluid and recent head injury makes a basal skull fracture the most likely underlying diagnosis.
A 4 year old is brought to the general practitioner by her mother. She has been distressed with ear pain for the past 14 hours. She is constantly touching and pulling at her ear. Whilst she is sat in the waiting room her mother notices a discharge of foul smelling fluid from the ear, following which the pain resolves. What is the most likely cause?
Acute otitis media Otitis externa Cholesteatoma Mastoiditis Otosclerosis
Acute otitis media
In young children acute suppurative otitis media is a common condition. Rupture of the tympanic membrane is a rare, but recognised complication.
A 40 year old woman presents as an emergency with a painful mass underneath her right mandible. The mass has appeared over the previous week with the pain worsening as the lump has increased in size. On examination, there is a 4cm mass underneath her mandible, there is no associated lymphadenopathy. What is the most likely diagnosis?
Submandibular gland cancer Submandibular gland calculus Carotid body tumour Papilloma of Whartons duct Carotid body aneurysm
Submandibular gland calculus
The sub mandibular gland is the most common site for salivary calculi. Patients will usually complain of pain, which is worse on eating. When the lesion is located distally the duct may be laid open and the stone excised. Otherwise the gland will require removal.
A 46-year-old woman is referred to endocrine surgery for a possible thyroidectomy. She has a tender neck swelling. Blood results are as follows:
TSH <0.1 mU/l
T4 188 nmol/l
Hb 14.2 g/dl
Plt 377 * 10^9/l
WBC 6.4 * 10^9/l
ESR 65 mm/hr
Technetium thyroid scan shows decreased uptake globally
What is the most likely diagnosis?
Sick thyroid syndrome Acute bacterial thyroiditis Hashimoto's thyroiditis Subacute thyroiditis Toxic multinodular goitre
Subacute thyroiditis
This patient does not need surgery! Subacute thyroiditis is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical. This should resolve without any active intervention.
Which of the following statements relating to branchial cysts is untrue?
The greater auricular nerve may be divided during excision They typically occur in young adults They move upwards on swallowing They are rare over the age of 40 years They are usually located in the anterior triangle of the neck
They move upwards on swallowing
They do not move on swallowing. They should be diagnosed with caution in those aged >40 years, as lumps in this age group may in fact be metastatic disease from oropharyngeal cancer.
A 30 year old lady is found to have a thyroglossal cyst that has been recently infected and the patient requests treatment. What is the most appropriate course of action?
Surgical treatment with resection of cyst, associated track, central portion of the hyoid and wedge of tongue muscle behind the hyoid Excision of the cyst alone with ligation of the track Laying open of the track and excision of the cyst Phenolisation of the cyst Marsupialisation of the cyst
Surgical treatment with resection of cyst, associated track, central portion of the hyoid and wedge of tongue muscle behind the hyoid
Recurrence following attempted resection of thyroglossal cysts is very common. Complete excision of the cyst and its track and origin is mandatory (Sistrunks procedure).
A 22 year old female attends clinic after noticing a painless neck lump. On examination she is noted to have bilateral thyroid masses and multicentric nodes near the base of the thyroid. Her corrected Ca is 2.18. What is the most likely diagnosis?
Sporadic medullary carcinoma of the thyroid Medullary carcinoma of the thyroid associated with multiple endocrine neoplasia Follicular thyroid carcinoma Anaplastic thyroid carcinoma Toxic nodular goitre
Medullary carcinoma of the thyroid associated with multiple endocrine neoplasia
Medullary thyroid cancer is a tumour of the parafollicular cells of the thyroid. Less than 10% of thyroid cancers are of this type. Patients typically present in children or young adults. Diarrhoea occurs in 30% of cases. Toxic nodular goitre are very rare. In sporadic medullary thyroid cancer, patients typically present with a unilateral solitary nodule and it tends to spread early to the neck lymph nodes. In association with multiple endocrine neoplasia (MEN) syndromes, medullary thyroid cancers are always bilateral and multicentric
A 45 year old man presents with a facial swelling. On examination, he has a swelling that lies inferolaterally to the nose. When the area is palpated, it feels like the underlying bone is cracking. What is the most likely diagnosis?
Maxillary sinus cancer Ameloblastoma Nasal polyps Maxillary sinusitis Mucocele
Ameloblastoma
Ameloblastomas are rare tumours of the odontogenic epithelium. They are slow growing and expand with a rim of periosteum that surrounds them. It is the palpation and disruption of this layer that gives rise to the crepitus.
A 42 year old singer is admitted for a thyroidectomy. Post operatively the patient develops stridor and is unable to speak. What is the most likely underlying cause?
Bilateral superior laryngeal nerve injury Unilateral recurrent laryngeal nerve injury Unilateral superior laryngeal nerve injury Bilateral recurrent laryngeal nerve injury Hypoglossal nerve injury
Bilateral recurrent laryngeal nerve injury
This patient has aphonia due to bilateral damage to the recurrent laryngeal nerve.
A 50 year old women presents with a diffuse swelling in the region of her right parotid together with facial pain. On examination, she has a right sided facial nerve palsy. What is the most likely underlying cause?
Pleomorphic adenoma Adenoid cystic carcinoma Warthins tumour Lymphoma Sarcoid
Adenoid cystic carcinoma commonly infiltrates the facial nerve and may cause neuropathy and facial pain.
A 10 year old girl presents with epistaxis. From which of the following regions is the bleeding most likely to originate?
Posterior nasal space Alar rim Kiesselbach's plexus Cribriform plate None of the above
Kiesselbachs plexus has an arterial supply derived from both the internal and external carotid arteries and is the commonest area for bleeding in idiopathic epistaxis.
A 56 year old man presents with a painless swelling in the upper part of the anterior triangle of his neck. On examination a mass lesion involving the sub mandibular gland is identified. On CT scanning this is shown to be a solid lesion. There is no regional lymphadenopathy. Two fine needle aspirates have failed to be diagnostic. Which of the following is the most appropriate management option?
Sub mandibular gland excision Incisional biopsy of the mass Manage conservatively and repeat the CT scan in 6 months Sub mandibular gland excision and radical neck dissection Diagnostic excision of the superficial lobe of the submandibular gland
Sub mandibular gland excision
There is a 50% risk that this lesion is malignant (in some series up to 70%). Therefore the gland should be excised entirely. At this stage a radical neck dissection is not justified.
A 36-year-old woman who presented with a goitre is diagnosed with autoimmune thyroiditis. Which one of the following types of thyroid cancer is she predisposed to developing?
Anaplastic Lymphoma Medullary Follicular None of the above
Hashimoto’s thyroiditis is associated with thyroid lymphoma
A 50 year old lady presents with symptoms of a dry mouth that has been present for the past few months. She also has a sensation of grittiness in her eyes. On examination, she has a diffuse swelling of her parotid gland. There is no evidence of facial nerve palsy. What is the likely underlying diagnosis?
Sarcoid Sjogrens syndrome Adenoid cystic carcinoma Pleomorphic adenoma Lymphoma
Sjogrens syndrome
Most patients with Sjogrens present in the post menopausal years. Multi system involvement is common.
An elderly diabetic male presents with a severe deep seated otalgia and a facial nerve palsy, he has completed a course of amoxycillin with no benefit. What is the most likely diagnosis?
Malignant otitis externa Otosclerosis Acoustic neuroma Meniers disease Viral illness
Malignant otitis externa
A combination of severe otalgia and facial nerve palsy in a diabetic should raise suspicion of malignant otitis externa. This is a condition caused by pseudomonas. It commences as otitis externa and then progresses to involve the temporal bone.
A 25 year old lady presents with an swelling located at the anterior border of the sternocleidomastoid muscle. The swelling is intermittent and on examination it is soft and fluctuant. What is the most likely diagnosis?
Thyroglossal cyst Branchial cyst Carotid body tumour Infection with Bartonella Dental abscess
Branchial cyst
Branchial cysts are remnants of the branchial cleft. They may become infected.
A 4 year old child presents with a 4-5 day history of feeling generally unwell and also of having a sore throat. On examination, there is marked cervical lymphadenopathy, the oropharynx is covered with a thick grey membrane which bleeds following attempted removal. What is the most likely diagnosis?
Acute streptococcal pharyngitis Infection with Epstein Barr virus Diptheria Ludwigs angina Ingestion of caustic soda
Diptheria
Infection with diphtheria classically causes a systemic illness that lasts several days. The tonsils or pharynx can be covered in a thick grey membrane which bleeds on attempted removal. There is often quite marked cervical adenopathy and some individuals can have a bulls neck appearance. Death can occur through airway compromise, which is why the often described attempted removal of the pseudomembrane so beloved of examiners, is, in practice rather a foolish thing to attempt in a young child!
A 43 year old lady presents with symptoms of chronic ear discharge and a right sided facial nerve palsy. On examination, she has foul smelling fluid draining from her right ear and a complete right sided facial nerve palsy. What is the most likely cause?
Adenoid cystic carcinoma Cholesteatoma Acute otitis media Chronic sinusitis Cerebrovascular accident
Cholesteatoma
Foul smelling ear discharge and facial nerve weakness is likely to be due to cholesteatoma. The presence of a neurological deficit is a sinister feature.
A 40 year old professional singer is admitted for a right thyroid lobectomy. Post operatively, she is unable to sing high notes. Which of the following muscles is likely to demonstrate impaired function?
Thyroarytenoid Posterior cricoarytenoid Cricothyroid Thyrohyoid Lateral cricoarytenoid
Cricothyroid
The most likely injury is to the superior laryngeal nerve which innervates the cricothyroid muscle. Since this tenses the vocal cords, singing high notes becomes a problem.
Which of the following does not cause parotid enlargement?
Liver cirrhosis Myxoedema Amiodarone Tuberculosis Sjogrens syndrome
Amiodarone
Drugs commonly implicated in parotid gland enlargement include:
Thiouracil, isoprenaline, phenylbutazone, high oestrogen dose contraceptive pills.
At which of the following time frames is secondary haemorrhage most likely to occur following tonsillectomy?
Between 5 and 10 days after surgery During the first 6 hours after surgery Between 6 and 12 hours after surgery Upon resumption of normal feeding Between 2 and 3 days post operatively
Between 5 and 10 days after surgery
Haemorrhage in the first 24 hours after surgery is termed reactionary haemorrhage. Feeding does not increase the risk and may actually lower the risks of infection developing.
A 4 year old child is brought to the clinic by his father. They are concerned because the child has been noted to have a small epithelial defect anterior to the left ear and is has been noted to discharge foul smelling material for the past 2 days. What is the most likely explanation?
Otitis externa Otitis media Pre auricular sinus Cholesteatoma Long standing pars flaccida perforation
Pre auricular sinus
Pre auricular sinuses that are deeper may accumulate secretions and produce foul smelling discharge.
A 56 year old man presents with symptoms of nasal pain, anosmia and rhinorrhea. He has been well until recently and has worked as a wood carver for many years. What is the most likely diagnosis?
Ethmoid sinus cancer Ameloblastoma Maxillary sinus cancer Fibrous dysplasia Haemangiopericytoma
Ethmoid sinus cancer
Nasopharyngeal cancer is strongly associated with wood work. Most cases require an occupational exposure of greater than 10 years and are adenocarcinomas on histology.
Most cases are ethmoidal in origin
A 32 year old lady is referred to the clinic with recurrent infections and abscesses in the neck. On examination, she has a midline defect with an overlying scab, which moves upwards on tongue protrusion. What is the most likely diagnosis?
Branchial cyst Branchial fistula Thyroglossal cyst Sebaceous cyst Dermoid cyst
Thyroglossal cyst is always located in the midline as it is this route that the thyroid takes during its embryological descent. Its connection with the foramen caecum means it will move on tongue protrusion.
A 8 year old boy with recurrent attacks of otitis media is suspected of developing a glue ear. If his sound conduction is tested, which of the following is most consistent with a unilateral middle ear effusion?
Negative Rinne's test on the ipsilateral side Positive Rinne's test on the ipsilateral side Positive Webers and Rinnes tests on the ipsilateral side Positive Rinne's test on the contralateral side Negative Webers test only on the contralateral side
Negative Rinne’s test on the ipsilateral side
Rinne’s test will localise to the affected side (i.e. it is negative in conductive deafness). In a positive Rinne’s test sound heard by air conduction is better than that conveyed by bone conduction. Reduction of both air and bone conduction in equal measure is a feature of sensorineural hearing loss.
A 10 year old child presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice peticheal haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly. What is the most likely cause?
Lymphoma Acute Epstein Barr virus infection Diptheria Streptococcal throat infection Quinsy
Acute Epstein Barr virus infection
A combination of pharyngitis and tonsillitis is often seen in glandular fever. Antibiotics containing penicillin may produce a rash when given in this situation, leading to a mistaken label of allergy.
