HEENT Flashcards
This type of cyst is congenital, located on the midline at the level of the hyoid
bone, and seems to be somehow connected to the tongue. Typically 1-2 cm.
Thyroglossal duct cyst
Surgical removal of a thyroglossal duct cyst
Remove the cyst, the middle segment of the hyoid bone, and the track that leads to the base of the tongue. Some practitioners insist that the location of the normal thyroid should first be ascertained by radionuclide scan.
These congenital cysts occur along the anterior edge of the sternomastoid muscle, anywhere from in front of the tragus to the base of the neck. They are several centimeters in diameter and sometimes have a little opening and blind tract in the skin overlying them.
Branchial cleft cysts
This congenital cyst is found at the base of the neck as a large, mushy, ill-defined mass that occupies the entire supraclavicular area and seems to extend deeper into the chest. They often extend into the mediastinum, so CT scan before attempted surgical removal is mandatory.
Cystic hygroma
Cystic hygroma is associated with which genetic anomalies?
Turner syndrome and Down’s Syndrome
Suspect this in young people who have multiple enlarged nodes (in the neck and elsewhere) and have been suffering from low-grade fever and night sweats.
Lymphoma
Usual diagnostic tool and treatment of lymphoma
FNA can be done, but usually a node has to be removed for pathologic study to determine specific type. Chemotherapy is the usual treatment.
Usual demographic of people with squamous cell carcinoma of the mucosae of the head and neck
Old men who smoke and drink and have rotten teeth. Also people with AIDS.
Surgical treatment of squamous cell carcinoma of the mucosae of the head and neck
Treatment involves resection, radical neck dissection, and very often radiotherapy and platinum-based chemotherapy.
Manifestations of Squamous cell carcinoma of the mucosae
Often the first manifestation is a metastatic node in the neck (typically to the jugular chain). Other presentations include persistent hoarseness, persistent painless ulcer in the floor of the mouth, and persistent unilateral earache.
Suspect in an adult who has sensory hearing loss in one ear, but not the other (and who does not engage in sport shooting that would subject one ear to more noise than the other).
Acoustic nerve neuroma
Suspect in a patient with gradual unilateral facial nerve paralysis affecting both the forehead and the lower face.
Facial nerve tumors
These tumors are visible and palpable in front of the ear or around the angle of the mandible. Most are pleomorphic adenomas, which are benign but have potential for malignant degeneration.
Parotid tumors
Dx and Surgical tx of parotid tumors
FNA of these tumors may be done, but open biopsy is absolutely contraindicated. A formal superficial parotidectomy (or superficial and deep if the tumor is deep to the facial nerve) is the appropriate way to excise (and thereby biopsy) parotid tumors, preventing recurrences and sparing the facial nerve. Enucleation alone leads to recurrence. In malignant tumors the nerve is sacrificed and a graft done.
most likely cause of a 2-year-old with unilateral earache, unilateral rhinorrhea, or unilateral wheezing
A foreign body lol like a toy truck or something lodged in the ear, nose, bronchus
What should you suspect when you see an abscess in the floor of the mouth, often the result of a tooth infection. What unique problem can it cause?
Ludwig angina. The usual findings of an abscess are present, but the special issue here is the threat to the airway. Incision and drainage are done, but intubation and tracheostomy may also be needed.
What produces sudden paralysis of the facial nerve for no apparent
reason?
Bell’s palsy.
Medical treatment of bell’s palsy
Antivirals, early. Also steroids.
How do you tell the difference between dizziness with an inner ear origin and dizziness with a cerebral origin?
When the inner ear is the culprit, the patients describe the room spinning around them. When the problem is in the brain, the patient is unsteady but the room is perceived to be stable.
What can you offer medically to a person with an inner ear disorder who c/o dizziness?
Meclizine, Phenergan, or diazepam
may help.
Differential for anterior mediastinal mass
4 T’s: thymoma, teratoma, thyroid neoplasm, terrible lymphoma
What to suspect in an anterior mediastinal mass when the patient has elevated alpha-fetoprotein and beta-HCG
Germ cell tumor
Consider this in a pt w/ a chronic hard, bony growth on his hard palate
torus palatinus, a benign congenital bony growth on the midline suture of the hard palate.
Most common cause of hoarseness
Viral Laryngitis
Single greatest risk factor for squamous cell carcinoma of the upper aerodigestive tract?
Tobacco use (both smoked and chewed)
Most common kind of laryngeal cancer
Squamous cell carcinoma
What is the innervation of the larynx
Superior laryngeal nerve, recurrent laryngeal nerve (both are branches of the vagus nerve)
Causative agent of laryngeal papilloma
HPV (6 and 11)
Workup for laryngeal cancer
Indirect or direct laryngoscopy. Also chest X-rays, to rule out lung cancer or metastasis, and CT to show metastasis to lymph nodes. So the aim is to stage it.
Tx for laryngeal cancer (early vs late stage)
Early stage: radiation and surgical resection.
Late stage: Chemotherapy and radiation, surgery and radiation, possible tracheostomy.
Differential diagnosis for a neck mass
KITTENS: K - congenital Infectious/inflammatory Toxins Trauma Endocrine Neoplastic Systemic
Virchow’s node, and why it is concerning
Enlarged left supraclavicular node. It occurs on the left as this is where the cisterna chyli (dilated lymph sac at the end of the thoracic duct) empties into the subclavian vein. Virchow’s node is suggestive of metastatic lung or GI malignancy.
How do you biopsy a neck mass to assess for malignancy?
FNA
If you are looking for the primary tumor after finding a metastatic neck mass, what procedure can you do?
Panendoscopy: laryngoscopy + bronchoscopy + esophagoscopy
After PE, imaging, labs, FNA and panendoscopy, what should you do to assess the malignant potential of a solitary neck mass?
Open neck biopsy, frozen section
First steps in a patient who presents w/ a solitary neck mass
Thorough physical exam, followed by flexible endoscopy, FNA biopsy, imaging w/ CT with contrast, and any other imaging necessary
Suspect this in a young (6 yo) patient who presents with conductive hearing loss. Otoscopic findings typically include an immobile TM and air-fluid levels with partial opacification. No sign of acute infection.
Otitis media with effusion (OME)
Think along this line in a small child who regresses in language
Suspect hearing loss
Automatically suspect this in a child with unilateral hearing loss
Foreign body stuck in ear
What should you think when you see a pt w/ otorrhea?
middle ear disease with TM perforation
How Does One Distinguish on History and Physical Exam Between External Otitis and Otitis Media?
Otitis externa (“swimmers ear”) typically occurs in pts after exposure to warm water. Common sx are otalgia when moving external ear, pruritus, and hearing loss. On otoscopic examination, a pt w/ otitis externa will have an edematous and erythematous external ear canal. The TM is typically intact and freely mobile with no evidence of air-fluid levels (i.e., normal).
Consider this in a pt w/ conductive hearing loss secondary to fluid within the middle ear space. The presence of an air-fluid level or visible bubbles within the middle ear space is associated w/ less hearing loss. Aside from hearing loss, patients with OME may also have sleep disturbance, ear fullness, tinnitus, or even balance problem.
Otitis media with effusion (OME)
Most common reason for sudden hearing loss
Viral infections, leading to sensorineural hearing loss. The most common viruses are herpes simplex and herpes zoster.
Which pathogens are most common in OME
Streptococcus pneumonia, nontypable Haemophilus influenza, and Moraxella catarrhalis. Other microbes may include Pseudomonas aeruginosa
(more common with otitis externa), Streptococcus pyogenes , and other anaerobes
Tx of Acute Otitis Media (AOM) vs Otitis Media with otitis media with effusion (OME)
(AOM) antibiotics
(OME) PE tubes mostly.
If a child with strabismus does not have their vision corrected in the first 6 or 7 years of life, what may happen?
Amblyopia, a vision impairment resulting from interference with the processing of images by the brain. Faced with two overlapping images, the brain suppresses one of them, and if not corrected leads to permanent cortical blindness of the suppressed eye, even though the eye is perfectly normal.
When you see a white pupil on a baby, what is the greatest threat?
may be caused by retinoblastoma
Suspect this in a patient who presents with very severe eye pain or frontal headache, typically starting in the evening when the pupils have been dilated for several hours (watching a double feature at the movies, or watching TV in a dark room). The patient may report seeing halos around lights. On physical exam the pupil is mid-dilated and does not react to light, the cornea is cloudy with a greenish hue, and the eye feels “hard as a rock.”
Acute angle closure glaucoma
Suspect this in a patient whose eyelids are hot, tender, red, and swollen, and the patient is febrile. The key finding when the eyelids are pried open is that the pupil is dilated and fixed, and the eye has very limited motion.
Orbital cellulitis
What should you do about orbital cellulitis
There is pus in the orbit, and emergency CT scan and drainage have to be done.
What should you do about chemical burns to the eye
massive irrigation ASAP
Suspect this in a pt who reports seeing flashes of light and having “floaters”
in the eye.
Detached retina
What should you do about a detached retina
Emergency intervention, with laser “spot welding,” will protect the remaining retina.
Consider this when a patient (typically elderly) describes sudden loss of vision from one eye.
Embolic occlusion of the retinal artery.
