HEENT

Question 1

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.

Answer 1

Thyroglossal duct cyst

Question 2

Surgical removal of a thyroglossal duct cyst

Answer 2

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.

Question 3

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.

Answer 3

Branchial cleft cysts

Question 4

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.

Answer 4

Cystic hygroma

Question 5

Cystic hygroma is associated with which genetic anomalies?

Answer 5

Turner syndrome and Down’s Syndrome

Question 6

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.

Answer 6

Lymphoma

Question 7

Usual diagnostic tool and treatment of lymphoma

Answer 7

FNA can be done, but usually a node has to be removed for pathologic study to determine specific type. Chemotherapy is the usual treatment.

Question 8

Usual demographic of people with squamous cell carcinoma of the mucosae of the head and neck

Answer 8

Old men who smoke and drink and have rotten teeth. Also people with AIDS.

Question 9

Surgical treatment of squamous cell carcinoma of the mucosae of the head and neck

Answer 9

Treatment involves resection, radical neck dissection, and very often radiotherapy and platinum-based chemotherapy.

Question 10

Manifestations of Squamous cell carcinoma of the mucosae

Answer 10

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.

Question 11

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).

Answer 11

Acoustic nerve neuroma

Question 12

Suspect in a patient with gradual unilateral facial nerve paralysis affecting both the forehead and the lower face.

Answer 12

Facial nerve tumors

Question 13

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.

Answer 13

Parotid tumors

Question 14

Dx and Surgical tx of parotid tumors

Answer 14

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.

Question 15

most likely cause of a 2-year-old with unilateral earache, unilateral rhinorrhea, or unilateral wheezing

Answer 15

A foreign body lol like a toy truck or something lodged in the ear, nose, bronchus

Question 16

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?

Answer 16

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.

Question 17

What produces sudden paralysis of the facial nerve for no apparent
reason?

Answer 17

Bell’s palsy.

Question 18

Medical treatment of bell’s palsy

Answer 18

Antivirals, early. Also steroids.

Question 19

How do you tell the difference between dizziness with an inner ear origin and dizziness with a cerebral origin?

Answer 19

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.

Question 20

What can you offer medically to a person with an inner ear disorder who c/o dizziness?

Answer 20

Meclizine, Phenergan, or diazepam

may help.

Question 21

Differential for anterior mediastinal mass

Answer 21

4 T’s: thymoma, teratoma, thyroid neoplasm, terrible lymphoma

Question 22

What to suspect in an anterior mediastinal mass when the patient has elevated alpha-fetoprotein and beta-HCG

Answer 22

Germ cell tumor

Question 23

Consider this in a pt w/ a chronic hard, bony growth on his hard palate

Answer 23

torus palatinus, a benign congenital bony growth on the midline suture of the hard palate.

Question 24

Most common cause of hoarseness

Answer 24

Viral Laryngitis

Question 25

Single greatest risk factor for squamous cell carcinoma of the upper aerodigestive tract?

Answer 25

Tobacco use (both smoked and chewed)

Question 26

Most common kind of laryngeal cancer

Answer 26

Squamous cell carcinoma

Question 27

What is the innervation of the larynx

Answer 27

Superior laryngeal nerve, recurrent laryngeal nerve (both are branches of the vagus nerve)

Question 28

Causative agent of laryngeal papilloma

Answer 28

HPV (6 and 11)

Question 29

Workup for laryngeal cancer

Answer 29

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.

Question 30

Tx for laryngeal cancer (early vs late stage)

Answer 30

Early stage: radiation and surgical resection.

Late stage: Chemotherapy and radiation, surgery and radiation, possible tracheostomy.

Question 31

Differential diagnosis for a neck mass

Answer 31

KITTENS:
K - congenital
Infectious/inflammatory
Toxins
Trauma
Endocrine
Neoplastic
Systemic

Question 32

Virchow’s node, and why it is concerning

Answer 32

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.

Question 33

How do you biopsy a neck mass to assess for malignancy?

Answer 33

FNA

Question 34

If you are looking for the primary tumor after finding a metastatic neck mass, what procedure can you do?

Answer 34

Panendoscopy: laryngoscopy + bronchoscopy + esophagoscopy

Question 35

After PE, imaging, labs, FNA and panendoscopy, what should you do to assess the malignant potential of a solitary neck mass?

Answer 35

Open neck biopsy, frozen section

Question 36

First steps in a patient who presents w/ a solitary neck mass

Answer 36

Thorough physical exam, followed by flexible endoscopy, FNA biopsy, imaging w/ CT with contrast, and any other imaging necessary

Question 37

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.

Answer 37

Otitis media with effusion (OME)

Question 38

Think along this line in a small child who regresses in language

Answer 38

Suspect hearing loss

Question 39

Automatically suspect this in a child with unilateral hearing loss

Answer 39

Foreign body stuck in ear

Question 40

What should you think when you see a pt w/ otorrhea?

Answer 40

middle ear disease with TM perforation

Question 41

How Does One Distinguish on History and Physical Exam Between External Otitis and Otitis Media?

Answer 41

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).

Question 42

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.

Answer 42

Otitis media with effusion (OME)

Question 43

Most common reason for sudden hearing loss

Answer 43

Viral infections, leading to sensorineural hearing loss. The most common viruses are herpes simplex and herpes zoster.

Question 44

Which pathogens are most common in OME

Answer 44

Streptococcus pneumonia, nontypable Haemophilus influenza, and Moraxella catarrhalis. Other microbes may include Pseudomonas aeruginosa
(more common with otitis externa), Streptococcus pyogenes , and other anaerobes

Question 45

Tx of Acute Otitis Media (AOM) vs Otitis Media with otitis media with effusion (OME)

Answer 45

(AOM) antibiotics

(OME) PE tubes mostly.

Question 46

If a child with strabismus does not have their vision corrected in the first 6 or 7 years of life, what may happen?

Answer 46

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.

Question 47

When you see a white pupil on a baby, what is the greatest threat?

Answer 47

may be caused by retinoblastoma

Question 48

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.”

Answer 48

Acute angle closure glaucoma

Question 49

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.

Answer 49

Orbital cellulitis

Question 50

What should you do about orbital cellulitis

Answer 50

There is pus in the orbit, and emergency CT scan and drainage have to be done.

Question 51

What should you do about chemical burns to the eye

Answer 51

massive irrigation ASAP

Question 52

Suspect this in a pt who reports seeing flashes of light and having “floaters”
in the eye.

Answer 52

Detached retina

Question 53

What should you do about a detached retina

Answer 53

Emergency intervention, with laser “spot welding,” will protect the remaining retina.

Question 54

Consider this when a patient (typically elderly) describes sudden loss of vision from one eye.

Answer 54

Embolic occlusion of the retinal artery.