Intro Lecture and neck mass Flashcards
What is Ozena or empty nose syndrome?
After resection of all the turbinates
Patient will complain of chronic congestion and have severe nasal crusting rather than feeling more open
What is kiesselbach’s plexus?
Area particularly prone to bleed
Place where the blood vessels supplying the nose converge in the nasal septum
What are vibrissae? What happens after they do their job?
Special hairs within nostrils that filter larger particles
Cilia then beat things trapped in mucus to pharynx where it is swallowed and sent to acidic stomach to be disposed of
What is rhinorrhea? What do different colors signify?
Nasal discharge
Clear - allergic, viral vasomotor or CSF
Green - sinusitis, foreign body
How can clear rhinorrhea be differentiated from CSF?
CSF has higher glucose content
Beta 2 transferrin present in CSF but not mucus
Bloody CSF forms ring sign when dripped onto paper towel
What is anosmia?
Loss of sense of smell
Can occur with severe blockage
Can be conductive or sensorineural
Can tat with alcohol, mustard, or other pungent items
What is epistaxis? What can cause it?
Nose bleeds
Clotting problems, high pressure, trauma, dryness and irritation, vascular abnormalities
JVN - vascular mass seen in adolescent boys with frequent unilateral severe nose bleeds
Hereditary hemorrhagic telangiectasia
What is the source of pain in the nose?
Often from sinuses
Nose innervation by branches of V
What is rhino sinusitis?
Most common cause of congestion
Inflammation of nose and sinuses
Includes allergic and viral rhinitis as well as rhinitis medicamentosa
What is meningocele?
Evagination of meninges into nasal cavity through dehiscence in floor of cranium
Why can a vasoconstrictor help during a nasal exam?
Cause turbinates to shrink and allow more light to enter nose
Can now see more of the middle and superior turbinates
What is the general rule of thumb regarding use of ct or MRI to evaluate nose?
CT better for bony structure
MRI better for soft tissue
What is xerostomia?
Dry mouth
What are dysphagia and odynophagia?
Difficulty swallowing
Pain with swallowing
What is an insidious symptom of the OC/OP to look out for?
Otalgia
Common complaint in primary oropharyngeal cancer is result of referred pain from CN IX
Can also be present in tonsillitis
Chronic intermittent pain that waxes and wanes, worsens acutely, but then goes back to dull roar most of the time
Pain under the chin
Submandibular gland inflammation
History of medication exposure such as chemotherapy or recent antibiotics would raise suspicion for what?
Thrush
Ddx for sore throat and odynophagia
Infectious and inflammatory processes (tonsillitis, peritonsillar abscess, thrush, epiglottitis, and cancer)
Absence of odynophagia can narrow differential
Ddx of sore throat and voice change
Peritonsillar abscess - hot potato voice
Seen in mono or tonsillitis and sometime lymphoma
Ddx of sore throat and lymphadenopathy
Infectious and neoplastic processes
Posterior - mono, ear and scalp inf
Anterior - tonsillitis, strep pharyngitis
Ddx of sore throat and globus (sensation of something stuck in throat)
LPR (reflux), PND, neoplasm, vocal cord granuloma, tonsillitis, actual foreign body
If fever is present, what can be ruled out of the differential?
Thrush - does not present with fever
Small painful ulcerations of unknown etiology that resolve over time
Apthous ulcers (canker sores)
White patch of mucosa in mouth
Leukoplakia
May indicate premalignant state
Smooth tongue
Glossitis
Thrush vs. leukoplakia
Thrush can be scraped away, leukoplakia cannot
White plaque on reddened pharynx
Strep pharyngitis
Painful, red bulging of tissues around tonsil and possible deviation of uvula to opposite side
Peritonsillar abscess
Why do laryngeal cancers tend to not metastasize if caught early enough?
Not a lot of lymphatics in the glottis
Intermittent hoarseness in patient also experiencing nasal discharge, itchy nose, eyes and soft palate
Allergic rhinitis causing hoarseness
Post nasal drip related hoarseness
What is reinke’s edema?
Diffuse vocal cord edema that causes low gravely voice
Causes are cigarette smoke, vocal abuse
Hoarseness and cancer
Common finding in laryngeal carcinoma or disruption of recurrent laryngeal by lung neoplasm
Supraglottis neoplasms cause problems swallowing before hoarseness
Waxing and waning symptoms of hoarseness vs. persistent or worsening
Voice misuse, reflux, post nasal drip, or combo vs.
Structural problem
Sore throat, odynophagia, fever, stridor, and hoarseness in children
Epiglottitis - caused by bacteria
What is stridor and what can cause it?
Impediment to normal laminar flow causes noisy breathing from larynx
Infection - croup or epiglottitis
Neoplasm - laryngeal, thyroid, or lung
Dev. Phenomenon
Allergy/immune phenomenon - angioedema, anaphylaxis, ACEI use
Trauma
Increased respiratory rate, use of accessory muscle of breathing in chest, pallor or cyanosis, tripod positioning, difficulty handling secretions, waning level of consciousness
Signs of severe stridor that may need emergency airway management
When should certain ancillary studies be used to evaluate the larynx?
X ray - for foreign ladies, airway narrowing in croup, epiglottitis
CT of neck/pharynx - first study of choice for laryngeal, neck masses, injuries
MRI - soft tissue better than bone
Barium swallow - helpful for dysphagia
What are the different triangles of the neck?
Sub mental (nodal level Ia)
Submandibular (nodal level Ib)
Vascular (anterior) (nodal levels II, III, IV)
Posterior (nodal level v)
What are the different nodal groups of the neck?
Pre auricular Post auricular Occipital Superficial (to scm, along external jugular vein) Peri facial (along facial artery) Supraclavicular (virchows) Para tracheal
What are the different categories of neck masses?
Normal variant anatomy
Congenital or dev anomaly
Inf or inflammatory process
Neoplasm
Midline mass
Thyroglossal duct cyst
Lateral (level II) mass, fluctuating in size
Branchial cleft cyst
When is gender an important determination in neck masses?
Adult neck masses
Females more prone to have thyroid masses
Males more prone to squamous cell carcinomas
Different origins of cancers
What possible neck masses have otalgia?
Lesion anywhere with referred pain
What neck masses have hearing loss or fullness?
Lesion in NP obstructing Eustachian tube and causing otitis media
What kind of lesion does trismus (trouble swallowing or opening mouth) suggest?
Lesion in OP extending deep
Mass with surrounding soft tissue inflammation
Deep neck abscess
Soft mass is usually?
Benign reactive node
Mass moves with deglutination
Thyroid mass
When should a CBC be obtained?
If infection or neoplasm is suspected
Erythrocytes sedimentation rate and routine electrolytes never really useful
When is a plain x ray indicated with a neck mass?
Never
When is a chest x ray indicated with neck masses?
Can rule out pulmonary lesions
When is ultrasound indicated with neck masses?
Mass suspected of being cystic
Standard for diagnosing thyroid masses
When is nuclear medicine indicated with neck masses?
Good for evaluating cancer
Cold more likely to be cancer than hot nodules
When is CT scan indicated with neck masses?
Best initial scan
But must have good kidney function
When is an MRI indicated with neck masses?
Soft tissue detail when CT insufficient
When CT cannot be used
When is an angiogram indicated with neck masses?
Vascular tumors
Determines resectability - Pre-OP study
What is the role of biopsies in neck masses?
Never biopsy until all other diagnostic modalities have been completed, then use experienced head and neck surgeon
When is endoscopy indicated with neck masses?
To search for primary lesion in upper aerodigestive tract if neck mass is found to be a malignancy and imaging studies fail to reveal primary site
What is the first step if you have an unknown primary carcinoma in the neck?
Take out the tonsils
