Otolaryngology

Question 0

15-year-old girl has a round, 1 cm cystic mass in the midline of her neck at the level of the hyoid bone. When the mask is palpated at the same time that the tongue is pulled, there seems to be a connection between the two. The mass has been present for 10 years, but only recently bother the patient because it got infected. What is it? What is the management?

Answer 0

Thyroglossal of duct cyst

Sistrunk operation– Removal of the mass and the tract to the base of the tongue, along with medial segment of the hyoid bone.

Question 1

Name the categories of neck masses.

Answer 1

Congenital, neoplastic, inflammatory.

Question 2

18-year-old woman has a 4 cm, fluctuant round mass on the side of her neck, just beneath and in front of the sternomastoid. She reports that it has been there at least 10 years, although she thinks it has become somewhat larger than the last year or two. CT scan shows the mass to be cystic.

Answer 2

Branchial cleft cyst. Do Elective surgical removal.

Question 3

Mushy, fluid filled mass at the base of the neck is been noted for several years. 6 cm, occupies most of the supraclavicular area and seems by physical examination to go deeper into the neck and chest.

Answer 3

Cystic hygroma
Get a CT scan to see how deep this thing goes. They can extend down into the chest and mediastinum. Surgical removal will eventually be done

Question 4

Name three types of congenital masses.

Answer 4

Thyroglossal duct cyst
Branchial cleft cyst
Cystic hygroma

Question 5

Enlarged lymph node in the neck that is 2 cm, firm, not tender, discovered six weeks ago. History of low-grade fever and night sweats for the past three weeks. Physical exam reveals enlarged lymph nodes in both exit was in the left groin. What is it? What is the next step in management?

Answer 5

Lymphoma.
Tissue diagnosis will be needed. Start with fine needle aspiration of available notes, but eventually node biopsy will be needed to establish diagnosis and type of lymphoma

Question 6

4 cm hard mass in the left supraclavicular area. Nontender, present for three months. 20 pound weight loss in the past two months. What is it? What is the next step?

Answer 6

Malignant metastasis to a supper clavicular node from a primary tumor below the Neck

Look for obvious primary tumors: lung, stomach, colon, pancreas, kidney. Node May be biopsied

Question 7

69-year-old man who smokes and drinks and has rotten teeth has a hard, fixed, 4 cm mass in his neck. Mass is just medial and in front of the sternomastoid muscle, at the level of the upper notch of the thyroid cartilage. It has been there for at least six months, and is growing. Diagnosis and management?

Answer 7

Metastatic squamous cell carcinoma to a jugular chain node, from a primary in the mucosa of the head and neck.

Don’t biopsy! Triple endoscopy – examination under anesthesia of the mouth, pharynx, larynx, esophagus, and tracheobronchial tree, also known as a panendoscopy.

Treatment includes radiation, platinum based chemotherapy, surgery

Question 8

Young patient, asymptomatic, with a mass present for years. Location midline, at the level of the hyoid bone

Answer 8

Thyroglossal duct cyst

Question 9

Young patient, asymptomatic, with a mass present for years. In front of and under the sternocleidomastoid muscle

Answer 9

Congenital, branchial cleft cyst

Question 10

Young patient, asymptomatic, but mass present for years. In the supraclavicular area, Mushy

Answer 10

Congenital, cystic hygroma

Question 11

Neck mass that is relentlessly growing for a few months.

Answer 11

It is neoplastic

Question 12

Young patient multiple enlarged nodes, low-grade fever, night sweats

Answer 12

Lymphoma

Question 13

Supper clavicular node

Answer 13

Metastasis from a primary location below the clavicles

Question 14

On the side of the neck. In an old man who smokes and drinks and has rotten teeth

Answer 14

Metastasis from squamous cell carcinoma of the mouth, pharynx, or larynx

Question 15

Explain a nasal hemorrhage pathophysiology?

Answer 15

90% anterior epistaxis from keisselbach’s plexus at septum (anterior ethmoid artery from ophthalmic artery)
10% posterior epistaxis from Internal maxillary artery - SPHENOPALATINE BRANCH - more common in elderly.

Question 16

Old man who smokes and drinks and has rotten teeth with hard, fixed, 4 cm mass in his neck. Mass is just medial and in front of the sternomastoid muscle, at the level of the upper notch of the thyroid cartilage. It has been there for at least 6 months and is growing. What is it? Management?

Answer 16

Metastatic SCC to jugular chain node from primary in mucosa of the head and neck

Don’t biopsy the node! TRIPLE ENDOSCOPY - mouth, pharynx, larynx, esophagus, tracheobronchial tree. CT scan. Radiation, platinum based chemotherapy, surgery if possible.

Question 17

56-year-old man develops slow progressive paralysis of the facial nerve. It took several weeks for the full-blown paralysis to become obvious and it is been present for three months. It affects both the fore head and the lower face. What is it? Diagnosis.

Answer 17

Gradual, unilateral nerve paralysis suggests a neoplastic process.
Diagnosed with gadolinium enhanced MRI

Question 18

45-year-old man presents with a 2 cm firm mass in front of the left ear, present for four months. The mass is deep to the skin, and it is painless. The patient has normal function of the facial nerve. What is it? How do you diagnose it?

Answer 18

Pleomorphic adenoma (mixed tumor) of the parotid gland.
Never biopsy in office or under local anesthesia!
Referred to head and neck surgeon for formal superficial parotidectomy

Question 19

A two-year-old has unilateral ear ache.
A two-year-old has unilateral foul-smelling purulent rhinorrhea.
A two-year-old has unilateral wheezing, and along on that side looks darker on x-rays then the other side

Answer 19

Unilateral versions of common bilateral ENT conditions and Tabers suggest foreign body. Appropriate x-rays, physical examination or endoscopies, and extraction obviously under anesthesia

Question 20

45-year-old lady with a history of recent tooth infection shows up with huge, hot, red, tender fluctuant mass occupying the lower left side of face and upper neck, underside of the mouth. She is febrile. What is it? Management.

Answer 20

Ludwig angina – an abscess of the floor of the mouth.

Maintain airway. Incision and drainage, intubation or tracheostomy may also be required.

Question 21

29-year-old lady called your office at 10 AM with a history that she woke up that morning with one side of her face paralyzed.

Answer 21

Bell palsy. Start right away on antiviral medication and steroids.

Question 22

Patient with multiple trauma from car accident. The next day it is noted that he has a facial nerve paralysis on one side.

Answer 22

Trauma to the temporal bone can transect the facial nerve, but when that happens the nerve is paralyzed right there. Paralysis appearing late is from edema. Nothing needs to be done.

Question 23

Middle aged lady with a history of repeated episodes of sinusitis. Six days ago was started on decongestants and oral antibiotics for what you diagnosed as frontal and ethmoid sinusitis. She woke up today and is seeing double. What is it? Management.

Answer 23

Cavernous sinus thrombosis vs. Orbital cellulitis
Emergency. Immediate hospitalization,
High-dose IV antibiotic treatment,
surgical drainage of the paranasal sinus or the orbit.
CT scan needed to guide the surgery
This is a big fucking problem

Question 24

The patient reports dizziness. The patient is lightheaded and unsteady. The room is not spinning around them, what type of problem is this?

Answer 24

Neurological problem.

Question 25

The patient reports dizziness. The patient is lightheaded and unsteady. The room is spinning around them, what type of problem is this?

Answer 25

Vestibular problem

Question 26

18-year-old boy has epistaxis. Denies picking his nose. No source of anterior bleeding can be seen by physical examination. What is it?

Answer 26

Either a septal perforation from cocaine abuse, or

posterior juvenile nasal pharyngeal angiofibroma