Pathology Part 1 Flashcards
1
Q
Acute otitis media
A
A painful type of ear infection. Middle ear becomes inflamed and infected.
2
Q
Common organisms that cause Acute otitis media
A
Most infections are secondary to bacteria, particularly Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
3
Q
Features of Acute otitis media
A
> Otalgia
May tug or rub their ear
Fever 50% of cases
Hearing loss
Recent viral URTI symptoms (e.g. coryza)
Ear discharge if tympanic.m perforates
4
Q
Possible otoscopy findings in Acute otitis media
A
> Bulging tympanic.m → loss of light reflex
Opacification or erythema of tympanic.m
Perforation with purulent otorrhoea
Decreased mobility using pneumatic otoscope
5
Q
Otorrhoea
A
Drainage of liquid from the ear
6
Q
Acute otitis media management
A
- Usually self-limiting
- Antibiotics in some cases (criteria)
- Analgesia
- Seek medical help if symptoms worsen or do not improve after 3 days.
7
Q
When are antibiotics indicated in Acute otitis media?
A
> Symptoms lasting more than 4 days or not improving
Systemically unwell but not requiring admission
Immunocompromise or high risk of complications
Younger than 2 years with bilateral otitis media
Otitis media with perforation and/or discharge
8
Q
If antibiotics are given in Acute otitis media, what is the antibiotic of choice?
A
A 5-7 day course of amoxicillin is first-line
Penicillin allergy ; erythromycin or clarithromycin
9
Q
Chronic suppurative otitis media (CSOM)
A
Defined as perforation of the tympanic membrane with otorrhoea for > 6 weeks
10
Q
Common sequelae after Acute otitis media
A
> Perforation tympanic mem. → otorrhoea
Unresolved acute otitis media with perforation may develop into CSOM
Hearing loss
Labyrinthitis
11
Q
Complications of Acute otitis media
A
- mastoiditis
- meningitis
- brain abscess
- facial nerve paralysis
12
Q
Sinusitis
A
Describes inflammation of the mucous membranes of the paranasal sinuses. The sinuses are usually sterile
13
Q
Most common organisms to cause Sinusitis
A
Streptococcus pneumoniae
Haemophilus influenzae
Rhinoviruses.
14
Q
Predisposing factors that lead to Sinusitis
A
- Nasal obstruction e.g. septal deviation or nasal polyps
- Recent local infection e.g. rhinitis or dental extraction
- Swimming/diving
- Smoking
15
Q
Features of Sinusitis
A
Facial pain - pressure pain worse on bending forward
Nasal discharge: usually thick and purulent
Nasal obstruction
16
Q
Management of Sinusitis
A
- Analgesia
- Intranasal decongestants
- Intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days
- Oral antibiotics given for severe presentations
17
Q
Antibiotics which may be given in Sinusitis
A
Phenoxymethylpenicillin first-line, co-amoxiclav if ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications’
18
Q
When are antibiotics indicated in sinusitis?
A
Given for severe presentations - ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications’
19
Q
When are intranasal corticosteriods indicated in sinusitis?
A
May be considered if the symptoms have been present for more than 10 days
20
Q
Most common organism to cause Acute tonsillitis
A
Streptococcus pyogenes the most common organism
21
Q
Characteristics of Acute tonsillitis
A
Pharyngitis, fever, malaise and lymphadenopathy
22
Q
One condition that mimics Acute tonsillitis
A
Infectious mononucleosis
23
Q
Treatment for Acute tonsillitis
A
Penicillin type antibiotics is indicated for bacterial tonsillitis
24
Q
Complication of Acute tonsillitis
A
May result in local abscess formation (quinsy)
25
Allergic rhinitis
An inflammatory disorder of the nose where it become sensitized to allergens such as house dust mites and grass, tree and weed pollens
26
The three classifications of Allergic rhinitis
1. seasonal:
2. perennial
3. occupational
27
Seasonal Allergic rhinitis
Symptoms occur around the same time every year. Seasonal rhinitis which occurs secondary to pollens is known as hay fever
28
Perennial Allergic rhinitis
Symptoms occur throughout the year
29
Occupational Allergic rhinitis
Symptoms follow exposure to particular allergens within the work place
30
Features of Allergic rhinitis
```
> sneezing
> bilateral nasal obstruction
> clear nasal discharge
> post-nasal drip
> nasal pruritus
```
31
Management for Allergic rhinitis
1. Allergen avoidance
2. Mild-to-moderate intermittent, or mild persistent symptoms: oral or intranasal antihistamines
3. Moderate-to-severe persistent symptoms, or initial drug treatment is ineffective - intranasal corticosteroids
32
Management of mild-to-moderate intermittent, or mild persistent symptoms of Allergic rhinitis
Oral or intranasal antihistamines
33
Management of moderate-severe and persistant symptoms of Allergic rhinitis
Intranasal corticosteroids
34
Oxymetazoline
Nasal decongestant
35
Complications of prolonged use of nasal decongestants
As increasing doses are required to achieve the same effect
Rebound hypertrophy of the nasal mucosa may occur upon withdrawal
36
Rhinitis medicamentosa
Rebound hypertrophy of the nasal mucosa
37
Audiogram findings in sensorineural hearing loss
Both air and bone conduction are impaired
38
Audiogram findings in conductive hearing loss
Only air conduction is impaired
39
Audiogram findings in mixed hearing loss
Both air and bone conduction are impaired, with air conduction often being 'worse' than bone
40
Normal Audiogram findings
Anything above the 20dB line is essentially normal
41
Sensorineural hearing loss (SNHL)
Caused by damage to the structures in your inner ear or your auditory nerve.
42
Conductive hearing Loss
When the natural movement of sound through the external ear or middle ear is blocked, and the full sound does not reach the inner ear.
43
Auricular haematomas
Describes a collection of blood within the cartilaginous auricle (outer ear) which typically results from blunt trauma - common in rugby players and wrestlers.
44
Management of Auricular haematomas
1. Need same-day assessment by ENT
| 2. Incision and drainage
45
Benign paroxysmal positional vertigo
Characterised by the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it is less common in younger patients.
Benign paroxysmal positional vertigo Tiny calcium "stones" inside your inner ear canals help you keep your balance. Sometimes these stones move into an area of your inner ear - the semicircular canal. When you move your head in certain ways, the stones in the semicircular canal move. Sensors in the semicircular canal are triggered by the stones, which causes a feeling of dizziness
46
Features of Benign paroxysmal positional vertigo (BPPV)
Vertigo triggered by change in head position (e.g. rolling over in bed)
May be associated with nausea
Each episode typically lasts 10-20 seconds
Positive Dix-Hallpike manoeuvre, indicated by: patient experiences vertigo & rotatory nystagmus
47
Diagnosis of BPPV
Dix-Hallpike manoeuvre
| Positive result indicated by indicated by vertigo & rotatory nystagmus
48
Management of BPPV
Epley manoeuvre
Exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises
49
Prognosis for BPPV
Good prognosis and usually resolves spontaneously after a few weeks to months
Around half of people with BPPV will have a recurrence of symptoms 3–5 years after their diagnosis
50
Black hairy tongue
Common condition which results from defective desquamation of the filiform papillae. Despite the name the tongue may be brown, green, pink or another colour.
51
Predisposing factors that lead to Black hairy tongue
```
> poor oral hygiene
> antibiotics
> head and neck radiation
> HIV
> intravenous drug use
```
52
Management of Black hairy tongue
1. Tongue scraping
| 2. Topical antifungals if Candida
53
Branchial cleft cyst
A lump that develops in the neck or just below the collarbone. May have a fistula and are therefore prone to infection. They may enlarge following a respiratory tract infection.
54
Cholesteatoma
A non-cancerous growth of squamous epithelium that is 'trapped' within the skull base causing local destruction. Most common in patients aged 10-20 years.
55
What congenital abnormality increases the risk of Cholesteatoma by 100 fold
Being born with a cleft palate
56
Features of Cholesteatoma
```
> foul-smelling, non-resolving discharge
> hearing loss
> vertigo
> facial nerve palsy
> cerebellopontine angle syndrome
```
57
Otoscopy findings in cholesteatoma
'attic crust' - seen in the uppermost part of the ear drum
58
Management of cholesteatoma
Referred to ENT for consideration of surgical removal
59
Chronic rhinosinusitis
An inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer.
60
Predisposing factors for Chronic rhinosinusitis
1. atopy: hay fever, asthma
2. nasal obstruction e.g. Septal deviation or nasal polyps
3. recent local infection e.g. Rhinitis or dental extraction
4. swimming/diving
5. smoking
61
Features of Chronic rhinosinusitis
Facial pain: frontal pressure pain which is worse on bending forward
Nasal discharge: usually clear if allergic or vasomotor. Thicker, purulent discharge suggests secondary infection
Nasal obstruction: e.g. 'mouth breathing'
Post-nasal drip: may produce chronic cough
62
Management of Chronic rhinosinusitis
1. avoid allergen
2. intranasal corticosteroids
3. nasal irrigation with saline solution
Defined by the presence of at least two out of four cardinal symptoms (i.e., facial pain/pressure, hyposmia/anosmia, nasal drainage, and nasal obstruction) for at least 12 weeks
63
Red flag symptoms for Chronic rhinosinusitis
1. unilateral symptoms
2. persistent symptoms despite compliance with 3 months of treatment
3. epistaxis
64
Cochlear implant
An electronic device that may be offered to patients with severe-to-profound hearing loss.
65
Criteria for getting a cochlear implant
In children, audiological assessment and/or difficulty developing basic auditory skills.
In adults, patients should have completed a trial of appropriate hearing aids for at least 3 months which they have been objectively demonstrated to receive limited or no benefit from.
66
Contraindications for receiving cochlear implant
Lesions of cranial nerve VIII or in brain stem causing deafness
Chronic infective otitis media, mastoid cavity or tympanic membrane perforation
Cochlear aplasia
67
Acoustic neuroma features
Features predicted by affected cranial nerves
> cranial nerve VIII: hearing loss, vertigo, tinnitus
> cranial nerve V: absent corneal reflex
> cranial nerve VII: facial palsy
68
Another name for acoustic neuroma
Vestibular schwannomas
69
Bilateral acoustic neuromas
Seen in neurofibromatosis type 2
70
Acoustic neuroma
A benign tumor that develops on the balance (vestibular) and hearing, or auditory (cochlear) nerves leading from your inner ear to the brain
71
Noise damage frequency
Workers in heavy industry are particularly at risk
Hearing loss is bilateral and typically is worse at frequencies of 3000-6000 Hz
72
Drug ototoxicity
Examples include aminoglycosides (e.g. Gentamicin), furosemide, aspirin and a number of cytotoxic agents
73
Another name for glue ear
Otitis media with effusion
74
Glue ear
Glue ear, known as adhesive otitis, is a condition that occurs when the middle part of your ear fills with fluid.
75
Complications that arise with Glue ear
Speech and language delay, behavioural or balance problems may also be seen
76
What kind of hearing loss does ear wax cause?
Conductive hearing loss
77
Ear wax treatment
Ear drops or irrigation
The following drops may be used:
olive oil, sodium bicarbonate 5% & almond oil
78
When should ear wax not be treated?
Treatment should not be given if a perforation is suspected or the patient has grommets.
79
Epistaxis classification
Anterior and posterior bleeds
80
Anterior epistaxis cause
Often has a visible source of bleeding and usually occurs due to an insult to the network of capillaries that form Kiesselbach’s plexus.
81
Posterior epistaxis cause
More profuse and originate from deeper structures unlike anterior. They occur more frequently in older patients and confer a higher risk of aspiration and airway compromise.
82
Epistaxis that has failed all emergency management
May require sphenopalatine ligation in theatre
83
Epistaxis which has failed to resolve after 10-15 minutes of continuous pressure on the nose
Cautery should be used initially if the source of the bleed is visible and cautery is tolerated
Packing may be used if cautery is not viable or the bleeding point cannot be visualised
84
Initial management of epistaxis
> Sit with their torso forward &mouth open
> Avoid lying down unless they feel faint
> Pinch the cartilaginous area of the nose firmly for at least 20 minutes
85
Trigeminal neuralgia type facial pain
Unilateral facial pain characterised by brief electric shock-like pains, abrupt in onset and termination
May be triggered by light touch, emotion
86
Temporal arteritis type facial pain
Tender around temples
| Raised ESR
87
Drug causes of gingival hyperplasia
> phenytoin
> ciclosporin
> calcium channel blockers (especially nifedipine)
88
Head and neck cancer
An umbrella term. It typically includes:
> Oral cavity cancers
> Cancers of the pharynx
> Cancers of the larynx
89
Head and neck cancer features
neck lump
hoarseness
persistent sore throat
persistent mouth ulcer
90
Laryngeal cancer referral criteria
Referral (for an appointment within 2 weeks) in people aged 45 and over with:
persistent unexplained hoarseness or
an unexplained lump in the neck
91
Thyroid cancer referral criteria
Referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump
92
Oral cancer referral criteria
Referral (for an appointment within 2 weeks) in people with either:
unexplained ulceration in the oral cavity lasting for more than 3 weeks or
a persistent and unexplained lump in the neck.
93
Causes of hoarseness
```
> voice overuse
> smoking
> viral illness
> hypothyroidism
> gastro-oesophageal reflux
> laryngeal cancer
> lung cancer
```
94
Laryngopharyngeal reflux (LPR)
Caused by gastro-oesophageal reflux resulting in inflammatory changes to the larynx/hypopharynx mucosa.
95
Laryngopharyngeal reflux features
```
A lump in the throat - 'globus'
Typically worse when swallowing saliva rather than eating or drinking
hoarseness
chronic cough
dysphagia
heartburn
sore throat
```
96
Management of Laryngopharyngeal reflux
> lifestyle measures & avoid triggers
> proton pump inhibitor
> sodium alginate liquids (e.g. Gaviscon)
97
Ludwig's angina
Type of progressive cellulitis that invades floor of mouth & soft tissues of neck. Most cases result from odontogenic infections which spread into the submandibular space.
98
Features of Ludwig's angina
neck swelling
dysphagia
fever
99
Management of Ludwig's angina
1. airway management
| 2. intravenous antibiotics
100
Malignant otitis externa
Uncommon type of otitis externa that is found in immunocompromised individuals (90% cases found in diabetics)
101
Common cause of Malignant otitis externa
Pseudomonas aeruginosa
102
Infection spread in Malignant otitis externa
Infection commences in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues and into the bony ear canal
Progresses to temporal bone osteomyelitis
103
Features of Malignant otitis externa
```
Diabetes (90%) or immunosuppression
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea
Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
```
104
Diagnosis of Malignant otitis externa
A CT scan is typically done
105
Management of Malignant otitis externa
Non-resolving otitis externa with worsening pain should be referred urgently to ENT
Intravenous antibiotics that cover pseudomonal infections
106
Mastoiditis features
> Severe otalgia classically behind the ear
> History of recurrent otitis media
> Fever
> Very unwell
> The external ear may protrude forward
> Swelling, erythema & tenderness over mastoid process
107
Meniere's disease
A disorder of the inner ear that can lead to vertigo and hearing loss. In most cases, Meniere's disease affects only one ear. Can occur at any age, but it usually starts between young and middle-aged adulthood.
108
Meniere's disease features
1. recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural).
2. Aural fullness or pressure
3. nystagmus and a positive Romberg test
4. episodes last minutes to hours
109
Management of acute attacks of Meniere's disease
Buccal or intramuscular prochlorperazine. Admission is sometimes required
110
Samter's triad
The association of asthma, aspirin sensitivity and nasal polyposis is known as Samter's triad.
111
Associations that lead to nasal polyps
```
asthma
aspirin sensitivity
infective sinusitis
cystic fibrosis
Kartagener's syndrome
Churg-Strauss syndrome
```
112
Features of nasal polyps
nasal obstruction
rhinorrhoea, sneezing
poor sense of taste and smell
113
Management of nasal polyps
All patients should be referred to ENT
| Topical corticosteroids shrink polyp size
114
Medication to shrink nasal polyps
Topical corticosteroids
115
Nasal septal haematoma
Important complication of nasal trauma which should always be looked for. Describes the development of a haematoma between the septal cartilage and the overlying perichondrium.
116
Management of Nasal septal haematoma
surgical drainage
| intravenous antibiotics
117
Complication of untreated Nasal septal haematoma
Irreversible septal necrosis may develop within 3-4 days. Due to pressure-related ischaemia of the cartilage resulting in necrosis. This may result in a 'saddle-nose' deformity
118
What virus is associated with development of Nasopharyngeal carcinoma?
Associated with Epstein Barr virus infection
119
What part of the world is Nasopharyngeal carcinoma mostly found?
Rare in most parts of the world, apart from individuals from Southern China
120
Carotid aneurysm
Pulsatile lateral neck mass which doesn't move on swallowing
121
Thyroglossal cyst
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
122
Otitis externa
A condition that causes inflammation of the external ear canal
123
Causes of otitis externa
infection: bacterial
seborrhoeic dermatitis
contact dermatitis (allergic and irritant)
recent swimming is a common trigger
124
Common bacterial cause of otitis externa
Staphylococcus aureus
| Pseudomonas aeruginosa
125
Features of otitis externa
ear pain, itch, discharge
| otoscopy: red, swollen, or eczematous canal
126
Management of otitis externa
Topical antibiotic or a combined topical antibiotic with a steroid
If the tympanic membrane is perforated aminoglycosides are traditionally not used*
Canal debris then consider removal
Canal is extensively swollen then an ear wick is sometimes inserted
127
Otosclerosis
Describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window.
128
Features of Otosclerosis
```
Onset is usually at 20-40 years
conductive deafness
tinnitus
normal tympanic membrane*
positive family history
```
129
Otosclerosis inheritance
Autosomal dominant
130
Management of Otosclerosis
hearing aid
| stapedectomy
131
Most common parotid neoplasm (80%)
Benign pleomorphic adenoma or benign mixed tumor
132
Second most common benign parotid tumor (5%)
Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma)
133
Most common cause of a perforated tympanic membrane
Infection
134
Management of perforated tympanic membrane
> No treatment - heal after 6-8 weeks
> Antibiotics to perforations which occur following an episode of acute otitis media.
> Myringoplasty if does not heal by itself
135
A complication of bacterial tonsillitis
Peritonsillar abscess (quinsy)
136
Features of bacterial tonsillitis
Severe throat pain, lateralises to one side
Deviation of uvula to unaffected side
Trismus (difficulty opening the mouth)
Reduced neck mobility
137
Management of bacterial tonsillitis
Patients need urgent review by an ENT specialist.
Needle aspiration or incision & drainage + IV antibiotics
Tonsillectomy should be considered to prevent recurrence
138
Pathophysiology of Pleomorphic adenoma
Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components
Slow-growing, lobular, and not well encapsulated
139
Post-operative complications of tonsillectomy
Primary and secondary haemorrhages
Primary, in first 6-8 hours following surgery. It is managed by immediate return to theatre.
Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection.
140
Presbycusis
Age-related hearing loss is the gradual loss of hearing in both ears. It's a common problem linked to aging.
141
What kind of hearing loss is Presbycusis?
Sensorineural - high-frequency hearing is affected bilaterally
142
Features of Presbycusis
Sensorineural - high-frequency hearing is affected bilaterally
143
Audiometry features of Presbycusis
Bilateral sensorineural pattern hearing loss
144
Investigations in Presbycusis
Otoscopy: Normal
Tympanometry: Normal middle ear function with hearing loss (Type A)
Audiometry: Bilateral sensorineural pattern hearing loss
145
Features of Ramsay Hunt syndrome
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus
146
Ramsay Hunt syndrome
Caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.
147
Management of Ramsay Hunt syndrome
Oral aciclovir and corticosteroids
148
Rinne's and Weber's test
Allows differentiation of conductive and sensorineural deafness.
149
Rinne's test
Tuning fork is placed over the mastoid process until the sound is no longer heard,
'positive test': air conduction (AC) is normally better than bone conduction (BC)
'negative test': if BC > AC then conductive deafness
150
Weber's test
Tuning fork is placed in the middle of the forehead equidistant from the patient's ears - asked which side is loudest
In unilateral sensorineural deafness, sound is localised to the unaffected side
In unilateral conductive deafness, sound is localised to the affected side
151
Conductive hearing loss
Rinne's test
Bone conduction > air conduction in affected ear
Air conduction > bone conduction in unaffected ear
Weber test - Lateralises to affected ear
152
Sensorineural hearing loss
Rinne's - Air conduction > bone conduction bilaterally
| Weber's - Lateralises to unaffected ear
153
Salivary glands
parotid (serous)
submandibular
sublingual
154
What salivary gland do tumors usually affect?
Parotid glands (80%)
155
Sore throat
encompasses pharyngitis, tonsillitis, laryngitis
156
FeverPAIN criteria
```
Fever over 38°C.
Purulence (pharyngeal/tonsillar exudate).
Attend rapidly (3 days or less)
Severely Inflamed tonsils
No cough or coryza
```
157
Centor criteria
(fever >38.5°C, swollen, tender anterior cervical lymph nodes, tonsillar exudate and absence of cough) are an algorithm to assess the probability of group A β haemolytic Streptococcus (GABHS) as the origin of sore throat, developed for adults
158
Majority of sensorineural hearing loss
Idiopathic
159
Management of all cases of sensorineural hearing loss
Urgent referral to ENT.
| High-dose oral corticosteroids
160
Causes of tinnitus
```
Idiopathic
Meniere's disease
Otosclerosis
Sudden onset sensorineural hearing loss
Acoustic neuroma
Excessive loud noise
Presbycusis
Impacted ear wax
```
161
Drug causes of tinnitus
Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine
162
Causes of Vertigo (dizziness)
```
Viral labyrinthitis
Vestibular neuronitis
Benign paroxysmal positional vertigo
Meniere's disease
Vertebrobasilar ischaemia
Acoustic neuroma
```
163
Vestibular neuronitis
A cause of vertigo that often develops following a viral infection. Affects the vestibular branch of 8th cranial nerve.
164
Features of Vestibular neuronitis
1. Recurrent vertigo lasting hours or days
2. Nausea and vomiting may be present
3. Horizontal nystagmus is usually present
4. No hearing loss or tinnitus
165
Management of Vestibular neuronitis
Vestibular rehabilitation exercises
Buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases
Short oral course of prochlorperazine, or an antihistamine may be used to alleviate less severe cases
166
Examples of oral antihistamines
cinnarizine, cyclizine, or promethazine
167
Labyrinthitis
An inflammatory disorder of the membranous labyrinth, affecting both the vestibular and cochlear end organs. Labyrinthitis can be viral, bacterial or associated with systemic diseases. Viral labyrinthitis is the most common form of labyrinthitis.
168
Difference between Labyrinthitis and vestibular neuritis
Vestibular neuritis is used to define cases in which only the vestibular nerve is involved, hence there is no hearing impairment;
Labyrinthitis is used when both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment.
169
Infectious mononeucleois
Infectious mononeucleois - aka glandular fever has petechial heamorrhages, mimics tonisilits due to enlarged tonsils and fever - may cause splenomegaloy and hepatomegaly.
170
Likely association of oropharynx sqamous cell carcinoma
HPV
171
Likely association with nasopharynx cancers
EBV
