Pestana Chap 10 - Otolaryngology (ENT)

Question 1

What are the three classifications of neck masses?

Answer 1

1) Congenital
2) Inflammatory
3) Neoplastic

Question 2

In what population do you see congenital masses? What is the timetable for development of inflammatory masses? What about neoplastic masses?

Answer 2

1) Congenital masses are seen in young people, and typically have been present for years before they become symptomatic (get infected) and medical help is sought
2) The timetable of inflammatory masses is typically measured in days or weeks. After a few weeks an inflammatory mass has reached some kind of resolution (drained or resolved)
3) The timetable of neoplastic masses is typically several months of relentless growth

Question 3

What is characteristic of a thyroglossal duct cyst in terms of location, presentation, and size?

Answer 3

1) Located on the midline at the level of the hyoid bone
2) Is somehow connected to the tongue (pulling at the tongue retracts the mass)
3) They are typically 1 or 2 cm in diameter

Question 4

What does surgery for a thyroglossal duct cyst include? What do some surgeons insist must be done before surgery?

Answer 4

1) Surgical removal includes the cyst, the middle segment of the hyoid bone, and the track that leads to the base of the tongue
2) Some practitioners insist that the location of the normal thyroid should first be ascertained by radionuclide scan

Question 5

What is characteristic of a branchial cleft cyst in terms of location, size, and presentation?

Answer 5

1) Occur along the anterior edge of the sternomastoid muscle, anywhere from in front of the tragus to the base of the neck
2) They are several centimeters in diameter
3) Sometimes they have a little opening and blind tract in the skin overlying them

Question 6

Where is a cystic hygroma found? What must be done before surgical removal?

Answer 6

1) Cystic hygroma 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
2) Indeed, they often extend into the mediastinum, and therefore CT scan before attempted surgical removal is mandatory

Question 7

For inflammatory vs neoplastic masses of the neck, what should be done about recently discovered enlarged lymph nodes?

Answer 7

1) Most recently discovered enlarged lymph nodes are benign, and therefore an expensive workup should not be undertaken right away
2) Complete history and physical should be followed by an appointment in 3 to 4 weeks. If the mass is still there, workup then follows

Question 8

For persistent enlarged lymph nodes (a history of week or months), what should be ruled out?

Answer 8

They could still be inflammatory, but neoplasia has to be ruled out

Question 9

Is lymphoma typically seen in young or old people? How do they present?

Answer 9

1) Young people
2) They often have multiple enlarged nodes (in the neck and elsewhere) and have been suffering from low-grade fever and night sweats

Question 10

What test can be done for lymphoma diagnosis? What is the usual treatment?

Answer 10

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

Question 11

Where does metastatic tumor to supraclavicular nodes invariably come from? What are the usual primary tumors that metastasize to these nodes? What can be done to help establish a diagnosis?

Answer 11

1) Comes from below the clavicles (and not from the head and neck)
2) Lung or intraabdominal tumors are the usual primaries
3) The node itself may be removed to help establish a tissue diagnosis

Question 12

Who typically develops squamous cell carcinoma of the mucosae of the head and neck?

Answer 12

Squamous cell carcinoma of the mucosae of the head and neck is seen in old men who smoke and drink and have rotten teeth. Patients with AIDS are also prime candidates

Question 13

What is the first manifestation of squamous cell carcinoma of the mucosae of the head and neck? What are other manifestations of squamous cell carcinoma? What is the ideal diagnostic workup?

Answer 13

1) A metastatic node in the neck (typically to the jugular chain)
2) Other presentations of squamous cell carcinoma include persistent hoarseness, persistent painless ulcer in the floor of the mouth, and persistent unilateral earache
3) The ideal diagnostic workup is a triple endoscopy (or panendoscopy) looking for the primary tumor or tumors

Question 14

What establishes diagnosis of squamous cell carcinoma of the mucosae of the head and neck? What establishes extent? Can a biopsy of a neck mass be done for diagnosis and why?

Answer 14

1) Biopsy of the primary or primaries establishes the diagnosis
2) CT scan demonstrates the extent
3) FNA of the node may be done, but open biopsy of the neck mass should never be performed. An incision in the neck for that purpose will eventually interfere with the appropriate surgical approach for the tumor

Question 15

What does treatment of squamous cell carcinoma of the mucosae of the head and neck involve?

Answer 15

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

Question 16

In which patient should acoustic nerve neuroma be suspected in? What is the best diagnostic modality?

Answer 16

1) 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)
2) MRI

Question 17

What do facial nerve tumors cause? What is the best diagnostic study to be done?

Answer 17

1) Gradual unilateral facial nerve paralysis affecting both the forehead and the lower face (Paralysis of sudden onset suggests Bell’s palsy)
2) Gadolinium-enhanced MRI is the best diagnostic study

Question 18

Where are parotid tumors located? What type of tumor are they? Do they produce pain or facial nerve paralysis and what would this be a sign of?

Answer 18

1) They are visible and palpable in front of the ear or around the angle of the mandible
2) Most are pleomorphic adenomas, which are benign but have potential for malignant degeneration
3) They do not produce pain or facial nerve paralysis. A hard parotid mass that is painful or has produced paralysis is a parotid cancer

Question 19

Can FNA be done to sample a parotid tumor? What diagnostic method is absolutely contraindicated? What the appropriate way to excise parotid tumors and why? What alone leads to recurrence? What must be done differently in the excision of a malignant parotid tumor?

Answer 19

1) Yes
2) Open biopsy
3) 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
4) Enucleation alone leads to recurrence
5) In malignant tumors the nerve is sacrificed and a graft done

Question 20

What are the cause of unilateral ENT problems in toddlers? How is it removed?

Answer 20

1) Foreign bodies. A 2-year-old with unilateral earache, unilateral rhinorrhea, or unilateral wheezing has a little toy truck (substitute for your favorite toy if you wish) in his ear canal, up his nose, or into a bronchus
2) The appropriate endoscopy under anesthesia will allow extraction

Question 21

What is Ludwig angina?

Answer 21

1) It is an abscess of the floor of the mouth, often the result of a bad tooth infection
2) The usual findings of an abscess are present, but the special issue here is the threat to the airway
3) Incision and drainage are done, but intubation and tracheostomy may also be needed

Question 22

What is Bell’s palsy? How is it treated?

Answer 22

1) Bell’s palsy produces sudden paralysis of the facial nerve for no apparent reason
2) Although not an emergency per se, current practice includes the use of antiviral medications-and as is the case for other situations in which antivirals are used, prompt and early administration is the key to their success. Steroids are also typically prescribed

Question 23

How quickly do facial nerve injuries in a patient who has sustained multiple trauma present? What will happen if a patient has normal functioning nerve function and develops the paralysis later on?

Answer 23

1) Instant paralysis

2) They will have nerve swelling that will resolve spontaneously

Question 24

What is cavernous sinus thrombosis usually heralded by? How is cavernous sinus thrombosis managed?

Answer 24

1) The development of diplopia (from paralysis of extrinsic eye muscles) in a patient suffering from frontal or ethmoid sinusitis
2) This is a serious emergency that requires hospitalization, IV antibiotics, CT scan or MRI, and drainage of the affected sinuses

Question 25

What is epistaxis in children usually a result of? Where does the bleeding come from and how is it controlled?

Answer 25

1) Nosepicking

2) The bleeding comes from the anterior septum, and phenylephrine spray and local pressure controls the problem

Question 26

What are the prime suspects in 18 year olds for epistaxis? What is required for these two causes?

Answer 26

1) Cocaine abuse (with septal perforation) and juvenile nasopharyngeal angiofibroma
2) Posterior packing may be needed for the former, and surgical resection is mandatory for the latter (the tumor is benign, but it eats away at nearby structures)

Question 27

In which patients can epistaxis be dangerous in? What must therefore be controlled? What is the only way to control the problem sometimes?

Answer 27

1) In the elderly and hypertensive, nosebleeds can be copious and life-threatening
2) The blood pressure has to be controlled, and posterior packing is usually required
3) Sometimes surgical ligation of feeding vessels is the only way to control the problem

Question 28

What is dizziness caused by?

Answer 28

Dizziness may be caused by inner ear disease or cerebral disease

Question 29

What does the patient describe is happening when they have dizziness caused by the inner ear? What about dizziness caused by a cerebral disease? What treatment can be used for dizziness caused by the inner ear? What is done for dizziness caused by cerebral disease?

Answer 29

1) When the inner ear is the culprit, the patients describe the room spinning around them
2) When the problem is in the brain, the patient is unsteady but the room is perceived to be stable
3) In the first case, meclizine, promethazine, or diazepam may help
4) In the second case, neurologic workup is in order

Question 30

What does full-fledged Meniere disease cause?

Answer 30

1) Vertigo
2) Tinnitus
3) Hearing loss

Question 31

What is Meniere disease treated primarily with?

Answer 31

Diuretics