Surgery Flashcards
1
Q
Anatomy and Physiology of Facial Nerve
A
- Special Visceral Afferent Fibers
- Sense of Taste on Anterior 2/3 of Tongue
- Via the Lingual and Chorda Tympani Nerves
- Geniculate Ganglion
- Nervus Intermedius to the Tractus Solitarius
- General Visceral Afferent Fibers
- Controversial
- Skin of the Concha and Auricle
- Special Visceral Efferent Fibers
- Stapedius Muscle
- Auricular Muscles
- Posterior Belly of Digastric Muscle
- Stylohyoid Muscle
- Platysma Muscles
- Superficial Facial Muscles
- General Visceral Efferent Fibers
- Parasympathetic System
- Greater Superficial Petrosal Nerve
- Lesser Petrosal Nerve
- Chorda Tympani Nerve → Lingual Nerve
- Parasympathetic System
2
Q
Pathophysiology of Nerve Injury
A
- Neurapraxia - Loss of Axoplasm Flow
- Axonotmesis - Wallerian Degeneration w/ the Preservation of Endoneural Sheaths
- Neurotmesis - Wallerian Degeneration + Loss of Endoneural Tubules
- Sunderland’s Five Levels of Neural Injury
- First Degree - Neurapraxia
- Second Degree - Axonotmesis
- Third Degree - Neurotmesis w/ Loss of Endoneurium
- Fourth Degree - Neurotmesis w/ Loss of Endoneurium and Perineurium
- Fifth Degree - Neurotmesis w/ Loss of Endo, Peri, and Epineurium
3
Q
Classification of Recovery From Facial Paralysis
A
- Grade I - Normal
- Grade II - Slight Weakness
- Grade III - Obvious, but not disfiguring difference b/t the two sides, Complete closure of eye w/ effort
- Grade IV - Obvious weakness and/or disfiguring asymmetry, Incomplete closure of eye
- Grade V - Slight Movement
- Grade VI - Total Paralysis
4
Q
Differential Diagnosis of Facial Paralysis
A
- Infection
- Bell’s Palsy
- Herpes Zoster Oticus
- Otitis Media/Mastoiditis
- Malignant Otitis Externa
- Tuberculosis
- Lyme Dz
- Acquired immunodeficiency Syndrome
- Infectious Mononucleosis
- Trauma
- Temporal Bone Fracture
- Birth Trauma
- Facial Contusions/Lacerations
- Penetrating Wounds
- Iatrogenic Injury
- Neoplasia
- Cholesteatoma
- Glomus Jugulare or Tympanicum
- Carcinoma
- Facial Neuroma
- Schwannoma
- Meningioma
- Leukemia
- Histiocytoses
- Rhabdomyosarcoma
- Congenital
- Compression Injury
- Mobius Syndrome
- Lower Lip Paralysis
- Idiopathic
- Recurrent Facial Palsy
- Melkersson-Rosenthal Syndrome
- Metabolic and Systemic
- Sarcoidosis
- Guillain-Barre Syndrome
- Autoimmune Disorders
5
Q
Evaluation of Facial Paralysis
A
- Hx
- Onset
- Duration
- Rate of Progression
- Recurrent or Familial
- Associated Symptoms
- Major Medical Illness/Major Surgery
- Physical Exam
- Microscopic Otoscopy
- URT Examination
- Cranial Nerve Assessment
- Palpation of Parotid Gland and Neck
- Neurologic
- Cerebellar Signs
- Motor
- Facial Nerve Function
- Complete vs. Incomplete (Paresis)
- Segmental vs. Uniform
- Unilateral vs. Bilateral
- Lab Studies
- Audiometry
- Electrophysiology Tests
- Nerve Excitability Test
- Maximal Stim Test
- Electroneurography
- Electromyography
- Radiographic Studies
- CT
- MRI
- Possible Additional Studies
- CBC w/ Differential
- Erythrocyte Sedimentation Rate
- Serum Antibody
- Serum Antinuclear
- Rheumatoid Factor
- CXR
- Lumbar Puncture w/ CSF Assay
- Topographic Testing
- Includes Schirmer Test, Stapedial Reflex, Electrogustometry, and Salivary Flow
- NOW considered “OBSOLETE”
6
Q
Electrophysiologic Tests
A
- NET, MST, and ENOG provide the most accurate information w/in the first 3 weeks
- EMG cannot differentiate b/t a total neurapraxia vs. completely degenerated nerve in acute phase
- Paresis does NOT warrant electrophysiologic tests
7
Q
Bell Palsy
A
- ACUTE onset w/ limited duration
- Diagnosis of exclusion
- 1/3 develop only a paresis w/ >95% recovery
- 2/3 w/ paralysis w/ 85% havings some return of facial tone w/in 3 weeks
- 71% of all pts achieve H-B grade 1
- ENOG w/ 90% degeneration in the first 2 weeks recover to H-B grade I or II in only 50% of pts
- Maximal nerve injury occurs at meatal foramen
- Decompression is directed at the labyrinthine portion
- Treatment Regimen
- Prednisone 1 mg/kg/day in divided doses and tapered over 7-10 days
- Acyclovir 2000 mg/day in 5 doses for 7 days
- Delay of more than 3 days precludes any additional benefit
*
8
Q
Herpes Zoster Oticus
A
- Ramsay Hunt Syndrome
- Facial Paralysis, Ear Pain, and Vesicular Eruption
- Pain precedes paralysis by a few days
- SNHL and vestibular dysfunction in 20%
- Poorer prognosis for spontaneous recovery than Bell Palsy
- Management
- Steroid Taper
- Valacyclovir 1000 mg TID x 7days
- Consider IV Doses
9
Q
Otitis Media
A
- Incidence of facial palsy in AOM about 1:20,000
- COM w/ facial paralysis is more ominous
- Aural toilet and antibiotics
- Myringotomy and Tube
- CT Scan
- Consider Tympanomastoidectomy w/ decompression of the mastoid/tympanic facial nerve
- Incision of Epineurium not recommended
10
Q
Trauma Related Facial Paralysis
A
- Temporal bone fractures are categorized according to otic capsule involvement
- Less than 5% involve otic capsule
- Facial nerve injury occurs in 50% of all otic capsule fractures
11
Q
Eye Care Related to Facial Paralysis
A
- Corneal desiccation = Most Common Complication
- Warn pt about itching redness, FB sensation, and visual blurring
- Prevention = lubricants, tape or moisture chambers, and avoidance of wind, vents, and fans
- Consider gold weight implants, canthoplasty, tarsorrhaphy, and upper eyelid springs
12
Q
Swallowing Phases
A
- Preparatory and Oral Phase
- Voluntary Phase
- Pharyngeal Phase
- Reflexive Phase; < 1 second in normal pts
- Esophageal Phase
- Fluid is passive, solid is active
13
Q
Management of Dysphagia
A
- Treat underlying cause
- Iron, pyridostigmine, benzotropine, abx
- Reflux regimen
- Aspiration pneumonia
- Botox injections
- Swallowing rehabilitation
- Change food consistency
- Supraglottic swallow
- Mendelsohn maneuver
- Surgery
- Esophageal dilation
- Cricopharyngeal myotomy
- G or J tube
- Vocal fold medialization
- Tracheotomy
- Laryngectomy
14
Q
Upper Esophageal Sphincter
A
- Cricopharyngeus muscle
- Tonic closure prevents reflux, aspiration, and regurgitation
- Relaxes during pharyngeal phase
15
Q
Lower Esophageal Sphincter
A
- Normal tone: 10-40 mmHg
- Achalasia >40
- Scleroderma <10
- Physiologic Sphincter (Aided by Diaphragm)
- Hiatal Hernia = LES Above Diaphragm
16
Q
GERD/LPR Diagnosis
A
- May begin antireflux regimen from hx
- Flex Laryngoscopy
- Barium Swallow
- 24-hour pH Probe = Gold Standard (but not practical)
- Esophagoscopy/TNE
17
Q
Achalasia
A
- Degeneration of Auerbach’s Plexus
- Aperistalsis and Increased LES Pressure
- Increased Risk of Esophageal Cancer
- Treatment
- Dilation
- “Wash” meals down w/ fluids
18
Q
Progressive Systemic Sclerosis (Scleroderma)
A
- Autoimmune, smooth muscle atrophy, collagen deposition
- Esophageal dysmotility of the lower 2/3
- GERD
- Fixed Face
- CREST Syndrome
- Treatment
- Reflux control
- Steroids
- NSAIDs
- Ca channel blockers
19
Q
Polymyositis
A
- Idiopathic inflammatory myopathy of striated muscle
- Dermatomyositis - variation w/ rash
- Proximal muscle wasting
- Dysmotility of the proximal 1/3 of esophagus
- EMG, Muscle Biopsy, Increased CPK
- Treatment
- Reflux control
- Steroids
- Immunosuppressives
- Antimetabolites
20
Q
Zenker’s Diverticulum
A
- Pulsion diverticulum at Killians Triangle
- False diverticulum = mucosa/submucosa only
- 80% on L Side
- Treatment
- Cricopharyngeal myotomy +/- diverticulectomy
21
Q
Esophageal Rupture
A
- Iatrogenic instrumentation most common
- Mallory-Weiss Syndrome - incomplete tear from increased pressure (emesis)
- Boerhaave Syndrome - rupture of all 3 layers, risk of mediastinitus
- Hammer’s Sign - crunching over the heart
- Needs early surgery and drainage
22
Q
Dysphagia Lusoria
A
- AKA Bayford Syndrome
- Retroesophageal R Subclavian Artery
- Intermittent Dysphagia
- Dx = Barium Swallow and Esophagoscopy
- Tx = Ligate and Reanastomose to R Common Carotid
23
Q
Eagle Syndrome
A
- Elongated Styloid Process or Ossified Stylohyoid Ligament
- Odynophagia, Unilateral Throat Pain
- Dx - Radiography
- Tx - Intraoral or External Excision
24
Q
Plummer-Vinson Syndrome
A
- Iron Deficiency ?
- Dysphagia, Microcytic Anemia, PE webs, chelitis, hypothyroidism, hiatal hernia
- Tx: iron supplementation, esophageal dilation
25
Q
Tracheoesophageal Fistulas
A
- Treatment
- Division and Reconstruction
- Congenital
- Immediate gagging and cyanosis after birth
- Acquired
- Secondary to trachs, intubations, tumor, inflammation, trauma
26
Q
Esophageal Malignancy
A
- More common than benign tumors
- Dysphagia that turns into odynophagia, hemoptysis, cough, hoarseness, weight loss, emesis
- Early Transmural Spread
- Poor prognosis 10% 3-Year Survival
- Types
- Squamous Cell Carcinoma
- Most Common
- Middle 1/3 of Esophagus
- Adenocarcinoma
- Associated w/ Barrett’s
- Squamous Cell Carcinoma
27
Q
Acute Pharyngitis
A
- Most Commonly Viral
- Adeno and Rhino
- Supportive Care
28
Q
Strep Pharyngitis
A
- GABHS
- Most common cause of bacterial pharyngitis
- Rapid Antigen Test
- Rheumatic Fever
- Minor Jones 2 + 1 Major
- Arthralgia, Fever, ARF
- Major Jones Criteria 2+
- Carditis, Polyarthritis, Subcutaneous Nodules, Erythema Marginatum, Chorea
- Minor Jones 2 + 1 Major
29
Q
Herpangina
A
- Hand Foot Mouth Disease
- Coxsackie A
- Small oropharyngeal vesicular lesions
- Self-Limiting
30
Q
Mononucleosis
A
- EBV
- High Fever, LAD, Exudative Tonsils, Enlarged Spleen
- Dx w/ serology or mono-spot
- Resolves in 2-6 weeks
- Protect spleen, liver, and airway
31
Q
Congential Webs
A
- Benign
- Anterior
- Incomplete Recanalization
- Glottic in 75%
- Weak Cry, Aphonia, Inspiratory Stridor
- Dx
- Flex Endoscopy
- Tx
- Endoscopic lysis if >50%
32
Q
Congenital Subglottic Stenosis
A
- <4 mm
- Third most common laryngeal anomaly
- Membranous, Cartilaginous, or Mixed
- Grades I-IV
- Biphasic Stridor
- Dx
- Endoscopy
- CXR
- Tx
- Reflux Mangement
- Endoscpopic Mangaement for Grade I and II
- Open Surgery Grades III and IV
33
Q
Laryngomalacia
A
- MOST COMMON congenital laryngeal anomaly
- MOST COMMON cause of stridor in neonate and chronic pediatric
- SSx
- Intermittent inspiratory stridor
- Worse w/ feeding/crying
- Inward collapse of A-E folds to glottis
- Tx
- Observation
- Rarely Surgery
34
Q
Tracheomalacia
A
- Immature tracheal cartilage
- Rare
- Expiratory Stridor
- Usually self-limited; improves w/ growth
- Treat GERD
35
Q
Vascular Rings
A
- Double Aortic Arch
- Most common vascular anomaly to caused stridor
- Retroesophageal Right Subclavian Artery
- Most common vascular anomaly to compress the aerodigestive tract
- Dx
- MRI/CT
- Tx
- Symptomatic compression requires surgery
36
Q
Cri du Chat
A
- Deletion of short arm of chromosome 5
- High-pitched stridor, mental retardation, and microencephaly
- Narrowed endolarynx and interarytenoid cleft
37
Q
Recurrent Respiratory Papillomatosis
A
- Second most common cause of hoarseness in children
- 2/3 present before age of 15
- HPV Types 6 and 11
- 50% born from mothers w/ condyloma
- Stridor dyspnea, dysphagia
- Tx
- Frequent endoscopic CO2 ablation
- Avoid tracheotomy
- Cydofovir
38
Q
Lymphangiomas (Cystic Hygroma)
A
- 90% present before age of 3
- Soft solitary painless compressible mass
- Lymphoendothelial hyperplasia
- Tx
- Conservative excision
- Low rate of recurrence if completely removed
39
Q
Hemangioma
A
- Most common head and neck neoplasm in children
- Presents by 6 months and then usually involutes by 2 years of age
- Types
- Infantile, capillary, cavernous
- Tx
- Observe
- Laser Excision
- Radiation
- Embolization
- Steroids
40
Q
Acute Sialadenitis
A
- S. aureus most common
- Tx
- Hydration
- Heat
- Abx
- Sialogogues
41
Q
Acute Sialolithiasis
A
- Most common in submandibular gland
- 90% of SM or radiopaque
- 90% of Parotid are radiolucent
- Consider CT or MRI after exam
- Tx
- Gland massage
- Transoral incision
- Gland excision
42
Q
Radiation Sialadenitis
A
- Permanent if exposed to >40-50 Gy
- Xerostomia, hypogeusia, ageusia, dental caries
- Gland w/ interstitial fibrosis
- Tx
- Symptomatic w/
- Artificial saliva
- Dental care
- Frequent drinks
- Pilocarpine drops
- Symptomatic w/
43
Q
Most comon salivary gland malignancy in adults and children?
A
Mucoepidermoid Carcinoma
44
Q
Most common submandibular and minor salivary gland malignancy?
A
Adenoid Cystic Carcinoma
