Top 100 Examination Pearls Flashcards
Best imaging modality for looking at temporal bone fractures & lesions
CT Scan
Best imaging modality for looking at acoustic neuromas
MRI of IAC w/ contrast
Best imaging modality to evaluate thyroid nodules
Ultrasound
Who most commonly gets malignant otitis externa?
Immunocompromised patients
Diabetics
What is the most common pathogen for malignant otitis externa?
Pseudomonas aerugeinosa
What is Ludwig’s Angina?
Odontogenic infection of submental & submandibular spaces
Leads to:
Progressive swelling of FOM
Upper airway obstruction
How do you diagnose invasive fungal sinusitis?
Histopathology:
Fungal invasion into submucosal tissues & vessels w/ associated necrosis
Which infections can extend into the danger space?
Parapharyngeal space infections
Prevertebral space infections
Retropharyngeal space infections
What happens in the danger space?
Unrestricted spread of infection into the mediastinum
Classic PTA presentation
Trismus
Uvular deviation
Muffled voice
Soft palatal edema
Elevated risk factors for OSA
Age > 65 years old BM > 30 Male or Postmenopausal African American or Asian Neck circumference (>17” in men, >16” in women)
Histology of mucormycosis
Nonseptate wide-angled branching hyphae
Histology of Aspergillus
Septate hyphae with 45-degree branching angles
Most common type of headache/facial pain
Tension-type headache
First-line treatment of persistent idiopathic facial pain
Tricyclic antidepressants
Types of papillae on the tongue
Fungiform
Foliate
Circumvallate
Filliform
Which type of tongue papillae don’t contain taste buds?
Filliform
Most common bronchial cleft to develop an anomaly
Second
Most important prognostic factor in melanoma
Depth of invasion
What must be preserved in conservation laryngeal surgery?
At least one cricoarytenoid joint
What is notable about hypopharyngeal cancer?
Frequent submucosal spread
Worse prognosis than cancer of the larynx
Most common benign salivary gland tumor
Pleomorphic adenoma
Most common malignant salivary gland tumor
Mucoepidermoid carcinoma
Most common malignancy of the thyroid
Papillary carcinoma
Most common neoplasm of the thyroid
Follicular adenoma
Factors that can increase risk of regional lymphatic involvement of a tumor
Tumor site Stage Thickness Perineural invasion Angiolymphatic invasion Tumor differentiation
Most common head and neck paragangliomas
Carotid body tumors
Presentation of carotid body tumor
Pulsatile neck mass
Splaying of external & internal carotids on CT, MRI or angiography (Lyre’s sign)
Lyre’s Sign
Splaying of external and internal carotids on CT, MRI or angiography
Characteristic of carotid body tumor
Typical presentation of juvenile nasopharyngeal angiofibroma
Teenage boy
Unilateral nasal obstruction
Epistaxis
Bluish mass filling nasal cavity
Classic radiographic findings for juvenile nasopharyngeal angiofibroma
Expansion of the PPF on axial view (Holman-Miller sign)
Widening of the sphenopalatine & vidian formina
Bony destruction of the pterygoid process
Holman-Miller Sign
Expansion of the PPF on axial radiography
Classic for juvenile nasopharyngeal angiofibroma
Often seen with widening of the sphenopalatine & vidian foramina, as well as bony destruction of the pterygoid process
Exposures linked to adenoma rhino a of the paranasal sinuses
Wood
Leather dust
Exposures associated with squamous cell carcinoma of the paranasal sinuses
Chromium
Nickel
Mustard gas
Aflatoxin
Ohngren’s line
From the medial canthus to the angle of the mandible
Maxillary sinus tumors above this line on presentation carry poorer prognosis
Structures within the cavernous sinus
III IV V1 V2 IV Internal carotid arteries & venous channels
Most medial nerve in the cavernous sinus
VI
It is the most commonly injured nerve in this space
Normal rate of CSF production
20 mL/hr
Microbes usually responsible for symptoms in acute rhinosinusitis
Viruses, not bacteria
Chandler classification for orbital infection
I - Preseptal cellulitis II - Orbital cellulitis III - Subperiosteal abscess IV - Orbital abscess V - Cavernous sinus thrombosis
Major nasal tip support mechanisms
Attachments between the following structures:
Septum
Lower lateral cartilages
Upper lateral cartilages
Minor nasal tip support mechanisms
Intermodal ligament Dorsal septum Sesamoid complex Skin and subcutaneous tissue of nasal tip Maxillary spine
Nose anomalies in a unilateral cleft lip/palate
Ipsilateral lower lateral cartilage displaced:
Inferiorly
Posteriorly
Laterally
Structures displaced toward noncleft side:
Nasal tip
Caudal septum
Columella
Structures deviated toward cleft side:
Bony septum
Most common complications of untreated septal hematoma
Septal perforation
Saddle nose deformity
Toxic shock syndrome
Rare complication of S. Aureus infection
High fever Rash Hypotension Vomiting Diarrhea Multiorgan failure
Treatment for toxic shock syndrome
Remove nasal packing
IV antibiotics
Supportive/Rescuscitative care
Keros classification of olfactory fossa depth
Class I - 1 to 3 mm
Class II - 4 to 7 mm
Class III - 8mm and greater
Most common site of iatrogenic CSF leak during FESS
Lateral lamella of cribriform
Spontaneous CSF leak
Likely associated with IIH
Cause of thyroid eye disease
Autoimmune inflammation of muscle and fat
Autoantigen is TSH receptor
Physical properties of cochlear basilar membrane
Base:
Thick
Stiff
Narrow
Apex:
Thin
Flexible
Wide
These are responsible for tonotopic properties
What greatly affects severity of cochlear deformities?
Gestational age at growth arrest or disruption
Top causes of conductive hearing loss
Cerumen impaction
Otitis media with effusion (most common cause in children)
TM perforation
Otosclerosis
Top causes of sensorineural hearing loss
Presbycusis
Noise exposure
Hereditary
Most common ototoxic medications
Aminoglycosides
Cisplatin
Loop diuretics
Salicylates
Most common radiographic finding in pediatric SNHL
Enlarged vestibular aqueduct
Pure tone average
Average air conduction hearing threshold at frequencies associated with speech:
500 Hz
1000 Hz
2000 Hz
Masking
Simultaneous presentation of of sound to nontest ear while testing the other ear with the stimulus
Alexander’s Law
Peripheral nystagmus becomes faster and more apparent when the patient gazes in the direction of the fast phase
Four main components of conventional hearing aid
Microphone
Amplifier
Receiver
Battery
When does acoustic feedback occur with a hearing aid?
When amplified sound leaks out of the receiver, back into the microphone
Most common bacterial pathogens in acute otitis media
Streptococcus pneumoniae (35 - 40%) Haemophilus influenza (30 -35%) Moraxella catarrhalis (15 - 25%)
First-line therapy for acute otitis media
Amoxicillin
80% of bacterial isolates remain susceptible
Requirements for diagnosis of otitis media
Middle ear effusion present
Confirmed by pneumatic otoscopy or tympanometry
Indications for a canal wall down mastoidectomy
Semicircular canal fistula
Posterior canal wall damage due to cholesteatoma
Sclerotic mastoid prevents visualization with a wall up mastoidectomy
Patient is unable to follow up or undergo additional surgeries for proper monitoring of recurrent cholesteatoma
Most common presentation of otosclerosis
Progressive conductive hearing loss
Can rarely present with SNHL
Many patients will have positive family history
Classifications of cholesteatomas
Congenital
Primary acquired
Secondary acquired
Mechanisms of upper eyelid closure
Activation of VII
Relaxation of III (Levator palpebrae)
Upper eye closure can not be relied upon as indicative of intact facial nerve
Area of VII most susceptible to entrapment neuropathy during nerve swelling
Labyrinthine segment
It is in the narrowest portion of fallopian canal
How might superior semicircular canal dehiscence mimic otosclerosis?
Conductive hearing loss
How might superior semicircular canal dehiscence mimic a patulous Eustachian tube?
Ear fullness and autophony
How might superior semicircular canal dehiscence mimic Meniere’s?
Vertigo
Hitzelberger Sign
Numbness of the medial, posterior or superior EAC
Caused by acoustic neuroma compressing VII
Raccoon eyes
Periorbital ecchymoses following basal skull fracture
Battle sign
Mastoid ecchymoses following basal skull fracture
CSF leak in the setting of temporal bone fracture
Common
Usually resolves within 7 days
Pediatric vs. Adult airway
Significantly smaller
The same degree of inflammation and edema can be much more clinically significant in an infant
Respiratory distress and cyanosis at birth, resolves with crying
Bilateral choanal atresia
Most common cause of stridor in an infant
Laryngomalacia
Most common cause of UVFP in children
Iatrogenic
Second most common cause of stridor
Most common cause of subglottic stenosis
Iatrogenic scarring related to endotracheal intubation
Most common tumors of infancy
Infantile hemangiomas
Majority are found within head & neck
Beard distribution of hemangioma in a stridulous child
Raises suspicion for subglottic hemangioma
What distinguishes hemangiomas from vascular malformations?
GLUT-1 positivity
First-line treatment for infantile hemangiomas
Propranolol
Submucosal cleft palate
Higher incidence of postadenoidectomy VPI
Medication to avoid if mono is suspected
Amoxicillin (may cause salmon-colored rash)
Pattern of branchial cleft anomalies
Track deep to structures of their own arch
Track superficial to structures of the subsequent arch
Differential for pediatric midline nasal mass
Glioma
Dermoid
Encephalocele
Always get imaging prior to excision to rule out intracranial extension
What is rate of concordance between cleft lip & cleft palate?
50% have both
35% have cleft palate alone
15% have cleft lip alone
Left unilateral cleft lip and palate is the most common
Most common indication for tonsillectomy
Sleep disordered breathing
Recurrent tonsillitis is second most common indication
Where do facial mimetic muscles receive their innervation?
From their deep surface, as they are superficially situated
Nasal projection
How far the tip projects from the face
Nasal Rotation
Movement of the tip along an arc from the EAC
What structures comprise the internal nasal valve?
Upper lateral cartilage
Nasal septum
Nasal floor
Cottle Maneuver
Helps diagnose internal nasal valve collapse
Pollybeak Deformity
Complication of rhinoplasty
Supratip fullness results in parrot’s beak appearance
Due to:
Loss of tip support
OR
Supratip scar tissue
Layers of the eyelid (Anterior to posterior)
Skin Orbicularis Oculi Orbital Septum Preaponeurotic Fat Levator Aponeurosis Muller’s Muscle Conjunctiva
Baker-Gordon Formula
Phenol 88%
Croton Oil
Septisol
Distilled Water
What does the Baker-Gordon formula’s depth of penetration depend on?
More dependent on croton oil than the concentration of phenol
Danger of phenol chemical peels
Cardiac toxicity
Apply to individual facial subunits in 15-minute intervals, for safety
Most common complication from facelift surgery
Hematoma
Up to 10% of cases
More common in men
Most commonly injured nerve in facelift surgery
Great auricular nerve
Most commonly injured MOTOR nerve is the marginal mandibular
How does botulinum toxin work?
Presynaptic neuromuscular junction
Prevents acetylcholine release
Leads to temporary muscle paralysis
What are the benefits of full-thickness skin graft, compared to other graft options?
Limits graft contraction
Improved texture
Improved color match
Early clinical finding of optic nerve injury
Loss of red color vision
Most common facial bone fractured
Nasal bone
Most common site of mandible fracture
Angle
Abductor muscle of the true vocal folds
Posterior cricoarytenoid
Which intrinsic laryngeal muscle is not innervated by the RLN?
Cricothyroid
What innervates the cricothyroid?
Superior Laryngeal Nerve
Which intrinsic laryngeal muscle has bilateral innervation?
Interarytenoid
What causes recurrent respiratory papillomatosis?
HPV type 6 and 11
Primary management for vocal fold nodules
Voice therapy
What does Laryngeal EMG measure?
Motor unit recruitment in the larynx
Laryngeal EMG findings of denervated muscle
Fibrillation potentials
Positive waves
Laryngeal EMG findings when reinnervation occurs
Polyphasic motor units
Management of an airway fire
Turn off flow of O2
Douse fire with saline
Remove damaged tube
Reintubate (as atraumatically as possible)
Administer IV steroids and antibiotics
Bronchoscopy before leaving the OR (remove charred tissue or debris & evaluate extent of airway injury)
Delayed extubation w/ repeat endoscopic airway examinations
Hearing loss w/ enlarged vestibular aqueduct or Mondini dysphasia on imaging
Test for mutations in SLC26A4
Associated with Pendred Syndrome
Key to a Sistrunk procedure
Don’t just resect central portion of the hyoid bone
Resect tongue musculature between hyoid bone & foramen cecum in the tongue
Antibiotics associated with increased risk of C. Diff Colitis
Clindamycin
Fluoroquinolones
Cephalosporins
Carbapenems
Less frequently:
Macrolides
Penicillins
Sulfonamides
Difference between radical, modified radical, and selective or functional neck dissections
Radical:
Modified Radical:
Selective or Functional:
Where and how can sinus disease spread?
Orbit
Intracranial Cavity
Can spread via vascular channels
Care for a patient requiring posterior nasal packing
Must be admitted to the hospital
Telemetry
Continuous pulse ox
How long should you counsel patients to wait before undergoing scar revision surgery?
6 - 12 months at least
Most improve without revision within 1 - 3 years
Exception: If there are obvious scar characteristics that aren’t expected to improve
