METASTASIS
1. CA of tongue: jugulodigastric
2. CA of buccal mucosa: submental and submandibular 3. CA of gingival and hard palate: mandibular and
subdigastric
4. CA of lips: submental and submandibular 5. CA of floor of mouth: mandibular and subdigastric
1. epstein’s pearl or bohn’s nodules: GINGIVAL CYST 2. rodent ulcer: BCC
3. large vessel type of hemangioma: cavernous hemangiomas 4. immature forms of capillary hemangioma: hypertrophic
hemangioma
5. with spindle-‐shaped cells surrounding capillaries: hemangiopericytoma
6. bryces sign: laryngocoele 7. cold abscess: lymphadenitis 8. horner syndrome: laryngocoele
9. location of koch’s nodule: posterior triangle
1. chorda tympani: CN VII 2. tensor tympani: CN V 3. tympanic plexus: CN IX 4. stapedius: CN VII
1. hypotympanium: floor
2. opening to tympanic membrane: medial wall 3. Eustachian tube opening: anterior wall 4. canal for tensor tympani muscle: anterior wall 5. epitympanium: roof
6. ossicles: medial wall 7. lateral semicircular 8. aditus: posterior wall
1. ampulla: crista ampullaris 2. macula: otoliths
3. organ of corti: hair cells for shearing
1. hot potato voice: PERITONSILLAR ABSCESS
2. chronic mouth breathing, snoring, hyponasal speech: ADENOIDS
3. mesopharynx: OROPHARYNX 4. epipharynx: NASOPHARYNX 5. psueudomembrane: DIPHTHERIA
6. trench mouth: VINCENT’s / PLAUT’S ANGINA
1. below cricopharyngeus posteriorly where the longitudinal esophageal fibers separate: LAIMER-‐HACKERMANN AREA 2. below lowest fibers of the cricopharyngeus and upper
circular fiber of the esophagus on lateral aspect :KILLIAN-‐ JAMIESON AREA
3. between alar and prevertebral sheaths: SPACE OF 4 or DEGREE SPACE
4. space between the base of the skull and the superior constrictor thru w/c the Eustachian tube passes: SINUS OF MORGAGNI
1. butterfly rash: LUPUS ERYTHEMATOSUS 2. encephalocoele: NASAL GLIOMA
3. failure of nasobuccal membrane to canalize: CHOANAL ATRESIA
4. sebaceous gland hypertrophy: RHINOPHYMA 5. apple jelly nodules: LUPUS VULGARIS 6. pre-‐malignant lesion: SENILE KERATOSIS
7. excoriation and infection of vestivule: VESTIBULITIS 8. MC acute infection: FURUNCULOSIS
9. acute inflammation of skin and subcutaneous tissue: ERYSIPELAS
10. esicupusular formation w/ yellow crust: IMPETIGO
1. chemical-‐respiratory sensitizers: OCCUPATIONAL RHINITIS 2. greenish nasal secretion and crust: ATROPHIC RHINITIS 3. hallmark of inflammation: NASAL POLYPS
4. non-‐allergic rhinitis: IDIOPATHIC RHINITIS 5. CN II-‐VI: ORBITAL APEX SYNDROME 6. common cold: AINFECTIOUS RHINITIS
7. IgE-‐mediated inflammation: ALLERGIC RHINITIS 8. pott’s puffy tumor: OSTEOMYELITIS
9. pregnancy rhinitis: HORMONAL RHINITIS
1. sphenopalatine vessels: POSTEROINFERIOR BLEEDING 2. jarjavay type: SEPTAL DEVIATION (LATERAL)
3. chevallet fracture: CLASS 1 FRACTURE
4. foster-‐kennedy syndrome: FRONTAL LOBE TUMOR 5. pig-‐nose appearance: CLASS 3 FRACTURE
FLAPS VS GRAFTS
1. can bridge defect: FLAPS 2. requires pressure dressing: FLAPS 3. more likely to contract: GRAFTS
4. depends on recipient site for nutrition: GRAFTS 5. less adaptable to weight bearing: GRAFTS
1. proptosis and lateral rectus palsy: PTERYGOID / TEMPORAL SPACE INFECTION
2. torticollis: CAROTID SPINE ABSCESS
3. horner’s syndrome: CAROTID SPINE ABSCESS
4. hot potato voice: RETROPHARYNGEAL SPACE ABSCESS 5. respiratory distress: PARAPHARYNGEAL SPACE INFECTION 6. osteomyelitits: MASSETER SPACE INFECTION
1. fissures of santorini: DEFICIENCY IN CARTILAGENOUS EAC 2. foramen of huschke: DEFICIENCY IN BONY EAC
3. pars flaccida: SHRAPNELL’S MEMBRANE
4. notch of rivinus: AREA DEFICIENT OF ANNULUS FIBROSUS 5. otitis externa circumscripta: STAPHYLOCOCCUS
6. diffuse otitis externa: PSEUDOMONAS 7. epistaxis: KIESSELBACH’S PLEXUS 8. tripod fracture: ZYGOMA
9. blow out fracture of orbit: FORCED DUCTION TEST 10. temporal bone fracture: BATTLE’S SIGN
1. bactidol: HEXITIDINE 2. docusate: OTOSOL
3. nystatin, gramicidin: POSTOTOC, APLOSYN OTIC 4. lidocaine, benzoxonium: OROFAR-‐L
5. antipyrine: AURALGAN OTIC
6. neomycin, polymyxin: KENACOMB OTIC
1. syphilis: PENICILLIN
2. ludwig’s angina: INCISION AND DRAINAGE 3. salpingitis: PENICILLIN
4. herpes: ACYCLOVIR 5. candida: NYSTATIN
1. aerotitis media: BAROTRAUMA
2. apical petrositis: GRADENIGO SYNDROME
3. lateral sinus thrombophlebitis: PICKET FENCE SYNDROME 4. otitic hydrocephalus: QUECKENSTEDT
RHINITIS
1. IgE mediated : ALLERGIC RHINITIS 2. tuberculosis: CHRONIC RHINITIS 3. prolonged use of decongestant: RHINITIS
MEDICAMENTOSA 4. pregnancy-‐related: NOTA 5. with dryness: ATROPHIC RHINITIS 6. emotional stress: VASOMOTOR RHINITIS 7. infectious/inflammation: ACUTE RHINITIS
1. unilateral hearing loss: NOTA 2. bilateral hearing loss: NOTA
3. benign paroxysmal positional vertigo: CULPOLITHIASIS 4. meniere’s dse: TINNITUS
1. staphylococcus: CLOXACILLIN 2. streptococcus: AMOXICILLIN 3. herpes ACYCLOVIR 4. candida: NYSTATIN 5. psueomonas: OFLOXACIN GRADENIGO VS MENIERE 1. diplopia: GRADENIGO 2. hearing loss: MENIERE 3. ear fullness: MENIERE 4. dizziness: MENIERE 5. tinnitus: MENIERE 6. ear discharge: GRADENIGO
1. frontal sinus – MIDDLE MEATUS
2. anterior ethmoid sinus – MIDDLE MEATUS 3. posterior ethmoid sinus – SUPERIOR MEATUS 4. sphenoid sinus – SPHENOETHMOIDAL RECESS 5. mastoid – ADITUS AD ANTRUM
6. maxillary sinus – MIDDLE MEATUS 7. cavernous sins – OPHTHALMIC VEIN
8. middle meningeal sinus – FORAMEN SPINOSUM 9. highmore of antrum – AD IC ANTRUM
10. middle ear – EUSTACHIAN TUBE
11. nasolacrimal duct – INFERIOR MEATUS 12. tensor tympani -‐ ROOF
13. bony ear canal – EXTERNAL CAROTID 14. jugular vein -‐ FLOOR
15. CN VII -‐ AICA
16. Eustachian tube: MIDDLE EAR 17. lacrimal gland: INFERIOR MEATUS 18. ethmoid hair cells
1. Sheehan syndrome: ISCHEMIC NECROSIS OF THE ANTERIOR PITUITARY
2. cavernous sinus syndrome: MC CAUSE IS ETHMOIDITIS 3. charcot’s triad: NYSTAGMUS, SCANNING SPEECH AND
INTENTION TREMOR SEEN IN MULTIPLE SCLEROSIS 4. digeorge syndrome: THYMUS AGENESIS
5. frey’s syndrome: AURICULOTEMPORAL NERVE SENDS ITS PARASYMPATHETIC FIBERS TO INNERVATE THE SWEAT GLANDS
6. carotid sinus syndrome: NOTA
7. gilles de la tourette’s syndrome: CHOREA, COPROLALIA, TICS
8. markus-‐gunn syndrome JAW WINKING
9. campomelic syndrome: DWARFISM, CRANIOFACIAL ANOMALIES, BOWING OF TIBIA AND FEMUR 10. zaufal’s syndrome: SADDLE NOSE
11. ortner’s syndrome: CARDIOMEGALY ASSOCIATED W/ LARYNGEAL PARALYSIS SECONDARY TO COMPRESSION 12. bezold’s abscess: SECONDARY TO PERFORATION OF THE
TIP OF THE MASTIOD BY INFECTION
13. carcinoid syndrome: TUMOR SECRETES SEROTONIN 14. semon’s law: PARALYSIS OF THE CRICOARYTENOID
POSTICUS BEFORE PARALYSIS OF THE ADDUCTORS 15. ondine’s curse: FAILURE OF RESPIRATORY CENTER
AUTOMATICITY W/ APNEA ESPECIALLY EVIDENT DURING SLEEP
SALIVARY GLANDS
1. U-‐shaped bend on mylohyoid: SUBMANDIBULAR GLAND 2. Wharton duct: SUBMANDIBULAR GLAND
3. rivinus duct: SUBLINGUAL GLAND
4. stensen duct: PAROTID GLAND – drains opposite/upper 2nd molar
5. MC tumor occur: PAROTID GLAND
6. most sialolithiasis occur: SUBMANDIBULAR GLAND 7. mixed glands: PAROTID and SUBMANDIBULAR 8. serous glands: PAROTID
9. mucous glands: SUBLINGUAL
AREAS OF INJURY
1. I: intracranial penetration 2. II: orbital and globe injury 3. III: head and neck injuries
EPITHELIAL COVERING
1. lips: NONKERATINIZING SQUAMOUS 2. cheeks: NONKERATINIZING SQUAMOUS 3. nasopharynx: CILIATED
4. oropharynx: NONKERATINIZING SQUAMOUS 5. hypopharynx: NONKERATINIZING SQUAMOUS 6. pharyngeal tonsil: CILIATED
7. palatine tonsil: NONKERATINIZING SQUAMOUS 8. lingual tonsil: NONKERATINIZING SQUAMOUS 9. middle ear: CILIATED
10. external ear: KERATINIZING SQUAMOUS
LYMPHATIC DRAINAGE 1. lips: LEVEL I 2. cheeks: LEVEL I 3. tongue: LEVEL I 4. palatine tonsil: LEVEL II 5. middle: LEVEL II
ORAL MANIFESTATION OF SYSTEMIC DSE 1. syphilis: GUMMAS and ENANTHEMS
2. melkersson-‐rosenthal syndrome: FISSURED TONGUE 3. anaphylaxis: ANGIOEDEMA
4. pernicious anemia: HUNTER’S GLOSSITIS NOTES
• EXTERNAL EAR 1. auricle/pinna
2. external auditory canal 3. tympanic membrane • MIDDLE EAR
1. tympanum/middle cavity 2. antrum and mastoid air cells 3. eustachian tube
• INNER EAR
1. bony labyrinth 2. membranous labyrinth
MIDDLE EAR BOUNDARIES • roof – tegmen tympani • lateral – tympanic membrane • anterior – eustachain tube opening
• posterior – aditus / opening into tympanic membrane • floor – hypotympoanum
• medial – promontory, labyrinthine windows, horizontal part of CN VII, lateral semicircular canal
BOUNDARIES
• superior – tegmen antri • posterior – sigmoid sinus
• anterior – posterior wall of external auditory canal • inferior – digastrics ridge
CENTRAL PATHWAY
• dorsal and ventral cochlear nucleus i. superior olivary complex ii. lateral lemniscus
iii. inferior quadrigeminal body iv. medial geniculate
v. auditory complex
AUDIOGRAM KEY / AUDIOMETRY
right left
AC unmasked O X
AC masked triangle square BC mastoid unmasked < > BC mastoid masked [ ]
red blue
DEGREE OF HEARING LOSS
• 0-‐25 dB – normal hearing threshold • 26-‐40 – mild hearing loss
• 41-‐60 – moderate hearing loss • 56-‐70 -‐ moderately severe hearing loss • 71-‐90 – severe hearing loss
• >90 – profound hearing loss
BERKESY TEST
TYPE FINDINGS INTERPRETATION
I pulsed and continuous across all frequencies
normal or middle ear dse
II pulsed and continuous interweave in low and mid frequencies but at 1000Hz continuous drop but no more than 20 dB
cochlear dse (meniere’s)
III similar to type II, but the drop is more than 20 dB
retrocochlear pathology (acoustic schwannoma IV pulsed and continuous tones do
not interweave
retrocochlear pathology V pulsed drops below the
continuous ones
non-‐organic hearing loss
WAVES
• I – distal portion of auditory nerve • II – proximal portion of auditory nerve • III – cochlear nucleus
• IV – superior olivary complex
• V – lateral lemniscus as it teminates at interior colliculus
OTITIS MEDIA VS OTITIS EXTERNA
OTITIS EXTERNA OTITIS
MEDIA
pain very severe not severe
tenderness on pinna
manipulation (+) (-‐)
fever usually (-‐) usually (+)
hx of URTI usually (-‐) usually (+) hx of scratching or
cleaning of ear (+) usually (-‐)
hearing not impaired unless
canal obliterated impaired
matoid xray normal mastoiditis
COMPLICATIONS OF OTITIS MEDIA AND MASTOIDITIS • extracranial
o facial nerve paralysis o labyrinthitis
o subperiosteal abscess o apical petrositis (gradenigo)
o sensorineural hearing loss • intracranial
o extradural abscess o subdural abscess
o lateral sinus thrombophlebitis o meningitis
o brain abscess o otitic hydrocephalus
LABYRINTHITIS
TYPE VERTIGO HEARING LOSS PATHOLOGY circumscribed mild conductive erosion w/o actual
erosion of the labyrinth w/ a fistula
serous moderate mixed localized invasion to severe w/ toxins of the organism suppurative severe sensorineural
then total actual penetration and invasion by the organisms
COCHLEAR DISEASES
ONSET LATERALITY VESTIBULAR
SYMPTOMS presbycussis gradual bilateral -‐
infection sudden uni or bi + noise-‐
induced gradual uni or bi -‐ ototoxicity sudden bilateral +/-‐
trauma sudden unilateral +
barotrauma sudden unilateral + systemic dse gradual bilateral -‐ meniere’s fluctuant unilateral
(bilateral 30%) +
VESTIBULAR DISORDERS
VERTIGO
(DURATION) HEARING LOSS VESTIBULAR STATUS meniere’s episodic
(20mins-‐hour)
fluctuant (low freq in early stage)
decreased vestibular
neuronitis acute; aggravated by head mov’t (>24hrs)
no loss decreased
acute labyrinthitis
acute (>24hrs) severe SNHL decreased benign positional recurrent;
related to position and aggravated by head mov’t (seconds)
no loss normal
acoustic neuroma or vestibular schwannoma progressive progressive SNHL decreased vertebrobasilar insufficiency acute and aggravated by head mov’t (variable) compatible normal
PERMISSIBLE NOISE EXPOSURE DURATION/DAY SOUND LEVEL 8 hrs/day 90 dBA 6 92 4 95 3 97 2 100 1.5 102 1 105 0.5 110 <0.25 115
DEGREE OF ATTENUATION OF SOUND BY PROTECTORS PROTECTION TYPE ATTENUATION AT LOW FREQUENCIES cotton (pain) 0
waxed cotton 3.8 ear plugs 30 ear muff 40 ear muss w/ insert 70
CENTRAL AND PERIPHERAL CAUSES OF VERTIGO
PERIPHERAL CENTRAL
duration may be intermittent, usually hrs to days w/ normal periods
may be persistent, usually wks to mos w/ no normal periods
s/sx CNS (-‐) usually (+)
fixation suppresses nystagmus no effect spontaneous
nystagmus
fatigue, jerk or rotator and occurs in one particular direction
non-‐fatigable, does not change w/ different plane of gaze; oblique or vertical types usually central in origin nystagmus enhanced
by eye closure
nystagmus decreases w/ eye closure
induced
nystagmus fatigable duration <1 min. follows “COWS” (cold opposite warm same)
non-‐fatigable>1 min. doesn’t follow “COWS” causes meniere’s, vestibular
neuronitis, benign paroxysmal positional vertigo, acoustic neuroma tumors, multiple sclerosis, epilepsy, vascular problems
FACIAL NERVE TESTS FOR LOCALIZATION
• schirmer’s hearing test -‐ test for lacrimation • stapedial reflex -‐ test of loudness tolerance • taste test
• test for salivation
FACIAL NERVE TEST INTERPRETATION
SITE UM N VESTIBU LAR SCHIRM ER SALIVATI ON STAPED IAL TAS TE CNS + + + + + + CPA -‐ + + + + + IAC -‐ -‐/+ + + + + middle ear -‐ -‐ -‐ -‐ + + betwe en chorda & -‐ -‐ -‐ -‐ + stapedi us -‐ -‐ -‐ -‐ + SMF -‐ -‐ -‐ -‐ -‐
OPERATIONS ON THE EXTERNAL EAR
• surgery for perichondritis – for perichondritis in fluctuant stage
• meatoplasty canalplasty – for meatal atresia
• myringotomy – for serous otitis media ; pus in middle ear; to insert ventilation tube
OPERATIONS ON THE MIDDLE EAR
• simple or cortical mastoidectomy of schwartze -‐ for coalescent mastoidectomy; as preliminary exposure of facial nerve, labyrinthine or internal auditory canal surgeries
• radical mastoidectomy – for complication of middle ear dse; no cochlear reserve
• modified radical mastectomy – for good cochlear nerve; preliminary surgery for reconstructive surgery; ears not responsive to medical treatment
• tympanoplasty – for reconstruction of middle ear o types: I – graft on malleus
II – incus III – stapes IV – footplate
V – fenestration operation
OPERATIONS OF THE INNER EAR
• labyrinthine surgery – for vertigo • conservative – preserve hearing
• surgery of the internal auditory canal – removal of acoustic neuromas/vestibular schwannomas; sectioning of
vestibular nerve for severe vertigo; facial nerve decompression in tumors
• transotic extension – for petrous apex lesion
CONGENITAL HEARING LOSS
GENETIC NON-‐GENETIC
alport synd rubella synd
treacher-‐collins synd kernicterus & neonatal hyperbiliruinemia waardenburg’s synd congenital syphilis jervel-‐lange synds premturity pendred’s synd anoxia at birth kearns-‐sayne synd teratogens -‐ drugs GJB2 or connexin 26 mutation EXTERNAL NOSE • bony framework o nasal bone
o frontal process of maxilla o nasal process of frontal bone • cartilaginous framework
o lower lateral (greater alar) cartilage o quadrilateral cartilage
o upper lateral (lateral nasal) cartilage o lesser alar cartilage
o sesamoid cartilage
• constrictors o nasalis o depressor septi o depressor alaque nasi • dilators
o procerus o dilator nasi
o angular head of quadratus labii superioris INTERNAL NOSE
• BOUNDARIES
o superior – cribriform plate of ethmoid o inferior – maxillary bone
o medial – septum o lateral – maxillary bone o posterior – sphenoid sinus • nasal septum
o septal cartilage o vomer
o perpendicular plate of ethmoid o maxillary crest
o premaxilla • turbinates
o inferior turbinate – largest
o middle turbinate – part of ethmoid bone o superior turbinate -‐ part of ethmoid bone o supreme turbinate – occasionally found • meatuses
o inferior meatus – drains nasolacrimal duct o middle meatus – drains frontal, maxillary,
anterior ethmoid sinus o superior meatus o supreme meatus o sphenoethmoid recess
NASAL BONE FRACTURES class 1 (chevallet fracture)
along quadrilateral cartilage & distal thin portion of nasal bone
due to low-‐velocity trauma
class 2 nasal bones, frontal process of maxilla, structures / iin class 1
due to medium-‐velocity trauma w/ jarjavay cartilaginous fracture class 3 extends thru ethmoid labyrinth w/ inward
telescoping nasal skeleton “pig-‐nose”
SEPTAL DEVIATION lateral (jarjavay) type
lateral nasal fracture w/ displacement of septum from vomerian groove & maxillary crest
depressed (chevallet) type
frontal nasal fracture w/ twisting, buckling, reduplication & fibrosis of quadrilateral septum
laterofrontal type combination of lateral & depressed types
NASAL BONE FRACTURE
• MC fracture in the body • assault – MC cause MANDIBLE FRACTURE
• 2nd to nasal bone fracture
• 10th most fractured in the whole body • angle – 35%, symphysis
• case: primary assault FRONTAL BONE FRACTURE
• least common of all fractures • 5-‐15%
MAXILLARY FRACTURE CLASSIFICATION • “dishpan” or “panface” le fort I: GUERIN
(horizontal separation)
-‐ horizontal separation
-‐ palate separated from the rest of maxilla -‐ interdental & intermaxillary fixation, 4-‐ 6wks
lefort II: PYRAMIDAL (midfacial fracture)
-‐ MC of maxillary fracture
-‐ palate w/ maxilla is separated from zygoma and the ethmoid
-‐ as above fixation from zygomatic suture or orbital rim
lefort III: CRANIOFACIAL DYSJUNCTION
-‐ nasofrontal suture -‐ across floor of orbit
-‐ maxilla and zygoma are separated from the cranium
-‐ interdental & intermaxillary fixation, suspension from zygomatic suture & wiring from infraorbital rim BENIGN PEMPHIGUS BULLOUS PEMPHIGUS PEMPHIGUS VULGARIS
site oral mucosa nasal, oral
lesions small & w/ bleeding on rupture
larger, may leave denuded area on rupture
histopath no acantholysis massive acantholysis immunoflourescence fluorescence at
basement membrane
at area of acantholysis
prognosis benign high mortality if
untreated
OBSTRUCTIVE SLEEP APNEA
ADULT PEDIATRIC
etiology multiple usually enlarged tonsils & adenoids sleep manifestations snoring, restless sleep, frequent awakening
snoring, restless sleep, odd sleeping positions daytime manifestation excessive daytime sleepiness hyperactivity, inattention, sleepiness sleep study
findings decreased oxygenation, sleep fragmentation oxygenation usually maintained, CO2 retention & hyperventilation, sleep architecture maintained management often medical
(positive airway pressure therapy) often surgical (tonsillectomy & adenoidectomy) potential morbidity of untreated vehicular accidents, cognitive impairment, medical conditions medical, neuroanatomic & cognitive
ACUTE EPIGLOTTITIS VS CROUP
ACUTE
EPIGLOTTITIS CROUP (ACUTE LARYNGOTRACHEOBRONCHITIS)
area laryngeal
surface of epiglottis
area just below vocal cords etiology H.influenza,
type B viral -‐ parainfluenza type I-‐IV peak age 3-‐6yrs 6mos-‐3yrs
s & s/x sit up w/ mouth open & chin forward not hoarse cough not croupy may have dysphagia
tends to lie down
hoarse
very croupy cough no dysphagia
course rapid, can be fatal w/in hrs w/o treatment
less rapid
recurrence rare more common
laryngoscopy cherry-‐ red,markedly swollen epiglottis
subglottic swelling seen thru glottis
UNILATERAL MIDLINE PARALYSIS VS BILATERAL MIDLINE PARALYSIS
UNILATERAL BILATERAL
paralysis of abductor & adductors,
except cricothyroid initially both cords are intermediate à breathy voice
initially paralyzed cord assumes intermediate or cadaveric position à hoarse voice
tracheostomy to relieve obstruction
cricothyroid still functions to lengthen
paralyzed cord can do arytenoidectomy & arytenoidopexy 6wks after onset paralyzed cord
assumes paramedia (adducted) position if paralyzed cord is slighty lateral to midline (paramedia) the normal cord can still coaptate w/ paralyzed cord by compensating
no airway obstruction in any stage no intervention needed except when no compensation occurs
LARYNGEAL TUMORS
BENIGN NEOPLASM MALIGNANT NEOPLASM
types polyps, cysts, l ipomas, chondromas, papillomas SCC or epidermoid carcinoma; adenocarcinoma etiologic factor
vocal abuse (polyps, nodules)
smoke >1 pack/day x 15-‐ 20yrs
sex
predilection female male
s & s/x hoarseness, discomfort, no bleeding, no cervical lymphadenopathy
hoarseness, neck mass, cervical lymphadenopathy, bleeding, stridor,
respiratory distress, sensation of rawness management surgery; remove only
the tumor; preserve all normal tissues & laryngeal function surgery – radical laryngectomy w/ neck node dissection, reconstruct w/ trachaeoesophageal shunt to restore speech; RT, chemo
NASAL POLYPS GRADING 0 -‐ no polyps
I – polyps do not prolapse beyond middle turbinate & may require endoscopy for visualization
II – polyps extend below middle turbinate. visible w/ nasal speculum
III – polyps touch nasal floor. may occlude entire nasal cavity. seen thru vestibule w/o aid of nasal speculum
NASAL POLYP VS TURBINATES
NASAL POLYP TURBINATES
color skinned/seedless
grapes
pink to red decongestant
effect (-‐) (+)
mobility mobile fixed
sensation (-‐) (+)
location osteomeatal complex along entire lateral nasal wall
consistency soft hard
TRIANGLES OF THE NECK • POSTERIOR TRIANGLE: o supraclavicular o occipital • ANTERIOR TRIANGLE o muscular o digastrics/submandibular/submaxillary o submental/suprahyoid o carotid FLAP VS GRAFT pp FLAP
limited to transplantation of skin can carry other tissues depends on recipient site for
nutrition has own blood supply
may discolour; likely to contract better color; less likely to contract
less adaptable to weight bearing more adaptable to weight bearing
less able to survive on a bed w/
questionable nutrition can be used on a bed w/ questionable nutrition requires pressure dressing not require pressure dressing cannot bridge defect can bridge defect
HEMOLYTIC STREP / S.AUREUS -‐ MC pathogenic organism of the head and neck
POTT’S DSE -‐ retropharyngeal space infection in adults
OROPHARYNX
• soft palate to dorsum of tongue inferiorly • lateral – palatine arches (fauces) • waldeyer’s ring:
o lingual tonsils – base of tongue
o faucial tonsils – paired and w/in palatine fauces o adenoids
o lateral pharyngeal bands
o tonsils of gerlach – w/in tip of fossa of rosenmuller
NASOPHARYNX • boundaries:
o superior – base of skul o anterior – nasal cavity
o inferior – oropharynx and soft palate o lateral – opening of Eustachian tubes o posterior – cervical vertebrae • pharyngeal bursa
o saclike depression in posterior wall o remnant of notochord
DIFFERENTIATION S & S/X ANGIOFIBROM A JUVENILE TYPE NASOPHARYNGEA L MALIGNANCY NASAL MALIGNANC Y
age 1-‐18yrs 30-‐60yrs 40-‐70yrs
sex male more male female
bleeding profuse scanty to mild minimal to moderate nasal passage obstructio n minimal to
severe minimal to the beginning moderate to severe neck nodes (-‐) early, bilateral &
large
late cranial
nerve
Nil CN VI initially, then V, IX, X
CN V for advanced cases ear occasional can be an early
sign
(-‐) treatment surgery radiation /che&
mo surgery & RT and/or chemo
ACUTE TONSILLITIS CAUSES
• GABHS, H.influenza, S.pneumonia • tx: penicillin
CHRONIC TONSILITTIS • tx: tonsillectomy
• tonsillitis occurrence to be candidate for tonsillectomy: o 3/yr for 3yrs
o 5/yr for 2yrs o 7 or more for 1yr
o >2wks school/work missed in 1 yr
INDICATIONS FOR TONSILLECTOMY • ABSOLUTE
o obstruction causing dysphagia, airway obstruction
o pharyngeal or peritonsillar abscess o suspected mignancy
• RELATIVE
o recurrent GABHS infection
o tonsil hyperplasia w/ functional obstruction, such as dysphagia or sleep apnea
o rheumatic fever w/ heart damage w/ recurrent tonsillitis & poor antibiotic control
INDICATIONS FOR ADENOIDECTOMY • obstruction dse – nasal obstruction • middle ear dse due to adenoid hypertrophy • suspicion of malignancy
CONTRINDICATIONS TO TONSILLECTOMY & ADENOIDECTOMY • cleft palate • blood dyscrasias • medical contraindications LARYNGEAL CARTILAGES • thyroid -‐ biggest
• cricoids – only complete cartilaginous ring • arytenoids – paired; hitching posts for vocal cords • corniculate – paired; on top of arytenoids
• cuneiform – paired; lateral to corniculate on aryepiglottic folds
• epiglottis
EXTRINSIC MUSCLES OF LARYNX
• depressors: omohyoid, sternohyoid, sternothyroid • elevators: mylohyoid, geniohyoid, genioglossus,
hyoglossus, digastrics stylohyoid
• pharyngeal constrictor, inferior pharyngeal constrictor
INTRINSIC MUSCLES OF LARYNX
• adductors: lateral cricoarytenoid, thyroarytenoid, transverse arytenoid, oblique arytenoid
• abductors: posterior cricoarytenoid
• tensors: cricothyroid, thyroarytenoid, vocalis
INFERIOR LARYNGEAL NERVE – motor supply of all intrinsic laryngeal muscles except cricothyroid
SUBMANDIBULAR NODES
• most significant and largest • 6-‐12 nodes
SUBMANDIBULAR INFECTION
• haemolytic streptococci – MC pathologic organism • ludwig’s angina – MC etiology is from dental cries MANDIBULOTOMY – cutting thru the mandible temporarily JUVENILE NASOPHARYNGEAL ANGIOFIBROMA
• benign
• male; adolescent
EBV -‐ viral etiology of nasopharyngeal carcinomas
MOST COMMON TUMORS a) BCC
o MC epidermal tumor of the head and neck o rodent ulcer
b) SCC
o MC malignancy in the oral cavity
o lip: lower lip = 95%; upper lip = 5% o tonue
o MC malignancy in the phrynx o MC malignancy in the larynx o MC malignancy in the esophagus o MC carcinoma of the pranasal sinuses
o followed by adenocarcinoma c) papillary carcinoma
o MC thyroid carcinoma o psamomma bodies o orphan annie eye o adenocarcinoma
o MC benign tumor of larynx – HPV 16 (18) d) follicular carcinoma
o hurthle cell – cord-‐like e) pleomorphic adenoma
o benign mixed tumor
o MC benign tumor of salivary glands o orphan annie eye
f) warthin’s tumor
o papillary cystadenoma lymphomatosum o MC bilateral parotid gland tumor g) acinic carcinoma – parotid (MC at tail) h) medullary carcinoma
o C-‐cells
o pheochromocytoma i) adenoma – MC thyroid neoplasm
j) hemangioma -‐ MC benign tumor of salivary glands in children
k) adenoid cystic carcinoma
o MC tumor of submandibular gland o MC minor salivary gland malignancy l) nodal type / reed Sternberg – Hodgkin lymphoma m) extranodal / nodal dse – non-‐hodgkin
n) mucoepidermoid carcinoma
o MC malignancy of salivary gland in children o MC malignant tumor of salivary glands
o MC malignancy in the parotid gland/hard palate o 2nd MC of the submandibular gland
o) neurofibroma – von Recklinghausen
ANAPLASTIC CA – rapid growth and fixation to underlying structures MIXED – follicular tumors behave like papillary tumors
BENIGN TUMORS IN THE PAROTID GLAND – 80% PAROTID -‐ MC site of all salivary gland tumor
MINOR SALIVARY GLANDS -‐ 2nd MC site of all salivary gland tumor SUBMANDIBULAR GLAND -‐ 3rd MC site of all salivary gland tumor LATERAL BORDERS OF TONGUE – 2nd MC tumor of the oral cavity CARCINOMA OF FLOOR OF MOUTH – 3rd MC oral cavity tumor PERIAPICAL CYST – MC odontogenic cyst
RETROPHARYNGEAL NODES/NODES OF RANVIER – first nodes affected in nasopharyngeal and maxillary carcinoma
NASOPALATINE FISSURAL CYST –MC fissural cyst MELANOMA – MC site is the cheek, scalp, ear and neck THYROGLOSSAL DUCT CYST
• MC found at the level of the hyoid bone
• sistrunk procedure – part of the hyoid bone is removed to prevent recurrence
CARCINOMA OF THE LARYNX • HPV 6, 11
• clinical picture:
o glottic -‐ hoarseness -‐ MC early symptom o floor of ventricle including TVC o supraglottic – dysphagia
o tip of epiglottis including false VC o subglottic – dyspnea – late
o 1cm below TVC to cricoid o transglottic – advance and large tumors
o lesions that cross the ventricle or involves larynx above and below TVC
CORNICULATE CARTILAGE – cartilage of santorini CUNEIFORM CARTILAGE – cartilage of wrisberg
BILATERAL ABDUCTOR PARALYSIS – MC form of bilateral motor paralysis
LARYNGOMALACIA – MC congenital anomaly of larynx INSPIRATORY STRIDOR – major symptom of laryngomalacia PTYALISM SIALORRHEA – excessive saliva production XEROSTOMIA – dry mouth
SJOGREN -‐ absence of saliva production TB – cols abscess
SCARLET FEVER / KAWASAKI – strawberry tongue DIPHTHERIA – bull’s neck
2:1 – incidence of oral CA
FREY SYNDROME – gustatory sweating after parotidectomy S.AUREUS: MC cause of acute sialodenitis
EXTERNAL AUDITORY CANAL • outer 1/3 cartilaginous • inner 2/3 bony
• fissures of santorini – deficiency in cartilaginous portion à infection spread to parotid
• foramen of huschke – deficiency in bony meatus à infection spread to periauricular and parotid
TYMPANIC MEMBRANE • pars flaccid
o shrapnell’s membrane § triangular
§ above malleolar fold
§ common site of retraction pockets • pars tensa – below
ACUTE CIRCUMSCRIBED OTITIS EXTENA / FURUNCULOSIS • s.aureus
• s and s/x: earache, tender pinna/tragus, hearing decreased, purulent ear discharge, circumscribed swelling/abscess
MALIGNANT OTITIS EXTERNA / SKULL BASE OSTOMYELITIS NECROTIZING OTITIS EXTERNA-‐ p.aeruginosa
ACUTE NECROTIZING OTITIS MEDIA – beta haemolytic streptococcus MENIERE’S DSE / IDIOPATHIC ENDOLYMPHATIC HYDROPS
• intermittent SNH, tinnitus, vertigo, ear fullness
• cochlea hydrops – fluctuating sensorineural hearing loss and tinnitus
• vestibular hydrops – episosdic vertigo and aural fullness • lermoyez hydrops – increasing tinnitus, hearing loss, and
aural fullness
• crisis of tumarkin / drop attack – loss of extensor power BENIGN PAROXYSMAL POSITIONAL VERTIGO
• canaliths • cupulolithiasis
• confirmed by hallpike test – positional nysgatmus w/ latency
• cause: canaliths – free-‐floating abnormally dense particles RAMSAY HUNT SYNDROME
• herpes zoster oticus of CN VII • vascular eruption and facial paralysis CN X
• Arnold’s/alderman’s nerve
• cough reflex when external canal is stimulated • laryngeal pain in cancer
CN IX
• jacobson’s nerve
• oropharyngeal pain in cancer EUSTACHIAN TUBE
• upper 1/3 bony
• anteromedial 2/3 cartilaginous SWIMMER’S EAR
• diffuse otitis externa • pseudomonas CAULIFLOWER EAR
• hematoma auris • severe perichondritis • abscess
APICAL PETROSITIS / GRADENIGO SYNDROME • discharging ear • retroorbital pain • diplopia MELKERSSON’S SYNDROME • peripheral palsy • jewish • postulated hypersensitivity JERVELL and LANGE-‐NIELSEN SYNDROME
• autosomal recessive
• SNHL with prolonged QT interval GJB2 / CONNEXIN 26 -‐ MC cause of SNHL ETHMOID BULLA -‐ 1st ethmoid cell
RHINOLOGIST ARTERY -‐ largest vessel supplying the nose LUPUS VULGARIS
• TB in the nose • apple jelly nodules
LUPUS ERYTHEMATOSUS -‐ butterfly rash CHOANAL ATRESIA
• bony / membranosseous 80-‐90% • membranous 10-‐20%
RHINITIS
1) infections – most prevalent; common cold 2) allergic – IgE mediated, high socioeconomic class 3) non-‐allergic
a. vasomotor
− idiopathic rhinitis
− cholinergic glandular activity − heightened sensitivity b. gustatory – eating; vagally-‐mediated
c. non-‐allergic rhinitis with eosinophilia syndrome) − unknown etiology
− paroxysmal exacerbations of sx
4) occupational
a. protein and chemical allergies – IgE mediated b. chemical respiratory sensitizers – uncertain
immune mechanism c. work – aggravated rhinitis 5) hormonal – pregnancy / menstrual cycles 6) drug-‐induced – rhinitis medicamentosa
7) atrophic rhinitis – thinning and drying of nasal mucosa EPISTAXIS
• mucositis – MC in children • HPN – mc in adults
• keisselbach’s plexus – 90% of epistaxis HYPEROSMIA
• hypersensitive sense of smell • cystic fibrosis PAROSMIA • perverted smell • streptomycin HYPOSMIA • impaired smell • smoking ANOSMIA – loss of smell ACUTE PHARYNGITIS
• viral • sore throat
• colds and conjunctivitis ENDOSCOPY
• rod telescope – clinic • rigid – O.R. o direct laryngoscopy o bronchoscopy o esophagoscopy • flexible – office EOPHAGEAL DISORDERS
• achalasia – degeneration of auerbach plexus • diffuse esophageal spasm – spiral/corkscrew • scleroderma – atrophy of smooth muscle
• presbyoesophagus – abnormal esophageal motor function d/t aging
CLEFT DEFECT
• 90% unilateral, 20% bilateral • 2/3 left sided, 1/3 right sided CLEFT PALATE
• 70% unilateral, 30% bilateral • MC in females
NASOPHARYNX – base of skull/posterior choanae to soft palate ORAL CAVITY
• vermillion border to junction of soft and hard palate • except soft palate and base of tongue
oropharynx – soft palate to hyoid hypopharynx – hyoid to cricoids
esophagus – cricoids to cardia of stomach STAPHYLOCOCCI – first oral microbe in neonate
PLAUT’S ANGINA/TRENCH MOUTH/VINCENT’S ANGINA • acute necrotizing ulcerative gingivitis • B. vincente
• tx: penicillin
THORNWALDT’S DSE – nasopharyngeal bursitis QUINSY
• peritonsilar abscess • tx: clindamycin PAROTID ABSCESS
• MC organism is staph • MC cause is salivary stone ANKYLOGLOSSIA – tongue tie FISSURED/SCROTAL TONGUE
• trisomy 21
• melkerson Rosenthal syndrome LEUKOPLAKIA – whitish patches in oral cavity ERYTHROPLAKIA – red plaques
NODULAR LEUKOPLAKIA – mixed white and red plaques LATERAL WALL/FOSSA OF ROSENMULLER – MC site for nasopharyngeal carcinoma
posterior suspensory ligament of thyroid -‐ LIGAMENT OF BERRY hypothyroidism -‐ MYXEDEMA, INCREASED TSH, DECREASED TH hyperthyroidism -‐ THYROTOXICOSIS
MC cause of thyroiditis and goiter -‐ HASHIMOTO’S DSE MC single thyroid dse -‐ HASHIMOTO’S DSE
MC cause of painful thyroid -‐ SUBACUTE GRANULOMATOUS THYROIDITIS (DE QUERVAIN’S THYROIDITIS)
lymphocytic thyroiditis -‐ SILENT/PAINLESS/POSTPARTUM THYROIDITIS
HYPERTHYROIDISM VS HYPOTHYROIDISM
HYPERTHYROIDISM HYPOTHYROIDISM
nervousness fatigue, lethargy
wt loss wt gain
excessive sweating cool, dry, coarse skin; hair loss
warm, smooth, moist skin swelling face, hands, legs, non-‐pitting edema
heat intolerance cold intolerance
muscular weakness, tremor weakness, muscle cramps, arthralgia, paresthesia lid lag, exophthalmos, stare periorbital puffiness palpitations, hyperdynamic cardiac
pulsations, accentuated S1 dec heart sound intensity
tachycardia bradycardia
inc SBP, dec DBP dec SBP, inc DBP frequent bowel mov’t constipation