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1
Q

rhinosinusitis
diagnostic criteria
major symptoms (6)
minor symptoms (5)

A

inflammation/infection of nose and sinuses
2 major or 1 major and 2 minor criteria

major: facial pain/pressure, nasal obstruction/congestion, hyposmia (dec smell), nasal drainage, fever (acute), purulence on nasal exam
minor: headache, fatigue, dental pain, cough, ear pain/pressure

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2
Q

acute sinusitis duration
subacute?
chronic?
recurrent acute?

A

acute: 4 weeks
subacute: 4 wks?12 wks
chronic: 12+ weeks
recurrent acute: 4+ episodes per year

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3
Q

aute rhinosinusitis

A

ostium gets inflamed, impairs your drainage and ventilation, can lead to secondary bacterial infection
most common: viral (rhinovirus, coronavirus, influenza, respiratory syncytial virus, parainfluenza)

bacterial: secondary?? 7?10 days after
strep pneumo, haemophilis influenza, moraxella cararhalis

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4
Q

how do you diagnose acute rhinosinusitis?

A

clinical dx and physical
NOT CT, x ray, MRI
(sinus culture can be appropriate)

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5
Q

tx of acute rhinosinusitis

A

self limited? symptomatic management
if symptoms persist, treat with 10?14 days of antibiotics (amoxicillin?clauvunate, doxy or fluoroquinolone)
intranasal steroid can be used to reduce time/symptoms
saline irrigations, nasal decongestants

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6
Q

complications of rhinosinusitis

A

cross orbit or anterior cranial fossa or by hematologic spread

orbital cellulitis or abscess, meningitis, subdural absecess, etc

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7
Q

chronic rhinosinusitis

how is it classified?

A

12+ weeks
considered more of an inflammatory disorder than infectious
(can be assoc w/ cystic fibrosis, autoimmune disorders)
classified as with or without nasal polyposis

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8
Q

what is gold standard for dx of chronic rhinosinusitis?

A

computed tomography
symptom?based dx can be unreliable
sinus all the time” headache and facial pressure, stopped up..”

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9
Q

predisposing factors for chronic rhinosinusitis?

A

systemic (allergic rhinitis, immunodeficiency, genetic?? CF, ciliary dyskinesia)
local (anatomic obstruciton, GE reflux, mucociliary dysfunction)
microorganisms (viral infxn from daycare, fungi, resistant bacteria, bioflims)
pollutants (cigarrette)
meds (inappropriate use of decongestant)

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10
Q

tx for chronic rhinosinusitis

A

allergen avoidance, saline, AB for 3?6 wks, surgery
to attenuate inflammation; steroids, immunotherapy, antiluekotrienes, macrolides

saline irrigation: inc. mucociliary flow rates, give vasoconstricitve effect (adding baking soda leads to thinning of mucus)

mucolytics (guaifenesin?? high doses show desired effect but also emesis and abd pain)

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11
Q

are antihistamines effective in CRS?

A

ineffefective in relieving nasal congestion
first generation: have Ach effects?? drowsiness, drying of seretions
2nd gen: no anticholinergic effects?? higher affinity to histamine receptors (zyrtec, claritin, allegra)

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12
Q

corticosteroids

contraindications?

A

stabalize mast cells, block formation of inflammatory mediators, inhibit chemotaxis of inflammatory cells
short courses: manage nasal mucosal congestion in allergic patients

contraindications: diabetes, PUD, glaucoma, severe HTN, advances osteoporosis

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13
Q

topical corticosteroids

adverse effects

A

improve patency of ostiomeatal complex (reduces mucosal swelling)
inhibits immediate and late phase rxns to antigenic stimulation (after 7 days tx)
will improve 90% of allergic rhinitis!

adverse effects: nasal irritation, mucosal bleeding (give saline to lessen effects)

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14
Q

antibiotics in CRS

A

based on culture results
s aureus, anaerobes, gram neg, psuedomonas aeruginosa?? different than acute!
first line: amoxicillin?clavulunate or cephalosporin
second line: qinolones (ciprofloxacin, levofloxacin)
broad spectrum antibiotic for up to 3 wks (symptoms improve within 3?5 days, resolution of symp within 7?10, +another week to diminish mucosal edema)

if there is rapid recurrence after prior tx, add 3?6 wk course of once daily phrophylactic ab

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15
Q

malignant sinonasal/extradural tumors

A

esthesioneuroblastoma, squamous cell carcinoma, sinonasal undiff carcinoma, adenocarcinoma, sarcoma

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16
Q

benign sinonasal/exradural tumors

A

juvenile nasopharyngeal angiofibroma
bone neoplasms
inverting papilloma
schwannoma

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17
Q

symptom of sinonasal tumor

A

nosebleeds, sinonasal discharge, sinus pain, visual changes, excessive tearing, neck nodes (atypical symptoms)

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18
Q

when do you do surgery for chronis rhinosinusitis?

A

after you have exhausted medical options

you want to restore sinus ventilation

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19
Q

pharyngitis

A

inflammation of pharynx

sore throat””

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20
Q

bacterial pharyngitis

A

5?10% adults, 30?40% children
symptoms: severe sore throat, odynophagia, cervical lymphadenopathy, fevers, chills, malaise, HA, neck stiffness, anorexia
physical exam: big, purulent tonsils

group A beta hemolytic strep pyogenes most common!

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21
Q

tx of bacterial pharyngitis

A

patients are contagious
prompt AB tx: penicillin or amoxicillin for 10 days
macrolide or clindamycin if allergic to penicillin

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22
Q

viral pharyngitis

A

most common cause of pharyngitis in adults
rhinovirus, coronavirus, parainfluenzae, influenza A, B, C
HIV, adenovirus, HSV

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23
Q

what causes infectious mononucleosis?

A

epstein barr virus (double stranded DNA)
latent in B lymphocytes, intermittently replicating in oropharyngeal epithelial cells to enable transmission through saliva
incubates for 3?7 wks?? malaise, fevers, chills, then sore throat, fever, lymphadenopathy, anorexia
70?90% test positive on monospot test

complicatioN: secondary bacterial infxn, upper airway obstruction, meningitis, splenic rupture

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24
Q

tx for mono

A

supportive care, rest, antiypretics, analgesics, avoid contact sports
antivirals are NOT helpful, abs only helpful for secondary bact. ifxn
no ampicillin/amoxicillin?? maculopapular rash
steroids for impending upper airway obstruction, severe hemolytic anemia, severe thrombocytopenia, persistant severe disease

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25
Q

peritonsillar abscess

A

associated with trismus (lock jaw), hot potato voice (muffled), drooling
tx: I&D, IV ab

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26
Q

retropharyngeal abscess
symptoms?
cause?

A

goes from base of skull to mediastinum?? behind buccopharyngeal fascia, in front of prevertebral fascia
symptoms: sore throat, fever, neck stiffness, odynophagia (pain w/ swallowing), SOB

polymicrobial

aerobic: beta hemolytic stretococci and staph aureus
anaerobic: bacteroides, veillonella
gram neg: haemophilus parainfluenza, bartonella henselae
complications: airway obstruction, jugular venous thrombosis, necrotizing fascitis, sepsis

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27
Q

ludwigs angina
symptoms?
cause?
tx?

A

inflammation and cellulitis of submandibular space spreading from sublingual space to fascial planes
airway obstruction can occur if floor of mouth becomes indurated and tongue is forced upward and backward
source: dental origin
symptoms: drooling, trismus (lockjaw), pain, dysphagia, submandibular mass, dyspnea

life threatening condition: airway control by tracheotomy?? IV ab, I&D
mixed flora, aerobes, anaerobes (strep, staph, bacteroides)

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28
Q

pt comes in with severe sore throat, odynophagia, cervical lymphaedenopathy, fevers. what do they have?

A

bacterial pharyngitis

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29
Q

pt comes in with sore throat, odynophagia, cervical lymphadenopathy, trismus, drooling, hot potato voice, fevers. what do they have?

A

peritonsillar abscess

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30
Q

pt comes in with drooling, trismus, pain, dysphagia, submandibular mass, dyspnea. what do they have?

A

ludwigs angina

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31
Q

pt comes in with sore throat, fever, neck stiffness, odynophagia, SOB. what do they have?

A

retroperitoneal abscess

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32
Q

contributors to vocal production

A

generator: lungs
oscillator: larynx: tone and pitch
restonator: pharynx/sinuses? ?shape, resonate, articulate sound into individual voice

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33
Q

what should you do if you have 2 weeks of hoarsness? what other symptoms accompany?

A

refer to otolaryngologist
accompanied by otalgia (ear pain), dysphagia, difficulty breathing
dysphonia >2 weeks suggests possibility of other diagnosis besides acute viral laryngitis

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34
Q

cause of hoarsness

A

neuro injury:
recurrent laryngeal nerve injury
iatrogenic injury, neoplasm, viral, idiopathic

alterations of vocal cord lining?? non lesion (gerd, sinus disease/allergic rhinitis, dehydration)
lesion

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35
Q

where are lesions that cause hoarseness?

A

in the superficial layers of the vocal fold (superficial lamina propria and epithelial cover)
nodules, polyps, cysts, hemorrhage, carcinoma

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36
Q

cause of most benign vocal fold lesions?

A

phonotrauma

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37
Q

recurrent respiratory papillomatosis

A

exophytic ariway lesions that may involve entire aerodigestive tract
most common benign neoplasm of larynx in children
HPV 6 and 11?? benign
childhood disease: linked to mom’s genital HPV
adult onset?? oral?genital contact
gardasil: 6, 11, 16, 18

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38
Q

what is most common cause of unilateral vocal cord paralysis?

A

iatrogenic

then neosplasm then idiopathic

39
Q

what is most common cause of vocal cord lesions?

A

phonotrauma

40
Q

laryngeal carcinoma
what type is it?
cause?
cure rates?

A

> 90% is squamous cell carcinoma
smoking is largest risk factor, EtOH has synergistic effect
good cure rate for early stage disease
(inactivated p16/Rb), p53 mutation, EFGR overexpression, infection with HPV (inactivates p53 and Rb)
4:1 male predilection, common among socioeconomic class

41
Q

if you are a younger patient with head and neck cancer, what is suspected agent?

A

HPV (inactivates p53 and Rb)

42
Q

molecular progression to cancer

A

normal mucosa ??> hyperplasia ?> dysplasia ?> carcinoma in situ ?> carcinoma

43
Q

work up for cancer

A

CT neck or MRI
chest xray or chest CT
PET/CT used more often now
direct laryngoscopy, bronchoscopy, esophagoscopy

44
Q

how do you treat early stage cancer (I or II)?

A

single modality therapy

surgery or radiation?? 85?95% local control rate

45
Q

tx advanced stage cancer (II or IV)

A

combined modality therapy (primary surgery followed by raidiation)
concurrent chemo
if it recurs, do CRT or RT with surgery

46
Q

complications of radiation

A

high energy rays, 6?7 wks dialy

skin changes, mucositis, odynophagia, laryngeal edema, xerostomia, stricture and fibrosis, radionecrosis, hypothryoidism

47
Q

chemo

A

cisplatin
chemo thought to sensitize cells to radiation
n/v, loss of appetite, fatigue, neuropathy, susceptible to infxn

48
Q

total layrngectomy

A

take out entire voice box

49
Q

different voice rehabs

A

electrolarynx (voice box?? external device)
pure esophageal speech (force bolus thorugh cricopharyngeus, air bolus regurgitated and vibrates to produce sound)
tracheoesophageal speech?? diversion of exhaled air into pharynx by way of surgically constructed tracheoesophageal fistula?? segment above fistula vibrates, producing neovoice

50
Q

what is a neck mass in an adult?

what should you suspect in a smoker with prolonged hoarseness?

A

cancer

51
Q

epiglottitis

A

tripod stance, stridor (high pitch sound on expiration and inspiration)
thumb sign on X ray
more common in children
bacteria: haemophilus influenza type B, steptococcus species
tx: secure airway, flexible fiberoptic nasotracheal intubation, tracheotomy, cricothryotomy
AIRWAY EMERGENCY! anesthesia and ENT should be notified immediately?? dont waste time imaging, mainipulating pt
avoid agitating patient

52
Q

stridor

what does stridor indicate?

A

high pitch breathing from turbulent airflow through larynx or trachea caused by narrowing or osbruction
can be inspiratory, expiratory, biphasic

stridor indicates upper airway obstruction

53
Q

croup
cause?
symptoms?
tx?

A

common primarily pediatric viral respiratory illness
15% childrne 6 mo? 6 yrs
barking cough, stridor, hoarseness, difficulty breathing
usually viral?parainfluenza, influenza, measles, adenovirus, RSV
swelling from inflammation leads to airway narrowing
mostly managed as outpatient, recover with no issues
steroids, nebulized racemic epinephrine, cool mist (soothes inflamed mucosa)

54
Q

other causes of stridor in kids

A 
most common: laryngomalacia
vocal cord paralysis
laryngeal web
layrngeal atresia
subglottic stenosis
subglottic hemangioma
recurrent respiratory papillomatosis
55
Q

laryngomalacia

tx?

A

congenital abnorm of laryngeal cartilage, usually leads to collapse and inspiratory stridor

56
Q

laryngeal atresia

A

incomplete or complete (may be stillbirth)
from failed recanalization of layrnx and trachea
can be diagnosed prenatally in ultrasound
requires immediate tracheostomy

57
Q

management of bilateral vocal cord paralysis

A

static conservative: botox, lateralization
static destructive: cordotomy, partial vs total artenoidectomy
dynamic: arytenoid abduction, reinnervation, laryngeal pacing

58
Q

subglottic stenosis

A

congenital or acquired
iatrogenic injuries is most common
often it has an insidious onset and early manifestations are mistaken for asthma, bronchitis

59
Q

which disorders can be misdiagnosed as asthma or bronchitis?

A

bilateral vocal cord paralysis, glottic, and subglottic stenosis ?? progressive, have protracted couse

60
Q

muscles of mastication
which ones open jaw?
which ones close jaw?
which nerve are they innervated by?

A

masseter, temporalis, medial pterygoid close jaw
lateral pterygoid abducts jaw
all innervated by CN V, mandibular branch V3

61
Q

oral cavity cancer

A

largely preventable and easy to detect early
>90% squamous cell carcinoma
common in devleoping world?? sri lanka, pakistan, india, bangladesh it common cancer
tobacco, alcohol, betel, dna repair gene defects, immune defects are risk factors

62
Q

how do you treat oral cavity cancer?

A

multimodality therapy indicated primarily for advanced stage tumors
clear advaced XRT locoregional control if: positive margins, perineural or lymphovascular invasion, >1 positive lymph node, nodes with extracapsular extension
use chemo for radiosensitivity
usually surgery _ adjuvant therapy

63
Q

oropharyngeal cancer? what causes it?
what do you do upon dx?
how is it managed?

A

older patients: tobacco and alcohol
younger patients: HPV
biopsy and stage CT, CXR
radiation +/? chemo, surgery

64
Q

seqeulae of chemo

A

mucositis, stomatitis, dysphagia, permanent salivary gland dysfunction, smell and taste alteration, oral microbial infxn (reactivation of HSV, VZV, C albicans)

65
Q

sjoren syndrome

A

systemic autoimmune disorder associated with inflammation of epithelial tissues
most common medical disorder associated with xerostomia and salivary dysfunction
primary: salivary and lacrimal gland disorder
secondary: autoimmune diseases such as RA, SLE, scleroderma

66
Q

what is sjogrens syndrome associated with?
hallmark of SS?
symptoms?

A

increased incidence of non?hodgkins lymphoma
hallmark of SS: predominantly T cell infiltrates in exocrine tissues
autoantibodies anti?Ro and anti?La and rheumatoid factor
symptoms: cracked lips, dessicated oral tissues, fungal infxn, difficulty speaking without fluids, xerostomia and keratoconjuctivitis sicca

67
Q

dx test for sjogrens syndrome

A

schirmers test: measures production of tears
lip/salivary gland biopsy
lab eval
tx is not curative

68
Q

what is oral hairy luekoplakia associated wtih?

A

immunosuppression (HIV)
along lateral tongue margins bilaterally, corrugated, shaggy surfaces
white patch or plaque?? can be dysplasia, carcinoma in situ, or invasive carcinoma
requires biopsy

69
Q

between leukoplakia and erythroplakia, which has higher malignant potential?

A

erythroplakia

70
Q

what are factors for oral candidiasis?

A

common opportunistic infection

factors include smoking, foreign bodies, diabetes, immunosuppression

71
Q

linchen planus

A

common T cell mediated disease that is treated with topical steroids

72
Q

xtraesophageal reflux

A

lack of classic heartburn and regurgitation symptoms
hoarseness, throat clearing, cough, dysphagia, increased phlegm, globus sensation
can lead to pharyngeal and laryngeal edema, ulceration, granulomas, leukoplakia

73
Q

zenkers diverticulum
what is killians triangle?
symptoms of zenkers?

A

caused by incomplete relaxation of the UES
killians triangle?? weakness between inferior constrictor and cricopharyngeus
dysphagia, regurgitation of undigested food, bad breath, cough, aspiration pneumonia

74
Q

what are 3 areas of narrowing in esophagus where foreign bodies can be stuck?
which ingestion is an emergency?

A

UES, aorta, LES

disc battery ingestion is an emergency?? esophageal perforation can occur in 6 hours

75
Q

management of foreign body ingestion

A

urgent removal?? drooling, unable to handle secretions, sharp objects
emergent removal?? batteries (But if in stomach, safe)?? if not it can cause necrosis
80% of coins at LES will pass in 24?48 hrs

76
Q

what does acidic ingestion do?

A

coagulation necrosis?? forms an eschar/coagulum
stomach affected
(toilet bowl cleaners, battery fluid, rust removal products)

77
Q

what do alkaline substances do (drain cleaners, oven cleaners, dishwasher detergent, hair relaxers )?

A

liquefactive necrosis
severe injury in minutes, granulation at 2 weeks, stricture
tissue edema to oral cavity, oropharynx, hypopharynx

78
Q

what are worrisome symptoms after ingestion?

A

dyspnea, dysphagia, odynphagia, chest pain, N/V, pain
hoarseness, stridor/resp distress, tachy, oropharyngeal burns, drooling, subcutaneous air, peritonitis, fever, chest pain/abd pain

79
Q

how do you manage pts after ingestion?

A 
identify product
do not induce emesis or neutralize
secure airway
chest and abd films?? look for free air
endoscopy in 12?48 hr in symptomatic pt
place NGT to serve as stent for 6 weeks
steroids/ab?
80
Q

how much saliva is produced a day? from which glands (and which proportions?)

A

1.5 L
submandibular glands?? 70% (basal flow)
parotid glands?? 25% (stimulated flow)
sublingual and minor salivary glands?? 5%

81
Q

parotid glands
where odes the parotic (stensens) duct go?
which nerve splits the parotid gland into deep and superficial lobes?

A

transverses the masseter and buccinator muscles, enters oral mucosa at level of 2nd maxillary molar
facial nerve

82
Q

what duct is associated with submandibular glands?

where does it terminate?

A

submandibular duct (whartons duct) emerges from deep lobe, terminates as an elevated papilla just lateral to the frenulum of the tongue

83
Q

sublingual glands?? covered only by __

A

oral mucosa?? lies along distal half of the submandibular duct superficially
drained series of ductules?? open either into the SM duct or directly into the floor of the mouth

84
Q

what is the parotid gland innervated by?

A

preganglionic PS fibers originate in inferior salivatory nucleus, travel via CN 9 and jacobsens nerve in teh middle ear, exti middle eary via lesser superfiical petrosal nerve (otic ganlion)

postganglionic fibers travel via the auriculotemporal nerve (branch of V3)

85
Q

submandibular & sublingual gland innervations

A

preganglionic PS fibers originate in superior salivatory nucleus
travel via CN VII and the chorda tympani through the middle ear
exit via the petrotympanic fissure and travel with the lingual nerve to the submandibular ganglion
postganglionic fibers travel onto SM and SL glands

86
Q

what predominates in the parotid gland? the submandibular gland?

A

parotid: serous acini predominate
SB: serous and mucinous acini abundant
contractile myoepithelial cells surround acini, help to drain saliva

87
Q

how is salivary flow broken down between glands?

A

parotid gland: 25% of daily salivary flow, serous
SM: 70%, serous and mucinous
sublingual: 5%, mucinous
during stimulated flow, contribution of parotid and submandibular glands are reversed
controlled by ANS (parasymp)

88
Q

what are salivary functions?

A

lubricate food, facilitate swallowing, protect teeth, deliver secretory IgA, lysozyme, peroxidase to the oral cavityho

89
Q

what is sialolithiasis?

how do patients with sialolothiasis present?

A

formation of calculi in ductal system of salivary glands
most common form of inflammation
80?90 in submand gland
postprandial pain, recurrent swelling in submandibular gland
not related to serum Ca or Ph

90
Q

what is sialorrhea? what is it from?

how is chronic sialorrhea treated?

A

increase in salivary flow (drooling?? results from disturbance in oral phase of swallowing, assoc with poor synchronization of lip closure)
can be related to cerebral palsy
conservatively with meds and/or botox (can also be surgically treated after 6 mo of conservative managment and after 6 yo)

91
Q

what is most common benign salivary gland tumor?

A

pleomorphic adenoma
architectural pleomorphism
slow growing, painless, firm, single, mobile
FNA: sensitivity of 90%
treatment: resection?? parotidectomy?? its recurrent, so may need to take out whole thing including CN7!

92
Q

what is most common malignant salivary gland tumor?

A

mucoepdermoid carcinoma

93
Q

wharthin tumor (papillary cystadenoma lymphomatosum)

A

benign tumor associated with smoking

cystic spaces w/ germinal centers

94
Q

adenoid cystic carcinoma

A

most common malignancy of submandibular gland

slow growing, distant mets

ENT (1 decks)

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