Daily Questions Flashcards

Question

What is the first line antibiotic of choice for acute otitis media? A) Cefpodoxime 10 mg/kg/d B) Augmentin 90 mg/kg/d C) Cefuroxime 30 mg/kg/d D) Amoxicillin 90 mg/kg/d E) Ceftriaxone 50 mg/kg/d

Answer 1

D; Amoxicillin is the recommended 1st line antibiotic for AOM, the rest are all second line. Amoxicillin should be given for 10 days in children under 5 and 5-7 days in children older than 6. Use a second line antibiotic if there is no clinical improvement within 3 days. Note that all of the choices are oral antibiotics except for Ceftriaxone which is given as a single IM injection.-See KJ Lee 10th ed pg 311-312

Answer 2

C; Pneumothorax is an uncommon intraoperative complication of tracheostomy, but can be caused by direct injury to the pleura or rupture of an alveolar bleb. The incidence has been reported to be as high as 4.3% but rarely is intervention required. Clinically the rate is much lower so there is no need to obtain routine screening chest x rays postop. -See Cummings 6th ed pg 100-101

Answer 3

A; Use the 24-12-6 rule. The anterior ethmoid artery is 24mm posterior to the orbital rim/lacrimal crest, the posterior ethmoid is 12 mm posterior to the anterior ethmoid artery and the optic nerve is 6 mm posterior to the posterior ethmoid artery. These relationships are crucial when approaching the orbital floor or ligating these vessels to control epistaxis. -http://emedicine.medscape.com/article/835021- overview

Answer 4

A; Cytomegalovirus is the most common infection to cause congenital hearing loss and the vast majority of patients are asymptomatic at birth. Hearing loss is often delayed and may not be diagnosed for several years. Syphilis is the only infectious cause of hearing loss that is potentially treatable with antibiotics. Patients with congenital rubella can suffer from cataracts in addition to hearing loss. Exposure to cats is a risk factor for toxoplasmosis. -See KJ Lee 10th ed pg 815-816

Answer 5

D; Patients who have a tracheostomy tube for over 4 months have a 70% chance of developing a tracheocutaneous fistula. This is due to epithelialization of the tracheostomy tract. Bjork flaps and prior radiation exposure are also risk factor for tracheocutaneous fistula. - See Cummings 6th ed pg 101.

Answer 6

C; The conus elasticus (aka cricovocal membrane or triangular membrane) extends from the superior border of the cricoid inferiorly up to the deep surface of the apex of the thyroid cartilage and the vocal process of the arytenoid. Its superior free edge is the vocal ligament. -See KJ Lee 10th ed pg 530

Answer 7

A; The left RLN loops around the ligamentum arteriosum and has a relatively vertical course. The right RLN wraps around the subclavian artery and enters the neck more laterally creating a more obtusely angulated course. Both nerves ultimately run within the tracheoesophageal groove on their way to innervating the larynx. - See KJ Lee 10th ed pg 577-579

Answer 8

A; The maturation phase of wound healing occurs between 2 weeks and 18 months and involves replacement of type III collagen with type I collagen which makes the scar softer and smaller. The wound reaches its maximal strength (80% of its preinjury strength) during this phase. -See KJ Lee 10th ed pg 766

Answer 9

``` C; IgA is present in salivary secretions and exists as a dimer. IgG is involved in secondary immune responses and is the only Ig class that crosses the placenta. IgM is primarily associated with early immune responses and exists as a pentamer. IgD is found on circulating B cells. Of all immunoglobulins, the body has the least amount of IgE which is involved in type I hypersensitivity reactions (anaphylaxis) as well as atopy. -See KJ Lee 10th ed pg 452-453 ```

Answer 10

E; The posterior cricoarytenoid is the only abductor of the larynx. The cricothyroid is the only laryngeal muscle innervated by the external branch of the superior laryngeal nerve. The interarytenoid is the only unpaired muscle in the larynx. -See KJ Lee 10th ed pg 531- 532

Answer 11

B; The lateral lip is created by fusion of the medial nasal prominence to the maxillary prominence. This failure to fuse can also create a cleft in the primary palate. Failure of the maxillary prominence to fuse with the lateral palatine process results in a cleft of the secondary palate. Risk factors for clefts include pregestational maternal diabetes, fetal alcohol and tobacco exposure, folic acid deficiencies, retinoic acid derivatives and anticonvulsant medications. -See KJ Lee 10th ed pg 285-287

Answer 12

D; 80% of children with AOM will show clinical improvement within 3 days with no intervention. That rate goes up to 92% if antibiotics are started immediately. However, this should be weighed against the 30% of children who will develop a rash and 80% of children who will develop diarrhea with antibiotics.-See KJ Lee 10th ed pg 311

Answer 13

B; The most common cause of epiglottitis in children is Haemophilus influenzae, however the incidence of epiglottitis has decreased significantly since vaccination against this bacteria was introduced. While IgA is the immunoglobulin most represented in the mucosa, failure to mount an immune response after vaccination represents a failure of the IgG antibody as this is the immunoglobulin stimulated by vaccines. The most common IgG deficiency in children is IgG2. - Oxelius, Aurivillius, Carlsson and Musil (1999), Serum Gm Allotype Development During Childhood. Scandinavian Journal of Immunology, 50: 440–446.

Answer 14

D; This patient has classic signs and symptoms of necrotizing fasciitis. In the head and neck, dental infections are the most common cause and patients who are immunocompromised have an elevated risk. The infection should be treated aggressively with broad spectrum antibiotics, ICU level of care and surgical exploration/debridement. Although all of the bacteria listed can cause necrotizing fasciitis, Strep pyogenes and Staph Aureus are the most common causes. The LRINEC score can be used to help make the diagnosis and consists of six blood test: CRP, WBC, Hg, Na, Cr and glucose. -See KJ Lee 10th ed pg 573 and -Wong, Chin-Ho, Lay- Wai Khin, Kien-Seng Heng, Kok-Chai Tan, and Cheng-Ooi Low. "The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) Score: A Tool for Distinguishing Necrotizing Fasciitis from Other Soft Tissue Infections*." Critical Care Medicine 32.7 (2004): 1535-541.

Answer 15

``` A; IgG is involved in secondary immune responses and is the only Ig class that crosses the placenta. IgA is present in salivary secretions and exists as a dimer. IgM is primarily associated with early immune responses and exists as a pentamer. IgD is found on circulating B cells. Of all immunoglobulins, the body has the least amount of IgE which is involved in type I hypersensitivity reactions (anaphylaxis) as well as atopy. ``` -See KJ Lee 10th ed pg 452-453

Answer 16

D; Deep chemical peels penetrate down to the reticular dermis. This is a thick layer made of compact collagen. Care must be taken with deep chemical peels as damage to this layer results in permanent scarring. Medium depth peels reach the papillary dermis or the superficial reticular dermis. Superficial peels remove the epidermis (of which both the stratum granulosum and stratum basale are sublayers of) and some of the superficial papillary dermis. -See KJ Lee 10th ed pg 756

Answer 17

C; This patient presents with symptoms and history concerning for postoperative cerebrospinal fluid(CSF) leak. While B2 transferrin is the best test to confirm a CSF leak it can take several days for these test results to return. Glucose testing is a fast way to differentiate CSF rhinorrhea from other nasal discharge. CSF fluid is expected to have 60-70% of the serum glucose level present whereas normal nasal discharge has very low levels of glucose. Normal CSF glucose levels are 40-80 mg/dL but it would be higher in this patient given her elevated serum glucose. -https://en.wikipedia.org/wiki/CSF_glucose

Answer 18

B; The patient presents with classic symptoms of peritonsillar abscess (PTA). Appropriate treatment involves needle aspiration and/or incision and drainage. Once the patient can tolerate PO they are usually prescribed systemic antibiotics (clindamycin) for 10 days. 16% of adults and 7% of children will have a recurrence of their PTA. If a patient has a recurrence of their PTA they should be offered a delayed tonsillectomy as they are at significantly increased risk of a third episode. -KJ Lee 10th ed pg 571

Answer 19

C; Jet ventilation is commonly used during treatment of recurrent respiratory papillomatosis (RRP) because it allows better visualization and access to the airway. Complications include abdominal distention, subcutaneous emphysema, pneumomediastinum, pneumothorax and hypoventilation. Although in theory a pneumothorax could be caused by iatrogenic trauma to the tracheal/laryngeal wall, this is not common and would not cause abdominal distention. Sudden opening of a previously chronic obstruction can lead to pulmonary edema but not pneumothorax. -KJ Lee 10th ed pg 1003

Answer 20

C; While respiratory events including apneas and hypopneas occur in all stages of sleep, they are least likely to occur during stage 3 sleep. Apneas that occur during REM tend to be associated with lower oxygen desaturations. -See KJ Lee 10th ed pg 417

Answer 21

A; The space that spans from the glottis to the inferior border of the cricoid is the subglottis and its lateral border is the conus elasticus (in addition to the cricoid). The conus elasticus attaches to the superior border of the cricoid inferiorly. Superior it attaches to both the deep surface of the apex of the thyroid cartilage and the vocal process of the arytenoid and forms the median cricothyroid ligament. Its superior free edge forms the vocal ligament. -See KJ Lee 10th ed pg 530-531

Answer 22

B; A Waters' view xray is taken at a 45° angle to the orbitomeatal line and best shows the maxillary sinuses, although it also can help evaluate the anterior ethmoids and orbital floor. Other plain films views of the sinuses include the Lateral view (frontal, maxillary and sphenoid sinus), Caldwell view (Frontal sinuses and posterior ethmoid cells) and Submentovertex view (sphenoid and anterior/posterior walls of frontal sinuses). - Williams, John W., Leroy Roberts, Bruce Distell, and David L. Simel. "Diagnosing Sinusitis by X-ray." J Gen Intern Med Journal of General Internal Medicine 7.5 (1992) : 481-85.

Answer 23

A; Unlike in the oropharynx where p16/HPV+ tumors are correlated with better outcomes, HPV+ nasopharyngeal carcinomas (NPC) are associated with poorer outcomes. Epstein Barr Virus (EBV) is a double stranded DNA virus found in the vast majority of patients with NPC. -Stenmark, Matthew H., "Nonendemic HPV-Positive Nasopharyngeal Carcinoma: Association With Poor Prognosis." and KJ Lee 10th ed pg 716-719

Answer 24

A; This patient presents with symptoms concerning for myasthenia gravis which is caused by antibodies blocking the postsynaptic endplates of the neuromuscular junction. Symptoms include voice fatigue, double vision, ptosis, oropharyngeal muscle weakness, head drop, limb weakness. These symptoms tend to be worse later in the day or after activity. Diagnosis can be made with a tensilon (edrophonium chloride) test. CT scan of the chest is indicated in all of myasthenia patients to rule out tumors of the thymus which are present in 10-15% of patients. -See KJ Lee 10th ed pg 883

Answer 25

D; Because the course of the left recurrent laryngeal nerve is longer (passing under the ligamentum arteriosum) there is a higher chance that this patient's vocal cord paralysis is on the left side compared to the right given the otherwise unexplained etiology. Bilateral vocal cord paralysis is unlikely given that the patient has no evidence of respiratory distress. Vocal cord nodules are unlikely to cause a breathy voice and would not contribute significantly to aspiration. -Lalwani 3rd ed pg 476

Answer 26

B; Superficial chemical peels penetrate past the epidermis (including the stratum corneum) and penetrate to the superficial papillary dermis. Deep chemical peels penetrate down to the reticular dermis. Medium depth peels reach the papillary dermis or the superficial reticular dermis. -See KJ Lee 10th ed pg 756

Answer 27

E; A 2009 Cochrane review demonstrated no benefit to adenoidectomy in decreasing the number of episodes of AOM. Adenoidectomy should only be offered to patients with otitis media with effusion in an effort to help resolution of a persistent effusion, however this is not routine and should be performed on an individual basis. -Aardweg. "Adenoidectomy for Recurrent or Chronic Nasal Symptoms and Middle Ear Disease in Children up to 18 Years of Age." Protocols Cochrane Database of Systematic Reviews (2009).

Answer 28

D; The subsites of the hypopharynx are the "3 Ps": postcricoid region, posterior pharyngeal wall and pyriform sinus. The valleculae is a subunit of the oropharynx. Other subunits of the oropharynx include the soft palate/uvula, base of tongue, pharyngoepiglottic/glossoepiglottic folds, palatine arch, and oropharyngeal walls. -See KJ Lee 10th ed pg 506

Answer 29

B; This patient most likely has superior laryngeal nerve paralysis given that her voice changes are limited to singing (otherwise recurrent laryngeal nerve damage would be suspected). Gutman sign is when lateral pressure over the thyroid cartilage causes decreased voice pitch whereas anterior pressure causes increased voice pitch which is indicative of superior laryngeal nerve paralysis. In a normal individuals the opposite is true. -See KJ Lee 10th ed pg 255

Answer 30

C; Fisch Type C tumors extend to the infralabyrinthine region, Type D tumors have less than 2 cm diameter and intracranial extension. - See KJ Lee 10th ed pg 186

Answer 31

B; Contents of the foramen lacerum include the internal carotid artery (not external), deep petrosal nerve, greater petrosal nerve (aka superficial petrosal nerve), terminal branch of the ascending pharyngeal artery and emissary veins. Nodes of Krause are found in the posterior jugular foramen. The middle meningeal artery is found in foramen spinosum. The labyrinthine artery is found in the internal auditory canal. - See KJ Lee 10th ed pg 954

Answer 32

C; The patient has bilateral acoustic neuromas (characteristically isointense on T1, hyperintense on T2 and enhances w/ contrast). This is pathognomonic for neurofibromatosis type 2 which is caused by deletions in the NF2 gene which codes for the tumor suppressor protein Merlin. As a side fact, Merlin is an acronym for "Moesin- Ezrin-Radixin-Like Protein". -See Lalwani 3rd ed pg 715

Answer 33

B; Pseudoepitheliomatous hyperplasia is a benign condition which demonstrates overgrowth of squamous epithelium on histology and can be confused for SCC. Mucoepidermoid carcinoma can also mimic SCC however it is not a benign condition. RRP, vocal cord polyp and Reinke's are all benign conditions but are unlikely to be confused for SCC. Necrotizing sialometaplasia is another benign condition that can be confused for SCC, however it is extremely rare in the larynx. -Cummings 6th ed pg 1612

Answer 34

C; The patient presents with symptoms most consistent w/ Hashimoto's thyroiditis. It is most common in females age 30-50 and most patients are euthyroid. Presentation is usually a painless, firm, enlarged goiter. FNA will reveal lymphocytic infiltration with germinal center formation, Hurthle cell metaplasia, fibrosis and follicular acinar atrophy. 70-90% of patients will have elevated thyroid peroxidase antibodies. -See KJ Lee 10th ed pg 586

Answer 35

C; Per Fallucco 2012, 83% of patients will have a supraorbital notch instead of a foramen. It should be noted that these notches still have a fascial band holding the contents of the notch in place in the majority of specimens. -Fallucco "The Anatomical Morphology of the Supraorbital Notch." Plastic and Reconstructive Surgery 130.6 (2012): 1227-233.

Answer 36

D; I = normal facial function II = slight weakness and/or slight synkinesis but normal tone and symmetry at rest. III = obvious asymmetry with noticeable synkinesis, contracture or hemifacial spasm. There is normal symmetry and tone at rest and complete eye closure with effort. IV = obvious asymmetry but normal tone and symmetry at rest with incomplete eye closure V = barely perceptible motion with asymmetry at rest VI = no movement -See KJ Lee 10th ed pg 198

Answer 37

B; This is likely an incidental finding and not related to her headaches. Although cholesterol granulomas can cause symptoms as they expand and impinge upon other structures, they are often asymptomatic. Cholesterol granulomas have very distinct MRI findings. They do not enhance with contrast and demonstrate hyperintensity on both T1 and T2. -Cummings 6th ed pg 2093

Answer 38

C; This is a classic presentation for Winkler disease (i.e. Chondrodermatitis Nodularis Helicis) which is a benign condition often mistaken for a neoplastic process on exam. The key to differentiating it from neoplasm is that these lesions are very painful, whereas skin cancer usually is not. Treatment involves complete excision of the nodule. Villaret Syndrome is jugular foramen syndrome with the addition of Horner syndrome. Vail syndrome is unilateral, nocturnal, vidian neuralgia associated with sinusitis. -See KJ Lee 251-252

Answer 39

E; Thyroglobulin is used to monitor for recurrence of well differentiated thyroid cancer after total thyroidectomy and radioactive iodine ablation. Levels above 10 mg/dL are concerning for recurrent disease. Thyroglobulin is made by follicular cells but then secreted into the follicular lumen in the form of colloid. It is important to test for anti-thyroglobulin antibodies at the same time, as elevated levels of these antibodies invalidate the use of thyroglobulin as a tumor marker. - See KJ Lee 10th ed pg 581.

Answer 40

A; The medial wall of the orbit is made up of the lacrimal bone, sphenoid, lamina papyracea (of the ethmoid bone) and the frontal process of the maxilla. The palatine bone contributes to the orbit as part of the orbital floor. The frontal bone and zygoma also contribute to the structure of the orbit. -See KJ Lee 10th ed pg 895

Answer 41

B; The blood supply of the sternocleidomastoid is made up of the occipital artery (upper third), branches of the superior thyroid artery (middle third) and branches of the thyrocervical trunk which gives off the suprascapular artery (lower third). For a superiorly based flap the corresponding vessel is the occipital artery. -See KJ Lee 10th ed pg 731.

Answer 42

D; The patient presents with classic symptoms and MRI findings consistent with a cholesteatoma (hypointense T1, hyperintense T2 with rim enhancement). Although the question used an MRI to test your knowledge, be aware that a noncontrast CT scan is the initial imaging modality of choice for cholesteatoma workup. Canal wall up mastoidectomy would be an appropriate surgical intervention for this patient depending on the the extent of their disease and patient preference. MRI scans can be used to followup these patients and evaluate for residual/recurrent disease and carries a sensitivity of 91% and specificity of 96%. -See Cummings 6th ed Pg 2088-2093

Answer 43

B; For well differentiated thyroid cancer, patients under the age of 45 have a much better prognosis than those older than 45 and therefore can only be stage I or II. Stage II is for patients with distant metastasis, and Stage I is for those without. The size of their primary lesion and the location/size of their regional metastasis are irrelevant to their staging. -See KJ Lee 10th ed pg 640.

Answer 44

A; This patient presents with classic symptoms of achalasia. This disorder is characterized by failure of the lower esophageal sphincter to relax and lack of peristalsis which leads to the class "bird's beak" appearance on esophagram. The underlying etiology is idiopathic degeneration of Auerbach plexus (aka myenteric plexus) which provides innervation to the muscular layer of the digestive tract. Treatment options include calcium channel blockers and botox injections into the lower esophageal sphincter however Heller myotomy (aka lower esophageal sphincter myotomy) is the definitive treatment method. -See KJ Lee 10th ed pg 524

Answer 45

B; Melkersson-Rosenthal syndrome is associated with recurrent facial palsy, chronic/recurrent facial edema and fissuring of the tongue. Patients tend to be in their 20s. The etiology of this syndrome is unknown. Ramsay Hunt is facial paralysis due to herpes zoster and presents with vesicular eruptions on the ear. Heerfordt disease (aka uveoparotid fever) is a rare form of sarcoidosis which can cause bilateral facial nerve paralysis, parotid swelling and uveitis. Lyme disease is caused by borrelia burgdorferi and is associated with erythema migrans. 10% of lyme disease patients will have facial nerve palsy and bilateral involvement is not uncommon. Almost 100% of patients will have a full recovery. Mobius syndrome is a form of congenital facial paralysis which presents with bilateral facial paralysis and unilateral or bilateral abducens palsy. -See KJ Lee 10th ed pg 215

Answer 46

B; The jugular foramen is divided into anteromedial and posterolateral segments called the par nervosa and par vasculara respectively. CNs IX, X, XI and the inferior petrosal sinus pass through par nervosa whereas the internal jugular vein and posterior meningeal artery pass through the par vasculara. -See KJ Lee 10th ed pg 235

Answer 47

B; This patient has the classic presentation for a glomus tympanicum. These tumors are most common in caucasian females and present with pulsatile tinnitus and conductive hearing loss. They are often found on the promontory. Brown sign is blanching of the middle ear mass on pneumatic otoscopy which is strongly suggestive of a glomus tumor. 10% of glomus tumors are multicentric so it is important to evaluate the patient with imaging for potential additional masses. -See KJ Lee 10th ed pg 681-683

Answer 48

D; All patients with anaplastic thyroid cancer are considered stage IV due to the extremely poor prognosis. Tumor size, regional and distant metastasis or irrelevant to their staging. -See KJ Lee 10th ed pg 640

Answer 49

C; While both D and E likely represent well differentiated thyroid carcinoma if an FNA is performed at these sites it does not provide information as to regional metastasis and a second FNA will be required for the suspicious cervical nodes. If you perform an FNA on the suspicious lymph node (larger than 1 cm, microcalcifications, abnormal round shape and increased echogenicity) and it is positive for thyroid cancer then you know the patient has regional spread and you can treat him appropriately. Spongiform thyroid nodules are categorized as "very low suspicion" in the 2015 ATA thyroid nodule guidelines. -See 2015 ATA Thyroid Nodule Guidelines

Answer 50

E; This patient presents with signs and symptoms of malignant otitis externa. A noncontrast CT temporal bone scan can be used to make/confirm the initial diagnosis as can an MRI of the skull base or a technetium radioisotope scan. These scans are not great at monitoring treatment however. It should be noted that once a technetium scan becomes positive it will remain so indefinitely. Gallium scans are best for detecting inflammatory response and a reduction in uptake correlates with clinical improvement therefore making them useful to track treatment response. -See KJ Lee 10th ed pg 207-208

Answer 51

C; The most common benign salivary gland neoplasm is pleomorphic adenoma (benign mixed tumor), which most commonly presents in the parotid gland. The rate of transformation to carcinoma ex- pleomorphic adenoma is ~ 25%. -See KJ Lee 10th ed pg 501

Answer 52

B; This patient has a presentation most consistent with superior semicircular canal dehiscence. The most appropriate imaging modality to order is a CT scan in the planes of Poschel and Stenver as they transect the superior canal and allow the dehiscence to be seen. The line of Ohngren connects the medial canthus of the eye to the angle of the mandible and helps with prognostication of midface tumors. The Frankfurt horizontal plane connects the inferior orbital rim and the superior ear canal and helps define standard anatomic positioning. MRI is not an appropriate scan to detect superior canal dehiscence. -See KJ Lee 10th ed pg 355

Answer 53

A; Factors that affect a study's power include the statistical significance criteria, the magnitude of the effect in the population and the sample size used. B refers to the null hypothesis, C refers to the P value, and D refers to the confidence interval. -See Cummings 6th ed pg 16

Answer 54

``` D; For children less than 6 months, behavior observation audiometry is preferred (in addition to ABR and OAE). For children 6 months to 3 years (as in our patient) visual response audiometry is preferred. Play audiometry can be used in children 3-6 years and conventional audiometry can usually be achieved in children over the age of 6. - See KJ Lee 10th ed pg 51-53 ```

Answer 55

D; Cochlear implants are inserted into the scala tympani which can be accessed via the round window or adjacent cochleostomy. The scala vestibuli can be accessed via the vestibule through the oval window (although this will likely cause a sensorineural hearing loss). The scala media cannot be accessed surgically without causing significant damage to the inner ear and is located between the scala vestibuli and scala tympani. The saccule detects linear acceleration and is not involved in hearing. -See KJ Lee 10th ed pg 157-158.

Answer 56

B; Endochondral bones of the skull include the petrous, occipital, ethmoid, mastoid and sphenoid bones. The remaining bones are all membranous. During the ossification of endochondral bone cartilage is present as an intermediary whereas this is not the case in membranous bone. -See KJ Lee 10th ed pg 955.

Answer 57

C; The patient presents with findings consistent with a glomus tympanicum. These tumors arise from Jacobson's nerve (aka Tympanic nerve) which is branch of the glossopharyngeal nerve (CN IX). Arnold's nerve is also known as the auricular branch of the vagus nerve (CN X) and it provides sensation to the ear canal, tragus and auricle. The auriculotemporal nerve is a branch of the mandibular branch of the trigeminal nerve (CN V3) and provides sensation to the ear canal, tympanic membrane and auricle. It also carries parasympathetic fibers to the parotid gland. -See KJ Lee 10th ed pg 4

Answer 58

D; This patient's presentation is consistent with adductor spasmodic dysphonia. Classic symptoms include strained voice with frequent voice breaks and difficulty with words beginning in vowels. The NIDCD established four diagnostic criteria for spasmodic dysphonia including: 1) Increased effort with speaking 2) difficulty fluctuates over time 3) Symptoms last more than 3 months 4) At least one nonspeaking task is normal (laugh, whisper, sing, yawn, shout, cry) Botox injections of the thyroarytenoid muscle is currently the most effective management option. The Berke procedure involves transection of the adductor branches of the recurrent nerve with reinnervation using ansa cervicalis. Recurrent nerve transection was previously used however this often leads to significant breathiness and symptoms will often return within 3 years. Speech therapy is not effective in patients with spasmodic dysphonia. Botox injections of the posterior cricoarytenoid is used in patients with abductor spasmodic dysphonia which is much less common and presents with breathy voice and voice breaks during plosive sounds. -See KJ Lee 10th ed pg 543-544

Answer 59

B; Albumin is a good marker for patients' long term nutritional status and has a half life of 20 days. Values less than 3.0 g/dL are associated with increased morbidity. Prealbumin and transferrin are both markers for a patient's nutritional status but they have short half lifes (2 and 10 days respectively) and are therefore more likely to be normal in this patient who has been receiving adequate nutrition for the past 10 days. Glucose is not a commonly used marker to evaluate for malnutrition and would be expected to be normal in this patient who is currently receiving adequate nutrition. -See KJ Lee 10th ed pg 921 - 922

Answer 60

D; The "Lyre sign" refers to the splaying of the internal and external carotid artery that is caused by a carotid body tumor. This splaying resembles the classic Greek instrument of the Lyre. These tumors are paragangliomas and as such also demonstrate the classic "salt and pepper" appearance caused by areas of slow flow (salt) and flow voids (pepper). -Baser, Husniye, Baris Ayhan, Meryem Ilkay Eren Karanis, Salih Baser, Deniz Karasoy, Kemal Kalkan, and Samil Ecirli. "A Carotid Body Tumor Mimicking a Thyroid Nodule: A Case Report." Endocrine Abstracts EJEA (2014).

Answer 61

C; The pathway for parasympathetic innervation of the parotid gland is as follows: Inferior salivary nucleus --> Jacobson's nerve (CN IX) --> Lesser superficial petrosal nerve --> Auriculotemporal nerve (V3) --> Parotid gland. The nervus intermedius carries parasympathetic fibers from the Superior salivary nucleus to the chorda tympani which eventually innervates the submandibular and sublingual glands, but not the parotid gland. -See KJ Lee 10th ed pg 488-489

Answer 62

B; Erosive esophagitis is most commonly classified using the Los Angeles classification scheme which is divided into 4 categories: Grade A: >1 isolated mucosal breaks <5 mm long Grade B: > 1 isolated mucosal breaks >5 mm long Grade C: > 1 mucosal breaks bridging the tops of folds but involving <75% of the circumference Grade D: > 1 mucosal breaks bridging the tops of folds and involving >75% of the circumference. The remaining answer choices are all various classification schemes used to categorize Zenker's diverticulum. -See Cummings 6th ed pg 1008

Answer 63

A; The utricle detects linear acceleration (accelerating in a car) whereas the saccule detects vertical acceleration (descending in an elevator). The semicircular canals detect rotational acceleration. - See KJ Lee 10th ed pg 83

Answer 64

A; While transverse temporal bone fractures are more likely to cause a facial nerve injury, there are far more longitudinal fractures and therefore they are the most common cause of facial nerve injuries. Labyrinthine concussion is a more common cause of posttraumatic vertigo than BPPV. -See KJ Lee 10th ed pg 264-265

Answer 65

B; The sphenopalatine foramen can be located directly behind the crista ethmoidalis in the majority of individuals. This is useful when performing a sphenopalatine artery ligation to control epistaxis. It should also be kept in mind that the artery branches medial to the crista in almost all patients, with some patients having up to 10 individual branches. -See KJ Lee 10th ed pg 407 and Bolger "The Role of the Crista Ethmoidalis in Endoscopic Sphenopalatine Artery Ligation" American Journal of Rhinology

Answer 66

A; The fourth branch off the external carotid is the facial artery. Use the mnemonic "Some Attendings Like Freaking Out Potential Med Students" (Superior thyroid, ascending pharyngeal, lingual, facial, occipital, posterior auricular, internal maxillary, superficial temporal). The superior labial artery is a branch off the facial. The superior laryngeal is a branch from superior thyroid, the sublingual is a branch off of lingual and the middle temporal is a branch off of superficial temporal. -See KJ Lee 10th ed 958-959.

Answer 67

A; The maxillary sinus develops out of a furrow in the lateral nasal wall at ~ the 65th day of development and the ethmoid sinuses develop in the second trimester. These are the only two sinuses you are born with. The sphenoid sinuses are not present until ~ 2 years of age and the frontals do not appear until the age of 7. -See KJ Lee 10th ed pg 783-784

Answer 68

B; Fanconi's Anemia is a rare congenital disorder characterized by spontaneous bleeding, decreased platelets, bone marrow megakaryocytes and anomalies of the inner, middle and external ear. Approximately 1:130,000 children are born with this disorder. It is autosomal recessive and therefore the chances that a second child has this disorder is 25%. -See KJ Lee 10th ed pg 229-230.

Answer 69

C; This patient's presentation is most consistent with relapsing polychondritis. This disorder is characterized by recurring inflammation of cartilaginous structures including the auricles, septum and airway. Symptoms develop rapidly and resolve after 1-2 weeks. Inflammatory markers such as ESR and CRP are often significantly elevated and treatment consists of oral steroids and immune modulating agents. ~ 50% of patients will develop progressive destruction of the airway cartilages which result in airway symptoms. -See KJ Lee 10th ed pg 549

Answer 70

D; Cortisporin contains hydrocortisone, polymyxin B and neomycin which is a common cause of contact dermatitis. The other ototopical medications listed can cause allergic reactions but are less likely to do so. Ciprodex contains ciprofloxacin and dexamethasone. Polysporin contains polymyxin and lidocaine. -Epstein E. Allergy to Dermatologic Agents. JAMA. 1966;198(5):517-520.

Answer 71

E; All of the structures listed are poststyloid structures except for the lingual nerve. In general, poststyloid masses are more concerning given the importance of the structures in that region. Prestyloid: Internal maxillary artery, inferior alveolar nerve, lingual nerve, auriculotemporal nerve Poststyloid: Carotid artery, internal jugular vein, CN IX, X, XI, XII, cervical sympathetic chain. -See KJ Lee 10th ed pg 491 and 963.

Answer 72

A; This patient demonstrates a classic presentation of malignant otitis externa (MOE). They have a history of diabetes, pain out of proportion to exam and granulation tissue (which is usually present at the bony/cartilaginous junction). A technetium scan is the most appropriate scan for initial diagnosis although CT temporal bones are sometime ordered as well. Gallium scans and ESR can be used to monitor response to treatment. The most common organism to cause MOE is Pseudomonas (98% of cases) and the patient should be treated with ciprofloxacin with a 3rd/4th generation cephalosporin for at least 6 weeks. -See KJ Lee 10th ed pg 207-208

Answer 73

C; This patient presents with symptoms and imaging consistent with a chordoma. These tumors, which develop from notochord remnants, often present in the midline clivus and are locally aggressive with involvement of Dorello's canal and CN VI being common. Surgical resection is the standard treatment but 5 year survival is only ~ 50%. On imaging, projection of the mass posteriorly such that it indents the pons is called a "thumb sign" and is characteristic of these lesions. On histology cells with small round nuclei and abundant vacuolated cytoplasm (physaliferous cells) are seen. Antoni A and B patterns are present in vestibular schwannomas. Psammoma bodies and orphan Annie eye nuclear inclusions are seen in papillary thyroid carcinoma. Zellballen are characteristic of paragangliomas. -See KJ Lee 10th ed pg 685-686

Answer 74

C; This patient presents with a family history of goiter, multiple skin masses (hamartomas) and concern for thyroid cancer which is consistent with Cowden syndrome. Cowden syndrome (aka Multiple Hamartoma Syndrome) is an autosomal dominant disorder caused by mutations of phosphatase and tensin homolog (PTEN) gene. It is important to make this diagnosis as these patients are at increased risk of multiple malignancies including thyroid, colon, breast and renal cancer. 89% of these patients will develop some form of cancer during their lifetime. Cogan Syndrome = interstitial keratitis and Meniere's like symptoms likely related to periarteritis nodosa. Von Recklinghausen disease = NF1, Multiple neurofibromas and cafe au lait spots Pendred Syndrome = Congenital sensorineural hearing loss and euthyroid goiter Rosai-Dorfman = Benign lymphadenopathy which is often self limiting -See KJ Lee 10th ed pg 227 and 1056.

Answer 75

D; The most likely diagnosis is a Thornwaldt's Cyst. These are benign masses in the midline nasopharynx that represent a remnant of the notochord. They can sometimes cause symptoms such as neck pain, eustachian tube dysfunction and postnasal drip however they are commonly asymptomatic and noticed incidentally on imaging. If they are symptomatic they can be marsupialized, otherwise no intervention is indicated. -See KJ Lee 10th ed pg 404

Answer 76

D; Mucosal melanoma has a much worse prognosis than cutaneous melanoma and is therefore staged differently. T stage begins at T3 if it is limited to mucosa and does not involve any underlying structures. Unlike cutaneous melanoma, depth does not matter (and often is not reported). Lesions that involve cartilage or bone are considered T4a and those that are locally advanced involving skull base, brain, dura, cranial nerves, etc. are T4b. See staging below: T3N0 = Stage III T4aNx = Stage IVa T4bNx = StageIVb M1 = Stage IVc If this was a cutaneous melanoma the correct staging would be T2a (1-2mm thickness w/o ulceration)N0M0 - Stage Ib. - See KJ Lee 10th ed pg 650.

Answer 77

A; This patient's presentation is most consistent with fungal otitis externa. This can commonly occur after a course of topical antibiotics and classically has more pruritus than bacterial otitis externa. Fungal elements are often visualized in the external canal on exam. 2% (or less) of acute otitis externa is caused by fungus. - See KJ Lee 10th ed pg 935.

Answer 78

D; Tachycardia and hyperthermia in a patient with poorly controlled graves and an acute insult such as thyroid surgery is concerning for thyroid storm. Treatment of thyroid storm involves all of the listed medications however iodine should not be given until 1 hour after propylthiouracil and methimazole. Propylthiouracil and propranolol blocks T4 conversion to T3. Methimazole prevents new thyroid hormone synthesis. Corticosteroids are used as prophylaxis against adrenal insufficiency. -See Bahn "Management Guidelines of the ATA and AACE" pg 607.

Answer 79

A; Local anesthetic agents can be divided into esters and amides. Esters more commonly cause allergies and it is recommended that if a patient has a history of allergic reactions to one class of anesthesia that the opposite class be used. Lidocaine is the only amide anesthetic agent listed. Given the fact that previously this patient most likely had a reaction to an ester medication, an amide such as Lidocaine is the best answer choice. Remember that all amide anesthetic agents have two "i"s in their names. -See KJ Lee 10th ed pg 830-831

Answer 80

C; The recurrent laryngeal nerve (RLN) travels in the tracheoesophageal groove as it moves superiorly entering the larynx just posterior to the cricothyroid joint. Prior to entering the larynx it dives underneath the inferior constrictor muscle. The RLN innervates the inferior constrictor muscle and all the intrinsic muscles of the larynx except the cricothyroid muscle. -See KJ Lee 10th ed Pg 577- 578

Answer 81

D; There are four main factors that affect the prognosis of untreated sudden sensorineural hearing loss. 1. Severity of the hearing loss (the worse the loss the worse the prognosis) 2. Audiogram shape (flat and down sloping audiograms are worse than mid frequency or up sloping audiograms) 3. Presence of vertigo 4. Age of the patient (children and patients over 40 have a worse prognosis) Additionally, the longer a patient goes untreated the less effective treatment is and many practitioners will not treat sudden sensorineural hearing loss after 6 weeks due to the low rate of any meaningful recovery at that time. Gender has not been shown to be a significant prognostic factor in sudden sensorineural hearing loss. Men and women are affected roughly equally. - See Cummings 6th ed pg 2332.

Answer 82

C; Removing the cephalic margin of the lateral crura of the lower lateral cartilages (cephalic trim) is a maneuver used in rhinoplasty to improve nasal tip shape and definition. It is recommended that at least 7-9mm of alar width be left in place to prevent alar retraction and external nasal valve collapse. -See KJ Lee 10th ed pg 759.

Answer 83

A; The patient demonstrates signs of dwarfism consistent with achondroplasia. These patients often suffer hearing loss due to fusion of the ossicles. The condition is inherited in an autosomal dominant fashion. As a general rule (with several exceptions) autosomally dominant hearing loss syndromes demonstrate some external exam finding (such as white forelock for Waardenburg), whereas recessive hearing loss syndromes have a relatively benign exam (such as connexin 26 related hearing loss). - See KJ Lee 10th ed pg 129.

Answer 84

E; Multiple studies have demonstrated that clindamycin is a poor choice for perioperative antibiotic coverage prior to total laryngectomy. Both the rate of postoperative fistulas and infections are increased with the use of this antibiotic compared to the other antibiotics that are listed. - See Langerman "Laryngectomy Complications Are Associated with Perioperative Antibiotic Choice" and Mitchell "Antibiotic Prophylaxis in Patients Undergoing Head and Neck Free Flap Reconstruction"

Answer 85

B; Gentian Violet is known to be extremely ototoxic and should be used very carefully (or not at all) in patients with TM perforations. Mastoid powder (cipro, clotrimazole, dexamethasone and boric acid) is safe to use in the middle ear and is not ototoxic, nor is ciprodex or cipro otic. There is a hypothetical risk of ototoxicity with Cortisporin due to the neomycin. Iatrogenic hearing loss has been shown in an animal model, however the data on its ability to cause hearing loss in humans is conflicting and it is not the most likely medication listed to cause hearing loss. - See Cummings 6th ed pg 2128-2130.

Answer 86

C; High pitched nonpulsatile tinnitus can be distressing to patients causing significant anxiety and even depression. Although many treatment options are available very few have evidence supporting their use. Cognitive behavioral therapy (CBT) is one of the few treatment modalities that is evidence based. A Cochrane review demonstrated tinnitus patients who underwent CBT, while not having any decrease in tinnitus volume, did had improved quality of life scores and lower depressions scores compared to controls. Hearing aids can improve tinnitus but are not indicated in this patient given his normal audiogram. An MRI IAC to rule out retrocochlear pathology is generally not recommended in patients with symmetric tinnitus and a normal audiogram. Gabapentin has been used to treat tinnitus but evidence for its use is conflicting and would not be the best treatment option in this patient. - See Cochrane Database "Cognitive behavioural therapy for tinnitus." 2010.

Answer 87

B: Primary acquired cholesteatoma is due to persistent and deepening retraction pockets (usually in the pars flaccida) which cause accumulation of keratin debris and formation of a cholesteatoma. Secondary acquired is due to perforations and/or tympanostomy tubes which allow for migration of squamous epithelium into the middle ear space. The etiology of congenital cholesteatomas is unclear but by definition they originate in the middle ear in patients who have never had a perforation of the tympanic membrane. - See Cummings 6th ed pg 2142-2144.

Answer 88

B; Malignant melanoma T staging is relatively straightforward. Anything less than 1 mm thick is T1, between 1-2 mm is T2, 2-4 mm is T3 and over 4mm is T4. "a" and "b" are determined by whether there is ulceration (or mitosis in T1 lesions). If ulceration is present then add a "b" to their stage. Therefore, this patients T stage is T1b. -See KJ Lee 10th ed pg 650

Answer 89

D; Adenoid cystic carcinoma is associated with perineural spread and has three distinct histological subtypes which include tubular, solid and cribriform. Tubular patterns represents a low grade tumor and solid tumors are a high grade subtype. Cribriform subtypes demonstrate a "swiss cheese" type pattern and is associated with the best prognosis of all of the subtypes. - See KJ Lee 10th ed pg 500- 501.

Answer 90

E; Use the mnemonic SCALP (Skin, subCutaneous tissue, galea Aponeurosis, Loose alveolar tissue, Periosteum) to remember the order of the layers of the scalp. - See Tolhurst, "Surgical Anatomy of the Scalp"; Plastics and Reconstructive Surgery, 1991.

Answer 91

A; Statement 9 of the clinical practice guidelines for tympanostomy tubes in children states that, "Clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly, as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer." While the guidelines recommend waiting 3 months and reexamining the patient in an otherwise healthy child to see if the effusion has resolved, given that this patient is at high risk for persistent effusion because of his Down's syndrome and currently experiencing a speech delay it is reasonable to place tympanostomy tubes. Antibiotics are never recommended for serous effusions. While an adenoidectomy can decrease the rate of acute otitis media it is not generally recommended as first line management of serous effusions. - See Rosenfeld "Clinical Practice Guideline - Tympanostomy Tubes in Children—Executive Summary" 2013.

Answer 92

D; The patient has a presentation most consistent with a glomus tympanicum (glomus tumor). The classic histology for glomus tumors shows clusters of round/cuboidal cells called Zellballen (German for balls of cells). Brown sign (blanching of the mass on pneumatic otoscopy) and Aquino sign (blanching of the mass with compression of the ipsilateral carotid) would both be positive. Urine vanillylmandelic acid (VMA) and metanephrines could be elevated if the tumor was functional although this is uncommon (less than 5%). MRI demonstrates a characteristic "salt and pepper" appearance due to flow voids within the tumor. Antoni A and B patterns are seen in schwannomas and would not be consistent with the diagnosis of glomus tympanicum. - See KJ Lee 10th ed pg 357 and 681-683.

Answer 93

E; Superficial spreading melanoma is the most common subtype accounting for 75% of all cases. It generally has a good prognosis as it remains superficial for a significant amount of time and therefore is often diagnosed at a relatively early stage. Desmoplastic is rare, can be amelanotic and has high affinity for perineural spread. Acral lentiginous is most often found on the soles and palms, is more common in darker skinned individuals and is not related to sun exposure. Lentigo maligna is the least common subtype and can have a radial growth phase that lasts for decades. Nodular has no radial growth phase and instead very quickly demonstrates vertical growth leading to a late stage at diagnosis and poor prognosis. - See KJ Lee 10th ed pg 645-646.

Answer 94

B; This patient's presentation is most consistent with Cogan syndrome which is characterized by nonsyphilitic interstitial keratitis, vertigo, tinnitus, nystagmus and hearing loss. It is thought to be related to periarteritis nodosa. While tertiary syphilis can cause similar symptoms including interstitial keratitis there is not usually evidence of active inflammatory changes. Meniere's disease is often confused for Cogan syndrome but does not involve interstitial keratitis. Vogt-Koyanagi-Harada is similar to Cogan but also involves alopecia and decreased melanin. Giant cell arteritis (aka temporal arteritis) presents w/ fever, headaches, jaw claudication, vision loss and polymyalgia rheumatica. It can be diagnosed with a temporal artery biopsy. - See KJ Lee 10th ed pg 226.

Answer 95

B; The patient presents with the full triad of Gradenigo syndrome which is due to petrositis. The patient's diplopia is due to abducens nerve palsy which is caused by involvement of Dorello's canal which transmits CN VI. The deep facial pain is likely due to involvement of CN V in Meckel's cave. Huschke's foramen is a nonossified portion of the anterior external auditory canal that is present in a portion of the population. The Fissures of Santorini are vertical fissures in the cartilaginous external auditory canal through which infections can travel to the mastoid and surrounding tissue. Huguier's canal is lateral to the roof of the protympanum and transmits the chorda tympani out of the temporal bone. - See KJ Lee 10th ed pg 3.

Answer 96

E; The key information in this question is that the patient's mandibular defect is located anteriorly. While lateral mandibular defects can be closed with a variety of techniques, this is not the case anteriorly. Anterior defects have a much higher rate of plate extrusion due to the tension of the soft tissue over the reconstructed region. Therefore, covering an anterior reconstruction plate with primary closure, regional flap or soft tissue free flap leads to unacceptable morbidity. Osseous free flaps are preferred and several factors determine which osseous free flap is best. In this patient, dental reconstruction should be a consideration. While a radial forearm flap can be used to reconstruct the defect it is not thick enough to support future dental restoration and therefore is not the best choice. The fibula free flap is a good choice as it allows for dental implants in the future, has minimal donor site morbidity, can be accompanied by a large skin paddle and can provide up to 25 cm of donor bone. Other options include an iliac crest, lateral scapula border or scapula tip graft. None of these would be ideal however due to donor site morbidity, decrease length and poor shape of the harvested bone. - See Cummings 6th ed pg 1393-1394.

Answer 97

E; This patient demonstrates signs concerning for intracranial complications of chronic otitis media. This could include meningitis, lateral sinus thrombosis, epidural abscess, intraparenchymal abscess or subdural empyema. It is inappropriate to perform a lumbar puncture prior to ruling out elevated intracranial pressure (ICP) as this can lead to tonsillar herniation therefore E is not an appropriate next step. CT scans and ophthalmoscopic exams (looking for papilledema) can help rule out elevated ICP. Neurosurgery should be consulted in any patient with an intracranial complication and IV antibiotics should be started as soon as possible. - See KJ Lee 10th ed pg 325.

Answer 98

C; Age related hearing loss (aka presbycusis) can be divided into four categories (Neural, Sensory, Mechanical, Strial). Neural presbycusis is due to degeneration of the spiral ganglion and spiral lamina nerves. It's characteristic presentation is downward sloping sensorineural hearing loss with speech discrimination scores lower than what would be expected. Noise induced hearing loss is likely to present with a "noise notch" at 4 kHz. Strial presbycusis is due to breakdown of the stria vascularis and presents sensorineural hearing loss that appears flat on audiogram. Sensory presbycusis is due to atrophy of the inner hair cells and supporting cells in the organ of corti. It presents with downward sloping sensorineural hearing loss but speech discriminations that correlate with pure tone averages. Mechanical presbycusis (aka inner ear conductive hearing loss) is poorly understood and likely due to stiffening of the basilar membrane. - See Cummings 6th ed pg 231-232.

Answer 99

E; Given this patient's characteristic "peanut butter" like nasal discharge, symptoms of chronic sinusitis and fact that he is from the south, allergic fungal sinusitis (AFS) is the suspected diagnosis. In 1994 Bent and Kuhn delineated five criteria for diagnosis of AFS which include: 1. Presence of eosinophilic mucin (which contains Charcot-Leyden crystals) 2. Presence of noninvasive fungal hyphae 3. Presence of nasal polyps 4. Characteristic radiographic findings (including hyperdense central material surrounded by hypointense rim) 5. Type 1 hypersensitivity (by skin test, blood work or history) - See KJ Lee 10th ed pg 409 and Bent "Diagnosis of allergic fungal sinusitis." 1994.

Answer 100

A; The largest anterior ethmoid cell is the ethmoid bulla. It is also one of the most consistent cells and is located in the middle meatus directly anterior to the basal lamella and posterior to the uncinate process. It often extends superiorly to the skull base in which case it forms the posterior border of the frontal recess (if it does not then a suprabullar recess is formed). The most anterior ethmoid cell is the agger nasi. Haller cells are based on the orbit and extend into the superior medial maxillary sinus potentially obstructing the osteomeatal complex. An Onodi cell can extend superior to the sphenoid and involve the carotid artery and optic nerve. The posterior ethmoid cells begin directly behind the basal lamella. - See KJ Lee 10th ed pg 366-371.

Answer 101

B; Age related hearing loss (aka presbycusis) can be divided into four categories (Neural, Sensory, Mechanical, Strial). Strial presbycusis is due to breakdown of the stria vascularis and presents as sensorineural hearing loss that appears flat on audiogram. Noise induced hearing loss is likely to present with a "noise notch" at 4 kHz. Neural presbycusis is due to degeneration of the spiral ganglion and spiral lamina nerves. It's characteristic presentation is downward sloping sensorineural hearing loss with speech discrimination scores lower than what would be expected by pure tone averages. Sensory presbycusis is due to atrophy of the inner hair cells and supporting cells in the organ of corti. It presents with downward sloping sensorineural hearing loss but speech discriminations that correlate with pure tone averages. Mechanical presbycusis (aka inner ear conductive hearing loss) is poorly understood and likely due to stiffening of the basilar membrane. - See Cummings 6th ed pg 231-232

Answer 102

D; The parotid space contains the facial nerve and parotid gland. It is located lateral to the carotid space and posterior to the masseter space. It extends inferiorly to the angle of the mandible and superiorly to the mid squamous temporal bone. The carotid space is also known as the poststyloid parapharyngeal space. It contains the carotid artery, jugular vein, lymph nodes, sympathetic plexus and CNs IX-XII. The parotid space is separated from the carotid space by the posterior belly of the digastric muscle. - See Cummings 6th ed pg 124.

Answer 103

C; If you examine the 2010 AJCC cutaneous melanoma staging criteria ulceration is the only criteria that is used across all stages. All T stages are divided into "A" and "B", without or with ulceration respectively. This ultimately affects the staging of the patient and their prognosis. Location of the primary melanoma is not significantly correlated with prognosis in all stages of cutaneous melanoma. Although the Clark's level of invasion was previously used when assessing T1 lesions, this was removed in the updated 2010 guidelines. Mitotic rate is still used in T1 lesions, but is not a prognostic factor in all stages of disease. Sun exposure does not significantly affect the patient's prognosis although it is a risk factor for developing cutaneous melanoma in the first place. The other factor that significantly affects prognosis across all stages is tissue depth. Deeper invasion is associated with poorer prognosis. Along this line, subtypes of melanoma which rapidly invade vertically such as nodular melanoma have a worse prognosis. Melanoma subtypes such as lentigo maligna and superficial spreading melanoma have long axial radial growth phases and therefore an overall better prognosis. - See Cummings 6th ed pg 1166-1167.

Answer 104

E; Gardner syndrome is an autosomal dominant disease characterized by multiple osteomas of the mandible, maxilla and skull as well as fibromas of the soft tissue and epidermoid inclusion cysts. These patients also have multiple polyps of the colon that are predisposed towards developing malignancy. They most commonly present to the ENT clinic with well differentiated thyroid cancer to which they are also predisposed. Pendred syndrome presents with congenital sensorineural hearing loss and euthyroid goiter. Cowden disease (aka multiple hamartoma syndrome) is characterized by hypoplasia of the maxilla, mandible and soft palate as well as microstomia, papillomatosis of the lips/pharynx, multiple thyroid adenomas, pectus excavatum and scrotal tongue. Multiple Endocrine Neoplasia Type IIb includes medullary thyroid cancer, pheochromocytomas, and marfanoid habitus. Alport syndrome is characterized by congenital hearing loss, end stage renal disease and vision problems. - See KJ Lee 10th ed pg 231.

Answer 105

E; Bony dehiscence of the fallopian canal is quite common and makes facial nerve dysfunction due to middle ear infections more likely. Estimates of how common this dehiscence is ranges widely. KJ Lee states that 20% of the population has a dehiscence however Baxter dissected 535 temporal bones at Mass Eye and Ear in 1971 and found 294 dehiscences (55%). The take home message is that you should expect a dehiscence of the facial nerve in a large number of patients. - See KJ Lee 10th ed pg 321.

Answer 106

A; This patient's presentation is most consistent with a Zenker's diverticulum which is a dehiscence in Killian's triangle (midline, inferior constrictor muscles and cricopharyngeus). The most common presenting symptom is progressive dysphagia however other symptoms include regurgitating undigested food, weight loss, borborygmi (noisy swallowing), halitosis, aspiration, choking, globus, and hoarse voice. It is thought that overactivation of the cricopharyngeus muscle prevents distal migration of food boluses and leads to pressure on the pharyngeal wall at Killian's triangle, eventually leading to dehiscence. The cricoarytenoid muscle is actually two separate muscles, the posterior cricoarytenoid and the lateral cricoarytenoid. The posterior cricoarytenoid is the only muscle which abducts the vocal folds. While the inferior constrictor muscle does form one border of Killian's triangle, overactivation does not cause a dehiscence. The superior constrictor muscle is well above this region and is not involved in this process. While overactivation of the esophageal musculature can cause dysphagia this is typically a painful process and is less common than Zenker's. - See KJ Lee 10th ed pg 523.

Answer 107

C; This is a description of Kernig sign. Meningitis should be suspected if the patient has significant pain or restriction on extending the knee. Brudzinski's sign is when when the examiner flexes the neck of the patient which causes reflexive flexion of the legs as well. Bruns sign is vertigo and headache associated with sudden movement that is caused by tumors of the fourth ventricle. Griesinger sign is edema of the mastoid tip due to venous sinus thrombosis. - See KJ Lee 10th ed pg 254-256.

Answer 108

D; The Bethesda grading system is used to report thyroid FNA results. Bethesda V indicates suspicion for malignancy (60-75%) and therefore warrants intervention. Assuming this patient has well differentiated thyroid carcinoma they would be categorized as Stage II (T2N0M0). The most recent 2015 guidelines suggested a thyroid lobectomy for patients with low risk well differentiated cancer (unifocal disease less than 4cm w/o extrathyroidal extension) due to substantial evidence that performing a total thyroidectomy does not improve the already excellent prognosis. Given the high chance of malignancy for Bethesda category V there is no need for a repeat FNA. Observation with repeat ultrasound in 1 year is not appropriate for a nodule that has a 75% chance of being malignant. Radioactive iodine ablation cannot be performed in a patient who still has their thyroid. - See ATA Thyroid Nodule Guidelines 2015.

Answer 109

C; Eagle syndrome is thought to be caused by an elongated styloid process (or calcified stylohyoid ligament) which compresses the glossopharyngeal nerve (or perhaps the carotid, the etiology is not well understood). A normal styloid process is 2.5cm or less. However, it should be noted that ~4% of the population has a styloid process greater than 3cm, yet only a small fraction of those patients have symptoms consistent with Eagle syndrome. Treatment involves tonsillectomy and excision of the distal end of the elongated styloid process. - See Cummings 6th ed pg 1350.

Answer 110

A; By far the most common cause of stridor in the neonatal period is laryngomalacia. Despite sounding concerning to the parents, the majority of these patients will do well with observation and will not require any intervention as the stridor resolves spontaneously, usually within a year. If the patient's stridor does not improve or they demonstrate severe laryngomalacia with failure to thrive then supraglottoplasty can be considered. Diagnosis of laryngomalacia can only be made using a flexible laryngoscope which will demonstrate floppy arytenoid tissue and infolding of the epiglottis. An omega shaped epiglottis is often found but can be present in healthy patients as well. There is a significant chance of synchronous lesions in laryngomalacia patients, but the incidence is lower than 75% (estimates range from 8-58%). The laryngomalacia stridor often worsens with feeding and but can improve with crying. While this patient's stridor will likely resolve spontaneously, as the child becomes more active, oxygen demands increase and they will often have subjective worsening of the stridor initially. - See Cummings 6th ed pg 3123-3124.

Answer 111

E; The patient's exam is concerning for a maxillary antrostomy not connected to the natural os. The mucociliary clearance pathway directs mucous through the natural os however it can fall back into an unconnected antrostomy and be recirculated leading to intermittent nasal congestion and discharge. This can be addressed with revision maxillary antrostomy to connect it to the natural os. While increasing nasal saline irrigation may help clear some of the nasal discharge it will not address the underlying issue. Septoplasty and medialization of the middle turbinate with a spacer can both improve nasal airflow but would not address nasal discharge. Middle meatus culture and antibiotics would be the appropriate management if the patient had evidence of an infection but his discharge is nonpurulent and he has no other signs of acute sinus infection. - See Cummings 6th ed pg 767.

Answer 112

E; This patient presents with signs and symptoms concerning for lateral sinus thrombosis which classically has severe headaches, papilledema, septic emboli to the lungs, otorrhea and edema/tenderness over the mastoid (Griesinger sign). CT brain with contrast will often show a rim enhancement of the sinus with central hypodensity known as a "Delta sign". Another common sign is "picket fence" fevers which are fevers that tend to cluster during a particular part of the day. - See KJ Lee 10th ed pg 321-325.

Answer 113

E; HPV+ SCC most commonly affects the oropharynx and is becoming increasingly prevalent. It tends to present with small primary lesions and advanced nodal disease making them far more likely to present as asymptomatic neck masses with unknown primaries. On imaging these neck masses often demonstrate cystic nodes that can be misdiagnosed as branchial cleft cysts. HPV+ SCC does not usually present with pain or significant obstruction therefore odynophagia and dysphagia are incorrect. Dysphonia would not be expected from a lesion of the oropharynx. While HPV+ SCC can present as an asymptomatic oropharyngeal lesion this is less commonly noticed than a neck mass. - See Cummings 6th ed pg 1084.

Answer 114

C; The upper lid crease is formed by insertion of the levator aponeurosis and orbital septum into the orbicularis oculi muscle and adjacent skin. It is an important landmark that needs to be identified preoperatively as it forms the border of the resectable tissue. In women the crease is usually 10-12 mm above the lid margin, however in men it is only 7-8 mm. - See Cummings 6th ed pg 442-443.

Answer 115

E; The most commonly injured segment of the facial nerve during temporal bone trauma is the perigeniculate region. It is thought that this is due to the greater superficial petrosal nerve (GSPN) which may cause an avulsion injury to the nerve in this area during trauma. However, a significant number of patients will have a second lesion in the mastoid segment and therefore this region must be explored and decompressed as well for optimal results. - See Cummings 6th ed pg 2226.

Answer 116

A; One of the advantages of the lateral graft technique is that it can be used for any size tympanic membrane perforation. Extending healing time, increased demand on the technical proficiency of the surgeon and risk of blunting/lateralization of the graft are all risks of the lateral technique. Regardless of technique however, in experienced hands closure can be expected in ~90% of cases. - See Cummings 6th ed pg 2180-2183.

Answer 117

A; Erythroplakia is a much more concerning finding on examination of the oral cavity. On biopsy, approximately 50% of lesions will demonstrate severe dysplasia or carcinoma in situ. Leukoplakia is less concerning, however there is still a 10% chance of severe dysplasia/carcinoma and therefore biopsy is warranted. - See KJ Lee 10th ed pg 516.

Answer 118

E; None of the above tests are warranted because the patient demonstrates some facial nerve function. Surgery is only indicated for patients with immediate onset total facial nerve paralysis in patients who demonstrate >90% degeneration on ENoG within 2 weeks of injury. However, since this patient is HB V (instead of total paralysis which is HB VI) no further testing or intervention other than steroids and observation is recommended. - See Cummings 6th ed pg 2227.

Answer 119

C; Furnas technique refers to conchal setback which involves placing permanent sutures to approximate the conchal cartilage against the mastoid periosteum. Overly aggressive conchal setback can create a telephone ear deformity by pulling the middle third of the auricle more posterior compared to the upper and lower poles. Ely and Monks techniques are both historical otoplasty techniques that are no longer commonly used. Mustarde technique is used to create an antihelical fold and involves placing 3-6 sutures along the scapha. Cartilage sculpting involves scoring or excising cartilage along the area where an antihelix is desired in order to allow for the cartilage to conform to the desired shape. In both the Mustarde and cartilage sculpting techniques, overcorrection of the antihelix can result in the antihelix being the most lateral structure on the frontal view (aka hidden helix deformity) or buckling of the helical rim creating a vertical scaphal fold (aka vertical post deformity). - See Cummings 6th ed pg 468-472.

Answer 120

C; Both Dysport and Botox® are botulinum toxin A which can be used for therapeutic and cosmetic muscle paralysis. Botox® is produced by Allergan (USA) whereas Dysport is made by Galderma (UK) and although they have similar functions their dosing is different. In general 4 units of Botox® is equivalent to 10 units of Dysport. - See Cummings 6th ed pg 436.

Answer 121

C; This patient's lesion is most consistent with a benign papilloma given its stable size, asymptomatic nature and exam findings that do not demonstrate ulceration. Oral papillomas are HPV related lesions most commonly caused by HPV subtypes 6 and 11. Squamous cell carcinoma is most commonly caused by HPV subtypes 16, 18, 31 and 33. It is thought that the HPV antibodies to E6 and E7 are oncogenes which downregulate p53 and retinoblastoma protein (Rb) respectively leading to the development of neoplasia. - See Cummings 6th ed pg 3143.

Answer 122

E; The parotid gland obtains its parasympathetic innervation via the glossopharyngeal nerve. The preganglionic nerve bodies originate in the inferior salivatory nucleus, travel along the glossopharyngeal nerve, through the lesser petrosal nerve and into the otic ganglion. At this point they synapse with postganglionic fingers and travel via the auriculotemporal nerve to the parotid gland. The facial nerve does not have a role in this pathway. The lacrimal and nasal glands are innervated by the facial nerve via the greater superficial petrosal nerve. The sublingual and submandibular glands are also innervated by CN 7 via the chorda tympani and the lingual nerve. - See KJ Lee 10th ed pg 194-196.

Answer 123

B; This patient's presentation of painful blistering of the skin and oral mucosa is most consistent with either pemphigus vulgaris or bullous pemphigoid. Systemic lupus erythematosus, syphilis and wegener's are unlikely to cause such blisters. Differentiating pemphigus from pemphigoid cannot be done clinically. Pemphigus vulgaris blisters are caused by desmogleins which break connections between the epithelial cells. Bullous pemphigoid blisters are due to destruction of the basement membrane and therefore is the most likely diagnosis in this patient given the biopsy results. An easy way to remember this is that the "Bs" stick together, Bullous pemphigoid attacks the Basement membrane. - See KJ Lee 10th ed pg 549.

Answer 124

B; The malleus and incus lever mechanism is estimated to create 1.3 dB of gain however the ratio of the round window to oval window creates 26 dB of gain. In combination there is a theoretical gain of 28 dB gain however in reality inefficiencies in the system cause a final average gain of only 23 dB. - See KJ Lee 10th ed pg 148.

Answer 125

C; While 95% of lip cancers are located on the lower lip, those located on the upper lip or involving the oral commissure have a 10- 20% lower 5 year survival. Overall survival for lip carcinoma is 91% however this drops down to 30-70% with advanced stage disease. Lip carcinoma develops regional metastases later than other site of cancer and has ~ 10% chance of regional metastasis overall. Basal cell carcinoma is more common on the upper lip compared to the lower lip, however, it should be pointed out that the most common cancer of the upper lip is still squamous cell carcinoma given that fact that it represents 95% of all lip cancer. Lip carcinoma is the most common site for oral cavity cancer (oral tongue is the second most common comprising 30%). - See KJ Lee 10th ed pg 700-702.

Answer 126

A; The patient has a classic presentation for ossicular discontinuity which occurs commonly after longitudinal temporal bone fractures. In a conductive loss, Weber will localize to the affected side and Rinne will be negative (i.e. BC>AC) if the loss is large enough. Ossicular discontinuity creates a type Ad tympanogram which demonstrates increased tympanic compliance. Remember that the "d" stands for discontinuity. "As" indicates decreased tympanic compliance and is seen in otosclerosis (s for sclerosis). Type A is present in healthy ears. Type B indicates a middle ear effusion or a perforation. Type C indicates persistent negative pressure. - See KJ Lee 10th ed pg 40.

Answer 127

B; While the cricoid/subglottis is the narrowest portion of the airway in the pediatric population as the laryngeal framework grows into adulthood the glottis becomes the narrowest portion. All of the cartilages of the airway are made of hyaline cartilage (except the cuneiform and corniculate). Ossification of the laryngeal framework starts with the inferior margin of the thyroid cartilage at ~ age 20 years old. The three paired cartilages include the corniculate, cuneiform and arytenoids. The three unpaired cartilages include the epiglottis, thyroid and cricoid cartilages. The laryngeal prominence is 120 degrees in women and 90 degrees in men (creating an Adam's apple) - See KJ Lee 10th ed pg 794.

Answer 128

B; Glomus tumors are on the differential for pulsatile tinnitus and demonstrate irregular destruction of the jugular foramen (unlike schwannomas which create smooth widening of the foramen). The blood supply to glomus jugulares is the ascending pharyngeal artery. - See Cummings 6th ed pg 2757.

Answer 129

B; Intrathecal fluorescein is a useful tool to help identify the site of small CSF leaks in the operating room. The standard dose that is considered safe and effective is 10mg. This is typically given by drawing up 0.1cc of 10% fluorescein and mixing it with 10cc of the patients CSF before reinjecting it into a lumbar drain. The dose does not vary based on the patient's weight and it should not be injected continuously or multiple times if no leak is identified. Fluorescein is neurotoxic and can cause seizures if an inappropriate dose is given. More common side effects include lower extremity weakness and numbness. It should be noted that intrathecal fluorescein is not a foolproof method for identifying CSF leak and failure to identify fluorescein endoscopically does not rule out a CSF leak as there is a 26% false negative rate with this technique. - See Seth "The utility of intrathecal fluorescein in cerebrospinal fluid leak repair" 2010.

Answer 130

B; The vein of Labbe (aka the inferior anastomotic vein) provides a connection between the transverse sinus and middle cerebral vein. It is not always present and is found more commonly on the left (77% vs. 66%). Ligation of this vessel can lead to poor venous outflow of the temporal lobe causing edema and potential infarction. - See Cummings 6th ed pg 2721.

Answer 131

C; This patient's presentation is most consistent with a pleomorphic adenoma which is the most common neoplasms of the salivary glands. If the capsule of the tumor is violated in surgery and tumor contents spill into the wound bed there is a risk of seeding and patients can present with multiple small recurrences in the parotid bed. Pleomorphic adenomas do have a small but significant risk of malignant transformation. This risk is ~ 1.5% within the first 5 years of diagnosis, however tumors that are neglected and do not receive treatment for 15 years or more have a 10% chance of malignant transformation. - See Cummings 6th ed pg 1246.

Answer 132

C; This question tests your knowledge of the stages of healing for skin grafts. Initially, skin grafts obtain their nutrients via plasmatic imbibition which supports the graft for the initial ~24 hours. The next stage in healing is inosculation (24-48 hours), where the vessels from the graft and the graft bed grow together end to end. Lastly, new capillaries form and begin to establish a permanent blood supply for the graft. This last steps begins 72 hours after grafting and is completed during the first week. - See Pasha 3rd ed pg 465.

Answer 133

E; The borders of the sinus tympani are as follows: Inferior = Subiculum Superior = Ponticulus Lateral = Mastoid Segment of Facial Nerve Medial = Posterior Semicircular Canal The sinus tympani is a difficult location to visualize during surgery for cholesteatoma and is a common area for recurrence and residual disease. - See KJ Lee 10th ed pg 3.

Answer 134

B; The subarcuate artery can be found in a canal running through the bone surrounded by the superior semicircular canal. This artery is frequently used as a rough guide during labyrinthectomy by keeping this area of bleeding in the center of the surgical field. - See Cummings 6th ed pg 2666.

Answer 135

D; This patient has symptoms concerning for anaphylaxis. This occurs very rarely, some have estimated the incidence to be as low as 5 events in every 1 million injections. Risk factors for the development of anaphylaxis or increased severity of anaphylaxis include asthma (especially if poorly controlled), dosing errors, concomitant medications (especially B-blockers such as metoprolol), injections during pollen season, the first injection from a new vial, high sensitivity to the offending allergen, a history of previous systemic reactions and large local skin reactions. Use of ACE inhibitors (such as lisinopril) are not a risk factor for development of anaphylaxis during immunotherapy. - See Lieberman "The risk and management of anaphylaxis in the setting of immunotherapy" 2012.

Answer 136

B; In adults an AHI under 5 is normal, 5-15 is mild, 15-30 is moderate and 30+ is severe. However, in children an AHI between 1-4 is mild, 5-10 is moderate and 10+ is severe. Adenotonsillectomy is the first line therapy recommended for pediatric patients with sleep apnea and cures ~ 60% of patients. Daytime fatigue is not a common indicator in children and is present in only 13-20% of these patients. Behavioral changes and poor school performance are much more common. Only 25-40% of pediatric patients with OSA are obese. Males are affected much more commonly than females for reasons that are not entirely clear. - See Cummings 6th ed ch 184.

Answer 137

B; Phonation times using TEPs are pulmonary based and therefore reach near normal levels. Normal maximum phonation is ~ 20 seconds and TEP users can voice for ~ 16-17 seconds. Use of esophageal air for voicing produces very short phonation times (usually 1-2 seconds) due to limited availability of air (just 60-80 ml). Use of an electrolarynx leads to indefinite phonation time in theory. - See Cummings 6th ed pg 1734-1735.

Answer 138

B; The Keros classification is divided into three categories (there is no Keros Type IV). Each is based on the height of the lateral lamella. Keros Type I = 1-3 mm Keros Type II = 4-7 mm Keros Type III = 8-16 mm This classification is used to help assess for the risk of skull base injury and CSF leak. Patients with a high Keros classification have more exposure of the lateral lamella that is susceptible to injury and surgeons should be aware of this preoperatively in order to mitigate this risk. - See KJ Lee 10th ed pg 371.

Answer 139

C; HPV is thought to promote oncogenesis via two proteins E6 and E7. E7 degrades the retinoblastoma protein (rB) which releases transcription factor E2F and causes cell cycle proliferation. E6 degrades p53 which normally acts as a tumor suppressant. VEGF and Raf Kinase are not involved in the HPV pathway. Alterations in the Merlin protein are responsible for NF2. - See Cummings 6th ed pg 1080.

Answer 140

B; The rate of facial nerve dehiscence varies from 20-50%. 80% of the time, this dehiscence is found in the area superior to, or adjacent to, the round window. 7% of the time it is dehiscent in the anterior epitympanic space and 1% of the time it is dehiscent in the mastoid segment. Patients over the age of 19 are 3.6 times more likely to have facial nerve dehiscence than patients under the age of 18. - See Cummings 6th ed pg 2198.

Answer 141

A; The location of an odontogenic infection in relation to the mylohyoid determines which space it can spread to. Infections above the mylohyoid attachment to the mandible will spread into the sublingual space whereas infection below it will spread into the submandibular space. - See Cummings 6th ed pg 168.

Answer 142

E; Management of high output chyle leaks almost always requires surgical intervention. There is no clear definition of how much output is required to be considered, "high output" however various authors have used 500, 600 or 1000cc over a 24 hour period. Chyle leaks are more common on the left due to the presence of the thoracic duct but up to 25% will occur on the right. A valsalva can be used intraoperatively to assess for presence of a chyle leak and should be performed at the end of a neck dissection if lymphatic duct injury is suspected. Medium chain fatty acid diets, compression dressings and octreotide injections all aim to decrease the flow of chyle and help heal seal the chyle leak. These options would be more appropriate in a patient with low flow leaks. Short chain fatty acid diet is not a treatment for chyle leaks. - See Cummings 6th ed pg 1869-1870.

Answer 143

A; Many processes can involve the retropharyngeal space, however this patient is asymptomatic indicating a benign process. One of the more common "pseudotumors" in this region is a tortuous common carotid artery which can be pressed up against the retropharyngeal space giving the impression of a mass. - See Cummings 6th ed pg 133.

Answer 144

D; It is important to know both the normal and abnormal locations of the parathyroid glands in parathyroid surgery. The inferior parathyroid glands are derived from the 3rd branchial arch and descend with the thymus. Therefore, glands that are not in their typical location are most commonly found in the thyrothymic ligament or further down in the thymus itself. Abnormal locations of superior parathyroid glands include the retroesophageal and retrolaryngeal regions as well as inside the carotid sheath. Parathyroid glands can also occasionally be found in the thyroid capsule or in the thyroid gland itself, however this is extremely rare. - See KJ Lee 10th ed pg 607.

Answer 145

B; Telecanthus (widening of the intercanthal distance) is a sign of NOE fractures. This is caused by fracture of the lacrimal bone/frontal process of the maxilla or complete avulsion of the medial canthal tendon from these structures. Typically the intercanthal distance is 1/2 of the interpupillary distance and equal to the horizontal palpebral width. In most people this is ~30mm. In NOE fractures the intercanthal distance is widened making B the correct answer. Another test that can be used to assess for the process of an NOE fracture is to pull laterally on the medial canthal tendon and the palpate it. If a "guitar string" is felt the tendon is attached however if there is no resistance and no palpable tendon, suspicion for a NOE fracture is heightened. - See Cummings 6th ed pg 332.

Answer 146

C; In general cervical lymph nodes can enlarge up to 1cm and still be considered normal. Jugulodigastric nodes can range up to 1.5cm before they become concerning based on size criteria alone. The exception to this rule is the retropharyngeal nodes which are considered abnormally enlarged in adults if they are greater than 5mm. In children retropharyngeal nodes can range up to 1 cm and still be considered normal. - See Cummings 6th ed pg 141.

Answer 147

C; Benign paroxysmal positional vertigo (BPPV) can be evaluated with use of the Dix-Hallpike maneuver. Most patients have posterior semicircular canalithiasis which will demonstrate vertical upbeating and torsional nystagmus, a latency period of ~10 seconds and decrease nystagmus on repeat testing (fatigable). ~12% of BPPV is caused by lateral semicircular canalithiasis which demonstrates horizontal nystagmus (that can be geotropic or ageotropic), shorter latency period and less fatigability. The superior semicircular canal is responsible for only 2% of BPPV. Treatment for PC-BPPV consists of the Epley and Semont maneuvers. LC-BPPV can be treated with the log roll or lying on ones side with the affected ear up for several hours. - See Cummings 6th ed pg 2551-2553.

Answer 148

A; This patient presents with signs and symptoms consistent with superior semicircular canal dehiscence (SSCD) including a conductive hearing loss, autophony and Tullio's phenomenon. Given this diagnosis we would expect a normal middle ear to be found intraoperatively, acoustic reflexes to be present (which differentiates SSCD from otosclerosis), a low frequency conductive hearing loss and suprathreshold bone lines. VEMP (Vestibular-evoked myogenic potential) thresholds are typically low in these patients. - See KJ Lee 10th ed pg 248-249.

Answer 149

E; This patient's presentation is consistent with Kawasaki disease (aka mucocutaneous lymph node syndrome). Kawasaki is a multisystem vasculitis most commonly seen in children less than 5. Diagnostic criteria include a fever for 5 days or more and 4 or more of the following: Conjunctivitis Strawberry tongue/fissured lips Polymorphous exanthem (i.e. a widespread rash) Palmar erythema/desquamation around the fingernails/nonpitting edema Nonsuppurative cervical adenopathy >1.5cm Treatment involves aspirin and IVIG however an echocardiogram should also be ordered to evaluate the patient's heart as Kawasaki is the most common cause of acquired heart disease in the pediatric population. IV antibiotics are not appropriate in Kawasaki patients. Further workup with needle aspiration/biopsy/CT are not warranted given the patient meets diagnostic criteria for Kawasaki disease. - See KJ Lee 10th ed pg 822-823.

Answer 150

D; This patient's presentation is classic for otosclerosis. Pregnancy has been found to accelerate the process of otospongiosis and many patients will present with conductive hearing loss during or shortly after their first pregnancy. Otosclerosis is an autosomal dominant condition, however it has variable penetrance and expressivity. -See KJ Lee 10th ed pg 345.

Answer 151

C; Downslanting palpebral fissures and malar hypoplasia describes the classic face of a patient with Treacher Collins. Microtia and ossicular abnormalities causing conductive hearing loss are also associated with this disorder and help confirm the suspected diagnosis. Treacher collins is an autosomal dominant disorder with variable penetrance. It is associated with palate clefting in 35% of patients and some patients will have significant airway compromise requiring surgical intervention due to the abnormal development of the facial bones. Kyphosis is common in this population. This is thought to be due to normal brain volume causing increased resorption of the clivus during development causing flexion at the skull base. These patients have normal intelligence. - See Cummings 6th ed pg 2886-2887 and 2900.

Answer 152

C; The Meyer-Cotton grading system is the most frequently used method to describe subglottic stenosis. It is divided into 4 grades: Grade I = 0-50% obstruction Grade II = 51-70% Grade III = 71-99% Grade IV = 100% obstruction/No detectable lumen The McCaffrey system (answer choices D and E) can also be used for laryngotracheal stenosis and is based on subsite and length of obstruction instead of lumen obstruction. - See Cummings 6th ed pg 983.

Answer 153

D; This patient's physical exam is consistent with achondroplasia. These patients have mutations in the Fibroblast Growth Factor Receptor 3 (FGFR3) gene. They will also have midface hypoplasia but a normal sized mandible which makes the mandible appear abnormally large. Remember that as a general rule of thumb, disorders with visible physical stigmata tend to be autosomal dominant. - See Cummings 6th ed pg 2886-2887.

Answer 154

C; Multiple endocrine neoplasia (sometimes called multiple endocrine adenomatosis) has 3 variations. MEN I is made up of the three Ps: Pituitary Adenomas, Pancreatic islet cell tumors, Parathyroid hyperplasia. MEN IIA and IIB both present with medullary thyroid cancer and pheochromocytomas. MEN IIA also has parathyroid adenomas (you can remember this because it is "carried over" from MEN I). The unique feature of MEN IIB is marfanoid habitus and mucosal neuromas. - KJ Lee 10th ed pg 239.

Answer 155

E; All of the listed medications can be used as part of standard "triple therapy" for H Pylori. A proton pump inhibitor such as omeprazole is always used. Clarithromycin is preferred as well but can be replaced by metronidazole if there is evidence of clarithromycin resistance. A third antibiotic is also added which can be metronidazole or amoxicillin. Note that only 3 medications are used in any given treatment but that there are several options from which to choose to create the treatment regime. Duration of treatment is controversial but 14 days is most commonly used. - See http://emedicine. medscape.com/article/2172395-overview? pa=U9fXbjJqN0s0xTdakAgbvBksPaPbxUW5kLIi4AXD9XwMcboPY1 HB0GeYrkg902dPJyGvMX%2Fu%2BWdIXoARf%2FT0zw%3D%

Answer 156

C; There are two superior (medial and central) and three inferior orbital fat pads. Remember that the lacrimal gland fills in the space where the third upper fat pad would otherwise go. The important structure to be aware of when reducing the size of these fat pads is the inferior oblique muscle which runs between the medial and central fat pads. Damage to the inferior oblique can lead to diplopia. - See Cummings 6th ed pg 444

Answer 157

B; A FNA with cells containing amyloid (birefringence green on congo red staining) is pathognomonic for medullary thyroid carcinoma (MTC). It should be noted that the absence of amyloid does not rule out MTC. The diagnosis of MTC can also be made with a peripheral blood test which is likely to show elevated levels of carcinoembryonic antigen (CEA) and calcitonin. In fact, it is polymerization of the calcitonin that creates the amyloid deposits. A complete blood count is likely to be abnormal in a patient with lymphoma which can also present with a thyroid mass but will not show amyloid on FNA. TSH, T3 and T4 can be abnormal in MTC but often times the patient is euthyroid. Serum Amyloid A Precursor can be detected in patients with amyloidosis, but they are unlikely to have a thyroid mass with amyloid in it. - See Cummings 6th ed pg 1917

Answer 158

A; This patient has conductive hearing loss and demonstrates Schwartze sign (reddish blush over promontory) which is caused by active otospongiosis. Stapes piston prostheses are 0.6mm in diameter (the drill used to make the stapedotomy is 0.7mm). Ideally the prosthesis extends into the vestibule just 0.25mm. The most common length is 4.25 mm although this is variable from patient to patient. - See Cummings 6th ed pg 2215.

Answer 159

C; The trichion is the lowest point of the midfrontal hairline and is typically positioned between 7-10 cm above the glabella. The distances between the trichion and the glabella makes up the superior 1/3rd of the face. In patients with more advanced hair loss and/or limited donor reserves consider making the hairline higher. - See Cummings 6th ed pg 376-378.

Answer 160

D; Delayed facial nerve paralysis almost always experiences a complete recovery. Immediate onset paralysis is more likely to represent a higher degree of injury to the nerve and is less likely to recover. Otic capsule involving transverse fractures are more likely to cause facial nerve paralysis. The fact that the patient has no past medical history and does not smoke is unlikely to affect the course of his facial nerve recovery. - See Cummings 6th ed pg 2224-2225

Answer 161

C; For every 5 days a child is intubated their risk of developing subglottic stenosis increases by ~50%. 90% of subglottic stenosis in the pediatric population is caused by intubation related trauma with an incidence of 1- 8%. The subglottis is prone to trauma in children due to the delicate pseudostratified respiratory epithelium and submucosal areolar tissue which can quickly develop edema as well as the complete cricoid ring which contains the edema in the airway. Major factors that influence subglottic stenosis include length of intubation, size of the endotracheal tube and movement of the tube. - See Manica 2013.

Answer 162

C; Tullio phenomenon is vertigo caused by loud noise exposure. It is caused by abnormal movement of the endolymphatic fluid in response to pressure changes caused by loud noises. Hennebert is similar but evoked by direct pressure changes. For Tullio phenomenon to be present there must be an intact conductive mechanism including tympanic membrane, ossicular chain and footplate. Therefore, if a patient's stapes footplate is fixed (as in otosclerosis) they cannot have Tullio's phenomenon. Syphilis, superior semicircular canal dehiscence, barotrauma (that does not interrupt the conductive mechanism) and perilymphatic fistula can all present with Tullio's. - See KJ Lee 10th ed pg 259.

Answer 163

A; Normal intraocular pressures are typically less than 20mm Hg (and typically greater than 10 mm Hg). Anything over 20mm Hg is considered elevated. In the setting of retrobulbar hematoma pressure can rise significantly, compressing the ophthalmic arteries and creating ischemia. Some authors have suggested that intraocular pressures over 30mm Hg is an indications for surgical intervention. Options for interventions include lateral canthotomy/cantholysis, medial orbital wall decompression and use of diuretics such as mannitol. - See Mohammadi Jama Oto 2015.

Answer 164

E; Nasal dermoids occur sporadically and are not inherited. There is a slight male>female predominance. Nasal dermoids account for 1-3 % of dermoids however they represent ~ 10% of head and neck dermoids. Dermoids do not enlarge with crying and do not transilluminate which is important when trying to differentiate them from encephaloceles. About half of nasal dermoids will demonstrate a dimple however there is a wide spectrum of presentation. Dermoids contain ectoderm and mesoderm and therefore often contain hair, teeth, sebaceous glands and other structures. Unlike dermoids, teratomas contain all three germ layers. - See Cummings 6th ed pg 2947.

Answer 165

D; The most common cause of conductive hearing loss after temporal bone trauma is hemotympanum, however by two months post injury this should have resolved. The most common ossicular chain injury is incudostapedial dislocation (82%) and is the most likely source of this patient's persistent conductive hearing loss. - See Cummings 6th ed pg 2230.

Answer 166

D; The use of propranolol has radically changed the management of subglottic hemangiomas given how effective it is at treating these masses and preventing the need for surgical intervention. The standard dosing is 1 mg/kg/day divided into three doses (i.e. 0.33 mg/kg/dose TID). This can then be titrated up to a maximum of 2-3 mg/kg/day (still divided into TID dosing) pending decrease in size of the hemangioma. Common side effects include hypoglycemia, bradycardia, hypotension, gastric reflux and bronchospasm. Patients under the age of 8 weeks should initially be treated as inpatients, but most others can be treated in an outpatient setting. - See Cummings 6th ed pg 3127-3128.

Answer 167

C; This patient has the classic triad for Churg-Strauss, eosinophilia, asthma and vasculitis. The disease usually starts with a prodrome of asthma and rhinitis followed by gastroenteritis and/or chronic eosinophilic pneumonia (Loeffler's syndrome) and ultimately results in systemic vasculitis of small and medium vessels. Treatment is similar to that of Wegner's and involves corticosteroids and sometimes cyclophosphamide. Mutations of HLA-DRB4 is the underlying cause. C-ANCA is specific (but not sensitive) for Wegner's and will not be positive in Churg-Strauss patients. - See Cummings 6th ed pg 203-204.

Answer 168

E; Inverting papilloma (aka schneiderian papilloma) is a benign tumor of the sinonasal tract. It is present in a small portion (1-5%) of excised nasal masses and is important to identify on pathology due to its association with synchronous malignant lesions. It was previously thought that ~ 50% of inverting papillomas were associated with malignant squamous cell carcinoma however more recent data shows that it is far less. Current estimates range from 3.4-9.7%. Recurrence rates given modern endoscopic techniques is ~ 10%. A key aspect of the technique to remove inverting papilloma is to dissect in the subperiosteal plane and drill down any involved bone. The incidence is 0.6-1.5 per 100,000 people per year. The lateral nasal wall in the posterior fontanelle is the most commonly affected site, the maxillary sinus is the second most affected region. - See Cummings 6th ed pg 741-743.

Answer 169

E; The patient's mass is most consistent with a vocal fold polyp. These are often caused by vocal fold trauma (singing in a heavy metal band) and can cause persistent hoarse voice. They are most commonly located at the junction of the anterior 1/3rd and middle 1/3rd of the vocal fold. Unlike vocal fold nodules which are always bilateral, polyps are unilateral. While vocal fold nodules can often be treated with voice therapy, polyps rarely resolve with voice therapy alone and surgery is often required. - See Cummings 6th ed pg 3141.

Answer 170

D; Where exactly the facial nerve is located can become confusing but it is important to know that the nerve lies above the upper layer of the deep temporal fascia in the superficial fascia (temporal fascia). The deep temporal fascia splits to form deep and superficial layers (of the deep temporal fascia) wrapping around the temporal fat pad and temporalis muscle. For this reason, when performing a Gillies approach one must incise down to the temporalis muscle and stay under the superficial layer of the deep temporal fascia in order to avoid damage to the nerve. - See Cummings 6th ed pg 2681.

Answer 171

B; Third branchial arch anomalies are much less common than either 1st or 2nd branchial arch anomalies. They often present as recurrent thyroiditis with fistula tracts opening into the pyriform sinus (with the left side being more common). The third arch is the embryological origin for the stylopharyngeus muscle, greater horn and lower body of the hyoid bone, thymus, glossopharyngeal nerve, common and internal carotid arteries. The handle of the malleus is derived from the second arch whereas the head is from the 1st arch. The posterior belly of the digastric has its origin in the second arch (anterior belly is 1st). Tensor veli palatini is the only muscle of the soft palate that is derived from the 1st arch, all the others come from the 4th arch. The corniculate and cuneiform cartilages come from the 6th arch. - See Cummings 6th ed pg 2828.

Answer 172

B; Complete facial analysis is an important part of the workup of any nasal deformities. It is also a rich source of inservice and board questions. A common mistake is to confuse the nasofacial angle with the nasofrontal angle. The nasofrontal angle is between the nasal dorsum and a line tangent to the glabella and this is ideally 115-135 degrees. However, the nasofacial angle is between the place of the face (usually glabella to pogonion) and the nasal dorsum. The ideal nasofacial angle is 36 degrees (although it can vary from 30-40 degrees). They are easy to confuse on an exam so make sure to know the difference. All the other facial analysis measurements are correct and are also common topics on board exams. - See KJ Lee 10th ed pg 757-758.

Answer 173

B; The facial nerve is most susceptible to injury from blunt trauma at the geniculate ganglion (1st genu). This may be due to several factors including thin bone in this area which is susceptible to fracturing as well as tethering of the genu by the greater superficial petrosal nerve (GSPN) which anchors the nerve and may lead to shearing or stretch injuries when trauma occurs. - See Cummings 6th ed pg 1985.

Answer 174

E; In a patient with a cholesteatoma limited to the attic in an only hearing ear the best approach is a modified radical mastoidectomy, also known as a Bondy procedure. In this surgical approach the superior and posterior canal next to the cholesteatoma is removed allowing it to be exteriorized, however the middle ear is not manipulated in any way. This approach is only applicable to small cholesteatomas limited to the epitympanum but is ideal in patients where hearing preservation is needed. A simple mastoidectomy (removal of mastoid cortex and limited air cells) is not appropriate for cholesteatoma surgery as it does not provide access to the diseased region. The fact that the patient lives far away and may have poor follow up does help determine the need for canal wall up vs canal wall down but both involve entering the middle ear which is not ideal in this patient's only hearing ear. Radical mastoidectomy involves removing the ossicles and tympanic membrane as well as plugging the eustachian tube leading to significant hearing loss and is not appropriate in this patient's remaining hearing ear if it can be avoided. - See Cummings 6th ed pg 2190.

Answer 175

A; While aminoglycoside medications can cause hearing loss in any patient, there are some individuals with genetic point mutations (1555 A-G) in the mitochondrial 12S ribosomal RNA which makes them significantly more sensitive to their effects. As this is a defect of the mitochondrial RNA its mode of inheritance is mitochondrial and we would expect all of these patients children to have this same mutation. - See KJ Lee 10th ed pg 943.

Answer 176

B; There are many ways one can find the sphenoid ostium (besides using imaging guidance). One classic description of its location is its angle and distance from the nasal spine. This has been described as ~7 cm (6.2-8.0cm) at a ~30 degree angle (can range up to 34 degrees). The sphenoid ostium can also be located 1.5 cm superior to the floor of the choana or 1 cm superior to the posteroinferior aspect of the superior turbinate. It is almost always located medial to the superior turbinate. There is not a described distance of the sphenoid os relative to the skull base (likely because in most cases the sphenoid is located prior to defining the skull base). - See Cummings 6th ed pg 758.

Answer 177

C; This patient's presentation is concerning for an atypical mycobacterial infection. A patient with fevers/weight loss and unilateral, enlarging, nontender neck mass with overlying purple/erythematous discoloration should raise suspicion of this diagnosis. A skin test can usually diagnose mycobacterial infections. As lesions grow they can progress to suppuration. There is controversy as to the ideal management however incision and drainage is not recommended as it often creates a chronically draining wound which prolongs the patient's clinical course. Antibiotic therapy with two antibiotics (including clarithromycin) is often performed and with good results. Surgical excision and curettage is often the treatment of choice and can significantly shorten the patient's clinical course. Observation will often lead to a longer clinical course however it is a reasonable option in a stable patient who is otherwise resistant to therapy. - See KJ Lee 10th ed pg 822.

Answer 178

C; Juvenile recurrent respiratory papillomatosis (RRP) is the most common benign neoplasm of the larynx in children and the second most common cause of hoarseness. 30% of patients will display extralaryngeal involvement and providers should consider the possibility of sexual abuse in children who present after the age of 7 (most patients present between 2-4 years old). RRP is caused by HPV subtypes 6 and 11 most commonly. HPV 42/43 are low risk HPV subtypes but are not commonly associated with RRP. Subtypes 16/18, 31/33 and 45/52 are known high risk subtypes for malignancy but do not cause RRP. - See KJ Lee 10th ed pg 798-799.

Answer 179

A; Hearing loss after head trauma and a CT scan demonstrating a vestibular aqueduct larger than 1.5mm at its midpoint (the width of the horizontal canal) is consistent with enlarged vestibular aqueduct. SLC26A4 is the gene responsible for this mutation. SLC26A4 mutations are also the cause of Pendred syndrome (hearing loss and euthyroid goiter) and these two conditions are often seen together. Both DFNB1 and GJB-2 are associated with connexin related nonsyndromic autosomal recessive hearing loss. DFNA1 was the first gene associated with hearing loss and is relatively rare. COL2A1 causes the most common variant of Stickler syndrome (hearing loss, ocular changes and joint disease). - See Cummings 6th ed pg 2565.

Answer 180

B; The saccharine test is a low tech way to assess mucociliary clearance. Mucociliary flow moves at ~ 1 cm/minute. In normal patients transport of the sweet tasting saccharin from the head of the inferior turbinate to the oropharynx takes ~ 10 minutes, however the test is still considered within normal limits up to 30 minutes. Blue dye can be added to the saccharine and used to confirm the rate of mucociliary transport with nasal endoscopy. - See Cummings 6th ed pg 645

Answer 181

D; The Lund-MacKay scoring system is the most widely used method to objectively evaluate radiographic studies of sinus disease. 6 sites are evaluated on each side including: Anterior Ethmoids Posterior Ethmoids Maxillary Sinus Sphenoid Sinus Frontal Sinus Ostiomeatal Complex Each site is given a score of 0, 1 or 2 for normal, partial opacification and complete opacification respectively. Therefore in a patient with pansinusitis and complete opacification of all her sinuses the maximum score is 24. -See Cummings 6th ed pg 666

Answer 182

D; T3 salivary gland neoplasms are stage III or higher. N1 lesions are stage III but N2 bumps this up to Stage IVA. N3 lesions are stage IVB and M1 disease is IVC. T3 lesions are larger than 4cm and/or demonstrate extracapsular spread macroscopically (microscopic extracapsular spread on final path does not count). N2b disease is multiple ipsilateral lymph nodes none greater than 6cm. Bilateral lymphadenopathy is categorized as N2c disease. Tubular, cribriform or solid growth patterns are descriptions of adenoid cystic carcinoma, not mucoepidermoid carcinoma. Mucoepidermoid carcinoma is classified as low, intermediate or high grade based on multiple criteria (cystic components, tumor front invasion, nuclear atypia, lymphatic/vascular invasion, neural invasion, necrosis, 4+ mitosis by high powered field and bony invasion). - See Cummings 6th ed pg 1261-1264.

Answer 183

D; The vidian nerve is formed by the greater petrosal nerve and deep petrosal nerve. It synapses at the sphenopalatine ganglion and then sends parasympathetic fibers to the nose and lacrimal glands to stimulate secretions. Vidian neurectomy can be offered for intractable rhinorrhea, however damage to the nerve can also cause decreased lacrimation due to its innervation of the lacrimal gland. This can occur in extensive sinus surgery, especially if bone is drilled down as is often the case in treatment of inverting papilloma. Damage to the lamina papyracea can place the contents of the orbit at risk but would not cause decreased lacrimation. Damage to the lacrimal duct is likely to cause epiphora. Given the lateral position of the lacrimal sac it would be difficult to injure it during sinus surgery. The maxillary nerve (V2) provides sensation but is not involved in lacrimation. - See Cummings 6th ed pg 700.

Answer 184

B; It is important to recognize that Schneiderian papillomas come in 3 subtypes, exophytic, oncocytic and inverting. We are most familiar with inverting papillomas due to their high rate of malignant transformation (~15%) however ~ 50% of sinonasal papillomas consist of the exophytic subtype which is not known to undergo malignant transformation (although there are a few case reports). The oncocytic subtype is rare accounting for only 3-5% of these tumors. Although inverting papilloma most commonly arises from the maxillary sinus and lateral nasal wall, exophytic papillomas are almost always based on the septum. Treatment for all of these papillomas is surgical unless otherwise contraindicated. Inverting papillomas have a recurrence rate of up to 60% however exophytic subtypes are less likely to recur (~20%). - See Vorasubin "Schneiderian papillomas: Comparative review of exophytic, oncocytic, and inverted types" 2013.

Answer 185

A; Arytenoid adduction involves placing suture between the muscular process of the arytenoid through the paraglottic space and into the inferior thyroid ala. This internally rotates the arytenoid causing adduction of the cord. This motion mimics the action of the lateral cricoarytenoid. Done in conjunction with type 1 thyroplasty it is felt to improve voice outcomes but can also increase the rate of airway obstruction. Arytenoid adduction (unlike type 1 thyroplasty or injection medialization) can address differences in the level of the folds as its action moves the vocal fold caudally. Revision type 1 thyroplasty is a reasonable option for this patient and repositioning of the existing implant or replacement with a larger implant will often improve vocal quality. <3% of patients will suffer a significant complication after type 1 thyroplasty, however 10-15% of patients will have incomplete glottic closure. Injection laryngoplasty can also be performed in patients such as this with counseling that the effect is temporary. - See Cummings 6th ed pg 945-948

Answer 186

B; The superior extent of the uncinate process can attach to the lamina papyracea, skull base or middle turbinate. This attachment determines whether the frontal sinus drains laterally (into the infundibulum) or medially (into the middle meatus). Attachment to the lamina papyracea is the most common anatomic formation and leads to frontal sinus drainage medial to the uncinate into the middle meatus. Both attachment to the skull base or middle turbinate cause frontal sinus drainage to be diverted laterally into the infundibulum. This is an important relationship when attempting to locate the frontal sinus ostium. The frontal recess boundaries are the agger nasi anteriorly, ethmoid bulla posteriorly, lamina papyracea laterally and middle turbinate medially. - See Cummings 6th ed pg 752-754.

Answer 187

C; The superior and lateral semicircular canals end in ampullae that are adjacent to each other in the anterior vestibule. The ampullae of the posterior canal is located on the opposite end of the vestibule. It should be noted that the superior and posterior canal share a common crus where the nonampullated ends enter the vestibule. - See Cummings 6th ed pg 2010.

Answer 188

A; By definition adult chronic sinusitis must present with at least 2 out of four of the following: Anosmia/hyposmia Nasal congestion Purulent nasal discharge Facial pressure/pain In addition, these symptoms must be present for at least 12 weeks and the patient must have endoscopic or radiographic evidence of sinusitis. In the pediatric population anosmia/hyposmia is not a common presenting symptom and is difficult to evaluate. Instead, post nasal drip and cough are much more common and should be considered symptoms consistent with a diagnosis of chronic sinusitis. -See KJ Lee 10th ed pg 409 and 785.

Answer 189

D; For patients age 0-5 the narrowest portion of their airway is the subglottis (which corresponds to the cricoid cartilage). In older children and adults the cricoid expands and the narrowest portion of the airway becomes the glottis itself. This is thought to be part of the reason neonatal patients are at elevated risk of developing subglottic stenosis after intubation. - See KJ Lee 10th ed pg 794.

Answer 190

B; The patient's symptoms are consistent with allergic rhinitis however these symptoms do not vary significantly amongst different allergens. However, the seasonal nature and timing of his symptoms are a clue as to a possible causative allergen. Allergies to tree pollens present most commonly in the winter and spring (Feb - May) and therefore is the most likely source of this patient's allergic symptoms. Grasses (Timothy, Johnson, Bermuda) cause allergies in the late spring and summer. Weeds (Ragweed, Sage, Lamb's quarter) cause allergies in late summer and fall. Dust mites and cat dander are perennial allergies and would be less common in a patient with seasonal variance. - See KJ Lee 10th ed pg 462-463.

Answer 191

A; Lee Silverman Voice Treatment (LSVT) was developed in the 1980s with the goal of improving speech in patients with Parkinson's disease but patients with severe depression and dementia have found success with it as well. Treatment is intense (four times per week for a month) and centers around increasing phonatory effort. LSVT is the vocal training program of choice for patients with Parkinson's disease. Although this patient should receive treatment (often with levodopa) for her Parkinson's disease, changing this dose is unlikely to significantly affect vocal quality. Injection vocal fold augmentation or Type 1 Thyroplasty can be performed for vocal fold bowing but would not be first line in this patient. Pallidotomy (destroying the globus pallidus) is a neurosurgical procedure sometimes used for the treatment of Parkinson's but it has not been shown to be effective in improving these patient's voice. Speech therapy would likely not be successful in managing a voice disorder. - See Ramig "Parkinson's Disease: Speech and Voice Disorders and Their Treatment with the Lee Silverman Voice Treatment" 2004.

Answer 192

B; Osteoradionecrosis is a feared side effect of radiation therapy and most commonly presents as exposed bone in the oral cavity with or without pain. ORN has been shown to be most common with hyperfractionated radiation therapy (23%) compared to traditional radiation (9-10%) especially if the doses are timed close together. The mandible is the most commonly affected bone, likely due to its unilateral blood supply and fact that the mandible is more commonly directly in the field of radiation. While ORN occurs in 9-10% of patients receiving traditional radiation therapy, only 2% have severe ORN. While patients should receive dental care prior to radiation including removal/repair of damaged teeth, healthy teeth do not need to be removed. Hyperbaric oxygen is often used to treat ORN but to date the data is mixed as to whether it is effective. - See Cummings 6th ed pg 1108. - See also http://www.newyorker. com/magazine/2008/05/12/a-man-of-taste

Answer 193

C; A lateral neck mass anterior to SCM in the mid neck which appears to arise due to an infection and is cystic in nature is most consistent with a second branchial arch cleft cyst. Second arch cyst/fistulae are the most common. They course from anterior to the SCM then penetrate platysma and travel superiorly between the internal/external carotids, over CN IX and XII and below the styloid ligament to end in the palatine tonsillar fossa. Third branchial cleft fistulas travel from the medial edge of SCM, lateral to the common carotid but medial/posterior to the internal carotid, over CN XII and under CN IX, through the thyrohyoid membrane and into the piriform sinus. First branchial cleft anomalies present as preauricular cysts/sinuses or duplications of the external auditory canal and can be divided into Type 1 (duplication of ectodermal EAC) or Type II (duplication of ectoderm and mesoderm). Fourth branchial cleft abnormalities are exceedingly rare. - See Cummings 6th ed pg 2828.

Answer 194

C; This patient has a presentation consistent with Stickler syndrome. These patients develop early onset myopia, retinal detachment, cataracts and blindness. They also have significant micrognathia which can lead to clefting and eustachian tube dysfunction. Most patients will have some degree of sensorineural hearing loss as well. The responsible gene is COL2A1 and is inherited in an autosomal dominant fashion. TCOF1 causes Treacher Collins syndrome. NF2 is the gene which is responsible for the protein merlin which is abnormal in patients with neurofibromatosis type 2. EYA1 defects cause Branchio-oto-renal syndrome. Both type 1 and type 3 Waardenburg syndrome are caused by PAX3 mutations. - See KJ Lee 10th ed pg 120-122.

Answer 195

D; This patient has a presentation consistent with Schwannomatosis (sometimes referred to as NF-3). Schwannomatosis is a relatively new diagnosis whose diagnostic criteria were first set forth in 2005 and were updated in 2011. The clinical diagnosis can be made two ways: 1. "Two or more non-intradermal schwannomas, one with pathological confirmation including no bilateral vestibular schwannoma by high-quality MRI." 2. "One pathologically confirmed schwannoma or intracranial meningioma and affected first-degree relative" The diagnosis can also be considered in patients with more than one likely schwannoma but without tissue diagnosis if the patient has concurrent chronic pain associated with the tumor. It is thought that schwannomatosis arises due to genetic mutations in the SMARCB1 and NF2 genes and requires four separate mutations for the schwannoma to develop. NF1 is associated with Von Recklinghausen Syndrome (neurofibromatosis type 1). GJB2 is the gene responsible for connexin deficiencies leading to congenital hearing loss. Merlin is the protein made from the NF2 gene which is responsible for neurofibromatosis type 2. SLC26A4 is mutated in Pendred syndrome and patients with enlarged vestibular aqueducts. - See Plotkin "Updates From the 2011 International Schwannomatosis Workshop: From Genetics to Diagnostic Criteria" 2011.

Answer 196

A; In the Ricketts method of facial analysis a line is drawn between the nasal tip and the pogonion. On the ideal face the upper lip should be 4mm behind this line and the lower lip should be 2mm behind this line. Burstone analysis = Line is drawn between subnasale and pogonion, upper lip is 3.5mm anterior to this line. Lower lip is 2.2 mm anterior to this line. Steiner = If a line is drawn between the inflection point on the columella and the pogonion, the upper and lower lips should just touch this line. Goodes and Crumley methods are for evaluating nasal projection. Goodes states that tip projection should be 55-60% of nasal length. Crumley states that tip projection to nasal height to nasal length should be 3:4:5. - See Cummings 6th ed pg 454.

Answer 197

D; The patient has symptoms consistent with hemicrania continua which is a primary headache disorder. Diagnostic criteria include: Headache for more than 3 months fulfilling the other 3 criteria: 1. All of the following characteristics: Unilateral pain without side-shift Daily and continuous, without pain-free periods Moderate intensity, but with exacerbations of severe pain 2. At least one of the following autonomic features occurs during exacerbations and ipsilateral to the side of pain: Conjunctival injection and/or lacrimation Nasal congestion and/or rhinorrhea Ptosis and/or miosis 3. Complete response to therapeutic doses of indomethacin, although cases of hemicrania continua that do not resolve with indomethacin treatment have been documented. It is important to recognize hemicrania continua and paroxysmal hemicrania (similar symptoms but repeated attacks for 2-30 minutes) because it is easily treatable with indomethacin. - See Cummings 6th ed pg 250.

Answer 198

B; While chronic serous otitis media can be caused by many organisms, Pseudomonas and Staph aureus are the most common causes. Acute otitis media is most commonly caused by Streptococcus pneumoniae (in addition to Haemophilus influenzae and Moraxella catarrhalis; Streptococcus pyogenes). - See Cummings 6th ed pg 2401 and 3021.

Answer 199

A; In a newborn who passes a newborn hearing screening (often performed using otoacoustic emissions (OAE)) but has absent ABRs the most common diagnosis is auditory neuropathy. This is a rare condition which presents with poorer word recognition than would be expected based on pure tone averages. OAEs are often present as this is a disorder of the auditory nerve and not the hair cells. It can be unilateral or bilateral. A significant number (64%) of these patients will demonstrate an abnormal finding on MRI and therefore this is the next best step in the management of this patient. CT scans can be ordered as well but are less likely to detect an abnormality. Repeating an ABR would not be recommended as it is unlikely to be a false positive and would only delay the patient's care. A full audiogram is a reasonable next step, however it would be unlikely to provide you more information than you already have with the ABRs and OAEs at this time. Reassuring the parents without further workup is not a reasonable alternative. - See Roche "Imaging characteristics of children with auditory neuropathy spectrum disorder." 2010

Answer 200

D; Third branchial cleft fistulas travel from the medial edge of SCM, lateral to the common carotid but medial/posterior to the internal carotid, over CN XII and under CN IX, through the thyrohyoid membrane and into the piriform sinus. They are the only branchial cleft tract that passes under the glossopharyngeal nerve. Second arch cyst/fistulae are the most common. They course from anterior to the SCM then penetrate platysma and travel superiorly between the internal/external carotids, over CN IX and XII and below the styloid ligament to end in the palatine tonsil. First branchial cleft anomalies present as preauricular cysts/sinuses or duplications of the external auditory canal and can be divided into Type 1 (duplication of ectodermal EAC) or Type II (duplication of ectoderm and mesoderm). Fourth branchial cleft abnormalities are exceedingly rare. -See Cummings 6th ed pg 2828.

Answer 201

D; The most common classification scheme for NOE fractures was introduced by Markowitz and Manson in 1991. It revolves around the connection between the medial canthal ligament and the NOE complex. Class I = Medial canthus is attached to a large piece of the NOE complex. Class II = NOE complex is comminuted but the medial canthus is attached to a small piece of bone. Class III = The medial canthal tendon is avulsed entirely from the bone. The Chandler classifications refer to orbital complications from sinusitis. Chandler group I refers to preseptal cellulitis and group II refers to postseptal/orbital cellulitis. - See Cummings 6th ed pg 334.

Answer 202

A; Forced duction testing involves firmly grasping the sclera and pulling the eye superior, inferior, medial and lateral. The eye should move freely however if there is entrapment significant resistance will be encountered. Occasionally, the entrapment can resolve while performing this test. It is the best way to confirm entrapment however it is uncomfortable for the patient so topical anesthetic eye drops are required. Measuring intraocular pressure can provide information regarding injuries to the globe but do not help confirm the presence of entrapment. An MRI is not a practical test to confirm entrapment and would not be expected to provide significantly more information than a CT scan. The Snellen vision test measures visual acuity but would not reflect the function of an extraocular muscle. An "H" test would detect entrapment of the inferior rectus as the patient would demonstrate diplopia on upward gaze, however this diplopia could be due to other sources as well (hematoma, edema, nerve damage, severed extraocular muscle) and is not specific to entrapment. - See Cummings 6th ed pg 505.

Answer 203

C; This patient has persistent otitis externa after multiple rounds of antibiotic otic drops and an exam consistent with fungal elements in the ear canal. All of the answer choices except ofloxacin can treat fungal otitis externa but this patient has a tympanostomy tube and should only be given topical medications that are safe to enter the middle ear. Acetic acid has been found to be ototoxic. Vosol HC is made of acetic acid with hydrocortisone. Clotrimazole has been shown to be safe in the middle ear of guinea pigs. - Tom "Ototoxicity of common topical antimycotic preparations." 2000

Answer 204

C; While early administration of epinephrine is the most crucial aspect in management of anaphylaxis the standard dose for adults is 0.3 mg, not 0.6. This is the dose in a standard EpiPen. The pediatric dose is 0.15mg. Additional treatment of anaphylaxis include, continuous monitoring of vital signs and airway, intubation if necessary, laying the patient down, providing O2, placing a tourniquet proximal to the injection site, obtaining IV access, providing benadryl 50 mg IV, providing dexamethasone 8mg IV and transferring to the ED/ICU. - See KJ Lee 10th ed pg 482.

Answer 205

D; Acoustic rhinometry is an objective measure of the nasal airway. It measures the cross sectional area of the nasal cavity by evaluating changes in reflected sound waves after playing a "click" in the nose. It is essentially nasal sonar. It is mostly used in research and does not have a strong clinical role. It has been found to be useful in identifying the presence of nasal obstruction but not its severity. Transnasal pressure and nasal resistance are both evaluated by rhinomanometry which measures pressure changes at the front and the back of the nose. Peak nasal airflow is a measure of the maximum flow through the nasal cavity but this is not measured by acoustic rhinometry. - See Cummings 6th ed pg 648-653.

Answer 206

E; The nasoseptal flap, commonly used to repair CSF leaks, is a pedicle flap that is able to cover most defects of the anterior skull base. Its vascular supply is the posterior septal artery (branch of sphenopalatine artery) which travels from lateral to medial across the anterior wall of the sphenoid. Removing this wall in an inferior direction to expose the floor of the sphenoid risk damage to the vascular supply of this flap. Removing the anterior sphenoid wall in a lateral direction is dissection in parallel to the artery and less likely compromise the flap. A septectomy is commonly performed for improved access and is not expected to interrupt this blood supply nor is excision of any part of the middle turbinate. - See Cummings 6th ed pg 1198.

Answer 207

E; There are several ultrasound characteristics of high risk thyroid lesions. Use the mnemonic SHITM&M. Solid Halo sign absent Iso/hypoechoic Tall>Wide (on axial view) Margins irregular Microcalcifications Vascularity can also be used to assess thyroid nodules for malignancy, but the data is less robust and it is not used commonly. Peripheral or absent vascularity is felt to be a sign that the nodule is benign, whereas intranodular vascularity may be a sign of neoplasm. - See 2015 ATA Thyroid Guidelines.

Answer 208

E; Many thyroid nodules are found incidentally on a PET scan. Focal uptake in the thyroid gland is found on 1-2% of all PET scans and warranties US evaluation of the gland as part of the workup. Approximately 1 in 3 PET positive thyroid nodules will harbor neoplasm and therefore fine needle aspiration is warranted in all PET positive thyroid nodules greater than 1 cm regardless of the nodules other characteristics. - See 2015 ATA Thyroid Guidelines.

Answer 209

C; The Bethesda system is used to report the results of thyroid fine needle aspirations and categorizes FNA results into 6 categories which have corresponding risks of malignancy. 1. Nondiagnostic = 1- 4% 2. Benign = 0-3% 3. Atypia of undetermined significant/Follicular lesion of undetermined significance = 5-15% 4. Follicular neoplasm = 15-30% 5. Suspicious for malignancy = 60-75% 6. Malignant = 97- 99% - See Cibas "The Bethesda System for Reporting Thyroid Cytopathology" 2009.

Answer 210

D; Patients presenting with a workup consistent with primary hyperparathyroidism (elevated serum calcium and PTH, normal Vitamin D levels, decreased/low-normal phosphate) and symptoms of hyperparathyroidism (stones, groans, and psychic overtone) are clear candidates for surgery. However, in the asymptomatic patient (which is more common) the indications are less clear. In 2002 the NIH provided guidelines for indications for parathyroidectomy in these patients. They include: 1. Serum calcium is greater than 1 mg/dL above the upper limit of normal. 2.Creatinine clearance is reduced more than 30% for age in the absence of another cause. 3. Measurement of 24-hour urinary calcium is greater than 400 mg/dL. 4. Patients are younger than 50 years of age. 5. Bone mineral density measurement at the lumbar spine, hip, or distal radius is reduced more than 2.5 standard deviations (by T-score). 6.Patients request surgery, or patients are unsuitable for long-term surveillance. Given this patient is less than 50 surgery is indicated. His urine calcium, creatinine clearance, serum calcium and bone density do not meet criteria. PTH is used to diagnose hyperparathyroidism but is not used to determine whether or not a patient is a candidate for surgical intervention. -See Cummings 6th ed pg 1943.

Answer 211

Donaldson Line The Donaldson line extends inferiorly from the lateral semicircular canal and bisects the posterior semicircular canal. It is used in ear surgery as a guide to find the endolymphatic sac. The endolymphatic sac is always inferior to this line. The other borders of the endolymphatic san include the sigmoid sinus posteriorly, the jugular bulb anteroinferiorly and the mastoid segment of the facial nerve laterally. - See Cummings 6th ed pg 2586.

Answer 212

Sacrifice of the Chorda Tympani The facial recess is the area defined by the facial nerve, incus butress and chorda tympani. This allows access to the middle ear. When icreased exposure is required the chorda tympani can be sacrificed to enlarge the opening and this is referred to as an "extended" facial recess. - See Cummings 6th ed pg 2725.

Answer 213

Lateral = Lamina Papyracea Medial = Midde Turbinate Anterior = Posterior Wall of Agger Nasi Posterior = Anterior Wall of Ethmoid Bulla - See KJ Lee 10th ed pg 269

Answer 214

Sphenopalatine Foramen Juvenile angiofibromas are benign, highly vascular tumors which affect teenage males. They commonly present with epistaxis and nasal obstruction and should not be biopsied in clinic due to risk fo significant hemmorhage. Diagnosis whould be made with imaging and the history. Treatment involves rpeoperative embolization and excision (usually endoscopic). - See KJ Lee 10th ed pg 782-783

Answer 215

1. Tonsillar Pillars 2. Circumvallate Papillae 3. Junction of Hard and Soft Palate The oral cavity extends from the cutaneous vermilion junction of the lips anteriorly to the above structure posteriorly. There are 7 subsite of the oral cavity which include the lips, oral tongue, floor of mouth, buccal mucosa, alveolar ridge, retromolar trigone and hard palate. - See KJ Lee 10th ed 696.

Answer 216

1. Omega shaped epiglottis 2. Epiglottis falls backwars on inspiration 3. Collapse of the arytenoids Laryngomalacia is the most common cause of stridor in newborns and aften presents with intermittent inspiratory stridor that slowly resolves over the first few months of life. It is important to note that an omega shaped epiglottis can also be found in healthy infants and is not pathognomonic for laryngomalacia. Up to 50% of these patients will have a synchronous airway lesion so bronchoscopy may be indicated. Acid reflux is also more common in this group and treatment with proton pump inhibitors may improve symptoms. Most patients can be observed but for patients with aspiration, feeding diffculties and/or failure to thrive supraglottoplasty is the treatment of choice. - See Cummings 6th ed 2132-3124

Answer 217

1. Muller's Muscle = Sympathetic Chain 2. Oculomotor Nerve (CN III) Muller's muscle attaches from the undersurface of the levator aponeurosis to the superior tarsal plate and produces 2-3 mm of eupper eyelid lift. The levator superioris originates from the lesser wing of the sphenoid, extends anteriorly to Whitnall's ligament where it makes a 90 degree turn and inserts on the superior tarsal plate. It is responsible for the majority of upper eyelid retraction. - See Cummings 6th ed pg 444.

Answer 218

1 cm/min This knowledge is useful when performing a saccarine test for ciliary dysfunction. A small amount of sweet tasting saccarine placed on the inferior turbinate should take ~10 minutes to reach the oropharynx (although up to 30 minutes is still considered normal). - See Cummings 6th ed pg 645.

Answer 219

Internal Carotid --> Opthalmic --> Anterior (and posterior) ethmoid artery This is important to know with regards to epistaxis management. Embolization of the anterior ethmoid artery is contraindicated due to the risk of retrograde flow potentially occluding the opthalmic artery and resulting in blindness. Additionally, performing a sphenopalatine ligation will not control epistaxis if it's origin is the ethmoidal arteries so consider ligation of these vessels via a transorbital approach at the same time. - See https://en. wikipedia.org/wiki/Anterior_ethmoidal_artery

Answer 220

Q = Pi x r^4 x (delta P) / 8 x n x l Q = Flow r = radius of the tube delta P = difference in pressure between the begining and the end of the tube n = dynamic viscosity l = tube length This equation is important specifically for airway flow and blood flow. The key aspect that is frequently tested on the inservice and boards is the fact that even a small increase in the radius of the tube increases flow significantly given that its impact is r ^ 4. - See Cummings 6th ed pg 1124.

Answer 221

1.Upper Transverse Midface Buttress 2.Lower Transverse Midface Buttress 3. Lateral Vertical Midface Buttress 4. Medial Maxillary Butress There are two vertical and two horizontal butresses: -Upper Transverse Midface Buttress = Extends from the squamosal portion of the temporal bone to the nasofrontal junction across the zygomatic arch and inferior orbital rim. It extends posteriorly into the orbital floor. -Lower Transverse Maxillary Buttress = Extends along the maxilla above the alveolar ridge with posterior extension into the hard palate. -Lateral Vertical Midface Buttresses = Vertical columns of bone from the posterior maxillary molars across the zygomaticomaxillary suture and body of zygoma extending superiorly along the lateral orbital rim and across the zygomaticofrontal suture. It extends posteriorly into the lateral orbital wall and lateral maxillary sinus. -Medial Maxillary Butresses = Extends from the anterior nasal spine along the rim of the piriform aperature, up to the frontal process of the maxilla and across the nasofrontal junction to the frontal bone. It projects posteriorly to the medial orbital wall. - See Cummings 6th ed pg 339-341.

Answer 222

6mm While bilateral choanal atresia often presents early with respiratory distress and difficulty feeding which improves withe crying, unilateral atresia or stenosis can often present later in life with rhinorrhea, recurrent sinonasal infections, mouth breathing, eustachian tube dysfunction, and failure to thrive. While atresia can be diagnosed with failure to pass a catheter, stenosis is better delineated on a CT scan. - See Cummings 6th ed pg 2953.

Answer 223

Passavant's Ridge This ridge can be seen on the posterior pharyngeal wall just inferior and posterior to the opening of the eustachian tubes. It forms the inferior border of the adenoids. It can assist in anterior-posterior closure of the palate. Damage to this ridge may result in velopharyngeal insufficiency (VPI) and patients with VPI may benefit from procedures to enlarge this ridge. - See KJ Lee 10th ed pg 510.

Answer 224

Electrocardiogram / Propranolol Sensorineural hearing loss and syncopal episodes should raise concerns for Jervell Lange-Nielsen Syndrome. This diagnosis can be confirmed with an EKG which will reveal large T waves and prolongation of the QT interval. Because this is potentially fatal, providers should have a low threshold for ordering EKGs in cases of congenital hearing loss. The patients cardiac condition should be treated with propranolol. - See KJ Lee 10th ed pg 123.

Answer 225

5% / 95% Neurofibromatosis type 1 is characterized by cafe-au-lait spots, cutaneous neurofibromas, plexiform neuromas, lisch nodules of iris and optic gliomas. It occurs in ~1:3000 people and 5% of patients develop acoustic neuromas (usually unilateral). Neurofibromatosis type 2 is much less common and occurs due to deletions of the NF2 gene on chromosome 22q12. 95% of patients with NF2 develop bilateral acoustic neuromas. - See KJ Lee 10th ed pg 120-121.

Answer 226

Non-Hodgkin Lymphoma While Hodgkins lymphoma has a 5 year survival rate around 90-95%, non-hodgkin lymphoma is much lower at ~67%. Hodgkins lymphoma is more common in adults and histology demonstrates the classic Reed-Sternberg cells. Non- Hodgkin lymphoma is seen most commonly in children age 2 to 12 and is more ommon in males ompared to females. - See KJ Lee 10th ed pg 820-821.

Answer 227

Advantages include all of the following: -Decreased dead space - Improve pulmonary toilet -Increased patient comfort and decreased need for sedation - Easier weaning from a ventilator -Decreased long term airway complications such as subglottic stenosis It is generally recommended that tracheostomy be performed if more than 21 days of intubation are anticipated and that intubation is preferred if less than 10 days of airway support is needed. The timing of when to perform a tracheostomy is controversial with some studies demonstrating decreased sedation requirements and shorter ICU stays if tracheostomy is performed earlier, while others did not find this difference. - See Cummings 6th ed pg96.

Answer 228

Michel Deformity and Cochlear Nerve Agensis Michel deformity involves congenital agenisis of the cochlea and therefore there is no neural elements which can be stimulated with a cochlear implant. Similarly, a narrowing of the internal auditory canal can represent absence of the cochlear nerve which also indicates absence of the necessary neural pathway. Most other congenital defects of the inner ear have at least some neural elements present making them relative contraindications to implantation. Labyrinthitis ossificans is not a contraindication to implantation, although it may significantly limit the depth of insertion. Anomalous facial nerves and thin cribiform region should be identified preopreratively and may increase the risk of surgery, but are not absolute contraindications. - See KJ Lee 10th ed pg 155.

Answer 229

1) Fever 2) Anterior Cervical Lymphadenopathy 3) Tonsillar Exudates 4) Absence of Cough If 3 of 4 are positive then the positive predictive value is 40-60% that Group A B-hemolytic Strep Pyogenes (GABHS) infection is present and treatment with antibitics is warranted (although many will still do a rapid strep test prior to treating) . If only 1 of the 4 is positive there is a negative predictive value of 80% that the patient does not have GABHS and no further treatment is needed (again, some will still perform a rapid strep test. - See Cummings 6th ed pg 155.

Answer 230

Advantages: 1. Can be inserted blindly and quickly. 2. No neck movement required 3. 95-99% success rate 4. Easy to learn 5. Less postoperative sore throat, cough and laryngeal injury. Disadvantage: 1. Increased risk of aspiration of gastric contents compared with standard endotracheal intubation. - See Cummings 6th ed pg 71-72.

Answer 231

87% Several studies support closed reduction as initial modality for nasal fractures. The timing of closed reduction is important as excessive delay (past 10 days) can make realigning the bones difficult due to the formation of scar tissue. Younger patients and athletes can heal particularly quickly whereas older patients can be reduced as time points more removed from their initial injury. Reduction within the first 1-2 days can also be difficult due to edema. 91% of pts are satisfied with the results of closed approach at 3 months and 87% at 3 years. - See Cummings 6th ed pg 498.

Answer 232

Nervus Intermedius. This nerve is formed by general viscerel exits the brainstem adjacent to the motor branch of cranial nerve 7 and provides general visceral efferent fibers which are preganglionic parasympathetic to the lacrimal, submandibular, sublingual and minor salivary glands. - See Cummings 6th ed pg 2665.

Answer 233

Kaposi Sarcoma, Non Hodgkins Lymphoma, Invasive Cervical Cancer. There are three aids defining malignancies. The most commonly known is Kaposi sarcoma which is an angioproliferative disorder characterized by dark lesions which demonstrate spindle cell proliferation on histology. Kaposi sarcoma is associated with HHV8 infections and 70% will involve the head and neck. Nonhodgkins lymphoma is also significantly increased in HIV patients and is associated with EBV infections. While both cervical cancer and oropharyngeal carcinoma are associated with HPV infections and both are more common in HIV patients, only cervical cancer is considered aid defining. - See Cummings 6th ed pg 180.

Answer 234

Coins Aerodigestive tract foreign bodies are most common in boys under the age of 3. Esophageal foreign bodies are twice as common as bronchial foreign bodies are most commonly involve coins. Organic matter is more common in bronchial foreign bodies but commonly this is expelled via the cough mechanism. Other common objects include toys, batteries, fish bones and jewlery. - See Cummings 6th ed pg 3185.

Answer 235

1. Internal Audiotry Canal 2. Vestibular Aqueduct 3. Cochlear Aqueduct 4. Subarcute Fossa -See KJ Lee 10th ed pg 3.

Answer 236

Vasculitis of the upper respiratory tract, lungs and kidneys. Wegner granulomatosis is characterized by necrotizing vasculitis of the small arteries. Head and neck manifestations include septal perforations, nasal congestion, loss of structural support of the nose, voice change and subglottic stenosis. 10-20% of Wegner patients will develop airway involvement and management involves endoscopic dilation techniques, although tracheostomy may be required. - See Cummings 6th ed pg 208.

Answer 237

Per the McAdam criteria to diagnose relapsing polychondritis, 3 or more of the following must by present: 1. Auricular chondritis 2. Nonerosive seronegative inflammatory polyarthritis 3. Nasal chondritis 4. Ocular inflammation 5. Respiratory tract chondritis 6. Audiovestibular damage - See Medscape "Relapsing Polychondritis Clinical Presentation"

Answer 238

Squamous Petrous Tympanic Mastoid - See Cummings 6th ed pg | 1977.