Diagnostic Assessments Flashcards
(499 cards)
1
Q
Question
A
Answer
2
Q
What does each wave represent?
A
- *I-** Eighth nerve.
- *II-** Cochlear nucleus.
- *III-** Superior olivary complex.
- *IV**-Lateral lemniscus.
- *V-** Inferior colliculus.
3
Q
What disorders are associated with down-beating nystagmus?
A
- Arnold-Chiari
- cerebellar degeneration
- multiple sclerosis
- brainstem infarction
- Lithium intoxication
- magnesium and thiamine deficiency.
4
Q
What are the indications for hearing evaluation every 6 months until age 3?
A
- Family history of hereditary childhood hearing loss.
- In utero infection (TORCH). Neurodegenerative disorders.
5
Q
What are the indications for performing hearing screening in neonates if universal screening is not available?
A
- Family history of hereditary childhood SNHL. Congenital perinatal infection (TORCH).
- Head or neck malformation. Birth weight
- Hyperbilirubinemia requiring an exchange transfusion (>20).
- Bacterial meningitis.
6
Q
What are the indications for performing hearing screening in infants 29 days to 2 years?
A
- Parent concern.
- Developmental delay.
- Bacterial meningitis.
- Head trauma associated with loss of consciousness or skull fracture.
- Ototoxic medications.
- Recurrent or persistent otitis media with effusion for at least 3 months.
7
Q
What are the three types of evoked OAEs?
A
- SFOAE (stimulus frequency).
- TEAOE (transient evoked).
- DPOAE (distortion product).
8
Q
What are the neural pathways of the acoustic reflex?
A
- VIII to the ipsilateral ventral cochlear nucleus to the trapezoid body to the motor nucleus of VII to VII to the ipsilateral stapedius.
- VIII to the ipsilateral ventral cochlear nucleus to the trapezoid body to the ipsilateral medial superior olive to the motor nucleus of VII to VII to the ipsilateral stapedius.
- VIII to the ipsilateral ventral cochlear nucleus to the medial superior olive to the contralateral motor nucleus of VII to the contralateral VII to the contralateral stapedius.
9
Q
What is the normal interaural attenuation value for bone conduction?
A
0dB.
10
Q
What are the clinical features of benign paroxysmal positional vertigo (BPPV)?
A
10-20-second attacks of rotational vertigo, precipitated by head movements, with spontaneous resolution after several weeks to months in So-go%.
11
Q
A patient has a negative Rinne at 256 Hz AS. At 512 and 1024 Hz, it is positive as it is at all three frequencies AD. The Weber test lateralizes to the left at all three frequencies. He hears a soft whisper AD and a soft to medium whisper AS. What is his hearing loss?
A
15 dB CHLAS.
12
Q
In patients with chronic otitis media but no cholesteatoma, what level of hearing loss is associated with ossicular chain disruption or fixation?
A
30 dB or more.
13
Q
What is normal interaural attenuation of air-conducted tones?
A
40-80 dB depending on whether ear inserts or headphones are used and also on the frequency being tested.
14
Q
What percent of the time will the Rinne test miss an air-bone gap
A
50%.
15
Q
In the normal ear, contraction of middle ear muscles occurs at which pure tones?
A
65-95 dB HL.
16
Q
What is a normal word recognition score?
A
90-100%.
17
Q
What is rollover?
A
A decrease in speech discrimination scores when presented at higher intensities; suggestive of a retrocochlear lesion.
18
Q
When comparing the summating to the compound action potential in electrocochleography, what value is considered abnormal?
A
A ratio 0-45.
19
Q
How is stapedius reflex measured?
A
A signal is presented 10 dB above the acoustic reflex threshold for 10 seconds; if the response decreases to one half or less of the original amplitude within 5 seconds, the response is considered abnormal and suggestive of retrocochlear pathology.
20
Q
What stimulus is used to evoke the ABR?
A
A simple acoustic click, between 2000 and 4000 Hz.
21
Q
What is a spondee?
A
A two-syllable word spoken with equal stress on both syllables.
22
Q
What is cryptotia?
A
Absence of the retroauricular helix.
23
Q
What technique can be used to differentiate the SP from the nerve potential of VIII (AP)?
A
AP is a neural response that will respond to higher rates of stimulation. SP is a preneural response that is not affected by higher rates of stimulation. Therefore, increasing the click rate of the stimulus will affect the AP but not the SP.
24
Q
Where are the recording electrodes for elctrocochleography placed?
A
As close as possible to the cochlea and auditory nerve (promontory, tympanic membrane, EAC).
25
What test can be use to exclude the absence of aidable hearing when the ABR is absent at maximum levels?
ASSEP (auditory steady-state evoked potentials).
26
What is the significance of a negative Rinne at 256 Hz, 512 Hz, and 1024 Hz?
At least a 15 dB conductive hearing loss (CHL), 25-30 dB CHL, and 35dB CHL, respectively.
27
What test should be used to assess auditory function in these patients?
Auditory brainstem response (ABR).
28
What disorders are associated with bidirectional gaze-fixation nystagmus?
Barbiturate, phenytoin, and alcohol intoxication.
29
What three audiometric test techniques are used to obtain behavioral response levels from a child?
Behavioral observation audiometry (BOA), visual reinforcement audiometry (VRA), and conditioned play audiometry (CPA).
30
Where is the peak pressure point in a normal tympanogram in an adult?
Between -100 and +40 daPa.
31
What is lobule colobomata?
Bifid lobule.
32
When does masking dilemma occur?
Bilateral so dB or greater air-bone gaps.
33
What is the best audiometric method to use when assessing the hearing level of a 15-month-old child?
BOA (observing reflexive/behavioral responses to sound stimuli at different frequencies) and VRA (employing lighted transparent toys to reinforced responses (head turn) to auditory stimuli.)
34
What disorders are associated with up-beating nystagmus?
Brainstem tumors, congenital abnormalities, multiple sclerosis, hemangiomas, vascular lesions, encephalitis, and brainstem abscess.
35
How are air and bone conduction thresholds measured?
By first obtaining a positive response, then lowering the intensity by 10 dB increments until no response is obtained.
36
How is SRT measured?
By starting at minimal intensity and ascending in 10 dB increments until the correct response is identified.
37
What features distinguish BPPV from vertigo due to CNS disease?
CNS disease: no latent period, direction of nystagmus varies, nystagmus and vertigo are nonfatigable.
38
What is measured in electrocochleography?
Cochlear microphonic action potential (CM), action potential of VIII (AP), the summating potential (SP), and compound action potentials.
39
What does the audiogram typically look like in a child with SNHL secondary to rubella?
Cookie-bite pattern.
40
What is the best audiometric method to use for a 4-year-old child?
CPA where the child is trained to respond to auditory stimuli with a motor response (e.g., pointing to pictures).
41
In the workup of congenital hearing loss, what test has the highest diagnostic yield?
CT scan.
42
What are the typical objective auditory findings in patients with auditory neuropathy?
Decreased or absent ABR, normal OAEs, absent auditory reflexes, very poor speech discrimination, mild-to-profound pure tone hearing loss.
43
Where is bone-conducted sound transmitted?
Directly to the cochlea.
44
What findings on videonystagmography (VNG) are seen with central vestibular disorders?
Disconjugate eye movements, skew deviation, vertical gaze palsy, inverted Bell's phenomenon, seesaw nystagmus, bidirectional nystagmus, periodic alternating nystagmus, and nystagmus that is greater with eyes open and fixed on a visual target than in darkness.
45
Which type of OAEs is evoked by two pure tones?
DPOAE.
46
How is the diagnosis of idiopathic intracranial hypertension (IIH) syndrome made?
Exclusion of lesions producing intracranial hypertension, lumbar puncture with CSF pressure of more than 200 mm H 20 and normal CSF constituents.
47
What instrument is most helpful in examining nystagmus on physical exam?
Frenzel goggles.
48
What is the speech detection threshold (SDT)?
Hearing level at which so% of the spondaic words are detected; usually 6-7 dB lower than the SRT.
49
What is Hitzelberger's sign?
Hypoesthesia of the postauricular area associated with VIIth nerve compression secondary to an acoustic neuroma.
50
When determining interpeak latencies, which waves are compared?
I-III, I-V.
51
What finding on pneumatic otoscopy is most specific for otitis media?
Immobility of the tympanic membrane.
52
How does the hearing impairment from malleus ankylosis differ from that of otosclerosis?
In patients with malleus ankylosis, hearing impairment is mostly unilateral (78%); the air-bone gap is smaller (majority less than 20 dB); SNHL is more frequent, particularly at 4 kHz; acoustic reflex is more likely to be present on the contralateral ear and absent on the impaired ear.
53
What is the difference in these interpeak latencies?
Increased I-III intervals are almost always indicative of retrocochlear pathology, whereas increased I-V intervals is more likely associated with noise-induced SNHL.
54
What is the significance of the ability to hear a tuning fork placed on the teeth?
Indicates that cochlear reserve is present and surgery may be beneficial.
55
What maneuvers on physical exam will decrease or completely eliminate pulsatile tinnitus of venous origin?
Light digital pressure over the ipsilateral internal jugular vein and head turning toward the ipsilateral side.
56
In patients with IIH, what is the usual pitch of the tinnitus?
Low frequency.
57
Why is it particularly difficult to assess the auditory function in patients with bilateral aural atresia?
Masking dilemma.
58
What does an abnormal ratio suggest?
Meniere's disease.
59
What is the significance of hearing loss in the absence of middle ear effusion in patients with congenital cholesteatoma?
Most lesions begin anterosuperiorly and extend posteriorly with growth. Hearing loss indicates posterior extension with involvement of the stapes superstructure and/ or the lenticular process of the incus.
60
Why are OAEs useful as a screening tool in infants?
Nearly 100% of people demonstrate evoked OAEs; testing is noninvasive and inexpensive; test time is short; cochlear hearing loss exceeding 30 dB can be detected.
61
If otoacoustic emissions are present, can retrocochlear pathology be ruled out?
No.
62
What proportion of patients with IIH will have an abnormal ABR?
One-third.
63
Apgar 0-4 at 1minute or o-6 at 5 minutes. Prolonged ventilation (\>5 days).
Ototoxic medications.
64
What is the significance of speech discrimination scores?
Patients with cochlear and retrocochlear pathology will have poor to very poor scores, respectively; those with only CHL will have normal scores when the intensity level is sufficiently loud.
65
How is speech discrimination testing performed?
Phonetically balanced monosyllabic word lists (so) are administered at 30-50 dB above threshold and the correct percentage is identified.
66
What auditory tests are performed in tinnitus analysis?
Pitch matching, loudness matching, minimum masking level (MML), and residual inhibition.
67
What does computerized dynamic platform posturography specifically measure?
Postural stability and sway.
68
What sort of hearing loss is most common in patients with Cogan's syndrome?
Progressive to total deafness.
69
How will a retrocochlear lesion affect the ABR?
Prolongation of absolute wave V latency, I-V latency, and interaural wave V latency.
70
What is the likely diagnosis for someone who presents with vesicles on the pinna and external auditory canal (EAC), facial nerve weakness, and sensorineural hearing loss (SNHL)?
Ramsey-Hunt syndrome.
71
What is opsoclonus?
Rapid, uncontrolled, mulitvectorial, conjugate eye movements, usually seen on physical exam and difficult to detect on VNG.
72
What is "Schwartze's sign"?
Reddish hue on the promontory associated with otosclerosis.
73
How can one differentiate between relapsing polychondritis involving the ear and other causes of external otitis?
Relapsing polychondritis spares the lobule.
74
What does the finding of elevated acoustic reflex in the presence of normal hearing or mild SNHL and a normal tympanogram suggest?
Retrocochlear pathology
75
A patient with an SRT of 55 dB HL and a speech discrimination score of 64% at 75 dB HL has what kind of hearing loss?
Sensorineural.
76
What is the Brown sign?
Sign seen with glomus tympanicum tumors where the tympanic membrane blanches when pressure is applied from the pneumatic otoscope.
77
What are the stimuli used to obtain a speech reception threshold (SRT)?
Spondees.
78
What finding on VNG is pathognomonic for a lesion at the craniocervical junction?
Spontaneous downbeat nystagmus with the eyes open, in the primary position that increases with lateral gaze or head extension.
79
What do the peaks of the ABR represent?
Synchronous neural discharge at various locations along the auditory pathway.
80
What is the Stenger's test?
Test to see if the patient is malingering; appropriate to administer if there is \>20 dB difference between ears in voluntary thresholds.
81
What does acoustic reflex delay measure?
The ability of the stapedius muscle to maintain sustained contraction.
82
What is crossover?
The attained responses represent the performance of the nontest ear rather than the test ear due to a large sensitivity difference between the ears.
83
Which part of the auditory system is assessed by air conduction tests?
The entire auditory system.
84
What is the definition of SRT?
The lowest hearing level at which half of the words are heard and repeated correctly, followed by at least two correct ascending steps. SRT should be within 10 dB dB of pure tone average (PTA).
85
What is the definition of auditory threshold?
The lowest level at which the patient can detect a sound so% of the time.
86
What is the acoustic reflex threshold?
The lowest stimulus level that elicits the stapedial reflex.
87
What is inter-aural attenuation?
The reduction of sound when it crosses from one ear to another.
88
What does the interwave latency reflect?
The time necessary for neural information to travel between places in the auditory pathway; any pathology that interferes with this transmission will prolong the latency.
89
How is ABR most commonly used?
To test newborns, difficult to test children, and malingerers.
90
True/False: The acoustic reflex threshold is absent in patients with middle ear disease.
True.
91
True/False: Brainstem lesions may abolish the acoustic reflex without affecting the pure tone thresholds.
True.
92
True/False: The ABR is unaffected by state of sleep or medications.
True.
93
True/False: ASSEP has little predictive value for hearing levels in children with auditory neuropathy.
True.
94
True/False: ASSEP cannot distinguish between cochlear and retrocochlear hearing loss.
True.
95
What is cockleshell ear?
Type III cup ear where the ear is malformed in all directions.
96
When is the interaurallatency difference of wave V important?
Used to document retrocochlear pathology when wave I is absent.
97
Is the acoustic reflex present in patients with otosclerosis?
Usually it is absent bilaterally, even if the disease is unilateral.
98
Which of the ABR waves is the largest and most consistent?
V (representing inferior colliculus)
99
What is Tullio's phenomenon?
Vertigo with loud noise, commonly seen in patients with superior semicircular canal dehiscence.
100
What would the tympanogram look like in an ear with an interrupted ossicular chain?
Very steep amplitude, high peak (type Ad).
101
How is hearing threshold estimation performed using ABR?
Wave Vis tracked with decreasing sound intensity until it can no longer be observed.
102
When is wave I absent?
When hearing loss exceeds 40-45 dB at higher frequencies.
103
When should masking be used?
When the air conduction threshold of the test ear exceeds the bone conduction threshold of the nontest ear by a value greater than interaural attenuation.
104
What are the physical exam findings in patients with BPPV?
With the Dix-Hallpike maneuver, rotatory nystagmus toward the undermost ear accompanied by vertigo, both with a latent period of 5-30 seconds and duration
105
Is the acoustic reflex present in patients with superior semicircular canal dehiscence?
Yes.
106
What is the ideal alar-to-lobular ratio?
1:1
107
What is the ideal ratio of the length of the lower lip to the upper lip?
0.0840277777777778
108
What is the ideal nasofrontal angle?
125-135 degrees.
109
What is the normal incline of the vertical axis of the auricle?
20 degrees.
110
What is the normal angle between the ear and the head?
25-30 degrees.
111
What is the normal intercanthal width?
30-35 mm in Caucasians or roughly the width of the alar base.
112
What is the ideal nasofacial angle?
36-40 degrees.
113
What is the ideal nasolabial angle?
90-120 degrees.
114
How do adnexal carcinomas arising from hair follicles classically present?
A tuft of white hair emerges from the central portion of the tumor.
115
What is the "bowstring sign"?
An obvious give that occurs with lateral tension on the lower lid, indicating disruption of the medial canthal tendon.
116
In a female, where should maximum brow elevation occur?
At a line tangent and vertical to the lateral limbus of the eye.
117
What is the ideal brow position in a man?
At the level of the supraorbital rim with a less pronounced arch.
118
What is the significance of a "negative vector" profile?
Describes patients with protuberant eyes and hypoplastic malar eminence-fat should not be removed from these patients during blepharoplasty.
119
A 6-year-old boy presents with the following rash on his face. What is the most likely diagnosis?
Erythema infectiosum, or Fifth disease. Usually the first sign of illness is the characteristic maculopapular rash on the cheeks that coalesces to give a "slapped-cheek" appearance.
120
What test is performed to evaluate for entrapment of the extraocular muscles?
Forced duction test.
121
How is lower lid laxity defined?
If \>10 mm or \> 25% of the skin can be gathered without distortion of the rim.
122
Where should the chin lie in relation to a vertical line dropped from the lips?
In men, the chin should meet the line; in women, the chin should lie 2-3 mm posterior.
123
Skin that rarely burns and tans more than average is which Fitzpatrick's class?
IV.
124
A 3-year-old boy presents with a to-day history of irritability, diarrhea, and malaise followed by a s-day history of swollen, red lips, a polymorphous rash, fever, and peeling of the skin on his hands and feet. What is the diagnosis?
Kawasaki disease or mucocutaneous lymph node syndrome.
125
On physical examination, the nose and the maxillary alveolar process are found to be free floating. What type of fracture has occurred?
LeFort II.
126
What are two angles used to determine chin projection?
Legan angle (normal 12 degrees +/- 4), Merrifield Z angle (normal So degrees +/-5).
127
What is the ideal brow position in a woman?
Medial segment club shaped and inferior to the lateral segment; peak of arch above the orbital rim at the lateral limbus; lid margin to brow distance \>2 em.
128
The pneumonic "AEIOU" is useful for which type of tumor?
Merkel cell carcinoma; "A" is for asymptomatic-nontender (seen in 88% patients); "E" is for expanding rapidly (63% of patients); "I" is for immune suppressed (8% of patients); "O" is for over age 50; "U" is for ultraviolet light exposed site (81% of patients); 89% of patients with Merkel cell carcinoma will have three of these features at presentation.
129
Which angle used for measuring chin projection uses the Frankfort horizontal line as a reference?
Merrifield Z angle.
130
What is the difference between microgenia and micrognathia?
Microgenia is a small mandible with normal occlusion; micrognathia is an underdeveloped mandible with class II occlusion.
131
Define mild, moderate, and marked ptosis.
Mild: 1-2 mm, moderate: 2-3 mm, marked: \> 4 mm.
132
How does the ideal supratip break differ between men and women?
More pronounced in women.
133
What is retrognathia?
Normal sized mandible with class II occlusion.
134
What is the most commonly used system to classify alopecia?
Norwood's system.
135
What is the most sensitive test to detect optic nerve injury after facial trauma?
Pupillary reaction to light.
136
What physical exam findings are classic for measles?
Rash, conjunctivitis, and Koplik's spots.
137
What is the ideal configuration of the alar margin?
S-shaped, exposing 2-3 mm of the caudal columella on lateral view.
138
What is the single most important aesthetic quality of the nasal tip and base?
Symmetry.
139
What measurement can be used to determine deficiency in the malar area?
The distance from the malar prominence to the nasolabial groove on lateral projection (ideally \> 5 mm).
140
What is the normal superior limit of the auricle?
The level of the brow.
141
What is the normal position of the lower lip in relation to the upper lip and chin?
The most anterior portion of the white roll should lie slightly posterior to the upper lip and lie in the same plane as the soft tissue chin point.
142
What are the physical signs of aponeurosis disinsertion?
Thin upper lid skin and high lid fold with good levator function (\>10 mm).
143
On physical examination, digital pressure on the nasal tip causes prolapse of the distal nose into the pyriform aperture. Which type of nasoethmoidal fracture is this according to Gruss' classification of nasoethmoidal injuries?
Type II
144
What is Hering's law?
Unilateral ptosis with contralateral lid retraction-if you cover the ptotic eye with a patch for 30-60 minutes, the retracted eye will settle into the normal position and the ptotic eye will reveal itself.
145
What is the significance of the presence of a cerebrospinal fluid (CSF) leak when assessing a patient with a frontal sinus fracture?
Usually associated with a displaced posterior table fracture and a dural tear.
146
What are the levels defined in Clark's system for classifying malignant melanomas?
* Level I: Epidermis.
* Level II: Invasion of basal lamina into the papillary dermis.
* Level III: Fill the papillary dermis.
* Level IV: Invasion into the reticular dermis. Level V: Invasion into subcutaneous fat.
147
What are the classifications of nasopharyngeal cancer designated by the WHO?
* Type I: Well-differentiated, keratinizing SCCA.
* Type II: Poorly differentiated, nonkeratinizing SCCA.
* Type III: Lymphoepithelioma or undifferentiated.
148
The low-grade malignant tumor shown below is most commonly found in the parotid gland, typically encased in a fibrous capsule, and is more common in females.What is your diagnosis?
Acinic cell carcinoma, characterized histologically by two cell types: serous-acinar cells and cells with clear cytoplasm.
149
Which genus is responsible for the infection shown below, sometimes referred to as lumpy Jaw
Actinomyces
150
Which genus is responsible for the infection shown below, sometimes referred to as "lumpy jaw"?
Actinomyces. Histopathology shows a sulfur granule.
151
What cell patterns are characteristic of vestibular schwannomas?
Antoni A (tightly arranged) and Antoni B (loosely arranged).
152
In which cell pattern of vestibular Schwannoma are Verocay's bodies found?
Antoni A (tightly packed).
153
The benign tumor shown below accounts for 2% of salivary gland tumors, occurs most frequently in the parotid gland, is slightly more common in females, and shows a number of histologic patterns. What is your diagnosis?
Basal cell adenoma.
154
The tumor shown below occurs most frequently in the parotid gland, is slightly more common in females, is benign and shows a number of histologic patterns. What is your diagnosis
Basal cell adenoma.
155
What feature seen on renal biopsy with electron microscopy is pathognomonic for Alport syndrome?
Basket-weave configuration of the glomerular basement membrane.
156
Which malignant melanoma classification system is millimeters?
Breslow's. This system is based on the depth of invation.
157
What are the histologic differences between a hemangioma and avascular malformation?
Cellular proliferation is characteristic of hemangiomas; vessel dilatation is characteristic of vascular malformations.
158
This lesion is from the mandible of a 19-year-old female near the mental foramen, what is the diagnosis
Central giant cell granuloma.
159
Which classification system for melanoma is based on histologic layers?
Clark's.
160
What are the histologic features of basal cell carcinoma of the skin?
Clefting, lack of intracellular bridges, nuclear palisading, and peritumorallacunae.
161
What are the histologic features of vascular malformations?
Dilated, ectatic vascular channels with a normal endothelial lining and areas of thrombosis.
162
What are the three main histologic types of rhabdomyosarcoma?
Embryonal, alveolar, and pleomorphic.
163
Which rhabdomyosarcoma is most common in the head and neck?
Embryonal.
164
What is the cell of origin of parotid gland squamous cell carcinoma?
Excretory duct cell.
165
What are the characteristic histologic findings of recurrent respiratory papillomatosis?
Exophytic papillary fronds of multilayered benign squamous epithelium containing fibrovascular cores; cytologic atypia, in particular, koilocytotic atypia, is not unusual.
166
True/False: Tumors with a high percentage of Antoni A cells relative to Antoni B cells have a better prognostic outcome.
False: Outcome is independent of cell proportions.
167
Name the thyroid tumor. Cuboidalepithelialcells with large nuclei in a well-structured follicularpattern extending beyond the tumor's capsule
Follicular thyroid cancer
168
This firm, noncompressible nasal mass was resected from a young child. What is your diagnosis?
Glial heterotopia (nasal glioma).
169
This soft, polypoid nasal mass was resected from a young child. What is your diagnosis
Glial heterotopia (nasal glioma).
170
What histological pattern is characteristic of olfactory neuroblastoma?
Homer-Wright rosettes.
171
Name the thyroid tumor. Large polygonal thyroid follicular cells with abundant granular cytoplasm and numerous mitochondria
Hurthle cell thyroid cancer
172
What are the histologic findings of invasive fungal sinusitis?
Hyphae with tissue invasion and noncaseating granulomas.
173
What histologic characteristic of recurrent basal cell cancers has negative prognostic significance?
Irregularity in the peripheral palisade.
174
15-year-old boy presented with nasal obstruction and recurrent epistaxis. The polypoid mass shown below was resected and bled extensively. What is your diagnosis?
Juvenile nasopharyngeal angiofibroma. Histological features include an unencapsulated admixture of vascular tissue and fibrous stroma where the vessel walls lack elastic fibers and have decreased or no smooth muscle; mast cells are abundant in the stroma.
175
15-year-old boy presented with nasal obstruction and the polypoid mass shown above was resected and bled extensively. What is your diagnosis
Juvenile nasopharyngeal angiofibroma.
176
What are the histologic features of squamous cell carcinoma of the skin?
Keratin pearls in well-differentiated lesions; poorly differentiated lesions may require identification with a cytokeratin or vimentin.
177
Name the thyroid tumor. Nests of small,round cells;amyloid;dense,irregular areas of calcification
Medullary thyroid carcinoma
178
Which of these is most common in North America? Least common?
Most common is type III (70%); least common is type II (10%).
179
The tumor below is the most common malignant tumor of the salivary glands and is more common in females. What is your diagnosis?
Mucoepidermoid carcinoma, showing the low-grade variant, which has a s-year survival rate of 70% and 1s-year disease-free survival rate of so%.
180
What are the typical histologic characteristics of lymphatic malformations?
Multiple dilated lymphatic channels lined by a single layer of epithelium.
181
The tumor shown below is shown ultrastructurally to be composed of tumor cells filled with abundant mitochondria. It is most commonly found in the parotid gland but accounts for less than 1% of salivary gland tumors. What is your diagnosis?
Oncocytoma.
182
The tumor shown below is shown ultrastructurally to be composed of tumor cells filled with abundant mitochondria. What is your diagnosis
Oncocytoma.
183
Calcified laminated bodies called psammoma bodies; elongated,pale nuclei with a ground glass appearance (Orphan Annie eyes)
Papillary thyroid cancer
184
Which cells in the thyroid gland secrete calcitonin?
Parafollicular or C cells.
185
What are the histopathologic features of synovial sarcoma of the head and neck?
Poorly differentiated, high-grade malignant neoplasms arising from pluripotential mesenchymal cells; biphasic cellular pattern containing spindle cells and epithelioid cells; microcalcifications in 30-60%; the existence of monophasic forms, containing either spindle or epithelioid cells, is controversial.
186
What cells are unique to Hodgkin's lymphoma?
Reed-Sternberg cells.
187
The tumor shown below most commonly arises in the parotid gland of older males and is highly aggressive with a mean survival of 3 years. What is your diagnosis?
Salivary duct adenocarcinoma.
188
The tumor shown below most commonly arises in the parotid gland of older males and is highly aggressive. What is your diagnosis
Salivary duct carcinoma.
189
The tumor depicted below is most commonly found near the eyelid and in previously irradiated areas and is more common in patients with Muir-Torre syndrome. What is your diagnosis?
Sebaceous carcinoma, characterized histologically by variously sized and irregularly shaped groups of sebaceous cells that contain lipid globules.
190
The tumor depicted below is most commonly found near the eyelid and is associated with a poor prognosis. What is your diagnosis
Sebaceous carcinoma.
191
What other test can be useful in diagnosing Alport syndrome?
Skin biopsy.
192
What histologic finding distinguishes cholesteatoma from cholesterol granuloma?
Squamous epithelium is present only in cholesteatomas.
193
What histological subtypes of thyroid tumors are associated with an increased risk of local recurrence and metastasis?
Tall cell, columnar, insular, solid variant, and poorly differentiated.
194
What feature distinguishes low-grade from high-grade mucoepidermoid carcinoma?
The amount of mucin in the tumor.
195
Which histologic growth pattern of the tumor shown below is associated with the highest recurrence rate
The three growth patterns of adenoid cystic carcinoma are tubular, cribiform, and solid. The solid pattern is associated with essentially 100% recurrence, the cribiform is characterized by a 90% recurrence rate, while the tubular pattern is associated with a 60% recurrence rate.
196
How does one differentiate between a benign and a malignant paraganglioma?
There are no clear histologic characteristics of malignancy; malignant lesions are defined by the presence of metastases.
197
Following are three histopatholgical slides taken from parotid gland tumors. Narne the type of tumor and their subtypes.
These are all adenoid cystic tumors. "A" shows the cribriform pattern, which is the most common subtype (44%) and has a "Swiss cheese" appearance. "B" shows the cribriform and tubular pattern, which is slightly less common (35%) and has the best prognosis. "C" shows the solid pattern, which is the least common subtype (21%) and has the worst prognosis.
198
What test is used to diagnose invasive fungal sinusitis?
Tissue biopsy.
199
What are the two primary cells of paragangliomas?
Type I granule-storing chief cells and type II Schwann-like sustentacular cells (S-100 positive) arranged in a cluster called a Zellballen.
200
Which of these is not associated with positive Ebstein-Barr virus titers?
Type I.
201
Which of these is characterized by syncytia (fused multinuclear giant cells)?
Type III.
202
The lesion below is also known as "papillary cystadenoma lymphomatosum," represents approximately 12% of benign tumors of the parotid gland, and is seen more commonly in smokers. What is the tumor?
Warthin tumor, characterized histologically by papillary structures with lymphocytic infiltration, cystic areas, and double layers of granular eosinophilic cells.
203
What is the bilateral benign cystic lymphoepithelial lesion shown below
Warthin's tumor.
204
What is Schaefer's classification system of laryngeal injuries?
* **Group I:** Minor hematomas or lacerations, no fractures, and minimal airway compromise.
* **Group II:** Moderate edema, lacerations, mucosal disruption without exposed cartilage, nondisplaced fractures, and varying degrees of airway compromise.
* **Group III:** Massive edema, mucosal disruption, displaced fractures, cord immobility, and varying degrees of airway compromise.
* **Group IV:** Same as group III but with two or more fracture lines and/ or skeletal instability or significant anterior commissure trauma.
205
What is the typical appearance of a type 1 posterior laryngeal cleft?
A soft tissue defect in the interarytenoid musculature without a defect in the cricoid cartilage.
206
What is the only clinical sign that is strongly associated with a synchronous airway lesion?
Cyanosis.
207
What are the three hypopharyngeal cancer symptoms?
Dysphagia, neck mass, and sore throat (in descending order of incidence).
208
How is the cricopharyngeus muscle identified with EMG?
Electrical activity occurs at rest and diminishes or stops with swallowing.
209
What is the test of choice for diagnosing laryngomalacia?
Flexible fiberoptic laryngoscopy in the office.
210
What is the typical presentation of child with a laryngeal cleft type 2 or greater?
History of aspiration, pneumonia, choking, coughing during feeds, and symptoms of airway obstruction.
211
What is the significance of a "picket fence" pattern on EMG?
Indicates partial reinnervation (polyphasic action potentials).
212
How does one assess for involvement of the prevertebral fascia from a hypopharyngeal tumor?
Intraoperative evaluation is most accurate. During endoscopy, one can attempt to mobilize the posterior pharyngeal wall to assess for involvement. Video esophagography and CT scan are also helpful.
213
What is the significance of vocal cord fixation in patients with laryngeal carcinoma?
Invasion of the vocalis muscle has occurred, and lymph node metastasis is more likely.
214
Stridor that increases in intensity with crying, agitation, or straining is characteristic of what disorders?
Laryngomalacia and subglottic hemangioma.
215
A 45-year-old woman presents with dysphonia and on exam is found to have left vocal cord paralysis in the paramedian position. Complete history and physical exam are otherwise unremarkable. CT scan of the neck and chest and laboratory findings, including electrolytes, RPR, and thyroid function tests, are normal. What are the next steps?
Magnetic resonance imaging (MRI) of the neck and chest followed by laryngoscopy/bronchoscopy if necessary.
216
A 78-year-old man presents with a weak, breathy voice and was recently treated for pneumonia. On exam, he was found to have left vocal paralysis in the intermediate position with a wide posterior gap that does not close with vocalization. What is the most appropriate test?
MRI of the brain/skull base (his history and exam suggest a nerve lesion above the recurrent laryngeal nerve).
217
Which voice analysis test graphs multiple vocal parameters at once and is very useful for showing changes over time?
Multidimensional voice profile.
218
What disease does a fatiguing pattern on EMG suggest?
Myasthenia gravis.
219
An EMG wave pattern of decreased amplitude with normal frequency suggests what sort of disorder?
Myopathy.
220
An EMG wave pattern of decreased frequency with normal amplitude suggests what sort of disorder?
Neuropathy.
221
Which voice analysis test plots minimums and maximums of loudness at selected levels of fundamental frequency and reflects the patient's vocal capacity?
Phonetogram.
222
A patient complains of total aphonia yet generates sound with coughing. What is the likely diagnosis?
Psychosomatic conversion dysphonia.
223
What are the indications for rigid bronchoscopy in children with laryngomalacia?
Severe or atypical stridor, an abnormal high kilovolt cervical radiograph, or a high degree of suspicion for a synchronous airway lesion.
224
What are the features of a denervation pattern on EMG?
Sharp waves or fibrillation potentials, complex repetitive discharges, and little or no electrical activity during attempts at voluntary contraction.
225
Which voice analysis test gives a three-dimensional representation of sound (time, intensity, and frequency)?
Spectrogram.
226
What is the significance of a denervation pattern 1 year after injury?
Spontaneous recovery is very unlikely.
227
Which laryngeal muscles are typically analyzed with EMG?
Thyroarytenoid and cricothyroid muscles.
228
What is the primary purpose of laryngeal electromyography (EMG) in patients with vocal cord paralysis?
To distinguish paralysis from mechanical fixation.
229
True/False: Any laryngeal tumor with vocal cord fixation is at least stage T3.
True.
230
What common cause of congenital airway obstruction is characterized by inspiratory stridor at birth that decreases when placed on the side of the lesion?
Unilateral vocal cord paralysis.
231
How can one diagnose exercise-induced laryngomalacia?
With exercise flow-volume spirometry.
232
What percentages of cold, warm/cool, and hot nodules on radioiodine scanning of the thyroid gland are malignant?
17%, 13%, and 4%, respectively.
233
What is the half-life of FDG?
20% is excreted quickly by the renal system; So% remains in the tissues with a half-life of 110 minutes.
234
What is the earliest gestational age that complete glottic atresia could be detected on ultrasound?
22 weeks.
235
What percent of patients, asymptomatic with regard to their sinuses and undergoing CT scan of the head for other indications, have mucosal thickening of their sinuses?
24-39%.
236
What percent of thoracic esophageal perforations will be missed with water-soluble contrast agents?
25%.
237
How small of a lesion can MRI with gadolinium detect?
2mm.
238
What is the optimal TSH value prior to radioiodine therapy?
30 mU/L or higher.
239
What is the incidence of incidental ethmoid mucosal thickening on CT scan in children?
30%.
240
How small of a lesion can fast-spin echo MRI detect?
4-5 mm.
241
What percent of cervical esophageal perforations will be missed with water-soluble contrast agents?
50%.
242
What is the sensitivity of barium in detecting esophageal perforations?
50-80%.
243
After ablation therapy, how often are repeat scans performed?
6-12 months after ablation, then every 2 years.
244
What is the sensitivity and specificity of inspiratory:expiratory and lateral decubitus films for foreign body aspiration?
67% sensitive, 67% specific.
245
What is the accuracy of CT imaging in detecting bony erosion?
85%.
246
What is the accuracy of CT imaging in detecting bony erosion
85%.
247
What is the accuracy of MRI in detecting sinonasal tumors
94°/o, 98% if done with gadolinium.
248
What study should be performed prior to reoperation for persistent or recurrent hyperparathyroidism?
99Tc sestamibi is 85% sensitive in experienced centers; accuracy is increased if the patient is placed on cytomel prior to the scan to suppress thyroid uptake.
249
A 62-year-old woman comes in for cerumen removal. Medial deviation of her soft palate is noted incidentally on examination and the rest of her physical examination is unremarkable. MRI of the neck is likely to show what?
A deep-lobe parotid tumor with a "dumbbell' shape as it extends into the parapharyngeal space.
250
What is the Mondini deformity
Absence of the anterior I I /2 turns of the cochlea in the presence of a normally developed basal tum.
251
In a patient with aural atresia and no evidence of sensorineural hearing loss, when should a CT scan of the temporal bones be obtained?
Age 4 or 5.
252
A 23-year-old man comes in with chronic nasal congestion, sneezing, sinus pressure, and rhinorrhea. CT scan of the sinuses shows a peripheral rim of low-density edematous mucosa surrounding homogeneous, high-attenuation material in the maxillary and ethmoid sinuses bilaterally with scattered calcifications and sinus wall expansion. What is the likely diagnosis?
Allergic fungal sinusitis.
253
Name the tumor based on findings from plain radiographs of the mandible. **Displaced surrounding structures,with multiple loculations and a honeycomb appearance**
Ameloblastoma
254
Which cardiovascular medication will interfere with radioiodine scanning?
Amiodarone.
255
What problems can occur with MRI fat suppression at the skull base
Artifact, secondary to air meeting soft tissue, can obscure important anatomical details (i.e. foramina).
256
What problems can occur with MRI fat suppression at the skull base?
Artifact, secondary to air meeting soft tissue, can obscure important anatomical details (i.e., foramina).
257
An asymptomatic patient has an incidental finding of a high signal in the left petrous apex on Tt-weighted images. What is the significance of this finding?
Asymmetric pneumatization of the petrous tip is present in 4% of patients; the high signal is from the bone marrow.
258
An asymptomatic patient has an incidental finding of a high signal in the left petrous apex on Tl-weighted images. What is the significance of this finding
Asymmetric pneumatization of the petrous tip is present in 4% of patients; the high signal is from the bone marrow.
259
What are the criteria of abnormal swelling of the retropharynx on a lateral neck film
At the level of C2, 7mm or greater thickness of the retropharynx is abnormal; at the level of C6, 22mm or greater thickness of the retropharynx is abnormal.
260
~Diag005~ Below is the axial CT scan temporal bone of a patient with mild right SNHL. What advice should the patient receive in regard to preventing further hearing loss?
Avoid contact sports and wear head protection when possible; avoid roller coasters, weight lifting, scuba diving, and extreme/rigorous activities. (CT scan shows enlarged vestibular aqueduct.)
261
On CT imaging of the temporal bone, which ear structures are best seen on axial views?
Body of the malleus and incus, incudostapedial joint, and the round window.
262
Why is speed important in head and neck imaging
Breathing and swallowing can limit resolution.
263
What are the typical findings of a meningioma on MRI?
Broad based with "dural tail sign" on MRI with gadolinium.
264
What are the typical findings of a meningioma on MRI
Broad-based with "dural tail sign" on M RI with gadolinium.
265
What are the advantages of ultrasound in the evaluation of thyroid nodules?
Can detect nodules as small as 2-3mm; can differentiate between solid, cystic or mixed nodules with over 80% accuracy; can detect the presence of lymphadenopathy
266
What are the contraindications to MRI
Cardiac pacemaker, cochlear implant, pacer wires, Swan-Gantz catheter, metallic intraocular foreign body, intracranial aneurysm clips.
267
What are the absolute contraindications to MRI?
Cardiac pacemaker, metallic intraocular foreign body, intracranial aneurysm clips.
268
What tumor is shown below?
Carotid body tumor. Angiogram shows splaying of the carotid bifurcation by a well-defined tumor blush ("lyre sign").
269
A 52-year-old man presents with a neck mass. Axial T1-weighted images of his neck show a round soft tissue mass with prominent flow voids at the level of the carotid bifurcation displacing the internal carotid artery posteriorly and the external carotid artery anteriorly. Postgadolinium, the mass enhances intensely. What is the likely diagnosis?
Carotid body tumor.
270
Name the tumor based on findings from plain radiographs of the mandible. **Well-circumscribed lesion with a dense core and lucent rim; the core enlarges and rim diminishes with maturation**
Cemento-ossifyling fibroma
271
Name the tumor based on findings from plain radiographs of the mandible. **Soft tissue mass with amorphous "popcorn" calcifications**
Chondrosarcoma
272
Which imaging device has the highest sensitivity and specificity for identifying and delineating residual and recurrent tumors of treated head and neck cancer?
Combined FDG-PET/CT scan.
273
In patients with an unknown primary of the head and neck, how useful is a combined FDG-PET/CT scan in detecting the primary tumor site?
Combined FDG-PETICT scan will identify the primary in approximately 35% of cases of unknown primary.
274
What is the alternative method used to image the skull base
Comparison of pre- and post-gadolinium images.
275
What is a flow void?
Complete lack of signal after contrast due to moderate to high blood flow.
276
What is a flow void
Complete lack of signal after contrast due to moderate to high blood flow.
277
What is the differential diagnosis of a soft tissue mass on the promontory?
Congenital cholesteatoma, paraganglioma, aberrant carotid artery, persistent stapedial artery, and glomus tympanicum.
278
What is in the differential diagnosis of a soft tissue mass on the promontory
Congenital cholesteatoma, paraganglioma, aberrant carotid artery, persistent stapedial artery, and glomus tympanicum.
279
What finding on barium swallow is classic for cricopharyngeal dysfunction?
Cricopharyngeal bar.
280
Why should radionuclide scanning precede CT scan imaging of the thyroid gland?
CT scan contrast will linger in the thyroid gland for up to 6 months and interfere with radionuclide scanning.
281
Why should radionuclide scanning precede CT scan imaging of the thyroid gland
CT scan contrast will linger in the thyroid gland for up to 6 months and interfere with radionuclide scanning.
282
What is the initial test of choice in patients with pulsatile tinnitus and a retrotympanic mass?
CT scan of the temporal bones.
283
A 45-year-old woman with type I diabetes comes into the emergency room with severe left otalgia. She has been on topical ciprofloxin eardrops for the past 2 weeks without improvement. On examination, she has significant swelling of the pinna and external auditory canal (EAC) and granulation tissue is seen in the lateral portion of the canal. What imaging studies should be ordered?
CT scan with contrast and technetium-ggm bone scan to evaluate for osteomyelitis ofthe temporal bone.
284
What is the most common long-term side effect from radioactive iodine therapy?
Decreased saliva production.
285
What would the ultrasound show in a fetus with complete glottic atresia?
Distension of the airway and lung parenchyma; flattening of the diaphragm; edema of the placenta; compression of the heart, great vessels, and thoracic duct.
286
What is the initial test of choice in patients with pulsatile tinnitus and normal otoscopy?
Duplex carotid ultrasound and echocardiogram in patients suspected of carotid/coronary artery disease; otherwise, MRI/MRA/MRV brain and neck.
287
How does otosclerosis appear on CT scan?
Early on, areas of deossification, in particular, a double low attenuation ring paralleling the cochlear turns and lucencies along the margins of the oval window are present. As the disease progresses, foci of denser bone develop, eventually resulting in obliteration.
288
How does otosclerosis appear on CT scan
Early on, areas of deossification, in particular, a double low attenuation ring paralleling the cochlear turns and lucencies along the margins of the oval window are present. As the disease progresses, foci of denser bone develop, eventually resulting in obliteration.
289
A 49-year-old woman comes in with headache and unilateral rhinorrhea. CT scan of the brain and sinuses shows an enlarged foramen cecum, crista galli erosion, increased interorbital distance, and a mixed soft tissue and fluid density mass. What is the likely diagnosis?
Encephalocele.
290
What is the advantage of multidetector CT imaging over conventional CT imaging
Extremely fast, thin slices with high resolution.
291
True/False: Cholesteatomas enhance with gadolinium.
False.
292
T/F: Cholesteatomas enhance with gadolinium
False.
293
What should be applied when using fast-spin echo MRI?
Fat saturation (otherwise fat will remain bright on T2 images with fast-spin echo).
294
A 7-year-old boy is found on examination to have stenosis of his right EAC. CT scan shows ground glass appearance of the temporal bone. What is the likely diagnosis?
Fibrous dysplasia.
295
What is FDG?
Fludeoxyglucose; a glucose analog with the radioactive isotope fluorine-18 substituted for one of the normal hydroxyl groups on the glucose molecule. It competes with glucose to enter into metabolically active cells. Like glucose, it is phosphorylated inside the cell, but unlike glucose-6-phosphate, FDG-6-phosphate cannot undergo further metabolism and becomes trapped.
296
Which temporal bone structures are best visualized with T2-weighted MRI?
Fluid-filled compartments.
297
Which temporal bone structures are best visualized with T2-weighted MRI
Fluid-filled compartments.
298
A limited coronal CT scan of the sinuses is least sensitive for detecting disease in which sinus?
Frontal sinus.
299
What scan can be used for monitoring the progress of malignant otitis externa
Gallium citrate scan.
300
What imaging study is used to monitor the response to therapy for osteomyelitis?
Gallium-67 scan.
301
On CT scan with axial cuts, what structures are seen in the same plane as the porus acousticus (mouth of the lAC)
Head of the malleus, horizontal SCC, and epitympanic recess.
302
On CT scan temporal bone with axial cuts, what structures are seen in the same plane as the porus acousticus?
Head of the malleus, horizontal semicircular canal (SCC), and epitympanic recess.
303
How does cholesterol granuloma appear on MRI?
High signal on both T1- and T2-weighted images.
304
How does cholesterol granuloma appear on MRI
High signal on both Tl and T2-weighted images.
305
Arteriography before surgery is recommended for stable injuries to which zones of the neck?
I and III.
306
How does a cholesteatoma appear on MRI
Intermediate signal on T I and high signal on T2-weighted images.
307
How does a cholesteatoma appear on MRI?
Intermediate signal on T1-weighted images and high signal on T2-weighted images.
308
What findings on thyroid ultrasound are associated with an increased risk of malignancy?
Irregular/indistinct margins, heterogeneous nodule echogenicity, intranodular vascular images, microcalcifications, complex cysts, and diameter \>1em.
309
What is the most commonly identified inner ear malformation on temporal bone imaging studies?
Isolated lateral SCC defects.
310
A 16-year-old boy comes in with recurrent epistaxis. CT scan of the sinuses shows anterior bowing of the posterior wall of the maxillary antrum (Holman-Miller sign). What is the likely diagnosis?
Juvenile nasopharyngeal angiofibroma.
311
A 72-year-old man presents with a 3-month history of worsening dysphagia. He was recently treated for pneumonia and reports frequently spitting up undigested food. His barium swallow is shown below: What would be the likely findings if esophageal manometry were performed on this patient?
Lack of coordination between the pharynx and cricopharyngeus muscle, hypertensive upper esophageal sphincter, hypotensive lower esophageal sphincter, and abnormal esophageal peristalsis.
312
A 1-year-old child comes into the emergency room with a 3-day history of rhinorrhea and cough and now has stridor. Below are his AP neck films. What is the diagnosis?
Laryngotracheobronchitis (croup).
313
What is the main problem with using CT imaging to evaluate sinonasal tumors?
Limited accuracy in differentiating soft tissue masses from secretions.
314
What is the main problem with using CT imaging to evaluate sinonasal tumors
Limited accuracy in differentiating soft tissue masses from secretions.
315
What is the imaging modality of choice for lymphatic malformations?
Magnetic resonance imaging (MRI). Chest X-ray (CXR) should also be performed to rule out mediastinal extension or pleural effusion.
316
~Diag006~ CT scan of the temporal bones is performed on a 6-year-old boy with hearing loss. Findings include absence of the anterior tl/2 turns of the cochlea, a normally developed basal turn, wide vestibular aqueduct, plumb-deformed vestibule, and "empty cochlea." What is the likely diagnosis?
Mondini malformation.
317
~IMAGE~ A 54-year-old man presents with high fever, nausea, hypotension, and severe left-sided headache. Two weeks ago he was treated for left otitis media with azithromycin. On examination, he has severe edema and erythema over his left mastoid. Noncontrast CT scan of the brain shows the delta sign and contrast CT scan of the brain shows the reverse delta sign. What test should be ordered next?
MRI with gadolinium and MRV brain to confirm sigmoid sinus thrombophlebitis.
318
What is the Steeple sign
Narrowing of the airway 5 - I 0 mm below the true vocal cords on an AP neck film; seen in 50 - 60% of children with croup.
319
How is atlantoaxial subluxation diagnosed?
Neck pain and torticollis with an atlas-dens interval of \>4 mm in children and \>3 mm in adults.
320
Which temporal bone structures are best visualized with Tt-weighted MRI?
Nerves within the lAC.
321
Which temporal bone structures are best visualized with Tl-weighted MRI
Nerves within the lAC.
322
How long after ablation therapy should a woman avoid getting pregnant?
One year.
323
Where does mucosal thickening most often occur on CT scans of the sinuses?
Osteomeatal complex.
324
Name the tumor based on findings from plain radiographs of the mandible. **Sunburst appearance,radiating periosteal, new bone**
Osteosarcoma
325
What other diseases can mimic otosclerosis radiographically?
Paget's disease and osteogenesis imperfecta.
326
What other diseases can mimic otosclerosis radiographically
Paget's disease and osteogenesis imperfecta.
327
In patients with an unknown primary of the head and neck, how useful is a PET scan in detecting the primary tumour site
PET scan will identify the primary in approximately 35% of cases of unknown • pnmary.
328
What are the problems with using PET in the head and neck
Poor resolution (a focus of SCCA needs to be several mm to be detected) and difficult to correlate with exact anatomy.
329
How well do CT scan findings correlate with patient symptoms and endoscopic findings in patients with chronic rhinosinusitis?
Positive endoscopic findings correlate well with positive CT scans, but only 71% of patients with negative endoscopic findings will have a negative CT scan. CT scan findings correlate poorly with patient symptoms.
330
How does a PET/SPECT scan work?
Radionuclide metabolic substrates are injected intravenously and detected by either production of positrons (PET) or by a directionally sensitive gamma camera (SPECT)-metabolically active tissues light up.
331
How do PET/SPECT work
Radionuclide metabolic substrates are injected IV and detected by either production of positrons (PET) or by a directionally sensitive gamma camera (SPECT)... metabolically active tissues light up.
332
A 3-year-old boy presents to the emergency room with drooling but is breathing normally. Below is his chest radiograph. What is the diagnosis?
Retained coin in the esophagus.
333
A 6-month-old child comes into the emergency room with fever, dysphagia, and drooling. Below is his lateral neck film. What is the diagnosis?
Retropharyngeal abscess; criteria for diagnosis on lateral neck film are 7 mm or greater thickness of the retropharynx at the level of C2 or 22 mm or greater thickness of the retropharynx at C6.
334
Which type of tumors in the head and neck are less likely to be detected byFDG-PET?
Salivary gland tumors and tumors with a large amount of necrosis.
335
How does a glomus jugulare tumor appear on MRI
Salt and pepper appearance on Tl -weighted images with gadolinium.
336
What temporal bone malformation is classic for rubella?
Scheibe malformation.
337
What are the typical MRI findings of hemangiomas?
Serpentine high-volume flow voids surrounded by nonvascular soft tissue.
338
On CT scan temporal bone with axial cuts, what structures are seen in the same plane as the stapes?
Sinus tympani, handle of the malleus, vestibule, cochlea, and pyramidal eminence.
339
On CT scan with axial cuts, what structures are seen in the same plane as the stapes
Sinus tympani, handle of the malleus, vestibule, cochlea, and pyramidal eminence.
340
What is the SUV?
Standardized uptake value; ratio of FDG concentration in a region of interest to its concentration in the whole body.
341
On CT imaging of the temporal bone, which ear structures are best seen on coronal views?
Stapes, oval window and the vestibule.
342
Which radiographic view on plain films of the face is best for visualizing the zygomatic arches?
Submental vertex.
343
~Diag007~ A 33-year-old woman complains of chronic disequilibrium and difficulty keeping her balance while jogging. Her physical examination is normal and complete audiometric examination shows unilateral low frequency conductive hearing loss (CHL) and normal acoustic reflexes. Below is aCT scan of her inner ear:What is the diagnosis?
Superior SCC dehiscence.
344
What substrate is used in lymph node functioning imaging?
Superparamagnetic iron oxide coated dextran.
345
What substrate is used in lymph node functioning imaging
Superparamagnetic iron oxide coated dextran.
346
What is the signal intensity produced by fat on Tl and T2-weighted MRI
T 1 - high signal; T2 - low signal.
347
What is the signal intensity produced by water on Tl and T2-weighted MRI
T I - low signal; T2 - high signal.
348
What is the signal intensity produced by fat on Tt- and T2-weighted MRI?
T1-high signal; T2-low signal.
349
What is the signal intensity produced by water on Tt- and T2-weighted MRI?
T1-low signal; T2-high signal.
350
What scan can be used for diagnosis of malignant otitis externa
Techneti urn 99 •
351
What distinguishes otosclerosis from Paget's disease radiographically
The radiographic changes are more extensive and pronounced with Paget's disease; they also are more likely to be bilateral and may include narrowing of the lAC.
352
What distinguishes otosclerosis from Paget's disease radiographically?
The radiographic changes are more extensive and pronounced with Paget's disease; they are also more likely to be bilateral and may include narrowing of the internal auditory canal (lAC).
353
Which plating material has been shown to have significantly less streak artifacts on CT scans?
Titanium (as compared with stainless steel and vitallium).
354
What is the most useful application of thyroid scanning in patients with thyroid cancer?
To detect residual thyroid tissue or occult distant metastases after thyroidectomy.
355
True/False: CT scan of the larynx underestimates the stage of laryngeal cancer.
True.
356
True/False: PET scans typically have minimal impact on T-staging following conventional assessment of head and neck tumors.
True: PET scans are more valuable for providing additional information in relation to nodal and distant disease staging.
357
Using MRI, how can one distinguish inflammation from tumor in the sinuses
Tumor will be isointense on both T I and T2 weighted images, while inflammation will be hyperintense on T2 weighted images.
358
Using MRI, how can one distinguish inflammation from tumor in the sinuses?
Tumor will be isointense on both T1- and T2-weighted images, while inflammation will be hyperintense on T2-weighted images.
359
What are the indications for MRI in a patient with tinnitus?
Unilateral unexplained tinnitus with or without hearing loss; bilateral symmetrical or asymmetrical hearing loss suspicious for retrocochlear etiology (poor discrimination, absent acoustic reflexes, acoustic reflex decay, abnormal auditory brainstem response).
360
What is the best radiographic test to evaluate swallowing?
Videofluoroscopic barium swallow.
361
How does it appear on CT scan
Wide vestibular aqueduct, plumb-deformed vestibule, and "empty cochlea".
362
What percent of patients with immune-mediated Meniere's disease will have a positive anti-68-kD Western blot test?
30-50%.
363
What is the false-negative rate of RET analysis?
5%.
364
What is the sensitivity of this test?
50% (less if already on antibiotics).
365
What percent of patients with WHO types II and III tumors have abnormally increased titers to EBV VCA and NA?
50-80%
366
What is the latency period for seroconversion following exposure to the HIVvirus?
6-12 months.
367
What test provides prognostic information in patients with NPC?
Antibody-dependent cellular cytotoxicity (ADCC) assay.
368
What test should be ordered in a patient with an elevated TSH?
Antimicrosomal antibody (antithyroperoxidase level) to rule out Hashimoto's thyroiditis.
369
What test should be performed in a patient with suspected allergic fungal sinusitis who does not have classic findings on CT scan or positive middle meatal cultures?
Aspergillus skin test and precipitins.
370
What laboratory workup is necessary in patients with MTC?
Basal and pentagastrin stimulated calcitonin levels, serum calcium, 24-hour urine catecholamines, VMA, and metanephrine, +I-CEA.
371
What tests confirm the diagnosis of infectious mononucleosis?
Blood smear showing atypical mononuclear cells and a positive Paul-Bunnell test (elevated heterophile titer of Epstein-Barr virus).
372
What is the difference in the Ca/Cr clearance ratio in someone with FHH and someone with primary hyperparathyroidism?
Ca/Cr clearance 0.02 in primary hyperparathyroidism.
373
What lab test should be obtained in patients with a family history of medullary thyroid cancer (MTC)?
Calcitonin.
374
What lab test is most specific for Wegener's?
c-ANCA.
375
Patient with Cogan's syndrome usually have elevated titers to what organism?
Chlamydia.
376
What adjunctive test should be performed in a female with suspected juvenile nasopharyngeal angiofibroma?
Chromosome analysis.
377
What are the histochemical characteristics of MTC?
Congo red dye positive, apple-green birefringence consistent with amyloid; immunohistochemistry positive for cytokeratins, CEA, and calcitonin.
378
Why is measurement of the C-terminal of PTH not accurate for diagnosis of secondary hyperparathyroidism?
C-terminal fragments are cleared by the kidney; elevation may indicate either renal insufficiency or hyperparathyroidism.
379
What test is used to diagnose pertussis?
Culture from the nasopharynx using a Dacron or calcium alginate swab placed on a Regan-Lowe or Bordet-Gengou agar plate.
380
What is the most useful study of nontuberculous mycobacterial adenitis of the head and neck region in children?
Culture.
381
What laboratory test is associated with lymphoproliferative malignancy in patients with Sjogren's syndrome?
Decreased level of serum IgM.
382
What are the typical laboratory findings in patients with relapsing polychondritis?
Elevated ESR, moderate leukocytosis, mild-to-moderate anemia.
383
What are the most common immunologic findings among patients with nasopharyngeal carcinoma (NPC)?
Elevated IgA and IgG antibodies against the viral capsid antigen of EBV.
384
What are the characteristics of CSF in the presence of meningitis?
Elevated protein, WBC, and pressure; decreased glucose.
385
True/False: FfA-ABS becomes negative once a patient has been adequately treated for syphilis.
False.
386
What are the only antigen-specific tests for syphilis?
Fluorescent treponema!antibody-absorption (FTA-ABS) and microhemagglutination assay-treponema pallidum (MHA-TP) tests.
387
The 68 kDa antigen is thought to represent what protein?
Heat shock protein 70.
388
What are some common laboratory findings in patients with sarcoidosis?
Hypergammaglobulinemia, elevated liver function tests, calcium, ESR, and angiotensin-converting enzyme (ACE).
389
How is congenital cytomegalovirus (CMV) diagnosed in the newborn?
Identification of serum anti-CMV IgM, "owl eye" bodies in the urinary sediment, and intracerebral calcifications on radiographs.
390
What serum albumin level is associated with malnutrition?
Less than 3 gjdL.
391
What is an abnormal Schirmer test?
Less than 5 mm wetting after 5 minutes; less than 10 mm wetting after stimulation with 10% ammonia.
392
How does this assay predict survival?
Low levels are associated with worse prognosis.
393
What is the role of ascertaining EBV titers in patients with NPC?
May be a valuable screening tool in high-risk populations and can help establish the diagnosis of NPC in the patient with an unknown primary. In patients with type I disease, EBV titers are not elevated and have no prognostic significance.
394
How do you test for multiple myeloma in a patient with extramedullary plasmacytoma?
Measure serum M-protein and urine Bence Jones protein; bone survey; bone marrow biopsy.
395
What laboratory tests can be used to diagnose CSF leak?
Measurement of glucose (nasal secretions are devoid of glucose), P-2-transferrin.
396
What is the most accurate test for diagnosis of primary hyperparathyroidism?
Measurement of intact PTH.
397
What tests are use to diagnose Sjogren's syndrome?
Minor salivary gland biopsy showing mononuclear cell infiltration, SS-A, SS-B, ANA, and RF.
398
What is the most accurate method of determining if otorrhea is CSF?
P-2-transferrin assay.
399
What autoantibody is present in 75% of patients with rheumatoid arthritis?
Rheumatoid factor
400
HLA-DW4 antibodies are most commonly seen in which autoimmune disease?
Rhuematoid arthritis.
401
What is the single best measure of nutritional status?
Serum albumin level.
402
What test is used to distinguish a hypothalamic defect from a pituitary defect in a patient with hypothyroidism?
The thyrotropin-releasing hormone (TRH) stimulation test.
403
What is the purpose of obtaining a thyroglobulin level prior to thyroidectomy?
Thyroglobulin has been shown to correlate well with histologic tumor type and is useful as a marker for tumor recurrence.
404
Which serum proteins can be used to assess short-term nutritional status?
Transferrin (half-life of 8-g days), prealbumin (half-life of 2 days), and retinal-binding globulin (half-life of 12 hours).
405
True/False: Thyroglobulin levels should be obtained prior to performing FNA on a thyroid nodule.
True: FNA will falsely elevate thyroglobulin levels.
406
What is the latency period for developing antibodies to hepatitis C?
Up to 4 months.
407
What is the significance of a rising c-ANCA titer in a patient with Wegener's?
Usually indicates a relapse of active disease.
408
What test is used to screen for syphilis?
Venereal disease research laboratory (VDRL).
409
What is the most specific diagnostic test for Cogan's syndrome?
Western blot antigen test
410
What is the most specific test for the diagnosis of autoimmune sensorineural hearing loss?
Western blot assay for 68 kD inner ear antigen (Otoblot) (95% specific).
411
What percentge of nodules with follicular or Hiirthle cells on FNA are malignant?
10-20%.
412
When is the ideal time to perform endoscopy after ingestion?
24-48 hours postingestion.
413
What is the incidence of a nondiagnostic or "suspicious" result on thyroid nodule FNAs?
25%.
414
What is the incidence of false positives and false negatives with FNA of thyroid nodules?
4% false positive; 4% false negative.
415
What percent of thyroid nodules are benign on FNA?
70%.
416
What is the sensitivity of the 24-hour pH probe for gastroesophageal reflux disease (GERD)?
92-94%.
417
What would be the likely PFf results in a 44-year-old woman with pneumonia?
Both FEV1 and FVC would be decreased but FEV1/FVC would be normal.
418
What would be the likely PFf results in a 75-year-old man with a so-pack-year smoking history?
Both FEV1and FEV1/FVC would be decreased and RV and TLC would be increased.
419
What diseases may present with hemoptysis in children?
Bronchiectasis, cystic fibrosis, foreign body, pulmonary hemosiderosis, tuberculosis.
420
What is the most common head and neck manifestation of neuroblastoma?
Cervical metastatic disease.
421
What illness is characterized by a staccato cough?
Chlamydia pneumonia.
422
What illness is characterized by a seal-like barking cough?
Croup.
423
What test has the highest yield for diagnosis of vascular rings?
Direct laryngoscopy and bronchoscopy.
424
What is the test of choice in the evaluation of caustic ingestion?
Endoscopy.
425
What kind of stridor is heard in patients with tracheomalacia?
Expiratory.
426
True/False: Enlargement of the preauricular lymph nodes is indicative of parotid pathology.
False: These nodes enlarge from inflammation or metastasizing tumors from the scalp.
427
Which thyroid tumors cannot be diagnosed as malignant with FNA?
Follicular and Hiirthle cell.
428
What percent of thyroid nodules are malignant when FNA is suspicious?
For papillary and Hiirthle, the risk of malignancy is 57%. For follicular, the risk is 20-25%.
429
What is the classic physical finding of carotid body tumors?
Freely moveable in the lateral direction but fixed in the cephalic-caudal direction.
430
Most false positive FNAs are due to what disease?
Hashimoto's thyroiditis.
431
A supraclavicular stab wound is in which neck zone?
I.
432
What is the risk of performing fine needle aspiration (FNA) on scrofula?
May lead to a chronically draining cutaneous fistula.
433
What is the most common presentation of a parapharyngeal space tumor?
Medial displacement of the lateral oropharyngeal wall or as a palpable mass beneath the angle of the mandible.
434
What is the "Waterson sign"?
Obliteration of the right radial pulse by compressing the anterior tracheal indentation with the tip of the bronchoscope.
435
What is the best test to distinguish obstructive from restrictive lung disease?
Pulmonary function test (PFT).
436
What is the typical endoscopic appearance of innominate artery compression?
Pulsatile compression of the anterior tracheal wall in the distal trachea.
437
True/False: FNA should be performed on a 6-mm nodule if the ultrasound shows microcalcifications.
True.
438
What information does esophageal manometry provide?
Upper esophageal sphincter responsiveness and pharyngeal peristalsis.
439
How can one differentiate a vagal paraganglioma from a carotid body tumor?
Vagal paragangliomas displace the internal and external carotid anteriorly and medially, whereas carotid body tumors displace the internal carotid artery posteriorly and the external carotid artery anteriorly.
440
What factors significantly increase the risk of sampling error from FNA?
Very small (4 em) nodules, hemorrhagic nodules, or multinodular glands.
441
What is the Euler-Byrne formula?
X + 4Y, where X= number of episodes the pH is 5 minutes; a score of 50+ is clinically significant for GERD.
442
When testing for dysarthria, problems with saying "Ka, Ka, Ka"; "La, La, La"; and "Me, Me, Me" indicate deficits in which nerves?
* "KA KA KA": IX and X
* "LA LA LA": XII
* "ME ME ME" VII
443
What is the incidence of cranial nerve palsy at initial presentation in patients with nasopharyngeal carcinoma?
12-18%.
444
When is myelination of individual axons of the facial nerve complete?
Age 4•
445
How does the course of the facial nerve differ between adults and children?
At birth, the nerve is located superficially within the poorly formed mastoid; with maturation, the nerve is displaced medially and inferiorly.
446
When is ENoG evaluation meaningful?
Between days 3 and 21 after complete loss of voluntary function.
447
When are all five divisions of the facial nerve present in the fetus?
By the 8th week of gestation.
448
What electrophysiologic test is more useful 3 weeks after the onset of complete facial paralysis?
EMG.
449
What test should be performed on Afro-Caribbean migrants with idiopathic facial nerve palsy?
HTLV-1 antibody screen.
450
What is the next most accurate test when ENoG is unavailable?
Maximal stimulation test.
451
Small, irregular pupils that react irregularly to light but better to accommodation suggest what infectious disease?
Neurosyphillis.
452
What should be done if motor unit potentials are detected on EMG?
No further therapy is indicated.
453
What prognostic information does electroneurography (EnoG) provide for facial nerve paralysis?
Patients with 95% degeneration or greater have a so% chance of unfavorable recovery; if at least 10% function is retained in the first 21 days of paralysis, 80-100% functional recovery is highly likely.
454
What is the Myerson sign?
Persistent blinking when the forehead is tapped repeatedly is an abnormal manifestation of the glabellar reflex, a primitive reflex seen in infants that may be a sign of frontal lobe disease in adults.
455
Which cranial nerves are tested with the corneal reflex test?
Tests V and VII on the side stimulated and VII consensually.
456
True/False:True diplopia should resolve with one eye closed.
True.
457
What test should be performed when too% neural degeneration is recorded with ENoG?
Voluntary electromyography (EMG) recording; regenerating nerve fibers conducting at different rates can result in an overestimation of neural degeneration on ENoG.
458
Winging of the scapula is seen with deficits in which nerve?
XI
459
Topical decongestants have a statistically significant different response between normal and allergic subjects are given a topical decongestant. For which valley on acoustic rhinometry will a statistically different response be seen?
1st valley.
460
What do the three valleys on acoustic rhinometry represent?
1st valley-nasal valve; 2nd valley-anterior portion of the middle turbinate; 3rd valley-middle portion of the middle turbinate.
461
What percent of patients with nasopharyngeal carcinoma will have a normal exam by fiberoptic endoscopy at the time of initial evaluation?
6%.
462
What is the reservoir sign?
A rush of clear rhinorrhea occurs with sudden upright position.
463
When is lumbar puncture indicated in patients with preseptal cellulitis?
Age less than 2 months, meningeal or focal neurologic signs, clinical toxicity.
464
What percent of patients with sinonasal tumors are asymptomatic at presentation?
Approximately 10%.
465
What study confirms the diagnosis of primary ciliary dyskinesia?
Electron microscopic study of cilia from nasal respiratory mucosa.
466
What three signs are classically present in patients with sinonasal neoplasms?
Facial asymmetry, tumor bulge in the oral cavity, and nasal mass; the presence of all three is seen in about so% of patients and is significant for advanced disease.
467
What signs on physical exam are suggestive of cerebrospinal fluid leak?
Halo sign and reservoir sign.
468
What is the most common symptom of isolated sphenoid disease?
Headache.
469
What effect do nasal dilator strips have on nasal airflow as measured by spirometry?
Increase peak inspiratory flow rates.
470
What is stertor?
Inspiratory low-pitched sound resulting from turbulent airflow through the nasal cavity and nasopharynx.
471
A 30-year-old man presents with chronic sneezing, pruritus, rhinorrhea, and nasal congestion. His past medical history is significant for asthma. Comprehensive allergy testing and serum lgE are normal. What is the most likely diagnosis and what test should be ordered to confirm this?
NARES (nonallergic rhinitis with eosinophilia syndrome); nasal smear will show marked eosinophilia (\>2S%).
472
What are the most common symptoms of chronic rhinosinusitis?
Nasal congestion and obstruction.
473
What is the most common presenting symptom of sinonasal neoplasms?
Nasal obstruction (50%).
474
What are the diagnostic criteria for sarcoidosis of the sinuses?
Radiographic evidence of sinusitis, histopathologic confirmation of noncaseating granulomas in the sinus tissue, negative serologic test for syphilis and c-ANCA, and negative stains for fungus and AFB.
475
Acoustic rhinometry showing decreased cross-sectional area and nasal volume that does not improve with a topical decongestant suggests what disorder?
Septal deviation.
476
What is Sluder's syndrome?
Sinonasal headaches secondary to irritation of the sphenopalatine ganglion.
477
In an adult, what number is the left 3rd molar of the mandible?
17
478
How many deciduous teeth are there?
20
479
In an adult, what number is the right 3rd molar of the mandible?
32
480
How are deciduous teeth numbered?
A to T.
481
What is the bite abnormality if the maxillary incisiors are lingual to the mandibular incisors?
Anterior crossbite.
482
What are the physical signs associated with submucous cleft palate?
Bifid uvula, abnormal palatal motion, midline diastasis of the palatal muscles, V-shaped notch of the hard palate.
483
Anterior open bite suggests which type of fracture?
Bilateral condylar fractures.
484
What is the most common oral manifestation of AIDS?
Candidiasis.
485
If the mesiobuccal cusp of the maxillary 1st molar lies anterior to the mesiobuccal groove of the mandibular 1st molar, what is the occlusion?
Class II.
486
What are the typical presenting features of ankyloglossia?
Infant has difficulty latching on during breast feeding and mother experiences prolonged nipple pain.
487
What is an open bite?
Lack of anterior incisal contact when the posterior teeth are in occlusion.
488
What is the difference between overbite and overjet?
Overbite occurs in the vertical plane, whereas overjet occurs in the horizontal plane.
489
What is lingua plicata?
Scrotal tongue (seen in Melkersson-Rosenthal syndrome).
490
What is class I occlusion?
The mesiobuccal cusp of the maxillary 1st molar articulates with the mesiobuccal groove of the mandibular 1st molar.
491
What substance can be applied to the mucosa of the oral cavity to help detect malignant and premalignant lesions?
Toluidine blue
492
What is the Occupational Safety and Health Administration's limit for noise exposure without hearing protection?
140 dB.
493
In patients with head and neck cancer undergoing chemoradiation, when do quality of life scores rise above pretreabnent QOL scores?
6-12 months after treatment.
494
What is the primary limitation of the University of Washington Quality of Life Instrument, version 4?
Does not assess psychological issues.
495
What is the leading cause of years lost to disability in the world today?
Major depression.
496
A patient with a Karnovsky scale score between 50% and 70% is at what level of functioning?
Not able to work but able to care for most of his/her personal needs and live at home.
497
What methods have been shown to help ameliorate the adverse effects of chemoradiation in head and neck cancer patients?
Speech therapy, swallowing therapy, intensity-modulated radiation therapy, amifostine.
498
True/False: Laryngeal cancer patients who undergo chemoradiation with organ preservation have overall better quality of life than those who undergo total laryngectomy.
True.
499
What are the two most common residual symptoms after successful treatment of head and neck cancer with chemoradiation?
Xerostomia and dysphagia.
