Golden Flashcards
(208 cards)
1
Q
Potassium depletion IV infusion rate for central line vs. PIV
A
Central line: 20 mEQ/hr (40 max), requires continuous tele
PIV: 10 mEQ/hr IV infusion
2
Q
W’s: Cause of post op fever
A
Wind: POD 1-2, lungs: pneumonia, aspiration, PE, atelectasis
Water: 3-5, UTI, Cather-associated
Wound: 5-7, Surgical incisions
Wabscess (abscess): 5-7, infection of organ or space
Weins (veins): POD 5+, DVT, PE
Wonder drugs: anytime, drug fever, reaction to blood products
3
Q
5 Ps for discharge
A
PO, pain, pee, poop, ambulating (amPulating)
4
Q
Do you hold DVT prophylaxis for orbital floor fracture
A
Hold
5
Q
Heparin reversal
A
Protamine sulfate
1-1.5 mg IV for every 100 IU of active heparin
PTT should be monitored at 5-15 min after dose
6
Q
Heparin gtt dose and target therapeutic range
A
Initial: 80U/kg bolus + IV infusion 18 u/kg/hr
Therapeutic range: aPTT 70-110; draw PTT q6h
7
Q
Relationship between Mg and K
A
-K is secreted into the connecting tubule via ROMK channels, which is inhibited by magnesium
-If mg is low, K will be secreted more
-Low K requires correction of Mg
8
Q
6 Medications to address thyroid storm
A
- Propranolol 60 mg q4h: control increased adrenergic tone
- PTU 200 mg q4h: thionamide to block new hormone synthesis
- Iodine solution: block RELEASE of thyroid hormone
- Iodinated radiocontrast agent: inhibit peripheral conversion of T4 to T3
- Glucocorticoids: reduce T4–> T3 conversion, promote vasomotor stability, reduce autoimmune process of Graves, treat adrenal insufficiency
- Cholestyramine 4g QID: bile acid sequestration to decrease enterohepatic recycling of thyroid hormones
9
Q
Arterial oxygen content equation
A
O2 content = 1.34(HgB)(O2sat) + 0.003(PaO2)
10
Q
Neuroleptic malignant syndrome vs. Serotonin syndrome: Precipitated by
A
NMS: Dopamine antagonists
SS: Serotonergic agents
11
Q
NMS vs SS: Time of onset
A
NMS: 1-3 days
SS: <12 hrs
12
Q
NMS vs SS: Identical vital signs, mucosal, skin findings
A
Vital signs: HTN, tachycardia, tachypnea, hyperthermia >40 C
Mucosa: hypersalivation
Skin: diaphoresis
13
Q
NMS vs SS: muscular tone, reflexes, pupils, bowel sounds
A
NMS: Muscles: Lead-pipe rigidity in all muscles, HYPOreflexia, NORMAL pupils
SS: Increased tone, esp in lower extremities, HYPERreflexia and clonus, DILATED pupils
14
Q
Serotonin syndrome treatment
A
Cyproheptadine 12 mg PO, versed 2 mg IV
15
Q
Malignant hyperthermia treatment
A
2.5 mg/kg dantrolene IV loading dose, 1 mg/kg subsequent boluses
Ryanodex
16
Q
Neuroleptic malignant syndrome treatment
A
Dantrolene, bromocriptine (dopamine agonist), and amantadine (Dopamine agonist), lorazepam 2 mg IV/IM
17
Q
2 piece LF reliably expands how much
A
5-7 mm
Need SARPE if planning 10+ mm
Expansions greater than this are unstable
18
Q
What is a left shift in terms of cytokines
A
Left shift: increase in # of immature leukocytes in the peripheral blood (neutrophil band cells)
- Cytokines accelerate the release of cells from postmitotic reserve pool
19
Q
Why does decadron increase WBC
A
DEMARGINATION of leukocytes
-decreases inflammation by suppressing neutrophil migration into tissues
20
Q
Functional residual capacity in restrictive diseases vs obstructive
A
FRC decreased in restrictive diseases, pregnancy, obesity
Normal in COPD
21
Q
Hyperkalemia treatment
A
C BIG K Drop
1. Calcium gluconate or chloride: stabilize cardiac myocytes
2. Beta-2 agonist (albuterol) drives K into cells
3. Bicarb - buffer H release from cells as K goes in
4. Insulin w/ glucose (drives K into cells)
5. Kayexalate (SPS) - increased K excretion
6. Diuretic (loop)
7. Dialysis
22
Q
Tx for venous congestion after otoplasty
A
Leeches (can go into canal) and nitropaste
23
Q
How do medical leeches help with venous congestion
A
Secretes saliva that
1. Anesthetizes the skin
2. Relaxes tissues
3. Interferes with clotting cascade
4. Extracts an avg of 5 mL of blood and fluids while feeding and another 50 ml after detaching as the wound continues to ooze
24
Q
Infection from leech therapy
A
Aeromonas
25
Characteristics of arterial occlusion vs. venous congestion
1. Arterial occlusion: pale, mottled, cap refill >3 sec, prune-like, cool, scant amount of blood on pinprick
2. Venous congestion: dusky, cyanotic, blue, cap refill <3 sec, tense, swollen, cool, pinprick = rapid bleeding, dark blood
26
Should you do an otoplasty or sarpe first when doing combined case
Otoplasty = sterile then SARPE = nonsterile
27
Post-op instructions for otoplasty
Head wrap in 2 weeks 24/7, then 2 weeks just at night, no tennis sweat band
- no pressure on the ear during the day and only at night to prevent inadvertent pulling forward of the repaired auricle
- only tight enough that it doesn’t fall off
28
Mustarde technique vs. Davis technique for otoplasty
Mustarde: addresses anti helical fold
Davis: addresses conchal bowl hypertrophy
- postauricular conchal bowl wall min 8-10 mm preserved after kidney bean excision of cartilage
- need this minimum to prevent collapse of EAC,
29
Definition of success in terms of MMA for OSA
50% reduction in AHI, less than 20 events/hr
30
Definition of OSA cure after MMA
AHI <5
31
Hybrid arch bar vs. Erich arch bar for MMF adv and disadvantages
Hybrid arch bar: more cleansable, no orthodontic movement possible, mucosal overgrowth
Erich arch bar: can do ortho movements, difficult to cleanse
32
Pt with anterior open bite and macroglossia
Partial glossectomy, tongue reduction
33
Treatment options for VPI
Superiorly based pharyngeal flap (when intact activity laterally) vs sphincter pharyngoplasty
34
Advantage of intraoral vestibular incision for placement of AICBG
Natural pocket, stop for graft placement
35
Name the polysomnography monitors
EKG (heart), EOG (eye movements), EMG (muscle contractions), EEG (brain wave) pulse ox
36
How much time is spent in stage 2 (N2)
50%
Largest amt of time spent in N2
-25% spent in REM
37
How much sleep is spent in REM
25%
38
Maximum cc from AICBG, how much to take per 1 cm of defect
50 CC
- 10 cc per 1 cm defect
- 5 x 3 x 2 cm block
39
Triple abx solution for AICBG
Baci, ancef, gentamicin
40
Blood supply to AICBG
Deep circumflex iliac artery
Iliohypogastric (L1, L2 most lateral) - most commonly injured
Lateral femoral cutaneous (most medial)
41
Injury to what nerve during AICBG causes meralgia paresthetica
Lateral femoral cutaneous (most medial)
42
7 Muscle attachments of ASIS
1. External oblique m.
2. Transverse abdominal m.
3. Iliacus m.
4. Tensor fascia lata - gait disturbance
5. Gluteus medius and minimus
6. Inguinal ligament
7. Sartorius
43
Lateral femoral cutaneous n. Passes over ASIS ___% of the time
2.5%
Stay 2 cm lateral/posterior for incision
ASIS most likely to fracture
44
For young patients (age 10-14), DDX for ameloblastoma
Ameloblastic fibroma, ameloblastic fibro-odontoma
Tx: E&C with low recurrence rate
45
Contraindications of rhBMP
Synthetic recombinant bone morphogenetic protein from humans
- FDA-approved
- Contraindicated in pts with active cancer
46
Name substances from lowest to greatest hounsfield units
HU: describes radiodensity
Air (-1000) < fat < transudate < exudate < blood < soft tissue < bone
47
Name the ICU monitors and what they measure
1. External ventricular drain
2. A-line
3. PA cath
4. PCWP: indirect measure of left atrial pressure, looks for left ventricular failure
5. Central line = subclavian, IJ, or femoral veins
6. CVP: indirect measure of r atrial pressure and preload, elevated in R heart failure
48
What is a REBOA
Resuscitative endovascular balloon occlusion aorta (zones 1-3)
L subclavian —> celiac trunk, lowest renal a., iliac (aortic bifurcation)
49
What is cordis
Sheath introducer for central line, large bore for rapid infusion
50
Midodrine MOA
Alpha-1 agonist for orthostatic hypotension, hypotension in ICU, ween from IV pressors
51
Milrinone MOA
PDE3 inhibitor —> vasodilates, decreases afterload, increases contractility, inotropic, not chronotropic
- treats pulm artery HTN, treats heart failure
52
Dobutamine MOA
Beta-1 agonist
Lowers CVP and PCWP
-for cardio genie shock and inotropic support in advanced heart failure
53
Levophed MOA
Norepi, treats septic shock, treats hypotension that persists after fluid volume replacement
- alpha1, alpha2, beta1 agonist
54
Ephedrine MOA
Indirect agonist, releases stores of norepi
-increases HR, BP
- treats anes induced hypotension
55
Phenylephrine MOA
Direct alpha agonist
-increases BP, decreases HR reflexively, increases SVR, decreases HR and CO
56
Glucagon MOA
- promotes hepatic glycogenolysis and gluconeogenesis raising blood glucose
- Indicated for hypoglycemia when no IV access to give dextrose, beta-blocker overdose, Ca-blocker overdose, anaphylaxis
57
Succinylcholine MOA
Depolarizing muscle relaxant
- 2 Ach linked together
58
Succinylcholine risks to kids
Asystole, bradycardia, hyperkalemia, MH
- premeditate with atropine
- 10 mg (peds) dose for laryngospasm
- 1 mg/kg intubating dose
59
Mycophenolate (Cellcept) MOA
Inhibits T/B lymphocytes, inhibits inosine monophosphate dehydrogenase, inhibits guanosine nucleotide synthesis
- off label use for myasthenia gravis when pyridostigmine causes too many SE’s
60
Tacrolimus MOA
Inhibits T-lymphocyte activation (cellular immunity), inhibits calcineurin phosphatase
61
Keppra (Leviteracetem) MOA
Anticonvulsant used for seizure prophy
MOA unknown but may block Ca channels
62
Mupirocin (Bactroban) MOA
Topical antibiotic
Superficial skin infections, inhibits bacterial protein/RNA synthesis
63
Insulin MOA
Causes glucose uptake into cells, stimulates glycogen synthesis, inhibits gluconeogenesis
64
Salicylate poisoning symptoms and treatment
Symptoms: resp alkalosis 1st, then metabolic anion gap acidosis, tinnitus, n/v, AMS, pulmonary edema, arrhythmia (sinus tach most common)
Treatment: activated charcoal, sodium bicarb, hemodialysis
65
What is an implantable loop recorder
Insertable cardiac monitor
66
How much maxillary bone alveolar height is required to place implant at same time as direct sinus lift
4-5 mm minimum
67
Radiographic features of central giant cell granuloma
Anterior mandible, crosses midline, age 10-20 years old
68
What work up is needed after central giant cell granuloma diagnosis
Hyperparathyroid workup to r/o brown tumor
69
2 common causes of secondary hyperparathyroidism
Renal failure or vit D deficiency (low calcium, high PTH, high phosphate)
70
Noonan syndrome is associated with what tumors
Multiple central giant cell granulomas
71
Cause of tertiary hyperparathyroidism
Excessive PTH secretion after long-term parathyroid stimulation in secondary hyperparathyroidism (negative feedback of Ca no longer effective)
Tx: removal of 3/4 parathyroids
72
Wilkes classification based on clinical features
1. Early - painless clicking, unrestricted function
2. Early/intermediate - intermittent PAINFUL CLICKING and intermittent locking
3. Intermediate - pain during FUNCTION, locked and restricted motion
4. Intermediate/late - CONTINUOUS pain, locked and restricted motion
5. Late - severe joint dysfunction (CREPITUS) with variable pain
73
Wilkes classification based on imaging
1. Mild disc displacement, normal condyle
2. Moderate anterior disc displacement WITH REDUCTION, disc deformity
3. Complete disc displacement WITHOUT REDUCTION, disc deformity, NO bony changes or early changes
4. Complete disc displacement without reduction, moderate DEGENERATIVE BONY CHANGES
5. PERFORATION OF RETRODISCAL TISSUE and possible disc perforation, severe degenerative bony changes
74
Classification for condylar hyperplasia (name)
Wolford classification
75
Wolford classification for condylar hyperplasia
1A: Bilateral mand elongation
1B: unilateral mandibular elongation, chin deviation, midline shift
2A: unilateral vertical elongation of face, condylar enlargement WITHOUT horizontal exophytic growth off condyle
2B: unilateral vertical elongation of face, condylar enlargement WITH HORIZONTAL exophytic growth off condyle
3: unilateral facial enlargement, BENIGN tumor growth
4. Unilateral facial enlargement, MALIGNANT tumor growth
76
What is Restylane
Injectable hyaluronic acids produced by streptococcal fermentation (non-animal stabilized HA)
- Restylane fine line, restylane, Perlane
- 20 mg/ml of HA
- difference is the size of gel particles
77
Name filler injection techniques
Serial puncture, linear threading, fanning, cross-hatching aka radial, depot injections + massage
78
Kenalog 40 or kenalog 10 meaning
40 mg/cc or 10 mg/cc
79
Sotradecol (sodium tetradecyl sulfate) MOA
Sclerosing agent used to treat small, uncomplicated varicose veins in legs
- not a cure for varicose veins and may not be permanent
80
Name 5 vascular tumors
- Hemangiomas of infancy: superficial, deep, mixed
- Congenital hemangiomas: noninvoluting congenital hemangioma, rapidly involuting congenital hemangioma
- Kaposiform hemangioendothelioma
- Tufted Angioma
- pyogenic granuloma (lobular capillary hemangioma)
81
Name 4 simple vascular malformations
- capillary malformation
- venous malformation
- lymphatic malformation
- arteriovenous malformation
82
RIFLE classification (kidney)
- Risk: increase in SCr x 1.5 or decreased GFR >25%
-Injury: increase in SCr x 2 or decreased GFR >50%
- Failure: Increase in SCr x 3 or decreased GFR >75% or SCr >0.5 mg/dL increase to atleast 4 mg/dl
- Loss of kidney function: complete loss of kidney function >4 weeks
- End stage kidney disease: complete loss of kidney function >3 months
83
Criteria for acute kidney injury
Patients must have one of the following
- increase in SCr >0.3 mg/dL within 48 hr
- increase in SCr >1.5x baseline that is known or presumed to have occurred within past 7 d
- urine volume <0.5 mg/kg/hr for 6 hr
84
Severity of acute kidney injury
Stage 1: 1.5-1.9 x baseline SCr or >0.3 mg/dL increase in baseline SCr
Stage 2: 2.0-2.9 x baseline SCr
Stage 3: 3.0 x baseline SCr or increase in SCr to greater than 4.0 or renal replacement therapy (i.e dialysis)
85
Treatment of hyphema
Hyphema - blood in the anterior chamber
- prevention of secondary hemorrhage and intraocular hypertension
- Monitor IOP: Intraocular hypertension >50 mmHg for 5 days, >35 mmhg for 7 days
- Limitation of activity for atleast 1 week
- eye shield for atleast 1 week
- cycloplegia for management of pain
- glucocorticoid eye drops to lower risk of rebleeding
86
Retinal detachment vs. hyphema
Hyphema: vision worse laying back, improves sitting up
Retinal detachment: not positional, pt describes curtain-like shadow over visual field = emergency
87
Orbital floor fracture: when is ideal timing for surgery
- Ideal to perform surgery within 2 weeks to avoid fibrosis
88
Orbital floor measurement cut offs for treatment
- 1 cm^2 of inferior displacement
- >50% of orbital floor displaced
- Enopthalmos > 2 mm
- Symptomatic diplopia that does not improve in 1-2 weeks
89
Contraindications to coronectomy
Pathology
Horizontal impact ion
Non-vital 3Ms
Mobility
Immunocompromised
Previous XRT
Diabetes mellitus
Osteosclerosis/petrosis
90
Etiologies of syncope
1. Neurocardiogenic (aka vasovagal): increase in sympathetic tone —> increased Vagal tone —> decrease in HR and BP (cough, deglutition, defecation, micturition)
2. Orthostatic hypotension: Hypovolemia, diuretics, reconditioning, vasodilation
3. Cardiovascular: arrhythmia, mechanical
4. Neurological: vertebrobasil insufficiency, cerebrovascular dissection, SAH, TIA/CVA
91
What workups to order after syncope
EKG
EEG: neurogenic causes
Labs: CBC (r/o symptomatic anemia), BMP (r/o hypoglycemia and other electrolyte problems that could alter mental status), pro-BNP, troponins
Rads: head CT/MRI r/o neurogenic trauma cause
92
Study if you suspect neurocardiogenic causes of syncope
Tilt-table testing
93
Lamictal (lamotrigine) MOA
Anticonvulsant
Na channel blocker
94
Pamelor (nortruptyline) MOA
TCA
95
Timing of maxillary labial frenectomy
Too early: removing the interdental fibers leads to scar tissue —> difficulties in diastema closure
- contraindicated prior to orthodontic treatment
- when the incisor teeth are orthodontically aligned and space closure is imminent
96
NPO status
Clear liquids: 2 hrs
Breast milk: 4 hrs
Infant formula: 6 hours
Non-human milk: 6 hrs
Solid food: 8 hrs
97
Airway fire algorithm
1. Remove tracheal tube
2. Stop flow of airway gases
3. Remove flammable and burning materials from airway
4. Pour saline or water into patient’s airway
5. Reestablish ventilation by mask (avoid O2 and NO2)
6. Extinguish and examine tracheal tube, consider bronchoscopy to look for tracheal tube fragments, assess injury, and remove debris
98
Airway in Down Syndrome
1. Atlanto-axial instability —> difficult intubation
2. Macroglossia
3. Tonsillar/adenoidal hypertrophy
4. Micrognathia
5. Short neck
6. 50% will have congenital heart disease
7. OSA, early development of pulmonary HTN in L to R shunts
99
Positioning of impacted canines (expose and bond)
Impacted mandibular canines: most commonly BUCCALLY located
Maxillary canines: PALATAL (2nd most common impacted tooth)
100
Expose and bond techniques for buccally vs palatally positioned canines
Bucally positioned: Apically positioned flap, closed flap, gingivectomy
Palatally positioned: closed flap, gingivectomy
101
Indications for extraction of impacted canines
Ankylosis, severe root dilaceration, lack of arch space, first PM in position of canine, pathologic changes around tooth, pt not willing to undergo orthodontic therapy, anatomic limitations (adj to floor of nose)
102
How much keratinized gingiva should be found between exposed tooth and MGJ after exposure of labially impacted canine
2-3 mm
103
How much tooth exposure for expose and bone
2/3 of the crown must be exposed to obtain stable bracketing, avoid exposure beyond CEJ (can cause external resorption of root)
104
What if you cant get bracket bonded on exposed tooth
2 stage approach
Expose then bond later
Hemostatic agent
Dont use wire
105
What is PCOS
Endocrine disorder
-elevated androgens in females, in particular testosterone due to
- release of excessive LH by the anterior pituitary gland
- through high levels of insulin in the goodly
106
Medications for PCOS
OCPs and metformin
- meds to induce fertility: clomiphene (SERM) or pulsation leuprelin (GnRH analog) to induce ovulation
107
Conditions associated with MEN1, MEN2A, MEN2B
MEN1: Pituitary, parathyroid, pancreatic
MEN2A: parathyroid, medullary thyroid, pheochromocytoma
MEN2B: medullary thyroid, pheochromocytoma, mucosal neuroma, Marfanoid
108
Pheochromocytomas arise from what cells
Chromaffin cells of the adrenal gland, which make, store, metabolize and sometimes release catecholamines
109
Diagnostic studies to diagnose pheochromocytoma or paraganglioma
Urinary fractionated metanephrines
- vanillylmandelic acid (VMA)
110
BSSO positional screws location and type
Should be positional and bicortical
Avoid lag screw effect - splays the condyles
111
On serial cephs, what are 2 important points to compare for growth
Condylion and pogonion
112
Discuss incision for AICBG harvest
- 2 cm lateral to the iliac crest: prevents injury by belt or low waistband
- 4-8 cm in length
- 2 cm short of anterior superior iliac spine to reduce injury in 2.5% population whose lateral femoral cutaneous n. Runs over ASIS
113
Accutane, isotretinoin MOA and dose
0.5 -1.0 mg/kg/day divided in 2 doses
Reduces sebaceous gland size and reduces sebum production in acne treatment (Retinoid)
114
Side effects of accutane (isotretinoin)
-Teratogenic, category X, requires contraception for a minimum of 1 month
- hepatitis - regular interval LFTs
-IBD, photosensitivity, depression/mood disturbances
-can disrupt wound healing and cause aberrant scarring
115
Is medium depth and deep resurfacing procedures (chemical peel and dermabrasion) contraindicated in pts on Accutane (isotretinoin)
Contraindicated in pts with isotretinoin (accutane) therapy within the last 6 months
116
Chem peel and other resurfacing pretreatment
1. All-trans-retinoic acid or tretinoin: speeds epidermal healing and enhances effect of the procedure; decreases thickness of stratum corneum
- restricted during post op healing period until there is complete re-epithelialization and diminished inflammatory erythema
2. Hydroquinone: blocks tyrosinase and can reduce the production of epidermal melanin during healing phase
- treats pigmentary dyschromias, i.e melasma
3. Jessner’s solution: ethanol, resorcinol, lactic acid, salicylic acid
117
Ileus labs
1. CBC - anemia (post op bleeding), WBC (intraabdominal infection, ischemia, or intraabdominal abscess)
2. Electrolyte: hypokalemia worsens ileus, Mg depletion will lead to hypokalemia
3. Creatinine and BUN - uremia can cause ileus
4. LFT, amylase, lipase - post op gallbladder dysfunction or pancreatitis
118
First diagnostic imaging for ileus
Plain abdominal films
- dilated loops of bowel
- air in colon and rectum without transition zone to suggest bowel obstruction
- no evidence of free air to suggest perforation
119
Ileus treatment
1. Pain: NSAIDs, use opioids sparingly
2. Maintenance and replacement fluid therapy
3. Electrolyte replacement
4. Bowel rest: clears as tolerated
- once dissection resolves and bowel sounds return, liquid diet
5. Bowel decompression - moderate to severe vomiting or significant abdominal distention —> NG tube
6. Nutritional support
7. Serial abdominal exams: more detailed imaging if conditions do not improve in 48-72 hrs
8. Gastrografin: treat adhesive SBO
120
Can disc repositioning be done at the same time as orthognathic surgery
YES
121
LF1 advancement effects on the nose
Upturns or over-rotates nasal tip
Accentuates the supratip break
122
What finding on Tech 99 is diagnostic of condylar hyperplasia
Difference in 10% or more between condyles
123
Fitzpatrick scale
Type 1. Very white or freckled, always burn
Type 2. White, usually burn
Tye 3. White to olive - sometimes burn
Type 4. Brown - rarely burn
Type 5. Dark brown - very rarely burn
Type 6. Black - never burn
124
Glogau photo-damage classification scale
Group 1: mild - no wrinkles
Group 2: moderate - wrinkles in motion
Group 3: advanced - wrinkles at rest, telangiectasias
Group 4: severe - only wrinkles
125
Name of photoaging classification
Glogau
126
Dedo classification
Dedo 1: normal, well-defined mental angle
Dedo 2: laxity of cervical SKIN
- tx: rhytidectomy with plication of the SMAS-platysma complex
Dedo 3: layer of subcutaneous FAT
- liposuction required
Dedo 4: PLATYSMA pathology
- diagnosed by voluntary facial grimacing —> anterior cervical cording
- surgical manipulation of platysma
Dedo 5: RETROGNATHIA
Dedo 6: abnormal HYOID position
- normal hyoid: C4
- hyoid is either too low or mandible-to-hyoid distance is too low
127
Dalpont osteotomy
Extended to the bony prominence located along the buccal aspect of the molar region (Dalpont prominence)
- bony cortex is thickest between the 1st/2nd molars and the IAN is most medial/lingual
128
Describe hunsuck modification
Involves splitting the mandible anterior to the posterior border by placing the reciprocating saw within the retrolingual depression superior to the insertion of the IAN and lingula
129
LF advancement: tooth to lip ratio
3:1
3 mm of advancement = 1 mm of increased tooth to lip
130
At first AICBG block graft f/u, graft is exposed through dehiscence. What do you do
Peridex, antibiotics, close f/u
131
Lag screw for securing block onlay graft (ramal, AICBG), why?
Lag screw technique is used for fixation of cortical onlay bone grafts
-screw engages and threads the host bone but fits passively through the cortical bone graft to compress and rigidly fixate the block
132
Name and describe the 2 approaches for an implant-supported fixed prosthesis
1. Metal-ceramic implant-supported fixed prosthesis
- consists of a ceramic layer bonded to a cast metal framework that can be cemented to transmucosal abutments or secreted with retention screws
2. Implant-supported hybrid
- acrylic and denture teeth are processed onto the milled titanium bar
133
How long to wait after AICBG for implants
4-6 months
If you wait too long —> bone resorption
134
How long to wait after allogenic block graft for implants
6-8 months
135
AICBG: Complications
1. Hematoma - edema/ecchymosis, concern for retroperitoneal, large amt of blood loss before recognized —> CT abdomen/pelvis
2. Seroma
3. Scar
4. Gait abnormality - no stripping of tensor fascia lata
5. Meralgia paresthetic (lateral femoral cutaneous n.)
6. ASIS fracture
7. Peritoneal perforation
136
AICBG: Cullen sign
Hemorrhagic discoloration of the umbilical area 2/2 intraperitoneal hemorrhage
137
AICBG: grey turner’s sign
Bruising of the flank which may indicate retroperitoneal bleeding
138
Origin of OKC
Originate from dental lamina, odontogenic epithelium
- rests of SERRES
-parakeratinized more concerning
139
Where and when are OKCs more common
Posterior mandible
- 3rd decade of life
140
Major criteria of Gorlin syndrome (NBCCS)
1. More than 2 BCCs or 1 BCC in a person younger than 20
2. OKC of the jaw
3. 2 or more palmar or plantar pits
4. Ectopic calcification or early calcification of falx cerebri
5. Bifid, fused, or splayed ribs
6. First degree relative with NBCCS
(Minor: microcephaly, cleft lip/palate, frontal bossing, hypertelorism)
141
3 most popular thyroid cancers
1. Papillary thyroid cancer (75-85% of cases): young females, excellent prognosis
- familial adenomatous polyposis and Cowden syndrome
2. Follicular thyroid cancer (10-20%)
3. Medullary thyroid cancer (5-8%) - cancer of parafollicular cells, MEN type 2!
142
Nerve at risk of damage during central compartment lymph node dissection
Recurrent laryngeal nerve.
143
Most common type of salivary gland tumor and most common tumor of parotid gland
Pleomorphic adenoma
- BENIGN SALIVARY GLAND NEOPLASM
- neoplasticism proliferation of parenchymatous glandular cells along with myoepithelial components
- malignant potentiality
144
Treatment of pleomorphic adenoma
Diagnose with FNA/CT/MRI
Resection
- may undergo malignant transformation —> carcinoma ex-pleomorphic adenoma (9.5% chance in 15 years
145
What is a sialocele
Collection of saliva in the subcutaneous tissue near the site of a leaking salivary duct or gland
146
What is a sialolith
Calcification within salivary gland/duct
147
Level A nerve test assesses what fibers
1. Brush stroke direction: large A-alpha and A-beta
2. 2 point discrimination: blunt -larger myelinated A-alpha; sharp - A-delta and unmyelinated C
148
Two tests to assess Level A nerves
1. 2 point discrimination: touch skin simultaneously with light pressure while pt’s eyes are closed. Separation of 2 points are gradually reduced from 20 mm at the chin and 10 mm lips to the moment where pt can feel one point only
Minimum separation at which 2 points can be reported is recorded.
2. Brush stroke direction: 2 interval trials delivered to verify that the direction of motion is identified correctly
149
Level B test of IAN nerve exam
A-a fibers
Contact detection/light tough
- minimum force of contact against the skin that is felt is measured with the use of monofilament mounted onto end of plastic handle
150
Level C tests of IAN nerve exam
1. Thermal testing: heat = A-delta fibers; cold = C fibers
2. Sharp, blunt discrimination
3. Pin prick test
151
Methotrexate MOA and implications on bone grafts
Inhibits osteoblasts, decreases success of bone grafts
- inhibits folate/cellular replication by inhibiting dihydrofolate reductase
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Side effects of methotrexate
Hepatotoxicity, ulcerative stomatitis, leukopenia —> infection, nausea, abdominal pain, fatigue, dizziness, acute pneumonitis, pulmonary fibrosis, kidney failure
CATEGORY X - teratogenic
153
What is Carnoy’s solution
CAO
C = 30% chloroform, 1 gm ferric Chloride
A= 10% acetic acid
O = 60% etOH
154
Indication for Carnoy solution
OKC
60% ethanol, 30% chloroform, 10% acetic acid, 1 gm of ferric chloride
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Dental injuries as complication of multipiece lefort
Cementum degenerates leading to ankyloses
156
How does ACE inhibitors affect RAAS
Decreases conversion of ATI —> ATII —> decreased vasoconstriction, less aldosterone release —> increased excretion of Na and water, retention of K
- ACE also breaks down bradykinin —> ACE inhibitors causes chronic cough
157
CKD staging by GFR
G1: Normal or high >90
G2: mildly decreased 60-89
G3a : Mildly to moderately decreased 45-59
G3b: Moderately to severely decreased 30-44
G4: Severely decreased 15-29
G5: kidney failure <15
158
CKD staging based on albuminuria
KDIGO
A1: normal to mildly increased <30 mg/g or <3 mg/mmol
A2: moderated increased 30-300 mg/g or 3-30 mg/mmol
A3: severely increased >300 mg/g or >30 mg/mmol
159
Parts of the temporal bone (5)
1. Squamous
2. Petromastoid
3. Tympanic
4. Zygomatic
5. Styloid
160
Treatment for non-displaced or minimally displaced fractures without CNS or vascular injury, stable neurological status
Observation
- no evidence of an intracranial mass lesion, CSF leak, or increase in intracranial pressure
- stable neuro status (high GSC)
161
Temporal bone fracture classifications based on reference to long axis of petrous bone
1. Longitudinal = parallel to axis
2. Transverse = perpendicular
3. Oblique
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When do you surgically manage temporal bone fx
Displaced fractures with evidence of CNS/vascular injuries
- injuries to visceral structures that pass through or are housed in the temporal bone
163
When do you do delayed management of hearing loss following temporal bone fracture
Persistent conductive hearing loss suggesting damage to middle ear
- hearing eval at 6 weeks after trauma to allow time for blood in middle ear to be absorbed
164
When would you do a lateral skull base approach for temporal fractures
To reach the lateral anterior and middle cranial fossa
- repair CSF leak associated with lateral skull base trauma
165
When would you do a transmastoid approach for temporal bone fractures
Facial nerve compression
- postauricular incision is commonly used
- skin, subcutaneous, temporalis fascia/temporalis, posterior auricular muscle, periosteum ??
166
Layers of retro mandibular/trans-parotid approach
1. Skin
2. Subcutaneous tissue
3. SMAS/platysma (marginal mandibular nerve travels JUST BELO W PLATYSMA)
4. Superficial layer of deep cervical fascia
5. Parotid capsule
6. Dissect through parotid
7. Periosteum of pterygomasseteric sling (masseter and medial pterygoid)
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What is the importance of closing parotid fascia/capsule well when doing transparotid/retro mandibular approach
Parotid fistulas/sialocele develop in <3% of cases
- look for persistent clear, serous drainage from incision
- tx with elastic pressure dressing, leaving drain, anticholinergics, Botox
168
What is the thickness of glenoid fossa temporal bone
Average: 0.9 mm (1-2 mm, can be as thin as 0.3 mm)
169
How much fluid should go in joint space during TMJ arthrocentesis
Super joint space: 1.2 cc
Inferior joint space: 0.9 cc
Full capsule: 2.2 cc
170
Inflammatory mediators found in joint space prior to TMJ arthrocentesis
IL1
IL6
TNF-alpha
After arthrocentesis: good to have IL10
171
Absolute indications for open treatment of condylar fractures
1. Bilateral fractures
2. Considerable dislocations in cases where closed treatment does not reestablish occlusion
3. Foreign bodies
4. Dislocation of condyle to MIDDLE CRANIAL FOSSA
(Deviation of more than 10 degrees or a shortening of the ramus greater than 2 mm)
172
Name some limitations of IVRO
1. Medial displacement of proximal segment —> impingement of IAN (muscle action rotates the proximal segment anteriorly)
2. Hinge movement of proximal segment —> limits MIO
3. Bony step at angle (can trim)
4. Can get further setback with BSSO
173
What is prednisone metabolized to and where
Metabolized to active form in the liver to prednisolone
174
MOA of steroids
Cell cycle inhibitor to immune B and T cells
175
Hydrocortisone, prednisone, decadron conversion
40 Hydrocortisone = 10 prednisone = 1.5 decadron
Prednisone = 4x stronger than hydrocortisone
Decadron 30x stronger than hydrocortisone
Decadron 6x stronger than prednisone
176
What are the rule of 2s in terms of steroid use
Adrenal suppression may occur if a pt is taking 20 mg of cortisone or its equivalent daily, for 2 weeks within 2 years of dental treatment
- avoid adrenal crisis by corticosteroid supplementation
177
What is the precedex loading dose and maintenance dose
Loading: 1mcg/kg over 10 min
Maintenance: 0.2-0.7 (~0.5) mcg/kg/hr infusion
178
Cavernous sinus contents
III, IV, V1, V2, VI
ICA
179
Routes to the cavernous sinus
1. Anterior facial v. —> superior ophthalmic v.: upper lip, tip of nose, medial cheeks
2. Deep facial v. Through pterygoid plexus
Venous plexus of maxillary sinus —> posterior wall of antrum of Highmore into deep facial v. —> pterygoid plexus —> rete foraminis ovalis —> cavernous sinus
180
Clinical manifestations of cavernous sinus thrombosis
- unilateral periorbital edema
- headache, photophobia
- proptosis
- CN palsies
- FIRST SIGN OF THROMBOSIS: Abducens paresis (loss of CN VI - lateral gaze palsy)
181
First sign of cavernous sinus thrombosis
Abducens paresis (loss of CN VI - lateral gaze)
182
Diagnosis of cavernous sinus thrombosis
Clinical exam
MRI using flow parameters more sensitive than CT scan
- venous wall thickening
- deformity of ICA within cavernous sinus
183
Treatment of cavernous sinus thrombosis
Antibiotic tx IV 6-8 weeks: broad spectrum
- surgical debridement or incision and drainage of source
- anticoagulation and steroid use are controversial
184
Signs of intracranial involvement in cavernous sinus thrombosis
Contralateral hemiparesis
185
How much insulin does the pancreas secrete per day
20 U insulin/day normally
Internet says 30-50 U
186
What is the stopping point for most proximal you can go with pedicle to RFFF
Recurrent radial branch
187
Bacteria in chronic sinusitis
1. Staph aureus
2. Anaerobic bacteria (prevotella, porphyromonas, fusobacterium, peptostreptococcus)
188
Classification for clefting of palate
VEAU classification
189
What is the veau classification for cleft palate
Veau 1: midline cleft of the velum (soft palate), intact hard palate
Veau 2: midline cleft of velum and secondary hard palate (posterior to invasive foramen), intact primary palate
Veau 3: velum cleft, extending unilaterally through secondary hard palate and through the primary hard palate and alveolus
- vomer remains attached to palatal shelf on greater segment
Veau 4: velum cleft, extending in midline through the secondary hard palate up to invasive foramen and then bilaterally through primary hard palate and alveolus on each side
- vomer remains in midline and attached to premaxilla
190
What is a submucous cleft palate and what are the signs
-Palate appears grossly intact
-Deep to intact mucosa, there may be a separation of levator palatini muscles —> palatal function affected
-Subtle signs: zona pellucida (pale coloring of midline of palate, indicative of submucous bony defect), notching of hard palate at posterior edge, Bifid uvula
191
Treatment for status asthmaticus
Epi 0.3 mg 1:1000 IM
Epi 0.3 mg 1:10,000 IV
192
Asthma Capnography sign
Shark fin
Pattern of obstruction —> increased expiratory phase —> may lead to breath stacking
193
Displaced frontal sinus fracture definition
More than the table thickness or ~2-4 mm depending on the source
194
Name 5 different incisions for frontal sinus fracture
Coronal
Existing laceration
Direct
Open sky
Gullwig
195
Algorithm of repair of frontal sinus fracture
1. If posterior table involved: cranialize and repair anterior table
2. If frontal nasal duct is not intact but posterior table intact: displaced ant table = obliterate and repair anterior table; nondisplaced = repair NOE component, repair anterior table
196
What is Gardner’s syndrome
Aka familial colorectal polyposis
- subtype of familial adenomatous polyposis
- AD
- multiple polyps in the colon with tumors outside of the colon
- osteomas of skull, thyroid cancer, epidermoid cysts, fibroma, dermoid tumors
197
MMA, why do you need 10 mm advancement to retain the improvement in AHI
Studies have shown lesser advancements result in relapse in AHI
198
Why do you not use CPAP after MMA
SUBCUTANEOUS EMPHYSEMA
199
BSSO plates vs. screws complications
Plates more likely to get infected compared to screws
- problem with dehiscence over plates —> exposure to oral cavity bacteria —> biofilm formation
- bone grafting between bony segments during BSSO requires cortical containment (within mandibular bony cortices)
- important for plates and screws to be immobile —> if mobile, shear capillaries, prevent neovascularization, leads to infection
200
In ACLS, how many breaths
1 breath every 5-6 seconds with ambu bag
201
Ramus vs. symphysis graft
Ramus has less cancellous, thinner
Symphysis is thicker with more cancellous
202
Why is thin scalloped bio type more amenable to vertical release incision
Less prone to scarring
More prone to attachment loss with sulcular incision
203
Why is thick flat bio type more amenable to sulcular incision
More prone to scarring so vertical release can lead to scarring
- sulcular is better tolerated bc less prone to attachment loss
204
Alternative to AICBG for alveolar cleft
Tibial graft
205
For an All-on-4, minimum distance from ridge to opposing dentition
15 mm minimum
(30 mm for edentulous)
206
Minimum edentulous mandibular height for mini plates
15 mm
207
What fibers are different on implants vs. real tooth
Circular fibers
208
3 major tip support mechanisms for nose
1. Size, shape and strength of lower lateral cartilages
2. Attachment of medial crura to the caudal septum
3. Attachment of lower lateral cartilages to the upper lateral cartilages
