Intro Lecture and neck mass

Question 0

What is Ozena or empty nose syndrome?

Answer 0

After resection of all the turbinates

Patient will complain of chronic congestion and have severe nasal crusting rather than feeling more open

Question 1

What is kiesselbach’s plexus?

Answer 1

Area particularly prone to bleed

Place where the blood vessels supplying the nose converge in the nasal septum

Question 2

What are vibrissae? What happens after they do their job?

Answer 2

Special hairs within nostrils that filter larger particles

Cilia then beat things trapped in mucus to pharynx where it is swallowed and sent to acidic stomach to be disposed of

Question 3

What is rhinorrhea? What do different colors signify?

Answer 3

Nasal discharge
Clear - allergic, viral vasomotor or CSF
Green - sinusitis, foreign body

Question 4

How can clear rhinorrhea be differentiated from CSF?

Answer 4

CSF has higher glucose content
Beta 2 transferrin present in CSF but not mucus
Bloody CSF forms ring sign when dripped onto paper towel

Question 5

What is anosmia?

Answer 5

Loss of sense of smell
Can occur with severe blockage
Can be conductive or sensorineural
Can tat with alcohol, mustard, or other pungent items

Question 6

What is epistaxis? What can cause it?

Answer 6

Nose bleeds
Clotting problems, high pressure, trauma, dryness and irritation, vascular abnormalities
JVN - vascular mass seen in adolescent boys with frequent unilateral severe nose bleeds
Hereditary hemorrhagic telangiectasia

Question 7

What is the source of pain in the nose?

Answer 7

Often from sinuses

Nose innervation by branches of V

Question 8

What is rhino sinusitis?

Answer 8

Most common cause of congestion
Inflammation of nose and sinuses
Includes allergic and viral rhinitis as well as rhinitis medicamentosa

Question 9

What is meningocele?

Answer 9

Evagination of meninges into nasal cavity through dehiscence in floor of cranium

Question 10

Why can a vasoconstrictor help during a nasal exam?

Answer 10

Cause turbinates to shrink and allow more light to enter nose
Can now see more of the middle and superior turbinates

Question 11

What is the general rule of thumb regarding use of ct or MRI to evaluate nose?

Answer 11

CT better for bony structure

MRI better for soft tissue

Question 12

What is xerostomia?

Answer 12

Dry mouth

Question 13

What are dysphagia and odynophagia?

Answer 13

Difficulty swallowing

Pain with swallowing

Question 14

What is an insidious symptom of the OC/OP to look out for?

Answer 14

Otalgia
Common complaint in primary oropharyngeal cancer is result of referred pain from CN IX
Can also be present in tonsillitis

Question 15

Chronic intermittent pain that waxes and wanes, worsens acutely, but then goes back to dull roar most of the time
Pain under the chin

Answer 15

Submandibular gland inflammation

Question 16

History of medication exposure such as chemotherapy or recent antibiotics would raise suspicion for what?

Answer 16

Thrush

Question 17

Ddx for sore throat and odynophagia

Answer 17

Infectious and inflammatory processes (tonsillitis, peritonsillar abscess, thrush, epiglottitis, and cancer)
Absence of odynophagia can narrow differential

Question 18

Ddx of sore throat and voice change

Answer 18

Peritonsillar abscess - hot potato voice

Seen in mono or tonsillitis and sometime lymphoma

Question 19

Ddx of sore throat and lymphadenopathy

Answer 19

Infectious and neoplastic processes
Posterior - mono, ear and scalp inf
Anterior - tonsillitis, strep pharyngitis

Question 20

Ddx of sore throat and globus (sensation of something stuck in throat)

Answer 20

LPR (reflux), PND, neoplasm, vocal cord granuloma, tonsillitis, actual foreign body

Question 21

If fever is present, what can be ruled out of the differential?

Answer 21

Thrush - does not present with fever

Question 22

Small painful ulcerations of unknown etiology that resolve over time

Answer 22

Apthous ulcers (canker sores)

Question 23

White patch of mucosa in mouth

Answer 23

Leukoplakia

May indicate premalignant state

Question 24

Smooth tongue

Answer 24

Glossitis

Question 25

Thrush vs. leukoplakia

Answer 25

Thrush can be scraped away, leukoplakia cannot

Question 26

White plaque on reddened pharynx

Answer 26

Strep pharyngitis

Question 27

Painful, red bulging of tissues around tonsil and possible deviation of uvula to opposite side

Answer 27

Peritonsillar abscess

Question 28

Why do laryngeal cancers tend to not metastasize if caught early enough?

Answer 28

Not a lot of lymphatics in the glottis

Question 29

Intermittent hoarseness in patient also experiencing nasal discharge, itchy nose, eyes and soft palate

Answer 29

Allergic rhinitis causing hoarseness | Post nasal drip related hoarseness

Question 30

What is reinke's edema?

Answer 30

Diffuse vocal cord edema that causes low gravely voice | Causes are cigarette smoke, vocal abuse

Question 31

Hoarseness and cancer

Answer 31

Common finding in laryngeal carcinoma or disruption of recurrent laryngeal by lung neoplasm Supraglottis neoplasms cause problems swallowing before hoarseness

Question 32

Waxing and waning symptoms of hoarseness vs. persistent or worsening

Answer 32

Voice misuse, reflux, post nasal drip, or combo vs. | Structural problem

Question 33

Sore throat, odynophagia, fever, stridor, and hoarseness in children

Answer 33

Epiglottitis - caused by bacteria

Question 34

What is stridor and what can cause it?

Answer 34

Impediment to normal laminar flow causes noisy breathing from larynx Infection - croup or epiglottitis Neoplasm - laryngeal, thyroid, or lung Dev. Phenomenon Allergy/immune phenomenon - angioedema, anaphylaxis, ACEI use Trauma

Question 35

Increased respiratory rate, use of accessory muscle of breathing in chest, pallor or cyanosis, tripod positioning, difficulty handling secretions, waning level of consciousness

Answer 35

Signs of severe stridor that may need emergency airway management

Question 36

When should certain ancillary studies be used to evaluate the larynx?

Answer 36

X ray - for foreign ladies, airway narrowing in croup, epiglottitis CT of neck/pharynx - first study of choice for laryngeal, neck masses, injuries MRI - soft tissue better than bone Barium swallow - helpful for dysphagia

Question 37

What are the different triangles of the neck?

Answer 37

Sub mental (nodal level Ia) Submandibular (nodal level Ib) Vascular (anterior) (nodal levels II, III, IV) Posterior (nodal level v)

Question 38

What are the different nodal groups of the neck?

Answer 38

``` Pre auricular Post auricular Occipital Superficial (to scm, along external jugular vein) Peri facial (along facial artery) Supraclavicular (virchows) Para tracheal ```

Question 39

What are the different categories of neck masses?

Answer 39

Normal variant anatomy Congenital or dev anomaly Inf or inflammatory process Neoplasm

Question 40

Midline mass

Answer 40

Thyroglossal duct cyst

Question 41

Lateral (level II) mass, fluctuating in size

Answer 41

Branchial cleft cyst

Question 42

When is gender an important determination in neck masses?

Answer 42

Adult neck masses Females more prone to have thyroid masses Males more prone to squamous cell carcinomas Different origins of cancers

Question 43

What possible neck masses have otalgia?

Answer 43

Lesion anywhere with referred pain

Question 44

What neck masses have hearing loss or fullness?

Answer 44

Lesion in NP obstructing Eustachian tube and causing otitis media

Question 45

What kind of lesion does trismus (trouble swallowing or opening mouth) suggest?

Answer 45

Lesion in OP extending deep

Question 46

Mass with surrounding soft tissue inflammation

Answer 46

Deep neck abscess

Question 47

Soft mass is usually?

Answer 47

Benign reactive node

Question 48

Mass moves with deglutination

Answer 48

Thyroid mass

Question 49

When should a CBC be obtained?

Answer 49

If infection or neoplasm is suspected | Erythrocytes sedimentation rate and routine electrolytes never really useful

Question 50

When is a plain x ray indicated with a neck mass?

Answer 50

Never

Question 51

When is a chest x ray indicated with neck masses?

Answer 51

Can rule out pulmonary lesions

Question 52

When is ultrasound indicated with neck masses?

Answer 52

Mass suspected of being cystic | Standard for diagnosing thyroid masses

Question 53

When is nuclear medicine indicated with neck masses?

Answer 53

Good for evaluating cancer | Cold more likely to be cancer than hot nodules

Question 54

When is CT scan indicated with neck masses?

Answer 54

Best initial scan | But must have good kidney function

Question 55

When is an MRI indicated with neck masses?

Answer 55

Soft tissue detail when CT insufficient | When CT cannot be used

Question 56

When is an angiogram indicated with neck masses?

Answer 56

Vascular tumors | Determines resectability - Pre-OP study

Question 57

What is the role of biopsies in neck masses?

Answer 57

Never biopsy until all other diagnostic modalities have been completed, then use experienced head and neck surgeon

Question 58

When is endoscopy indicated with neck masses?

Answer 58

To search for primary lesion in upper aerodigestive tract if neck mass is found to be a malignancy and imaging studies fail to reveal primary site

Question 59

What is the first step if you have an unknown primary carcinoma in the neck?

Answer 59

Take out the tonsils