Pre-Test: Otolaryngology Flashcards
A 14 y/o boy is brought to medical attention because of nasal fullness and bleeding. Inspection reveals enlarged cervical lymph nodes as well. Biopsy of a lymph node confirms nasopharyngeal carcinoma. What is the best mgmt strategy for this pt?
a. Chemoradiation
b. External beam radiation therapy
c. Intracavitary radiation therapy
d. Surgical resection
e. Surgical resection followed by adjuvant chemoradiation
How to diagnose nasopharyngeal carcinoma?
a. Chemoradiation
Chemoradiation = standard therapy for nasopharyngeal carcinoma
(Surgical resection for local recurrences)
Dx: biopsy of primary tumor
A young motorcycle driver is thrown against a concrete bridge abutment and sustains severe trauma about the face, with marked periorbital edema and ecchymosis as well as epistaxis. He is obtunded with rapid, shallow breathing. Which of the following is the next appropriate step in his workup and mgmt?
a. Evaluation of c-spine
b. Blind nasopharyngeal intubation with cervical in-line stabilization
c. Oropharyngeal intubation with cervical in-line stabilization
d. Emergency tracheostomy
e. Emergency cricothyroidotomy
c. Oropharyngeal intubation with cervical in-line stabilization
In pts with severe facial or mandibular trauma, airway difficulties may develop 2/2 the effects of massive hemorrhage, tissue swelling, or associated laryngeal trauma. Periorbital ecchymosis (i.e. raccoon eyes) indicative of concomitant basilar skull fracture
Oropharyngeal intubation with cervical in-line stabilization should be attempted first in this patient given his facial injuries, respiratory distress, and decreased mental status.
If oral or nasotracheal intubation cannot be performed easily, cricothyroidotomy or emergency tracheostomy should be performed.
A 48 y/o man with a strong history of cigarette use and heavy alcohol intake presents with an intraoral mass. Biopsy shows SCC. CXR shows hyperinflated lungs but is otherwise normal. Which of the following is indicated as part of his staging workup?
a. Measurement of serum AP and calcium levels.
b. Bronchoscopy.
c. Esophagoscopy.
d. Echocardiography.
e. No further workup.
c. Esophagoscopy.
Because of the chance of a synchronous cancer in the aerodigestive tract, bronchoscopy and esophagoscopy are recommended, although the former may be omitted in the face of a noraml CXR.
Imaging modalities such as CT, MRI, PET, or U/S may be useful in preop planning.
Treatment for:
- nasopharyngeal SCC
- oropharyngeal cancers
Treatment for:
-
nasopharyngeal SCC
- Radiation –> radical neck dissection if +lymph node mets
-
oropharyngeal cancers
- Radiation or surgery
Your pt presents with a complaint of a mass on her R cheek, which has been slowly enlarging. Biopsy shows a pleomorphic adenoma. Which is the next step in her mgmt?
a. Superficial parotidectomy with preservation of the facial n.
b. Superficial parotidectomy with resection of the facial n.
c. Total parotidectomy with preservation of the facial n.
d. Total parotidectomy with resection of the facial n.
e. Enucleation of the adenoma
a. Superficial parotidectomy with preservation of the facial n.
The treatment for pleomorphic adenomas (mixed tumors) of the parotid gland is superficial parotidectomy with preservation of the facial nerve. Unless adequately excised, they tend to recur locally in a high % of cases. Enucleation is not recommended given that tumor spillage at the time of resection can increase the chance of recurrence.
Pleeomorphic adenomas can occur in either the major (submandibular, parotid, and sublingual) or minor salivary glands. These round tumors have a rubbery consistency and are slow-growing; all are potentially malignant.
The sites most commonly affected = lips, tongue, palate.
A 5 y/o child presents with a small mass near the anterior border of the SCM muscle. The mass is associated with localized erythema and induration, and the child is febrile. Which of the following is the definitive treatment of this problem?
a. Abx
b. I&D
c. I&D –> complete excision after resolution of the inflammation and infection
d. Partial excision followed by clinical observation
e. Immediate excision followed by postop abx therapy for 1 week
c. I&D –> complete excision after resolution of the inflammation and infection
The child has a branchial cleft remnant (branchial cleft cysts, sinuses, and fistulas). These more commonly arise from the first and second branchial pouches, while those from the third and fourth branchial pouches are rarer. This child has an infected cyst due to accumulation of secretions. The treatment is I&D and then complete excision when the infection has resolved.
A 21 y/o woman asks you to evaluate a small painless lump in the midline of her neck that moves with swallowing. You make the clinical dx of thyroglossal duct cyst. Which of the following is the most appropriate mgmt of this pt?
a. Excision of cyst
b. Excision of cyst and central portion of the hyoid bone
c. Excision of cyst, central portion of hyoid bone, and tract to the base of the tongue
d. Excision of cyst, central portion of hyoid bone, and tract to the base of the tongue, with sampling of central cervical lymph nodes
e. Excision of cyst, central portion of hyoid bone, and tract to the base of the tongue, with biopsy of central cervical lymph nodes
b. Excision of cyst and central portion of the hyoid bone
Surgical resection = standard therapy for thyroglossal duct cysts.
Simple excision of cyst results in unacceptably high recurrence rate. Thyroglossal duct cysts result from retention of an epithelial tract between the thyroid and its embryologic origin in the foramen cecum at the base of the tongue.
A 60 y/o smoker is seen b/c of a 3-cm midline ulcerating mass that is visualized when he sticks out his tongue. Biopsy establishes that this is SCC. Which of the following is the most appropriate tx of his cancer?
a. Radiation therapy alone
b. Partial glossectomy
c. Partial glossectomy and cervical lymph node sampling
d. Partial glossectomy + b/l neck dissections
e. Partial glossectomy followed by chemoradiation
d. Partial glossectomy + b/l neck dissections
Tx = surgical–> wide local excision of the tumor and neck dissection as needed
B/c >2 cm, nodal dissections are performed for prognostic purposes
A 38 y/o woman who underwent total thyroidectomy for multi-nodular goiter 6 mo ago presents with persistent hoarseness. Which nerve was most likely injured during her operation?
a. Superior laryngeal n.
b. B/l recurrent laryngeal n.
c. Unilateral recurrent laryngeal n.
d. Hypoglossal n.
c. Unilateral recurrent laryngeal nerve
B/l recurrent laryngeal nerve injury –> complete airway obstruction and may require tracheostomy
A 4 y/o boy is brought into the ER by his parents for difficulty in breathing and swallowing. On exam, the child is febrile, tachycardic, and tachypneic. He is anxious, drooling, and becomes increasingly exhausted while struggling to breathe.
A lateral cervical spine radiograph show “thumb sign”. What is the most appropriate mgmt of this pt?
a. Examine larynx at bedside
b. Immediate endotracheal intubation in the ER
c. Immediate endotracheal intubation in OR
d. Immediate tracheostomy in OR
c. Immediate endotracheal intubation in OR
Pt has acute epiglottitis
“thumb sign” = thickened epiglottis which resembles distal thumb
Airway should be emergently secure in the OR; surgeon should be prepared to perform tracheostomy if endotracheal intubation is unsuccessful
Any attempts at visualization of larynx –> aspiration and respiratory arrest
A 58 y/o man is found to have a small mass in the R neck on a yearly physical exam. The patient reports that the mass has been slowly growing for the last few months and is not associated with pain or drainage. He has an otherwise negative ROS. On exam, there is a hard, mobile, 2-cm mass along the mid-portion of the R SCM. Which of the following is the most appropriate initial step in the workup of the neck mass?
a. No further workup is needed. Reevaluate the mass after a course of abx for 2 weeks.
b. FNA
c. Core needle biopsy
d. Incisional biopsy
e. Excisional biopsy
b. FNA
Neck masses in adults represent malignancy until proven otherwise. FNA has an overall accuracy of 95% for benign neck masses and 87% for malignant masses. It is the least invasive method to biopsy tissue but is more than adequate for ID-ing benign vs. malignant tissue.
A 62 y/o man presents witha 3-mo hx of an enlarged lymph node in the L neck. He is a long-time smoker of cigarettes and denies fever, night sweats, fatigue, or cough. On exam, there is a 1.5 cm hard, fixed mass below the angle of the mandible in the left neck. Which of the following is the most likely cause of an enlarged lymph node in the neck?
a. Thyroglossal duct cyst
b. Dermoid tumor
c. Carotid body tumor
d. Branchial cleft cyst
e. Metastatic SCC
e. Metastatic SCC
Most commonly, lymphadenopathy in an adult is indicative of metastatic SCC which originates most frequently from the nasopharynx, orophyarynx, hypopharynx.
In addition to lymphadenopathy, _persistent lateral neck masse_s in adults may represent neuromas, neurofibromas, carotid body tumors, branchial cleft cysts, lipomas, sebaceous cysts, parathyroid cysts, or a primary soft tissue tumor
Midline neck masses may represent thryoglossal duct cysts, dermoid tumors, thyroid masses, lipomas, or sebaceous cysts.
