Week 5 Flashcards

Question

Cystic hygroma

Answer 1

A cystic hygroma is a congenital lymphatic lesion which is typically identified prenatally or at birth. A cystic hygroma can arise anywhere but typically develops in the left posterior triangle of the neck. Cystic hygromas are benign but can be disfiguring and typically require surgical treatment including drainage and use of sclerosing agents to prevent reaccumulation of lymphatic fluid.

Answer 2

A cholesteatoma is an abnormal sac of keratinizing squamous epithelium and accumulation of keratin within the middle ear or mastoid air cell spaces which can become infected and also erode neighbouring structures. Cholesteatoma most commonly presents with a persistent or recurrent discharge from the ear that is often foul smelling. An associated conductive hearing loss may also occur. Rarely with progression of the disease, vertigo, sensorineural hearing loss, facial nerve palsy, meningitis, or intracranial abscess may develop. The diagnosis requires clear visualisation of the tympanic membrane. If the tympanic membrane can be seen, a cholesteatoma should be suspected if there is: Evidence of ear discharge. Presence of a deep retraction pocket, with or without granulation tissue and skin debris. Crust or keratin in the upper part of the tympanic membrane. The tympanic membrane may be perforated. Congenital cholesteatoma (rare) may appear as a white mass behind an intact tympanic membrane, in a person with no prior history of ear discharge, tympanic membrane perforation, or surgical procedures on the ear. If there is significant discharge occluding the tympanic membrane, referral for examination with an otomicroscope and micro-suctioning of the ear may be appropriate. Alternatively, clinical judgement should be used to decide whether to treat for presumed infection, in which case the person should be treated for either: Otitis externa, particularly if there are symptoms and signs of inflammation of the external auditory canal, or Acute otitis media if there has been an acute onset of pain associated with the purulent discharge.

Answer 3

Arachnoid cysts are fluid-filled sacs that occur on the arachnoid membrane that covers the brain (intracranial) and the spinal cord (spinal). There are three membranes covering these parts of the central nervous system: the dura mater, arachnoid, and pia mater. Arachnoid cysts appear on the arachnoid membrane, and they may also expand into the space between the pia mater and arachnoid membranes (subarachnoid space). The most common locations for intracranial arachnoid cysts are the middle fossa (near the temporal lobe), the suprasellar region (near the third ventricle) and the posterior fossa, which contains the cerebellum, pons, and medulla oblongata. In many cases, arachnoid cysts do not cause symptoms (asymptomatic). In cases in which symptoms occur, headaches, seizures and abnormal accumulation of excessive cerebrospinal fluid in the brain (hydrocephalus) are common. The most common symptoms associated with arachnoid cysts are usually nonspecific and include headaches, nausea, vomiting, dizziness and the accumulation of excessive cerebrospinal fluid in the brain (hydrocephalus), resulting in increased intracranial pressure In rare cases, in some children, an arachnoid cyst can cause malformation of certain cranial bones, resulting in an abnormally enlarged head (macrocephaly). . A variety of additional symptoms occur in some individuals with arachnoid cysts depending upon the size and location of the cyst. Most cysts occur near the middle fossa region of the brain. Such symptoms include lethargy, seizures, vision abnormalities and hearing abnormalities. Neurological signs may be present because arachnoid cysts may cause increased pressure on structures of the brain. Such neurological findings may include developmental delays, behavioral changes, an inability to control voluntary movements (ataxia), difficulties with balance and walking and cognitive impairment. Weakness or paralysis on one side of the body (hemiparesis) has also been reported. In addition to hydrocephalus, cysts located in the suprasellar region may be associated with vision disturbances, continuous bobbing of the head, and abnormalities affecting certain hormone-producing glands that help to regulate the rate of growth, sexual development, and certain metabolic functions (endocrine system). Although they occur much less often than those found within the skull (intracranial), arachnoid cysts may also arise near the spine (spinal arachnoid cysts). Spinal arachnoid cysts may be associated with progressive weakness of the legs, tingling or numbness in the hands or feet, abnormal side-to-side curvature of the spine (scoliosis), back pain, and involuntary muscle spasms (spasticity) that result in slow, stiff movements of the legs. In rare cases, these cysts may cause paralysis of the legs (paraplegia). Urinary tract infections may also occur in individuals with spinal arachnoid cysts. In cases where treatment is recommended, therapy traditionally consists of one of two procedures – an open craniotomy fenestration or ventriculoperitoneal shunting.

Answer 4

The typical features of PRS are: ``` Micrognathia or retrognathia (small or retracted mandible). Cleft palate (classically U-shaped but V-shaped may occur, usually without cleft lip). Glossoptosis (implying a relatively large tongue. In reality, the tongue may be normal size or small, so upper airway obstruction may be substituted for this feature). ``` Neonates with severe micrognathia present as emergencies at birth with significant respiratory obstruction, requiring a nasopharyngeal airway or intubation. Affected babies are at risk of obstructive sleep apnoea. Unrecognised or untreated airways obstruction may lead to chronic hypoxia and cerebral impairment, failure to thrive and cor pulmonale. The most common early problem is feeding difficulties, as the cleft palate prevents enough negative pressure to feed effectively. Careful examination for other somatic abnormalities, including examination of the eyes and ears, may indicate the presence of the malformation as one of the related syndromes. EG fetal alcohol syndrome, stickler's syndrome: PRS plus severe myopia, retinal detachment and blindness with abnormal epiphyseal development due to alpha-1 collagen II polypeptide mutation. Velocardiofacial syndrome: 22q deletion with neuropsychiatric impairments and cardiac abnormalities. Treatments may include distraction jaw osteogenesis, tongue-lip adhesion/glossopexy and tracheostomy.

Answer 5

Juvenile myoclonic epilepsy is an epilepsy syndrome characterized by myoclonic jerks (quick jerks of the arms or legs), generalized tonic-clonic seizures (GTCSs), and sometimes, absence seizures. The seizures often occur when people first awaken in the morning. Seizures can be triggered by lack of sleep, extreme fatigue, stress, or alcohol consumption. Onset typically occurs around adolescence in otherwise healthy children. Might self resolve in middle adulthood. The signs and symptoms of juvenile myoclonic epilepsy are: Myoclonic jerks or seizures, which are described as quick jerks of the arms and legs, and are the hallmark feature of the disease; they may be the only symptom in about 17% of the cases; in about 20% of the cases, the seizures occur in clusters, affecting only one side (unilateral) of the body, and start before a tonic-clonic seizure Generalized tonic-clonic seizures, appear a few months after onset of myoclonic jerks Absence seizures, usually the first symptom to present around 5 and 16 years of age Myoclonic status epilepticus is considered to be the most concerning problem of juvenile myoclonic epilepsy. It occurs when multiple myoclonic seizures do not readily stop and after sleep deprivation or missing medications. Anti-convulsants are typically needed and well tolerated. The majority of patients can be well-controlled on a single drug, most commonly valproic acid. Other medications that might be used separately or in combination include lamotrigine, levetiracetam, clonazepam, and topiramate.

Answer 6

It is a term to describe brain dysfunction. Thus there are many types. The primary symptom in all is an altered mental state. It can be cause by infection, alcohol toxicity, trauma, liver and kidney failure, hypoxia/reduced cerebral perfusion, metabolic disorders and malnutrition. Other symptoms can involve memory loss, lack of concentration, cognitive decline, loss of consciousness, muscle twitches, REM, muscle weakness, seizures.

Answer 7

Metastatic The most common brain tumor among adults, metastatic tumors are classified as secondary brain tumors, which means they arise from cancer that formed elsewhere in the body and then spread to the brain. Metastatic tumors most often stem from lung or breast cancer. Larger metastatic tumors will often be surgically resected and smaller tumors may be treated with a gamma knife. 2. Meningioma These tumors are technically not brain tumors, as they form in the meninges, which are the membranes that line the skull and vertebral canal. But their growth may affect the brain by causing various disabilities such as vision and hearing impairment, memory loss or seizures. Incidents of meningioma increase with age, and the tumors grow slowly, so symptoms could develop gradually over time. They are benign. The most common early sign of meningioma is chronic headaches but often they can be asymptomatic. 3. Glioblastoma Glioblastoma is the most common primary brain tumor, which means it originates in the brain. It has the worst prognosis. Treatment includes surgical resection, radiation therapy, and chemotherapy. Currently, the aim is to employ immunotherapy trials. Immunotherapy basically reprograms a patient’s immune system to target and attack cancer cells. 4. Astrocytoma These primary tumors originate in astrocytes, starting from the brain’s cerebrum. The grade of astrocytoma tumors varies; sometimes they grow slowly (Grade II) and sometimes they come on more aggressively (Grade III). Treatment approaches to astrocytomas always involve surgery, and occasionally involve chemotherapy and radiation therapy. Astrocytomas have more positive overall survival rates. On the whole, persistent headaches are the most common early signs of brain tumors. Some warning signs would be headaches that increase in frequency and intensity over days and weeks, and if the headaches become so intense that it wakes up a sleeping patient.

Answer 8

The arterial supply to the larynx is via the superior and inferior laryngeal arteries: Superior laryngeal artery – a branch of the superior thyroid artery (derived from the external carotid). It follows the internal branch of the superior laryngeal nerve into the larynx. Inferior laryngeal artery – a branch of the inferior thyroid artery (derived from the thyrocervical trunk). It follows the recurrent laryngeal nerve into the larynx. Venous drainage is by the superior and inferior laryngeal veins. The superior laryngeal vein drains to the internal jugular vein via the superior thyroid, whereas the inferior laryngeal vein drains to the left brachiocephalic vein via the inferior thyroid vein. Innervation The larynx receives both motor and sensory innervation via branches of the vagus nerve: Recurrent laryngeal nerve – provides sensory innervation to the infraglottis, and motor innervation to all the internal muscles of larynx (except the cricothyroid). Superior laryngeal nerve – the internal branch provides sensory innervation to the supraglottis, and the external branch provides motor innervation to the cricothyroid muscle. Anatomically, the internal cavity of the larynx can be divided into three sections: Supraglottis – From the inferior surface of the epiglottis to the vestibular folds (false vocal cords). Glottis – Contains vocal cords and 1cm below them. The opening between the vocal cords is known as rima glottidis, the size of which is altered by the muscles of phonation. Subglottis – From inferior border of the glottis to the inferior border of the cricoid cartilage. The interior surface of the larynx is lined by pseudostratified ciliated columnar epithelium. An important exception to this is the true vocal cords, which are lined by a stratified squamous epithelium. The laryngeal membranes and ligaments support the cartilaginous skeleton of the larynx. The extrinsic ligaments act to attach the components of the larynx to external structures (such as the hyoid and the cricoid cartilage). The intrinsic ligaments are responsible for holding the cartilages of the larynx together as one functional unit internally Extrinsic: Thyrohyoid membrane – Spans between the superior aspect of the thyroid cartilage and the hyoid bone. It is pierced laterally by the superior laryngeal vessels and internal laryngeal nerve (branch of the superior laryngeal nerve). Median thyrohyoid ligament – Anteromedial thickening of the membrane. Lateral thyrohyoid ligaments – Posterolateral thickenings of the membrane. Hyo-epiglottic ligament – Connects the hyoid bone to the anterior aspect of the epiglottis. Cricotracheal ligament – Connects the cricoid cartilage to the trachea. Median cricothyroid ligament – Anteromedial thickening of the cricothyroid ligament (see below), connecting the thyroid and cricoid cartilages. Intrinsic: Cricothyroid ligament – Originates from the cricoid cartilage and extends superiorly, where it terminates with an free (unattached) upper margin – which forms the vocal ligament. It is additionally attached anteriorly to the thyroid cartilage, and posteriorly to the arytenoid cartilage. Quadrangular membrane – Spans between the anterolateral arytenoid cartilage and the lateral aspect of the epiglottis. It has a free upper margin and lower margin. The lower margin is thickened to become the vestibular ligament. The vocal folds (true vocal cords) are the more important of the two sets. Under the control of the muscles of phonation, they are abducted, adducted, relaxed and tensed to control the pitch of the sound created. Vocal ligament – Lies at the free upper edge of the cricothryoid ligament. Vocalis muscle – Exceptionally fine muscle fibres that lie lateral to the vocal ligaments. The vocal folds are relatively avascular, and appear white in colour. The space between the vocal folds is known as the rima glottidis. The vestibular folds (false vocal cords) lie superiorly to the true vocal cords. They consist of the vestibular ligament (free lower edge of the quadrangular membrane) covered by a mucous membrane, and are pink in colour. They are fixed folds, which act to provide protection to the larynx.

Answer 9

Symptoms (remote and face-to-face assessments) sudden vomiting and diarrhoea. often bloody. Likely dehydrated if: Well child Perceived to be unwell or deteriorating Normal conscious state Excessive or unaccustomed irritability or lethargy Depressed conscious state Normal level of thirst Increased thirst Normal urine outputb Decreased urine outputb Normal skin colour Normal skin colour Pale or mottled skin Warm hands and feet Warm hands and feet Cold hands and feet Signs (face-to-face assessments only) Normal conscious state Irritability or lethargyDepressed conscious state Clinical feature of dehydration Normal skin colour and warm peripheries Normal skin colour and warm peripheries Pale or mottled skin and/or cold peripheries In children with clinical dehydration, including hypernatraemic dehydration: − treat with low osmolarity ORS − give 50 ml/kg of ORS over 4 hours in addition to maintenance fluids − administer the fluid frequently and in small amounts − consider supplementation with their usual fluids (including milk feeds or water, but not fruit juices) if they refuse to take adequate quantities of ORS and do not have red flag symptoms or signs of dehydration − consider administration of ORS via nasogastric tube if they are unable to drink ORS or vomit persistently − monitor the response to ORT by regular clinical reassessment. • Use intravenous fluid therapy (IVT) for dehydration: − if clinical assessment confirms or raises suspicion of shock − if, despite appropriate ORT, there are signs of deterioration with red flag symptoms or signs of dehydration • Following rehydration: − give full-strength milk from the outset − reintroduce the child’s usual solid food − avoid giving fruit juice until diarrhoea has stopped

Answer 10

Meniere's disease is a disorder affecting the inner ear which can affect balance and hearing. It is a clinical syndrome characterized by episodes of vertigo, fluctuating hearing loss, and tinnitus and is associated with a feeling of fullness in the affected ear. The cause of Meniere's disease is not known but it may be associated with endolymphatic hydrops (raised endolymph pressure in the membranous labyrinth of the inner ear). Meniere's disease is associated with complications of falls, adverse psychological impact and social effects. Suspect Meniere's disease if the person has classic symptoms of episodes of spontaneous vertigo, tinnitus, fluctuating sensorineural hearing loss, and aural fullness. Initially, symptoms of Meniere's disease fluctuate, resolving between episodes. Progression results in further hearing loss and persistent tinnitus. Eventually, vertigo symptoms may resolve, but the person may have residual hearing loss and tinnitus. short course of prochlorperazine or an antihistamine (for example cinnarizine, cyclizine, or promethazine teoclate) should be considered. If symptoms are severe enough, people may require hospital admission for intravenous (IV) labyrinthine sedatives and fluids to maintain hydration and nutrition. A trial of betahistine can be considered to reduce the frequency and severity of attacks.

Answer 11

Normal breath sounds are classified as bronchial, vesicular, or bronchovesicular, which have different acoustic properties based on anatomical characteristics of the location where you are auscultating. Bronchial sounds (also called tubular sounds) normally arise from the tracheobronchial tree and vesicular sounds normally arise from the finer lung parenchyma. Loud, harsh, and high pitched bronchial sounds are typically heard over the trachea or at the right apex. They are predominantly heard during expiration. If heard in other areas of the lung, bronchial sounds are abnormal. In contrast, vesicular breath sounds are soft, low pitched, predominantly inspiratory, and appreciated especially well at the posterior lung bases. Bronchovesicular sounds can be heard during inspiration and expiration and have a mid-range pitch and intensity. They are commonly heard over the upper third of the anterior chest.

Answer 12

Crackles, rhonchi, and wheezes. Stridor and rubs.

Answer 13

For example, bronchial (loud & tubular) breath sounds are abnormal in peripheral areas where only vesicular (soft & rustling) sounds should be heard. When bronchial sounds are heard in areas distant from where they normally occur, the patient may have consolidation (as occurs with pneumonia) or compression of the lung. These conditions cause the lung tissue to be dense. The dense tissue transmits sound better from the lung bronchi.

Answer 14

caused by fluid in the small airways or atelectasis. Crackles are referred to as discontinuous sounds; they are intermittent, nonmusical and brief. Crackles may be heard on inspiration or expiration. The popping sounds produced are created when air is forced through respiratory passages that are narrowed by fluid, mucus, or pus. Crackles are often associated with inflammation or infection of the small bronchi, bronchioles, and alveoli. Crackles that don't clear after a cough may indicate pulmonary edema or fluid in the alveoli due to heart failure or adult respiratory distress syndrome (ARDS). Fine (popping bubbles) are typically late inspiratory and coarse are usually early inspiratory Medium crackles are high pitched, very brief and soft. It sounds like rolling a strand of hair between two fingers. Fine crackles could suggest an interstitial process; e.g pulmonary fibrosis, congestive heart failure. Coarse crackles (velcro sound) are louder, more low pitched and longer lasting. They indicate excessive fluid on the lungs which could be caused by aspiration, pulmonary oedema from chronic heart disease, chronic bronchitis, pneumonia Overall list of causes: Pneumonia Heart disease Pulmonary fibrosis Cystic fibrosis COPD Lung infections, like bronchitis or bronchiolitis Asbestosis, a lung disease caused by breathing in asbestos Pericarditis, an infection of the sac that covers your heart

Answer 15

Wheezing is a term used to describe high whistling sounds in the lungs, and it is usually more pronounced with expiration. Or during both inspiration and expiration. They are caused by air moving through airways narrowed by constriction or swelling of airway or partial airway obstruction. Two of the most common causes of wheezing are lung diseases called chronic obstructive pulmonary disease (COPD) and asthma. But many other issues can make you wheeze, too, including: ``` Allergies Bronchitis or bronchiolitis Emphysema Epiglottitis (swelling of the top flap of your windpipe) Gastroesophageal reflux disease (GERD) Heart failure Lung cancer Sleep apnea Pneumonia Respiratory syncytial virus (RSV) Vocal cord problems An object stuck in your voice box or windpipe ``` Rhonchi- low pitched wheeze They often clear with coughing and are usually caused by an obstruction or build-up of mucus in the large airways. Squawks- Short inspiratory wheeze conditions such as pneumonia, lung fibrosis, or bronchiolitis obliterans.

Answer 16

Stridor is a high-pitched sound originating from the upper airway and occurring on inspiration. It is distinguished from other sounds by its intensity in the neck more so than the chest, timing (inspiratory), and pitch (high). Like wheezes, stridor is produced by airway narrowing, but only in the upper airways. Risk for obstruction. Laryngomalacia (softening of the vocal cords in babies) Paralyzed vocal cord Narrow voice box Macroglossia/micrognathia Unusual growth of blood vessels (hemangioma) just below your vocal cords Croup (Laryngotracheobronchitis) Laryngitis Epiglottitis Anaphylaxis You can also have stridor if an object gets stuck in your windpipe.

Answer 17

A rub is a raspy grating sound coming from inflamed pleura rubbing against one another. It is usually louder than other lung sounds due to its generation closer to the chest wall. Rubs usually occur during both inspiration and expiration at a mirrored point in the respiratory cycle. Rubs are most often confused with crackles but are distinguished by the rub's biphasic, localized quality, often with overlying point pain on the chest wall. ``` Pleurisy Lung tumors that extend to the pleura Pleural mesothelioma (a malignant tumor of the pleura) Pneumonia Pulmonary embolism ``` Pleural friction rubs are low-pitched, grating, or creaking sounds that occur when inflamed pleural surfaces rub together during respiration. More often heard on inspiration than expiration, the pleural friction rub is easy to confuse with a pericardial friction rub. To determine whether the sound is a pleural friction rub or a pericardial friction rub, ask the patient to hold his breath briefly. If the rubbing sound continues, its a pericardial friction rub because the inflamed pericardial layers continue rubbing together with each heart beat - a pleural rub stops when breathing stops.

Answer 18

Coarse crackles: originates within large bronchial tubes. Heard in consolidation, lung cavitation, abscess, pulmonary congestion or oedema and bronchiectasis. Fine crackles: localised sound made louder on coughing. Due to sticking of alveolar walls. Characteristic of early pneumonia, atelectasis, bronchitis, bronchiolitis, pulmonary oedema. Tracheal Rales/Death Rattle- heard over trachea or lungs of seriously ill who can't expectorate.

Week 5 Flashcards

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