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					1.   The following are associated with the unsafe type of chronic otitis media:
     a)     Marginal tympanic membrane perforation                          T
     b)     Central tympanic membrane perforation                           F
     c)     Accumulation of keratin material                                T
     d)     Recurrent aural discharge                                       T
     e)     Severe pain                                                     F

2.   Common symptoms of an acoustic neuroma include:
     a)   Acute vertigo                                                     F
     b)   Dysequilibrium                                                    T
     c)   Headache                                                          F
     d)   Sensorineural hearing loss                                        T
     e)   Tinnitus                                                          T

3.   A 65 year old male presents with pain and swelling over the maxilla. The
     differential diagnosis includes:
     a)      Chronic maxillary sinusitis                                   F
     b)      Dental abscess                                                T
     c)      Carcinoma of the maxillary sinus                              T
     d)      Anterochoanal polyp                                           F
     e)      A cyst of the maxillary sinus                                 F

4.   Nasal obstruction in children is commonly due to:
     a)     Allergic rhinitis                                               T
     b)     Nasal polyposis                                                 F
     c)     Adenoid hypertrophy                                             T
     d)     Septal hematoma                                                 T
     e)     Deviated nasal septum                                           F

5.   Pain in the salivary glands in usual with:
     a)      Viral parotitis (mumps)                                        T
     b)      Pleomorphic adenoma                                            F
     c)      Warthin’s tumor                                                ?
     d)      Sarcoidosis                                                    F
     e)      Sialolithiasis (Salivary calculi)                              T

6.   Complications of acute tonsillitis include:
     a)    Meningitis                                                       F
     b)    Parapharyngeal abscess                                           T
     c)    Septicemia                                                       T
     d)    Upper airways obstruction                                        T
     e)    Acute otitis media                                               T

7.   Anatomy of larynx
     a)    Sparse lymph nodes                                               F
     b)    Innervated by glossopharyngeal nerve                             F
8.    Esophageal foreign bodies
      a)    Are always visible on soft tissue xrays                         F
      b)    Are always associated with esophageal strictures                F
      c)    Most often lodge in the lower esophagus                         F
      d)    Require rigid esophagoscopy for removal                         T
      e)    Commonly occur in edentulous patients                           T

9.    Indicated whether the following statements on laryngeal anatomy are true or
      false
      a)      The cricoid is the only complete cartilaginous ring            T
                 in the upper respiratory tract
      b)      The hyoid is a laryngeal cartilage                             F
      c)      The vocal cord has sparse lymphatic drainage                   T
      d)      The thyroid notch indicates the level of the vocal cords       T
      e)      The arytenoid cartilage forms a boundary of the pyriform fossa T

10.   Complications of tracheotomy include
      a)    Surgical emphysema                                              T
      b)    Pneumothorax                                                    T
      c)    Vocal cord paralysis                                            F
      d)    Esophageal perforation                                          F
      e)    Dislodgement of the tracheotomy tube                            T

11.   Gram negative organisms are commonly responsible for:
      a)    Acute sinusitis                                                 T
      b)    Auricular perichondritis                                        T
      c)    Peritonsillitis                                                 F
      d)    Chronic otitis media                                            T
      e)    Neck space infection                                            T

12.   The following cranial nerves may be involved in referred otalgia
      a)     Vagus                                                          T
      b)     Abducens                                                       F
      c)     Glossopharyngeal                                               T
      d)     Hypoglossal                                                    F
      e)     Trigeminal                                                     T

13.   Complications of cocaine anesthesia include
      a)    Vasoconstriction                                                T
      b)    Vasovagal reaction                                              F
      c)    Cardiac arrhythmia                                              T
      d)    Rebound vasodilation                                            F
      e)    Respiratory failure                                             F
14.   Tracheostomy may be performed to
      a)    Bypass laryngeal obstruction                     T
      b)    Facilitate positive pressure ventilation         T
      c)    Remove tracheal foreign body                     F
      d)    Facilitate pulmonary toilet                      T
      e)    Manage pneumothorax                              F

15.   Stridor in children
      a)      Is commonly due to laryngomalacia              T
      b)      May be caused by vocal cord polyp              F
      c)      Demands that the patient have a laryngoscopy   F
      d)      Mandates a tracheostomy                        F
      e)      Is not due to a lesion in the vocal cord       T
                  if the child has a normal cry

16.   The following are features of peritonsillar abscess
      a)     Trismus                                         T
      b)     Dysphagia                                       T
      c)     Meningitis                                      F
      d)     Sleep apnea                                     F
      e)     Cervical lymphadenopathy                        T

17.   The following are usually associated with
         chronic otitis media with effusion
      a)     Purulent middle ear fluid                       T
      b)     Retracted tympanic membrane                     T
      c)     Otalgia                                         F
      d)     Fluctuating hearing loss                        T
      e)     Perforated tympanic membrane                    F

18.   Menieres disease is characterized by
      a)    Conductive hearing loss                          F
      b)    Tinnitus                                         T
      c)    Episodic vertigo                                 T
      d)    Recurrent otalgia                                F
      e)    Aural discharge                                  F

19.   Unilateral purulent discharge may be due to
      a)     Congenital choanal atresia                      T
      b)     Septal hematoma                                 F
      c)     Nasal foreign body                              T
      d)     Allergic rhinitis                               F
      e)     Rhinitis medicamentosa                          F
20.   Stridor can be caused by
      a)      Bronchial asthma                                      F
      b)      Vocal cord paralysis                                  T
      c)      Consolidation                                         F

21.   Calculi in the salivary glands
      a)     Are more common in the submandibular than parotid      T
      b)     Are always radioopaque                                 F
      c)     Reflect an underlying sialectasis                      F
      d)     Are a feature of Sjogrens disease                      F
      e)     Always require surgical removal                        T

22.   Facial nerve paralysis may be associated with the following
      a)      Head injury                                           T
      b)      External auditory canal osteoma                       F
      c)      Acute otitis media                                    T
      d)      Pleomorphic adenoma                                   T
      e)      Acoustic schwannoma                                   T

23.   Direct relations of maxillary sinus
      a)      Hard palate                                           T
      b)      Lamina paprycea                                       F
      c)      Middle turbinate                                      F
      d)      Optic nerve                                           F
      e)      Orbit                                                 T

24.   Direct relations of the parotid gland
      a)      Ramus of mandible                                     T
      b)      Mastoid process                                       F
      c)      Vagus nerve                                           F
      d)      Internal jugular vein                                 F

25.   Contents of the posterior triangle
      a)    Carotid sheath                                          F
      b)    Accessory nerve                                         T
      c)    Vagus nerve                                             F
      d)    Lymph nodes                                             T
      e)    Submandibular gland                                     F

26.   Branches of the facial nerve include
      a)    Parasympathetic to lacrimal gland                       T
      b)    Parasympathetic to parotid gland                        F
      c)    Sensory to stapedius                                    F
      d)    Sensory to posterior 1/3 of tongue                      F
27.   Adenoid cystic carcinoma
      a)    Occurs most commonly in salivary glands               T
      b)    Presents as a painful swelling in the parotid gland   T
      c)    Is prone to perineural extension                      T
      d)    Often occurs bilaterally                              F

28.   Vestibuloneuritis
      a)     Can occur in epidemic                                T
      b)     Causes momentary episodes of vertigo                 F
      c)     Often has association with tinnitus                  F
      d)     Can be preceded by viral illness                     T
      e)     Never associated with deafness                       T

29.   Globus pharyngeus
      a)    Occurs commonly in females                            T
      b)    May be associated with anemia                         F
      c)    Indicates pathology in the oropharynx                 F
      d)    Can be associated with GORD                           T
      e)    Dysphagia                                             F

30.   The cochlea
      a)     Is situated in the part of the temporal bone         T
      b)     Is sensorial damaged in longitudinal                 F
                  fractures of the temporal bone
      c)     Contains perilymph                                   T
      d)     Gives information regarding posture control          F

31.   Squamous cell carcinoma commonly occurs in
      a)   Vocal cords                                            T
      b)   Middle ears                                            F
      c)   Nasopharynx                                            T

32.   Facial paralysis
      a)      All type of malignant tumors in the parotid gland   T
                  may cause facial paralysis
      b)      Causes the affected side to be pulled down          T

33.   Acute retropharyngeal abscess
      a)     Usually occurs in children                           T
      b)     The swelling is central                              F
      c)     The swelling is to one side of the midline           T
      d)     The patient extends the head and opens               T
             the mouth to maintain an airway
      e)     Does not obstruct respiration                        F
34.   Which of the following are presenting features of
      nasopharyngeal carcinoma
      a)    Epistaxis                                                 T
      b)    Dysphagia                                                 F
      c)    Paraplegia                                                F
      d)    Enlarged cervical lymph nodes                             T
      e)    Otalgia                                                   T

35.   The earliest signs of carcinoma of hypopharynx include
      a)     Enlarged lymph node behind angle of the jaw              F
      b)     Facial nerve paralysis                                   F
      c)     Dysphagia                                                T
      d)     Dyspnea                                                  F
      e)     Hoarseness                                               F

36.   The tonsil appears enlarged on inspection. This may be due to
      a)     Tonsillitis                                              T
      b)     Tonsil carcinoma                                         T
      c)     Lymphoma of tonsil                                       T
      d)     Parotid tumor                                            T
      e)     Amyloidosis                                              F

37.   Polyps histopathology appearance
      a)     Malignant neoplasia                                      F
      b)     Benign neoplasia                                         F
      c)     Granulation tissue                                       T
      d)     Edematous pouches                                        T
      e)     Fatty degeneration                                       F

38.   Ethmoid sinuses have direct anatomical relation with
      a)    Optic nerve                                               F
      b)    Inferior turbinate                                        F
      c)    Nasal process of maxillary bone                           F
      d)    Lamina capricus                                           F

39.   Bells palsy is associated with
      a)     Herpes zoster virus                                      F
      b)     Part of polyneuropathy                                   F
      c)     Recurrence                                               T

40.   Unilateral hearing loss may be caused by
      a)     Presbycusis                                              F
      b)     Otological drugs                                         F
      c)     Mumps                                                    T
      d)     Acoustic neuromas                                        T
41.   Submandibular gland
      a)   Can be below hyoid bone                          T
      b)   Can go beyond angle of mandible                  F
      c)   Opens opposite lower canine                      F
      d)   Common place for neoplasm                        F

42.   Trismus can be caused by
      a)    TMJ                                             T
      b)    Tonsillar carcinoma                             T
      c)    Peritonsillitis (quinsy)                        T
      d)    Nasopharyngeal carcinoma                        T

43.   Nasopharyngeal carcinoma can cause
      a)    Proptosis                                       F
      b)    Ulcers of the palate                            F
      c)    Epistaxis                                       T
      d)    Enlarged neck mass                              T

44.   A 50 year old man with enlarged lymph nodes between
      digastric and jugulo-hyoid may be caused by:
      a)      Old TB                                        T
      b)      Chronic tonsillitis                           T
      c)      Nasopharyngeal carcinoma                      T
      d)      GI tumors                                     F

45.   Glandular fever features
      a)    Cervical lymphadenopathy                        T
      b)    Hypersplenism                                   T
      c)    Polyneuritis                                    F
      d)    Pain                                            T

46.   Facial nerve paralysis may be caused by
      a)      Cystadenolymphoma                             T
      b)      Acoustic schwannoma                           T
      c)      Pleomorphic adenoma                           T
      d)      Head trauma                                   T

47.   Sjogrens syndrome
      a)     Painful swelling                               F
      b)     Predispose to lymphoma                         T
      c)     Dry eyes                                       T
      d)     Presents with osteoarthritis                   F
      e)     Diagnosed with sublabial biopsy                T
48.   Longitudinal fractures of the temporal bone
      a)     Hard to see on Xray                                           T
      b)     Commonly cause facial nerve paralysis                         T
      c)     Cause inner ear damage                                        F
      d)     Cause bloody ear discharge                                    F
      e)     Cause conductive hearing loss                                 T

49.   Positional vertigo
      a)     Can have CNS causes                                           T
      b)     Usually associated with inner ear problems                    T
      c)     Prolonged vomiting                                            T
      d)     Head trauma                                                   T

50.   Clinical features of maxillary sinus Carcinoma include
      a)     Anosmia                                                       T
      b)     Diplopia                                                      T
      c)     Facial swelling                                               T
      d)     Supraclavicular neck lymphadenopathy                          F
      e)     Epistaxis                                                     T

51.   SCC is common in
      a)     Thyroid gland                                                 F
      b)     Middle ear                                                    F
      c)     Oropharynx                                                    T
      d)     Mouth                                                         T
      e)     Submandibular gland                                           F

52.   Laryngotracheobronchitis
      a)    Commonly occurs in >6 years old                                F
      b)    Always requires hospitalization                                F
      c)    Affects epiglottis                                             F

53.   Cliical features indicative of complications of acute Otitis media
      a)      Vertigo                                                      T
      b)      Tinnitus                                                     T
      c)      Severe otalgia                                               F
      d)      Progressive hearing loss                                     T

54.   Temporal bone
      a)    Cochlea is in petrous part                                     T
      b)    Cochlea contains scala media                                   T
      c)    Cochlea is commonly damaged in                                 F
                longitudinal fractures of temporal bone
      d)    Cochlea involved in balance                                    F
55.   Carcinoma of the lip
      a)     More often affects lower lip then upper                        T
      b)     Metastasizes early to internal jugular lymph nodes             F
      c)     Affects men more often than women                              T
      d)     Has a poor prognosis if it occurs at the angle of the mouth    T
      e)     Is best treated by surgical excision                           T

56.   Malignant disease of
      a)    The tonsil most commonly arises in the lymphoid tissue          F
      b)    The tongue can cause pain radiating to the ear                  F
      c)    The nasopharynx may present with deafness                       T
      d)    The floor of the mouth is most commonly an ulcerating SCC       T
      e)    The buccal mucosa can arise in a patch of leukoplakia           T

57.   In acute mastoiditis
      a)      Inspection from behind may reveal the pinna is pushed forward T
      b)      Conductive deafness is present                                T
      c)      Perceptive deafness is present                                F
      d)      Moving pinna up and back is painful                           T
      e)      Patient is a child                                            T

58.   Which of the following are true of the varieties of nasal sinusitis
      a)    Frontal sinusitis is a disease of the aged                      F
      b)    Frontal sinusitis is a disease of the young                     T
      c)    Ethmoiditis is largely confined to infants and young children   T
      d)    Maxillary sinusitis is found only before the 12th year          F

59.   In otosclerosis
      a)      Deafness is commonly bilateral                                T
      b)      Tinnitus is common                                            T
      c)      Tympanic membranes are normal                                 T
      d)      Audiometry shows normal bone conduction                       T
                  but impaired air conduction

60.   Acute otitis media:
      a)      commonly caused by hemophilus influenzae                      T
      b)      commonly associated with tinnitus                             T
      c)      commonly associated with vertigo                              F
61.   Organisms commonly causing chronic otitis media include
      a)      Gram positive                                                 T
      b)      Staph                                                         T
      c)      Haemophilus influenza                                         T
62.   Indications for myringotomy/tympanocentesis include:
      a)      Neonates                                                      F
      b)      Failure of antibiotic treatment                               T
      c)      Intracranial complications                                    T
ENT answers explained:
1. Chronic otitis media arises because of late or ineffective treatment of acute otitis
    media, lowered resistance (malnutrition, anemia, etc) or upper airways sepsis. There
    are two types of chronic otitis media, being mucosal and bony (aka attico-antral
    disease). Both give rise to discharging ear, but the two can be differentiated on the
    basis of discharge type, complications, perforation location and location of disease.
      COM type    Discharge               Complications   Perforation            Location      .
      Mucosal     mucoid                  deafness        central (pars tensa)   tubo-tympanic
      Bony        scanty, foul-smelling   granulations    postero-superior       attico-antral
                        but persistent    Aural polyps       (pase flaccida)
                                          Cholesteotoma

      Granulations and aural polyps are both made out of granulation tissue.
      Treatment of BONY disease involves regular aural toilet or suction toilet (removes
      small cholesteotoma). If cholesteotoma is present, mastoidectomy is needed

      Treatment of MUCOSAL disease requires frequent aural toilet. If the performation
      requires repair, a myringoplasty can be done.

      Earache and deafness can be present in both forms of the disease, although neither
      are as pronounced as in acute otitis media.

2.    Acoustic neuromas (aka vestibular Schwannomas) are benign tumors of the
      superior vestibular nerve. They are usually unilateral except in neurofibromatosis-2
      (Chromosome22) in which case bilateral vestibular Schwannomas may be present.
      Symptoms include:        - EARLY signs are: - hearing loss (sensorineural)
                                                      - imbalance
                               - LATE signs are due to impingement on other structures
                                      and include: - loss of corneal sensation
                                                              (impingement on CN V)
                                                      - facial nerve palsy (CN VII)
                                                      - Increased intracranial pressure
                                                          ( headache, nausea,
                                                          papilloedema)

        Since late signs would be rare, headache would be a rare symptom in acoustic
        neuroma.

        Since any form of deafness can cause tinnitus, acoustic neuromas cause tinnitus.

     3. Chronic maxillary sinusitis usually has very few symptoms, but MAY include
        nasal obstruction, anosmia, nasal/postnasal mucopus discharge or cacosmia.
        There is not a visible mass although there may be a fluid level or opacity on
        radioimaging.
   While swelling of the cheek is rare in maxillary sinusitis, when it IS present, it is
   often dental of origin. Usually cheek swelling over the maxilla is due to
   carcinoma of the maxillary antrum.

   Antro-choanal polyps extend from maxillary antrum BACK through ostium,
   presenting as a smooth swelling in the nasopharynx. Treatment involves avulsion
   within nose.

   A cyst in the maxillary sinus would not be painful and would not expand onto the
   cheek.

4. Nasal obstruction in children can occur from:
   -      adenoid hypertrophy (adenoids begin atrophy at 7, gone by 16/17)
   -      unilateral choanal atresia (presents about age 5 with thick mucus)
   -      bilateral choanal atresia (presents at birth since newborns aren’t
          able to mouthbreath)
   -      foreign body in nose
   -      acute or chronic maxillary sinusitis
   -      allergic or non-allergic rhinitis

           RARE causes include:
   -       septal hematoma (hemorage between 2 sheets perichondrium,after trauma)
   -       septal deviation (maybe due to injurytreat with SMR or reduction)
   -       nasal polyposis (RARE unless child has CF)

5. Pain in the salivary glands can arise from acute inflammation or stones.
   Malignancies are not characteristically painful.
           Parotitis can be caused by mumps or bacterial infection (Staph aureus,
   Strep pyogenes, Strep pneumoniae). It presents with a painful lump, usually of the
   parotid gland (rarely, the submandibular gland can be affected).
           Pleomorphic adenoma is a benign tumor that accounts for 90% of adult
   benign parotid tumors. They are painless slowly expanding lesions.
           Warthin’s tumor is also known as a cystic lymphoepithelial lesion. It is
   exclusive to the parotid gland and causes a cystic smooth swelling to the tail of
   the gland.
           Sarcoidosis rarely involves a salivary gland, causing a slowly expanding
   swelling. It is painless.
           Sialolithiasis (salivary calculi) are acutely painful, and characteristically
   more painful after eating. They can be expelled through the mouth, or
   superficially removed from the gland. All salivary calculi should be removed.

6. Complications of acute tonsillitis include: (remember acute tonsillitis looks like
   “CORN”)
   - Chest infection (pneumonia, etc)
   - Otitis media (acute)
   - Rheumatism (acute)
      -   Nephropathy (IgA mediated)
      -   quinsy (PERItonsillar abscess); abscesses in the deep neck spaces and around
          the pharynx (parapharyngeal) may also occur.

      Obviously, as a focus of infection, vascular access may cause septicaemia, so
      septicaemia is a potential complication of acute tonsillitis.

      Moreover, one of the symptoms of a grossly enlarged tonsil is upper airway
      obstruction.

      Complications of acute otitis media include:
      - Abscess (cerebral, subdural, epidural)
      - Meningitis
      - Acute mastoiditis
      - Labyrinthitis
      - Thrombosis (of lateral sinus)
      - Facial nerve paralysis
      - Petrositis (don’t forget DeGagliano’s syndrome CN VI palsy

7.   The muscles of the larynx are innervated by the vagus nerve’s recurrent laryngeal
     branch, except for the cricothyroids which are supplied by the vagus nerve’s
     superior laryngeal nerve. The larynx is well supplied with lymphatics though
     generally, tumors of the larynx tend to spread locally and only to lymphatics late.

8.   The esophagus is composed of three narrowings which tend to be the most common
     sites for obstruction. The first site is at the junction between the top 1/3 and the
     middle 1/3 of the esophagus, where the skeletal muscle becomes smooth muscle.
     Here about 70% of obstructions are likely to take place. The next narrowing is
     where the aortic arch and carina cross the esophagus, where 15% of obstructions
     occur. The final narrowing is at the gastroesophageal junction, where another 15%
     of obstructions occur.

     Obstructions are rarely caused by esophageal strictures, although a stricture clearly
     increases the likelihood of an obstruction from occurring. Depending on what is
     causing the obstruction, the object may be radioopaque or radiolucent (fish or
     chicken bones, wood, plastic, most glass, and thin metal objects) and thus a
     negative Xray is considered inconclusive and thus, if symptoms of obstruction
     (dysphagia, vomiting, respiratory distress, hematemesis, perforation, etc) persist, an
     esophagoscopy is required.

     Given the edentulous commonly have dentures, and elderly commonly swallow
     their dentures, being edentulous can cause obstruction!

     The tonsillar area is a popular area for fish bones!!
     The vocal folds are at the level of the middle of the laryngeal prominence (“Adam’s
     apple”) which is made of the thyroid cartilage.

9.   The laryngeal part of the pharynx extends from the superior part of the epiglottis to
     the inferior cricoid cartilage, where it is continuous with the esophagus. A small
     piriform fossa on each side of the laryngeal inlet is bounded medially by the
     aryepiglottic fold (includes aryepiglottic cartilage) and laterally by the thyroid
     cartilage and thyrohyoid membrane.

     There are several cartilaginous rings in the neck- the cricoid cartilaginous ring is
     complete while all others are incomplete (C-rings of trachea are all inferiorly
     incomplete).

     The laryngeal lymphatic drainage is delineated into superior and inferior drainage at
     the level of the vocal cords, but there are extensive anastomoses here. Superior
     drain into the superior deep cervical lymph nodes while inferior to the vocal cords
     drain into the inferior deep cervical lymph nodes. Curiously, however, the vocal
     cords themselves are devoid of lymphatic drainage.

10. Complications of tracheostomy include:
     Tracheostomy is to be performed by:
        1.      Transverse incision, halfway between
                    cricoid cartilage and sternal notch
        2.      Identify and retract strap muscles
        3.      Incise thyroid isthmus
        4.      Incise 3rd of 4th C-ring of trachea

       If inserted too low  pneumothorax or mediastinal emphysema
       If inserted too high perichondritis or subglottic stenosis (esp. if cricoid cartilage
                                     injured)
       After tube inserted complete or partial dislodgement
       Obstruction of tube (can be fatal)

11. Organisms that commonly cause:
    Condition              Organisms
    Acute sinusitis        Viral (RSV, influenza, coronavirus, parainfluenza)
                           Gram(+)= S. pneumoniae, S.aureus
                           Gram(-)= Moraxella catarrhalis, H. influezae
    Peritonsillitis        Viruses and group A Strep (pyogenes)
    Chronic otitis media SUPPURATIVE:
                           Gram(+)=Staph aureus,
                           Gram(-)=Pseudomonas, Proteus
                                   Bacteroides,
    Chronic otitis media SEROUS (microbes same as AOM)
                           Gram(+)=S.pneumoniae, S. aureus
                           Gram (-)=Moraxella catarrhalis, H. influenzae
     Neck space infusion      Gram(+)=S.pneumoniae
                              Gram (-)=H. influenzae, P. aeruginosa
     Auricular perichondritis Gram (+)=Staph aureus
                              Gram (-)=P. aeruginosa

12. Nerves involved in referred otalgia include cranial nerves 5,7,9,10 and cervical
    nerves 2 and 3.

13. Cocaine anesthesia can cause effects related to its inhibition of catecholamine
    uptake by noradrenaline and dopamine transporters. It causes psychomotor
    stimulation and euphoria. It’s effects on peripheral sympathomimetic actions cause
    tachycardia, vasoconstriction and increased blood pressure. Toxic effects include
    cardiac dysrhymias and coronary/cerebral thrombosis. Prolonged use can cause
    myocardial damage leading to cardiac failure. On overdose, respiratory and
    vasomotor depression can occur.

   14. Indications for tracheostomy include:

           1.      Conditions causing upper airways obstruction
           2.      Conditions necessitating protection of the tracheobronchial tree
           3.      Conditions causing respiratory failure
           Conditions necessitating protection of the tracheobronchial tree include:
           “Tracheostomy Can Protect Fantastically in MS and MG”
           Tetanus, Coma, Polio, Fractures of face, Multiple Sclerosis, Stroke,
               Myasthenia Gravis, Guillain-Barre syndrome
       In cases of respiratory failure, tracheostomy tubes facilitates reduction of dead
       space (decreases by 70mL), administer positive airways pressure, bypass
       laryngeal resistance or obstruction, clean/toilet the pulmonary/bronchial
       secretions and administer humidified O2.

   15. Stridor is a high pitched noise produced by narrowing in the larynx or trachea. In
       laryngeal obstruction, the stridor is inspiratory, in tracheal it is usually inspiratory
       AND expiratory. It indicates airways obstruction. The signs of airways
       obstruction include:
           1.      Stertor (low pitched sound from supra-laryngeal obstruction)
           2.      Stridor (high pitched sound from laryngeal/tracheal obstruction)
           3.      Accessory muscles of respiration
           4.      Tachycardia
           5.      Cyanosis
           6.      Pallor, sweating, restless
           7.      Intercostal recession
       BEWARE! When asphyxia is of long duration, exhaustion sets in.
       Causes of stridor include causes of laryngeal or tracheal obstruction, which
       include:
       ACUTE causes:
       1. Acute epiglottitis
   2. Laryngotracheobronchitis
   3. Laryngeal diphtheria
   Chronic causes (singer’s nodules, tumors, TB larynx, Syphilis of larynx,
   Hyperkeratosis of larynx) tend to cause hoarseness rather than stridor

   CONGENITAL causes (present at or close to birth)
   1. Laryngomalacia: Stridor shortly after birth because of collapse of soft
      laryngeal tissues on inspiration. It is surgically remedied by incision of
      aryepiglottic folds.
   2. Congenital subglottal stenosis: at level of cricoid cartilage
   3. Laryngeal webs: anteriorly situated
   4. Laryngeal cysts
   5. Vascular ring: anomaly of aorta that encirculates esophagus and trachea
      causing constriction. Surgery…

       It is not always necessary to do tracheostomy as antibiotics and humidified air
       are often sufficient for some acute causes, and endotracheal tube intubation
       with surgery is sufficient for most congenital causes.

16. Peritonsillar abscesses can arise as a complication of acute tonsillitis (as can chest
    infections, otitis media, acute rheumatic disease and IgA mediated nephropathy).
    They are collections of pus outside the capsule of the tonsil but close to its upper
    pole. Symptoms include:
        1.       Dysphagia
        2.       Otalgia (referred)
        3.       pyrexia
        4.       TRISMUS (motor disturbance of CN V, causing spasm of masticatory
                 muscles with difficulty opening mouth- should be able to insert three
                 fingers-breadth into mouth as general rule).
    As peritonsillar abscesses are associated with acute tonsillitis, symptoms of
    tonsillitis (cervical lymphadenopathy, earache, dysphagia, pyrexia, headache and
    malaise) can also be expected.

   While meningitis is a complication of otitis media, it is not a common
   complication of tonsillitis or quinsy.

   Sleep apnea is caused by obstruction by enlarged tonsils or adenoids. Peritonsillar
   abscess may be associated with enlarged tonsils but is not itself a cause of sleep
   apnea.

17. Chronic otitis media with effusion is also known as “glue ear” and is a
    considerably important condition to recognize as it can cause deafness. It is
    caused by:
       1.      nasopharyngeal obstruction Eustachian tube dysfunction
       2.      Acute otitis media
       3.      allergic rhinitis
      4.      parental smoking, winter months
      5.      Otitic barotraumas
   Symptoms include deafness, discomfort (NOT otalgia) and tinnitus or
   unsteadiness (NOT vertigo).

   On examination of the tympanic membrane, it appears retracted with a fluid level.
   It may have a yellow/orange tinge. Tuning fork tests show conductive deafness.
   The tympanic membrane is NOT perforated!

18. Menieres disease is caused by distension of the membranous labyrinth by
    excessive endolymph. It is usually unilateral (25% bilateral), comes on age 40-60,
    and presents with:
         1.      Intermittent vertigo vomiting
         2.      “Fullness” in ear
         3.      Deafness (sensorineural) which is progressive and severe
         4.      Tinnitus (persistent)
         Otalgia is not a common feature in Menieres
    It is treated by antiemetics (prochlorperazine), and restriction of salt and fluids.
    Avoidance of alcohol, cigarettes and coffee may also be effective.

   If medical treatments are ineffective, surgical options include:
   1.     Labyrinthectomy (cures vertigo but kills hearing)
   2.     Drain endolymphatic sac
   3.     Divide vestibular nerve (very hazardous)
   4.     Intra-tympanic gentamycin (reduces vestibular but 10% risk of worsening
          hearing)

19. Purulent discharge of a unilateral basis can be caused by:
       1.      unilateral choanal atresia (~age5 with mucoid discharge in one nostril)
       2.      nasal foreign body (often foul smelling purulent discharge)

       Allergic rhinitis and rhinitis medicamentosa both cause discharge but of a
       runny (watery) nature rather than purulent. Septal hematoma causes nasal
       obstruction but not discharge. In fact, the hematoma is wedged between two
       layers of perichondrium.

20. Vocal cord paralysis causes hoarseness and weak voice but not stridor.
    Consolidation does not cause stridor as there is no obstruction present.
    Bronchial asthma causes a wheeze, not a stridor.

   Vocal cord paralysis can be caused by recurrent laryngeal nerve palsies. Usually
   the left recurrent laryngeal nerve is affected because it is more vulnerable given it
   recurs over the arch of the aorta to return to the larynx. Causes of recurrent
   laryngeal nerve palsy include:

       1.      Carcinoma of:    - bronchus
                               - esophagus
                               - thyroid
                               - hypopharynx
       2.     Surgery of:      - cardiac, esophagus, thyroid or cervical spine
       3.     Aortic aneurysm (left only)
       4.     Malignant mediastinal nodes (left only)
       5.     Trauma
       6.     Virus (can be transient or recurrent)

21. Calculi of the salivary glands are more common in the submandibular gland than
    the parotid, because of the submandibular glands mixed mucous and serous
    secretion, rather than parotid’s mainly serous secretion. The sublingual gland
    secretes a mainly mucus secretion, but calculi are less common than in the
    submandibular gland.

       Calculi of the salivary glands are not always radioopaque. When they ARE
   radioopaque, they may be visualized using plain X-ray. If they can not be seen on
   plain x-ray, a ultrasound can be useful (although only radiologists can read them).
   Finally, a sialogram will outline the duct system and highlight any strictures,
   radiolucent calculi or sialectasis (die looks like drops).

   Sialectasis refers to a dilatation of the salivary gland duct. This has nothing to do
   with salivary gland calculi.

22. Facial nerve paralysis can be associated with “Some Very Big PAROTid Tumor”
            Sarcoidosis
            Vascular lesions in cerebrum
            Bells palsy
            Poliomyelitis
            Acoustic neuroma
            Ramsay Hunt (herpes zoster of geniculate ganglion, causing extreme pain
                    in ear, vertigo, decreased hearing and cranial nerve palsies in 7
                    most commonly, and 5,6,9,10,12 less commonly)
            Otitis media (acute and chronic)
            Trauma (facial)
            Tumors (acoustic neuroma, parotid tumors, cerebral tumors, middle ear
                    tumors)

23. The relations of the sinuses are as follows:
    Maxillary sinus       Superior = orbit
                         Posterior = pterygo-palatine fossa
                          Inferior = hard palate
                         Medially = medial and inferior turbinate bones/recess/meatus
    Ethmoid sinus        between lamina proprycea (orbit) and upper nose
   ALL sinuses open into ostiomeatal complex under middle turbinate. However,
   given the maxillary sinus communicates with a duct which opens in to the middle
   turbinate, the relation is not “direct.”

24. The parotid gland relates to the styloid muscles and styloid process of the
    temporal bone, the angle and ramus of the mandible and the ear. The facial nerve
    goes through it and divides into its branches (temporal, zygomatic, buccal,
    marginal mandibular, cervical, posterior auricular). The external jugular vein
    crosses it superficially.

   The mastoid process is behind the ear and thus not considered related to the
   parotid gland.

25. The anterior and posterior triangles of the neck are separated by the
    sternocleidomastoid.
    Anterior triangle of neck: lies from the median line of the neck
                                          Anterior border of SCM
                   CONTAINS: Submandibular gland
                                   Thyroid and parathyroid glands
                                   Carotid sheath (common carotid+IJV+vagus nerve)
                                   ECA
                                   CN XII (hypoglossal nerve)
                                   CN XI (accessory nerve)
                                   CN X (vagus nerve)
                                   Larynx and pharynx
                                   Submandibular lymph nodes
                                   Branches of cervical plexus

   Posterior triangle of neck: lies from posterior border of SCM to
                                       anterior border of trapezius
                 CONTAINS: EJV
                               CN XI (accessory nerve)
                               Trunks of brachial plexus
                               Cervical and supraclavicularlymph nodes
                               Subclavian artery, subclavian vein

26. The facial nerve supplies
       1.      Taste anterior 2/3 tongue and soft palate
       2.      Sensory external ear
       3.      Motor to: -         muscles of facial expression
                          -        stapedius
                          -        posterior digastric and stylohyoid
       4.      Parasympathetic to:
                          -        submandibular and sublingual salivary glands
                          -        lacrimal gland
   Despite the facial nerve passing through the parotid gland, it is in fact the
   glossopharyngeal nerve (CN IX) that supplies it with parasympathetic
   innervation.

27. Adenoid cystic carcinoma is a malignant neoplasm of the salivary glands. It
    comprises about 4% of neoplasms in the salivary glands. It presents as a slowly
    expanding mass, painless at first, that become painful if it involves nerves. It is
    especially known to cause perineural invasion by skipping lymphatics and
    metastasizing to lungs, bones and other tissues. It is most often unilateral.

28. Vestibular neuritis is of viral origin and causes vestibular failure and thus
    explosive persistent vertigo. Cochlear symptoms are absent (tinnitus and hearing
    loss). It can occur in epidemics, and resolution occurs over 6-12 weeks with the
    acute phase lasting 2 weeks. It is thought that the herpes virus may be implicated.
    It is rarely painful.

29. Globus pharyngeus is a sensation of a lump in the throat. It is sometimes caused
    by cricopharyngeal spasm. Eating can make the sensation better, but anxiety and
    introspection can make it worse. Globus pharyngeus is commonly associated with
    at least mild dysphagia; however, our class notes and the ENT department’s
    handouts say that globus pharyngeus does NOT cause dysphagia-go with false. If
    symptoms persist, barium swallow then esophagoscopy is essential. It is
    commonly associated with older anxious women.

30. The inner ear is buried in the petrous part of the temporal bone and consists of
    bony labyrinth (perilymph) and membranous labyrinth (endolymph; sacs and
    ducts suspended in bony labyrinth).

   Cochlea                 The outer bony parts have perilymph, the inner membrane
                                  (cochlear duct) has endolymph

   Semicircular canals     The CANALS have perilymph while the inner semicircular
                                 DUCTS have endolymph

   The cochlea is the organ for hearing-the semicircular canals, vestibule (saccule
          and utricle) are for balance.

   Transverse fractures affect the cochlea

31. Cancers of the larynx are almost all SCC. Adenoid cystic carcinoma and sarcoma
    occur but rarely. Glottic (60%), subglottic (10%) and supraglottic (30%)

   Cancers of the nasopharynx are most commonly SCC. Rarely lymphoma
   or adenoid cystic carcinoma can occur as well.
          While SCC is the most common middle ear malignant neoplasm, these are
   extremely rare.
32. Since all malignant neoplasms in the parotid gland can impinge on the facial
    nerve, all can cause facial nerve palsies, which present by the face being pulled
    down.

33. Retropharyngeal abscess occurs, as a rule, in infants and young children. Upper
    respiratory tract infection causes adenitis in the retropharyngeal lymph nodes,
    which suppurate. The abscess is limited to one side of the midline because of the
    median raphe of buccopharyngeal fascia.
            Clinically, the child is ill and pyrexic. Dysphagia and stridor may occur,
    and the head is often held to one side (abscess on one side, holds head to one side,
    dancing RETRO!). Alternatively, the kid can extend the head and open the mouth
    to keep his airway open, according to Bull ENT book.

    Treatment involves full dose antibiotics, and abscess incision. Incision is done
    under general anesthesia with great care, since abscess rupture can cause pus
    aspiration and ultimately…DEATH! Hwa ha ha ha…
    The high mortality rate of RPA is owing to its association with airway
    obstruction, mediastinitis, aspiration pneumonia, epidural abscess, jugular venous
    thrombosis, and erosion into the carotid artery.

   Aerobic organisms (beta-hemolytic streptococci and Staphylococcus aureus)
   Anaerobic organisms, such as species of Bacteroides and Veillonella
   Gram-negative organisms, such as Haemophilus parainfluenzae

34. Nasopharyngeal carcinoma causes a clinical picture reflective of it’s invasion of:
          Local structures    nasal obstruction and blood-stained discharge
          Otological          unilateral serous otitis media from Eustachian tuba
                               obstruction
          Neurological        invasion at skull base causes
                               paralysis of CN III, IV, V, VI, IX, X, XII
          Cervical            deep cervical lymphadenopathy
                               (often between mastoid and angle of jaw)

    Otalgia can be referred as a result of involvement of involvement of CN 5,7,9,10.
    Nasal obstruction with epistaxis can occur.

35. Malignant disease of the hypopharynx, as a general rule:
          Carcinoma of piriform fossa (just above vocal cords)= disease of men
          Post-cricoid carcinoma=disease of women, perhaps related to Patterson-
                  Brown-Kelly aka Plummer-Vinson syndrome

    Clinically, it cause:   - dysphagia and weight loss
                            - cervical lymphadenopathy
                            - hoarseness (LATE sign though)
                            - referred otalgia (worse on swallowing)
                                -   mirror exam shows malignant ulcer

                 I think the “lymph node behind angle of the jaw” refers to nasopharyngeal
                 carcinoma, which causes cervical lymphadenopathy between mastoid and
                 angle of jaw, thus I think this is False…

36.      Causes of enlarged tonsils include:     - acute tonsillitis
                                                 - neoplasm (often unilateral; includes
                                                         lymphoma and carcinoma)
                While amyloid can be found in the tonsil (NCBI does report a case of
         primary amyloidosis affecting the tonsil), it is so rare I would prefer to think this
         question is to differentiate the student who realizes that amyloidosis in this area
         MOST often affects the tongue or salivary glands, and not the tonsil.

         Enlargement of the parotid gland can push the tonsils outwards, causing them to
         appear enlarged on examination.

      37. Polyps are loose edematous stroma, infiltrated by inflammatory lymphocytes and
          covered by respiratory epithelium. They are not neoplastic in either a malignant or
          benign fashion.

38.      The ethmoid sinuses are bound:         - laterally to the orbit by lamina papyracea
                                                - superiorly they communicate with frontal
                                                   sinus
                                                - inferiorly they empty under middle
                                                   turbinate (indirectly via duct)
                                                - medially upper part of nose

         A google search, and looking into my Dorlands and free medical dictionary found
         no mention of lamina capricus. I give up.

      39. Between 2 and 7% of people who get Bells’ palsy will have a recurrence. Bell’s is
          a lower motor neuron facial palsy of unknown cause, but possibly viral. It is part
          of the group of idiopathic cranial mononeuropathies. It may be complete or
          incomplete, and the worse the severity, the worse the prognosis. It is treated with
          steroids with or without nerve decompression. It recovers in 85% of cases.

         A herpes zoster infection that affects the facial nerve is referring to Ramsay-Hunt
         syndrome, in which case the primary Herpes infection remains dormant in the
         geniculate ganglion, and the HZV then erupts in CN V, VI, VII, IX, X, XII. The
         patient is usually elderly and the patient gets a vesicular eruption in the ear,
         vertigo and impaired hearing. Treatment is with acyclovir. Giving steroids in this
         condition will make it worse.

40.      Causes of UNIlateral hearing loss:     - Trauma
                                                - Meniere’s disease
                                                 - Acoustic neuroma
                                                 - mumps
         Causes of Bilateral hearing loss:       - Presbycusis
                                                 - Noise trauma
                                                 - Ototoxicity (esp. aminoglycosides)
                                                 - Autoimmune

         Otosclerosis may be unilateral (20%) or bilateral (80%) but usually one ear is
         affected worse than the other, so unilateral stapedectomy can “save hearing.” It
         can cause conductive (99%) or sensorineural hearing loss depending on whether
         the middle ear or the labyrinthine cavity are affected.

      41. The parotid gland lies on the side of the face in close relationship to ear, angle of
          mandible and styloid muscles. The facial nerve enters the posterior pole and
          divides within its substance into branches. It’s duct opens opposite the second
          molar tooth. Saliva produced is serous and secretomotor supply is from
          glossopharyngeal nerve.

         The submandibular gland is in floor of the mouth below and medial to mandible.
         Deep part of gland goes around mylohyoid and duct opens at sublingual papilla.
         Secretomotor supply from facial nerve (chorda tympani). Saliva is mixed.

42.      Limited jaw mobility can result from trauma, surgery, radiation treatment, or even
         TMJ problems. The limitation in opening may be a result of muscle damage, joint
         damage, rapid growth of connective tissue (i.e. scarring) or a combination of these
         factors. Limitations caused by factors external to the joint include neoplasms,
         acute infection, myositis, systemic diseases (lupus, scleroderma, and others)
         pseudoankylosis, burn injuries or other trauma to the musculature surrounding the
         joint.

         Limitations caused by factors internal to the joint include bony ankylosis (bony in
         growth within the joint), fibrous ankylosis, arthritis, infections, trauma and
         (perhaps) micro-trauma that may include brusixm.

         Central Nervous System disorders can also cause limitations to mouth opening.
         Tetanus, lesions that affect the trigeminal nerve and drug toxicity may all be
         suspects in this condition.

         Finally, there are iatrogenic causes, such as third molar extraction (in which the
         muscles of mastication may be torn, or the joint hyperextended) hematomas
         secondary to dental injection and late effects of intermaxillary fixation after
         mandibular fracture or other trauma.

         Quinsy and nasopharyngeal carcinoma commonly cause trismus. In
         nasopharyngeal carcinoma, trismus usually indicates a younger patient and a more
         advanced tumor.
         Cancer of the tonsil accounts for approximately 0.6% of malignancies diagnosed
         in the United States each year. Presentation of this disease is often delayed
         because of the lack of early symptoms. Patients usually present with a large mass
         in the oropharynx, accompanied by a neck mass, as well as pain, trismus, otalgia,
         and weight loss. Most patients present during the fifth or sixth decade, and men
         outnumber women 3:1.

      43. Nasopharyngeal carcinoma rarely invades the orbit, thus proptosis rarely occurs
          with nasopharyngeal carcinoma. Nasopharyngeal carcinoma will present with
          symptoms dependent on invasion of:
                 - local nasal obstruction and bloody discharge
                 - otological Eustachian tube obstruction  unilateral serous otitis media
                 - neurological invades skull base palsies of CN V, VI, IX, X, XII
                 - cervical upper deep cervical lymph nodes, often wedged between
                                mastoid process and angle of jaw.

      44. The gentleman presents with upper deep cervical lymphadenopathy. GI tumors
          classically present at Virchow’s node (left supraclavicular if gastric Ca), or the
          abdominal lymph nodes otherwise, thus a gi aetiology is unlikely in this
          gentleman. However, nasopharyngeal carcinoma often presents as an expansile
          mass in the neck, often between the angle of the mandible and the mastoid
          process. Thus, this is a possibility in this gentleman.
                  The physician should consider the diagnosis of chronic tonsillitis when the
          patient has a sore throat or pain with swallowing that last longer than 4 weeks.
          Associated symptoms include tonsilloliths, halitosis, excessive tonsillar debris,
          peritonsillar erythema, and persistent tender cervical lymphadenopathy. On exam,
          one may see erythema, dilated surface vessels and a smooth tonsillar surface.

45.      Glandular fever is also known as infectious mononucleosis. It is usually caused by
         EBV although CMV and toxoplasmosis may produce milder clinical forms less
         commonly. The EBV variant is associated with marked fever, headache (“pain”),
         sore throat (“pain”), lymphadenopathy (esp. posterior cervical), pyrexia,
         splenomegaly and malaise. Mild hepatitis, myocarditis, meningitis, encephalitis
         occur less often. Diagnosis is made by a monospot test. When treating tonsillitis,
         we should avoid using amoxicillin as this can precipitate infectious
         mononucleosis.

      46. Causes of facial nerve paralysis include: “Some Very Big PAROTid Tumors”
                 Sarcoidosis
                 Vascular lesions in cerebrum
                 Bell’s palsy
                 Poliomyelitis
                 Acoustic neuroma
                 Ramsay-Hunt syndrome
                 Otitis media (acute)
             Trauma
             Tumors (acoustic neuroma, pleomorphic adenoma, adenoid cystic
                   carcinoma, Warthin’s tumor)

47.   Sjogren's syndrome classically features a combination of dry eyes, dry mouth, and
      another disease of the connective tissues, most commonly rheumatoid arthritis.
      Sjogren's syndrome that involves the gland inflammation (resulting in dryness of
      the eyes and mouth, etc.), but not associated with a connective tissue disease, is
      referred to as primary Sjogren's syndrome. Secondary Sjogren's syndrome
      involves not only gland inflammation, but is associated with a connective tissue
      disease, such as rheumatoid arthritis, systemic lupus erythematosus, or
      scleroderma.

      90% of Sjogren's syndrome patients are female

      Symptoms of Sjogren's syndrome can involve the glands, as above, but there are
      also possible affects of the illness involving other organs of the body
      (extraglandular manifestations).

      When the tear gland (lacrimal gland) is inflamed from Sjogren's, the resulting eye
      dryness can progressively lead to eye irritation, decreased tear production, "gritty"
      sensation, infection, and serious abrasion of the dome of the eye (cornea).

      Inflammation of the salivary glands can lead to mouth dryness, swallowing
      difficulties, dental decay, gum disease, mouth sores and swelling, stones and/or
      infection of parotid gland inside of the cheeks.

      Other glands that can become inflamed, though less commonly, in Sjogren's
      syndrome include those of the lining of the breathing passages (leading to lung
      infections) and vagina (sometimes noted as pain during intercourse).

      A small percentage of patients with Sjogren's syndrome develop cancer of the
      lymph glands (lymphoma). This usually develops after many years with the
      illness. Unusual gland swelling should be reported to the physician.

      The diagnosis of Sjogren's syndrome involves detecting the features of dryness of
      the eyes and mouth. The dryness of the eyes can be determined in the doctor's
      office by testing the eye's ability to wet a small testing paper strip placed under
      the eyelid (Schirmer's test). More sophisticated eye testing can be done by an eye
      specialist (ophthalmologist). Salivary glands can become larger and harden or
      become tender. Salivary gland inflammation can be detected by radiologic
      salivary scans. Also the diminished ability of the salivary glands to produce saliva
      can be measured with salivary flow testing. The diagnosis is strongly supported
      by the abnormal findings of a biopsy of salivary gland tissue.
   Depending on the source, Sjogrens can cause a painless or mildly painful
   swelling. I’d go with false here. In Ireland, Sjogrens is diagnosed with sublabial
   biopsy (as it says in class notes…).

48. Longitudinal fractures typically result from trauma to the temporal or parietal
    region, and fractures of the temporal squamosa or parietal bone are common. The
    line of force runs roughly from lateral to medial. Because a fracture line may
    extend through the facial nerve canal, injury to this nerve may result. In addition,
    associated injury, such as transection or intraneural hemorrhage, may cause facial
    nerve paralysis. The fracture also may disrupt the ossicular chain and result in
    conductive hearing loss.

   Transverse fractures typically result from trauma to the occiput or cranial-cervical
   junction. The line of force runs roughly anterior to posterior. When the fracture
   passes through the vestibulocochlear apparatus, both sensorineural hearing loss
   and disorders of equilibrium may occur. Injury to the facial nerve is common in
   this type of injury as well, since the fracture often courses close to the
   labyrinthine segment of the facial nerve.


   Fracture type CN VII damage            Hearing loss type      Trauma location
   Longitudinal Yes (CNVII canal)         Conductive             parietal/temporal
   Transverse    Yes (labyrinthine)       Sensorineural          occiput/craniocervical

   Generally, diagnosis of temporal bone fracture (transverse and longitudinal) by
   plain film is difficult and requires confirmation by CT.

   A longitudinal fracture roughly parallels the petrous bone long axis. Involvement
   of the middle ear, carotid canal, bony labyrinth, and external auditory canal
   should be noted.

   A transverse fracture is perpendicular to the petrous bone long axis. Involvement
   of the inner ear structures and facial nerve course should be noted.

   The longitudinal temporal bone fracture can cause bleeding in the middle ear,
   leading to hemotypanum. Since there is no perforation of the tympanic
   membrane, discharge is unlikely.

49. Positional vertigo is an inner ear problem. It causes brief but sometimes severe
    feelings of spinning. Some people feel that their head or body is spinning. Others
    feel the room is spinning. People often say they are dizzy, but dizzy is a very
    general term. Vertigo, on the other hand, is the very specific feeling of
    uncontrollable spinning.

   Positional vertigo happens suddenly when you change the position of your head.
   Another name for this problem is benign paroxysmal positional vertigo.
   In the inner part of your ear are 3 semicircular canals. Movement of the fluid in
   these canals helps your brain maintain your balance and know what position you
   are in (for example, standing up, lying down, or standing on your head).
   Sometimes small crystals of calcium develop and float in the fluid in the inner
   ear. This can happen after a head injury (trauma), with a severe cold, or simply
   as a part of normal aging. The crystals can cause vertigo when you change head
   position and they strike against nerve endings in the semicircular canals. Usually
   the calcium crystals dissolve in a few weeks and stop causing vertigo. However,
   sometimes the crystals do not dissolve and the vertigo returns from time to time.

   A sudden feeling that you are spinning, or that the room is spinning, is the main
   symptom. You may feel the vertigo when you first wake up. It may seem that any
   turn of your head brings on brief but intense spells of vertigo. It may happen when
   you tilt your head, look up or down, or roll over in bed.

   You may have nausea and vomiting along with the vertigo. Even if a spell of
   vertigo is brief, you may have a feeling of queasiness for several minutes or
   even hours afterward.

50. Maxillary sinus is the most common paranasal sinus affected by carcinoma (80%)
    with ethmoid (15%) and the facial and sphenoid sinuses (<5%) being less
    common. Symptoms of maxillary sinus carcinoma include nasal symptoms of
    unilateral nasal obstruction, epistaxis, anosmia, nasal drainage, and hyponasal
    speech. Facial symptoms are the next most common and include: loss of
    definition of the nasolabial fold of the involved side, facial asymmetry, obvious
    cheek mass, cutaneous fistula, facial edema, and pain. Hypesthesia of the cheek
    may also occur secondary to invasion of the infraorbital nerve. Oral cavity
    symptoms include: ill fitting upper dentures, widened alveolus, dental pain, or an
    obvious palatal mass.

51. Thyroid carcinomas are usually papillary (65%), anaplastic (5%), follicular (20%)
    or medullary (10%).

   In the middle ear, the most common benign tumor is cholesteotoma. Malignant
   tumors in the middle ear and mastoid are very uncommon. Of these very
   uncommon tumors, the squamous cell cancers are the most prevalent

   More than 90% of cancers of the oral cavity and oropharynx are squamous cell
   carcinomas, also called squamous cell cancer. These are seen more commonly
   than in middle ear…What they mean by “common” though? I say true…

   Tumors in the salivary glands are more commonly in the parotid gland, where
   pleomorphic adenoma accounts for the majority. Warthin’s tymor and
   hemangiomas are also rare benign tumors. Malignant tumors include adenoid
   cystic carcinoma, muco-epidermoid tumor, acinic cell tumors, lymphoma…The
   point is that while SCCs DO happen in submandibular and parotid glands, they
   are very uncommon and have a poor prognosis.

52. Laryngotracheobronchitis (“croup”) (larynx, trachea and bronchi but epiglottis not
    usually involved) occurs in infants and toddlers. It is a viral (parainfluenzae,
    influenzae, adenovirus) generalized respiratory infection accompanied by thick
    tenacious secretions that block the trachea and small airways. There is a harsh,
    croupy cough. Mild cases settle with humidified air, but severe cases require
    airway support and possible ventilation.

53. Complications of acute otitis media include: (“FAT PALM”
        - Facial nerve paralysis
        - Abscess (extradural, subdural, brain abscess)
        - Thrombosis of lateral sinus
        - Petrositis (don’t forget forever important Gradenigo’s syndromeCN
                  VI palsy)
        - Acute mastoiditis
        - Labyrinthitis ( vertigo)
        - Meningitis

   Acute otitis media can lead to chronic otitis media, especially if poorly treated.
   Otalgia, tinnitus and progressive hearing loss are features in chronic otitis media.
   Whether the otalgia is severe or not I can’t establish. Given the long-duration
   nature of chronic otitis media, I’d be willing to bet this is false.


54. Scala media (or cochlear duct) is a endolymph filled cavity inside the cochlea,
    located in between the scala tympani and the scala vestibuli, separated by the
    basilar membrane and Reissner's membrane (the vestibular membrane)
    respectively. Scala media houses the organ of Corti.

   Sound waves from the middle ear pass from stapes to the oval window (fenestra
   vestibuli), which pass to the perilymph filled scala vestibuli, which pass through
   the Reissner’s membrane, to the endolymph filled cochlear duct (scala media),
   which stimulate Organ of Corti. The sound dissipates through the scala tympani to
   the round window.

   The cochlea is found in the petrous part of the temporal bone, and is dedicated to
   hearing. It has no role in balance, although other inner ear structures (semicircular
   canals) do.

           Longitudinal fractures of the temporal bone commonly occur after trauma
   to the parietal or temporal regions. Usually the middle ear is affected and
   conductive deafness may occur.
             Transverse temporal fractures occur after trauma to the occipital or cranio-
      cervical region. They often involve the inner ear and sensorineural deafness may
      occur.
             Both transverse and longitudinal temporal bone fractures can cause
      damage to the facial nerve.

55.   Lip cancer patients typically present in their 7th or 8th decade. The male to
      female ratio approaches 79-to-1 for cancer of the lower lip and 5-to-1 for the
      upper lip.
      Several factors have been implicated in the etiology of lip cancer. Sunlight has
      been implicated as a major contributor to the development of lip cancer. Since the
      lip lacks a pigmented layer for protection, it is susceptible to actinic changes.
      Moderate to heavy cigarette and pipe smoking also play a causative role. In earlier
      studies, an association of carcinoma of the lip and positive serology or clinical
      evidence of syphilis was implied to be as high as 20%. More recent papers report
      not more than a 2% association. Poor oral hygiene results in persistent irritation
      and possibly lip cancer. Chronic alcoholism has been associated with the
      development of carcinoma of the lip as well as other sites in the oral cavity.
      The most frequent location of lip cancer is the lower lip where it is reported being
      found between 91.3% and 97.3%. The upper lip is involved between 1.8% and
      7.7% of the time, while the commissure is involved in 1% to 2%.

      Almost 95% of lip cancers are squamous cell carcinoma. They are most
      frequently well differentiated. Basal cell carcinoma may extend onto the labial
      surface.

      The primary goal of treatment is eradication of the disease. In decreasing order of
      priority, the goals of therapy are: 1) preservation of oral competence; 2)
      preservation of an adequate buccal sulcus; 3) minimalization of the deformity;
      and 4) restoration of a cosmetically acceptable appearance. Primary surgical
      excision offers the advantage of eradication of disease, pathological survey of
      margins, and reconstruction of the defect in a single stage.

      Overall, 5% to 15% of patients with lip cancer will present with regional
      metastasis. An additional 15% will subsequently develop nodal metastasis. The
      five-year survival of patients with lip carcinoma and confirmed regional
      metastasis approaches 50%. The literature suggests that the survival rate for
      treatment of the initial neck metastasis by elective neck dissection and for salvage
      for the subsequent development of neck nodes is essentially the same.

      A review of the literature indicates several prognostic indicators for lip
      carcinoma. Carcinoma of the upper lip and commissure carry a worse prognosis
      and the five-year survival is 10% to 20% lower than the overall rate. Cervical
      metastasis, especially when large, bilateral, or fixed indicate a poor prognosis as
      does the presence of distant metastasis. Poorly differentiated squamous cell
      carcinoma, as well as melanoma carry a worse prognosis. Recurrent squamous
   cell carcinoma at the site of the primary carries a worse prognosis and may be an
   indication of an aggressive neoplasm. The presence of mandibular involvement
   drops the five-year survival rate to 30%.

   At presentation, 15-20% of lip carcinomas have metastasized, most commonly to
   submandibular and less commonly to submental and internal jugular lymph
   nodes. In a recent evaluation of sentinel lymph node biopsy at presentation of lip
   SCC, only 15% of sentinel lymph nodes were found to have disease.

56. The most common malignancy in the tonsil is SCC, while the second most
    common is a lymphoma.

   The most common malignancy on the tongue is SCC. Symptoms of tongue cancer
   may include:
          - red/white patch on tongue that doesn’t go away
          - sore throat that lingers
          - pain swallowing
          - numb mouth
          - unexplained bleeding in mouth
          - otalgia (referred, not radiating)

   Carcinoma of the nasopharynx results in:
          Local nasal obstruction and epistaxis
          Otological Eustachian tube blockage unilateral serous otitis media
                 (Which can deafness)
          Neurological palsies of CN III, IV, V, VI, IX, X, XII
          Cervical deep cervical lymph nodes (often between angle of
                               mandible and mastoid process)

   Leukoplakia (red plaque) and erythroplakia (red plaque) are lesions commonly
   seen on buccal mucosa and commisures of mouth. They are commonly associated
   with SCC. The question SHOULD be “leukoplakia can arise in buccal mucosa”
   but even in the convoluted way it’s written it’s still probably true.

57. Mastoiditis is the result of extension of acute otitis media into the mastoid air cells
    with suppuration and bone necrosis.

   Acute mastoiditis symptoms: - pain
                             - otorrhea (creamy and profuse)
                             - increasing deafness (conductive)

                   Signs:         - pyrexia and malaise
                                 -  tenderness over maxillary antrum
                                 -  postauricular swelling pinna pushed down and
                                    forward (moving ear up and back hurts)
                                 - tympanic membrane bulging or perforated
   Perceptive deafness refers to sensorineural or inner ear deafness. Acute
   mastoiditis affects the middle ear and causes conductive deafness.

   Mastoiditis is most common 15-18 months of age when middle ear infections are
   most common. Adults rarely get mastoiditis, and it’s usually associated with
   immunocompromise.

58. The sinuses include as below:
    Sinus          Location                              Age of presentation
    Ethmoid        Around bridge of nose                 Birth
    Maxillary      Around cheeks over maxilla            Birth
    Frontal        Forehead                              7 years of age-adolescence
    Sphenoid       Behind nose                           adolescence

   OK, no source for this, but my thoughts: Most cases of sinusitis occur as pediatric
   cases, and certainly most before 30 (my arbitrary cut-off of “aged”). However,
   maxillary sinusitis can certainly occur later than 12, since web search revealed
   multiple cases of patients in 30s getting it (not COMMON, but still happens).

59. Otosclerosis may be unilateral (20%) or bilateral (80%) but usually one ear is
    affected worse than the other, so unilateral stapedectomy can “save hearing.” It
    can cause conductive (99%) or sensorineural hearing loss depending on whether
    the middle ear or the labyrinthine cavity are affected. Since “bone conduction”
    refers to sensorineural, we can see they are trying to confuse us, given the stapes
    being prominently affected would lead us to believe “bone” conduction is
    affected. However, outer and middle ear is referred to as “air” conduction while
    inner ear is “bone” conduction, so therefore most of the time otosclerosis doesn’t
    affect bone conduction.

   Otosclerosis doesn’t affect the tympanic membrane. It is a disease of the middle
   ear and doesn’t cause tympanic membrane damage or signs.

60. Acute otitis media commonly causes otalgia, deafness and tinnitus. The ear pain is
    relieved when the tympanic membrane is perforated (and the annoying kid stops
    screaming).

   Causative organisms include Streptococcus pneumoniae (35%), Moraxella
   catarrhalis (15%), Haemophilus influenzae (25%), Group A Strep (Streptococcus
   pyogenes), and Staphyloccus aureus.

61. Organisms commonly causing chronic otitis media include:
       Chronic SUPPURATIVE otitis media
       - Pseudomonas (MOST commonly)
       - Staphylococcus (gram positive)
       - Other gram-negative (especially Proteus)
       Chronic otitis media with effusion (glue ear)
           (same as acute otitis media)
       - Strep.pneumoniae, Staph aureus,
       - Moraxella catarrhalis, Haemophilus influenzae

62. OK, indications for this couldn’t be found anywhere (as in a list). Given
    symptoms need to be present for at least 4 weeks before surgery is indicated,
    neonates are out. As for failure of antibiotic treatment? Well if the antibiotics
    don’t sufficiently eliminate the ear effusion, then yes, the myringotomy would
    help, so let’s say TRUE. As for intracranial complications? I thought this was
    more in line with chronic otitis media (attico-antral type abscess) or acute otitis
    media (can  meningitis), but in COM there is already a perforation, and in acute
    otitis media the tympanic membrane will usually burst…but will doing a
    myringotomy aid intracranial complications when it HASN’T yet burst? I assume
    it would but I don’t know…

				
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