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Page 1 of 1 Otorhinolaryngology /epcapul UPCM09

OTORHINOLARYNGOLOGY

MASTOID SERIES (MaST M[eyer]aS[chuller]Townes)

Townes View Meyers View Schullers ViewProjection AP projection of the skull with

the beam source 30 abovethe canthomeatal line

AP projection of the skull with the head

turned 45 toward the side one wishes

to examine & the beam source 45above the canthomeatal line

Lateral projection of the skull with the

beam source 30 above thecanthomeatal line

View Clear view of the foramen,comparison of the petrouspyramid & mastoids

Provides axial view of the externalauditory meatus, mastoid, & petrousbone

Shows extent of pneumatization of themastoid(1) Pneumatic well-developed mastoidair cells(2) Diploic with few large air cells(3) Sclerotic with opacity due tocalcification

PARANASAL SINUS SERIESWaters View Caldwell View Skull Lateral Basal View

Occipitomental view or

chin-nose view

Occipitofrontal view

orforehead-nose view

Submentovertical view

Projection Patients head is tiltedwith the nose & the chinon the film,

orbitomeatal line is 37from the film, x-rays aredirected horizontally

PA viewofthe skull with

the beam 15-20 fromthe horizontal

Pts infraorbitomeatalline is parallel to thefilm, x-raysperpendicular to theinfraorbitomeatal linethrough the sella turcica

Best view Maxillary sinusOpen mouth Watersview sphenoid sinus

Frontal sinus Sphenoid sinus Zygomatic archfractures

Also shows Frontal & anteriorethmoid sinusesNasal bones, requestedif suspecting nasalfractures together withNose STL

Anterior ethmoid &sphenoid sinuses,lamina papyracea

Posterior ethmoid,frontal, & maxillarysinues & sella turcica

Sphenoid, posteriorethmoid, maxillary &frontal sinuses

Panorex View Provides the best view of the mandible

Requested when suspecting mandibular fractures (most common site being the angle, having the thinnest bone), dentoalveolarabscess (DAA), ameloblastoma, & oseteomyelisis of the mandible

Neck soft tissue lateral (Neck STL)

Requested when suspecting foreign body lodged in the neck, epiglottitis (seen as thumb sign), laryngotracheobronchitis (seenas steeple sign)

CXR AP-L to include the neck and abdomen

Requested when suspecting foreign body in the aerodigestive tract

Possible for children, otherwise request for CXR AP-L to include the neck (or a separate STL when not possible), plain abdomen

Nose soft tissue lateral (Nose STL)

Requested together with Waters view when suspecting nasal bone fractures

IMPACTED CERUMENSigns and Symptoms

a. sense of ear fullnessb. otalgia (ear pain) usually felt after getting water into the ear, because the cerumen swells, impinging on the pain

receptors in the external ear. May occur with secondary otitis externa because of the clumsy efforts to remove thecerumen.

c. Conductive hearing loss usually not clinically significant. On Webers, there is lateralization to the affected ear (may notbe appreciated when impaction is not significant)

THE EAR

RADIOLOGY

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TreatmentSoftening of cerumen with baby oil or commercially available ceruminolytics, such as Docusate Na (Otosol) 0.5% X 10mL (Lie onthe side, turning the head sideways, slightly towards the surface on which you are lying. Fill the ear canal & stay in this position for 5minutes then insert a cotton wool plug. Repeat to the other ear if necessary. Max of 2 consecutive nights.). Have the pt come backafter 1 week for aural irrigation with clean lukewarm water. Aural irrigation is done with the stream directed behind the cerumen andnot directly at it, which may push it further down the canal.

OTITIS EXTERNA May result from ear manipulation (e.g. sharp metal objects) or the presence of foreign objects/foreign body (FB)

Most common etiologic agent is Staphylococcus aureus, a normal flora of the external earClassification

a. Diffuse swimmers ear. Swelling of the entire external auditory meatus (EAC)b. Circumscribed furunculosis. There is only a circumscribed swelling affecting the hairy portion of the EAC

Signs and Symptomsa. otalgiab. serous ear dischargec. tenderness on manipulation of pinna or tragusd. hearing loss if swelling occludes the external ear

e. swelling on otoscopyOtitis Externa Otitis Media

Pain Severe Not as severeTenderness on pinna / tragus Present Absent

Fever Absent PresentHistory of URTI Usually none Usually present

History of ear manipulation Present Absent

Hearing Not impaired ImpairedMastoid series Normal With evidence of mastoiditis

Treatmenta. Systemic oral antibiotic treat the infection. For children: Cloxacillin 50 mg/kg/day in 4 divided doses X 7 days

(125mg/5mL preparation)b. Topical steroid reduce the swelling; usually prepared with antibiotic

1. Corticosporin: Hydrocortisone + Polymyxin B + Neomycin2. Aplosyn: Fluocinilone + Polymyxin B + Neomycin3. Synalar: Fluocinolone + Polymyxin B + Neomycin

c. Oral analgesic for pain.1. For the elderly or those with PUD: COX-2 Inhibitors

i. Etoricoxib (Arcoxia) 120 mg OD preferred by ENTii. Celecoxib (Clebrex 200mg ODiii. Rofecoxib (Vioxx) 25 mg OD

2. On a full stomach: Mefenamic Acid 500mg QID prn3. For children: Paracetamol 10 mg/kg/day prn (125mg/5mL and 250mg/5mL preparations)

d. Aural toilette is done prior to application of Corticosporin.If there is no response after 1 week, then suspect Pseudomonasinfection and give a quinolone with anti-Pseudomonasactivitysuch as Ciprofloxacin 500 mg tab

ACUTE OTITIS MEDIA

Infection of the middle ear

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Predisposing factorsa. young age ET is wider, shorter & more horizontal compared to adultsb. immunocompromised state causes recurrent URTIc. altitude changesd. bottle feeding greater risk than breastfeedinge. congenital defects (cleft palate)f. benign or malignant masses in the nasopharynx

Stages

a. Hyperemia onset of disease; presents with otalgia, ear fullness, hearing loss, fever, (+) peripheral congestion of the eardrum on otoscopyb. Exudative pouring of fluid in the middle ear; presents with increased otalgia, ear fullness, hearing loss and feverc. Suppurative rupture of TM with discharge; presents with mucupurulent discharge, decreased pain, decreased fever, but

increased hearing lossd. Resolution / Complications a surgical ear is those with complicationse. Coalescence thickening of mucoperiosteum drainage is blocked venous stasis local inflammation?

decalcification pus; nocturnal fever; simple mastoidectomyTreatment

a. Antibiotic to treat the infection1. For children, give Amoxicillin 40 mg/kg/day divided in 3 doses X 14 days (125mg/5mL and 250mg/5mL

preparations available)2. If with TM perforation, such as during the stage of suppuration, a topical antibiotic such as Corticosporin, may

be given because of perforation allows for the delivery of the drug into the ear.3. If there is no response after 1 week, suspect Pseudomonas infection and give a quinolone with anti-

Pseudomonasactivity like Ciprofloxacinb. Aural toilette is done only if there is active discharge. It is done prior to application of corticosporin.

c. ET opening exercises are done to open the ET and thus provide drainage of middle ear secretions1. Valsalva maneuver Ask pt to blow nose against a closed mouth and nose opens ET

2. Toynbee maneuver Ask pt to swallow with mouth & nose closed opens ET3. Chewing gum

Complicationsa. Extracranial complications (FLAPS)

Facial nerve paralysis

LabyrynthitisAbscess

Subperiosteal abscessBezolds abscess abscess in the SCMCittellis abscess - digastric

Petrositis Gradenigos syndrome (DRE)Diplopia due to lateral rectus palsyRetroorbital pain due to involvement of the optic nerveEar discharge

Sensorineural hearing lossb. Intracranial complications (MATH)

Meningitis most commonAbscess (epidural, subdural, cerebral)Thrombophlebitis picket-fence fever(caused by emboli of abscess)Hydrocephalus

CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM) Infection of the middle ear >4 weeks; persistent ear discharge on a perforated ear >6weeks

Fever not a constitutional signClassification

a. Active (+) dischargeb. Inactive (-) discharge > 3 monthsc. Quiescent (-) discharge < 3 months

Treatment Mastoid series is requested to assess pneumatization of the mastoid and aseess for cholesteatoma

Pure tone audiometry and speech test to assess severity of hearing loss

Tympanometry is requested if TM is retracted, dull or suspecting chronic infection of the middle ear

Amoxicillin 500mg/cap 1 cap TID X 14 daysCorticosporin otic 3 gtts TID X 14 days (only if suppurative)Aural toilette with H2O2 3 gtts TID X 14 days (only i f suppurative)AEM, increase OFI, KEDFrequent ET opening exercisesTCB after 7 days for re-assessment

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Benign DangerousPerforation is central regardless of size or shape Perforation is total or located at the margin, attic (pars flaccida)

or postero-superiorMucosa lining in the middle ear is edematous Mucosa around the perforation is replaced by stratified

squamous epithelium. Cholesteatomatous debris may be seenaround the perforation or in the attic

There may be granulation tissue or polyps arising from themiddle ear mucosa

Granulation or polyps are frequently seen in the canal obscuringthe drainage

Discharge is mucoid to purulent & non-foul smelling Discharge is purulent & foul-smellingHearing loss is conductive Hearing loss is conductive and sensorineural

Mastoid series show no cholesteatoma Mastoid series reveal cholesteatoma. On PE, there may beposterior auricular or subperiosteal abscess or fistula.

CHOLESTEATOMA Concurrent with CSOM

Seen radiographically as an enlarged mastoid antrum (>1cm). It appears as a radiolucency surrounded by areas of sclerosis withno trabeculations. Bony destruction or erosions may be seen. Clinically, there is pearly white ear discharge, very foul smellingwith TM perforation.

Plain & contrast CT scan with 1mm temporal bone cuts is requested if clinically positive for cholesteatoma for OR planning priorto possible tympanomastoidectomy

AURAL POLYP

Squamous hypertrophy from the middle or external ear

PRESBYCUSIS

Hearing loss related to aging process

Normal otoscopy

SENSORINEURAL HEARING LOSS

May be due to chronic exposure to loud noise, as a complication of CSOM, as a result of infection or tumor

On Weber, there is lateralization to the unaffected ear

PTA-STTCB once with results

PTA-STFor possible application of hearing aidTCB once with results

Mastoid seriesPTA-STCranial CT scan, plain & contrast, with 1mm temporal bone cutsPen G 4 million units IV LD ( ) ANST then 2 million units q6hClindamycin 600mg IV LD ( ) ANST then 300mg q6hCorticosporin otic 3 gtts TID (only if suppurative)Aural toilette with H2O2 3 gtts TID (only if active)

AEM, increase OFI, KEDFrequent ET opening exercisesTCB after 7 days for re-assessment

Mastoid seriesPTA-STAmoxicillin 500mg/cap 1 cap TID X 14 daysCorticosporin otic 3 gtts TID X 14 days (only if active)Aural toilette with H2O2 3 gtts TID X 14 days (only i f active)AEM, increase OFI, KEDFrequent ET opening exercisesTCB after 7 days for re-assessment

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SPEECH DELAY SECONDARY TO HEARING IMPAIRMENT

First, rule out other causes such as autism

EXTERNAL AUDITORY CANAL BLEEDING SECONDARY TO EAR MANIPULATION

Rule out other causes

Antibiotic is given due to damage to EAC mucosa predisposing to infection

SINUSITIS Most common etiologic agents: S. pneumonia, H. influenza, Moraxella catarrhalis, anaerobesSigns and Symptoms

a. nasal obstructionb. mucopurulent nasal dischargec. paranasal paind. headachee. paranasal tendernessf. congested nasal mucosa on rhinoscopyg. absent illumination(frontal / maxillary sinuses)h. fever may be presenti. opacities on x-ray

Classificationa. Acute - < 3 months

b. Chronic - > 3 months, most common cause is untreated acute sinusitis; usually mized flora

TreatmentNasal douche is prepared by mixing 1 tsp rock salt, 1 tsp baking soda, and 1L of boiled tap water made to cool.

ALLERGIC RHINITISSigns and Symptoms

a. rhinorrheab. sneezing (>4x/day, usually in the morning)c. nasal obstructiond. nasal prurituse. congested nasal mucosa on rhinoscopyf. allergic salute (crease near the tip of the nose due to frequent rubbing)g. allergic shiners (skin hyperpigmentation below the lower eyelid)h. triggers may be present; most common allergens are household dust mite, cockroach, grass pollen, moldsi. family history of allergy j. personal history of bronchial asthma or eczema

PNS seriesCo-amoxiclav 625 mg/cap TID or 1g BID X 7 daysIncreased OFINasal douche BID on each nostril, increased OFITCB after 1 week for re-asessment

Co-amoxiclav 625 mg/cap TID or 1g BID X 7 daysIncreased OFITCB after 1 week for re-asessment

SuctionCloxacillin 500 mg/cap 1 cap QID X 7 daysEtoricoxib 120 mg/tab 1 tab OD prn for painTCB after 1 week for re-assessment

PTA-STRefer to Pedia for evaluation and co-managementTCB once with results

THE NOSE

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Treatmenta. Topical steroid relieve the inflammation

1. Fluticasone (Flixotide) Fluticasone nasal spray 2 puffs / nostril BID X 14 days & prn Usually prescribed byENT

2. Budesonide (Budecort) nasal spray 64 mcg/dose [X 120 doses] Initially 2 puffs in each nostril daily.Maintenance: 1 puff in each nostril daily.

b. Oral anti-pruritus1. Cetirizine (Virlix) 10 mg/tab 1tab OD at HS X 14 days & prn

2. Loratidine (Claritin) 10 mg/tab 1tab OD at HS X 14 days & prnc. Decongestant are not of proven benefit and may cause rebound rhinitis (rhinitis medicamentosa) if used for more than 5days

NASAL POLYPOSIS Usually arises from the osteomeatal complex (MIM HUBAd: Middle meatus, Infundibulum, Maxillary sinus ostium, Hiatus

semilunaris, Uncinate process, Bulla ethmoidalis, Agger nasi)Signs and Symptoms

a. Nasal obstruction may cause sinusitis due to obstruction of the drainage of frontal and maxillary sinusesb. Anosmiac. Rhinorrhea (watery to mucoid)d. Smooth, gelatinous, semitransparent to pale white mass on anterior rhinoscopy

Grading0 No polypsI Polyps do not prolapse beyond the middle turbinate & may require endoscopy for visualization

II Polyps extend below the middle turbinate. Visible with nasal speculum.III Polyps touching the nasal floor. May occlude the entire nasal cavity. May be seen through the vestibule without the aid of a

nasal speculumComparison of Nasal Polyp & Turbinates

Nasal Polyps Turbinates

Color skinned grapes Pink to redDecongestant effect (-) (+)

Mobility Mobile FixedSensation (-) (+)

Location Usually at osteomeatal complex Along entire lateral nasal wallConsistency Soft Hard

Treatmenta. Surgery: (PEA) Polypectomy, Ethmoidectomy, Anthrostomy. Done under LA if middle-aged. Done under GA in children &

elderly.b. Steroids given 1 week prior to OR to decrease the swelling & minimize bleeding intraop

1. Prednisone 10mg/kg OD X 1 week prior to OR2. Methylprednisolone 16 mg 2 tab OD every other day for 1 week

c. SAPOD clearance: CBC with PC & DC, BUN/Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR

NASAL FOREIGN BODY Usually presents as a unilateral, foul-smelling, purulent nasal discharge, usually in children & handicapped

Removal may be done with theuse of Hartmann forceps, alligator forceps, or a blunt right-angled hook. Done in office setting withthe use of restraints for uncooperative patients, especially children.

INVERTING PAPILLOMA

Most common benign neoplasm in the nose & sinuses

Pre-malignant lesion usually unilateral

10% develops SCCA

Complete excision

PEA/LA c/o minor ORPrednisone 10mg/kg OD X 1 week prior to ORSAPOD clearance: CBC with PC & DC, BUN/Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXRTCB once with results for OR scheduling

Fluticasone nasal spray 2 puffs / nostril BID X 14 days & prnCetirizine (Virlix) 10 mg/tab 1tab OD at HS X 14 days & prnAvoid exposure to allergenRefer to Allergy Clinic Re: Skin testingTCB after 2 weeks for re-assessment

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Hyperthyroidism HypothyroidismNervousness Fatigue, lethargy

Weight loss Weight gainExcessive sweating Cool, dry, coarse skin; loss of hair

Warm, smooth, moist skin Swelling of the face, hands, legs, non-pitting edemaHeat intolerance Cold intoleranceMuscular weakness, tremor Weakness, muscle cramps, arthralgia, paresthesia

Lid lag, exophthalmos, stare Peri-orbital puffiness

Palpitations, hyperdynamic cardiac pulsations, accentuated S1 Decreased intensity of heart soundsTachycardia Bradycardia

SBP, DBP SBP, DBPFrequent bowel movements Constipation

Toxic SSx: Heat intolerance, palpitations, dysphagia/dyspnea, finger tremors

NODULAR NON-TOXIC GOITER (NTNG)

Present as an asymmetric anterior neck mass (ANM) that moves with deglutition and usually nodular on palpation; no or minimalsymptoms of hypo/hyperthyroidism

DIFFUSE TOXIC GOITER (DTG)

Presents as symmetric ANM which moves with deglutition and smooth on palpation; with symptoms of hyperthyroidism

FT4 is requested and not total T4 because it is the active form. Free T3 is only requested when both FT4 & TSH are normal andthe pt is clinically hyperthyroid. Between the two, TSH is more diagnostic of hyperthyroidism.

NODULAR TOXIC GOITER

Not very common; presents as an asymmetric ANM which moves with deglutition and nodular on palpation, but presents withsymptoms of hyperthyroidism

TreatmentFNAB is done because of higher rate of occurrence of CA in nodular goiter

DIFFUSE NONTOXIC GOITER Not very common, presents with symmetric ANM which moves with deglutition and smooth on palpation but has no symptoms of

hyperthyroidismTreatmentFNAB is not done due to low incidence of CA in DNTG. Thyroid scan is requested to determine the size and activity of the ANM.

Thyroid scanFT4. TSHTCB once with results

FNABFT4, TSHPTU 50mg/tab 2 tabs TID (Maximum of 600mg/day)Propranolol 10mg/tab 1 tab BID (for tachycardia, palpitations, and anxiety)Refer to ENDO re: NTG

FT4, TSHCBC with PC & DC12L ECGPTU 50mg/tab 2 tabs TID (Maximum of 600mg/day)Propranolol 10mg/tab 1 tab BID (for tachycardia, palpitations, and anxiety)Refer to ENDO re: DTG

FNABFT4, TSHTCB once with results

THE THYROID GLAND

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TONSILOPHARYNGITIS

Treated with Roxithromycin 150mg/tab BID X 1 week

CHRONIC HYPERTROPHIC TONSILS

Treated with tonsillectomy if with indications:Absolute indications:

a. Malignancy

b. Obstructive sleep apneac. Dysphagia leading to significant weight loss

Relative indication:Recurrent tonsillitis (>6x/year)

LARYNGITIS

Acute if 4 weeks.

LARYNGOPHARYNGEAL REFLUX

Characterized by foreign body sensation in the throat

Treated with Omeprazole 20mg/tab 1 tab OD X 2 weeks

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Characterized by retrosternal chest pain

Treated with Omeprazole 20mg/tab 1 tab OD X 2 weeks

Diet modification: No spicy & sour food, eat small-portioned meals

Sleep at 30 angle and rest the voice

FOREIGN BODY INGESTION

Pt may feel pain on the anatomic location where the FB was lodged (cricopharynx, notch on esophagus, arch of the aorta, Lbronchus, lower esophageal sphincter)

Diagnostics is through radiographic studies which may be repeated every 12 hours. FB appears slit-like when in the esophaguson lateral x-rays. If FB is in the stomach, refer to Surgery. If it is in the airway but beyond the main bronchi, refer to TCVS. ENTmanages FB in the esophagus and upper airway (trachea & main bronchi)

Barium swallow is done when plain radiographs are non-diagnostics. It is not requested if FB is metallic.

CELLULITIS

ABSCESSES

SOFT TISSUE INFECTIONS

Cloxacillin 500mg/cap 1 cap QID X 7 daysEtoricoxib 120 mg/tab 1 tab OD prn for painTCB after 1 week for re-assessment

NPO nowIVF: D5 0.9 NaCl 1L X 8CXR-APL to include neck and abdomen (in children)CXR-APL to include the neck, plain abdomen (in adults, a separate neck STL may be requested when not possible)

Lonazolac 200mg/tab 1 tab BID X 2 weeksVoice rest

Increased OFIWarm saline gargleTCB after 2 weeks once with results

For tonsillectomy/GASAPOD clearance: CBC with PC & DC, BUN/Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXRTCB once with results for OR scheduling

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Include dentoalveolar abscess (DAA), tonsillar abscess, parotid abscess, and parapharyngeal abscessTreatment

a. Incision and Drainage. Local analgesic is not used since it is not effective in the presence of an abscess.b. Antibiotics. To cover for G (+) & (-), Pen G is given. To cover for anaerobes, Clindamycin or Metronidazole.

1. For adults:i. Pen G 4 million units IV LD ( ) ANST then 2 million units q6hii. Clindamycin 600mg IV LD ( ) ANST then 300 mg q6h OR

Metronidazole 500mg IV LD ( ) ANST then 250 mg q6h

2. For children:i. PenG 50,000 units/kg IV LD ( )ANST then 25,000 units/kg q6hii. Clindamycin 20 mg/kg IV LD ( ) ANST then 10 mg/kg q6h OR

Metronidazole 15 mg/kg IV LD ( ) ANST then 7.5 mg/kg q6h3. Preparations

i. Pen G is available in 1 million units/amp preparationii. Clindamycin is available in 1,600 mg/amp preparation

4. After IV loading and I&D, the pt may be sent home with the following meds:i. Pen G 250 mg/tab 1 tab QID to complete 7days (40,000 units = 250mg)ii. Clindamycin 300mg/tab 1 tab QID to complete 7 days

LUDWIGS ANGINA

Abscess dissecting the muscle planes of the chin which pushes the floor of the mouth upwards

Palpated as a board-like mass in the floor of the mouth

Usually originates forma DAA

Commonly caused by Borreliaor spirochete which is responsive to Pen G / Metronidazole / Clindamycin

REACTIVE LYMPHADENOPATHY

Usually has a focus of infection

Commonly due to dental carries, hair lice, skin infection in the head and neck

Should rule out TB adenitis

TB ADENITIS

May or may not present with chronic cough (>2 weeks), weight loss, failure to gain weight, anorexia

Should rule out reactive LAD

PAROTIDITS

FNABCXR AP-LSputum AFB X 3TCB once with results

FNABCo-amoxiclav 625 mg/tab TID or 1 g/tab BID X 7 days

-

S/P I & DPen G 4 million units IV LD ( ) ANST then 2 million units q6hClindamycin 600mg IV LD ( ) ANST then 300 mg q6h OREtoricoxib 120mg/tab 1 tab OD prn for painMGH

AdvisedTCB after 1 week for re-assessment

S/P I & DPen G 4 million units IV LD ( ) ANST then 2 million units q6hClindamycin 600mg IV LD ( ) ANST then 300 mg q6h OREtoricoxib 120mg/tab 1 tab OD prn for pain

MGHAdvised

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If viral (mumps), treatment is supportive with Etoricoxib 120 mg/tab 1 tab OD prin for pain, bed rest, increased OFI, andavoidance of close contact with household members

If bacterial, treat with Co-amoxiclav 625 mg/tab TID or 1 g/tab BID X 7 days

NASAL BONE FRACTURE

Common due to its midline location on the face Most common mechanism of injury is mauling, followed by vehicular accidents

Usually associated with a history of impact to the midfacial area

Said to be neglected if f racture >14 days post-injury

Signs and Symptomsa. crepitationb. step-down deformityc. nasal speculum deviationd. shortening of the nosee. increased mobility of the nosef. anosmiag. epistaxish. CSF rhinorrhea

Treatmenta. Imaging Radiographic studies cannot distinguish between recent and old fractures. Therefore, these are not useful for

medico-legal cases, with a high rate of false negatives and false positives.1. Waters view information regarding lateral displacement2. Nose STL demonstrates fracture in the anterior nasal bone

b. Packing control bleeding using antibiotic impregnated nasal pack for 2-5 days. Antibiotics are given as prophylaxisbecause nasal bone fractures are usually associated with lacerations of the nasal mucosa or skin.

c. Antibiotics Penicillin (Cloxacillin) and first generation cephalosporin (Cefalexin Cefalexin 500mg cap or 125mg/5mLsuspension) are usually given as prophylactic antibiotics.

d. Pain Medicationse. Closed reduction is done when swelling has subsided to allow for better assessment of the deformity. In children, swelling

usually subsides in

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MANDIBULAR FRACTURETypes of muscles acting on Fracture Segments

a. Posterior group upward, forward movement; stronger group. Masseter, lateral & medial pterygoids, & temporalisb. Anterior group down, backward movement. Geniohyoid, digastric, mylohyoid, genioglossus

Types of mandibular fracturea. Favorable muscle forces tend to keep fragments togetherb. Unfavorable muscle forces tend to pull fragments apart

Imaging studies

a. Panorex view single best radiographb. AP- oblique, modified Townes

ZYGOMATIC FRACTURETypes

a. simple fracture of the archb. trimolar or tripod fracture involves all 3 suture linesc. quadripod fracture maxillary-zygomatic buttress considered

Imaging:Waters, axial or submentovertical views.

CLEFT LIP

May be unilateral or bilateralClassification

a. Complete cleft reaches the vestibule

b. Incomplete does not reach the vestibuleRule of Ten:Pt should be at least 10 lbs, 10 weeks, and has 10 mg/dL Hgb

CLEFT PALATE

Reconstruction is performed before 2 years of age to aid in normal speech development. Early attention to nutrition is importantbecause sucking is impaired.

Thallwitz classification: L_A_H_S_H_A_L_Divide the key areas of the face (Lip, Alveolus, Hard palate & Soft palate) into thirds. LAH right, HAL - left

LEVELS OF LYMPH NODESIA submental

IB submandibularII, III, IV along SCMV posterior triangleVI pre-trachealVII - paratracheal

NASOPHARYNGEAL CARCINOMA

Presents with epistaxis, nasal obstrucstion, anosmia, constitutional SSx of malignancy

On rhinoscopy, (+) for fungating mass in the nasopharynx

StagingPrimary tumor stageT1 Tumor confined to nasopharynxT2 Tumor extends to soft tissues of oropharynx or nasal fossa

T2a Without parapharyngeal extensionT2b With parapharyngeal extension

T3 Tumor invades bony structures or paranasal sinusesT4 Tumor with intracranial extension or involvement of cranial nerves, infratemporal fossa, hypopharynx, or orbitStage groupings

Punch Biopsy /LA

SAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXRTCB once with results

HEAD & NECK TUMORS

CLEFT LIP AND PALATE

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I T1 N0 M0IIA T2a N0 M0IIB T1,2a N1 M0; T2b N0, N1 M0III T1,2 N2 M0; T3 N0,1,2 M0IVA T4 N0,1,2 M0IVB Any T N3 M0IVC Any T Any N M1Treatment

Primary tumors: RT alone (bilateral) is used for both the primary tumor and the regional nodal metastases. Surgery is not feasiblebecause of the inadequacy of the surgical margins at the base of the skull and the frequent involvement of the retropharyngeal andcervical nodes bilaterally.

PAROTID TUMOR

Benign tumors are more common than malignant ones

If bilateral, probably Warthins tumor

Most common histologic types are1. Benign mixed tumor major salivary gland; with pseudopods so remove mass with margins; with 1% malignant

transformation.2. Malignant adenoid cystic CA more common in minor salivary glands.3. Mucoepidermoid cyst - malignant

Staging of Salivary Gland CarcinomaPrimary tumor stageTX Primary tumor cannot be assessedT0 No evidence of primary tumorT1 Tumor 2 cm but 4 cm but 6 cmStage groupings for major salivary gland carcinomasI T1,2,3 N0 M0II T3 N0 M0III T1,2 N1 M0IV T4 N0 M0; T3,4 N1 M0; any T N2,3 M0; any T any N M1

MAXILLARY CARCINOMA

Most common type is SCCA, followed by adenoid cystic CA

MUCOUS RETENTION CYST

Originates from the maxillary sinuses

Usually not touched, but may do puncture via Caldwell-luc if hard enough

LARYNGEAL CARCINOMA

Presents with hoarseness (other causes included VC mass, VC inflammation, VC paralysis)

Involvement of the cricoid cartilage indicates a subglottic extension which has a poorer prognosis

Pt is sent to the ER if with dyspnea for emergency tracheostomy and then possible admission for further work-up Total laryngectomy with next dissection is done for proven laryngeal CA

StagingPrimary Tumor

FNABSAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXRTCB once with results

FNABSAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR

TCB once with results

Direct laryngoscopy with biopsy of laryngeal mass/LASAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXRTCB once with results

Sample Chart Entry

Sample Chart Entry

Sample Chart Entry

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Supraglottis Glottic SubglotticTis Carcinoma-in-situ Carcinoma-in-situ

T1 Tumor confined to site of origin with normalmobility

Tumor confined to vocal cord(s) withnormal vocal cord mobilityT1a limited to one vocal cordT1b with involvement of anteriorcommisure

Tumor confined to subglotticarea

T2 Tumor involves adjacent supraglottic sites or

glottis without fixation

Supraglottic or subglottic extensionof

tumor with normal or impaired mobility

Tumor extension to vocal cords

with normal or impaired cordmobility

T3 Tumor limited to larynx with fixation or extensionto involve postcricoid area, medial wall ofpyriform sinus or pre-epiglottic space

Tumor confined to larynx with cordfixation

Tumor confined to larynx withcord fixation

T4 Massive tumor extending beyond the larynx tooropharynx, skin or soft tissues of neck, ordestruction of thyroid cartilage

Massive tumor with thyroid cartilagedestruction or extension beyondconfines of larynx or both

Massive tumor with cartilagedestruction or extension beyondconfines of larynx

Nodal InvolvementNx minimum requirements to assess the regional nodes cannot be metNO no clinically positive nodesN1 clinically positive homolateral nodesN2 contralateral or bilateral nodes not fixedN3 fixed nodes

Distant MetastasisMx minimum requirements for assessment of distant metastasis cannot be metMO no distant metastasisM1 distant metastasis present

StagingI T1 NO MOII T2 NO MOIII T3 NO MO; T1, T2, T3 N1 MOIV T4 NO MO; T4 NO MO; Any T N2, N3 MO; Any N M1Indications for Emergency Tracheostomy

a. Foreign body occluding the airwayb. Retropharyngeal abscessc. Tetanusd. Severe myasthenia gravise. Laryngeal CA with Obstruction

THYROID CARCINOMA

PAPILLARY CANCER Most common, affect younger patients.

Psammoma bodies are usually present in histologic sections.

Distant metastases to lungs, bone, skin, and other organs occur late.

Papillary = Popular = Psammoma = Palpable lymph nodes = Positve131I uptake = Positive prognosis = Post-op 131I scan to

diagnose/treat metastasesStagingPrimary tumor (T)

TX: Primary tumor cannot be assessed.T0: No evidence of primary tumor is found.T1: Tumor size is 2 cm or less in greatest dimension and is limited to the thyroid.T2: Tumor size is greater than 2 cm but less than 4 cm, and tumor is limited to the thyroid.T3: Tumor size is greater than 4 cm, and tumor is limited to the thyroid or any tumor with minimal extrathyroidal extension(extension to sternothyroid muscle of perithyroid soft tissues).T4a: Tumor extends beyond the thyroid capsule and invades any of the following: subcutaneous soft tissues, larynx, trachea,esophagus, or recurrent laryngeal nerve.T4b: Tumor invades prevertebral fascia, mediastinal vessels, or encases the carotid artery.

Regional lymph nodes (N)NX: Regional nodes cannot be assessed.N0: No regional node metastasis is found.N1a: Metastasis is found in level VI (pretracheal and paratracheal, including prelaryngeal and Delphian) lymph nodes.N1b: Metastasis is found in unilateral, bilateral, or contralateral cervical or upper/superior mediastinal lymph nodes.

Distant metastasis (M)MX: Distant metastasis cannot be assessed.M0: No distant metastasis is found.M1: Distant metastasis is present.

Stages

Stage Younger Than 45 Years Age 45 Years and Older

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I Any T, Any N, M0 T1, N0, M0II Any T, Any N, M1 T2, N0, M0

III T3, N0, M0, T1, T2, T3, N1a, M0IVa T1, T2, T3, N1b, M0, T4a, N0, N1, M0IVb T4b, any N, M0

IVc Any T, any N, M1

FOLLICULAR CANCER

Peak incidence at 40 years of age. They tend to invade blood vessels and to metastasize hematogenously to visceral sites, particularly bone. Lymph node

metastases are relatively rare, especially compared with papillary cancers.

Hrthle cell cancer is a variant of foll icular carcinoma and has a relatively aggressive metastatic course.

Follicular = Far-away metastasis = Female (3:1) = FNAB NOT (diagnosed by tissue structure) = Favorable prognosisStagingStage Younger Than 45 Years Age 45 Years and Older

IAny T, any N, M0 (Cancer is in the thyroidonly)

T1, N0, M0 (Cancer is in the thyroid only and may be found in one or bothlobes)

IIAny T, any N, M1 (Cancer has spread todistant organs)

T2, N0, M0 and T3, N0, M0 (Cancer is in the thyroid only and is larger than1.5 cm)

IIIT4, N0, M0 and any T, N1, M0 (Cancer has spread outside the thyroid butnot outside of the neck)

IV Any T, any N, M1 (Cancer has spread to other parts of the body)

MEDULLARY THYROID CANCER

Secrete calcitonin. ACTH, histaminase, and an unidentified substance that produces diarrhea may also be secreted by thesetumors. Large amounts of amyloid are evident by histologic examination.

Metastases are mostly found in the neck and mediastinal lymph nodes and may calcify. Widespread visceral metastases occurlate.

Medullary = MEN II = aMyloid = Median lymph node dissection = Modified neck dissection if lateral nodes are positiveStagingI Cancer is less than 1 centimeter (about 1/2 inch) in size.II Cancer is between 1 and 4 centimeters (about 1/2 to 1 1/2 inches) in size.III Cancer has spread to the lymph nodes.IV Cancer has spread to other parts of the body.

ANAPLASTIC GIANT AND SPINDLE CELL CANCER

Occur most often in patients older than 60 years of age. Anaplastic thyroid cancers are aggressive cancers, which rapidly invadesurrounding local tissues and metastasize to distant organs.

There is no number staging system used for anaplastic cancer.

Other tumors found in the thyroid include Hodgkin lymphomas, a variety of soft tissue sarcomas, and metastatic cancers of lung,colon, and other primary sites. Small cell cancers of the thyroid are rare, are histologically similar to lymphoma, and spread to bothlymph nodes and distant sites.

References:

Braganza, RA, Otolaryngology, Head & Neck Surgery.

Blackbourne, L. Surgical Recall 4th ed. 2006.

Caparas, et. al. Basic Otolaryngology. 1993.

Class 2004. Otorhinolaryngology Reviewer.

eMedicine

Jarell et. al. Surgery NMS. 5th ed. 2008.

Oncology. 4th Ed.

www.craniofacialcenter.com/book/Trauma/Trauma_3.htm

www.medscape.com
http://rds.yahoo.com/_ylt=A0S020mHPPxHGBQA5d6jzbkF/SIG=12e0konnt/EXP=1207799303/**http%3A/www.craniofacialcenter.com/book/Trauma/Trauma_3.htmhttp://rds.yahoo.com/_ylt=A0S020mHPPxHGBQA5d6jzbkF/SIG=12e0konnt/EXP=1207799303/**http%3A/www.craniofacialcenter.com/book/Trauma/Trauma_3.htm

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