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101 Cards in this Set
- Front
- Back
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What structures are preserved in a supraglottic laryngectomy? |
True cords, arytenoid and thyroid cartilages are preserved - Try to save SLN to prevent post-op aspiration
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What is preserved in a supracricoid laryngectomy?
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Cricoid and at least one of the arytenoid cartilages - 50% remain trach dependent
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What is a tracheoesophageal prosthesis prone to?
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Candidal infection
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Vocal fold position when the RLN is cut?
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paramedian
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Vocal fold position when the Vagus is cut?
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lateral/intermediate
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What are three airway lengthening techniques?
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1. Mobilization after blunt dissection of the larynx and trachea (3cm) 2. Incision of the annular ligaments on one side of the trachea proximal to the anastamosis and on the opposite side distally (1.5cm) 3. Laryngeal release - suprahyoid (5cm) or infrahyoid (often results in dysphagia)
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Where do autoimmune diseases of the larynx appear?
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SAW Sarcoid - supraglottic Amyloid - glottic Wegener's - subglottic
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What is Gutman sign? (associated with SLN paralysis)
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Normally lateral pressure over thyroid cartilage causes an increase voice pitch and anterior pressure causes a decrease in pitch - In SLN paralysis the reverse is true
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What causes vocal fatigue that improves with rest?
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Myasthenia gravis - Test with edrophonium (Tensilon test)
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How does a passy muir valve aid in swallowing and preventing aspiration?
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Increase in subglottic pressure
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Most common cause of supraglottitis in adults?
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S. aureus
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Complications of Venturi jet venillation?
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Hypoventillation pneumothroax pneumomediastinum subcutaneous empysema abdominal distension mucosal dehydration distal seeding of papillomatous particles
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Most common bacteria associated with necrotizing fasciitis?
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Strep pyogenes (group A hemolytic streptococci) and S. aureus
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Bacteria that can cause necrotiing fasciitis?
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Strep pyogenes (group A hemolytic streptococci) and S. aureus (most common 2) Also - bacteroides, C. perfringens, peptostreptococcus, proteus, pseudomonas, klebsiella
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Treatment of necrotizing fasciitis?
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Blood sugar control Surgical debridement Broad spectrum antibiotics with anaerobic and aerobic coverage (Pen G classic first line agent) Hyperbaric oxygen
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From where do paragangliomas arise?
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Neuroendocrine cells (paraganglia) of the autonomic nervous system
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Where are carotid paraganglia located?
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Adventitia of the posteromedial aspect of the bifurcation of the common carotid artery
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Where are temporal bone paraganglia located?
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Accompanying Jacobson serve (from CN IX) or Arnold nerve (CN X), or in the adventitia of the jugular bulb
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Where are vagal paraganglia located?
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In the perineuium of the vagus nerve
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What vasoactive substances are produced by paragangliomas?
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Catecholamines norepinephrine dopamine somatostatin VIP (vasoactive intestinal polypeptide) calcitonin
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What are the symptoms associated with a vasoactive secreting paraganglioma?
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Headache, palpitations, flushing, diarrhea or HTN
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Can paragangliomas be familial?
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Yes (autosomal dominant) - family members should have screening MRI's every 2 years
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Can paragangliomas be multicentric, malignant or hormonally active?
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Yes, rule of 10's
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What is the gold standard for diagnosing a paraganglioma?
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Arteriography
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What are the MRI and CT findings for a paraganglioma?
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CT shows post contrast enhancement and MRI shows mild enhancement on T2 images; intense post contrast enhancement and "salt and pepper" appearance secondary to flow voids
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What is the histology of a paraganglioma?
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Chief cells (amine precursor and uptake decarboxylase cells) and sustentacular cells (modified schwan cells) orgaized in clusters known as Zellballen
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What % of paragangliomas are Carotid body tumors?
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60%
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What is the classic arteriography associated with a carotid body tumor
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Lyre sign - splaying of the internal and external carotid arteries
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Treatment of carotid body tumors?
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surgery +/- preoperative embolization with recurrence, incomplete resection and elderly may consider XRT as primary therapy
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What is the second most common tumor of the temporal bone after acoustic neuroma?
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Glomus jugulare and glomus tympanicum
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What is the most common tumor of the middle ear?
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Glomus tympanicum
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F:M ratio for glomus tumors (jugulare and tympanicum)?
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4:01
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What is the classic exam finding for a glomus tumor?
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Vascular middle ear mass that blanches with pneumatic otoscopy (Brown sign)
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How common are glomus vagale?
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3% of paragangliomas
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Where do glomus vagale originate?
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Nodose ganglion (inferior ganglion of vagus nerve)
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How does a glomus vagale often present?
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Painless neck mass with tongue weakness, hoarseness, dysphagia, and a Horner's syndrome
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How does angiography of a glomus vagale appear?
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Vascular lesion that displaces the internal carotid artery anteromedially
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What are two peripheral nerve sheath tumors?
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Schwannomas and Neurofibromas
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What is the histology of a schwannoma?
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Antoni A and Antoni B tissue
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Which is more common: Schwannoma or Neurofibroma?
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Neurofibroma
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What disease are neurofibromas associated with?
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Neurofibromatosis type I - von Recklinghausen disease
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Features of von Recklinghausen disease type I?
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Neurofibromas and café au-lait spots
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How do you treat chyle fistulas with volumes of less than 500-700 mL/day?
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1. Pressure and low-fat diet 2. medium chain triglycerides 3. octreotide
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How do you treat chyle fistulas with volumes greater than 500-700 mL/day?
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Exploration and ligation
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What is the most commonly mutated proto-oncogene in H&N cancer?
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c-myc
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What is the most commonly mutated tumor suppressor gene in H&N cancer?
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p53
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What is the blood supply of the deltopectoral flap?
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first to fourth perforators of the internal mammary artery
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Blood supply of the paramedian forehead flap
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supratrochlear artery
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Blood supply of the pericranial flap?
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supraorbital and supratrochlear
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Blood supply of the temporoparietal flap?
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superficial temporal
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What are 5 examples of myocutaneous regional flaps and their blood supply
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1. Latissimus dorsi - thoracodorsal artery 2. Pectoralis major - thoracoacromial artery and internal mammary perforators 3. Platysma - occipital, postauricular, facial, superior thyroid and transverse cervical 4. SCM flap - occipital, superior thryoid, transverse cervical 5. Trapezius - occipital, dorsal scapular and transverse cervical
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What are 3 examples of osteomyocutaneous regional flaps?
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1. Pectoralis major with rib 2. SCM with clavicle 3. Trapezius with scapular spine
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Name 9 classic free flaps:
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1. Fibula 2. Iliac crest 3. Jejunum 4. Lateral Arm 5. Lateral Thigh 6. Latissimus Dorsi 7. Radial Forearm 8. Rectus 9. Scapula
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Blood supply for fibula free flap
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Peroneal artery/vein
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Blood supply for Iliac crest free flap
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Deep circumflex iliac artery
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Blood supply for Jejunum free flap
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Superior mesenteric arterial arcade
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Blood supply lateral arm free flap
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Posterior radial collateral artery
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Blood supply for lateral thigh free flap
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Profunda femoris artery
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Blood supply for Latissiumus dorsi free flap
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Thoracodorsal artery
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Blood supply for Radial Forearm free flap
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Radial artery
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Blood supply for Rectus free flap
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Deep inferior epigastric artery
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Blood supply for Scapula free flap
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Circumflex scapular artery
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Which subtypes of HPV are associated with SCCA?
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16 and 18
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Which type of lip cancer is more frequently seen on the upper lip?
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BCCA
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Which type of lip cancer is more frequently seen on the lower lip?
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SCCA
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Which is worse - upper or lower lip SCCA?
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Upper lip metastasizes early
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(TNM Staging) - Define N1
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Less than and equal to 3cm
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(TNM Staging) - Define N2a
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single ipsilateral lymph node greater than 3cm, less than or equal to 6cm
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(TNM Staging) - Define N2b
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multiple ipsilateral nodes, none greater than 6cm
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(TNM Staging) - Define N2c
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bilateral or contralateral lymph nodes, none greater than 6cm
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(TNM Staging) - Define N3
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greater than 6cm
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Which node involvment makes post laryngectomy patients at a higher rate of recurrence?
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Delphian node: A midline prelaryngeal lymph node
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What factors warrant postoperative radiation therapy in H&N cancer?
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1. Advanced stage 2. Close or positive margins 3. Lymph node involvment 4. Extracapsular spread 5. Perineural invasion
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When should postoperative radiation begin?
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Started by 6 weeks, even if there is a healing wound
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In the setting of SIADH what can happen from bilateral neck dissections?
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Increased intracranial pressure
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Histology of a thyroid follicle:
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Spheroidal, cyst-like compartment with follicular epithelium, colloid center, parafollicular cells, capillaries, connective tissue and lymphatics
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What is the principal component of colloid?
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Thyroglobulin - an iodinated glycoprotein
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What enzyme is responsible for iodination of thyroglobulin?
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Thyroid peroxidase
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Which is more active T3 or T4?
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T3
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Where is calcitonin produced?
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thyroid C cells
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Function of calcitonin?
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lower blood calcium
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Which malignancy is followed with calcitonin levels?
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medullary thyroid cancer
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Low TSH and high T4?
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Hyperthyroidism
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Low TSH and low T4?
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Secondary hypothyroidism
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Low TSH and normal T4
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Order T3 - could be subclinical hyperthyroidism or T3 toxicosis
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Low TSH, normal T4, normal T3
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subclinical hyperthyroidism
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Low TSH, normal T4, high T3
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T3 toxicosis
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How is thyroglobulin used?
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Marker for persistent disease - values about 10 mg/dL
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What marker is elevated in Hashimoto's thyroiditis?
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Antithyroid peroxidase antibodies
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Which marker is elevated in Graves Disease?
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Thyroid-stimulating antibody
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How common are clinally apparent thyroid nodules?
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4-7% of the population
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M:F ratio of clinically apparent thyroid nodules?
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1:05
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What are 95% of thyroid nodules?
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Adenomas, colloid nodules, cysts, thyroiditis or carcinoma
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What findings of thyroid nodules are of concern?
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1. Age less than 20 or greater than 60 2. Male 3. Size greater than 4cm 4. History of radiation exposure 5. Vocal fold fixation 6. Rapid growth
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When do you perform an FNA
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Nodules greater than 1cm
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What are the four cytopathologic categories of FNA of a thryoid nodule?
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1. Malignant 2. Suspicious (microfollicular, Hurthle cell predominant) 3. Benign (macrofollicular) 4. Non-diagnostic
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What can a FNA showing microfollicular cells respresent?
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Follicular adenoma or follicular carcinoma
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How do you distinguish between follicular adenoma or carcinoma?
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Need biopsy to evaluate for vascular or capsular invasion
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What can hurtle cell predominant FNA's represent?
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Adenoma or carcinoma
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What two benign pathologies have Hurthle cells? |
Hashimoto and multinodular goiters have Hurthle cells
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Which isotopes are used for thyroid scintigraphy?
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Radioisotopes of iodine or Technetium
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