MT

METASTASIS
1. CA of tongue: jugulodigastric
2. CA of buccal mucosa: submental and submandibular
3. CA of gingival and hard palate: mandibular and subdigastric
4. CA of lips: submental and submandibular
5. CA of floor of mouth: mandibular and subdigastric

1. epstein’s pearl or bohn’s nodules: GINGIVAL CYST

2. rodent ulcer: BCC
3. large vessel type of hemangioma: cavernous hemangiomas
4. immature forms of capillary hemangioma: hypertrophic hemangioma
5. with spindle-shaped cells surrounding capillaries: hemangiopericytoma
6. bryces sign: laryngocoele
7. cold abscess: lymphadenitis
8. horner syndrome: laryngocoele
9. location of koch’s nodule: posterior triangle

1. chorda tympani: CN VII

2. tensor tympani: CN V
3. tympanic plexus: CN IX
4. stapedius: CN VII

1. hypotympanium: floor
2. opening to tympanic membrane: medial wall
3. Eustachian tube opening: anterior wall
4. canal for tensor tympani muscle: anterior wall
5. epitympanium: roof
6. ossicles: medial wall
7. lateral semicircular
8. aditus: posterior wall

1. ampulla: crista ampullaris

2. macula: otoliths
3. organ of corti: hair cells for shearing

1. hot potato voice: PERITONSILLAR ABSCESS

2. chronic mouth breathing, snoring, hyponasal speech: ADENOIDS
3. mesopharynx: OROPHARYNX
4. epipharynx: NASOPHARYNX
5. psueudomembrane: DIPHTHERIA
6. trench mouth: VINCENT’s / PLAUT’S ANGINA

1. below cricopharyngeus posteriorly where the longitudinal esophageal fibers separate: LAIMER-
HACKERMANN AREA
2. below lowest fibers of the cricopharyngeus and upper circular fiber of the esophagus on lateral
aspect :KILLIAN-JAMIESON AREA
 3. between alar and prevertebral sheaths: SPACE OF 4 or DEGREE SPACE
4. space between the base of the skull and the superior constrictor thru w/c the Eustachian tube
passes: SINUS OF MORGAGNI

1. butterfly rash: LUPUS ERYTHEMATOSUS

2. encephalocoele: NASAL GLIOMA
3. failure of nasobuccal membrane to canalize: CHOANAL ATRESIA
4. sebaceous gland hypertrophy: RHINOPHYMA
5. apple jelly nodules: LUPUS VULGARIS
6. pre-malignant lesion: SENILE KERATOSIS
7. excoriation and infection of vestivule: VESTIBULITIS
8. MC acute infection: FURUNCULOSIS
9. acute inflammation of skin and subcutaneous tissue: ERYSIPELAS
10. esicupusular formation w/ yellow crust: IMPETIGO

1. chemical-respiratory sensitizers: OCCUPATIONAL RHINITIS

2. greenish nasal secretion and crust: ATROPHIC RHINITIS
3. hallmark of inflammation: NASAL POLYPS
4. non-allergic rhinitis: IDIOPATHIC RHINITIS
5. CN II-VI: ORBITAL APEX SYNDROME
6. common cold: AINFECTIOUS RHINITIS
7. IgE-mediated inflammation: ALLERGIC RHINITIS
8. pott’s puffy tumor: OSTEOMYELITIS
9. pregnancy rhinitis: HORMONAL RHINITIS

1. sphenopalatine vessels: POSTEROINFERIOR BLEEDING

2. jarjavay type: SEPTAL DEVIATION (LATERAL)
3. chevallet fracture: CLASS 1 FRACTURE
4. foster-kennedy syndrome: FRONTAL LOBE TUMOR
5. pig-nose appearance: CLASS 3 FRACTURE

FLAPS VS GRAFTS
1. can bridge defect: FLAPS
2. requires pressure dressing: FLAPS
3. more likely to contract: GRAFTS
4. depends on recipient site for nutrition: GRAFTS
5. less adaptable to weight bearing: GRAFTS

1. proptosis and lateral rectus palsy: PTERYGOID / TEMPORAL SPACE INFECTION

2. torticollis: CAROTID SPINE ABSCESS
3. horner’s syndrome: CAROTID SPINE ABSCESS
4. hot potato voice: RETROPHARYNGEAL SPACE ABSCESS
5. respiratory distress: PARAPHARYNGEAL SPACE INFECTION
6. osteomyelitits: MASSETER SPACE INFECTION

1. fissures of santorini: DEFICIENCY IN CARTILAGENOUS EAC

2. foramen of huschke: DEFICIENCY IN BONY EAC
3. pars flaccida: SHRAPNELL’S MEMBRANE
 4. notch of rivinus: AREA DEFICIENT OF ANNULUS FIBROSUS
5. otitis externa circumscripta: STAPHYLOCOCCUS
6. diffuse otitis externa: PSEUDOMONAS
7. epistaxis: KIESSELBACH’S PLEXUS
8. tripod fracture: ZYGOMA
9. blow out fracture of orbit: FORCED DUCTION TEST
10. temporal bone fracture: BATTLE’S SIGN

1. bactidol: HEXITIDINE
2. docusate: OTOSOL
3. nystatin, gramicidin: POSTOTOC, APLOSYN OTIC
4. lidocaine, benzoxonium: OROFAR-L
5. antipyrine: AURALGAN OTIC
6. neomycin, polymyxin: KENACOMB OTIC

1. syphilis: PENICILLIN
2. ludwig’s angina: INCISION AND DRAINAGE
3. salpingitis: PENICILLIN
4. herpes: ACYCLOVIR
5. candida: NYSTATIN

1. aerotitis media: BAROTRAUMA

2. apical petrositis: GRADENIGO SYNDROME
3. lateral sinus thrombophlebitis: PICKET FENCE SYNDROME
4. otitic hydrocephalus: QUECKENSTEDT

RHINITIS
1. IgE mediated : ALLERGIC RHINITIS
2. tuberculosis: CHRONIC RHINITIS
3. prolonged use of decongestant: RHINITIS MEDICAMENTOSA
4. pregnancy-related: NOTA
5. with dryness: ATROPHIC RHINITIS
6. emotional stress: VASOMOTOR RHINITIS
7. infectious/inflammation: ACUTE RHINITIS

1. unilateral hearing loss: NOTA

2. bilateral hearing loss: NOTA
3. benign paroxysmal positional vertigo: CULPOLITHIASIS
4. meniere’s dse: TINNITUS

1. staphylococcus: CLOXACILLIN
2. streptococcus: AMOXICILLIN
3. herpes ACYCLOVIR
4. candida: NYSTATIN
5. psueomonas: OFLOXACIN

GRADENIGO VS MENIERE
1. diplopia: GRADENIGO
 2. hearing loss: MENIERE
3. ear fullness: MENIERE
4. dizziness: MENIERE
5. tinnitus: MENIERE
6. ear discharge: GRADENIGO

1. frontal sinus – MIDDLE MEATUS

2. anterior ethmoid sinus – MIDDLE MEATUS
3. posterior ethmoid sinus – SUPERIOR MEATUS
4. sphenoid sinus – SPHENOETHMOIDAL RECESS
5. mastoid – ADITUS AD ANTRUM
6. maxillary sinus – MIDDLE MEATUS
7. cavernous sins – OPHTHALMIC VEIN
8. middle meningeal sinus – FORAMEN SPINOSUM
9. highmore of antrum – AD IC ANTRUM
10. middle ear – EUSTACHIAN TUBE
11. nasolacrimal duct – INFERIOR MEATUS
12. tensor tympani - ROOF
13. bony ear canal – EXTERNAL CAROTID
14. jugular vein - FLOOR
15. CN VII - AICA
16. Eustachian tube: MIDDLE EAR
17. lacrimal gland: INFERIOR MEATUS
18. ethmoid hair cells

1. Sheehan syndrome: ISCHEMIC NECROSIS OF THE ANTERIOR PITUITARY

2. cavernous sinus syndrome: MC CAUSE IS ETHMOIDITIS
3. charcot’s triad: NYSTAGMUS, SCANNING SPEECH AND INTENTION TREMOR SEEN IN MULTIPLE
SCLEROSIS
4. digeorge syndrome: THYMUS AGENESIS
5. frey’s syndrome: AURICULOTEMPORAL NERVE SENDS ITS PARASYMPATHETIC FIBERS TO
INNERVATE THE SWEAT GLANDS
6. carotid sinus syndrome: NOTA
7. gilles de la tourette’s syndrome: CHOREA, COPROLALIA, TICS
8. markus-gunn syndrome JAW WINKING
9. campomelic syndrome: DWARFISM, CRANIOFACIAL ANOMALIES, BOWING OF TIBIA AND FEMUR
10. zaufal’s syndrome: SADDLE NOSE
11. ortner’s syndrome: CARDIOMEGALY ASSOCIATED W/ LARYNGEAL PARALYSIS SECONDARY TO
COMPRESSION
12. bezold’s abscess: SECONDARY TO PERFORATION OF THE TIP OF THE MASTIOD BY INFECTION
13. carcinoid syndrome: TUMOR SECRETES SEROTONIN
14. semon’s law: PARALYSIS OF THE CRICOARYTENOID POSTICUS BEFORE PARALYSIS OF THE
ADDUCTORS
15. ondine’s curse: FAILURE OF RESPIRATORY CENTER AUTOMATICITY W/ APNEA ESPECIALLY
EVIDENT DURING SLEEP

SALIVARY GLANDS
 1. U-shaped bend on mylohyoid: SUBMANDIBULAR GLAND
2. Wharton duct: SUBMANDIBULAR GLAND
3. rivinus duct: SUBLINGUAL GLAND
4. stensen duct: PAROTID GLAND – drains opposite/upper 2 nd molar
5. MC tumor occur: PAROTID GLAND
6. most sialolithiasis occur: SUBMANDIBULAR GLAND
7. mixed glands: PAROTID and SUBMANDIBULAR
8. serous glands: PAROTID
9. mucous glands: SUBLINGUAL

AREAS OF INJURY
1. I: intracranial penetration
2. II: orbital and globe injury
3. III: head and neck injuries

EPITHELIAL COVERING
1. lips: NONKERATINIZING SQUAMOUS
2. cheeks: NONKERATINIZING SQUAMOUS
3. nasopharynx: CILIATED
4. oropharynx: NONKERATINIZING SQUAMOUS
5. hypopharynx: NONKERATINIZING SQUAMOUS
6. pharyngeal tonsil: CILIATED
7. palatine tonsil: NONKERATINIZING SQUAMOUS
8. lingual tonsil: NONKERATINIZING SQUAMOUS
9. middle ear: CILIATED
10. external ear: KERATINIZING SQUAMOUS

LYMPHATIC DRAINAGE
1. lips: LEVEL I
2. cheeks: LEVEL I
3. tongue: LEVEL I
4. palatine tonsil: LEVEL II
5. middle: LEVEL II

ORAL MANIFESTATION OF SYSTEMIC DSE

1. syphilis: GUMMAS and ENANTHEMS
2. melkersson-rosenthal syndrome: FISSURED TONGUE
3. anaphylaxis: ANGIOEDEMA
4. pernicious anemia: HUNTER’S GLOSSITIS

NOTES
 EXTERNAL EAR
1. auricle/pinna
2. external auditory canal
3. tympanic membrane
 MIDDLE EAR
1. tympanum/middle cavity
2. antrum and mastoid air cells
 3. eustachian tube
 INNER EAR
1. bony labyrinth
2. membranous labyrinth

MIDDLE EAR BOUNDARIES

 roof – tegmen tympani
 lateral – tympanic membrane
 anterior – eustachain tube opening
 posterior – aditus / opening into tympanic membrane
 floor – hypotympoanum
 medial – promontory, labyrinthine windows, horizontal part of CN VII, lateral semicircular canal

BOUNDARIES
 superior – tegmen antri
 posterior – sigmoid sinus
 anterior – posterior wall of external auditory canal
 inferior – digastrics ridge

CENTRAL PATHWAY
 dorsal and ventral cochlear nucleus
i. superior olivary complex
ii. lateral lemniscus
iii. inferior quadrigeminal body
iv. medial geniculate
v. auditory complex

AUDIOGRAM KEY / AUDIOMETRY

right lef
AC unmasked O X
AC masked triangle square
BC mastoid unmasked < >
BC mastoid masked [ ]
red blue

DEGREE OF HEARING LOSS

 0-25 dB – normal hearing threshold
 26-40 – mild hearing loss
 41-60 – moderate hearing loss
 56-70 - moderately severe hearing loss
 71-90 – severe hearing loss
 >90 – profound hearing loss

BERKESY TEST

TYPE FINDINGS INTERPRETATION

I pulsed and continuous across all frequencies normal or middle ear dse
II pulsed and continuous interweave in low and mid frequencies cochlear dse (meniere’s)
but at 1000Hz continuous drop but no more than 20 dB
III similar to type II, but the drop is more than 20 dB retrocochlear pathology
(acoustic schwannoma
IV pulsed and continuous tones do not interweave retrocochlear pathology
V pulsed drops below the continuous ones non-organic hearing loss

WAVES
 I – distal portion of auditory nerve
 II – proximal portion of auditory nerve
 III – cochlear nucleus
 IV – superior olivary complex
 V – lateral lemniscus as it teminates at interior colliculus

OTITIS MEDIA VS OTITIS EXTERNA

OTITIS EXTERNA OTITIS MEDIA

pain very severe not severe
tenderness on pinna manipulation (+) (-)
fever usually (-) usually (+)
hx of URTI usually (-) usually (+)
hx of scratching or cleaning of ear (+) usually (-)
hearing not impaired unless canal obliterated impaired
matoid xray normal mastoiditis

COMPLICATIONS OF OTITIS MEDIA AND MASTOIDITIS

 extracranial
o facial nerve paralysis
o labyrinthitis
o subperiosteal abscess
o apical petrositis (gradenigo)
o sensorineural hearing loss
 intracranial
o extradural abscess
o subdural abscess
o lateral sinus thrombophlebitis
o meningitis
o brain abscess
o otitic hydrocephalus

LABYRINTHITIS

TYPE VERTIGO HEARING LOSS PATHOLOGY

circumscribed mild conductive erosion w/o actual erosion of the labyrinth w/ a
fistula
serous moderate mixed localized invasion to severe w/ toxins of the
organism
suppurative severe sensorineural then actual penetration and invasion by the organisms
total

COCHLEAR DISEASES

ONSET LATERALITY VESTIBULAR SYMPTOMS

presbycussis gradual bilateral -
infection sudden uni or bi +
noise-induced gradual uni or bi -
ototoxicity sudden bilateral +/-
trauma sudden unilateral +
barotrauma sudden unilateral +
systemic dse gradual bilateral -
meniere’s fluctuant unilateral (bilateral 30%) +

VESTIBULAR DISORDERS

VERTIGO (DURATION) HEARING LOSS VESTIBULAR

STATUS
meniere’s episodic (20mins-hour) fluctuant (low freq decreased
in early stage)
vestibular neuronitis acute; aggravated by head mov’t no loss decreased
(>24hrs)
acute labyrinthitis acute (>24hrs) severe SNHL decreased
benign positional recurrent; related to position and no loss normal
aggravated by head mov’t
(seconds)
acoustic neuroma or progressive progressive SNHL decreased
vestibular schwannoma
vertebrobasilar acute and aggravated by head compatible normal
insufficiency mov’t (variable)

PERMISSIBLE NOISE EXPOSURE

DURATION/DAY SOUND LEVEL

8 hrs/day 90 dBA
6 92
4 95
3 97
2 100
1.5 102
1 105
0.5 110
<0.25 115

DEGREE OF ATTENUATION OF SOUND BY PROTECTORS

PROTECTION TYPE ATTENUATION AT LOW FREQUENCIES

cotton (pain) 0
waxed cotton 3.8
ear plugs 30
ear muff 40
ear muss w/ insert 70

CENTRAL AND PERIPHERAL CAUSES OF VERTIGO

PERIPHERAL CENTRAL
duration may be intermittent, usually hrs to may be persistent, usually wks to mos w/ no
days w/ normal periods normal periods
s/sx CNS (-) usually (+)
fixation suppresses nystagmus no effect
spontaneous fatigue, jerk or rotator and occurs in non-fatigable, does not change w/ different
nystagmus one particular direction plane of gaze; oblique or vertical types
usually central in origin
nystagmus enhanced by eye closure nystagmus decreases w/ eye closure
induced fatigable duration <1 min. follows non-fatigable>1 min. doesn’t follow
nystagmus “COWS” (cold opposite warm same) “COWS”
causes meniere’s, vestibular neuronitis, tumors, multiple sclerosis, epilepsy, vascular
benign paroxysmal positional vertigo, problems
acoustic neuroma

FACIAL NERVE TESTS FOR LOCALIZATION

 schirmer’s hearing test - test for lacrimation
 stapedial reflex - test of loudness tolerance
 taste test
 test for salivation
 differentiating upper vs lower motor neuron causes

FACIAL NERVE TEST INTERPRETATION

SITE UMN VESTIBULAR SCHIRMER SALIVATION STAPEDIAL TASTE

CNS + + + + + +
CPA - + + + + +
IAC - -/+ + + + +
middle ear - - - - + +
between chorda & - - - - +
stapedius - - - - +
SMF - - - - -
OPERATIONS ON THE EXTERNAL EAR
 surgery for perichondritis – for perichondritis in fluctuant stage
 meatoplasty canalplasty – for meatal atresia
 myringotomy – for serous otitis media ; pus in middle ear; to insert ventilation tube

OPERATIONS ON THE MIDDLE EAR

 simple or cortical mastoidectomy of schwartze - for coalescent mastoidectomy; as preliminary
exposure of facial nerve, labyrinthine or internal auditory canal surgeries
 radical mastoidectomy – for complication of middle ear dse; no cochlear reserve
 modified radical mastectomy – for good cochlear nerve; preliminary surgery for reconstructive
surgery; ears not responsive to medical treatment
 tympanoplasty – for reconstruction of middle ear
o types: I – graf on malleus
II – incus
III – stapes
IV – footplate
V – fenestration operation

OPERATIONS OF THE INNER EAR

 labyrinthine surgery – for vertigo
 conservative – preserve hearing
 surgery of the internal auditory canal – removal of acoustic neuromas/vestibular schwannomas;
sectioning of vestibular nerve for severe vertigo; facial nerve decompression in tumors
 transotic extension – for petrous apex lesion

CONGENITAL HEARING LOSS

GENETIC NON-GENETIC
alport synd rubella synd
treacher-collins synd kernicterus & neonatal hyperbiliruinemia
waardenburg’s synd congenital syphilis
jervel-lange synds premturity
pendred’s synd anoxia at birth
kearns-sayne synd teratogens - drugs
GJB2 or connexin 26 mutation

EXTERNAL NOSE
 bony framework
o nasal bone
o frontal process of maxilla
o nasal process of frontal bone
 cartilaginous framework
 o lower lateral (greater alar) cartilage
o quadrilateral cartilage
o upper lateral (lateral nasal) cartilage
o lesser alar cartilage
o sesamoid cartilage

 constrictors
o nasalis
o depressor septi
o depressor alaque nasi
 dilators
o procerus
o dilator nasi
o angular head of quadratus labii superioris

INTERNAL NOSE
 BOUNDARIES
o superior – cribriform plate of ethmoid
o inferior – maxillary bone
o medial – septum
o lateral – maxillary bone
o posterior – sphenoid sinus
 nasal septum
o septal cartilage
o vomer
o perpendicular plate of ethmoid
o maxillary crest
o premaxilla
 turbinates
o inferior turbinate – largest
o middle turbinate – part of ethmoid bone
o superior turbinate - part of ethmoid bone
o supreme turbinate – occasionally found
 meatuses
o inferior meatus – drains nasolacrimal duct
o middle meatus – drains frontal, maxillary, anterior ethmoid sinus
o superior meatus
o supreme meatus
o sphenoethmoid recess

NASAL BONE FRACTURES

class 1 (chevallet fracture) along quadrilateral cartilage & distal thin portion of nasal bone
due to low-velocity trauma
class 2 nasal bones, frontal process of maxilla, structures / iin class 1
due to medium-velocity trauma
 w/ jarjavay cartilaginous fracture
class 3 extends thru ethmoid labyrinth w/ inward telescoping nasal skeleton
“pig-nose”

SEPTAL DEVIATION

lateral (jarjavay) type lateral nasal fracture w/ displacement of septum from vomerian groove &
maxillary crest
depressed (chevallet) frontal nasal fracture w/ twisting, buckling, reduplication & fibrosis of
type quadrilateral septum
laterofrontal type combination of lateral & depressed types

NASAL BONE FRACTURE

 MC fracture in the body
 assault – MC cause
MANDIBLE FRACTURE
 2nd to nasal bone fracture
 10th most fractured in the whole body
 angle – 35%, symphysis
 case: primary assault
FRONTAL BONE FRACTURE
 least common of all fractures
 5-15%

MAXILLARY FRACTURE CLASSIFICATION

 “dishpan” or “panface”

le fort I: GUERIN (horizontal - horizontal separation

separation) - palate separated from the rest of maxilla
- interdental & intermaxillary fixation, 4-6wks
lefort II: PYRAMIDAL (midfacial - MC of maxillary fracture
fracture) - palate w/ maxilla is separated from zygoma and the ethmoid
- as above fixation from zygomatic suture or orbital rim
lefort III: CRANIOFACIAL - nasofrontal suture
DYSJUNCTION - across floor of orbit
- maxilla and zygoma are separated from the cranium
- interdental & intermaxillary fixation, suspension from zygomatic
suture & wiring from infraorbital rim

BENIGN PEMPHIGUS

BULLOUS PEMPHIGUS PEMPHIGUS VULGARIS

site oral mucosa nasal, oral
lesions small & w/ bleeding on rupture larger, may leave denuded area on
rupture
histopath no acantholysis massive acantholysis
immunoflourescence fluorescence at basement at area of acantholysis
 membrane
prognosis benign high mortality if untreated

OBSTRUCTIVE SLEEP APNEA

ADULT
etiology multiple
sleep manifestations snoring, restless sleep,
frequent awakening
daytime excessive daytime sleepiness
manifestation
sleep study findings decreased oxygenation, sleep
fragmentation
management ofen medical (positive airway
pressure therapy)
potential morbidity vehicular accidents, cognitive
of untreated impairment, medical conditions
PEDIATRIC
usually enlarged tonsils & adenoids
snoring, restless sleep, odd sleeping positions
hyperactivity, inattention, sleepiness
oxygenation usually maintained, CO2 retention
& hyperventilation, sleep architecture
maintained
ofen surgical (tonsillectomy &
adenoidectomy)
medical, neuroanatomic & cognitive

ACUTE EPIGLOTTITIS VS CROUP

ACUTE EPIGLOTTITIS CROUP (ACUTE

LARYNGOTRACHEOBRONCHITIS)

area laryngeal surface of epiglottis area just below vocal cords

etiology H.influenza, type B viral - parainfluenza type I-IV
peak age 3-6yrs 6mos-3yrs
s & s/x sit up w/ mouth open & chin forward tends to lie down
not hoarse
cough not croupy hoarse
may have dysphagia very croupy cough
no dysphagia
course rapid, can be fatal w/in hrs w/o less rapid
treatment
recurrence rare more common
laryngoscopy cherry-red,markedly swollen epiglottis subglottic swelling seen thru glottis
treatment penicillin, ampicillin, sulbactam

UNILATERAL MIDLINE PARALYSIS VS BILATERAL MIDLINE PARALYSIS

UNILATERAL BILATERAL
paralysis of abductor & adductors, except cricothyroid initially both cords are
intermediate  breathy voice
initially paralyzed cord assumes intermediate or cadaveric position tracheostomy to relieve
 hoarse voice obstruction
cricothyroid still functions to lengthen paralyzed cord can do arytenoidectomy &
arytenoidopexy
6wks afer onset paralyzed cord assumes paramedia (adducted)
position
if paralyzed cord is slighty lateral to midline (paramedia) the normal
cord can still coaptate w/ paralyzed cord by compensating
no airway obstruction in any stage
no intervention needed except when no compensation occurs

LARYNGEAL TUMORS

BENIGN NEOPLASM MALIGNANT NEOPLASM

types polyps, cysts, l ipomas, SCC or epidermoid carcinoma; adenocarcinoma
chondromas, papillomas
etiologic vocal abuse (polyps, nodules) smoke >1 pack/day x 15-20yrs
factor
sex female male
predilection
s & s/x hoarseness, discomfort, no hoarseness, neck mass, cervical
bleeding, no cervical lymphadenopathy, bleeding, stridor, respiratory
lymphadenopathy distress, sensation of rawness
management surgery; remove only the tumor; surgery – radical laryngectomy w/ neck node
preserve all normal tissues & dissection, reconstruct w/ trachaeoesophageal
laryngeal function shunt to restore speech; RT, chemo

NASAL POLYPS GRADING

0 - no polyps
I – polyps do not prolapse beyond middle turbinate & may require endoscopy for visualization
II – polyps extend below middle turbinate. visible w/ nasal speculum
III – polyps touch nasal floor. may occlude entire nasal cavity. seen thru vestibule w/o aid of nasal
speculum

NASAL POLYP VS TURBINATES

NASAL POLYP TURBINATES

color skinned/seedless grapes pink to red
decongestant effect (-) (+)
mobility mobile fixed
sensation (-) (+)
location osteomeatal complex along entire lateral nasal wall
consistency sof hard

TRIANGLES OF THE NECK

 POSTERIOR TRIANGLE:
o supraclavicular
o occipital
 ANTERIOR TRIANGLE
o muscular
o digastrics/submandibular/submaxillary
 o submental/suprahyoid
o carotid

FLAP VS GRAFT

pp FLAP
limited to transplantation of skin can carry other tissues
depends on recipient site for nutrition has own blood supply
may discolour; likely to contract better color; less likely to contract
less adaptable to weight bearing more adaptable to weight bearing
less able to survive on a bed w/ questionable nutrition can be used on a bed w/ questionable nutrition
requires pressure dressing not require pressure dressing
cannot bridge defect can bridge defect

HEMOLYTIC STREP / S.AUREUS - MC pathogenic organism of the head and neck

POTT’S DSE - retropharyngeal space infection in adults

OROPHARYNX
 sof palate to dorsum of tongue inferiorly
 lateral – palatine arches (fauces)
 waldeyer’s ring:
o lingual tonsils – base of tongue
o faucial tonsils – paired and w/in palatine fauces
o adenoids
o lateral pharyngeal bands
o tonsils of gerlach – w/in tip of fossa of rosenmuller

NASOPHARYNX
 boundaries:
o superior – base of skul
o anterior – nasal cavity
o inferior – oropharynx and sof palate
o lateral – opening of Eustachian tubes
o posterior – cervical vertebrae
 pharyngeal bursa
o saclike depression in posterior wall
o remnant of notochord
o site of thornwaldt’s cyst

DIFFERENTIATION

S & S/X ANGIOFIBROMA NASOPHARYNGEAL NASAL MALIGNANCY

JUVENILE TYPE MALIGNANCY
age 1-18yrs 30-60yrs 40-70yrs
sex male more male female
bleeding profuse scanty to mild minimal to moderate
nasal passage minimal to severe minimal to the beginning moderate to severe
obstruction
neck nodes (-) early, bilateral & large late
cranial nerve Nil CN VI initially, then V, IX, X CN V for advanced
cases
ear occasional can be an early sign (-)
treatment surgery radiation /che& mo surgery & RT and/or
chemo

ACUTE TONSILLITIS CAUSES

 GABHS, H.influenza, S.pneumonia
 tx: penicillin

CHRONIC TONSILITTIS
 tx: tonsillectomy
 tonsillitis occurrence to be candidate for tonsillectomy:
o 3/yr for 3yrs
o 5/yr for 2yrs
o 7 or more for 1yr
o >2wks school/work missed in 1 yr

INDICATIONS FOR TONSILLECTOMY

 ABSOLUTE
o obstruction causing dysphagia, airway obstruction
o pharyngeal or peritonsillar abscess
o suspected mignancy
 RELATIVE
o recurrent GABHS infection
o tonsil hyperplasia w/ functional obstruction, such as dysphagia or sleep apnea
o rheumatic fever w/ heart damage w/ recurrent tonsillitis & poor antibiotic control

INDICATIONS FOR ADENOIDECTOMY

 obstruction dse – nasal obstruction
 middle ear dse due to adenoid hypertrophy
 suspicion of malignancy

CONTRINDICATIONS TO TONSILLECTOMY & ADENOIDECTOMY

 clef palate
 blood dyscrasias
 medical contraindications

LARYNGEAL CARTILAGES
 thyroid - biggest
 cricoids – only complete cartilaginous ring
 arytenoids – paired; hitching posts for vocal cords
 corniculate – paired; on top of arytenoids
 cuneiform – paired; lateral to corniculate on aryepiglottic folds
  epiglottis

EXTRINSIC MUSCLES OF LARYNX

 depressors: omohyoid, sternohyoid, sternothyroid
 elevators: mylohyoid, geniohyoid, genioglossus, hyoglossus, digastrics stylohyoid
 pharyngeal constrictor, inferior pharyngeal constrictor

INTRINSIC MUSCLES OF LARYNX

 adductors: lateral cricoarytenoid, thyroarytenoid, transverse arytenoid, oblique arytenoid
 abductors: posterior cricoarytenoid
 tensors: cricothyroid, thyroarytenoid, vocalis

INFERIOR LARYNGEAL NERVE – motor supply of all intrinsic laryngeal muscles except cricothyroid
SUBMANDIBULAR NODES
 most significant and largest
 6-12 nodes
SUBMANDIBULAR INFECTION
 haemolytic streptococci – MC pathologic organism
 ludwig’s angina – MC etiology is from dental cries
MANDIBULOTOMY – cutting thru the mandible temporarily
JUVENILE NASOPHARYNGEAL ANGIOFIBROMA
 benign
 male; adolescent
EBV - viral etiology of nasopharyngeal carcinomas

MOST COMMON TUMORS

a) BCC
o MC epidermal tumor of the head and neck
o rodent ulcer
b) SCC
o MC malignancy in the oral cavity
o lip: lower lip = 95%; upper lip = 5%
o tonue
o MC malignancy in the phrynx
o MC malignancy in the larynx
o MC malignancy in the esophagus
o MC carcinoma of the pranasal sinuses
o followed by adenocarcinoma
c) papillary carcinoma
o MC thyroid carcinoma
o psamomma bodies
o orphan annie eye
o adenocarcinoma
o MC benign tumor of larynx – HPV 16 (18)
d) follicular carcinoma
o pericapsular vascular invasion
 o hurthle cell – cord-like
e) pleomorphic adenoma
o benign mixed tumor
o MC benign tumor of salivary glands
o orphan annie eye

f) warthin’s tumor
o papillary cystadenoma lymphomatosum
o MC bilateral parotid gland tumor
g) acinic carcinoma – parotid (MC at tail)
h) medullary carcinoma
o C-cells
o pheochromocytoma
i) adenoma – MC thyroid neoplasm
j) hemangioma - MC benign tumor of salivary glands in children
k) adenoid cystic carcinoma
o MC tumor of submandibular gland
o MC minor salivary gland malignancy
l) nodal type / reed Sternberg – Hodgkin lymphoma
m) extranodal / nodal dse – non-hodgkin
n) mucoepidermoid carcinoma
o MC malignancy of salivary gland in children
o MC malignant tumor of salivary glands
o MC malignancy in the parotid gland/hard palate
o 2nd MC of the submandibular gland
o) neurofibroma – von Recklinghausen
ANAPLASTIC CA – rapid growth and fixation to underlying structures
MIXED – follicular tumors behave like papillary tumors
BENIGN TUMORS IN THE PAROTID GLAND – 80%

PAROTID - MC site of all salivary gland tumor

MINOR SALIVARY GLANDS - 2nd MC site of all salivary gland tumor
SUBMANDIBULAR GLAND - 3rd MC site of all salivary gland tumor

LATERAL BORDERS OF TONGUE – 2nd MC tumor of the oral cavity

CARCINOMA OF FLOOR OF MOUTH – 3rd MC oral cavity tumor
PERIAPICAL CYST – MC odontogenic cyst
RETROPHARYNGEAL NODES/NODES OF RANVIER – first nodes affected in nasopharyngeal and maxillary
carcinoma
NASOPALATINE FISSURAL CYST –MC fissural cyst
MELANOMA – MC site is the cheek, scalp, ear and neck
THYROGLOSSAL DUCT CYST
 MC found at the level of the hyoid bone
 sistrunk procedure – part of the hyoid bone is removed to prevent recurrence
CARCINOMA OF THE LARYNX
 HPV 6, 11
 clinical picture:
o glottic - hoarseness - MC early symptom
o floor of ventricle including TVC
o supraglottic – dysphagia
o tip of epiglottis including false VC
o subglottic – dyspnea – late
o 1cm below TVC to cricoid
o transglottic – advance and large tumors
o lesions that cross the ventricle or involves larynx above and below TVC

CORNICULATE CARTILAGE – cartilage of santorini

CUNEIFORM CARTILAGE – cartilage of wrisberg
BILATERAL ABDUCTOR PARALYSIS – MC form of bilateral motor paralysis
LARYNGOMALACIA – MC congenital anomaly of larynx
INSPIRATORY STRIDOR – major symptom of laryngomalacia
PTYALISM SIALORRHEA – excessive saliva production
XEROSTOMIA – dry mouth
SJOGREN - absence of saliva production
TB – cols abscess
SCARLET FEVER / KAWASAKI – strawberry tongue
DIPHTHERIA – bull’s neck
2:1 – incidence of oral CA
FREY SYNDROME – gustatory sweating afer parotidectomy
S.AUREUS: MC cause of acute sialodenitis

EXTERNAL AUDITORY CANAL

 outer 1/3 cartilaginous
 inner 2/3 bony
 fissures of santorini – deficiency in cartilaginous portion  infection spread to parotid
 foramen of huschke – deficiency in bony meatus  infection spread to periauricular and parotid

TYMPANIC MEMBRANE
 pars flaccid
o shrapnell’s membrane
 triangular
 above malleolar fold
 common site of retraction pockets
 pars tensa – below

ACUTE CIRCUMSCRIBED OTITIS EXTENA / FURUNCULOSIS

 s.aureus
 s and s/x: earache, tender pinna/tragus, hearing decreased, purulent ear discharge,
circumscribed swelling/abscess
MALIGNANT OTITIS EXTERNA / SKULL BASE OSTOMYELITIS NECROTIZING OTITIS EXTERNA- p.aeruginosa
ACUTE NECROTIZING OTITIS MEDIA – beta haemolytic streptococcus
MENIERE’S DSE / IDIOPATHIC ENDOLYMPHATIC HYDROPS
 intermittent SNH, tinnitus, vertigo, ear fullness
 cochlea hydrops – fluctuating sensorineural hearing loss and tinnitus
 vestibular hydrops – episosdic vertigo and aural fullness
 lermoyez hydrops – increasing tinnitus, hearing loss, and aural fullness
 crisis of tumarkin / drop attack – loss of extensor power
BENIGN PAROXYSMAL POSITIONAL VERTIGO
 canaliths
 cupulolithiasis
 confirmed by hallpike test – positional nysgatmus w/ latency
 cause: canaliths – free-floating abnormally dense particles
RAMSAY HUNT SYNDROME
 herpes zoster oticus of CN VII
 vascular eruption and facial paralysis
CN X
 Arnold’s/alderman’s nerve
 cough reflex when external canal is stimulated
 laryngeal pain in cancer
CN IX
 jacobson’s nerve
 oropharyngeal pain in cancer
EUSTACHIAN TUBE
 upper 1/3 bony
 anteromedial 2/3 cartilaginous
SWIMMER’S EAR
 diffuse otitis externa
 pseudomonas
CAULIFLOWER EAR
 hematoma auris
 severe perichondritis
 abscess
APICAL PETROSITIS / GRADENIGO SYNDROME
 discharging ear
 retroorbital pain
 diplopia
MELKERSSON’S SYNDROME
 peripheral palsy
 jewish
 postulated hypersensitivity
JERVELL and LANGE-NIELSEN SYNDROME
 autosomal recessive
 SNHL with prolonged QT interval
GJB2 / CONNEXIN 26 - MC cause of SNHL
ETHMOID BULLA - 1st ethmoid cell
RHINOLOGIST ARTERY - largest vessel supplying the nose
LUPUS VULGARIS
  TB in the nose
 apple jelly nodules
LUPUS ERYTHEMATOSUS - butterfly rash
CHOANAL ATRESIA
 bony / membranosseous 80-90%
 membranous 10-20%
RHINITIS
1) infections – most prevalent; common cold
2) allergic – IgE mediated, high socioeconomic class
3) non-allergic
a. vasomotor
 idiopathic rhinitis
 cholinergic glandular activity
 heightened sensitivity
b. gustatory – eating; vagally-mediated
c. non-allergic rhinitis with eosinophilia syndrome)
 unknown etiology
 paroxysmal exacerbations of sx
4) occupational
a. protein and chemical allergies – IgE mediated
b. chemical respiratory sensitizers – uncertain immune mechanism
c. work – aggravated rhinitis
5) hormonal – pregnancy / menstrual cycles
6) drug-induced – rhinitis medicamentosa
7) atrophic rhinitis – thinning and drying of nasal mucosa
EPISTAXIS
 mucositis – MC in children
 HPN – mc in adults
 keisselbach’s plexus – 90% of epistaxis
HYPEROSMIA
 hypersensitive sense of smell
 cystic fibrosis
PAROSMIA
 perverted smell
 streptomycin
HYPOSMIA
 impaired smell
 smoking
ANOSMIA – loss of smell
ACUTE PHARYNGITIS
 viral
 sore throat
 colds and conjunctivitis
ENDOSCOPY
 rod telescope – clinic
 rigid – O.R.
o direct laryngoscopy
 o bronchoscopy
o esophagoscopy
 flexible – office
EOPHAGEAL DISORDERS
 achalasia – degeneration of auerbach plexus
 diffuse esophageal spasm – spiral/corkscrew
 scleroderma – atrophy of smooth muscle
 presbyoesophagus – abnormal esophageal motor function d/t aging

CLEFT DEFECT
 90% unilateral, 20% bilateral
 2/3 lef sided, 1/3 right sided
CLEFT PALATE
 70% unilateral, 30% bilateral
 MC in females
NASOPHARYNX – base of skull/posterior choanae to sof palate
ORAL CAVITY
 vermillion border to junction of sof and hard palate
 except sof palate and base of tongue
oropharynx – sof palate to hyoid
hypopharynx – hyoid to cricoids
esophagus – cricoids to cardia of stomach
STAPHYLOCOCCI – first oral microbe in neonate
PLAUT’S ANGINA/TRENCH MOUTH/VINCENT’S ANGINA
 acute necrotizing ulcerative gingivitis
 B. vincente
 tx: penicillin
THORNWALDT’S DSE – nasopharyngeal bursitis
QUINSY
 peritonsilar abscess
 tx: clindamycin
PAROTID ABSCESS
 MC organism is staph
 MC cause is salivary stone
ANKYLOGLOSSIA – tongue tie
FISSURED/SCROTAL TONGUE
 trisomy 21
 melkerson Rosenthal syndrome
LEUKOPLAKIA – whitish patches in oral cavity
ERYTHROPLAKIA – red plaques
NODULAR LEUKOPLAKIA – mixed white and red plaques
LATERAL WALL/FOSSA OF ROSENMULLER – MC site for nasopharyngeal carcinoma
posterior suspensory ligament of thyroid - LIGAMENT OF BERRY
hypothyroidism - MYXEDEMA, INCREASED TSH, DECREASED TH
hyperthyroidism - THYROTOXICOSIS
MC cause of thyroiditis and goiter - HASHIMOTO’S DSE
MC single thyroid dse - HASHIMOTO’S DSE
MC cause of painful thyroid - SUBACUTE GRANULOMATOUS THYROIDITIS (DE QUERVAIN’S THYROIDITIS)
lymphocytic thyroiditis - SILENT/PAINLESS/POSTPARTUM THYROIDITIS

HYPERTHYROIDISM VS HYPOTHYROIDISM

HYPERTHYROIDISM HYPOTHYROIDISM
nervousness fatigue, lethargy
wt loss wt gain
excessive sweating cool, dry, coarse skin; hair loss
warm, smooth, moist skin swelling face, hands, legs, non-pitting edema
heat intolerance cold intolerance
muscular weakness, tremor weakness, muscle cramps, arthralgia,
paresthesia
lid lag, exophthalmos, stare periorbital puffiness
palpitations, hyperdynamic cardiac pulsations, dec heart sound intensity
accentuated S1
tachycardia bradycardia
inc SBP, dec DBP dec SBP, inc DBP
frequent bowel mov’t constipation