OTORHINOLARYNGOLOGY

RADIOLOGY
MASTOID SERIES (MaST M[eyer]aS[chuller]Townes) Townes View Meyers View Projection AP projection of the skull with AP projection of the skull with the head the beam source 30 above turned 45 toward the side one wishes the canthomeatal line to examine & the beam source 45 above the canthomeatal line View Clear view of the foramen, Provides axial view of the external comparison of the petrous auditory meatus, mastoid, & petrous pyramid & mastoids bone Schullers View Lateral projection of the skull with the beam source 30 above the canthomeatal line Shows extent of pneumatization of the mastoid (1) Pneumatic well-developed mastoid air cells (2) Diploic with few large air cells (3) Sclerotic with opacity due to calcification

PARANASAL SINUS SERIES Waters View Occipitomental view or chin-nose view Patients head is tilted with the nose & the chin on the film, orbitomeatal line is 37 from the film, x-rays are directed horizontally Maxillary sinus Open mouth Waters view sphenoid sinus Frontal & anterior ethmoid sinuses Nasal bones, requested if suspecting nasal fractures together with Nose STL Caldwell View Occipitofrontal view orforehead-nose view PA viewofthe skull with the beam 15-20 from the horizontal Skull Lateral Basal View Submentovertical view Pts infraorbitomeatal line is parallel to the film, x-rays perpendicular to the infraorbitomeatal line through the sella turcica Zygomatic arch fractures Sphenoid, posterior ethmoid, maxillary & frontal sinuses

Projection

Best view

Frontal sinus

Sphenoid sinus

Also shows

Anterior ethmoid & sphenoid sinuses, lamina papyracea

Posterior ethmoid, frontal, & maxillary sinues & sella turcica

Panorex View Provides the best view of the mandible Requested when suspecting mandibular fractures (most common site being the angle, having the thinnest bone), dentoalveolar abscess (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 (seen as 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

THE EAR
IMPACTED CERUMEN Signs and Symptoms a. sense of ear fullness b. 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 the cerumen. c. Conductive hearing loss usually not clinically significant. On Webers, there is lateralization to the affected ear (may not be appreciated when impaction is not significant)

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Treatment Softening of cerumen with baby oil or commercially available ceruminolytics, such as Docusate Na (Otosol) 0.5% X 10mL (Lie on the side, turning the head sideways, slightly towards the surface on which you are lying. Fill the ear canal & stay in this position for 5 minutes then insert a cotton wool plug. Repeat to the other ear if necessary. Max of 2 consecutive nights.). Have the pt come back after 1 week for aural irrigation with clean lukewarm water. Aural irrigation is done with the stream directed behind the cerumen and not directly at it, which may push it further down the canal. Sample Chart Entry Apply 3 baby oil drops 3gtts TID X 7 days on affected ear Avoid ear manipulation (AEM) TCB after 7 days for aural irrigation

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 ear Classification 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 Symptoms a. otalgia b. serous ear discharge c. tenderness on manipulation of pinna or tragus d. hearing loss if swelling occludes the external ear e. swelling on otoscopy Otitis Externa Otitis Media Pain Severe Not as severe Tenderness on pinna / tragus Present Absent Fever Absent Present History of URTI Usually none Usually present History of ear manipulation Present Absent Hearing Not impaired Impaired Mastoid series Normal With evidence of mastoiditis Treatment a. 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 + Neomycin 2. Aplosyn: Fluocinilone + Polymyxin B + Neomycin 3. 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 ENT ii. Celecoxib (Clebrex 200mg OD iii. Rofecoxib (Vioxx) 25 mg OD 2. On a full stomach: Mefenamic Acid 500mg QID prn 3. 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 Pseudomonas infection and give a quinolone with anti-Pseudomonas activity such as Ciprofloxacin 500 mg tab Sample Chart Entry Cloxacillin 500mg/cap 1 cap PO QID X 7 days (adults) Corticosporin Otic Drops 3gtts TID X 7 days Etoricoxib 120 mg/tab 1 tab OD prn for pain (adults) Aural toilette with H2O2 3 gtts TID X 7 days priorto application of Corticosporin Avoid ear manipulation TCB after after 7 days for reassessment. ACUTE OTITIS MEDIA Infection of the middle ear <4 weeks Usually results from obstruction of the Eustachian Tube (ET), which serves as drainage of the middle ear. Sniffing too hard causes a negative pressure in the middle ear, closing the ET tube; blowing the nose hard creates a positive pressure in the middle ear, opening the ET tube Obstruction can be either a. Mechanical e.g. benign or malignant tumors b. Functional e.g. cleft palate

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Predisposing factors a. young age ET is wider, shorter & more horizontal compared to adults b. immunocompromised state causes recurrent URTI c. altitude changes d. bottle feeding greater risk than breastfeeding e. 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 ear drum on otoscopy b. Exudative pouring of fluid in the middle ear; presents with increased otalgia, ear fullness, hearing loss and fever c. Suppurative rupture of TM with discharge; presents with mucupurulent discharge, decreased pain, decreased fever, but increased hearing loss d. Resolution / Complications a surgical ear is those with complications e. Coalescence thickening of mucoperiosteum drainage is blocked venous stasis local inflammation? decalcification pus; nocturnal fever; simple mastoidectomy Treatment a. Antibiotic to treat the infection 1. 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 antiPseudomonas activity like Ciprofloxacin b. 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 secretions 1. 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 ET 3. Chewing gum Sample Chart Entry Amoxicillin 500mg/cap 1 cap TID X 14 days Corticosporin otic 3 gtts TID X 14 days (only if suppurative) Aural toilette with H2O2 3 gtts TID X 14 days (only if suppurative) AEM, increase OFI, KED Frequent ET opening exercises TCB after 7 days for re-assessment Complications a. Extracranial complications (FLAPS) Facial nerve paralysis Labyrynthitis Abscess Subperiosteal abscess Bezolds abscess abscess in the SCM Cittellis abscess - digastric Petrositis Gradenigos syndrome (DRE) Diplopia due to lateral rectus palsy Retroorbital pain due to involvement of the optic nerve Ear discharge Sensorineural hearing loss b. Intracranial complications (MATH) Meningitis most common Abscess (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 sign Classification a. Active (+) discharge b. Inactive (-) discharge > 3 months c. 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

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Benign Perforation is central regardless of size or shape Mucosa lining in the middle ear is edematous

There may be granulation tissue or polyps arising from the middle ear mucosa Discharge is mucoid to purulent & non-foul smelling Hearing loss is conductive Mastoid series show no cholesteatoma Sample Chart Entry Mastoid series PTA-ST Amoxicillin 500mg/cap 1 cap TID X 14 days Corticosporin otic 3 gtts TID X 14 days (only if active) Aural toilette with H2O2 3 gtts TID X 14 days (only if active) AEM, increase OFI, KED Frequent ET opening exercises TCB after 7 days for re-assessment

Dangerous Perforation is total or located at the margin, attic (pars flaccida) or postero-superior Mucosa around the perforation is replaced by stratified squamous epithelium. Cholesteatomatous debris may be seen around the perforation or in the attic Granulation or polyps are frequently seen in the canal obscuring the drainage Discharge is purulent & foul-smelling Hearing loss is conductive and sensorineural Mastoid series reveal cholesteatoma. On PE, there may be posterior 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 with no trabeculations. Bony destruction or erosions may be seen. Clinically, there is pearly white ear discharge, very foul smelling with TM perforation. Plain & contrast CT scan with 1mm temporal bone cuts is requested if clinically positive for cholesteatoma for OR planning prior to possible tympanomastoidectomy Sample Chart Entry Mastoid series PTA-ST Cranial CT scan, plain & contrast, with 1mm temporal bone cuts Pen G 4 million units IV LD ( ) ANST then 2 million units q6h Clindamycin 600mg IV LD ( ) ANST then 300mg q6h Corticosporin otic 3 gtts TID (only if suppurative) Aural toilette with H2O2 3 gtts TID (only if active) AEM, increase OFI, KED Frequent ET opening exercises TCB after 7 days for re-assessment AURAL POLYP Squamous hypertrophy from the middle or external ear PRESBYCUSIS Hearing loss related to aging process Normal otoscopy Sample Chart Entry PTA-ST For possible application of hearing aid TCB once with results 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 Sample Chart Entry PTA-ST TCB once with results

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SPEECH DELAY SECONDARY TO HEARING IMPAIRMENT First, rule out other causes such as autism Sample Chart Entry PTA-ST Refer to Pedia for evaluation and co-management TCB once with results EXTERNAL AUDITORY CANAL BLEEDING SECONDARY TO EAR MANIPULATION Rule out other causes Antibiotic is given due to damage to EAC mucosa predisposing to infection Sample Chart Entry Suction Cloxacillin 500 mg/cap 1 cap QID X 7 days Etoricoxib 120 mg/tab 1 tab OD prn for pain TCB after 1 week for re-assessment

THE NOSE
SINUSITIS Most common etiologic agents: S. pneumonia, H. influenza, Moraxella catarrhalis, anaerobes Signs and Symptoms a. nasal obstruction b. mucopurulent nasal discharge c. paranasal pain d. headache e. paranasal tenderness f. congested nasal mucosa on rhinoscopy g. absent illumination(frontal / maxillary sinuses) h. fever may be present i. opacities on x-ray Classification a. Acute - < 3 months Sample Chart Entry Co-amoxiclav 625 mg/cap TID or 1g BID X 7 days Increased OFI TCB after 1 week for re-asessment b. Chronic - > 3 months, most common cause is untreated acute sinusitis; usually mized flora Sample Chart Entry PNS series Co-amoxiclav 625 mg/cap TID or 1g BID X 7 days Increased OFI Nasal douche BID on each nostril, increased OFI TCB after 1 week for re-asessment Treatment Nasal douche is prepared by mixing 1 tsp rock salt, 1 tsp baking soda, and 1L of boiled tap water made to cool. ALLERGIC RHINITIS Signs and Symptoms a. rhinorrhea b. sneezing (>4x/day, usually in the morning) c. nasal obstruction d. nasal pruritus e. congested nasal mucosa on rhinoscopy f. 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, molds i. family history of allergy j. personal history of bronchial asthma or eczema

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Treatment a. Topical steroid relieve the inflammation 1. Fluticasone (Flixotide) Fluticasone nasal spray 2 puffs / nostril BID X 14 days & prn Usually prescribed by ENT 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-pruritus 1. 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 & prn c. Decongestant are not of proven benefit and may cause rebound rhinitis (rhinitis medicamentosa) if used for more than 5 days Sample Chart Entry Fluticasone nasal spray 2 puffs / nostril BID X 14 days & prn Cetirizine (Virlix) 10 mg/tab 1tab OD at HS X 14 days & prn Avoid exposure to allergen Refer to Allergy Clinic Re: Skin testing TCB after 2 weeks for re-assessment 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 sinuses b. Anosmia c. Rhinorrhea (watery to mucoid) d. Smooth, gelatinous, semitransparent to pale white mass on anterior rhinoscopy Grading 0 No polyps I 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 speculum Comparison of Nasal Polyp & Turbinates Nasal Polyps Turbinates Color skinned grapes Pink to red Decongestant effect (-) (+) Mobility Mobile Fixed Sensation (-) (+) Location Usually at osteomeatal complex Along entire lateral nasal wall Consistency Soft Hard Treatment a. 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 OR 2. 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 Sample Chart Entry PEA/LA c/o minor OR Prednisone 10mg/kg OD X 1 week prior to OR SAPOD clearance: CBC with PC & DC, BUN/Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR TCB once with results for OR scheduling 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 with the 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

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THE THYROID GLAND

Hyperthyroidism Hypothyroidism Nervousness Fatigue, lethargy Weight loss Weight gain Excessive sweating Cool, dry, coarse skin; loss of hair Warm, smooth, moist skin Swelling of the face, hands, legs, non-pitting edema Heat intolerance Cold intolerance Muscular weakness, tremor Weakness, muscle cramps, arthralgia, paresthesia Lid lag, exophthalmos, stare Peri-orbital puffiness Palpitations, hyperdynamic cardiac pulsations, accentuated S1 Decreased intensity of heart sounds Tachycardia Bradycardia SBP, DBP SBP, DBP Frequent 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 minimal symptoms of hypo/hyperthyroidism Sample Chart Entry FNAB FT4, TSH TCB once with results 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 and the pt is clinically hyperthyroid. Between the two, TSH is more diagnostic of hyperthyroidism. Sample Chart Entry FT4, TSH CBC with PC & DC 12L ECG PTU 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 NODULAR TOXIC GOITER Not very common; presents as an asymmetric ANM which moves with deglutition and nodular on palpation, but presents with symptoms of hyperthyroidism Treatment FNAB is done because of higher rate of occurrence of CA in nodular goiter Sample Chart Entry FNAB FT4, TSH PTU 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 DIFFUSE NONTOXIC GOITER Not very common, presents with symmetric ANM which moves with deglutition and smooth on palpation but has no symptoms of hyperthyroidism Treatment FNAB is not done due to low incidence of CA in DNTG. Thyroid scan is requested to determine the size and activity of the ANM. Sample Chart Entry Thyroid scan FT4. TSH TCB once with results

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Most common complications of thyroid surgery a. Hemorrhage if this occurs post-op, remove the sutures immediately to protect the airway b. Hypocalcemia occurs if all parathyroid glands are inadvertently removed or if ischemia occurs c. Recurrent laryngeal nerve transaction Pt would present with hoarseness

THE UPPER AERODIGESTIVE TRACT

BELLS PALSY Facial nerve paralysis (CN VII) usually following viral infection Grading of Facial Nerve Involvement 1-2 risorius involved; cant smile 3-4 cheeks involved 5 orbicularis involved; cant close eyes 6 frontalis involved; cant wrinkle forehead Sample Chart Entry EMG-NCV Prednisone 5mg/tab 4 tabs AM, 3 tabs lunch, 2 tabs PM X 2 weeks Etoricoxib 120 mg/tab for pain Refer to Neuro Refer to Ophtha re: Exposure keratitis

TEMPOROMANDIBULAR JOINT DYSFUNCTION Most common: Myofascial pain and dysfunction, usually the result of bruxism or jaw clenching, related to stress/ anxiety/ depression/ chronic pain. Less commonly due to mechanical problem or OA. Or primary internal derangement of joint (has clicking during open/close) leading to disc displacement, due to many causes. Etiology a. Traumatic (OA, condylar fx, TMJ subluxation, whiplash, capsulitis synovitis) b. Dental (malocclusion, reconstruction, poor fitting prosthesis/ dentures/ orthodontics) c. Iatrogenic (ETT intubation, surgical) d. Systemic (RA, gout, Pagets, psoriasis) e. Infectious (GC, syphilis, TB, actinomycosis, RF, Lyme dz --> cyclic pain q1-3mo lasting 7-14d) f. Congenital (aplasia, hyperplasia, hypoplasia, bifid condyle) g. Others: stress, bruxism, idiopathic, myofascial pain. 3 Cardinal features a. orofacial pain Classic: pain in front of tragus with radiation to ear/ lower jaw/ cheek/ temple. Preauricular, temporal, ear that may radiates to head/face/eye. Pt also may c/o pain in the neck/ shoulder, tinnitus, H-A, insomnia. Pain worse in AM, may occur in cyclical episodes b. restricted jaw function - Jaw movement is described as a tightness/ sticking/ catching/locking. c. noise in the joint (crunch-pop-grind). Physical Examination a. Clicking TMJ b. Check ROM 1. Open & close, <30mm between teeth is abnormal. Should be able to insert your digits 2,3,4 in between pts incisor teeth. 2. Check the lateral excursion of mandible, ask pt to move his jaw from side to side. Palpate masseter and temporalis m. Note any excessive occlusal wear, tooth mobility, buccal mucosal ridging, lateral tongue scalloping. Treatment a. Conservative effective for 80%: education, stress reduction/ relaxation therapy, modify chewing and other habit that cause excessive jaw movement. Massage, local moist heat and aerobic exercise. NSAIDs & restricted opening, soft diet to reduce painful loads. b. Silicone Night Guard = Interocclusional Appliance/ splint stabilize an occlusion & dec the load on the inflamed joint X 46 week trial c. Closed reduction and Bartons Manuever Sample Chart Entry Soft diet X 1 week Etoricoxib 120 mg/tab 1 tab OD X 1 week for pain Wear dentures all the time except during sleep TONSILLITIS Most commonly caused by Streptococcus sp. Treated with Clindamycin 150mg/tab (children) or 300mg/tab (adults) a tab TID X 1 week

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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 apnea c. Dysphagia leading to significant weight loss Relative indication: Recurrent tonsillitis (>6x/year) Sample Chart Entry For tonsillectomy/GA SAPOD clearance: CBC with PC & DC, BUN/Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR TCB once with results for OR scheduling LARYNGITIS Acute if <4 weeks; Chronic if >4 weeks. Sample Chart Entry Lonazolac 200mg/tab 1 tab BID X 2 weeks Voice rest Increased OFI Warm saline gargle TCB after 2 weeks once with results 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, L bronchus, lower esophageal sphincter) Diagnostics is through radiographic studies which may be repeated every 12 hours. FB appears slit-like when in the esophagus on 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. ENT manages 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. Sample Chart Entry NPO now IVF: D5 0.9 NaCl 1L X 8 CXR-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)

SOFT TISSUE INFECTIONS

CELLULITIS Sample Chart Entry Cloxacillin 500mg/cap 1 cap QID X 7 days Etoricoxib 120 mg/tab 1 tab OD prn for pain TCB after 1 week for re-assessment ABSCESSES

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 Include dentoalveolar abscess (DAA), tonsillar abscess, parotid abscess, and parapharyngeal abscess Treatment 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 q6h ii. 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 q6h ii. 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 q6h 3. Preparations i. Pen G is available in 1 million units/amp preparation ii. 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 Sample Chart Entry S/P I & D Pen G 4 million units IV LD ( ) ANST then 2 million units q6h Clindamycin 600mg IV LD ( ) ANST then 300 mg q6h OR Etoricoxib 120mg/tab 1 tab OD prn for pain MGH Advised 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 Borrelia or spirochete which is responsive to Pen G / Metronidazole / Clindamycin Sample Chart Entry S/P I & D Pen G 4 million units IV LD ( ) ANST then 2 million units q6h Clindamycin 600mg IV LD ( ) ANST then 300 mg q6h OR Etoricoxib 120mg/tab 1 tab OD prn for pain MGH Advised TCB after 1 week for re-assessment 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 Sample Chart Entry FNAB Co-amoxiclav 625 mg/tab TID or 1 g/tab BID X 7 days TCB after 1 week for re-assessment TB ADENITIS May or may not present with chronic cough (>2 weeks), weight loss, failure to gain weight, anorexia Should rule out reactive LAD Sample Chart Entry FNAB CXR AP-L Sputum AFB X 3 TCB once with results

PAROTIDITS

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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, and avoidance of close contact with household members If bacterial, treat with Co-amoxiclav 625 mg/tab TID or 1 g/tab BID X 7 days

MAXILLO-FACIAL TRAUMA
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 fracture >14 days post-injury Signs and Symptoms a. crepitation b. step-down deformity c. nasal speculum deviation d. shortening of the nose e. increased mobility of the nose f. anosmia g. epistaxis h. CSF rhinorrhea Treatment a. 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 displacement 2. 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 prophylaxis because 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/5mL suspension) are usually given as prophylactic antibiotics. d. Pain Medications e. Closed reduction is done when swelling has subsided to allow for better assessment of the deformity. In children, swelling usually subsides in <3 days while in adults, it takes 3-5 days. If with airway compromise, dont wait for the swelling to subside. f. Open reduction with internal fixation (ORIF) is done only if the fracture is comminuted. Sample Chart Entry Waters View Nose STL Cloxacillin 500mg/cap 1 cap QID X 7 days Etoricoxib 120 mg/tab 1 tab OD prn for pain Cold compress X 15 min TID for the 1st 24 hours then warm compress thereafter TCB after Complications a. septal hematoma irreversible damage to the underlying cartilage can occur within 3-4 days if not drained b. infection c. CSF leak MAXILLARY FRACTURE Classification Lefort I (Guerin fracture) Horizontal separation. The palate is separated form the rest of the maxilla.

Lefort II (Pyramidal fracture) Midfacial fracture. The palate with the maxilla is separated from the zygoma & ethmoids.

Lefort III (Craniofacial dysjunction) The maxilla and the zygoma are separated from the cranium passing through the fronto-ethmoid and the frontozygomatic sutures.

Imaging: Waters view, Caldwell view, Lateral view. CT scan

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MANDIBULAR FRACTURE Types of muscles acting on Fracture Segments a. Posterior group upward, forward movement; stronger group. Masseter, lateral & medial pterygoids, & temporalis b. Anterior group down, backward movement. Geniohyoid, digastric, mylohyoid, genioglossus Types of mandibular fracture a. Favorable muscle forces tend to keep fragments together b. Unfavorable muscle forces tend to pull fragments apart Imaging studies a. Panorex view single best radiograph b. AP- oblique, modified Townes ZYGOMATIC FRACTURE Types a. simple fracture of the arch b. trimolar or tripod fracture involves all 3 suture lines c. quadripod fracture maxillary-zygomatic buttress considered Imaging: Waters, axial or submentovertical views.

CLEFT LIP AND PALATE

CLEFT LIP May be unilateral or bilateral Classification a. Complete cleft reaches the vestibule b. Incomplete does not reach the vestibule Rule 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 important because 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

HEAD & NECK TUMORS

LEVELS OF LYMPH NODES IA submental IB submandibular II, III, IV along SCM V posterior triangle VI pre-tracheal VII - paratracheal

NASOPHARYNGEAL CARCINOMA Presents with epistaxis, nasal obstrucstion, anosmia, constitutional SSx of malignancy On rhinoscopy, (+) for fungating mass in the nasopharynx Sample Chart Entry Punch Biopsy /LA SAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR TCB once with results Staging Primary tumor stage T1 Tumor confined to nasopharynx T2 Tumor extends to soft tissues of oropharynx or nasal fossa T2a Without parapharyngeal extension T2b With parapharyngeal extension T3 Tumor invades bony structures or paranasal sinuses T4 Tumor with intracranial extension or involvement of cranial nerves, infratemporal fossa, hypopharynx, or orbit Stage groupings

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I T1 N0 M0 IIA T2a N0 M0 IIB T1,2a N1 M0; T2b N0, N1 M0 III T1,2 N2 M0; T3 N0,1,2 M0 IVA T4 N0,1,2 M0 IVB Any T N3 M0 IVC Any T Any N M1 Treatment Primary tumors: RT alone (bilateral) is used for both the primary tumor and the regional nodal metastases. Surgery is not feasible because of the inadequacy of the surgical margins at the base of the skull and the frequent involvement of the retropharyngeal and cervical nodes bilaterally. PAROTID TUMOR Benign tumors are more common than malignant ones If bilateral, probably Warthins tumor Most common histologic types are 1. 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 Sample Chart Entry FNAB SAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR TCB once with results Staging of Salivary Gland Carcinoma Primary tumor stage TX Primary tumor cannot be assessed T0 No evidence of primary tumor T1 Tumor <2 cm without extraparenchymal extension T2 Tumor >2 cm but <4 cm extraparenchymal extension T3 Tumor >4 cm but <6 cm or having extraparenchymal extension without seventh cranial nerve involvement T4 Tumor invades base of skull or seventh nerve or is >6 cm Stage groupings for major salivary gland carcinomas I T1,2,3 N0 M0 II T3 N0 M0 III T1,2 N1 M0 IV 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 Sample Chart Entry FNAB SAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR TCB once with results 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 Sample Chart Entry Direct laryngoscopy with biopsy of laryngeal mass/LA SAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR TCB once with results Staging Primary Tumor

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Tis T1

Supraglottis Carcinoma-in-situ Tumor confined to site of origin with normal mobility

T2

Tumor involves adjacent supraglottic sites or glottis without fixation

Glottic Carcinoma-in-situ Tumor confined to vocal cord(s) with normal vocal cord mobility T1a limited to one vocal cord T1b with involvement of anterior commisure Supraglottic or subglottic extensionof tumor with normal or impaired mobility

Subglottic Tumor confined to subglottic area

T3

Tumor limited to larynx with fixation or extension Tumor confined to larynx with cord to involve postcricoid area, medial wall of fixation pyriform sinus or pre-epiglottic space T4 Massive tumor extending beyond the larynx to Massive tumor with thyroid cartilage oropharynx, skin or soft tissues of neck, or destruction or extension beyond destruction of thyroid cartilage confines of larynx or both Nodal Involvement Nx minimum requirements to assess the regional nodes cannot be met NO no clinically positive nodes N1 clinically positive homolateral nodes N2 contralateral or bilateral nodes not fixed N3 fixed nodes Distant Metastasis Mx minimum requirements for assessment of distant metastasis cannot be met MO no distant metastasis M1 distant metastasis present Staging I T1 NO MO II T2 NO MO III T3 NO MO; T1, T2, T3 N1 MO IV T4 NO MO; T4 NO MO; Any T N2, N3 MO; Any N M1 Indications for Emergency Tracheostomy a. Foreign body occluding the airway b. Retropharyngeal abscess c. Tetanus d. Severe myasthenia gravis e. Laryngeal CA with Obstruction THYROID CARCINOMA

Tumor extension to vocal cords with normal or impaired cord mobility Tumor confined to larynx with cord fixation Massive tumor with cartilage destruction or extension beyond confines of larynx

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 = Positve 131I uptake = Positive prognosis = Post-op 131I scan to diagnose/treat metastases Staging Primary 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 II III IVa IVb IVc

Any T, Any N, M0 Any T, Any N, M1

T1, N0, M0 T2, N0, M0 T3, N0, M0, T1, T2, T3, N1a, M0 T1, T2, T3, N1b, M0, T4a, N0, N1, M0 T4b, any N, M0 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 follicular carcinoma and has a relatively aggressive metastatic course. Follicular = Far-away metastasis = Female (3:1) = FNAB NOT (diagnosed by tissue structure) = Favorable prognosis Staging Stage Younger Than 45 Years Age 45 Years and Older Any T, any N, M0 (Cancer is in the thyroid T1, N0, M0 (Cancer is in the thyroid only and may be found in one or both I only) lobes) Any T, any N, M1 (Cancer has spread to T2, N0, M0 and T3, N0, M0 (Cancer is in the thyroid only and is larger than II distant organs) 1.5 cm) T4, N0, M0 and any T, N1, M0 (Cancer has spread outside the thyroid but III not 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 these tumors. 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 occur late. Medullary = MEN II = aMyloid = Median lymph node dissection = Modified neck dissection if lateral nodes are positive Staging I 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 invade surrounding 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 both lymph 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

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