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What is the most common site of origin of
ocular sebaceous carcinoma?
(A) Meibomian gland
(B) gland of Zeis
(C) lacrimal gland
(D) caruncle
(E) multicentric origin
Answer A.
Explanation: Sebaceous carcinoma, also called Meibomian gland
carcinoma, represents an aggressive primary malignancy of the adnexal
epithelium of sebaceous glands. About 75% of sebaceous carcinomas are
ocular in origin, while the remaining 25% of tumors are considered
extraocular. Ocular sebaceous carcinomas account for 1.5–5% of all
malignant eyelid neoplasms. The tumor most frequently develops on the
upper eyelid of elderly patients (Fig. 33-18).
FIG. 33-18
Sebaceous carcinoma of upper eyelid in elderly female.
Clinically, the lesion may present as a firm yellowish nodule, resembling a
chalazion, or may mimic an inflammatory condition such as
blepharoconjunctivitis or keratoconjunctivitis. Often, the diagnosis is
delayed from 1 to 3 years.
Between 51 and 70% of ocular sebaceous carcinomas originate from
Meibomian glands of the tarsus. Less commonly, the tumor is either
multicentric in origin or develops from the glands of Zeis, the lacrimal
gland, or the caruncle.
Histologically, the tumor appears as an infiltrative, nonencapsulated dermal
Answer A.
Explanation: Sebaceous carcinoma, also called Meibomian gland
carcinoma, represents an aggressive primary malignancy of the adnexal
epithelium of sebaceous glands. About 75% of sebaceous carcinomas are
ocular in origin, while the remaining 25% of tumors are considered
extraocular. Ocular sebaceous carcinomas account for 1.5–5% of all
malignant eyelid neoplasms. The tumor most frequently develops on the
upper eyelid of elderly patients (Fig. 33-18).
FIG. 33-18
Sebaceous carcinoma of upper eyelid in elderly female.
Clinically, the lesion may present as a firm yellowish nodule, resembling a
chalazion, or may mimic an inflammatory condition such as
blepharoconjunctivitis or keratoconjunctivitis. Often, the diagnosis is
delayed from 1 to 3 years.
Between 51 and 70% of ocular sebaceous carcinomas originate from
Meibomian glands of the tarsus. Less commonly, the tumor is either
multicentric in origin or develops from the glands of Zeis, the lacrimal
gland, or the caruncle.
Histologically, the tumor appears as an infiltrative, nonencapsulated dermal
Depicted in Fig. 38-2 is an 18-year-old
male whose left eye was struck with a
baseball. He complains of double
vision, a headache, and tenderness in
his left cheek. The most likely injury is
FIG. 38-2
(A) orbital floor fracture
(B) intracranial hemorrhage
(C) retinal detachment
(D) LeFort III fracture
Answer A.
Explanation: This most likely represents an orbital floor fracture. A black
eye finding on physical examination is not an innocuous finding. It must be
followed through with a thoroughly directed head/neck examination
including cranial nerves II through XII, palpation for tenderness, and an
ophthalmologic consultation. A CT scan with coronal and axial scanning
cuts is recommended (Figs. 38-41 and 38-42). Typically after localized
trauma to the periorbital region, bony sheer forces create an orbital floor
blowout fracture. Periorbital muscles and fat can become herniated and
trapped in the fracture line along the orbital floor causing restriction of eye
movement resulting in diplopia. Intraocular hemorrhage, such as hyphema,
may accompany the bony injury. An orbital floor fracture can also be part of
a series of fractures such as in the case of a zygomatical maxillary
complex fracture.
FIG. 38-41
FIG. 38-42
In this case, the physical findings do not represent a LeFort III fracture
A 36-year-old female presents with pain and loss of vision in her right eye,
worsening over 3 days. Her past medical history is significant for left TN
treated with carbamazepime for 4 years and depression controlled with
sertraline. On neurologic examination, her right eye vision in 20/400, left is
20/40. She has a Marcus-Gunn pupil (afferent pupillary defect) on the right.
Her extraocular movements are intact although testing causes increased
pain in the eye. Fundoscopic examination reveals no abnormality in either
eye.
The most likely diagnosis for this patient is
(A) hysteria
(B) carbamazepime toxicity
(C) optic neuritis
(D) amaurosis fugax
Answer C.
Explanation: This patient is suffering from optic neuritis. It has been described as
a syndrome in which "the patient can't see anything and the doctor can't see
anything," owing to a lack of findings on examination. This may lead the examiner
to believe the patient is hysterical. The patient will have a relative afferent
papillary defect (RAPD or Marcus-Gunn pupil), which is diagnosed with the
swinging light test. The pupils are equal at baseline and constrict in the light;
however, when swinging the light from the normal eye to the affected eye, the
pupils will dilate. This is due to a relative decrease in afferent stimulation of the
affected eye. Significant monocular vision loss does not occur without an RAPD.
Optic neuritis is the initial presentation of MS in 15% of cases, and 50% of
patients with MS will develop optic neuritis at some point in their course. MS is a
chronic demyelinating disease that is usually diagnosed in young adulthood, and
affects women twice as often as men. Its cause is unknown. The diagnosis is
made based on the history of neurologic symptoms combined with MRI evidence
of lesions explaining the deficits. Lumbar puncture for elevated IgG index and
oligoclonal bands. It can be a relapsing-remitting or chronic-progressive disease.
TN usually presents in the sixth decade. Its diagnosis in a young person should
prompt a workup for MS.
Amaurosis fugax is usually very transient (minutes), painless, and the vision loss if
How many bones make up the orbit?
(A) 7
(B) 8
(C) 9
(D) 6
(E) 4
Answer A.
Explanation: The following seven bones make up the orbit: frontal,
zygoma, maxilla, palatine, greater and lesser wings of the sphenoid,
lacrimal, and ethmoid bones. Of note, the nasal and temporal bones do not
contribute. Orbital anatomy is very intricate, and surgery on or around the
eye requires thorough knowledge of it. The optic nerve passes through the
optic foramen. The superior orbital fissure, located between the greater
and lesser wings of the sphenoid, permits passage of cranial nerves III, IV,
V1, and VI. The greater wing of the sphenoid is separated from the orbital
floor by the inferior orbital fissure that provides passage of the infraorbital
artery, V2, branches of the inferior ophthalmic vein to the pterygoid plexus,
and branches of the sphenopalatine ganglion. The supraorbital vessels
and nerve are transmitted through the supraorbital notch/foramen, while
the infraorbital vessels and nerve travel via the infraorbital notch.
Five orbital fat compartments exist in the eyelids: two in the upper lid and
three in the lower lid. These are manipulated and/or removed during
blepharoplasty, but excessive removal may cause a hollowed-out
appearance. Hemostasis is key during a blepharoplasty as blindness is
likely to ensue following an untreated hematoma. You may be called into
the recovery room after a blepharoplasty because the patient is
A 36-year-old female presents with pain and loss of vision in her right
eye, worsening over 3 days. Her past medical history is significant for left
TN treated with carbamazepime for 4 years and depression controlled
with sertraline. On neurologic examination, her right eye vision in
20/400, left is 20/40. She has a Marcus-Gunn pupil (afferent pupillary
defect) on the right. Her extraocular movements are intact although
testing causes increased pain in the eye. Fundoscopic examination
reveals no abnormality in either eye.
The most likely diagnosis for this patient is optic neuritis.
The most appropriate next step in the above patient's management is
(A) psychologic evaluation
(B) serum carbamazepime level and liver function testing
(C) MRI of the brain and possible lumbar puncture
(D) carotid duplex imaging
Answer C.
Explanation: This patient is suffering from optic neuritis. It has
been described as a syndrome in which "the patient can't see
anything and the doctor can't see anything," owing to a lack of
findings on examination. This may lead the examiner to believe the
patient is hysterical. The patient will have a relative afferent
papillary defect (RAPD or Marcus-Gunn pupil), which is diagnosed
with the swinging light test. The pupils are equal at baseline and
constrict in the light; however, when swinging the light from the
normal eye to the affected eye, the pupils will dilate. This is due to
a relative decrease in afferent stimulation of the affected eye.
Significant monocular vision loss does not occur without an RAPD.
Optic neuritis is the initial presentation of MS in 15% of cases, and
50% of patients with MS will develop optic neuritis at some point in
their course. MS is a chronic demyelinating disease that is usually
diagnosed in young adulthood, and affects women twice as often
as men. Its cause is unknown. The diagnosis is made based on the
history of neurologic symptoms combined with MRI evidence of
Which of the following statements
about cholesteatoma is true?
(A) It is a malignant tumor.
(B) The primary symptom is tinnitus.
(C) It is caused from eustachian tube
dysfunction.
(D) It is a disease of the inner ear.
Answer C.
Explanation: Cholesteatoma is an epidermoid cyst of the middle ear
and/or mastoid, which causes bone destruction secondary to its expansile
nature and through enzymatic destruction. Cholesteatoma develops as a
consequence of eustachian tube dysfunction and chronic otitis media
secondary to retraction of squamous elements of the tympanic membrane
into the middle ear space. Squamous epithelium may also migrate into the
middle ear via a perforation. Chronic mastoiditis that fails medical
management or is associated with cholesteatoma is treated by
mastoidectomy. (See Schwartz 8th ed., Chapter 17, Ear Infections.)
Laryngoscopic findings after a
superior laryngeal nerve injury include
(A) Ipsilateral vocal cord in a paramedian
position
(B) Ipsilateral vocal cord in a middling
position
(C) Asymmetry of the glottic opening
(D) Normal examination
Answer C.
Explanation: Superior laryngeal nerve
injury is less debilitating, providing the
patient's profession is not related to their
vocal performance, as the common
symptom is loss of projection of the voice.
The glottic aperture is asymmetrical on
direct laryngoscopy and management is
based on clinical observation. (See
Schwartz 8th ed., Chapter 11, Organ
System Complications.)
See all AccessSurgery content on:
Which of the following statements
about acute suppurative parotitis is
NOT correct?
(A) Decreased oral intake is a causative
factor
(B) Most patients are older than 70 years
of age
(C) Parotitis usually develops during the
postoperative period
(D) Poor oral hygiene is a contributing
factor
Answer C.
Explanation: These infections develop in elderly individuals with poor oral
hygiene and limited oral intake. The majority of infections are caused by
staphylococci which invade Stensen's duct where there is minimal parotid
secretion. Although these infections can occur in the postoperative period,
the majority of cases are not related to an operation. (See Schwartz 7th
ed.)
Diagnosis of chronic sinusitis is best
made by
(A) Computed tomography scan
(B) Magnetic resonance imaging
(C) Nuclear medicine scanning
(D) History, physical, and nasal
endoscopy
Answer D.
Explanation: Nasal endoscopy is a critical element of the diagnosis of
chronic sinusitis. Anatomic abnormalities, such as septal deviation, nasal
polyps, and purulence may be observed. The finding of purulence by nasal
endoscopy is diagnostic of sinusitis, regardless of whether other criteria
are met. In a setting in which symptoms persist for at least 12 weeks,
purulence on nasal exam represents an acute exacerbation of chronic
sinusitis. Pus found on endoscopic exam may be cultured, and subsequent
antibiotic therapy can be directed accordingly. The spectrum of bacteria
found in chronic sinusitis is highly variable and includes higher prevalences
of polymicrobial infections and antibiotic-resistant organisms. Overall, S.
aureus, coagulase-negative staphylococci, gram-negative bacilli, and
streptococci are isolated, in addition to the typical pathogens of acute
sinusitis. (See Schwartz 8th ed., Chapter 17, Benign Conditions of the
Head and Neck.)
Which of the following statements
concerning surgery for sleep apnea is
true?
(A) Surgery is indicated in all patients.
(B) Most patients improve with time, and
surgery is therefore not indicated.
(C) The majority of patients are treated
with tracheostomy alone.
(D) The most common procedure
performed is correction of soft palate
collapse.
Answer D.
Explanation: Sleep disorders represent a continuum from simple snoring
to upper airway resistance syndrome (UARS) to obstructive sleep apnea
(OSA). UARS and OSA are associated with excessive daytime
somnolence and frequent sleep arousals. In OSA, polysomnogram
demonstrates at least 10 episodes of apnea or hypopnea per hour of
sleep. The average number of apneas and hypopneas per hour can be
used to calculate a respiratory disturbance index (RDI), which, along with
oxygen saturation, can be used to grade the severity of OSA. These
episodes occur as a result of collapse of the pharyngeal soft tissues during
sleep. In adults, it should be noted that in addition to tonsil size, factors
such as tongue size and body mass index are significant predictors of
OSA. Other anatomic findings associated with OSA include obese neck,
retrognathia, low hyoid bone, and enlarged soft palate. Surgery should be
considered after failure of more conservative measures, such as weight
loss, elimination of alcohol use, and continuous positive airway pressure,
and should be tailored to the particular patient's pattern of obstruction. In
children, surgical management typically involves tonsillectomy and/or
adenoidectomy, because the disorder is usually caused by hypertrophy of
these structures. In adults, uvulopalatoplasty is frequently performed to
Trauma of the auricle of the ear with
hematoma formation
(A) Requires transcartilage sutures for
approximation
(B) Requires bolstering for most injuries
(C) Can be treated conservatively with
dressings only
(D) Aggressive débridement is essential
Answer B.
Explanation: With laceration of the auricle, key structures such as the
helical rim and antihelix must be carefully aligned. These injuries must be
repaired such that the cartilage is covered. The principles of auricular
repair are predicated on the fact that the cartilage has no intrinsic blood
supply and is thus susceptible to ischemic necrosis following trauma. The
suture should be passed through the perichondrium, while placement
though the cartilage itself should be avoided. Auricular hematomas should
be drained promptly, with placement of a bolster as a pressure dressing. A
pressure dressing is frequently advocated after closure of an ear
laceration. It also deserves note that the surgeon must avoid the
temptation to perform aggressive débridement after injuries to the eyelid or
auricle. Given the rich vascular supply to the face and neck, many softtissue components that appear devitalized will indeed survive. (See
Schwartz 8th ed., Chapter 17, Trauma of the Head and Neck.)
Le Fort II fracture entails injuries to all
of the following EXCEPT
(A) Medial wall of the orbit
(B) Alveolus
(C) Zygomaticomaxillary articulation
(D) Nasofrontal buttress
(E) Mandible
Answer E.
Explanation: Le Fort I fractures occur transversely across the alveolus,
above the level of the teeth apices. In a pure Le Fort I fracture, the palatal
vault is mobile while the nasal pyramid and orbital rims are stable. The Le
Fort II fracture extends through the nasofrontal buttress, medial wall of the
orbit, across the infraorbital rim, and through the zygomaticomaxillary
articulation. The nasal dorsum, palate, and medial part of the infraorbital
rim are mobile. The Le Fort III fracture is also known as craniofacial
disjunction. The frontozygomaticomaxillary, frontomaxillary, and frontonasal
suture lines are disrupted. The entire face is mobile from the cranium. It is
convenient to conceptualize complex midface fractures according to these
patterns; however, in reality, fractures reflect a combination of these three
types. (See Schwartz 8th ed., Chapter 17, Trauma of the Head and Neck.)
Which of the following is the preferred
treatment of tracheal stenosis after
prolonged intubation?
(A) Observation
(B) Balloon dilatation
(C) Laser ablation of scar
(D) Resection and primary anastomosis
Answer D.
Explanation: The treatment of tracheal stenosis is resection and primary
anastomosis. In nearly all postintubation injuries the injury is transmural,
and significant portions of the cartilaginous structural support are
destroyed. Measures such as laser ablation are temporizing. In the early
phase of evaluating patients, dilatation using a rigid bronchoscope is useful
to gain immediate dyspnea relief and to fully assess the lesion as well as
its length, position, and relation to the vocal cords. Rarely if ever is a
tracheostomy necessary. For patients unable to tolerate general
anesthesia because of comorbidities, internal stents, typically silicone T
tubes, are useful. Wire mesh stents should not be used, given their known
propensity to erode through the wall of the airway. (See Schwartz 8th ed.,
Chapter 18, Trachea.)
The most common branchial cleft
fistula originates from the
(A) 1st branchial cleft
(B) 2nd branchial cleft
(C) 3rd branchial cleft
(D) 4th branchial cleft
Answer B.
Explanation: Paired branchial clefts and arches develop early in the fourth
gestational week. The first cleft and the first, second, third, and fourth
pouches give rise to adult organs. The embryologic communication
between the pharynx and the external surface may persist as a fistula. A
fistula is seen most commonly with the second branchial cleft, which
normally disappears, and extends from the anterior border of the
sternocleidomastoid muscle superiorly, inward through the bifurcation of
the carotid artery, and enters the posterolateral pharynx just below the
tonsillar fossa. The branchial cleft remnants may contain small pieces of
cartilage and cysts, but internal fistulas are rare. A second branchial cleft
sinus is suspected when clear fluid is noted draining from the external
opening of the tract at the anterior border of the lower third of the
sternocleidomastoid muscle. Rarely, branchial cleft anomalies occur in
association with biliary atresia and congenital cardiac anomalies, an
association that is referred to as Goldenhar's complex. (See Schwartz 8th
ed., Chapter 38, Neck Masses.)
The most common area of the
mandible to be fractured is the
(A) Condyle
(B) Ramus
(C) Angle
(D) Body
Answer A.
Treatment of a 3-mm displaced fracture
of the anterior wall of the frontal sinus
is
(A) Observation
(B) Antibiotics alone
(C) Open reduction
(D) Open reduction, demucosalization,
and packing of fat into the sinus
Answer C.
Explanation: The most common surgical approach to the frontal sinus is
through a coronal incision. Treatment of frontal sinus fractures is
predicated on the number of walls involved and the status of the
nasofrontal duct (Fig. 44-34). In nondisplaced anterior wall fractures, no
treatment is indicated. If the anterior wall is displaced, then elevation and
recontouring of the anterior table is executed. The patient should be
observed for any sinus opacification or obstruction. If the nasofrontal duct
is involved in the fracture, one can assume that this is a dysfunctional
sinus. Therefore, the sinus must be demucosalized, the nasofrontal duct
must be plugged with bone graft, and sinus cavity obliterated with
cancellous bone or fat. The technique of frontal sinus exenteration or
removal of the anterior table, with demucosalization plugging of the ducts,
is an antediluvian procedure not routinely performed because of the
significant contour deformity. (See Schwartz 8th ed., Chapter 44,
Maxillofacial Trauma.)
Three days after an accident in which a
25-year-old woman suffers a maxillary
and mandibular fracture, she develops
facial nerve palsy with oral
incompetence and slurred speech. The
facial nerve problem should be
managed by
(A) Facial nerve graft
(B) Facial nerve suture
(C) Nonoperative management
(D) Transfer of part of the masseter
muscle to the oral commissure
Answer C.
Explanation: When facial nerve palsy is incomplete or late in appearance,
the nerve injury is partial. With observation, the palsy will regress over
time, and intervention is not required. The operative techniques listed may
be necessary with a complete nerve injury. (See Schwartz 7th ed.)
Which of the following is the best
treatment of a septal hematoma in a
patient with a nasal fracture?
(A) Observation
(B) Aspiration of the hematoma
(C) Closed reduction of the fracture and
aspiration of the hematoma
(D) Operative repair of the fracture
Answer B.
Explanation: The nose is the most commonly fractured facial region. The
nose is either laterally or posteriorly displaced, and the fracture may
involve the cartilaginous septum, or both the nasal bones and septum.
Patients commonly present with swelling, nasal deformity, epistaxis, septal
deviation, and/or crepitus on palpation. Intranasal inspection should be
performed, and if a septal hematoma is noted, it should be percutaneously
drained. Diagnosis by computed tomography (CT) scan is not obligatory
but is implemented to rule out other injuries. Immediate treatment consists
of reduction of both the pyramid and septum, followed by nasal splinting. In
spite of early reduction, there is usually a residual deformity or deviations,
which will require formal rhinoplasty in an elective setting after swelling and
bruising have resided. (See Schwartz 8th ed., Chapter 44, Maxillofacial
Trauma.)
Which of the following is the most
common nerve deficit after resection
of a poststyloid compartment
parapharyngeal neurilemmoma?
(A) ptosis
(B) painful shoulder syndrome
(C) deviation of tongue to the operated
side
(D) voice change or hoarseness
(E) corneal exposure
Answer A.
Explanation: The parapharyngeal space (PPS) can be thought of as an
inverted pyramid. The boundaries of this space are the base of skull
superiorly and the hyoid bone inferiorly. The space itself is deep to the
pharyngeal mucosa and superficial to the carotid sheath and it
communicates with the submandibular space. It can be divided into a
prestyloid and poststyloid or retrostyloid space by the syloid muscles and a
band of fascia from the tensor veli palatini. These spaces are important
when discussing tumor pathology and surgical approaches. The prestyloid
space contains fat, the mandibular branch of the facial nerve, the pterygoid
venous plexus, whereas the poststyloid space contains cranial nerves IX–
XII, the cervical sympathetic chain and the internal carotid artery and
internal jugular vein (IJV).
The differential of masses in the PPS is large but can be broken into four
categories: salivary gland tumors, neurogenic tumors, lymph node
enlargement, or miscellaneous tumors. Patients can present with
symptoms of airway obstruction from poststyloid masses, pain or cranial
nerve palsies of nerves in the PPS. Patients can also present with a
unilateral serous otitis media from Eustachian tube dysfunction. A CT scan
and/or MRI would be the initial test(s) of choice to delineate between pre-
All of these are part of the oral cavity
except
(A) floor of mouth
(B) soft palate
(C) base of tongue
(D) upper gingivae
(E) retromolar trigone
Answer C.
Explanation: The oral cavity is bounded by the vermilion border of the lips
and the junction of the hard and soft palate and circumvallate papillae. It
can be thought of having eight subunits: lips, buccal mucosa, floor of
mouth, anterior two-thirds of the tongue (i.e., oral tongue), upper and lower
alveolar ridges, hard palate, and retromolar trigone. The retromolar trigone
is a triangular spaced area from the distal surface of the last molar tooth to
the maxillary tuberosity. This area is important in cancer spread as the
mucosa of the mandible is tightly adherent to the underlying periosteum
and therefore a weak barrier to tumor extension. The vestibule is the area
lateral to the alveolar ridges and the oral cavity proper the area medial to
the teeth. The layers of the cheek itself from superficial to deep are as
follows: skin, subcutaneous tissue, the buccinator muscle, the buccinator
fat pad, the pharyngobuccal fascia, and the mucosa/lip complex. The
salivary ducts traverse the mucosa to drain into the oral cavity. These
include Stensen's duct of the parotid gland, the papilla of which is located
lateral to the second molars; Wharton's duct of the submandibular gland
which is found in the midline floor of mouth adjacent to the frenulum of the
tongue; and ducts of Rivinius of the sublingual gland which drain into the
floor of mouth or into Wharton's duct itself.
The treatment of choice for cystic
hygromas is
(A) Observation
(B) Antibiotics
(C) Intralesional sclerotherapy
(D) Surgical excision
Answer D.
Explanation: The diagnosis of cystic hygroma by prenatal ultrasound (US)
before 30 weeks' gestation has detected a "hidden mortality," as well as a
high incidence of associated anomalies, including abnormal karyotypes
and hydrops fetalis. Occasionally, very large lesions can cause obstruction
of the fetal airway. Such obstruction can result in the development of
polyhydramnios by impairing the ability of the fetus to swallow amniotic
fluid. In these circumstances, the airway is usually markedly distorted,
which can result in immediate airway obstruction unless the airway is
secured at the time of delivery. Orotracheal intubation or urgent emergency
tracheostomy while the infant remains attached to the placenta, the ex
utero intrapartum technique (EXIT) procedure, may be necessary to
secure the airway. (See Schwartz 8th ed., Chapter 38, Neck Masses.)
A 2-year-old child swallows a short
straight pin and is brought to the
emergency room (ER) by his parents.
On examination, he is alert and able to
control his secretions (i.e., saliva). He
has not experienced any respiratory
distress and is afebrile. What is the
appropriate course of action?
(A) see the child in the clinic again in 10
days
(B) perform endoscopy if the pin is found
in the stomach or esophagus on x-ray
Answer E.
Explanation: Young children make up the majority of patients suffering
from foreign body aspiration: children under 3 account for between 70 and
80% of all foreign body aspirations. Children in this age group tend to
explore with their mouths. Another factor is the lack of development of
molars for grinding and lack of maturity of swallowing and airway
protection processes. Boys outweigh girls by 2:1 in frequency. Whereas
the most common airway foreign body is vegetable matter, esophageal
foreign bodies are coins in 75% of cases. Others may include disc
batteries, screws, tacks, nails, and other hardware items. Increasing in
frequency are toy plastic parts.
The esophagus has four layers: the mucosa, submucosa, inner circular
layer of muscle, and outer longitudinal layer of smooth muscle. The upper
5 cm are skeletal muscle, the upper midsection is an overlap of striated
(skeletal) and smooth muscle, and the lower half is smooth muscle. The
myenteric plexus of Auerbach is found within muscle layers and the
submucosal plexus of Meissner is found in the submucosa. Both plexi are
parasympathetic in innervation. The mucosa of the esophagus contains
stratified squamous epithelium with poor absortion and low level secretory
functions. Because there is no serosa, the esophagus is relatively more
A 19-year-old woman presents to the ER with few days history of
fever and pain in the submandibular region. She says that over the
last several hours she has been having more trouble speaking with
pain in her tongue and is afraid to lie down. On oral examination,
you see that the floor of mouth is indurated and swollen and very
tender. The patient has very poor dentition but you do not
appreciate an abscess. Her submandibular and submental regions
are also tender and indurated with some fluctuance. What entity in
the differential diagnosis are you most worried about?
(A) Vincent's angina
(B) Bezold's abscess
(C) Ludwig's angina
(D) a retropharyngeal abscess
(E) submandibular and sublingual gland sialadenitis
Answer C.
Explanation: This scenario describes a neck space infection with
abscess. Historically these types of infections were caused by pharyngeal
or tonsillar infections with involvement of the PPC, but since the advent of
antibiotics, these infections are treated early in their course. Most
contemporary adult neck space abscesses are caused by odontogenic or
salivary gland infections, although tonsillar and pharyngeal infections still
account for the majority of pediatric neck space infections. Other etiologies
include preexisting congenital anomalies (branchial cleft sinuses and the
like), trauma, upper respiratory tract infections, iatrogenic causes, or
spread from a superficial infection.
The neck spaces are divided by fascial layers. The most superficial fascia
is the superficial cervical fascia beginning at the zygomatic process and
extending into the thorax. It envelops the platysma muscle and muscles of
facial expression and is rarely involved in serious neck space infections.
The next deeper layer is the superficial layer of the deep cervical fascia
which covers the strap muscles, trapezius, SCM, major salivary glands,
and muscles of mastication (temporalis, masseter, and pterygoids). This
superficial layer of the deep fascia or "investing fascia" splits around the
superior surface of the manubrium to form the suprasternal space of burns.
A 14-year-old male is involved in a dirt bike accident in which he
suffers a "clothesline" injury. On examination in the ER you see a 7
cm laceration in the anterior neck, subcutaneous emphysema, and
a hematoma which does not appear to be expanding. He is unable
to lay flat and has a muffled voice. On flexible laryngoscopy, you
see diffuse but mild edema of the supraglottis and glottis, reduced
vocal cord abduction, and bloody secretions in the subglottis. Initial
management of this patient would involve
(A) nasal intubation, laryngeal and cervical spine CT, exploration
and repair with intraoperative tracheotomy
(B) tracheostomy under local anesthesia, cervical spine series,
endoscopy, exploration and repair
(C) percutaneous tracheostomy, cervical spine series, exploration
and repair with stenting
(D) oral intubation, laryngeal and cervical spine CT, endoscopy,
exploration and repair
(E) tracheostomy under general anesthesia, CT of the larynx and
cervical spine, endoscopy, exploration and repair with stenting over
a T-tube
Answer B.
Explanation: External laryngeal trauma is diagnosed on the basis of
history and physical findings. A patient who presents with evidence of
anterior neck trauma should be assumed to have upper airway trauma.
This compounded with subcutaneous emphysema, voice changes, and
orthopnea should arouse suspicion for disruption of the larynx or trachea.
As in any trauma situation, the "ABCs" come first: airway, breathing and
circulation. Although on fiberoptic examination this patient had "mild
edema" it is presumable early after the trauma and the entire injury may
have not evolved. There is potential for worsening of the edema and
bleeding in the next 8–12 h. As a result, an awake tracheostomy is the best
option. The addition of general anesthesia in this situation may cause
laryngospasm and resultant complete airway obstruction. In addition,
"clothesline" injuries are high risk for being associated with laryngotracheal
separation. Any situation in which this is considered precludes oral or nasal
intubation as intubation may worsen the existing damage or convert a
partial laryngotracheal or cricotracheal separation into a complete
separation.
The pathophysiology behind blunt trauma to the larynx involves crushing of
the laryngeal skeleton against the cervical spine. There is a shearing effect
A 20-year-old man involved in an altercation presents to the ER
with epistaxis and nasal airway obstruction. When inspecting his
nose externally, you feel crepitus when moving the nasal bones
and mild flattening of the dorsum; there is no active bleeding. On
anterior rhinoscopy, you see an ecchymotic, swollen area on either
side of the caudal septum (Fig. 14-6). The next step in
management would be to
(A) reduce the nasal fracture externally and employ an external
nasal splint
(B) place internal nasal splints to stabilize the fracture
(C) drain the septal hematoma
(D) place anterior nasal packing to treat the epistaxis
(E) get facial x-rays if they were not already performed
Answer C.
Explanation: A history of trauma to the nose with epistaxis should raise
concern for a nasal fracture. Signs of crepitus of the nasal cartilaginous
and bony framework and obvious external deformity are virtually
pathognomic for a nasal fracture. The nasal bone is the most frequently
fractured facial bone. Diagnosis rests on the physical examination
especially after topical decongestion; x-rays have not been helpful in
adding to diagnostic accuracy. In nearly 50% of cases, nasal x-rays may
not reveal a fracture when one is actually present. Photographic
documentation is important, however. A careful rhinoscopic examination
should be performed as there are few injuries and/or complications
associated with nasal trauma to the nose that require immediate repair or
attention. One of these is the septal hematoma (Fig. 14-6).
A septal hematoma presents with nasal airway obstruction, usually
bilaterally. Less often do patients with a septal hematoma present with
epistaxis. The hematoma develops in the plane between the
perichondrium of the septal cartilage and the cartilage itself. As the
cartilage receives its blood supply from the perichondrium, the hematoma
causes ischemic injury and eventually degeneration of the cartilaginous
septum. A devastating cosmetic and functional consequence of this is the
A 60-year-old male with a history of
hypertension and coronary artery
disease presents to the ER with steady
bleeding from the right nare. He is on
aspirin 325 mg a day as well as Plavix;
he had a percutaneous transluminal
coronary angioplasty (PTCA) with
stenting 5 years ago. You first examine
him and are not sure where the
bleeding is arising from so you place
an anterior nasal pack. He has no
bleeding until 20 min later, but then
Answer C.
Explanation: Epistaxis or nosebleeding is one of the most common ear,
nose and throat (ENT) emergencies. The role of the nose in humidification,
filtration and warming of inspired air and its copious blood supply all put it
at risk for bleeding. Epistaxis more commonly occurs in older individuals
because of vessel wall aging with fibrosis and slower vasoconstriction and
in the winter months because of cold, dry air exposure. Other risk factors
include trauma (nose picking, most common in children), nasal sprays
including nasal steroids, intranasal or sinus tumors, allergies, medications
such as antiplatelet agents and anticoagulants, and anatomic deformities
such as septal deviation. Systemic factors and diseases putting patients at
epistaxis risk include hypertension, hereditary hemorrhagic telangiectasia
(Osler-Weber-Rendu disease, an autosomal dominant disease with
associated mucosal telangiectasias and pulmonary AVMs), von Willebrand
disease, hemophilia, nutritional deficiencies, alcohol abuse with associated
hepatic disease, and lymphoreticular disorders or malignancies.
Epistaxis most commonly occurs in the anterior portion of the nasal cavity,
specifically the septum and the area known as Kiesselbach's plexus (in
90%). This area is particularly susceptible to trauma and drying effects.
The first step in management of epistaxis is fluid resuscitation and control
Nasal blood supply. Major nasal blood
vessels and their relative positions are
depicted. Note that the nasal sept um has
been reflected superiorly. A, Anterior
ethmoidal artery; B, Posterior ethmoidal
artery; C, Posterior septal nasal artery; D,
Lateral nasal artery; E, Sphenopalatine
artery; F, Sphenopalatine foramen; G,
Greater palatine foramen; H, Greater
palatine artery; I, Incisive canal.
A 47-year-old man is brought to the physician's office by his wife
who is having difficulty sleeping because of her husband's
extremely loud snoring. He does complain of headaches and
daytime sleepiness as well as some irritability. On examination, his
collar size is 18 in. and he is moderately obese. In addition you
note a septal deviation to the right and an elongated redundant
uvula and posterior pharyngeal mucosa. You obtain a
polysomnogram because you suspect sleep apnea: the patient's
RDI is 40 with a low saturation of 80%. Appropriate treatment
options include all of the following except:
(A) nasal continuous positive airway pressure (CPAP)
(B) septoplasty with uvulopalatopharyngoplasty (UPPP)
(C) encourage weight loss as the sole treatment
(D) orthodontic devices in conjunction with CPAP
(E) tracheostomy
Answer C.
Explanation: In the United States, OSA has a prevalence of 4% in men
and 2% in women. There are several systemic consequences to sleep
apnea including hypertension, myocardial infarction, and stroke. Patients
with sleep apnea have three to seven times the risk of having motor
vehicle accidents. As a result of these statistics, sleep apnea is being
diagnosed earlier and treated aggressively. There is a continuum of sleep
disordered breathing which ranges from sleep apnea to the Pickwickian's
syndrome. OSA is caused by an obstruction at any level of the upper
airway above the glottis. The muscle relaxation occurring in the deeper
stages of sleep occurs in the upper airway as well and patients
predisposed to OSA have excess tissue in the upper airway, causing an
airway collapse during inspiration. The patient is then awakened by
desaturation, signaled as a snorting or gasping noise, and then resumes
the pattern.
The RDI is the respiratory disturbance index which is obtained by
polysomnography. An RDI of greater than 5 is abnormal. Apnea itself is
defined as cessation of airflow for at least 10 s, and hypopneas are
desaturations without complete cessation. The RDI is the number of
apneas and hypopneas in 1 h. This measure allows stratification of
Which of the following is an indication
for tonsillectomy?
(A) Patient's request
(B) Chronic middle ear infection
(C) Three or more infections per year
(D) Missing more than one week of school
per year
Answer C.
Explanation: Tonsillectomy and adenoidectomy are indicated for chronic
or recurrent acute infection and for obstructive hypertrophy. The American
Academy of Otolaryngology–Head and Neck Surgery Clinical Indicators
Compendium (2000) suggests tonsillectomy after three or more infections
per year despite adequate medical therapy. Some feel that tonsillectomy is
indicated in children who miss 2 or more weeks of school annually
secondary to tonsil infections. Multiple techniques have been described,
including electrocautery, sharp dissection, laser, and radiofrequency
ablation. There is no consensus as to the best method. In cases of chronic
or recurrent infection, surgery is considered only after failure of medical
therapy. (See Schwartz 8th ed., Chapter 17, Benign Conditions of the
Head and Neck.)
A 50-year-old man has a 2-day history of headaches
and of proptosis with failing vision in the right eye.
Vision has been reduced to light perception only and
the globe is displaced inferior and laterally. Rhinoscopy
shows swelling in the middle meatus with some
purulence. The next step in management would be to
(A) obtain a CT scan of the orbits and sinuses and
immediate ethmoidectomy
(B) IV aqueous penicillin G, 2 million U every 4 h
(C) IV levaquin 500 mg every 24 h
(D) immediate exploration of the orbits
(E) oral dexamethasone, 4 mg daily for 1 week
Answer A.
Explanation: The most common complication of acute sinusitis
necessitating immediate operative intervention involves the eye. All the
sinuses can be culprits of orbital complications but the ethmoid is the most
common because of its adjacency. The indication in this patient to operate
immediately would be the visual acuity change as complications can lead
to blindness. As the ethmoids are the culprit, decompressing the infection
or abscess if present can be performed via the lamina papyracea, the
medial wall of the orbit. Infections spread by direct extension and
thrombophlebitis of ethmoidal veins. Other complications may include
neurologic infections: subdural and epidural abscesses and meningitis.
Orbital complications are stratified by the Chandler classification system.
Stage I is simply inflammatory edema or preseptal cellulitis (orbital septum
of the eyelid) of the lids and extraocular muscles are not involved. Stage II
indicates orbital cellulitis with edema of the contents of the orbit. The first
two stages should be aggressively treated with medical therapy with
antibiotics against Streptoccocus pneumoniae and Haemophilus
influenzae to prevent progression to stage III. Stage III is the subperiosteal
abscess which is beneath the periosteum of the lamina papyracea; the
globe is displaced inferolaterally and vision is affected. Stage IV is an
Orbital complications are typically treated with an external approach rather
than and endoscopic approach although the trend is changing. Since the
ethmoid sinuses are the most frequently involved, at minimum, an external
ethmoidectomy is performed with removal of a portion of the lamina
papyracea.
Acute bacterial rhinosinusitis is diagnosed by the symptomatology of nasal
congestion and rhinorrhea lasting for 7–14 days. Other symptoms include
facial pain or dental pain, headache, fever and malaise. Anterior
rhinoscopy may reveal unilateral or bilateral purulent drainage and
tenderness on palpation of soft tissue over the sinuses. Various processes
may lead to acute or chronic sinusitis. The first is obstruction of sinus ostia
which can be caused by anatomic factors (septal deviation), edema from
allergens or polyps. The second process is ciliary dysfunction either
primary or acquired such as after a viral upper respiratiory infection (URI).
The last is changes in mucus quality or quantity systemic factors may
include steroid use, diabetes or immune compromise in general.
Nosocomial sinusitis may be caused by indwelling nasogastric catheters or
nasotracheal intubation. A critically ill patient may present with a fever of
unknown origin; acute rhinosinusitis should be given careful consideration,
usually with an original or reconstructed coronal CT scan (optimal images
for sinuses). These patients should be treated for gram-positive and gram-
The most likely pathogen to be
involved with supraglottitis
(epiglottitis) is
(A) Streptoccocus pneumonia
(B) H. influenzae
(C) influenza virus
(D) parainfluenza virus
(E) S. aureus
Answer A.
Explanation: Le Fort I fractures occur transversely across the alveolus,
above the level of the teeth apices. In a pure Le Fort I fracture, the palatal
vault is mobile while the nasal pyramid and orbital rims are stable. The Le
Fort II fracture extends through the nasofrontal buttress, medial wall of the
orbit, across the infraorbital rim, and through the zygomaticomaxillary
articulation. The nasal dorsum, palate, and medial part of the infraorbital
rim are mobile. The Le Fort III fracture is also known as craniofacial
disjunction. The frontozygomaticomaxillary, frontomaxillary, and frontonasal
suture lines are disrupted. The entire face is mobile from the cranium. It is
convenient to conceptualize complex midface fractures according to these
patterns; however, in reality, fractures reflect a combination of these three
types. (See Schwartz 8th ed., Chapter 17, Trauma of the Head and Neck.)
Le Fort II fracture entails injuries to all
of the following EXCEPT
(A) Medial wall of the orbit
(B) Alveolus
(C) Zygomaticomaxillary articulation
(D) Nasofrontal buttress
(E) Mandible
Answer A.
Explanation: Le Fort I fractures occur transversely across the alveolus,
above the level of the teeth apices. In a pure Le Fort I fracture, the palatal
vault is mobile while the nasal pyramid and orbital rims are stable. The Le
Fort II fracture extends through the nasofrontal buttress, medial wall of the
orbit, across the infraorbital rim, and through the zygomaticomaxillary
articulation. The nasal dorsum, palate, and medial part of the infraorbital
rim are mobile. The Le Fort III fracture is also known as craniofacial
disjunction. The frontozygomaticomaxillary, frontomaxillary, and frontonasal
suture lines are disrupted. The entire face is mobile from the cranium. It is
convenient to conceptualize complex midface fractures according to these
patterns; however, in reality, fractures reflect a combination of these three
types. (See Schwartz 8th ed., Chapter 17, Trauma of the Head and Neck.)
Le Fort II fracture entails injuries to all
of the following EXCEPT
(A) Medial wall of the orbit
(B) Alveolus
(C) Zygomaticomaxillary articulation
(D) Nasofrontal buttress
(E) Mandible
Answer B.
Explanation: Despite the advent and widespread use of the HIB vaccine,
H. influenzae type b still remains the most common cause of epiglottitis.
Historically, the disease was more common in children between ages 2
through 6; however, with vaccine use, the incidence in children has
dropped from 3.5 in 100,000 to 0.6 in 100,000, whereas that in adults has
remained the same or has risen slightly. Other bacteria that are found
commonly include other types of H. influenzae, -hemolytic streptococci,
Staphylococcus, Klebsiellae pneumoniae, Bacteroides melanogenicus,
and Mycobacterium tuberculosis. The presentation in children is fever, sore
throat of a rapid onset with inspiratory stridor; adults will also complain of
odynophagia. The key is the rapid onset of pain with a paucity of
oropharyngeal findings (such as lack of evidence of acute tonsillitis or
peritonsillar abscess). Children may have trouble handling secretions and
may drool and patients in general may have a muffled or "hot potato" voice
all related to edema of the epiglottis. Patients sit forward and upright in a
"sniffing" position to relieve some of the respiratory obstruction.
Diagnosis is based chiefly on history and physical examination. Though a
classic "thumbprint" sign of the epiglottis on lateral neck x-ray has been
described in the setting of supraglottitis, the sensitivity of lateral neck films
A 12-year-old female presents for evaluation of a
neck mass. Which of the following pairs are
correct?
(A) branchial cleft cyst/sinus: most commonly involves
the third branchial cleft remnant
(B) thyroglossal duct cyst (TGDCs): mesodermal
remnants that produce lateral swelling over neck
(C) cystic hygroma: a salivary gland disorder related to
a hypersecretory cyst
(D) torticollis: unilateral shortening of trapezius muscle
(E) medullary thyroid cancer: most common cause of
death in multiple endocrine neoplasia (MEN) 2B
Answer E.
Explanation: Commonly encountered developmental neck abnormalities
in children are of congenital origin yet may not cause problems or be
detected until adulthood. While some of these neck lesions may appear
asymptomatic at birth, they may precipitously become enlarged and
disfiguring as a result of local or regional infection or hemorrhage.
Developmental abnormalities of the branchial apparatus represent a
common source of congenital lateral neck masses. Branchial anomalies
may present as a cyst, sinus, or fistula. Branchial cleft anomalies arise
most commonly (greater than 90%) from the second branchial cleft
system. Eight percent arise from the first branchial anomaly whereas third
and fourth branchial malformations are rare. Usually the second branchial
cleft sinus or fistula presents with drainage from a small pit in the skin just
anterior to the lower third of the sternocleidomastoid muscle. Treatment of
choice is surgical excision due to the risk of infection (Fig. 34-27).
Answer E.
Thyroglossal duct cysts (TGDCs) represent the most common head and
neck midline masses in children. It is reported that they account for about
70% of all congenital neck abnormalities. TGDCs are embryonic
ectodermal rests that can present as midline structures as they follow the
descent along the thyroid gland tract. Normally, the thyroglossal duct
regresses once the thyroid gland reaches the anterior neck. Faulty thyroid
migration or persistence of the thyroglossal duct can lead to the formation
of lingual/ectopic thyroid tissue, pyramidal thyroid lobe, or a TGDCs. Since
TGDCs are attached to the hyoid bone, clinical presentation typically
shows a midline mass that moves with swallowing. Treatment is based on
the Sistrunk procedure in which complete surgical excision of the cyst and
tract up to the base of the tongue including the central portion of the hyoid
bone is preformed (see Fig. 34-28).
Answer E.
Lymphatic malformations commonly referred to as cystic
hygromas are developmental abnormalities of the lymphoid
system that occur at sites of lymphatic-venous connection,
most commonly in the posterior neck (Fig. 34-29). The
cysts may become enlarged and disfiguring not only as a
result of infection or hemorrhage but also due to increases
in fluid and endothelial cell growth. Imaging by US, CT, and
MRI (for complex and extensive lesions) is mandated to
determine whether involvement of deeper airway structures
is present. This also gives pertinent clues as to the planning
of the operative approach. When these lesions are
diagnosed prenatally, the overall prognosis is poorer than
those diagnosed after birth. Treatment of these lesions is
primarily surgical but another therapy is injection
sclerotherapy with such agents as bleomycin, OK-432,
sodium morrhuate, 22.5% glucose, and triamcinolone.
Sclerotherapy is usually reserved for extensive disease or
recurrences.
Torticollis is a deformity characterized by the
unnatural tilted or turned position of the head. The
most common form is due to shortening of the
sternocleidomastoid muscle, although a number of
other conditions can potentially cause torticollis
(cervical hemivertebrae, adenitis, fascitis, and
oculomotor abnormalities). Birth trauma was once
thought to contribute to the cause of torticollis by
injury to the sternocleidomastoid or the spinal
accessory nerve, but this is rarely the case. The
mother or primary physician usually notes the classic
presentation of an otherwise healthy 2–8-week-old
infant who preferentially turns their head to one side.
Compete resolution of untreated torticollis occurs in
50–70% of cases by 6 months of age, but because it
is difficult to predict which infants will develop an
irreversible deformity, a passive range-of-motion
exercise regimen is advocated. In cases that present
with or develop facial hemihypoplasia, surgery to
divide the sternocleidomastoid on the affected side is
indicated
Answer E.
Medullary thryroid cancer can occur sporadically, in association with MEN
types 2A or 2B, or with the familial medullary cancer syndrome. A mutation
in the ret protooncogene in individuals with MEN and the familial variant
predisposes family members (autosomal dominant inheritance) to the
development of medullary thyroid cancer at an early age. This tumor is the
first to develop in MEN children and is the most common cause of death.
In these children, early thyroidectomy is advocated after the genetic
mutation has been confirmed. MEN 2A children should undergo
thyroidectomy prior to 5 years of age; whereas children of MEN 2B require
thyroidectomy prior to 1 year of age due to the more virulent nature of the
disease.
An 80-year-old woman who is a nursing home patient is
brought to the hospital with a GI bleed. She ultimately
undergoes a left hemicolectomy for diverticulosis and
has a lengthy postoperative ileus. Postoperative day 5
she complains of a sour taste in her mouth and her right
cheek feeling warm and very tender. You notice a
swelling in the parotid area and that she is febrile at the
time. All of the following would be part of the treatment
of this disorder except:
(A) IV antibiotics against S. aureus
(B) heat application to the area over the parotid
(C) IV hydration
(D) lemon drops
(E) cannulation of the right Stensen's duct with drainage
Answer E.
xplanation: This case is typical of acute bacterial parotitis or sialadenitis.
This disorder occurs in individuals with dehydration from any cause. The
dehydration may be a result of being NPO for an extended period of time
or in the patient being in a relative state of anorexia after surgery and
patients who have undergone abdominal procedures are at the most risk.
Chronic and/or debilitating illnesses also may predispose a patient to
development of acute parotitis such as in the case of a nursing home
patient. Other causes may be radiation, chemotherapy or
immunosuppression in general, medications with anticholinergic side
effects, and Sjogren's disease. The incidence is reported at approximately
1 in 1–2000 operative procedures. Acute parotitis presents with symptoms
of pain, erythema, and diffuse enlargement of the gland which is usually
unilateral; gentle milking of Stensen's duct with manual pressure on the
gland and intraorally causes purulent exudate to be expressed from the
orifice.
The pathophysiology of acute parotitis is retrograde bacterial infection
through Stensen's duct. Mucoid saliva which has a high molecular weight
glycoprotein and sialic acid has superior bacteriostatic activity because of
the ability to trap bacteria. Mucoid saliva also has a higher lysozyme and
Which of the following statements
concerning cleft lip and cleft palate is
true?
(A) Cleft lip is a midline failure of lip
closure.
(B) Development of cleft lip is related to
environmental factors and not to familial
tendencies.
(C) Deformities of the nose occur in
approximately 50% of patients who have
a cleft lip.
(D) Middle ear infections are common
Answer D.
Explanation: The incidence of cleft palate, cleft lip, or both is variously
reported as 1 in 1000 to 1 in 2500 live births in the United States. If a
parent or sibling has a cleft lip, the chance of a subsequent child's being
born with the same defect is higher. Cleft lip may be unilateral or bilateral
when the nasomedial and nasolateral processes fail to unite during
embryologic development. Cleft palate is due to isolated failure of palatal
process fusion. Almost all cleft lips, even minor ones, are associated with
nasal distortions, and many plastic surgeons advocate rhinoplasty at the
time of repair of the cleft lip. Malocclusion is a uniform problem, and all
patients with cleft palates have drainage problems of the middle ear, which
may lead to recurrent ear infections. Normal speech is achieved in more
than 75% of cases of corrective surgery in which the cleft palate is closed
entirely by the age of 12 to 14 months. (See Schwartz 7th ed.)
What study is used to monitor
response to therapy for malignant
otitis externa?
(A) technetium-99 scan
(B) gallium-67 scan
(C) CT scan
(D) MRI
(E) culture
Answer B.
Explanation: Malignant otitis externa (or necrotizing otitis externa, NOE)
does not refer to a neoplastic process but rather a potentially lifethreatening infectious external ear infection. Though newer antibiotics have
somewhat decreased the incidence, there are certain patient groups at
risk. These at-risk groups are the elderly, diabetics, and the
immunocompromised. In fact, up to 80% of cases are found in diabetics.
NOE is associated with a skull base osteomyelitis which is the source of its
lethal nature.
Diagnosis rests on a few key symptoms and signs. These include a
persistent and severe otalgia that has lasted for more than 1 month,
purulent otorrhea with granulation tissue for several weeks,
immunocompromised because of age, diabetes or other condition and a
lower cranial neuropathy of nerves VII, IX, X, or XI. The granulation tissue
is seen at the posteroinferior aspect of the external auditory canal at the
tympanomastoid suture line. The granulation tissue seen in an AIDS
patient is less exuberant but suspicion should be maintained, as these
patients are usually severely immunocompromised. Granulation tissue can
be seen in severe otitis externa when there is a tympanic membrane
perforation. SCC can present in a similar fashion, so biopsies should be
What structure passes through the
foramen ovale?
(A) infraorbital nerve
(B) V3
(C) meningeal artery
(D) sphenopalatine artery
(E) V2
Answer B.
Explanation: The skull base is a complex anatomical region which houses
multiple vital structures. Any disease process in this region has the
potential to affect the function of the various contents of the skull base
foramina. The skull base can be simplified by separating it into an anterior,
middle, and posterior cranial fossa (Fig. 14-27).
FIG. 14-27
Skull base foramina from internal aspect. (Source: Reprinted from Lee, et
al. Essential Otolaryngology Head and Neck Surgery, 8th ed., copyright
2003, with permission from McGraw-Hill).
The anterior cranial fossa (ACF) is the most shallow. The main component
is the frontal bone and the floor is chiefly composed of the orbital plates of
the frontal bone and ends at the anterior border of the greater wing of
sphenoid. The fovea ethmoidalis is the portion of the ethmoid sinuses that
forms part of the ACF floor. The main foramina of the ACF are those in the
cribriform plate which transmit the olfactory nerve axons. Other important
foramina are those for the anterior and posterior ethmoidal neurovascular
bundles. The optic nerve is located 5–6 mm behind the posterior ethmoidal
artery. A vestigial foramen cecum is seen between the crista galli and
frontal crest and in 1% it is open and transmits a nasal emissary vein.
Answer B.
Explanation: The skull base is a complex anatomical region which houses
multiple vital structures. Any disease process in this region has the
potential to affect the function of the various contents of the skull base
foramina. The skull base can be simplified by separating it into an anterior,
middle, and posterior cranial fossa (Fig. 14-27).
FIG. 14-27
Skull base foramina from internal aspect. (Source: Reprinted from Lee, et
al. Essential Otolaryngology Head and Neck Surgery, 8th ed., copyright
2003, with permission from McGraw-Hill).
The anterior cranial fossa (ACF) is the most shallow. The main component
is the frontal bone and the floor is chiefly composed of the orbital plates of
the frontal bone and ends at the anterior border of the greater wing of
sphenoid. The fovea ethmoidalis is the portion of the ethmoid sinuses that
forms part of the ACF floor. The main foramina of the ACF are those in the
cribriform plate which transmit the olfactory nerve axons. Other important
foramina are those for the anterior and posterior ethmoidal neurovascular
bundles. The optic nerve is located 5–6 mm behind the posterior ethmoidal
artery. A vestigial foramen cecum is seen between the crista galli and
frontal crest and in 1% it is open and transmits a nasal emissary vein.
Pott's puffy tumor is seen most
commonly with which of these
conditions?
(A) otitis media
(B) frontal sinus fracture
(C) ethmoid sinusitis
(D) bacterial pharyngitis
(E) cervical spinal infection
Answer B.
Explanation: Pott's puffy tumor is a term used to describe a soft tissue
swelling because of a subperiosteal abscess over the region of the frontal
sinus. This occurs when the anterior table of the frontal sinus is involved in
an osteomyelitic process which is usually because of a sinusitis but may
be a result of a mucocele from a fracture. The offending organism in many
cases is S. aureus. A malignancy of the frontal sinus, though exceedingly
rare, should be considered in the differential. The pathophysiologic of
development of a mucocele with subsequent osteomyelitis is an obstructed
frontal sinus outflow tract. This occurs by thrombophlebitis of the diploic
veins of the frontal bone or via direct extension.
The treatment of frontal sinus fractures depends on which table(s) of bone
are fractured and the degree of displacement or comminution.
Nondisplaced noncomminuted anterior table fractures can usually be
observed unless CT scan shows persistent opacification, in which case
endoscopic exploration or trephination of the sinus may be warranted.
Displaced anterior table fractures produce obvious cosmetic deformity and
can be reduced with low profile miniplates and preservation of as much
native bone as possible. Nondisplaced posterior table fractures that do not
cause CSF leaks can be observed with antibiotic treatment. Indications for
Answer B.
Mucoceles can develop several years after the initial
fracture, the average being 7.5 years. Other
complications of frontal sinus fractures include sinusitis,
headache, forehead numbness (from supraorbital or
supratrochlear nerve trauma), meningitis, brain
abscess, cosmetic deformity, and diplopia and eye
pulsations in the event of a carotid-cavernous fistula.
Other intracranial complications of sinusitis in general
include meningitis, epidural, subdural and intracerebral
abscesses, and superior sagittal sinus thrombosis as
well as Pott's puffy tumor. Pott's abscess is an eponym
to describe tuberculosis of the spine and the other
answer choices are merely distractors.
The overall success rate of cervical
myotomy for patients with a
pharyngoesophageal swallowing
dysfunction is
(A) 20%
(B) 35%
(C) 65%
(D) 90%
Answer C.
Explanation: The more liberal application of myotomy to problems of the
oropharyngeal phase of swallowing has resulted in an overall success rate
in the relief of symptoms of only 64%. When patients are selected using
radiographic or motility markers of disease as outlined above, it is unusual
for patients not to see benefit. (See Schwartz 8th ed., Chapter 24, Motility
Disorders of the Pharynx and Esophagus.)