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Differential List
NEURO OTOLOGY
FACIAL NERVE PALSY
1.
2.
3.
4.
5.
6.
Bells Palsy
50%
Trauma
25%
Zoster
12%
Infection
5%
(AOM, CSOM, cholesteatoma, malignant otitis, BOSO)
Tumour
5%
(schwannoma, haemangioma)
Other
3%
A:
autoimmune
B:
BIH, bone dysplasia eg osteopetrosis or fibrous dysplasia
C:
congenital (mobius, goldenhars)
D:
diabetic neuropathy
E:
dEmyelination
F:
funny infections eg lyme disease, leprosy
G:
granulomatous (sarcoid),
BILATERAL FACIAL NERVE PALSY
1. Congenital (mobius)
2. Acquired
a. Bells
b. Traumatic (base of skull, brainstem)
c. Guillain Barre
d. Rare (sarcoid, leukemia, osteopetrosis)
e. CENTRAL
Clot eg embolism/infarction
E dEmyelination
Nutritional
Tumour
Retrocochlear lesion
Alcohol
Lesion of Posterior cranial fossa
CONGENTAL FACIAL N PALSY
1. congenital
a. mononeuritis agenesis
b. syndromal
i. Mobius
ii. Hemifacial microsomia
c. Teratogen, rubella, thalidomide
2. early acquired
a. birth trauma
b. bells
c. infectious
i. EBV
ii. Meningitis
iii. Poliomyelitis
iv. AOM
CEREBELLOPONTINE ANGLE
Primary tumours of the CP angle
(%) - Gonzales
1)
2)
3)
4)
5)
75%
6%
6%
5%
6%
Acoustic Schwannoma
Meningioma
Epidermoid
Cranial nerve Schwannoma
Petrous Apex infilt CPA
Benign
1.
2.
3.
4.
5.
Arachnoid cyst
Aneurysm
Asymmetrical pneumatisation
Chondroma
A rare benign neoplasm eg paraganglioma, adenoma, haemangioma
Malignant
1.
2.
3.
4.
5.
SCC
Chondrosarcoma
Adenocarcinoma
MSG
Metastases (KOTLPTB)
Intraaxial tumours
1. haemangioblastoma
2. medulloblastoma
3. astrocytoma
4. glioma – brainstem
5. ependymoma
Points to mention about Radiology for CPA angle
A:
B:
C:
D:
F:
G:
Asymmetry or symmetry with IAC, Acute or obtuse angle with tumour/petrous face
Bone changes - widening of IAC (AS) or hyperostosis (meningioma)
Calcification with Meningioma
Dural tail
Fluid density (epidermoid or Arachnoid cyst) – look for CSF cap for VIII
Gadolinium enhancement
CLIVUS AREA
1.
2.
3.
4.
5.
Pituitary Macroadenoma
Clival Chordoma
Chondrosarcoma
Meningioma
Sphenoid Malignancy
PETROUS APEX
Cystic
1. cholesterol granuloma
2. cholesteatoma
3. mucocoele
a. exclude – bone marrow, abnormal pneumatization
b. other ddx = petrous carotid aneurysm, petrous apex encephalocoele
Solid
1. chondroma
2. chondrosarcoma
3. giant cell tumour
4. haemangioma
5. metastatic tumour
6. lymphoma, myeloma, plasmacytoma
7. meningioma
8. trigeminal schwannoma
PARAPHARYNGEAL SPACE MASS
1.
2.
3.
4.
Salivary gland tissue
Neurogenic (shwannomata, neurofibroma)
Paraganglioma (CBT>GJ>GV)
Other (adult = SCC, NPC, child = RMS, lymphoma)
-
50%
25%
15%
10%
DESTRUCTIVE BASE OF SKULL
1.
2.
3.
4.
5.
6.
Metastases
Osteomyelitis
Paraganglioma
Plasmacytoma
Eosinophilic granuloma (histiocytosis X)
Leukaemic deposits
JUGULAR FORAMEN
1.
2.
3.
4.
5.
6.
Paraganglioma GJ>GV>GT
Shwannoma
Chordoma
Chondroma
Chondrosarcoma
Metastases (KOTLPTB)
HYPEROSTOTIC BONE
1. chronic osteomyelitis
2. bone dysplasia
a. pagets disease
b. osteopetrosis
3. meningioma
4. osteoblastic metastases
ULCER IN EAC
1.
2.
3.
4.
5.
Malignancy (SCC, adenoid cystic, BCC, MSG, Lymphoma)
Malignant otitis externa
Osteoradionecrosis of temporal bone
External canal cholesteatoma
Other
a. First arch anomaly
b. Dermatologic disorders
c. Trauma - burns, chemical
d. Viral, fungal inflammation
MASS in EAC
1. Neoplastic
a. Malignant (SCC, MSG)
b. Benign (exostoses, osteoma, ceruminoma)
2. Cholesteatoma
3. Temporal bone #
st
4. 1 branchial arch abnormality
EAC TUMOUR
benign
1. osteoma / exostoses
2. adenoma
3. papilloma
4. ceruminoma
5. pleomorphic adenoma
6. chondroma
7. haemangioma
malignant
1. SCC
2. BCC
3. Melanoma
4. adenocarcinoma
5. malignant ceruminoma
6. mucoepidermoid / adenoid cystic
7. other
paediatric
1. rhabdomyosarcoma
2. neuroblastoma
3. histiocytosis X
CANAL STENOSIS
1.
2.
3.
4.
5.
6.
7.
Congenital (atresia)
Infective
Inflammatory (cicatrizing otitis externa)
Neoplastic (eosinophilic granuloma)
X-rays eg Radiotherapy
Post surgical eg blind sac
Trauma
RED MASS IN ME
1.
2.
3.
4.
Neoplasm
a. glomus
b. adenoma
c. meningioma
d. minor salivary gland neoplasm
e. schwannoma
f. histiocytosis
g. plasmacytoma
Normal variant
a. high jugular bulb
b. ectopic ICA / persistent stapedial artery
Inflammatory
a. schwartz’s sign – otosclerosis
b. cholesterol granuloma
c. fibrous dysplasia
Trauma
a. haemotympanum
WHITE MASS IN MIDDLE EAR
1.
2.
3.
4.
5.
Cholesteatoma
Tympanosclerosis
Endostosis
Graft/prosthesis
Tumour
a. Schwannoma
b. Osteoma
c. other
PINNA INFLAMMATION
1.
2.
Infective:
a. Bacterial
b. Viral – HZO
Inflammatory:
a. Allergy - HA/ topical meds
b. Relapsing polychondritis
c. SLE
d. Dermatologic disorders
MIDDLE EAR EFFUSION
1.
2.
3.
4.
Infective
a. B, V
Traumatic
a. Barotraumas
Inflammatory –
a. wegner's
b. sarcoid
Neoplasia
TM Perforation
1.
2.
3.
4.
CSOM
a. Cholesteatoma
Iatrogenic
Trauma
Inflammation - TB, Syphilis, Wegner's
AURAL POLYP
1.
2.
3.
4.
5.
Neoplasia
Sentinel polyp – cholesteatoma
Skull Base Osteomyelitis
CSOM
Others:
a. 1st arch abnormalities
b. Traumatic
c. Inflammatory - wegners, TB etc
MENIERE’S DISEASE
Central
1. acoustic neuroma
2. glioma
3. meningioma
4. Arnold chiari
5. MS
6. CVA / TIA
7. aneurysm
Peripheral
1. BPPV
2. viral labrynthitis
3. perilymph fistula
4. trauma
5. autoimmune ear disease
6. migrainous vertigo
Metabolic
1. diabetes
2. hyperthyroidism
3. neurosyphillis
4. cogan’s
RHINOLOGY
UNILATERAL PROPTOSIS
ADULT
1.
2.
3.
4.
5.
Inflammatory (graves disease – usually bilateral but still most common)
Infective (complication sinusitis, orbital apex syndrome, mucocele, granulomatous)
Neoplastic (extra orbital and intraorbital)
Pseudotumour (non-granulomatous local inflammation of unknown cause)
Trauma
CHILD
1. Inflammatory
2. Congenital (dermoid, vascular anomaly)
3. Neoplastic (rhabdomyosarcoma, lymphoma, neuroblastoma, leukaemia)
PTOSIS
1. congenital
2. IIIrd Nerve palsy
3. Horner’s Syndrome
4. Myasthenia gravis
5. Myopathy
6. pseudoptosis – eyelid oedema
UNILATERAL SINUS OPACITY
1.
2.
3.
4.
5.
6.
Infective (unilateral sinusitis)
Mycetoma
Antrochoanal polyp
Inverted papilloma
inflammatory – wegeners, sarcoid, churg-strauss)
Neoplasia
MIDLINE NASAL MASS IN CHILD
1.
2.
3.
4.
5.
6.
Dermoid, teratoma
encephalocele
Glioma
Adenoid
Thornwalt’s
Neoplastic (JNA, rhabdomyosarcoma, lymphoma or leukaemia)
MIDLINE DESTRUCTION
1.
2.
3.
4.
5.
6.
7.
8.
lymphoma
wegener’s
mucormycosis
cocaine
malignancy
syphilis
TB
churg-strauss
NASAL MASS IN CHILD
1.
2.
3.
4.
encephalocele
dermoid, teratoma
glioma
nasolacrimal duct cyst, nasopalatine duct cyst
NASAL VESTIBULE LESION
1. Infective (B – Staph vestibulitis, V – HSV, F/P – ringworm)
2. Inflammatory (sarcoid, wegeners)
3. Neoplastic
a. (include squamous papilloma – most common, SCC, BCC, Melanoma, Sarcoma,
Lymphoma)
SEPTAL PERFORATION / SADDLING
1.
2.
3.
4.
5.
Infective (TB, syphilis, invasive fungal, rhinoscleroma, leprosy)
Inflammatory (sarcoid, wegeners, relapsing PC, Churg-Strauss, SLE)
Neoplastic (lymphoma, melanoma, SCC)
Pharmacologic (rhinitis medicomentosa, cocaine)
Trauma (iatrogenic, digital)
NASAL MASS MEDIAL TO MIDDLE TURBINATE
1.
2.
3.
4.
5.
SCC
MSG (adenocarcinoma, mucoepidermoid, adenoid cystic, acinic cell)
esthesioneuroblastoma
Mucosal melanoma
SNUC
RHINOSINUSITIS
1. Allergic (50%)
2. Non-Allergic (50%)
a. Infective include anatomical factors and physiological factors
b. Hormonal (menstruation, menopause, pregnancy, puberty)
c. Atrophic (primary Vs secondary)
d. Traumatic (thermal, chemical, physical)
e. Endocrine (thyroid disease)
f. Drugs (medicomentosa, cocaine, OCP, antihypertensives, NSAID)
g. Choanal atresia (abnormal airflow)
h. Vasomotor
NASAL MASS IN CHILD
1.
2.
3.
4.
5.
6.
7.
8.
9.
Dermoid (midline, frontotemporal, parietal, orbital, nasoglabellar)
encephalocele
glioma
Dacrocystocele (nasolacrimal duct cyst)
Tornwalt’s cyst
Rathke’s pouch cyst
angiofibroma
Lymphoma
Rhabdomyosarcoma
FIBROOSSEOUS LESIONS of Paranasal sinuses
•
•
Of the nonepithelial tumors that involve the sinonasal cavities,
o 25% are osseous or fibroosseous lesions.
Grouped
o abnormal bone development causing masses eg
 Paget’s disease,
 fibrous dysplasia,
 cemento-ossifying dysplasia,
 cherubism,
 giant cell reparative granuloma
o benign osseous tumors eg
 osteoma,
 osteochondroma,
 exostosis,
 osteoid osteoma,
 osteoblastoma,
 ossifying fibroma,
 chondroma,
 giant cell tumor
o malignant tumors eg
 chondrosarcoma,
 osteogenic sarcoma
VAULT NOSE MASS
1.
2.
3.
4.
5.
6.
7.
SCC
Adenocarcinoma
Esthesioneuroblastoma
Melanoma
minor salivary gland neoplasm
SNUC
Lymphoma
FACIAL LESION
1. SCC
2. BCC
3. Melanoma
4. Merkel cell Sarcoma
5. Karposi Sarcoma
6. Lymphoma
7. Others:
8. Benign - KA, Actinic keratosis, Seborrheic keratosis, Bowen's disease
9. Inflammatory - B, V, F inc TB
10. Traumatic
ATROPHIC RHINITIS
1. Secondary
a. Postop
b. post inflammatory
c. Underlying inflammation (sarcoid, WG) or neoplasia
2. Primary - Kebsiella Ozena
VPI
1. congenital
1.
Idiopathic insufficiency of the musculature
2.
Congenital palatal insufficiency - cleft palate, short palate, pharynx too
capacious (palatopharyngeal disproportion)
3.
Submucous cleft palate or “occult submucous cleft palate” - absence of
musculus uvulae on nasal surface on nasopharyngoscopy
2. post-op
1.
Following cleft palate repair - incidence of VPI = 15%-30%
2.
After mid-face advancement (Le Fort I or bimaxillary osteotomy)
3.
After adenoidectomy
3. enlarged tonsils restrict airway t/f open sphincter
4. neurogenic 1.
hemifacial microsomia w unilateral weakness,
2.
peripheral neuritis,
3.
myasthenia gravis,
4.
nuclear lesions,
5.
bulbar poliomyelitis, supranuclear paresis (usually congenital & typified by
cerebral palsy)
6.
upper & lower motor neuron lesions
7.
Functional hypernasality in deaf patients.
8.
Hysterical hypernasality
HEAD AND NECK
PAROTID LUMP
1. Infective
a. (TBATS) (toxo, bartonella (cat-scratch), actinomycoses, TB, syphilis)
b. Viral – paramyxovirus, EBV CMV
c. Sialoadenitis
2. Inflammatory
a. Wegeners
b. Sarcoid
c. Necrotising sialometaplasia
d. Benign lymphoepithelial lesion (HIV, Sjogrens, Miculicz, punctuate parotitis)
3. Neoplastic
a. Benign
i. Pleomorphic
ii. Monomorphic
1. Warthins
2. Oncocytoma
iii. Papilloma
1. inverted
2. intraductal
iv. haemangioma
v. neurofibroma
vi. lipoma
b. malignant
i. mucoepidermoid
ii. acinic cell
iii. adenoid cystic
iv. carcinoma ex pleomorphic
v. lymphoma (MALT)
vi. basal cell adenocarcinoma
vii. epithelial – myoepithelial ca
viii. sebaceous carcinoma
ix. adenocarcinoma
x. myoepithelial malignancy
xi. small cell carcinoma
xii. malignant oncocytoma
c. Metastatic
i. SCC
ii. Melanoma
iii. Renal cell ca
iv. Thyroid ca
MIDLINE NECK MASS
1.
2.
3.
4.
5.
6.
dermoid, epidermoid, teratoma
thyroglossal duct cyst
thyroid nodule
thyroid malignancy
delphian node (draining aerodigestive malignancy)
direct extension of upper aerodigestive malignancy
PULSATILE NECK MASS
1.
2.
3.
4.
ectatic carotid
aneurysm
paraganglioma
transmitted pulsation
LATERAL NECK MASS
1. Lymph node
a. Reactive lymph node
b. Suppurative lymph node
c. Granulomatous disease of head and neck
d. Metastatic disease in lymph node from upper aerodigestive tract or skin
e. Primary malignancy of lymph node eg lymphoma or leukaemia
2.
3.
4.
5.
6.
Branchial anomaly (cyst, sinus, fistula)
Lipoma, Fibroma, Vascular anomaly
Schwannoma
Paraganglioma (glomus vagale, carotid body tumour)
Direct extension of upper aerodigestive tumour
CALCIFICATION IN LYMPH NODE
1. Neoplastic – (SCC, Papillary Ca thyroid, ~medullary thyoird Ca)
2. Infective (TB)
3. Dystrophic calcification
CYSTIC NECK MASS
benign
1.
2.
3.
4.
5.
6.
7.
8.
thyroglossal duct cyst
ranula
sebaceous cyst
dermoid, teratoma
branchial anomaly
lymphatic malformation / vascular malformation
cystic thyroid nodule
lipoma
malignant
1. cystic metastatic lymph node (usually waldeyers ring SCC)
2. papillary Ca Thyroid
3. branchiogenic carcinoma
SUBMANDIBULAR MASS
1.
2.
3.
4.
5.
Infective (sialadenitis)
Inflammatory
Neoplastic (primary salivary gland or Lymph node)
sialadenosis
plunging ranula
SKIN
1.
2.
3.
4.
BCC (rodent ulcer)
SCC
Neuroendocrine (cutaneous melanoma, merckel cell carcinoma
skin metastases (rare)
MOUTH ULCER
1. infective
a. bacterial
i. vincent’s, TB, syphilis
b. viral
i. HSV,CMV,HIV,Coxsackie
c. Fungal
i. Erosive candida
2. inflammatory (
a. aphthous ulcer –inflammatory bowel
b. pemphigus, pemphigoid,
c. autoimmune
i. lichen planus
d. bechet’s
e. reiter’s
f. necrotizing sialometaplasia
3. neoplastic (SCC, variant SCC, MSG)
4. xerostomia
5. pharmacologic
a. aspirin,
b. erythema multiforme,
c. steven - johnson
6. trauma
a. chemical
b. physical
c. radiation
7. anaemia
a. B12 / folate deficiency
MOUTH LESION (BLUE)
1.
2.
3.
4.
ranula
vascular anomaly
jaw cyst
neoplastic
MOUTH LESION (WHITE)
1.
2.
3.
4.
Leukoplakia
Lichen Planus
Candidiasis
Chemical burn (eg aspirin)
MOUTH LESION (BROWN)
1.
2.
3.
4.
5.
Melanosis (racial, smoking, addison’s, Puetz Jegher)
Melanoma
Amalgam tattoo
Black hairy tongue
Kaposi’s sarcoma
MOUTH LESION (RED)
1.
2.
3.
4.
erythroplakia
candidiasis
lichen planus
vascular anomaly
XEROSTOMIA
1.
2.
3.
4.
5.
6.
radiotherapy
drugs
a. anticholinergics / phenothiazides
b. chemotherapy / antiparkinsons
surgery – salivary glands
sjogren’s syndrome
sarcoidosis
lymphoma
JAW LESION
1. Non Odontogenic
a. Nasoplatine (midline)
b. Nasolabial
2. True Odontogenic
a. Inflammatory (radicular, paradental)
b. Developmental (follicular, OKC, periodontal, glandular)
c. Neoplastic (ameloblastoma, ameloblastic Ca)
3. Infiltration from other area eg (Oral cavity, Salivary gland)
4. Metastases (KOTLPTB)
ANGLE OF JAW MASS
1. Parotid lump
2. Lymph node mass
a. Neoplasia
b. Inflammatory
3. Parapharyngeal mass
4. Aneurysm
5. Lipoma
6. Jaw / teeth – cyst tumour
7. Mesenchymal tumour
LARYNX / HYPOPHARYNX – MASS
Congenital
1. saccular cyst
2. cystic hygroma
3. epidermoid
Inflammatory
1. pyogenic granuloma
2. epiglottitis
3. laryngopyocoele
4. ductal retention cyst
Granulomatous
1. wegeners
2. amyloidosis
3. sarcoidosis
4. TB
5. syphilis
Neoplastic – benign
1. papilloma
2. adenoma
3. oncocytoma
4. granular cell tumour
5. chondroma
6. rhabdomyoma
7. haemangioma
8. neurolemmomma
9. leiomyoma
10. lipoma
11. paraganglioma
12. lymphangioma
Neoplastic – malignant
1. SCC
2. verrucous SCC
3. chondrosarcoma
4. adenoid cystic
5. mucoepidermoid
6. neuroendocrine
a. merkel cell
b. carcinoid
c. atypical carcinoid
d. small cell
7. melanoma
8. synovial sarcoma
9. malignant schwannoma
10. liposarcoma
11. rhabdomyosarcoma
12. karposi’s sarcoma
13. lymphoma
a. HL
b. NHL
14. Metastases
SUPRACLAVICULAR MASS
1. metastatic nodal mass
a. GIT
b. Breast
c. Chest
d. Locoregional
2. primary nodal malignancy – lymphoma
3. cystic hygroma
4. lipoma
5. meurilemoma
6. angioma
7. anurysm of surpraclavicular vessels
LATERAL NECK MASS - POSTERIOR TRIANGLE
1. Congenital
a. Vascular malformation / haemangioma
b. Dermoid / teratoma
2. Acquired
a. Inflammatory – LN
b. Neoplastic – B or M
c. Vascular
LATERAL NECK MASS - ANTERIOR TRIANGLE
1.
2.
3.
4.
Neoplastic – LN or salivary
Inflammatory – LN or SG
Branchial cyst
Carotid body / neural tumour
GINGIVAL ENLARGEMENT
1. Leukaemia
2. Hormonal – pregnancy, puberty
3. Medications – phenytoin, cyclosporine
MACROGLOSSIA
1. Primary
a. Down syndrome, or developmental eg Beckwith Wiedemann, Hurlers, cretinism
2. Tumors
a. Hemangioma, lymphangioma, neurofibroma, neurilemmoma, or thyroglossal duct
cyst
3. Infections
a. Actinomycosis, tuberculosis, histoplasmosis, or syphilis
4. Metabolic –
a. Hypothyroidism, acromegaly, multiple myeloma, or amyloidosis
5. Other
a. Amyloid,
b. Angioedema,
c. sarcoidosis,
d. superior vena cava syndrome
ORAL NEUROFIBROMATA
1. NF1
2. NF2
3. Tuberous sclerosis
PALATE ULCER
1.
2.
3.
4.
5.
SCC
MSG tumour
Lymphoma
Necrotising sialometaplasia
Others:
a. Neoplastic
b. Inflammatory - TB, sarcoid, Wegners
c. Traumatic - denture granuloma
PALATE LUMP
1.
2.
3.
4.
5.
Congenital - alveolar, developmental cyst
Neoplastic B or M
Inflammatory - wegner's, sarcoid, NecrotisingSM, mucocele
Infective - TB, Rhinoscleroma
Traumatic - denture granuloma
LARYNGOLOGY
UNILATERAL VOCAL CORD IMMOBILITY
Cricoarytenoid fixation
1. trauma haemarthrosis
2. local inflammation (infection or FB)
3. arthritis
RLN palsy
1. Neoplastic
a. Ca Larynx (RLN palsy or cricoarytenoid invasion or significant tumor bulk)
b. Ca Lung
c. Mediastinal Pathology
d. Skull base, central
2. Trauma
a. Iatrogenic –
a. thyroid, carotid endartectomy, anterior cervical fusion
b. intubation
b. blunt, penetrating trauama
3. Neuritis
a. Toxic (ETOH, lead, arsenic)
b. Diabetic neuropathy
c. Ischaemic (collagen vascular disaease)
4. Infective
a. Viral
b. TB
5. Central – bulbar palsy, ALS
6. Idiopathic (20%)
BILATERAL VOCAL CORD IMMOBILITY
1. thyroid surgery (almost all cases)
2. intubation trauma (posterior glottic stenosis)
3. inflammatory arthritis
4. neuromuscular weakness
a. myasthenia gravis
b. muscular dystrophy
c. multiple sclerosis
d. Arnold chiari / hydrocephalus
VOCAL CORD PALSY (CHILDREN)
1. Neurological disease –benign congenital hypotonia, cerebral palsy, leukodystrophy,
Charcot –Marie – Tooth disease
2. Meningomyelocele with Arnold-Chiari malformation and hydrocephalus
3. Birth trauma
4. Surgical trauma – TOF repair, Cardiac surgery, Intubation injury to RLN
5. Malignancy
6. Idiopathic
SUBGLOTTIC STENOSIS
1. Congenital (5%)
2. traumatic – aquired stenosis (prolonged ETT), granuloma
3. inflammatory –
4. infectious – croup, TB, Syphilis, klebsiella rhinoscleroma
5. Autoimmune – Wegener’s, sarcoid, relapsing polychondrittis
6. Other - GORD
7. neoplastic – Haemangioma, papilloma, SCC
8. Idiopathic
STRIDOR (CHILDREN)
1.
2.
3.
4.
5.
6.
Laryngomalacia 70%
Subglottic Stenosis / Webs
Vocal cord palsy
Tracheomalacia
Subglottic haemangioma
Others – clefts, cysts etc
VOCAL CORD LESION
Specific lesions
1. Nodules
2. Polyp
3. Cyst
a. Ductal retention
b. Squamous inclussional (epidermoid)
4. Granuloma
5. Reinkes oedema
Inflammatory
1. amyloidosis
2. wegener’s
3. TB
4. leprosy
5. sarcoid
6. histoplasmosis
Dysplasia
1. mild
2. moderate
3. severe
4. CIS
Tumour
Benign
1. papilloma
2. pyogenic granuloma
Malignant
See Ddx mass in larynx
CYSTIC LARYNGEAL LESION
1.
2.
3.
4.
anterior saccular cyst (small ant, mucous filled)
lateral saccular cyst / laryngocoele
cystic hygroma (endodermal anomaly of lymphatic vessels)
intracordal cyst
a. ductal retention cyst
i.
rupture → sulcus
b. epidermoid
OPERATIVE CASES
RETROBULBAR BLEED
1.
2.
3.
4.
5.
caused by retraction of significant vessel, usually anterior ethmoid
if on table assessment by orbital balottment only way
if in recovery visual acuity and balottment (most sensitive = light/dark sat + red colour)
immediate lateral canthotomy and cantholysis
simultaneous administration of steroids (8mg dexamethasone) and mannitol (10%-20%
infusion)
reassessment of orbital pressure via balottment
external anterior ethmoid artery ligation
1. injection + tarsorrhaphy
2. lynch incision (midway between nasal midline and lacrimal puncta)
3. down to periosteum
4. periosteum lifted off lacrimal and ethmoid bone
5. fronto-ethmoidal suture encountered and followed (24mm, 12mm, 6mm)
6. using malleable brain retractor gently retract orbital periosteum
7. clip or bipolar vessels
if still significant orbital pressure - medial wall decompression (diploplia 20%)
6.
7.
8.
FACIAL NERVE PALSY POST EAR SURGERY
1.
2.
3.
4.
5.
6.
7.
wait for local anaesthetic to wear off
protect eye
loosen bandage
administer IV steroids
remove dressing from ear
IF NO improvement get senior otologist involved
I would expect the senior otologist will take the patient for exploration within 72 hours)
INTRA-OP FACIAL NERVE INJURY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
cease drilling
inform anaesthetist
optimize conditions eg hemostasis with speed ball, decrease BP etc
visualize defect
use methylene blue (taken up by connective tissue)
contact senior otologist and ask for intraop assisstance
decompress proximal and distal to injury
steroids
if safe close and refer to senior otologist
discuss with patient and family
I would expect senior otologist will explore within 48 hours
less than 33% no further treatment
33%-50% controversial
>50% complete transaction and reconstruct with GA or Sural nerve graft
best outcome HB III
FACIAL NERVE PALSY AFTER EAR SURGERY
1.
2.
3.
4.
local anaesthetic
nd
direct trauma 2 genu or tympanic segment
retrograde trauma after injury to chorda tympani
reactivation of herpes simplex or zoster with bells phenomenon
LASER FIRE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
STOP laser
inform anaesthetist
cease ventilation and disconnect circuit
extubate and place ETT in bucket of water
douse airway with 5 mls of saline
reintubate with fresh ETT
laryngoscopy/bronchoscopy to assess damage
assess face and oropharynx
+/- low tracheostomy if severe burns
root cause analysis
RECALCITRANT EPISTAXIS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
appropriate assessment with history and exam
LOCAL = examine nose and appropriate preparation
REGIONAL = manage blood pressure
SYSTEMIC = take blood, check for coagulopathy and G+ H
pack nose (merocel/rapid rhino pack)
formal pack using foleys catheter or epistat balloon and guaze
indication for OT
greater palatine block
ipsilateral sphenopalatine
contralateral sphenopalatine
external clipping of anterior ethmoidal
interventional radiology with embolisation ipsilateral IMAX, FACIAL
repeat embolisation with contralateral IMAX and FACIAL
if continues despite this and appropriate pack
external carotid artery ligation above superior thyroid
BLEEDING ADENOID
•
•
•
•
•
•
Post adenoidectomy
Bleeding in recovery
Simple measures
o Lie on side
o Drixine down nose
o Bloods Hb Coags G and H
o Cant attempt foleys catheter as temporizing measure or as treatment and
remove next day by slowly deflating ml by ml
Take back to OT
Full stomach
o Will need rapid sequence induction with cricoid pressure
Have available
o Tonsil/adenoid tray
o With drixine on swab
o Suction x 2
Light sources
Laryngoscopes
Bronchoscopes
 In case anaesthetist cant get airway because of blood
Place tonsil gag then place drixine/adrenalin soaked swab in nasopharynx suck out blood
Wait
Feel for remaining adenoid tissue
o Recurrette any remaining adenoid tissue
Look
o Direct vision nasoendoscope
o Mirror
Suction diathermy to bleeders
o Replace pack
o Wait
If still bleeding
o Check for any obvious bleeders if cant stop
o Formal pack
o Rolled gauze suture 3 threads one out each nostril and tied on thru mouth
o Leave intubated
o Check coags
o Remove pack next day in OT
o
o
o
•
•
•
•
•
•
FOREIGN BODY IN PAEDIATRIC AIRWAY
•
Take to OT
o Tell want senior anaesthetist
•
•
•
•
Discuss anaesthetic with anaesthetist
Gaseous induction with sevoflurane
No positive pressure
Have available
o 2 light source
o A range of slotted laryngoscopes
o Range of bronchoscopes
o Range of peanut removing forceps
o Optical guided forceps
•
IV access after induction
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Slotted laryngoscope visualize airway
Connect or and gases to laryngoscope
Topical anaesthetic to airway and down trachea
Rigid telescope down scope look at airway
Look good side first
Look at foreign body
Place bronchoscope remove laryngoscope
Change gases tube
Wait till stable
Suction out secretions
Place adrenalin/drixine on any friable granulaton tissue
Carefully remove with bronchoscope
Do not take into bronchoscope will shear off
Rotated so that long axis of FP is in the line of the cords to avoid damage
Scenario
• If drop
• Go in and retrieve if cannot
•
push down to right main bronchus again
• Wait till numbers stabilize then re attempt removal
Scenario
• Drop down left main bronchus
• Granulation down right main bronchus
• Starting to desaturate
• Bring bronchoscope to back above carina
• This is the only time you can use positive pressure
• When sats stable
• Remove
Scenario
• Attempted removal lots of bleeding
• Place adrenalin or drixine down
• Wait
• Reattempt
• Removal if cannot remove
• Abort procedure
• Antibiotics and steroids
• Reattempt in 24 hours
• If unsuccessful second attempt get cardiothoracic input
•
•
After removal recheck for any further FBs
Place some drixine on granulation tissue
CAUSTIC INJURIES
Child
Immediate LBO indicated if:
- airway compromise
- drooling
- liquid agent ingested
Otherwise, LBO indicated at 24 hours to assess extent of damage, if mucosal injury is evident
beyond posterior tongue
Flexible Gastroscopy only indicated if:
- liquid agent ingested (possible gastric outlet injury)
Ba swallow + meal at 3 weeks – for stricture
FB / Caustic Injuries
Partial Thickness Oesophageal Injuries
NGT passed via oesophagoscope
NBM
iv antibiotics
Consider contrast swallow at 1 day
Full Thickness Oesophageal Injuries in:
Neck = NGT passed via oesophagoscope
NBM
iv antibiotics
Contrast swallow at 1 week
Thoracic = NGT passed via oesophagoscope
NBM
iv antibiotics
immediate Cardiothoracic consult
(? patch repair with bowel or pericardium to prevent mediastinitis)
Abdominal = NGT passed via oesophagoscope
NBM
iv antibiotics
immediate Upper GIT Surgery consult
(? laparatomy to prevent peritonitis)
NECK DISSECTION INCISIONS
1. Modified Apron
2. Hockey stick
3. Inverted Hockey stick
-
selective neck
levels II-V
levels I-V
RADICAL NECK
1. Use inverted hockey stick with horizontal limb from submental to mastoid tip parallel to
mandible – with descending limb from posterior over lateral portion of posterior triangle
2. commence with level I
EXTERNAL-INTERNAL CAROTID ANASTOMOSIS
1.
2.
3.
4.
orbit (supraorbital-STA, lacrimal-meningeal)
nose (anterior ethmoid-sphenopalatine-superior labial-ascend GP)
middle ear (tympanic plexus – caroticotympanic-inferior/superior tympanic)
dura