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584 Section III / Subspecialty Surgery

 

What is Dupuytren’s

Fibrosis of palmar fascia, causing

contracture?

contracture of and inability to extend digits

What is Gamekeeper’s

Injury to the ulnar collateral ligament of

thumb?

the thumb

How should a subungual Release pressure by burning a hole in hematoma be treated? the nail (use hand-held disposable

battery-operated coagulation probe)

CARPAL TUNNEL SYNDROME

What is it?

Compression of the median nerve in the

 

carpal tunnel

Carpal tunnel

7 0 ‘

F R H

What is the most common cause?

What are other causes?

What are the symptoms?

What are the signs?

What is Wartenberg’s sign?

What is the workup?

What is initial treatment?

What are indications for surgery?

What surgery is performed?

Chapter 69 / Hand Surgery 585

Synovitis

“MEDIAN TRAPS”: Median artery (persistent) Edema of pregnancy Diabetes

Idiopathic

Acromegaly

Neoplasm (e.g., ganglioneuroma)

Thyroid (myxedema)

Rheumatoid arthritis

Amyloid

Pneumatic drill usage

SLE

Pain and numbness in the median nerve distribution

Tinel’s sign (symptoms with percussion over median nerve), Phalen’s test (symptoms with flexion of wrists), thenar atrophy, Wartenberg’s sign

With hand resting on a surface, the fifth digit (“pinky”) rests in ABduction compared to the other 4 fingers

EMG, nerve conduction study

Nonoperative, rest, wrist splint, NSAIDs

Refractory symptoms, thenar atrophy, thenar weakness

Release transverse carpal ligament

586 Section III / Subspecialty Surgery

C h a p t e r 70

Otolaryngology:

Head and Neck

Surgery

Define:

 

Anosmia

Inability to smell

Otorrhea

Fluid discharge from ear

Dysphagia

Difficulty swallowing

Odynophagia

Painful swallowing

Globus

Sensation of a “lump in the throat”

Otalgia

Ear pain (often referred from throat)

Trismus

Difficulty opening mouth

ANATOMY

 

 

 

Define the cranial nerves:

 

I

Olfactory nerve

II

Optic nerve

III

Oculomotor nerve

IV

Trochlear nerve

V

Trigeminal nerve

VI

Abducens nerve

VII

Facial nerve

VIII

Vestibulocochlear nerve

IX

Glossopharyngeal nerve

X

Vagus nerve

Chapter 70 / Otolaryngology: Head and Neck Surgery 587

XI

Accessory nerve

XII

Hypoglossal nerve

Define motor/sensory

 

actions of the following

 

cranial nerves:

 

I

Smell

II

Sight (sensory pupil reaction)

III

Eyeball movement, pupil sphincter,

 

ciliary muscle (motor pupil reaction)

IV

Superior oblique muscle movement

V

Motor: chewing (masseter muscle)

 

Sensory: face, teeth, sinuses, cornea

VI

Lateral rectus muscle (lateral gaze)

VII

Motor: facial muscles, lacrimal/

 

sublingual/submandibular glands

 

Sensory: anterior tongue/soft palate, taste

VIII

Hearing, positioning

IX

Motor: stylopharyngeus, parotid, pharynx

 

Sensory: posterior tongue, pharynx,

 

middle ear

X

Motor: vocal cords, heart, bronchus,

 

GI tract

 

Sensory: bronchus, heart, GI tract,

 

larynx, ear

XI

Motor: trapezius muscle,

 

sternocleidomastoid muscle

XII

Motor: tongue, strap muscles (ansa

 

cervicalis branch)

What are the three divisions

1. Ophthalmic

of the trigeminal nerve

2. Maxillary

(cranial nerve V)?

3. Mandibular

588 Section III / Subspecialty Surgery

What happens when the hypoglossal nerve (cranial nerve XII) is cut?

Name the duct of the submandibular gland.

Name the duct of the parotid gland.

What is the source of blood supply to the nose?

When the patient sticks out the tongue, it deviates to the same side as the injury (wheelbarrow effect)

Wharton’s duct

Stensen’s duct

1.Internal carotid artery: anterior and posterior ethmoidal arteries via ophthalmic artery

2.External carotid artery: superior labial artery (via facial artery) and sphenopalatine artery (via internal maxillary artery)

Name the three bones that

1.

Ethmoid (perpendicular plate)

make up the posterior nasal

2.

Vomer (Latin for “plow”)

septum.

3.

Palatine (some also include maxillary

 

 

crest)

Name the seven bones of

1.

Frontal

the bony eyeball orbit.

2.

Zygoma

 

3.

Maxillary

 

4.

Lacrimal

 

5.

Ethmoid

 

6.

Palatine

 

7.

Sphenoid

Name the four strap muscles.

“TOSS”:

 

 

1.

Thyrohyoid

 

 

2. Omohyoid

 

 

3.

Sternothyroid

 

 

4.

Sternohyoid

Which muscle crosses the

Digastric muscle

external and internal carotid

 

 

 

arteries?

 

 

 

In a neck incision, what is

Platysma

the first muscle incised?

 

 

 

Which nerve supplies the

Ansa cervicalis (XII)

strap muscles?

 

 

 

Chapter 70 / Otolaryngology: Head and Neck Surgery 589

What are the anterior and posterior neck triangles?

Two regions of the neck, divided by the sternocleidomastoid muscle

 

Posterior

 

triangle

 

Sternocleidomastoid

 

muscle

Which nerve runs with the

Vagus

carotid in the carotid sheath?

 

Which nerve crosses the

Hypoglossal nerve

internal carotid artery at

 

approximately 1 to 2 cm

 

above the bifurcation?

 

Anterior

triangle

Name the three auditory

1.

Malleus (hammer)

ossicle bones.

2.

Incus (anvil)

 

3.

Stapes (stirrup)

What comprises the middle

Eustachian tube, ossicle bones, tympanic

ear?

membrane (“ear drum”), mastoid air cell

What comprises the inner

Cochlea, semicircular canals, internal

ear?

auditory canal

EAR

 

 

 

 

OTITIS EXTERNA (SWIMMER’S EAR)

 

 

 

What is it?

Generalized infection involving the

 

external ear canal and often the tympanic

 

membrane

590 Section III / Subspecialty Surgery

 

What is the usual cause?

Prolonged water exposure and damaged

 

squamous epithelium of the ear canal

 

(e.g., swimming, hearing aid use)

What are the typical

Most frequently Pseudomonas, may be

pathogens?

Proteus, Staphylococcus, occasionally

 

Escherichia coli, fungi (Aspergillus,

 

Candida), or virus (herpes zoster or

 

herpes simplex)

What are the signs/

Ear pain (otalgia); swelling of external

symptoms?

ear, ear canal, or both; erythema; pain on

 

manipulation of the auricle; debris in

 

canal; otorrhea

What is the treatment?

Keep the ear dry; mild infections respond

 

to cleaning and dilute acetic acid drops;

 

most infections require complete removal

 

of all debris and topical antibiotics with or

 

without hydrocortisone (anti-inflammatory)

MALIGNANT OTITIS EXTERNA (MOE)

 

 

What is it?

Fulminant bacterial otitis externa

Is it malignant cancer?

NO!

Who is affected?

Most common scenario: elderly patient

 

with poorly controlled diabetes (other

 

forms of immunosuppression do not

 

appear to predispose patients to MOE)

What are the causative

Usually Pseudomonas aeruginosa

organisms?

 

What is the classic feature?

Nub of granulation tissue on the floor

 

of the external ear canal at the

 

bony–cartilaginous junction

What are the other signs/ symptoms?

Severe ear pain, excessive purulent discharge, and usually exposed bone

Chapter 70 / Otolaryngology: Head and Neck Surgery 591

What are the diagnostic

1. CT scan: shows erosion of bone,

tests?

inflammation

 

2. Technetium-99 scan: temporal bone

 

inflammatory process

 

3. Gallium-tagged white blood cell scan:

 

to follow and document resolution

What are the complications?

Invasion of surrounding structures to

 

produce a cellulitis, osteomyelitis of

 

temporal bone, mastoiditis; later, a facial

 

nerve palsy, meningitis, or brain abscess

What is the treatment?

Control of diabetes, meticulous local

 

care with extensive debridement,

 

hospitalization and IV antibiotics (anti-

 

Pseudomonas: usually an aminoglycoside

 

plus a penicillin)

TUMORS OF THE EXTERNAL EAR

What are the most common types?

From what location do they usually arise?

What is the associated risk factor?

What is the treatment of the following conditions:

Cancers of the auricle?

Extension to the canal?

Middle ear involvement?

Squamous cell most common; occasionally, basal cell carcinoma or melanoma

Auricle, but occasionally from the external canal

Excessive sun exposure

Usually wedge excision

May require excision of the external ear canal or partial temporal bone excision

Best treated by en bloc temporal bone resection and lymph node dissection

TYMPANIC MEMBRANE (TM) PERFORATION

What is the etiology? Usually the result of trauma (direct or indirect) or secondary to middle ear infection; often occurs secondary to slap to the side of the head (compression injury), explosions

592 Section III / Subspecialty Surgery

 

What are the symptoms?

Pain, bleeding from the ear, conductive

 

hearing loss, tinnitus

What are the signs?

Clot in the meatus, visible tear in the TM

What is the treatment?

Keep dry; use systemic antibiotics if there

 

is evidence of infection or contamination

What is the prognosis?

Most (90%) heal spontaneously, though

 

larger perforations may require surgery

 

(e.g., fat plug, temporalis fascia

 

tympanoplasty)

CHOLESTEATOMA

 

 

 

What is it?

Epidermal inclusion cyst of the middle

 

ear or mastoid, containing desquamated

 

keratin debris; may be acquired or

 

congenital

What are the causes?

Negative middle ear pressure from

 

eustachian tube dysfunction (primary

 

acquired) or direct growth of epithelium

 

through a TM perforation (secondary

 

acquired)

What other condition is it

Chronic middle ear infection

often associated with?

 

What is the usual history?

Chronic ear infection with chronic,

 

malodorous drainage

What is the appearance?

Grayish-white, shiny keratinous mass

 

behind or involving the TM; often

 

described as a “pearly” lesion

What are the associated

Ossicular erosion, producing conductive

problems?

hearing loss; also, local invasion resulting in:

 

Vertigo/sensorineural hearing loss

 

Facial paresis/paralysis

 

CNS dysfunction/infection

What is the treatment?

Surgery (tympanoplasty/mastoidectomy)

 

aimed at eradication of disease and

 

reconstruction of the ossicular chain

Chapter 70 / Otolaryngology: Head and Neck Surgery 593

BULLOUS MYRINGITIS

What is it?

Vesicular infection of the TM and

 

adjacent deep canal

What are the causative

Unknown; viral should be suspected

agents?

because of frequent association with viral

 

URI (in some instances, Mycoplasma

 

pneumoniae has been cultured)

What are the symptoms?

Acute, severe ear pain; low-grade fever;

 

and bloody drainage

What are the findings on

Large, reddish blebs on the TM, wall of

otoscopic examination?

the meatus, or both

Is hearing affected?

Rarely; occasional reversible sensorineural

 

loss

What is the treatment?

Oral antibiotics (erythromycin if

 

Mycoplasma is suspected); topical

 

analgesics may be used, with resolution of

 

symptoms usually occurring in 36 hours

ACUTE SUPPURATIVE OTITIS MEDIA (OM)

 

 

What is it?

Bacterial infection of the middle ear,

 

often following a viral URI; may be

 

associated with a middle ear effusion

What is the cause?

Dysfunction of the eustachian tube that

 

allows bacterial entry from nasopharynx;

 

often associated with an occluded eustachian

 

tube, although it is uncertain whether

 

this is a cause or a result of the infection

What are the predisposing

Young age, male gender, bottle feeding,

factors?

crowded living conditions (e.g., day care),

 

cleft palate, Down’s syndrome, cystic fibrosis

What is the etiology? 1. Streptococcus pneumoniae (33% of cases)

2.Haemophilus influenzae

3.Moraxella catarrhalis

4.Staphylococcus

5.-hemolytic strep

6.Pseudomonas aeruginosa

7.Viral/no culture

594 Section III / Subspecialty Surgery

What is the etiology in infants younger than 6 months?

What are the symptoms?

1.Staphylococcus aureus

2.E. coli

3.Klebsiella

Otalgia, fever, decreased hearing, infant pulls on ear, increased irritability; as many as 25% of patients are asymptomatic

What are the signs?

Early, redness of the TM; later, TM

 

bulging with loss of the normal landmarks;

 

finally, impaired TM mobility on pneumatic

 

otoscopy

If pain disappears instantly,

TM perforation!

what may have happened?

 

What are the complications?

TM perforation, acute mastoiditis,

 

meningitis, brain abscess, extradural

 

abscess, labyrinthitis; if recurrent or

 

chronic, OM may have adverse effects on

 

speech and cognitive development as a

 

result of decreased hearing

What is the treatment?

10-day course of antibiotics; amoxicillin is

 

the first-line agent; if the patient is allergic

 

to PCN, trimethoprim-sulfamethoxazole

 

or erythromycin should be administered

What is the usual course?

Symptoms usually resolve in 24 to 36 hours

What are the indications for

1. Persistent middle ear effusion over

myringotomy and PE tube

3 months

placement?

2. Debilitated or immunocompromised

 

patient

 

3. More than three episodes over

 

6 months (especially if bilateral)

What is a PE tube?

What is a Bezold’s abscess?

Pneumatic Equalization tube (tube placed across tympanic membrane)

Abscess behind the superior attachment of the sternocleidomastoid muscle resulting from extension of a mastoid infection

What are causes of chronic

Mixed, S. aureus, P. aeruginosa

otitis media?

 
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