Term
| What are the most commonly found dental cysts and what risks do they carry? |
|
Definition
1) Radicular cyst most common
2) Dentigerous (follicular) cyst second most common. Slight risk of transformation into ameloblastoma, SCCa, or mucoepidermoid. Treat with enucleation and dental extraction.
3) Odontogenic keratocysts- Gorlin syndrome, AD inheritance, multiple BCCs |
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Term
| What is the staging system for supraglottic SCCA? |
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Definition
T1) one subsite
T2) more than one adjacent subsite of suptaglottis or glottis
T3) VC fixation or invasion of postcricoid area, preepiglottic space, paraglottic space of inner cortex of thyroid cartilage
T4a: thyroid cartilage invasion through or tissues beyond larynx |
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Term
| What is the staging system for nodal disease in laryngeal carcinoma? |
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Definition
N1: single ipsilateral LN <3cm
N2a: single ipsi LN 3-6cm
N2b: multiple ipsi
N2c: contralateral
N3: >6cm (a or b determined by ENE) |
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Term
| What primary parotid malignancies require a neck dissection? |
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Definition
1) clinically apparent neck disease
2) High grade histology
3) >4cm (risk of neck goes from 4% to 20%)
** or radiation if no neck done** |
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Term
| What is the current staging system for HPV+ oropharyngeal SCCa? |
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Definition
T1<2cm, T2 2-4, T3 >4 or lingual epiglottis, T4, additional invasion
CN1: unilateral <6, CN2: Bilateral or contralateral <6, CN3: >6cm
pN1 <=4 LNs, pN2 >4 LNs |
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Term
| How is skin melanoma T staged? |
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Definition
TiS: CIS
T1a: <0.8mm and no ulceration
T1b: >0.8 <1.0, or <0.8mm w/ ulceration
T2a: 1-2mm without ulceration
T2b: 1-2 mm with ulceration
T3a/b: 2-4 +/- ulceration
T4a/b: >4 +/- ulceration
T2b or higher makes Stage II disease. If nodes, get Stage III. |
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Term
| How is skin melanoma N staged? |
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Definition
Automatically at least stage III if nodes. if distant mets, its stage IV.
N1a: clinically occult 1 node
N1b: 1 clinically detected
N1c: in transit, microsattelite
N2a: 2-3 occult
N2b: 2-3, at least 1 clinically detected
N2c: in transit
N3a: 4 or more occult
N3b: 4 or more with 1 clinically detected |
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Term
| When is total laryngectomy with partial pharyngectomy indicated in piriform sinus cancer? |
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Definition
1) Medial extension to the larynx with VC fixation
2) Involvement of apex or lateral wall without midline cross
** if crosses midline, need total pharyngectomy** |
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Term
| When should post-op radiation therapy be initiated for head and neck cancer? When could it be delayed? |
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Definition
Within 6 weeks if risk for locoregional recurrence is >20%.
Delay if exposed carotid, but NOT for fistula, open wound, bony exposure or other post-op issues |
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Term
| What is the most common site for a minor salivary gland pleomorphic adenoma? |
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Definition
Palate, followed by lip then buccal mucosa and FOM.
Small risk of transformation to carcinoma |
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Term
| Staging of anaplastic thyroid carcinoma |
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Definition
Always stage IV
IVa limited to thyroid, IVa beyond locally or regional LN mets, IVc distant mets |
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Term
| Which nerve innervates the carotid body and can be activated during carotid body tumor surgery? |
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Definition
Carotid sinus nerve off of CN IX.
Unopposed adrenergic activity can occur |
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Term
| Which osteotomy needs to be done last during subtotal or total maxillectomy? |
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Definition
| Pterygomaxillary fissure because of Imax bleeding |
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Term
| What are the intraoperative anatomical landmarks relevant for finding the facial nerve during parotidectomy? |
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Definition
1) Tragal pointer: CN VII is 1cm inferior and 1cm deep
2) Styloid: Nerve is located posterolateral (if you see styloid, you have gone too far)
3) Tympanomastoid suture line: CNVII 6-8mm deep
4) Posterior belly of digastric: Nerve is anterior and medial to insertion |
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Term
| What are the subtypes of adenoid cystic carcinoma and how does this impact prognosis? |
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Definition
Look out of distant mets. Also can have perineural
1) Cribriform (44%)
2) Tubular (35%): best prognosis
3) Solid (21%): worst prognosis |
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Term
| What maneuvers should be done to achieve a tension free anastomosis during a cervical tracheal resection? |
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Definition
1) Neck flexion (15-35 degrees) give 4-4.5cm added length
2) Blunt dissection along anterior tracheal wall (attempted first)
3) hilar release, and suprahyoid and infrahyoid releases can also be done. |
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Term
| What is the nodal met rate for hypopharyngeal cancer? |
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Definition
| 50-70%. Poor prognosis in general. |
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Term
| What are the functional of E6 and E7 in tumorigenesis in HPV related cancers? |
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Definition
E6 binds p53 (tumor suppressor gene) and leads to degredation
E7 binds to and inhibits RB tumor suppressor gene. |
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Term
| Which paragangliomas have the highest malignant potential? |
|
Definition
Orbital and Laryngeal (25%)
Carotid body (3-6%), vagal (10%), jugulotympanic (5%) are less likely |
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Term
| What is the T and N staging for nasopharyngeal cancer? |
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Definition
- T1 restricted to naso/oropharynx
- T2 in parapharyngeal space or pterygoid muscle, no bone
- T3 in bone and/or sinuses
- T4 intracranial, ITF, orbit or cranial nerve
N1 unilateral met <6 and above cricoid
N2 Bilateral <6 above cricoid
N3 >6cm or below cricoid |
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Term
| During sentinal lymph node biopsy, what % of the counters per minute should a second sentinal node have compared to the hottest node? |
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Definition
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Term
| How can you tell between a vagal paraganglioma and a carotid body tumor on clinical exam? |
|
Definition
Both will be mobile laterally and fixed medially
Vagal tumors typically are not pulsatile and typically won't splay the ICA and ECA (Lyre sign).
Carotid body tumors fall into 3 types (Shamblin). Type 1 is small with minimal vessel attachments. Type 2 is large with moderate attachments. Type 3 is encasement. |
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Term
| Who are good candidates for vertical partial laryngectomy? |
|
Definition
Bulky T1/T2 disease involving the anterior commissure and <1cm of the subglottis. Also need good pulmonary status.
Contraindications:
1) subglottis extension >10mm anteriorly or >5mm posteriorly
2) T3/T4
3) Arytenoid fixation
4) Thyroid cartilage invasion
5) Poor pulmonary status |
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|
Term
| What is Gottfredson's syndrome and what is it commonly associated with? |
|
Definition
Abducens and Hypoglossal palsy
Generally metastatic tumor to clivus. Second most common is infiltrating NPC. |
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Term
| What are the contents of the infratemporal fossa? |
|
Definition
1) Lateral and medial pterygoids
2) V3 and chorda tympani
3) Otic ganglion
4) Maxillary artery and branches |
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Term
| Which malignancies are associated with Sjogren's disease? |
|
Definition
| MALT lymphoma and other NHLs |
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|
Term
| What are the developmental origins of the glottis and subglottis? |
|
Definition
Sixth branchial arch
Supraglottic larynx is 3rd and 4th |
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Term
| What are the appropriate surgical margins for T2b or T3 melanoma? |
|
Definition
| 1-2cm (along with WLE and SLNB) |
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|
Term
| What are the boundaries of the paraglottic space? |
|
Definition
1- Ventricle- mid-medial
2- Quadrangular memebrane- superomedial
3- Conus eleasticus_inferomedial
4- wall of piriform sinus- posterior
5. thyroid cartilage- lateral |
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|
Term
| What is thyroid cancer staging for PTC? |
|
Definition
<55, T1 unless distant mets, then T2
>55, T3 unless distant mets |
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|
Term
| When is concurrent chemotherapy indicated after surgery for head and neck cancer? |
|
Definition
1) Positive margins
2) ENE
3) Distant mets |
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|
Term
| What is the typical anatomic distribution of lip carcinomas? |
|
Definition
**most common site of oral cavity cancer**
1) 95% of lip carcinomas occur in lower lip and 95% of lip tumors are SCC.
2) BCC tends to occur on upper lip, but most common upper lip carcinoma is still SCC
3) risk of cervical mets is 10%
4) upper and lower lip cancers have similar prognosis |
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Term
| What is the likely pattern of metastatic spread for follicular carcinoma? |
|
Definition
Hematogenously often to lungs.
PTC often goes to LNs |
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Term
| Which types of laryngeal SCC are appropriate for a supraglottic laryngectomy? |
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Definition
T1-T2 supraglottic/glottic cancers and T3 supraglottic with pre-epiglottic space involvement.
Cannot have base of tongue, bilateral arytenoid, bicortical thyroid cartilage |
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Term
| How does ENE play into the staging system for HPV- oropharynx and larynx/hypopharynx cancer? |
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Definition
| Clinical ENE in any LN >3cm or ENE in any node which is part of multiple ispsilateral or contralateral or bialteral disease automatically makes stage N3b. |
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|
Term
| What is the rate of malignancy in a follicular lesion with atypia of undetermined significance in the thyroid? |
|
Definition
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|
Term
| How does Octreotide work to treat chyle leaks? |
|
Definition
Used in low volume leaks <500
Reduces GI and pancreatic secretions and reduces splanchnic blood flow |
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|
Term
| How can EBC cell-free DNA be used in the treatment of NPC? |
|
Definition
| To monitor treatment response to RT. |
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|
Term
| What level of therapeutic RT delivered to salivary glands will result in temporary or permanent dysfunction? |
|
Definition
>1000 cGy temporary xerostomia
>2600 cGy permanent |
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|
Term
| What is the most likely diagnosis of a pediatric parotid neoplasm? |
|
Definition
Mucoepidermoid carcinoma (often low grade)
Unlike adults, in kids most salivary gland masses are malignant |
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Term
| When should radiation be included in the treatment of parotid adenoid cystic carcinoma? |
|
Definition
| T3/T4 disease, intermediate or high grade tumor, or T1/T2 if concern for PNI or tumor spillage |
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|
Term
| What are the indications for post-thyroidectomy I-131 treatment? |
|
Definition
1) >4cm tumor
2) Known distant mets
3) Gross ETE
4) Extensive vascular invasion
5) Bulky LNs
6) Post-op TG levels >5-10 ng/ml |
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|
Term
| When is use of laryngeal EMG appropriate after suspected nerve injury? |
|
Definition
| 3-6 months. Earlier is of no prognostic value. |
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|
Term
| When does vocal quality improve in cases of spasmodic dysphonia? |
|
Definition
Sedative use, yelling, singing, whispering or laughing.
Worse with stress (public speaking). |
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|
Term
| What are the risks of malignant transformation for mild/moderate and severe dysplasia in vocal cord lesion? |
|
Definition
Mild-moderate= 10%
Severe= 30-35% |
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|
Term
| How does the RLN relate to the inferior thyroid artery on the left and right? |
|
Definition
Can be variable.
Usually anterior to ITA on the right and posterior to the ITA on the left
Extralaryngeal branching of the right RLN is common |
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|
Term
Where does a Zenker's Diverticulum occur?
What is the most common complication of this condition? |
|
Definition
posterior pharyngoesophageal junction at region of inferior pharyngeal constrictor and cricopharyngeal muscle.
Aspiration, which may cause pneumonia |
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|
Term
| What is the treatment for adductor and abductor spasmodic dysphonia? |
|
Definition
1) Adductor: Botox to TA, vocalis
2) Abductor: Botox to PCA |
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|
Term
| What cartilages make up the laryngeal framework? |
|
Definition
| 3 paired (arytenoid, corniculate, cuneiform) and 3 unpaired (epiglottis, thyroid and cricoid) cartilages predominantly made of hyaline cartilage. |
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|
Term
| What is the action and innervation of the cricothyroid muscle? |
|
Definition
External branch of superior laryngeal
Lengthens and tenses VCs (increases pitch) |
|
|
Term
| What is the most common presenting symptom of RRP in children? |
|
Definition
Dysphonia.
Classic triad is progressive hoarseness, stridor and respiratory distress. |
|
|
Term
| What percentage of congenital VF paralysis is bilateral? |
|
Definition
| 50%. >50% of time requires tracheotomy. |
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|
Term
| What type of material is best for early management of vocal cord dysfunction unilaterally leading to dysphonia and swallowing difficulties? |
|
Definition
Absorbing short-term.
Start with HA.
CAHA also an option but lasts 6-12 months. |
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|
Term
| What are the vocal performance manifestations of abductor vs. adductor spasmodic dysphonia? |
|
Definition
1) Abductor: trouble counting from 60-69. Inject botox into PCA
2) Adductor: Trouble counting 80-89, trouble pronouncing vowels. Inject TA muscle. |
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Term
| What are the histological stains that diagnose a granular cell tumor and where are they found in the larynx? |
|
Definition
Often posterior aspect of true vocal cord.
Pseudoepitheliomatous hyperplasia
+PAS and +S100
3% risk of malignant degeneration. |
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|
Term
| Which is the only intrinsic laryngeal muscle that receives bilateral innervation from the RLN? |
|
Definition
Interarytenoid.
Remember cricothyroid is EBSLN |
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|
Term
| What percentage of unilateral true vocal cord paralysis is idiopathic and what is the prognosis? |
|
Definition
25%.
1/3 completely resolve, 40% show partial return and 25% show no improvement in 1 year.
If nothing for 1 year, unlikely to resolve. |
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Term
| What percentage of unilateral true vocal cord paralysis is idiopathic and what is the prognosis? |
|
Definition
25%.
1/3 completely resolve, 40% show partial return and 25% show no improvement in 1 year.
If nothing for 1 year, unlikely to resolve. |
|
|
Term
| What types of variable extrathoracic obstruction are created by bilateral vocal cord paralysis and tracheomalacia? |
|
Definition
Inspiratory effected without expiratory.
Negative part of flow-volume loop |
|
|
Term
| How are the internal and external carotid arteries diplaced with carotid body and vagal paragangliomas? |
|
Definition
1) Carotid body: external anterior and internal posterior
2) Vagal: External medial, internal anterior |
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|
Term
| Which molecular markers indicate poor prognosis in well differentiated thyroid cancer? |
|
Definition
TERT, BRAF (higher chance of cervical mets, older patients, higher in PTC, higher TNM stage, specific for PTC)
RAS is found in 45% of follicular carcinomas |
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|
Term
| What is the most common cause of primary hyperparathyroidism? |
|
Definition
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|
Term
| What medications can be used in hypercalemic crisis? |
|
Definition
1) Aggressive fluid hydration
2) Loop diuretics
3) Bisphosphonates (first line but take 3-6 days)
4) Calcitonin (within hours) |
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|
Term
| What are the indications for surgery in asymptomatic primary hyperparathyroidism? |
|
Definition
1) Serum Ca >1.0 mg/dL above normal
2) Cr clearance <60 ml/min
3) <50 years old
4) BMD < 2.5 SD by T score or previous fracture fragility |
|
|
Term
| What is the blood supply of the superior and inferior parathyroid glands? |
|
Definition
| Both are inferior thyroid artery |
|
|
Term
| How is T4 produced and how is it available as medication? |
|
Definition
Levothyroxine
Less biologically active than T3, which is formed as deiodination of T4
Half life is 6-7 days (biomarker of choice) vs. 1 day for T3.
90% of thyroid hormone production is in the form of T4 |
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|
Term
| How is subacute (DeQuervain) thyroiditis managed? |
|
Definition
NSAIDs
Can present as thyroiditis after URI |
|
|
Term
| When should elective lateral neck dissection be considered in the management of medullary thyroid cancer>? |
|
Definition
Often find amyloid deposits
1) Primary lesion >1cm
2) Serum calcitonin >20 pg/mL (ispilateral)
3) Serum calcitonin >200 pg/mL (bilateral)
If pheo co-exists, it should be removed first
Monitor with calcitonin post-operatively |
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|
Term
| When do women with hypothyroidism need to increase their T4 dosage? |
|
Definition
If on estrogen (not progesterone) therapy
If pregnant (around fifth week of gestation and plateus by 16-20) |
|
|
Term
| What is the probability of a palpable hypofunctional nodule in graves disease being thyroid cancer? |
|
Definition
| Higher than general population (2x). 45% |
|
|
Term
| In what situation can PTU given when methimazole cannot? |
|
Definition
| 1st trimester of pregnancy. Methimazole can be given for remainder |
|
|
Term
| How do thionamide anti-thyroid drugs work to treat hyperthyroidism? |
|
Definition
Methimazole and PTU block thyroid hormone biosynthesis by inhibiting oxidation and organification of iodine and coupling of iodotyrosines.
BOth drugs reduce T cell activity and inhibit lymphocyte function.
Agranulocytosis occurs in 0.2% of patients
PTU also inhibits conversion of T4 to T3 |
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|
Term
| What are the most common causes of mortality in patients with parathyroid carcinoma? |
|
Definition
Effects of excessive PTH secretion and uncontrolled hypercalcemia
Gray-to-white surface color. Most commonly metastasize to lungs. Often slow, indolent growth |
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