Otolaryngology Board Review Pearls of Wisdom - 3rd Edition

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 DEDICATION

To Peter, Jack, Charlie, and Thomas

for their love and support.
 CONTENTS

Preface viii

SECTION I: ANATOMY AND BASIC SCIENCE

1. Ear 3

2. Nose and Paranasal Sinuses 17

3. Oral Cavity and Oropharynx 25

4. Salivary Glands 29

5. Pharynx and Esophagus 33

6. Larynx/Trachea 37

7. Thyroid and Parathyroid Glands 43

8. Face, Neck, Integument, and Muscles 45

9. Facial Skeleton and Skull Base 49

10. Nervous System Structures 53

11. Orbit 55

12. Basic Science 59

iv
 • * • Contents v

SECTION I I : DIAGNOSTIC AND ASSESSMENT PROCEDURES

13. Face 7 3

14. Ear 7 7

15. Nose and Paranasal Sinuses 8 7

16. Oral Cavity 8 9

17- Hypopharynx/Larynx 9 1

18. Neck - 9 5

19- Neurological 9 9

20. Imaging Studies 1 0 1

21. Histopathology 1 1 5

22. Laboratory Studies 1 2 5

23. Psychological, Social, and Occupational Assessment 131

SECTION I I I : DISEASES, DISORDERS, AND CONDITIONS

24. Neoplastic • 1 3 5

25- Trauma and Foreign Bodies 1 6 9

26. Idiopathic 1 7 9

27. Congenital • 1 8 5

28. Degenerative 2 0 3

i
}
vi Contents • • *

29- Infectious ,.. 209

30. Inflammatory 221

31. Iatrogenic 229

32. Cosmetic and Reconstructive 233

33. Metabolic 235

S E C T I O N IV: PHARMACOLOGY

34. Anaphylaxis 241

35. Antibiotics ,245

36. Pain Medications .4251

37. Antineoplastic Agents - 253

38. Skin Modifying Agents 257

39. Miscellaneous Drugs 261

S E C T I O N V: BASIC SURGICAL CONCEPTS

40. Preoperative and Postoperative Care • 267

41. Anesthesia and Intraoperative Fluids and Medications 271

42. Airway Management -277

43. Wound Care 279

44. Grafts (Autografts, Homografts, and Ailoplasts)

45. Flaps and Prosthetics

46. Endoscopic and Laser Surgery

47. Common Surgical Complications

S E C T I O N VI: SPECIFIC SURGICAL PROCEDURES

48. Head and Neck

49. Laryngology

50. Paranasal Sinuses

51. Otology

52. Pediatric Otolaryngology

53. Plastic and Reconstructive

SECTION VII: GENERAL TOPICS

54. Rehabilitation
 PREFACE

Otolaryngology Board Review: Pearls of Wisdom is designed to help you prepare you for the In Service and Board
Examination for Otolaryngology.

Since Otolaryngology Board Review is primarily intended as a study aid, the text is structured in a question and answer
format. Most of the questions arc short with short answers. This is to facilitate moving quicldy through a large body of
information. Such a format, while quite unlike the format used in the actual Board Examination, is useful to enable you
to assess your strengths and weaknesses in a particular area. This allows you to concentrate further studies on areas of
interest or weakness. Emphasis has been placed on distilling key facts that are easily overlooked, that are quickly forgotten,
and that somehow seem to occur frequendy on in-service or board examinations.

It must be emphasized that any question and answer book is most useful as a learning tool when used in conjunction with
a subject-specific textbook. Truly assimilating these facts into a framework of knowledge absolutely requires further
reading on the surrounding concepts. The more active the learning process, the better the understanding. Use this book
with your preferred source texts handy and open. When you encounter a. question that you cannot recall the
answer or that you find of particular interest, you are strongly encouraged to review the pertinent area in the
textbook at hand.

The third edition has been completely reorganized to to follow the format of the board exam as oudined by the American
Board of Otolaryngology. New to this edition are high-yield images to test yourself on visual diagnosis. All aspects of
otolaryngology are included, though some areas are covered more thoroughly than others. The questions within each'..
chapter are randomly arranged to simulate board examinations and the way questions arise in real life. You may encounter
several areas of redundancy. This is intentional - redundancy is a good thing when preparing for board examinations.

While great effort has been made to verify that the questions and answers are accurate, discrepancies and inaccuracies
sometimes occur. Most often this is attributable to variance between original sources. We have tried to verify in several
references the most accurate information. In addition, this book risks accuracy by aggressively pruning complex concepts
down to the simplest level; the dynamic knowledge base and clinical practice of medicine is not like that. Furthermore,
new research and current practice occasionally deviates from that which likely represents the correct answer for test
purposes. Keep in mind that this book is designed to maximize your score on a test and answers may not be the ones you
prefer. Refer to your most current sources of information and mentors for direction in daily practice.

We welcome your comments, suggestions, and criticism. Please make us aware of any errors you find. We hope to make
continuous improvements and would greatly appreciate any input with regard to format, organization, content,
presentation, or about specific questions.

Study hard and good luck on the Boards!

Mary Talley Bowden, M.D.

viii
Section I
ANATOMY AND BASIC
SCIENCE
 CHAPTER. 1 ar

O What embryologic structures is the auricle developed from?

The hillocks of His.

O How many hillocks are there and which branchial arches do they arise from?
Six; the first three arise from the first arch and the last three arise from the second arch.

O What does each hillock become?

1. Tragus. 4. Antihelix.
2. Helical crus. 5- Antitragus.
3. Helix. 6. Lobule and lower helix.

O How does a preauricular sinus tract form?

From improper fusion of the 1st and 2nd branchial arches.

O When does development of the external auditory canal (EAC) begin?

The canal begins to develop at 28 weeks gestation.

O At what month(s) gestation does the ear canal open?

Seventh.

O At what age does the EAC reach adult size?

Nine years.

O What is the significance of a congenitally malformed auricle?

The auricle develops early, making malformations of the middle ear, mastoid, and VII more likely.

O What is the significance of a normal auricle with canal atresia?

The EAC begins formation late (28th week), so the middle ear and ossicles are more likely to be normal.

3
4 Otolaryngology Board Review • • •

O Which ossicles develop from the first branchial arch (Meckel's cartilage)?
Head and neck of the malleus, body, and short process of the incus.

O Which ossicles develop from the second branchial arch (Reichert's cartilage)?
Manubrium of the malleus, long process of the incus, and stapes (except footplate).

O What does the stapes footplate develop from?

Otic mesenchyme.

O Which.ossicular component develops from membranous bone?

Anterior process of the malleus.

O Which ossicular components never completely ossify?

Part of the manubrium and the vestibular portion of the stapes footplate.

O When do the ossicles reach adult size and shape?

At the 16th week gestation, they are adult-sized, and by birth, they are adult-shaped.

O Why is the development of the bony otic capsule unique?

It is formed from 14 centers of ossification that fuse and leave no suture lines; the centers are formed from cartilage,
but retain no areas of chondral growth. The bone retains its fetal character, with Haversian canals.

O When does the otic capsule begin formation?

At 8 weeks, the precursors of the otic capsule are present; at 15 weeks, the ossification centers are present.

O When does the otic capsulefinishdeveloping?

By 21-24 weeks, it reaches adult size.

O What is the last part of the otic capsule to ossify?

Fissula ante fenestrum.

O When does the fallopian canal begin developing?

Fifth week gestation; its development is not complete until several years after birth.

O What is the last structure of the inner ear to develop?

Endolymphatic sac.

O What does the eustachian tube (ET) develop from?

From the 1st pouch, between the 2nd arch and the pharynx.
 < • • CHAPTER 1 Ear 5

O Which branchial arch does the tensor tympani muscle arise from?
First branchial arch.

O True/False: The tympanic membrane is derived from ectoderm.

False; ii is derived from ectoderm, mesoderm, and endoderm.

O At what age is the mastoid process completely pneutnatized?

Age 2.

O What is the sensory innervation of the auricle?

Greater auricular nerve (C3), auriculotemporal nerve (V3), lesser occipital nerve (C2, 3), auricular branch of the
vagus, and sensory branches of V I I and DC.

O What is Arnold's nerve?

Auricular branch of the vagus that innervates skin of the external auditory canal and auricle.

O What is the foramen of Huschke?

An embryologic remnant that normally obliterates in the anteroinfetiot portion of the medial bony EAC.

O What is the clinical significance of the foramen of Huschke?

Serves as a potential route for spread of tumor from the parotid gland to the temporal bone.

O Which wall of the EAC is shorter—the anteroinferior or posterosuperior?

Posterosuperiot (approximately 25 mm, whereas anteroinferior wall is 31 mm).

O How much of the EAC is cartilaginous?

One-third.

O How much of the ET is cartilaginous?

Two-thirds.

O Where is the tympanic notch of Rivinus?

Superior portion of the tympanic ring (squamous portion of temporal bone).

O How does the composition of gas in the middle ear differ from that of room air?
Lower oxygen level and higher carbon dioxide and nitrogen levels.

o What are the layers of the tympanic membrane?

Squamous epithelium, radiatingfibrouslayer, circumferentialfibrouslayer, and mucosa.
6 Otolaryngology Board Review see

O Which has greater sensory innervation—pars tensa or pars flaccida?

Pars flaccida.

O What are the three nerves of thetympanicplexus?

V3, DC (Jacobson's nerve), and X.

O Which part of the ossicular chain has the most tenuous blood supply and is most prone to necrosis?
Long process of the incus.

O Which part of the malleus articulates with the incus?

Head.

O Where in the ossicular chain does the tensor tympani muscle insert?
Manubrium of the malleus.

O Which part of the malleus does the anterior ligament attach to?
The neck, near the anterior process.

O Which part of the incus articulates with the stapes?

Lenticular process (medial side of long process).

O What ligament supports the stapes?

Annular ligament.

O Where does most of the movement of the stapes occur?

Anterior-superior portion of the footplate.

O Where in the ossicular chain does the stapedius muscle insert?

Posterior neck of the stapes.

O What is the scutum?

Lateral wall of the epitympanum.

O What are the boundaries of the epitympanum?

Superiorly, the tegmen; interiorly, the fossa incudis; anteriorly, the zygomatic arch; posteriorly, the aditus; medially,
the lateral semicircular canal (SCC) and VII; and laterally, the scutum.

o Which ossicles can be found in the epitympanic recess?

Head of the malleus, body, and short process of the incus.
 « a • CHAPTER 1 Ear 7

O What is the inferior boundary of the tympanic cavity?

Jugular bulb.

O What structures are anterior to the tympanic cavity?

The carotid artery ET, and the canal for the tensor tympani muscle.

O What structures are posterior to the tympanic cavity?

Adieus, posterior sinus, chorda tympani, fossa incudis, pyramidal prominence, and stapedial tendon.

O What is the promontory?

Elevation of the medial wall of the tympanic cavity formed by the basal turn of the cochlea.

o Which three cranial nerves are found beneath the floor of the middle ear cavity?
IX, X and XI.

O Below is a diagram of a right middle ear showing its relationship with the inner ear. Name the structures.

Reproduced, with permission, from Lalwani AK (ed.)- Current Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery, 3rd edn.
New York McGraw-Hill, 2012.

A—Facial nerve.
B—Ponticulus.
C—Subiculum.
D—Geniculate ganglion.

O What structure is located inferior to the subiculum and posteroinferior to the promontory?
Round window.

O What structure lies between the subiculum and ponticulus?

Sinus tympani.
8 Otolaryngology Board Review a a a

O What structure lies superior to the ponticulus?

Oval window.

O What structure lies between the prominence of SCC and the promontory/oval -window?
Prominence of the facial canal.

O The following diagram is of a right middle ear viewed from below. Name the structures.

Reproduced, with permission, from Lalwani AK (cd.). Current Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery, 3rd cdn.
New York: McGraw-Hill, 2012.

A—Facial recess.
B—Facial nerve.
C—Sinus tympani.

O What is the most anterior structure of the medial wall of the tympanic cavity?
Cochleariforrn process.

O Cochleariform process: tensor tympanipyramidal process: ?

Stapedius.

O What structure is situated just medial to the tip of the cochleariform process?
Geniculate ganglion of the facial nerve.

O Between which ossicles does the chorda tympani run?

Manubrium of the malleus and long process of the incus.

O What is the function of the chorda tympani nerve?

Parasympathetic innervation to the submandibular and sublingual glands, and taste to the anterior 2/3 of the
tongue.
 • o • CHAPTER 1 Ear

O Which planes are the oval and round windows oriented in?
Oval window is in the sagittal plane; round window is in the transverse plane.

O What structure ends blindly at the round window?

Scala tympani (lower compartment of the cochlea).

O What is the name of the central bony core of the cochlea through which nerves and vessels travel?
Modiolus.

O What is the name of the area of communication between the scala vestibuli and the scala tympani?
Helicotrema.

O What fluid surrounds the membranous labyrinth?

Perilymph.

O How does perilymph differ from endolymph?

Perilymph has a pH of 7.2, is high in sodium, low in potassium, and does not contain chloride; endolymph has
pH of 7.5, is low in sodium, and relatively high in potassium and chloride.

O True/False: The membranous labyrinth is a self-contained system.

True.

O What are the main structures of the vestibular portion of the membranous labyrinth?
Utricle, saccule, and SCCs.

O Which of these main structures receives the crura from the three SCCs?
Utricle.

O What structures house the crista?

Ampullae.

O What is the blood supply to the inner ear?

Labyrinthine artery (branch of anterior inferior cerebellar artery). ( F V i P ^

O What structure produces endolymph?

Stria vascularis.

O Where does most of the resorption of endolymph occur?

Endolymphatic sac.
10 Otolaryngology Board Review • • •

O What docs the vestibular aqueduct carry?

Endolymphatic duct and accompanying vein.

O Where is the primary auditory cortex?

Brodmann's area 41 in the superficial portion of the temporal lobe.

O Which part of the vestibular labyrinth detects angular acceleration?

SCCs.

O What do the utricle and saccule detect?

Linear acceleration.

O Where are cupula found?

SCCs.

O What three systems determine balance?

Vestibular, vestibulo-ocular (visual), and vestibulospinal (proprioceptive) systems.

O Which part of the cochlea represents high-frequency sounds?

The basal end.

O What range of frequencies can the human ear detect?

20-20,000 Hz (greatest sensitivity is from 500 to 3000 Hz).

O What noise level begins to cause pain?

140 dB.

O How many times louder is 60 dB than 0 dB?

1,000,000 times.

O What are normal ear canal volumes in children and adults?

0.5-1-0 cm in children; 0.6-2.0 cm in adults.
3 3

O Which cells emit otoacoustic emissions (OAEs)?

Outer hair cells.

O What percent of normal ears emit spontaneous OAEs?

35-60%.