General ENT

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General ENT
2016-06-07 10:48:11
General ENT FRCS

General ENT FRCS
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  1. WHO Performance status
    • 0: able to carry out all normal activity without restriction
    • 1: restricted in strenuous activity but ambulatory and able to carry out light work
    • 2: ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours
    • 3: symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden
    • 4: completely disabled; cannot carry out any self-care; totally confined to bed or chair.
  2. Clinical outcome questionnaires
    • Lacrimal symptom score
    • PROMS Paediatric Tonsillectomy T-14 tool - 14 questions 0-5, obstructive & infective parts
    • Snoring Symptoms Inventory and Questionnaire
    • Sino-Nasal Outcome Test-22 (SNOT) Questionnaire
    • VoiSS (Voice Symtoms Scale) 
    • Voice Handicap Index
  3. Nerve stimulation
    • Bone covered nerve 5mA
    • Exposed nerve neck 1-2mA
    • CPA angle nerve 0.05mA

    Frequency 30Hz unparalysed, 3Hz partial paralysis
  4. Radiation doses
    • Units =  millisievert (mSv)
    • Natural exposure 3 mSv/year ave
    • CXR = 0.02 mSv
    • CT Head/temporal bone/sinus  = .7 mSv
    • White cells scan - 3 mSv
  5. Professional atheletes
    Therapeutic Use Exemptions (TUEs) form
  6. Buccinator muscle
    Quadrilateral muscle, between the maxilla and the mandible at the side of the face.Arises from the outer surfaces of the alveolar processes of the maxilla and mandible, corresponding to the three molar teeth;Arises from the anterior border of the pterygomandibular ligament (raphe).The fibres converge toward the angle of the mouth, upper continuous with orbicularis oris.Facial nerve2nd arch structure
  7. Mandibular ligaments
    • Sphenomandibular: sphenoid spine to lingula
    • Pterygomandibular: hamulus to posterior end of mylohyoid (additional attachment for superior constrictor)
    • Stylomandibular: styloid to angle (between masseter and medial pterygoid
  8. Superior orbital fissure
    • CONTENT:
    • EYE MOVEMENTS 3, 4, 6
    • V1

    • PTOSIS
  9. Styloid attachments
    • Stylohyoid ligament (distal tip to lesser cornu of hyoid (also attachment for middle constrictor)
    • Stylomandibular - separates the parotid from the submandibular gland and medial pterygoid, and from its deep surface some fibers of the styloglossus take origin.
    • Stylopharyngeus (IX) 
    • Styloglossus (XII) 
    • Stylohyoid muscle (VII)
  10. Inferior tympanic canal
    • hole between carotid canal and EAC
    • Lesser petrosal nerve (parasympathetic) from IXMiddle ear (Jacobson)
  11. Superior constrictor
    • Medial pterygoid plate (upper part)pterygomandibular ligament (raphe) – from pterygoid hamulus to posterior end of mylohyoid line on mandible;
    • PML is also attachment for buccinator
  12. Thyrocervical branch
    • branch of the subclavian artery
    • 3 Branches
    • :inferior thyroid artery
    • suprascapular artery
    • transverse cervical artery

    • Costocervical trunk:
    • Branches:
    • Deep cervical artery
    • Supreme intercostal artery
  13. Sternocleidomastoid blood supply
    • Upper third supplied by branches of the occipital artery
    • Middle third supplied from the superior thyroid artery (42%), the external carotid artery (23%), or branches of both (27%; sometimes also from inferior thyroid artery from thyrocervical trunk.
    • Lower third from the suprascapular artery (80%)/ transverse cervical (20%).
  14. Temporalis muscle blood supply
    • Superficial and middle temporal branches from superficial temporal artery from ECA
    • Deep temporal artery from IMAX
  15. MacEwen’s triangle
    • 1.Inferior temporal line
    • 2.Posterior EAC canal wall
    • 3.Tangential line joing the temporal line to post wall of EAC

    1.5cm lateral to antrum
  16. Koerners Septum
    A plate of bone that extends from the tegmen for a variable distance and represents the plane between the squamous and petrous parts of the mastoid.
  17. Digastric ridge
    • located by following sigmoid sinus towards the mastoid tip (it divides mastoid tip into medial and lateral compartments)
    • lateral to facial nerve and sigmoid sinus
    • flip-side of the digastric groove which is occupied by digastric muscle
  18. Posterior tympanotomy
    • Facial recess = triangular area: fossa incudus facial nerve, chorda tympani; it is lateral to VII.
    • Finding the facial recess: Lift EAM skin down to annulus, 1mm behind and deep to bony annulus = facial recess
    • Enter near incus bridge/buttress, stay above or in line with short process of incus, use 2mm diamond bur and then 1mm diamond Don’t perforate canal wall (by drilling lateral to chorda) Don’t disrupt chorda Don’t transect annulus
  19. Donaldsons line
    Donaldson’s line – imaginary line from Lat SCC bisecting perpendicularly to posterior SCC; it identifies the superior aspect of the endolymphatic sac (ELS).
  20. Trautman’s triangle
    • sigmoid sinus
    • dura containing superior petrosal sinus
    • labyrinth anteriorly (hard angle and posterior fossa dura)
    • Hard or solid angle is the angle formed by 3SSCs; it protects the posterior SSC.

    Potential weak area through which infections of temporal bone may spread to cerebellum. A large sigmoid sinus reduces the size of this triangle and also increases the angulation of the superior petrosal sinus with it. This impedes the venous drainage predisposing to the development of endolymphatic hydrops (asymptomatic hydrops vs symptomatic hydrops)
  21. Uncinate process attachments
    • Inferior: Inferior turbinate
    • Superior: LP/skull base/ MT
    • Anterior: maxillary bone posterior and adjacent to NLD)
    • Posterior: Concave free margin medial to palatine bone
  22. MRI
    • T1 ‘spin-lattice relaxation time’time taken for excited protons to return to initial energy states
    • T2 ‘ spin-spin relaxation time’time taken for dephasing of spins in the direction of the applied RF pulse

    • STIR = Fat-suppressed sequences
    • FLAIR = nullifies signal from flowing CSF
  23. Syndrome/Sequence/Association
    • Syndrome = Combination of abnormalities with cause known
    • Association = Combination of abnormalites with cause unknown 
    • Sequence = If one abnormality leads to other abnormalities
  24. Carcinoid tumours
    • Slow growing neuroendocrine tumour
    • Commonest site mid gut, can be respiratory tract
    • 10% develop carcinoid syndrome
    • can occur with men 1 syndrome
  25. Lymes disease
    • Borrelia burgdorferi
    • Affects nervous system
    • Cranial nerves 15%
    • Hearing loss(SN), otalgia, dizziness
    • DXBlood/CSF serolgy
    • Variable prognosis
  26. MR
    • T1 water black, fat white
    • T2 water white, fat white
    • STIR( short time/face inversion recovery) water white, fat black

    If vestibular aqueduct > SCC = big

    carotid jugular spine = bone between carotid & jugular

    turbinates light up with contrast

    anterior ethmoid = posterior level of globe, between where superior oblique & medial rectus muscles meet
  27. Maxillary artery
    • Part 1 - deep to mandible(5)
    • Deep auricular
    • Anterior tympanic
    • Middle meningeal
    • Accessory meningeal
    • Inferior alveolar

    • Part 2 - superficial lateral ptergoid(4)
    • Deep temporal
    • Pterygoid artery
    • Masseter artery
    • Buccal artery

    • Part 3 - Ptergopalantine fossa(5(
    • Posterior superior alveolar
    • Descending palatine
    • Artery pterygoid canal
    • Sphenopalatine artery
    • Infraorbital artery
  28. Facial nerve
    • frontal division of the temporal branches of the facial nerve may be approximated by a line 0.5 cm below the tragus to 1.5 cm lateral to the eyebrow.
    •  buccal branches (usually 2) are easily seen lying over the masseter muscle deep to the parotideomasseteric fascia.
    • marginal mandibular branch of the facial nerve usually emerges from the parotid gland about 1 cm below the angle of the mandible
    • Buccal branch: runs parallel to and 1 cm below the arch of the zygoma traveling toward the corner of the mouth. Thin-walled parotid duct travels closely adjacent, usually just below this branch.
  29. Friedman staging system for snoring/OSA
    • combines palate-tongue position, tonsil size & BMI
    • predicts success of vulopalatopharyngoplasty
    • Stage 1 - palate is grade 1 or 2, tonsil
    • grade III or IV.
    • Stage 2 - palate grade 1 or 2 with a tonsil grade I or II, or a palate grade 3 or 4 with a
    • tonsil grade III or IV.
    • Stage 3 corresponds to palate grade 3 or 4 with tonsil grade I or II.
    • Stage 4 BMI >40 kg/m2 or with gross
    • craniofacial abnormalities.
    • Stage 1 correlates with surgical success and 
    • is one of the few positive predictive factors in sleep surgery.
    • Success ranges decrease as stage increases
    • Stage 4 not surgical candidates.
    • Woodson et al have shown improved
    • surgical success with UPPP in Friedman stage 2 and 3 patients using modified techniques for UPPP.
  30. Sleep stages
    • Stage N1
    • Stage N2
    • Stage N3
    • REM sleep 90 mins to reach in adults, 25% of sleep
  31. Friedman tongue position
    • Mallampati  evaluates the tongue with the tongue protruded
    • FTP evaluates the tongue in a neutral position inside the mouth.
  32. Friedman staging system

    • Stage I patients who underwent UPPP had a success rate of 80.6%
    • stage II patients had a success rate of 37.9%,
    • and stage III/IV patients had a success rate of 8.1%.
  33. Lingual tonsil hypertrophy grading system

    our belief that LTH grades 3 and 4 are clinically significant and may be indicators for surgical removal of tonsillar tissue
  34. Systemic Lupus Erythematousis
    American Academy of Rhematologists diagnostic criteria
    4+ = sensitivity of 85% and a specificity of 99.7%
    • American Academy of Rhematologist diagnostic criteria
    • "SOAP BRAIN MD" mnemonic:
    • Serositis
    • Oral ulcers
    • Arthritis
    • Photosensitivity
    • Blood disorders
    • Renal involvement
    • Antinuclear antibodies
    • Immunologic phenomena (eg, dsDNA; anti-Smith [Sm] antibodies)
    • Neurologic disorder
    • Malar rash
    • Discoid rash
  35. Churg Strauss
    American Academy of Rheumatologists diagnostic criteria
    4+ = sensitivity of 85% and a specificity of 99.7%
    • Asthma (wheezing, expiratory rhonchi) Eosinophilia of more than 10% in peripheral blood
    • Paranasal sinusitis
    • Pulmonary infiltrates (may be transient) Histological proof of vasculitis with extravascular eosinophils
    • Mononeuritis multiplex or polyneuropathy