PPT - UCLA Head and Neck Surgery

Report
In-Service Review
Quinton Gopen, M.D.
U.C.L.A. Medical School
Division of Otolaryngology
Feb 29th, 2012
General points
• Exam setup
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Little to no time pressure
Only half of the questions are scored
Different versions of same question are test questions
Many questions ambiguous and difficult to interpret
• If everyone get them right, they are thrown out
• If everyone get them wrong , they are thrown out
• Don’t fall for traps
– Question seems too straight forward, probably is!
– What is clinically done not always right answer
Question 1
• 24y.o. male is involved in a motor vehicle
accident. Patient has left bloody otorrhea and
complains of hearing loss. Patient has obvious
facial fractures. What is the first imaging test
you should order?
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•
•
•
•
A.
B.
C.
D.
E.
MRI scan brain and internal auditory canals
CT scan of the temporal bones
AP and lateral neck films
Chest X-ray
CT scan facial bones
Question 1
Answer
• C. AP and lateral neck films
• Explanation: clearing the C-spine is an
important first step in trauma management.
Question 2
FREQUENCY IN HERTZ (Hz)
HEARING LEVEL (HL) IN DECIBELS (dB)
• 46 year old woman
complains of hearing loss in
both ears. Weber test
localizes to the right ear and
bone conduction greater
than air conduction on right
side. Otoscopy normal, no
history of ear infections.
What is the best
management?
• A. Observation
• B. Left stapedotomy
• C. Right stapedotomy
• D. CROS hearing aid
• E. Bi-CROS hearing aid
X
X X X X
X
X
WRS RT76%
WRS LT 26%
Question 2
• Answer E Bi-Cros hearing aid
• YOU CAN NEVER OPERATE ON THE BETTER
HEARING EAR!!!! *
• *UNLESS THERE IS A DESTRUCTIVE PROCESS
WHICH WILL INJUR THE EAR FURTHER
WITHOUT SURGERY
– Cholesteatoma
– Mastoiditis
Question 3
• A 33 y.o. man has bilateral Meniere’s disease. He
has undergone a left labyrinthectomy. ENG shows
no left sided vestibular function and 50% reduced
right sided vestibular function. Persistent frequent
disabling vertigo attacks. Management?
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–
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A.
B.
C.
D.
E.
left intratympanic gentamicin
Right intratympanic gentamicin
Left vestibular nerve section
Right vestibular nerve section
Right endolymphatic sac decompression
Question 3
• Answer: Choice E Right endolymphatic sac
decompression
• This is an example of the default choice. All other
choices can be eliminated, and tough sac
decompression is controversial, it is the only
answer that is not contra-indicated
Question 4
An 8 y.o. girl has profound bilateral deafness.
She presents with a syncopal episode while
playing at school. Her parents are interested in
pursuing a cochlear implant. What should your
work up include?
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•
•
•
•
A.
B.
C.
D.
E.
An EKG
A CT scan of the temporal bones
A MRI of the brain and internal auditory canals
A promontory stimulation test
An ABR test
Question 4
• Answer: A – An EKG
• This patient has Jervel-Lange-Nielson syndrome.
Profound deafness and prolonged Q-T interval places
them at significant risk for sudden death, particularly
with exercise or surgical procedures. Critical to
identify.
• This is an example of many appropriate choices, but
one is more correct than the others.
Question 5
• What is the most likely place of
recurrent cholesteatoma?
• A. Eustachian tube
• B. Anterior epitympanic space
• C. Angle of Citelli
• D. Sinus tympani
• E. Retrofacial air cells
Question 5
• Answer: D – Sinus tympani
• A classic question. Sinus tympani cannot be seen
directly as the facial nerve lies on top of this space.
It cannot be opened from the mastoid side as the
labyrinth blocks the approach
• Extra credit. The subiculum is the inferior
boundary of the sinus tympani, and the ponticulus
is the superior boundary of the sinus tympani
Question 6
A 17y.o. man has a large left acoustic
neuroma. Postoperatively he has
complete facial paralysis. He has waited
14 months and has no return of volitional
movement of his face. What is his best
rehabilitative option?
•A.
•B.
•C.
•D.
•E.
Revision left retrosigmoid approach with cable graft
XII-VII left nerve crossover graft
Left brow lift
Botox injection to the right face
Botox injectin to the left face
Question 6
• Answer B XII-VII crossover graft
• Although a cable graft sounds good, the facial
nerve is almost always intact after acoustic
neuroma resection. If the nerve was torn, a cable
graft should be done at the time of surgery. Since
no mention of this, assume the proximal part of
the nerve is not viable. XII-VII better than static
reanimation.
Question 7
• A 14 y.o. boy falls down a hill into a tree
branch that punctures his right eardrum. He
is brought into the ER and is vertiginous with
nausea and vomiting. He complains of right
hearing loss. What is the best treatment.
• A. IV dexamethasone 10mg
• B. CT scan of the temporal bones
• C. Middle ear exploration
• D. Scopolamine patch
• E. IV rehydration
Question 7
• Answer: C Middle ear exploration
• The vertigo is of concern. May be a subluxed stapes
or worse, a foreign body of wood in the vestibule.
Urgent surgery to seal the inner ear and remove and
foreign material is crucial. The other choices are all
reasonable, but exploring the ear is the best answer.
Question 8
• Which of the following is the best
candidate for cochlear implantation?
A. A child with Mondini malformation
B. A child with a small IAC on CT scan
C. An adult patient who was born
profoundly deaf
D. A child with Michel’s malformation
E. An adult with neurofibromatosis
type II s/p bilateral acoustic neuroma
resections.
Question 8
• Answer: A Mondini malformation
• The key issue for cochlear
implantation is a viable cochlear
nerve. All the other choices, the nerve
is either not present or not viable.
Mondin malformations have an
increased risk of spinal fluid leaks but
otherwise do reasonably well with
cochlear implantation
Question 9
• A 47 y.o. woman undergoes a glomus jugular
resection. After obtaining distal and proximal
control of the sigmoid sinus and jugular vein,
profuse bleeding occurs during resection of the
tumor. What is the most likely source?
• A. Transverse sinus
• B. Straight sinus
• C. Superior petrosal sinus
• D. Inferior petrosal sinus
• E. Confluence of the sinuses
Question 9
• Answer: D. Inferior petrosal sinus
• This sinus plugs into the jugular bulb from
its medial aspect and is a common source
of bleeding. Packing must be limited as
over packing results in lower cranial
dysfunction from compression injury.
Question 10
Which is the best hearing test for an 18 month old
baby girl?
A. Conventional audiometry
B. VEMP testing
C. Conditioned play audiometry
D. Dichotic testing
E. Visual reinforcement audiometry
Question 10
Answer: E - Visual reinforcement
audiometry
This is the most appropriate test for this age.
Conditioned play audiometry is more for 23years old. Dichotic testing is for central
processing disorders, usually not testable
unitl around 8y.o.
Question 11
What runs within the cochlear
aqueduct?
A.
B.
C.
D.
E.
Endolymhatic duct
Ductus Reuniens
Perotic duct
Endolymphatic sac
Helicotrema
Question 11
• Answer: C Perotic duct
• The perotic duct is analagous to the endolymphatic
duct within the vestibular aqueduct. The perotic duct is
comprised of loose connective tissue and contains
CSF as it turns into perilmph within the inner ear. The
cochlear aqueduct runs from the posterior cranial
fossa to the basal turn of the cochlea inferior to the
internal auditory canal
Question 12
• Which of the following is a false statement
about a patulous Eustachian tube?
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•
•
•
•
A.
B.
C.
D.
E.
It causes autophony
It improves with exercise
It improves with lying supine
It is associated with extreme weight loss
It is associated with rheumatologic cases
Question 12
• Answer B - It improves with exercise.
• This is false, the condition worsens
with exercise as the exercise causes
vasoconstriction of the mucus
membranes in the nose to increase
airflow through the nose during
exercise. This causes the condition to
get worse.
Question 13
• This condition is:
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•
•
A.
B.
C.
D.
E.
Autosomal recessive
Is associated with retinitis pigmentosum
X-linked
Is associated with thyroid dysfunction
Results from a defect in neural crest development
Question 13
– E. Results from a defect in neural crest development
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Pendred’s
Usher’s
Jervel Lange Nielson
Alport’s
thyroid dysfunction
retinitis pigmentosum (blindness)
cardiac (prolonged QT)
kidney dysfunction
Question 14
A patients presents with right hearing loss. A 30dB
pure tone at 1k Hz is presented to the right ear at
the same time a 15dB pure tone at 1k Hz is
presented to the left ear. The patient does not hear
any sound. What is your diagnosis?
A. Pseudohypoacusis
B. Right mild sensorineural hearing loss
C. Right conductive hearing loss
D. Central hearing loss
E. Right profound sensorineural hearing loss
Question 14
•
Answer: A – Pseudohypoacusis (also known
as malingering). This is an example of the
Stenger’s test. Same tone to both ears, the
louder side is the only side a normal patient
will hear. The malingerer only hears the
sound on the ear that they are lying about
the hearing, so they claim to hear nothing.
Pt with true hearing loss hears the sound in
the only hearing ear.
Question 15
A patient has a lesion within the petrous apex that is
hypointense on T1 and hyperintense on T2 imaging. It
does not enhance with Gadolinium. What is the most
likely pathology?
A.
B.
C.
D.
E.
Asymmetric bone marrow
Vestibular schwannoma
Cholesterol granuloma
Cholesteatoma
meningioma
Question 15
Answer: D Cholesteatoma
Although variable, cholesteatoma is
usually bright on T2 and does not
enhance with gadolinium. It is bright on
diffusion weighted images. Cholesterol
granuloma is bright on T1/T2 images,
bone marrow on T1 and tumors enhance
with gadolinium.
Question 16
What is the most common
complication of cochlear implant
surgery?
A.
B.
C.
D.
E.
Facial paralysis
Malpositioned device
Meningitis
Spinal fluid leak
Device exposure
Question 16
Answer E – Device extrusion.
These are all complications of cochlear
implantation, but flap necrosis with device
extrusion is the most common
complication I believe.
Question 17
A 57 y.o. man has a 4mm enhancing mass in
the fundus of the left internal auditory canal.
There is a moderate left sensorineural hearing
loss with a discrimination score of 62%. What
is the best approach to this tumor?
A.
B.
C.
D.
E.
Middle fossa craniotomy
Translabyrinthine craniotomy
Transotic craniotomy
Retrosigmoid craniotomy
Infracochlear approach
Question 17
Answer: A Middle fossa craniotomy
Although controversial, the correct
answer is middle fossa for small tumors
in the fundus of the IAC. The fundus is
the lateral most part of the IAC,
whereas the porus is the more medial
part of the IAC. A translabyrinthine
approach is good for any sized tumor,
huge to tiny, but does not preserve
hearing.

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