triangle BONE-FORMING TUMOURS .1
Figure 56. Codman’s triangle
A radiographic finding in
malignancy,where the partially
ossified periosteum islifted off the
cortex byneoplastic tissue
Osteoid Osteoma
• benign bone tumour arising from osteoblasts; not known to metastasize
• peak incidence in 2nd and 3rd decades, M:F=2-3:1
• proximal femur>tibia diaphysis most common locations;spine (can cause painfulscoliosis)
• radiographic findings:small, round radiolucent nidus (<1.5 cm) surrounded by dense sclerotic bone
(
"
bulf'
s-eye” )
• symptoms: constant and progressive pain from prostaglandin secretion and COXI/2 expression
• pain worse at night (diurnal prostaglandin production); characteristically relieved by NSAIDs
• treatment: NSAIDs are first-line; percutaneous radiofrequenev ablation or surgical resection for
refractory lesions
FIBROUS LESIONS
Fibrous Cortical Defect (i.e. non-ossifying fibroma, fibrous bone lesion)
• developmental defect in which areas that normally ossify are filled with fibrous connective tissue
• most common benign bone tumour in children,typically asymptomatic and an incidental finding
• occur in as many as 35% of children, peak incidence between 2-25 yr old
• distal femur > distal tibia > proximal tibia most common locations
• radiographic findings:diagnostic, metaphyseal eccentric ‘bubbly’ lytic lesion near physis;thin,
smooth/lobulated, well-defined sclerotic margin
• multiple lesions can be present;large lesions may be associated with pathologic fractures
• treatment: most lesions resolve spontaneously;curettage and hone grafting for symptomatic lesions or
to prevent pathologic fractures in larger lesions
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Osteochondroma
• cartilage capped bony lesion arising on the external surface of a bone
• 2nd and 3rd decades, M>1
:
• most common benign bone tumour (~30%); true incidence unknown as many asymptomatic
• 2 types:sessile (broad based and increased risk of malignant degeneration) vs. pedunculated (narrow
stalk)
• metaphysis of long bone near tendon attachment sites(distal femur, proximal tibia, or proximal
humerus)
• radiographic findings: cartilage-capped bony spur on surface of bone (“mushroom"
on x-ray)
• may be multiple (hereditary, autosomal dominant form)
- higher risk of malignant change
• generally very slow growing and asymptomatic unless impinging on neurovascularstructure
(‘painless mass’)
growth usually ceases when skeletal maturity is reached
• malignant degeneration occursin 1-2% (becomes painful or rapidly grows)
• treatment: observation;surgical excision ifsymptomatic or concern for malignant transformation
Enchondroma
• benign hyaline cartilage growth; abnormality of chondroblasts, develops in medullary cavity
single/multiple enlarged rarefied areas in tubular bones
lytic lesion with sharp margination and irregular central calcification (stippled/punctate/popcorn
appearance)
• majority asymptomatic, presenting as incidental finding or pathological fracture
• 2nd and 3rd decades
• 60% occur in the small tubular bones of the hand and foot; others in femur (20% - Figure 57),
humerus, ribs
• radiographic findings:well-defined,lucent, central medullary lesions that calcify over time
• malignant degeneration to chondrosarcoma occurs in 1-2% (rest/nocturnal pain in absence of
pathologic fracture is an important clue)
• treatment: observation with serial x-rays;surgical curettage if symptomatic or lesion grows
Figure 57. T1MRI of femoral
enchondroma
CYSTIC LESIONS
Unicameral/Solitary Bone Cyst
• most common cystic lesion;serousfluid-filled lesion with fibrouslining
• children and young adults, peak incidence during first 2 decades
• proximal humerus and femur most common
• symptoms: asymptomatic, or localized pain; complete pathological fracture (50% of presentations) or
incidental detection
• radiographic findings:lytic translucent area on metaphyseal side of growth plate, cortex thinned/
expanded; well-defined lesion
• treatment:observation with serial radiography 4-6 mo;if needed, aspiration followed by steroid
injection; curettage ± bone graft indicated if structural integrity of bone is compromised
Benign Aggressive Bone Tumours
Giant Cell Tumours/Aneurysmal Bone Cyst/Osteoblastoma
• affects patients of skeletal maturity, peak 3rd decade
• osteoblastoma: most commonly found in posterior elements of spine
• giant cell tumour: pulmonary metastases in 3%
• aneurysmal bone cysts: either solid with fibrous/granular tissue, or blood-filled
• radiographic findings
• giant cell tumour: eccentric lytic lesions in epiphyses adjacent to subchondral bone; may break
through cortex;T2 MRI enhances fluid within lesion (hvper-intense signal)
aneurysmal bone cyst:expansile, eccentric,and lytic lesion with bony septae (“bubbly
appearance"); will have fluid-fluid levels on MRI
osteoblastoma:often nonspecific; calcified central nidus (>2 cm) with radiolucent halo and
sclerosis
• symptoms: local tenderness and swelling, pain may be progressive (giant cell tumours), ± symptoms
of nerve root compression (osteoblastoma)
Treatment
• intralesional curettage + bone graft or cement
• wide local excision of expendable bones
• recurrence rates of up to 20%
Figure 58. X-ray of aneurysmal bone
cyst
Note the aggressive destruction of
bone
Figure 59. X-ray of osteosarcoma of
distal femur
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Malignant Bone Tumours
Table 26. Most Common Malignant Tumour Types for Age
Age Tumour
«1 Neuroblastoma
Ewing’s ol tubular bones
Osteosarcoma. Ewing'
s ol Hat bones
Reticulum cell sarcoma,fibrosarcoma, periosteal osteosarcoma,malignant giant cell tumour, lymphoma
Metastatic carcinoma, multiple myeloma, chondrosarcoma
1-10
10-30
30 40
>40
Osteosarcoma
• malignant bone tumour
• 2nd most common primary malignancy in adults after myeloma
• majority occur in 2nd decade oflife,second peak in elderly patients with history of Paget’s disease
• predilection forsites of rapid growth:distal femur (45% -Figure 59,OR51 ),proximal tibia (20%), and
proximal humerus(15%)
• invasive, variable histology;frequent metastases without treatment (lung most common)
• painful symptoms: progressive pain, night pain, poorly defined swelling, decreased ROM
• radiographic findings: characteristic blastic and destructive lesion (“sunburst"
pattern),
periosteal reaction (Codman's triangle),soft tissue mass with maintenance of bone cortices;
destructive lesion in metaphysis may cross epiphyseal plate
• bone scan -rule outskeletal metastases; CT chest-rule out pulmonary metastases
• treatment:staging, neo-adjuvant chemotherapy, re-staging, limb salvage resection/reconstruction
(rarely amputation), post-surgical neo-adjuvant chemotherapy
• prognosis:90% survival forlow-grade; 70% survival for high-grade
Chondrosarcoma
• malignant chondrogenic tumour
• primary (2/3 cases)
• previous normal bone, patient >40 yr;expandsinto cortex to cause pain, pathological fracture
• secondary (1/3 cases)
malignant degeneration of pre-existing cartilage tumour such as enchondroma or
osteochondroma
• age range 25-45 yr, better prognosis than primary chondrosarcoma
• symptoms: progressive pain, uncommonly palpable mass or pathologic fracture
• radiographic findings:in medullary cavity, irregular "popcorn"
calcification
• treatment:no role for neo-adjuvant chemotherapy or radiation; treat with wide surgical resection +
reconstruction;regular follow-up x-rays of resection site and chest
• prognosis:90% ten-yearsurvival for low-grade; 29-55% survival for high-grade
Ewing's Sarcoma
• malignant,small round cell sarcoma; metastases frequent without treatment
• most occur between ages 5-25 yr
• tlorid periosteal reaction in metaphysis oflong bone with diaphyseal extension
• signs/symptoms: presents with pain, fever, erythema, and swelling; anemia, increased WBC, HSR,
LDH (mimics an infection)
• radiographic findings: destructive lesion with moth-eaten appearance and periosteal lamellated
pattern (“onion-skinning")
treatment:resection + chemotherapy ± radiation (can be treated solely with radiation in younger
patientsin select anatomic locations)
• prognosis: 70% survival;distant metastasessignificantly lowersurvival (<30%)
Figure 60.X-ray of femur
chondrosarcoma
Signs ol Hypercalcemia
"Bones.Stones. Moans, Groans.
Psychiatric overtones"
CNS: headache, confusion, irritability,
blurred vision
Gl: N19,abdominal pain, constipation,
weight loss
MSK:fatigue,weakness, unsteady gait,
bone and joint pain
GU:nocturia, polydipsia, polyuria, UTIs
Most Common Tumours
Metastatic to Bone
.Thyroid ,
Breast Breast
Lung Lung
^
Melanotna^
)
Kidney Kidney
Multiple Myeloma
• proliferation of neoplastic plasma cells
• most common primary bone malignancy
• 90% occur in people >40 yr; M:l-
'
=2:1; twice as common in individuals of African descent
• signs/symptoms:localized bone pain (cardinal early symptom), compression/pathological fractures,
renal failure, nephritis, high incidence of infections (e.g. pyelonephritis/pneumonia),systemic
(weakness, weight loss, anorexia)
• labs: anemia, thrombocytopenia, increased HSR, hypercalcemia, increased Cr
• radiographic findings:multiple, “punched-out” well-demarcated lesions, no surrounding sclerosis,
marked bone expansion
• diagnosis
• serum/urine immunoelectrophoresis (monoclonal gammopathy)
• CT-guided biopsy of lytic lesions at multiple bony sites
Prostate
BLT with a Kosher Pickle
Breast
Lung
Thyroid
Kidney
Prostate
n
LJ
• treatment
• multiagent chemotherapy ± stem cell transplantation ± bisphosphonates
• surgery for impending fractures: debulking, internal fixation +
• prognosis:5 yr survival 52%, prognosis increases with decreasing age
• see Hematology, H5I
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OR53Orthopaedic Surgery Toronto Notes 2023
Bone Metastases
• most common cause of bone lesions in adults; typically age >40
• majority arise from breast or prostate;some arise from lung, thyroid, and kidney
• usually osteolytic lesions; prostate occasionally osteoblastic
• may present with mechanical pain and/or night pain, pathological fracture, hypercalcemia
• bone scan for MSK involvement; MR1 if suspected spinal involvement
• treatment: pain control, bisphosphonates, surgical stabilization of impending fractures if Mirel’s
Critera >8
Table 27. Mirel’s Criteria for Impending Fracture Risk and Prophylactic Internal Fixation
Variable Number Assigned
1 2 3
Site Upper arm Lower extremity Peritrochanleric
Moderate
Mixed
1/3-2Z3 diameter
Pain Mild Severe
Lesion Elastic
<1/3 bone diameter
lytic
Siie >2/3 dtamcler
Common Medications
Table 28. Common Medications
Drug Name Dosing Schedule Indications Comments
ccfazolin (Anccl ) 12 g IV qS h Preoperativcanlibiolic
prophylaxis
First generation cephalosporin;can
be used withpenicillin allergy|< t0%
cross-reactivity;significantly higher
rales olSSI/PTI with alternative ABx)
Fixed dose,no monitoring, improved
bioavailability,increased bleeding
rates
Predictable,no monitoring,oral
administration
Reversal agents:
idarucirumab(dabigatran)
andexanet alia|rivaroxaban,
apixaban)
Recent evidence suggests similar
efficacy to IMWH and Rlvaroxaban
with belter side effect profile (lower
hematoma/sliffness in TJA)
Reduce perioperative blood loss No evidence for increase in
thromboembolic events
Analgesia for pain control Max dose up to 4000 mg every 24h
Higher doses can be hepatotoxic in
susceptible individuals
S000 IUSC once daily
30- 40 mgSC once daily to BIO
2.5mg SC once daily
110 mg P0 x1then 220 mg P0
once daily
10 mg P0 once daily
2.5 mg P0 BID
IMWH 0VIprophylaxis
dalteparin (Fragmin ')
enoxaparin (Lovenox:
)
oral anticoagulants
dabigatran |Pradaxa!
)
rivaroxaban fXarelto
apixaban (Eliquis 5)
DVT prophylaxis
Aspirin (ASA) gtmgPOBIO 0VI prophylaxis
tranexamicacid(TXA) 10-20 mg/kg IV
Topical application to wound
1000mg POqGh or q8 h
and transfusion
acetaminophen (Tylenol- )
ibuprofen (Advil .Motrin ) 200-800 mg P0q6-8 Ir
(max 3200 mg/d|
Analgesia for inflammatory pain NSAID.maycause gastric erosion
(arthritis) and bleeding;avoid il concurrent
advancedrenaldisease
triamcinolone (Aristocort ')
- 0.5 -1mlol 25 mg/ml
an injectable steroid
Suspension (Injected inlo Potent anti inflammatory died;
inflamed joint or bursa);amount increased pain for 24 h.rarely
varies by joint sire causes falnetrosis and skin
depigmentalion
naproxen (Aleve -
,Naprosyns) 250-500 mg BID Analgesia for pain due to
inflammation,arthritis,soft
tissue injury
Component of multimodal pain
control and prophylaxis of HO
after THA
Prophylaxis of HO alter 1HA
NSAID.maycause gastric erosion
and bleeding;avoid if concurrent
advanced renal disease
celecoxib (Celebrex -) 200 mg P0 BID NSAID (COX-2 inhibitor),cardiotoxic
indomethacin (Indocid ) 2SmgP0IID Use with misoprostol
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0R51Orthopaedic Surgery Toronto Notes 2023
Landmark Orthopaedic Trials
Trial Name Reference Clinical Trial Details
NEJM 2019:381:2199-2208 Title: Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture
Purpose:Despite being amongst the top10 causes of disability in adults,there is still ambiguity in the treatmentof displaced
femoral neck fractures.
Methods:1495 patients who were 50- years old and had a displaced femoral neck fracture were randomly assigned to have a total
hip arthroplasty or hemiarthroplasty.
Results:A secondary hip procedure within 24 months of follow up occurred in 7.9% of the total hip arthroplasty and 8.3% of the
hemiarthroplasty group.Hip Instability occurred in 4.7% ol the total hip arthroplasty,and 2.4% of the hemiarthroplasty group.
Function was modestly better in totalhip arthroplasty over hemiarthroplasty.
Conclusions: The incidence ol secondary procedures,and function over 24 months between the total hip arthroplasty and
hemiarthroplasty group did not have a significant difference.
Title:Surgical vs.Honsurgical Treatment of Adults with Displaced Fractures of the Proximal Humerus:the PROFHER Randomized
Clinical Trial
Purpose: To evaluate the efficacy of surgical management in adults with displaced fractures of the proximal humerus involving the
surgical neck.
Methods: A randomized clinical trial where 260 palienls. who presented to 32 UK hospitals alter sustaining a displaced fracture of
the proximal humerus involving the surgical neck were randomizedinto surgicaland nonsurgical lioatmcnt groups, then followed
for 2 years.
Results:No significant mean treatment group differences inOxford Shoulder Score averaged over 2 years (39.07 points for the
surgical group vs.38.32points for the nonsurgical group:difference of 0.75 points (95% Cl,-1.33 to 2.84 points);P *.48).
Conclusions:No significant differences between surgical treatmentvs.non-surgrcal treatment.These results do notsupport the
use of surgery for patients with displaced proximalhumerus fractures involving the surgical neck.
Title: A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds
Purpose: toinvestigate the effects of castile soap versus normal saline irrigation delivered by means of high, low, or very low
Irrigation pressures.
Methods: 2551palienls from 41clinical centers,who had an open fracture olan extremity undergoing irrigation were randomly
assigned to one of threeirrigation pressures (high,low, and very low) and one of two irrigationsolutions (castile soap versus normal
saline).The primary outcome in this study was reoperation within12 months after the initial surgery.
Results:Hazardratio showed no significant difference between the rates of reoperation within12 months between the different
irrigation pressures.Reoperation occurred in14.8% in the soap group and in11.6% in the saline group (hazard ratio.1.32.95%Cl,
1.06 to1.66;P-0.01).
Conclusions:Rates of reoperation were similar regardless of irrigation pressure. The reoperation rate was higher in the soap group
than in the saline group.These findings indicate low pressure saline irrigationis an acceptable form olwound irrigation.
HEALTH
PR0FHER JAMA 2015 Mar 10:313(10):1037-47
FLOW N Engl J Med 2015:373:2629 2641
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Miller. TT.Bone Tumors and Tumorllke Conditions:Analysis with Conventional Radiography.Radiology 2008;246(3):662 674.
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Miyamoto RG,Bosco JA.Sherman OH.Treatment of medial collateral ligament Injuries.J Am Acad Orthop Surg 2009:17(31:152 161.
Mordecai SC.Al-Hadilhy N.Ware HE.et al. Treatmenlof meniscal tears:an evidence based approach.World J Orthop 20M:5(3):233-241.
Murphy RF.Kim YJ. Surgical managementof pediatric developmental dysplasia of the hip.J Am Acad Orthop Surg 2016:24(9):615-624.
Murrell GA.Walton JR.Diagnosis of rotator cuff tears.Lancet 2001:357:769-770.
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Otolaryngology
Alyssa Li,Jessica Trac, and Sheila Yu, chapter editors
Chunyi Christie Tan and Vrati Mehra, associate editors
Arjan S. Ohoot, KBM editor
Dr. Yvonne Chan, Dr. Antoine Hskander, and Dr. Jonathan Irish,staff editors
Epistaxis
Hoarseness
Acute Laryngitis
Chronic Laryngitis
Vocal Cord Polyps
VocalCord Nodules
Recurrent Respiratory Papillomatosis
Laryngeal Carcinoma
Salivary Glands
Sialadenitis
Sialolithiasis
Salivary Gland Neoplasms
Parotid Gland Neoplasms
Neck Masses
Approach to a Neck Mass
Evaluation
Congenital Neck Masses
Branchial Cleft Cysts/Sinuses/Fistulae
Thyroglossal Duct Cysts
Lymphatic,Venous,or Mixed Venolymphatic Malformations
Neoplasms of the Head and Neck
Thyroid Carcinoma
Paediatric Otolaryngology
Acute Otitis Media
Otitis Media with Effusion
Adenoid Hypertrophy
Adenoidectomy
Sleep-Disordered Breathing in Children
Peritonsillar Abscess (Ouinsy)
Tonsillectomy
Airway Problems in Children
Signs of Airway Obstruction
Acute Laryngotracheobronchitis (Croup)
Acute Epiglottitis
Subglottic Stenosis
Laryngomalacia
Foreign Body
Deep Neck Space Infection
Common Medications
Landmark Otolaryngology - Head and Neck Surgery Trials OT50
References
Acronyms
Basic Anatomy Review.
OT2 OT27
OT2 OT28
Ear
Nose
Throat
Head and Neck
Anatomical Triangles of the Neck
Differential Diagnoses of Common Presentation
Dizziness
Otalgia
Hearing Loss
Tinnitus
Nasal Obstruction
Hoarseness
Neck Mass
Hearing
Types of Hearing Loss
Pure Tone Audiometry
Speech Audiometry
Impedance Audiometry
Auditory Brainstem Response
Otoacoustic Emissions
Aural Rehabilitation
Vertiga
Evaluation of the Dizzy Patient
Benign Paroxysmal Positional Vertigo
Meniere's Disease (Endolymphatic Hydrops)
Vestibular Neuronitis (Labyrinthitis)
Acoustic Neuroma (Vestibular Schwannoma)
Tinnitus
Diseases of the External Ear
Cerumen Impaction
Exostoses
Otitis Externa
Malignant (Necrotizing) Otitis Externa (Skull Base Osteomyelitis)
Diseases of the Middle Ear.
Acute Otitis Media and Otitis Media with Effusion
Chronic Otitis Media
Cholesteatoma
Mastoiditis
Otosclerosis
Diseases of theInner Ear.
Congenital SensorineuralHearing Loss
Presbycusis
Sudden Sensorineural Hearing Loss
Autoimmune Inner Ear Disease
Drug Ototoxicity
Noise-Induced Sensorineural Hearing Loss
Temporal Bone Fractures
Facial Nerve (CN VII) Paralysis
Rhinitis.
Allergic Rhinitis (i.e.Hay Fever)
Vasomotor Rhinitis
Rhinosinusitis
Acute Bacterial Rhinosinusitis
Chronic Rhinosinusitis
OT6
OT30
OT32
OT9
OT 33
OT35
OT12 OT39
OT15
OT16
0T17
0T48
OT51 OT19
OT22
OT23
OT25
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OT1 Otolaryngology Toronto Notes 2023
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0T2 Otolaryngology Toronto Notes 2023
Acronyms
ABR auditory brainstem response
AC air conduction
AOM acute otitis media
BAHA bone-anchored hearing aid
BC bone conduction
BPPV benign paroxysmal positional
vertigo
CHL conductive hearing loss
CMV cytomegalovirus
CNS central nervous system
CP cerebellopontine angle
CPAP continuous positive airway
pressure
cerebrovascular accident
external auditory canal
endoscopic sinus surgery
Epstein-Barr virus
familial adenomatous polyposis OE
fine needle aspiration
gastroesophageal reflux disease OME
granulomatosis withpolyangiitis OPC
head and neck
hearing loss
HPV human papillomavirus
herpes simplex virus
intranasal corticosteroids
middle car effusion
middle ear inflammation
multiple sclerosis
otitis externa
otitis media
otitis media with effusion
oropharyngeal cancer
obstructive sleep apnea
polymorphonuclear leukocytes
rheumatoid arthritis
RSV respiratory syncytial virus
SCC squamous cell carcinoma
SCM sternocleidomastoid
SNHL sensorineural hearing loss
SRI speech reception threshold
TEF tracheoesophageal fistula
TM tympanic membrane
TMJ temporomandibular joint
TMP-SMX trimethoprim/sulfamethoxazole
URTI upper respiratory tract infection
RA
HSV
CVA INCS
tiL MEE
ESS MEI
EBV MS
FAP
FNA OM
GERD
GPA
H&N CSA
HI PMN
Basic Anatomy Review
Ear
External
Temporalis fascia Auditory ossicles
and muscle
Middle Inner
Semicircular canals
Triangular
fossa
Helical crus
Vestibular
e r v e
— Vestibulocochlear
terve (CN VIII)
Antihelix
Cochlear
nerve
Scapha
Facial nerve (CN VIII
Cochlea
Antitragus
Lobule
Eustachian tube
HD Susan Park 2009
acoustic Tympanic
®
meatus membrane Aarti Inamdar
Figure1.Surface anatomy of the external ear;anatomy of ear
Tympanic mombrano viewed
through speculum
View into tympanic cavity after
removal of tympanic membrane
3
3
Pars flaccida
Neck of malleus
^ "
-Lateral process
-
of malleus
Incus long process
Stapes
r 1 Tendon of f
stapedius muscle '
: —Long process of —H
malleus
Umbo
(flat portion!
Fossa of round -
(cochlear) window
—Cone of light
s
©
Tensor tympani
tendon
-J—Tensor tympani
> 1 muscle
Tympanic plexus
(branch of CN IXI
Hypotympanum
Annulus
L tensa
Figure 2.Normal appearance of right tympanic membrane on otoscopy
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0T1 Otolaryngology Toronto Notes 2023
Head and Neck
Temporal branch
Zygomatic branch
/
Superficial temporal a. Buccal branch
Styloid process
Mastoid process
Stylomastoid foramen
Facial n.lCN VII)
Posterior belly of
digastric nt.
Parotid gland
Mandibular branch
Marginal mandibular
branch
Cervical branch
Maxillary a.
Angular a.
^
/
Lateral nasal a ./ %
Occipital a.
Posterior auricular a.
-
-
Ascendingpharyngeal a,
Superior labial a.
- ;
Internal carobd a.
barotd a.
Inferior labial a.-—-"
-^External
\
— Facial a s
"
y
Lingual a S
Superior thyroid a
- Common carobd a ?:
VI
0
Figure 7. Extratemporal segment of facial nerve
Branches of facial nerve (in order from superior to inferior)
To Zanzibar By Motor Car
Figure 8. Blood supply to the face
Branches of the external carotid artery (in order from inferior to superior)
Some Anatomists Like Freaking Out Poor Medical Students
Post,belly
digastric m.
— Common carotid
a.bifurcation
Sternocleidomastoid m.
Ant. belly
digastric m.
—'
Hyoid bone /
Sternohyoid m.'
Omohyoid m.
Anterior Triangle
•submental triangle
Posterior Triangle
occipital triangle *
(
•
or
submandibular
digastric) triangle
—
•carotid triangle -
•muscular triangle
Posterior triangle
Trapezius m
subclavian triangle *
Anterior triangle **
'
Lisa Qlu 2019. altor
Hyoid bone
•Thyrohyoid membrane External
carotid a *
Thyroid cartilage
Common
carotid a.
Internal
bifurcation
— jugularv.
Ant. belly
omohyoid m."
|i\ W
1)l
Median cricothyroid
ligament '
•
|
Si Sternocleidomastoid m.
Greater auricular n.
Lesser occipital n.
^
Ventral ramus (C2)
Ventral ramus IC3)
Accessory n.(CN XI)
Ventral ramus (C5)
Anterior scalene m.
Phrenic n.
V r Digastric m.
Hypoqlossal n.
(CN XII)
Superior root
ansa cervicalis
Inferior root /
ansa cervicalis /
*
1 / Sternocleidomastoid m.
!/
I
- km
Cricoid cartilage r T
Post, belly ,
omohyoidm.
L J
Thyroid gland Vagus n.
Sternohyoid m. Brachial plexus
Trache. Clavicle
© Kateryna Procunier 2014.after ©’J-'
W*
-
15
y
© Inessa Stanishevskaya 2012 after Subclavian
a. and v.
Figure 9. Anatomy of the neck
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0T5 Otolaryngology Toronto Notes 2023
Anatomical Triangles of the Neck Paired Parasympathetic Ganglia of the
Head and Neck
• Ciliary (supplied by CN III):pupillary
constriction
• Pterygopalatine (supplied by CN
VII):lacrimal gland,nasal mucosa
• Submandibular (supplied by CN
VII): submandibular, sublingual
glands
• Otic (supplied by CN IX):parotid
gland
Anterior triangle
• bound by anterior border of SCM, midline of neck, and lower border of mandible
• divided into:
.submental triangle: bound by both anterior bellies of the digastric muscles from the mentum to
the hyoid bone
digastric triangle: bounded by anterior and posterior bellies of the digastric muscles and Inferior
border of mandible
carotid triangle: bounded by SCM,anterior belly of the omohyoid muscles, and posterior belly of
digastric muscles
• contains: tail of parotid,submandibular gland, hypoglossal nerve, carotid bifurcation, and
lymph nodes
Posterior triangle
• bound by posterior border of the SCM, anterior border of trapezius, and middle third of clavicle
• divided into:
occipital triangle:superior to posterior belly of the omohyoid
subclavian triangle:inferior to posterior belly of omohyoid
• contains:spinal accessory nerve and lymph nodes
Functions of the Facial Nerve
“Ears. Tears, Face, Taste"
Ears: stapedius muscle, sensory around
concha of auricle,EAC. and TM
Tears:lacrimation (lacrimal gland)
and salivation (submandibular and
sublingual glands)
Face:muscles of facial expression
Taste: sensory anterior AS of tongue
Table1Lymphatic Drainage of Nodal Groups and Anatomical Triangles of the Neck (via chorda tympani)
Nodal Group/Level Location Drainage
1.Suboccipital (S)
2. Rclroauricular (R)
Base of skull,posterior
Superficial to mastoid process
Posterior scalp
Scalp,temporalregion, external auditory
meatus,posterior pinna
External auditory meatus, anterior pinna,soft
tissue ol frontal and temporal regions,root ol
nose,eyelids,palpebral conjunctiva
Lymphadenopathy
• Left-sided enlargement of a
supraclavicular node (Virchow's
node) may indicate an abdominal
malignancy or malignancy below the
clavicle
• Right-sided enlargement may
indicate malignancy of the
mediastinum, lungs,or esophagus
• Occipital and/or posterior auricular
node enlargement may indicate
rubella
3.Parotid-proauricular (P) Anterior to car
4.Submental(Level 1A) Anterior bellies (midline) of digastric muscles. Floor of mouth,anterior tongue,anterior
mandibular alveolar ridge,lower lip
Anterior belly of digastric muscles,stylohyoid Oral cavity,anterior nasal cavity,soft tissues
muscle,body of mandible
Skull base to inferior border of hyoid bone
along SCM muscle
Inferior border of hyoid bone to inferior border Oral cavity,naso/oro,
'
hypopharynx.larynx
of cricoid cartilage along SCM muscle
Inferior border of cricoid cartilage to clavicle
along SCM muscle
Posterior border of SCM, anterior border of
trapezius,from skull base to clavicle
Hyoid bone (midline) to suprasternal notch
betvreen the common carotid arteries
tip of mandible,and hyoid bone
S. Submandibular (levelI8)
ol the mid- face,submandibular gland
6.Upper jugular (levels IIA and MB) Oral cavity,nasal cavrty.naso/orof
hypopharynx.larynx,parotid glands
7. Middle jugular (LevelIII)
8. Lower jugular*(Level IV) Hypopharynx.thyroid,cervical esophagus,
larynx
Nasopharynx and oropharynx. cutaneous
structures of the posterior scalp and neck
Thyroid gland,glottic,and subglottic larynx,
apex of piriform sinus,cervical esophagus
4 Strap Muscles of the Neck
• Thyrohyoid
• Omohyoid
• Sternohyoid
• Sternothyroid
9.Posterior triangle"(levels VA and VB)
10. Anterior compartment"* (Level VI)
'Virchow's node:left lower jugular [levelIV) supraclavicular node
"Includes some supraclavicular nodes
'"Includes prclrachcal.precrlcold.paratracheal.and perllhyroldal nodus
- Superior thyroid artury
- Common carotid artery
- Internal lugularvem
- Inlenorthyrord artery
- Right recurrent laryngeal nBrve
- Thyroid cartilage
- Cricoid cartilage
- Supurior parathyroid gland
- Thyroid gland
- Inferior parathyroid gland
VNICNXI - Vagus nerve ICN XI
IAIN - Lett recurrent laryngeal nerve
*Thyroidea ima artery present m 3% af population,
arises from aortic arch or innominate anery +
Figure 10. Anatomy of the thyroid
gland
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0T6Otolaryngology Toronto Notes 2023
Differential Diagnoses of Common
Presentation
Dizziness
( Dizziness ) True nystagmus and vertigo caused
by a peripheral lesion usually do not
last longer than a few wk,due to
compensation from the cerebellum
(unless there is a history of cerebellar
ischemiafstroke). Central lesions do not
compensate,therefore nystagmus and
vertigo will persist
[ True Vertigo J Non-Vortiginous )
T
( Peripheral (Vestibular) J ( Central ] ( Organic Diseases ] [ Functional ]
v jr
Cardiac
Arrhythmias
Aortic stenosis
Vasovagal
Orthostatic hypotension
Anemia
Peripheral neuropathy
Visual impairment
Cerebrovascular disorders
Vertebrobasilar insufficiency
Transient ischemic attacks
Wallenberg syndrome
Cerebellar infarction
Migrainous vertigo
Multiple sclerosis
Inflammation
Meningitis
Cerebellar abscess
Trauma:cerebellar contusion
Toxic:alcohol,hypnotics,drngs
Tumours
CPA tumours
Posterior fossa tumours
Glomus tumours
Depression
Anxiety
Panic disorder
(hypeiventilabon)
Personality disorder
Phobic dizziness
Benign paroxysmal positional
vertigo (BPPV)
Labyrinthitis
Meniere's disease
Vestibular neuronitis
Autoimmune inner ear disease
Cholesteatoma
Ototoxic drug exposure
Perilymph fistula
Recurrent vesbbulopathy
Superior semicircular canal dehiscence
Temporal bone fracture
Findings Suggestive of Central Vertigo
Acute onset and continuous
Normal head impulse test
Multidirectional nystagmus
Skew deviation present
5 Ds of Vertebrobasilar Insufficiency
Drop attacks
Diplopia
Dysarthria
Dizziness
Dysphagia
Common causes inbold
Figure 11. Differential diagnosis of dizziness
Otalgia
Otalgia -Referred Pain
Sensory innervation to the ear is
supplied by CN V,VII.IX and X resulting
in many sources of referred pain that can
cause otalgia
( Otalgia )
’
r
'
r
f
External Ear Middle/Inner Ear j
f
Referred Pain ]
The 10 Ts of Referred Pain which Cause
Otalgia
Teeth:Impacted wisdom teeth,caries,
infant teething
TMD: Temporomandibular Joint Disease
Tubal Area:Eustachian tube dysfunction,
nasopharynx (area behind the nose (rule
out tumour)
Tonsils:Infections,tumours
Throat: Infections,tumours of pharynx,
larynx (voice box)
Tongue:inflammation,tumour
Trachea:(windpipe).Larynx (voice box)
Thyroid Gland:infections,tumours
Tempora Arteritis:inflammation of the
artery above the ear
Trauma
Infection
Auricular cellulitis
External canal abscess
HSV/zoster
Infection
AOM
Mastoiditis
Myringitis
OME '
Skull base infections
Trauma
Barotrauma
Traumatic perforation
Other
Cholesteatoma
Neoplasm
Infection
Ramsay Hunt syndrome
Tonsillitis
Tracheitis
Trauma
Cervical arthritis
Thyroiditis
Trigeminal neuralgia
Dental disease
Sinusitis
Other
Glossopharyngeal neuralgia
Neoplasm of oral cavity,
larynx,pharynx
TMJ syndrome
Trismus
OE
Perichondritis
Trauma
Burns
Frostbite
Hematoma
Lacerations
Other
Cerumen impaction
Foreign body
Neoplasm ol external canal
GPA
Figure 12. Differential diagnosis of otalgia
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0T7 Otolaryngology Toronto Notes 21)23
Hearing Loss
[ Hearing Loss ]
T 1
(Conductive J (Sensorineural J
T I
( External Ear j ( Middle Ear ] ( Congenital ) ( Acquired J
. '
T
'
Impacted cerumen
Otitis externa
Foreign body
Keratosis obturans
Exostoses,osteomas
Tumour of canal
Congenital stenosis/microtia
Presbycusis
Noise-induced
Meniere'
s disease
Labyrinthitis
Idiopathic sudden SNHL
Autoimmune inner ear disease
Ototoxic drug exposure
Temporal bone trauma
Infectious
Postmeningitis
Syphilis
Viral:mumps,CMV,HSV
Neoplastic
Acoustic neuroma
CPA tumours
Vascular occlusion/emboli
Auditory neuropathy
Genetic
Non-syndrome associated
Syndrome associated
Intrauterine infections
le.g. TORCH!
Teratogens
Perinatal hypoxia
Prematurity/low birth weight
Hyperbilirubinemia
OME
TM perforation
Otosclerosis
Tympanosclerosis
Eustachian tube dysfunction
Cholesteatoma
Ossicular malformations
Ossicular discontinuity
Hemotympanum
Middle ear tumour
Congenital stenosis/microtia
Common causes inbold
Figure 13. Differential diagnosis of hearing loss
Tinnitus
f Tinnitus J
Tinnitus is most commonly associated
with SNHL
j 1
Subjective
Only heard by patient (common)
Objective
Can be heard by others (rare)
Glomus Tympanicum/Jugulare Tumour
Signs and Symptoms
• Pulsatile tinnitus
• HL
• Blue mass behind TM
• Brown's sign (blanching of the TM
with pneumatic otoscopy)
T
Otologic
Presbycusis
Noise-induced HL
OME
Meniere's disease
Otosclerosis
Cerumen
Foreign body against TM
Drugs
ASA
NSAIDs
Aminoglycosides
Antihypertensives
Heavy metals
Metabolic
Hyper/hypothyroidism
Hyperlipidemia
Vitamin A,B,Zinc deficiency
Neurologic
Head trauma
Vascular
Benign intracranial hypertension
Arteriovenous malformation
Glomus tympanicum
Glomus jugulare
Arterial bruits:
High-riding carotid artery
Vascular loop
Persistent stapedial artery
Carotid stenosis
Venous hum:
High jugular bulb
HTN
Hyper/hypothyroidism
Mechanical
Patulous Eustachian tube
Palatal myoclonus
Stapedius muscle spasm
MS
CPA tumours
Psychiatric
Anxiety
Depression
Common causes inbold
r“i
Figure 14. Differential diagnosis of tinnitus L J
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0T8 Otolaryngology Toronto Notes 2023
Nasal Obstruction
Table 2. Differential Diagnosis of Nasal Obstruction
Acquired Congenital
Nasal Cavity Pyriform aperture stenosis
Choanal atresia
Rhinitis
Acute/chronic
Vasomotor
Allergic
Rhinosinusitis
Foreign bodies
Enlarged turbinates
tumour
Benign:polyps,inverting papilloma (can
become malignant)
Malignant
Dermoid cyst
Encephalocele
Glioma
see
Eslhesioneuroblastoma (olfactory
neuroblastoma)
Adenocarcinoma
Septal deviation
Septal dislocation
Septal hematoma/abscess
Adenoid hypertrophy
tumour
Benign:juvenile nasopharyngeal angiofibroma
(JHA).polyps
Malignant:nasopharyngeal carcinoma
GPA.diabetes,vasculitis
Nasal Septum Septal deviation
Septal dislocation
Septal hematoma/abscess
Nasopharynx
Systemic
Hoarseness
Table 3. Differential Diagnosis of Hoarseness
Infectious Acute/chronic laryngitis
LaryngDtracheobronchitis (croup)
GERD
Vocal cord polyps/nodules
lifestyle:smoking,chronic alcohol use
External laryngeal trauma
Endoscopy and endotracheal lube (c.g.intubation granuloma)
Benign tumour
Papillomas|HPVinfection)
Minor salivary gland tumours
Other
Retention cysts
Endocrine
Hypothyroidism
Vrriliialion
Central lesions
Lung malignancy is the most common
cause of extralaryngeal vocal cord
paralysis Inflammatory
traumatic
Neoplastic Malignant tumours (e.g.thyroid)
sec
Other
Cysts
Systemic Connective tissue disease
RA
SIE
Neurologic (vocal cord
paralysisdue to superiors
recurrent laryngeal nerve
injury)
Iatrogenic injury:thyroid,parathyroid surgery,carotid
endarterectomy,patent ductus arteriosus(PDA) ligation
Bilateral
Iatrogenic injury:bilateral thyroidsurgery,forceps
delivery
Neuromuscular
Myasthenia gravis
CVA
Head injury
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