You are asked to evaluate a 6-year-old child with nasal pain. She is on the pediatric hematology-oncology service, and is undergoing chemotherapy for acute lymphoblastic leukemia. She has no other pertinent medical history. The pain has been present for 12 hours. On examination, you note no abnormalities in the oral cavity, oropharynx, or external head and neck examination. Her pulse is regular and her respirations are nonlabored. On nasal examination you note a slight duskiness to the anterior face of the left middle turbinate. An appropriate response would be
A. Reassure the child and her parents that she is most likely fine, and schedule a follow-up visit for the following day
B. Take her to the operating room immediately for an emergent biopsy
C. Order a contrasted MRI of the nose/face/orbits and a complete blood count (CBC) with differential
D. Start her on nasal decongestant spray (oxymetazoline) twice daily, nasal saline irrigations, and an oral antihistamine once daily
B. Take her to the operating room immediately for an emergent biopsy. Invasive fungal sinusitis is usually seen in immunocompromised patients, such as the patient described here. It is caused by uncontrolled infiltrative growth of usually nonpathogenic fungal organisms such as Rhizopus or Aspergillus species. Even with prompt diagnosis, aggressive surgical therapy, and modern antifungal agents, the disease still carries a significant mortality rate (up to 30%). The index of suspicion for invasive fungal sinusitis must be high for any immunocompromised patient, as the symptoms can be subtle and the disease rapidly progressive. If invasive fungal sinusitis is suspected, biopsies should be taken of the suspicious areas and sent for immediate pathologic examination. Note that this can often involve calling a pathologist in from home in the middle of the night or on a weekend, if they are not in-house. In the case presented here, the likelihood of the child cooperating with an examination and biopsy is low, thus an emergent posting to the operating room is the most prudent action.
You are asked to evaluate a patient in the emergency room with rapid onset of lip and tongue swelling. He develops shortness of breath and stridor during your examination. Following an emergent tracheotomy to establish his airway you do a thorough review of his medication history. Which of the following drug class(es) is/are known to be associated with acute angioedema?
A. Angiotensin converting enzyme inhibitors (ACE inhibitors, such as lisinopril)
B. Angiotensin II receptor blockers (ARBs, such as losartan)
C. Recombinant tissue plasminogen activators (r-tPAs, such as alteplase)
D. Anticoagulant direct thrombin inhibitors (such as lepirudin)
E. All of the above. Acute angioedema is characterized by localized swelling of subcutaneous and submucosal tissue of the head and neck. The swelling usually begins with mild facial involvement but may progress to involve the oral cavity, tongue, pharynx, and larynx. The underlying pathophysiology of angioedema involves vasoactive mediators such as bradykinin and histamine, causing interstitial edema through endothelial-mediated vasodilation of arterioles with subsequent capillary and venule leakage. Drug-induced angioedema has classically been associated with the use of angiotensin-converting enzyme inhibitors (ACE inhibitors), although many other medications can also cause this phenomenon. Other drugs known to be associated with angioedema include rituximab, alteplase, fluoxetine, laronidase, lepirudin, angiotensin II receptor blockers (ARBs), and tacrolimus.
A 34-year-old woman is seen in the emergency department with submandibular swelling, fever, and pain. She is unable to open her mouth more than a few millimeters. One hour later she collapses, and she has only minimal air movement with bag-mask ventilation. Attempts at oral intubation are unsuccessful. Fortunately, you are standing nearby and offer to perform an emergency cricothyrotomy. Where is the best place to rapidly create an airway inferior to the vocal cords with a minimum danger of hemorrhage?
A. Immediately superior to the cricoid cartilage
B. Immediately superior to the hyoid bone
C. Immediately superior to the jugular notch
D. Immediately superior to the third tracheal ring
E. Immediately superior to the thyroid cartilage
A. Immediately superior to the cricoid cartilage. The patient described has Ludwig’s Angina, an uncommon life-threatening condition characterized by cellulitis involving the submental, sublingual, and submandibular spaces. The source of the infection is odontogenic and spreads rapidly. The infection is usually polymicrobial with aerobic and anaerobic gram-positive cocci and gram-negative rods. Airway compromise in these patients is common, and should be of primary concern. A cricothyroidotomy is performed through the cricothyroid membrane which spans the midline area between the cricoid cartilage inferiorly and the thyroid cartilage superiorly. It can be easily palpated just inferior to the thyroid cartilage in greater than 90% of individuals, and has no major blood vessels or structures. While an emergency tracheotomy can be performed through the second or third intertracheal ring space, this often involves either going through or dissecting part of the thyroid gland off the tracheal wall. As the thyroid’s blood supply is quite robust, the bleeding encountered can be quite significant. Therefore, in an emergency situation the cricothyroid space is almost universally preferred.
A 25-year-old man sees his surgeon for follow up care 1 month after undergoing a parathyroidectomy. The patient has vocal hoarseness, so a transnasal endoscopy is performed. The left vocal fold is found to be immobile and paramedian. Denervation of which of the following muscles is most likely responsible for the vocal fold position noted?
A. Left cricothyroid muscle
B. Left lateral cricoarytenoid muscle
C. Left posterior cricoarytenoid muscle
D. Left thyroarytenoid muscle
C. Left posterior cricoarytenoid muscle. Innervation to the larynx is provided by the vagus nerve (cranial nerve X). The recurrent laryngeal nerves branch from the vagus nerve and provide motor innervation to all of the intrinsic muscles of the larynx except the cricothyroid muscle. All of the intrinsic muscles of the larynx serve to tense the vocal folds or adduct the vocal folds except one—the paired posterior cricoarytenoid muscles. Current understanding of peripheral nerve injury and regeneration presents the following scenario when the nerve supply to the larynx is injured. After nerve injury, neuronal axon regrowth results in reinnervation of the target muscles but in a random pattern. Since only one of the muscles abducts the vocal folds, reinnervation is unlikely to result in a tonically abducted vocal fold. Instead, the vocal fold usually assumes a paramedian position, accompanied by loss of muscle bulk and atrophy due to loss of innervation. This can lead to hoarseness and vocal fatigue when one side is injured, but often causes airway obstruction if both sides are injured.
Which of the following patients with squamous cell carcinoma of the head and neck most likely has the worse prognosis?
A. 46-year old woman, nonsmoker and occasional drinker with oral tongue cancer measuring 2.5 cm × 1.0 cm. No neck nodes or distant metastases are noted on examination.
B. 84-year old woman, 48 pack-year smoking history and drinks 2-3 liquor drinks per day. Has a hoarse voice for 3 months and is found to have a T2N0M0 laryngeal cancer.
C. 45-year old man, nonsmoker who drinks 1 glass of red wine daily. Has a prominent right level III neck mass. On oral examination has a 2.5 cm right tonsil mass consistent with an oropharyngeal primary.
D. 25-year old man with 12 pack-year tobacco history and chronic severe gastroesophageal reflux. Presents with throat pain and dysphagia (trouble swallowing). On fiberoptic endoscopy is found to have a 3 cm ulcerated hypopharyngeal mass. No palpable neck adenopathy is present.
D. 25-year old man with 12 pack-year tobacco history and chronic severe gastroesophageal reflux. Presents with throat pain and dysphagia (trouble swallowing). On fiberoptic endoscopy is found to have a 3 cm ulcerated hypopharyngeal mass. No palpable neck adenopathy is present. Assuming appropriate treatment, outcomes for patients with oral cavity cancer are generally good with 5-year survival rates of 72% for stage I-II, 44% for stage III-IVb, and 35% for stage IVc. Outcomes for patients with laryngeal cancer can be excellent. For early stage I glottis carcinoma (tumor limited to the true vocal folds), 5-year overall survival rates of 90% can be expected. Overall, laryngeal cancer carries a 5-year survival for stage I-II disease of 79%. Survival for oropharyngeal cancer is somewhat worse: stage I-II oropharyngeal cancer 5-year survical average is 58% and stage III-IVb 41%. The hypopharynx is invested with an abundant lymphatic drainage network, and patients with hypopharyngeal cancer typically present with advanced stage disease. Hypopharyngeal cancer carries the worst prognosis of any head and neck subsite. Five-year survival for stage I-II hypopharyngeal cancer is 47%, stage III-IVb is 30%, and stage IVc only 16%.