ENT www.ketabpezeshki.com 66485457-66963820 FOURTH EDITION MELISSA A. SCHOLES, MD Assistant Professor Department of Otolaryngology University of Colorado Aurora, CO VIJAY R. RAMAKRISHNAN, MD Assistant Professor Department of Otolaryngology Co-Director, CU Skull Base Program University of Colorado Aurora, CO ENT www.ketabpezeshki.com 66485457-66963820 Copyright © 2005, 2001, 1996 by Elsevier Inc. All rights reserved. Library of Congress Cataloging-in-Publication Data ENT secrets / [edited by] Melissa A. Scholes, Vijay R. Ramakrishnan.—Fourth edition. p. ; cm.—(Secrets series) Includes bibliographical references and index. ISBN 978-0-323-29856-8 (pbk. : alk. paper) I. Scholes, Melissa A., editor. II. Ramakrishnan, Vijay R., editor. III. Series: Secrets series. [DNLM: 1. Otorhinolaryngologic Diseases–Examination Questions. WV 18.2] RF57 617.5′10076–dc23 2015009820 Senior Content Strategist: James Merritt Content Development Specialist: Amy Meros Publishing Services Manager: Hemamalini Rajendrababu Senior Project Manager: Beula Christopher Design Direction: Ryan Cook Printed in United States Last digit is the print number: 9 8 7 6 5 4 3 2 1 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 ENT SECRETS, FOURTH EDITION ISBN: 978-0-323-29856-8 Copyright © 2016 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. www.ketabpezeshki.com 66485457-66963820 v PREFACE ENT Secrets has been a learning tool used by medical students, residents, and health care providers since the first edition, published in 1996 by Bruce Jafek and Anne Stark. Dr. Jafek went on to edit two subsequent editions with the goal of sharing knowledge and insight in the field of otolaryngology. Our newest edition aims to provide updates on that knowledge as well as introduce new concepts and technologies in the ever-changing field of otolaryngology. We were fortunate to be residents under Dr. Jafek, who loved teaching and training students of all types. We want to carry on that tradition with this latest edition of ENT Secrets. This has been possible with the support of the University of Colorado Otolaryngology Department faculty, alumni, and residents, and other contributors of this book. We sincerely thank them. www.ketabpezeshki.com 66485457-66963820 vi CONTRIBUTORS Gregory C. Allen, MD, FACS, FAAP Associate Professor Departments of Otolaryngology—Head and Neck Surgery and Pediatrics University of Colorado School of Medicine; Department of Pediatric Otolaryngology Children’s Hospital Colorado Aurora, CO Jeremiah A. Alt, MD, PhD Sinus and Skull Base Surgery Program Division of Otolaryngology University of Utah Salt Lake City, UT Marcelo B. Antunes, MD Private Practice Northwest Facial Aesthetic Center Marietta, GA Ronald Balkissoon, MD Division of Pulmonology National Jewish Health Denver, CO Renee Banakis Hartl, MD, AuD Department of Otolaryngology University of Colorado School of Medicine Aurora, CO Henry P. Barham, MD Department of Otolaryngology—Head and Neck Surgery University of Colorado Aurora, CO Kenneth T. Bellian, MD, MBA Assistant Professor Department of Otolaryngology—Head and Neck Surgery University of Colorado; Chief of Clinical Operations Denver Health Medical Center Denver, CO Carly Bergey, MA, CCC-SLP CCC-SLP- Rehabilitation National Jewish Health Denver, CO Daniel W. Bowles, MD Assistant Professor Department of Medicine University of Colorado School of Medicine Aurora, CO Allison Brower, AuD, MS Department of Audiology University of Colorado Hospital Aurora, CO Mariah Brown, MD Assistant Professor Department of Dermatology—Mohs Surgery University of Colorado School of Medicine Aurora, CO Cristina Cabrera-Muffly, MD, FACS Assistant Professor Department of Otolaryngology University of Colorado School of Medicine Aurora, CO Thomas L. Carroll, MD Director Voice Program Brigham and Women’s Hospital; Division of Otolaryngology Harvard Medical School Boston, MA Justin Casey, MD Department of Otolaryngology—Head and Neck Surgery University of Colorado Hospital Aurora, CO Stephen P. Cass, MD Professor Department of Otolaryngology University of Colorado Denver School of Medicine Aurora, CO Jeffrey Chain, MD Private Practice Comprehensive ENT, Head and Neck Surgery Denver, CO www.ketabpezeshki.com 66485457-66963820 CONTRIBUTORS vii Kenny H. Chan, MD Department of Otolaryngology University of Colorado School of Medicine; Department of Pediatric Otolaryngology Children’s Hospital Colorado Aurora, CO Henry H. Chen, MD, MBA Department of Otolaryngology Facial Plastic and Reconstructive Surgery Cedars-Sinai Medical Center Los Angeles, CA Tendy Chiang, MD Department of Otolaryngology—Head and Neck Surgery The Ohio State University College of Medicine; Department of Pediatric Otolaryngology—Head and Neck Surgery Nationwide Children’s Hospital Columbus, OH Matthew S. Clary, MD Department of Otolaryngology University of Colorado School of Medicine Aurora, CO Stacy Claycomb, AuD University of Colorado Hospital Aurora, CO Alexander Connelly, MD University of Colorado School of Medicine Aurora, CO Mark S. Courey, MD Department of Otolaryngology—Head and Neck Surgery Division of Laryngology University of California, San Francisco San Francisco, CA Brett W. Davies, MD, MS Oculoplastic and Orbital Surgery San Antonio Military Medical Center/Wilford Hall San Antonio, TX Allison M. Dobbie, MD Department of Otolaryngology University of Colorado School of Medicine; Department of Pediatric Otolaryngology Children’s Hospital Colorado Aurora, CO Vikram D. Durairaj, MD, FACS Oculoplastic and Orbital Surgery Director ASOPRS Fellowship Texas Oculoplastic Consultants Austin, TX Marcia Eustaquio, MD Assistant Professor Department of Otolaryngology—Head and Neck Surgery Denver Health Medical Center University of Colorado Denver Denver, CO Vincent Eusterman, MD, DDS Associate Professor University of Colorado School of Medicine; Director Otolaryngology—Head and Neck Surgery Denver Health Medical Center Denver, CO Geoffrey R. Ferril, MD Resident Physician Department of Otolaryngology—Head and Neck Surgery Facial Plastic and Reconstructive Surgery University of Colorado School of Medicine Aurora, CO Lindsay K. Finkas, MD National Jewish Health; Department of Allergy/Immunology University of Colorado Denver Denver, CO Carol A. Foster, MD Departments of Otolaryngology, Audiology, and Rehabilitative Medicine University of Colorado Denver School of Medicine Aurora, CO Norman R. Friedman, MD Department of Otolaryngology University of Colorado School of Medicine; Department of Pediatric Otolaryngology Children’s Hospital Colorado Aurora, CO Sandra Abbott Gabbard, PhD Associate Professor Department of Pediatrics Department of Speech, Language, Hearing Sciences University of Colorado; President/CEO Marion Downs Center Denver, CO Anne E. Getz, MD Department of Otolaryngology—Head and Neck Surgery University of Colorado Denver, CO www.ketabpezeshki.com 66485457-66963820 viii CONTRIBUTORS Sarah A. Gitomer, MD Baylor College of Medicine Bobby R. Alford Department of Otolaryngology— Head and Neck Surgery Houston, TX John C. Goddard, MD Associate House Ear Clinic; Clinical Instructor University of Southern California Los Angeles, CA Julie A. Goddard, MD, FACS Department of Otolaryngology—Head and Neck Surgery University of California, Irvine Orange, CA Elizabeth A. Gould, BA Department of Otolaryngology University of Colorado Aurora, CO Leah J. Hauser, MD Department of Otolaryngology—Head and Neck Surgery University of Colorado Aurora, CO Herman Jenkins, MD Department of Otolaryngology University of Colorado School of Medicine Aurora, CO Kristina L. Johnston, MA, CCC-SLP CCC-SLP-Rehabilitation National Jewish Health Denver, CO Sana D. Karam, MD, PhD Department of Radiation Oncology University of Denver Colorado Aurora, CO Rohit K. Katial, MD, FAAAAI, FACP Professor of Medicine Program Director, Allergy/Immunology Director Weinberg Clinical Research Unit Denver, CO Peggy E. Kelley, MD Department of Otolaryngology University of Colorado School of Medicine; Department of Pediatric Otolaryngology Children’s Hospital Colorado Aurora, CO Todd T. Kingdom, MD Professor and Vice Chair Department of Otolaryngology—Head and Neck Surgery University of Colorado School of Medicine Aurora, CO Ted H. Leem, MD, MS Department of Otolaryngology University of Colorado School of Medicine Aurora, CO J. Eric Lupo, MD, MS Clinical Fellow House Ear Clinic Los Angeles, CA Jon Mallen-St. Clair, MD, PhD Department of Otolaryngology—Head and Neck Surgery University of California, Los Angeles Los Angeles, CA Scott Mann, MD Assistant Professor Department of Otolaryngology University of Colorado Denver School of Medicine Aurora, CO Jameson K. Mattingly, MD Department of Otolaryngology University of Colorado School of Medicine; Department of Pediatric Otolaryngology Children’s Hospital Colorado Aurora, CO Brook K. McConnell, MD Department of Otolaryngology University of Colorado School of Medicine; Department of Pediatric Otolaryngology Children’s Hospital Colorado Aurora, CO Jessica D. McDermott, MD Fellow Division of Medical Oncology University of Colorado School of Medicine Aurora, CO Benjamin Milam, MD Resident Physician Department of Otolaryngology—Head and Neck Surgery University of Colorado Aurora, CO David M. Mirsky, MD Pediatric Neuroradiologist Children’s Hospital Colorado; Assistant Professor of Radiology University of Colorado Aurora, CO www.ketabpezeshki.com 66485457-66963820 CONTRIBUTORS ix Paul Montero, MD Division of Gastrointestinal, Tumor, and Endocrine Surgery University of Colorado Hospital Aurora, CO Pamela A. Mudd, MD Assistant Professor Pediatric Otolaryngology Children’s National Medical Center Washington, DC Vignesh Narayanan, MD Division of Medical Oncology University of Colorado School of Medicine Denver, CO Stephen S. Newton, MD Assistant Professor of Otolaryngology University of Colorado; Pediatric Otolaryngologist Children’s Hospital of Colorado Colorado Springs, CO Sarah J. Novis, MD Department of Otolaryngology—Head and Neck Surgery University of Michigan Ann Arbor, MI Matthew Old, MD, FACS Assistant Professor Department of Otolaryngology—Head and Neck Surgery The James Cancer Hospital and Solove Research Institute Wexner Medical Center at The Ohio State University Columbus, OH Richard R. Orlandi, MD Sinus and Skull Base Surgery Program Division of Otolaryngology University of Utah Salt Lake City, UT Anju K. Patel, MD Otolaryngology Resident Department of Otolaryngology—Head and Neck Surgery Tufts Medical Center Boston, MA Erik Peltz, DO Division of Trauma and Acute Care Surgery University of Colorado Hospital Aurora, CO Daniel A. Pollyea, MD, MS Division of Hematology University of Colorado School of Medicine Denver, CO Kavitha K. Prabaker, MD Instructor Department of Internal Medicine Division of Infectious Diseases University of Colorado School of Medicine Aurora, CO Jeremy D. Prager, MD Department of Otolaryngology University of Colorado School of Medicine; Department of Pediatric Otolaryngology Children’s Hospital Colorado Aurora, CO Craig Quattlebaum, MD Resident Physician University of Colorado Aurora, CO Jeevan B. Ramakrishnan, MD Raleigh-Capitol Ear, Nose, and Throat, P.A. Raleigh, NC Brianne Barnett Roby, MD Department of Pediatric ENT and Facial Plastic Surgery Children’s Hospitals and Clinics of Minnesota St. Paul, MN; Associate Professor Department of Otolarynology University of Minnesota Minneapolis, MN Victor I. Scapa, MD Department of Otolaryngology—Head and Neck Surgery Group Health Permanente Seattle, WA Ameer T. Shah, MD Department of Otolaryngology—Head and Neck Surgery Tufts Medical Center Boston, MA Kaylee Skidmore, MA, CCC-SLP Speech Language Pathologist Department of Rehabilitation University of Colorado Hospital Aurora, CO Franki Lambert Smith, MD Clinical Associate Dermatology Mayo Clinic Health System-Franciscan Healthcare La Crosse, WI www.ketabpezeshki.com 66485457-66963820 x CONTRIBUTORS Mofiyinfolu Sokoya, MD Resident Department of Otolaryngology—Head and Neck Surgery Facial Plastic and Reconstructive Surgery University of Colorado School of Medicine Aurora, CO John Song, MD Associate Professor Department of Otolaryngology University of Colorado School of Medicine Aurora, CO Sven-Olrik Streubel, MD, MBA Department of Otolaryngology University of Colorado School of Medicine; Department of Pediatric Otolaryngology Children’s Hospital Colorado Aurora, CO Jeffrey D. Suh, MD Assistant Professor Rhinology and Skull Base Surgery Department of Head and Neck Surgery David Geffen School of Medicine at UCLA Los Angeles, CA Masayoshi Takashima, MD Director Sinus Center at BCM; Associate Professor Bobby R. Alford Department of Otolaryngology— Head and Neck Surgery Baylor College of Medicine Houston, TX Adam M. Terella, MD Assistant Professor Department of Otolaryngology—Head and Neck Surgery Facial Plastic and Reconstructive Surgery University of Colorado School of Medicine Aurora, CO Lisa Treviso-Jones, MS, CCC-SLP Speech Language Pathologist Department of Rehabilitation University of Colorado Hospital Aurora, CO Kristin Uhler, PhD University of Colorado Denver School of Medicine Aurora, CO Craig R. Villari, MD Department of Otolaryngology—Head and Neck Surgery Division of Laryngology University of California, San Francisco San Francisco, CA Sean X. Wang, MD Department of Otolaryngology—Head and Neck Surgery Division of Laryngology University of California, San Francisco San Francisco, CA Taylor M. Washburn, MD Instructor Division of Infectious Disease University of Colorado Denver Denver, CO Timothy V. Waxweiler, MD Department of Radiation Oncology University of Denver Colorado Aurora, CO Edwin F. Williams, III, MD Department of Otolaryngology Albany Medical Center Albany, NY; Department of Facial Plastic and Reconstructive Surgery Williams Center Plastic Surgery Specialists Latham, NY Todd M. Wine, MD Children’s Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, CO Andrew A. Winkler, MD Associate Professor Department of Otolaryngology; Director Division of Facial Plastic and Reconstructive Surgery University of Colorado Denver School of Medicine Aurora, CO Justin M. Wudel, MD Renew Facial Plastic Surgery Edina, MN William C. Yao, MD Assistant Professor Department of Otorhinolaryngology—Head and Neck Surgery University of Texas Medical School at Houston Houston, TX Patricia J. Yoon, MD Department of Otolaryngology—Head and Neck Surgery University of Colorado School of Medicine; Department of Pediatric Otolaryngology Children’s Hospital Colorado Aurora, CO www.ketabpezeshki.com 66485457-66963820 I GENERAL www.ketabpezeshki.com 66485457-66963820 9 CHAPTER 1 GENERAL ANATOMY AND EMBRYOLOGY WITH RADIOLOGY CORRELATES Cristina Cabrera-Muffly, MD, FACS 1. Eight branches of the external carotid artery: • Superior thyroid • Ascending pharyngeal • Lingual • Facial • Occipital • Posterior auricular • Maxillary • Superficial temporal 2. Layers of fascia in the neck: • Superficial cervical fascia • Superficial layer of deep cervical fascia • Middle layer of deep cervical fascia • Deep layer of deep cervical fascia 3. Characteristics of malignant lymph nodes on neck CT with contrast: • Size >1–1.5 cm • Round shape • Necrotic center • Ill-defined margins 4. Facial nerve landmarks: • Tragal pointer • Tympanomastoid suture line • Insertion of the posterior belly of digastric muscle onto the mastoid 5. Best imaging study by region: • Cerebellopontine angle—MRI with contrast • Neck and salivary glands—CT with contrast or MRI with contrast • Sinus—CT without contrast • Temporal bone—CT without contrast • Thyroid—Ultrasound KEY POINTS Pearls 1. CT scan is better for looking at temporal bone masses and lesions, but MRI (of the internal auditory canal with contrast) is the best test for evaluation of acoustic neuromas. 2. When you suspect a temporal bone fracture, the best test is a fine cut CT temporal bones without contrast. 3. On T1 MRI, if the nasal turbinates light up, that means the study has contrast. 4. MRI scans commonly over call sinus disease. The most appropriate study to determine chronic sinus disease is CT without contrast (Figure 1-1). 5. The best imaging to evaluate thyroid nodules is ultrasound. www.ketabpezeshki.com 66485457-66963820 10 I GENERAL QUESTIONS 1. When do the sinuses develop? The maxillary sinus is the first to develop in utero. After birth, this sinus enlarges in two stages, once at age three and then again between ages 7 and 12. Neonates have three to four ethmoid cells at birth, which multiply to become ten to fifteen cells by the age of 12. The sphenoid sinus begins pneumatization at 3 years of age, while the frontal sinus is the last to develop at about age 5. The sphenoid and frontal sinuses do not reach adult size until the teenage years. 2. What is the difference between agger nasi, Onodi, and Haller ethmoid cells? The agger nasi cell is the most anterior of the ethmoid cells. It is found anterior and superior to the attachment of the middle turbinate to the lateral wall. The Onodi cell is an ethmoid cell that pneumatizes lateral or posterior to the anterior wall of the sphenoid. This cell can be adjacent to the optic nerve or carotid artery, so it is important to recognize this variation during sinus surgery. A Haller cell forms when the ethmoid pneumatizes into the medial and inferior orbital walls. If this cell is large, it can cause obstruction of the maxillary ostium. 3. Name the branches of the internal carotid artery in the neck. Trick question! The internal carotid artery does not branch in the neck. 4. Name the eight branches of the external carotid artery in the neck. From proximal to distal, the branches are: the superior thyroid, ascending pharyngeal, lingual, facial, occipital, posterior auricular, maxillary, and superficial temporal arteries. 5. Name the four types of tongue papillae. Where are they located? The four types are circumvallate, fungiform, foliate, and filiform papillae. The circumvallate are located at the junction of the anterior two thirds and posterior one third of the tongue in a V shape. Fungiform papillae are found at the tip and lateral edges of the anterior two thirds of the tongue. Foliate papillae are found at the posterolateral base of tongue. Filiform papillae are found all over the tongue, and do not participate in taste sensation. 6. Describe the landmarks used to find the facial nerve during parotid surgery. The typical landmarks used to find the facial nerve during parotid surgery are the tragal pointer, the tympanomastoid suture line, and the posterior digastric muscle. The tragal pointer refers to the tragus cartilage, which “points” to the location of the nerve one centimeter anterior, inferior, and deep to the cartilage. Another method of identification is to follow the tympanomastoid suture line inferiorly to its drop-off point. Six to eight millimeters medial to this point, the facial nerve can be found passing through the stylomastoid foramen. Finally, the nerve can be located just medial to the insertion of the posterior belly of the digastric on the mastoid. Figure 1-1. Chronic sinusitis with nasal polyposis on CT scan. www.ketabpezeshki.com 66485457-66963820 1 GENERAL ANATOMY AND EMBRYOLOGY WITH RADIOLOGY CORRELATES 11 7. Name each of the major salivary glands and describe the types of saliva produced by each. There are three paired major salivary glands: the parotid, submandibular, and sublingual glands. Each gland has acinar cells that produce either serous or mucinous solution. The parotid glands produce mostly serous saliva. The sublingual glands produce mostly mucinous saliva, and the submandibular glands produce a mixture of the two. 8. How do the salivary glands develop embryologically? The major salivary glands develop from the first pharyngeal pouch. The glands form during weeks 4 to 9 of gestation. The parotids form by an ectodermal outpouching into the surrounding mesenchyme. The submandibular and sublingual glands form from endoderm growing either into the submandibular triangle or the floor of the mouth (sublingual). 9. Describe the embryology of the parathyroid glands. The superior parathyroid glands develop from the fourth dorsal branchial pouch, whereas the inferior parathyroid glands develop from the third dorsal branchial pouch. This apparent inversion occurs because the fourth branchial pouch does not migrate during development, but the third branchial pouch descends with the thymus to lie inferior to the fourth pouch. Ectopic parathyroid tissue is present in up to 20% of patients. 10. Describe the fascial planes of the neck. The neck fascia has two main layers, the superficial and deep cervical fascia. The superficial cervical fascia envelops the platysma, muscles of facial expression, and SMAS. The deep cervical fascia splits into three parts, the superficial, middle, and deep layers. The superficial layer of the deep cervical fascia envelops the trapezius, sternocleidomastoid, and masseter muscles as well as the parotid and submandibular glands. The middle layer of the deep cervical fascia contains the strap muscles as well as the trachea, esophagus, thyroid, pharynx, and larynx. The deep layer of the deep cervical fascia envelops the cervical vertebrae and paraspinal muscles. All three layers of the deep cervical fascia come together to form the carotid sheath, enveloping the carotid artery, jugular vein, and vagus nerve (Figure 1-2). 11. Describe the lymph node levels of the neck used for staging head and neck cancer. The neck is divided into six areas for the purposes of staging head and neck cancer. The location of the primary tumor determines the likelihood of spread to each particular area. Level I includes the Figure 1-2. Fascial layers of the neck. (From Goldstone: Netter’s Surgical Anatomy and Approaches, 389–398 © 2014 by Saunders, an imprint of Elsevier Inc.) Superficial (investing) layer of deep cervical fascia Recurrent laryngeal nerve Esophagus Common carotid artery Carotid sheath Subcutaneous tissue Superficial (investing) layer of deep cervical fascia roofing posterior cervical triangle Fat in posterior cervical triangle Prevertebral layer of (deep) cervical fascia Cervical vertebra (C7) Cross section Skin Platysma muscle Trachea Thyroid gland Omohyoid muscle Sternocleidomastoid muscle Internal jugular vein Vagus nerve (X) Sympathetic trunk FASCIAL LAYERS OF NECK