Pimps and Pearls

ASA slows growth of a vestibular schwanomma

Cox-B inhibitor slows the growth of HPV

Ductus Reuniens (with Valve of Bast) connects the cochlea with the Saccule of the Vestibule.

The styoloid has 3 muscles with 3 nerves. (Styloglossus 12, Stylohyoid 7, Stylopharyngeus 9)

CN 9 is responsible for Eagles Syndrome.

Palatoglossus= CN X—–All other glossus (hyo, genio, and styloglossus) are 12

Lingual Nerve is part of the mandibular branch of the Trigeminal (V3)

90% of sinus headaches will meet the IHS criteria for migraines.

Human bites are best treated with debridement and copious irrigation, tetanus prophylaxis, and intravenous bolus of a second-generation cephalosporin.   Often leave open.

Brain literally washes itself with sleep, the morbidity from lack of sleep exceeds starvation

AHI > 10 think PICU

Orbital Fractures can really almost always be managed expectantly, with the exception of mechanical entrapment.  Look for the presence or absence of the muscles on orbital CT

Medical and surgical treatment of CRS is still lacking good evidence based recommendations.

Celiac Sprue, Crohn’s Disease, and gastroplasty may impair calcium absorbtion and may require chronic calcium supplementation.

HPV related SCCa (16 > 18) has a 95% 2 year survival vs non HPV at 62%

long term macrolide therapy may be more beneficial in pts with low IgE levels

Epistaxis has a prevalence of about 6% in general population and 20% in pregnancy

Sarcoidosis—can manifest in Lupus Pernio (raised violaceous papules or plaques seen on the face) Distinguised from discoid Lupus (in Systemic Lupus Erythematosis) that is usually red and scaly.

SSNHL is not indicative of pending stoke, however, CRS is a stroke risk factor.

Cochlear implant is ok with a PET

Santorini fissures are found in the cartilaginous external auditory canal.  Can allow infections or tumor to pass thru from the external auditory canal to the parotid.

Class I occlusion: The mesial cusp of the maxillary first molar approximates the buccal groove of the mandibular first molar.

Chondrosarcoma is the most common tumor of the TMJ

Champy’s Lines are lines of ideal lines of osteosynthesis within the mandible.

The cochleariform process (processus cochlerariformis) contains the tensor tympani tendon.

SNHL is a manifestation of Sickle Cell Anemia

Sulcus Vocalis looks like a line along the vocal ligament.

Metopic Synostosis can lead to a triangular (cone) shaped forhead when viewed from above.

Gradenigo Syndrome is a rare complication of otitis media—-Petrous Apex (petrous apocitis)—triad of ear discharge, Diplopia (involvement of the abducens CN6 nerve) and hemifacial pain (involvement of the trigeminal nerve)

Vernet’s Syndrome is worse as it represents skull base spread to the 9th 10th and 11th nerve.


Wegeners Granulomatosis is more common in females.  20% subglottic stenosis, worse if you contract the disease before 20.

80% of kids with bronchiolitis present with concurrent Otitis Media.

Aeromonas hydrophilia is a bacteria leeches carry, similar to a pseudomonas, needs to be covered with a quinolone or 3rd generation cephalosporin

Staph aureus is the most common isolate in nasal rinse kits and biofilms are frequent.

Alderman’s nerve = Arnold’s nerve = CN X—when the Alderman of the Roman Senate overate they would induce vomiting by having their slaves pour cold water in there ear.

Nasal airway surgery helps nasal breathing and lessens daytime sleepiness.  It has very little effect on RDI.

Forehead flap is primarily supplied by the supratrochlear artery.

Temporary tinnitus happens in >75% of us, usually lasts 30 seconds to 10 minutes, is usually monaural R>L.

Tinnitus patients may have some “hidden hearing loss” that even the audio does not pick up (have a lower wave 1 amplitude (coclear hair cells) on ABR) and then there is some “Central Gain” that makes up for the loss and results in the tinnitus.  May represent some recruitment of the underlying auditory nerve, which has its nerve cell body in the brainstem.

The more sup the tumor is within the thyroid gland, the more likely regional mets in papillary thyroid ca

ct temporal bone is very sensitive for sup scc dehissence(SSCD), and actually overestimates the size of the defect making it less specific.

Benjamin and Inglis classification of PLC—1-4

Clival chordoma with physaiferous cells.

Wegeners subglottic repairs need more dilations than non auto immune pts.

costs 770k to diagnose 1 unsuspected tonsil lymphoma.  Only send when suspicious or transplant pts.

persistent stapedial artery—ant oval window is a contraindication for stapedectomy —incidence is 0.03%

there is no proof or consensus on voice rest after laryngeal procedures.  Tell them they are “vocal athletes” and need to heal.

Chandler classification of orbital complications of rhinosinusitis—class 1 is preseptal cellulitis, class 5 is cavernous sinus thrombosis

Trachealization of the esophagus occurs with EE  “ringed esophagus”

Laryngeal carcinoma requires some functional data to stage.

Hassell’s Corpuscles are found in Thymic cysts.  1849 Arthur Hill Hassal.

Alcohol based hand rubs seem to be as effective of aqueous scrubbing in reducing bacteria.

Oral Hairy Luekoplakia is endemic in HIV

Rhinoscleroma is a slowly progressive infectious disease.  Can lead to “Hebra Nose” massive deformity and should be treated with Cipro.

AVN is the most common cause of lawsuits for oral steroids.

Definitive Chemo RT is the most expensive treatment for oropharyngeal CA

Aquired Methamoglobinemia is due to a problem with cytochrome b5 reductase and can be elicited by of infants eating nitrate rich beets.  Pts get blue (cyanotic) as the hemoglobin is unable to release the oxygen to the tissues, the ferric iron becomes oxidized to Fe3+ rather than reduced Fe2+.  ABG’s and a blood test can be diagnostic.  Methylene blue is used to treat.   Ascorbic acid, HBO, and transfusions are options.

Preeclampsia is a risk factor for permanent hearing loss

Soft triangle of the nose—avoid “notching” injury in rhinoplasty.

There is not clinical advantage to RLN monitoring.

Palatovaginal canal can sometimes be seen on coronal ct thru the sphenoid.  The Vidian canal is bigger, more visible, more lateral

TORS for oncologic disease has only a 5% overall g tube dependency rate.

Hypoplastic maxillary is associated with orbital risk at surgery.

VEMP (vest evoked myogenic potentials)  ocular vemps are lower/smaller in Meneires Disease

Antibiotics for 24 hours (Ancef 2 g iv q 8 hours) for head and neck cases supported.

Close a cervical chyle fistula if >500cc per day after 1 week medical treatment, persistent low output over a long period of time, electrolyte complications.

Optimal timing of PET is 12 weeks after completion of chemo RT—no sooner

If there is a non active node of any size—observe (PET is good at ruling out CA)

Caprini Risk Assessment Scale—For DVT

“White-eyed blowout fracture”—more common in pediatrics where the orbital contents  get trapped in more pliable trap door type fractures

4.4 x higher risk of complications in an obese tracheotomy pt vs a non obese pt

antibiotics seem to help resolve MEE 23% over those that get no abx  (1992 meta analysis)

Oral cavity scca have a 14% chance of a second primary

smoking, etoh, low folate, factor 5 leiden are all risk factors for SSNHL

Topical nasal steroids are at least as effective post operatively as they are pre operatively.

Cognitive Behavioral therapy appears to be the best treatment for debilitating tinnitus.

97% of pts with a q tip traumatic perf will heal spontaneously.

Vestibular Rehab appears to be the best treatment for vertigo.

Pillar procedure seems to be of little to no benefit after 4 years.

SSHL 90 % idiopathic—Steroids-(oral)–intratympanic–HBO—-eventualy MRI if no resolution.

Pts with Papillary Micro carcinoma (<1cm) observation seems appropriate—less than 7% grow more than 3 mm in 5 years.

Spont CSF leak may be assoc with benign intracranial hypertension (papilledema/optic nerve compression, obesity, headache and or pulsatile tinnitus)

Larynx CA incidence is going down.—Most other H&N Ca are increasing due to HPV.

10% Ext Otitis is fungal.

Arnold’s or Alderman’s nerve (auricular br of the Vagus) causes coughing during cerumen removal.

ABR might have lower wave 1 on tinnitus.

Bucconasal membrane is the choanal atresia.

nystatin has the best efficacy for otomycosis

erythema is the stop point to microdermabrasion

Traumatic anosmia has a grim prognosis, expecialy after 18 months.  27% improved up to 18 months.

Proximal C-cell hyperplasia is indicative of familial medullary thyroid carcinoma

a ptyerygomaxillary space mass that enhances and “bowes” forward the posterior maxillary sinus wall “Holman-Miller” sign = JNA juvenille nasoangiofibroma in adult young males

Hyperparathyroidism–hypercalcemia–bones, stones, abdominal groans, with psychic overtones—even calciphylaxis =systemic calcification of the arteries needs to have the hypercalcemia treated aggressively, hyper vit D can contribute to the problem.

Vit D is made in kidney and skin, increases gut calcium absorbtion, and although it seems paradoxic, increases calcium bone reabsorbtion (osteoclast)—but overall contributes to bone strength—is paramount in decreasing osteopenia/osteoporosis.

New data touting its role in immune function and as an anti inflammatory, controlling allergies and more specifically asthma.  Vit D is to be considered in all our sinus and allergy patients.

PTH increases calcium in the blood by increasing bone reabsorption, kidney reabsorption, and stimulating (kidney) production of vitamin D.  It actually decreases the kidney reabsorption (reducing blood levels) of PO4.

Calcitonin from the parafollicular C cells of the thyroid really has the opposing effects of PTH—calcitonin tones the bones (osteoblast+, osteoclast -)

Rickets is vit D deficiency, low blood CA, low phos (PO4)

completely endoscopic transsphenoidal approach may be superior to trans nasal transeptal or sublabial transeptal

chimani Mooss test—modification of the webber for malingering.  Plug the good ear and should accentuate the webber.  The malingerer will usually deny any hearing.

Claudius and Boettcher cells are in the organ of corti in the Cochlea.

The blind passage of Maloney bougies was most commonly associated with perfs.

Rhabdomyosarcoma—staging is complex—”kitchen sink” therapy.

acupuncture has been shown to help with post op pain and xerostomia in H&N pts.

cn 7 cn 8 and labyrinthine artery (an internal auditory branch of the basilar artery) all traverse the porus acusticus of internal acoustic meatus.

Crouzon’s Syndrome: Maxillary hypoplasia with relative mandibular prognathism.  Auto D, chromosome #10, Patent ductus arteriosus, aortic coarctation, and Meniere’s Disease.

Can really fly anytime after tympanoplasty, still sneeze with mouth open, and dont blow nose.

T&A is only 88% cure in obese childhood osa.  Need to lose weight!

Most assymtric tonsils are just an inny and an outy—really the same size.

dog and cat bites—pasturella multocida

tinnitus retraining therapy (TRT) = direct counseling and sound therapy to achieve habituation.  The aim is to redirect the brains attention and focus away from the tinnitus.

Oral Hairy Leukoplakia is common in immunocompromised individuals.

Transoral drainage of submandibular gland abscesses can be just as effective as transcervical.

Young’s procedure(1967) (suturing the ant nose shut) is a treatment option for ozena–atrophic rhintitis–Johnathan hoffman.

Central Presbycusis—best identified by speech in noise testing (dichotic sentence identification) testing.  “I have difficulty understanding speech with any background noise”

liver disease of cirrhosis can give you a false positive detection of beta -2 transferrin in secretions.

Hemangiomas–the most common neoplasm of infancy is linked with atopic disease.

high riding jugular bulb plateaus around age 40—-rare in pediatrics.

OSA with AHI > 10, age < 3, or sate < 80% should be admitted after surgery.

Trauma to the External Branch of the Anterior Ethmoidal Nerve is responsible for tip hypesthesia post open rhino.

Median growth rate of a vestibular schwannoma is 1 mm year.

Invasive sinusitis—slightly better sensitivity on Peri sinus involvement with MRI over CT

92 % resolution or Compressive symptoms after thyroid surgery.

25% of chyle fistulas occur on the right side of the neck!

Sinonasal is the most common place for mucosal melanomas.  Younger folks do better.

Superior parathyroids develope and decend with the thymus.

Anaphalaxic and anaphylactoid reactions give tachycardia (10% Bezold-Jarisch reflex-brady), hypotension, respiratory (wheeze/stridor) and high tryptase.

Vasovagal—-hypotension and bradycardia—no mast cell degranulation

mast cells —-tryptase,  no significant tryptase in basophils

niacin flush—a prostaglandin / seratonin phenom.  Often prevented with asa or nsaids

Pediatric / neonatal NAO—Dexamethasone Ophthalmic Drops–1 drop TID for 2 weeks, BID for 2 weeks, and QD for 2 weeks.

Lidex, Cleocin, and Bactroban water miscible ointments are excellent for ant nasal cares.

Horizontal plane of the cricoid divides zone Va and Vb of the neck

Reasonable to wait 6 months between procedures

VNO—Vomeronasal Organ of Jacobson is a primitive chemoreceptor/phermone receptor in the inferior septum.

Ostman fat pad is in the Eustacian tube—abrupt loss of weight in bariatric surgery (21%) and post partum patients —patulous ETT

Leech therapy can lead to Aeromonas Hydophilia, should be treated with quinolones, TMP-SMX, or 3rd Gen Cephalosporin

Submandibular Gland generates 75% of saliva.  Para—watery, Symp—mucoid.

If pt has medullary thyoid Ca, do a distant work met work up for Calcitonin levels > 400 mg/ml

Any Anaplastic Thyroid Ca is by definition Stage 4—-survival is essentially zero.

Age related hearing loss is less prevalent than 50 years ago.

Otoacoustic emmissions are produced by the outer hair cells as they expand and contract.  4 types

1) spontaneous 2)Transient Evoked (clicks) 3) Distortion Product–sounds emitted in response to 2 simultaneous tones 4) Sustained

Melanoma is most common in the extremities (44%) and trunk (34%).  30-43% present with mets.

Abducent nerve is juxtaposed to internal carotid in cavernous venous sinus.

ptosis (blepharoptosis) repair has a 10% revision rate primarily for undercorrection

Jack Anderson came up with the “tripod” theory of tip support—largely unchallenged since the 60’s

bioabsorbable plates are effective in large orbital floor defects

OAVS (Oculo-Auricul-Vertebral Spectrum) comprises from mild to severe: Oculo-auriculo-vertebral disorder—Hemifacial Microsomia—Goldenhar Syndrome

Gorlins sydrome = Basal Cell Nevus Syndrome

only 7% of Papillary MicroadenoCarcinoma less than 1 cm in size will grow > 3mm over 5 years

17 % of small cell lung CA will have supraclavicular mets

This is a Bezold’s abscess, with erosion of the inferior mastoid tip, and a large neck abscess resulting from inferior tracking along the sternocleidomastoid muscle.

The “Signet Ring” on an axial t-bone scan is the Horizontal SCC.  The dreaded “Snake Eyes” on mastoidectomy.

Allergic Rhinitis impairs productivity more than HTN or Diabetes.

Nasal Steroids are the best and least disruptive therapy—-HbA1C and blood sugars and growth and cataracts and glaucoma and bone loss are not issues!

Sade Grades of Tympanic Membrane retraction.  1) slight  2)MISP (Severe Retraction) 3)Promontory (Adhesive Otitis) 4) TM Adherent to the Promontory (Adhesive Otitis)

Small Round Blue Cell Tumors in Peds Patients on histo path: Lymphoma, Esthesioneuroblastoma, Wilm’s tumor, Sarcomas (rhabomyosarcoma, Ewings sarcoma), Small Cell and Merkel cell carcinomas, Neuroblastic Tumors

most litigation regarding molds is based on bad science

A low level of autoimmunity is crucial for normal immune function.

The recent RTOG and EORTC chemoradiation trials high dose Cisplatin (100mg/m2 on days 1, 23, and 43 of RT) gave improved local control and disease specific survival!!! vs RT alone.

Ewald’s first law=stimulation of a certain semicircular canal leads to the stimulus of the EOM’s in that plane.

Despite what we have been taught—there is probably no detriment to an excisional biopsy of a SCCA.  An incisional biopsy however is poor form.  SCCA should never be a surprise—-repeat FNA’s–prepart patients etc…

Survival for regionally metastatic Skin SCCA is about 30%

NP CA drains primarily to the RP lymph nodes.

post op T&A osa kids should avoid codeine.  Maybe should avoid opiates all together.

safest post op pain regimen  Tylenol 15 mg/kg Q 4 not to exceed 75mg/kg/day.   Ibuprofen 10mg/kg Q 4 not to exceed 40 mg/kg/day.

Bones, Stones, Abd groans with psychic overtones—-interestingly Neurocognitive issues are more likely associated with hyperplasia than the more common adenoma.

Latham appliance is used for palatal positioning in displaced clefts.

If you are looking for a GI tract leak—-use gastrograffin if you suspect a leak into the interstitial tissues.  Use Barium if you suspect a leak into the pulmonary system.

Gastrografin can cause a chemical pneumonitis in the lungs but is the contrast agent of choice if there is concern for an abdominal leak/fistula.  In contrast, barium is better tolerated by the lungs than the GI system and should be used to evaluate for airway fistulae.

Gastrografin  (Diatrizoate Meglumine)
Water-soluble iodine containing contrast medium
Water-soluble contrast agents also are absorbed rapidly from the mediastinum, so follow-up radiographic studies to assess the status of a leak are not compromised by residual contrast material in the mediastinum
Less caustic to the peritoneum and mediastinum
Believed to achieve lower level of musical detail due to its decreased opacity, may fail to reveal a significant portion of perforations or leaks
Osmolarity of gastrografin is 6-10 times that of plasma – may induce dangerous hypovolemia
Contraindicated in cases where a communication with tracheobronchial tree is suspected due to risk of chemical pulmonary edema

Inert in the lungs
Higher opacity allows for greater mucosal detail and may identify leaks not visualized with water soluble agents
Small theoretic risk that extravasated barium in the mediastinum may cause a granulomatous reaction with mediastinitis or mediastinal fibrosis, as previously shown in studies on laboratory cats

Puberphonia = when an adolescent male voice does not change

External auditory canal cholesteatoma tends to progress to the mastoid cavity by destruction of the posterior boney canal

Concha bullosa and Haller cells tend to diminish mucociliary clearance out of the OMC

Very little evidence that “contact points” lead to headaches

Osteogenesis Imperfecta can lead to otosclerosis or fracture or atrophy of the stapes, making stapectomy a good treatment provided the oval window is not obliterated.

There is some evidence that silver oxide tubes have less biofilms and otorhea, and prolonged use of neomycin containing drops may have an increased risk of SNHL

OPMD may inherited in either an autosomal dominant or autosomal recessive manner, and is characterized by late-onset (age >45), ptosis, dysphagia, and a positive family history. Early manifestations of dysphagia include increased time required to complete a meal and an acquired avoidance of dry foods. Signs of more progressive disease may include tongue atrophy, proximal extremity weakness (lower > upper), dysphonia, and facial weakness. Life expectancy is not reduced. There is some evidence that these patients may experience benefit with extramucosal cricopharyngeal myotomy.

BioGlue’s two components, purified bovine serum albumin (BSA) and glutaraldehyde, are dispensed by a controlled delivery system. Once dispensed, the two components are fully mixed within the applicator tip. BioGlue, upon application to the tissue at the repair site, creates a flexible mechanical seal independent of the body’s clotting mechanisms.

Tisseel is a 2 component fibrin sealant  The sealer protein solution contains human fibrinogen and a synthetic fibrinolysis inhibitor, aprotinin, which helps prevent premature degradation of Fibrin Clot. The thrombin solution contains human thrombin and calcium chloride.  When mixed together, the 2 components combine and mimic the final stages of the body’s natural clotting cascade to form a rubber-like mass that adheres to the wound surface and achieves hemostasis and sealing or glueing of tissues.

Butyl-cyanocrylate and 2-Octyl cyanoacrylate are glues similar to “Superglue” that are used to closed small skin cuts, lacerations (tears in skin), or surgical incisions (wounds from sharp objects such as a scalpel).

Platelet-rich plasma (PRP) is blood plasma that has been enriched with platelets. As a concentrated source of autologous platelets, PRP contains several different growth fcators and other cytokines that stimulate healing of bone and soft tissue.

Just cut the Greater Auricular Nerve in parotidectomy and Level 2 Neck Dissections

Hemostasis in sinus surgery with hot water (47-50 degrees Celcius), raise HOB, BP control, and 1/1000 topical epi without Afrin (Occupy same receptor)

Classic Medical Sayings

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