SRG. P03.01 Disorders of the Head & Neck.pdf

PCC SOM 2026 SURGERY 2 P 03.01 DISORDERS OF THE HEAD & NECK SURGERY LECTURE MALIGNANT OTITIS EXTERNA LECTURER: DR QUINN DAHILAN...

PCC SOM 2026 SURGERY 2 P 03.01 DISORDERS OF THE HEAD & NECK SURGERY LECTURE MALIGNANT OTITIS EXTERNA LECTURER: DR QUINN DAHILAN  Seen in insulin-dependent diabetes, elderly, and DATE: Aug 20, 2024 immunocompromised patients Fulminant necrotizing infection of the soft tissues with TOPIC OUTLINE osteomyelitis of the temporal bone I. Benign Conditions of the Head & Neck  Classic finding: granulation tissue along the floor of the A. Ear external auditory canal near the bony cartilaginous junction B. Facial Nerve  Sign/Symptoms: C. Sinuses ✓ Persistent otalgia (earache) for longer than one month D. Pharynx & Tonsils ✓ Purulent otorrhea (ear drainage) persisting for several E. Larynx weeks II. Trauma of the Head & Neck  Treatment: ✓ Ototopical and IV antibiotics targeting Pseudomonas ▪ Aminoglycosides I. BENIGN CONDITIONS OF THE HEAD & NECK ▪ Antipseudomonal beta-lactam drugs ▪ Quinolones OTOLOGY ✓ Anti-fungal if with fungal infection Ear Infection ✓ Culture-directed therapy  Infectious processes of the ear may be considered by their ▪ For Gram negative bacteria & fungi location (external, middle, or inner ear), their time course (acute or chronic), and the presence of complications. OTITIS MEDIA OTITIS EXTERNA  Infection of the middle ear  Infection of the skin of the external auditory canal  Most common bacterial infection of childhood  also known as “Swimmer’s Ear”  Infection before 2y/o: due to immature Eustachian tube  MC offending organism is Pseudomonas aeruginosa, although  Other factors: upper airway infection, other conditions such as other bacteria and fungi may also be involved cleft palate  Signs and symptoms include: Acute Otitis Media (AOM) ✓ Itching during the initial phase  Less than 3 weeks duration ✓ Pain and swelling of the canal soft tissues leading to  Bulging, opaque tympanic membrane thickening of the skin  Otalgia and fever  Treatment:  The most common organisms responsible are: ✓ Removal of debris under otomicroscopy ✓ Streptococcus pneumoniae, ✓ Application of appropriate ototopical antimicrobials, such ✓ H. influenzae, and as neomycin/polymyxin or quinoline-containing ear drops ✓ Moraxella catarrhalis ▪ The topical steroid component of these drops (e.g., hydrocortisone or dexamethasone) addresses swelling and, as a result, decreases the intense pain ▪ Acetic acid: flake out the thickening in the auditory canal ✓ Systemic antibiotics are reserved for those with severe infections, diabetics, and immunosuppression Subacute Otitis Media  For marked ear canal edema, the use of otowick is  more than 3 weeks up to 8 weeks required to facilitate delivery of ototopical medication medially into the ear canal Chronic Otitis Media  Fungal infections may call for the addition of 2% acetic  More than 8 weeks acid to re-establish the premorbid pH balance  Otalgia, ear fullness, conductive hearing loss  Air-fluid level in otoscope  Treatment: ✓ Uncomplicated OM: oral antibiotic therapy ▪ Beta-lactamase resistant combinations ▪ Cephalosporins, Macrolides ▪ Amoxicillin: first line drug ✓ Chronic OM: ▪ Myringotomy with tube placement - to remove/relieve effusions >3 months Note Takers: Agullana, Challoy, Ferrer, Santiago, Sangdaan 1|8  PCC SOM 2026 ▪ SURGERY 2 P 03.01 DISORDERS OF THE HEAD & NECK Indicated for frequent episodes and significant FACIAL NERVE DISORDERS hearing loss ▪ Route for middle ear ventilation BELL’S (FACIAL NERVE) PALSY  Tympanic Membrane perforations in AOM  Idiopathic facial paralysis ✓ Relieve ear fullness and pain  Most common etiology of CN VII paralysis ✓ Provides drainage of purulent fluid  Viral neuropathy caused by herpes simplex ✓ Heal spontaneously after resolution of infection  Treatment: steroid and antiviral therapy  Tympanic Membrane perforations in COM  Surgery ✓ Notable persistent otorrhea; nonhealing perforation ✓ decompression of the nerve via exposure of the mastoid ✓ Use of topical drops is recommended and middle cranial fossa ✓ Avoid aminoglycosides (ototoxic) ✓ Avoid acetic acid (toxic to middle ear) RAMSAY-HUNT SYNDROME  Sequelae of Chronic OM:  Facial nerve paralysis due to Varicella-zoster virus ✓ Non-healing perforation ✓ Shingles – sakit ng mga matatanda ▪ Requires tympanoplasty (clearance of residual  Signs and symptoms infection is warranted/surgical closure) ✓ Severe otalgia ✓ Erosion of ossicular chain ✓ vesicles in the external ear ▪ Reconstruction using prosthesis  Treatment ✓ Cholesteatoma ✓ Same treatment with Bell’s Palsy ▪ Epidermoid cyst of middle ear/mastoid causing bone  Full recovery seen in 65-70% of cases destruction due to expansile nature and enzymatic destruction ▪ Consequence of Eustachian tube dysfunction and of Chronic OM due to retraction of squamous elements of the TM into the middle ear ▪ Mastoiditis can ensue ▪ Treated with mastoidectomy vs  Tympanoplasty  Reconstructing the TM with or without the ossicular   https://www.youtube.com/watch?v=87huzZSUR18 https://www.youtube.com/watch?v=RPRRfCrZmA0 chain  Utilize autografts (temporal fascia or perichondrium) TRAUMATIC FACIAL NERVE INJURIES or alloplastic grafts  May be due to accidental trauma or surgical injury  Wullstein classification  Iatrogenic injury: most often occurs during mastoidectomy; *See Appendix may also occur in parotid surgery  Treatment Reading Assignment! ✓ Explore the nerve  Complications of OM with or w/o cholesteatoma are ✓ Primary re-anastomosis or nerve graft if >50% is severed categorized into: ✓ Complete recovery of nerve function is uncommon 1. Intratemporal  The sural nerve is particularly well suited to use in cross-face  Include acute coalescent mastoiditis, petrositis, grafting applications facial nerve palsy, and labyrinthitis  Managed by myringotomy tube placement in SINUS INFLAMMATORY DISEASES addition to appropriate IV antibiotics.  Diagnosis is established with 2 major factors or 1 major and 2 2. Intracranial minor factors (according to AAO-HNS)  Otologic meningitis; MC  Otologic meningitis in children is mostly associated  Classification: with H. influenzae type B infection ✓ Acute: 7-10 days symptoms but 1mo) ✓ Stasis of secretions, tissue hypoxia, and ciliary dysfunction  Fungus ball: blowing crusty debris with foul odor ✓ Promote bacterial proliferation and acute inflammation,  Seen in sphenoid sinus pathology teary eyes  Can be intracavitary or allergic fungal sinusitis  Treatment  Diagnosis for Classic Allergic Fungal Sinusitis ✓ Antibiotics (S. pneumoniae, H. influenzae, M. catarrhalis) ✓ CT scan reveals florid polyposis with inspissated mucin ✓ If nosocomial: treatment directed to Pseudomonas or containing fungal debris and products of eosinophilic S. aureus breakdown ✓ If the infection was acquired from the community, often, ✓ Dermatiaceae or Aspergillus family we treat S. pneumoniae  Treatment ✓ Other treatment: decongestants, nasal saline spray ✓ Systemic steroids, nasal irrigation, oral antifungal (methylpropanolamine), nasal steroids, or oral steroids medications ✓ Surgery: reserved for complicated cases (orbital ✓ Surgery to remove debris and re-establish sinus cellulitis/abscess and/or intracranial abscess; meningitis) ventilation which needs drainage ✓ Abscess formation: when this comes out as a complication INVASIVE FUNGAL SINUSITIS of sinusitis, this will eat away the bones (osteomyelitis); this is hard to treat  Seen in diabetics, immunocompromised patients, elderly  Common cold  Notable ischemic necrosis and black eschar formation in the ✓ A form of sinusitis sinonasal mucosa ✓ Resolves within 7 days  Aspergillus or Mucoraceae family (seen in DM patients)  Treatment: Aggressive surgical debridement and IV antifungal CHRONIC SINUSITIS  High mortality rate  Persistent signs and symptoms are present in at least 12 weeks PHARYNGEAL & ADENOTONSILLAR DISEASE ✓ Fullness, clogged  Waldeyer’s Ring ✓ Fever  Ring of lymphoid tissue consisting of the palatine tonsils,  Multifactorial etiologies lingual tonsils, and the adenoids  Also associated with nasal polyps (heavy eosinophilic  Most common to occur is Chronic or recurrent adenotonsillitis inflammation) and Adenotonsillar hypertrophy  Neutrophilic predominance in cases that no polyp is found  Diagnostics: ✓ Nasal endoscopy ▪ (+) purulence or polypoid change is usually seen ▪ S. aureus, coagulase (-) staphylococci, Gram (-) bacilli and streptococci ▪ MRSA is a mounting concern ▪ CT Scan: mucosal thickening  Treatment TONSILLITIS ✓ Medical  Signs & symptoms: sore throat, dysphagia, fever ▪ Antibiotics: 3-6 weeks course ✓ If with hoarseness and colds: most likely viral if (-) for ▪ Oral steroids: use is individualized exudates ▪ Saline irrigation ✓ Mucosal inflammation with tonsillar exudates can be seen ▪ Antihistamines: if with underlying allergic component ✓ Group A beta hemolytic streptococci (S. pyogenes) ✓ Surgical ✓ S. pneumoniae ▪ Polypectomy ✓ Group C and G streptococcus cocci ▪ Enlargement of sinus ostia ✓ H. influenzae or anaerobes ▪ Drainage of inspissated mucin or pus: subjected to C&S  Treatment to direct antibiotic therapy ✓ Penicillin, Macrolides – if allergic to penicillin → C&S is done at 48hrs-3days antibiotic use to ✓ Cephalosporin identify MRSA Note Takers: Agullana, Challoy, Ferrer, Santiago, Sangdaan 3|8  PCC SOM 2026 SURGERY 2 P 03.01 DISORDERS OF THE HEAD & NECK  Special care to S. pyogenes infection TONSILLECTOMY & ADENOIDECTOMY ✓ Timely antibiotic therapy is done ✓ Risk of rheumatic fever (seen in 3% of cases) if not treated TONSILLECTOMY timely  Advocated if 3 or more tonsillitis per year even with adequate medical therapy Reading Assignment!  Children who miss 2 or more weeks of school annually  Complications of S. pyogenes pharyngitis can be systematic secondary to tonsillitis and include:  Severe inflammation, systemic toxicity, and impending airway  Post-streptococcal glomerulonephritis compromise  Scarlet fever  Complications:  Rheumatic fever ✓ Perioperative bleeding  Peritonsillar ✓ Airway obstruction  The incidence of glomerulonephritis is not influenced by ✓ Dehydration to post-op dysphagia antibiotic therapy. ✓ Death  Scarlet fever results from production of erythrogenic toxins ADENOIDECTOMY by streptococci.  causes a punctate rash, first appearing on the trunk and  Beneficial in chronic OM with myringotomy and tube then spreading distally, sparing the palms and soles. placement  The so-called strawberry tongue also is seen.  1st line of surgical treatment in children with chronic sinusitis  Locoregional complications include peritonsillar abscess and,  Complications: rarely, deep-neck space abscess. ✓ Bleeding  Peritonsillar abscess is typically drained with transoral ✓ Nasopharyngeal stenosis technique under local anesthesia, but some suggest that needle aspiration without incision is sufficient.  Deep neck space infections/abscess are rare from  In both procedures, there is risk of velopharyngeal pharyngitis but can occur from odontogenic and salivary insufficiency. gland infections.  In the latter condition, the patient experience:  These typically require a transcervical approach for ✓ Nasal regurgitation of liquids/fluids incision and drainage ✓ Hypernasal speech  Candida albicans is the most common fungal organism to Special care for Down Syndrome Cases cause pharyngitis.  a normal component of the oral flora, but under  Due to atlantoaxial instability, may result in cervical injury if conditions of immunosuppression, broad-spectrum neck is hyperextended during surgery antibacterial therapy, poor oral hygiene, or vitamin  Be sure to have baseline radiographs, orthopedic consult and deficiency, it may become pathogenic. neurosurgery consult pre-operatively  Whitish-cheesy or creamy mucosal patches are observed with underlying erythema. Reading Assignment!  Diagnosis is easily established by Gram’s stain of this material, revealing budding yeast and pseudohyphae.  OBSRUCTIVE SLEEP APNEA  Oral (-azole) and topical (nystatin) antifungals are usually  Occurs when the muscles in the back of the throat relax effective, and immunosuppressed patients may require too much to allow normal breathing prophylactic therapy.  Massively enlarged tonsils can cause episodes of cessation of breathing  Atypical cases of pharyngitis may be caused by:  Tonsillectomy, usually with adenoidectomy if the  Corynebacterium diphtheriae, adenoids are enlarged, is often performed on an  Bordetella pertussis (whooping cough), outpatient basis unless the patient is males  Etiology: reflux, smoking, hypothyroidism, vocal hyperfunction ✓ Focal unilateral lesion seen in males using anticoagulants or antiplatelet drugs as risk factor  Treatment: ✓ Stop smoking  Adult RRP: ✓ Reflux management: PPI ✓ Occurs at age 30-40 ✓ Voice therapy ✓ Less severe ✓ Surgery ✓ More likely to involve extra laryngeal site ▪ Microlaryngoscopy to evacuate the fluid and trim ✓ Significant sign: Hoarseness excess mucosa with the use of cold steel or CO2 laser ✓ Seen via endoscopy  Treatment: No cure Normal vocal cord Reinke’s edema ✓ Microlaryngoscopy with ablation or excision: Recurrence ✓ HPV vaccination ✓ CIDOFOVIR injection ✓ Oral indole-3 carbinol to retard recurrence Before excision After excision VOCAL CORD CYST  Seen in the laryngeal mucosa ✓ Mucus-secreting glands at the supraglottic area LARYNGEAL GRANULOMA  Seen at posterior larynx (arytenoid mucosa)  May be due to reflux, voice abuse, chronic throat clearing, ET intubation, vocal fold paralysis  S/Sx: odynophagia > vocal changes  Congenital cyst may be due to remnants of branchial arch  Diagnosis:  Video stroboscopic laryngoscopy is done to differentiate with ✓ laryngoscopy, polyps ✓ laryngeal EMG,  May compromise airway if large ✓ pH probe testing,  Treatment: ✓ voice analysis ✓ Marsupialization – surgical  Treatment: alteration of a cyst or similar ✓ Voice rest; voice retraining therapy; antireflux therapy enclosed cavity by making ✓ Fundoplication is warranted an incision and suturing the ✓ Excision if carcinoma is suspected; for voice restoration (if flaps to the adjacent tissue, artist) creating a pouch ✓ Important during excision: preserve the arytenoid perichondrium to promote epithelialization postoperatively Note Takers: Agullana, Challoy, Ferrer, Santiago, Sangdaan 5|8  PCC SOM 2026 SURGERY 2 P 03.01 DISORDERS OF THE HEAD & NECK  Venular malformation LEUKOPLAKIA OF THE VOCAL CORD → Port-wine stains  Notable white patch on the vocal fold (mucosal surface) → Follow facial dermatomes  May represent squamous hyperplasia, dysplasia, or carcinoma → Thicken with age  History of smoking and alcohol abuse  Venous malformation  Ulceration and erythroplasia are suggestive of malignancy → Composed of ectatic veins within the lips  Treatment: → Tongued buccal mucosa ✓ Stop smoking and alcohol abuse → Seen as purple masses or subcutaneous/submucosal ✓ Eliminate vocal abuse folds ✓ Anti-reflux therapy (PPIs)  AV malformation → Rare malformations of arteriovenous channels that Reading Assignment!! failed to regress during development  Vocal Cord Paralysis  Lymphatic malformations  The most common cause of unilateral vocal cord → Lymphangioma that usually involve the cervical area paresis is iatrogenic in origin, following surgery to the → More commonly macrocystic and well-demarcated thyroid, parathyroid, carotid, spine through an → Those arising above the hyoid bone are microcytic anterior approach, or cardiothoracic structures and infiltrative in nature  May also be secondary to malignant processes in the → May become infected and rapidly enlarge causing lungs, thoracic cavity, skull base, or neck.  Bilateral vocal cord paralysis: in adults airway compromise  Requires tracheotomy because the cords are left in a → Associated with feeding difficulties and failure to paramedian position leaving a slit-like glottic aperture thrive  If the paralysis is permanent, then a cordectomy with  Treatment or without arytenoidectomy can be used to open up ✓ based on the depth, size, and growth pattern the airway in an attempt to eventually decannulate  Capillary hemangioma and port-wine stains the patient. → FPDL → KTP and Nd:YAG reserved for deeper lesions VASCULAR LESIONS OF THE HEAD & NECK  Venous malformation → Laser HEMANGIOMA → Sclerotherapy: should be used with caution due to  Most common vascular lesion in infancy and childhood significant risk of cavernous sinus thrombosis  Seen at birth in 30% of cases or apparent at first few weeks of  AV malformation life → Surgical excision with negative margins  Involution may begin at age 2 until age 12; 40% resolve → Preoperative angiographic embolization is frequently completely done for best results  Surgery indicated if no significant involution at age 3-4  Microcystic lymphangioma  Surgery is reserved to those with severe functional or cosmetic → Surgical excision of CO2 laser ablation (for superficial problems lesions) ✓ Flashlamp-pumped pulsed-dye laser (FPDL)  Macrocystic lesions ✓ Potassium titanyl phosphate (KTP) laser → Sclerotherapy ✓ Neodymium yttrium-aluminum-garnet (Nd:YAG) laser II. TRAUMA OF THE HEAD & NECK ✓ Repeated every 4-6 weeks until lesion is cleared  Other treatment: SOFT TISSUE ✓ Systemic steroids to halt rapidly proliferating lesions (use  Most lacerations can be closed primarily if there is not soft with caution) tissue loss; even some devitalized soft tissue should be ✓ Propranolol to inhibit hemangioma growth preserved because of the excellent blood supply to head and ▪ Beta Blockers “-olol” neck tissue that allows it to recover at a higher rate  Minimal debridement is required VASCULAR MALFORMATION  Thorough irrigation to remove foreign bodies and clean the  Almost always present at birth and slowly enlarge without tissue is required proliferation  Eyelid lacerations are closed in layers with careful  May arise from capillaries, venules, veins, AV channels or reapproximation of the orbicularis oculi as a separate layer lymphatics  Lip injuries follow the same principle with a three-layer  Capillary malformation closure involving the orbicularis oris, which is the strength → Involves midline neck and forehead → Fade with age Note Takers: Agullana, Challoy, Ferrer, Santiago, Sangdaan 6|8  PCC SOM 2026 SURGERY 2 P 03.01 DISORDERS OF THE HEAD & NECK layer, followed by careful reapproximation of the vermillion TEMPORAL BONE FRACTURES border to avoid a step-deformity  Occur in approximately one fifth of skull fractures  Otic capsule sparing fractures present with: FACIAL FRACTURES ✓ Conductive hearing loss  The most common facial fracture involves the mandible ✓ Ossicular injury  Midface fractures are rarely isolated and include multiple ✓ Bloody otorrhea subsites ✓ Labyrinthine concussion  Isolated zygoma fractures are typically displaced inferior  Regardless of the fracture pattern, when CSF leak is inferiorly and medially with disruption of the suture lines suspected, it usually resolves with conservative measures between the temporal, frontal, and maxillary bones and the including: zygoma ✓ Bed rest  Signs of midface fractures: ✓ Elevation of the head of the bed ✓ Subconjunctival hemorrhage ✓ Stool softeners ✓ Ocular signs/symptoms ✓ Avoiding sneezing or straining ✓ Malocclusion ✓ Facial asymmetry Checkpoint! ✓ Midface hypoesthesia (V2) 1. Chronic otitis media is diagnosed when signs and ✓ Hematoma symptoms persist for: ✓ Mobile maxillary complex a. 2 weeks c. 6 weeks  Midface fractures are classically described in three patterns: b. 4 weeks d. 8 weeks ✓ Le Fort I, II, & III 2. Sequelae of chronic otitis media as a consequence of ✓ Three vertical buttresses support the midface: eustachian tube dysfunction and retraction of squamous ▪ the nasofrontal-maxillary, elements of the tympanic membrane to the middle ear. ▪ the frontozygomaticomaxillary, and a. Cholesteatoma c. Sinus inflammatory disease ▪ pterygomaxillary. b. Otalgia d. Erosion of ossicular chain ✓ The five horizontal buttresses include the: frontal bone, 3. Most common complication of OM associated with H. nasal bones, upper alveolus, zygomatic arches, and the influenzae infection in children infraorbital region. a. Intratemporal c. Intracranial b. Intercranial d. Interventricular LE FORT 4. Waldeyer’s ring is consists of the following except a. Sublingual tonsils c. Palatine tonsils  Le Fort I fractures a b. Pharyngeal tonsils d. Tubal tonsils ✓ occur transversely across the alveolus, above the level of 5. First line of surgical treatment in children for chronic the teeth apices. sinusitis. ✓ In a pure Le Fort I fracture, the palatal vault is mobile a. Marsupialization c. Tonsillectomy while the nasal pyramid and orbital rims are stable. b. Myringotomy d. Adenoidectomy  T/F Le Fort II fracture b ✓ extends through the nasofrontal buttress, medial wall of 6. Invasive fungal sinusitis is characterized by ischemic the orbit, across the infraorbital rim, and through the necrosis and black eschar formation in the sinonasal zygomaticomaxillary articulation. mucosa. 7. Diagnosis of sinus inflammatory disease is established ✓ The nasal dorsum, palate, and medial part of the with 2 major and 2 minor criteria. infraorbital rim are mobile. 8. Treatment for allergic fungal sinusitis include  Le Fort III fracture c debridement, systemic steroids, and nasal irrigation.  also known as craniofacial disjunction 9. Reinke’s edema arise from injuries to the capillaries of the  The frontozygomaticomaxillary, frontomaxillary, and lamina propria of the vocal cord leading to extravasation frontonasal suture lines are disrupted. of fluid.  The entire face is mobile from the cranium. 10. AV malformation is composed of ectatic veins in the lips  It is convenient to conceptualize complex midface fractures and cervical areas. according to these patterns 1D2A3C4A5D6T7F8T9T10F Note Takers: Agullana, Challoy, Ferrer, Santiago, Sangdaan 7|8  PCC SOM 2026 SURGERY 2 P 03.01 DISORDERS OF THE HEAD & NECK APPENDIX Allergic Fungal Sinusitis Invasive Fungal Sinusitis *Le Fort Classification Note Takers: Agullana, Challoy, Ferrer, Santiago, Sangdaan 8|8