Ear

1. Auricular Hematoma
   1. Treatment: Drainage
      1. Needle aspiration
      2. Incision with or without drain (rubber band)
      3. Pressure dressing
      4. Antibiotics for incision or multiple aspirations
2. Foreign Body in the External Auditory Canal
   1. Treatment: Remove gently. If not easy, perform with microscope under general mask anesthesia.
3. Otitis Externa
   1. Symptoms
      1. Pain
      2. Itching
      3. Decreased hearing
   2. Signs
      1. Auricular pain (elicited by shaking auricle)
      2. Erythema of external auditory canal
      3. Edema of external auditory canal
      4. White keratinous debris in canal
   3. Etiology
      1. Prolonged water exposure
      2. Q-tip or other foreign body trauma
   4. Organisms
      1. Pseudomonas aerugionsa (95-99%)
      2. Fungal (<5%)
   5. Treatment
      1. Domeboro Otic (aluminum sulfate and calcium acetate) 30 ml bottle, two drops qid in affected ear or Cortisporin Otic Solution (polymyxin B-neomycin-hydrocortisone), 10 ml bottle, two drops qid in affected ear or gentamycin or tobramycin ophthalmic qtts 10cc; 2 qtts tid
      2. For pain: aspirin, aspirin or tylenol with codeine or non steroidal anti-inflammatory agents and
      3. Local heat application (e.g. heating pad)
4. Surfer's Ear (External Auditory Canal Exostoses)
   1. Associated with prolonged cold salt water exposure; seen in surfers and professional divers
   2. Symptoms: Usually present with otitis externa
   3. Signs: Generally three exostoses seen in external auditory canal, often white, firm to palpation, adjacent to tympanic membrane
   4. Treatment: If occluding more than 50 percent of canal, surgical removal recommended.
5. Acute Otitis Media
   1. Symptoms
      1. Fever
      2. Otalgia (pain)
      3. Decreased hearing
      4. Pressure in the ear
      5. Discharge only with perforation
   2. Signs
      1. Red, bulging tympanic membrane
      2. Conductive hearing loss - diagnose with tuning forks
   3. Treatment
      1. Adults: Amoxicillin, 250-500 mg
         #30
         1 PO tid
      2. Children 5 years old or under: Amoxicillin, or amoxicillin with clavulonic acid ; 40 mg/kg/day (3 doses daily for 10-14 days)
   4. Follow-up: Appointment in 10-14 days
6. Chronic Otitis Media
   1. Symptoms
      1. Chronic drainage, often foul-smelling
      2. Decreased hearing
   2. Signs
      1. Foul-smelling drainage during periods of exacerbation
      2. Tympanic membrane perforation, often at the margin
      3. White keratinous debris
         These are all signs of what is often called cholesteatoma
   3. Treatment
      1. ortisporin Otic Solution, 10 ml bottle:
         2 drops qid in affected ear
         and
         penicillin, 250 mg #100 1 PO qid or
         amoxicillin #75,1 PO tid
      2. Surgery (when not infected): tympanomastoidectomy
   4. Complications
      1. Brain abscess
      2. Meningitis
      3. Lateral sinus (sigmoid sinus) thrombosis
      4. Facial nerve paralysis
      5. Labyrinthitis
      6. Hearing Loss
7. Serous Otitis Media
   1. Symptoms
      1. Decreased hearing
      2. Feeling of fullness in ears
   2. Signs
      1. Retracted tympanic membrane with no movement or reverse movement on pneumomassage
      2. Conductive hearing loss: Can be measured with 256 and 512 cps tuning forks, audiometry, or tympanometry
   3. Etiology
      1. Poor eustachian tube function
      2. Allergic upper respiratory tract disease
      3. Bacterial rhino sinusitis
      4. Chronic sinusitis
      5. Residual otitis media
      6. Nasopharyngeal obstruction: Adenoids, nasopharyngeal tumor
      7. Cleft palate
   4. Treatment
      1. Observe, for 2 weeks
      2. If no change, prescribe nasal steroids (age 5 and older) for 4-6 weeks
      3. If no success, add antibiotics (amoxicillin or penicillin)
      4. If still no success, change to another antibiotics for 2 weeks with or without a short course of systemic steroids
      5. If no success, observe for 2 weeks with no therapy
      6. If no change, myringotomy and insertion of middle ear ventilation tube should be performed by head and neck surgeon
8. Otosclerosis
   1. Symptoms
      1. Hearing loss
      2. Tinnitus
   2. Signs
      1. Conductive hearing loss with normal otoscopy
      2. Audiogram: Conductive
   3. Treatment: Stapedotomy
9. Meniere's Disease
   1. Symptoms
      1. Fluctuating hearing loss
      2. Tinnitus
      3. Vertigo
      4. Feeling of fullness in the ear
   2. Signs
      1. Fluctuating hearing loss on audiograms
      2. Otherwise negative results on vertigo work-up
   3. Treatment
      1. Environmental Control
      2. Stress Reduction
      3. Low salt (Na) diet
      4. Hydrochlorthiazine 25 mg p.o. q. day with
         Kcl 8-10 meq. p.o. q. day
      5. For dizziness diazepam or phenothiazine
      6. See Vertigo IV.E
   4. Follow-up care by specialist in head and neck surgery or otology.
10. Presbycusis
    1. Symptoms
       1. Decreased hearing
       2. Ringing in ears (tinnitus)
    2. Signs: Sensorineural hearing loss on audiogram
    3. Treatment
       1. Rule out noise-induced hearing loss by history and audiogram
       2. Hearing aid if recommended by specialist in ear disease
11. Acoustic Neuroma
    1. Symptoms
       1. Hearing loss or
       2. Vertigo or
       3. Facial paralysis
    2. Signs
       1. Asymmetric sensorineural hearing loss with poor discrimination
       2. Abnormal BERA
       3. Unilateral weakness on electronystagmography
       4. MRI showing cerebellopontine angle tumor
    3. Treatment: Refer to specialist in head and neck surgery
12. Temporomandibular Joint Syndrome (TMJ)
    1. Symptoms
       1. Patient complains of ear pain. Pain is anterior to ear canal; pain involves muscles innervated by C.N. V, particularly the muscles of mastication.
       2. Clicking in temporomandibular joint
    2. Signs
       1. Pain on finger pressure over joint when opening and closing mouth
       2. Poor dental occlusion or loose-fitting dentures
       3. Spasm of involved muscles
       4. Anxious, depressed or hysterical patient often with bruxism and teeth clenching
    3. Treatment
       1. Treat psychosomatic aspects if cause is stress
       2. Refer to general dentist or orthodontist with experience in TMJ and occlusal problems
       3. Refer to TMJ clinic

Otalgia Work-up
Rule out lesions by history and physical examination.

1. External Auditory Canal
   1. Auricular hematoma
   2. Foreign body in the ear canal
   3. Otitis externa
   4. External auditory canal tumor
   5. Otitis media - acute or chronic
2. Temporomandibular Joint
3. Referred Pain from Inflammatory or Neoplastic Lesion
   Pain referred from
   1. Nasopharynx
   2. Tonsil
   3. Base of tongue
   4. Larynx
   5. Pharynx and hypopharynx

   Evaluate by examination, endoscopy, cultures and biopsies

Hearing Loss Differential Diagnosis

1. External Auditory Canal Obstruction
   1. Wax
   2. Foreign body
   3. Otitis externa
   4. Exostoses
   5. Tumor
2. Middle Ear
   1. Acute otitis media
   2. Chronic otitis media
   3. Serous otitis media
   4. Tympanic membrane perforation
   5. Otosclerosis
   6. Ossicular discontinuity
   7. Round window rupture (barotrauma)
3. Inner Ear
   1. Meniere's disease
   2. Presbycusis
   3. Noise-induced hearing loss
   4. Otosclerosis
4. Central Nervous System
   1. Cerebrovascular accident
   2. Brain tumor
   3. Psychiatric disease

Vertigo Work-up

1. History
   1. Vertigo
      1. Onset
      2. Intensity
      3. Duration
      4. Association with nausea and vomiting
   2. Hearing loss
   3. Tinnitus
   4. Feeling of fullness in ear
   5. History of ear pain, infection, surgery, trauma, etc.
   6. Recent illness
   7. Current medications
2. Examination
   1. Hearing (tuning fork)
   2. Otoscopic
   3. Ophthalmic, to include extraocular movements, examination for nystagmus, and retinoscopy
   4. Cranial nerves, with particular attention to nerves 3,4,5 (especially corneal), 6,7,9 and 10
   5. Neck examination to recognize carotid artery disease
   6. Blood pressure, to consider hypertension and orthostatic changes
   7. Pulse, to diagnose arrhythmia
   8. Neurologic, to exclude neurologic disease, especially multiple sclerosis and cerebrovascular accident
3. Laboratory
   1. Complete blood count to rule out anemia
   2. Electrolyte determinations
   3. Calcium determinations to detect hypocalcemia
   4. T4 and TSH to detect hypothyroidism
   5. VDRL and FTA-ABS to rule out tertiary syphilis
   6. Cholesterol and triglyceride determinations to detect hyperlipidemia
   7. Blood and urine tests for diabetes
   8. Electrocardiography with rhythm strip to diagnose cardiac disease
   9. Audiogram and tympanogram to evaluate hearing: if a loss exists, to evaluate type of loss
   10. Brainstem Evoked Response Audiometry
   11. Electronystagmogram (ENG) to test labyrinthine function, gaze nystagmus, response to caloric irrigation; extremely useful to identify labyrinthine disease and also helps localize lesions either in the labyrinth or in the central nervous system.
   12. MRI or, if unavailable, CT scan of the internal auditory canal to evaluate cerebellopontine angle tumors, particularly acoustic neuroma
   13. Cervical spine series - the cervical spine is closely connected to the labyrinth via a vestibulospinal reflex. Cervical spine disease can cause vertigo and hence must be evaluated.
4. Differential Diagnosis: This is not intended as an exhaustive differential, but rather to give you some insight into the different diseases that can cause vertigo. With persistence a diagnosis can be made in over 90 percent of vertiginous patients.
   1. Otologic
      1. Acute otitis media
      2. Serous otitis media
      3. Chronic otitis media
      4. Perilymph fistula
         1. Traumatic
         2. Post-stapedectomy
         3. Barotrauma (round window rupture)
      5. Labyrinthitis
         1. Bacterial
         2. Viral
         3. Toxic
      6. Meniere's disease
      7. Vestibular neuronitis
      8. Benign positional vertigo
      9. Acoustic neuroma or other cerebellopontine angle tumors
   2. Central nervous system
      1. Stroke
      2. Transient ischemia attacks
      3. Multiple sclerosis
      4. Neurosyphilis
      5. Meningitis or encephalitis
      6. Migraine
   3. Neck
      1. Osteoarthritis
      2. Carotid artery stenosis
      3. Vertebrobasillar artery insufficiency
      4. Subclavian steal syndrome
   4. Metabolic
      1. Hyper- or hypoglycemia
      2. Hyper- or hypothyroidism
      3. Electrolyte imbalance
      4. Hypercalcemia
      5. Anemia
      6. Polycythemia
      7. Leukemia
   5. Infections
      1. Influenza
      2. Herpes zoster
      3. Measles
      4. Mumps
      5. Other viral illness
   6. Drugs
      1. Streptomycin
      2. Kanamycin
      3. Gentamicin
      4. Diazepam
      5. Sedatives
      6. Opiates
      7. Alcohol
      8. Neuroleptics
      9. Aspirin
      10. Nicotine
      11. Caffeine
   7. Cardiac
      1. Arrhythmia
      2. Hypertension
      3. Hypotension
      4. Poor cardiac output
5. Treatment
   1. Mild: Promethazine hydrochloride, 25 mg every 6 hours by mouth as needed, or diazepam, 5 mg every 6 hours by mouth as needed
   2. Moderate: Promethazine hydrochloride intravenously until stable, then promethazine by mouth or by rectal suppository
   3. Severe or with dehydration: Intravenous fluids and parenteral phenothiazines; occasionally use supplemental diazepam or droperidol

Facial Paralysis Work-up and Treatment

1. History
   1. Gradual versus sudden onset
   2. Family history
   3. Pregnancy
   4. Head trauma
   5. Ear disease
   6. Parotid neoplasm
2. Examination must include
   1. Otoscopy
   2. Hearing test, including tympanometry
   3. Eyes: Test tearing with Schirmer paper
   4. Mouth: Check tongue - chorda tympani is responsible for taste on anterior two thirds of tongue and for submandibular gland salivary stimulation
   5. Face: Examination for muscle and nerve function; may need to test function electrically
   6. Neck: Check for parotid tumor
   7. Temporal bone tomography to rule out cerebellopontine angle tumor and temporal bone infection or tumor.
3. Treatment of Acute Paralysis
   1. Treat specific cause if known
   2. For idiopathic cases
      1. Prednisone 60mg p.o. q A.M. for 5-7 days
      2. Total paralysis with no electrical conduction: otology consultation to consider total facial nerve decompression
   3. If the eye does not close or tearing is decreased, or both, treat eye to prevent corneal drying with eye drops during the day and moisture chamber and lacrilube at night
4. Facial Rehabilitation
   1. Facial nerve graft
   2. Hypoglossal to facial nerve anastomosis
   3. Temporalis muscle sling

Nose

1. Epistaxis
   1. Anterior bleeding site: Identify by visual examination
      1. Hold cocaine-impregnated pledget against bleeding site
      2. Inject with lidocaine with 1% epinephrine
      3. Apply commerical Merocel sponge
      4. Electrocautery; AgN03 is second choice
      5. Apply _-inch gauze anterior nasal pack
   2. Posterior bleeding site
      1. Anterior posterior balloons
      2. Use 30 ml Foley balloon or nasal balloon as a posterior pack
      3. Use _-inch gauze as an anterior nasal pack
      4. Admit patient to hospital, apply 02 mask, give minimal sedation or analgesia
   3. If bleeding continues or if it recurs after removing pack at 3 to 4 days, then surgery (internal maxillary artery ligation and ethmoid artery ligation) should be performed
2. Sinusitis
   1. Symptoms
      1. Pain
      2. Pressure
      3. Elevated temperature
      4. Nasal discharge or postnasal drip
   2. Signs
      1. Pain elicited by tapping directly over sinus
      2. Elevated temperature
      3. Erythematous oropharynx
   3. Acute episodes are often associated with upper respiratory tract infections or episodes of acute allergic rhinitis
   4. Nasal endoscopy - ostiomeatal complex disease
   5. If chronic, sinus CT
   6. Treatment for acute sinusitis
      1. Amoxicillin 250-500 mg 1 p.o. tid for 10 to 21 days.
      2. See algorithm
   7. Treatment for chronic sinusitis
      1. antibiotics for 3 to 12 weeks
      2. Nasal evaluation
         1. cytology
         2. Skin tests
         3. endoscopy
         4. sinus CT
      3. Appropriate allergic therapy
         1. environmental control
         2. nasal steroids
         3. desensitazation
         4. endoscopic sinus surgery
3. Nasal Obstruction
   1. Unilateral causes
      1. Foreign body
      2. Nasal polyp
      3. Nasal or nasal pharyngeal tumor
      4. Septal deviation
   2. Bilateral causes
      1. Nasal polyps
      2. Septal deviation
      3. Chronic sinusitis
      4. Aging
   3. Treatment For all conditions mentioned, except allergic rhinitis, surgery maybe required; patient should be referred to a head and neck surgeon
   4. Allergic rhinitis
      1. Environmental control
      2. Nasal saline irrigation
      3. Intranasal steroids
      4. If unsuccessful, refer the patient to an allergist for allergic testing and possible desensitization
4. Olfactory Dysfunction
   1. Causes
      1. Inflammatory rhinitis
      2. Trauma
      3. Post viral
      4. Toxin
      5. Congenital
      6. Psychiatric
      7. Alzheimer's Disease or other dememtia
      8. Aging
   2. Evaluation
      1. Smell test
      2. Nasal cytology
      3. Skin tests for inhalant allergens
      4. Nasal endoscopy
      5. Sinus CT
      6. Consider trial of systemic steroids
   3. Treatment
      1. Specific treatment for specific disease
      2. Smoke detectors, gas detectors, spoiled food patrol
      3. Taste rehabilitation

Throat
Oral Cavity, Oropharynx, Larynx, Hypopharynx, Esophagus, Trachea

1. Tonsillitis
   1. Symptoms
      1. Sore throat: Usually severe; occasionally interferes with swallowing, rarely with breathing
      2. Elevated temperature: Children, 103-105_F; adults, 101-103_F
      3. Patient feels sick
      4. No runny nose
   2. Signs
      1. Reddened tonsils, often with white lymphoid exudates
      2. Pharynx and nose are normal on examination
      3. Cervical lymph nodes often enlarged
      4. Elevated temperature
   3. Throat Culture: If positive, will show beta-hemolytic streptococcus, but unfortunately is positive only two thirds of the time; culture is often expensive and for both reasons can be limited to
      1. Patients with known valvular or rheumatic heart disease
      2. Immunosuppressed patients
      3. Patients who insist, or whose parents insist, on having a culture performed
   4. Treatment
      1. Adults: Penicillin, 250 mg by mouth four times daily for 10 days
      2. Children: Penicillin, 75 mg/kg/day in four equal doses, not to exceed 1 g/day
      3. Patients allergic to penicillin should be given erythromycin
   5. Indications for Surgery
      1. A single episode requiring hospitalization for dysphagia or dyspnea
      2. More than four episodes per year for at least 2 years, causing patient to miss 10 days of school or work annually
      3. Recurrent tonsillitis causing recurrent otitis media
2. Viral Pharyngitis
   1. Symptoms
      1. Sore throat
      2. Usually followed closely by runny nose
   2. Signs
      1. Diffuse pharyngitis including but not confined to tonsils
      2. Clear or purulent rhinitis; usually without significant cervical adenopathy
   3. Treatment: This is a viral disease and is not altered by antibiotic therapy. Decongestant or decognestant-antihistamine combination therapy will diminish nasal symptoms. Antibiotics indicated for otitis media, or sinusitis. Tonsillectomy is not indicated.
3. Peritonsillar Abscess (PTA)
   1. Symptoms: Severe sore throat, often unilateral, usually with significant dysphagia, temperature elevation, and malaise
   2. Signs: Unilateral protuberant tonsil, often with soft palate or uvular edema and occasionally with uvular deviation away from the involved side
   3. Diagnosis: Confirmed by anesthetizing the superior pole of tonsils and adjacent soft palate and then aspirating or incising
   4. Culture and sensitivity tests and Gram stain will often show mixed anaerobic infection
   5. Treatment Plan I
      1. Incision and drainage
      2. Hospitalization
      3. Intravenous fluids and I.V. antibiotic
      4. Antibiotics for 10 days; not necessarily intravenously for all 10 days
      5. Elective tonsillectomy 6 weeks after recovery
   6. Treatment Plan II
      1. Aspirate pus, confirming diagnosis and obtaining material for culture and sensitivity tests
      2. Admit patient to hospital and begin intravenous penicillin therapy
      3. Immediate tonsillectomy by head and neck surgeon
   7. Treatment Plan III
      1. Needle aspiration up to 3 times
      2. Oral antibiotics
      3. Follow-up prn
4. Differential Diagnosis for Sore Throat
   1. Beta-hemolytic streptococcal tonsillitis
   2. Viral pharyngitis
   3. Peritonsillar abscess
   4. Mononucleosis: Positive mononucleosis spot test
   5. Gonococcal pharyngitis: Positive sexual history and positive gonococcal culture
   6. Atypical infection, such as with Myobacterium, Treponema, or Candida: diagnose by proper culture
   7. Recurrent herpes pharyngitis: Diagnose by typical history
   8. Oro-pharyngeal neoplasm: Biopsy
   9. Allergic pharyngitis: Often food allergy
   10. Smokers' and drinkers' pharyngitis
   11. Pharyngitis sicca: A condition seen in mouth breathers, especially in low-humidity conditions, or in elderly patients with atrophic mucosa and poor fluid intake. Also seen in patients after radiation therapy or in patients with Sjsgren's syndrome
5. Oral Cavity Venereal Disease
   1. Gonorrhea: usually pharyngitis, diagnosed by positive sexual history and culture
   2. Syphilis: Primary chancre, positive sexual history and culture, positive VDRL test
   3. Papilloma: Venereal warts, usually multiple; positive sexual history. Treat with cryotherapy, diathermy, or surgical excision. Papillomas are also found without sexual history
   4. Recurrent Herpes Pharyngitis: Usually found in patients with venereal herpes; tends to recur during periods of stress. Physical findings show a few clear, fluid-filled vesicles in oro-pharynx
6. Globus Hystericus
   1. Symptoms: A feeling of fullness in throat, a lump in throat associated with swallowing, or tightness in throat
   2. Signs: Normal findings on head and neck examination
   3. Diagnosis 1. This is most commonly caused by Gastroesophageal Reflux (GERD)
   4. Diagnosis 2. This is a psychologic response to (See Algorithm) stress, almost always revealed by taking a careful history. Refer the patient for appropriate psychologic or psychiatric counseling. Barium swallow rarely indicated.
7. Foreign Bodies in the Airway
   1. Occurs most commonly in the very young, usually 8 months to 3 or 4 years
   2. Symptoms
      1. Aphonia and acute respiratory obstruction when there is total airway obstruction
      2. Coughing with inspiratory or expiratory stridor breathing when there is partial obstruction
   3. Treatment
      1. Total obstruction: Use the Heimlich Maneuver for young and old alike. If unsuccessful emergency cricothyrotomy is required
      2. Partial obstruction: Keep the patient quiet and transport to operating room for removal of the foreign body under anesthesia. Obtain cervical or chest x-rays, or both, to localize the foreign body
8. Foreign Bodies in the Esophagus
   1. Symptoms: Choking while eating often on a fish or chicken bone. Frequently hurts at first and then the pain subsides. If foreign body remains, signs of infection will begin to develop approximately 3 days after ingestion
   2. Evaluation: Includes careful history and soft tissue x-rays; if these are not diagnostic, perform a barium swallow with cotton pledget soaked in barium
   3. Treatment: If history or x-rays give even a slight suspicion of a foreign body, rigid endoscopy under general anesthesia is required
9. Hoarseness: Voice changes resulting in breathy, rough, or coarse sound. Common causes include
   1. Acute viral laryngitis: Often associated with upper respiratory infection; this is self-limiting and will disappear in 7 to 10 days, but patient should use voice sparingly
   2. Vocal cord nodules: These are caused by voice abuse (usually screaming and yelling excessively), smoking, GERD and endotracheal intubation. Diagnosis is made by laryngoscopy; treat patient by ordering voice rest, speech therapy and sometimes microlaryngoscopy with vocal cord stripping
   3. Vocal cord paralysis: This is caused by trauma, laryngeal cancers, and occasionally superior mediastinal diseases or cardiac dilation affecting the left recurrent laryngeal nerve. Diagnosis is by mirror laryngoscopy and then by complete work-up to determine its pathogenesis. Treatment depends on the cause
   4. Laryngeal cancer: This is usually found in middle-aged or older smokers. Diagnosis is by mirror laryngoscopy followed by direct laryngoscopy with biopsies. These tumors are treated primarily by head and neck surgeons
10. Acute Epiglottitis (Supraglottitis)
    1. Symptoms: Acute respiratory distress, primarily inspiratory. Patient is toxic, prefers sitting up, and as symptoms progress develops increasing air hunger and inspiratory stridor
    2. Signs: Toxic, febrile child. Epiglottis swollen and red. Blood cultures reveal Haemophilus influenza
    3. Treatment: Intravenous dexamethasone and ampicillin, humidified air, oxygen, and racemic epinephrine by mask. Patients with mild cases can be observed in intensive care; if they begin to improve, they will recover rapidly. Patients with severe cases are brought directly to the operating room with a head and neck surgeon and an anesthesiologist in attendance. If under anesthesia the patient can be intubated, that is sufficient. If not, emergency tracheostomy will be necessary. A 7- to 10-day course of ampicillin is necessary. Patient can be extubated after 48 to 72 hours or the tracheostomy tube can be removed after 3 to 4 days

Neck Masses Differential Diagnosis and Evaluation

1. Congenital neck masses: Occur predominantly between birth and 30 years of age
   1. Branchial cleft cyst: Occurs often as an infected cyst; appears in the high lateral neck along the jugular vein
   2. Thyroglossal duct cyst: Appears in the midline between the hyoid bone and sternal notch; often appears as an infected cyst
   3. Hemangioma and lymphangioma: These can appear anywhere in the head and neck and can be localized or extensive.
2. Traumatic Neck Masses
   1. Arteriovenous fistula secondary to penetrating trauma; diagnose by history and bruit
   2. Laryngocele: Usually found on left side in patients playing a musical instrument such as bugle or trumpet; diagnosis is by history, physical examination, and laryngography or CT scan
3. Inflammatory Neck Masses
   1. Viral lymphadenitis: Common in children with viral upper respiratory tract infection; lymph nodes are multiple, soft, mobile and rarely larger than 2 cm across
   2. Bacterial abscess: May be secondary to direct penetrating injury, abscessed viral lymph node, or a primary infective process in the head and neck, such as a dental abscess. Patient is usually sick, often toxic. Mass can be firm if under pressure or fluctuant. Aspiration of pus is diagnostic. Organisms are often anaerobic. Treat is surgical drainage
   3. Other common infectious causes
      1. Tuberculosis
      2. Coccidiomycosis
      3. Mycobacterium
      4. Syphilis
      5. Cat-scratch fever
   4. Ludwig's angina: This is an abscess under the floor of the mouth that presents under the chin. The lesion is of particular concern because it may push the tongue posteriorly, thereby causing respiratory obstruction.
   5. AIDS: Various HIV related illnesses can present as a cervical mass; biopsy is often required
4. Neoplastic Neck Masses
   1. Lymphoma: Masses are often multiple and can be unilateral or bilateral; they can be large (up to 10cm) or small, and are usually soft and mobile
   2. Epidermoid carcinoma: This is a tumor found in the fourth decade of life and later. It results from effects of tobacco use that are enhanced by alcohol intake. The cervical disease is metastatic from a primary lesion somewhere in the mucosa of the upper aerodigestive tract. The neck mass can be large. It is usually hard and may be fixed. Diagnosis is by discovery and biopsy of the primary lesion
   3. Metastatic cancers from the chest and abdomen: Spread is usually via the lymphatics and the mass is in the supraclavicular fossa. Full work-up and then biopsy are indicated
   4. Thyroid Cancer: The thyroid mass or cervical metastases may be the initial presenting feature. Careful examination should reveal the thyroid primary tumor. Diagnosis is by fine needle aspiration (FNA); ultrasound, thyroid scan or open biopsy
   5. Other Tumors: A variety of other tumors, such as melanoma, sarcoma, plasmacytoma and adenocarcinoma may present in the neck. If one of these is suspected, diagnosis is made by a full evaluation and finally a biopsy
5. Metabolic Neck Masses
   1. Graves' disease
   2. Goiter
   3. Parathyroid Tumors

   All of these should be obvious. The Graves' tumor and parathyroid tumors should have endocrine manifestations. A full evaluation is indicated.

Head and Neck Cancer

1. Salivary Gland Cancer
   1. Constitutes about 3 percent of head and neck tumors; 80 percent involve the parotid gland. Of parotid tumors, 80 percent are benign (60 percent are pleomorphic adenomas), where as 50 percent of submandibular and sublingual tumors are malignant and 80% of minor salivary gland tumors are malignant.
   2. Benign tumors include pleomorphic adenoma, papillary cystadenoma lymphomatosum (Warthin's tumor), and oncocytoma. Malignant tumors include mucoepidermoid carcinoma, adenoid cystic carcinoma, adenocarcinoma, epidermoid carcinoma and undifferentiated carcinoma
2. Epidermoid Carcinoma of the Mucosal Surfaces of the Upper Aerodigestive Tract
   1. Includes tumors of the nasal cavity and paranasal sinuses, oral cavity, oropharynx, nasopharynx, hypopharynx, larynx, and cervical esophagus
   2. These tumors are induced by tobacco; the tobacco effect is enhanced by alcohol intake
   3. Symptoms
      1. Pain
      2. Hoarseness
      3. Obstruction to respiration or swallowing
      4. Weight loss
      5. Malaise or neck masses
   4. Evaluation: Includes a complete history and physical examination, biopsy of the primary site, complete blood count, urinalysis, determinations of creatinine, blood urea nitrogen, serum glutamic pyruvic transaminase, alkaline phosphatase, and bilirubin (total and direct) levels and chest x-ray
   5. Direct laryngoscopy and esophagoscopy should be performed to evaluate the extent of the cancer fully, to rule out second primary lesions and to discover the primary lesion in patients presenting with neck masses
   6. Treatment: Includes surgery and radiation therapy, often in combination; chemotherapy is only adjunctive or palliative
3. Thyroid Cancer
   1. Includes papillary carcinoma, follicular carcinoma, mixed papillary and follicular carcinoma, HYrthle cell carcinoma, medullary carcinoma, and anaplastic carcinoma
   2. Patient usually presents with an asymptomatic thyroid or cervical mass
   3. History may include previous radiation to neck
   4. Evaluation includes T4,T3 TSH and thyroid scan, ultrasound and/or FNA (fine needle aspiration)
   5. Diagnosis is by observation to see if the mass is enlarging, fine needle aspiration, and finally lobectomy
   6. Treatment: Total thyroidectomy and excision of all cervical metastases; patient should be maintained on thyroid extract after surgery
4. Skin Cancer
   1. Basal cell tumors
      1. Diagnosis is by inspection and punch biopsy
      2. Treatment: Includes curettage and desiccation for superficial lesions and surgery for large and deeper lesions
      3. Recurrent basal cell tumors and sclerosing basal cell tumors should be treated with microscopically controlled excision called MOHS
   2. Epidermoid cancer
      1. Diagnosis is by inspection and punch biopsy
      2. Treatment: Surgical excision
      3. Recurrent, large or invasive epidermoid cancers should be removed with microscopically controlled excision (MOHS)
   3. Melanoma
      1. Diagnosis is by inspection and excisional biopsy
      2. Staging by depth of invasion is important
      3. Treatment: Wide surgical excision with neck dissection only if metastasis exists
      4. Postoperative radiation therapy is indicated for advanced lesions
      5. Immunologic and chemotherapy consultations should always be requested

Maxillofacial Trauma

1. Evaluation
   1. For soft tissue trauma, evaluate
      1. Skin
      2. Muscle
      3. Nerves
      4. Major vessels
      5. Mucosa
   2. For trauma to facial bones, evaluate by observations, palpation, and x- rays
   3. Eyes: Check vision and extraocular eye movements
   4. Ears: Test hearing and look for hemotympanum
   5. Nose: Look for bleeding and cerebrospinal fluid leak
   6. Mouth: Examine teeth and occlusion
2. X-rays if bony trauma is suspected
   1. Facial series
      1. Posteroanterior
      2. Waters
      3. Submental vertical
      4. Lateral
   2. Mandibular series
      1. Posteroanterior
      2. Right and left oblique
      3. Transorbital view of condyle and/or
      4. Panorex
   3. CT scan
   4. Nose: Nasal x-rays are not indicated
3. Treatment
   1. Soft tissue
      1. Clean
      2. Debride dead tissues
      3. Stop bleeding
      4. Repair nerves
      5. Repair muscles
      6. Close subcutaneous tissue and skin
   2. Bone: Bony fractures are repaired if functional or cosmetic defects exist; common fractures include
      1. Trimalar (Zygoma or malar, or both) fracture
         1. Elevate zygomatic arch
         2. Reduce fracture to restore normal facial contour
      2. Orbital floor fracture
         1. Observe for enophthalmos
         2. Observe for diplopia with muscular entrapment
         3. Explore and repair only when diplopia with entrapment or enophthalmos is present
      3. Nasal fracture
         1. Reduce for cosmetic reasons
         2. Look for and treat septal hematoma
      4. Maxillary fractures: All fractures (often called LeFort) must be repaired to restore normal dental occlusion. All patients receive arch bars with interdental fixation
      5. Mandibular fracture: Reduce fracture and place arch bars for interdental fixation
   3. Larynx
      1. All laryngeal fractures require indirect or direct laryngoscopy by head and neck surgeons.
      2. Fractures are opened and reduced. The larynx or trachea is then stented.