EN4.{30,35-36,46} | Head Neck and Systemic ENT — Graded Quiz

Correct. A fracture parallel to the long axis of the petrous temporal bone is a longitudinal temporal bone fracture — the most common type (~80%), classically presenting with haemotympanum, bloody otorrhoea, and Battle's sign.

Longitudinal temporal bone fracture (80%): runs parallel to the petrous bone's long axis; causes haemotympanum, bloody otorrhoea, Battle's sign, conductive hearing loss; facial nerve injury ~20%. Transverse (20%): perpendicular to petrous bone; causes SNHL, vertigo, facial nerve palsy ~50%.

A transverse temporal bone fracture runs perpendicular to the petrous bone's long axis, causing sensorineural hearing loss, vertigo, and higher risk of facial nerve palsy — NOT haemotympanum or bloody otorrhoea.

Correct. Descending necrotising mediastinitis (DNM) is the term for deep neck infection spreading downward via the retropharyngeal/danger space to the posterior mediastinum — a rapidly fatal complication.

Descending necrotising mediastinitis (DNM): retropharyngeal/parapharyngeal infection descends via the danger space to the posterior mediastinum; mortality 20–40% even with aggressive treatment. Bezold's abscess: mastoiditis spreading beneath sternocleidomastoid. Citelli's abscess: mastoiditis spreading to digastric fossa.

Superior vena cava syndrome is caused by mediastinal mass compressing the SVC — not by descending neck infection. Bezold's abscess is a complication of mastoiditis spreading beneath the sternocleidomastoid. Citelli's abscess is mastoiditis spreading to the digastric fossa — these are otogenic complications, not deep neck space infection sequelae.

Correct. Ludwig's angina is bilateral cellulitis involving the submandibular, sublingual, and submental spaces — classically odontogenic. The non-fluctuant 'woody' brawny swelling and tongue elevation are hallmarks; it is a surgical airway emergency.

Ludwig's angina: bilateral, non-fluctuant brawny cellulitis/abscess involving ALL THREE floor-of-mouth spaces (submandibular, sublingual, submental). Usually odontogenic (lower molar root infection). Key features: woody non-fluctuant swelling, tongue displacement, trismus, drooling, airway compromise — airway FIRST.

Parotid abscess is a complication of parotitis — involving the parotid gland, not the floor of the mouth. Peritonsillar abscess presents unilaterally with uvular deviation and muffled 'hot potato' voice. Retropharyngeal abscess causes posterior pharyngeal wall bulging — distinct from floor-of-mouth Ludwig's angina.

Correct. Pleomorphic adenoma carries a ~5-10% long-term risk of malignant transformation into carcinoma ex-pleomorphic adenoma. This is a key reason why surgical excision (parotidectomy with facial nerve preservation) is recommended even for asymptomatic PA — not observation.

Pleomorphic adenoma (PA): most common parotid tumour; carries ~5-10% risk of malignant transformation (carcinoma ex-pleomorphic adenoma) over years if untreated — higher with recurrent/multiple operations. Warthin's tumour: bilateral in 10%, essentially NEVER malignant. Oncocytoma and basal cell adenoma have very low malignant potential. This is the justification for surgical removal of PA even when benign-appearing.

Warthin's tumour essentially never undergoes malignant transformation. Oncocytoma and basal cell adenoma also have negligible malignant potential. Pleomorphic adenoma is unique among common benign parotid tumours for its significant long-term malignant transformation risk.

Correct. HIV-associated parotid lymphoepithelial cyst (LEC) is strongly associated with HIV infection. It often occurs early in HIV disease, can be bilateral, and FNAC shows cystic spaces lined by squamous/columnar epithelium surrounded by lymphoid tissue. The HIV context makes this the most likely diagnosis.

HIV-associated parotid lymphoepithelial cyst (LEC): pathognomonic of HIV; can be bilateral; cystic parotid enlargement; FNAC shows lymphoid tissue with cystic spaces; strongly associated with HIV — its presence should prompt HIV testing if status unknown. Warthin's tumour also has lymphoid stroma but is not HIV-associated. Pleomorphic adenoma is solid. Mucoepidermoid carcinoma is malignant.

Pleomorphic adenoma is a solid tumour without the HIV-specific lymphoid cystic pattern. Warthin's tumour has lymphoid stroma and cystic spaces but is associated with smoking, bilateral in 10%, not HIV-associated. Mucoepidermoid carcinoma is malignant and would show mucus cells + epidermoid cells on FNAC.

Correct. OHL is caused by EBV (Epstein-Barr virus) reactivation in severely immunosuppressed patients. Its presence on the lateral border of the tongue is pathognomonic of significant HIV immunosuppression.

Oral hairy leukoplakia (OHL): caused by EBV reactivation in the setting of severe immunosuppression; classic site = lateral border of tongue; corrugated/hairy non-removable white plaque; pathognomonic of HIV/AIDS (CD4 typically <200). Candida causes thrush (removable). HPV causes oral condylomata/verrucous lesions. CMV causes ulcers, esophagitis, retinitis, SNHL.

Candida albicans causes oral thrush (pseudomembranous candidiasis) — white plaques that CAN be wiped off, leaving an erythematous base. HPV causes oral warts/condylomata. CMV causes mucosal ulcers, retinitis, and sensorineural hearing loss — not the lateral tongue corrugated plaque of OHL.

Correct. The danger space (space 4) lies between the alar fascia and the prevertebral fascia, extending from the skull base to the diaphragm. It is called 'dangerous' because it provides an unobstructed route for infection to descend into the posterior mediastinum.

Danger space (Grodinsky and Holyoke, space 4): between alar fascia (anterior) and prevertebral fascia (posterior), skull base to diaphragm. Retropharyngeal space: between buccopharyngeal fascia and alar fascia, skull base to T6. Parapharyngeal space: lateral to pharynx. Prevertebral space: posterior to prevertebral fascia down to coccyx.

The retropharyngeal space lies between the buccopharyngeal fascia and the alar fascia — it communicates with but is anterior to the danger space. The parapharyngeal space is the lateral pharyngeal space. The prevertebral space lies posterior to the prevertebral fascia and extends to the coccyx.

Correct. Contrast-enhanced CT neck and thorax is the gold standard for deep neck space infection — it maps the extent of involvement, identifies gas (necrotising infection), shows vascular complications, and most crucially extends to the chest to detect descending necrotising mediastinitis.

Contrast-enhanced CT scan (CECT) neck and thorax: gold standard for deep neck space infection — delineates the extent of infection, shows all fascial space involvement, identifies gas (necrotising infection), shows vascular complications (IJV thrombosis), and extends to mediastinum to detect descending necrotising mediastinitis. Plain X-ray shows prevertebral soft tissue widening and gas but cannot delineate extent. Ultrasound is good for superficial abscesses but poor for deep spaces.

Plain lateral X-ray shows prevertebral soft tissue widening and gas but cannot define extent across multiple deep spaces. Ultrasound is limited for deep neck spaces — good for superficial assessment only. MRI provides excellent soft tissue detail but is slower, less available in emergencies, and not standard first-line.

Correct. AFB-positive organisms on FNAC of a cervical node in an HIV patient confirm tuberculous cervical lymphadenopathy (scrofula). TB is the most common opportunistic infection in HIV-positive patients in India, and HIV co-infection dramatically increases risk of reactivation TB.

Cervical lymphadenopathy in HIV: the most common cause is reactive lymphadenopathy (generalised), but the most important to diagnose is TB (scrofula) — FNAC showing AFB-positive organisms is diagnostic. HIV co-infection dramatically increases the risk of TB reactivation. TB is the commonest opportunistic infection in HIV-positive patients in India. KS can involve lymph nodes but FNAC would show spindle cells. NHL (B-cell type) is associated with EBV in HIV.

Non-Hodgkin's lymphoma (NHL) in HIV presents with lymphadenopathy; FNAC shows lymphoid cells but AFB negative. Kaposi's sarcoma lymph node involvement shows spindle cells on FNAC. Reactive lymphadenopathy from candidiasis would not be AFB positive.

Correct. An untreated septal haematoma leads to avascular necrosis of the septal cartilage (as cartilage is avascular and relies on the perichondrium for nutrition). This progresses to septal abscess, perforation, and ultimately saddle nose deformity — the classic preventable complication of missed septal haematoma.

Septal haematoma: blood between septal cartilage and perichondrium. MUST be drained urgently — cartilage is avascular and receives nutrients only from perichondrium. If left: perichondrium separates, cartilage undergoes avascular necrosis → septal abscess → septal perforation → loss of structural support → saddle nose deformity. This is the 'most preventable catastrophe' in ENT trauma.

Cavernous sinus thrombosis is a complication of facial or sphenoidal sinusitis, not a septal haematoma. Epistaxis from Kiesselbach's plexus is a separate entity. A deviated nasal septum is a structural deformity not caused by untreated haematoma — that causes avascular necrosis and perforation.