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Clinical Cases in ENT
Geetha Chary
CHAPTER 1:
Chronic Otitis Media
HISTORY OF PRESENT ILLNESS
PAST HISTORY
How did it start?
What is the pain due to?
Why is there no hearing loss?
General Examination
Fever
Pulse
ENT EXAMINATION
Is the polyp arising from the external canal or middle ear?
Abnormalities
Why do perforations occur in the posterior margin?
What are the signs of retraction?
What are the grades of pars flaccida retraction (Tos's)?
What are the structures seen through a perforation?
What are the uses of pneumatic otoscopy?
What is the differential diagnosis for a vascular mass seen behind tympanic membrane?
What is the differential diagnosis for a white mass seen behind tympanic membrane?
In the absence of audiometry, how can the degree of conductive hearing loss be assessed?
Which is the more sensitive test, Weber or Rinne?
What are the types of mucosal chronic otitis media?
Can you classify safe and unsafe ear depending on site of perforation?
How will you investigate this patient?
How do you take an ear swab for culture and sensitivity?
What are biofilms?
Are organisms responsible for persistent COM?
What does air bone gap depend on?
What is masking?
How is pure tone audiometry (PTA) done?
What is audiometric zero?
What is speech audiometry?
What is a decibel?
When will you do a CT scan?
What causes COM and its persistence?
How will you treat this patient?
Why is temporalis fascia used and are there other materials that can be used?
What is myringoplasty?
What are the factors affecting graft uptake?
How do you know you are competent to do a myringoplasty?
What happens to the graft following myringoplasty?
Which ear will you operate on?
What are the complications of myringoplasty?
If ear is discharging, what will be your treatment?
What are the indications for canal wall up mastoidectomy (cortical mastoidectomy)?
Describe cortical mastoidectomy
What is Korner's septum?
CHAPTER 2:
Chronic Otitis Media with Cholesteatoma
HISTORY OF PRESENT ILLNESS
Examination of the ear
What are the causes for sensorineural loss in chronic otitis media?
What are the types of chronic otitis media squamous type?
How does cholesteatoma destroy bone?
What are the causes of granulation in the external auditory canal?
What is the etiology of cholesteatoma?
How will you investigate?
How will you treat polyps associated with chronic otitis media?
How will you treat the patient?
What is facial recess and sinus tympanic?
How do you approach attic through antrum?
What are the reasons for failure of cholesteatoma surgery?
How to get a dry ear following cholesteatoma surgery?
What is bridge, ridge, anterior and posterior buttress?
Which is the ossicle most likely to be destroyed and how will you do ossiculoplasty?
What are the factors for failed ossiculoplasty?
Describe outcomes after ossiculoplasty
What is Belfast rule of thumb?
How will you treat retraction pockets?
What is the effect of long-standing retraction?
What is the cause of sensorineural loss after mastoidectomy?
What are the indications for radical mastoidectomy?
CHAPTER 3:
Facial Nerve Palsy
HISTORY OF PRESENT ILLNESS
GENERAL EXAMINATION
Examination of face
Examination of ears
How will you proceed?
What are topo diagnostic tests?
What are electrophysiological tests?
What is the role of HRCT?
What are the causes of recurrent facial nerve paralysis?
What is the cause of alternating facial nerve palsy?
What are the causes of bilateral concurrent facial palsy?
What are the degrees of facial nerve paralysis?
What is House Brackman's Classification?
Degrees of Facial Paralysis and Brackmann's Grade Correlate
Forehead
Eye
Mouth
Synkinesis
How will you manage traumatic facial nerve palsy following surgery?
What is the cause of facial paralysis following mastoidectomy?
What are the most common intratemporal complications of COM?
What are the most common intracranial complications of COM?
What are routes of spread of infection?
How does a fistula occur?
Describe tuberculosis otitis media
Describe salient features of intracranial complications
CHAPTER 4:
Vertigo
HISTORY OF PRESENT ILLNESS
How long does it last?
Do you feel the room is rotating or you are rotating?
Is it associated with deafness?
Is there ear discharge or any other ear symptoms
Is it episodic?
Is there syncope or history of migraine?
Are you on any long-term drugs?
General Examination
Examination of Postural Balance
How will you test vestibular functions in a person with congenital nystagmus?
What the tests for saccular functions?
What is click evoked vestibular myogenic potential?
What are the features of superior semicircular canal dehiscence?
What the differences between Peripheral and Central Vertigo?
How is Alexander's law explained?
What is ossiculopsia?
CHAPTER 5:
Hard of Hearing
CHAPTER 6:
Deviated Nasal Septum
HISTORY OF PRESENT ILLNESS
Local Examination
What is the nasal valve and false negative Cottle's test?
Anterior Rhinoscopy
What are the investigations you would like to do?
Do you clinically feel there is rhinosinusitis?
Are there any objective tests to confirm the presence of patients symptoms?
What will you do after investigations?
Describe septoplasty
Will you remove the inferior turbinate?
What is nasal cycle?
What are the types of septal deviation?
If obstruction is in nasal valve area, how will you correct it?
What are the types of inferior turbinate hypertrophy and how can it be treated?
What is empty nose syndrome?
How will you treat empty nose syndrome?
CHAPTER 7:
Sinonasal Polyps
HISTORY OF PRESENT ILLNESS
FAMILY HISTORY/PERSONAL HISTORY
General physical examination as in all cases
On Examination
What is your differential diagnosis?
Why are polypi from ethmoids multiple?
Why does an antrochoanal polyp present posteriorly?
How do you differentiate a polyp from a turbinate?
What is the etiology of polyps?
How will you investigate this patient?
Why are standard radiographs not useful?
What are the views taken during CT of nose and PNS and why?
What is Hounsfield unit?
What is the radiological classification of sinonasal polyps?
How do you endoscopically stage polyps?
What is helical scanning?
Is magnetic resonance imaging (MRI) a good aid for functional endoscopic sinus surgery (FESS)?
Why do polyps occur in the osteomeatal complex?
In this case how will you do a polypectomy?
Describe uncinectomy?
What is basal lamella?
How do you interpret a CT of the nose and paranasal sinuses?
What is the role of MRI in sinus disease?
What are Messerklinger and Wigand techniques?
Describe the course of anterior ethmoidal artery
How frequently will you remove debris from a postoperative cavity?
What are the complications of FESS?
What is Kero's classification?
What are the results of endoscopic polypectomy?
How do steroids help?
What are the boundaries of the frontal recess and how do you approach it?
How do you approach the sphenoid sinus ostia endoscopically?
How do you avoid optic nerve injury during this procedure?
What is the best time to do a CT scan of nose and peripheral nervous system (PNS)?
What anatomical structures can block the osteomeatal complex?
What are Onodi cells?
Describe the various superior attachment of the uncinate process
CHAPTER 8:
Inverted Papilloma
HISTORY OF PRESENT ILLNESS
Rest of history/general examination as usual
On examination
There is blood stained nasal discharge; Can it occur in benign nasal masses?
Can benign masses cause pain?
What are the symptoms of benign nasal tumors?
How will you classify benign tumors?
What do you think this is?
Why do you think it is inverted papilloma?
Why should bone be resected in inverted papilloma?
What histopathological changes denote malignancy?
How will you treat the patient?
What is medial maxillectomy?
What can be done for alveolar or palatal tumors?
What are the other common benign tumors of nose and PNS?
What are the syndrome associated with benign tumors of the nose and PNS?
What is the role of CT/MRI in benign sinonasal masses?
CHAPTER 9:
Sinonasal Malignancy
HISTORY OF PRESENT ILLNESS
How does extension to orbit occur?
What is the stage?
Describe TNM/Staging of maxillary malignancies
What are the subsites of the nasal cavity?
What is the histological grading?
What is the lymphatic drainage of this region?
What are the investigations?
How do tumors spread from maxilla?
What is Ohngren's Line?
What is the treatment protocol for maxillary sinus tumor?
What is postoperative RT?
What is the treatment protocol for ethmoid sinus tumors?
What are types of radiotherapy for maxillary tumors?
What will you do for this patient?
What is total maxillectomy?
How will you manage the orbit?
What are the contraindications for surgical excision of mass?
Are there any procedures for more extensive disease?
What are the other malignant tumors of nose and PNS other than squamous cell carcinoma?
What is Anesthesio-neuroblastoma?
CHAPTER 10:
Nasopharyngeal Angiofibroma
CHAPTER 11:
Nasopharyngeal Carcinoma
HISTORY OF PRESENT ILLNESS
What is your probable diagnosis?
Which is more likely?
On Examination
Clinical Diagnosis
Can it present as a lobulated mass?
How will you confirm your diagnosis?
Why do you feel there is a genetic predisposition for nasopharyngeal carcinoma?
Describe the genetic factors
Describe environmental factors responsible for nasopharyngeal carcinoma
Describe fossa of rosenmüller
What stage is the disease in?
How do you stage nasopharyngeal carcinoma?
Is there any other method of staging?
What is supraclavicular region?
How will you treat the patient?
How will you treat if disease is M1?
How will you treat local recurrence?
What are the approaches to the nasopharynx?
What is the prognosis for nasopharyngeal carcinoma?
What are the complications of irradiation?
CHAPTER 12:
Oral Cavity
HISTORY OF PRESENT ILLNESS
Is there any unexplained dental problem (falling of teeth) non-fitting denture or sharp tooth?
Do you have an ear pain?
Is there trismus ?
Do you have a bad smell in the mouth?
Is there any weight loss?
Is there odynophagia/dysphagia?
Is there difficulty in speech?
Is there anesthesia/hypoanesthesia over face?
PAST HISTORY
PERSONAL HISTORY
GENERAL EXAMINATION
Examination of Oral Cavity
How does oral cancer present?
Diagnosis
What is the Stage?
Name some benign ulcers of the oral cavity
How do you stage oral cavity malignancies?
TNM Staging
What are the essential investigations?
How will you treat this patient?
Why do you want to do a neck dissection?
What are the premalignant conditions for oral cavity malignancies?
Describe buccal carcinoma
What is the general treatment plan for oral cavity carcinoma?
Radiotherapy
How will you treat stage IVB and IVc?
What is performance status?
What are the common tumors of the oral cavity?
At what stage do patients with oral cancer present?
When is surgery better than radiotherapy?
When is radiotherapy better?
Describe carcinoma tongue
Surgery
Describe carcinoma floor of mouth
Describe carcinoma involving mandible
Describe malignancy of hard palate
Differential diagnosis for palatal mass
How will you treat lip cancer?
Upper lip defects
What is the prognosis in lip cancer?
CHAPTER 13:
Oropharyngeal Mass
HISTORY OF PRESENT ILLNESS
Does the ulceration/wound on the tongue bleed spontaneously?
Is there a foul smell emanating from it?
What are the structures mistaken for cancer by the patient?
Single persistent ulcer lasting for more than 2–3 weeks should be viewed with suspicion and investigated
Do you have increased sensitivity to spicy foods?
Do you have change in your voice?
Do you have any difficulty in breathing?
Describe the swelling in your neck
Is it painful?
Are there any other swellings in the neck?
Where is this swelling exactly?
Do you have any ear problem?
Do you have any impairment of tongue movements?
Have you lost weight? Do you have evening rise of temperature or cough or loss of appetite?
PAST HISTORY
Do you have diabetes mellitus, hypertension, syphilis, dental problems such as sharp teeth?
Family History
Personal History
Can it be tuberculosis?
Examination
INVESTIGATIONS
What are the histological variations of malignancies of oropharynx with percentage frequency of presentation?
How is squamous cell carcinoma histologically graded?
Can metastasis occur in oropharynx from distant sites?
What are the common sub-sites in which malignancies occur?
So, how will you treat this patient?
What are the surgical procedures available for oropharyngeal malignancies?
How will the wound heal? Do you need to reconstruct?
If you decide on radiotherpy/chemoradiation how will you proceed?
How do you assess or predict programs for your patient?
What is resectable/unresectable as opposed to moderately advanced/ very advanced?
Classify Neck Dissection
CHAPTER 14:
Vocal Nodules
HISTORY OF PRESENT ILLNESS
Is there breathiness? Yes, sometimes.
Do you have vocal fatigue?
Is the dynamic range reduced?
Is there diurnal variation of voice?
Is there pain during phonation?
Did you have an upper respiratory tract infection/chronic cough?
Is there any reason for dehydration like climate change/insufficient water intake?
Has there been any inhalation of chemicals/noxious fumes?
History of thyroid insufficiency like weight gain, loss of hair can be associated with hoarseness.
Is there any cause of dysarthria?
Is there history of previous surgery?
Are you on any medication?
Are you a diabetic?
Do you have nasal aspiration?/Do you have any central nervous system symptoms?
Do you have dysphagia or odynophagia?
Is there history of acid regurgitation or regurgitation of food?
Do you have stridor?
Is the voice rough?
Is it breathy?
Is the voice weak?
Is the voice strained?
What is Grade, Rough, Breathiness, Asthenia, Strain (GRBAS)?
Is there any swelling in the neck?
What are the structures not seen on indirect laryngoscopy?
Who discovered indirect laryngoscopy?
How is the image seen on indirect laryngoscopy?
Examination of the neck
What are vocal nodules?
What are the layers of the vocal fold?
How will you confirm your diagnosis?
What are the other mucosal lesions?
How are nodules caused?
How does it differ from a polyp?
What are cysts/vocal sulcus?
What is the treatment for mucosal lesions?
What is the surgical treatment?
What is Reinke's edema?
CHAPTER 15:
Left Vocal Cord Paralysis
HISTORY OF PRESENT ILLNESS
Why do you say idiopathic/what are the causes of recurrent laryngeal nerve paralysis?
Do you think the superior laryngeal nerve is involved?
What are the causes of superior laryngeal nerve involvement?
What are signs and symptoms of superior laryngeal nerve paralysis?
How will you investigate?
How do you classify nerve paralysis?
Why is the left recurrent laryngeal nerve commonly involved?
What is non-recurrent laryngeal nerve?
What is electromyography?
What are the chances of recovery?
What are treatment modalities available for cord palsies?
How does compensation occur in recurrent laryngeal nerve paralysis?
What will you do for bilateral vocal cord paralysis?
What is muscle tension dysphonia?
What are the common causes of voice alteration?
CHAPTER 16:
Supraglottic Carcinoma
HISTORY OF PRESENTING ILLNESS
Do people not exposed to tobacco and alcohol get cancer larynx?
What is the genetic process leading to head and neck cancers?
What does this tell us?
On Examination
Examination of the neck
Do you feel it could be tuberculosis?
What is transglottic tumor?
What are the symptoms of supraglottic tumors?
How do you stage supraglottic tumors?
What are the subsites of the supraglottis?
What is the lower limit of supraglottis?
How do you stage supraglottic tumors?
How do supraglottic tumors spread?
What are the natural barriers to tumor spread?
What does not resist tumor spread?
What is pre-epiglottic space?
What is paraglottic space?
How will you investigate this patient?
After the investigations will the staging change?
What are the fallacies of staging in supraglottic tumors?
What is TANIS?
How will you Treat this Patient?
Do you want to try altered fractionation?
What will you do for smaller supraglottic tumors?
What are the contraindications for supraglottic laryngectomy?
What is supraglottic laryngectomy?
Should patient stop smoking now, will it help?
Describe endoscopic resection for supraglottis?
CHAPTER 17:
Glottic Cancer
HISTORY OF PRESENT ILLNESS
On Examination
What is T Staging of glottis?
When does glottic mass restrict vocal cord mobility?
What are the radiological findings in paraglottic space involvement?
What is carcinoma in situ?
What is lymphatic watershed?
What is glottis?
How does glottic cancer spread?
What prevents spread of glottic cancer?
How do you perform direct laryngoscopy?
What is the treatment for this patient?
Describe vertical partial laryngectomy
What are other conservative (voice preserving) surgeries?
Describe total laryngectomy
Describe voice rehabilitation after laryngectomy.
What causes poor prognosis in laryngeal cancers?
What influences distant metastasis?
What are the symptoms of laryngeal cancer?
What will stroboscope show in laryngeal cancer?
What are the fallacies in TNM Classification in glottic cancer?
How do you treat glottic cancer?
What is the behavior of subglottic tumors?
What is the differential diagnosis of squamous cell carcinoma of vocal cord?
Can prognosis of tumor be assessed by histopathology of tumor?
Can Da Vinci's surgical robot be used in treatment of carcinoma larynx?
CHAPTER 18:
Laryngopharyngeal Carcinoma
HISTORY OF PRESENT ILLNESS
Do you have any acid reflux, heart burn?
Do you aspirate?/Is there aspiration of undigested food?
Is there any weight loss?
Do you have any difficulty in swallowing liquids?
Has there been any trauma to the upper aerodigestive tract?
Has there been any cardiovascular incident, central nervous systems disorders?
Is there chest pain?
Is there a problem in initiating swallowing?
From the history what do you think it is?
Why do you think it is referred otalgia?
What is the incidence of various hypopharyngeal malignancies?
What is the stage?
What is the TNM classification for hypopharynx?
What are the subsites of the hypopharyx?
How does hypopharyngeal cancer spread?
How does vocal cord palsy occur in pyriform fossa tumors?
What is the lymphatic drainage of hypopharynx?
Where does it metastatize?
What are the symptoms of hypopharyngeal tumor?
What are the predisposing causes of hypopharyngeal tumors?
What is Plummer-Winson's syndrome?
How will you investigate this patient with pyriform fossa mass?
How will you know if it is a second primary or a secondary in the chest?
Does the final outcome depend on whether it is a second primary or secondary in the lung?
How will you treat this patient?
How will you treat hypopharyngeal malignancies?
What are the complications of radiotherapy?
What is Partial Pharyngectomy?
What are the causes of failure in hypopharyngeal cancer?
CHAPTER 19:
Thyroid Neoplasm
HISTORY OF PRESENT ILLNESS
Is it or has it ever been associated with pain?
Have you had accidental or operation trauma in the head and neck region?
Is there fever, evening rise of temperature, night sweats, loss of weight or appetite?
Does the swelling increase in size during deglutition?
Is there a change in size during inspiration?
Has your hoarseness progressed?
Do you have difficulty in swallowing?
Do you have difficulty in breathing?
Do you have increased (voracious) appetite, loss of weight, palpation, diarrhea, intolerance to heat?
Have you put on weight, do you feel weak, have hair loss, constipation, anorexia, vomiting, intolerance to cold?
Do you have hearing loss; dizziness, tinnitus?
PAST HISTORY
Is there any history of diabetes, hypertension, asthma, allergies, epilepsy?
Did you have any previous surgeries in the neck?
Have you ever been irradiated with 131I or any form of irradiation, accidental leak of nuclear material?
Have you been on prolonged medication for any diseases?
Do you have diabetes or hypertension?
FAMILY HISTORY
Are there any other family members who have neck swelling or have been treated in the past for the same?
PERSONAL HISTORY
Do you consume millets cassava, cabbage frequently?
Do you smoke?
DISCUSSION
What is your diagnosis after history taking?
Can it be a lymph node?
Can it be tuberculosis?
General examination
Examination of the neck
Inspection
Palpation
Examination of the oral cavity/oropharynx
Indirect laryngoscopy
Examination of the eye specific to thyroid
Some classical eye signs in thyrotoxicosis
Cardiovascular system
CNS
Examination of the ear
Skin
Why do you think it is thyroid?
Why do you think it is malignant?
What is the stage?
TNM staging for thyroid cancer (UICC 2007)
How will you manage this patient?
RADIOLOGY
Ultrasound of neck
Computed tomography (CT) scan
MRI Scan
Scintigraphy (Thyroid Scan)
FNAC
After the investigation and FNAC what do you expect?
If it is malignant what is your next line of action?
Treatment plan for papillary carcinoma
Treatment of cervical nodes
Treatment plan for follicular tumors
Treatment plan for medullary carcinoma
What are the types of medullary carcinoma thyroid? When do you investigate for them?
Describe the genetics of hereditary MCT
How do you look for recurrence in MCT?
What is the treatment for anaplastic carcinoma?
What will you do for distant metastasis (other than MCT)?
Can thyroid be a site for distant metastasis?
When is 131I Scan done after thyroidectomy?
What do you expect from 131I Scan?
How do you prepare the patient for 131I Scan?
Do all thyroid malignancies take up 131I?
How do you follow up the patient with 131I imaging and ablation after total thyroidectomy?
How do you treat a positive scan?
What are the long-term effects of radioiodine therapy?
What are the contraindications for radioiodine therapy?
What does prognosis of thyroid cancer depend on?
CHAPTER 20:
Goiter
HISTORY OF PRESENT ILLNESS
LOCAL EXAMINATION
PALPATION
Can it be malignant?
So why has the patient come to the hospital?
Do you advise surgery?
What will you do?
Among these, which do you feel is in important here?
Can T3 T4 TSH help towards diagnosis?
What percentages of nodules are malignant?
What are the factors which can be indicative of possible malignancy?
Will you suggest any medical treatment to your patient?
Does suppression of TSH help?
Which is the preferred surgical procedure?
What are the complications of 131I ablation?
What are thyroid incidentomas and thyroid microcarcinomas?
How will you identify the recurrent laryngeal nerve during surgery?
What is a non-recurrent laryngeal nerve?
How do you identify the superior laryngeal nerve?
What are the anatomical variations of the superior laryngeal nerve?
If thyroid surgery is done when T4 is raised, what complications can follow thyroid surgery?
How do you manage it?
What are the complications of thyroidectomy?
What is extracapsular dissection of thyroid gland?
What is Berry's ligament?
What is Loop of Galen?
What is Tubercle of Zuckerkandl?
What is the cause of asymmetry of two recurrent laryngeal nerves?
Why is right recurrent laryngeal nerve sometimes not recurrent?
What are the other forms of thyroid surgery?
CHAPTER 21:
Thyroglossal Cyst
HISTORY OF PRESENT ILLNESS
Can it be a branchial cyst?
Name some lateral neck swellings?
Is thyroglossal cyst always in the midline?
What is a thyroglossal cyst?
How will you treat this?
If histology reveals papillary carcinoma in the thyroglossal cyst, what is the management?
CHAPTER 22:
Parotid Swelling
HISTORY OF PRESENT ILLNESS
Does the swelling increase in size and cause pain during mastication?
Are there any other swellings or enlargement of other salivary glands?
Are there any ophthalmic symptoms like dry eyes, systemic symptoms including arthalgia?
Is there any ulcer or mass in the skin of the face?
Are there any symptoms of facial nerve paralysis?
Is there a history of irradiation/exposure to radiation even if it was 15–20 years ago?
Is there a history of cigarette smoking?
From the history what is your diagnosis?
Can it be malignant?
Can it be an inflammatory swelling?
Can it be a granulomatous lesion?
On Examination
Is the examination of the nose/ears and larynx significant?
What are the structures which mimic parotid enlargement?
What are the benign parotid swellings?
What are the clinical signs of parotid malignancy?
How will proceed to investigate?
What is a Warthin's Tumor?
What are the other common salivary tumors?
What are the inflammatory lesions of the parotid gland?
How does tuberculosis involve the parotid gland?
How does HIV involve the salivary glands?
If FNAC and other investigations reveal that the mass is a pleomorphic adenoma, how will you proceed?
Why not simply remove the mass?
Describe the incision for superficial parotidectomy
How will you Identify the Facial Nerve?
What are the complications of parotidectomy?
What are the types of parotidectomy?
What are the theories of salivary gland neoplasia?
CHAPTER 23:
Submandibular Gland Swelling
HISTORY OF PRESENT ILLNESS
Is there any abnormality of tongue movement?
Are there any other swellings in the neck?
Is there deviation of angle of the mouth?
From the history what is your diagnosis?
What is the commonest benign swelling of the submandibular gland?
What are the common malignant tumors of the submandibular salivary gland?
What is the common malignant tumor of parotid gland?
What do you know about these malignant tumors?
What are the other malignant tumors you know?
What tumors metastasize to the parotid?
How will you investigate the case?
How will you treat?
What is the incision for submandibular gland resection?
How do you avoid injury to the marginal mandibular nerve?
How do you approach the deep part?
What are the complications?
How will you treat recurrent pleomorphic adenoma?
What is the TNM Classification for salivary gland tumors?
CHAPTER 24:
Cervical Lymphadenopathy with Unknown Primary
HISTORY OF PRESENT ILLNESS
General Examination
What can the differential diagnoses be?
Where does the common unknown primary with occult metastasis usually occur?
Why is an unknown primary not seen?
What are the drainage areas for various nodal levels?
Describe N staging
What are the Fallacies of N Staging?
How does nodal metastasis occur?
What are the common areas that metastasize to cervical lymph nodes other than head and neck?
How will you treat this patient?
What are the general guidelines for treatment of neck secondaries with occult primary?
Describe the neck dissection to be done here
What are the four corners of consternation in neck dissection?
What is radical neck dissection?
What is comprehensive neck dissection?
What is extended radical neck dissection?
What is selective neck dissection?
What are the complications of neck dissection?
What are types of altered fractionation in radiotherapy?
What is the prognosis in secondary metastasis with occult primary?
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