ENT 94年度 17-33 題 整理: 溫青彥
17. 經由mastoid cavity欲作facial recess approach時，必須注意位於anteriolateral的什麼解剖構造，以免傷及它?
(A) Lateral semicircular canal
(B) Facial sinus
(C) Sigmoid sinus
(D) Chorda tympanic nerve
解析 : Bailey 下冊 P.1805 Fig.141.9
編者 : Facial recess 是磨temporal bone 時一個重要的三角landmark ,請大家詳記他的邊界, 其上邊為incus buttress , 前外側為chorda tympani , 後內側為facial nerve (decending segment)
Ans: D
18. 一名73歲男性，主訴右側漸近性聽力損失為期3個月而至醫院求診，除了聽損、耳鳴外，並無其他症狀，經詳細檢查後確定是右側聽神經瘤。試問下列的處置，何者較為合適?
A 建議立即手術
B若tumor size大於2cm，則立即手術
C立即以Gamma knife治療，以防腫瘤快速成長
D定期以MRI或CT追蹤，持續觀察腫瘤成長的狀況
解析 : Bailey 下冊 P.1905 主要是三種治療: observation, surgery and gamma knife
編者 : AN的治療要因患者狀況而定, 此案例因已70多歲, 並無其他重大complication, 考慮到AN生長慢(40% 為0.2mm), 且surgery and gamma knife亦造成其他的complication(hearing loss, facial palsy)故先觀察為宜. 另外三種不同手術方式各有優缺點也請大家要知道( translabyrinthine, Middle fossa, Retrosigmoid )
Ans: D
19. 最容易在手術後殘存膽脂瘤(residual tumor)及復發膽脂瘤(recurrent tumor)的膽脂瘤之部位分別是:
A、 Epitympanic cholesteatoma及hypotympanic cholesteatoma
B、 皆為posterior mesotympanic cholesteatoma
C、 Posterior mesotympanic cholesteatoma及epitympanic cholesteatoma
D、 Epitympanic cholesteatoma及Posterior mesotympanic cholesteatoma
解析 : Bailey 下冊 P.1792 左第二行:易 residual tumor : Posterior mesotympanic, 而易recurrent tumor 也就是最易發生的地方: epitympanic
編者: cholesteatoma 大家好好準備吧~我猜也會有口試題~~
ANS: C
20. 下列有關耳咽管(Eustachian tube)之敘述何者為非?
A、 打開耳咽管，主要是靠levator veli palatine
B、 耳咽管有pressure regulation; protection及clearance之功能
C、 耳咽管內襯著respiratory epithelium
D、 耳咽管約於7歲時達到成人之長度(3.5~4cm)
解析 : Bailey 上冊 P.1061
A: 為 Tensor veli muscle
B: 大家都知道吧..
C: 左文字第6行
D: p.1063左下文字….7 y/o.
Ans: A
21. 相較於非腭裂患者，腭裂患者容易產生之中耳膽脂瘤的種類是:
A、 Congenital cholesteatoma
B、 Primary acquired cholesteatoma
C、 Secondary acquired cholesteatoma
D、 以上皆非
解析 : Bailey 下冊 P.1788 右邊第二段 ……primary acquired cholesteatoma.
Ans: B
22. 一名3歲男童於3週前因急性上呼吸道感染且發燒而持續在小兒科診所就醫。經藥物治療後症狀皆已緩解。惟一週前小兒科醫師告知其父母懷疑有中耳積水，逐轉介至貴院耳鼻喉科。試問除了詳細問診外，現階段那些檢查應該馬上給予安排。
A、 Pneumatic otoscopy ; Impedance audiometry ; Temporal CT
B、 Pneumatic otoscopy ; Behavioral audiometry ; allergen test
C、 Impedance audiometry ; Behavioral audiometry ; Temporal CT
D、 Pneumatic otoscopy ; Impedance audiometry ; Behavioral audiometry
解析 : Bailey 上冊 P.1074 右下的table 89.1
CT是有complication時才必要
23. 兒童聽力保健，著重於早期診斷早期復健。目前針對於學齡前兒童(preschool children)最常用之聽力篩檢工具為:
A、 耳聲傳射檢查(OAEs)
B、 聽性腦幹反應檢查(ABR)
C、 溝通能力量表問卷
D、 純音聽力檢查(pure-tone audiometry)
解析 : Bailey 上冊 p.1075 hearing evaluation 這一段
編者: 簡單幫大家整理一下:
OAE , ABR: newborn就可做了(又以OAE為篩檢常用工具)
BOA : 5-6 months後可檢測
VRA : 1 y/o 後可檢測
Play audiometry : 2 y/o後可檢測
Speech 及 PTA : 3-4y/o(pre-school) 後可檢測
24. 關於Temporal bone之Paraganglioma，下列敘述何者為非。
A、 來自於glomus body
B、 屬於nonchromaffin paraganglioma
C、 多位於jugular fossa前外側及中耳腔
D、 壓迫患者同側carotid artery 則pulsatile tinnitus的症狀會消失，此稱為Brown sign
解析 : Bailey 下冊 p.1725
A: 左下…glomus body
B: 右中…. nonchromaffin paraganglioma
C: p.1726右下…anteriorly and superiorly
D: p.1728左中 此為Aquino sign (和Brown sign要分清楚)
Ans: D
25. 下列那些疾病之患者，確定是人工耳蝸植入(cochlear implantation)之禁忌(contra-indications):
A、 Common cavity of cochlea ; Auditory neuropathy
B、 Michel deformity ; Complete ossified cochlea
C、 Michel deformity ; Auditory neuropathy ; Complete ossified cochlea
D、 Auditory nruropathy ; Complete ossified cochlea ; Mondini deformity
解析 : Bailey 下冊 p.1952
編者: 這題Michel deformity 和complete ossification沒問題,問題在於auditory neuropathy,而我們在去年讀到一篇paper: auditory neuropathy按字面定義為第八對聽神經出問題,但依理學檢查(OAE正常但ABEP及PTA異常者)則還需考慮到spiral gg.的層面,故結論是CI對部分auditory neuropathy是有幫助的.
Ans: B
26. Lidocaine作為局部麻醉劑使用時，若合併血管收縮劑的狀況下，就成人而言，可使用的最大劑量為何?
A、 1.5 mg/kg
B、 3 mg/kg
C、 5 mg/kg
D、 7 mg/kg
解析 : Bailey 上冊 p.113 右下: 7 mg/kg for vasoconstrictive agent
Ans:D
27. 下列何者不是sinus mycetoma在電腦斷層上常見的特徵
A、 calcification
B、 air-fluid level
C、 heterogeneous density
D、 unilateral lesion
解析 : Bailey 上冊 p.113 右中 : mycetoma is a noninvasive fungal ball…
Ans: B
28. 關於鼻黏膜表皮細胞在過敏反應中之角色，下列何者正確?
1. Epithelial cells 會分泌IL-6, GM-CSF
2. Intraepithelial lymphocytes以B lymphocytes為主
3. Intraepithelial lymphocytes可分泌transforming growth factor b
4. Intraepithelial lymphocytes不具cytotoxic functions
(A) 1、2、4 (B) 1、3、4 (C) 2、4
(D) 1、3
Ans: D
解析 : Bailey 上冊 p.81 左下 In addition to their function…這一段
2. T cell為主
4.具有cytotoxic functions
編者: 感謝古教授相助~~
29. H1-antihistamine(抗組織胺)的副作用中的口乾，尿液蓄積和sinus tachycardia乃經由下列那一個receptor的作用？
(A) Serotonin receptor
(B) H2 receptor
(C) Muscarinic receptor
(D) H1 receptor
解析 : 出自20篇journal中的 Advances in H1 antihistamine p.2204 Fig1
其他recepto的作用也看一看吧
Ans: C
30. 抗組織胺與組織胺接受體的作用機轉，下列何者為是?
(A) Agoinsts
(B) Neutral antagonists
(C) Partial increase receptor signaling
(D) Inverse agonists
解析 : 同樣出自Advances in H1 antihistamine p.2204 Fig1
Abstract 的二段第四行
Ans: D
31. Macrolides治療慢性鼻竇炎的可能機轉，下列何者為正確:
1. 增加pro-inflammatory cytokines合成
2. 減少neutrophils migration
3. 抑制Mast cells的活性
4. 抑制proliferation of fibroblasts
(A) 1、2、4 (B) 1、3、4 (C) 2、4 (D) 2、3
解析 : 出自20篇journal中Macrolides on sinusitis 第一頁右中
Ans: C
32. 關於成人慢性鼻竇炎常見的感染細菌，下列何者錯誤?
(A) a-hemolytic streptococci
(B) Pseudomonas aeruginosa
(C) H. Influenzae
(D) Staph. Aureus
解析 : Bailey 上冊 p.352 右下 : 就是沒有pseudomonas
Ans: B
33. 鼻部中線腫塊(midline nasal mass)的外科處置，需注意到可能引發CSF leakage或meningitis的併發症。下列tumors中，選出手術較可能發生上列併發症者?
1. Neurofibroma
2. glioma
3. dermoid cyst (nasal dermal sinus cyst)
4. encephalocele
(A) 1, 2, 3 (B) 1, 2, 3, 4 (C) 2, 3, 4 (D) 2, 4
解析 : Bailey 上冊 p.312-313 可以知道只有Neurofibroma較無CSF leakage的併發症
Ans: C
編者: 考的真的滿細的(改成open book都還不一定找得到~),大家加油吧~~orz
2007年8月17日 星期五
94年 ENT 考題51~66
51.王小姐一個月前因疑似罹患甲狀腺癌接受甲狀腺右全葉切除術。術後康復良好，日前應朋友邀請至KTV歡唱慶生，但她發現自己在唱自己昔日拿手歌曲時，無法唱出高音且音域變窄。因而至耳鼻喉科求診。下列與王小姐病情有關之檢查及發現的敘述中何者為真?
(A) 後聲門偏向左側 (x)à 應偏向患側
(B) 聲門閉合時，右聲帶位置較左聲帶高 (o)
(C) 最精確的診斷方法為喉內視鏡檢查 (x)à應為EMG of cricothyroid muscle
(D) 右側聲帶之張度(tension)較強 (x) à較弱
Bailey p.614
52. 有關喉炎(laryngitis)，下列敘述何者為誤?
(A) 細菌性喉炎，在兒童較少發生會厭膿瘍的併發症–(o)
(B) 病毒性喉炎之致病原以鼻病毒(rhinovirus)最常見 (o)
(C) 結核性喉炎常表現於喉前側三分之一的充血、水腫黏膜 (x)à should be post. Third of laryngx or granular exophytic lesions
(D) 施打H.influenza type B疫苗，可降低兒童得到急性會厭炎的發生率 (o)
Bailey: p. 603
53. 有關喉部血管性水腫(laryngeal angioedema)之敘述下列何者錯誤?
(A) 組織血管擴張，血管通透性增加組織水腫，可能致命 ( o)
(B) 可由注射藥物，食物或昆蟲咬傷等所引起 (o)
(C) 治療須迅速使用epinephrine, O2, Antihistamine及corticosteroid (o)
(D) Angiotensin-Converting Enzyme inhibitor所引發的喉血管水腫乃藉由IgE反應所致 (X)
P.602
54. 以下有關於上消化呼吸道異物何者為非?
(A) 最常發生的年齡為5至7歲之幼童 (x) 2-4 y/o
(B) 通常食道異物多於呼吸道異物 (o)
(C) 食道異物最常發生在C-6 level (o)
(D) 不尋常的肺部症狀要懷疑是否為吸入異物 (o)
P. 929
55. 有關Recurrent respiratory papillomatosis以下何者為非?
(A) 為小孩喉部最常見的良性腫瘤 (o)
(B) 它是由Human papilloma virus感染造成，type6及11較常見 (o)
(C) Juvenil form好發於2-4歲，容易復發 (o)
(D) Adult form好發於40-60歲，男性稍多 (x) à 20-40 y/o
P.1029
56. 關於Obstructive sleep apnea syndrome何者為非?
(A) 病患罹患高血壓，心血管疾病比率較一般人為高 (o)
(B) Polysomnography是重要的診斷工具 (o)
(C) 病因為睡眠時上呼吸道塌陷所致 (o)
(D) 依據Respiratory disturbance Index及血中CO2 saturation來分為3級嚴重度 (x) à O2 saturation; p.582
57. 下列有關於Laryngeal stenosis何者為非?
(A) 長期插管是Acquired subglottic stenosis最常見的原因 (o) p.883
(B) 一般而言，以glottic stenosis最常見 (x) à subglottis p.881
(C) Gastric acid reflux會造成laryngeal stenosis (o) p.885
(D) Supraglottic stenosis在小孩較罕見 (o) p.881
58. 有關Reinke’s edema何者為非?
(A) 其發生的位置僅可能在Membranous vocal fold (o)
(B) 其主要症狀為低沉沙啞的嗓音 (o)
(C) 其治療主要在減少外來刺激如吸煙、胃酸逆流 (o)
(D) Steroid有助於減少水腫 (x) à no help, see journal (management of common voice problems: Committee report)
59. Chemotherapy在目前頭頸癌的治療，逐漸佔有較重要的地位，而cisplatin又是較常用的藥物，以下何者非其常見的副作用?
(A) Nausea and vomiting (o)
(B) Mucositis (x) à side effect by RT
(C) Renal toxicity (o)
(D) Ototoxicity (o)
p.1189
60. Radiation therapy (RT)在頭頸癌的治療佔有相當重要的地位，以下4 句 那些屬於錯誤?
Tumor cell在缺氧環境下，對RT反應較好 (x)
Tumor cell在S phase時對RT反應較好 (x)
RT對於較小的腫瘤，有較好的反應 (o)
Postoperative RT宜在術後3個月左右進行 (x) à 6 weeks
(A) 1、2、3 (B) 2、3、4
(C) 1、3、4 (D) 1、2、4
p.1202
61. 台灣地區最常見的頭頸部癌症為何?
(A) 喉癌
(B) 鼻咽癌
(C) 口腔癌
(D) 下咽癌
(See journal 晚期下咽癌之治療經驗)
62. 小兒最常見的惡性頭頸部腫瘤為何?
(A) Lymphoma (o) à NHL
(B) Rhabdomyosarcoma (x) à Second
(C) Thyroid carcinoma (x)
(D) Salivary gland carcinoma (x)
p.1051
63. 下咽部由於淋巴組織豐富，以致於下咽癌有相當高之機率發生頸部淋巴轉移(75%)，以下何者不是下咽癌常轉移的淋巴結?
(A) Jugulo-Omohyoid node (o)
(B) Retropharyngeal Lymph node (o)
(C) Paratracheal Lymph node (o)
(D) Submandibular Lymph node (x)
p.1444
64. Conservation surgery of larynx目地在徹底切除腫瘤，並保留喉部機能，以下何者非Conservation surgery?
(A) Vertical partial laryngectomy (o)
(B) Supra cricoid laryngectomy (o)
(C) Extended supraglottic laryngectomy (o)
(D) Near-total laryngectomy (x)
Ans: ABCà均保有喉部呼吸及sphincter, and speech function, 而Dà loss sphincter function, only preserve the speech function by speech shunt
See bailey chapter 120 (A)(B)(C)
65. 以下有關單側聲帶麻痺何者為非?
(A) Surgical trauma是成年人單側聲帶麻痺的原因最常見 (o) p.613
(B) 左側發生機率較右側常見 (o) p.613
(C) 一般而言，治療可先觀察六至十二個月再施行手術 (o) p.615
(D) Laryngeal reinnervation 是最理想的治療方式，可使聲帶重新恢復運動 (x) p.615
66. 有關Salivary gland tumor何者為非?
(A) Pleomorphic adenoma為最常見之良性腫瘤 (o) p.1279
(B) Mucoepidermoid carcinoma為最常見之腮腺惡性腫瘤，易有 perineural invasion (x) p.1282
(C) Adenoid cystic carcinoma 之治療為radical excision加上術後 radiation (o) p.1282
(D) Squamous cell carcinoma常為皮膚之浸犯或轉移癌 (o) p.1284
(A) 後聲門偏向左側 (x)à 應偏向患側
(B) 聲門閉合時，右聲帶位置較左聲帶高 (o)
(C) 最精確的診斷方法為喉內視鏡檢查 (x)à應為EMG of cricothyroid muscle
(D) 右側聲帶之張度(tension)較強 (x) à較弱
Bailey p.614
52. 有關喉炎(laryngitis)，下列敘述何者為誤?
(A) 細菌性喉炎，在兒童較少發生會厭膿瘍的併發症–(o)
(B) 病毒性喉炎之致病原以鼻病毒(rhinovirus)最常見 (o)
(C) 結核性喉炎常表現於喉前側三分之一的充血、水腫黏膜 (x)à should be post. Third of laryngx or granular exophytic lesions
(D) 施打H.influenza type B疫苗，可降低兒童得到急性會厭炎的發生率 (o)
Bailey: p. 603
53. 有關喉部血管性水腫(laryngeal angioedema)之敘述下列何者錯誤?
(A) 組織血管擴張，血管通透性增加組織水腫，可能致命 ( o)
(B) 可由注射藥物，食物或昆蟲咬傷等所引起 (o)
(C) 治療須迅速使用epinephrine, O2, Antihistamine及corticosteroid (o)
(D) Angiotensin-Converting Enzyme inhibitor所引發的喉血管水腫乃藉由IgE反應所致 (X)
P.602
54. 以下有關於上消化呼吸道異物何者為非?
(A) 最常發生的年齡為5至7歲之幼童 (x) 2-4 y/o
(B) 通常食道異物多於呼吸道異物 (o)
(C) 食道異物最常發生在C-6 level (o)
(D) 不尋常的肺部症狀要懷疑是否為吸入異物 (o)
P. 929
55. 有關Recurrent respiratory papillomatosis以下何者為非?
(A) 為小孩喉部最常見的良性腫瘤 (o)
(B) 它是由Human papilloma virus感染造成，type6及11較常見 (o)
(C) Juvenil form好發於2-4歲，容易復發 (o)
(D) Adult form好發於40-60歲，男性稍多 (x) à 20-40 y/o
P.1029
56. 關於Obstructive sleep apnea syndrome何者為非?
(A) 病患罹患高血壓，心血管疾病比率較一般人為高 (o)
(B) Polysomnography是重要的診斷工具 (o)
(C) 病因為睡眠時上呼吸道塌陷所致 (o)
(D) 依據Respiratory disturbance Index及血中CO2 saturation來分為3級嚴重度 (x) à O2 saturation; p.582
57. 下列有關於Laryngeal stenosis何者為非?
(A) 長期插管是Acquired subglottic stenosis最常見的原因 (o) p.883
(B) 一般而言，以glottic stenosis最常見 (x) à subglottis p.881
(C) Gastric acid reflux會造成laryngeal stenosis (o) p.885
(D) Supraglottic stenosis在小孩較罕見 (o) p.881
58. 有關Reinke’s edema何者為非?
(A) 其發生的位置僅可能在Membranous vocal fold (o)
(B) 其主要症狀為低沉沙啞的嗓音 (o)
(C) 其治療主要在減少外來刺激如吸煙、胃酸逆流 (o)
(D) Steroid有助於減少水腫 (x) à no help, see journal (management of common voice problems: Committee report)
59. Chemotherapy在目前頭頸癌的治療，逐漸佔有較重要的地位，而cisplatin又是較常用的藥物，以下何者非其常見的副作用?
(A) Nausea and vomiting (o)
(B) Mucositis (x) à side effect by RT
(C) Renal toxicity (o)
(D) Ototoxicity (o)
p.1189
60. Radiation therapy (RT)在頭頸癌的治療佔有相當重要的地位，以下4 句 那些屬於錯誤?
Tumor cell在缺氧環境下，對RT反應較好 (x)
Tumor cell在S phase時對RT反應較好 (x)
RT對於較小的腫瘤，有較好的反應 (o)
Postoperative RT宜在術後3個月左右進行 (x) à 6 weeks
(A) 1、2、3 (B) 2、3、4
(C) 1、3、4 (D) 1、2、4
p.1202
61. 台灣地區最常見的頭頸部癌症為何?
(A) 喉癌
(B) 鼻咽癌
(C) 口腔癌
(D) 下咽癌
(See journal 晚期下咽癌之治療經驗)
62. 小兒最常見的惡性頭頸部腫瘤為何?
(A) Lymphoma (o) à NHL
(B) Rhabdomyosarcoma (x) à Second
(C) Thyroid carcinoma (x)
(D) Salivary gland carcinoma (x)
p.1051
63. 下咽部由於淋巴組織豐富，以致於下咽癌有相當高之機率發生頸部淋巴轉移(75%)，以下何者不是下咽癌常轉移的淋巴結?
(A) Jugulo-Omohyoid node (o)
(B) Retropharyngeal Lymph node (o)
(C) Paratracheal Lymph node (o)
(D) Submandibular Lymph node (x)
p.1444
64. Conservation surgery of larynx目地在徹底切除腫瘤，並保留喉部機能，以下何者非Conservation surgery?
(A) Vertical partial laryngectomy (o)
(B) Supra cricoid laryngectomy (o)
(C) Extended supraglottic laryngectomy (o)
(D) Near-total laryngectomy (x)
Ans: ABCà均保有喉部呼吸及sphincter, and speech function, 而Dà loss sphincter function, only preserve the speech function by speech shunt
See bailey chapter 120 (A)(B)(C)
65. 以下有關單側聲帶麻痺何者為非?
(A) Surgical trauma是成年人單側聲帶麻痺的原因最常見 (o) p.613
(B) 左側發生機率較右側常見 (o) p.613
(C) 一般而言，治療可先觀察六至十二個月再施行手術 (o) p.615
(D) Laryngeal reinnervation 是最理想的治療方式，可使聲帶重新恢復運動 (x) p.615
66. 有關Salivary gland tumor何者為非?
(A) Pleomorphic adenoma為最常見之良性腫瘤 (o) p.1279
(B) Mucoepidermoid carcinoma為最常見之腮腺惡性腫瘤，易有 perineural invasion (x) p.1282
(C) Adenoid cystic carcinoma 之治療為radical excision加上術後 radiation (o) p.1282
(D) Squamous cell carcinoma常為皮膚之浸犯或轉移癌 (o) p.1284
94年 ENT 考題17~33
第17~33題 黃底的選項為正確答案
17. 一次小兒急性中耳炎發作，約有幾% 在3個月後仍有中耳腔積液？
A. 10 %
B. 20 %
C. 30 %
D. 40 %
出處：P. 1079 在HIGHLIGHTS 的第4點
18. 相較於一般室內氣體，有關中耳腔氣體成份之敘述，下列何者正確？
A. O2濃度較低
B. CO2濃度較低
C. N2濃度較低
D. O2， CO2， N2三者濃度皆較低
出處：很抱歉，目前仍找不到出處；如果找到出處的話會再mail給大家 sorry！！
19. 垂直局部喉切除(vertical partial laryngectomy)之適應症，何者不正確:
A. 腫瘤局限於單側聲帶，但前聯合及arytenoid body不可有侵犯
B. 腫瘤於下聲門之侵犯少於5 mm
C. 聲帶仍可移動 (mobile)
D. 局部復發性而非第二原發癌
出處：P. 1473【Open Partial Laryngectomy】這個段落的第19 - 22行
另外 contraindications 則參考第22 – 26 行
Indications for VPL and laryngoplasty are tumor involvement of the anterior commissure, externsion to involve the vocal process of the arytenoid, selected superficial transglottic lesions, and carcinoma recurring after radiation therapy. The contraindications for any of these procedures include a fixed vocal cord, involvement of the posterior commissure, invasion of both arytenoid cartilages, bulky transglottic lesions, and lesions invading the thyroid cartilage.
20. 聲帶結節及息肉，其病理變化最常見發生於:
A. covering epithelium of the vocal fold
B. superficial layer of the lamina propria
C. intermediate layer of the lamina propria
D. deep layer of the lamina propria
出處：P. 617【POLYPS】這個段落的第8 - 11行 arising in the subepithelial layer of
loose connective tissue, commonly referred to as the Reinke space
21. Reinke’s edema 之病人除有抽菸習慣外，也可能有下列狀態:
A. vocal hyperfunction
B. laryngopharyngeal reflux
C. hypothyroidism
D. all of above
出處：P. 617最後2行一直到P.618的第一段結束
22. 有關小兒鼻竇炎之併發症，下列何者為非？
A. 眼窩蜂窩性組織炎及膿瘍造成的視力損失，部分是因為視神經遭壓迫，部分是因為視神經炎
B. 腦膿瘍 (brain abscess)是最常見的顱內併發症
C. 鼻竇的感染最常經由小靜脈擴散至眼窩
D. 眼窩蜂窩性組織炎及膿瘍使用靜脈注射抗生素治療時，要注意抗生素是否能通過血-腦障壁 (blood-brain barrier)，以避免顱內併發症
出處：P. 956【Orbital Complications】這個段落的第6 - 9行
Infections from the sinuses can spread to the orbit through the arteries, veins, or rarely lymphatics but more often by direct extension through a dehiscence in the lamina papyracea.
23. 下列何者為非?
A. 急性鼻竇炎，大人和小孩最常見的致病菌類似，為Streptococcus pneumonia, Haemophilus influenzae, 和Moraxella catarrhalis
B. 慢性鼻竇炎大人常見培養出厭氧菌，小孩則很罕見
C. 平均來說，急性鼻竇炎的症狀要來得比慢性鼻竇炎嚴重
D. 鼻竇炎的抗生素治療通常至少需要十天，而常常到三個星期甚至更多
出處：P. 352【MICROBIOLOGY OF RHINOSINUSITIS】的倒數第14行 chronically
infected sinuses in both adults and children usually grow anaerobic bacteria
24. 下列關於鼻竇手術的併發症，何者為非?
A. 暫時性失明 (Blindness) 可能由眼框血腫(orbital hematoma)引起
B. 如果傷及前篩動脈，前篩動脈縮回眼球內並引起眼窩快速血腫，減壓措施必須要在15至30分鐘內執行，以避免失明的危險
C. 由於上頷竇天然開口只距離鼻淚管3至6mm，所以我們在擴大上頷竇竇口時，不得擴大至中鼻甲前緣之前
D. 依定義, 眼框血腫(orbital hematoma)是由眼臉膈前傷害 (preseptal injury)所引起
出處：P. 407 【Orbital Hematoma】這個段落的第6行 orbital hematoma is by definition
a postseptal injury
25. 下列何者為非？
A. 高腳杯細胞 (goblet cells)的密度在上頷竇的密度最高
B. 關於黏液纖毛運輸 (mucociliary transport)，在上頷竇為由底部往竇口運輸，在額竇則由外側壁到頂部，再由頂部到內側壁再至洞口
C. Onodi cell是後篩竇泡延伸，據統計比例為9~12%
D. 側板 (lateral lamella)是篩板 (cribrifrom plate)外側的構造，其長度取決於篩板和篩竇小窩 (fovea ethmoidalis) 的距離
出處：P. 327 見左下的figure 28.5
26. 下列有關於猩紅熱（Scarlet fever）的敘述，何者為非?
A. 屬於急性葡萄球菌咽扁桃腺炎（Acute staphylococcal pharyngotonsillitis）
B. 常伴隨著全身性的紅疹，由軀幹往四肢分佈
C. 理學檢查可見草莓舌（Strawberry tongue）
D. 可以做細菌培養來加以鑑定
出處：P. 546 第3段 Scarlet fever is an acute streptoccocal pharyngotonsillitis
27. 為確定單側聲帶麻痺之神經受傷位置，喉肌電圖檢查應至少檢查那兩條喉內肌?
甲、杓間肌 (2) 甲杓肌 (3) 環甲肌 (4) 環杓肌
A. (1), (2)
B. (2), (3)
C. (2), (4)
D. (1), (4)
出處：P. 610 第一段的第4 – 6行
Because the thyroarytenoid and cricothyroid are easiest to access using an EMG needle, they are the primary muscles studied. Information about recurrent and external braches of superior laryngeal nerve function can be obtained by testing these two muscles.
28. 關於阻塞型睡眠呼吸中止症侯群(obstructive sleep apnea syndrome)之敘述，何者為非?
A. 成年人之睡眠呼吸干擾系數(respiratory disturbance index)大於5者為異常
B. 打鼾及白天嗜睡為最常見之臨床表現
C. 多項睡眠生理檢查(Polysomnography )為最重要之診斷工具
D. 外科手術是第一線也是首先必須嘗試的治療方式
出處：P. 588
29. 有關小兒氣切之敍述何者為非？
A. 通常必須切除部份氣管前壁以便置入氣切管
B. 氣切管直徑和病人年齡及發育有關
C. 最常見之早期合併症為氣切管阻塞或滑脫
D. 最常見之晚期合併症為氣管肉芽組織增生
出處：P. 919【TECHNIQUE】這個段落以及P.920 – 921小兒氣切的圖解
30. 治療單側聲帶麻痺的手術有很多種，但其治療目的主要不在恢復患者之何種功能?
A. 聲門之閉合(glottal closure)
B. 聲帶張力之對稱(Symmetric stiffness)
C. 聲帶垂直位置之平衡(Equal vertical position)
D. 聲帶運動性(vocal movement)
出處：P. 614 – 616
P. 616 HIGHLIGHTS的第6點
31. We often keep stay (traction) sutures placed lateral to the tracheal incision at the final step of pediatric tracheostomy.
A. easier access for cleaning the wound
B. easier replacement of a displaced tube
C. a way to anchor the tracheostomy tube
D. a way to secure a ventilator hose to the tube
出處：P. 919的第19 – 22行
32. Which of the following is the best indicator to define the anatomic level of airway obstruction?
A. blood gas level
B. respiratory rate
C. posturing
D. respiratory phase during which stridor occurs
出處：P. 895【Stridor】這個段落的第3 – 12 行
33. Which of the following procedure should be done immediately after the removal of a bronchial foreign body from a young child?
A. obtain an immediate postoperative chest radiograph
B. perform a repeat bronchoscopy for a possible second foreign body
C. start systemic corticosteroid
D. obtain cultures of the foreign body and begin antibiotic therapy
出處：P. 930的第3 - 9行
17. 一次小兒急性中耳炎發作，約有幾% 在3個月後仍有中耳腔積液？
A. 10 %
B. 20 %
C. 30 %
D. 40 %
出處：P. 1079 在HIGHLIGHTS 的第4點
18. 相較於一般室內氣體，有關中耳腔氣體成份之敘述，下列何者正確？
A. O2濃度較低
B. CO2濃度較低
C. N2濃度較低
D. O2， CO2， N2三者濃度皆較低
出處：很抱歉，目前仍找不到出處；如果找到出處的話會再mail給大家 sorry！！
19. 垂直局部喉切除(vertical partial laryngectomy)之適應症，何者不正確:
A. 腫瘤局限於單側聲帶，但前聯合及arytenoid body不可有侵犯
B. 腫瘤於下聲門之侵犯少於5 mm
C. 聲帶仍可移動 (mobile)
D. 局部復發性而非第二原發癌
出處：P. 1473【Open Partial Laryngectomy】這個段落的第19 - 22行
另外 contraindications 則參考第22 – 26 行
Indications for VPL and laryngoplasty are tumor involvement of the anterior commissure, externsion to involve the vocal process of the arytenoid, selected superficial transglottic lesions, and carcinoma recurring after radiation therapy. The contraindications for any of these procedures include a fixed vocal cord, involvement of the posterior commissure, invasion of both arytenoid cartilages, bulky transglottic lesions, and lesions invading the thyroid cartilage.
20. 聲帶結節及息肉，其病理變化最常見發生於:
A. covering epithelium of the vocal fold
B. superficial layer of the lamina propria
C. intermediate layer of the lamina propria
D. deep layer of the lamina propria
出處：P. 617【POLYPS】這個段落的第8 - 11行 arising in the subepithelial layer of
loose connective tissue, commonly referred to as the Reinke space
21. Reinke’s edema 之病人除有抽菸習慣外，也可能有下列狀態:
A. vocal hyperfunction
B. laryngopharyngeal reflux
C. hypothyroidism
D. all of above
出處：P. 617最後2行一直到P.618的第一段結束
22. 有關小兒鼻竇炎之併發症，下列何者為非？
A. 眼窩蜂窩性組織炎及膿瘍造成的視力損失，部分是因為視神經遭壓迫，部分是因為視神經炎
B. 腦膿瘍 (brain abscess)是最常見的顱內併發症
C. 鼻竇的感染最常經由小靜脈擴散至眼窩
D. 眼窩蜂窩性組織炎及膿瘍使用靜脈注射抗生素治療時，要注意抗生素是否能通過血-腦障壁 (blood-brain barrier)，以避免顱內併發症
出處：P. 956【Orbital Complications】這個段落的第6 - 9行
Infections from the sinuses can spread to the orbit through the arteries, veins, or rarely lymphatics but more often by direct extension through a dehiscence in the lamina papyracea.
23. 下列何者為非?
A. 急性鼻竇炎，大人和小孩最常見的致病菌類似，為Streptococcus pneumonia, Haemophilus influenzae, 和Moraxella catarrhalis
B. 慢性鼻竇炎大人常見培養出厭氧菌，小孩則很罕見
C. 平均來說，急性鼻竇炎的症狀要來得比慢性鼻竇炎嚴重
D. 鼻竇炎的抗生素治療通常至少需要十天，而常常到三個星期甚至更多
出處：P. 352【MICROBIOLOGY OF RHINOSINUSITIS】的倒數第14行 chronically
infected sinuses in both adults and children usually grow anaerobic bacteria
24. 下列關於鼻竇手術的併發症，何者為非?
A. 暫時性失明 (Blindness) 可能由眼框血腫(orbital hematoma)引起
B. 如果傷及前篩動脈，前篩動脈縮回眼球內並引起眼窩快速血腫，減壓措施必須要在15至30分鐘內執行，以避免失明的危險
C. 由於上頷竇天然開口只距離鼻淚管3至6mm，所以我們在擴大上頷竇竇口時，不得擴大至中鼻甲前緣之前
D. 依定義, 眼框血腫(orbital hematoma)是由眼臉膈前傷害 (preseptal injury)所引起
出處：P. 407 【Orbital Hematoma】這個段落的第6行 orbital hematoma is by definition
a postseptal injury
25. 下列何者為非？
A. 高腳杯細胞 (goblet cells)的密度在上頷竇的密度最高
B. 關於黏液纖毛運輸 (mucociliary transport)，在上頷竇為由底部往竇口運輸，在額竇則由外側壁到頂部，再由頂部到內側壁再至洞口
C. Onodi cell是後篩竇泡延伸，據統計比例為9~12%
D. 側板 (lateral lamella)是篩板 (cribrifrom plate)外側的構造，其長度取決於篩板和篩竇小窩 (fovea ethmoidalis) 的距離
出處：P. 327 見左下的figure 28.5
26. 下列有關於猩紅熱（Scarlet fever）的敘述，何者為非?
A. 屬於急性葡萄球菌咽扁桃腺炎（Acute staphylococcal pharyngotonsillitis）
B. 常伴隨著全身性的紅疹，由軀幹往四肢分佈
C. 理學檢查可見草莓舌（Strawberry tongue）
D. 可以做細菌培養來加以鑑定
出處：P. 546 第3段 Scarlet fever is an acute streptoccocal pharyngotonsillitis
27. 為確定單側聲帶麻痺之神經受傷位置，喉肌電圖檢查應至少檢查那兩條喉內肌?
甲、杓間肌 (2) 甲杓肌 (3) 環甲肌 (4) 環杓肌
A. (1), (2)
B. (2), (3)
C. (2), (4)
D. (1), (4)
出處：P. 610 第一段的第4 – 6行
Because the thyroarytenoid and cricothyroid are easiest to access using an EMG needle, they are the primary muscles studied. Information about recurrent and external braches of superior laryngeal nerve function can be obtained by testing these two muscles.
28. 關於阻塞型睡眠呼吸中止症侯群(obstructive sleep apnea syndrome)之敘述，何者為非?
A. 成年人之睡眠呼吸干擾系數(respiratory disturbance index)大於5者為異常
B. 打鼾及白天嗜睡為最常見之臨床表現
C. 多項睡眠生理檢查(Polysomnography )為最重要之診斷工具
D. 外科手術是第一線也是首先必須嘗試的治療方式
出處：P. 588
29. 有關小兒氣切之敍述何者為非？
A. 通常必須切除部份氣管前壁以便置入氣切管
B. 氣切管直徑和病人年齡及發育有關
C. 最常見之早期合併症為氣切管阻塞或滑脫
D. 最常見之晚期合併症為氣管肉芽組織增生
出處：P. 919【TECHNIQUE】這個段落以及P.920 – 921小兒氣切的圖解
30. 治療單側聲帶麻痺的手術有很多種，但其治療目的主要不在恢復患者之何種功能?
A. 聲門之閉合(glottal closure)
B. 聲帶張力之對稱(Symmetric stiffness)
C. 聲帶垂直位置之平衡(Equal vertical position)
D. 聲帶運動性(vocal movement)
出處：P. 614 – 616
P. 616 HIGHLIGHTS的第6點
31. We often keep stay (traction) sutures placed lateral to the tracheal incision at the final step of pediatric tracheostomy.
A. easier access for cleaning the wound
B. easier replacement of a displaced tube
C. a way to anchor the tracheostomy tube
D. a way to secure a ventilator hose to the tube
出處：P. 919的第19 – 22行
32. Which of the following is the best indicator to define the anatomic level of airway obstruction?
A. blood gas level
B. respiratory rate
C. posturing
D. respiratory phase during which stridor occurs
出處：P. 895【Stridor】這個段落的第3 – 12 行
33. Which of the following procedure should be done immediately after the removal of a bronchial foreign body from a young child?
A. obtain an immediate postoperative chest radiograph
B. perform a repeat bronchoscopy for a possible second foreign body
C. start systemic corticosteroid
D. obtain cultures of the foreign body and begin antibiotic therapy
出處：P. 930的第3 - 9行
94年 ENT 考題1~16 秀傳 潘明勳
1. 臨床上，一些聽力學檢查現象，可以有助於耳蝸性及耳蝸後聽障之鑑別，下列那些具此特性?
ABR之第四波，波間潛時延長
OAE的消失
蹬骨肌反射(Acoustic reflex)之異常消失
語言測試的rollover現象
(A) 1, 3, 4 (B) 2, 3 (C) 3, 4 (D) 1, 4
ans: C
**Common ABR waveform patterns .(書上只強調一，三，五波) A well-formed and clear wave I at a delayed latency value for the maximum stimulus intensity level is characteristic of a conductive or mixed hearing loss. When wave I is small and poorly formed, but interwave latency values are within normal limits (the wave I–V latency value is less than 4.60 milliseconds), a high-frequency sensory (cochlear) hearing loss is suspected. Delayed interwave latency values are the signature of retrocochlear auditory dysfunction. Abnormal delays between the early wave components (e.g., I–III) are consistent with posterior fossa lesions involving the eighth nerve and/or lower brainstem, whereas a prolonged III–V latency suggests intraaxial auditory brainstem dysfunction. (p1664)
…wave IV 較無臨床上的價值
** . Clinical applications reported for otoacoustic emissions (p1668)
--Diagnostic audiologic assessment in difficult-to-test, neurologically impaired, developmentally delayed, or multiply-involved children.
--Newborn and infant hearing screening
--Monitoring hearing status during medical therapy with potentially ototoxic drugs
--Verification of normal cochlear function in patients undergoing central auditory processing assessment
--Neurodiagnosis of auditory dysfunction in adults (e.g., differentiation of sensory versus neural dysfunction)
--Verification of hearing status in patients suspected of malingering (pseudohypacusis or nonorganic hearing loss)
--Early detection and confirmation of noise/music induced cochlear hearing loss.
….由此看來 OAE也可助於cochlear vs retrocochlear的判別 ，不過題旨似乎在於retrocochlear lesion 的診斷，故未入選.
**Acoustic reflex If a reflex is present, reflex decay can be measured by presenting the signal 10 dB above the reflex threshold for 10 seconds. If the contraction of the stapedial muscle cannot be maintained for at least half strength for the 10 seconds, the result of the test is a positive retrocochlear finding. Significantly increased or absent thresholds (in comparison with cochlear norms) or decay (or both) has a sensitivity of about 85% for detecting retrocochlear problems (p1902)
**rollover A decrease in speech recognition performance (in percent correct) at high signal intensity levels versus lower levels. Rollover is an audiometric sign of retrocochlear auditory dysfunction. (p1671;1902)
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2. 一位四十幾歲女性，主訴單耳聽電話不清楚，先予以純音聽力及聽阻聽力檢查，試問下列那些狀況，仍需予以施行ABR以排除聽神經瘤。
高頻率聽損(high tone loss)
純音聽力檢查正常(Normal PTA threshold)
蹬骨肌反射閥值異常升高(ART threshold elevation)
(A) 1, 2, 3 (B) 1, 2 (C) 2, 3 (D) 1, 3
ans: A
**On pure-tone air and bone conduction testing, the patient who has a vestibular schwannoma typically has a sensorineural hearing loss unless there is also a middle-ear problem, in which case a mixed loss is present. Although any hearing loss configuration may be observed, a high-frequency sensorineural hearing loss is the most common pattern (65%), and it may be either a gradual slope or an abrupt configuration37. It is important to know that 5% of patients have normal hearing (p1902)
**Significantly increased or absent thresholds (in comparison with cochlear norms) or decay (or both) has a sensitivity of about 85% for detecting retrocochlear problems (p1902)
----------------------------------------------------------------------------------------------------------------------
3. 一位母親帶一位四歲幼兒至門診，主訴其四歲兒童聽力有問題，請問下列處置何者正確?
(A) 告之5-6歲時再來，因為屆時配合度高，做聽力檢查較準
(B) 予以做耳聲傳射檢查，若為正常，便予以告之聽力正常
(C) 予以安排純音聽力檢查
(D) 予以藥物令幼兒睡著，再施予精密ABR檢查(Click刺激音)，若為正常，即囑咐家長安心
ans:c
The ABR can provide a threshold estimate of hearing in the 1,000–4,000 Hz range in young or difficult to test children. With the use of a 500 Hz tone burst stimulus, low-frequency hearing sensitivity can also be estimated. (p1099)
…..click sti. :只能大約反映 1-4kHz 的聽力
OAE:Results are interpreted in terms of the presence of cochlear function in a defined frequency region as opposed to estimating actual sensitivity thresholds.(p1099)
By a developmental age of 5 years, standard adult testing techniques can be used in audiometric assessment; however, the audiologist remains flexible in implementing and reverting to any of the behavioral pediatric test techniques. .(p1099)
....臨床上四歲也可試著作PTA
-------------------------------------------------------------------------------------------------------------
4. 雙耳聽障患者，如能兩耳配戴助聽器，較之單耳配戴的優點好處，下列何者錯誤，
(A) 抵消頭遮蔽效用(Head shadow effect)，使高頻率聲音更高易聽清楚
(B) 聲音方向感較佳(Sound localization)
(C) 聲音響度不會有加成效果，但使得低音較清晰
(D) 增加在噪音環境下之語言辨識 (S/N )
ans:c
improved hearing with two hearing aids in noise conditions relates to the phase differences of the signal and noise occurring between the two ears. Another advantage to a second hearing aid is improved sound localization because the microphone is placed close to each ear. Binaural amplification also eliminates the head shadow effects, which reduce the high-frequency cues necessary for hearing many consonants. Furthermore, the use of a second hearing aid results in an increase in the loudness of the sound due to binaural summation31. (p1968)
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5. 耳聲傳射(OAEs)，在幼童之聽力學應用，下列何者錯誤?
(A) 新生兒聽力篩檢
(B) 無法客觀地評估聽力閥值
(C) 難以鑑別功能性聽障(functional hearing loss)
(D) 耳毒性藥物之監測
ans:C
** TABLE 132-2. Clinical applications reported for otoacoustic emissions (p1668)
--Diagnostic audiologic assessment in difficult-to-test, neurologically impaired, developmentally delayed, or multiply-involved children.
--Newborn and infant hearing screening
--Monitoring hearing status during medical therapy with potentially ototoxic drugs
--Verification of normal cochlear function in patients undergoing central auditory processing assessment
--Neurodiagnosis of auditory dysfunction in adults (e.g., differentiation of sensory versus neural dysfunction)
--Verification of hearing status in patients suspected of malingering (pseudohypacusis or nonorganic hearing loss)
--Early detection and confirmation of noise/music induced cochlear hearing loss.
---------------------------------------------------------------------------------
6. 有關於膽脂瘤之併發症—內耳瘻管(labyrinth fistula)，下列何者錯誤?
(A) 其發生比率約為10%
(B) 噪音可能使病患感到眩暈
(C) 施行外耳加壓之fistula test，病人一定會感眩暈，且有眼振
(D) 水平半規管之瘻管最為常見
ans:c
A labyrinthine fistula may be found in up to 10% of patients with long-standing cholesteatoma or in revision cases. Suspect a fistula in patients with chronic ear disease who have sensorineural hearing loss and/or vertigo induced by noise or pressure changes in the middle ear. Suppurative labyrinthitis with complete hearing loss and vestibular function may occur secondary to a fistula from a cholesteatoma. High-resolution, thin-section CT of the temporal bone may reveal a fistula of the semicircular canals or the basal turn of the cochlea. Fistulae of the horizontal semicircular canal are most common13. A positive fistula test with manipulation of the external canal may be present, although its absence does not preclude a fistula. (p1795)
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7. 有關耳聲傳射(OAEs)，下列何者正確?
(A) DPOAE之刺激音為Click
(B)TEOAE之刺激音為兩個純音F1, F2
(C)DPOAE之產生地點是介於F1, F2之間，且靠近F2處
(D)TEOAE具有頻率專一性，DPOAE則否
ANS:C
--Distortion-product otoacoustic emissions (DPOAEs) are produced when two pure-tone stimuli at frequencies f1 and f2 are presented to the ear simultaneously The most robust DPOAE occurs at the frequency determined by the equation 2f1-f2, whereas the actual cochlear frequency region that is assessed with DPOAE is between these two frequencies and probably close to the f2 stimulus for recommended test protocols2,17..
--Transiently evoked otoacoustic emissions (TEOAEs) are elicited by brief acoustic stimuli such as clicks or tone bursts. (P1668)
----------------------------------------------------------------------------------------------------------------------
8. 以下均是unilateral loss of peripheral vestibular function的sign，何者正確?
1. 自發性眼震，slow phase向lesion side
2. head motion時有visual disturbance (blurred vision或 disequilibrium)
3. vestibulospinal activity (past-pointing, Romberg sign) 之改變
4. Sensation of falling向lesion side
(A) 1, 2 (B) 1, 3, 4 (C) 2, 4
(D) 1, 2, 3
ANS:B
Sudden-onset Unilateral Disorders
A lesion involving one labyrinth reduces the action potentials going to the central nervous system from the affected labyrinth, resulting in a reduction of activity in the ipsilateral vestibular nucleus and a reduction in the tonic activity of oculomotor nerves that produce contralateral eye movements. If the right labyrinth is affected, slow eye movements to the right (fast-phase nystagmus to the left) and a sensation of falling to the right (P1973)
With severe loss of bilateral vestibular function, the vestibulo-ocular reflex stops working and patients experience severe visual disturbances with head movements. This condition, called oscillopsia, refers to an oscillating environment during head movements. Due to lack of vestibulo-ocular reflexes, head movements cause the visual field to slip across the retina, resulting in an inability to track visually during rapid head movements, particularly when head velocities exceed the limits of the smooth pursuit and optokinetic systems (30 to 50 degrees per second). (P1974)
----------------------------------------------------------------------------------------------------------------------
9. 對於sinus tympani中的膽脂瘤，以下那些手術法比較可以完全清除乾淨?
a. Facial recess approach
b. Intact canal wall procedure
c. Canal-wall down procedure
d. Bondy procedure
e. Oto-endoscopy
(A) a, c, d (B) a, c, e (C) c, e
(D) c, d, e
ANS:B
**Sinus tympani retraction cholesteatoma is perhaps technically the most difficult case for surgery because it involves working in an area that is usually not visualized. It is a fallacy that these cases must undergo a radical mastoidectomy for removal of disease.
With diligent dissection and use of Crabtree elevators (Storz Instrument Company, St. Louis) and the facial recess approach, disease can be removed
**there are several disadvantages of the intact canal wall approach. This approach results in an increased risk of residual and recurrent disease. Widely varying results using a canal-wall-up mastoidectomy have been reported in the literature; most larger series reveal residual cholesteatoma in 20% to 35% of cases and recurrent disease in 5% to 20%11–19. These results can be contrasted to those reported for open procedures with or without obliteration in which there is a 2% to 17% rate of residual disease and a 0% to 10% rate of recurrent disease11–13,18–21. The most common site for residual disease is the mesotympanum17. Another potential problem with the intact canal wall procedure is delayed breakdown of the posterior canal wall due to compromise of its blood supply. Other disadvantages of the intact canal wall approach are that residual disease behind the intact posterior canal may not be visible in the postoperative follow-up period, and there may be increased likelihood of leaving cholesteatoma in the lateral portion of the facial recess
The Bondy procedure34, is a variation of the modified radical mastoidectomy; this procedure is used in cases of large attic cholesteatomas. The posterior ear canal wall is removed down to the annulus superiorly and the facial ridge inferiorly. As in the modified radical mastoidectomy, the floor of the ear canal is level with the floor of the mastoid cavity. The scutum is removed, exposing the epitympanum. The cholesteatoma is marsupialized and the keratin content debrided. The medial wall of the cholesteatoma matrix is left in place over the body of the incus and malleus and seals the middle ear space. If the cholesteatoma is seen extending around the ossicles, the surgeon must be prepared to perform a standard modified radical mastoidectomy. In the Bondy procedure, the middle ear is not entered. This operation is reserved for those ears in which a large, primary acquired cholesteatoma is present but hearing is preserved and the ossicular chain and middle ear are free of disease.
**oto-endoscopy: 下面是我在網上找到的資料
DIA
可經由耳膜破洞伸進中耳腔探察以發現殘留的病灶，嚴格來說並不是一種手術，不過重點在於要能看的見才能處理吧
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10. 下列何種藥物所引起的ototoxicity，不是導因於內耳毛細胞的破壞？
(A) Neomycin
(B) Cisplatin
(C) Furosemide
(D) Aspirin
ANS:C
A) Neomycinàdamage to outer hair cells and vestibular receptors.
(B) Cisplatinà toouter hair cell damage，cell loss，degeneration of the stria vascularis and the spiral ganglion cells.
(C) Furosemideà injury to stria vascularis (potassium transport)
(D) Aspirin à maybe related to decreaed cochlear blood flow or alteration of outer hair cell function. (p1894-1896)
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11. 治療moderate stage的耳廓軟骨膜炎 (auricular perichondritis) 使用下列何種的抗生素組合最合理?
(A) Augmentin 口服加steroid耳滴劑
(B) Cleocin 口服加tarivid耳滴劑
(C) Minocin 口服加sulfadrug耳滴劑
(D) Ciproxin 口服加gentamicin耳滴劑
ANS:D
Recall the usual infecting gram-positive and gram-negative flora mentioned previously, and cover for them. In addition to anti-Pseudomonas ear drops, common choices of oral antibiotics are antistaphylococcal penicillins, first-generation cephalosporins, or one of the antipseudomonal fluoroquinolones such as ciprofloxacin. The last is an oral antibiotic effective against Pseudomonas species (p1717)
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12. 小耳症(microtia)是外耳(有時包括中耳)的發育異常。發育中止的時間，決定了最後外耳及中耳的形態。以下的外耳及中耳構造中，那一部份最晚發育成熟?
(A) auricle
(B) ear canal, lateral part
(C) ear canal, medial part
(D) middle ear
ANS:B
The deep portion of the EAC is apparent from the eighth week as a strand of epithelial cells running down to the disc-shaped precursor of the tympanic membrane3. At around 28 weeks, this epithelial core has canalized from medial to lateral to allow communication to the tympanic membrane. The epithelial core is the precursor of the bony EAC. (p1611)
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13. 下列特徵那些屬於central lesion之Nystagmus, 選出最適當的項目?
Vertical, horizontal 或torsional nystagmus
associated with nausea
directional clanging nystagmus
minimal suppression with visual fixation
(A) 1, 2 (B) 1, 3 (C) 1, 2, 4
(D) 1, 3, 4
ANS:D
(p1982; table 157.2)
nystagmus of central causes:
directionàvertical ，horizontal or tortional
direction changingàyes
associated nauseaàminimal
suppression with visual fixationàminimal
latencyànonefatigueà none
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14. 一位單側聽障患者，右耳PTA為90dB，左耳為20dB，請問其右耳之monoaural impairment (MI) 及 overall hearing handicap(HH) 各為何?
(A) 85%, 10%
(B) 92%, 50%
(C) 96.5%, 16%
(D) 100%, 75%
ANS:C
1. Hearing loss does not begin to be handicapping until the pure-tone average HTL at 0.5, 1, 2, and 3 kHz exceeds 25 dB.
2. Handicap grows at the rate of 1.5% per decibel of hearing loss beyond 25 dB HL.
3. Because unilateral deafness is only a mild handicap, the two ears should not be equally weighted. Specifically, a 5 to 1 weighting favoring the better ear is used.
The monaural impairment for each ear is first calculated from the four-frequency pure-tone average (PTA):
MI = 1.5 (PTA - 25)
The overall hearing handicap (HH), ranging from 0% to 100%, is then calculated as a weighted average favoring the better ear:
HH = [5 (MIb) + (MIw)]/6
(p1889)
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15. 急性或慢性中耳炎有時會引起顳骨內，甚至顱內的併發症，發生併發症的早期徵象(early sign)要特別小心，以下對併發症早期徵象，那一項是錯誤的?
(A) 急性發炎症狀持續2週以上
(B) 兩至三週內症狀又復發
(C) 慢性發炎中症狀急遽惡化，且伴有惡臭之耳漏
(D) 培養出厭氧菌
Impending complication
Persistence of acute infection for 2 weeks
Recurrence of symptoms within 2 weeks
Acute exacerbation of chronic infection, especially
if fetid
Fetid discharge during treatment
Haemophilus influenzae, type B, or anaerobes
ANS:D---應該也對才是?
----------------------------------------------------------------------------------------------------------------------
16. 當代數位式助聽器採用下列何種訊號處理方式可以有效增加配戴者在嘈雜環境下的訊雜比 (Signal/Noise ratio) ?
(A) 多頻道壓縮(multiple channel compression)
(B) 反饋音消除機制(feed back cancellation)
(C) 方向性麥克風(directional microphone)
(D) 移頻 (frequency transposition)
ANS:C directional microphone improves SNR based on the spatial location of the signal of interest (front hemisphere) (p1693)
ABR之第四波，波間潛時延長
OAE的消失
蹬骨肌反射(Acoustic reflex)之異常消失
語言測試的rollover現象
(A) 1, 3, 4 (B) 2, 3 (C) 3, 4 (D) 1, 4
ans: C
**Common ABR waveform patterns .(書上只強調一，三，五波) A well-formed and clear wave I at a delayed latency value for the maximum stimulus intensity level is characteristic of a conductive or mixed hearing loss. When wave I is small and poorly formed, but interwave latency values are within normal limits (the wave I–V latency value is less than 4.60 milliseconds), a high-frequency sensory (cochlear) hearing loss is suspected. Delayed interwave latency values are the signature of retrocochlear auditory dysfunction. Abnormal delays between the early wave components (e.g., I–III) are consistent with posterior fossa lesions involving the eighth nerve and/or lower brainstem, whereas a prolonged III–V latency suggests intraaxial auditory brainstem dysfunction. (p1664)
…wave IV 較無臨床上的價值
** . Clinical applications reported for otoacoustic emissions (p1668)
--Diagnostic audiologic assessment in difficult-to-test, neurologically impaired, developmentally delayed, or multiply-involved children.
--Newborn and infant hearing screening
--Monitoring hearing status during medical therapy with potentially ototoxic drugs
--Verification of normal cochlear function in patients undergoing central auditory processing assessment
--Neurodiagnosis of auditory dysfunction in adults (e.g., differentiation of sensory versus neural dysfunction)
--Verification of hearing status in patients suspected of malingering (pseudohypacusis or nonorganic hearing loss)
--Early detection and confirmation of noise/music induced cochlear hearing loss.
….由此看來 OAE也可助於cochlear vs retrocochlear的判別 ，不過題旨似乎在於retrocochlear lesion 的診斷，故未入選.
**Acoustic reflex If a reflex is present, reflex decay can be measured by presenting the signal 10 dB above the reflex threshold for 10 seconds. If the contraction of the stapedial muscle cannot be maintained for at least half strength for the 10 seconds, the result of the test is a positive retrocochlear finding. Significantly increased or absent thresholds (in comparison with cochlear norms) or decay (or both) has a sensitivity of about 85% for detecting retrocochlear problems (p1902)
**rollover A decrease in speech recognition performance (in percent correct) at high signal intensity levels versus lower levels. Rollover is an audiometric sign of retrocochlear auditory dysfunction. (p1671;1902)
---------------------------------------------------------------------------------------------------------------------
2. 一位四十幾歲女性，主訴單耳聽電話不清楚，先予以純音聽力及聽阻聽力檢查，試問下列那些狀況，仍需予以施行ABR以排除聽神經瘤。
高頻率聽損(high tone loss)
純音聽力檢查正常(Normal PTA threshold)
蹬骨肌反射閥值異常升高(ART threshold elevation)
(A) 1, 2, 3 (B) 1, 2 (C) 2, 3 (D) 1, 3
ans: A
**On pure-tone air and bone conduction testing, the patient who has a vestibular schwannoma typically has a sensorineural hearing loss unless there is also a middle-ear problem, in which case a mixed loss is present. Although any hearing loss configuration may be observed, a high-frequency sensorineural hearing loss is the most common pattern (65%), and it may be either a gradual slope or an abrupt configuration37. It is important to know that 5% of patients have normal hearing (p1902)
**Significantly increased or absent thresholds (in comparison with cochlear norms) or decay (or both) has a sensitivity of about 85% for detecting retrocochlear problems (p1902)
----------------------------------------------------------------------------------------------------------------------
3. 一位母親帶一位四歲幼兒至門診，主訴其四歲兒童聽力有問題，請問下列處置何者正確?
(A) 告之5-6歲時再來，因為屆時配合度高，做聽力檢查較準
(B) 予以做耳聲傳射檢查，若為正常，便予以告之聽力正常
(C) 予以安排純音聽力檢查
(D) 予以藥物令幼兒睡著，再施予精密ABR檢查(Click刺激音)，若為正常，即囑咐家長安心
ans:c
The ABR can provide a threshold estimate of hearing in the 1,000–4,000 Hz range in young or difficult to test children. With the use of a 500 Hz tone burst stimulus, low-frequency hearing sensitivity can also be estimated. (p1099)
…..click sti. :只能大約反映 1-4kHz 的聽力
OAE:Results are interpreted in terms of the presence of cochlear function in a defined frequency region as opposed to estimating actual sensitivity thresholds.(p1099)
By a developmental age of 5 years, standard adult testing techniques can be used in audiometric assessment; however, the audiologist remains flexible in implementing and reverting to any of the behavioral pediatric test techniques. .(p1099)
....臨床上四歲也可試著作PTA
-------------------------------------------------------------------------------------------------------------
4. 雙耳聽障患者，如能兩耳配戴助聽器，較之單耳配戴的優點好處，下列何者錯誤，
(A) 抵消頭遮蔽效用(Head shadow effect)，使高頻率聲音更高易聽清楚
(B) 聲音方向感較佳(Sound localization)
(C) 聲音響度不會有加成效果，但使得低音較清晰
(D) 增加在噪音環境下之語言辨識 (S/N )
ans:c
improved hearing with two hearing aids in noise conditions relates to the phase differences of the signal and noise occurring between the two ears. Another advantage to a second hearing aid is improved sound localization because the microphone is placed close to each ear. Binaural amplification also eliminates the head shadow effects, which reduce the high-frequency cues necessary for hearing many consonants. Furthermore, the use of a second hearing aid results in an increase in the loudness of the sound due to binaural summation31. (p1968)
-------------------------------------------------------------------------------------------------
5. 耳聲傳射(OAEs)，在幼童之聽力學應用，下列何者錯誤?
(A) 新生兒聽力篩檢
(B) 無法客觀地評估聽力閥值
(C) 難以鑑別功能性聽障(functional hearing loss)
(D) 耳毒性藥物之監測
ans:C
** TABLE 132-2. Clinical applications reported for otoacoustic emissions (p1668)
--Diagnostic audiologic assessment in difficult-to-test, neurologically impaired, developmentally delayed, or multiply-involved children.
--Newborn and infant hearing screening
--Monitoring hearing status during medical therapy with potentially ototoxic drugs
--Verification of normal cochlear function in patients undergoing central auditory processing assessment
--Neurodiagnosis of auditory dysfunction in adults (e.g., differentiation of sensory versus neural dysfunction)
--Verification of hearing status in patients suspected of malingering (pseudohypacusis or nonorganic hearing loss)
--Early detection and confirmation of noise/music induced cochlear hearing loss.
---------------------------------------------------------------------------------
6. 有關於膽脂瘤之併發症—內耳瘻管(labyrinth fistula)，下列何者錯誤?
(A) 其發生比率約為10%
(B) 噪音可能使病患感到眩暈
(C) 施行外耳加壓之fistula test，病人一定會感眩暈，且有眼振
(D) 水平半規管之瘻管最為常見
ans:c
A labyrinthine fistula may be found in up to 10% of patients with long-standing cholesteatoma or in revision cases. Suspect a fistula in patients with chronic ear disease who have sensorineural hearing loss and/or vertigo induced by noise or pressure changes in the middle ear. Suppurative labyrinthitis with complete hearing loss and vestibular function may occur secondary to a fistula from a cholesteatoma. High-resolution, thin-section CT of the temporal bone may reveal a fistula of the semicircular canals or the basal turn of the cochlea. Fistulae of the horizontal semicircular canal are most common13. A positive fistula test with manipulation of the external canal may be present, although its absence does not preclude a fistula. (p1795)
----------------------------------------------------------------------------------------------------------------------
7. 有關耳聲傳射(OAEs)，下列何者正確?
(A) DPOAE之刺激音為Click
(B)TEOAE之刺激音為兩個純音F1, F2
(C)DPOAE之產生地點是介於F1, F2之間，且靠近F2處
(D)TEOAE具有頻率專一性，DPOAE則否
ANS:C
--Distortion-product otoacoustic emissions (DPOAEs) are produced when two pure-tone stimuli at frequencies f1 and f2 are presented to the ear simultaneously The most robust DPOAE occurs at the frequency determined by the equation 2f1-f2, whereas the actual cochlear frequency region that is assessed with DPOAE is between these two frequencies and probably close to the f2 stimulus for recommended test protocols2,17..
--Transiently evoked otoacoustic emissions (TEOAEs) are elicited by brief acoustic stimuli such as clicks or tone bursts. (P1668)
----------------------------------------------------------------------------------------------------------------------
8. 以下均是unilateral loss of peripheral vestibular function的sign，何者正確?
1. 自發性眼震，slow phase向lesion side
2. head motion時有visual disturbance (blurred vision或 disequilibrium)
3. vestibulospinal activity (past-pointing, Romberg sign) 之改變
4. Sensation of falling向lesion side
(A) 1, 2 (B) 1, 3, 4 (C) 2, 4
(D) 1, 2, 3
ANS:B
Sudden-onset Unilateral Disorders
A lesion involving one labyrinth reduces the action potentials going to the central nervous system from the affected labyrinth, resulting in a reduction of activity in the ipsilateral vestibular nucleus and a reduction in the tonic activity of oculomotor nerves that produce contralateral eye movements. If the right labyrinth is affected, slow eye movements to the right (fast-phase nystagmus to the left) and a sensation of falling to the right (P1973)
With severe loss of bilateral vestibular function, the vestibulo-ocular reflex stops working and patients experience severe visual disturbances with head movements. This condition, called oscillopsia, refers to an oscillating environment during head movements. Due to lack of vestibulo-ocular reflexes, head movements cause the visual field to slip across the retina, resulting in an inability to track visually during rapid head movements, particularly when head velocities exceed the limits of the smooth pursuit and optokinetic systems (30 to 50 degrees per second). (P1974)
----------------------------------------------------------------------------------------------------------------------
9. 對於sinus tympani中的膽脂瘤，以下那些手術法比較可以完全清除乾淨?
a. Facial recess approach
b. Intact canal wall procedure
c. Canal-wall down procedure
d. Bondy procedure
e. Oto-endoscopy
(A) a, c, d (B) a, c, e (C) c, e
(D) c, d, e
ANS:B
**Sinus tympani retraction cholesteatoma is perhaps technically the most difficult case for surgery because it involves working in an area that is usually not visualized. It is a fallacy that these cases must undergo a radical mastoidectomy for removal of disease.
With diligent dissection and use of Crabtree elevators (Storz Instrument Company, St. Louis) and the facial recess approach, disease can be removed
**there are several disadvantages of the intact canal wall approach. This approach results in an increased risk of residual and recurrent disease. Widely varying results using a canal-wall-up mastoidectomy have been reported in the literature; most larger series reveal residual cholesteatoma in 20% to 35% of cases and recurrent disease in 5% to 20%11–19. These results can be contrasted to those reported for open procedures with or without obliteration in which there is a 2% to 17% rate of residual disease and a 0% to 10% rate of recurrent disease11–13,18–21. The most common site for residual disease is the mesotympanum17. Another potential problem with the intact canal wall procedure is delayed breakdown of the posterior canal wall due to compromise of its blood supply. Other disadvantages of the intact canal wall approach are that residual disease behind the intact posterior canal may not be visible in the postoperative follow-up period, and there may be increased likelihood of leaving cholesteatoma in the lateral portion of the facial recess
The Bondy procedure34, is a variation of the modified radical mastoidectomy; this procedure is used in cases of large attic cholesteatomas. The posterior ear canal wall is removed down to the annulus superiorly and the facial ridge inferiorly. As in the modified radical mastoidectomy, the floor of the ear canal is level with the floor of the mastoid cavity. The scutum is removed, exposing the epitympanum. The cholesteatoma is marsupialized and the keratin content debrided. The medial wall of the cholesteatoma matrix is left in place over the body of the incus and malleus and seals the middle ear space. If the cholesteatoma is seen extending around the ossicles, the surgeon must be prepared to perform a standard modified radical mastoidectomy. In the Bondy procedure, the middle ear is not entered. This operation is reserved for those ears in which a large, primary acquired cholesteatoma is present but hearing is preserved and the ossicular chain and middle ear are free of disease.
**oto-endoscopy: 下面是我在網上找到的資料
DIA
可經由耳膜破洞伸進中耳腔探察以發現殘留的病灶，嚴格來說並不是一種手術，不過重點在於要能看的見才能處理吧
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10. 下列何種藥物所引起的ototoxicity，不是導因於內耳毛細胞的破壞？
(A) Neomycin
(B) Cisplatin
(C) Furosemide
(D) Aspirin
ANS:C
A) Neomycinàdamage to outer hair cells and vestibular receptors.
(B) Cisplatinà toouter hair cell damage，cell loss，degeneration of the stria vascularis and the spiral ganglion cells.
(C) Furosemideà injury to stria vascularis (potassium transport)
(D) Aspirin à maybe related to decreaed cochlear blood flow or alteration of outer hair cell function. (p1894-1896)
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11. 治療moderate stage的耳廓軟骨膜炎 (auricular perichondritis) 使用下列何種的抗生素組合最合理?
(A) Augmentin 口服加steroid耳滴劑
(B) Cleocin 口服加tarivid耳滴劑
(C) Minocin 口服加sulfadrug耳滴劑
(D) Ciproxin 口服加gentamicin耳滴劑
ANS:D
Recall the usual infecting gram-positive and gram-negative flora mentioned previously, and cover for them. In addition to anti-Pseudomonas ear drops, common choices of oral antibiotics are antistaphylococcal penicillins, first-generation cephalosporins, or one of the antipseudomonal fluoroquinolones such as ciprofloxacin. The last is an oral antibiotic effective against Pseudomonas species (p1717)
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12. 小耳症(microtia)是外耳(有時包括中耳)的發育異常。發育中止的時間，決定了最後外耳及中耳的形態。以下的外耳及中耳構造中，那一部份最晚發育成熟?
(A) auricle
(B) ear canal, lateral part
(C) ear canal, medial part
(D) middle ear
ANS:B
The deep portion of the EAC is apparent from the eighth week as a strand of epithelial cells running down to the disc-shaped precursor of the tympanic membrane3. At around 28 weeks, this epithelial core has canalized from medial to lateral to allow communication to the tympanic membrane. The epithelial core is the precursor of the bony EAC. (p1611)
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13. 下列特徵那些屬於central lesion之Nystagmus, 選出最適當的項目?
Vertical, horizontal 或torsional nystagmus
associated with nausea
directional clanging nystagmus
minimal suppression with visual fixation
(A) 1, 2 (B) 1, 3 (C) 1, 2, 4
(D) 1, 3, 4
ANS:D
(p1982; table 157.2)
nystagmus of central causes:
directionàvertical ，horizontal or tortional
direction changingàyes
associated nauseaàminimal
suppression with visual fixationàminimal
latencyànonefatigueà none
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14. 一位單側聽障患者，右耳PTA為90dB，左耳為20dB，請問其右耳之monoaural impairment (MI) 及 overall hearing handicap(HH) 各為何?
(A) 85%, 10%
(B) 92%, 50%
(C) 96.5%, 16%
(D) 100%, 75%
ANS:C
1. Hearing loss does not begin to be handicapping until the pure-tone average HTL at 0.5, 1, 2, and 3 kHz exceeds 25 dB.
2. Handicap grows at the rate of 1.5% per decibel of hearing loss beyond 25 dB HL.
3. Because unilateral deafness is only a mild handicap, the two ears should not be equally weighted. Specifically, a 5 to 1 weighting favoring the better ear is used.
The monaural impairment for each ear is first calculated from the four-frequency pure-tone average (PTA):
MI = 1.5 (PTA - 25)
The overall hearing handicap (HH), ranging from 0% to 100%, is then calculated as a weighted average favoring the better ear:
HH = [5 (MIb) + (MIw)]/6
(p1889)
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15. 急性或慢性中耳炎有時會引起顳骨內，甚至顱內的併發症，發生併發症的早期徵象(early sign)要特別小心，以下對併發症早期徵象，那一項是錯誤的?
(A) 急性發炎症狀持續2週以上
(B) 兩至三週內症狀又復發
(C) 慢性發炎中症狀急遽惡化，且伴有惡臭之耳漏
(D) 培養出厭氧菌
Impending complication
Persistence of acute infection for 2 weeks
Recurrence of symptoms within 2 weeks
Acute exacerbation of chronic infection, especially
if fetid
Fetid discharge during treatment
Haemophilus influenzae, type B, or anaerobes
ANS:D---應該也對才是?
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16. 當代數位式助聽器採用下列何種訊號處理方式可以有效增加配戴者在嘈雜環境下的訊雜比 (Signal/Noise ratio) ?
(A) 多頻道壓縮(multiple channel compression)
(B) 反饋音消除機制(feed back cancellation)
(C) 方向性麥克風(directional microphone)
(D) 移頻 (frequency transposition)
ANS:C directional microphone improves SNR based on the spatial location of the signal of interest (front hemisphere) (p1693)
94年 ENT 考題84~100
84. 下列那種血管性腫瘤會伴隨染色體異常，需要作細胞遺傳學的檢查?
(A) 血管瘤(hemangioma)
(B) 動靜脈畸型(A-V malformation)
(C) 血管纖維瘤(angiofibroma)
(D) 囊狀水瘤(cystic hygroma)
Ans：D
Generalized Tumors
This category of benign vascular tumors of the head and neck includes diseases such as angiomatosis and cystic hygroma, both of which are closely related to lymphangioma. Cystic hygroma consists of painless nodules covered by normal skin. It is present at birth or appears in early infancy. Cystic hygroma of the posterior triangle of the neck has been associated with hydrops fetalis, Turner syndrome, other congenital malformations, chromosomal aneuploidy, and fetal death. Cytogenic analysis of fetuses born with cystic hygroma is indicated. In cystic hygroma, tumors tend to enlarge gradually and never involute. They have extensive infiltration beyond the apparent boundaries identified initially by the surgeon. For this reason, CT or MRI usually is performed to delineate the boundaries of the lesions (Fig. 125.6). Therapy for cystic hygroma is surgical excision. Complete excision is recommended if possible. If the tumor is intimately associated with vital structures, maximal excision without injury to these structures is recommended, because this is a benign lesion. Incomplete excision can account for recurrences at the margin of the previous excision. Careful follow-up evaluation and periodic MRI can alert the surgeon to early recurrence, which can decrease cosmetic and functional deficits.（P.1565）
85.下列下咽癌的原發腫瘤，何者最易有頸部淋巴結轉移?
(A) T1
(B) T2
(C) T4
(D) 與原發腫瘤之大小無關
Ans：D
Lymph node metastases are associated with hypopharyngeal cancer in about 75% of cases, with bilateral disease present in 10% of patients (Table 118.3). No relationship exists between the size of the primary lesion and the incidence of lymph node metastases. Most metastases are to the jugulodigastric nodes (7). Lesions in the piriform fossa apex and arytenoid may metastasize to the paratracheal, paraesophageal, and jugulo-omohyoid nodes or extend directly into the perilaryngeal compartments (Fig. 118.5) (8,9). Thyroid metastases also may be present. Involvement of the superior retropharyngeal lymph nodes is common, and treatment of the neck, both by radiation therapy and neck dissection, should be directed at these high, medially placed lymph nodes.（P.1447）
86. 口咽部鳞狀細胞癌的組織侵犯，何者不一定是發生於晚期
(A) 血管(blood vessel)侵犯
(B) 脊椎前筋膜(prevertebral fascia)侵犯
(C) 下顎骨膜(mandible periosteum)侵犯
(D) 神經周圍(perinenural)侵犯
Ans：D
NATURAL HISTORY
Prolonged exposure of the upper aerodigestive surfaces to carcinogens results in molecular changes throughout the mucosa. With time, certain areas may undergo further change, giving rise to premalignant and malignant lesions. This concept of “field cancerization” or “condemned mucosa” applies to all mucosal head and neck cancers and results in the high rates of second primaries in patients with oropharyngeal cancer
Squamous cell carcinoma starts on the surface and spreads superficially, deeply, and submucosally. Invasion of vessels, and thick fascia such as the prevertebral fascia or periosteum is uncommon until late stages, but perineural invasion may occur at any time. Bone involvement is also rare, occurring in only 17% of the lesions. Invasion into the parapharyngeal and retropharyngeal spaces allows easy spread to the skull base and neck with possible involvement of the internal carotid artery, cranial nerves IX through XII, and the sympathetic chain. Invasion of the masticator and infratemporal spaces results in trismus and possible involvement of the trigeminal nerve or any of its branches.（P.1429）
87. 下列有關NPC的血清檢測，何種正確?
(A) 以血清學而言，Anti-EBV，VCA，IgA及Anti-EA IgM的檢測最具臨床價值
(B) 若Anti-EBV VCA IgA的力價升高，則這病人約有90%的機會得NPC
(C) 血清學的診斷僅能用以輔助組織學的診斷，而可在NPC病人電療後的追蹤上有幫助
(D) 幾乎所有的NPC病人都可以血清學力價的高低來預測其預後
Ans：C
Laboratory Tests
Serologic testing may help to establish the diagnosis of NPC in the patient with an unknown primary tumor (Table 116.3). In a large series of North American patients, among those with occult and early (stage I) type II or III NPC, 86% had positive EA (immunoglobulin G, IgG) titers and 82% had positive VCA (IgA) titers compared with 18% and 31% in patients with other head and neck squamous cancers (Table 116.2). Epstein-Barr virus titers in patients with type I NPC are not significantly increased above those of control patients. If available, the antibody-dependent cellular cytotoxicity (ADCC) assay, which titrates sera for antibody to the EBV-induced membrane–antigen complex, provides valuable prognostic information (Fig. 116.9) (see later section on Prognosis). No association between ADCC titers and disease progression in type I NPC has been found. Although not cost effective for screening low-risk populations, studies of high-risk Chinese populations indicate that serologic testing for EBV may be a valuable screening tool. In contrast to ADCC titers, the VCA and EA antibody titers have not shown any significance as prognostic indicators. Additional laboratory studies performed at the time of the initial examination are selected to screen for distant metastasis and to assess the patient's general health status. Included in this workup are basic liver function tests and measurement of alkaline phosphatase to screen for liver and bone metastasis.（P.1418）
88. 有關聲門上癌(Supraglottic squamous cell carcinoma)的敘述，那些是正確的?
內視鏡雷射切除術或上喉切除術(supraglottic laryngectomy)可適用於一些早期(T1或T2)病例
聲門上喉部(Supraglottis)及聲門(glottis)源自於相同的胚胎來源
易有雙側頸部淋巴結轉移
接受全喉切除術(total laryngectomy)以防吸入性肺炎是唯一的選擇
(A) 1+2+3 (B) 2+4 (C) 1+3 (D) 3+4
Ans：C
Supraglottic laryngectomy is an accepted treatment for some patients who have primary stage T1, T2, and some T3 (Table. 120B.1) cancers of the supraglottic area. The procedure is founded on solid principles. Some of these principles are the following: (a) the understanding of the lymphatic and mucosal spread patterns of supraglottic cancers, (b) the clinicopathologic studies with whole laryngeal sections, and (c) patient survival and recurrence data. We have learned that cancers of the epiglottis tend to have pushing borders rather than infiltrating ones, which allows for resection with millimeter tumor-free margins. We understand that epiglottic cancers tend to remain supraglottic until late in their progression, when paraglottic spread leads to cordal fixation and upstaging. We have better ways to evaluate the cancer volume and breadth with scans, and we now better appreciate the potential of even early staged cancer of the epiglottis to metastasize to both sides of the neck. Finally, we understand the biologic difference between epiglottic cancer and supraglottic cancer that involves the hypopharynx. This information confirms the operation as predictable and safe in the proper clinical situation.（P.1483）
89. 下列有關人類乳突瘤病毒(Human Papillomavirus, HPV)和頭頸部鱗狀上皮細胞癌(Head and Neck Squamous Cell Carcinoma, HNSCC)的敘述中，何者正確？
(A) 目前證據顯示，約有15~25%的頭頸部鱗狀上皮細胞癌，其發生可能與人類乳突瘤病毒有關，特別是高危險性的HPV type 6
(B) 和HPV相關的頭頸部鱗狀上皮細胞癌(HPV-positive HNSCC)，通常發生在口咽部，尤其是扁桃腺的位置。病患大多較為年輕，亦多有抽煙及喝酒的習慣
(C) HPV-positive HNSCC的特徵是分化較差(poorly differentiated)，且常是advanced stage。然而和NPV-negative HNSCC比較，其治療預後(prognosis)卻較好
(D) 推測HPV可能的致癌機轉可能是HPV的E6蛋白質會和pRb結合，而E7蛋白質會和p53結合，導致細胞週期(cell cycle)的調控出了問題所致
Ans：C
Human Papillomavirus
Human papillomavirus (HPV) has been linked to development of papilloma in the nose and respiratory tract and to carcinogenesis in the genitourinary tract. Known oncogenic types 16, 18, and 31 have been found in squamous cell carcinoma of the tongue, tonsil, larynx, and pharynx. Human papillomavirus DNA was detected in 46% of archival tissue specimens of laryngeal and hypopharyngeal carcinoma, and the presence of this DNA appeared to correlate with a poorer prognosis than among cases in which there was no detectable HPV. Portugal et al. detected HPV (11%) and p53 mutation (66%) within the same specimens of squamous cell carcinoma of the oral cavity and tonsil, which showed that neither p53 gene mutation nor HPV infection serves as a prognosticator of tumor behavior, although survival rates were higher among persons with HPV-infected cancer of the tonsil. Among patients with a history of low alcohol and tobacco use, HPV infection was an independent risk factor for squamous cell carcinoma of the oral cavity and tonsil.
The exact role of HPV in carcinogenesis in the upper aerodigestive tract is unknown. Binding of E6 HPV proteins to the p53 tumor suppressor gene may lead to gene product degradation and unchecked cell proliferation. The E7 HPV protein is known to form complexes with the retinoblastoma tumor suppressor gene product pRB, and this process leads to tumorigenesis (18). No role for the retinoblastoma gene has been found in squamous cell carcinoma of the head and neck. An association of HPV with mutated H-ras oncogene has been suggested in squamous cell carcinoma of the mouth. However, the ras oncogene group is infrequently involved in head and neck cancer.（P.36）
90. 下列有關頭頸部感染，抗生素的一般選用原則的說明，何者正確？
(A) 一般來說，第三代的頭孢子素（cephalosporine）比第一代頭孢子素，對格蘭氏陽性菌的抗菌力強，因此針對第一代頭孢子素無效的金黃色葡萄球菌，宜選用第三代頭孢子素。
(B) 專門對抗Pseudomonas aeruginosa 的penicillin類似物（Anti-pseudomonal penicillins），通常也和其他penicillin一樣，對格蘭氏陽性菌具有好的療效。
(C) Vancomycin對methicillin-resistant的金黃色葡萄球菌以及其他penicillin-resistant肺癌鏈球菌（pneumococci）、腸球菌（enterococci）具有療效，因此宜作為後線藥物。
(D) Clindamycin對呼吸消化道的厭氧菌感染效果不佳。因此在使用Clindamycin治療深頸部感染宜加上metronidazole。
Ans：C
Cephalosporins also belong to the b-lactam family of drugs. This chemical relation probably means that patients with a history of penicillin anaphylaxis should avoid cephalosporins; however, cephalosporins are commonly and safely used by patients with a history of penicillin rashes. These drugs are categorized into first, second, and third generations. In general, first-generation agents are most active against gram-positive bacteria, and third-generation agents are highly active against gram-negative bacteria. Second-generation agents occupy an intermediate position.
Antipseudomonal penicillins are active against most gram-negative bacteria but not gram-positive organisms, such as Staph. aureus. The activity of these agents against P. aeruginosa separates them from most other antibiotics. They are administered parenterally. Ticarcillin is more active than is carbenicillin. Piperacillin is the most active of all drugs in this category. In the management of serious pseudomonal infection, these drugs often are used in combination with an aminoglycoside, such as gentamicin, for a synergistic effect.
Vancomycin (Vancocin, parenteral) is highly active against gram-positive cocci, including methicillin-resistant strains of Staph. aureus, penicillin-resistant strains of pneumococci, enterococci, and gonococci. Because it is unrelated to any other class of antibiotics, vancomycin is useful in the treatment of patients with penicillin allergies. High concentrations in the serum of patients with renal impairment can cause ototoxicity. Vancomycin does not cross the blood-brain barrier effectively, so when resistant pneumococcal infections extend intracranially, vancomycin therapy should be combined with ceftriaxone or trovafloxacin. Because vancomycin may be the last remaining agent still effective against highly resistant strains of staphylococci, pneumococci, and enterococci, this drug should be reserved for such serious infections and not used against bacteria that can be effectively controlled with other antimicrobial agents.
Clindamycin (Cleocin, oral or parenteral) is highly active against gram-positive cocci, including many but not all strains of penicillin-resistant pneumococci. Clindamycin is especially effective in the management of Staph. aureus infection, including infection with many methicillin-resistant strains. It is also highly effective against anaerobic infections of the aerodigestive tract, particularly with B. fragilis, which causes infection deep in the neck and draining ears and causes septic shock. Osteomyelitis is successfully managed with clindamycin because the organism is concentrated in bone. The combination of clindamycin and gentamicin is effective prophylaxis against all the common contaminants of surgical wounds, such as Staph. aureus, P. aeruginosa, and anaerobic organisms.（P.48-9）.
91. 腫瘤細胞會利用各種機制來避開人體免疫系統的攻擊，下列何種不是腫瘤細胞逃過免疫系統攻擊的機制？
(A)分泌各種抑制免疫反應的物質，如IL-10、p15e等。
(B)使血液中CD34+前樹突狀細胞（dendritic cell precusors）無法轉變成CD31+的血管內皮細胞（endothelial cell），而使免疫細胞無法經由新生血管進入腫瘤內。
(C)改變腫瘤細胞本身的抗原性（antigenic modulation），使免疫系統不易辨認。
(D) 降低進入腫瘤內的CD8+細胞（CD8+ cell influx），並改變腫瘤中CD4+細胞的功能。
Ans：B
The mechanisms include tumor production of interleukin-10 (IL-10) and production of a material that interferes with many aspects of immune response, p15e, a retroviral antigen similarity to interferon-alpha (IFN-a). It also appears that tumors may be able to influence differentiation of CD34 cells to CD31+ endothelial cells. Therefore, tumors recruit predendritic cells but pervert the response by changing them into cells, which only contribute to neovascularization of the tumor and inhibit immune potential. Another tumor-associated immunosuppressive product produced by squamous cell carcinoma of the head and neck is prostaglandin E2, which inhibits growth of T cells in a system in which specific tumor-associated lymphocytes are harvested and grown in culture. Prostaglandin E2 influences tumor neovascularization. Experiments with implantation of corneal tumors in rabbits have shown cessation of solid tumors elsewhere than in the head and neck. Neovascularization with cyclooxygenase inhibitors raises the possibility of therapeutic intervention with this class of drugs (21). In an evaluation of immune suppression, Young et al. (20) found a multiplicity of non–mutually exclusive mechanisms of immune suppression that reduced CD8+ cell influx and altered function of intratumor CD4 cells. Other possible mechanisms of tumor immunosuppression are listed in Table 102.1.（P.1214）
92. 下列有關唾液腺惡性腫瘤(malignant salivary gland neoplasms)的敘述，何者錯誤？
(A) 腮腺最常見的癌症是Mucoepidermoid carcinama，而下頷腺及小唾液腺常見的癌症是adenoid cystic carcinoma。
(B) Mucoepidermoid carcinama惡性度的高低是以mucous cells和epidermoid cells的比例來區分；mucous cells比例高者，惡性度也高。
(C) Adenoid cystic carcinoma常有perineural invasion，宜考慮手術切除及追加術後放射線治療。
(D) Acinic cell carcinoma較常發生於女性，並且和warthin’s tumor一樣，有時會有雙側腮腺侵犯的情形。
Ans：B
Mucoepidermoid carcinoma is the most common malignant tumor involving the parotid gland and the second most common malignant tumor of the submandibular gland, after adenoid cystic carcinoma.
Mucoepidermoid carcinomas are usually classified as low-grade or high-grade tumors. The low-grade tumors have a higher ratio of mucous cells to epidermoid cells. Low-grade tumors behave like benign neoplasms but are capable of local invasion and metastasis. High-grade mucoepidermoid carcinomas have a higher proportion of epidermoid cells and may resemble squamous cell carcinoma.
Perineural invasion is a typical feature of adenoid cystic carcinoma seen in most cases of the tumor, which explains the difficulty in tumor eradication despite the extent of surgical excision. Complete surgical excision and postoperative radiation therapy is recommended for the management of this tumor.
Acinic cell carcinoma occurs most commonly in women. This tumor is the second most common salivary gland malignancy in childhood after mucoepidermoid carcinoma. Bilateral involvement occurs about 3% of the time, ranking acinic cell carcinoma second behind Warthin's tumor for frequency of bilateral parotid gland involvement（P.1282-3）
93. 下列有關TxN0的頭頸部鱗狀上皮細胞癌(HNSCC)，針對其occult cervical metastasis的處置，下列敘述何者錯誤？
(A) 一般認為，如果 occult cervical metastasis的機會大於20%，施行elective neck treatment是合理的選擇。
(B) 如果primary tumor是以放射線治療，那麼elective neck irradiation是有效而可以考慮的elective neck treatment方式。
(C) 對於一個T2N0，位在梨狀窩(pyriform sinus)外側壁(lateral wall)的下咽癌而言， lateral neck dissection是合理而可以接受的elective neck treatment。
(D) 對於一個T2N0的maxillary sinus cancer而言，施行同側的lateral neck dissection是合理而可以接受的elective neck treatment。
Ans：D
Decision Analysis
Weiss et al. (16) used a decision tree with a computer model to compare the results in the literature using the three management strategies and suggested that elective treatment should be considered if the probability of occult cervical metastasis was greater than 20%. The relative utility of surgery over radiation became apparent if the probability was greater than 50%.
The decision to treat the N0 neck electively depends on the estimated rate of metastasis, morbidity of treatment, and the probability that END will be more effective than treatment for regional failure during observation. With few exceptions, if the primary site is treated with radiation, the neck is also treated for practical reasons. Therefore, the controversy centers mainly around the need for END when the primary is treated surgically.
The clinical practice guidelines state that bilateral metastasis are common and that there is a risk of retropharyngeal metastasis for pharyngeal wall primaries. Regions II through IV are at risk, and rarely are regions I and V involved in absence of regions II through IV involvement. Region VI is at risk in extensive T3 and T4 pyriform sinus cancer. The guidelines recommend that all patients be treated with END or ENI but are not more specific.
Bilateral SND (regions II through V) is recommended for these patients. However, it is acceptable to perform dissection of levels V and VI at the surgeon's discretion. Patients with tumors involving only the lateral hypopharynx can be treated with unilateral neck dissection if the ipsilateral neck does not have suspicious nodes. Elective region I dissection can be considered optional in hypopharyngeal cancer. As in oropharyngeal cancer, retropharyngeal nodes are at risk (bilaterally for tumors near midline). Radiation therapy should be given postoperatively for most pyriform tumors because of the higher failure rates at the primary site.（P.1370-2）
94. 列有關下咽癌(hypopharyngeal cancer)的敘述，何者錯誤？
(A) 下咽癌最常發生的位置是pyriform sinus，其次是posterior pharyngeal wall，最少見的是postcricoid area。
(B) 大部份下咽癌的患病都是有煙酒習慣的男性。但是有Plummer-Vinson syndrome的女性，卻有較高的機會罹患posterior pharyngeal wall的下咽癌。
(C) 在病理組織檢查方面，下咽癌常見submucosal spread以及skip或satellite lesions。
(D) 位在pyriform apex以及postcricoid area位置的下咽癌容易較容易有paratracheal和paraesophageal淋巴結的轉移。
Ans：B
Most patients who develop hypopharyngeal cancer have been exposed to tobacco and alcohol. Chronic inflammation of the hypopharynx associated with reflux, combined with local and systemic insults from tobacco and alcohol, is also thought to be part of the triggering mechanism for the development of cancer in certain susceptible patients (1). Although men are about eight times more susceptible than women to cancers of the hypopharynx, women with Plummer-Vinson syndrome are a unique group. They have a high incidence of cancer of the postcricoid region.
The lymphatic drainage from this region is directed toward the upper deep cervical lymph nodes (Fig. 118.3). There are, however, channels that extend superiorly from the hypopharynx into the retropharyngeal nodes as high as the nodes of Rouvier. Inferiorly (piriform apex and postcricoid regions), the lymphatics extend laterally to the jugulo-omohyoid nodes and inferiorly to the paratracheal, paraesophageal, and thyroid nodes. In the medial wall of the piriform fossa, there is crossover with the lymphatics of the larynx at the level of the aryepiglottic folds and the arytenoids. Extensive submucosal lymphatics are found in the hypopharynx, particularly in the inferior portions.
Most hypopharyngeal cancers are located in the piriform fossae (Table 118.2) . The next most common location is the posterior hypopharyngeal wall. The postcricoid site is the least common location.
The association of satellite tumors is also a characteristic of cancers in this region. Whether these smaller tumors, or skip areas, are micrometastases or separate primary tumors in areas of condemned mucosa is difficult to determine. The presence of submucosal spread and skip areas is significant because these findings dictate the use of wide surgical margins and/or radiation therapy when treating these malignancies. Adequate superior margins consist of 2 to 3 cm of mucosa from the gross tumor edge. The inferior margin should be 4 to 6 cm from the gross tumor if the tumor involves the cervical esophagus. Therefore, one must carefully consider reconstructive options and prepare to proceed if tumor margins dictate total laryngopharyngectomy with or without esophagectomy.（P.1443-7）
95. 下列有關喉癌(laryngeal cancer)侵犯或轉移過程的敘述，何者錯誤？
(A) 位於 anterior commissure或 infrahyoid epiglottis的喉癌能夠侵入 pre-epiglottic space，然後由 thyroid membrane進入頸部的軟組織。
(B) False cord的infiltrating cancer能夠經由 paraglottic space而侵犯到true vocal cord，並且會伴隨有高比例的subglottic spread。
(C) 一般來說，喉癌如果沒有舌部的侵犯，或是同時有N2以上(包含N2 )的頸部轉移時，並不容易轉移至submental或 submandibular area的淋巴結。
(D) Glottic cancer會首先轉移到 delphian node，然後再到upper jugular , mid-jugular , 和lower jugular node。
Ans：D
PATTERNS OF SPREAD
Anatomic studies confirm the existence of laryngeal spaces or compartments within which cancer can spread more freely and through which cancer may spread out of the larynx. Tumors at first tend to spread by the path of least resistance into these preexisting compartments. The preepiglottic space is bound by the hyoepiglottic ligament superiorly, the thyroid cartilage and the thyrohyoid membrane anteriorly, and the epiglottis and thyroepiglottic ligament posteriorly. Cancer in the anterior commissure or infrahyoid epiglottis may spread to the preepiglottic space, from which it may spread to the soft tissues of the neck by means of the dehiscences in the thyrohyoid membrane created by the superior laryngeal vessels and nerves.
The paraglottic space, lateral to the ventricles, allows the passage of deeply infiltrating cancers from the false cord to the true cord or vice versa. Tumors that pass through this space and are superior and inferior to the ventricle are called transglottic tumors. Invasion of this space is also associated with a high rate of subglottic or extralaryngeal spread of tumor. In a study by Kirchner, 31 of 52 transglottic cancers invaded the laryngeal framework. The proximity of the thyroid cartilage to this space explains this finding (Fig. 121.3, Fig. 121.4 and Fig. 121.5). Tumors at the anterior commissure tend to spread to the anterior subglottis and invade the thyroid cartilage because of the lack of thyroid perichondrium in the region of the anterior commissure tendon. Subglottic tumors frequently invade the laryngeal cartilages (e.g., four of eight in Kirchner's study), often present late in the course of the disease, and are associated with a poor prognosis. Most tumors involving the subglottic region are extensions of large laryngeal cancers rather than primary tumors of the subglottis.
In addition to the spread of these tumors throughout each compartment, it is interesting that the very fibrous membranes responsible for helping to contain the disease also may serve as conduits for tumor invasion. Histologic studies have revealed that cancer cells can grow between the collagen bundles and invade the laryngeal cartilages through the attachment sites of the membranes. The most common sites of cartilage invasion are at the attachments of the strongest membranes: (a) the anterior commissure tendon, (b) the attachments of the cricothyroid membrane to the adjacent cartilage, (c) the anterior portion of the thyroid lamina near the origin of the thyroarytenoid muscle, (d) the posterior border of the thyroid lamina adjacent to the piriform sinus, and (e) the capsule of the cricoarytenoid joint. The perichondrium remains the major barrier to cartilage invasion.
The patterns of lymphatic spread have been described well by Linberg and by Byers et al. for N0 and node-positive disease. For the N0 neck, the lymphatic flow remains as Fisch first described it, unimpeded by a large metastasis. Lymph flow is from the superior portion of the neck toward the clavicle, from posterior to anterior. Only after large metastases appear, as can be found associated with advanced laryngeal tumors, do we find paradoxical lymphatic flow causing unusual sites of lymph node metastases. Nodal metastases are more common in supraglottic cancers than in glottic or subglottic cancers. Also, larger tumor surface area and advanced stage cause increased regional metastases (3). Tumors of the supraglottic larynx spread to the upper and middle jugular first prior to involving the lower jugular level. Glottic tumors metastasize to the delphian or pretracheal node followed by the middle and lower jugular regions. Subglottic tumors spread to the pretracheal, paratracheal, middle, and lower jugular lymph nodes. It is unusual for laryngeal cancers of any site to metastasize to the submandibular and submental regions in the absence of tongue invasion, or in disease advanced beyond the N1 stage. This also holds true for the posterior triangle. These data provide the basis for the preservation of these regions in neck dissections for laryngeal primary tumors with less than N2 disease. The anterior lateral neck dissection therefore remains the standard for these lesions. With advanced neck disease, a more traditional complete lymphadenectomy such as a modified radical or radical neck dissection would therefore be more appropriate.（P.1506-7）
96. 以下關於Laryngeal Papillomatosis的敘述，何者有誤?
(A) 為最常見的喉部良性腫瘤
(B) 大多是從聲帶長出
(C) 最常見的症狀是呼吸道阻塞
(D) Juvenile-onset者較易復發
Ans：C
LARYNGEAL PAPILLOMATOSIS
Recurrent respiratory papillomatosis is a condition that affects mucous membranes of the respiratory tract. It is characterized by multiple and recurrent squamous papillomata, most commonly involving the larynx, but other areas of the upper and lower respiratory tract may be involved, causing hoarseness and some degree of respiratory obstruction, particularly in children.
These lesions are thought to be of viral etiology (2), and are the most common benign laryngeal tumors (3). This condition may develop in all age groups, but is more prevalent in children and less common in individuals over 30 years of age. It is believed that transmission of human papillomavirus (HPV) to the child occurs in the birth canal. Shah and Kashima (4) found only one case of juvenile-onset respiratory papillomas in a child born by cesarean section in their review of 109 cases. The risk of transmission of HPV infection from mother to child was estimated to be in the range of 1:80 to 1:500. Total remission may sometimes take place at puberty; however, this is not always the case.
Papillomatosis of the larynx, the most common site of these tumors, is a serious and difficult problem in the pediatric population. Hoarseness is the most common early symptom, followed by airway obstruction and respiratory difficulty. The vocal folds and the subglottic larynx are the most common laryngeal sites. Nasopharyngeal, subglottic, tracheal, and bronchial papillomas are thought to be due to contamination from glottic and supraglottic lesions. Lower airway contamination is seen commonly after a tracheotomy, which therefore should be avoided if possible. Pulmonary papillomas are rare, but if they are present they can cause severe complications such as hemorrhage and abscess formation (Table 53.1). Laryngeal papillomas presenting in adults seem to be less aggressive than the juvenile form, but the remission rate is unpredictable. Papilloma growth may be rapid and dangerous to airway patency during periods of hormone change, such as during pregnancy. Malignant degeneration of laryngeal papillomas is rare and usually is associated with a history of radiotherapy, tobacco abuse, or both.（P.630-1）
97. 下列有關頭頸部血管性腫瘤(vascular tumors)的敘述，何者錯誤？
(A) Hemangioma 及 cystic hygroma 常見於出生時或出生後不久。Hemagioma 可能同時影響頭頸部的皮膚以及黏膜表面，而cystic hygroma 常是一無痛性的腫塊，而表面皮膚正常。
(B) 一般來說，hemangioma 及cystic hygroma 都有可能隨著時間而逐漸增生變大。但cystic hygroma在追蹤的過程中較有可能自己消退(involution)。
(C) 頭頸部的血管擴張性病變(telangiectasis)可能和 hereditary hemorrhagic telangiectasis 或Osler-Weber-Rendu 疾病有關，必須詳細詢問病人的家族史。
(D) Paraganglioma可能是一多發性 (multicentric origin)並有家族遺傳傾向的腫瘤。除了一般病變處的CT 或MRI之外，並應執行動脈攝影 (arteriography)檢查以及詳細詢問病人的家族史。
Ans：B
Hemangioma can be present at birth or appear soon thereafter. It affects the skin of the head and neck and can remain quiescent or undergo a period of rapid growth. Some hemangiomas involve deeper structures and have a more aggressive course. Many hemangiomas that initially appear benign can become proliferative with age. In general, however, a phase of rapid growth of these tumors is almost always followed by gradual involution.
Cystic hygroma consists of painless nodules covered by normal skin. It is present at birth or appears in early infancy. Cystic hygroma of the posterior triangle of the neck has been associated with hydrops fetalis, Turner syndrome, other congenital malformations, chromosomal aneuploidy, and fetal death. Cytogenic analysis of fetuses born with cystic hygroma is indicated (14). In cystic hygroma, tumors tend to enlarge gradually and never involute.
Telangiectasis most commonly occurs in the head and neck region in association with hereditary hemorrhagic telangiectasis or Osler-Weber-Rendu disease.
There is a definite proclivity for multicentric origin; many synchronous tumors are discovered incidentally during arteriography. There is a familial tendency. The incidence of bilaterality and multicentricity of these tumors increases from about 3% normally to 26% among persons with a familial tendency.
Patients typically have asymptomatic tumors found at routine physical examination. Evaluation and diagnosis include CT, MRI, and in almost every instance, arteriography with venous-phase inspection. Arteriography also allows assessment of the collateral circulation at the time of diagnosis. The extent of the tumor and its relation to the vascular structures of the neck or base of the skull can be established.（Ch.125, P.1571-73）
98. 下列關於局部皮瓣（local skin flap）的敘述，何者有誤？
(A) Random-pattern flap的主要血流供應是來自於flap base的cutaneous arterial perforator，再供應到dermal和subdermal plexus。
(B) 就random-pattern flap來說，只要長寬的比例一定，增加flap的寬度就可以無限制增加Flap的長度。
(C) 我們可以利用delay phenomenon來增加random-pattern flap的長度。
(D) Nasolabial flap是一種axial-pattern flap；deltopectral flap也可以視為是一種axial-pattern flap。
Ans：B
Random-Pattern Flaps
Random-pattern flaps do not have named arterial or venous vessels. They rely on flow through the dermal and subdermal plexus, which eventually connects with perforating vessels at the base of the flap. Because most facial local skin flaps rely on a random-pattern blood supply, there are limits with regard to length and width
Axial-Pattern Flaps
Axial-pattern flaps rely on blood from named direct cutaneous arteries and veins that course along the longitudinal axis of the flap (Table 161.3). These vessels course in the subcutaneous tissue superficial to the muscle, and the blood supply of the flap is considered secure for at least the length of these vessels. Axial flaps can gain further length by incorporating a random-pattern portion of the flap distal to the termination of the axial vasculature. The only local flap commonly considered to have an axial-pattern blood supply is the nasolabial flap, which has angular and infratrochlear vessels. Regional flaps with an axial blood supply are the deltopectoral, lateral forehead, and midline forehead flaps.（P.2035-7）
99. 對於晚期鼻咽癌(advanced stage NPC, AJCC stage III/IV)的治療，目前認為可增加overall survival 及progressive-free Rate的方法為:
(A) R/T
(B) Induction C/T + R/T
(C) CCRT
(D) R/T + adjuvant C/T
Ans：C
A recent study comparing the outcome of patients with NPC treated by radiation alone versus concurrent chemoradiation concluded that combined therapy yields slightly higher absolute survival rates.
Such results suggest that adjunctive chemotherapy soon may enhance disease-free survival significantly among patients with advanced NPC. Chemotherapy already has been well established as a valuable modality for the palliation of unresectable disease（P.1422）
100. 下列有關禽流感於人類之感染, 以下敘述何者為誤?
(A) 人類感染主要經由禽鳥傳染
(B) 目前已發現之禽流感病毒可在人體繁殖，而且大多數人無抗體 但未能有效地在人群中傳染
(C) 禽流感病毒是DNA病毒，發現者為H5N1禽流感病毒
(D) 症狀似一般流感，發燒、咳嗽、喉嚨痛，甚至以肺炎死亡
Ans：C
禽流感病毒（Avian Influenza virus, or Bird flu）屬於A型流感（Influenza A）的一支，流感病毒的粒徑大小約為0.08～0.12μm，為RNA病毒，通常以兩種醣蛋白作為分類（HA及NA），目前已知有15種HA與9種NA組合，禽鳥類皆可感染，以H5、H7兩種亞型為主，人則是較容易被H1、H3兩種亞型感染。2003～2004年發生的禽流感病毒株多為H5N1，台灣則曾爆發H5N2，其他地區則曾出現H2、H7、H9，其病徵如下痛、發高燒、咳嗽、流鼻水、喉嚨痛、肌肉關節痛、嘔吐、食慾不振、腹瀉等，與流感極為相似，難以辦別。一般認為多數人類感染禽流感是由於接觸染病家禽或是感染物
(A) 血管瘤(hemangioma)
(B) 動靜脈畸型(A-V malformation)
(C) 血管纖維瘤(angiofibroma)
(D) 囊狀水瘤(cystic hygroma)
Ans：D
Generalized Tumors
This category of benign vascular tumors of the head and neck includes diseases such as angiomatosis and cystic hygroma, both of which are closely related to lymphangioma. Cystic hygroma consists of painless nodules covered by normal skin. It is present at birth or appears in early infancy. Cystic hygroma of the posterior triangle of the neck has been associated with hydrops fetalis, Turner syndrome, other congenital malformations, chromosomal aneuploidy, and fetal death. Cytogenic analysis of fetuses born with cystic hygroma is indicated. In cystic hygroma, tumors tend to enlarge gradually and never involute. They have extensive infiltration beyond the apparent boundaries identified initially by the surgeon. For this reason, CT or MRI usually is performed to delineate the boundaries of the lesions (Fig. 125.6). Therapy for cystic hygroma is surgical excision. Complete excision is recommended if possible. If the tumor is intimately associated with vital structures, maximal excision without injury to these structures is recommended, because this is a benign lesion. Incomplete excision can account for recurrences at the margin of the previous excision. Careful follow-up evaluation and periodic MRI can alert the surgeon to early recurrence, which can decrease cosmetic and functional deficits.（P.1565）
85.下列下咽癌的原發腫瘤，何者最易有頸部淋巴結轉移?
(A) T1
(B) T2
(C) T4
(D) 與原發腫瘤之大小無關
Ans：D
Lymph node metastases are associated with hypopharyngeal cancer in about 75% of cases, with bilateral disease present in 10% of patients (Table 118.3). No relationship exists between the size of the primary lesion and the incidence of lymph node metastases. Most metastases are to the jugulodigastric nodes (7). Lesions in the piriform fossa apex and arytenoid may metastasize to the paratracheal, paraesophageal, and jugulo-omohyoid nodes or extend directly into the perilaryngeal compartments (Fig. 118.5) (8,9). Thyroid metastases also may be present. Involvement of the superior retropharyngeal lymph nodes is common, and treatment of the neck, both by radiation therapy and neck dissection, should be directed at these high, medially placed lymph nodes.（P.1447）
86. 口咽部鳞狀細胞癌的組織侵犯，何者不一定是發生於晚期
(A) 血管(blood vessel)侵犯
(B) 脊椎前筋膜(prevertebral fascia)侵犯
(C) 下顎骨膜(mandible periosteum)侵犯
(D) 神經周圍(perinenural)侵犯
Ans：D
NATURAL HISTORY
Prolonged exposure of the upper aerodigestive surfaces to carcinogens results in molecular changes throughout the mucosa. With time, certain areas may undergo further change, giving rise to premalignant and malignant lesions. This concept of “field cancerization” or “condemned mucosa” applies to all mucosal head and neck cancers and results in the high rates of second primaries in patients with oropharyngeal cancer
Squamous cell carcinoma starts on the surface and spreads superficially, deeply, and submucosally. Invasion of vessels, and thick fascia such as the prevertebral fascia or periosteum is uncommon until late stages, but perineural invasion may occur at any time. Bone involvement is also rare, occurring in only 17% of the lesions. Invasion into the parapharyngeal and retropharyngeal spaces allows easy spread to the skull base and neck with possible involvement of the internal carotid artery, cranial nerves IX through XII, and the sympathetic chain. Invasion of the masticator and infratemporal spaces results in trismus and possible involvement of the trigeminal nerve or any of its branches.（P.1429）
87. 下列有關NPC的血清檢測，何種正確?
(A) 以血清學而言，Anti-EBV，VCA，IgA及Anti-EA IgM的檢測最具臨床價值
(B) 若Anti-EBV VCA IgA的力價升高，則這病人約有90%的機會得NPC
(C) 血清學的診斷僅能用以輔助組織學的診斷，而可在NPC病人電療後的追蹤上有幫助
(D) 幾乎所有的NPC病人都可以血清學力價的高低來預測其預後
Ans：C
Laboratory Tests
Serologic testing may help to establish the diagnosis of NPC in the patient with an unknown primary tumor (Table 116.3). In a large series of North American patients, among those with occult and early (stage I) type II or III NPC, 86% had positive EA (immunoglobulin G, IgG) titers and 82% had positive VCA (IgA) titers compared with 18% and 31% in patients with other head and neck squamous cancers (Table 116.2). Epstein-Barr virus titers in patients with type I NPC are not significantly increased above those of control patients. If available, the antibody-dependent cellular cytotoxicity (ADCC) assay, which titrates sera for antibody to the EBV-induced membrane–antigen complex, provides valuable prognostic information (Fig. 116.9) (see later section on Prognosis). No association between ADCC titers and disease progression in type I NPC has been found. Although not cost effective for screening low-risk populations, studies of high-risk Chinese populations indicate that serologic testing for EBV may be a valuable screening tool. In contrast to ADCC titers, the VCA and EA antibody titers have not shown any significance as prognostic indicators. Additional laboratory studies performed at the time of the initial examination are selected to screen for distant metastasis and to assess the patient's general health status. Included in this workup are basic liver function tests and measurement of alkaline phosphatase to screen for liver and bone metastasis.（P.1418）
88. 有關聲門上癌(Supraglottic squamous cell carcinoma)的敘述，那些是正確的?
內視鏡雷射切除術或上喉切除術(supraglottic laryngectomy)可適用於一些早期(T1或T2)病例
聲門上喉部(Supraglottis)及聲門(glottis)源自於相同的胚胎來源
易有雙側頸部淋巴結轉移
接受全喉切除術(total laryngectomy)以防吸入性肺炎是唯一的選擇
(A) 1+2+3 (B) 2+4 (C) 1+3 (D) 3+4
Ans：C
Supraglottic laryngectomy is an accepted treatment for some patients who have primary stage T1, T2, and some T3 (Table. 120B.1) cancers of the supraglottic area. The procedure is founded on solid principles. Some of these principles are the following: (a) the understanding of the lymphatic and mucosal spread patterns of supraglottic cancers, (b) the clinicopathologic studies with whole laryngeal sections, and (c) patient survival and recurrence data. We have learned that cancers of the epiglottis tend to have pushing borders rather than infiltrating ones, which allows for resection with millimeter tumor-free margins. We understand that epiglottic cancers tend to remain supraglottic until late in their progression, when paraglottic spread leads to cordal fixation and upstaging. We have better ways to evaluate the cancer volume and breadth with scans, and we now better appreciate the potential of even early staged cancer of the epiglottis to metastasize to both sides of the neck. Finally, we understand the biologic difference between epiglottic cancer and supraglottic cancer that involves the hypopharynx. This information confirms the operation as predictable and safe in the proper clinical situation.（P.1483）
89. 下列有關人類乳突瘤病毒(Human Papillomavirus, HPV)和頭頸部鱗狀上皮細胞癌(Head and Neck Squamous Cell Carcinoma, HNSCC)的敘述中，何者正確？
(A) 目前證據顯示，約有15~25%的頭頸部鱗狀上皮細胞癌，其發生可能與人類乳突瘤病毒有關，特別是高危險性的HPV type 6
(B) 和HPV相關的頭頸部鱗狀上皮細胞癌(HPV-positive HNSCC)，通常發生在口咽部，尤其是扁桃腺的位置。病患大多較為年輕，亦多有抽煙及喝酒的習慣
(C) HPV-positive HNSCC的特徵是分化較差(poorly differentiated)，且常是advanced stage。然而和NPV-negative HNSCC比較，其治療預後(prognosis)卻較好
(D) 推測HPV可能的致癌機轉可能是HPV的E6蛋白質會和pRb結合，而E7蛋白質會和p53結合，導致細胞週期(cell cycle)的調控出了問題所致
Ans：C
Human Papillomavirus
Human papillomavirus (HPV) has been linked to development of papilloma in the nose and respiratory tract and to carcinogenesis in the genitourinary tract. Known oncogenic types 16, 18, and 31 have been found in squamous cell carcinoma of the tongue, tonsil, larynx, and pharynx. Human papillomavirus DNA was detected in 46% of archival tissue specimens of laryngeal and hypopharyngeal carcinoma, and the presence of this DNA appeared to correlate with a poorer prognosis than among cases in which there was no detectable HPV. Portugal et al. detected HPV (11%) and p53 mutation (66%) within the same specimens of squamous cell carcinoma of the oral cavity and tonsil, which showed that neither p53 gene mutation nor HPV infection serves as a prognosticator of tumor behavior, although survival rates were higher among persons with HPV-infected cancer of the tonsil. Among patients with a history of low alcohol and tobacco use, HPV infection was an independent risk factor for squamous cell carcinoma of the oral cavity and tonsil.
The exact role of HPV in carcinogenesis in the upper aerodigestive tract is unknown. Binding of E6 HPV proteins to the p53 tumor suppressor gene may lead to gene product degradation and unchecked cell proliferation. The E7 HPV protein is known to form complexes with the retinoblastoma tumor suppressor gene product pRB, and this process leads to tumorigenesis (18). No role for the retinoblastoma gene has been found in squamous cell carcinoma of the head and neck. An association of HPV with mutated H-ras oncogene has been suggested in squamous cell carcinoma of the mouth. However, the ras oncogene group is infrequently involved in head and neck cancer.（P.36）
90. 下列有關頭頸部感染，抗生素的一般選用原則的說明，何者正確？
(A) 一般來說，第三代的頭孢子素（cephalosporine）比第一代頭孢子素，對格蘭氏陽性菌的抗菌力強，因此針對第一代頭孢子素無效的金黃色葡萄球菌，宜選用第三代頭孢子素。
(B) 專門對抗Pseudomonas aeruginosa 的penicillin類似物（Anti-pseudomonal penicillins），通常也和其他penicillin一樣，對格蘭氏陽性菌具有好的療效。
(C) Vancomycin對methicillin-resistant的金黃色葡萄球菌以及其他penicillin-resistant肺癌鏈球菌（pneumococci）、腸球菌（enterococci）具有療效，因此宜作為後線藥物。
(D) Clindamycin對呼吸消化道的厭氧菌感染效果不佳。因此在使用Clindamycin治療深頸部感染宜加上metronidazole。
Ans：C
Cephalosporins also belong to the b-lactam family of drugs. This chemical relation probably means that patients with a history of penicillin anaphylaxis should avoid cephalosporins; however, cephalosporins are commonly and safely used by patients with a history of penicillin rashes. These drugs are categorized into first, second, and third generations. In general, first-generation agents are most active against gram-positive bacteria, and third-generation agents are highly active against gram-negative bacteria. Second-generation agents occupy an intermediate position.
Antipseudomonal penicillins are active against most gram-negative bacteria but not gram-positive organisms, such as Staph. aureus. The activity of these agents against P. aeruginosa separates them from most other antibiotics. They are administered parenterally. Ticarcillin is more active than is carbenicillin. Piperacillin is the most active of all drugs in this category. In the management of serious pseudomonal infection, these drugs often are used in combination with an aminoglycoside, such as gentamicin, for a synergistic effect.
Vancomycin (Vancocin, parenteral) is highly active against gram-positive cocci, including methicillin-resistant strains of Staph. aureus, penicillin-resistant strains of pneumococci, enterococci, and gonococci. Because it is unrelated to any other class of antibiotics, vancomycin is useful in the treatment of patients with penicillin allergies. High concentrations in the serum of patients with renal impairment can cause ototoxicity. Vancomycin does not cross the blood-brain barrier effectively, so when resistant pneumococcal infections extend intracranially, vancomycin therapy should be combined with ceftriaxone or trovafloxacin. Because vancomycin may be the last remaining agent still effective against highly resistant strains of staphylococci, pneumococci, and enterococci, this drug should be reserved for such serious infections and not used against bacteria that can be effectively controlled with other antimicrobial agents.
Clindamycin (Cleocin, oral or parenteral) is highly active against gram-positive cocci, including many but not all strains of penicillin-resistant pneumococci. Clindamycin is especially effective in the management of Staph. aureus infection, including infection with many methicillin-resistant strains. It is also highly effective against anaerobic infections of the aerodigestive tract, particularly with B. fragilis, which causes infection deep in the neck and draining ears and causes septic shock. Osteomyelitis is successfully managed with clindamycin because the organism is concentrated in bone. The combination of clindamycin and gentamicin is effective prophylaxis against all the common contaminants of surgical wounds, such as Staph. aureus, P. aeruginosa, and anaerobic organisms.（P.48-9）.
91. 腫瘤細胞會利用各種機制來避開人體免疫系統的攻擊，下列何種不是腫瘤細胞逃過免疫系統攻擊的機制？
(A)分泌各種抑制免疫反應的物質，如IL-10、p15e等。
(B)使血液中CD34+前樹突狀細胞（dendritic cell precusors）無法轉變成CD31+的血管內皮細胞（endothelial cell），而使免疫細胞無法經由新生血管進入腫瘤內。
(C)改變腫瘤細胞本身的抗原性（antigenic modulation），使免疫系統不易辨認。
(D) 降低進入腫瘤內的CD8+細胞（CD8+ cell influx），並改變腫瘤中CD4+細胞的功能。
Ans：B
The mechanisms include tumor production of interleukin-10 (IL-10) and production of a material that interferes with many aspects of immune response, p15e, a retroviral antigen similarity to interferon-alpha (IFN-a). It also appears that tumors may be able to influence differentiation of CD34 cells to CD31+ endothelial cells. Therefore, tumors recruit predendritic cells but pervert the response by changing them into cells, which only contribute to neovascularization of the tumor and inhibit immune potential. Another tumor-associated immunosuppressive product produced by squamous cell carcinoma of the head and neck is prostaglandin E2, which inhibits growth of T cells in a system in which specific tumor-associated lymphocytes are harvested and grown in culture. Prostaglandin E2 influences tumor neovascularization. Experiments with implantation of corneal tumors in rabbits have shown cessation of solid tumors elsewhere than in the head and neck. Neovascularization with cyclooxygenase inhibitors raises the possibility of therapeutic intervention with this class of drugs (21). In an evaluation of immune suppression, Young et al. (20) found a multiplicity of non–mutually exclusive mechanisms of immune suppression that reduced CD8+ cell influx and altered function of intratumor CD4 cells. Other possible mechanisms of tumor immunosuppression are listed in Table 102.1.（P.1214）
92. 下列有關唾液腺惡性腫瘤(malignant salivary gland neoplasms)的敘述，何者錯誤？
(A) 腮腺最常見的癌症是Mucoepidermoid carcinama，而下頷腺及小唾液腺常見的癌症是adenoid cystic carcinoma。
(B) Mucoepidermoid carcinama惡性度的高低是以mucous cells和epidermoid cells的比例來區分；mucous cells比例高者，惡性度也高。
(C) Adenoid cystic carcinoma常有perineural invasion，宜考慮手術切除及追加術後放射線治療。
(D) Acinic cell carcinoma較常發生於女性，並且和warthin’s tumor一樣，有時會有雙側腮腺侵犯的情形。
Ans：B
Mucoepidermoid carcinoma is the most common malignant tumor involving the parotid gland and the second most common malignant tumor of the submandibular gland, after adenoid cystic carcinoma.
Mucoepidermoid carcinomas are usually classified as low-grade or high-grade tumors. The low-grade tumors have a higher ratio of mucous cells to epidermoid cells. Low-grade tumors behave like benign neoplasms but are capable of local invasion and metastasis. High-grade mucoepidermoid carcinomas have a higher proportion of epidermoid cells and may resemble squamous cell carcinoma.
Perineural invasion is a typical feature of adenoid cystic carcinoma seen in most cases of the tumor, which explains the difficulty in tumor eradication despite the extent of surgical excision. Complete surgical excision and postoperative radiation therapy is recommended for the management of this tumor.
Acinic cell carcinoma occurs most commonly in women. This tumor is the second most common salivary gland malignancy in childhood after mucoepidermoid carcinoma. Bilateral involvement occurs about 3% of the time, ranking acinic cell carcinoma second behind Warthin's tumor for frequency of bilateral parotid gland involvement（P.1282-3）
93. 下列有關TxN0的頭頸部鱗狀上皮細胞癌(HNSCC)，針對其occult cervical metastasis的處置，下列敘述何者錯誤？
(A) 一般認為，如果 occult cervical metastasis的機會大於20%，施行elective neck treatment是合理的選擇。
(B) 如果primary tumor是以放射線治療，那麼elective neck irradiation是有效而可以考慮的elective neck treatment方式。
(C) 對於一個T2N0，位在梨狀窩(pyriform sinus)外側壁(lateral wall)的下咽癌而言， lateral neck dissection是合理而可以接受的elective neck treatment。
(D) 對於一個T2N0的maxillary sinus cancer而言，施行同側的lateral neck dissection是合理而可以接受的elective neck treatment。
Ans：D
Decision Analysis
Weiss et al. (16) used a decision tree with a computer model to compare the results in the literature using the three management strategies and suggested that elective treatment should be considered if the probability of occult cervical metastasis was greater than 20%. The relative utility of surgery over radiation became apparent if the probability was greater than 50%.
The decision to treat the N0 neck electively depends on the estimated rate of metastasis, morbidity of treatment, and the probability that END will be more effective than treatment for regional failure during observation. With few exceptions, if the primary site is treated with radiation, the neck is also treated for practical reasons. Therefore, the controversy centers mainly around the need for END when the primary is treated surgically.
The clinical practice guidelines state that bilateral metastasis are common and that there is a risk of retropharyngeal metastasis for pharyngeal wall primaries. Regions II through IV are at risk, and rarely are regions I and V involved in absence of regions II through IV involvement. Region VI is at risk in extensive T3 and T4 pyriform sinus cancer. The guidelines recommend that all patients be treated with END or ENI but are not more specific.
Bilateral SND (regions II through V) is recommended for these patients. However, it is acceptable to perform dissection of levels V and VI at the surgeon's discretion. Patients with tumors involving only the lateral hypopharynx can be treated with unilateral neck dissection if the ipsilateral neck does not have suspicious nodes. Elective region I dissection can be considered optional in hypopharyngeal cancer. As in oropharyngeal cancer, retropharyngeal nodes are at risk (bilaterally for tumors near midline). Radiation therapy should be given postoperatively for most pyriform tumors because of the higher failure rates at the primary site.（P.1370-2）
94. 列有關下咽癌(hypopharyngeal cancer)的敘述，何者錯誤？
(A) 下咽癌最常發生的位置是pyriform sinus，其次是posterior pharyngeal wall，最少見的是postcricoid area。
(B) 大部份下咽癌的患病都是有煙酒習慣的男性。但是有Plummer-Vinson syndrome的女性，卻有較高的機會罹患posterior pharyngeal wall的下咽癌。
(C) 在病理組織檢查方面，下咽癌常見submucosal spread以及skip或satellite lesions。
(D) 位在pyriform apex以及postcricoid area位置的下咽癌容易較容易有paratracheal和paraesophageal淋巴結的轉移。
Ans：B
Most patients who develop hypopharyngeal cancer have been exposed to tobacco and alcohol. Chronic inflammation of the hypopharynx associated with reflux, combined with local and systemic insults from tobacco and alcohol, is also thought to be part of the triggering mechanism for the development of cancer in certain susceptible patients (1). Although men are about eight times more susceptible than women to cancers of the hypopharynx, women with Plummer-Vinson syndrome are a unique group. They have a high incidence of cancer of the postcricoid region.
The lymphatic drainage from this region is directed toward the upper deep cervical lymph nodes (Fig. 118.3). There are, however, channels that extend superiorly from the hypopharynx into the retropharyngeal nodes as high as the nodes of Rouvier. Inferiorly (piriform apex and postcricoid regions), the lymphatics extend laterally to the jugulo-omohyoid nodes and inferiorly to the paratracheal, paraesophageal, and thyroid nodes. In the medial wall of the piriform fossa, there is crossover with the lymphatics of the larynx at the level of the aryepiglottic folds and the arytenoids. Extensive submucosal lymphatics are found in the hypopharynx, particularly in the inferior portions.
Most hypopharyngeal cancers are located in the piriform fossae (Table 118.2) . The next most common location is the posterior hypopharyngeal wall. The postcricoid site is the least common location.
The association of satellite tumors is also a characteristic of cancers in this region. Whether these smaller tumors, or skip areas, are micrometastases or separate primary tumors in areas of condemned mucosa is difficult to determine. The presence of submucosal spread and skip areas is significant because these findings dictate the use of wide surgical margins and/or radiation therapy when treating these malignancies. Adequate superior margins consist of 2 to 3 cm of mucosa from the gross tumor edge. The inferior margin should be 4 to 6 cm from the gross tumor if the tumor involves the cervical esophagus. Therefore, one must carefully consider reconstructive options and prepare to proceed if tumor margins dictate total laryngopharyngectomy with or without esophagectomy.（P.1443-7）
95. 下列有關喉癌(laryngeal cancer)侵犯或轉移過程的敘述，何者錯誤？
(A) 位於 anterior commissure或 infrahyoid epiglottis的喉癌能夠侵入 pre-epiglottic space，然後由 thyroid membrane進入頸部的軟組織。
(B) False cord的infiltrating cancer能夠經由 paraglottic space而侵犯到true vocal cord，並且會伴隨有高比例的subglottic spread。
(C) 一般來說，喉癌如果沒有舌部的侵犯，或是同時有N2以上(包含N2 )的頸部轉移時，並不容易轉移至submental或 submandibular area的淋巴結。
(D) Glottic cancer會首先轉移到 delphian node，然後再到upper jugular , mid-jugular , 和lower jugular node。
Ans：D
PATTERNS OF SPREAD
Anatomic studies confirm the existence of laryngeal spaces or compartments within which cancer can spread more freely and through which cancer may spread out of the larynx. Tumors at first tend to spread by the path of least resistance into these preexisting compartments. The preepiglottic space is bound by the hyoepiglottic ligament superiorly, the thyroid cartilage and the thyrohyoid membrane anteriorly, and the epiglottis and thyroepiglottic ligament posteriorly. Cancer in the anterior commissure or infrahyoid epiglottis may spread to the preepiglottic space, from which it may spread to the soft tissues of the neck by means of the dehiscences in the thyrohyoid membrane created by the superior laryngeal vessels and nerves.
The paraglottic space, lateral to the ventricles, allows the passage of deeply infiltrating cancers from the false cord to the true cord or vice versa. Tumors that pass through this space and are superior and inferior to the ventricle are called transglottic tumors. Invasion of this space is also associated with a high rate of subglottic or extralaryngeal spread of tumor. In a study by Kirchner, 31 of 52 transglottic cancers invaded the laryngeal framework. The proximity of the thyroid cartilage to this space explains this finding (Fig. 121.3, Fig. 121.4 and Fig. 121.5). Tumors at the anterior commissure tend to spread to the anterior subglottis and invade the thyroid cartilage because of the lack of thyroid perichondrium in the region of the anterior commissure tendon. Subglottic tumors frequently invade the laryngeal cartilages (e.g., four of eight in Kirchner's study), often present late in the course of the disease, and are associated with a poor prognosis. Most tumors involving the subglottic region are extensions of large laryngeal cancers rather than primary tumors of the subglottis.
In addition to the spread of these tumors throughout each compartment, it is interesting that the very fibrous membranes responsible for helping to contain the disease also may serve as conduits for tumor invasion. Histologic studies have revealed that cancer cells can grow between the collagen bundles and invade the laryngeal cartilages through the attachment sites of the membranes. The most common sites of cartilage invasion are at the attachments of the strongest membranes: (a) the anterior commissure tendon, (b) the attachments of the cricothyroid membrane to the adjacent cartilage, (c) the anterior portion of the thyroid lamina near the origin of the thyroarytenoid muscle, (d) the posterior border of the thyroid lamina adjacent to the piriform sinus, and (e) the capsule of the cricoarytenoid joint. The perichondrium remains the major barrier to cartilage invasion.
The patterns of lymphatic spread have been described well by Linberg and by Byers et al. for N0 and node-positive disease. For the N0 neck, the lymphatic flow remains as Fisch first described it, unimpeded by a large metastasis. Lymph flow is from the superior portion of the neck toward the clavicle, from posterior to anterior. Only after large metastases appear, as can be found associated with advanced laryngeal tumors, do we find paradoxical lymphatic flow causing unusual sites of lymph node metastases. Nodal metastases are more common in supraglottic cancers than in glottic or subglottic cancers. Also, larger tumor surface area and advanced stage cause increased regional metastases (3). Tumors of the supraglottic larynx spread to the upper and middle jugular first prior to involving the lower jugular level. Glottic tumors metastasize to the delphian or pretracheal node followed by the middle and lower jugular regions. Subglottic tumors spread to the pretracheal, paratracheal, middle, and lower jugular lymph nodes. It is unusual for laryngeal cancers of any site to metastasize to the submandibular and submental regions in the absence of tongue invasion, or in disease advanced beyond the N1 stage. This also holds true for the posterior triangle. These data provide the basis for the preservation of these regions in neck dissections for laryngeal primary tumors with less than N2 disease. The anterior lateral neck dissection therefore remains the standard for these lesions. With advanced neck disease, a more traditional complete lymphadenectomy such as a modified radical or radical neck dissection would therefore be more appropriate.（P.1506-7）
96. 以下關於Laryngeal Papillomatosis的敘述，何者有誤?
(A) 為最常見的喉部良性腫瘤
(B) 大多是從聲帶長出
(C) 最常見的症狀是呼吸道阻塞
(D) Juvenile-onset者較易復發
Ans：C
LARYNGEAL PAPILLOMATOSIS
Recurrent respiratory papillomatosis is a condition that affects mucous membranes of the respiratory tract. It is characterized by multiple and recurrent squamous papillomata, most commonly involving the larynx, but other areas of the upper and lower respiratory tract may be involved, causing hoarseness and some degree of respiratory obstruction, particularly in children.
These lesions are thought to be of viral etiology (2), and are the most common benign laryngeal tumors (3). This condition may develop in all age groups, but is more prevalent in children and less common in individuals over 30 years of age. It is believed that transmission of human papillomavirus (HPV) to the child occurs in the birth canal. Shah and Kashima (4) found only one case of juvenile-onset respiratory papillomas in a child born by cesarean section in their review of 109 cases. The risk of transmission of HPV infection from mother to child was estimated to be in the range of 1:80 to 1:500. Total remission may sometimes take place at puberty; however, this is not always the case.
Papillomatosis of the larynx, the most common site of these tumors, is a serious and difficult problem in the pediatric population. Hoarseness is the most common early symptom, followed by airway obstruction and respiratory difficulty. The vocal folds and the subglottic larynx are the most common laryngeal sites. Nasopharyngeal, subglottic, tracheal, and bronchial papillomas are thought to be due to contamination from glottic and supraglottic lesions. Lower airway contamination is seen commonly after a tracheotomy, which therefore should be avoided if possible. Pulmonary papillomas are rare, but if they are present they can cause severe complications such as hemorrhage and abscess formation (Table 53.1). Laryngeal papillomas presenting in adults seem to be less aggressive than the juvenile form, but the remission rate is unpredictable. Papilloma growth may be rapid and dangerous to airway patency during periods of hormone change, such as during pregnancy. Malignant degeneration of laryngeal papillomas is rare and usually is associated with a history of radiotherapy, tobacco abuse, or both.（P.630-1）
97. 下列有關頭頸部血管性腫瘤(vascular tumors)的敘述，何者錯誤？
(A) Hemangioma 及 cystic hygroma 常見於出生時或出生後不久。Hemagioma 可能同時影響頭頸部的皮膚以及黏膜表面，而cystic hygroma 常是一無痛性的腫塊，而表面皮膚正常。
(B) 一般來說，hemangioma 及cystic hygroma 都有可能隨著時間而逐漸增生變大。但cystic hygroma在追蹤的過程中較有可能自己消退(involution)。
(C) 頭頸部的血管擴張性病變(telangiectasis)可能和 hereditary hemorrhagic telangiectasis 或Osler-Weber-Rendu 疾病有關，必須詳細詢問病人的家族史。
(D) Paraganglioma可能是一多發性 (multicentric origin)並有家族遺傳傾向的腫瘤。除了一般病變處的CT 或MRI之外，並應執行動脈攝影 (arteriography)檢查以及詳細詢問病人的家族史。
Ans：B
Hemangioma can be present at birth or appear soon thereafter. It affects the skin of the head and neck and can remain quiescent or undergo a period of rapid growth. Some hemangiomas involve deeper structures and have a more aggressive course. Many hemangiomas that initially appear benign can become proliferative with age. In general, however, a phase of rapid growth of these tumors is almost always followed by gradual involution.
Cystic hygroma consists of painless nodules covered by normal skin. It is present at birth or appears in early infancy. Cystic hygroma of the posterior triangle of the neck has been associated with hydrops fetalis, Turner syndrome, other congenital malformations, chromosomal aneuploidy, and fetal death. Cytogenic analysis of fetuses born with cystic hygroma is indicated (14). In cystic hygroma, tumors tend to enlarge gradually and never involute.
Telangiectasis most commonly occurs in the head and neck region in association with hereditary hemorrhagic telangiectasis or Osler-Weber-Rendu disease.
There is a definite proclivity for multicentric origin; many synchronous tumors are discovered incidentally during arteriography. There is a familial tendency. The incidence of bilaterality and multicentricity of these tumors increases from about 3% normally to 26% among persons with a familial tendency.
Patients typically have asymptomatic tumors found at routine physical examination. Evaluation and diagnosis include CT, MRI, and in almost every instance, arteriography with venous-phase inspection. Arteriography also allows assessment of the collateral circulation at the time of diagnosis. The extent of the tumor and its relation to the vascular structures of the neck or base of the skull can be established.（Ch.125, P.1571-73）
98. 下列關於局部皮瓣（local skin flap）的敘述，何者有誤？
(A) Random-pattern flap的主要血流供應是來自於flap base的cutaneous arterial perforator，再供應到dermal和subdermal plexus。
(B) 就random-pattern flap來說，只要長寬的比例一定，增加flap的寬度就可以無限制增加Flap的長度。
(C) 我們可以利用delay phenomenon來增加random-pattern flap的長度。
(D) Nasolabial flap是一種axial-pattern flap；deltopectral flap也可以視為是一種axial-pattern flap。
Ans：B
Random-Pattern Flaps
Random-pattern flaps do not have named arterial or venous vessels. They rely on flow through the dermal and subdermal plexus, which eventually connects with perforating vessels at the base of the flap. Because most facial local skin flaps rely on a random-pattern blood supply, there are limits with regard to length and width
Axial-Pattern Flaps
Axial-pattern flaps rely on blood from named direct cutaneous arteries and veins that course along the longitudinal axis of the flap (Table 161.3). These vessels course in the subcutaneous tissue superficial to the muscle, and the blood supply of the flap is considered secure for at least the length of these vessels. Axial flaps can gain further length by incorporating a random-pattern portion of the flap distal to the termination of the axial vasculature. The only local flap commonly considered to have an axial-pattern blood supply is the nasolabial flap, which has angular and infratrochlear vessels. Regional flaps with an axial blood supply are the deltopectoral, lateral forehead, and midline forehead flaps.（P.2035-7）
99. 對於晚期鼻咽癌(advanced stage NPC, AJCC stage III/IV)的治療，目前認為可增加overall survival 及progressive-free Rate的方法為:
(A) R/T
(B) Induction C/T + R/T
(C) CCRT
(D) R/T + adjuvant C/T
Ans：C
A recent study comparing the outcome of patients with NPC treated by radiation alone versus concurrent chemoradiation concluded that combined therapy yields slightly higher absolute survival rates.
Such results suggest that adjunctive chemotherapy soon may enhance disease-free survival significantly among patients with advanced NPC. Chemotherapy already has been well established as a valuable modality for the palliation of unresectable disease（P.1422）
100. 下列有關禽流感於人類之感染, 以下敘述何者為誤?
(A) 人類感染主要經由禽鳥傳染
(B) 目前已發現之禽流感病毒可在人體繁殖，而且大多數人無抗體 但未能有效地在人群中傳染
(C) 禽流感病毒是DNA病毒，發現者為H5N1禽流感病毒
(D) 症狀似一般流感，發燒、咳嗽、喉嚨痛，甚至以肺炎死亡
Ans：C
禽流感病毒（Avian Influenza virus, or Bird flu）屬於A型流感（Influenza A）的一支，流感病毒的粒徑大小約為0.08～0.12μm，為RNA病毒，通常以兩種醣蛋白作為分類（HA及NA），目前已知有15種HA與9種NA組合，禽鳥類皆可感染，以H5、H7兩種亞型為主，人則是較容易被H1、H3兩種亞型感染。2003～2004年發生的禽流感病毒株多為H5N1，台灣則曾爆發H5N2，其他地區則曾出現H2、H7、H9，其病徵如下痛、發高燒、咳嗽、流鼻水、喉嚨痛、肌肉關節痛、嘔吐、食慾不振、腹瀉等，與流感極為相似，難以辦別。一般認為多數人類感染禽流感是由於接觸染病家禽或是感染物
94年 ENT 考題67~83
67. 以下關於Caustic ingestion的處置何者正確?
(A) 依酸鹼中和原理，若誤吞酸時應馬上喝碳酸鈉來中和
(B) 緊急插鼻胃管以洗胃
(C) 誤食的12小時內要作內視鏡檢查以減少食道穿孔機會
(D) Barium swallow最主要目的是評估有否穿孔
Ans : D
Bailey 76 page 927
A. 不可喝酸或鹼去中和 會產生exothermic chemical reaction造成食到更嚴重受傷 可喝water或milk
B. Gastric levage and induced vomiting are contraindicated
C. 於24-48小時內作食道鏡
68. 以下關於phonation的敘述，何者為非?
(A) 聲帶振動的mucosal wave是由下往上傳的
(B) 所謂falsetto voice，是聲帶變薄，mucosal wave變小
(C) 年紀大的人的pitch會稍微上揚
(D) 有聽力受損的人，其發聲的基頻會較增加
Ans : B
A: Bailey 52 page 609
B : Falsetto voice: 變聲性假嗓 ： 青春期未能由男童高音轉變低沉聲音 通常為心因問題
C. 年紀大的人聲帶變薄, 音調較高
69. 急診送來一位頭部外傷需要建立airway的病人，雖無midfacial trauma，但懷疑有合併cervical spine fracture, 請問以下何方式最不適合為其建立呼吸道?
(A) blind nasotracheal intubation
(B) cricothyrotomy
(C) conventional tracheotomy
(D) orotracheal intubation with manual inline axial traction of the cervical spine
Ans: C
Bailey 61 page 719-720
Tracheotomy 用於合併有laryngeal trauma, tracheal trauma 不可用cricothyrotomy時
70. Laryngeal trauma的手術處理時常需要放Stents，以下何者為非Stent的作用?
(A) 預防endolaryngeal scarring
(B) 維持the internal configuration of the larynx
(C) 預防web formation over anteriocommissure
(D) 預防granulation tissue formation
Ans: D
Bailey 63 page 746
放stent可防止 endolaryngeal scarring and maintain internal configuration of the larynx
但會增加infection and formation of granulation tissue
71. 以下關於laryngomalacia的敘述，何者有誤?
(A) 早產兒較常見
(B) Laryngomalacia為嬰兒哮喘(stridor)最常見原因
(C) 大多數嬰孩至12到18個月大後會逐漸好轉
(D) 在嬰兒仰睡或激動時症狀較明顯
Ans: A
Bailey 74 page 902 most common cause of stridor in infancy
72. 以下關於oral candidiasis的敘述，何者錯誤?
(A) Atrophic candidiasis是最容易有癌化的一型
(B) Chronic atrophic candidiasis是常見的一型
(C) Angular cheilitis其實是 chronic atrophic candidiasis的一種
(D) Median rhomboid glossitis也是一種 candidiasis的表現
Ans: A
Bailey46 page 536-537
Heperplastic candidiasis or candidal leukoplakia 才是最常癌化的一型
73. 以下關於human papilloma virus的敘述，何者為是?
(A) 屬於Herpes group的雙股DNA病毒
(B) E 6為HPV type 16最強的oncogene之一
(C) 此病毒於basal cells內複製後，使細胞裂解破壞, 以將病毒顆粒傳播開
(D) 此病毒與頭頸癌中喉癌的致癌機轉最有關
Ans: B
Paper Role of Human Papillomavirus in the Development of Head and Neck SCC
A. 非Herpes group雙股DNA病毒
C. proliferating epidermal or mucosal cells ( in basal layer) 非 basal cells
D. Oropharyngeal and tonsillar cancer
74. 以下關於味覺的敘述，何者正確?
(A) Circumvallate papillae的味覺由chorda tympani 傳入
(B) Fungiform papillae的taste buds只與cranial n. VII synapse
(C) 味覺的傳入，一直到cortex都是走在同側
(D) taste在口腔內有明確的localization
Ans: C
Bailey45 page 511
A. Circumvallate papillae的味覺由 glossopharyngeal nerve
B. Fungiform papillae的taste buds與 VII ,IX
D. taste在口腔內無明確的localization
75. 有關喉癌的基礎研究已有許多令人振奮的結果，以下相關的敘述何者有誤?
(A)PH-20可為tumor marker，尤其有遠隔轉移時
(B)P53 gene的突變與喉癌的預後很有關
(C)P16 gene在喉癌病人的表現會增加
(D)Retinoblastoma protein表現下降者較易有淋巴結轉移
Ans: C
Bailey p1469 , P16 與laryngeal ca 無關
76.下列有幾種物質可作為攜帶藥物，吸附到癌細胞的載具(vector)?
核酸(nucleic acid)
抗體(antibody)
胜肽(peptide)
蛋白質(protein)
(A) 一種 (B) 二種 (C) 三種 (D) 四種
Ans: B
找不到出處
詢問結果應該是 核酸及抗體 因為分子較小
77. 下列四句有關唾液腺癌症的敘述，有幾句是對的?
鳞狀細胞癌(squamous cell carcinoma)好發於年紀大的男性
鳞狀細胞癌(squamous cell carcinoma)是常見的癌症，發現時也較早期
整體而言，唾液腺癌的頸部潛伏轉移(occult metastasis)有五分之一，其中以腺泡細胞癌(acinic cell carcinoma)最不易頸部轉移
神經周圍侵犯(perineural invasion)不是腺樣囊腫癌(adenoid cystic carcinoma)的專有特性，其他種類的唾液腺癌也會
(A) 一句 (B) 二句 (C) 三句 (D) 四句
Ans: B
Bailey107 page 1282-1284
SCC a rare neoplasm 0.3-1.5% of salivary gland tumors, 70歲左右 男性
神經周圍侵犯(perineural invasion是腺樣囊腫癌(adenoid cystic carcinoma)的專有特性
所以選項1,3正確
78. 鼻竇-鼻腔癌(sinonasal cancer)侵犯到下列那些解剖位置時，應該要對頸部作選擇性治療(elective treatment)?
a. 眼窩 b. 軟腭 c. 鼻咽 d. 顳下窩(infratemporal fossa) e. 齒根
(A) a、b、d (B) a、d、e (C) b、c (D) c、d
Ans: C
Bailey P.1373
Soft palate and nasopharynx, 在nasal/ethmoid and maxillary sinus那一段
79. 下列四句敘述有幾句是對的?
大人最常見的良性眼窩腫瘤是皮樣囊腫(dermoid cyst)
大人最常見的惡性眼窩腫瘤是淋巴瘤(lymphoma)
小孩最常見的良性血管性眼窩腫瘤是微血管性血管瘤(capillary hemangioma)
小孩最常見的惡性眼窩腫瘤是橫紋肌肉瘤(rhabdomyosarcoma)
(A) 一句 (B) 二句 (C) 三句 (D) 四句
Ans: C
Bailey106 page 1278 highlights
1. 錯 大人最常見的良性眼窩腫瘤是 cavernous hemangioma
2. 對 3. 對 4. 對
80. 下列那一種鼻竇-鼻腔癌(sinonasal cancer)在10到19歲及50到59歲均有較高的發生率(bimodal frequency)?
(A) 鳞狀細胞癌(squamous cell carcinoma)
(B) 腺樣囊腫癌(adenoid cystic carcinoma)
(C) 惡性黑色素瘤(malignant melanoma)
(D) 嗅神經母細胞癌(olfactory neuroblastoma)
Ans: D
Bailey105 page 1249
olfactory neuroblastoma has a bimodal frequency at 10 to 20 and 50 to 60 years of age
81. 整體而言，口腔和口咽癌的 ”潛伏”和 ”摸得到”的頸部轉移百分比約多少?
(A) 30%
(B) 40%
(C) 70%
(D) 90%
Ans: C
Bailey p.1373
70%, 在summary of incidence of occult metastasis最後一行
82. 分化良好的甲狀腺癌包括乳突癌(papillary carcinoma)和濾泡癌(follicular carcinoma)。下列四句敘述有幾句是對的?
分化良好的甲狀腺癌皆為多發性(multicentric)，且頸部淋巴結轉移率高
分化良好的甲狀腺癌多好發於女性
腫瘤大小對分化良好的甲狀腺癌皆為重要的預後因素
血管侵犯(angioinvasion)是濾泡癌最重要的預後因素
(A) 一句 (B) 二句 (C) 三句 (D) 四句
Ans:B
Bailey ch114
1) 錯 p.1386- PTC: multicentric; p.1387 FTC: multicentric is uncommon
2) 對 p1386-7: both higher in female (2-3 times)
3) 錯 p.1387: size isn’t a critical factor in the prognosis of FTC
4) 對 p.1387: prognosis is related directly to the degree of angioinvasion- correct
83. 下列何者是喉癌最重要的存活決定因子?
(A) 原發腫瘤大小
(B) 頸部轉移有無
(C) 年齡大小
(D) 抽煙習性有無
Ans:B
找不到出處
頸部轉移有無為重要的存活決定因子
(A) 依酸鹼中和原理，若誤吞酸時應馬上喝碳酸鈉來中和
(B) 緊急插鼻胃管以洗胃
(C) 誤食的12小時內要作內視鏡檢查以減少食道穿孔機會
(D) Barium swallow最主要目的是評估有否穿孔
Ans : D
Bailey 76 page 927
A. 不可喝酸或鹼去中和 會產生exothermic chemical reaction造成食到更嚴重受傷 可喝water或milk
B. Gastric levage and induced vomiting are contraindicated
C. 於24-48小時內作食道鏡
68. 以下關於phonation的敘述，何者為非?
(A) 聲帶振動的mucosal wave是由下往上傳的
(B) 所謂falsetto voice，是聲帶變薄，mucosal wave變小
(C) 年紀大的人的pitch會稍微上揚
(D) 有聽力受損的人，其發聲的基頻會較增加
Ans : B
A: Bailey 52 page 609
B : Falsetto voice: 變聲性假嗓 ： 青春期未能由男童高音轉變低沉聲音 通常為心因問題
C. 年紀大的人聲帶變薄, 音調較高
69. 急診送來一位頭部外傷需要建立airway的病人，雖無midfacial trauma，但懷疑有合併cervical spine fracture, 請問以下何方式最不適合為其建立呼吸道?
(A) blind nasotracheal intubation
(B) cricothyrotomy
(C) conventional tracheotomy
(D) orotracheal intubation with manual inline axial traction of the cervical spine
Ans: C
Bailey 61 page 719-720
Tracheotomy 用於合併有laryngeal trauma, tracheal trauma 不可用cricothyrotomy時
70. Laryngeal trauma的手術處理時常需要放Stents，以下何者為非Stent的作用?
(A) 預防endolaryngeal scarring
(B) 維持the internal configuration of the larynx
(C) 預防web formation over anteriocommissure
(D) 預防granulation tissue formation
Ans: D
Bailey 63 page 746
放stent可防止 endolaryngeal scarring and maintain internal configuration of the larynx
但會增加infection and formation of granulation tissue
71. 以下關於laryngomalacia的敘述，何者有誤?
(A) 早產兒較常見
(B) Laryngomalacia為嬰兒哮喘(stridor)最常見原因
(C) 大多數嬰孩至12到18個月大後會逐漸好轉
(D) 在嬰兒仰睡或激動時症狀較明顯
Ans: A
Bailey 74 page 902 most common cause of stridor in infancy
72. 以下關於oral candidiasis的敘述，何者錯誤?
(A) Atrophic candidiasis是最容易有癌化的一型
(B) Chronic atrophic candidiasis是常見的一型
(C) Angular cheilitis其實是 chronic atrophic candidiasis的一種
(D) Median rhomboid glossitis也是一種 candidiasis的表現
Ans: A
Bailey46 page 536-537
Heperplastic candidiasis or candidal leukoplakia 才是最常癌化的一型
73. 以下關於human papilloma virus的敘述，何者為是?
(A) 屬於Herpes group的雙股DNA病毒
(B) E 6為HPV type 16最強的oncogene之一
(C) 此病毒於basal cells內複製後，使細胞裂解破壞, 以將病毒顆粒傳播開
(D) 此病毒與頭頸癌中喉癌的致癌機轉最有關
Ans: B
Paper Role of Human Papillomavirus in the Development of Head and Neck SCC
A. 非Herpes group雙股DNA病毒
C. proliferating epidermal or mucosal cells ( in basal layer) 非 basal cells
D. Oropharyngeal and tonsillar cancer
74. 以下關於味覺的敘述，何者正確?
(A) Circumvallate papillae的味覺由chorda tympani 傳入
(B) Fungiform papillae的taste buds只與cranial n. VII synapse
(C) 味覺的傳入，一直到cortex都是走在同側
(D) taste在口腔內有明確的localization
Ans: C
Bailey45 page 511
A. Circumvallate papillae的味覺由 glossopharyngeal nerve
B. Fungiform papillae的taste buds與 VII ,IX
D. taste在口腔內無明確的localization
75. 有關喉癌的基礎研究已有許多令人振奮的結果，以下相關的敘述何者有誤?
(A)PH-20可為tumor marker，尤其有遠隔轉移時
(B)P53 gene的突變與喉癌的預後很有關
(C)P16 gene在喉癌病人的表現會增加
(D)Retinoblastoma protein表現下降者較易有淋巴結轉移
Ans: C
Bailey p1469 , P16 與laryngeal ca 無關
76.下列有幾種物質可作為攜帶藥物，吸附到癌細胞的載具(vector)?
核酸(nucleic acid)
抗體(antibody)
胜肽(peptide)
蛋白質(protein)
(A) 一種 (B) 二種 (C) 三種 (D) 四種
Ans: B
找不到出處
詢問結果應該是 核酸及抗體 因為分子較小
77. 下列四句有關唾液腺癌症的敘述，有幾句是對的?
鳞狀細胞癌(squamous cell carcinoma)好發於年紀大的男性
鳞狀細胞癌(squamous cell carcinoma)是常見的癌症，發現時也較早期
整體而言，唾液腺癌的頸部潛伏轉移(occult metastasis)有五分之一，其中以腺泡細胞癌(acinic cell carcinoma)最不易頸部轉移
神經周圍侵犯(perineural invasion)不是腺樣囊腫癌(adenoid cystic carcinoma)的專有特性，其他種類的唾液腺癌也會
(A) 一句 (B) 二句 (C) 三句 (D) 四句
Ans: B
Bailey107 page 1282-1284
SCC a rare neoplasm 0.3-1.5% of salivary gland tumors, 70歲左右 男性
神經周圍侵犯(perineural invasion是腺樣囊腫癌(adenoid cystic carcinoma)的專有特性
所以選項1,3正確
78. 鼻竇-鼻腔癌(sinonasal cancer)侵犯到下列那些解剖位置時，應該要對頸部作選擇性治療(elective treatment)?
a. 眼窩 b. 軟腭 c. 鼻咽 d. 顳下窩(infratemporal fossa) e. 齒根
(A) a、b、d (B) a、d、e (C) b、c (D) c、d
Ans: C
Bailey P.1373
Soft palate and nasopharynx, 在nasal/ethmoid and maxillary sinus那一段
79. 下列四句敘述有幾句是對的?
大人最常見的良性眼窩腫瘤是皮樣囊腫(dermoid cyst)
大人最常見的惡性眼窩腫瘤是淋巴瘤(lymphoma)
小孩最常見的良性血管性眼窩腫瘤是微血管性血管瘤(capillary hemangioma)
小孩最常見的惡性眼窩腫瘤是橫紋肌肉瘤(rhabdomyosarcoma)
(A) 一句 (B) 二句 (C) 三句 (D) 四句
Ans: C
Bailey106 page 1278 highlights
1. 錯 大人最常見的良性眼窩腫瘤是 cavernous hemangioma
2. 對 3. 對 4. 對
80. 下列那一種鼻竇-鼻腔癌(sinonasal cancer)在10到19歲及50到59歲均有較高的發生率(bimodal frequency)?
(A) 鳞狀細胞癌(squamous cell carcinoma)
(B) 腺樣囊腫癌(adenoid cystic carcinoma)
(C) 惡性黑色素瘤(malignant melanoma)
(D) 嗅神經母細胞癌(olfactory neuroblastoma)
Ans: D
Bailey105 page 1249
olfactory neuroblastoma has a bimodal frequency at 10 to 20 and 50 to 60 years of age
81. 整體而言，口腔和口咽癌的 ”潛伏”和 ”摸得到”的頸部轉移百分比約多少?
(A) 30%
(B) 40%
(C) 70%
(D) 90%
Ans: C
Bailey p.1373
70%, 在summary of incidence of occult metastasis最後一行
82. 分化良好的甲狀腺癌包括乳突癌(papillary carcinoma)和濾泡癌(follicular carcinoma)。下列四句敘述有幾句是對的?
分化良好的甲狀腺癌皆為多發性(multicentric)，且頸部淋巴結轉移率高
分化良好的甲狀腺癌多好發於女性
腫瘤大小對分化良好的甲狀腺癌皆為重要的預後因素
血管侵犯(angioinvasion)是濾泡癌最重要的預後因素
(A) 一句 (B) 二句 (C) 三句 (D) 四句
Ans:B
Bailey ch114
1) 錯 p.1386- PTC: multicentric; p.1387 FTC: multicentric is uncommon
2) 對 p1386-7: both higher in female (2-3 times)
3) 錯 p.1387: size isn’t a critical factor in the prognosis of FTC
4) 對 p.1387: prognosis is related directly to the degree of angioinvasion- correct
83. 下列何者是喉癌最重要的存活決定因子?
(A) 原發腫瘤大小
(B) 頸部轉移有無
(C) 年齡大小
(D) 抽煙習性有無
Ans:B
找不到出處
頸部轉移有無為重要的存活決定因子
94年 ENT 考題34~50 題 李彥德
94年 34~50 題 李彥德
34. 鼻內黏液主要由杯狀細胞(goblet cells)、黏膜下黏液細胞(submucosal mucus cells)、及漿黏液腺(seromucous glands)所製造，分泌過多時即造成鼻漏，下列何種物質能終止鼻內黏液的分泌?
(A) leukotrienes
(B) acetylcholine
(C) substance P
(D) atropine
An: (D) CH23 , P262左邊兩段,考鼻腔生理,Substance P, Leucotriene D4, Ach 皆與分泌有關
Atropin 為副交感阻斷劑,答案在最後一行
35. 使用口服去充血劑(oral decongestant)時，必須特別注意病人狀況及與其他藥物的交互作用，當病人具有下列那些情況時，就應避免使用口服去充血劑，選出最適當者?
1. glaucoma
2. hyperthyroidism
3. 使用monoamine oxidase (MAO)inhibitors
4. high-level athletes
(A) 1, 3, 4 (B) 1 , 2, 3 (C) 1, 2, 4
(D) 1, 2, 3, 4
An: (D) Ch25 P285左下角,考過敏性鼻炎一線用藥, decongestion drug 會有CNS, hypertension 的side effect, MAO inhibitor 可加強其作用( persist for 14 days) , 而glucoma(HTNà眼壓),hyperthyroidism , athlete 皆與血壓有關,故要注意
36. 對於使用類固醇下鼻甲注射來治療過敏性鼻炎，常會引起併發症，下列何者為誤?
(A) 會併發Blindnessàreflex vasospasm 或retrograde embolization into retinal circulation
(B) 會引起cavernous sinus thrombosis而致命 à有此可能
(C) 無法局部抑制炎症反應 à在適當條件下仍為安全有效
(D) 使用鼻噴劑類固醇，較安全有效 à鼻噴劑非侵入性,且無上述危險
An( C) CH25 P287 適當條件有四項
37. 過敏性黴菌性鼻竇炎(allergic fungal sinusitis)的診斷依據需包含下列各項，何者例外?
(A) eosinophilic mucin
(B) Charcot-Leyden crystals
(C) fungal hyphae
(D) serum fungal-specific IgE
An:(D) CH30 P348 .Patho: allergic mucin 含 sheets of eosinophils, Charcot-Leyden crystals, occasional fungal hyphae 另 Joural 8 P1245 discussion處前5行及右邊第10行有明確答案
38. 治療急性社區感染型鼻竇炎(acute community-acquired rhinosinusitis)可選用的第一線抗生素，何者正確?
1. Amoxicillin
2. Cephalexin and trimethoprim-sulfamethoxazole
3. Quinolones
4. Clarithromycin
5. Erythromycin-sulfisoxazole
(A) 1、2、4 (B) 2、3、5 (C) 1、4、5
(D) 1、2、5
An:(D) CH30 P353敘述及P354 Table 30.5 ( answer就在table中)
39. 對於鼻竇炎所引發的疼痛，下列敘述何者為誤?
(A) 慢性鼻竇炎多無頭痛或顏面痛
(B) 急性蝶竇炎會造成雙側顳部(bitemporal)頭痛及Vertex頭痛
(C) 額竇炎會造成眼後(retro-orbital)疼痛 à ethmoid / sphenoid
(D) 急性蝶竇及篩竇炎會造成疼痛可延及頸部及肩痛
An(D) CH P349 symptom 整段 及Table 30.2
Ethmoid: medial nasal & retroorbital
Sphenoid:vertex & bitemperal
Maxillary: dental pain
Sphenoid & ethmoid: occipital (後) vertex(上) parietal(側) nasal&retroorbital(內)radiation to neck & shoulder(下)
40. 半胱氨酸白三烯素(cysteinyl leukotrienes, cysLTs)在炎症反應中扮演重要角色，下列敘述何者有誤?
(A) 它會促成specific cytokines secretion
(B) 它由細胞膜上之磷脂為原料, through cyclo-oxygenase pathway 造成
(C) 它會促成纖維化及呼吸道重新朔型(airway remodeling)
(D) 它會造成血管擴張引發黏膜腫脹(mucosal edema)
An:(B) Gournal 11 Fig1 pathway, LTx synthesis走lipoxygenase ( * 字首皆L)
Table 1為其他選項
41. 關於小孩之急性鼻竇炎下列何者為真?
(A) 症狀表現與成人者相同àpresentatin of children different from adults
(B) 小孩較會產生頭痛àmuch less likely to report classic headeches
(C) 小孩常表現如感冒àusual presentation is a cold( for more than 7-10 days)
(D) 小孩常會有fetid breath and high-grade fever àlow-grade fever
An(C) Ch 30P349
42. 與過敏性鼻炎相關之全身性免疫反應何者為誤?
(A) 血液中IgE升高
(B) 血液中嗜伊紅血球增加
(C) 帶有CD25之淋巴球減少
(D) 血液中嗜鹼性血球增加
An(C) C or D 找不到出處 (help me)
43. 關於鼻出血，下列何者正確?
(A) 前鼻出血主要位於鼻中隔前側，亦即Little’s area之處，常源於動脈àvenous
(B) 後鼻出血, 最多是在後鼻部外側壁，和Woodruff naso-nasopharyngeal plexus相關à次常
(C) 前鼻出血，主要位於下鼻甲前端，常源於靜脈à鼻中隔前側
(D) 後鼻出血，最多是後鼻中隔處，常源於動脈
An:(D) CH36 P420 右邊中間
44.有關過敏性黴菌鼻竇炎Allergic Fungal Sinusitis (AFS)，下述何者為誤?
(A)常合併有鼻息肉增生,治療上為移除鼻息肉和mucin,及給予類固醇àintroduction第2段
(B) 若serum與sinus mucin fungal IgE陽性比率很高，表示IgE-mediated hypersensitivity是AFS致病機轉之重要機制
(C) Serum eosinophil count, total IgE, 與eosinophilic cationic protein(ECP)在AFS都顯著增加
à(P1246中間)serum tototal IgE 顯著增加, mucin ECP 有增加, 但serum ECP 沒增加
(D)AFS之sinus mucin, 其fungal IgE陽性比率較高
An(C) Journal 8 key point: fungal (antigen) specific IgE & ECP 只有 mucin (local) 增加
Serum 中沒影響 (與37 題比較)
45. B cells 經 allergens stimulate 會產生 IgE, 此IgE 的 half-life span about:
(A) 7.5 days
(B) 14 days
(C) 2.5 days
(D) 9.5 days
CH8 P79 右上角 although…… 那3行 (考觀念)
46. 有關小兒鼻竇炎之併發症，下列何者為非?
(A) 眼眶蜂窩性組織炎及膿瘍造成的視力喪失，部分是因視神經遭壓迫，部分是因視神經炎 à? 視力喪失從grooup 3 or 4 以後才有
(B) 腦膜炎(meningitis)是最常見之顱內併發症à brain abscess
(C) 眼窩感染最常由紙狀板直接擴散，而非經由血管傳遞àO
(D) 併發眼窩感染之治療，一定要考慮選用可通過血-腦障壁之抗生素àO prevent intracranial infection
送分CH79 P956~958
47.下列構造因天生的裂縫(dehiscence)於maxillary sinus內，因而常在作sinus curretage時被傷及，選出最不會被傷者?
(A) First molar tooth 第2段 5th~6th 行
(B) Second molar tooth 第2段 5th~6th 行
(C) infraorbital nerve 7th~8th 行
(D) nasolacrimal duct
An(D) CH28 P325 maxillary sinus
48. 下列何者為非?
(A) 急性鼻鼻竇炎在大人和小孩的常見致病菌類似 CH 30 table 30.4
(B) 慢性鼻鼻竇炎於大人常培養出厭氧菌，小孩則罕見 CH 30 table 30.4 CH49 table5
(C) 一般說來，急性鼻鼻竇炎的症狀較慢性鼻鼻竇炎嚴重
(D) 鼻竇炎的抗生素治療通常須要至少十天，甚至須要三個星期以上
An(B) CH79 CH30
49. 關於倒生性乳頭瘤，下列何者為誤?
(A) CT scan罕見破壞Maxillary sinus之後壁 àeroode lat. Nasal wall then into antrum(CH 29)
(B) 可能轉變為惡性à lateral:15% >septum (CH27)
(C) 多發生於鼻中隔 CH 105 table3 (fungiform papilloma over septum)
(D) 手術治療方法與鼻息肉不同 CH27 P315 (polyp不需lateral rhinotomy 或endoscopic medial maxillectomy)
An(C) CH27, 29 ,105
50. 抗組織胺的抗發炎作用可能經由下列何者作用來降低proinflammatory cytokines和adhesion proteins的產生?
(A) H3 receptor
(B) Calcium-ion channels
(C) Nuclear factor-kB
(D) Ikr
An(C) Journal 19 figure1 上面
34. 鼻內黏液主要由杯狀細胞(goblet cells)、黏膜下黏液細胞(submucosal mucus cells)、及漿黏液腺(seromucous glands)所製造，分泌過多時即造成鼻漏，下列何種物質能終止鼻內黏液的分泌?
(A) leukotrienes
(B) acetylcholine
(C) substance P
(D) atropine
An: (D) CH23 , P262左邊兩段,考鼻腔生理,Substance P, Leucotriene D4, Ach 皆與分泌有關
Atropin 為副交感阻斷劑,答案在最後一行
35. 使用口服去充血劑(oral decongestant)時，必須特別注意病人狀況及與其他藥物的交互作用，當病人具有下列那些情況時，就應避免使用口服去充血劑，選出最適當者?
1. glaucoma
2. hyperthyroidism
3. 使用monoamine oxidase (MAO)inhibitors
4. high-level athletes
(A) 1, 3, 4 (B) 1 , 2, 3 (C) 1, 2, 4
(D) 1, 2, 3, 4
An: (D) Ch25 P285左下角,考過敏性鼻炎一線用藥, decongestion drug 會有CNS, hypertension 的side effect, MAO inhibitor 可加強其作用( persist for 14 days) , 而glucoma(HTNà眼壓),hyperthyroidism , athlete 皆與血壓有關,故要注意
36. 對於使用類固醇下鼻甲注射來治療過敏性鼻炎，常會引起併發症，下列何者為誤?
(A) 會併發Blindnessàreflex vasospasm 或retrograde embolization into retinal circulation
(B) 會引起cavernous sinus thrombosis而致命 à有此可能
(C) 無法局部抑制炎症反應 à在適當條件下仍為安全有效
(D) 使用鼻噴劑類固醇，較安全有效 à鼻噴劑非侵入性,且無上述危險
An( C) CH25 P287 適當條件有四項
37. 過敏性黴菌性鼻竇炎(allergic fungal sinusitis)的診斷依據需包含下列各項，何者例外?
(A) eosinophilic mucin
(B) Charcot-Leyden crystals
(C) fungal hyphae
(D) serum fungal-specific IgE
An:(D) CH30 P348 .Patho: allergic mucin 含 sheets of eosinophils, Charcot-Leyden crystals, occasional fungal hyphae 另 Joural 8 P1245 discussion處前5行及右邊第10行有明確答案
38. 治療急性社區感染型鼻竇炎(acute community-acquired rhinosinusitis)可選用的第一線抗生素，何者正確?
1. Amoxicillin
2. Cephalexin and trimethoprim-sulfamethoxazole
3. Quinolones
4. Clarithromycin
5. Erythromycin-sulfisoxazole
(A) 1、2、4 (B) 2、3、5 (C) 1、4、5
(D) 1、2、5
An:(D) CH30 P353敘述及P354 Table 30.5 ( answer就在table中)
39. 對於鼻竇炎所引發的疼痛，下列敘述何者為誤?
(A) 慢性鼻竇炎多無頭痛或顏面痛
(B) 急性蝶竇炎會造成雙側顳部(bitemporal)頭痛及Vertex頭痛
(C) 額竇炎會造成眼後(retro-orbital)疼痛 à ethmoid / sphenoid
(D) 急性蝶竇及篩竇炎會造成疼痛可延及頸部及肩痛
An(D) CH P349 symptom 整段 及Table 30.2
Ethmoid: medial nasal & retroorbital
Sphenoid:vertex & bitemperal
Maxillary: dental pain
Sphenoid & ethmoid: occipital (後) vertex(上) parietal(側) nasal&retroorbital(內)radiation to neck & shoulder(下)
40. 半胱氨酸白三烯素(cysteinyl leukotrienes, cysLTs)在炎症反應中扮演重要角色，下列敘述何者有誤?
(A) 它會促成specific cytokines secretion
(B) 它由細胞膜上之磷脂為原料, through cyclo-oxygenase pathway 造成
(C) 它會促成纖維化及呼吸道重新朔型(airway remodeling)
(D) 它會造成血管擴張引發黏膜腫脹(mucosal edema)
An:(B) Gournal 11 Fig1 pathway, LTx synthesis走lipoxygenase ( * 字首皆L)
Table 1為其他選項
41. 關於小孩之急性鼻竇炎下列何者為真?
(A) 症狀表現與成人者相同àpresentatin of children different from adults
(B) 小孩較會產生頭痛àmuch less likely to report classic headeches
(C) 小孩常表現如感冒àusual presentation is a cold( for more than 7-10 days)
(D) 小孩常會有fetid breath and high-grade fever àlow-grade fever
An(C) Ch 30P349
42. 與過敏性鼻炎相關之全身性免疫反應何者為誤?
(A) 血液中IgE升高
(B) 血液中嗜伊紅血球增加
(C) 帶有CD25之淋巴球減少
(D) 血液中嗜鹼性血球增加
An(C) C or D 找不到出處 (help me)
43. 關於鼻出血，下列何者正確?
(A) 前鼻出血主要位於鼻中隔前側，亦即Little’s area之處，常源於動脈àvenous
(B) 後鼻出血, 最多是在後鼻部外側壁，和Woodruff naso-nasopharyngeal plexus相關à次常
(C) 前鼻出血，主要位於下鼻甲前端，常源於靜脈à鼻中隔前側
(D) 後鼻出血，最多是後鼻中隔處，常源於動脈
An:(D) CH36 P420 右邊中間
44.有關過敏性黴菌鼻竇炎Allergic Fungal Sinusitis (AFS)，下述何者為誤?
(A)常合併有鼻息肉增生,治療上為移除鼻息肉和mucin,及給予類固醇àintroduction第2段
(B) 若serum與sinus mucin fungal IgE陽性比率很高，表示IgE-mediated hypersensitivity是AFS致病機轉之重要機制
(C) Serum eosinophil count, total IgE, 與eosinophilic cationic protein(ECP)在AFS都顯著增加
à(P1246中間)serum tototal IgE 顯著增加, mucin ECP 有增加, 但serum ECP 沒增加
(D)AFS之sinus mucin, 其fungal IgE陽性比率較高
An(C) Journal 8 key point: fungal (antigen) specific IgE & ECP 只有 mucin (local) 增加
Serum 中沒影響 (與37 題比較)
45. B cells 經 allergens stimulate 會產生 IgE, 此IgE 的 half-life span about:
(A) 7.5 days
(B) 14 days
(C) 2.5 days
(D) 9.5 days
CH8 P79 右上角 although…… 那3行 (考觀念)
46. 有關小兒鼻竇炎之併發症，下列何者為非?
(A) 眼眶蜂窩性組織炎及膿瘍造成的視力喪失，部分是因視神經遭壓迫，部分是因視神經炎 à? 視力喪失從grooup 3 or 4 以後才有
(B) 腦膜炎(meningitis)是最常見之顱內併發症à brain abscess
(C) 眼窩感染最常由紙狀板直接擴散，而非經由血管傳遞àO
(D) 併發眼窩感染之治療，一定要考慮選用可通過血-腦障壁之抗生素àO prevent intracranial infection
送分CH79 P956~958
47.下列構造因天生的裂縫(dehiscence)於maxillary sinus內，因而常在作sinus curretage時被傷及，選出最不會被傷者?
(A) First molar tooth 第2段 5th~6th 行
(B) Second molar tooth 第2段 5th~6th 行
(C) infraorbital nerve 7th~8th 行
(D) nasolacrimal duct
An(D) CH28 P325 maxillary sinus
48. 下列何者為非?
(A) 急性鼻鼻竇炎在大人和小孩的常見致病菌類似 CH 30 table 30.4
(B) 慢性鼻鼻竇炎於大人常培養出厭氧菌，小孩則罕見 CH 30 table 30.4 CH49 table5
(C) 一般說來，急性鼻鼻竇炎的症狀較慢性鼻鼻竇炎嚴重
(D) 鼻竇炎的抗生素治療通常須要至少十天，甚至須要三個星期以上
An(B) CH79 CH30
49. 關於倒生性乳頭瘤，下列何者為誤?
(A) CT scan罕見破壞Maxillary sinus之後壁 àeroode lat. Nasal wall then into antrum(CH 29)
(B) 可能轉變為惡性à lateral:15% >septum (CH27)
(C) 多發生於鼻中隔 CH 105 table3 (fungiform papilloma over septum)
(D) 手術治療方法與鼻息肉不同 CH27 P315 (polyp不需lateral rhinotomy 或endoscopic medial maxillectomy)
An(C) CH27, 29 ,105
50. 抗組織胺的抗發炎作用可能經由下列何者作用來降低proinflammatory cytokines和adhesion proteins的產生?
(A) H3 receptor
(B) Calcium-ion channels
(C) Nuclear factor-kB
(D) Ikr
An(C) Journal 19 figure1 上面
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