10 ENT/Otolaryngology Flashcards
A 15-year-old girl has a round, 1-cm cystic mass in the midline of her neck at the level of the hyoid bone. When the mass is palpated at the same time that the tongue is pulled, there seems to be a connection between the two. The mass has been present for at least 10 years, but only recently bothered the patient because it got infected.
What is it? Thyroglossal duct cyst.
Management. Sistrunk operation (removal of the mass and the track to the base of the tongue, along with the medial segment of the hyoid bone). Some people insist that the location of the normal thyroid must be ascertained first with radioisotope scanning.
An 18-year-old woman has a 4-cm, fluctuant round mass on the side of her neck, just beneath and in front of the sternomastoid. She reports that it has been there at least 10 years, although she thinks that it has become somewhat larger in the last year or two. A CT scan shows the mass to be cystic.
This is a branchial cleft cyst. Do elective surgical removal.
A 6-year-old child has a mushy, fluid-filled mass at the base of the neck that has been noted for several years. The mass is about 6 cm in diameter, occupies most of the supraclavicular area and seems by physical examination to go deeper into the neck and chest.
What is it? Cystic hygroma.
Management. Get a CT scan to see how deep this thing goes. They can extend down into the chest and mediastinum. Surgical removal will eventually be done.
A 22-year-old lady notices an enlarged lymph node in her neck. The node is in the jugular chain, measures about 1.5 cm, is not tender, and was discovered by the patient yesterday. The rest of the history and physical examination are unremarkable.
Management. Before you spend a ton of money doing a million tests, let time be your ally. Schedule the patient to be rechecked in 3 weeks. If the node has gone away by then, it was inflammatory and nothing further is needed. If it’s still there, it could be neoplastic and something needs to be done. Three weeks of delay will not significantly impact the overall course of a neoplastic process.
A 22-year-old woman seeks help regarding an enlarged lymph node in her neck. The node is in the jugular chain, measures about 2 cm, is firm, not tender, and was discovered by the patient 6 weeks ago. There is a history of low-grade fever and night sweats for the past 3 weeks. Physical examination reveals enlarged lymph nodes in both axillas and in the left groin.
What is it? Lymphoma.
Management. Tissue diagnosis will be needed. You can start with FNA of the available nodes, but eventually node biopsy will be needed to establish not only the diagnosis but also the type of lymphoma.
A 72-year-old man has a 4-cm hard mass in the left supraclavicular area. The mass is movable and not tender and has been present for 3 months. The patient has had a 20-pound weight loss in the past 2 months, but is otherwise asymptomatic.
What is it? Malignant metastases to a supraclavicular node from a primary tumor below the neck. The vignette may include a few clues to suggest which one.
Diagnosis. Look for the obvious primary tumors: lung, stomach, colon, pancreas, kidney. The node itself may eventually be biopsied.
A 69-year-old man who smokes and drinks and has rotten teeth has a hard, fixed, 4-cm mass in his neck. The mass is just medial and in front of the sternomastoid muscle, at the level of the upper notch of the thyroid cartilage. It has been there for at least 6 months, and it is growing.
What is it? Metastatic squamous cell carcinoma to a jugular chain node, from a primary in the mucosa of the head and neck (oropharyngeal–laryngeal territory).
Management. Don’t biopsy the node! FNA is okay, but the best answer is to do a triple endoscopy (examination under anesthesia of the mouth, pharynx, larynx, esophagus, and tracheobronchial tree), also known as a panendoscopy. CT scan will follow, to determine extent and operability. Most patients get combined therapy that includes radiation, platinum-based chemotherapy, and
surgery if possible.
I. A 69-year-old man who smokes and drinks and has rotten teeth has hoarseness that has persisted for 6 weeks in spite of antibiotic therapy.
II. A 69-year-old man who smokes and drinks and has rotten teeth has a painless ulcer in the floor of the mouth that has been present for 6 weeks and has not healed.
III. A 23-year-old man with AIDS has a painless ulcer in the floor of the mouth that has been present for 6 weeks and has not healed. He does not smoke or drink.
IV. A 69-year-old man who smokes and drinks and has rotten teeth has a unilateral earache that has not gone away in 6 weeks. Physical examination shows serous otitis media on that side, but not on the other.
What are they? These are all different ways for squamous cell carcinoma of the mucosa of the head and neck to show up. They all need triple endoscopy to find and biopsy the primary tumor and to look for synchronous second primaries. Although the classic candidate for this disease is the older man who smokes and drinks, patients with AIDS also have very high incidence—with similar presentations.
A 52-year-old man complains of hearing loss. When tested he is found to have unilateral sensory hearing loss on one side only. He does not engage in any activity (such as sport shooting) that would subject that ear to noise that spares the other side.
What is it? Unilateral versions of common ear, nose, and throat (ENT) problems in the adult suggest malignancy. In this case, acoustic nerve neuroma. Note that if the hearing loss had been conductive, a cerumen plug would be the obvious first diagnosis.
Diagnosis. MRI looking for the tumor.
A 56-year-old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full-blown paralysis to become obvious, and it has been present now for 3 months. It affects both the forehead and the lower face.
What is it? Gradual, unilateral nerve paralysis suggests a neoplastic process.
Diagnosis. Gadolinium-enhanced MRI.
A 45-year-old man presents with a 2-cm firm mass in front of the left ear, which has been present for 4 months. The mass is deep to the skin, and it is painless. The patient has normal function of the facial nerve.
What is it? Pleomorphic adenoma (mixed tumor) of the parotid gland.
Diagnosis. FNA is appropriate, but the point of the question will be to bring out the fact that parotid masses are never biopsied in the office or under local anesthesia. Look for the option that offers referral to a head and neck surgeon for formal superficial parotidectomy.
A 65-year-old man presents with a 4-cm hard mass in front of the left ear, which has been present for 6 months. The mass is deep to the skin, and it is fixed. He has constant pain in the area, and for the past 2 months has had gradual progression of left facial nerve paralysis. He has rock-hard lymph nodes in the left neck.
This one is parotid cancer, but the point is the same: let the experts manage it.
I. A 2-year-old has unilateral earache.
II. A 2-year-old has unilateral foul-smelling purulent rhinorrhea.
III. A 2-year-old has unilateral wheezing, and the lung on that side looks darker on X-rays (more air) than the other side.
What are they? Unilateral versions of common bilateral ENT conditions in toddlers suggest foreign body. Appropriate x-rays, physical examination or endoscopies, and extraction—obviously under anesthesia.
A 45-year-old lady with a history of a recent tooth infection shows up with a huge, hot, red, tender fluctuant mass occupying the left lower side of the face and upper neck, including the underside of the mouth. The mass pushes up the floor of the mouth on that side. She is febrile.
What is it? Ludwig angina (an abscess of the floor of the mouth).
Management. The special issue is the need to maintain an airway. Incision and drainage are needed, but intubation or tracheostomy may also be required.
A 29-year-old lady calls your office at 10 am with the history that she woke up that morning with one side of her face paralyzed.
Obviously Bell palsy. The latest trend is to start these patients right away on antiviral medication and steroids.
