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ENT > 2: Pharyngitis, Tonsillitis, Head and Neck Cancers > Flashcards

2: Pharyngitis, Tonsillitis, Head and Neck Cancers Flashcards

1
Q

What is pharyngitis

A

Inflammation of the pharynx

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2
Q

What are the viral causes of pharyngitis

A

EBV
Adenovirus
Influenza vira
Parainfluenza virus

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3
Q

What are the bacterial causes of pharyngitis

A

Group A Streptococcus

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4
Q

In low income countries, what may cause pharyngitis

A

Diptheria

Measles

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5
Q

What can cause pharyngitis in immunocompromised patients or those undergoing irradiation for cancer

A

Candida

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6
Q

What type of pharyngitis is more common in winter - spring

A

Bacterial

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7
Q

What are the bacterial causes of pharyngitis

A

Group A streptococcus

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8
Q

What type of pharyngitis is more common in summer-autumn

A

Viral

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9
Q

What are the viral causes of pharyngitis

A

EBV

Adenovirus

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10
Q

How will pharyngitis present

A 
Sore throat 
Fever 
Pharyngeal exudate 
Cervical lymphadenopathy 
Rhinorrhoea
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11
Q

What is first-line for all cases of pharyngitis

A

Paracetamol

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12
Q

What criteria is used in pharyngitis

A

CENTOR

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13
Q

What is the centor criteria used for

A

To determine if pharyngitis is due to bacterial infection and hence individual should have antibiotics

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14
Q

Outline the centor criteria

A

Individual needs >3/4 to be prescribed antibiotics:

(CENTor):
Cough absent

Exudate on tonsils

Nodes enlarged

Tender cervical lymphadenopathy

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15
Q

What is an alternative scoring system for pharyngitis/tonsillitis

A

Fever PAIN

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16
Q

Explain fever pain criteria

A

(F-PAIN)

Fever in past 24h 
Pus on tonsils
Anterior lymphadenopathy 
Inflamed tonsils
No coryzal
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17
Q

What does individual need on fever pain criteria to obtain antibiotics

A

4

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18
Q

What are the indications for sending someone with pharyngitis to hospital

A
  • Systemic infections

- Local complications: quinsy, parapharyngeal abscess, cellulitis, lemierre syndrome

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19
Q

What antibiotics are given first-line for pharyngitis

A

Phenoxymethylpenicillin

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20
Q

What are 3 complications of group A streptococcus pharyngitis

A
  1. Post-streptococcal
    glomerulonephritis
  2. Rheumatic fever
  3. Scarlet fever
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21
Q

Define tonsillitis

A

Inflammation of palatine tonsils

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22
Q

When are viruses a more common cause of tonsillitis

A

<5

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23
Q

When are bacteria a more common cause of tonsillitis

A

5-15

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24
Q

What are 2/3 tonsillitis caused by

A

Viruses

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25
Q

What are the viral causes of tonsillitis

A

Adenovirus
EBV
Influenza
Parainfluenza

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26
Q

What is the most common cause of bacterial tonsillitis

A

S. Pyogenes

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27
Q

What are 3 symptoms of tonsillitis

A
  1. Odynophagia
  2. Halitosis
  3. Fever
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28
Q

What are 3 signs of tonsillitis

A

Erythematous
Exudate
Cervical lymphadenopathy

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29
Q

What criteria is used in tonsillitis to determine probability it is bacterial and hence needs antibiotics

A

Centor

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30
Q

What is first-line management for tonsillitis for all individuals

A

Analgesia

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31
Q

What scoring systems are used to determine if someone needs antibiotics in tonsillitis

A

Fever Pain

Centor

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32
Q

What does the centor criteria state

A

Cough absent
Exudate
Nodes tender
T >38

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33
Q

What score is needed on centor criteria for antibiotics

A

> 3

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34
Q

What is the fever pain criteria

A 
Fever
Pus
Acute presentation - 3d
Inflammation
No coryzal symptoms
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35
Q

What score is needed on fever pain for antibiotics

A

> 4

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36
Q

If an individual scores fever 2-3 what is recommended

A

Provide ‘back-up’ antibiotic prescription. Recommend they use it if symptoms do not resolve in 2-3d

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37
Q

What antibiotic is given in tonsillitis

A

Phenoxymethylpenicillin

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38
Q

What are the 6 indications for tonsillectomy

A
  1. 7 episodes in 1y
  2. 5 episodes in 2y
  3. 3 episodes in 3y
  4. Quinsy
  5. Sleep apnea
  6. Malignancy
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39
Q

What is a complication of bacterial tonsillitis

A

Quinsy

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40
Q

What is quinsy

A

Peri-tonsillar abscess

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41
Q

How can quinsy be identified

A

Deviation of the uvula

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42
Q

How is quinsy managed

A

I+D, metronidazole, amoxicillin

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43
Q

What is pharyngeal abscess

A

Infection spreads from tonsil to fascial planes

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44
Q

What is a retropharyngeal abscess

A

Abscess formation in paravertebral space

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45
Q

What is a parapharyngeal abscess

A

Abscess spreads posterolateral to nasopharynx

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46
Q

How will a pharyngeal abscess present

A

Reduced neck movement and pain

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47
Q

What is used to investigate a pharyngeal abscess

A

CT w/IV contrast

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48
Q

What are the indications for tonsillectomy

A
  1. 7 episodes in 1-year (8)
  2. 5 episodes in 2-years (7)
  3. 3 episodes in 3-years (6)
  4. Quinsy
  5. Sleep apnea
  6. Suspected malignancy
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49
Q

what is the time frame for immediate complications of tonsillectomy

A

<24h

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50
Q

what are 3 immediate complications

A
  • Primary haemorrhage
  • Aspiration
  • Laryngospasm
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51
Q

what are 2 early complications.

A
  • Secondary haemorrhage

- Airway obstruction due to oedema

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52
Q

when does secondary haemorrhage occur

A

Usually 5-10d

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53
Q

what causes secondary haemorrhage

A

Infection of the tonsillar fossa

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54
Q

what are the two delayed complications of tonsillectomy

A

Abscess

Nasopharyngeal stenosis

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55
Q

what is the term head and neck cancer used to refer to

A

Cancers of:

  • Nasophargyneal
  • Orophargyneal
  • Pharynx
  • Larynx
  • Salivary glands
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56
Q

where type of cancer are 90% of head and neck cancers

A

Squamous Cell Carcinoma

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57
Q

what are head and neck cancers collectively referred to as

A

Head and Neck Squamous Cell Carcinoma (HNSCC)

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58
Q

what are three pre-malignant conditions for HNSCC

A

Leucoplakia = white patches

Erythroplakia = red patches

Erythroleucoplakia = red and white patches

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59
Q

what is leukoplakia

A

White patches

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60
Q

what is erythroplakia

A

Red patches

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61
Q

what is erythroleukoplakia

A

Red and White Patches

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62
Q

what are pre-malignant conditions associated with

A

Smoking and alcohol consumption

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63
Q

what is the risk of pre-malignant condition transforming to malignancy

A

20%

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64
Q

in which gender are HNSCC more common

A

Male

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65
Q

why is incidence of oral cancer thought to be increasing

A

Increased immigration - with other countries chewing more betel quid

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66
Q

why is incidence of oropharyngeal cancer increasing

A

Associated with HPV in younger people

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67
Q

why is incidence of laryngeal cancer decreasing

A

Decrease smoking rates

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68
Q

What is strongly linked to oropharyngeal cancer

A

HPV16

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69
Q

What is linked to oral cancer

A

Betel Quid

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70
Q

What is linked to sinonasal cancer

A

wood dust exposure

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71
Q

What is linked to nasopharyngeal cancer

A

EBV

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72
Q

What is a hoarse voice

A

Weak or altered voice

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73
Q

What is the most common cause of hoarse voice

A

Laryngitis

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74
Q

What are the 4 categories for dividing the aetiology of hoarse voice

A
  1. Benign
  2. Malignant
  3. Infective
  4. Neurological
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75
Q

What are the 6 benign causes of hoarse voice

A
  1. Vocal cord nodules
  2. Vocal cord papilloma
  3. Muscle tension dysphonia
  4. Vocal cord polyps
  5. Laryngeal papilloma
  6. Reflux laryngitis
  7. Reinke’s Oedema
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76
Q

What causes vocal cord nodules

A

Chronic vocal cord abuse

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77
Q

How do vocal cord nodules present clinically

A

Husky variable voice

78
Q

How do vocal cord nodules present on the vocal cords

A

Bilateral.

Commonly located between anterior and middle third of the vocal cords

79
Q

How are vocal cord nodules managed

A

SALT

80
Q

What causes progressive muscle tension dysphonia

A

Habitual mis-use of larynx

81
Q

How does muscle tension dysphonia present clinically

A

Hoarse voice worse towards end of the day

82
Q

How is muscle tension dysphonia managed

A

SALT

83
Q

How do vocal cord polyps present on the vocal cords

A

Unilateral, Benign

84
Q

What is the difference in presentation between vocal cord polyps and vocal cord nodules

A

Vocal cord polyp = unilateral

Vocal cord nodules = bilateral

85
Q

How are vocal cord polyps managed and why

A

Surgical excision to exclude cancer

86
Q

What is laryngeal papilloma

A

Benign lesions caused by HPV

87
Q

What is the problem with laryngeal papilloma

A

Can grow to cause airway obstruction

88
Q

How are laryngeal papilloma’s managed

A

Regular surgical debunking

89
Q

What is reflux laryngitis

A

GORD - cause hoarse voice

90
Q

What is Reinke’s oedema

A

Inflammation of the vocal cords

91
Q

What is the stereotypical presentation for Reinke’s oedema

A

Female, Smoker

92
Q

What are two risk factors for Reinke’s oedema

A

Hypothyroidism

Elderly

93
Q

How is Reinke’s oedema managed

A

Smoking cessation

Voice therapy

94
Q

What are the two infective causes of hoarse voice

A

Laryngitis

Acute epiglottis

95
Q

What is a malignant cause of hoarse voice

A

Laryngeal Cancer

96
Q

How will hoarse voice in laryngeal cancer present

A

Progressive hoarse voice

97
Q

What is a neurological cause of hoarse voice

A

Recurrent laryngeal nerve palsy

98
Q

What muscles of the larynx does the recurrent laryngeal nerve innervate

A

All intrinsic muscles of the larynx except the cricothyroid

99
Q

What are the symptoms of recurrent laryngeal nerve palsy

A
  • Bovine cough
  • Exertional Dyspnoea
  • Aspiration
100
Q

Why do individuals with recurrent laryngeal nerve palsy get exertion dyspnoea

A

At rest the other vocal cord (if intact recurrent laryngeal nerve) can compensate by abducting to let air through. On exertion, not enough air can pass

101
Q

What is bovine cough

A

Non-explosive cough when one of vocal cords cannot close

102
Q

What causes majority of recurrent laryngeal nerve palsies

A

Cancer (30%) - larynx, thyroid, oesophagus, hypo pharynx

103
Q

What is the second most-common cause of recurrent laryngeal nervepalsy

A

Iatrogenic (25%)

104
Q

What 3 iatrogenic procedures can cause recurrent laryngeal nerve palsy

A

Parathyroidectomy

Thyroidectomy

Oesophageal pouch surgery

105
Q

What CNS causes of recurrent laryngeal nerve palsy

A

MS

Polio

106
Q

What are 3 other causes of recurrent laryngeal nerve palsy

A

TB

Aortic aneurysm

Idiopathic (post-viral neuropathy)

107
Q

If someone has symptoms of recurrent laryngeal nerve palsy, with no recent history of surgery, what is first-line investigation

A

CXR

108
Q

If CXR is negative, what three investigations should be ordered

A
  1. CT Chest
  2. US Thyroid
  3. OGD
109
Q

Who should be investigated with hoarseness of voice

A

Any smoker with hoarseness for more than 3W should be investigated as this is the chief and only presenting symptom of laryngeal cancer

110
Q

What is first-line investigation for laryngeal carcinoma

A

Flexible nasoendoscopy

111
Q

What does flexible nasoendoscopy enable visualisation of

A

Vocal cords and larynx

112
Q

What is second-line investigation for laryngeal cancer

A

Microlaryngotracheobronchoscopy

113
Q

What does microlaryngealbronchoscopy enable visualisation of

A

Visualisation vocal cords, larynx and bronchioles

114
Q

Where is microlaryngobronchoscopy performed

A

In theatres - as it needs GA

115
Q

What is stroboscopy

A

Enables visualisation of function of vocal cords

116
Q

What enables voice

A

Abduction and adduction of vocal cords innervated by recurrent laryngeal and superior laryngeal nerves

117
Q

What is the most common head and neck cancer

A

Laryngeal cancer

118
Q

What is laryngeal cancer

A

SCC of the larynx

119
Q

In which age does laryngeal cancer occur

A

Elderly

120
Q

If laryngeal cancer occurs young patients what is it associated with

A

HPV

121
Q

What are 3 risk factors for laryngeal cancer

A

Smoking
Alcohol
Irradiation to head + neck

122
Q

How does laryngeal cancer present clinically

A
  • Progressive hoarseness
  • Dysphagia
  • Cough
  • Referred Otalgia
  • Stridor = late sign
123
Q

When will laryngeal cancer cause hoarse voice

A

If in glotting or on vocal cords

124
Q

How is the larynx divided

A

Supraglottis
Glottis
Subglottis

125
Q

When should a patient be referred in 2W pathway for laryngeal cancer

A

Unexplained neck lump

Hoarse voice

126
Q

What is first-line investigation for laryngeal cancer

A

Laryngoscopy and biopsy

127
Q

What is second-line investigation for laryngeal cancer

A

CXR

128
Q

What is third-line investigation for laryngeal cancer

A

CT Chest

129
Q

What is fourth-line investigation for laryngeal cancer

A

MRI Neck

130
Q

What is CT chest used to investigate for

A

Lung metastses

131
Q

What is MRI neck used to look for

A

Erosion thyroid cartilage and enlarged lymph nodes

132
Q

How are small tumours (T1,T2) of the supra glottis managed

A

Resection via trans-oral microsurgery with neck dissection.

133
Q

How are large tumours (T3,T4) of the supra glottis managed

A

Laryngectomy with chemoradiotherapy

134
Q

How are small tumours of the glottis (T1, T2) managed

A

Resection via trans-oral microsurgery with neck dissection.

135
Q

How are large tumours of the glottis (T4) managed

A

Laryngectomy with chemoradiotherapy and neck dissection

136
Q

How are small tumours of the subglottis (T1, T2) managed

A

Resection via trans-oral microsurgery with neck dissection.

137
Q

How are large tumours of the subglottis (T4) managed

A

Laryngectomy with chemoradiotherapy and neck dissection

138
Q

Explain laryngectomy

A

Removal of the larynx. The trachea is then brought out to the skin to enable voice. The pharynx is attached to the oesophagus.

139
Q

What are the two methods of voice restoration following laryngectomy

A
  • Trans-oesophageal puncture

- Artificial larynx

140
Q

Explain trans-oesophageal puncture

A

One-way prosthesis is inserted between the trachea and oesophageal/larynx segment. When patient occludes their stoma and breathes out, this prosthesis vibrates enabling speech.

141
Q

What is used of a trans-oesephageal puncture cannot be used

A

Artificial larynx (Servox)

142
Q

What is a servox

A

Vibrating larynx is placed against patients stoma - this enables vibration of pharynx to produce speech.

143
Q

Which laryngeal cancer patients have a better prognosis and why

A

Those with glottis tumours, as they present with hoarse voice earlier. Glottis also has poor lymphatic drainage preventing metastases.

144
Q

What are two complications of radiotherapy to the head and neck

A

Mucositis

Xerostomia

145
Q

What is oropharyngeal cancer

A

SCC of the oropharynx

146
Q

In which gender is oropharyngeal cancer more common

A

Male (4:1)

147
Q

Why is incidence of oropharyngeal cancer increasing in young people

A

Due to HPV

148
Q

What is a main risk factor for oropharyngeal cancer

A

HPV16

149
Q

What head and neck cancers is HPV16 associated with

A

Tongue
Tonsil
Oropharynx

150
Q

What are two risk factors for oropharyngeal cancers

A

Pipe smoking

Chewing tobacco

151
Q

What are the clinical signs of oropharyngeal cancer

A 
Odynophagia
Dysphagia
Stertor 
Referred otalgia 
Enlarged cervical lymph nodes
152
Q

If there is a neck lump what should be performed

A

FNA

Core biopsy

153
Q

What is used to grade oropharyngeal cancer

A

Panendoscopy and biopsy

154
Q

What is a panendoscopy

A 
Investigation of upper aerodigestive tract:
Larynx 
Pharynx 
Trachea
Oeseophagus
155
Q

What is a CT Chest used for

A

Staging

156
Q

What is an MRI neck used for

A

Staging

157
Q

How are small oropharyngeal cancers managed

A

Surgical resection with neck dissection and radiotherapy

158
Q

How are large oropharyngeal cancers managed

A

Chemoradiotherapy

159
Q

What is nasopharyngeal cancer

A

SCC of the nasopharynx

160
Q

What is the peak age for nasopharyngeal cancer

A

40-60

161
Q

What ethnicity is nasopharyngeal cancer more common

A

China

Mediterranean

162
Q

What is the syndrome classical for nasopharyngeal cancer

A

Trotter’s syndrome

163
Q

What is trotter’s syndrome

A
  1. Unilateral conductive deafness
  2. Unilateral trigeminal neuralgia
  3. Impaired mobility of the soft-palate
164
Q

What causes unilateral conductive deafness in nasopharyngeal cancer

A

Due to obstruction of the Eustachian tube results in effusion of the middle ear

165
Q

What causes trigeminal neuralgia in nasopharyngeal cancer

A

Peri-neural invasion

166
Q

What is the most common symptom of nasopharyngeal cancer

A

Enlarged painless cervical lymphandeopathy

167
Q

What are 3 other nasal symptoms of nasopharyngeal cancer

A

Bleeding
Obstruction
Discharge

168
Q

What investigations are used for nasopharyngeal cancer

A

Nasoendoscopy

MRI Neck

US-guided FNA of lymph nodes

169
Q

What is used to manage nasopharyngeal cancer

A

Chemoradiotherapy and surgical neck dissection

170
Q

What is hypo pharyngeal cancer

A

SCC of the hypo pharynx

171
Q

How common is hypo pharyngeal cancer

A

Rare

172
Q

Why do hypo pharyngeal cancers often present at a late stage

A

Due to rich lymphatic drainage of the hypopharynx

173
Q

How will hypo-pharyngeal cancers present

A
  • Lump in the throat which may cause dysphagia and odynophagia
  • Referred otalgia
  • Hoarse voice
174
Q

What is a pre-malignant condition of hypo pharyngeal cancer

A

Leucoplakia

Plummer-vinson

175
Q

How are hypo pharyngeal cancers investigated

A

Panendoscopy

CT Head and Neck

176
Q

What are oral cancers

A

SCC of oral mucosa, salivary glands or tonsils

177
Q

What are 4 risk factors for oral cancer

A
  1. HPV16
  2. Chewing betel quid
  3. Pre-malignant lesions (erythroplakia, leukoplakia or erythroleukoplakia)
  4. Smoking
178
Q

How may oral cancers present clinically

A
  • Painless mass
  • Bleeding
  • Jaw swelling
  • Referred otalgia
  • Enlarged lymph nodes
  • Pre-malignant conditions
179
Q

What are 4 reasons to refer someone under 2W pathway for oral cancer

A
  1. Persistent non-healing oral ulcer for more than 3W
  2. Oral lump
  3. Unexplained neck swelling
  4. Erythroplakia or erythroleukoplakia
180
Q

What four-investigations are ordered for oral cancer

A
  1. Biopsy
  2. Panendoscopy
  3. CT head and neck
  4. MRI head and neck
181
Q

Why is MRI ordered as well as CT

A

As MRI is superior for assessing oral and oropharyngeal cancers

182
Q

How are T1-T2 oral tumours managed

A

WLE

Neck dissection

183
Q

How are T3-T4 oral tumours managed

A

Surgical excision - w/flap
Neck dissection
Chemoradiotherapy

184
Q

How are metastatic tumours managed in oral cancer

A

Cetuximab

185
Q

What are two causes of parotid carcinoma

A

HPV

Previous irradiation

186
Q

How will parotid carcinoma present

A

Painless swelling

Facial paralysis - if infiltrates facial nerve

187
Q

What is used to diagnose parotid carcinoma

A

US-guided FNA

CT neck and chest

188
Q

How is parotid carcinoma removed

A

Parotidectomy, neck dissection and radiotherapy

189
Q

What is an early complication of parotidectomy

A

Facial paralysis

190
Q

What are two syndromes that are complications of parotidectomy

A

Frey Syndrome

Crocodile tears

191
Q

What is Frey Syndrome

A

Where gustatory stimuli cause facial flushing and sweating

192
Q

What are crocodile tears

A

Gustatory stimuli cause lacrimation

ENT (16 decks)

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