2: Pharyngitis, Tonsillitis, Head and Neck Cancers Flashcards
What is pharyngitis
Inflammation of the pharynx
What are the viral causes of pharyngitis
EBV
Adenovirus
Influenza vira
Parainfluenza virus
What are the bacterial causes of pharyngitis
Group A Streptococcus
In low income countries, what may cause pharyngitis
Diptheria
Measles
What can cause pharyngitis in immunocompromised patients or those undergoing irradiation for cancer
Candida
What type of pharyngitis is more common in winter - spring
Bacterial
What are the bacterial causes of pharyngitis
Group A streptococcus
What type of pharyngitis is more common in summer-autumn
Viral
What are the viral causes of pharyngitis
EBV
Adenovirus
How will pharyngitis present
Sore throat Fever Pharyngeal exudate Cervical lymphadenopathy Rhinorrhoea
What is first-line for all cases of pharyngitis
Paracetamol
What criteria is used in pharyngitis
CENTOR
What is the centor criteria used for
To determine if pharyngitis is due to bacterial infection and hence individual should have antibiotics
Outline the centor criteria
Individual needs >3/4 to be prescribed antibiotics:
(CENTor):
Cough absent
Exudate on tonsils
Nodes enlarged
Tender cervical lymphadenopathy
What is an alternative scoring system for pharyngitis/tonsillitis
Fever PAIN
Explain fever pain criteria
(F-PAIN)
Fever in past 24h Pus on tonsils Anterior lymphadenopathy Inflamed tonsils No coryzal
What does individual need on fever pain criteria to obtain antibiotics
4
What are the indications for sending someone with pharyngitis to hospital
- Systemic infections
- Local complications: quinsy, parapharyngeal abscess, cellulitis, lemierre syndrome
What antibiotics are given first-line for pharyngitis
Phenoxymethylpenicillin
What are 3 complications of group A streptococcus pharyngitis
- Post-streptococcal
glomerulonephritis - Rheumatic fever
- Scarlet fever
Define tonsillitis
Inflammation of palatine tonsils
When are viruses a more common cause of tonsillitis
<5
When are bacteria a more common cause of tonsillitis
5-15
What are 2/3 tonsillitis caused by
Viruses
What are the viral causes of tonsillitis
Adenovirus
EBV
Influenza
Parainfluenza
What is the most common cause of bacterial tonsillitis
S. Pyogenes
What are 3 symptoms of tonsillitis
- Odynophagia
- Halitosis
- Fever
What are 3 signs of tonsillitis
Erythematous
Exudate
Cervical lymphadenopathy
What criteria is used in tonsillitis to determine probability it is bacterial and hence needs antibiotics
Centor
What is first-line management for tonsillitis for all individuals
Analgesia
What scoring systems are used to determine if someone needs antibiotics in tonsillitis
Fever Pain
Centor
What does the centor criteria state
Cough absent
Exudate
Nodes tender
T >38
What score is needed on centor criteria for antibiotics
> 3
What is the fever pain criteria
Fever Pus Acute presentation - 3d Inflammation No coryzal symptoms
What score is needed on fever pain for antibiotics
> 4
If an individual scores fever 2-3 what is recommended
Provide ‘back-up’ antibiotic prescription. Recommend they use it if symptoms do not resolve in 2-3d
What antibiotic is given in tonsillitis
Phenoxymethylpenicillin
What are the 6 indications for tonsillectomy
- 7 episodes in 1y
- 5 episodes in 2y
- 3 episodes in 3y
- Quinsy
- Sleep apnea
- Malignancy
What is a complication of bacterial tonsillitis
Quinsy
What is quinsy
Peri-tonsillar abscess
How can quinsy be identified
Deviation of the uvula
How is quinsy managed
I+D, metronidazole, amoxicillin
What is pharyngeal abscess
Infection spreads from tonsil to fascial planes
What is a retropharyngeal abscess
Abscess formation in paravertebral space
What is a parapharyngeal abscess
Abscess spreads posterolateral to nasopharynx
How will a pharyngeal abscess present
Reduced neck movement and pain
What is used to investigate a pharyngeal abscess
CT w/IV contrast
What are the indications for tonsillectomy
- 7 episodes in 1-year (8)
- 5 episodes in 2-years (7)
- 3 episodes in 3-years (6)
- Quinsy
- Sleep apnea
- Suspected malignancy
what is the time frame for immediate complications of tonsillectomy
<24h
what are 3 immediate complications
- Primary haemorrhage
- Aspiration
- Laryngospasm
what are 2 early complications.
- Secondary haemorrhage
- Airway obstruction due to oedema
when does secondary haemorrhage occur
Usually 5-10d
what causes secondary haemorrhage
Infection of the tonsillar fossa
what are the two delayed complications of tonsillectomy
Abscess
Nasopharyngeal stenosis
what is the term head and neck cancer used to refer to
Cancers of:
- Nasophargyneal
- Orophargyneal
- Pharynx
- Larynx
- Salivary glands
where type of cancer are 90% of head and neck cancers
Squamous Cell Carcinoma
what are head and neck cancers collectively referred to as
Head and Neck Squamous Cell Carcinoma (HNSCC)
what are three pre-malignant conditions for HNSCC
Leucoplakia = white patches
Erythroplakia = red patches
Erythroleucoplakia = red and white patches
what is leukoplakia
White patches
what is erythroplakia
Red patches
what is erythroleukoplakia
Red and White Patches
what are pre-malignant conditions associated with
Smoking and alcohol consumption
what is the risk of pre-malignant condition transforming to malignancy
20%
in which gender are HNSCC more common
Male
why is incidence of oral cancer thought to be increasing
Increased immigration - with other countries chewing more betel quid
why is incidence of oropharyngeal cancer increasing
Associated with HPV in younger people
why is incidence of laryngeal cancer decreasing
Decrease smoking rates
What is strongly linked to oropharyngeal cancer
HPV16
What is linked to oral cancer
Betel Quid
What is linked to sinonasal cancer
wood dust exposure
What is linked to nasopharyngeal cancer
EBV
What is a hoarse voice
Weak or altered voice
What is the most common cause of hoarse voice
Laryngitis
What are the 4 categories for dividing the aetiology of hoarse voice
- Benign
- Malignant
- Infective
- Neurological
What are the 6 benign causes of hoarse voice
- Vocal cord nodules
- Vocal cord papilloma
- Muscle tension dysphonia
- Vocal cord polyps
- Laryngeal papilloma
- Reflux laryngitis
- Reinke’s Oedema
What causes vocal cord nodules
Chronic vocal cord abuse
How do vocal cord nodules present clinically
Husky variable voice
How do vocal cord nodules present on the vocal cords
Bilateral.
Commonly located between anterior and middle third of the vocal cords
How are vocal cord nodules managed
SALT
What causes progressive muscle tension dysphonia
Habitual mis-use of larynx
How does muscle tension dysphonia present clinically
Hoarse voice worse towards end of the day
How is muscle tension dysphonia managed
SALT
How do vocal cord polyps present on the vocal cords
Unilateral, Benign
What is the difference in presentation between vocal cord polyps and vocal cord nodules
Vocal cord polyp = unilateral
Vocal cord nodules = bilateral
How are vocal cord polyps managed and why
Surgical excision to exclude cancer
What is laryngeal papilloma
Benign lesions caused by HPV
What is the problem with laryngeal papilloma
Can grow to cause airway obstruction
How are laryngeal papilloma’s managed
Regular surgical debunking
What is reflux laryngitis
GORD - cause hoarse voice
What is Reinke’s oedema
Inflammation of the vocal cords
What is the stereotypical presentation for Reinke’s oedema
Female, Smoker
What are two risk factors for Reinke’s oedema
Hypothyroidism
Elderly
How is Reinke’s oedema managed
Smoking cessation
Voice therapy
What are the two infective causes of hoarse voice
Laryngitis
Acute epiglottis
What is a malignant cause of hoarse voice
Laryngeal Cancer
How will hoarse voice in laryngeal cancer present
Progressive hoarse voice
What is a neurological cause of hoarse voice
Recurrent laryngeal nerve palsy
What muscles of the larynx does the recurrent laryngeal nerve innervate
All intrinsic muscles of the larynx except the cricothyroid
What are the symptoms of recurrent laryngeal nerve palsy
- Bovine cough
- Exertional Dyspnoea
- Aspiration
Why do individuals with recurrent laryngeal nerve palsy get exertion dyspnoea
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
What is bovine cough
Non-explosive cough when one of vocal cords cannot close
What causes majority of recurrent laryngeal nerve palsies
Cancer (30%) - larynx, thyroid, oesophagus, hypo pharynx
What is the second most-common cause of recurrent laryngeal nervepalsy
Iatrogenic (25%)
What 3 iatrogenic procedures can cause recurrent laryngeal nerve palsy
Parathyroidectomy
Thyroidectomy
Oesophageal pouch surgery
What CNS causes of recurrent laryngeal nerve palsy
MS
Polio
What are 3 other causes of recurrent laryngeal nerve palsy
TB
Aortic aneurysm
Idiopathic (post-viral neuropathy)
If someone has symptoms of recurrent laryngeal nerve palsy, with no recent history of surgery, what is first-line investigation
CXR
If CXR is negative, what three investigations should be ordered
- CT Chest
- US Thyroid
- OGD
Who should be investigated with hoarseness of voice
Any smoker with hoarseness for more than 3W should be investigated as this is the chief and only presenting symptom of laryngeal cancer
What is first-line investigation for laryngeal carcinoma
Flexible nasoendoscopy
What does flexible nasoendoscopy enable visualisation of
Vocal cords and larynx
What is second-line investigation for laryngeal cancer
Microlaryngotracheobronchoscopy
What does microlaryngealbronchoscopy enable visualisation of
Visualisation vocal cords, larynx and bronchioles
Where is microlaryngobronchoscopy performed
In theatres - as it needs GA
What is stroboscopy
Enables visualisation of function of vocal cords
What enables voice
Abduction and adduction of vocal cords innervated by recurrent laryngeal and superior laryngeal nerves
What is the most common head and neck cancer
Laryngeal cancer
What is laryngeal cancer
SCC of the larynx
In which age does laryngeal cancer occur
Elderly
If laryngeal cancer occurs young patients what is it associated with
HPV
What are 3 risk factors for laryngeal cancer
Smoking
Alcohol
Irradiation to head + neck
How does laryngeal cancer present clinically
- Progressive hoarseness
- Dysphagia
- Cough
- Referred Otalgia
- Stridor = late sign
When will laryngeal cancer cause hoarse voice
If in glotting or on vocal cords
How is the larynx divided
Supraglottis
Glottis
Subglottis
When should a patient be referred in 2W pathway for laryngeal cancer
Unexplained neck lump
Hoarse voice
What is first-line investigation for laryngeal cancer
Laryngoscopy and biopsy
What is second-line investigation for laryngeal cancer
CXR
What is third-line investigation for laryngeal cancer
CT Chest
What is fourth-line investigation for laryngeal cancer
MRI Neck
What is CT chest used to investigate for
Lung metastses
What is MRI neck used to look for
Erosion thyroid cartilage and enlarged lymph nodes
How are small tumours (T1,T2) of the supra glottis managed
Resection via trans-oral microsurgery with neck dissection.
How are large tumours (T3,T4) of the supra glottis managed
Laryngectomy with chemoradiotherapy
How are small tumours of the glottis (T1, T2) managed
Resection via trans-oral microsurgery with neck dissection.
How are large tumours of the glottis (T4) managed
Laryngectomy with chemoradiotherapy and neck dissection
How are small tumours of the subglottis (T1, T2) managed
Resection via trans-oral microsurgery with neck dissection.
How are large tumours of the subglottis (T4) managed
Laryngectomy with chemoradiotherapy and neck dissection
Explain laryngectomy
Removal of the larynx. The trachea is then brought out to the skin to enable voice. The pharynx is attached to the oesophagus.
What are the two methods of voice restoration following laryngectomy
- Trans-oesophageal puncture
- Artificial larynx
Explain trans-oesophageal puncture
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.
What is used of a trans-oesephageal puncture cannot be used
Artificial larynx (Servox)
What is a servox
Vibrating larynx is placed against patients stoma - this enables vibration of pharynx to produce speech.
Which laryngeal cancer patients have a better prognosis and why
Those with glottis tumours, as they present with hoarse voice earlier. Glottis also has poor lymphatic drainage preventing metastases.
What are two complications of radiotherapy to the head and neck
Mucositis
Xerostomia
What is oropharyngeal cancer
SCC of the oropharynx
In which gender is oropharyngeal cancer more common
Male (4:1)
Why is incidence of oropharyngeal cancer increasing in young people
Due to HPV
What is a main risk factor for oropharyngeal cancer
HPV16
What head and neck cancers is HPV16 associated with
Tongue
Tonsil
Oropharynx
What are two risk factors for oropharyngeal cancers
Pipe smoking
Chewing tobacco
What are the clinical signs of oropharyngeal cancer
Odynophagia Dysphagia Stertor Referred otalgia Enlarged cervical lymph nodes
If there is a neck lump what should be performed
FNA
Core biopsy
What is used to grade oropharyngeal cancer
Panendoscopy and biopsy
What is a panendoscopy
Investigation of upper aerodigestive tract: Larynx Pharynx Trachea Oeseophagus
What is a CT Chest used for
Staging
What is an MRI neck used for
Staging
How are small oropharyngeal cancers managed
Surgical resection with neck dissection and radiotherapy
How are large oropharyngeal cancers managed
Chemoradiotherapy
What is nasopharyngeal cancer
SCC of the nasopharynx
What is the peak age for nasopharyngeal cancer
40-60
What ethnicity is nasopharyngeal cancer more common
China
Mediterranean
What is the syndrome classical for nasopharyngeal cancer
Trotter’s syndrome
What is trotter’s syndrome
- Unilateral conductive deafness
- Unilateral trigeminal neuralgia
- Impaired mobility of the soft-palate
What causes unilateral conductive deafness in nasopharyngeal cancer
Due to obstruction of the Eustachian tube results in effusion of the middle ear
What causes trigeminal neuralgia in nasopharyngeal cancer
Peri-neural invasion
What is the most common symptom of nasopharyngeal cancer
Enlarged painless cervical lymphandeopathy
What are 3 other nasal symptoms of nasopharyngeal cancer
Bleeding
Obstruction
Discharge
What investigations are used for nasopharyngeal cancer
Nasoendoscopy
MRI Neck
US-guided FNA of lymph nodes
What is used to manage nasopharyngeal cancer
Chemoradiotherapy and surgical neck dissection
What is hypo pharyngeal cancer
SCC of the hypo pharynx
How common is hypo pharyngeal cancer
Rare
Why do hypo pharyngeal cancers often present at a late stage
Due to rich lymphatic drainage of the hypopharynx
How will hypo-pharyngeal cancers present
- Lump in the throat which may cause dysphagia and odynophagia
- Referred otalgia
- Hoarse voice
What is a pre-malignant condition of hypo pharyngeal cancer
Leucoplakia
Plummer-vinson
How are hypo pharyngeal cancers investigated
Panendoscopy
CT Head and Neck
What are oral cancers
SCC of oral mucosa, salivary glands or tonsils
What are 4 risk factors for oral cancer
- HPV16
- Chewing betel quid
- Pre-malignant lesions (erythroplakia, leukoplakia or erythroleukoplakia)
- Smoking
How may oral cancers present clinically
- Painless mass
- Bleeding
- Jaw swelling
- Referred otalgia
- Enlarged lymph nodes
- Pre-malignant conditions
What are 4 reasons to refer someone under 2W pathway for oral cancer
- Persistent non-healing oral ulcer for more than 3W
- Oral lump
- Unexplained neck swelling
- Erythroplakia or erythroleukoplakia
What four-investigations are ordered for oral cancer
- Biopsy
- Panendoscopy
- CT head and neck
- MRI head and neck
Why is MRI ordered as well as CT
As MRI is superior for assessing oral and oropharyngeal cancers
How are T1-T2 oral tumours managed
WLE
Neck dissection
How are T3-T4 oral tumours managed
Surgical excision - w/flap
Neck dissection
Chemoradiotherapy
How are metastatic tumours managed in oral cancer
Cetuximab
What are two causes of parotid carcinoma
HPV
Previous irradiation
How will parotid carcinoma present
Painless swelling
Facial paralysis - if infiltrates facial nerve
What is used to diagnose parotid carcinoma
US-guided FNA
CT neck and chest
How is parotid carcinoma removed
Parotidectomy, neck dissection and radiotherapy
What is an early complication of parotidectomy
Facial paralysis
What are two syndromes that are complications of parotidectomy
Frey Syndrome
Crocodile tears
What is Frey Syndrome
Where gustatory stimuli cause facial flushing and sweating
What are crocodile tears
Gustatory stimuli cause lacrimation