23 - Gland Pathology and H+N Cancers Flashcards
What is the most common histological type of H+N cancers and what are the risk factors for this?
Squamous Cell Carcinoma
- Alcohol
- Tobacco (chewing and smoking)
- Beetle nut chewing
- HPV (oropharyngeal)
- Chinese ethnicity (nasopharyngeal cancers)
- Wood dust exposure
- EBV (nasopharyngeal)
What are some pre-malignant oral conditions?
- Leukoplakia
- Erythroplakia
- Leukoerythroplakia
- Oral lichen planus
- Acitinic chelitis
NEED A BIOPSY TO DIAGNOSE DUE TO RISK OF TURNING MALIGNANT
What are some of the symptoms of the following head and neck cancers:
- Oral cavity
- Pharyngeal
- Laryngeal
All may have weight loss and lymphadenopathy
Oral Cavity:
- Painless mass on inner lip, tongue, palate or floor of mouth
- Premalignant lesions
- Pain or bleeding
Pharyngeal (found late and metastasise early)
- Odynophagia
- Dysphagia
- Stertor
- Referred otalgia
- Nasal blockage
- Neck lump
Laryngeal
- Hoarse voice/Dysphonia
- Stridor (if advanced) or dyspnea
- Dysphagia
- Persistent cough
- Referred otalgia
What is Trotter’s syndrome?
Triad of features suggestive of nasopharyngeal cancer:
1. Unilateral conductive deafness (due to middle ear effusion from obstruction)
2. Trigeminal Neuralgia (due to perineural invasion)
3. Defective mobility of the soft palate
How is laryngeal cancer split up and which has the best prognosis?
Supraglottic, glottic, subglottic
Glottic is the best as difficult to metastasise due to lack of lymphatic drainage
What are some red flags that may indicate a Head and Neck malignancy?
What investigations are done to diagnose and stage a head and neck cancer?
- FNE to view lesion
- Biopsy under general anesthesia with panendoscopy. If just lymphadenopathy then US guided FNA and cytology
3. CT neck to chest to look for metastases (particularly lung), tumour extension and local invasion. If oral cancer an MRI is better
Why should you not open biopsy cervical lymphadenopathy?
Risk of seeding the cancer onto the skin
In general what is the mainstay of management for head and neck cancers if it is not palliative?
Surgical resection +/- adjuvant radiotherapy or chemotherapy
OR
Primary radiotherapy +/- adjuvant chemotherapy
How are oral cavity carcinomas managed?
Small tumours: WLE with neck dissection
Large tumours: Surgical resection +/- flap reconstruction and neck dissection +/- post operative radiotherapy +/- chemotherapy
How are oropharyngeal cancers managed?
Tonsil: resection and neck dissection and radiotherapy
Tongue Base: Surgical resection using Transoral Robotic Surgery with neck dissection or primary radiotherapy
If larger then primary radiotherapy and adjuvant chemotherapy
How are laryngeal cancers managed?
What are some complications of treatment of head and neck cancers?
- Cancer recurrence
- Dysphagia (from oesophageal stricture)
- Pharyngocutaneous fistula (following laryngectomy)
- Injury to the accessory, vagus, hypoglossal, or marginal mandibular nerves (following neck dissection), or chyle leak (following neck dissection)
- Mucositis or xerostomia (complication of radiotherapy)
- Chronic pain, persistent hoarse voice, or hearing loss (following chemoradiotherapy)
What are the lymph node levels in the neck?
How can voice be restored after a laryngectomy?
What is removed in a radical neck dissection?
- All neck lymph nodes (level I–V)
- Spinal accessory nerve
- Internal jugular vein
- Sternocleidomastoid muscle;
Where is the incision made for a cricothyroidotomy?
Medium cricothyroid ligament
What is the arterial supply and venous drainage of the thyroid gland?
Arterial
- From ECA (superior artery) and thyrocervical trunk (middle and inferior arteries)
- Superior and inferior thyroid arteries
Venous
- Superior, middle and inferior thyroid veins
What nerve runs close to the thyroid gland and can be damaged on thyroid surgery?
- Recurrent laryngeal nerve (branch of vagus)
- Runs in tracheoesophageal groove
- Right side branches at subclavian artery, left side branches at arch of the aorta
What is the function of the recurrent laryngeal nerve and the symptoms if this nerve is damaged?
If damaged can cause vocal cord paralysis so hoarse voice and if both are involved then airway obstruction
What is a common electrolyte disturbance after a thyroidectomy and why?
Hypocalcaemia due to accidental removal of parathyroid glands
If a patient comes in with a thyroid nodule or a goitre, what are some pathologies you need to rule out?
Goitre: obstruction and dysphagia
Thyroid lump: malignancy, hyperthyroidism due to toxic nodule
What are some differentials for a thyroid lump?
- Multinodular goitre
- Benign hyperplastic nodules
- Thyroid cysts
- Thyroid adenomas (benign tumours the can release excessive thyroid hormone)
- Thyroid cancer (PFAM)
- Parathyroid tumour
When a patient presents with a thyroid lump what should you do next?
- Airway obstruction/Stridor:
- Admit to hospital immediately
- Unexplained lump:
- TFTs
- 2 week wait for a triple assessment. (clinical examination, US +/- fine needle aspiration cytology)
What are the different types of thyroid cancer and some risk factors for thyroid cancer?
Types: Papillary, Follicular, Anaplastic, Medullary, Lymphoma
Risk Factors:
- Female
- FHx (and MEN1 association)
- Radiation exposure as child
- Full body radio for bone marrow transplant
- Hashimoto’s (lymphoma type)
How do each of the subtypes of thyroid act in terms of: features, spread, prognosis?
Papillary: Most common, usually younger patients who have had radio to neck, spread to lymphatics
Follicular: Haematogenous spread to bones and lungs, more common in women
Medullary: Parafollicular cells (C-cells) so high calcitonin and associated with MEN2 syndrome. Spreads via lymphatics, poor prognosis if nodal
Anaplastic: Occurs in elderly >65, highly aggressive and poor prognosis (weeks or months)
Lymphoma: very rare, can grow rapidly, B-symptoms
If a patient presents with a thyroid lump, what are some red flags that this could be a malignancy?
- Rapid growth
- Pain
- Cough, hoarse voice, or stridor
- Multiple enlarged cervical lymph nodes
- Tethering
What investigations should you do with a thyroid lump and what might they show?
TFTs: calcitonin raised could be medullary thyroid cancer, low TSH or raised T3 or T4 could be toxic nodule that is unlikely to malignant
US of nodule and lymph nodes:
- Microcalcifications
- Hypoechongenicity
- Irregular margin
If the above then want to do FNA
How are non malignant thyroid lumps managed?
- Usually conservatively
- Can do surgery if compressive symptoms or hyperthyroidism but restricted to hemithyroidectomy to reduce risks and need for lifetime levothyroxine
How are malignant thyroid lumps managed?
Mainstay Treatment = Surgery
- Total thyroidectomy for PFM but anaplastic is palliative
- Hemithyroidectomy if small low grade tumour
- Neck dissection if lymph nodes involved
Adjuvant Treatment
- Radioiodine therapy after total thyroidectomy
- External beam radiotherapy
What are some complications with thyroid surgery?
- Post op bleeding and haematoma: must reopen wound on ward and take back to theatre to stop bleeding
- Vocal cord palsy
- Hypocalcaemia: tetany and paraesthesia, monitor PTH and Ca
- Airway obstruction: secondary to haemorraghe and bilateral vocal cord palsy
What is the prognosis with thyroid cancer?
Depends on type
What is sialadenitis and what are the causes of this?
Inflammation of the salivary gland, usually parotid, that is acute or chronic
- Viral: paramyxovirus (mumps), Coxsackie, HIV
- Bacterial: staph infections in dehydrated and immunocompromised
- Stones
- Malignancy
- Autoimmue: Sjogren’s, Sarcoidosis
- Idiopathic
What is Heerfordt’s syndrome?
Form of sarcoidosis:
- Parotid enlargement
- Anterior uveitis
- Facial nerve palsy
What are some of the complications of mumps?
NOTIFIABLE DISEASE!! Can be prevented with MMR. Supportive treatment
- Orchitis
- Deafness
- Meningitis/Encephalitis
- Pancreatitis
How does sialadenitis present?
- Painful swelling and tenderness of the gland
- Fever
- Can be pus leakage
How is sialadenitis investigated?
- Bloods: FBC/CRP for infective causes, ESR/Autoimmune screen for autoimmune causes
- Viral serology: mumps
- Pus swabs
- FNA: if suspicious of malignancy
- US or CT: if suspect deep neck space abscess
How is sialadenitis managed?
Conservative:
- Hydration, moist heat, NSAIDs, paracetamol
Medical:
- If bacterial give co-amoxiclav
- Sialogogues (e.g lemon juice) to promote saliva production
- Massage/milk gland
Surgical (if abscess)
- I+D
- If recurrent, e.g due to stones or strictures, can remove whole gland
What are some complications of sialadenitis?
- Abscess formation: can lead to airway obstruction which is emergency
- Cutaneous fistula: if chronic/recurrent
- Lymphoma: autoimmune parotitis linked to increased risk of lymphoma
What is sialolithiasis and what are the risk factors for this?
Stones in the salivary ducts causing obstruction, usually the submandibular gland as secretions are more mucoid, duct is longer and goes against gravity
Risks:
- Medication, commonly diuretics or anti-cholinergics
- Dehydration
- Gout
- Smoking
- Chronic periodontal disease
- Hyperparathyroidism (hyper Ca)
How does sialolithiasis present?
- Often asymptomatic
- Intermittent facial swelling during meals that can be painful
- Unilateral
- May feel stone on palpation
What are some other causes of swollen salivary glands apart from sialolithiasis?
- Infection e.g mumps
- Sjrogen’s syndrome
- Sarcoidosis
- Salivary gland tumour
How is sialolithiasis investigated?
- US or plain film radiograph
- Sialogram (not routinely performed as invasive as the salivary duct is cannulated, dye injected and then radiograph)
How is sialolithiasis managed?
Conservative (most will settle with this):
- Analgesia
- Hydration
- Sialogogues e.g lemon juice
- Massage gland
- Abx if get’s infected
Surgical
- If recurrent then can do interventional radiology or endoscopy to remove
- Transoral surgical removal but risk of damaging hypoglossal, facial or lingual nerve
- Last resort is salivary gland removal
What are some of the complications of sialolithiasis?
- Recurrent sialadenitis
- Abscess formation
- Chronically tender salivary gland
Why may Sjogren’s syndrome present to ENT?
Autoimmune disease causing lymphocytic infiltration into ductal tissue of glands.
Causes dry eyes (xeropthalmia), dry mouth (xerostomia) and enlarged salivary glands
Increased risk of developing lymphoma
How is Sjogren’s syndrome diagnosed?
- History and exam
- Biopsy of minor salivary glands on inner lip
- Autoantibody screen e.g ANA, Anti-Jo, AntiLa
What are the different types of tumours that can occur in the salivary glands?
(image is important)
80% of tumours are in parotid, 80% are benign and 80% are pleomorphic adenomas
Benign:
- Pleomorphic adenoma
- Warthin’s tumour
Malignant:
- Mucopeidermoid carcinoma
- Adenoid cystic carcinoma
- Acinic cell carcinoma
- Squamous cell carcinoma
- Adenocarcinoma
What is the issue with a pleomorphic adenoma?
- Can cause facial nerve palsy
- Can undergo malignant change and they are aggressive
What are the risk fators for developing a salivary gland tumour?
- Direct radiation exposure
- EBV
- Smoking (Warthin’s)
- Genetic alterations (p53 mutations)
What are the clinical features of a salivary gland tumour?
- Painless slowly enlarging mass
- If malignant often facial nerve palsy, overlying erythema and ulceration
- If large can cause airway obstruction, dysphagia, hoarsenes
- Cervical lymphadenopathy
What are some signs that a salivary gland tumour is malignant over benign?
- Hard and fixed
- Does not change size with eating
- Overlying skin ulceration
- Cervical lymphadenopathy
- Facial nerve palsy
How should you investigate someone with a salivary gland tumour?
- Bloods: FBC, U+Es, CRP to rule out infection
- US and FNA
- Staging CT of neck and thorax if FNA is malignant
How is a salivary gland tumour managed?
- Surgical excision (if parotid causing facial nerve palsy have to sacrifice facial nerve)
- Selective neck dissection if lymph node involvement
- Adjuvant radiotherapy or for non-resectable tumours
What are some complications of salivary gland excision?
Early
- Haemtoma: can lead to airway obstruction
- Nerve Injury: Parotidectomy facial nerve, Submandibularectomy is marginal mandibular, hypoglossal and lingual nerve
Late
- Frey’s syndrome: excessive sweating whislt eating as autonomic fibres reinnervativing form wrong
- Salivary fistula
Where is the opening of each of the salivary glands?
Parotid (serous): opposite second upper molar
Submandibular (mucous): frenulum of the tongue
Sublingual (tumours here rare but when they do form often malignant): floor of mouth
What is the prognosis following surgical excision of a salivary gland for a salivary gland tumour?
- Dependent on pathology, around 75% 5 year survival
- If benign pleomorphic adenoma and leave some behind then can recur
