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4.5. Neurology and SS > 7. Throat > Flashcards

7. Throat Flashcards

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1
Q

What is OSA?

A

Involves cessation or significant decrease in airflow in the presence of breathing effort

Characterized by recurrent episodes of upper airway collapse during sleep

OSA that is associated with excessive daytime sleepiness is commonly called obstructive sleep apnea syndrome

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2
Q

How does OSA present?

A

Night time:

  • Snoring (loud, habitual, bothersome to others)
  • Witnessed apnoea’s, which often interrupt the snoring and end with a snort
  • Gasping/choking sensations that arouse from sleep
  • Nocturia
  • Insomnia
  • Restless sleep

Daytime:

  • Nonrestorative sleep (waking up as tired as when they went to bed)
  • Morning headache, dry or sore throat
  • Excessive daytime sleepiness (EDS)
  • Cognitive deficits
  • Personality and mood changes
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3
Q

How should OSA be Ix and Mx?

A

Ix = BMI, TFT (hypo), CXR (obstructive lung disease), ECG (R ven failure), sleep study

Lifestyle advice = weight loss, exercise, reducing alcohol intake and sedative use, and smoking cessation

Refer to a sleep centre = confirmation of Dx, using sleep studies (polysomnography or limited sleep study)

CPAP = for moderate or severe OSAS

Intra-oral devices (mandibular advancement device) = people who snore or have mild OSAS

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4
Q

What are the causes of tonsillitis?

A

Viral (70%) – adenovirus, rhinovirus, influenza, RSV, EBV

Bacterial – strep pyogenes (group A), staph, H.influenzae, e.coli

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5
Q

Outline the pathophysiology of tonsillitis

A

Inflammatory infection of the tonsils caused by invasion of the mucous membrane by microorganisms.

Subtype of pharyngitis

Could be EBV - which would mean they also could have an enlarged liver + spleen, must NOT do any contact sports for 6w

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6
Q

What are the signs and symptoms of tonsillitis?

A

Red, swollen tonsils

+/- White or yellow coating or patches on the tonsils

Sore throat

Difficult or painful swallowing

Fever

Bilateral cervical lymphadenopathy

A scratchy, muffled or throaty voice

Bad breath

Stomach-ache, particularly in younger children

Stiff neck

Headache

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7
Q

How should tonsillitis be investigated?

A

Centor criteria: (3/4 40-60% GABHS)

  • Absence of cough
  • Tonsillar exudates (ooze)
  • High fever
  • Tender anterior cervical LN

Throat exam

Throat swab (if bacterial suspected)

Fever/pain score

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8
Q

How is tonsillitis best managed?

A

Rest, hydration, saltwater gargle, lozenges, avoid irritants, ibuprofen/paracetamol, topical analgesia (difflam), dex

Centor Criteria 3/4 = Abx – penicillin V 500mg QDS for 10d

Recurrent, disabling = surgery – tonsillectomy

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9
Q

Give a DDx for neck lumps

A

Ix if = >2w, >2cm, >2 regions affected

  • Kawasaki Disease = unilateral, >15mm, painful nodes
  • Viral infections (EBV, CMV)
  • Bacterial infections (strep, staph, TB)
  • Malignancy (lymphoma, leukaemia)
  • Juvenile chronic arthritis, SLE, atopic eczema
  • Lipoma
  • Dermoid cyst (midline, <20y)
  • Sebaceous cyst
  • Thyroglossal cyst (moves on swallow, below hyoid)
  • Branchial cyst (IV Abx, aspiration, excision)
  • Abscess
  • Chondroma (bony hard)
  • Branchial cyst (under anterior border of sternomastoid)
  • Parotid tumour (superoposterior area of anterior triangle)
  • Cervical ribs (posterior triangle)
  • Pharyngeal pouch

*** Paed: 20% mal, 80% benign VS Adult: 80% mal, 20% benign

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10
Q

How should a neck lump be Ix?

A

Exam = site, size, shape

Flexible endoscopy = nose, nasopharynx, oropharynx, hypopharynx, larynx

USS = structure, vasculature

CT = relation to other anatomical structures

Bloods = FBC, CRP, monospot

Virology + Mantoux test

CXR = may show malignancy, or in sarcoid bilateral hilar lymphadenopathy

Fine-needle aspiration cytology, formal biopsy - MAKE SURE NOT PULSATILE

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11
Q

What are salivary gland stones?

A

Sialolithiasis = mineral salt clump

Most located in submandibular glands

Pre-existing dehydration = reduced salivary flow = stones = more prone to infection

S+S = pain/tense swelling of gland after meal, may be palpable in floor of mouth

Ix = x-ray, sialogram

Mx = small pass spontaneously, larger require surgery

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12
Q

Outline sialadenitis

A

Acute inflam of the submandibular or parotid glands (Staph aureus, viral mumps, autoimmune)

S+S = painful diffuse swelling, fever, pressure may cause pus to leak

Ix = FBC, LFT, autoimmune screen (sjogrens), OPG (teeth, calculus), sialography (calculus, stenosis, sialectasis), UCC/CT/MRI, FNAC

Mx = rehydrate, IV Abx + good oral hygiene, lemon drops that stimulate salivation may help, surgical drainage may be require

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13
Q

List the RF associated with head, neck and thyroid cancers

A

Alcohol

Tobacco use

Age

Gender = male

Epstein-Barr virus

Chewing of betel quid

Long term exposure to sunlight/sunbeds

HPV

Leucoplakia - thick white plaques, higher risk for mouth cancer

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14
Q

Outline the presentation, investigation and treatment of lip/oral cancer

A

90% SCC

S+S = lump, painless ulcer/lump, pain (late sign, inc referred pain to ear), fixation of tongue, dysphagia, odynophagia (pain on swallowing), discolouration, leukoplakia, lichen planus, non-healing ulcer

Ix = CT/MRI of chest as lung cancer associated with smoking too

Mx = excision, RT, surgery – hemiglossectomy or total glossectomy

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15
Q

Outline the presentation, investigation and treatment of pharynx cancer

A

RF = smoking, alcohol, HPV, EBV, radiation

S+S = cervical LN, dysphagia, Odynophagia (painful swallow), Lump secondary to cervical mets, Pain (referred pain otalgia), weight loss

Ix = naso/panendoscopy, biopsy, FNAC LN, imaging – CT/MRI, barrium swallow

Mx =

  • supportive – feed via gastronomy tubes
  • pharyngeal - chemo, RT
  • oropharynx - surgery +/- RT or chemo
  • hypopharynx (may incurable) - surgery + RT +/- neoadjuvant chemo
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16
Q

Outline the presentation, investigation and treatment of larynx cancer

A

69% glottic Ca, 90% SCC

S+S = dysphonia (hoarse), dysphagia, referred otalgia (earache), neck lump, Weight loss, cachexia (body wasting), stridor, cough, haemoptysis

Ix = flexiable nasoendoscopy, biopsy, CT nech/chest

Mx = support long term voice issues and swallowing problems, surgical excision, chemo, RT

Laryngectomy: removal of larynx, pt breathes through opening in the neck known as a stoma

Tracheostomy: opening created at front of neck so a tube can be inserted into trachea

17
Q

Outline the presentation, investigation and treatment of thyroid Ca

A
  • ** most commonly papillary adenocarcinoma (70-80%)
  • then follicular adenocarcinoma

S+S = lump in thyroid or neck nodal metastasis, problems swallowing, feeling like strangled, voice change, rarely problems with thyroid status

Ix = Hx, examination, imaging via ultrasound, fine needle aspiration cytology
- MEDULLARY = calcitonin (tumour marker)

Mx = thyroidectomy, radioactive iodine, RT/chemo

18
Q

As a general rule what type of cancer are HNCs (including the lips and oral cavity)?

A

Squamous cell carcinoma

19
Q

Outline a parapharyngeal abscess

A

Deep neck abscess = in the parapharngeal space which is shaped like an inverted pyramid, base at the skull and apex at hyoid bone

S+S = fever, sore throat, odynophagia, and swelling in the neck down to the hyoid bone

Ix = CT

Mx = secure airway, IV Abx, surgical drainage

20
Q

Outline a retropharyngeal abscess

A

Retropharyngeal space = buccopharyngeal fascia anteriorly and the prevertebral fascia posteriorly

S+S = fever, neck held rigid/upright, noisy breathing, dysphagia, odynophagia, systemically unwell, young children commonly after URTI

Ix = x-ray, CT

Mx = IV Abx, secure airway, surgical drainage

21
Q

Describe a Ludwig’s angina

A

Rare severe cellulitis between the floor of the mouth and mylohyoid (submandibular space)

Ae = dental infection, parapharyngeal abscess, mandibular fracture, cut/piercing inside the mouth, or submandibular salivary stones

S+S = dysphagia, odynophagia, drooling, external bilateral lower facial swelling around the mandible and upper neck, SOB, fever

Ix = dental x-ray, CT neck

Mx = airway management, IV Abx, surgical drainage

22
Q

Outline epiglottitis

A

Inflammation of the epiglottis, commonly 2-6y, EMERGENCY

Ae = H. influenza (dec due to vac), strep pneumonia, pyogenes, aureus, burns, trauma

S+S = dysphagia, drooling, changes to the voice, fever, increased breathing rate, inspiratory stridor, sore throat
- swelling can lead to cyanosis and asphyxiation

Ix = indirect fiberoptic laryngoscopy (carried out in theatre due to risk of spasm), neck x-ray (thumbprint sign)

***call paed anaesthetist + ENT surgeon

Mx = endotracheal intubation IN THEATRE, IV Abx (ceftriaxone), corticosteroids

23
Q

What is sjigrens syndrome?

A

Chronic inflam autoimmune disorder

  • primary
  • sec = associated with CT disease (RA, SLE, systemic sclerosis)

Lymphocytic infiltration and fibrosis of exocrine glands esp lacrimal + salivary

S+S = dec tear prod (dry eyes, keratoconjuctivitis sicca), dec salivation (xerostomia), parotid swelling, vaginal dryness, dyspareunia, dry cough, dysphagia
- systemic: polyarthritis, raynauds, lymphadenopathy, vasculitis, lung/liver/kidney involvement peripheral neuropathy

Ix = Schirmer’s test (tear prod)rose Bengal staining (keratitis), Anti-Ro, Anti-La Ab, ANA, rheumatoid factor, biopsy (focal lymphocytic aggregation),

Mx = hypromellose (artificial tears), frequent drinks, NSAIDs + hydroxychloroquine (arthralgia), immunosuppressants (severe)

24
Q

What are the non-neoplastic causes of thyroid enlargement and how should they be Ix?

A

Diffuse goitre:
- Ae = iron def, congenital, sec to goitrogens (dec iodine uptake), acute thyroiditis (de Quervains), physiological (preg, puberty), autoimmune (graves, hashimotos)

Nodular goitre:

  • Multinodular goitre = euthyroid, hyperthyroid
  • Fibrotic goitre = Reidels thyroiditis
  • Solitary thyroid nodule = cyst, adenoma, Ca

Ix = T3/4, TSH, anti-thyroid peroxidase, anti-thyroglobulin, plain films (OPG, scintigraphy), CXR with thoracic inlet view, USS, radionucleotide scans, FNAC

25
Q

How should an adult vs paediatric obstructed airway be Mx?

A

Adult = O2, IV steroids, Iv Abx, adrenaline neb, anti-histamines (anaphylaxis), adjuncts (nasopharyngeal airway, guedel), secure airway (intubation, cricothyrocotomy, tracheostomy)

Paed = intubate in theatre by paed anaesthetist with ENT surgeon on stand by (FIRST), then Tx underlying pathology (SEC)

26
Q

How should benign thyroid disease be managed?

A

Hypo = thyroxin replacement

Hyper = carbimazole

Surgical = make euthyroid first, then hemi/subtotal/total thyroidectomy

27
Q

What are the causes of hoarseness and how should this be Ix?

A

Ae = vocal nodules, muscle tension, vocal polyp, Reinke’s oedema, Ca, vocal cord palsy (tumour, trauma, idiopathic)

Ix = ENT exam, microlaryngoscopy, biopsy, CXR, USS (thyroid), CT (neck/chest), MRI

***hoarseness of >3w duration necessitates visualisation of vocal cords

28
Q

How should hoarseness be Mx?

A

Vocal nodules ‘singers nodules’ = speech therapy

Muscle tension = reassure, speech therapy

Vocal polyp = microlaryngoscopy, removal

Reinke’s oedema (submucosal oedema of cords) = stop smoking, control hypothyroidism, surgery, internal excision

29
Q

Outline dysphagia

A

Control = skeletal + smooth muscle of pharynx and oesophagus, centre in medulla + pons, reflex initiated by touch R, ANS

  • Oral stage: voluntary
  • Pharyngeal stage: voluntary, involuntary
  • Oesophageal stage: involuntary

Ae = Cs, pharyngeal pouch, webs, goiter, post-surgical, RT, infection, neuromuscular disease, stroke

Ix

  • Exam: nutrition, wt, tremor, CN, gag reflex, muscle strength
  • RF present: Ba swallow, panendoscopy, flexible OGD, CT/MRI neck
  • SALT dieticians
30
Q

Outline parathyroid disease

A

Hypo

  • Ae: iatrogenic
  • Tx: Ca replacement

Hyper

  • Ae: PT adenoma, PT hyperplasia
  • Tx: surgery

Parathyroid malignancy RARE

31
Q

What are the causes of dysphagia?

A
  • Head/neck Ca
  • Pharyngeal pouch
  • Webs
  • Goiter
  • Cervical osteophytes
  • Post-surgical/RT
  • Infections (tonsillar enlargement/abscess)
  • Caustic oesophagitis
  • Neuromuscular disease
32
Q

How should dysphagia be Ix?

A

Normal exam, no RF = SALT, reassure, ?PPI trial

RF = Ba swallow or videofluoroscopy, panendoscopy, flexible OGD, CT/MRI neck

Neurological = SALT, dieticians

4.5. Neurology and SS (17 decks)

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