ENT 2 Flashcards
what is dysphagia?
difficulty swallowing
when taking a history about dysphagia what specific questions would you want to ask?
- establish the level of dysphagia (pharynx, upper, mid or lower oesophagus)
- is it solid, liquids or saliva?
- any associated symptoms - hoarseness, odynophagia (painful swallowing), otalgia, regurgitation, GI bleeding, weight loss
- are symptoms progressing
- ask about oesophageal and pharyngeal cancer risk factors - smoking and alcohol
what are some causes of dysphagia?
extrinsic causes (mediastinal masses, cervical spondylosis)
oesophageal wall (achalasia, diffuse oesophageal spasm, hyptertensive lower oesophageal sphincter)
intrinsic - tumours, strictures, oesophageal web, schatzki ring
neurological - CVA, parkinson’s, MS, brainstem pathology, MG
what in the history of someone with dysphagia would be suggestive of oesophageal cancer?
Dysphagia may be associated with weight loss, anorexia or vomiting during eating
Past history may include Barrett’s oesophagus, GORD, excessive smoking or alcohol use
what in the history of someone with dysphagia would be suggestive of oesophagitis?
There may be a history of heartburn
Odynophagia but no weight loss and systemically well
what in the history of someone with dysphagia would be suggestive of oesophageal candidiasis?
There may be a history of HIV or other risk factors such as steroid inhaler use
what in the history of someone with dysphagia would be suggestive of achalasia?
Dysphagia of both liquids and solids from the start
Heartburn
Regurgitation of food - may lead to cough, aspiration pneumonia etc
what in the history of someone with dysphagia would be suggestive of pharyngeal pouch?
More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen
what in the history of someone with dysphagia would be suggestive of systemic sclerosis?
Other features of CREST syndrome may be present, namely Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased. This contrasts to achalasia where the LES pressure is increased
what in the history of someone with dysphagia would be suggestive of myasthenia graves?
Other symptoms may include extraocular muscle weakness or ptosis
Dysphagia with liquids as well as solids
what in the history of someone with dysphagia would be suggestive of globes hystericus?
There may be a history of anxiety
Symptoms are often intermittent and relieved by swallowing
Usually painless - the presence of pain should warrant further investigation for organic causes
what investigations may you perform for dysphagia?
FBC
CXR
CT or MRI main if malignancy is suspected
barium swallow
panendoscopy which includes laryngoscopy and upper oesophagoscopy
dynamic investigations e.g. video fluoroscopy if investigating motility disorders
what is dysphonia?
Dysphonia means hoarseness. It is disorder characterised by altered
vocal quality, pitch, loudness or vocal effort that impairs
communication.
what are the causes of dysphonia?
- Malignant e.g. squamous cell carcinoma
- Benign e.g. vocal cord nodules, papillomas, or cysts
- Neuromuscular e.g. Vocal cord palsy
- Trauma e.g. surgery, intubation, excess use
- Endocrine e.g hypothyroidism
-Infective e.g. laryngitis, candida (inhaled corticosteroids may
predispose to this) - Iatrogenic e.g. recurrent laryngeal nerve palsy secondary to thyroid
surgery - Functional e.g. muscle tension dysphonia
what are the red flags in patients with dysphonia?
- history of smoking and alcohol use
- concomitant neck mass
- unexplained weight loss
- accompanying neurological symptoms
- accompanying haemoptysis, dysphagia, odynophagia, otalgia
- hoarseness that is persistent and worsening (rather than intermittent)
- hoarseness in an immunocompromised patient
what is tonsillitis?
tonsillitis refers to inflammation of the palatine tonsils, most commonly due to infection
what causes tonsillitis?
viral infection (50-80%) - adenovirus, rhinovirus, influenza and parainfluenza.
Bacteria (around one third of cases) - s. pyogenes, s.aureus, and M. catarrhalis
what are the clinical features of tonsillitis?
Tonsillitis presents with odynophagia (pain on swallowing) or dysphagia (difficulty swallowing), often with associated pyrexia or halitosis (bad breath)
a cough and coryzal may also be present.
on examination the tonsils will appear erythematous and swollen
a purulent exudate may be present (more common in bacterial cases) as well as anterior cervical lymphadenopathy
what criteria can be used to asses for the likelihood of bacteria infection in tonsillitis?
fever pain
centor criteria
antibiotics should be considered if >2 criteria are met: history of pyrexia tonsillar exudates no cough tender anterior cervical lymphadenopathy
how is tonsillitis managed?
regular analgesics
topical analgesics e.g. benzdyamine - difflam
fluids
antibiotics - amoxicillin
what are the complications of tonsillitis?
peritonsillar abscess (quinsy)
deep space neck infection - . Infection can spread from the tonsils into the surrounding potential spaces between the fascial planes of the neck either as a parapharyngeal abscess or a retropharyngeal abscess
what are the indications for tonsillectomy?
Tonsillectomy can be performed by cold steel excision or diathermy. Typical indications are:
- ≥7 episodes in the preceding year, or ≥5 episodes in each of preceding 2 years, or ≥3 episodes in each of preceding 3 years
- Suspected malignancy
- Presence of sleep apnoea
- Previous peritonsillar abscess formation
The main complication from tonsillectomy is secondary bleeding (>24hrs post-op) from infection, occurring in around 5% of cases and most at post-operative days 5-9.
This is often treated conservatively, with antibiotic and hydrogen peroxide mouth wash. Fortunately, surgical re-intervention is rarely required
what is a pharyngeal pouch?
Also known as Zenker’s diverticulum, this is an out-pouching of the
mucosa and submucosa in the pharynx. It occurs between 2 muscles (cricopharyngeus and thyropharyngeus) of the upper oesophageal sphincter on the posterior pharyngeal wall in an area of weakness termed Killian’s dehiscence.
what are the features of a pharyngeal pouch?
> progressive dysphagia (difficulty swallowing)
regurgitation
aspiration
neck swells which gurgles on palpitation
bad breath due to stasis of undigested food in the pouch
recurrent chest infection due to aspiration
what investigations would you perform for pharyngeal pouch?
- barium swallow is the definitive investigation
- rigid oesophagoscopy may be useful to exclude carcinoma of the pouch wall
how is a pharyngeal pouch managed?
if asymptomatic - conservative management
if symptomatic - surgery particularly if risk of aspiration and recurrent pneumonia
what is globus pharyngeus?
This is the sensation of a lump, discomfort or foreign body in the throat without an obvious cause. It is a diagnosis of exclusion, linked to stress or anxiety and a form of somatization.
It is associated with laryngopharyngeal reflux (30%), cricopharngeal spasm and oesophagitis. It is a very common presenting symptom to an ENT clinic.
investigations should be performed to rule out other pathology
treatment is with reassurance, lifestyle advice and optimal anti-reflux therapy
when someone presents with a thyroid mass what investigations should you perform?
- USS of the neck to risk stratify thyroid lesions and look for malignant cervical lymphadenopathy (this will help to distinguish whether a patient has a solitary thyroid nodule or a suspicious nodule within a multinoduar goitre)
if it has suspicious nodules they should undergo ultrasound guided fine needle aspiration cytology. this can diagnose papillary carcinoma but cannot distinguish follicular adenoma (benign) from follicular carcinoma therefore the entire nodule must be assessed by performing a diagnostic hemithyroidectomy.
Follicular carcinoma has perivascular or pericapsular invasion
which can only be detected by histology rather than cytology
TFT
what is a thyroglossal cyst?
thyro (thyroid) and glossal (tongue).
The thyroid develops from the floor of the pharynx and descends into the neck during its development. It is connected to the tongue by the thyroglossal duct. The foramen cecum is the point of attachment of the thyroglossal duct to the tongue. The thyroglossal duct normally atrophies but in some people may persist and give rise to a thyroglossal duct cyst
what are the symptoms and signs of a thyroglossal cyst?
often asymptomatic
may enlarge/become tender in upper respiratory tract infections
may become infected, form an abscess or discharging sinus
- there will be a palpable neck lump, small, midline. can occur anywhere between base of tongue and trachea.
- usually in proximity to the hyoid bone
- moves on tongue protrusions and swallowing
what are the investigations and treatment for a thyroglossal cyst?
USS +/- fine needle aspiration cytology.
most require no treatment unless there are complications e.g. recurrent infections
what causes a multi nodular goitre?
occurs as a result of continuous change in thyroid activity
what are the symptoms and signs of a multi nodular goitre?
- neck lump which can be asymptomatic
- cosmetic deformity
- if it is very large they may experience pressure symptoms e.g. breathlessness, or dysphagia
- if cyst rupture/haemorrhage into cyst - pain and acute swelling
signs:
there may be a palpable/visible neck lump which moves on swallowing
dullness on percussion of manubrium in retrosternal goitre
what investigations should you perform for a goitre?
Blood tests- TSH. Consider free T4 and FBC
Thyroid US +/- Fine needle aspiration cytology
CT scan neck and chest if concerns of retrosternal extension.
Pulmonary function tests can show obstructive pattern.
how do you manage a toxic multi nodular goitre?
the treatment choice is radioiodine therapy
what are the different types of thyroid cancer?
Papillary carcinoma - the most common type (75%), most commonly seen in woman aged 40-50. they are usually multiple lesions within the gland. They commonly spread via the lymphatics.
Follicular carcinoma - usually seen at 40–60 years old and in woman - the second most common form. usually present as a focal encapsulated lesion. metastasis usually occurs via haematogenous spread to bones and lungs
medullary carcinoma - 3% of thyroid cancers rise in the parafollicular cells (C-cells, derived from the neural crest cells). Consequently, they produce raised calcitonin levels (leads to hypocalcaemia) and are associated (20% of cases) with MEN 2 syndrome (both 2a and 2b).
Anaplastic thyroid cancer - rare tumours - usually present in the elderly and are very aggressive. they tend to grow rapidly with early local invasion
lymphoma - thyroid lymphomas are very rare and usually present in people over the age of 60. they grow quite rapidly with marked compression symptoms and B cell symptoms. they are associated with hashimotos thyroiditis
what are the risk factors for thyroid cancer?
female gender fam history radiation exposure during childhood full body radiotherapy hashimoto's disease - predisposes lymphoma subtype
what are some clinical features of thyroid cancer?
thyroid cancers may present as a palpable lump, multiple lumps or be found incidentally on imaging the neck.
the red flag signs
- rapid growth
- pain
- cough, hoarse voice or stridor
- multiple enlarged cervical lymph nodes
- tethering of the lump to surrounding strictures
what is an adenoma?
a benign tumour formed from glandular structures in epithelial tissue.
what are the differential diagnosis for thyroid cancer?
benign thyroid adenoma or thyroid cyst
toxic multi-nodular goitre
non-toxic multi nodular goitre ( a goitre that does not produce symptoms of hyper or hypothyroid)
thyroglossal duct cyst
what are the investigations for thyroid cancer?
initially - TFTs
Any evidence of a toxic nodule (low TSH or raised T3 or T4, or radio-nucleotide imaging showing a “hot” nodule), then no further investigation for malignancy will be required as overactive nodules are very rarely malignant.
serum calcitonin may be useful
USS
fine needle aspiration
what features on USS would make you suspect thyroid malignancy?
Microcalcifications
Hypoechongenicity
Irregular margin
how is thyroid cancer managed?
MDT (ndocrinologists, histopathologists, radiologists, oncologists, and ENT surgeons, alongside of specialist nurses and speech and language therapists)
surgical - hemi or total thyroidectomy
chemotherapy
radiotherapy
radio iodine therapy
what is the peak age for onset of benign and malignant salivary gland tumours?
benign - 40 years of age
malignant will often affect the older patient
what are the different types of benign salivary gland tumours?
pleomorphic adenoma (middle age, slow growing painless lump, superficial parotidectomy but risk of CN VII damage)
Warthin’s tumour (males, middle age, softer, more mobile and fluctuant (although difficult to differentiate))
what are the main malignant salivary gland tumour types?
malignant tumour have a short history, painful, hot skin, hard, fiction and CN VII involvement.
1=most common, 5=least common
(1) Mucopeidermoid carcinoma (2) Adenoid cystic carcinoma (3) Acinic cell carcinoma (4) Squamous cell carcinoma (5) Adenocarcinoma
which benign salivary gland tumour can undergo malignant change?
Pleomorphic adenomas can undergo malignant change, termed carcinoma ex-pleomorphic adenoma. They are aggressive and are associated with a poor prognosis.
This occurs in around 2-4% of salivary gland malignancies and should be suspected in cases of sudden rapid growth of a previously stable mass is.
what are the red flags for malignant salivary gland tumour?
- hardness
- rapid growth
- tenderness
- infiltration of surrounding structures
- overlying skin ulceration
- facial weakness
facial nerve palsies are common adenoid cystic carcinoma
malignant tumours may have overlying erythema or ulceration
what are the risk factors for salivary glad tumours?
direct radiation exposure
EBV infection
smoking - tobacco smoke has been associated with the development specifically to Warthin’s tumour
- genetic alterations - p53 mutations
what are the clinical features of a salivary gland tumour ?
slowly enlarging mass
typically painless
when pain occurs it is often due to suppuration or haemorrhage into the mass or infiltration of malignancy to surrounding tissues
larger salivary tumours may result in eventual airway obstruction, dysphagia or hoarseness
ones protruding into the nasal cavity and paranasal sinuses can present with nasal obstruction or sinusitis
what are the differentials for salivary gland tumours?
sialoliathiasis
chronic sialedenitits
autoimmune disease
lypmhoproliferative disorders
what investigations for salivary gland tumours?
Bloods
USS with fine needle aspiration cytology
CT scan of neck and thorax for staging
what are the complications of salivary gland tumours?
haematoma
facial nerve injury
late - Frey’s syndrome can develop following parotidectomy where the autonomic fibres supplying the gland reform inappropriately and the stimulus to salivate results in an inappropriate response of redness and sweating.
what is sialadenitis ?
inflammation of the salivary gland
can be acute or chronic
most commonly affects the parotid glad
what are the causes of sialadenitis?
infective - viral (mumps) or bacterial stones malignancy autoimmune idiopathic
what are the clinical features of sialadenitis ?
- painful swelling and tenderness of the gland
- pyrexia
- lymphadenopathy
- erythema
- infections may also cause a purulent discharge
what investigations would you perform for sialadenitis?
routine bloods
pus swaps
blood cultures if any evidence pf systemic involvement
if suspicion of malignant disease a fine needle aspiration cytology should be performed
USS
how is sialadenitis managed?
mostly conservative management with hydration and analgesia
antibiotics should be given if bacterial cause is suspected
if abscess has formed then incision and drainage will be needed
what is Heerfordt’s syndrome?
Heerfordt’s syndrome is a form of sarcoidosis, composed of parotid enlargement, anterior uveitis, and facial nerve palsy
what is sialolithiasis?
very rare
Sialolithiasis is the presence of calculi in the salivary glands or ducts. Stones will form in the salivary gland or ducts following the stagnation of saliva; they are typically composed of calcium phosphate and hydroxyapatite, as the saliva is rich in calcium
what can carcinoma of the oral cavity affect?
lips tongue floor of the mouth alveolar ridge hard palate buccal lining
most of the them are squamous carcinomas
what are risk factors for carcinoma of the oral cavity ?
usually multifactorial
- smoking
- alcohol
- Betel Nut
- Chronic dental infection
- immunosuppression
what are the symptoms and signs of carcinoma of the oral cavity?
painless ulcer or lump
pain is a late symptom
increasing size of the tumour can affect speech and swallowing
signs:
painless swelling
discolouration
Red, erythematous, velvety mucous membrane (erythroplakia)
which is strongly associated with malignancy
White (leukoplakia) or mixed red/white lesions (speckled
leukoplakia)
Lichen planus
Non healing ulcer
Neck swelling if metastases are present
what is sjogren syndrome characterised by?
Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicca
90% of cases occur in females
Second most common connective tissue disorder
Bilateral, non tender enlargement of the gland is usual
Histologically, the usual findings are of a lymphocytic infiltrate in acinar units and epimyoepithelial islands surrounded by lymphoid stroma
Treatment is supportive
There is an increased risk of subsequent lymphoma
what can carcinoma of the pharynx be subdivided int?
nasopharynx - This is a rare tumour of the postnasal space. Highest incidence in
the South Asian and North Asian population. EBV is believed to
have a major causative role in this carcinoma.
oropharynx - Tumours of the tongue base (posterior third of the tongue) and the
tonsils (or tonsillar fossae if the tonsils have been previously
removed). 70% of tonsillar carcinomas are SCC and minority are
lymphomas.
hypopharynx - Most cancers
arise in the pyriform sinus. Virtually all malignant tumours are of SCC
origin. Metastases are very common from the primary site. Patients
are typically men aged 55-70 years old with a history of tobacco use
and/or alcohol use.
what are the risk factors for carcinoma of the pharynx?
smoking
alcohol
virus - HPV (oropharynx) EPV (nasopharynx)
radiation
how does pharyngeal cancer present?
Many cases of pharyngeal cancer can present* initially as odynophagia, dysphagia, stertor, or referred otalgia. Nasopharyngeal carcinoma patients can present initially with a neck lump.
Majority of these tumours, specifically of the hypopharynx, frequently will have an advanced stage at the time of diagnosis as they will often metastasise early due to the extensive lymphatic network.
*Trotters Syndrome is a triad of clinical features suggestive of nasopharyngeal malignancy, comprised of (1) unilateral conductive deafness (secondary to middle ear effusion), (2) trigeminal neuralgia (secondary to perineural invasion), and (3) defective mobility of the soft palate
what are the symptoms/signs of carcinoma of the nasopharynx?
Cervical lymphadenopathy.
Ear pain, secretory otitis media, hearing loss and cranial nerve
palsies.
The nasal involvement can present with epistaxis*, discharge, changes in smell and nasal obstruction
Persistent unilateral otitis media with effusion and no preceding
URTI
what investigations and management would you perform for carcinoma of the nasopharynx?
investigations:
- detailed head and neck exam
- nasendoscopy
- formal biopsy
- FNA of any neck nodes
- imaging
- MRI
- CT
management
- chemo and radio
what does carcinoma of the oropharynx have a strong association with?
strong association with HPV 16 and HPV 18
what are the symptoms of carcinoma of the oropharynx?
- painless tonsillar swelling (unilateral)
- history of throat discomfort with worsening dysphagia
- referred otalgia (involvement of arnold’s nerve- branch of vagus)
- a lump in the throat sensation or evidence of metastatic cervical lymphadenopathy; jugulodigastric lymphadenopathy is often present
- trismus is a red flag for surrounding structure infiltration
what are the investigations and treatment for carcinoma of the oropharynx?
- detailed head and neck exam
- panendoscopy and biopsy
- FNA of any neck nodes
- imaging - MRI to delineate the margins of tumour. Staging CT neck and chest/abdomen
Treatment
- surgery +/- radiotherapy or chemotherapy
- chemoradiotherapy
what are the symptoms of carcinoma of the hypo pharynx?
Cervical lymphadenopathy, pain that radiates from the throat to ear, sore throat, progressive difficulty with or painful swallowing, voice changes Paterson- Brown- Kelly syndrome: dysphagia , hypochromic microcytic anaemia, oesophageal webs and potential development of postcricoid carcinoma
what are the investigations and management of carcinoma of the hypopharynx?
investigations:
- endoscopy
- biopsy
- pharygo- oesophagoscopy
- imaging
- barium swallow
- MRI
- staging CT neck and chest/abdo
Management
Early cancers (rare)- surgery + radiotherapy.
Advanced cancers- surgery + radiotherapy +/- neoadjuvant
chemotherapy
Many hypopharyngeal cancers are incurable at presentation and best supportive care may be the most appropriate option for
management
what is nasopharyngeal carcinoma associated with ?
EBV infection
what can carcinoma or the larynx be divided into?
Laryngeal carcinoma can be subdivided into supraglottic (27%), glottic (69%) and subglottic (4%). Glottic cancer is the most common. Histology is squamous cell origin in 90% .
what the risk factors for laryngeal cancer?
smoking
alcohol
what are the symptoms of laryngeal cancer?
- hoarseness is the most common presentation and comments in glottic cancer.
- noisy breathing/stridor
- cough. haemoptysis
- odynophagia
- dysphagia
- neck lymphadenopathy
what are the investigations and treatment for laryngeal cancer?
- oral cavity, ENT and neck examination
- flexible nasoendoscopy
- microlaryngoscopy for biopsy
- CT neck and chest staging
- MRI neck and PET CT occasionally indicated
- TNM classification to stage disease
TREATMENT:
- MDT team
- small tumour - treatment is single modality with options being radiotherapy or endoscopic laser excision
- larger tumours - multimodality which may be larynx sparing (chemo and radio) or larynegectomy with postoperative radiotherapy
what is larygopharyngeal reflux?
LPR describes a group of upper respiratory tract symptoms secondary to irritation from gastric contents.
what are the symptoms of laryngopharygeal reflux?
hoarseness throat clearing chronic cough globus pharygeus dysphagia
what is the treatment of laryngopharygeal reflux ?
the gold standard for diagnosing is a 24 hour dual probe pH manometry combined with intraluminal impedance studies.
treatment:
conservative measures including lifestyle modification
avoid eating three hours before going to sleep
stop smoking and reduce alcohol intake
addressing obesity
avoid fizzy drinks
avoid throat clearing
in general what investigations would you perform for head and neck cancers?
biopsy of the lesion
flexible nasal endoscopy allowing for direct visualisation of the lesion
what is obstructive sleep apnoea?
a clinical condition of intermittent and recurrent collapse of the upper airways during sleep
what are the risk factors of sleep apnoea?
obesity male gender middle aged smoking ecxcess alcohol use of sedating drugs
marinas syndrome and macroglossia can also predispose to it
in children, tonsillar and adenoid enlargement can cause partial obstruction of the upper airways leading to obstructive sleep apnoea
what are the clinical features of obstructive sleep apnoea?
excessive daytime sleepiness
reduced concentration
witnessed sleeping disturbances is commonly described by others, such as choking episodes or observed apnoea.
other less specific features include personality changes, reduced libido and restlessness.
NICE recommends that you should also enquire about the possibility le presence of any symptoms of head and neck cancers during the assessment?
what scale is used to assess obstructive sleep apnoea ?
the epworth sleepiness scale
what are the differential diagnosis for obstructive sleep apnoea?
DD fo daytime sleeepiness: sleep disturbance (from anxiety or depression) narcolepsy hypothyroid meds
other causes of nocturnal choking or gasping
- GORD
- nocturnal asthma
- HF presenting as paroxysmal nocturnal dyspnoea or orthopnoa
what investigations would you perform for obstructive sleep apnoea?
gold standard - formally diagnosed via sleep studies - polysomnography (PSG) which aims to measure the number of apnoea or hyponoeic episodes per night calculated as an apnoea-hyopnoea index
how is obstructive sleep apnoea managed?
lifestyle changes where appropriate
in moderate to severe cases, CPAP is first line
Surgical interventions that can be trialled include uvulopalatopharyngoplasty (UPPP), laser-assisted uvulopalatopharyngoplasty (LAUP), radiofrequency ablation of the tongue base, or suspension of the hyoid bone. Select patients may also benefit from orthognathic surgery.
what are the complications of obstructive sleep apnoea?
any patients on CPAP treatment should inform the DVLA
Obstructive sleep apnoea can result in significant cardiovascular co-morbidity, increasing the risk of developing hypertension, ischaemic heart disease and stroke.
there are long term effects on memory, cognitive function and mood.
what is Rinne’s and webers test?
In Weber’s test, a vibrating tuning fork is placed in the centre of the head. The sound then travels to both ears. If the sound is her loudest in one ear, in this case the left, it can indicate either a conductive hearing loss of the left ear or a sensorineural loss of the right ear.
In Rinne’s test, the tuning fork is placed next to each ear in turn. The fork is struck causing it to vibrate, placed on the skull near the ear, and then placed next to the ear. If when placed on the bone it is louder, it indicates a conductive hearing loss.
what is exostosis?
Exostosis is caused by repeated exposure to cold water and wind which causes a benign bony growth in the external auditory canal, this is a form of conductive hearing loss
if the is perforation of a tympanic membrane when should it be reviewed?
review in 4 weeks time
keep ear dry
if still there in 4 weeks then ENT referral should be considered
