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
