ENT

Question 1

A 19 year old man presents to his GP with an asymptomatic right sided neck lump that he noticed four weeks previously. On examination, the lump is soft and mobile, is within the dermal layer of the skin and on transillumination, the area is equal to the surrounding tissue. There is no central punctum. What is the most likely diagnosis?

(A) Branchial cleft cyst
(B) Epidermoid cyst
(C) Lipoma
(D) Cystic hygroma 
(E) Deep cervical abscess

Answer 1

(C) Lipoma

Epidermoid cysts are common cutaneous cysts that result from proliferation of epidermal cells within a circumscribed space of the dermis. They can occur at any age and are typically asymptomatic. On physical examination they are typically firm, round nodules of various sizes and a central punctum may be present.

Cystic hygromas are congenital lymphatic lesions that are typically found in the neck and Axilla regions with a predilection for the left side. The majority present by 2 years of age. On physical examination, cystic hygromas are often soft, painless and transilluminate brightly.

Bronchial cleft cysts are congenital epithelial cysts that develop due to failure of obliteration of the second bronchial cleft in embryonic development. They typically present by early adulthood. On physical examination, they are typically smooth, painless and do not transilluminate.

Deep cervical abscesses typically occurs following a source of infection such as recent dental work, upper respiratory tract infections, neck or oral cavity trauma. They can occur at any age. On physical examination, the patient typically presents with a painful and tender swelling that may be hot to the touch. The patient may also have other signs of infection such as fever, chills, aches and pains.

Question 2

A 59 year old man presents with a severe pain deep within his right ear. He feels dizzy and reports the room is ‘spinning’. Clinical examination shows a partial facial nerve palsy on the right hand side and vesicular lesions on the anterior two thirds of his tongue. What is the most likely diagnosis?

(A) Ménière's disease
(B) Herpes zoster ophthalmicus
(C) Ramsay Hunt syndrome
(D) Acoustic neuroma
(E) Trigeminal neuralgia

Answer 2

(C) Ramsay Hunt Syndrome

Ramsay hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.

Features include:

• auricular pain (often the first feature)
• facial nerve palsy
• vesicular rash around the ear
• vertigo and tinnitus

Management - oral aciclovir and corticosteroids are usually given

Question 3

A 17 year old man presents to the ENT clinic to discuss the results from a fine needle aspirate taken from a smooth, fluctuant non-tender, non-translucent mass located anterior to his left sternocleidomastoid muscle. It does not move on tongue protrusion. The aspirate reveals an acellular fluid with cholesterol crystals.

Based on the clinical and pathological information, what is the mass most likely to be?

(A) Branchial cyst
(B) Thyroglossal cyst
(C) Cystic hygroma
(D) Reactive lymphadenopathy
(E) Dermoid cyst

Answer 3

(A) Branchial cyst

A branchial cyst is typically a benign lesion that is situated in the lateral neck, superficial to the sternocleidomastoid muscle. The classical pathological finding in a branchial cyst is an acellular fluid with cholesterol crystals.

A thyroglossal cyst is typically midline and moved with tongue protrusion. A cystic hygroma typically presents in infancy and lymph would be aspirated. Reactive lymphadenopathy would present secondary to another pathological process and would unlikely be multifocal. Dermoid cysts are more typically found in the midline.