ENT Flashcards
Paranasal Cancers
Suspect when Chronic Sinusitis presents for first time in later life
o Blood stained nasal discharge, nasal obstruction, cheek swelling; Squamous cell
(50%), Lymphoma (10%), Adenocarcinoma, Adenoid-cystic, Olfactory NB etc
o Mgmt with RT ± radical surgery
Nasopharyngeal Carcinoma
Rare in UK
o P/c Neck Lump, 90% have cervical LNadenopathy, Unilateral CHL due to Eustachian
blockage, CN palsy due to skull base extension
o Dx with Endoscopy/Biopsy, staging by MRI
o Mgmt with RT ± CT ± Radical neck dissection; Good survival if stage I
Differential for Voice Hoarseness: Common
• Acute and Chronic Laryngitis • Reflux Laryngitis • Vocal fold nodule, cyst, polyps, scars • Reinke’s Oedema (Chronic irritation causes gelatinous fusiform enlargement; Typically, hypothyroid, elderly, female smokers) • Disorders of Speech Articulation
Differential for Voice Hoarseness: Uncommon
- Laryngeal Cancer
- Granuloma/Contact ulcers
- Unilateral and bilateral VF paresis
- Leucoplakia
- Vocal fold cancer
HEAD AND NECK SQUAMOUS CELL CARCINOMAS
• 90% Head and neck cancer are squamous cell carcinoma – Lining of upper aerodigestive tract;
Oral cavity, Oropharynx, Hypopharynx, Larynx and Trachea
o >80% arise in >50y, incidence in young increasing; Spreads via lymphatics
o RF: Smoking 10x, Alcohol, Vitamin A and C deficiency, Nitrosamines, HPV, GORD
• Present as Neck pain/lump, Hoarseness or Sore throat >6/52, Mouth bleeding and numbness,
Sore tongue, Painless ulcers, Oral patches, Otalgia/Effusion, Speech change and Dysphagia
• Dx: FNE, FNA/ Biopsy of masses, CT/MRI for staging of primary and nodal disease, MDT
o Staging by TNM (<2cm = T1, T4 extends to
bone/muscle/skin/antrum/neck; Nodes in
the neck are divided into 6 areas of the
neck; Mets)
Oral and Lingual Carcinomas
Rare in UK; P/c Persistent, painful ulcers; White/red patches on tongue, gum or mucosa,
Otalgia, Odynophagia, LNadenopathy
o Surgery/RT >80% 5y survival if early disease
Oropharyngeal Carcinoma
• Often Advanced presentation; 5:1 M, Older patient, Smokers, Referred Otalgia/Fullness in
throat; RF: Pipe/chewing tobacco; 20% node positive at ppt
o Ix: MRI; Mgmt: Surgery and RT; RT first line if ≤T2
o Tonsillar cancer has better prognosis; 5y Survival 50% if stage I
o High risk HPV (especially HPV16) linked to Lingual, Tonsillar and Pharyngeal cancer;
Vaccination might reduce risk
Hypopharyngeal Carcinoma
• Hypopharynx – Hyoid bone to lower edge of Cricoid
• Rare, present as lump in throat, dysphagia, odynophagia, referred otalgia, hoarseness
• Mgmt: RT and surgery; Very poor prognosis
o Pre-malignant conditions – Leukoplakia (Hyperparakeratosis ± Underlying epithelial
hyperplasia), Plummer-Vinson (Pharyngeal web associated with Fe deficiency); 2%
risk post-cricoid cancer
Laryngeal Cancer
• Typically, older patient; Progressive hoarseness to Stridor, difficulty/pain on swallowing,
haemoptysis, otalgia; If in younger patient, tends to be HPV +ve
o Described as Supra, Infra or Glottic; Glottic tumours cause hoarseness earlier = Better
prognosis; Spread to nodes occurs typically late
• Ix: Laryngoscopy, Biopsy, HPV status; Staging by MRI
• Mgmt: Radical RT for small tumours, Partial/Total Laryngectomy for larger tumours ± block
dissection of neck glands
o 5y survival rate 66%
Post-Laryngectomy Management
• Voice restoration if larynx is removed, and trachea is brought to skin as end-stoma on neck
• Post-Laryngectomy, Oesophagus and Trachea are no longer united; New swallowing
technique required, breathing through stoma
• NGT initially post-op as pharynx heals + Analgesia; SALT-led rehabilitation, Stoma care
o Trans-oesophageal puncture – One-way valve (Voice prosthesis) between trachea
and pharynx/oesophagus; Valve activated when patient occludes stoma and breathes
o Artificial Larynx (Servox) – Artificial vibrating larynx held against neck
The Lump in the Neck
• Duration – <3/52 likely Reactive LNadenopathy from self-limiting infection
• Tissue Layer – Intradermal: Sebaceous cyst with central punctum, Lipoma
• Imaging: Ultrasound – Architecture, Vascularity, Guidance for FNAC; CT – Anatomy; CXR for
malignancy or sarcoid (Bihilar LNadenopathy)
o Virology and Mantoux test
Midline Lumps
If <20yrs – Likely dermoid cyst If moves up with protruding tongue, and is Infrahyoid – Thyroglossal cyst If bony hard – Chondroma
Submandibular
Triangle
If <20yrs – Likely reactive LNadeno; If >20 exclude Malignancy: Firm, Non-tender, B-sym Is TB likely? Other Dx: Stone, Submand Tumour, Sialadenitis
Anterior Triangle
LNadenopathy B-sym? Lymphoma Upper third junction of SCM – Brachial cyst (Squamous lined, Cholesterol) Parotid Ca esp if >40y; Other Dx: Laryngocoele, Carotid pathology
Posterior Triangle
Pharyngeal pouch Cystic Hygroma (Lymphatic malformations, very transilluminable) LNadenopathy if many small lumps (TB, HIV, EBV; if >20y think Lymphoma or mets Cervical Ribs
EMERGENCY MANAGEMENT OF UPPER AIRWAY OBSTRUCTION
• Positioning – Let patient to sit or lie down to position most comfortable
• Oxygen or Heliox (79% He, 21% O2); Less dense than air, more laminar flow
• Nebulised Racemic Adrenaline, IV Dexamethasone or Hydrocortisone
• Crash Bleep to ENT Registrar and Anaesthetist; Get Crash Tracheostomy kit ready
• Discern History where possible and identify based on common reasons for Stridor
o Acute DDx: Anaphylaxis, Laryngotracheobronchitis, Epiglottitis, Laryngitis,
Oesophageal Foreign Body, Vocal Cord Paralysis
• ABG where possible without delay or stress; if Stridor improves, Flexi Nasoendoscopy to
identify cause and visualise airway
• AP plus lateral XR Neck and Chest
• Definitive Airway – Needle Cricothyrotomy in
Children (15L/min Oxygen through 14G cannula; 1
sec oxygenating jet, 4 sec expiratory pause);
Surgical Cricothyroidectomy (>12yrs)
• Tracheostomy in Theatre within 30 mins as Jet
insufflation oxygenates rather than ventilates;
CO2 build up can occur
VOCAL CORD PARALYSIS
• Superior Laryngeal Nerve splits into External (Supplies Cricothyroideus muscle) and Internal
(Supplies sensation above the vocal folds); Recurrent Laryngeal Nerve supplies most of the
intrinsic muscles of the Larynx
o Posterior Cricoarytenoid muscles – Only muscle to open the vocal folds
• Vocal Cord Paralysis can present as Hoarseness with a ‘Breathy’ voice and Weak Cough;
Repeating Coughing and Aspiration (Due to weak sphincter and poor supraglottic sensation),
Exertional Dyspnoea (Due to airway narrowing; At rest, a unilateral paralysis can be
compensated by contralateral abduction)
o 30% due to Cancer (Laryngeal, Thyroid, Oesophageal, Hypopharynx, Bronchus), 25%
Iatrogenic; Also, due to CNS disease, TB; 15% Idiopathic
• Investigate with CXR, Barium swallow, MRI, Endoscopy
• Treat underlying tumour; If no additional pathology, SALT opinion regarding whether
spontaneous recovery can occur
o Non-resolving paresis – Injection
Medialisation (allows vocal fold to contact
contralateral fold, allowing better
phonation); Medialisation Thyroplasty
EPISTAXIS
• Described as anterior or posterior bleeds; Anterior easily seen with rhinoscopy, simpler to treat, less severe than posterior • General principles: Resuscitate (IVI, O2, etc) • Hx: Trauma, Quantity of loss, On anticoagulation, other PMHx • Pinch lower part of nose 20 minutes, breathe through nose, sit forward and spit blood into bowl; Ice pack on nasal dorsum • Strategies – Cauterise with Ag Nitrate, 1: 200,000 adrenaline soaked cotton balls, local anaesthetic spray (Lidocaine) o Never cauterise both sides of septum – Risk perforation; If unable to see bleeding point, refer to ENT o Anterior Nasal pack (e.g. Rapid Rhino, Merocel) if bleeding continues despite; Remove after 24h if bleeding stops; If failed, apply Postnasal pack/Foley catheter
• Anterior Epistaxis – Almost invariably septal
• Serious posterior bleed requires EUA, Endoscopic Arterial Ligation or Embolisation of e.g.
Internal Max, Facial Artery (however, risk of causing stroke)
Aetiology of Epistaxis
RF: Allergic Rhinitis, Chronic Sinusitis, HTN, Haem malignancies, Coagulopathy
Epistaxis: Local
- Trauma – Most common cause
- Mucosal Irritation/Infection/ Topical Rx
- Septal Abnormality
- Inflammatory Diseases
- Tumour
Epistaxis: Systemic
• Dyscrasias – E.g. Haemophilia, von-
Willebrand’s disease
- Arteriosclerosis
- Anticoagulation
- HHT (Osler-Weber-Rendu)
Retained Nasal Foreign Body
- Mainly self-inserted by children; Organic material presents early with purulent discharge
- Auroscopic Examination; If possible, removal by Crocodile forceps; Batteries = Urgent
- Ask child to blow nose, or ‘Parental kiss’ technique (>70% success rate)
Nasal Fracture
• Exclude HI or C-spine; Most commonly direct trauma or fall, often with brief/short-lived
epistaxis; P/c New nasal deformity, facial swelling/contusion
• XR can help exclude other facial #; Treat Epistaxis, + Analgesia, Ice, closure of skin injuries
• If MUA required, perform 10-14d after injury before nasal bones set
• Septal Haematoma – Boggy swelling of septum; near-total obstruction; Requires urgent I+D
Xerostomia
can result from a variety of causes, including Sjögren’s Syndrome, Drugs
(Antimuscarinics, Antiparkinsonian, Antihistamines, MAOIs, TCAs and Clonidine);
Radiotherapy, Dehydration, Shock and CKD
o Simulation and Replacement (Glycerine, Lemon Mouthwash, Artificial Saliva)
Sialadenitis
Acute Sialadenitis is typically Viral
(Mumps) or Bacterial; Bacterial Sialadenitis is painful
ascending infection (S aureus, S pyogenes or
pneumoniae); Pus can be expressed
o DDx: TB, HIV, ALL, Heerfordt’s Syndrome
(Uveoparotid Fever of Sarcoidosis)
Salivary Duct Obstruction
Usually due to calculus;
Painful swelling of Submandibular gland, especially
after eating; Plain XR and Sialography will show
calculus; Endoscopic removal
Parotid Tumours
• Salivary Neoplasia accounts for 3% of all tum ours worldwide, majority in Parotid gland
o Pleomorphic Adenoma is the most common (80%), of which 15% undergo Malignant
transformation; Classically results in CN VII signs
o Recurrence after surgical incision is common
o Other DDx includes Warthin’s Tumour (Benign Adenolymphoma), Haemangioma or
Lymphangioma (In Children), Mucoepidermoid Tumours (Intermediate)
o Malignancies include Adenoid Cystic, Adenocarcinoma or Squamous Cell Carcinoma
• Lumpectomy is inadequate; Partial Parotidectomy required due to risk of seeding
• Sialograms and CT are useful for pre-operative planning
Primary Sjögren’s Syndrome
• Dry Eyes (Keratoconjunctivitis Sicca) in absence of RA or other autoimmune disease;
Association with HLA-N8/DR3; Dryness of Mouth, Skin or Vagina; Salivary and Parotid
Enlargement; Other Autoimmune Phenomena (Arthralgia, Raynaud’s, Dysphagia and
abnormal motility, Other Organ-specific disease)
• Biopsy of Salivary gland shows focal infiltration with Lymphocytes and Plasma cells
• Raised Ig, Circulating Immune Complexes and AutoIg; RF typically positive, ANA 80%, Anti-
Mitochondrial 10%; Anti-Ro (SSA) 60-90%
o Anti-Ro can cross placenta; Potentially cause Congenital Heart Block
• Symptomatic Management with Artificial tears and Saliva replacement; Hydroxychloroquine
may help Fatigue and Arthralgia; Corticosteroids rarely needed, but used in treating
Persistent Salivary Gland Swelling or Neuropathy
