ENT - Common Conditions of the Head, Neck and Throat

Question 1

A 56 year old man presents with a slight cough and no
other symptoms. “Doc, I have been smoking 20 per day and working on the roads for 38 years”. He has a left lateral neck mass.

Identify the problem and what to examine

Answer 1

Most likely to be associated with the lympho-reticular system of the head and neck

Take a Hx & examine the neck.

Question 2

What (3) is in the Lympho-reticular System of the Head and Neck?

Answer 2

a) . Inner Ring – Waldeyer’s Ring: Adenoids (pharyngeal tonsils), Tubal tonsils, Tonsils (palatine tonsils), Lingual tonsils, Pharyngeal Bands
b) . Outer Ring – Lymph Node Groups: Submental, Submandibular, Jugulo-digastric (relationship to tonsils), Post-auricular, Sub-occipital

c). Lymphatic Chain associated with the Great Vessels of the Neck and the Thoracic Duct
Jugulo-digastric LN Group, Jugulo-omohyoid LN Group

Question 3

What are the likely sites of origin of lateral mass pathology?

Answer 3

a) . External – Skin of the Head and Neck
- SCC
- Melanoma

b) . Internal – Upper Aero-digestive Tract
- Oral cavity including tonsils, larynx, pharynx, (remember CXR to investigate lungs)
- Nasopharynx, especially if patient is of Cantonese/ SE Asian Extraction (nasopharyngeal cancer often drains to the posterior cervical triangle LN)

c) . Other
- primary salivary gland pathology
- thyroid differentiated tumours, especially papillary carcinoma
- lymphoma
- supraclavicular LN associated with visceral malignancy (Virchow’s node or Troisier’s Sign)

Question 4

How do you examine a neck?

Answer 4

1. Inspection
   - Central anterior neck (thyroglossal duct cyst, thyroid)
   - Lateral neck
   - Posterior cervical triangle
2. Palpate
   - anteriorly (examine outer ring of LN groups, carotid triangle, posterior triangle of neck)
   - posteriorly (examine the outer ring of LN groups & cervical anterior neck)
3. Inspect mouth & tonsils. Use a tongue depressor

Question 5

How well can you identify primary site of SCC origin in upper aero-digestive tract?

Answer 5

initially identified in 90% of patients with diligent examination and simple investigation

Question 6

What can fine needle aspiration cytology identify in the neck?

Answer 6

skin SCC, melanoma, papillary thyroid carcinoma, and possibly nasopharyngeal carcinoma

Hence open neck biopsy is rarely needed.

Question 7

What Ix could you do for a neck mass?

Answer 7

a) . Fine Needle Aspiration Cytology (FNAC)
b) . CT scan of neck, oral cavity and nasopharynx
c) . CXR

Question 8

Why is CXR needed in a neck mass Ix?

Answer 8

up to 5% chance of another SCC in upper part of aero-digestive tract or lower respiratory tract SCC

Question 9

Name (5) oral pathologies

Answer 9

• Leukoplakia
• Persistent Mouth Ulceration
• Quinsy or Peritonsillar abscess
• Tonsillitis
• Tongue Base and Floor of Mouth Swelling

Question 10

What is leukoplakia? What can it lead to

Answer 10

areas of keratosis appearing as firmly attached white patches on the mucous membranes of the oral cavity

3% chance of SCC

Question 11

What should you suspect in a persistent mouth ulceration?

Answer 11

Suspicion of malignancy

especially with other factors such as smoking, sun exposure (lips) and presence of a neck lump

Question 12

Describe Quinsy or Peri-tonsillar Abscess

Answer 12

• Displaced uvula and unilateral swelling
• Point of drainage and relationship to local structures
• Potential spread to other fascial spaces and potential fatal sequelae (tongue base, spread to become mediastinitis)

Question 13

Describe bacterial tonsillitis

• follicular appearance
• Rx

Answer 13

• Follicular appearance “strawberries and cream”. White follicles on tonsils + swollen uvula.
• Consider tonsillectomy if has recurrent bacterial tonsillitis (e.g. x6 in one year) or OSA (Obstructive Sleep Apnoea) especially in children

Question 14

Describe infectious mononucleosis tonsillitis

• appearance of tonsils
• other system manifestations

Answer 14

• More diffuse coating on tonsils

* Hepato-splenomegaly, diffuse lymphadenopathy and impaired liver function

Question 15

Describe Tongue Base and Floor of Mouth Swelling

• Causes
• its significance
• Rx

Answer 15

a) . Infective causes – spread from other head and neck fascial space source such as a quinsy, neglected #jaw, mandibular molar tooth root abscess
b) . Malignancy, haematoma

IMPORTANCE DUE TO POSSIBLE FATAL AIRWAY OBSTRUCTION

• consider nasopharyngeal airway or tracheostomy

Question 16

Describe the causes of otalgia & referred pain

Answer 16

• Ear Pain can be from otitis externa or otitis media or referred pain to the ear from elsewhere.
• This can often be from the TMJ (Temporo-Mandibular Joint), especially with anxiety, teeth clenching, poor molar support and bruxism.
• Other referred sources of ear pain

Question 17

Describe the association between otalgia & CN IX/X

Answer 17

• Sensory distribution of glossopharyngeal nerve in the oral cavity
• Vagus nerve sensory distribution to larynx and pyrifom fossae;
• The importance of a protective laryngeal reflex and aspiration.

Question 18

(4) causes of hoarseness

Answer 18

• SCC of larynx
• Paralysed Vocal Cord
• Reflux of pepsin and acid (GORD, laryngo-pharyngeal reflux)
• Vocal Nodules

Question 19

Discuss emergency airway management in hospital

Answer 19

a) . Adrenaline
- Give 0.5mL if over 40kg (0.01mL/kg) deep I/M (NOT IV!)
- Ampoule 1:1000 contains 1 mg of adrenaline per mL of solution in a 1 mL glass vial

b) . Secure the airway
- Guedel airway
- Naso-pharyngeal tube
- Crico-thyroid puncture with two 19 Guage needles
- Tracheostomy

Question 20

Discuss tracheostomy & crico-thyroid puncture

Answer 20

relatively bloodless crico-thyroid membrane c.f. upper trachea where relatively bloody thyroid isthmus often gets in the way

Hence crico-thyroid puncture often preferred for rapid airway patency.

But Tracheostomy is preferable below the 2nd (second) tracheal ring for better medium and long term management of the airway (subglottic stenosis, hoarseness from prolonged C-T membrane disruption)