ENT JC099: Infections And Tumours In Pharynx And Oral Cavity Flashcards
Head and neck surgery
Subspecialty of ENT
Manage diseases in:
1. Upper aerodigestive tract
2. Salivary gland (Parotid, Submandibular, Sublingual, Minor salivary gland)
3. Thyroid
4. LN
5. Skin + Soft tissue in HN region
Upper aerodigestive tract
Upper 1/3:
- Nasal cavity + Paranasal sinuses
- Nasopharynx (posteriorly divided at hard palate)
Middle 1/3:
- Oral cavity (anterior to hard palate)
- Oropharynx (posterior to hard palate)
—> divided at hard palate into anterior 2/3 + posterior 1/3 of tongue
Lower 1/3:
- Larynx
- Hypopharynx
Oral cavity + Oropharynx
Oral cavity:
1. Lip
2. Buccal mucosa with Parotid duct opening
3. Gingival sulcus
4. Teeth
5. Hard palate
6. Oral tongue (anterior 2/3) —> different pathology to posterior tongue ∵ different embryonic origin
7. Floor of mouth with Submandibular duct opening
Oropharynx:
1. Tonsils
2. Soft palate
3. Pharyngeal mucosa (lateral + posterior)
4. Tongue base (posterior 1/3) —> different pathology to anterior tongue ∵ different embryonic origin
—> vs Floor of mouth!!!
—> Ventral: under surface of tongue
—> Dorsal: superior surface of tongue
History taking of ENT
- Age
- Sex
- Duration: Acute (infection) vs Chronic (neoplastic)
- Symptoms
- Ear: unilateral hearing loss, pain
- Nose: blood stained discharge, unilateral nasal obstruction
- Mouth: non-healing ulcers, mass, blood-stained saliva, loosen denture
- Throat: hoarseness, blood-stained sputum, SOB
- Pharynx: globus, dysphagia, blood-stained saliva
- Neck: salivary gland, LN
- Constitutional symptoms - Risk factors:
- Smoking
- Alcohol
- Family history (NPC / other HN cancers) - Functional disturbance
- breathing
- chewing
- swallowing
- phonation
- articulation - Co-morbidities
- to prepare patient for surgery
P/E of ENT
- Oral cavity + Oropharynx
- ALL subsites
- Inspection + Palpation (tenderness, underlying mass, induration) - Neck
- location of neck mass / LN (region / level)
—> Level 1-6 (Submental + Submandibular, Jugular chain, Posterior neck, Anterior neck)
- shape + size (measure)
- consistency
- mobility
- inflammation (changes in skin) - Scalp / Skin
- if no obvious origin in neck mass
- skin cancer (e.g. melanoma, SCC) hidden under hair
Acute tonsillitis: Causative organisms + S/S
Infection + Acute inflammation of tonsils
Causative organisms:
1. Virus
- Influenza
- Parainfluenza
- Adenovirus
- Enterovirus
- Rhinovirus
- Bacteria
- β-haemolytic Streptococcus (Strept pyogenes)
- Streptococcus pneumoniae
- H. influenzae
- Anaerobes
- Mixed - Others
- Corynebacterium diphtheria
- Candida
- Syphilis
- TB (usually chronic)
Clinical features:
Symptoms:
- Sore throat
- Fever
- Dysphagia
- Odynophagia
- Muffled voice (***“Hot potato” voice ∵ enlargement of tonsils in oropharynx obstructing airway)
- Otalgia (∵ CN8 attaching from ear to throat —> referred pain)
- Systemic: Abdominal pain, Vomiting
Signs:
- Hyperaemic tonsils with exudates / pus
- ***No / minimal trismus
- Tender cervical lymphadenopathy
Management of Acute tonsillitis
Investigations:
1. CBP + D/C (neutrophil —> bacterial, lymphocyte —> viral)
2. ***Throat swab for culture
Treatment (mostly supportive esp. viral):
1. Bed rest
2. Analgesics
3. Fluid replacement, IV line
4. Penicillin, Erythromycin (if bacterial origin)
Complications:
Local:
1. **Abscess: Peritonsillar / Parapharyngeal / Retropharyngeal
2. **AOM (∵ ascending infection into ear)
Systemic (esp. immunocompromised, but uncommon now):
1. **Septicaemia (spread to other area e.g. pneumonia, meningitis)
2. **Acute rheumatic fever (Streptococcus pyogenes) (Molecular mimicry: similar structure between M protein and Cardiac protein)
3. ***Acute GN (Molecular mimicry, Immune complex deposition, Streptococcal antigen deposition)
4. Meningitis
Infectious mononucleosis
Glandular fever
- Acute infection by EBV —> ***Systemic condition (NOT only tonsillitis: only one of manifestations)
- Young adult
- Transmitted through saliva
- Incubation period 5-7 weeks
- Prodromal period 4-5 days
Investigations:
- ↑↑ WBC (**Mononuclear cells)
- Blood smear: **Atypical lymphocytes
- ↓ Plt
- Deranged LFT, Clotting profile
- Positive monospot test (diagnostic of MN)
Treatment:
1. Supportive treatment (Bed rest, Fluid replacement, Analgesics)
2. Avoid **Ampicillin —> **Rubelliform rash
Complications:
1. Sepsis (secondary bacterial infection)
2. Hepatomegaly (10%)
3. Splenomegaly (50%) —> avoid contact sports for 1 month
Peritonsillar abscess (Quinsy)
Collection of pus between tonsillar capsule + superior constrictor (lateral side)
Causative organisms:
Mixed aerobic + anaerobic organisms
—> **Bacteroides, **Strept pyogenes, Peptostreptococcus
Symptoms (***~Tonsillitis):
- Sore throat
- Fever
- Dysphagia
- Odynophagia
- Muffled voice
- Otalgia
- Airway obstruction
Signs:
- **Unilateral Peritonsillar swelling (pushing tonsils medially)
- **Deviation of uvula
- ***Trismus (abscess causing spasm of mastication muscles)
Treatment:
Definitive:
1. **Transoral incision + drainage
2. **Antibiotics
Symptomatic:
1. Analgesic
2. Fluid replacement
3. Chart I/O
Consider elective tonsillectomy (∵ 20% recurrence of Quinsy)
Tonsillitis vs Quinsy
Tonsillitis:
- Bilateral without Trismus
Quinsy:
- Unilateral with Trismus
Acute epiglottitis
***ENT emergency
- mainly paediatric problem
- less common in adult
S/S:
- **Stridor (airway obstruction)
- **Drooling
- Sore throat
- Odynophagia
- Dysphagia
Investigations:
- X-ray (when patient stable!!!): Thumb sign
- Endoscopy: Cherry red epiglottis
Treatment:
1. Secure airway by Intubation
2. IV antibiotics
Ludwig’s angina
Severe inflammation / abscess of ***floor of mouth
Causes:
- Dental origin
S/S:
- **Stridor (airway obstruction ∵ push tongue **upwards + **posteriorly)
- **Submental swelling + tenderness + fullness
- Sore throat
- Drooling
- Dysphagia / Odynophagia
Management:
1. Secure airway (+ CT to check extent if stable)
2. Surgical drainage
3. IV antibiotics
4. Dental consultation
Other Deep neck abscesses
Retropharyngeal space, Parapharyngeal space (~ to Quinsy but more lateral near to mandible), Masticator space, Parotid space
S/S:
- ***Neck swelling
- Fever
- Sore throat
Management:
1. Secure airway (+ CT to check extent if stable)
2. Surgical drainage
3. IV antibiotics
4. Dental consultation
Parapharyngeal space tumour
- Usually ***asymptomatic (∵ it is an expandable potential space)
- Incidental finding
—> Present during URTI
—> **Extend medially —> Swelling at tonsil / peritonsilar region
—> **No trismus (vs Quinsy / Ludwig’s angina / Parapharyngeal abscess) - 80% benign
Tongue lesions
Benign lesions:
1. Lipoma (fatty, smooth)
2. Papilloma (small)
3. Haemangioma (bluish, compressible, refill after release)
4. Giant cell tumour (smooth, firm)
Floor of mouth lesions
- Ranula (belly of frog) (Mucocele)
- Bluish cystic swelling in FOM
- **Mucus retention cyst from **blocked sublingual gland
- **Excision of pseudocyst + **Resection of sublingual gland (to ↓ recurrence) - Salivary ductal stone
- Submandibular > Parotid > Sublingual
—> ∵ flow of saliva is **against gravity from bottom upwards —> stasis
—> viscosity of submandibular saliva more **viscous (esp. in dehydrated elderly)
- **Colicky postprandial glandular swelling + Pain
- Treatment in past: Marsupialisation, Calculus removal, Submandibular gland excision
- Treatment now: **Sialendoscopy (pull out stone from duct)
Complications:
- ***Sialadenitis —> pus expressed from ductal orifice
Palate lesions
Benign:
1. Torus palatinus
- Torus: to stand out
- Bony outgrowth on hard palate (**hard texture on palpation)
- **Midline, ***smooth mucosa
- Pain, Foreign body sensation, Swallowing problem
- Surgical removal if symptomatic
—> Ulceration
—> Affecting dentures placement
—> Associated periodontal disorder (e.g. trapping of food debris)
- Torus mandibularis
- Bony protuberance on ***lingual aspect of mandible (commonly between canine and premolar areas)
Benign vs Malignant:
- **Ulcerative: Mucosa in origin
- **Normal mucosa: Likely underlying structure in origin e.g. minor salivary gland with swelling
- Tumour may come from nose / maxillary sinus —> extending downwards —> no nasal symptoms —> present with submucosal swelling (with smooth surface) instead!!!
- If ***NOT bony nature —> refer!!!
Oral cavity lesions
- Leukoplakia
- Whitish plaque on oral cavity mucosa membrane that cannot wipe away
- Clinical description with **many pathological conditions
—> **Lichen Planus (autoimmune disease causing changes in mucosa)
—> **Candidiasis (esp. immunocompromised)
—> **Linea Alba (horizontal white line that runs along inside of cheek —> associated with frictional irritation from teeth)
—> **Cancer
- **Associated with malignancy (5%) —> ***Biopsy needed - Erythroplakia
- Erythematous patch +/- granular / nodular lesion
- **Dysplasia without keratosis (i.e. no surrounding epithelium)
- **High malignant potential
—> 15x ↑ risk of SCC
—> 90% CIS / SCC at time of biopsy - Ulcer
- Apthous
- Trauma (denture related)
- Infective (bacterial, viral (herpes virus, EBV))
- Systemic manifestation (Behcet’s disease, Autoimmune, Blood disease)
- Malignant
—> typical: irregular, rolled / everted edge, induration, painless
—> presentation same as benign but ***persists
***Message: Early referral if persistent / suspicious
***Malignancy of Oral cavity
Subsites:
1. ***Oral tongue (commonest)
2. Buccal mucosa
3. Floor of mouth
4. Upper / Lower alveolus
5. Hard palate
6. Lip
Histology:
1. Epithelium (ulcerative): ***SCC, Adenocarcinoma
2. Underlying structure (present as smooth surface, submucosal swelling): Lymphoma, Minor salivary gland
Clinical features:
1. Exophytic mass
2. **Non-healing ulcer
3. Painless at first, painful when infiltrating nerve
4. Surrounding leukoplakia / erythroplakia
5. **Induration / Fixation (need to palpate: may be normal on inspection)
6. **Loosen teeth (∵ teeth pushed out) +/- Non-healing tooth socket after tooth extraction
7. Bleeding, swallowing / speech difficulty (*Ankyloglossia: difficulty moving tongue ∵ CN12 infiltrated)
8. 15-20% of occult nodal metastasis —> Elective neck dissection recommended
***Malignancy of Oropharynx
Subsites:
1. ***Tonsil (commonest)
2. Tongue base (hard to examine)
3. Soft palate
4. Posterior wall
Histology:
1. Epithelium: SCC
2. Lymphoma (∵ rich of lymphoid tissue in tonsil, tongue base) / Minor salivary gland
Clinical features:
- **NO fever
- **Prolonged duration
- **Sore throat
- Referred otalgia
- Dysphagia, Odynophagia
- Muffled speech
- Risk factors: Smoking, Alcohol, **Oral sex (HPV-related: CA tonsil, CA tongue base)
P/E:
- Mass / ulcer
- ***Trismus (∵ infiltration of mastication muscles)
- Asymmetrical tonsil
- 50% Cervical LN
***Hypopharyngeal carcinoma
Hypopharynx:
- Level of Hyoid —> Lower border of Cricoid
- Posterior to Larynx
- Connection between Oropharynx and Esophagus
- Very difficult to see
Nature, Presentation, Risk factors, Prognosis similar to ***CA esophagus
3 sites:
- ***Piriform fossa (60%)
- Post-cricoid (30%)
- Posterior pharyngeal wall (10%)
S/S:
- Sore throat
- **Globus (Dysphagia later)
- Otalgia
- **Hoarseness (∵ RLN infiltration)
- Risk factors: ***Alcohol, (Smoking)
P/E:
- 30% LN metastasis
- **Loss of Laryngeal crepitus (i.e. rotate larynx —> larynx is fixated —> indicate infiltration to posterior pharyngeal wall —> prevertebral fascia)
- **Paterson-Brown Kelly syndrome (aka Plummer-Vinson syndrome) (esophageal + laryngeal web, ***Fe deficiency anaemia, dysphagia, glossitis, cheilosis —> female predominant, young —> ↑ risk of CA esophageal + hypopharynx)
—> examine nail for Koilonychia
***Management of HN cancer
Rmb: 90% HN malignancies are ***SCC (NOT including Nasopharynx (non-keratinising undifferentiated) + Thyroid (papillary carcinoma))
Etiology:
1. **Smoking, Smoking, Smoking!!!
2. **Alcohol (synergistic effect with smoking (except for Hypopharyngeal carcinoma: Alcohol primary risk factor))
3. **Chewing Betel nut (檳榔) (Oral cavity carcinoma)
4. **HPV (Oropharyngeal carcinoma)
5. **Poor oral hygiene with chronic infection (causing dysplasia)
6. **Previous irradiation / malignancy, immunocompromised
7. Family history
Workup:
1. History
2. P/E
3. **Pan-endoscopy (nasal cavity, nasopharynx, larynx, esophagus, bronchus) + **Biopsy (10% risk of synchronous / metasynchronous tumour (field cancerisation))
4. Tonsillectomy / EUA (examine under anaesthesia)+Biopsy
5. **USG neck +/- FNAC
6. CXR
7. **CT / MRI
8. ***PET/CT scan (if already locally advanced)
Treatment framework (Based on TNM staging):
Early stage (1, 2):
- Single modality: Surgery / RT alone
Late stage (3, 4):
- Combined modality
—> Chemoirradiation
or
—> Surgery with adjuvant RT +/- Chemotherapy
General rule:
- Early stage: Minimal invasive surgery (Laser / Robotic) / RT
- Late stage: Surgery with Adjuvant treatment
BUT 2 exceptions:
1. Oral cavity + Thyroid (NOT irradiation sensitive —> **Surgery in early stage)
2. NPC (Nasopharynx more sensitive to RT —> **Chemoirradiation in late stage unless recur / persistent then surgery)
General principle:
- Tumour clearance with long term survival benefit
- Organ + function preservation
Indications for surgery (3Rs):
1. **Resection with adequate margins
2. **Reconstruction for form + function (e.g. Flap reconstruction)
3. ***Rehabilitation always: swallowing, phonation, hearing
Surgical techniques
Flap reconstruction:
- complex + long operation
- may need microvascular anastomosis
- restore form + function
Minimally invasive surgery:
- Laser / Endoscopic / Robotic
- +/- Reconstruction
Open major surgery with reconstruction:
- Circumferential
- Pharyngo-Laryngo-Esophagectomy (PLO)
Summary
Clinical presentation of Oral cavity + Oropharyngeal conditions:
- Infective: Acute + Febrile
- Neoplastic (congenital, developmental (benign), malignant): Chronic + Afebrile
Airway issue in infections / abscesses —> need to secure airway by intubation / tracheostomy
Early referral to ENT surgeons when suspecting malignancy:
- Malignancy can mimic benign lesions
- **Persistent 2-4 weeks after conservative / empirical treatment
- **Clinically suspicious: Irregular, Induration, >2 cm, Cervical LN enlargement, (Painless, Roll / Everted edge)
