ENT JC099: Infections And Tumours In Pharynx And Oral Cavity

Question 1

Head and neck surgery

Answer 1

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

Question 2

Upper aerodigestive tract

Answer 2

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

Question 3

Oral cavity + Oropharynx

Answer 3

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

Question 4

History taking of ENT

Answer 4

1. Age
2. Sex
3. Duration: Acute (infection) vs Chronic (neoplastic)
4. 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
5. Risk factors:
   - Smoking
   - Alcohol
   - Family history (NPC / other HN cancers)
6. Functional disturbance
   - breathing
   - chewing
   - swallowing
   - phonation
   - articulation
7. Co-morbidities
   - to prepare patient for surgery

Question 5

P/E of ENT

Answer 5

1. Oral cavity + Oropharynx
   - ALL subsites
   - Inspection + Palpation (tenderness, underlying mass, induration)
2. 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)
3. Scalp / Skin
   - if no obvious origin in neck mass
   - skin cancer (e.g. melanoma, SCC) hidden under hair

Question 6

Acute tonsillitis: Causative organisms + S/S

Answer 6

Infection + Acute inflammation of tonsils

Causative organisms:
1. Virus
- Influenza
- Parainfluenza
- Adenovirus
- Enterovirus
- Rhinovirus

2. Bacteria
   - β-haemolytic Streptococcus (Strept pyogenes)
   - Streptococcus pneumoniae
   - H. influenzae
   - Anaerobes
   - Mixed
3. 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

Question 7

Management of Acute tonsillitis

Answer 7

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

Question 8

Infectious mononucleosis

Answer 8

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

Question 9

Peritonsillar abscess (Quinsy)

Answer 9

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)

Question 10

Tonsillitis vs Quinsy

Answer 10

Tonsillitis:
- Bilateral without Trismus

Quinsy:
- Unilateral with Trismus

Question 11

Acute epiglottitis

Answer 11

***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

Question 12

Ludwig’s angina

Answer 12

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

Question 13

Other Deep neck abscesses

Answer 13

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

Question 14

Parapharyngeal space tumour

Answer 14

• 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

Question 15

Tongue lesions

Answer 15

Benign lesions:
1. Lipoma (fatty, smooth)
2. Papilloma (small)
3. Haemangioma (bluish, compressible, refill after release)
4. Giant cell tumour (smooth, firm)

Question 16

Floor of mouth lesions

Answer 16

1. 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)
2. 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

Question 17

Palate lesions

Answer 17

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)

2. 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!!!

Question 18

Oral cavity lesions

Answer 18

1. 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
2. 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
3. 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

Question 19

***Malignancy of Oral cavity

Answer 19

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

Question 20

***Malignancy of Oropharynx

Answer 20

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

Question 21

***Hypopharyngeal carcinoma

Answer 21

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

Question 22

***Management of HN cancer

Answer 22

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

Question 23

Surgical techniques

Answer 23

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)

Question 24

Summary

Answer 24

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)

Question 25

Summary of Oral / Oropharynx diseases

Answer 25

***Oropharynx:
Infection:
1. Acute tonsillitis
2. Infectious mononucleosis
3. Peritonsillar abscess (Quinsy)
4. Acute epiglottitis
5. Ludwig’s angina
6. Other Deep neck abscesses

Neoplasm:
1. Parapharyngeal space tumour
2. Hypopharyngeal carcinoma

***Oral cavity:
Tongue neoplasms:
1. Lipoma (fatty, smooth)
2. Papilloma (small)
3. Haemangioma (bluish, compressible, refill after release)
4. Giant cell tumour (smooth, firm)

Floor of mouth lesions:
1. Ranula (belly of frog)
2. Salivary ductal stone

Palate lesions:
1. Torus palatinus
2. Torus mandibularis

Oral cavity lesions:
1. Leukoplakia
2. Erythroplakia
3. Ulcer