ENT lesions Flashcards

Question

Thyroglossal cyst or sinus

Answer 1

Cyst of epithelial remnants of the thyroglossal tract Most commonly in children. But 1/3 present in over-20s. Most common congenital cyst in neck. Embryological remnant of thyroglossal tract during descent of the thyroid from the foramen caecum at the tongue base

Answer 2

Often asymptomatic . **May enlarge/become tender in upper respiratory tract infections** May become infected, form an abscess or discharging sinus **Palpable neck lump, small, midline** . Can occur anywhere between base of tongue and trachea Usually in proximity to the hyoid bone **Moves up on tongue protrusion and swallowing**

Answer 3

**USS +/- Fine needle aspiration cytology**. Delineates anatomy and demonstrates normal thyroid gland. Must ensure that thyroid gland is present. Removal of the only thyroid tissue in thyroglossal cysts renders patient hypothyroid ** Treatment** Most require no treatment unless there are complications e.g recurrent infections. **Surgical treatment (Sistrunk’s procedure)** entails excision of cyst, thyroglossal tract and central portion of hyoid bone

Answer 4

Exposure radiation Women Family history

Answer 5

Thyroid nodules undergo further cytological classification, which is called THY, * * **THY1**: non diagnostic due to lack of cellularity. **THY2**: non-neoplastic. * **THY3**: follicular lesion. surgical resection of the nodule (lobectomy) to distinguish between a follicular adenoma and carcinoma (as cytology insufficient to assess perivascular or pericapsular invasion). * . **THY4**: Suspicious but non-diagnostic of malignancy. Surgery is indicated as there is a 60-75% risk of malignancy. If the results are non-diagnostic and medullary carcinoma or lymphoma are suspected, then the FNAC should be repeated. * **THY5**: Diagnostic of malignancy MDT will recommend appropriate combination of surgery +/- radiotherapy +/- chemotherapy if indicated

Answer 6

1. Most common 85% 2. Adolescents, young adults 34-40 years 3. RF : Radiation

Answer 7

Multifocal papillary structure, Psomma bodies, Lymphatic invasion Spread : Lymphatic, cervical lymph nodes

Answer 8

1. Solitary or multiple nodules 2. Painless 3. Cold - euthyroid 4. Cervical lymphadenopathy

Answer 9

1. USS 2. FNAC - This can diagnose papillary carcinoma but cannot distinguish follicular adenoma (benign) from follicular carcinoma therefore the entire nodule must be assessed (by performing a diagnostic hemithyroidectomy) 3. SCinotography - cold nodules 4. Non contrast CT of Neck and chest

Answer 10

2nd most common thyroid ca - 5-15% Middle aged and older adults RF : Iodine deficiency

Answer 11

RAS proto-oncogene mutlatiion

Answer 12

Unifocal, Haemorrhage Haemategenous spread : brain, bone, lungs, liver

Answer 13

1. Slowly enlarging painless solitary nodule 2. Euthyroid 3. Evidence of metastases

Answer 14

1. USS 2. FNAC 3. SCinotography - cold nodules 4. Non contrast CT of Neck and chest

Answer 15

1. Thyroid lobectobectomy <1 cm or > 1 cm Thyridectomy 2. Neck dissection : established metastasic cervical lymphadenopathy 3. Post operative radio-iodine ablation - if well differentiated to remove residual microscoptc disease

Answer 16

Medullary thyroid cancers originate from the parafollicular cells (C cells) of the thyroid. Middle-aged patients are most commonly affected. It is the 3rd most common thyroid cancer and it represents 5% of all thyroid cancers. 80% are sporadic. Hence, 20% are inherited-

Answer 17

80% are sporadic, 20% inherited FMTC: familial medullary thyroid cancer MEN 2A: MTC, phaechromocytoma, hyperparathyroidism MEN 2B: MTC, phaechromocytoma, Marfanoid habitus, mucosal neuromas

Answer 18

USS neck FNA Tumour markers (calcitonin and carcinoembyronic antigen) as well as genetic screening (RET proto-oncogene in both MEN 2A and 2B). A urine sample (24 hours urine metanephrine) study can be used to assess for phaeochromocytoma (which is important to assess prior to potential surgical intervention)

Answer 19

**total thyroidectomy and neck dissection** Radioiodine cannot be used as there is no iodine uptake (since the cancer is of neuroendocrine cells and not follicular cells).

Answer 20

rare and aggressive undifferentiated thyroid cancer. It represents 1% thyroid cancer and has a tendency to affect the elderly. It presents as a rapidly enlarging bulky, hard, neck mass. Appears over 2-3 months. Diagnosis often requires an **ultrasound guided core biopsy or open biopsy rather than FNA**. Prognosis is extremely poor and treatment is mostly palliative.

Answer 21

subdivided into the following regions: Nasopharynx Oropharynx Hypopharynx

Answer 22

Highest incidence in the South Asian and North Asian population. EBV is believed to have a major causative role in this carcinoma.

Answer 23

lymphadenopathy. Ear pain, secretory otitis media, hearing loss and cranial nerve palsies. The nasal involvement can present with epistaxis*, discharge, changes in smell and nasal obstruction Persistent unilateral otitis media with effusion and no preceding URTI

Answer 24

Nasendoscopy Formal biopsy FNA of any neck nodes MRI (better to assess soft tissue involvement)

Answer 25

Combined chemotherapy and radiotherapy.

Answer 26

Tumours of the tongue base (posterior third of the tongue) and the tonsils (or tonsillar fossae if

Answer 27

moking Alcohol Strong association with HPV 16 and HPV 18

Answer 28

1. Painless tonsillar swelling (unilateral) 2. History of throat discomfort with worsening dysphagia 3. Referred otalgia (involvement of Arnold’s nerve- branch of vagus) A ‘lump in the throat sensation’ or evidence of metastatic cervica Trismus is a red flag for surrounding structure infiltration *condition characterized by difficulty in opening the mouth due to muscle spasms. The muscles involved in jaw movement are affected, leading to limited jaw mobility. This restriction can make it challenging for an individual to fully open their mouth, and it may be accompanied by pain or discomfort.*

Answer 29

Panendoscopy + Biopsy FNA of any neck nodes Treatment Surgery +/- radiotherapy or chemotherapy Chemoradiotherapy

Answer 30

Hypopharyngeal cancers are named for their location. Most cancers arise in the pyriform sinus atients are typically men aged 55-70 years old with a history of tobacco use and/or alcohol use

Answer 31

Cervical lymphadenopathy, pain that radiates from the throat to ear, sore throat, **progressive difficulty with or painful swallowing**, voice changes Progressive dysphagia from solids to liquid Paterson- Brown- Kelly syndrome: dysphagia , hypochromic microcytic anaemia, oesophageal webs and potential development of postcricoid carcinoma Endoscopy Biopsy Pharyngo- oesophagoscopy

Answer 32

Commonly affect left laryngeal nerve caused by - Lung cancer tumor compression - Thyroid surgery Bilateral vocal chord paralysis : stridor and osbstruction of airway Mx - Immediate tracheostomy

Answer 33

Hoarse voice without pain in singers

Answer 34

Endoscopy Biopsy Pharyngo- oesophagoscopyy Management Early cancers (rare)- surgery + radiotherapy. Advanced cancers- surgery + radiotherapy +/- neoadjuvant chemotherapy

Answer 35

he larynx is subdivided into 3 components. Supraglottis: from tip of epiglottis to laryngeal ventricle Glottis: true vocal folds and 1cm inferiorly Subglottis: down to lower border of cricoid cartilage Glottic cancer is the most common. Histology is squamous cell origin in 90% .

Answer 36

Risk factors Smoking (most important) Alcohol consumption (cumulative risk increases with smoking) Hoarseness is the most common presentation Progressively worsening over 6- 12 weeks Noisy breathing/stridor Noisy breathing/stridor. Supraglottic cancer ; Odynophagia Dysphagia (commonest in supraglottic carcinoma) Neck lymphadenopathy (commonest in supraglottic carcinoma)

Answer 37

Flexible nasoendoscopy Microlaryngoscopy for biopsy CT neck and chest for staging Second line : Laryngoscopy Mx smaller tumours : radiotherapy or endoscopic laser excision Larger tumours : (Chemoradiotherapy) or larynegectomy with postoperative radiotherapy Most - squamous cell carcinoma Mx : partial or total laryngectomy

Answer 38

describes a group of upper respiratory tract symptoms secondary to irritation from gastric contents.

Answer 39

upper respiratory tract symptoms secondary to irritation from gastric contents. Symptoms The commonest symptoms are hoarseness, throat clearing, chronic cough, globus pharygeus and dysphagia. Symptoms of indigestion and heartburn are poorly correlated with LPR. Diagnosis The Reflux Symptom Index (RSI) is a commonly used self-report patient questionnaire. A score of >13 signifies LPR

Answer 40

Visualisation of the larynx using a fibreoptic laryngoscopy or video laryngostroboscopy may demonstrate laryngeal (or specifically vocal cord) oedema or erythema, The gold standard for diagnosing LPR is 24 hour dual probe pH manometry combined with intraluminal impedance studies.

Answer 41

Treatment Conservative measures include lifestyle modification. This includes Speech therapy can help as well as acid suppression using alginates or proton pump inhibitors. Alginates are seaweed compounds that has been proven to reduce reflux

Answer 42

Snoring and Obstructive Sleep Apnoea (OSA) Snoring implies upper airway resistance that causes an undesirable sound during sleep that affects up to 50% of the population. However, OSA is associated with apnoea (breath-holding for >10 sec leading to arousal from sleep) or hypopnea (reduced airflow with oxygen desaturation). is classified using the **apnoea-hypopnea index (AHI**

Answer 43

Cause In children, the most common cause are large tonsils and adenoids. n adults it is predominately multifactorial. A raised body mass index is not uncommon but consider each potential anatomical level that may obstruct airflow Nasal obstruction – e.g. obstructive nasal polyps Oropharynx – large tonsils Pharyngeal airway collapse: obesity

Answer 44

witnessed breath-holding / gasping / choking, restlessness, daytime sleepiness and irritabilit

Answer 45

Flexible nasopharyngolaryngoscopy to assess anything that may obstruct the passage of airflow from the nasal cavity to the level of the vocal cords. The Epworth Sleepiness Score (a self-reported patient questionnaire) is often used to screen for excessive daytime sleepiness (abnormal score is >10) The gold standard for diagnosis of OSA is nocturnal polysomnography which can record upper airway airflow oxygen saturation monitoring, ECG, EMG, EEG, and body position.

Answer 46

Treatment Conservative measures include lifestyle modification. In children this commonly includes adenotonsillectomy, which is highly effective. In adults, surgery may be considered if the patient fails conservative measures or as an adjunct to conservative measures in the setting of moderate to severe OSA. Operations for adult OSA include palatal surgery, tonsillectomy, septoplasty or endoscopic sinus surgery.

Answer 47

Nasendoscopy, if safe to perform, can help identify the cause Investigations which agitate patients Oxygen, Nebulised adrenaline. 1mL of 1:1000 adrenaline in 4 mL saline. Steroids. Nebulised and IV. 0.1mg-0.2mg/kg dexamethasone. If condition fails to improve/worsens- Intubation. Secures airway. Awake fibreoptic intubation can be useful. Nasopharyngeal airway may bypass obstruction if obstruction is high (e.g. swollen tongue secondary to angio-oedema) Tracheostomy. Front of Neck Access to the airway to bypass the obstruction may be necessary either by cricothyroidotomy or tracheostomy

Answer 48

A septal haematoma is blood which collects between the perichondrium and septal cartilage. There is an increased risk of devascularisation of the septal cartilage and this can lead to necrosis, perforation and deformit The patient needs an urgent incision and drainage under general anaesthetic

Answer 49

In children, this tends to be an inanimate object such as a coin In adults, it tends to be a food bolus. The most important question is whether there is any bone as this requires immediate removal because the oesophagus is at a higher risk of perforation.

Answer 50

Presentation Dysphagia, odynophagia, drooling In children, the presentation can be very non-specific. e.g. off their food, lethargic Batteries – removal as soon as possible. This is a surgical emergency Food bolus with bone – needs to be removed as soon as possible to minimize the possibility of perforation Food bolus without bone – this may spontaneously pass overnight (the oesophageal muscles & sphincters relax when a patient sleeps) or muscle relaxants such as hyoscine butylbromide (Buscopan) can be given f it does not pass, patient may need an upper rigid oesphagoscopy or an OGD (for a lower food bolus). Asking the patient to swallow a sip of water can be useful (immediate regurgitation implies a high obstruction whereas delayed regurgitation implies a low obstruction).

Answer 51

auses The causative agent is normally bacterial & it often originates from poor dental hygiene particularly in the case of Ludwig’s angina . In children, retropharyngeal infections tend to be more common than in adults. They present with difficulty swallowing and trismus and when examined have limited neck movement or torticollis (hold their neck in a twisted position) In adults, parapharyngeal infections are more common. Nasendoscopy may show a parapharyngeal bulge Symptoms to watch out for include pain, trismus (unable to open mouth fully), dysphagia, dysphonia, stridor and drooling. Patients typically look very unwell with pyrexia and malaise.

Answer 52

Fluid administration as are very dehydratedand broad-spectrum antibiotics need to be administered (e.g. Co-amoxiclav). Imaging (CT scan with contrast) is normally performed to confirm the diagnosis and delineate which deep neck space compartments are affected. Definite treatment involves surgical drainage of the abscess (surgery may be per-oral/external or both

Answer 53

this infection typically arises from poor dentition and spreads rapidly involving the floor of the mouth, submandibular space and into adjacent deep neck spaces. Treatment involves draining the collection and removing the source of infection (e.g. a rotten tooth)

Answer 54

This uses a flexible fibreoptic endoscope or a rigid straight or angled scope to examine the nose, postnasal space, pharynx and larynx. It can be performed in the outpatients department and is commonly done without the need of any anaesthetic spray To examine the nose, the sinuses, pharynx and larynx for pathology To assess the voice To evaluate swallowing To evaluate the airway and assist in intubation

Answer 55

Indications To examine an ear Removal of impacted ear wax Treatment of ear infections Removal of a foreign body

Answer 56

a subjective test that aims to evaluate the quietest sound that can be heard with each ear at various frequencies a whisper from 1m has an intensity of 30dB, normal conversational voice is 60dB, shouting equates to about 90dB and discomfort can be felt at around 120dB. Normal hearing is defined to be 20dB or better. Mild hearing loss is between 21-40dB. Moderate hearing loss is between 41-70dB. Severe hearing loss is considered to be 71-90dB. Profound hearing loss is worse than 90dB.

Answer 57

Impedance is the resistance to the passage of sound. Tympanometry indirectly measures the “compliance” or freedom of movement of the middle ear structures. Sound transmission from the outer to the middle ear is optimal when the pressure in the ear canal matches the middle ear pressure

Answer 58

**Otoacoustic Emissions Oute**r hair cell vibrations can be detected in the external auditory meatus as otoacoustic emissions and can be used as an objective measure of cochlear function NHS Newborn Hearing Screening Programme. This screens for congenital hearing loss **Behavioural Techniques Used in 0-6 months** age Based on presenting a sound stimulus and observing the baby’s response. A significant change in activity represents a positive response. **Distraction Techniques Used in 6-18 months** In this test the parents are given the instructions and advised that they must not react to the sounds. An assistant distracts the baby with a toy, which is then phased out. The tester in the mean time presents a sound from behind the baby and from the right or left side. A positive response is if the baby turns in response to the sound **Visual Reinforcement Audiometry Appropriate for 9-36 month**s his test involves the child sitting and playing with toys. Sound stimuli are produced by one of two loud speakers positioned at either side of the child. On turning to the sound the child is rewarded by a visual stimulus such as a flashing light or toy bobbing **ure tone audiograms Generally used in children above the age of 5 years.**

Answer 59

grommet is a ventilation tube which helps to ventilate the middle ear. The procedure can be performed under local or general anaesthetic. Indications Otitis media with effusion persisting for more than 3months Recurrent acute otitis media Tympanic membrane retraction secondary to impaired Eustachian tube function

Answer 60

A procedure to repair a perforation of the tympanic membrane

Answer 61

his involves reconstruction of the middle ear ossicles –the method used depends upon which ossicles are missing/present.

Answer 62

preservation/removal of the posterior external auditory canal wall respectively e.g. cholesteatoma A cortical mastoidectomy is a procedure to expose the mastoid air cells usually in acute mastoiditis. It is also performed as part of procedures for cochlear implantation and combined approach tympanoplasty,

Answer 63

Nasal obstruction +/- obstructive sleep apnoea Recurrent otitis media

Answer 64

Indications Acute or Chronic Sinusitis not relived by medical management Nasal Polyposis Orbital complication of Sinusitis Drainage of mucocoele/pyocoele or pneumatocele

Answer 65

Indications Almost always for metastatic carcinoma

Answer 66

A tracheostomy is a surgically created opening in the front of the neck into the trachea. It can be performed electively or as an emergency depending on the indication and can be permanent or temporary. Indications Airway obstruction (See Chapter on ENT Emergencies) Weaning. Tracheostomy reduces physiological dead space therefore helps with weaning patients from mechanical ventilation and allows trachea-bronchial suctioning.

Answer 67

Tonsillectomy indications Adenoids only removed if suffering from sx of sleep apnea > 7 documented sore throats in past year >5 in past 2 years\>3 in past 3 years

Answer 68

Nasal fracture R/v 7 days after fracture when swelling has subsided < 14 days - can be manipulated under anaesthesia > 14 days will require a rhinoplasty

Answer 69

Glue ear - advised not to fly, change in a atmospheric pressure with glue ear and result in pain, wetigo and hearing loss. Deconngestants can be use pre flight or during