ENT: NPC + H/N

Question 1

ENT History taking

Answer 1

***Quantification is important

4 categories:
1. Nasal symptoms (due to tumour)
- Nasal bleeding
—> Neovascularisation
—> NPC: frank nose bleeding rare —> usually go down to throat: blood stained post nasal drip, saliva
—> Bilateral bleeding (unilateral: bleeding in nasal cavity)

• Nasal obstruction (uncommon)
  —> Unilateral side
• Smell of blood

2. Ear symptoms
   - Ear discharge?
   - Tinnitis?
   - Vertigo?
   - Eustachian tube dysfunction
   —> **Hearing loss
   —> **Dullness in ear
   —> **Blockage
   —> Secretions
   —> **Tinnitus (continuous, louder when in quiet place)
   —> Few weeks to months
3. Neck symptoms
   - Neck mass: Cervical lymphadenopathy (Level 2, Skip metastasis rare)
   —> Retropharyngeal LN first to enlarge
   —> Bilateral LN enlargement N2
   —> Unilateral LN enlargement N1
4. Neurological symptoms (rare now): means advanced symptoms
   - Facial pain
   - Mid-Facial numbness: CNV2 (Pterygomaxillary fissure, Pterygopalatine ganglion: Infraorbital nerve), CNV3 (much more lateral: need bigger tumour to compress)
   - Constant dull headache at back of head (NPC: Infiltrative tumour —> invade through skull base of clivus)
   - EOM dysfunction, Diplopia: Sphenoid sinus (Cavernous sinus invasion: CN6 palsy (longest tract from pons)) (Other CN6 palsy: Mononeuritis multiplex from DM)
   - Paresthesia

Question 2

Case 1: History taking in NPC

Answer 2

• Mr Chan
• 45 yo
• Left ear hearing loss

P:
Q: no pain, compression? No nose congestion, no nasal bleeding, no swallowing problem, no facial pain, no headache, no fever, no constitutional symptoms
- Ear discharge?
- Tinnitis?
- Vertigo?
- Blood stained post-nasal drip, saliva
R:
S:
T: 2 days ago, sudden / gradual onset?, intermittent / continuous?

Medical history:

• No chronic history
• Drug allergy

Social history:
- no smoking / drinking

Family history:

• 遺傳病? No
• No ENT history

P/E:

• General condition, pallor
• Otoscope
• Hearing test
• Cervical LN

Findings:

• Enlarged Right LN
• Suspected Right ear effusion
• Otitis media
• Neck LN

DDx:

• Otitis media (less likely ∵ no pain)
• NPC
• Malignant NK-T cell lymphoma
• HIV patients (Otitis media + Effusion + Chronic LN enlargement)
• Sinusitis

Investigations:

• Endoscopy
• MRI
• PET

Findings:

• Undifferentiated carcinoma deep in fossa of rose muller
• Central necrosis of LN

Treatment:
Chemotherapy + Chemoradiotherapy

NPC:

• Dermatomyositis (Paraneoplastic syndrome)
• Cachexia / weight loss rare

Question 3

Case 2: History taking in Oral SCC

Answer 3

• Mr Wong
• 55 yo
• Recurrent Mouth ulcers
• Suspected peridontal disease / Gingivitis on PET scan but Suspected tumour by Dentist —> ENT referral

P:
Q: mouth ulcers with bleeding 2 months, no nose bleed, occasional cough with sputum with yellow, loss of appetite
R:
S:
T: biopsy done —> chronic minor rejection of BM: Graft vs Host disease —> immune reaction —> mouth ulcer

Medication history:

• 10 years BM transplantation: Previous Leukaemia
• Relapsed cancer
• 1X years ago Leukaemia
• Chronic illness —> bronchiectasis, emphysema, severe pneumonia —> bronchodilator
• DM / HT: No
• Antibiotic: recorded
• Anti-rejection medicine

Family history:
- Dad: Ca Colon

Social history:

• Stopped smoking for many years
• No drinking, occasional drinker

P/E:

• Irregular mucosa with ulceration + Exophytic growth
• Mucositis (minor Graft vs Host disease)

Investigations:

• Biopsy: SCC of hard palate
• PET
• USG: no suspicious metastatic LN
• Pan endoscopy: no other suspicious lesions in upper aerodigestive tract
• Lung function: FEV1 0.4L
• CT thorax: extensive bronchiectasis in both lungs
• Exercises tolerance: 3 flight of stairs
• Anaesthetic assessment: Higher perioperative anaesthetic risk

Treatment:
- Surgery: + Radiotherapy: Partial maxillectomy + reconstruction + Adjuvant radiotherapy
—> Free flap reconstruction
—> Local flap reconstruction
—> Prosthesis
- Concurrent chemoradiotherapy
- Radiotherapy
- Chemotherapy
- Palliative treatment

Surgery:

• Poor wound healing
• Poor lung function: Long anaesthesia difficult

Chemotherapy:

• BM suppression
• Toxicity to organs

Treatment opted:

• Partial maxillectomy + Dental prosthesis + Tracheotomy
• Shortest possible operation time —> minimise perioperative chest infection / other complications
• Followed by adjuvant RT when patient recovers from operation