ENT - Salivary Gland Pathology & H+N Cancer

Question 1

Sialolithiasis

Salivary Gland Anatomy
Pathophysiology 
Risk Factors
Clinical Features
Differential Diagnosis

Answer 1

1. ) Salivary Gland Anatomy
   - Parotid: superior to the angle of the mandible, superficial to the masseter, drains (via Stensen’s duct) opposite to the upper second molar
   - Submandibular: beneath the floor of the mouth in the submandibular triangle, drains (via Wharton’s duct) into the floor of the mouth, beside the frenulum (tongue)
   - Sublingual: below the mucous membrane of the floor of the mouth, drained by small ducts that empty into Wharton’s duct or into the floor of the mouth
2. ) Pathophysiology - the presence of calculi/stones in the salivary glands or ducts due to stagnation of saliva
   - stones are typically composed of calcium phosphate and hydroxyapatite, as the saliva is rich in calcium
   - most common in the submandibular gland as the duct is long and saliva flows against gravity
   - secretions from the submandibular gland are also more mucoid as opposed to serous from the parotid
3. ) Risk Factors
   - medication (diuretics, anticholinergics)
   - smoking, gout, dehydration, hyperparathyroidism, chronic periodontal disease,
4. ) Clinical Features
   - most cases are asymptomatic, some can present w/:
   - (often unilateral) intermittent facial swelling linked with eating which can either be painful or painless
   - on palpation, a stone may be palpable in the duct and the gland may feel tender in the presence of infection
5. ) Differential Diagnosis - swollen salivary glands
   - mumps: pain, bilateral, prodromal fever sx
   - Sjogren’s, sarcoidosis, salivary gland tumour

Question 2

Management of Sialolithiasis

Investigations
Conservative Management
Definitive Management

Answer 2

1. ) Investigations
   - USS: cheap and minimally invasive, good at analysing whole glands and periglandular structures
   - X-Ray: most sialolithiasis is radio-opaque so can be used to confirm the presence of a stone
   - sialography: radiopaque dye is injected into the duct with plain films taken, not routinely performed
2. ) Conservative Management
   - oral hydration, analgesia
   - ↑saliva production: sialogogues e.g. lemon juice, milking/massaging the gland can help as well
   - Abx if the gland becomes infected (sialadenitis)
   - complications: chronic sialadenitis, chronically tender glands, abscess formation in severe cases
3. ) Definitive Management - specialist treatment for patients with recurrent or persistent symptoms
   - IR procedures: sialoendoscopy, stones are viewed in the duct and then extracted with a basket
   - surgical: to remove more difficult stones, however, there’s risk to the hypoglossal, facial, lingual nerves
   - ECSLithotripsy: for stones in proximal ducts, where transoral retrieval of the stone is not possible
   - gland removal is a last resort and is only performed for patients with chronically persisting symptoms

Question 3

Sialadenitis

Pathophysiology
Mumps
Clinical Features

Answer 3

1. ) Pathophysiology - salivary gland inflammation
   - most commonly affects the parotid glands (parotitis)
   - acute or chronic, a wide range of possible causes:
   - viral: mumps, HIV, coxsackie, parainfluenza
   - bacterial: Saureus, Sviridans/pyogenes, Hinfluen…
   - autoimmune: sarcoidosis and Sjogren’s associated with chronic sialadenitis, Wegener’s granulomatosis
   - stones, malignancy, idiopathic
2. ) Mumps - highly contagious, transmitted by respiratory droplets or direct contact
   - prodromal sx followed by bilateral gland swelling, in comparison HIV parotitis is non-painful/asymptomatic
   - preventable with the MMR vaccine, no cure
   - notifiable disease, complications: orchitis, pancreatitis, meningitis/encephalitis, deafness,
3. ) Clinical Features
   - painful swelling and tenderness of the gland
   - fever, lymphadenopathy and erythema of the affected gland can all also develop
   - infectious causes may result in a purulent discharge from the duct, alongside any additional symptoms from any potential abscess formation

Question 4

Management of Sialadenitis

Investigations
Management
Complications

Answer 4

1. ) Investigations
   - bloods: FBC, CRP, blood cultures if systemic sx, ESR and other autoimmune bloods if suspected
   - pus swabs, viral serology if suspecting mumps
   - FNA cytology if suspecting malignancy
   - USS: identify solid masses or fluid collections
   - CT: suspect DNSInfection or malignancy
2. ) Management
   - conservative: hydration and analgesia (inc moist heat), artificial salvia if saliva production is impaired
   - ↑saliva production: sialogogues, gland massaging
   - Abx if suspecting bacterial sialadenitis is suspected,
   - abscess formation will require I+D
   - gland removal if recurrent depending on the cause
3. ) Complications
   - abscess formation in severe cases which may lead to airway obstruction (medical emergency)
   - cutaneous fistula may develop in chronic sialadenitis
   - chronically tender salivary glands
   - autoimmune parotitis increases risk of lymphoma

Question 5

Salivary Gland Tumours

Benign vs Malignant Tumours 
Tumour Classifications
Risk Factors
Clinical Features
Differential Diagnoses

Answer 5

1. ) Benign vs Malignant Tumours
   - generally uncommon, only 6% of H+N tumours
   - parotid: 80% benign, 20% malignant
   - submandibular: 50% benign, 50% malignant
   - sublingual: 20% benign, 80% malignant
   - benign tumours have a peak onset at 40 whilst malignant tumours affect the older patient
2. ) Tumour Classifications
   - benign: pleomorphic adenoma (80%), Warthin’s tumour
   - pleomorphic adenomas can undergo malignant change, termed carcinoma ex-pleomorphic adenoma, they are aggressive, rapid growth, and poor prognosis
   - malignant (all carcinomas): mucopeidermoid (most common), adenoid cystic, acinic cell, SCC, adenocarcinoma
3. ) Risk Factors
   - smoking: tobacco is associated w/ Warthin’s tumour
   - EBV, radiation exposure, genetic (p53 mutation)
4. ) Clinical Features
   - slowly enlarging mass in a salivary gland location
   - pleomorphic adenoma: slow-growing, painless, mobile lump in the parotid gland of an older female
   - malignant: CNVII palsy, erythema, ulceration
   - pain is rare but can occur due to suppuration or haemorrhage into the mass or infiltration of malignancy into the surrounding tissue
   - large malignancies: airway obstruction, dysphagia, or hoarseness, nasal obstruction or sinusitis
   - cervical lymphadenopathy
5. ) Differential Diagnoses - salivary mass
   - sialolithiasis, chronic sialadenitis, autoimmune disease, and lymphoproliferative disorders, HIV

Question 6

Management of Salivary Gland Tumours

Metastases/Disease Staging
Investigations
Management
Complications

Answer 6

1. ) Metastases/Disease Staging - TNM staging
   - local mets usually to cervical lymph nodes, highest rate occurring with the mucoepidermoid carcinoma
   - distant metastases to lungs and bone, most common with adenoid cystic carcinoma, can recur years after
2. ) Investigations
   - bloods to exclude infection: FBC, CRP, U+Es
   - USS: identify tumour location, margins, vascularity
   - FNA cytology: confirm the tumour type
   - CT of the neck and thorax for disease extent
3. ) Management - MDT at specialist centres
   - surgical: excision, more radical w/ malignant tumours, neck dissection if cervical lymphadenopathy, parotid malignancies often sacrifices the facial nerve
   - non-surgical: radiotherapy as adjuvant treatment (high-grade tumour) or curative for non-resectable tumours, chemo only used for palliative treatment
4. ) Complications
   - haematoma: post-op, can obstruct airways
   - facial nerve damage in parotid gland surgery, grafting w/ greater auricular nerve can be performed if noticed, transient facial nerve paresis resolves in 3-12 week
   - hypoglossal, lingual, marginal mandibular nerve damage in submandibular gland surgery
   - Frey’s syndrome after parotidectomy, whereby the autonomic fibres supplying the gland reform inappropriately; the stimulus to salivate results in an inappropriate response of redness and sweating
   - salivary fistula is a late complication of parotidectomy

Question 7

Thyroid Cancer Subtypes

Papillary Carcinoma
Follicular Carcinoma
Medullary Carcinoma
Anaplastic Thyroid Cancer
Lymphoma

Answer 7

1. ) Papillary Carcinoma - most common (75%)
   - there can be multiple lesions within the gland and they are rarely encapsulated
   - cytology: a mixture of papillary and colloid-filled follicles, w/ papillary projections and pale empty nuclei
   - they commonly spread to cervical lymph nodes
   - often presents in 40-50yr olds, F>M
   - good prognosis, 90% 10-yr survival rate
2. ) Follicular Carcinoma - next common (15%)
   - often presents in 40-60yr olds, F>M
   - focal encapsulated lesions w/ capsular invasion
   - spread via the blood to the lungs and bone
   - good prognosis, 85% 10-yr survival rate
3. ) Medullary Carcinoma - rare (makeup around 3%)
   - arise in parafollicular cells (C-cells) so they produce calcitonin, associated w/ MEN 2a/2b syndrome
   - spread via lymphatic and medullary routes
   - good prognosis, 90% 10yr survival rate
4. ) Anaplastic Thyroid Cancer - rare (5%)
   - very aggressive, grow rapidly with early local invasion and often have spread by the time of presentation
   - presents in the elderly so treatment is palliative
   - very poor prognosis, 10-20% 1-yr survival rate
5. ) Lymphoma - very rare (1-2%)
   - may grow quite rapidly, with marked compressive symptoms and B-Cell symptoms
   - presents in over 60s

Question 8

Thyroid Cancer

Risk Factors
Clinical Features
Differential Diagnoses
Investigations

Answer 8

1. ) Risk Factors
   - female, FH, MEN 2a/b (medullary carcinoma)
   - radiation exposure in childhood and full-body radiotherapy for bone marrow transplant
   - Hashimoto’s disease (↑risk of thyroid lymphoma)
2. ) Clinical Features
   - often present as a palpable neck lump(s) or are found incidentally on imaging of the neck
   - red flags: rapid growth, pain, cough, hoarse voice, stridor, lymphadenopathy, tethering of the lump
3. ) Differential Diagnoses - the majority of neck/thyroid lumps are non-cancerous
   - benign thyroid adenoma or thyroid cyst
   - multinodular goitre: non-toxic or toxic (make T3/T4)
   - thyroglossal duct cyst

4.) Investigations
- bloods: TFTs, serum calcitonin
- USS +/- FNA +/- diagnostic hemithyroidectomy
- TFTs: if signs of a toxic nodule (↑T3/T4 or ↓TSH), no further investigation is needed for malignancy as overactive nodules are very rarely malignant
- serum calcitonin: useful for medullary carcinoma
- thyroid USS: microcalcifications, hypo echogenicity,
irregular margin, cervical lymphadenopathy
- score calculated from USS: U1-U2 are low risk, U3-U5 are high risk so require FNA cytology
- FNAC: used to calculate a scoring system:
- Thy1 = inconclusive, Thy2 = non-malignant, Thy3 = follicular lesion needs diagnostic hemithyroidectomy, Thy4 = suspicious needing ^^, Thy5 = malignant

Question 9

Management of Thyroid Cancer

Surgical Management
Complications of Thyroid Surgery
Non-Surgical Treatment

Answer 9

1. ) Surgical Management
   - hemithyroidectomy: only suitable for certain tumours (small low-grade non-metastatic malignancy)
   - total thyroidectomy: most malignant diseases, will require lifelong thyroid hormone replacement
   - locally advanced disease may also require neck dissection to aid diagnosis and ↓disease spread
2. ) Complications of Thyroid Surgery
   - post-op bleeding –> haematoma which can cause airway obstruction (drained ASAP if this happens)
   - hypocalcaemia if damage to parathyroid glands, PTH and Ca levels should be checked the next day
   - damage to RLN –> vocal cord paralysis, bilateral paralysis is life-threatening, may need tracheostomy
3. ) Non-Surgical Treatment
   - radioiodine therapy can be used for papillary or follicular carcinomas after a total thyroidectomy
   - external beam radiotherapy can be used as primary or adjunct therapy (curative or palliative)
   - chemotherapy can be used similarly, classically used for lymphomas (sx can improve after few doses)

Question 10

Head and Neck Cancers

What are They?
Risk Factors
Clinical Features
Investigations

Answer 10

1. ) What are They? - cancer of the oral cavity, pharynx, larynx, paranasal sinuses, nasal cavity, salivary glands
   - >90% are SCC so referred as HNSCCs
2. ) Risk Factors
   - tobacco and alcohol account for 75% of HNSCCs
   - betal quid is linked with oral cancer
   - HPV (esp 16) is linked to oropharyngeal cancer
   - EBV linked to nasopharyngeal cancer
   - occupational wood dust exposure –> sinonasal
   - premalignant conditions (linked to oral cancer): erythro/leukoplakia, oral lichen planus, actinic cheilitis

3.) Clinical Features - each subtype can present differently but can all have non-specific cancer sx such as weight loss and cervical lymphadenopathy

4. ) Investigations
   - flexible nasal endoscopy (FNE) –> examination under anaesthesia (EUA) w/ biopsy (oral lesions do not require a GA to get a biopsy)
   - biopsy for all visible premalignant conditions
   - US-guided FNA for just lymphadenopathy
   - CT neck and chest used for staging, MRI neck for oropharyngeal cancers separately w/ CT chest
   - PET CT can be used for tumours of unknown origin

Question 11

Clinical Features of Head and Neck Cancers

Oral Cavity Cancer
Pharyngeal Cancer
Laryngeal Cancer

Answer 11

1. ) Oral Cavity Cancer
   - typically presents as a painless mass, being felt on the inner lip, tongue, floor of the mouth, or hard palate
   - however, may also have oral cavity bleeding, pain localised within the oral cavity or jaw swelling
   - may have visible pre-malignant conditions
   - urgent referral criteria to ENT: lump on the lip or in the oral cavity OR erythro/leukoplakia
   - consider referral in an unexplained ulcer for >3wks or a persistent and unexplained lump in the neck
2. ) Pharyngeal Cancer
   - typically presents with odynophagia, dysphagia, stertor, or referred otalgia, neck lump (nasopharyngeal)
   - Trotters syndrome is a clinical triad suggestive of nasopharyngeal cancer: conductive hearing loss, trigeminal neuralgia, defective mobility of soft palate
   - often at an advanced stage when diagnosed as they metastasize early due to extensive lymphatic network
3. ) Laryngeal Cancer
   - hoarse voice, neck lump, stridor, dysphagia, persistent cough, or referred otalgia
   - glottic tumours have a better prognosis as they present earlier with a hoarse voice and there is no lymphatic drainage from the glottis, hence limits any metastatic spread locally
   - urgent referral criteria: >45 w/ persistent unexplained hoarseness or an unexplained lump in the neck

Question 12

Management of Head and Neck Cancers

Oral Cavity
Oropharynx
Larynx
Hypopharynx
Complications

Answer 12

1. ) Oral Cavity
   - small tumours: WLE +/- neck dissection
   - larger tumours: surgical resection +/- flap reconstruction + neck dissection +/- adjuvant radiotherapy +/- chemotherapy
2. ) Oropharynx - tonsils
   - small tumours: surgical resection +/- neck dissection OR curative or adjuvant radiotherapy
   - larger tumours: curative radiotherapy +/- adjuvant chemotherapy
3. ) Larynx
   - small supraglottic tumours: surgical resection with bilateral neck dissection OR primary radio +/- chemo
   - larger supraglottic tumours: laryngectomy w/ post-op radio +/- adjuvant chemo OR radio +/- adjuvant chemo
   - small glottic tumours: surgical resection w/ bilateral neck dissection OR primary radiotherapy
   - larger glottic tumours: laryngectomy with neck dissection and post-op radio +/- adjuvant chemo OR primary radiotherapy +/- adjuvant chemotherapy
   - subglottic: rare, similar to glottic tumours
4. ) Hypopharynx
   - small: surgical resection w/ neck dissection OR primary radiotherapy +/- adjuvant chemotherapy
   - large: laryngopharyngectomy +/- gastric pull up/jejunal free flap + neck dissection OR radio +/- adjuvant chemo
5. ) Complications
   - dysphagia due to pharyngeal/oesophageal stricture
   - pharyngo-cutaneous fistula (following laryngectomy)
   - neck dissection: chyle leak, injury to the accessory, vagus, hypoglossal, or marginal mandibular nerves
   - radiotherapy: mucositis (early), xerostomia
   - chemoradiotherapy: chronic pain, persistent hoarse voice, or hearing loss
   - laryngectomy : cannot talk, become a neck breather
   - or tracheostomy

MDT - ENT, Maxillofacial, dental, dietician, SALT,