ENT - Throat Conditions

Question 1

Deep Neck Space Infections (DNSIs)

Pathophysiology
Clinical Features
Differential Diagnoses
Ludwig’s Angina

Answer 1

1. ) Pathophysiology - infection spreading from the oro-pharyngeal region and into the fascial planes
   - retropharyngeal: spreads to space anterior to the prevertebral fascia (young children, after an URTI)
   - parapharyngeal: infection spreads to the potential space posterolateral to the nasopharynx
   - organisms: polymicrobial: S. viridans, Staphylococcus, anaerobes, and Gram-negative bacilli
2. ) Clinical Features - wide range of symptoms:
   - severe sore throat w/ normal oropharyngeal exam
   - airway compromise: stridor, dyspnoea, drooling, dysphonia (voice changes), dysphagia/odynophagia
   - severe neck pain/stiffness or torticollis (wryneck)
   - fever, systemically unwell
   - parapharyngeal: febrile illness, odynophagia, trismus, pharyngeal swelling, cervical lymphadenopathy
3. ) Differential Diagnoses
   - foreign bodies, tonsillitis or peritonsillar abscess,
   - Ludwig’s angina, epiglottitis, meningitis, encephalitis
4. ) Ludwig’s Angina - infection of space between floor of mouth and mylohyoid (associated w/ dental infection)
   - sx: swelling of floor of mouth, painful mouth, protruding tongue, airway compromise, drooling
   - same management of other DNSI

Question 2

Assessment and Management of DNSIs

Investigations
General Management
Surgical Management

Answer 2

1. ) Investigations
   - nasal endoscopy: inflamed and oedematous airway and supraglottic structures
   - CT-neck w/ IV contrast (gold): to identify the location and extent of the infection
   - bloods: ↑↑↑inflammatory markers, signs of end-organ dysfunction if septic, blood cultures if suspected
   - lateral neck X-rays: widening of retropharyngeal tissue (>7mm at C2, >22mm at C7)
2. ) General Management
   - intubation if any signs of airway compromise
   - humidified oxygen w/ saline or NEB adrenaline
   - IV corticosteroids
   - broad-spec Abx (often ceftriaxone + clindamycin)
   - fluid resuscitation, keep nursed at >45 degrees
3. ) Surgical Management
   - washout of the DNSI via surgical drainage through the mouth or neck (or sometimes radiological-guided)
   - cardiothoracic involvement if spread to mediastinum
   - DNSIs can re-accumulate and spread so should be carefully observed, may need to repeat washout

Question 3

Tonsillitis

Clinical Features
Investigations
Management
Indications for Tonsillectomy

Answer 3

1. ) Clinical Features
   - odynophagia, dysphagia, halitosis, hoarse voice
   - coryzal sx: fever, sore throat, malaise, cough
   - lymphadenopathy in anterior cervical and submandibular regions
2. ) Investigations
   - FeverPAIN Score: fever <24hrs, Purulence, Attend rapidly (<3 days), Inflamed Tonsils, No cough
   - CENTor Criteria: Cervical lymphadenopathy, Exudates, No cough, Temperature (3/4 require abx)
   - rapid antigen test for Group A Strep in immuno-compromised (risk of rheumatic fever)
3. ) Management - symptoms resolve after 3-4 days
   - Abx if 4/5 in FeverPAIN: PO penicillin V QDS for 10d, clarithromycin used if allergic to penicillin
   - delayed antibiotics if 2/3 in FeverPAIN
   - ↑fluids, paracetamol/ibuprofen, lozenges, saltwater gargling, avoid hot drinks
   - avoid amoxicillin, NSAIDs, and codeine in patients with sleep apnoea
4. ) Indications for Tonsillectomy
   - ≥7 episodes in previous year, OR ≥5 in each of the last 2 years, or ≥3 in each of the last 3 years
   - two previous peritonsillar abscesses
   - sleep apnoea, suspected malignancy
   - complication: primary bleeding (<24hrs) requires an IMMEDIATE return to theatre, secondary bleeding (>24hrs post-op, days 5-9) from infection, requires ENT assessment and treatment w/ antibiotics and hydrogen peroxide mouth wash, tranexamic acid,

Question 4

Complications of Tonsillitis

Epiglottitis
Peritonsillar Abscess (quinsy)

Answer 4

1. ) Epiglottitis - inflammation and swelling of the epiglottis normally due to Haemophilus influenzae
   - mainly seen in young children (2-6yrs)
   - sx: stridor, drooling, dysphagia, dyspnoea, pyrexia
   - mx: secure the airway (intubation), IV antibiotics
2. ) Peritonsillar Abscess - rare complication w/ bacterial infection w/ trapped pus forming an abscess
   - sx: severe sore throat and odynophagia, stertor and trismus, unilateral neck swelling, neck pain
   - examination: erythema, swelling, deviated uvula
   - supportive mx: IV antibiotics, regular analgesia and topical analgesic throat sprays
   - definitive mx: needle aspiration (w/ LA) or I+D, can consider a tonsillectomy after 6 weeks

Question 5

Obstructive Sleep Apnoea

Pathophysiology
Clinical Features
Complications
Differential Diagnosis

Answer 5

1. ) Pathophysiology - intermittent and recurrent collapse of the upper airways during sleep which is defined as:
   - ≥5 respiratory events per hour (measured by polysomnography) with associated symptoms of OSA
   - risk factors: obesity (main risk factor), male, middle-aged, smoking, alcohol, use of sedative drugs
   - in children, tonsillar and adenoid enlargement can cause partial obstruction of the upper airways –> OSA

2.) Clinical Features
- witnessed sleeping disturbance: choking episodes or observed apnoea (breathing stops whilst asleep)
- excessive daytime sleepiness and ↓concentration:
can affect driving, work, relationships, mood
- snoring, morning headache, unrefreshed from sleep
- restlessness, personality changes, reduced libido
- enquire about sx of H+N cancers in assessment

3. ) Complications
   - must inform the DVLA if on CPAP treatment
   - ↑risk of cardiovascular co-morbidities: HTN, HF, MI, stroke (risk reduces with successful treatment of OSA)
   - ↓QoL: effects on memory, cognitive function, mood.
4. ) Differential Diagnosis
   - daytime sleepiness: depression/anxiety, narcolepsy, hypothyroidism, medication (sedatives, SSRIs etc)
   - nocturnal choking/gasping: GORD, nocturnal asthma, or heart failure (PND or orthopnoea)

Question 6

Assessment and Management of OSA

Investigations
Non-Pharmacological Intervention
Surgical Interventions

Answer 6

1. ) Investigations - diagnosed via sleep studies
   - exclude differentials: TFTs, CXR/ECG
   - polysomnography:measures no of apnoeic/hyponoeic episodes per night (Apnoea-Hypopnoea Index, AHI)
   - AHI determines severity: mild = 5-14 episodes/hour, moderate = 15-30 episodes, severe = >30 episodes
   - Epworth Sleepiness Scale: assesses impact of OSA, mild = 11-14, moderate = 15-18, severe = >18/24
2. ) Non-Pharmacological Intervention
   - lifestyle: weight loss, ↑exercise, ↓smoking, ↓alcohol
   - regular calculation of cardiovascular risk profile
   - intra-oral devices e.g. mandibular advancement can be tried in mild OSA or if patients cannot tolerate CPAP
   - CPAP (first-line for mod-severe OSA): provides positive pressure of air at night to keep airways open
   - CPAP can actually ↓BP but has a low compliance due to discomfort and patients feeling claustrophobic
3. ) Surgical Interventions
   - tonsillectomy and/or adenoidectomy in children with OSA due to tonsillar and/or adenoid enlargement
   - uvulopalatopharyngoplasty (UPPP) or laser-assisted UPPP (LAUP) (removes excess tissue to widen airway)
   - radiofrequency ablation of tongue base, suspension of the hyoid bone, orthognathic (jaw) surgery

Question 7

Neck Lumps

Clinical Features
Examinations
Red Flags Symptoms
Investigations

Answer 7

1. ) History Taking
   - duration of onset, change in size,
   - associated symptoms (esp red flag symptoms)
   - PMH: smoking, alcohol, radiation exposure
2. ) Examinations
   - neck: masses (effects of swallowing and sticking tongue out), lymph nodes, salivary glands, thyroid
   - oral: tongue, hard and soft palate, uvula, buccal area, the floor of the mouth, palatine tonsils
   - can also examine the ears if required
3. ) Red Flag Symptoms - H+N malignancy
   - lump: >6wks, fixed, hard and irregular, rapid growth
   - dysphagia, stridor, or hoarse voice, CN palsies
   - otalgia, epistaxis or unilateral nasal congestion
   - systemic sx: weight loss, night sweats, fever, rigours
   - children: also includes a supraclavicular mass, lumps > 2cm, previous history of malignancy
4. ) Investigations
   - 1° ultrasound: views lymph nodes, salivary glands, vascular structures, and thyroid nodules
   - 2° FNA: performed if suspicious features on the US unless lymphoma is suspected (core biopsy needed)
   - CT/MRI: if further imaging is needed, can also aid in the management of H+N cancer

Question 8

Differential Diagnoses for a Neck Lump

Infective 
Neoplastic
Inflammatory 
Traumatic 
Autoimmune 
Vascular (carotid body tumour)
Congenital

Answer 8

1. ) Infective - reactive lymphadenopathy: ↑ in size of the cervical lymph nodes in response to infection
   - sialadenitis is also an infective cause
2. ) Neoplastic
   - lymphoma, H+N cancer, salivary gland tumour, mets
   - skin lump: benign (lipoma), malignant (skin cancer)
3. ) Inflammatory - sarcoidosis
4. ) Traumatic - haematoma
5. ) Autoimmune/Anatomical
   - thyroid disease e.g. Graves’ disease
   - pharyngeal pouch
6. ) Vascular - carotid body tumour
   - benign neuroendocrine tumours that arise from the paraganglion cells of the carotid body
   - pulsatile painless neck lump, often w/ audible bruit, can be moved side to side but not up and down
   - slow-growing, but can eventually compress CNs
   - can be managed conservatively (serial imaging) or require surgical excision, radiotherapy if unresectable

7.) Congenital - thyroglossal cyst, branchial cyst, cystic hygroma, dermoid cyst

Question 9

Congenital Neck Lumps

Thyroglossal Cyst
Branchial Cyst
Cystic Hygroma
Dermoid Cyst

Answer 9

1. ) Thyroglossal Cyst - congenital fluid-filled sac due to incomplete obliteration of the thyroglossal duct
   - presents in younger patients (<20yrs)
   - palpable painless midline mass, moves up w/ tongue protrusion, can ↑size and become painful if infected
   - treatment is surgery: Sistrunk procedure for complete removal of the entire thyroglossal tract
2. ) Branchial Cyst - congenital mass due to incomplete obliteration of branchial clefts in the 4th week
   - unilateral palpable masses anterior to SCM (lateral), can ↑ size and become painful if infected (often URTI)
   - large ones –> dysphagia, dysphonia, SOB
   - FNA: acellular fluid with cholesterol crystals
   - treatment: surgical excision, sclerotherapy can be an alternative in certain cases
   - common differential is a cystic met from an SCC
3. ) Cystic Hygroma - benign fluid-filled sac caused by a malformation of the lymphatic system
   - soft painless fluctuant masses that transilluminates
   - classically presents in the posterior triangle or axilla
   - can cause airway obstruction or dysphagia
   - diagnosed < 2yrs, can be diagnosed antenatally so that an EXIT procedure can be carried out
   - treatment (symptomatic): surgical excision, lymphatic sclerotherapy (inject sclerosing agents into the cyst)

4.) Dermoid Cyst - cystic type teratoma, form along the lines of embryological fusion, can present as midline painless lumps, more common in children and young adults