Head and Neck Flashcards
What key questions to ask about hoarseness?
Duration
Progression
Quality
What are key risk factors for laryngeal cancer?
- Tobacco use, including chewing
2. Alcohol use
What is the pathophysiology of laryngeal cancer?
Chronic inflammation and increased cellular turnover from toxic insults cause dysplasia and invasive squamous cell carcinoma
At what point does hoarseness warrant consultation with an ENT?
Longer than 3-4 weeks
Would you expect a bloody sputum with laryngeal cancer?
No: suggests malignancy in upper aerodigestive tract or in lungs
What is the most common type of laryngeal cancer?
squamous cell carcinoma
What is the most common site of malignant lesions of the larynx?
Glottis
What 2 nerves innervate the larynx?
Superior laryngeal n.
Recurrent laryngeal n.
What does the superior laryngeal nerve innervate (motor)?
Inferior constrictor
Cricothyroid muscles
What does the recurrent laryngeal nerve innervate (motor)?
All intrinsic laryngeal muscles except cricothyroid
Do laryngeal papillomas cause cancer?
HPV 6, 11 - cause benign papillary tumors.
- RARELY are malignant
What is the examination for evaluation of the vocal cords?
Office: indirect laryngoscopy:
- Mirror laryngoscopy
- Flexible fiberoptic laryngoscopy
OR: Direct laryngoscopy
If laryngeal cancer is suspected, what additional tests are warranted?
CXR: r/o pulm disease
CT neck: look for mets
How is laryngeal cancer staged?
TNM
What is the treatment for early stage laryngeal cancer?
Surgery OR radiation
What is the treatment for late stage laryngeal cancer?
Combination therapy: surgery and radiation, chemo and radiation or combo
- May need cervical lymph node dissection
What is the goal in treating laryngeal cancer?
Try to preserve the larynx
What is the most prognostic factor for laryngeal cancer?
TNM
What may be necessary for late stage laryngeal cancer?
Tracheostomy to secure airway
What are the red flags in evaluation of a neck mass?
Otalgia Dysphagia Dysphonia Dyspnea Trismus Stridor Hemoptysis
What key exam maneuvers should be done in evaluation of a neck mass?
- Palpate base of tongue and tonsillar fossa for firmness
- Perform complete CN exam
What are risk factors for head and neck cancer?
Smoking Alcohol Age > 40 HPV EBV GERD Chinese ethnicity Plummer Vinson Syndrome
What are primary tumors of the neck?
Lymphoma thyroid carcinoma Salivary gland neoplasms Schwannaoma Paraganglioma Lipoma
What are the deep neck abscesses and who gets them?
Peritonsillar (kids > 10) - no airway obstruction usually
Retropharygneal (kids < 10) - cause cause airway obstruction
Parapharyngeal (all ages: dental infections, tonsillitis)
What is the first step in workup of a neck mass?
Thorough head and neck exam: test all CNs
After physical exam, what is the next step to workup a neck mass?
Flexible endoscopy: eval for primary tumor
After flexible largyngoscopy, what is the next step to eval for neck mass?
FNA biopsy, CT scan with contrast of head/neck
After FNA and CT head/neck, what next for neck mass to stage or look further?
chest CT, PET scan, CXR to see what else is present
What to do if primary tumor cannot be found for a neck mass?
Panendoscopy: complete endoscopic eval or upper aerodigestive tract: laryngoscopy, esophagoscope and bronchoscopy
What is the order of the workup for neck mass?
1 Full PE with CN testing
2 Flexible laryngoscopy
3 FNA biopsy/CT scan with contrast of head/neck
4 Chest CT, PET scan, CXR
5 Panendoscopy if primary can still not be located
When is open neck biopsy done for neck mass?
After complete workup, including panendoscopy
- Due to increased risk of local/distant recurrence, increased morbidity, seeding of tumor cells
What are key tipoffs for a malignant neck mass caused by cancer?
Unilateral neck mass: progressive in size, age > 40y
Unilateral otalgia, Dysphagia, Odynophagia, Dysphonia, Dyspnea, Trismus, stridor, hemoptysis
What are symptoms of acute otitis media?
Otalgia Fever Hearing loss Tinnitus Bulging and erythematous TM w/ decreased mobility, poor light reflex < 3 weeks
What are symptoms of otitis media with effusion (OME)?
Middle ear effusion w/o signs of acute infection
Hearing loss
What are symptoms of chronic otitis media (COM)?
Recurrent or chronic ear infections that result in perforation of the tympanic membrane +/- otorrhea
How does otitis external present?
Recent contact w/ warm water
Tender, swollen pinna
Erythematous ear canal
What might regression in language suggest in kids?
Early sign of hearing loss
What are 3 roles of Eustachian tubes?
- Maintain gas pressure homeostasis within the middle ear
- Prevent infection of the middle ear and reflux of contents from the nasopharynx
- Clears middle ear infections
What organisms cause acute otitis media?
S. pneumoniae
Nontypeable H. flu
Moraxella catarrhalis
What causes otitis media with effusion?
- residual fluid from suppurative AOM
2. isolated ETD
How does nasopharyngeal carcinoma present?
unilateral OME in adults, more common in China, assoc. with EBV
What is the best way to diagnose AOM?
H&P w/ otoscopy
What is the best way to diagnose otitis externa?
H&P w/ otoscopy
What is best way to diagnose OME?
Pneumatic otoscopy less invasive than myringotomy
- Adults: nasopharyngoscopy to eval for tumors obstructing ET
What is treatment of AOM?
Antibiotics
What is treatment generally of OME?
None: self resolve w/in 3 months
When are PE tubes used for OME?
1 Symptomatic OME >3 months
2 Recurrent AOM with OME
3 Bilateral OME w/ hearing impairment
4. OME w/ vestibular problems, poor school performance, behavioral problems, otalgia
What is most significant complication of OME?
conductive hearing loss
What are long-term complications of untreated OME?
Permanent hearing loss ruptured TM mastoiditis temporal bone osteomyelitis meningitis sigmoid sinus thrombosis brain abscess
What to consider in any pediatric patient with unilateral aural fullness or otalgia?
Foreign body obstruction
Any delay in language milestones, what is the next step?
Eval for hearing loss without an audiology consult
