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Head and neck | Flashcards

1
Q

Head and neck cancer include tumours that develop in which areas (6)?

A
  1. Oral cavity
  2. Pharynx
  3. Paranasal sinuses
  4. Nasal cavity
  5. Larynx
  6. Salivary glands
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2
Q

What are risk factors for developing head and neck cancers (7)?

A
  1. Male
  2. Increasing age
  3. Smoking/chewing tobacco or betal nuts
  4. Excessive alcohol
  5. Sun exposure - inc risk in lip, ears and skin of head+neck
  6. Breathing in certain chemicals and hardwood dusts - inc risk in nose/sinuses
  7. Presence of leukoplakia
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3
Q

Which type of cancer is more common among smokers, and those who drink lots of alcohol?

A

SCC

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4
Q

What are leukoplakia?

A

White spots of patches in the mouth which become cancerous in 1/3 patients

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5
Q

What types of cancers arise in the head and neck (6)? Which is most common?

A
  1. SCC -> most common
  2. Lymphoma (most often diffuse non-Hodkins lymphoma)
  3. Salivary gland tumours (include adenoid cystic, mucoepidermoid, acinic cell)
  4. Thyroid (papillary, follicular, medullary and anaplastic carcinomas)
  5. Sarcomas
  6. Undifferentiated carcinomas
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6
Q

What are the common symptoms of head and neck cancer (10)?

A
  1. Persistent pain in throat
  2. Bleeding in mouth or throat
  3. Persistent hoarseness or change in voice
  4. Persistent ulceration, leukoplakia or erythroplakia
  5. Odynophagia
  6. Dysphagia
  7. Referred pain to ear
  8. Enlarging neck node
  9. Weight loss
  10. Check for airway compromise
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7
Q

What are erythroplakia?

A

Red patches in the mouth (on a mucous membrane) that are not attributed to any other pathology. These are pre-malignant lesions

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8
Q

What should be done if a white or red lesion is present in the mouth for longer than 2 weeks?

A

It should be evaluated by a specialist and considered for biopsy

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9
Q

When does weight loss occur with head and neck cancers?

A

It is usually 2o to dysphagia or odynophagia

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10
Q

If weight loss is a predominant symptom, what malignancies should be considered?

A

Lung, stomach or other systemic cancers

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11
Q

What are some other symptoms that a patient may complain of with head and neck cancer (6)?

A
  1. Lump or thickening in oral soft tissues
  2. Soreness or feeling that something is stuck in the throat
  3. Difficulty chewing or opening of mouth
  4. Difficulty moving the tongue
  5. Numbness of the tongue or other parts of the mouth
  6. Swelling of the jaw that causes denture to fit poorly or become uncomfortable
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12
Q

What is done to diagnose head and neck cancers (2)?

A
  1. History and examination of upper aerodigestive tract
  2. Investigations:
    - Bloods (U&E, FBC, LFT, glucose, albumin, TFT)
    - ECG
    - Fine needle aspiration for cytology (FNAC) of neck nodes/lumps (may be done under US/CT guidance)
    - BIOPSY of identified suspected cancerous lesions or tumours
    - CT/MRI of neck from skull base to thoracic inlet
    - CXR or CT chest

-Assessment of nutritional status

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13
Q

What must be performed to confirm diagnosis of head and neck cancers?

A

Biopsy of any identified suspected cancerous lesions or tumours.
Involves detailed examination of the upper aerodigestive tract (panendoscopy) with biopsies of any suspicious areas usually under GA

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14
Q

What investigations are done for head and neck cancers (7)?

A
  1. (FNAC) of neck nodes/lumps
  2. Biopsy of tumours
  3. CT/MRI of neck from skull base to thoracic inlet
  4. CXR or CT chest
  5. Bloods (U&E, FBC, LFT, glucose, albumin, TFT)
  6. ECG
  7. Assessment of nutritional status
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15
Q

According to NICE guidelines, what are the criteria for people with suspected laryngeal cancer to be on the 2ww cancer pathway referral (2)?

A

Consider 2ww referral for laryngeal cancer in people aged 45 or over with:

  1. persistent unexplained hoarseness or
  2. an unexplained lump in the neck
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16
Q

According to NICE guidelines, what are the criteria for people with suspected oral cancer to be on the 2ww cancer pathway referral (2)?

A
  1. Unexplained ulceration in the oral cavity lasting for more than 3 weeks or
  2. A persistent and unexplained lump in the neck
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17
Q

According to NICE guidelines, what are the criteria for people with suspected oral cancer to be considered for an urgent referral (by 2 weeks) with the dentist (2)?

A
  1. a lump on the lip or in the oral cavity or

2. a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia

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18
Q

According to NICE guidelines, what are the criteria for people with suspected thyroid cancer to be on the 2ww cancer pathway referral?

A

Unexplained thyroid lump

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19
Q

What are red flags in head and neck cancer (7)?

A
  1. Unexplained neck lump
  2. Persistent unexplained hoarseness of voice
  3. Unexplained lump on lip/oral cavity
  4. Red/white patches in oral cavity >3weeks
  5. Dysphagia
  6. Cranial nerve involvement
  7. Persistent unilateral otalgia with normal otoscopy
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20
Q

How do oral cavity carcinomas present early (5) and late (2)?

A

Early:

  1. Non-healing ulcers
  2. Exophytic lesions in mouth
  3. Local pain
  4. Referred otalgia
  5. Loose teeth or poor fitting dentures

Later:

  1. Spread to lymph nodes
  2. Affects speech, swallowing , taste and appearance
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21
Q

What are the treatment options for oral cavity carcinomas cancers (2)?

A
  1. Surgery to primary site +/- neck

2. Adjuvant post op radiotherapy for patients at risk

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22
Q

What is the main type of cancer in the oropharynx?

A

SCC

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23
Q

What are the main presenting features of oropharynx tumours (9)?

A
  1. Sore throat/referred otalgia
  2. Odynophagia
  3. Dysphagia or sensation of mass in the throat
  4. Bleeding
  5. Change of voice
  6. Trismus
  7. Weight loss
  8. Can be asymptomatic with mass in the neck
  9. Obvious lesion - enlarged or ulcerated tonsil
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24
Q

What is the treatment of oropharyngeal cancer (2)?

A
  1. Planned combined surgery with adjuvant radiation

2. Radiation or chemoradiation with surgery for salvage

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25
Q

What is the challenge in treating oropharyngeal cancer?

A

Preserving speech and swallowing function

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26
Q

What are risk factors for oropharynx/hypopharyngeal tumours (5)?

A
  1. Smoking and alcohol abuse
  2. Betal-nut chewing
  3. Radiation
  4. Iron-deficiency anaemia
  5. HPV infection
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27
Q

What are the main presenting features of hypopharyngeal tumours (7)?

A

Does it usually present early or late?
Usually presents late

  1. Sore throat/foreign body sensation in the throat
  2. Hoarseness
  3. Odynophagia
  4. Increasing dysphagia with weight loss
  5. Stridor
  6. Otalgia
  7. Neck mass
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28
Q

What is the main type of hypopharyngeal tumour?

A

SCC

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29
Q

How are hypopharyngeal tumours treated?

  1. Early (1)
  2. Advanced (3)
A

Early
1. Radiation

Advanced

  1. Total laryngectomy +/- postoperative radiation
  2. Primary radiation with surgery for salvage
  3. Concurrent chemoradiation with surgery for salvage
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30
Q

What is the main type of laryngeal tumour?

A

SCC

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31
Q

What are risk factors for laryngeal tumour (3)?

A
  1. Smoking
  2. Alcohol abuse
  3. Previous neck radiation
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32
Q

What are the various locations of laryngeal cancer (3)?

A
  1. Glottis
  2. Supraglottic
  3. Subglottis (cancer here rare)
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33
Q

What are the clinical features of glottic cancer?

  1. Early (2)
  2. Late (4)

Do they usually present early or late?

A

Usually present early with good prognosis

Early

  1. Change in voice: constant gruff voice, progressive or hoarseness
  2. Rarely spread to lymph nodes

Later invade supraglottis or subglottis:

  1. Airway obstruction - dyspnoea/stridor
  2. Pain
  3. Dysphagia
  4. Spread to regional lymph nodes
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34
Q

What are the clinical features of supraglottic cancer (5)?

Does it usually present early or late?

A

Often presents late

  1. Local pain
  2. Referred otalgia
  3. Change in voice
  4. dysphagia
  5. Frequently spread to lymph nodes
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35
Q

What are the treatment options for early (3) and advanced (3) laryngeal cancer?

A

Early:

  1. Transoral laser resection
  2. Radiation
  3. Partial laryngectomy (rarely)

Advanced:

  1. Total larygectomy +/1 postoperative radiation
  2. Primary radiation with surgery for salvage
  3. Concurrent chemoradiation with surgery for salvage
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36
Q

What is the difference between a laryngectomy and a tracheostomy?

A

In laryngectomy, the trachea is brought to the skin, and there is no airway above the stoma. May need moisture exchange device or a speaking valve, may not need a tube.
In tracheostomy, the trachea and airway are all there, but there is a window in the trachea. Always needs a tube

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37
Q

What are the different histologies of thyroid cancer (3)?

A
  1. Papillary and follicular cancer (differentiated)
  2. Anaplastic (undifferentiated)
  3. Medullary (from parafollicular C cells – calcitonin)
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38
Q

What are risk factors for thyroid cancer (3)?

A
  1. MEN I/II
  2. Previous radiation exposure
  3. Thyroiditis is a risk factor for thyroid lymphoma
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39
Q

How do thyroid cancers present (3)?

A
  1. Neck lump in thyroid area
  2. May have airway compromise due to invasion of trachea
  3. May have vocal cord palsy due to invasion of recurrent laryngeal nerves
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40
Q

What investigations are done for thyroid cancers (3)?

A
  1. USS
  2. +/- FNA
  3. If FNA says “follicular”, you will need a diagnostic hemithyroidectomy to distinguish between follicular adenoma from carcinoma
    NB. no such thing as a papillary adenoma, only carcinoma
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41
Q

What are the treatment options for papillary and follicular thyroid cancer (2)?
What is the prognosis?

A
  1. Total (usually) thyroidectomy and central compartment neck dissection
  2. +/- radio-iodine

Good prognosis

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42
Q

What is the treatment of medullary thyroid cancer?

A

Surgery

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43
Q

What is the treatment of anaplastic thyroid cancer?

A

Palliative

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44
Q

What members of the MDT are needed in the assessment and management of head and neck cancer (4)?

A
  1. Oncologists
  2. Speech therapists - swallowing and speech
  3. Dietician
  4. Specialist nurse - laryngectomy care
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45
Q

What is vocal cord motion impairment?

A

Uncoordinated movements of the vocal cord which can lead to dyspnoea

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46
Q

Weak voice?

A

Damage to the recurrent laryngeal nerve - it supplies the posterior cricoarytenoid muscle which is the sole muscle responsible for opening the vocal cords

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47
Q

What is the recurrent laryngeal nerve a branch of and what does it supply?

A

Branch of the vagus nerve (cranial nerve X)

Supplies all the intrinsic muscles of the larynx, with the exception of the cricothyroid muscles

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48
Q

What are the 3 major salivary glands?

A
  1. Parotid
  2. Submandibular
  3. Sublingual
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49
Q

Which nerve divides the parotid gland into superficial and deep lobes?

A

Facial VII nerve

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50
Q

What structures pass through the parotid gland (6)?

A
  1. Facial nerve trunk and its 5 major branches
  2. Retromandibular vein
  3. External carotid artery dividing into terminal superficial temporal and maxillary arteries
  4. Parotid duct - leaves gland anteromedially passing through buccinator then medially to anterior border masseter: exits in mouth at level of upper 2nd molar
  5. Sympathetic fibres
  6. Secretemotor fibres from inferior salivary nucleus and otic ganglion
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51
Q

Where is the submandibular gland?

A

Fills the submandibular triangle below mandible

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52
Q

Which main structures pass through the submandibular gland (3)?

A
  1. Lingual and hypoglossal nerves are in close proximity to the deep surface
  2. Secretemotor fibres
  3. Sympathetic fibres
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53
Q

Where is the sublingual gland?

A

Floor of the mouth

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54
Q

What are the types of fluid that each of the main salivary glands secrete (3)?

A

Parotid - serous
Submandibular - mixed
Sublingual - mucus

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55
Q

What is the physiology of saliva production?

A

Varying proportions of serous and mucous cells are clumped together forming acini. These are surrounded by myoepithelial cells which are drained by short intercalated ducts. These in turn drain into striated ducts then excretory ducts before exiting into the main ducts.

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56
Q

Which cells are thought to be where salivary neoplasms originate from?

A

Reserve cells - found in the intercalated and excretory duct systems. They have the capacity to differentiate into different duct cell types.

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57
Q

What is the excretion of saliva controlled by (2)?

A
  1. Basal secretion of saliva

2. Regulation under neurotransmitter control via the ANS

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58
Q

What stimulates saliva production (5)?

A
  1. Smell
  2. Taste
  3. Psychic stimuli
  4. Chewing and mastication
  5. Parasympathomimetic drugs
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59
Q

What are the different kinds of pathology that can occur with salivary glands (7)?

A
  1. Inflammatory
  2. Infective: mumps, bacterial
  3. Sjorgens, sarcoid
  4. Stones
  5. Neoplastic
  6. Benign (pleomorphic adenoma, Warthin’s tumour)
  7. Carcinoma (mucoepidermoid, adenoid cystic, acinic)
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60
Q

What are the causes of parotitis (inflammation of the parotid gland) (4)?

A
  1. Viral (mumps, HIV)
  2. Bacterial (often staphlococcal)
  3. Fungal (candidiasis, but rare)
  4. Other
    - Sarcoid
    - Drugs (dextroprophoxyphene - opioid)
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61
Q

How does parotitis caused by HIV present?

A

Diffuse enlargement of the gland with multiple cysts

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62
Q

How do you investigate and treat parotitis caused by mumps?

A

Mumps titres

Treat with analgesia and hydration

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63
Q

How do patients with parotitis caused by a staphylococcal infection present (3)?

A
  1. Usually debilitated
  2. May be on anticholinergics
  3. Dehydrated
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64
Q

How do patients with parotitis caused by a staphlococcal infection get treated (2)?

A
  1. Sialogogues - drug that increases flow rate of saliva

2. Massage or drain pus if present

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65
Q

In what group of people do parotitis caused by a fungal infection occur in?

A

Immunocompromised

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66
Q

What is sarcoid of the parotid glands?

A

Sarcoidosis is a disease involving abnormal collections of inflammatory cells that form lumps known as granulomas

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67
Q

What is sialectasis and sialolithiasis?

What are the clinical features of sialolithiasis (2)?

A

Sialectasis: cystic dilation, stenosis and necrosis of the ducts of salivary glands (unknown cause).
It is the initial event in sialolithiasis (stones) 85% of which affect the submandibular gland duct

  1. Pain and swelling of the affected salivary gland (most commonly in submandibular), both of which get worse when salivary flow is stimulated
  2. Inflammation or infection of the gland may develop as a result
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68
Q

How is sialectasis and sialolithiasis investigated (2)and treated (3)?

A

Investigate with:

  1. plain x-ray
  2. sialogram ( radiographic examination of the salivary glands)

Treat with:

  1. Remove stone
  2. Marsupialise (surgically stitch open) duct
  3. Occasionally gland needs to be excised
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69
Q

What is Sjogren’s syndrome?

A

Long-term autoimmune disease in which the moisture-producing glands of the body are affected resulting primarily in the development of a dry mouth and dry eyes. There is a chance of developing lymphoma

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70
Q

What are the 4 classifications of Sjogen’s syndrome?

A
  1. Primary - dry eyes and mouth
  2. Secondary - dry eyes, mouth and connective tissue disease
  3. Benign lymphoepithelial lesion = prelymphomatous condition
  4. Aggressive lymphocytic behaviour confined to parotid glands
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71
Q

What are the symptoms of Sjogren’s syndrome (4)?

A
  1. Dry eyes, keroconjunctivitis
  2. Dry mouth, glossitis, 2o candidiasis, stomatitis, dental caries
  3. Dry vagina
  4. 40% have a parotid gland enlargement, only 20% show it
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72
Q

What is the risk with Sjogren’s syndrome?

A

1 in 6 will develop non-Hodgkin’s B-cell lymphoma also Waldenstrom’s Macroglobulinaemia and lymphoblastic sarcoma

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73
Q

What are the investigations for Sjogren’s syndrome (6)?

A
  1. HLA AI B8 ad DR3 (present esp in primary Sjogren’s)
  2. Specific antigens: SSA and SSB
  3. Schirmer’s test for lacrimation
  4. Carlsson-crittendon fro salivary flow
  5. Labial biopsy - diagnostic test for Sjogren’s
  6. Rapid growth: Diagnostic parotidectomy
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74
Q

What is the treatment of Sjogren’s syndrome (2)?

A
  1. Steroids for bouts of parotid swelling

2. Artificial tears, saliva, lubricants

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75
Q

What % of salivary tumours occur in the parotid and what % of these are benign?

A

80% salivary tumours occur in the parotid

80% of these are benign

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76
Q

What % of submandibular tumours are benign?

A

60%

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77
Q

What % of minor salivary gland tumours are benign?

A

30%

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78
Q

What % of minor salivary gland tumours away from the mouth and oropharynx are malignant?

A

100%

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79
Q

What types of benign salivary gland tumours are there and how common are they (3)?

A
  1. Pleomorphic adenomas (60-70%)
  2. Warthin’s tumour or adenolymphoma (2-6%) - not a lymphoma
  3. There are 7 other types of adenoma in salivary glands which are rare
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80
Q

What cells do pleomorphic adenomas arise from?

What do they look like histologically (3)?

A

Intercalacted duct reserve cells (progenitor cells for ductal cells and myoepithelial cells)

  1. Usually in superficial lobe, often in tail of gland
  2. Macroscopically: grey/blue cut surface, cystic, lobulated
  3. Mixed cell tumour
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81
Q

What are the investigations for a pleomorphic adenoma (2)?

A
  1. Fine needle aspiration cytology

2. USS/CT

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82
Q

What is the treatment of pleomorphic adenomas?

A

Superficial parotidectomy or tumour excision with complete cuff of normal tissue.
Occasionally total parotidectomy

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83
Q

What cells do Warthin’s tumours arise from?

How do they present (3)?

A

Probably parotid lymph nodes

  1. Soft, cystic masses in tail of parotid
  2. May be bilateral
  3. More often i males >40yo
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84
Q

What is the treatment of Warthin’s tumours?

A

Superficial parotidectomy or tumour excision with complete cuff of normal tissue.
Occasionally total parotidectomy

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85
Q

What tumours of variable malignancy and clinical behaviour can be found in salivary glands (2)?

A
  1. Mucoepidermoid carcinoma

2. Acinic cell

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86
Q

What cells do mucoepidermoid carcinomas arise from (2)?

A
  1. From epithelial cells of interlobar and intralobular ducts
  2. 90% found in parotid gland
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87
Q

What groups of people are mucoepidermoid carcinomas more common in (3)?

A
  1. Highest prevalence in 5th decade
  2. Most common salivary gland carcinoma in children
  3. More common in females
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88
Q

How do different grades of mucoepidermoid carcinomas behave over time (3)?

A
  1. Low grade = well-differentiated tumours grow slowly and painlessly
  2. High grade = poorly-differentiated tumours grow rapidly, painfullym invade local structures and metastasise to local lymph nodes, lungs, bones and brain
  3. Some are intermediate in differentiation
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89
Q

How are mucoepidermoid carcinomas treated?

  1. Low grade (2)
  2. High grade (2)
A

Low grade

  1. local resection and
  2. prolonged follow up

High grade

  1. Radical resection and
  2. adjuvant radiotherapy
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90
Q

What cells do acinic cell tumours arise from?

What are their clinical features (3)?

A

Reserve epithelial cells of terminal or intercalated ducts

  1. Can occur bilaterally (3%)
  2. Grow slowly
  3. 99% in parotid gland
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91
Q

What groups of people do acinic cell tumours arise in (3)?

A
  1. Prevalence highest in middle aged and elderly
  2. Can occur in children
  3. More common in females
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92
Q

What is the treatment for Acinic cell tumours?

A

Local resection with VII nerve preservation and prolonged follow-up

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93
Q

What malignant tumours of salivary glands are there and how common are they (4)?

A
  1. Adenoid cystic carcinoma (14% of partoid gland cancers) - most common malignant tumour
  2. Carcinoma ex pleomorphic adenoma (3-12% of all salivary gland cancers)
  3. Adenocarcinoma (2.5-4% of all parotid neoplasms)
  4. Lymphoma
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94
Q

What cells do adenoid cystic carcinomas arise from?

What are the clinical features (3)?

A

Reserve epithelial cells in the intercalated ducts

  1. Grow slowly and insidiously
  2. Propensity for perineural infiltration so presents with palsies and pain
  3. Can occur in the parotid, submandibular, sublingual and minor salivary glands)
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95
Q

What groups of patients are adenoid cystic carcinomas more common in depending on the location (3)?

A
  1. Majority of patients 40-60 yo
  2. Tumours in submandibular gland generally seen in women
  3. For minor salivary gland tumours, equal in men and women
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96
Q

What is the treatment of adenoid cystic carcinomas (3)?

A
  1. Wide local resection sometimes with sacrifice of VII nerve
  2. Radiotherapy controversial
  3. Prolonged follow-up
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97
Q

What is the prognosis of adenoid cystic carcinoma?

Where do they usually metastasise to?

A

15 year survival 10-26%
Local recurrence 50%
Distant metastasis usually to bone, liver and lung, can be associated with prolonged survival

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98
Q

What are the clinical features of carcinoma ex pleomorphic adenoma (3)?

A
  1. Can develop within a pleomorphic adenoma
  2. Present 10-15 years after a pleomorhic adenoma
  3. Pain or palsy occurs
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99
Q

What are the clinical features of adenocarcinoma (3)?

A
  1. Highly malignant
  2. Several histological types
  3. Poor prognosis
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100
Q

What are clinical features of lymphoma (4)?

How is diagnosis made?

A
  1. Comprise 40% of non-epithelial tumours of salivary glands
  2. non-Hodkin’s lymphoma the most common
  3. Usually arise between 5th-7th decades
  4. Present as firm rapidly enlarging masses and occasionally lymph node metastases

Diagnosis by open biopsy

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101
Q

Where do malignant tumours of the salivary glands usually metastasise to (5)?

A
  1. Skin - melanoma, SCC
  2. Lung
  3. Breast
  4. Kidney
  5. Upper GI tract
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102
Q

What can a medially deviated tonsil indicate (3)?

A
  1. Quinsy
  2. Malignancy of parotid
  3. Aneurysm of carotid
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103
Q

What is the pathophysiology of trismus?

A

Medial pterygoid or trigeminal nerve is affected so can’t open mouth

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104
Q

What are the ddx of a neck lump (10)?

A
  1. Skin - sebaceous cysts (anywhere), dermoids (usually midline)
  2. Subcutaneous - lipomas
  3. Congenital - thyroglossal cysts (midline), branchial cysts
  4. Lymph nodes - infected, inflammatory, neoplastic: benign or malignant (primary or secondary)
  5. Nerves - neuromas
  6. Blood vessels - haemangiomas, prominent normal vessels
  7. Paragangliomas - (carotid body tumours/glomus vagale)
  8. Salivary glands (parotid, submandibular) - infection, inflammation, neoplasia: benign or malignant (primary or secondary), autoimmune disease, stones
  9. Thyroid
    single - cyst, adenoma, carcinoma
    multiple/ diffuse - physiological, multinodular goitre, hashimotos
  10. Bone and cartilage - normal anatomy e.g. transverse process of C1, hyoid
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105
Q

What is globus?

A

Sensation of something sticking in throat, feeling of lump, present even when not swallowing.
(distinct from true dysphagia where food actually sticks)

It is a symptom

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106
Q

What pathologies must you exclude when presented with globus (4)?

A
  1. Cancer
  2. Masses
  3. Infection
  4. Reflux

Often no specific cause is found, just sensitivity/hyperawareness

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107
Q

What are some red flags in a patient with globus that could indicate cancer (4)?

A
  1. Older smoker
  2. Dysphagia
  3. Progressive
  4. Otalgia
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108
Q

What investigations would you do for someone with globus (4)?

A
  1. Examine mouth
  2. Examine oropharynx
  3. Examine neck
  4. ENT flexiscope
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109
Q

What is the management of globus wen no identified cause is found (3)?

A
  1. avoid irritants like caffeine, smoking, throat clearing, dry swallowing as this makes underlying sensitivity worse
  2. ice cold sparkling water sips
  3. treat laryngopharyngeal reflux (aka silent reflux): this is thought to be a common cause of globus / mucus feeling in throat, but diagnostic criteria and management are poorly defined
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110
Q

What are ddx for voice pathology (4)?

A
  1. Structural/neoplastic
    - Malignancy
    - Benign:
    a. Nodules
    b. Polyps
    c. Reinke’s oedema
    d. Cysts
  2. Inflammatory
    - Infectious
    a. Viral
    b. Bacterial
    c. Fungi
    - Non-infectious
    a. Extra-oesophageal reflux
    b. Allergies (rare)
  3. Neuromuscular
    - Underactive
    a. Recurrent laryngeal nerve palsy
    b. Myaesthenia (rare)
    - Overactive
    a. Spasmodic dysphonia (rare)
  4. Muscle tension imbalance
    - Primary
    a. Vocal cord demands/strain
    b. Occupational
    c. Psychogenic
    d. Presbylaryngis (age-related atrophy of the soft tissues of the larynx)
    e. Gender identity
    - Secondary
    a. Inflammation
    b. Structural/neoplastic
    c. Neuromuscular
    d. Breathing disorders
    e. Postural abnormalities
    f. Congenital laryngeal
    g. Anatomical abnormalities
111
Q

What must you consider in a patient with persistent hoarseness of the voice lasting >6 weeks?

A

Laryngeal carcinoma

112
Q

What are the causes of laryngeal carcinoma (2)?

A
  1. Smoking

2. Genetic

113
Q

What are the symptoms of laryngeal carcinoma (5)?

A
  1. Progressive hoarseness or change in voice
  2. Stridor
  3. Referred otalgia
  4. Dysphagia
  5. Cervical lymphadenopathy in late cases
114
Q

What are the signs of laryngeal carcinoma (3)?

A
  1. Raised, thickened, irregular mass with leukoplakia (white patch) and redness
  2. Narrowing of airway +/- vocal cord fixation on laryngeal visual exam
  3. Cervical lymphadenopathy
115
Q

What is the treatment of laryngeal carcinoma (2)?

A
  1. Radiotherapy and

2. Partial or total laryngectomy

116
Q

What are the causes of vocal nodules (3)?

A

1 Voice abuse - shouting, talking above background nose

  1. ?reflux
  2. More common in women and young adults
117
Q

What are the symptoms of vocal nodules (2)?

A
  1. Husky voice that worsens with use, loss of higher range of voice
  2. Peri-laryngeal discomfort
118
Q

What are the signs of vocal nodules?

A

Bilateral swellings in mid-membranous portion of vocal fold giving hourglass appearance

119
Q

What is the treatment of vocal nodules? (2)

A
  1. Voice therapy

2. Rarely surgery if unresponsive

120
Q

What are the causes of vocal polyps? (2)

A
  1. Shouting when suffering with a cold or extra-oesophageal reflux
  2. Men>women 30s-50s
121
Q

What are the symptoms of vocal polyps? (3)

A
  1. Husky voice worsens with use, may be deeper
  2. Voice cuts out during speaking
  3. Choking episodes if very large
122
Q

What are the signs of vocal polyps?

A

Usually unilateral grey or red swellings arising from mid-membranous portion of the vocal fold, smooth edge

123
Q

What is the treatment of vocal polyps?

A

Surgical excision +/- medical treatment +/- voice therapy

124
Q

What is Reinke’s oedema?

A

Deep voice in smoker caused by VC oedema

125
Q

What are the causes of Reinke’s oedema? (4)

A
  1. Smoking
  2. +/- a lot of talking
  3. +/- extra-oesophageal reflux
  4. Equal occurrence in men and women
126
Q

What are the symptoms of Reinke’s oedema? (2)

A
  1. Deep pitched gravelly voice (women mistaken for men on the phone)
  2. If severe can cause choking episodes
127
Q

What are the signs of Reinke’s oedema?

A

Bilateral grey or red swellings along whole length of membranous portion of the vocal fold

128
Q

What are the treatments of Reinke’s oedema? (4)

A
  1. Stop smoking
  2. Surgical reduction of polypoid swelling
  3. +/- medical treatment of reflux
  4. +/- Voice therapy
129
Q

What are the causes of VC cysts?

What are the 2 types of cysts?

A

Unknown, maybe laryngeal inflammation/congenital

Mucus retention cysts and epidermoid cysts

130
Q

What are the symptoms of VC cysts? (4)

A
  1. Husky voice
  2. Pitch breaks
  3. Loss of range of voice
  4. Increased effort to produce voice
131
Q

What are the signs of VC cysts?

A

Unilateral nodular swelling or localised bulge or stiffness of vocal fold

132
Q

What are the treatments of VC cysts? (2)

A
  1. Voice therapy can help reduce 2o muscle tension

2. Surgical excision

133
Q

What are the infectious causes of the larynx i.e. laryngitis? (3)

A
  1. Viral
    - URTI
    - Recurrent respiratory papillomatosis (RRP) due to HPV
  2. Bacterial (rare)
  3. Fungi
    - Secondary to steroid inhalers or immunosuppression
134
Q

What are the symptoms of acute viral or bacterial laryngitis? (5)

A
  1. Hoarse or croaky voice
  2. Complete loss of voice (aphonia) in severe cases
  3. Pain on voice use, coughing or swallowing
  4. Irritant paroxysmal coughing
  5. Generally other symptoms of an URTI
135
Q

What are the symptoms of a fungal laryngitis?

A

Same as viral/bacterial without symptoms of an URTI

136
Q

What are the signs of acute viral or bacterial causes of laryngitis?

A

Erythematous or sloughy vocal folds

137
Q

What are the signs of laryngitis caused by HPV?

A

Papillomas are usually multiple, raised erythematous lesions on the vocal folds and anywhere in the larynx

138
Q

What are the signs of laryngitis caused by fungi?

A

Candida appears as white dots of leukoplakia

139
Q

What is the treatment if acute viral or bacterial laryngitis? (6)

A

Usually self-limiting and settles with:

  1. Voice rest
  2. Analgesia
  3. Fluid hydration
  4. Steam inhalations
  5. Cough suppressants as necessary
  6. Occasionally Abx
140
Q

What is the treatment of RRP?

A

Usually needs surgical excision with laser or microdebrider

141
Q

What are the non-infectious causes of laryngitis? (2)

A
  1. Extra-oesophageal (or silent) reflux: damage from acid and pepsin
  2. Allergies (rare)
142
Q

What are the symptoms of laryngitis associated with extra-oesophageal reflux? (4)

A
  1. Variable huskiness
  2. Voice may worsen with use
  3. Loss of higher range of voice
  4. Associated throat symptoms e.g. chronic throat clearing, cough, choking episodes, globus sensation etc
143
Q

What are the signs of laryngitis associated with extra-oesophageal reflux?

A

General erythema and oedema of vocal folds and larynx

144
Q

What is the treatment of laryngitis associated with extra-oesophageal reflux? (3)

A
  1. Vocal hygiene and dietary advice
  2. PPI 2x a day before breakfast and evening meal for 2 months
  3. +/- alginates and H2 antagonists
145
Q

What is the main neuromuscular pathology of the larynx?

A

Recurrent laryngeal nerve palsy or paresis

146
Q

What are the main causes of recurrent laryngeal nerve palsy or paresis? (4)

A
  1. Idiopathic/miscellaneous
  2. Surgical trauma
    - thyroidectomy
  3. Malignant disease
    - Ca bonchus/thyroid/oesophagus
  4. Neurological disorders
147
Q

What are the symptoms of recurrent laryngeal nerve palsy/paresis? (7)

A
  1. Weak voice
  2. Tires on prolonged talking
  3. Perilaryngeal discomfort
  4. Choking with fluids
  5. Higher pitched voice
  6. Diplophonia (2 tone voice)
  7. Weak (bovine) cough
148
Q

What are the signs of recurrent laryngeal nerve palsy? (4)

A
  1. Immobile vocal cord
  2. Listen to voice (weak)
  3. Listen to cough (weak)
  4. Check for other cranial nerve lesions
149
Q

What investigations would you do for recurrent laryngeal nerve palsy? (3)

A
  1. CXR - exclude mediastinal mass
  2. CT scan skull base to midthorax - check for lesions along path of nerve
  3. ?Ba swallow if oesophageal lesion or aspiration suspected
150
Q

What is the treatment of recurrent laryngeal nerve palsy? (3)

A
  1. None - wait for spontaneous recovery (up to 1 year)
  2. Voice therapy - encourages compensation
  3. Vocal cord medialization procedure to add bulk to vocal cord e.g. collagen, fascia etc
151
Q

What is muscle tension imbalance or dysphonia?

A

Voice disorder which prevents a person from producing sounds from their vocal cords caused by imbalance of laryngeal muscles

152
Q

What are the two categories of causes of muscle tension dysphonia?

A
  1. Primary = imbalance or “pull” or excessive tension of the laryngeal muscles synergists and antagonists
  2. Secondary = excessive tension required to overcome a deficiency in the voice producing mechanism
153
Q

What are the 4 causes of primary muscle tension dysphonia?

A
  1. Stress, anxiety
  2. Neck/back problems
  3. Poor vocal hygiene
  4. Lifestyle/dietary
    - Talking above background noise for long periods etc
    - Not drinking enough fluids
    - Too much tea, coffee and colas
    - Eating late at night/large fatty meals
154
Q

What are the 3 causes of secondary muscle tension dysphonia?

A
  1. Poor respiratory function
  2. Structural defect of vocal folds
  3. Nasal blockage affecting resonance
155
Q

What are the 3symptoms of muscle tension dysphonia?

A
  1. Variable huskiness of voice, usually worsens with use
  2. May be a little deeper or higher than expected for age and sex
  3. Voice unstable, perilaryngeal soreness, dryness/uncomfortable sensation in throat
156
Q

What are the 3 signs of muscle tension dysphonia?

A
  1. Voice croaky/husky, breathy, bizarre, aphonic
  2. Cough often normal even when voice aphonic
  3. Vocal folds usually normal in appearance and movement but either constriction of false cord, antero-posterior constriction or extreme sphincteric closure when vocal folds disappear from view beneath false cords
157
Q

What is the treatment of muscle tension dysphonia?(3)

A
  1. Vocal hygiene and lifestyle advice
  2. Voice therapy
  3. Address underlying causative factors
158
Q

How would you instruct voice care to someone? (3)

A
  1. Avoid shouting and whispering
  2. Avoid irritants like smoking, air con, caffeine
  3. Stay well hydrated
159
Q

What is the function of the pharynx? (5)

A
  1. Serves as a chamber common to the respiratory and alimentary systems. Functions as a conducting airway for ventilation of the lungs and as a channel for fluids and food down to the oesophagus
  2. The pharyngeal muscles help with the pharyngeal phase of swallowing
  3. Involved in speech
  4. Contain sensory receptors for taste, pain etc
  5. Related to opening of Eustacean tube
160
Q

What are the 3 parts of the pharynx?

A

Nasopharynx
Oropharynx
Hypopharynx

161
Q

Where is the larynx in relation to the pharynx?

A

In front

162
Q

What are the 3 parts of the larynx?

A

Supraglottis
Glottis
Subglottis

163
Q

Which area of the larynx contain the vocal cords?

A

Glottis

164
Q

What are the 3 functions of the larynx?

A
  1. Protection of the lower airway
  2. Helps generate cough and expel matter from the airways
  3. Produced sound vibration for voice
165
Q

How does voice production occur? (3)

A
  1. Energy from the movement of air molecules causes the mucosa of the membranous part of the vocal folds to be set in oscillation
  2. This oscillation results in the generation of a sound wave
  3. Having 2 vocal folds apposing and oscillating in synchrony results in more efficient mechanism for voice production
166
Q

What are the 2 fundamental measurements of the sound produced by the vocal cords?

A

Frequency (F0) of vibration in Hertz

Intensity or pressure (in dB)

167
Q

What is frequency perceived as by the listener?

A

Pitch of the voice

168
Q

What is the frequency of the sound determined by?

A

Mass per unit length of vocal folds

169
Q

When a pathological condition increases the mass per unit length of the vocal cords, what happens to the frequency?
What is an example of this pathology?

A

It lowers

Reinke’s oedema

170
Q

What is intensity or sound pressure level perceived as by the listener?

A

Loudness of the voice

171
Q

What is the intensity of sound determined by?

A

Subglottic pressure

172
Q

What pathophysiology would result in a weak voice?

A

Any pathological condition that reduces the contact between the vocal folds e.g. a recurrent laryngeal nerve palsy will result in a reduced subglottic pressure as air escape, resulting in a weak voice

173
Q

What leads to vowel production?

A

Vocal fold vibration leads to vowel production

It is modulated by the vocal tract and the shape of the tongue in the mouth, pharynx and shaping of the lips

174
Q

How are consonants produced?

A

Produced by air being squirted through narrowings in the vocal tract producing turbulent airflow

175
Q

Overall, what does normal voice production require? (2)

A
  1. Vocal folds to vibrate in a coordinated manner

2. Adequate subglottic pressure generated from lungs to make the vocal cords vibrate

176
Q

What is dysphonia?

A

Any impairment of the voice or difficulty speaking

177
Q

What is dysarthria?

A

Imperfect articulation of speech due to disturbances of muscular control or incoordination

178
Q

What is dysphasia?

A

Impairment of speech and verbal comprehension (sensory dysphasia) or speech and verbal production (expressive dysphasia), especially when associated with brain injury

179
Q

What is snoring caused by?

A

Snoring is noisy breathing caused at the level of the oro/nasopharynx, by vibration of relaxed soft tissues of the nose, soft palate or pharynx whilst sleeping or drowsy

180
Q

What is obstructive sleep apnoea?

A

People with repetitive apnoeas and symptoms of sleep fragmentation with excessive daytime sleepiness

181
Q

What is obstructive sleep apnoea?

A

people with repetitive apnoeas and symptoms of sleep fragmentation with excessive daytime sleepiness

182
Q

What is the management of snoring? (5)

A
  1. Weight loss, stop smoking, less alcohol etc
  2. Posture adjustment and sleep position training e.g. tennis ball on back to stop them lying on their back, or pillows
  3. Decongestants and steroid nasal sprays can help nasal congestion
  4. For those who snore due to mouth-breathing, chin straps (to keep the mouth closed) or vestibular shields (essentially closing off the mouth and forcing breathing through the nose) may be of benefit
  5. Surgery - nasal surgery/adenotonsillectomy
183
Q

What is the management of OSA?

  1. Primary care (5)
  2. Secondary care (3)
A

Primary care

  1. Lifestyle changes
  2. Sleeping on side
  3. Monitoring risk of diabetes, CVD, and bp
  4. Driving advice
  5. Support groups

Secondary care

  1. Sleep study
  2. Continuous positive airway pressure (CPAP) is 1st line
  3. Intra-oral devices (such as a mandibular advancement device) are appropriate for people who snore or have mild OSAS with normal daytime alertness
184
Q

What is the definition of stridor?

A

Noisy breathing

185
Q

What are the 3 types of stridor and what level do they indicate?

A
  1. Inspiratory stridor - laryngeal level
  2. Expiratory stridor - Bronchi/bronchioles (the wheeze of asthma
  3. Mixed inspiratory and expiratory stridor - tracheal or laryngeal and lower airways
186
Q

What is the definition of stertor?

A

Noises produced at the level of the oro/nasopharynx i.e. snoring

187
Q

What are the common congenital and acquired causes of stridor?

  1. Supraglottic
  2. Glottic
  3. Subglottic
  4. Trachea
A
  1. Congenital:
    -laryngomalacia
    -bifid epiglottis
    -cysts
    Acquired:
    -traumatic
    -RRP
    -cysts
  2. Congenital:
    -atresia
    -Web (VCFS)
    -VCMI
    Acquired:
    -traumatic / web
    -RRP
    -VCMI
  3. Congenital:
    -congenital SGS
    -haemangioma
    Acquired:
    -traumatic SGS
    -cysts
    -croup
  4. Congenital:
    -malacia
    -stenosis / complete rings
    -extrinsic / vascular
    Acquired:
    -malacia
    -traumatic / iatrogenic
    -extrinsic
188
Q

What is laryngomalacia?

A

congenital abnormality of the laryngeal cartilage resulting in collapse of the supraglottic structures leading to airway obstruction during inspiration

189
Q

What is laryngeal papillomata?

A

HPV infections of the throat, in which benign tumors or papillomas form on the larynx or other areas of the respiratory tract that leads to audible changes in voice quality and narrowing of the airway

190
Q

What is subglottic stenosis?

A

Congenital or acquired narrowing of the subglottic airway

191
Q

What are signs and symptoms of upper airway obstruction (8)?

A
  1. stridor
  2. Use of accessory muscles
  3. Tracheal tug and intercostal/subcostal recession
  4. Cyanosis
  5. Tachycardia and tachypnoea
  6. Reduced consiousness
  7. Unable to complete full sentences
  8. Absence of breath sounds
192
Q

What is the general management of a patient with stridor? (5)

A
  1. Basic history
  2. First aid
  3. Assess severity of stridor
  4. Improve and secure airway as necessary
  5. Investigate and treat underlying cause as necessary
193
Q

What are the criteria to assess severity of stridor? (8)

A
  1. Only present on exertion
  2. Only present on deep inspiration
  3. Audible at all times but unable to hold a normal conversation
  4. Has to talk in short phrases
  5. Only able to get odd words out as concentrating on breathing
  6. Unable to talk, using accessory muscles of respiration (intercostal recession or tracheal tug)
  7. Cyanosed
  8. Respiratory arrest
194
Q

What are the first aid measures in the management of an acute airway obstruction?

  1. Respiratory arrest
  2. Cyanosed and still breathing
  3. Both (3)
A

Respiratory arrest
1. Clear mouth and oropharynx of vomit, foreign bodies etc by suction or sweeping the airway with a gloved finger.

Cyanosed and still breathing
1. Give heliox (mixture of helium and oxygen) via the brown iv cannula through the cricothyroid membrane

Both

  1. Use percutaneous cricothyroidotomy kit
  2. Then assess airway with a fibreoptic nasoendoscope if posible
  3. Endotracheal intubation or tracheostomy
195
Q

Why is heliox given (2)?

A
  1. Helium is a light carrier gas with a low viscosity and is easier to breath in than O2 alone
  2. Buys you time before getting expert help
196
Q

What is laryngotracheobronchitis (croup)?

A

Infective conditions affecting larynx in children

197
Q

What is the pathophysiology of airway obstruction associated with croup?

A

Oedema and vascular engorgement of airways, particularly of subglottis

198
Q

What are the clinical features of croup? (3)

A
  1. Begins with a low-grade RTI
  2. Then insipratory stridor with general deterioration and toxicity
  3. Then brassy cough like a bark of a dog
199
Q

When is croup life threatening?

A

Inspiratory stridor with recession - signals significant subglottic oedema

200
Q

What is the life threatening aspect of acute epiglottitis?

A

From airway obstruction and respiratory arrest

201
Q

What is the most common causative agent of acute epiglottitis?

A

Haemophilis influenzae type b (Hib)

202
Q

What age groups does acute epiglottitis affect?

A

Children and adults

203
Q

What is the pathophysiology of the airway obstruction in acute epiglottitis?

A

Hib causes marked erythema and oedema of the epiglottis and often extends onto the larynx

204
Q

What are the cardinal features of acute epiglottitis in children? (4)

A
  1. May start as an URTI
  2. Child is unwell, toxic, lethargic and febrile
  3. Young children DROOL as it is too painful to swallow
  4. Stridor can develop rapidly and can be rapidly followed by respiratory arrest
205
Q

What are the clinical features of acute epiglottitis in adults? (3)

A
  1. Complain of a severe sore throat
  2. Pain on swallowing
  3. Voice may be altered and muffled
206
Q

What must be considered in the immediate management of acute epiglottitis? What must you NOT do? (5)

A
  1. Do not make child cry
  2. Do not examine throat
  3. Do not send xrays
  4. Do not insert cannulas
  5. Take them to theatre where there is an experienced anesthetist and ENT surgeon to secure the airway
207
Q

What investigations/management would be done for acute epiglottitis after the airway has been secured? (5)

A
  1. Fibreoptic or direct laryngoscopy
  2. Endotracheal intubation for 3-4 days
  3. Blood cultures
  4. Heliox
  5. IV abx
208
Q

Is Hib a notifiable disease?

A

Yes

209
Q

What is a tracheostomy?

A

A operation whereby a small hole is made through the skin over the cricothyroid membrane into the trachea and a tracheostomy tube is inserted into the hole to keep it open

210
Q

What are the indications for a tracheostomy? (5)

A
  1. To bypass an obstruction in the throat or larynx which may be due to:
    - infections
    - growths
    - inhaled objects
  2. To prevent breathing problems due to swelling of tissues after major tongue/throat/jaw/facial skeleton operations
  3. To allow easier removal of secretions from air passages and prevent scarring of the larynx from long-term artificial ventilation
  4. To prevent overspill of secretions into lungs e.g. in certain neurological diseases that affect the ability to swallow and cough
  5. To provide an alternative means of air entry into the lungs after a laryngectomy
211
Q

What are the complications of a tracheostomy?

  1. Early (4)
  2. Late (rare) (3)
A

Early

  1. Tube displacement
  2. Blocked tube from dried secretions
  3. Pneumothorax (especially in babies)
  4. Surgical emphysema

Late (rare)

  1. Tracheocutaneous fistula on removing tube
  2. Tracheo-oesophageal fistula
  3. Tracheal stenosis
212
Q

What is a con of a tracheostomy when compared to normal breathing?

A

Normal air flow though the nasal passages on inspiration warms, moistens and removes dust particles from the air before it passes through the open vocal cords into the lungs. In the tracheostomy, the air passes in and out through the neck so these functions are lost. Can be replaced artificially by means of special filters or a damp bib over the hole.

213
Q

What are the 2 types of tracheostomy?

A
  1. End tracheostomy
    - Performed as part of a laryngectomy
    - The larynx is removed and the open lower end of the trachea is sutured to the edges of the skin in the lower neck, effectively separating the lower airways from the upper airways and the pharynx
  2. Side tracheostomy
    - Larynx is still in place and a small hole is created between the skin over the lower neck and the trachea
    - Two methods:
    a. Traditional open procedure
    b. Percutaneous procedure
214
Q

What are the downsides of the end tracheostomy?

How can this be addressed?

A

Inspired air can’t be warmed and humidified by the nose so mucus dries in the trachea and can form crusts

Artificial means of humidiication such as filters attached over the stoma, a moistened bib or a room humidification

215
Q

How is the traditional open side tracheostomy procedure performed? (3)

A
  1. A 3-5cm incision is made in the lower neck and hole made in trachea
  2. Fat, musckes thyroid gland etc are separated in the middle
  3. A 12mm vertical slit is made in the anterior wall of the trachea
216
Q

How is the percutaneous side tracheostomy procedure performed? (4)

A
  1. Needle inserted through skin into airway and confirmed by aspiration of air
  2. Guide wire inserted into airway though needle lumen
  3. Serial dilators threated over guide wire to dilate soft tissues
  4. Tracheostomy tube threaded over guide wire and introducer
217
Q

How long does the patient stay in hospital after a tracheostomy?

A

5-10 days depending on why tracheostomy was performed in the first place

218
Q

What is the management of the patient after a tracheostomy? (2)

A
  1. If the patient needs to go home with the tracheostomy tube, the tube is usually changed at 5 days
  2. Patient needs to be confident in looking after the tube at home or appropriate equipment and nursing care need to be arranged.
219
Q

What is the outcome of the tracheostomy?

A

The aim is to remove it as soon as possible - important to ensure that the patient can breathe normally again before taking the tube out. Done by examining the larynx with a mirror or fibreoptic telecope and by blocking off the tube and ensuring the breathing feels comfortable.

220
Q

What is pharyingitis?

A

Inflammation of the pharynx i.e. sore throat

221
Q

What are the clinical features of pharyngitis? (3)

A
  1. Dry sore throat in the mornings
  2. Nocturnal nasal obstruction
  3. Coryza common
222
Q

What 3 groups of organisms can cause pharyngitis?

A
  1. Virus
  2. Bacterial
  3. Fungi
223
Q

What are the 5 main viruses that cause pharyngitis?

A
  1. Adenovirus
  2. EBV (glandular fever)
  3. Enterviruses
  4. Cytomegalovirus
  5. Occasionally herpes simplex
224
Q

What are the 2 main bacteria that cause pharyngitis?

A
  1. B-haemolytic strep

2. Pneumococcus

225
Q

What are the main fungi that cause pharyngitis?

A

Candida

226
Q

What are 4 examples of pharyngitis?

A
  1. Tonsillitis
  2. Nasal pharyngitis (common cold)
  3. Glandular fever
  4. Strep throat
227
Q

What are the clinical features of follicular tonsillitis? (4)

A
  1. Sore throat
  2. Pain on swallowing
  3. Enlarged erythematous tonsils with ‘white spots’
  4. Systemic illness:
    - Fever
    - Malaise
    - Cervical lymphadenopathy
    - Halitosis
228
Q

What are the main bacterial causes of tonsillitis? (2)

A
  1. B-haemolytic strep Group A

2. Corynebacterium diptheriae (if travelled)

229
Q

What is the usual course of tonsillitis?

A

Usually self-limiting with resolution within 5 days

230
Q

What are the clinical features of glandular fever? (6)

A
  1. Sore throat and pain on swallowing
  2. Enlarged erythematous tonsils covered with white/grey exudates
  3. Systemic illness with:
    - Fever
    - Malaise
    - Marked cervical and generalised lymphadenopathy
    - Abdominal pain
  4. Patient looks unwell with nasal congestion and sterterous breathing
  5. Hepatosplenomegaly can occur
  6. Long incubation and prodromal illness
231
Q

What is the criteria for tonsillectomy?

A

If >7 episodes per year in 1 year
If >5 episodes per year in 2 years
If>3 episodes per year in 3 years or more

232
Q

What should you advise a patient when undergoing a tonsillectomy? (3)

A
  1. Painful for 1-2 weeks
  2. Need regular analgesia and normal diet
  3. Post-tonsillectomy bleed common
233
Q

What are the 2 types of post-tonsillectomy bleeds? Where do they need to be treated?

A

Primary bleed - to do with the op so may need theatre

Secondary bleed - to do with infection, usually settle conservatively on admission

234
Q

What would you advise a patient with glandular fever? (5)

A
  1. Symptoms usually last 2–3 weeks and fatigue is common.
  2. Exclusion from work or school is not necessary.
  3. Encourage return to normal activities but avoid contact sports/alcohol for 1 month as risk of splenic rupture
  4. Limit spread of disease by avoiding kissing and sharing utensils etc
  5. Give advice to seek urgent medical review if they develop symptoms such as stridor or respiratory difficulty
235
Q

What 2 investigations would you do for glandular fever?

How do you confirm diagnosis of glandular fever?

A
  1. FBC
  2. LFTs

Positive Monospot or Paul Bunnell test

236
Q

What are the clinical features of quinsy (9)?

A
  1. Severe unilateral tonsillar pain
  2. Unilateral swelling - pus made develop in soft tissues superolateral to the tonsil, displacing the tonsil and uvual inferomedially
  3. Odynophagia
  4. Dysphagia
  5. Trismus, drooling may occur
  6. Hot potato voice
  7. Referred otalgia
  8. Generally malaise and fever
  9. Cervical lymphadenopathy
237
Q

What usually precedes quinsy? (2)

A
  1. A past hx of tonsillitis may or may not be present

2. Can develop from acute tonsillitis

238
Q

What abx must you NOT give to someone with glandular fever? Why?

A

Ampicillin/amoxicillin

Rash

239
Q

What is quinsy?

A

Peritonsillar abscess

240
Q

What are the symptoms of a deep neck space infection (7)?

A
  1. Sore throat
  2. Odynophagia
  3. Dysphagia
  4. Trismus
  5. Drooling
  6. Fever
  7. Muffled voice
241
Q

What is the treatment of quinsy (5)?

A
  1. Drainage of abscess by lancing or aspiration
  2. IV fluids
  3. IV abx
  4. Analgesia
  5. Antipyretics
242
Q

What treatment can be considered if quinsy recurs?

A

Tonsillectomy

243
Q

In someone with quinsy, what must you consider if they are an older smoker?

A

Neoplasm

244
Q

What are the chain of serious complications that can occur with a throat infection?

A

Throat infection -> Lymphadenopathy -> Suppuration -> Neck abscess -> Deep Neck Space Infection (DNSI)

245
Q

What are the 3 main causes of a retropharyngeal infection?

A
  1. Adenitis (Rouviere’s node)
  2. Suppuration
  3. (trauma, foreign body, direct extension)
246
Q

What are the 7 signs of a DNSI?

A
  1. Septic
  2. Poor head movement
  3. Neck mass
  4. Airway compromise
  5. Displaced pharynx
  6. Tongue swelling
  7. Brawny induration - hardening of skin
247
Q

Where is the retropharyngeal space? Where does it extend? (3)

A
  1. Extending from the skull base to the mediastinum at the tracheal bifurcation
  2. The space lies anterior to the alar fascia of the deep layer and posterior to the buccopharyngeal fascia of the middle layer that lines the posterior pharynx and esophagus
  3. Behind the pharynx
248
Q

In what space does a retropharyngeal infection occur in?

A

Retropharyngeal or retrovisceral space

249
Q

What do DNSI usually arise from? (6)

A

Often from infections of the upper aerodigestive tract

  1. Pharyngitis
    - including tonsillitis
  2. Oral/dental infections
  3. Rhinosinusitis in children
  4. Oropharyngeal infections
  5. Foreign bodies
  6. Lymphadenitis/Suppuration of lymph nodes
250
Q

What are 2 complications of a retropharyngeal infection?

A
  1. Mediastinitis - 50% mortality

2. Spread to other deep neck spaces

251
Q

Where do parapharyngeal space (PPS) infections arise from? (5)

A

From areas of the mandible

  1. Odontogentic
  2. Tonsils
  3. Pharynx
  4. Nasopharynx
  5. Parotid gland
252
Q

What are the clinical features of Ludwig’s angina? (6)

A
  1. Bilateral (starts unilaterally)
  2. Cellulitis, not abscess
  3. Woody induration
  4. Swollen floor of moth
  5. Hot potato voice
  6. Airway compromise
253
Q

What are the different spaces in which deep neck space infections can occur? (11)

A
  1. Retropharyngeal
  2. Parapharyngeal
  3. Subandibular
  4. Sublingual
  5. Danger space
  6. Prevertebral space
  7. Parotid space
  8. Peritonsillar
  9. Masticator space
  10. Carotid
  11. Anterior visceral
254
Q

How do submandibular space infections present?

A

Anterior neck swelling with floor of the mouth oedema

255
Q

What is the aetiology of submandibular infections? (3)

A
  1. Odontogenic (70%)
  2. Sialadenitis: submandibular salivary gland infection +/- pus at duct opening (side of lingual frenulum)
  3. Lymphadenitis
256
Q

What is Ludwig’s angina?

A

A submandibular/sublingual space infection

257
Q

What is the most common cause of Ludwig’s angina?

A

Dental cause

258
Q

What are the principles of treating a DNSI (3)?

A
  1. Airway protection!!!
    - observation/intubation/trachy
  2. Iv abx
    - polymicrobial cover: guided by micro
  3. Surgical drainage/aspiration
    - trans-oral/external/radiological
259
Q

What are complications of DNSI? (5)

A
  1. Airway compromise
  2. Rupture: pneumonia, empyema, lung abscess
  3. Mediastinitis
  4. Lemierre’s syndrome
  5. Carotid artery erosion (ICA>ECA>CCA)
260
Q

What are the clinical features of mediastinitis? What is its mortality rate? (3)

A
  1. SOB
  2. Chest pain
  3. Wide mediastinum

50% mortality

261
Q

What is Lemierre’s syndrome?

A

IJV thrombosis and oropharynx infection

262
Q

How does carotid artery erosion present?

A

as “sentinel” bleeds: mouth, nose, ear

i.e. early warning bleed

263
Q

What is supraglottitis?

A

Infection of the supraglottis (the part of larynx above the true cords)

264
Q

What are the clinical features of supraglottitis? (2)

A
  1. Sore throat symptoms

2. Pharynx normal

265
Q

When someone has a sore throat with a normal pharynx, what must you consider?

A

Supraglottitis

266
Q

What is the management of supraglottitis? (3)

A
  1. Airway protection
    - may need intubation or trachy
  2. IV dexamethasone
  3. IV Abx
267
Q

In an emergency presentation of supraglottis, what would you give to the patient to buy time?

A

Nebulised adrenaline

Consider securing airway

268
Q

What can be given on the way to theatre for a trachy to buy time when a tumour is obstructing airway?

A

Nebulised adrenaline

269
Q

What are the 3 stages of swallowing? Are the voluntary or involuntary?

A
  1. Buccal - voluntary
  2. Pharyngeal - involuntary
  3. Oesophageal - involuntary
270
Q

What occurs to food in the mouth before swallowing ?

A
  1. Mastication - Food is broken down by chewing
  2. Salivary glands secrete lingual lipase and salivary amylase.
  3. Amylase begins the breakdown of starch
  4. Food forms a bolus that is swallowed
271
Q

What occurs in the buccal phase of swallowing (2)?

A
  1. Tongue moves up and back against the hard and soft palate

2. It pushes the bolus to the oropharynx

272
Q

What occurs in the pharyngeal phase of swallowing? (5)

A
  1. Involuntary movements push the bolus through pharynx into oesophagus
  2. Movement of bolus stimulates the receptors in oropharynx which signals to the degluttition centre in medullar oblungata and lower pons of brain stem
  3. Brain signals to the soft palate and uvula to close off the nasophaynx
  4. Brain also signals to the epiglottis to seal off the larynx to stop food going to the trachea
  5. The upper oesophageal sphincter relaxes so bolus moves into oesophagus and contracts to prevent backflow into pharynx
273
Q

What occurs in the oesophageal phase of swallowing? (2)

A
  1. Bolus pushed down oesophagus by peristalsis

2. As the bolus reaches the end, the lower oesophageal sphincter relaxes and food enters the stomach

274
Q

What are the 4 different causes/mechanisms of dysphagia?

A
  1. Oropharyngeal dysphagia e.g. tonsillitis
  2. Esophageal and obstructive dysphagia
  3. Neuromuscular symptom complexes
  4. Functional dysphagia

ENT (4 decks)

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