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ENT > Head and Neck > Flashcards

Head and Neck Flashcards

1
Q

What are the 6 triangles of the neck

A 
Submandibular 
Submental
Muscular
Carotid
Supraclavicular 
Occipital
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2
Q

Whats in the submandibular triangle

A

Submandibular gland

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3
Q

Whats in the submental triangle

A

Submental lymph

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4
Q

Whats in the muscular triangle

A

Thyroid and parathyroid glands

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5
Q

Whats in the carotid triangle

A

3 C’s

Carotid sheath
CN12
Ansa Cervicalis

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6
Q

What is in the carotid sheath

A

CNX
Common carotid
IJV

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7
Q

What is the ansa cervicalis

A

Part of the cervical plexus

Innervates most infrahyoids, except thyrohyoid

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8
Q

Whats in the occipital triangle

A

Charlie Sheen = Epic Blow

CN9
SCA
EJV
Brachial plexus trunks

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9
Q

what is the oropharynx

A

base of the tongue, tonsils and the soft palate + pharyngeal walls

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10
Q

whats the hypopharynx

A

bottom of the throat

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11
Q

what structures make up the layrnx

A

supraglottis, glottis, vocal cords and subglottis

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12
Q

what is the most common salivary gland tumour and by how much

A

parotid - 80-90%

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13
Q

What proportion of salivary gland tumours are benign

A

80-90%

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14
Q

How does the type of salivary gland tumour affect it’s severity

A

ones that aren’t parotid ones are more likely to be cancerous

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15
Q

How do you investigate a salivary gland tumour

A

FNAC

CT/MRI

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16
Q

What should you do if an FNAC of a salivary gland tumour is inconclusive

A

excision biopsy

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17
Q

Why should incisional biopsies be avoided for sampling salivary gland tumours

A

may lead to tumour seeding

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18
Q

what are features of benign salivary gland tumours

A

Slow growing
painless
decreased chance of CN7 palsy

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19
Q

what is the most common type of benign salivary gland tumour

A

pleomorphic adenoma

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20
Q

whats the epidemiology of salivary gland tumours

A

F>M, incidence 1:100,000 - mostly adults `

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21
Q

what cell is affected with pleomorphic adenomas

A

intercalated duct cell

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22
Q

what is the treatment for pleomorphic adenomas

A

surgical excision

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23
Q

apart from pleomorphic adenomas - what is the other type of benign salivary gland tumours seen

A

warthins’s tumour/adenolymphoma

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24
Q

what are examples of mixed type salivary gland tumours

A

mucoepidermoid carcinoma

acinic cell carcinoma

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25
Q

what is the epidemiology for mucoepidermoid carcinoma

A

peaks in 40s, F>M, 2-4:1

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26
Q

what is the most common salivary gland carcinoma in children

A

mucoepidermoid carcinoma

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27
Q

whats the treatment for low and high grade mucoepidermoid carcinomas

A

low grade = local excision and follow up

high grade = radical resection and adjuvant radiotherapy

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28
Q

whats the recurrence rate for mucoepidermoid carcinomas

A

30%

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29
Q

whats the 15 year survival for low and high grade mucoepidermoid carcinoma

A

50% low grade

25% mid-high

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30
Q

what proportion of parotid tumours are acinic cell carcinoma

A

2-4%

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31
Q

whats the epidemiology of acinic cell carcinoma

A

middle age- elderly

F>M

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32
Q

whats the treatment for acinic cell carcinoma

A

local resection with cranial nerve7 preservation + prolonged follow up

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33
Q

What are features of malignant salivary gland tumours

A

rapidly growing swelling with pain +/- facial nerve palsy

although facial nerve palsy with a parotid tumour is almost diagnostic

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34
Q

What are the types of malignant salivary gland tumour

A

Adenoid cystic carcinoma
carcinoma ex pleomorphic adenoma
adenocarcinoma
lymphoma

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35
Q

what is the most common malignant salivary gland tumour

A

adenoid cystic carcinoma

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36
Q

what proportion of parotid tumours are adenoid cystic carcinoma

A

14%

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37
Q

where is adenoid cystic carcinoma found most commonly

A

sublingual 28%
then submandibular/minor (12%)
parotid (2%)

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38
Q

whats the epidemiology of adenoid cystic carcinoma

A

40-60 peak incidence F>M

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39
Q

what is the most common presentation of adenoid cystic carcinoma

A

slow growing invasive lump with palsy and pain

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40
Q

whats the treatment for adenoid cystic carcinoma

A

wide local resection - NON CN7 SPARING

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41
Q

whats the 15 year survival of adenoid cystic carcinoma

A

10-26%

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42
Q

whats the local recurrence rate for adenoid cystic carcinoma

A

50%

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43
Q

whats the 5 year survival of adenocarcinoma

A

10%

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44
Q

whats the most common salivary gland lymphoma

A

non hogkins

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45
Q

what is a feature of a lymphoma

A

firm rapidly enlarging mass

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46
Q

What are some common causes of salivary gland inflammatory disease

A 
Viral Disease 
sialadenitis 
sialolithiasis 
granulomatous disease
sjorens
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47
Q

what are the main 2 symptoms of salivary gland pathology

A

pain + swelling

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48
Q

what virus causes mumps

A

paramyxovirus

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49
Q

what are some viral causes of parotitis

A

mumps virus (paramyxovirus), echo (type of enterovirus) or coxsackie virus

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50
Q

whats the treatment for viral parotitis

A

analgesia + hydration

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51
Q

how do you diagnose a viral parotitis

A

do a mumps titre and see results

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52
Q

what causes bacterial parotitis

A

Staphylococcal

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53
Q

how does bacterial parotitis present

A

unilateral pain/swelling with dehydration

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54
Q

whats the treatment for bacterial parotitis

A

sialogogues, drain pus

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55
Q

what causes fungal parotitis and when would you suspect it

A

candiasis

immunosuppression

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56
Q

What is sialadenitis

A

inflammation/infection of parotid and submandibular gland

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57
Q

what are symptoms of sialadenitis

A

pyrexia, systemic upset and visible pus (parotid)

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58
Q

what is a submandibular presentation of sialadenitis

A

odematous/swollen floor of mouth

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59
Q

whats the treatment for sialadenitis

A

high dose antibiotics, rehydration and oral hydgeine

sialogogues if required

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60
Q

what is an example of a sialogogue

A

citric acid/citrus mouthwash

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61
Q

what happens if you dont treat sialadenitis

A

abscess forms and sugery is required

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62
Q

what are features of and how do you treat chronic sialadenitis

A

pain/swelling after meals

excision of the gland

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63
Q

what is sialolithiasis

A

calculi forming in salivary gland

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64
Q

what is sialolithiasis commonly associated with

A

chronic sialadenitis

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65
Q

where does sialolithiasis mostly occur and why

A

submandibular gland due to its thicker secretions

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66
Q

whats the presentation of sialolithiasis

A

post-prandial swelling after eating + pain _/- recurrent infections

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67
Q

what imaging is used to find a sialolithiasis

A

X-ray

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68
Q

whats the treatment of sialolithiasis

A

oral fluids and sialogogues

stones usually pass themselves

surgery can be done if it needs removing

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69
Q

what is sialectasis

A

dilation, stenosis and necrosis of acini forming cysts

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70
Q

what is sialectasis a complication of

A

sialolithiasis

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71
Q

whats the treatment of sialectasis

A

removal of calculus or gand

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72
Q

What is Sjorens Syndrome

A

autoimmune disorder with multiple autoantibodies, including anti-ro, anti-la, rheumatoid factor, anti-nuclear and anti-cyclic citrullinated peptides

73
Q

what are some symptoms of sjorens syndrome

A

primary - xerostoma + xeropthalmia (dry mouth and eyes), glossitis, stomatitis, dental cavities, dry vagina

secondary - primary + connective tissue disease (mostly RA)

74
Q

what proportion of sjorens patients have parotid enlargement

A

40%

75
Q

what does parotid enlargement in sjorens indiciate

A

increased chance of lymphoma

76
Q

what are some associated conditions for sjorens

A 
primary biliary cirrhosis 
chronic hepatitis
vasculitis
cryoglobinaemia 
hypergammaglobinaemia purpura
polyarteritis 
pancreatitis 
waldenstroms macroglobinaemia
77
Q

how many people with sjorens have thyroiditis

A

15%

78
Q

how do you investigate a suspected sjorens case

A

HLA-A1, B8, DR3
Anti-Ro/Anti-la antigens
Schirmers test for lacrimation (-ve = normal)
carlsson-crittendon test for salivary flow
labial biopsy - DIAGNOSTIC

79
Q

what proportion of sjorens sufferers develop Non-hogkins lymphoma

A

1 in 6

80
Q

what is the treatment for sjorens

A

steroids for any parotid swelling

artificial tears/saliva

81
Q

what divides the parotid gland into its constituent lobes, and what are the lobes

A

CN7

superficial (80%) + deep (20%)

82
Q

what is the largest salivary gland

A

parotid

83
Q

what kind of secretion does the parotid gland produce

A

watery/serous saliva

84
Q

where is the parotid gland situated

A

between the mastoid process and the mandible , antero-superiorly to the tyloid process and carotd sheath

85
Q

what is another name for the parotid duct

A

stensons duct

86
Q

where does the parotid duct drain

A

2nd upper molar teeth

87
Q

what anterior, posterior and superior relatioships does the parotid gland have

A

post: tympanic bone, external ear canal, stylomastoid fssa, mastoid process, upper 1/4 of SCM
ant: posterior 1/2 of masseter
sup: zygomatic arch

88
Q

what structures are within the parotid gland

A

CN7 and its 5 branches (temporal, zygomatic, buccal, cervical and mandibular)

retromandibular vein, ECA and its division into superficial temporal and maxillary aa

parotid/stensons duct

secretomotor and sympathetic nerve fibres

89
Q

what type of secretion is the submandibular gland responsible for

A

mixed serous and mucus secretions

90
Q

where is the submandibular gland

A

in triangular space behind the mylohyoid muscle

91
Q

what lobes does the submandibular gland have and where do they articulate

A

superfcial lobe that lies on mylohyoid and a deep lobe that articulates with the floor of the mouth

92
Q

what are 3 important nerve interactions the submandibular gland has

A

hypoglossal and lingual nerves are associated with the deep portion

Marginal mandibular branch of the CN7 runs in skin overlying the gand

93
Q

what structures are in the submandibular gland

A 
submandibular duct 
secretomotor fibres (salivary nucleus, corda tympani, nervus intermedius, lingual nerve) 
sympathetic fibres (superior cervical gangion)
94
Q

what is the smallest salivary gland

A

sublingual gland

95
Q

what secretion is the sublingual gland responsible for

A

mucus

96
Q

how do salivary glands work

A

acini produce fluid, then striated portion actively secretes/exchanges nutrients and proteins

97
Q

how much saliva is produced in 24 hours

A

1-1.5 litres

98
Q

what stimulates saliva production

A 
smell
taste
psychic stimuli (thinking about food) 
mastication 
parasympathomimetic drugs
99
Q

what spinal level is the trachea on

A

C6 to T4/5

100
Q

what are the surface anatomy demarcations of the trachea

A

adams apple to the manubrostenial angle

101
Q

how do you palpate the thyroid

A

palpate thyroid prominence/cricoid cartilage and feel posterolateral

102
Q

what spinal level is the thyroid cartilage at

A

C3/4

103
Q

what spinal level is the hyoid bone on

A

C3

104
Q

where does the common carotid bifurcate

A

at superior edge of thyroid cartilage (C3)

105
Q

where is the carotid sinus found

A

at the point of bifurcatio

106
Q

what nerves are close to the carotid sinus

A

CN9, 10, 12

107
Q

what are the branches of the External carotid artery

A
  1. superior thyroid
  2. ascending pharyngeal
  3. lingual
  4. facial
  5. posterior auricular
  6. superior temporal
  7. maxillary
  8. occipital
108
Q

what spinal level is the cricoid bone

A

C6

109
Q

what does the cricoid bone indicate

A

superior end of oesophagus

110
Q

why is the cricoid bone important surgically

A

allows identification of cricothyroid ligament, through which the surgical airway is created

111
Q

what are the articulations of the SCM

A

mastoid process sternal head and clavicular head

112
Q

What is a branchial cyst

A

congenital epithelial cyst of the neck, characteristically in the anterior triangle just in front of the SCM

113
Q

what age are branchial cysts found at

A

<30

114
Q

what would an FNAC of a branchial cyst show

A

pus-like aspirate, rich in cholesterol

115
Q

whats the treatment of a branchial cyst

A

excision

116
Q

what is a thyroglossal duct cyst

A

congenital cyst present in childhood/adulthood rather than birth

found in the midline

117
Q

what is a characteristic feature of thyroglossal duct cysts

A

move up when the tongue is stuck out

118
Q

what is the treatment of thyroglossal duct cysts

A

excision of thyroglossal tract and hyoid bone

119
Q

what are causes for goitres

A

graves
iodine deficiency
pregnancy

120
Q

what kind of goitre is more likely to be malignant

A

nodular

121
Q

what are the types of thyroid cancer + the proportions

A

Papillary (50%)
Follicular (25%)
Anpastic (20%)
Medullary (5%)

122
Q

what age does papillary carcinoma present at usually

A

40-50

123
Q

what is the prognosis of papillary carcinoma

A

90% if confined to a gland

60% if not

124
Q

Treatment of papillary carcinoma

A

tota thyroidectomy + radioactive iodine

125
Q

what ages does follicular thyroid carcinoma usually present at

A

50-60

126
Q

how do you treat follicular carcinoma

A

total thyroidectomy + radioactive iodine

127
Q

what is the prognosis of anplastic thyroid carcinoma

A

1 year survival = 8%

128
Q

what are cardinal features of anplastic thyroid carcinoma

A

rapidly enlarging mass, ear pain, laryngea/oesophageal/tracheal invasion

129
Q

what is the only cure for anplastic thyroid carcinoma

A

radical radiotherapy - but recurrence is common

130
Q

who is anplastic carcinoma usually seen in

A

elderly women with long term thyroid enlargement

131
Q

what kind of cell is affected in medullary carcinoma

A

parafollicular cells

132
Q

what do parafollicular cells do

A

secrete calcitonin

133
Q

what is a haemotological feature of medullary carcinoma

A

increased calcitonin levels

134
Q

how do you treat medullary carcinoma

A

total thyroidectomy + radiotherapy

135
Q

what is a feature of an actively secreting benign adenoma

A

takes up radioiodine/technetium

136
Q

what does an actively secreting benign adenoma result in

A

thyrotoxicosis

137
Q

what percentage of non functioning benign adenomas become malignant

A

10-20%

138
Q

What is the definition of head and neck cancer

A 
tumour coming from: 
oral cavity
pharynx
paranasal sinus
nasal cait
larynx
salivary glands
139
Q

what type of head and neck cancer (histologically) is more common in smokers and alcoholics

A

SCC

140
Q

what are risk factors for developing head and neck cancer

A 
smoking - anything
alcohol intake
chewing tobacco 
increased sun exposure
certain chemical/wood inhalation 
leukoplakia (cancerous in 1/3)
141
Q

what are some common symptoms of head and neck cancer

A 
pain in the throat
odynophagia
dysphagia
persistent hoarseness
referred ear pain 
mouth/throat bleeding
increased node size
leukoplakia, erythroplakia, ulceration 
thickening of oral tissues
difficulty moving tongue 
numbness of tongue/mouth
142
Q

where do 50% of head and neck cancers originate

A

oral cavity

143
Q

what should cause suspicion of oral cavity cancer

A

oral lesions lasting for >2 weeks

144
Q

what is a common symptom of cancer that is unusual in H+N cancer

A

weight loss

145
Q

what is the most common type of head and neck cancer

A

mouth cancer

146
Q

what is the most common subtype of mouth cancer

A

SCC

147
Q

what type of person most commonly has mouth cancer

A

smokers/alcoholics

148
Q

what is the treatment for mouth cancer

A

surgery with skin grafts

149
Q

what types of cancer is commonly seen with nasopharyngeal cancer

A

SCC

lymphoepithelioma

150
Q

what is a risk factor for nasopharyngeal cancer

A

Nickel/hard wood dust inhalation

151
Q

what is oropharynx

A

soft palate, base of tongue and tonsils

152
Q

what is SCC of the tonsils strongly associated with

A

HPV

153
Q

what is the difference in prognosis between HPV + ve and HPV -ve oropharyngeal cancers

A

HPV positive cancers have a better outcome

154
Q

what are common signs of oropharyngeal cancer

A

lump in throat
sore throat
difficulty swallowing
trismus (lockjaw)

155
Q

what are some causes for oropharyngeal cancer

A 
betel nut chewing 
radiation 
IDA
HPV
smoking/alcohol abuse
156
Q

what is the histological breakdown of oropharyngeal cancers

A

SCC 90%
8% NHL
2% minor salivary gland tumours

157
Q

what is the hypopharynx

A

between the oropharynx and oesophagus/trachea

158
Q

what is the prognosis of hypopharyneal cancers and why

A

they tend to be the most advanced at the point of diagnosis and threfore have the worst prognosis of all the pahryngeal cancers - they also metastasise early due to extensive lymph networks around the larynx

159
Q

what type of cancers are hypopharyngeal cancers

A

SCC almost exclusively

160
Q

what are risk factors for hypopharyngeal cancers

A 
Betel-nut chewing 
IDA
Radiation 
HPV
Smoking + acohol abuse
161
Q

whats the presenting complaint of hypopharyngeal cancers

A 
sore throat
odynophagia
dysphagia
otalgia
haemoptysis
hoarsensess
stridor
neck mass
W/L if advanced
162
Q

what is the anatomical distribution of laryngeal cancers

A

supragottic 40%
glottic 50%
infraglottic 5%

163
Q

whats the presenting complaint for laryngeal cancer

A 
voice change
difficulty/pain when swallowing 
noise breathlessness
SOB
persistent cough
lump/swelling of neck
164
Q

what is laryngeal cancer strongly associated with

A

smoking

165
Q

what surgery is done for laryneal cancer

A

laser excision of small vocal cord lesion
partial laryngectomy
total laryngectomy

166
Q

what kind of cancer are laryngeal cancers

A

95% SCC
Sarcoma
minor salivary gland
neuroendocrine tumours

167
Q

what are the signs of nose/sinus cancer

A

unilateral persistent blocked nose
epistaxis
decreased smell
mucus running down nose/throat

168
Q

How is nodal status assessed for the TMN staging criteria for head and neck cancer

A

Nx - nodal status not assessed
N0 no nodal mets
N1 - mets in singe ipsilateral lymph node <3cm
N2a - mets in single ipsilateral lymph node 3cm-6cm
N2b - mets in multiple ipsilateral lymphs all <6cm
N2c - mets in ipsilateral or contralateral lymph <6cm
N3 - any mets >6cm

169
Q

How is metastases status assessed for the TMN staging criteria for head and neck cancer

A

Mx - presence of mets cannot be assessed
M0 - no evidence of distant mets
M1 - distant mets present

170
Q

How does the staging differ based on T+N status

A 
T4 = instant stage 4a, if T4N3 its 4b
T3N2a and above = stage 4b
N3 = instant stage 4b 
if N0staging follows the T number
if N1 stage is automatically 3 minimum
171
Q

what does the presence of M1 indicate for staging

A

immediate 4c staging

172
Q

what is the T staging criteria for supraglottic tumours

A

T1 - confined to site/origin, normal vocal cord mobility
T2 - supra/subglottic extension
T3 - larynx confinement with VC fixation
T4 - Massive tumour with extra-larygeal extensioin + thyroid cartilage

173
Q

what is the T staging criteria for subglottic tumours

A

T1 - confined to subglottic area
T2 - V/c extension
T3 - confined to arynx with cord fixation
T4 - similar to previous

174
Q

what is leukoplakia

A

unmovable white patches of hyperkeratosis adhering to submucosa of mouth

175
Q

what proportion of leukoplakias become malignant

A

3%

176
Q

how do you manage leukoplakias

A

retinoids help reduce irritation

surgery if that bad

177
Q

what is erythroplakia

A

red patches in mouth without obvious cause

almost always dysplasia and represents a precancerous lesion

178
Q

how do you manage erythroplakia

A

biopsy and surgical excision

179
Q

what is globus

A

feeling of something in throat causing dysphagia

diagnosis of exclusion - no throat pathology present (linked to anxiety)

ENT (8 decks)

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