Head and Neck/ ENT

Question 1

Risk factors for head and neck cancer

Answer 1

• >90%= SCC upper aeodigestive tract eg mouth, larynx, pharynx
• Heavy smoking
• Alcohol
• Poor dentition
• HPV-16
• EBV
• Asian (nasopharyngeal)

Question 2

Key features of laryngeal cancer

Answer 2

• 2ww: >45y with peristent unexplained hoarseness or unexplained neck lump
• Presentation: ENT and LN examination!
  
  • Hoarse voice >3w
  • Cough
  • Dysphagia, ‘lump in throat’
  • Earache
  • Halitosis
  • Pain
  • Weight loss
  • SOB
• Ix- nasendoscopy/ endoscopy, CXR, PET/CT, biopsy
• Tx- chemo/radio/surgery.

Question 3

Key features of mouth and oropharyngeal cancer

Answer 3

• 2ww for: ulcer >3w, persistent neck lump. R/v dentist for lump on lip/oral cavity, erythroleukoplakia
• Presentation:
  
  • Dysphagia
  • Speech change
  • Neck lump
  • Nasal obstruction
  • Weight loss
  • Halitosis
  • Reduced jaw movement
  • Leukoplaki/ erythroplaki- pre-cancer
  • Pain
  • Tooth loss
  • Persistent ulcer
• Ix;
  
  • Bedside- pic
  • Bloods- LFTs, U+Es, FBC, CRP
  • Imaging- x-ray, CT, MRI, PET, barium swallow
  • Special- LN biopsy
• Tx- chemo, radio, surgery

Question 4

Definition, diagnosis of sinusitis and common organismes

Answer 4

• = Rhinosinusitis +/- inflammation of nasal mucosa
• Commonly maxillary sinus
• Organisms- S. pneumoniae, H. Influenza, moraxella catarrhalis. Usually viral.
• Dx:
  
  • Facial pain/ congestion
  • Nasal obstruction
  • Loss of smell
  • +/- headache, fatigue, dental pain, cough, pressure/ fullness in ears, poor response to nasal decongestants

Question 5

Ix and Tx of sinusitis

Answer 5

• Ix- usally clinical.
  
  • Bloods- CRP/ESR
  • Imaging- X-ray, nasendoscopy, CT, MRI
• Tx:
  
  • Supportive- paracetamol, NSAIDs, nasal decongestants, nasal irrigation, warm pack, fluids, rest
  • ABx >5d (amox)
  • Surg

Question 6

Presentation, Dx and Tx of tonsillitis

Answer 6

• Presentation:
  
  • Voice change
  • Sore throat
  • Large/red tonsils with exudate
  • Headache
  • Lymphadenopathy
  • Vomiting
  • Fever
• Ix- throat swab, monospot
• Centor criteria- Abx if 3/4 of:
  
  • Fever
  • Tonsillar exudate
  • No cough
  • Tender ant. cervical lymphadenopathy
• Tx:
  
  • Cons- analgesia, fluids
  • Med- 10d phenoxymethylpenicillin
  • Surg- tonsillectomy (>6 this year, >4 prev year)

Question 7

RF and presentation of otitis media

Answer 7

• RF: 6-12m (short eustachian tube), male, smoker/ smoker in house, cranio-facial abnormality, cleft lip
• Presentation:
  
  • ++ Fever
  • Pain / pulling at ears/ irritable. Pain relieved with perf –> discharge
  • Prev. URTI
  • Lethargy, malaise
  • Rduced balance
  • Otoscopy- red/cloudy TM
  • Poor feeding

Question 8

Ix, Tx and complications of otitis media

Answer 8

• Ix- usually none. ?Swabs, audiometry
• Tx:
  
  • Cons- watchful waiting. Analgesia, fluids
  • Med- ABx (amox/clarith) if >3 days, systemically unwell, bilateral
• Complication= mastoidistis- Erythema, swelling, tenderness behind ear –> pushes ear forward. Tx= ENT, IV ABx

Question 9

Key features of otitis media

Answer 9

• Inflammation of middle ear with accumulation of fluid. No acute inflamm
• Presentation: Esp 2-7y
  
  • Earache
  • Conductive hearing loss –> poor performance at school
  • Poor balance
  • Recurrent URTIs
  • Dull retracted TM with fluid level
• Ix- tympanometry, audiometry
• Tx:
  
  • Cons- self resolving. >3m= val salva
  • Surg- Grommets

Question 10

RF and presentation of otitis externa

Answer 10

• = Inflammation of external canal
• Types- localised, diffuse, malignant
• RF: immunocompromise, DM, head and neck radio, swimming, elderly
• Precipitating factors- Ear trauma, moisture, chemicals
• Presentation:
  
  • Otalgia
  • Discharge
  • Conductive hearing loss
  • Lyphadenopathy
  • Inflammation of canal/ ear drug
  • ?? spreding cellulitis, mastoiditis

Question 11

Ix and Tx of otitis externa

Answer 11

• Ix- usually none. ?Swab if recurrent/ chronic
• Tx:
  
  • Cons- stop aggravating factor, analgesia, clean ear if affect penetration of topical treatment?
  • Med- Topical acetic acid 2% spray –> topical ABx +/- steroids 7-14d

Question 12

Sensorineural hearing loss- causes, Tx

Answer 12

• Sensorineural= usually from birth/ infancy. Profound (>95dB). Cochlear/ auditory nerve.
• Genetic
• Antenatal/perinatal- congenital infection, prem, HIE, hyperbilirubinaemia
• Post-natal- meningitis, head injury, drugs (furosemide, aminoglycosides), neurodegeneration, loud noise, vasculitis, stroke, menieres
• More in adults: Ototoxic drugs (vanc, gent, hydroxychloraquin), post- infective (meningitis, measles, mumps, flu, herpes, syphilis), menieres, trauma, acoustic neuroma, B12 def, MS, brain mets, prebycusis
• Tx- teaching support. Early amplification/ cochlear implant

Question 13

Conductive hearing loss- causes, Tx

Answer 13

• Abnormalities of ear canal. Max 60dB. Intermittent/ resolves
• Otitis media +/- effusion
• Eustachian tube dyfunction- Down’s, cleft palate, facial hypoplasia
• Wax, foreign body
• Drum perforation
• Neoplasia
• Tx- conservative –> grommets

Question 14

Interpretation of Rinnie’s and Weber’s

Answer 14

• Conductive hearing loss:
  
  • Rinnie’s: Bone > Air. Rinnie’s -ve
  • Weber’s: Heard in bad ear
• Sensorineural hearing loss:
  
  • Rinnie’s: Air > Bone. Rinnie’s false +ve.
  • Weber’s: Heard in good ear

Question 15

Key features of presbycusis

Answer 15

• = Most common sensorineural hearing loss in adults
• Age, related, bilar, high frequency SNHL
• Loss of high pitched sounds in 30s –> degeneration
• Hearing loss worse with background noise- can’t hear voices
• Tx- hearing aid

Question 16

Borders of the neck triangles

Answer 16

Question 17

Ix of neck lumps

Answer 17

• Bedside- NEWS, ask to swallow/ stick tongue out. ?Swabs
• Bloods- virology, mantoux, CRP, ESR, TFTs etc
• Imaging - USS, CT
• Special- biopsy/ FNA

Question 18

Midline Neck lumps

Answer 18

• Thryoid - goitre (>20y)
• Thyroglossal cyst - raises when stick tongue out
• Dermoid cyst (<20y)
• Chrondroma- hard

Question 19

Submandibular/ Anterior triangle neck lumps

Answer 19

• Submandibular- salivery stone/ tumour
• Lymphadenopathy
• Infected cyst
• Branchial cyst- contain cholesterol. Remove
• Parotid tumour
• Layrngocoele
• Carotid artery aneurysms/ carotid body tumour. Pulsatile

Question 20

Posterior triangle neck lumps

Answer 20

• Protrusion of cervical ribs
• Pharyngeal pouch
• Lymphadenopathy

Question 21

DDx and Ix of cervical/ supraclavicular lymphadenopathy

Answer 21

• Infection- URTI, dental abscess, GF, TB
• Malignancy- Head and neck cancer, thyroid, gastric (Virchow’s), lymphoma, ALL, AML, CML
• Unexplained lymphadenopthy (not infection):
  
  • Urgent FBC
  • >25y - ?2ww lymphoma
  • >40y - CXR ?lung Ca

Question 22

Key features of salivary gland stones

Answer 22

• = Sialithiasis
• Cellular debris + calcium –> stuck in duct (esp submandibular)
• Presentation:
  
  • Colicky pain before/during/after meal
  • Post-prandial lump swelling
  • Stone palpable?
• Ix- USS< x-ray, sialogram

Question 23

Key features of salivary gland infection

Answer 23

• = Sialoadenitis. More submandibular/ parotid
• RF: Elderly, poor hydration, poor oral hygiene
• S. Aureus
• Presentation:
  
  • Pain
  • Foul smelling/ tasting
  • Swelling
  • Pressure –> pus
• Tx: ABx, god oral hygiene, sialogues eg lemon, –> surgical drainage

Question 24

Inflammatory causes of salivary gland swelling

Answer 24

• Sialithiasis (stones)
• Sialoadenitis (infection)
• Sjogren’s
• Viral- Mumps, HIV
• Granulomatous disease - TB, sarcoidosis

Question 25

Key features of salivary gland cancer

Answer 25

• Most= parotid
• RF: Radiation, smoking
• Presentation:
  
  • Painless, progressively enlarging lump, skin changes
  • Local invasion –> CN7 palsy
  • O/E - hard, fixed, tender mass +/- overlying skin ulceration
• Ix: USS, MRI, biopsy/ FNA
• Tx: Radiotheraphy, surgery

Question 26

Classification of Epistaxis and causes

Answer 26

• Anterior- Usually septal. 90% Little’s Area/ Kiesselbach’s plexus. Causes: facial trauma, picking nose, dry weather, allergiic rhinitis
• Posterior- Further back. More likely in older people with HTN or coagulopathy. More complicated.

Question 27

Acute management of epistaxis

Answer 27

• ABCDE + resus. Sit forward and spit into bowl. Pinch nose for 20 mins.
• Ice pack
• Cotton bal soaked in 1:200,000 adrenaline for 2 mins
• Silver nitrate cautery (never both sides of septum)
• Can’t see bleeding point ?posterior –> admit + ENT
• Continued bleeding –> Nasal pack (horizontally), remove after 24h. Prophylactic ABx
• –> Postnasal pack
• –> ENT surg if posterior: diathermy under anaesthesia, arterial ligation, embolization
• After nosebleed - no blowing/ picking, stop smoking, avoid bending/ straining, no hot food/ drinks

Question 28

Treatment of recurrent epistaxis

Answer 28

Naseptin - Chlorhexadine + ABx. QDS for 10 days (not if peanut allergy)