Head and Neck/ENT Flashcards
What is a goitre and what are the different types?
A swelling of the neck resulting from enlargement of the thyroid gland. This can be:
- Diffuse
- Nodular
What causes a diffuse goitre?
- Iodine deficiency
- Congenital
- Acute thyroiditis (de Quervains)
- Pregnancy
- Puberty
- Autoimmune (Graves, Hashimotos)
What is a multinodular goitre?
Most common thyroid gland disorder involving multiple neck lumps. May be retrosternal or substernal
Patients usually euthyroid but may become hyperthyroid (toxic) - rare to have malignancy or hypothyroidism
What is Plummer’s disease?
Hyperthyroidism with a single toxic nodule
What is a fibrotic goitre?
aka. Riedel´s thyroiditis (RT)
A rare inflammatory disease of the thyroid gland, causing compression and fibrosis of adjacent tissues
What are the causes of a single thyroid nodule?
- Cyst
- Adenoma (hyperthyroid/toxic won’t go away after a course of antithyroid drugs)
- Malignancy (10%)
- Discrete nodule as part of MNG
What investigations should be done for a neck lump?
BLOODS: T3/T4/TSH, thyroid autoantibodies if suspecting Graves/Hashimotos, virology, mantoux test
IMAGING: USS (looks at consistency), CXR with thoracic inlet (may show malignancy), radionuclide scan (hot/cold), CT (defines mass in relation to anatomical neighbours)
OTHER: FNA biopsy and cytology
What is the significance of hot/warm/cold nodules on radionuclide scan?
Refers to the uptake of the dye on scan
HOT - produce excess thyroid hormone, rarely malignant, likely adenoma
WARM - normal thyroid function
COLD - nonfunctional tissue, more likely to be malignant
How should impalpable nodules that show up on US be managed?
<1cm, no past history of thyroid cancer/radiation or family history of medullary cancer - OBSERVATION
Otherwise do USS guided FNA for biopsy and cytology
How should non-malignant thyroid enlargement with normal thyroid function be managed (incl symptoms of compression)?
No treatment needed unless breathing difficult or clinical concern.
Repeat US and TSH if malignant/compression suspected
If compressive symptoms - surgery, radioactive iodine ablation or percutaneous thermal ablation
What are the main types of thyroid cancer?
- Papillary (60%)
- Follicular(25%)
- Medullary (5%)
- Lymphoma (5%)
- Anaplastic
What are the features of papillary cancer?
- Younger patients
- Spreads to lungs via jugulo-digastric nodes
- Differentiated (cancer cells function like thyroid cells)
What are the features of follicular cancer?
- Middle aged patients
- Spreads early via blood to bone and lungs
- Differentiated (cancer cells function like thyroid cells)
What are the features of medullary cancer?
- May be sporadic or part of MEN syndrome
- May produce calcitonin which can be used as a tumour marker
- No response to iodine
- Should perform phaeochromocytoma screen pre-op
What are the features of lymphoma thyroid cancer?
- May present with stridor/dysphagia
- Assess tissue for MALT origin (better prognosis)
How is thyroid cancer managed initially?
Total thyroidectomy
Node excision
Radioactive iodine to ablate residual cells
MUST BE RENDERED EUTHYROID PRE-OP BUT STOP 10 DAYS BEFORE SURGERY
What can be given for differentiated cancer after radioactive iodine?
Lenvatinib and sorafenib (as long as they haven’t had a tyrosine kinase inhibitor before)
What are the complications of thyroid surgery?
- Recurrent laryngeal nerve palsy
- Haemorrhage
- Hypoparathyoidism (check calcium)
- Thyroid dysfunction incl storm
What are the most common neck lumps?
<3 weeks - self-limiting infection
Intradermal - sebaceous cyst or lipoma
What lumps are common in the midline?
<20yo patient - dermoid cyst or thyroglossal cyst
> 20yo - thyroid isthmus mass, chondroma (if bony hard)
What is a thyroglossal cyst, and what symptoms does it produce?
A fluid-filled space resulting from incomplete closure of the thyroids migration path.
Lump will move up on tongue protrusion, situated below the hyoid.
What lumps are common in the submandibular triangle?
<20yo - self limiting lymphadenopathy
> 20yo - exclude malignant lymphadenopathy (firm, non tender). May be TB, salivary stone, sialadenitis (infection of salivary glands), tumour
What defines the submandibular triangle?
The mental process, mandible and the line between the two angles of the mandible
What defines the anterior triangle?
Midline, anterior border of sternocleidomastoid muscle and line between the two angles of the mandible
What defines the posterior triangle?
Behind sternocleidomastoid, in front of trapezius, above clavicle
What lumps may be found in the anterior triangle?
- Lymphadenopathy (benign/malignant)
- Branchial cysts
- Parotid tumour
- Laryngoceles
- Carotid artery aneurysm
- Tortuous carotid artery
- Carotid body tumours
What is a branchial cyst? How are they managed?
Oval, mobile, flucutant cystic mass found in under 20yos, emerges under the anterior border of sternocleidomastoid. Formed from non-disappearance of cervical sinus at birth
EXCISE
What is a laryngocele?
Congenital dilated of laryngeal saccule, filled with air and made worse by blowing. May give hoarseness. May be associated with laryngeal carcinoma.
Where is a parotid tumour most likely to be found?
Supero-posterior area of the anterior triangle
What are carotid body tumours? How are they managed?
Rare, move from side to side but not up and down. Firm but may be soft and pulsatile.
Diagnosis is by duplex USS or digital computer angiography.
Management is extirpation (complete excision) by a vascular surgeon
What lumps may be found in the posterior triangle?
- Cervical ribs
- Pharyngeal pouch
- Cystic hygromas (transilluminating lumps)
- Pancoasts tumour
- Subclavian artery aneurysm
What are the complications of cervical ribs?
Raynauds syndrome - the ribs compress the subclavian artery
Neurological symptoms - due to pressure on lower trunk of brachial plexus
What is a pharyngeal pouch?
aka Zenkers diverticulum
A diverticulum of the mucosa of the pharynx. More common if >70yo and in its with cervical webs. May protrude into posterior triangle on swallowing
What are the symptoms of a pharyngeal pouch?
- Asymptomatic
- Dysphagia
- Globus
- Regurgitation, cough and halitosis due to regurgitation of food
How is pharyngeal pouch diagnosed and managed?
Diagnosis - barium swallow and endoscopy
Management - can leave if small otherwise neck surgery, endoscopic stapling, laser
What are the 3 main salivary glands?
- Parotid (serous) most tumours
- Submandibular (mixed) most stones
- Sublingual (mucous)
What causes acute swelling of the salivary glands?
HIV, mumps
have to be cautious of acute airway compromise!
What causes recurrent unilateral pain and swelling? How is it managed?
Salivary stone (sialolith) - 80% submandibular
Causes colicky pain/swelling during eating.
Conservative - hydration, pain relief, sialogogues (pilocarpine)
Medical - antibiotics
Surgical - distal stones can be removed from the mouth but deeper ones may need surgical excision
What causes chronic bilateral salivary gland symptoms?
Autoimmune disease (hypothyroidism, sjorgens)
Bulimia
What causes a fixed salivary gland swelling?
Tumour
ALL
Sarcoid/amyloid
Wegeners
What is the typical salivary gland tumour?
80% parotid
80% of these are pleiomorphic adenomas
80% of these are in superficial lobe
Classically the ear is deflected outward or 7th nerve palsy
How are salivary gland tumours managed?
Pleimorphic adenoma - superficial parotidectomy
Adenolymphoma - enucleation
Carcinomas - surgery and radiotherapy
What investigations should be ordered in salivary gland pathology?
BEDSIDE: exudate C&S
BLOODS: FBC ?autoantibodies
IMAGING: facial xray, US
What causes lymphadenopathy?
COMMON
- EBV
- Infection
- HIV
- Adenovirus
- CMV
UNCOMMON
- Malignancy (hodgkins/nonhodgkins lymphoma, CLL, mets)
What are the three ossicles of the ear?
Three bones (malleus, incus and stapes) that lie within the middle ear and transmit sound from the tympanic membrane to the inner ear
What is the eustachian tube?
Tube connecting the middle ear to the nasopharynx - ventilates the middle ear and maintains equal air pressure across the tympanic membrane
What is the cochlea?
A spiralled hollow bone involved in hearing. Waves propagate from the base to the apex (centre of spiral)
What are the vestibule and semicircular canals?
Organs found in the inner ear that are responsible for balance
Describe the physiology of hearing
- Ossicles in middle ear transmit sound waves from tympanic membrane to cochlea
- Hair cells in basilar membrane of cochlea detect the vibrations
- Vibrations transducer to nerve impulses
- Impulses pass to cochlear nucleus and to superior olivary nuclei
What are the symptoms of otitis externa?
Severe ear pain, itch, hearing loss inflammation and debris. Lymphadenopathy
What bacteria most commonly causes otitis externa?
Psuedomonas aeruginosa, staphylococcus
How is otitis externa managed?
Acetic acid if uncomplicated
Topical antibiotic or combined with steroid
Refractory - Can use oral fluclox if spreading and refer to ENT
antifungals if fungal
What are the symptoms of otitis media?
Severe pain, hearing loss, systemic symptoms.
Otoscopy shows bulging red tympanic membrane
How is otitis media managed?
Do not give antibiotics as often viral cause - treatment is conservative and infection should settle within 72 hours.
If no improvement in 4 days or systemically unwell, <2yo or immunocompromised, give PO amoxicillin 5-7d
Complications include:
- Perforation of TM
- Chronic suppurative OM >6w
- Hearing loss
- Labarynthiti`s
- Mastoiditis; give IV abx
- Meningitis
- Brain abscess
- Facial nerve paralysis
What is otitis media with effusion (glue ear) and how is it managed?
Infection of the middle ear with discharge (will have fluid level on examination)
More common in children due to eustachian tube dysfunction
May present as poor hearing, delayed speech and behavioural problems
Usually managed conservatively
If persistent can insert a grommet
If unilateral in adults - urgent ENT referral ?nasopharyngeal tumour
What is chronic suppurative otitis media?
- Chronic cheesy otorrhoea (>6-12wks) through a perforated TM
- Usually due to pseudomonas aeruginosa
- May be accompanied by cholesteatoma
- Treat with quinolone or aminoglycoside eardrops
What is a cholesteatoma?
Keratinizing squamous epithelium within the middle ear - due to a retraction pocket and recurrent infections.
Presents with foul-smelling pyorrhoea +/- vertigo/facial nerve palsy/cerebellopontine angle syndrome if local invasion
How is cholesteatoma managed?
Diagnose with audiogram or CT.
Mastoid surgery. Give topical antibiotics to help reduce acute symptoms preop.
What are the complications of a cholesteatoma?
Cerebral abscess - if it erodes upwards
Infection in venous system, thrombophlebitis - if it erodes downwards
Brainstem, cerebellar signs - if it erodes medially
What is Rinnes test?
- Hold vibrating tuning fork in front of ear then on mastoid
- Ask which is louder
Rinne negative - bone conduction better than air conduction - CONDUCTIVE HEARING LOSS
RINNE UNDER THE PINNE
What is Webers test?
- Place vibrating tuning fork on centre of forehead and ask the patient which ear the sound is better heard it
Sound localizes to affected ear with conductive hearing loss , contralateral ear in sensorineural and to midline if normal.
What is otosclerosis?
The replacement of normal bone by vascular spongy bone, causing progressive conductive deafness due to the fixation of the stapes at the oval window.
Features:
- Autosomal dominant
- Onset 20-40y
- Deafness, tinnitus ‘flamingo tinge’ TM
Management:
- Hearing aid
- Stapedectomy
What causes chronic sensorineural hearing loss?
- Accumulated enivornmental toxicity
- Inherited disorders
- Presbyacusis
What is presbyacusis and how is it managed?
Loss of acuity for high frequency sounds - audiometry shows bilateral high-frequency hearing loss
Manage with hearing aids
What causes sudden sensorineural hearing loss?
- Noise exposure (typically worse at frequencies of 3000-6000Hz)
- Gentamicin/other toxin
- Mumps
- Acoustic neuroma (vestibular schwannoma)
- MS/stroke
- Vasculitis
- TB
Requires urgent referral to ENT - usually idiopathic, will be managed with high-dose oral corticosteroids
What investigations should be done for sudden sensorineural deafness?
BEDSIDE: obs, otoscopy
BLOODS: FBC, ESR, LFT, pANCA, viral titres, TB test
IMAGING: CXR, MRI
SPECIAL: evoked response audiometry, nasopharyngeal biopsy, tympanometry
What is an acoustic neuroma?
aka vestibular schwannoma
A benign tumour that develops in the vestibular or cochlear nerves, causing hearing loss and imblanace
This will keep growing therefore should be surgically removed. Associated with neurofibromatosis type 2
Features can be predicted by the affected cranial nerves:
- V: absent corneal reflex
- VII: facial palsy
- VIII: hearing loss, vertigo, tinnitus
When should sudden hearing loss be referred to emergency ENT within 24h?
- Hearing loss developed suddenly within past 30 days over 3 days or less (24h)
- Associated with facial droop
- Immunocompromised with otalgia/otarrhoea
When should sudden hearing loss be refered to ENT within 2 weeks?
- Hearing loss developed suddenly over 30 days ago
- Hearing loss worsened rapidly over last 4-90 days
- Hearing loss and asian origin with middle ear effusion (cancer)
When should patients with hearing loss get an MRI?
- Localising symptoms/signs that may indicate an acoustic neuroma or cerebellar lesion
- Asymmetry on pure tone audiometry of 15dB or more
How do you treat idiopathic sensorineural hearing loss?
Steroids
How is sensorineural hearing loss managed?
- Discuss communication strategies
- Hearing aids (acoustic or bone conduction)
- Cochlear implants
What is tinnitus? What causes it?
Ringing in the ears, may be unilateral or bilateral.
Caused by:
- Focal hyper-excitability in the auditory cortex
- hearing loss
- Wax
- Viral
- Presbyacusis
- Menieres
- Head injry
- Otitis media
- Anaemia
- Drugs
- Psychiatric
Which drugs can cause tinnitus?
Aspirin/NSAIDS
Loop diuretics
Aminoglycosides
Quinine
What causes pulsatile tinnitus?
Carotid artery stenosis
AV fistulae
Glomus jugulare tumours (in temporal bone)
How is tinnitus managed?
CONSERVATIVE: CBT, masking with white noise and hearing aids
MEDICAL: hypnotics
SURGICAL: cochlear nerve section (but causes dearfness!), nerve stimulation
What causes vertigo associated with hearing loss or tinnitus?
Disorders of the labyrinth or vestibulocochlear 8th cranial nerve:
- Menieres
- BPPV
- Motion sickness
- Viral labyrnithitis
- Trauma
- Ototoxic drugs eg. gentamicin
- Zoster, Ramsay Hunt
- Tullio phenomenon
NOT VESTIBULAR NEURITIS
What are some cerebral causes of vertigo?
- MS
- Acoustic neuroma
- Stroke/TIA
- Migraine
- Epilepsy
- (Alcohol)
What is BPPV? How is it diagnosed?
Brief periods (10-20 seconds) of vertigo after head movement, due to canalolithiasis - debris in the semicircular canal.
Nystagmus whilst doing Hallpike manoeuvre is diagnostic - rapidly lower patient to supine position with an extended neck - a positive test recreates the symptoms and rotatory nystagmus
What is nystagmus?
Involuntary eye movements usually triggered by inner ear stimulation when the head is stationary. It usually begins as a slow pursuit movement followed by a fast, rapid resetting phase
How is BPPV managed?
CONSERVATIVE: advise not to drive if dizzy, discuss falls risk, epley/semont manoeuvre, brandt-daroff exercises
No medical or surgical management advised.
Follow up in 1 month - refractory BPPV may require surgical intervention
What is acute labyrinthitis?
Abrupt onsent of severe vertigo, nausea, vomiting and prostration.
Features:
- Preceding URTI
- Spontaneous unidirectal horizontal nystagmus towards the unaffected side
- Sensorineural hearing loss
- Gait disturbance
Will cause hearing loss unlike vestibular neuritis (v similar presentation minus hearing loss - due to inflammation of the vestibular nerve)
How is acute labyrinthitis managed? How is it differentiated between a posterior circulation stroke ?
CONSERVATIVE: symptoms will settle after 3-4wks, give safety advice
MEDICAL: consider vestibular suppressant meds eg. anthistamines/antiemetics (prochlorperazine)
Do HiNts (head impulse, nystagmus, test of skew exam) to differentiate - positive in stroke
What is Menieres disease?
Recurrent attacks of vertigo lasting >20mins (but<24h) accompanied by nausea and vomiting, sensorineural hearing loss, a feeling of fullness in the ear, and tinnitus
Usually unilateral primarily but can become bilateral after a number of years
What causes Menieres disease?
Abnormal amount of fluid (endolymph) in the inner ear - unsure why this occurs!
How is Menieres disease diagnosed?
Audiometry - sensorineural hearing loss with above featuers
Positive Romberg test
How is Menieres disease managed?
Requires referral to ENT for diagnosis and should inform DVLA if ongoing uncontrolled attacks.
RAPID RELIEF: buccal/IM prochlorperazine or IM cyclizine
SEVERE: Admit to hospital if severe, give IV labyrinthe sedatives and fluid. Consider surgery/ablation with gentamicin.
PREVENTION: Betahistine and vestibular rehabilitation exercises may be of benefit
If symptoms persist/deteriorate after 5-7 days, consider alternative diagnosis
Which drugs are ototoxic?
Gentamicin, vancomucin, loop duiretics, cisplatin
When should a person with vertigo be admitted to hospital?
- Severe vomiting
- Very sudden onset not provoked by positional change
- Central neurological signs
- Acute deafness
What is the most common area for epistaxis?
Littles area - this is where the following four arteries anastamose to form the Kiesselbachs plexus:
- Anterior ethmoidal artery (from opthalmic artery)
- Sphenopalatine artery (from maxillary artery)
- Greater palatine artery (from maxillary artery)
- Septal branch of the superior labial artery (from facial artery)
How is acute epistaxis managed?
Within first 10-15 min:
- First aid measures (lean forward, pinch nose)
- Apply topical naseptin (chlorhexidine and neomycin) qds for 10 days
If no improvement:
- Topical adrenaline/lidocaine and nasal cautery with silver nitrate
- Nasal packing and hospital admission
- Nasal catheter (foley)
If no improvement:
- IV/oral tranexamic acid
- EUA and surgical intervention
Surgical interventions:
- Diathermy
- Septal surgery
- Arterial ligation/clipping
- Radiological arterial embolization
What is a nasal septal haematoma and how is it managed?
Features:
- often relatively minor trauma
- sensation of nasal obstruction, pain and rhinorrhoea
- bilateral red septal swelling o/e
- BOGGY
Management:
- ENT referral for surgical drainage and IV abx
- If untreated irreversible septal necrosis may develop within 3-4 days and saddle nose deformity
What are the red flags for a sino-nasal malignancy?
- Bloody discharge
- Unilateral nasal blockage
- Pain
- Loose teeth
> refer urgently to ENT
What causes nasal polyps?
Chronic inflammation due to asthma, recurring infection, allergies, drug sensitivity or certain immune disorders
What are the symptoms of sinusitis?
- Dull, constant ache over the sinuses
- Post-nasal drip
- Pain worse on bending over
- Coryzal symptoms
How is acute sinusitis managed?
<10days - conservative, usually viral cause
> 10days - high-dose nasal corticosteroids for 14 days
How is chronic sinusitis managed (>12 weeks)?
CONSERVATIVE: avoid triggers, smoking cessation, dental hygeine, nasal irrigation with saline, allergy testing
MEDICAL: 3 month course of intranasal corticosteroids eg. fluticasone
SURGICAL: adenoidectomy if under 6yo, endoscopic sinus surgery (last resort!)
What is TMJ disorder?
Pain and dysfunction of the muscles of mastication
What causes TMJ disorder?
- Teeth grinding
- Uneven bite
- Stress
- Trauma
How is TMJ disorder managed?
CONSERVATIVE: soft diet, analgesia, ice/warm packs, stress relief, physio
MEDICAL: benzodiazepines (acute), gabapentin (chronic)
When should you refer TMJ disorder?
- Chronic symptoms for over 3 months
- Persistent symptoms despite management
- Uncertain diagnosis/red flags
- Trauma/closed lock
What are the red flags for TMJ disorder?
- Previous hx of malignancy
- Neck lump
- Neurological symptoms
- Facial symmetry
- Recurrent epistaxis/discharge
- Constitutional symptoms
- New onset headache/scalp tenderness
- Occlusal changes (bite - may indicate cancer, RA, trauma, bone growth in acromegaly)
A man has a neck lump which moves with swallowing but not tongue protrusion. What is the diagnosis?
Thyroid enlargement
A man has a neck lump which moves with swallowing and tongue protrusion. What is the diagnosis?
Thyroglossal cyst (linked to the back of the tongue)
A man has a neck lump which does not move with swallowing. What is the diagnosis?
Dermoid cyst
Chondrome
What are the risk factors for head and neck cancer?
HPV, EBV, radiation exposure, smoking, alcohol, GORD, poor dentition, betal nut
What are the symptoms of head and neck cancer?
Mass in the neck
Neck pain
Bleeding from the mouth
Sinus congestion, especially with nasopharyngeal carcinoma
Bad breath
Sore tongue
Painless ulcer or sores in the mouth that do not heal
White, red or dark patches in the mouth that will not go away
Earache
Unusual bleeding or numbness in the mouth
Lump in the lip, mouth or gums
Enlarged lymph glands in the neck
Slurring of speech (if the cancer is affecting the tongue)
Hoarse voice which persists for more than six weeks
Sore throat which persists for more than six weeks
Difficulty swallowing food
Change in diet or weight loss
How can head and neck pathology be investigated?
Bloods: TFTs, thyroglobulin
Imaging: USS, barium swallow, CT neck, MRI, PET-CT (these are mostly for cancer staging)
Special: Flexible nasendoscopy
What are the 2WW criteria for referal for suspected laryngeal cancer?
Persistent hoarseness or unexplained neck lump in over 45yo
What are the 2WW criteria for referral for suspected oral cancer?
Unexplained ulceration for >3weeks or persistent/unexplained neck lump
Refer to dentist within 2W if lump on lip, red/white patch in mouth or erythroleukoplakia
What are the CENTOR criteria for bacterial tonsillitis?
Score of 3+ likely bacterial
- Tonsillar exudate
- Cervical lymphadenopathy
- Fever >38C
- Absence of cough
How is tonsillitis managed?
VIRAL - conservative management
BACTERIAL - phenoxymethylpenicillin (pen V) for 5-10 days (not amoxicillin in case it is EBV)
What are the indications for tonsillectomy?
All of:
- 5 or more episodes of sore throat (secondary to tonsillitis) in 1 year
- symptoms for at least 1 year
- episodes are disabling and prevent normal functioning
OR:
1. recurrent febrile convulsions
2. stridor/OSA/dysphagia secondary to enlarged tonsils
3. Quinsy unresponsive to standard treatment
What are the complications of a tonsillectomy?
- Pain
- Haemorrhage
- Primary occurs within 6-8 h; immediate return to theatre
- Secondary occurs within 5-10d; associated with wound infection, requires ENT admission and abx
What causes gingival hyperplasia?
Drugs:
- Phenytoin
- Ciclosporin
- Calcium channel blockers (nifedipine)
AML
What is Ramsay-Hunt syndrome?
aka herpes zoster oticus
Caused by reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve
Causes auricular pain, facial nerve palsy, vesicular rash, vertigo and tinnitus
How is Ramsay-Hunt managed?
Oral aciclovir + oral corticosteroids
Give eye protection (lubricants + tape shut) in patients with facial nerve palsy who are unable to close their eye
What is the FeverPAIN score?
Score 1 each for:
1. Fever >38C
2. Purulence
3. Attends within 3d or less
4. Severely inflamed tonsils
5. No cough/coryza
Used for tonsillitis. Give abx if 4 or over
What is black hairy tongue?
Defective desquamation of the filiform papillae due to:
- poor hygeine
- antibiotics
- head and neck radiation
- HIV
- IV drug use
Manage with tongue scraping and topical antifungals if candida
What is geographic tongue?
A benign chronic condition, more common in females
Causes erythematous areas with a white grey border and sensation of burning after eating certain foods
