JC99 (ENT) - Infections and Tumors in Pharynx and Oral cavity Flashcards
Divide upper aerodigestive tract into anterior and posterior portions
List salivary glands
o Parotid
o Submandibular
o Sublingual
o Minor salivary gland
Outline history taking questions for pharyngeal or oral infections
HPI:
- Duration: acute (infection) vs. chronic (neoplastic)
- Symptoms:
Ear: Hearing loss, pain
Nose: Nasal obstruction, blood-stained discharge, epistaxis
Mouth: Loose denture, non-healing ulcers, mass, bloody saliva
Throat: Hoarseness, SoB, bloody sputum
Pharynx: Globus sensation, dysphagia, bloody saliva
Neck: Salivary glands, lymph node enlargement
- Constitutionals symptoms
Risk factors for cancer: e.g. smoking, alcohol, family history …etc
Comorbidities: fitness for surgery
Risk factors for oral cavity cancers
- Smoking, alcohol
- Family history
- Betel nut (oral carcinoma)
- HPV (STD)
- Poor oral hygiene
- Previous radiation, malignancy
- Immunosuppression
Outline P/E for oral and pharyngeal lesions
Oral:
Systematic to all sub-sites
Inspection and palpation (underlying mass/ induration (hardening))
Neck: mass and LN Location (region/ level) Shape + size (measure) Consistency Mobility Inflammation (skin surface)
Scalp/ skin
- Melanoma, Skin SCC
Patient presents with Colicky postprandial glandular swelling and pain in mouth
Most likely dx?
Salivary duct stones
2 benign mass in oral cavity
Benign mass:
- Salivary ductal stone (usually submandibular)
- Ranula (Sublingual gland)
Salivary ductal stone
- Which gland most commonly affected
- Presentation
- Tx
- Complication
Glands: Submandibular (most common) > parotid > sublingual
Submandibular ducts tract against gravity + secretions more viscous = prone to precipitation and blockage
Presentation: Colicky postprandial glandular swelling and pain
Tx:
- marsupialization, calculus removal, submandibular gland excision
- Sialendoscopy
Complication: Sialadenitis (pus from ductal orifice, infection)
5 major etiologies of oral ulcers and example of causes
Ulcers:
- Apthous
- Traumatic: Dental-related (e.g. sharp teeth, ill-fitting denture)
- Infective:
Bacterial
Viral: Herpes virus, EBV - Systemic diseases
Behcet’s disease
Autoimmune (RA, SLE)
Blood disease - Malignant: irregular, rolled/everted edge, indurated, painless
Benign tongue cancer ddx
Haemangioma: Bluish, compressible
Lipoma: Like fatty origin: soft, smooth
Papilloma: Small, around teeth
Giant cell tumor: Smooth, firm
Ddx pre-malignant oral cavity lesions
Torus palatinus - bony outgrowth on hard palate
Torus mandibularis - bony outgrowth on lingual aspect of mandible
Leukoplakia - white patch on oral cavity mucosal membrane
Erythroplakia - erythematous patch with granular or nodular lesion, dysplasia without keratosis
Torus palatinus
- Anatomical location
- Presentation
- Tx options
Anatomy:
Bony outgrowth on hard palate
Usually in midline, smooth mucosa even though irregular
Presentation:
Pain
foreign body sensation
swallowing problem
Tx:
Surgical removal if symptomatic: Ulcer, affect denture, associated periodontal disorder
Differentiating features of Torus palatinus vs cancer
Torus
- Normal overlying mucosa
- Does not extend or invade
Cancer
- Ulceration
- Extends inferiorly from nose, maxillary sinus (nasal symptoms)
Torus mandibularis
- Morphology and anatomical position
Bony protuberance on the lingual aspect of the mandible (commonly between the canine and premolar areas)
Ddx white patches in the mouth
Leukoplakis
Lichen planus
Oral Candidiasis
Linea alba (white mark from pressure, friction, trauma in mouth)
Erythroplakia
Morphological features
Erythematous patch
+/- granular or nodular lesion
Dysplasia without keratosis (red without surrounding epithelium)
First-line investigations for pre-malignant lesions in oral cavity
Biopsy** to confirm malignancy
Wide base excision if malignant
Parapharyngeal space tumor
- Clinical presentation
- Differentiating factor with parapharyngeal infection
- Benign or malignant
Clinical presentation:
- Asymptomatic due to space for expansion
- Incidental finding during URTI: swelling at tonsil/ peritonsil region
No trismus unlike quinsy
80% benign
Presentation:
- Painless mass in mouth
- Persistent bleeding and ulcer that fails to heal
- Dysphagia
- Some dysarthria
Most likely dx
Ulcerative oral cavity cancer
- SCC
- Adenocarcinoma
Presentation:
Sore throat, odynophagia, dysphagia
Muffled speech
otalgia (referred pain)
Known HPV infection
Most likely Ddx
Oropharyngeal malignancy** HPV-related
Epithelium: SCC
Lymphoma tonsil and tongue base/ minor salivary gland
Acute tonsilitis
Acute epiglottitis
Ludwig angina
Presentation
Sore throat Globus sensation and dysphagia Hoarseness Otalgia Known alcoholic
Most likely Dx
Hypopharyngeal carcinoma (at level of hyoid to lower border of cricoid; between oral cavity and esophagus)
Oral cavity cancers
- Subsites
- S/S, features of mass
- Histological types
Subsites: Oral tongue (commonest) Buccal mucosa Floor of mouth Upper/ lower alveolus Hard palate Lip
S/S:
- Painless at first, painful when infiltrating nerve
- Bleeding
- Dysphagia
- Dysarthria (ankyloglossia due to size/ infiltration of hypoglossal nerve)
Mass features:
- Exophytic mass/ nonhealing ulcer
- Surrounding leukoplakia/ erythroplakia
- Loosen tooth +/- nonhealing tooth socket
Histological types ulcerative: SCC Adenocarcinoma smooth : Lymphoma Minor salivary gland
Oropharyngeal cancer
- Subsites
- S/S, features of mass
- Risk factors
- Histological types
Subsites: Tonsil (commonest) Tongue base (need endoscope) Soft palate Posterior wall
S/S:
- Sore throat, odynophagia, dysphagia
- Muffled speech
- Referred otalgia
- Mass with ulceration, asymmetrical tonsils
- Trismus
- Cervical LN
RF:
- Smoking, Alcohol
- HPV (Oral sex)**
Histology:
- SCC or Lymphoma of tonsils/ minor salivary gland
Hypopharyngeal carcinoma
- Subsites
- S/S
- RF
- Associated syndrome
Subsites:
- Piriform fossa (60%)
- Postcricoid (30%)
- Posterior pharyngeal wall (10%)
S/S: Sore throat Globus, dysphagia Hoarseness -infiltrate recurrent laryngeal nerve) Otalgia Loss of laryngeal crepitus 30% LN metastases
RF:(like CA esophagus):
Alcohol
Smoking
Associated syndrome: Paterson- Brown-Kelly syndrome
Paterson Brown Kelly syndrome
Define clinical features
triad of dysphagia, iron deficiency anemia, esophageal webs
Examine koilonychias in nails
Asso. high risk of CA hypopharynx
First-line investigation for pharyngeal and oral cavity cancers
Investigation (10% risk of synchronous/ metachronous tumour esp smoking):
Panendoscopy (nasal cavity, nasopharynx, esophagus, trachea, bronchus etc.) + biopsy
Tonsillectomy or EUA (examination under anaesthesia) to look for malignancy + Bx
Ultrasound neck +/- FNAC (cell type)
CXR
CT/ MRI (tumor extent)
PET scan
Typical histological types of Head and Neck Cancers
90% squamous cell carcinoma (SCC)
nasopharynx: mostly undifferentiated nonkeratinizing NPC
thyroid: mostly papillary thyroid cancer
General treatment options for pharyngeal and oral cavity cancers
Early stage:
Single modality:
Minimally invasive surgery (laser/robotic)
Elective neck dissection for nodal metastasis
Radiotherapy alone
Late stage:
Combined modality of treatment:
Surgery with adjuvant radiotherapy +/- chemotherapy
Concurrent chemo-irradiation
3Rs principles for surgical treatment of pharyngeal and oral cancers
3Rs
Resect with adequate margins (frozen section to confirm clear resection)
Reconstruct to restore form and function (e.g. flap reconstruction)
Rehabilitation always – recover swallowing, voice and hearing with therapy
Types of oral and pharyngeal reconstruction
Minimal invasion surgery: laser/ endoscopic/ robotic partial pharyngectomy +/- reconstruction
Open major surgery with reconstruction:
o Circumferential pharyngectomy + reconstruction
o Total pharyngolaryngoesophagectomy (PLO)
Flap reconstruction with microvascular anastomosis
Ddx oral and pharyngeal infections
Acute tonsillitis Infectious mononucleosis Peritonsillar abscess (quinsy) Acute epiglottitis Ludwig angina Deep neck abscesses: Retropharyngeal, parapharyngeal abscesses
Acute tonsillitis
Causative pathogens
URTI Virus (esp children):
- influenza, parainfluenza,
- adenovirus, enterovirus, rhinovirus
Bacteria:
- ß-haemolytic strep (Streptococcus pyogenes)
- Streptococcus pneumoniae,
- Haemophilus influenzae
Aerobic GPR:
- Corynebacterium diphtheriae (vaccine)
- Mycobacterium tuberculosis (chronic))
- Treponemia pallidum (syphilis)
Candida (immunocompromised)
Acute tonsillitis
Clinical presentation
Symptoms Sore throat, odynophagia Muffled voice, hot- potato voice Otalgia (glossopharyngeal nerve referred pain) Systemic: abdominal pain, vomiting
Signs Fever Hyperaemic tonsils with exudates/ pus (bilateral) No/ minimal trismus **** Tender cervical lymphadenopathy
Acute tonsillitis
First-line investigations and treatment options
Investigations:
- CBC with diff: neutrophilia or lymphopenia patterns
- Throat swab for C/ST
Treatment:
- Viral = rest, analgesics, fluid replacement, supportive
- Bacterial = analgesics, penicillin, erythromycin
Infectious mononucleosis
- Demographic
- Causative pathogen
- Incubation period and prodromal period
Demographic
Acute infection
Young adult
Causative:
Epstein barr virus (EBV): Transmitted through saliva
Incubation period: 5-7 weeks
Prodromal period: 4-5 days
Infectious mononucleosis
Clinical presentation
Symptoms Systemic: chills, aches Respiratory: cough Stomach: nausea, vomiting Spleen: abdominal pain*** Central: fatigue, loss of appetite, malaise, headache Visual: photophobia Throat: soreness
Signs: Systemic: high fever Spleen: enlargement Throat: reddening Tonsils: reddening, swelling, white patches Lymph nodes: swelling
Infectious mononucleosis
First-line investigations and treatment options
Investigation:
- CBC with diff - High WBC with mononuclear cell predominant
- Blood smear - atypical lymphocytosis
- Low plt
- Deranged LFT and clotting
- Positive MONOSPOT TEST
Treatment:
- Bed rest, analgesic, fluid replacement, supportive
- AVOID AMPICILLIN, gives rubelliform rash over trunk
Peritonsillar abscess/ quinsy
- Anatomical nidus of infection
- Causative pathogens
Anatomy:
Collection of pus between tonsillar capsule & superior constrictor
Mixed aerobic & anaerobic organisms:
Bacteroides
Peptostreptococcus
Peritonsillar abscess
Clinical presentation
Symptoms: Similar as tonsillitis Sore throat, odynophagia Muffled voice Otalgia Dysphagia, airway obstruction (dyspnea)
Signs: Fever Unilateral peritonsillar swelling Deviation of uvula Trismus (spasm in muscles of mastication)
Peritonsillar abscess/ quinsy
- Treatment options
Analgesics Fluid replacement* Chart I/O Transoral incision & drainage antibiotics
Consider elective tonsillectomy (20% recurrence in smokers)
Acute epiglottitis
- Demographic
- Causative organisms
ENT emergency (pediatric predominant)
Pathogens: Haemophilus influenzae type b β-haemolytic streptococci Pneumococcus Staphylococcus
Acute epiglottitis
Clinical presentation
First-line investigation and treatment
Symptoms: Sore throat, odynophagia Hot potato voice, muffled Signs: High fever Tripod sign Airway obstruction (inspiratory stridor) Drooling
Secure airway immediately
IV 3rd gen cephalosporins
Ludwig angina
- Anatomical location of infection
- Origin of infection
- Presentation
Severe inflammation/ abscess of floor of mouth, submental & submandibular space
Dental origin bacteria
S/S
Airway obstruction (stridor, dysphagia)
Trismus
Septic
Tender swelling at submental region
Superior, posterior displacement of tongue
Ludwig angina
First-line investigations and Tx
Secure airway
Urgent head CT
Surgical drainage + IV antibiotics
Dental consultation for tooth abscess/ infection
Deep neck abscess
- Subsites
- Causative organisms
Retropharyngeal abscess (paedi), Parapharyngeal abscess (masticator space, parotid space)
Causative organism:
- Tonsillitis organisms: URTI viruses, B-hemolytic bacteria, Candida
- Dental flora
Deep neck abscess
- Clinical presentation
Symptoms:
Sore throat
Neck swelling
Airway obstruction(dysphagia, dribbling)
Signs:
Fever
Toxic
Head hyperextended, stiff
Airway obstruction (inspiratory stridor)
Neck swelling, infected retropharyngeal LN
Deep neck abscess
First-line investigations and treatment
Secure airway
Urgent head CT
Urgent ENT surgery: transcervical drainage, IV antibiotics
Dental consultation for oral infections
Complications of acute tonsillitis
Local (spread of infection):
Abscess formation: peritonsillar/ parapharyngeal/ retropharyngeal
AOM (acute otitis media)
Systemic:
Immune-related hypersensitivity due to cross-reaction of Ab:
Acute rheumatic fever, rheumatic heart disease;
Acute glomerulonephritis (deposition of Ab- Ag in nephrons)
Septicaemia
meningitis, pneumonia
Complications of infectious mononucleosis
Sepsis (secondary bacterial infection)
Splenomegaly 50%
Hepatomegaly
