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MBBS IV - Junior Clerkship WCS > JC99 (ENT) - Infections and Tumors in Pharynx and Oral cavity > Flashcards

JC99 (ENT) - Infections and Tumors in Pharynx and Oral cavity Flashcards

1
Q

Divide upper aerodigestive tract into anterior and posterior portions

A
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2
Q

List salivary glands

A

o Parotid
o Submandibular
o Sublingual
o Minor salivary gland

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3
Q

Outline history taking questions for pharyngeal or oral infections

A

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

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4
Q

Risk factors for oral cavity cancers

A
  • Smoking, alcohol
  • Family history
  • Betel nut (oral carcinoma)
  • HPV (STD)
  • Poor oral hygiene
  • Previous radiation, malignancy
  • Immunosuppression
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5
Q

Outline P/E for oral and pharyngeal lesions

A

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

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6
Q

Patient presents with Colicky postprandial glandular swelling and pain in mouth

Most likely dx?

A

Salivary duct stones

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7
Q

2 benign mass in oral cavity

A

Benign mass:

  • Salivary ductal stone (usually submandibular)
  • Ranula (Sublingual gland)
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8
Q

Salivary ductal stone

  • Which gland most commonly affected
  • Presentation
  • Tx
  • Complication
A

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)

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9
Q

5 major etiologies of oral ulcers and example of causes

A

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
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10
Q

Benign tongue cancer ddx

A

Haemangioma: Bluish, compressible
Lipoma: Like fatty origin: soft, smooth
Papilloma: Small, around teeth
Giant cell tumor: Smooth, firm

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11
Q

Ddx pre-malignant oral cavity lesions

A

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

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12
Q

Torus palatinus

  • Anatomical location
  • Presentation
  • Tx options
A

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

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13
Q

Differentiating features of Torus palatinus vs cancer

A

Torus

  • Normal overlying mucosa
  • Does not extend or invade

Cancer

  • Ulceration
  • Extends inferiorly from nose, maxillary sinus (nasal symptoms)
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14
Q

Torus mandibularis

  • Morphology and anatomical position
A

Bony protuberance on the lingual aspect of the mandible (commonly between the canine and premolar areas)

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15
Q

Ddx white patches in the mouth

A

Leukoplakis
Lichen planus
Oral Candidiasis
Linea alba (white mark from pressure, friction, trauma in mouth)

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16
Q

Erythroplakia

Morphological features

A

 Erythematous patch
 +/- granular or nodular lesion
 Dysplasia without keratosis (red without surrounding epithelium)

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17
Q

First-line investigations for pre-malignant lesions in oral cavity

A

Biopsy** to confirm malignancy

Wide base excision if malignant

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18
Q

Parapharyngeal space tumor

  • Clinical presentation
  • Differentiating factor with parapharyngeal infection
  • Benign or malignant
A

Clinical presentation:

  • Asymptomatic due to space for expansion
  • Incidental finding during URTI: swelling at tonsil/ peritonsil region

No trismus unlike quinsy

80% benign

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19
Q

Presentation:

  • Painless mass in mouth
  • Persistent bleeding and ulcer that fails to heal
  • Dysphagia
  • Some dysarthria

Most likely dx

A

Ulcerative oral cavity cancer

  • SCC
  • Adenocarcinoma
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20
Q

Presentation:

 Sore throat, odynophagia, dysphagia
 Muffled speech
 otalgia (referred pain)

Known HPV infection

Most likely Ddx

A

Oropharyngeal malignancy** HPV-related

 Epithelium: SCC
 Lymphoma tonsil and tongue base/ minor salivary gland

Acute tonsilitis
Acute epiglottitis
Ludwig angina

21
Q

Presentation

Sore throat 
Globus sensation and dysphagia 
Hoarseness 
Otalgia 
Known alcoholic

Most likely Dx

A

Hypopharyngeal carcinoma (at level of hyoid to lower border of cricoid; between oral cavity and esophagus)

22
Q

Oral cavity cancers

  • Subsites
  • S/S, features of mass
  • Histological types
A 
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
23
Q

Oropharyngeal cancer

  • Subsites
  • S/S, features of mass
  • Risk factors
  • Histological types
A 
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

24
Q

Hypopharyngeal carcinoma

  • Subsites
  • S/S
  • RF
  • Associated syndrome
A

Subsites:

  1. Piriform fossa (60%)
  2. Postcricoid (30%)
  3. 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

25
Q

Paterson Brown Kelly syndrome

Define clinical features

A

triad of dysphagia, iron deficiency anemia, esophageal webs

Examine koilonychias in nails

Asso. high risk of CA hypopharynx

26
Q

First-line investigation for pharyngeal and oral cavity cancers

A

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

27
Q

Typical histological types of Head and Neck Cancers

A

90% squamous cell carcinoma (SCC)

nasopharynx: mostly undifferentiated nonkeratinizing NPC
thyroid: mostly papillary thyroid cancer

28
Q

General treatment options for pharyngeal and oral cavity cancers

A

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

29
Q

3Rs principles for surgical treatment of pharyngeal and oral cancers

A

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

30
Q

Types of oral and pharyngeal reconstruction

A

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

31
Q

Ddx oral and pharyngeal infections

A 
Acute tonsillitis 
Infectious mononucleosis 
Peritonsillar abscess (quinsy)
Acute epiglottitis 
Ludwig angina 
Deep neck abscesses: Retropharyngeal, parapharyngeal abscesses
32
Q

Acute tonsillitis

Causative pathogens

A

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)

33
Q

Acute tonsillitis

Clinical presentation

A 
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
34
Q

Acute tonsillitis

First-line investigations and treatment options

A

Investigations:

  • CBC with diff: neutrophilia or lymphopenia patterns
  • Throat swab for C/ST

Treatment:

  • Viral = rest, analgesics, fluid replacement, supportive
  • Bacterial = analgesics, penicillin, erythromycin
35
Q

Infectious mononucleosis

  • Demographic
  • Causative pathogen
  • Incubation period and prodromal period
A

Demographic
 Acute infection
 Young adult

Causative:
Epstein barr virus (EBV): Transmitted through saliva

Incubation period: 5-7 weeks
Prodromal period: 4-5 days

36
Q

Infectious mononucleosis

Clinical presentation

A 
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
37
Q

Infectious mononucleosis

First-line investigations and treatment options

A

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
38
Q

Peritonsillar abscess/ quinsy

  • Anatomical nidus of infection
  • Causative pathogens
A

Anatomy:
Collection of pus between tonsillar capsule & superior constrictor

Mixed aerobic & anaerobic organisms:
 Bacteroides
 Peptostreptococcus

39
Q

Peritonsillar abscess

Clinical presentation

A 
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)
40
Q

Peritonsillar abscess/ quinsy

  • Treatment options
A 
 Analgesics
 Fluid replacement*
 Chart I/O
 Transoral incision & drainage
 antibiotics

Consider elective tonsillectomy (20% recurrence in smokers)

41
Q

Acute epiglottitis

  • Demographic
  • Causative organisms
A

ENT emergency (pediatric predominant)

Pathogens: 
 Haemophilus influenzae type b
 β-haemolytic streptococci
 Pneumococcus
 Staphylococcus
42
Q

Acute epiglottitis

Clinical presentation
First-line investigation and treatment

A 
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

43
Q

Ludwig angina

  • Anatomical location of infection
  • Origin of infection
  • Presentation
A

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

44
Q

Ludwig angina

First-line investigations and Tx

A

Secure airway
Urgent head CT
Surgical drainage + IV antibiotics
Dental consultation for tooth abscess/ infection

45
Q

Deep neck abscess

  • Subsites
  • Causative organisms
A 
Retropharyngeal abscess (paedi),
Parapharyngeal abscess (masticator space, parotid space)

Causative organism:

  • Tonsillitis organisms: URTI viruses, B-hemolytic bacteria, Candida
  • Dental flora
46
Q

Deep neck abscess

  • Clinical presentation
A

Symptoms:
 Sore throat
 Neck swelling
 Airway obstruction(dysphagia, dribbling)

Signs:
 Fever
 Toxic
 Head hyperextended, stiff
 Airway obstruction (inspiratory stridor)
 Neck swelling, infected retropharyngeal LN

47
Q

Deep neck abscess

First-line investigations and treatment

A

Secure airway
Urgent head CT

Urgent ENT surgery: transcervical drainage, IV antibiotics

Dental consultation for oral infections

48
Q

Complications of acute tonsillitis

A

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

49
Q

Complications of infectious mononucleosis

A

 Sepsis (secondary bacterial infection)
 Splenomegaly 50%
 Hepatomegaly

MBBS IV - Junior Clerkship WCS (131 decks)

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