List III - Core clinical problems for the student and new doctor

Question 1

When should a 2 week wait referral be done in relation to mouth lesions?

Answer 1

• 2 week wait referral should to oral surgery should be done in all of the following cases:
• Unexplained oral ulceration or mass persisting for greater than 3 weeks
• Unexplained red, or red and white patches that are painful, swollen or bleeding
• Unexplained one sided pain in the head and neck area for greater than 4 weeks, which is associated with ear ache but does not result in any abnormal findings on otoscopy
• Unexplained recent neck lump, or a previously undiagnosed lump that has chaged over a period of 3 to 6 weeks
• Unexplained persistent sore or painful throat
• Signs and symptoms in the oral cavity persisting for more than 6 weeks, that cannot be definitively diagnosed as a benign lesion

Level of suspicion should be higher in patients who are over 40, smokers, heavy drinkers and those who chew tobacco or betel nut (areca nut)

Question 2

What types of common oral ulcers are there?

Answer 2

• Aphthous ulcers
• Erythematous, small, round or ovoid oral ulcers with circumscribed margins, typically presenting first in childhood or adolescence and not associated with systemic disease

Question 3

What are the different categories of aphthous ulcers?

Answer 3

• Minor ulcers - <1cm in diameter and heal spontaneously within 7 days
• Major ulcers - 1-3 cm in diameter and can last for 10 days to 6 weeks
• Herpetiform aphthous ulcer are very small (1-2 mm) grouped lesions - account for 5%, are extremely painful and persist for 7-10 days as many as 100 ulcers can be present and they may coalesce into larger erosive plagues

Question 4

How common are aphthous ulcers?

Answer 4

• Affect 25% of the population at some time
• Aphthous ulcers are more common in:
• Women
• People under 40 years of age
• Non-smokers
• People of high socioeconomic status

Question 5

What are the possible causes of aphthous ulceration?

Answer 5

• Genetic predisposition - 40%
• Smoking cessation
• Iron, folic acid, or vitamin B12 deficiency
• Hormonal factors
• Local trauma
• Anxiety
• Exposure to certain foods - chocolate, coffee, peanuts and/or gluten products

Question 6

What are the presenting features of a minor aphthous ulcer?

Answer 6

• Typically present as small round or ovoid ulcers of 2 to 4 mm in diameter, occur in groups of up to 6 at a time, and are found mainly on the non-keratinised mucosa of the lips, cheeks, floor of the mouth, sulci, or ventrum of the tongue
• Heal in 7 to 10 days and recur at intervals of 1 to 4 months generally leaving little or not evidence of scarring

Question 7

What are the presenting features of a major aphthous ulcer?

Answer 7

• Around 1 cm in diameter or larger, occur in groups of up to 6 at a time, and involve any oral site, including the keratinised mucosa (palate and dorsum of tongue)
• Heal slowly over 10 to 40 days often with scarring and may recur frequently

Question 8

What are the presenting features of a herpetiform aphthous ulcer?

Answer 8

• (uncommon) present as multiple pinhead-sized discrete ulcers that increase in size and coalesce to leave large areas of ulceration. They are often extremely painful and can involve any oral site, including the keratinised mucosa (palate and dorsum of tongue)
• Heal in 10 days or longer and may recur so frequently that ulceration seems continuous

Question 9

What are the differential diagnoses for aphthous ulcers?

Answer 9

• Oral malignancy
• B12 deficiency
• Folate deficiency
• Iron deficiency
• Coeliac disease
• IBD
• Behcets syndrome
• Reiters syndrome
• HIV
• EBV

Question 10

What is the management of aphthous ulcers?

Answer 10

• Refer for specialist assessment if concerning underlying cause is suspected
• Advise the person to avoid trigger factors
• Coffee, peanuts, chocolate, gluten containing products
• Offer information on the natural history of aphthous ulcers
• If ulcers are infrequent and mild and not interfering with ADL’s, treatment may not be required
• If treatment is required first line is topical corticosteroids such as hydrocortisone or beclometasone spray
• Other therapies that can be used alone or in addition are topical anaesthetics such as lidocaine, benzydamine and chlorhexidine gluconate or doxycycline rinses
• For people with recurrent aphthous ulceration a short course of systemic prednisolone can be prescribed
• Consider prescribing or advising the use of an oral vitamin B12 irrespective of serum B12 levels
• Specialist referral if not responding to topical treatments or systemic steroids

Question 11

What are the possible causes of hoarseness?

Answer 11

• Voice overuse
• Smoking
• Viral illness
• Hypothyroidism
• Gastro-oesophageal reflux
• Laryngeal cancer
• Lung cancer

Question 12

Why should a chest x-ray be considered when investigating hoarseness?

Answer 12

• To exclude apical lung lesions

Question 13

Which people with persistent unexplained hoarseness should be referred to a suspected cancer ENT specialist?

Answer 13

• Aged 45 and over with:
• Persistent unexplained hoarseness
• Unexplained lump in the neck

(Laryngeal cancer guidelines)

Question 14

What are the potential causes of a neck lump?

Answer 14

• Normal structures
• Skin infections
• Lymphadenopathy
• Benign tumours
• Malignant primary tumours
• Thyroid lumps
• Salivary gland lumps
• Congenital and developmental lumps
• Carotid body tumours and aneurysms
• Trauma

Question 15

What are the normal structures of the neck?

Answer 15

Patients may raise concerns regarding lumps when in fact it could be that they have identified a part of normal anatomy for the first time for example:

• Transverse process of C1 vertebra
• Hyoid bone
• Thyroid or cricoid cartilage

Question 16

What types of skin lumps can present on the neck?

Answer 16

• Abscess

* Infected sebaceous cyst

Question 17

What types of lymphadenopathy can present on the neck?

Answer 17

• Inflammatory lymphadenopathy - acute, painful swelling of the lymph nodes with possible symptoms of tonsillitis, pharyngitis or glandular fever
• Malignant lymphadenopathy - usually present as unilateral progressive swelling of single or multiple nodes
• Mass in the left supra-clavicular fossa (Virchow’s node) may indicate metastatic malignancy from a primary tumour below the clavicle
• Lymphoma can present as generalised lymphadenopathy - can present at any age as painless, rubbery lymphadenopathy often in the posterior triangle and sometimes nodes in the axillae and inguinal areas, fever, night sweats, fatigue and weight loss may be associated

Question 18

What are the benign tumours associated with the neck?

Answer 18

• Usually slow growing and non-invasive for example lipoma, firboma, chondroma, neuromas and vascular tumours
• Most common of the benign soft tissue tumours in the neck are lipomas - usually asymptomatic, soft, poorly defined masses deep to the skin

Question 19

What are the malignant primary tumours of the neck?

Answer 19

• May present as an asymptomatic nodule
• Arise as glandular tissue for example the salivary, thyroid or parathyroid glands
• Other types of malignant tumours include soft tissue tumours such as sarcomas and chondrosarcomas
• Malignancies of the skin for example squamous cell carcinoma or malignant melanoma may metastasize to the parotid or lateral cervical lymph nodes

Question 20

What are the thyroid lumps that may present on the neck?

Answer 20

• May be nodular or diffuse - all move upwards on swallowing
• Thyroid swellings may be associated with symptoms and signs of hyperthyroidism or hypothyroidism
• Most tumours of the thyroid are benign and include colloid nodules, hyperplastic nodules, cysts or follicular adenomas

Question 21

What are the salivary gland lumps associated with the neck?

Answer 21

• Salivary gland tumours
• More common in older people
• Most occur in the parotid gland and 80% are benign e.g. pleomorphic adenoma, adenolymphoma (Warthin’s tumour)
• Malignancy in the parotid gland is more common if there is pain, paraesthesia, facial nerve involvement or skin tethering
• Salivary gland calculi
• Stones can form resulting in swelling from sialadenitis leading to increased saliva production
• Salivary gland infection
• Acute infection of the saliva gland can be bacterial due to staphylococcus aureus
• Mumps is usually characterised by bilateral parotid swelling
• Salivary gland inflammation
• Chronic inflammation with disruption to the duct system may be caused by granulomatous disease such as tuberculosis or sarcoid or autoimmune disease such as Sjorgren’s syndrome

Question 22

What are the congenital and developmental lumps of the neck?

Answer 22

• Thyroglossal cyst
• Usually affects children
• Arises from persistent epithelial tissue along the thyroglossal duct, usually presents as a midline cystic lump that is near the hyoid bone and moves upwards when the person swallows or protrudes their tongue
• Brachial cyst
• More commonly present in early adult life as painless, slow growing, smooth, fluctuant swellings in the lateral neck
• Usually occur along the line of the deep cervical lymph nodes at the junction of the upper third and two thirds of the anterior border of the sternomastoid
• Laryngocele
• Arises from the laryngeal saccule and can extend through the thyroid membrane
• Usually presents with intermittent neck swelling which becomes palpable when the person performs the valsalva manoeuvre

Question 23

What other types of congenital and developmental neck lumps are there?

Answer 23

• Dermoid cyst - inclusion cyst occurring along lines of fusion e.g. under the tongue or palate
• Lymphangioma (cystic hygroma) - soft, fluctuant masses under the skin, usually in the posterior triangle
• Haemangioma - compressible lump which appears bluish on the over lying skin

Question 24

What are carotid body tumours and aneurysms?

Answer 24

• Corotid body tumours usually present in adults as slow growing painless lumps
• Usually pulsatile over the carotid bifurcation and can be moved from side to side, but not up and down

Question 25

What type of neck lump can trauma cause?

Answer 25

• May cause haematoma, subcutaneous surgical emphysema or subsequent fibrosis

Question 26

What is globus?

Answer 26

• Sensation of the feeling of having a lump in the throat (when there is nothing there)
• Can come and go
• Does not interfere with eating and drinking
• May also be called globus pharygeus

Question 27

What factors can contribute to globus?

Answer 27

• Muscles in the throat may not be relaxing properly when swallowing
• Reflux can contribute to the sensation in some people
• Stress can trigger globus sensation or make the symptoms worse, so can being very tired
• Excess mucus running from the nose down the back of the throat (post nasal drip) may also make these symptoms worse

Question 28

What are the main differentials to rule out when investigating globus?

Answer 28

• Dyphagia

* Cancer

Question 29

What is one of the main ways to determine the difference between globus and dysphagia?

Answer 29

• Unlike dysphagia - a person with globus sensation does not usually have any problems eating or drinking
• Dysphagia can be constant and may become gradually worse over time whereas globus sensation symptoms tend to come and go

Question 30

What are the investigations for globus?

Answer 30

• Diagnosis made of the basis of history and ruling out other causes
• ENT may examine the mouth, nose and throat in the outpatient clinic using a flexible telescope passed via the nose - nasolaryngoscopy

Question 31

What is the treatment for globus sensation?

Answer 31

• Many will only require their symptoms to be explained and given reassurance that they do not have a serious underlying condition - in many people the problem settles on its own with time
• Other people may benefit from specific management or treatments dependent on the cause:
• Physiotherapy for the muscles around the throat
• Nasal spray for the treatment of post nasal drip
• Treatment for acid reflux with antacid medicines and acid suppressing medicines
• Stopping smoking
• Treatment for stress - CBT

Question 32

What is stridor?

Answer 32

• Sound caused by abnormal air passage into the lungs and can exist in different degrees and be caused by obstruction located anywhere in the extra-thoracic (nose, pharynx, larynx, trachea) or intra-thoracic airway (tracheobronchial tree)
• Stridor may be congenitial or acquired, acute, intermittent or chronic

Question 33

What are the causes of stridor in children?

Answer 33

• Croup - parainfluenza virus
• Acute epiglottitis - rare, caused by haemophilus influenzae type B, less common since the Hib vaccine
• Inhaled foreign body
• Laryngomalacia - congenital abnormality of the larynx
• Infants typically present at 4 weeks of age with stridor

Question 34

What are the causes of stridor in adults?

Answer 34

• Neoplasms
• Larynx
• Trachea
• Major bronchi
• Anaphylaxis
• Goitre (retrosternal)
• Trauma e.g. strangulation, burns, irritant gases
• Other bilateral vocal cord palsy, Wegener’s granulomatosis, cricoarytenoid arthritis (RA), tracheopathia

Question 35

Which investigations can be used for stridor?

Answer 35

• Laryngoscopy (beware in acute epiglottitis)
• Bronchoscopy
• Flow volume loop
• Chest x-ray
• CT / thyroid scan

Question 36

What is the treatment of laryngeal obstruction?

Answer 36

• Treat underlying cause e.g. foreign body, removal, anaphylaxis
• Bag valve mask ventilation with high flow O2
• Cricothyroidotomy
• Tracheostomy