Remaining ENT lectures Flashcards
Differential diagnosis of neck masses?
- Congenital
- Inflammatory
- Neoplastic
Explain the flow chart of what to do with masses with different categories suspected?
Neoplastic causes of neck masses?
- Metastatic: unknown primary squamous cell carcinoma
- Primary: head and neck squamous cell carcinoma or melanoma
- Adenocarcinoma
- Thyroid cancer
- Lymphoma
- Salivary
- Angioma
- Lipoma
- Carotid body tumor
- Rhabdomyosarcoma
Branchial cleft cysts represent what?
- Branchial cleft cysts represent the most common pediatric congenital neck mass
- The second branchial cleft cyst is the most common of all branchial cleft cysts
What is the second most common type of congenital pediatric neck mass? they occur where? Occasionally?
- Thyroglossal duct cysts are the second most common type of congenital pediatric neck mass.
- They most commonly occur in the midline and elevate with swallowing.
- Occasionally, they will swell after an upper respiratory infection, bringing them to clinical attention.
How do we remove a thyroglossal duct?
- Excision of the thyroglossal duct cyst is performed by removing all remnants of the cyst as well as the middle portion of the hyoid bone – the Sistrunk procedure.
- Because of it’s embryological origin, the thyroglossal duct cyst will often extend through the hyoid bone. Failure to resect the middle portion of the hyoid bone will often lead to re-occurrence.
What are some inflammatory neck masses?
• Cervical lymphadenopathy:
– Bacterial, Viral, and Granulomatous
- Scrofula
- Cat scratch
- Sarcoidosis
- Fungal
- Sialadenitis: parotid, submandibular
- Congenital cysts
Triangles of the neck?
Location of the Carotid sinus?
Lymph node levels of the neck?
Steps in diagnosing neck masses?
- History: – When did it develop? – Associated symptoms: swallow, voice, ear pain. – Personal habits: tobacco, alcohol – Previous history of irradiation or surgery.
- Physical exam: – Complete physical exam. Be very specific to describe location, consistency, and mobility. – Flexible fiberoptic nasopharyngolaryngoscopy
Diagnosic tests to run to see neck masses?
- Fine needle aspiration
- CT neck with contrast
- MRI
- Ultrasound
Fine needle aspiration for neck masses?
- This has become standard
- Any neck mass that is not an obvious abscess
- Small gauge needle
- Theoretical concern of seeding the tumor is not a concern
CT for neck masses?
- When done with contrast allows evaluation for vascularity and relationship to vascular structures.
- Useful in evaluation of unknown primary.
- Pathologic node: lucent, >1.5 cm, loss of shape
- Avoid contrast with thyroid lesions
- Helpful to determine extent of lesion
MRI for neck masses?
- Similar information as CT
- Better for upper neck and skull base evaluation
Ultrasonography?
- Useful to determine cystic versus solid
- Useful for US guided FNA – Improves accuracy
Asymmetric neck mass on an adult?
• Any asymmetric neck mass in the adult must be considered malignant until proven otherwise.
How do we work up neck masses in the adult?
- Ipsilateral ear pain with normal otoscopy. Direct attention to tonsil, tongue base, supraglottis, and hypopharynx.
- Unilateral serous otitis media: must use fiberoptic scope to examine nasopharynx
Oral cancer makes up how much of head and neck cancer? Oral
- Oral cancer comprises 30% of all head and neck cancers and is the most common head and neck cancer.
- The oral cavity has the highest rate of second primaries.
- Signs and symptoms include nonhealing ulcers, denture difficulties, dysphagia, odynophagia, trismus, halitosis, numbness in the lower teeth.
Anatomically where is the oral cavity at? fasical plans?
- Oral cavity: extends from lips to junction of hard and soft palate and circumvallate papillae.
- Other than the mandibular periosteum, there is not finite fascial plane to inhibit tumor’s extension within the oral cavity.
Risk factors for oral cancer?
- Tobacco
- Alcohol
- Radiation exposure
- Ultraviolet radiation exposure
- Plummer Vinson Syndrome
- Human papilloma virus
- Leukoplakia
- Erythroplakia
Oral cancer subsites?
- Lips
- Buccal Mucosa
- Alveolar ridge
- Retromolar trigone
- Hard palate
- Oral Tongue
- Floor of Mouth
Types of oral cancer?
- Squamous cell carcinoma
- Verrucous carcinoma
- Basal cell carcinoma
- Salivary gland malignancies
- Melanoma
Surgical treatment of oral cancer?
- Anterior and small tumors may be approached intraorally
- Posterior and larger tumors may require a transmandibular or transcervical approach
Radiation treatment for oral cancer?
- Radiotherapy is given for 6-7 weeks
- Chemotherapy may be considered for adjuvant therapy for advanced disease
Oropharynx anatomy?
Subsites of oropharyngeal cancer?
- Soft palate
- Base of tongue
- Tonsil/Lateral pharyngeal wall
- Posterior pharyngeal wall
What are the types of oropharyngeal cancer?
- Squamous cell carcinoma
- Lymphopitheliomas
- Lymphomas
Surgical treatment or oropharyngeal cancer?
- Typically requires and initial tracheostomy
- Transoral, transcervical/visor flap, mandibulectomy, mandibulotomy, lateral pharyngotomy, transhyoid pharyngotomy
Radiation for oropharyngeal cancer?
- Radiotherapy is given for 6-7 weeks
- Chemotherapy may be considered for adjuvant therapy for advanced disease
Anatomy of the tonsils?
– Waldeyer’s Ring:
– Arterial supply
- Lingual arterydorsal lingual branch (lower pole)
- Facial arterydescending palatine artery and tonsillar artery (main supply, lower pole)
- External carotid arteryascending pharyngeal artery (upper pole)
- Internal maxillary arterygreater palatine artery and descending palatine artery (upper pole)
Anatomy of the adenoids?
– Similar to palatine tonsils, present at birth, enlarge in childhood, and regress in puberty
– Arterial supply: ascending pharyngeal artery from the external carotid artery, minor branches from the internal maxillary artery, and facial arteries (ascending palatine artery)
Explain acute pharyngitis?
– Primarily infectious
– May be secondary to sinonasal disease
– GERD
– Smoking
– Endotracheal intubation
– Pathogens: 60% viral
Group A beta hemolytic strep and pharyngitis?
- Most common cause of bacterial pharyngitis
- Diagnosis: clinical exam, GABHS rapid antigen test, throat culture (most sensitive)
- Treatment: all GABHS should be treated to prevent rheumatic fever
What other less common causes of infectious pharyngitis?
- Syphilis
- Pertussis
- Gonorrhea
- Diptheria (image)
- Candidiasis
explain Herpangina (Hand-FootMouth)?
- Coxsackie A
- Small oropharyngeal vesicular or ulcerative lesions
- Treatment: oral hygiene, observation, hydration, bed rest
Explain infectious mononucleosis?
- Epstein-Barr virus
- High grade fever
- Posterior triangle lymphadenopathy
- General malaise
- Associated hepatosplenomegaly
- Diagnosis: clinical history, monospoat test, EBV panel, atypical lymphocytes on smear
explain Peritonsillar abscess?
- Spread of infection outside of the tonsillar capsule into the peritonsillar space.
- Signs and symptoms: – Unilateral otalgia – Uvular deviation – Odynophagia
- Treatment: urgent incision and drainage
Tonsillectomy and Adenectomy facts? Absolute indications? relative?
• Most common major surgical procedure in children in the U.S.
- Multiple techniques – Cautery, cold, coblation, laser
- Absolute indications: – OSA – Possible malignancy
• Relative indications: – Recurrent acute tonsillitis: • 7 in one year • 5 per year in 2 years • 3 per year over 3 years – Peritonsillar abscess – Chronic tonsillitis – Streptococcus carrier
Complications of tonsillectomy and adenoidectomy?
- Immediate and delayed hemorrhage
- Anesthtic complications
- Dehydration
- Pulmonary edema – Caused by sudden relief of airway obstruction
- Velopharyngeal insufficiency
- Velopharyngeal stenosis.
explain the signs, symptoms, complications and treatment for parapharyngeal space abcess?
- Signs and symptoms: trismus, fever, muffled voice, dysphagia
- Complications: aspiration, airway compromise, cranial nerve palsies, carotid blowout
- Treatment: external drainage and frequently tracheostomy
Anatomy of the parotid gland?
- Largest of the major salivary glands (about 20 g)
- Deep portion of the gland is in contact with the parapharyngeal space
- Stensen’s duct parallels the zygoma and enteres the oral cavity opposite the 2nd upper molar
- Facial nerve is the most superficial structure passing through the gland
- Parasympathetic supply originates in the inferior salivatory nucleus and travels with the glossopharyngeal nerve to the otic ganglion, where it synapses
- Postganglionic fibers are carried by the auriculotemporal branch of V3 to the parotid gland.
Anatomy of submandibular gland?
- Second largest salivary gland in size (10 g)
- Hypoglossal nerve courses deep to the tendon of the digastric
- Facial artery courses medial to the posterior belly of the digastric muscle and then hooks over that structure to enter the submandibular gland
- Lingual nerve passes between the medial pterygoid muscle and ramus of the mandible, entering the mouth just below the lower third molar.
- Parasympathetic supply to the submandibular gland originates in the superior salivatory nucleus and travels via the nervus intermedius and chorda tympani
Explain the sublingual gland?
- Smallest of the salivary glands
- Lies in a submucosal plane in the anterior floor of the mouth
Minor salivary glands?
- Some 600 to 1000 minor salivary glands are distributed throughout the oral cavity and oropharynx
- The greatest density is in the hard and soft palate
Infections that cause problems with the salivary glands?
- Acute sialoadenitis –Common in dehydrated patients
- Chronic recurrent sialoadenitis –Recurrent slightly painful enlargement of the gland
- Mumps or viral parotitis
- Granulomatous, actinomycosis
non-infectious problems with salivary glands?
- Recurrent parotitis –Congenital or acquired sialectasis –Calculi or strictures
- Sialolithiasis
- Sjogren’s Syndrome
Benign neoplastic diseases of the salivary gland?
• Pleomorphic adenoma
Monomorphic adenoma
- Warthin’s tumor
- Oncocytoma
Malignant neoplastic diseases of the salivary glands?
- Mucoepidermoid carcinoma
- Malignant mixed tumors
- Adenocarcinoma
- Adenoid cystic carcinoma
- Accinic Cell Carcinoma
- Squamous cell carcinoma
