surgery - ENT neck Flashcards
most common malignancy of head and neck?
SCC
factors increasing incidence of oral cavity cancer?
immigration and betel quid chewing especially in the Indian subcontinent
factors increasing incidence of oropharyngeal cancer?
Human Papillomavirus (HPV) in younger population
RF for head and neck SCCs?
alcohol and tobacco use
HPV 16
betel quid
occupational wood dust or asbestos exposure
EBV infection
immunodeficiency
prior radiation
premalignant condiitons to head and neck cancer?
leukoplakia
erythroplakia
oral lichen planus
actinic cheilitis
non-specific features of head and neck cancer?
weight loss, night sweats, loss of appetite, or cervical lymphadenopathy
features of oral cavity cancer?
odynophagia, dysphagia, tonsillar lump or an asymmetrical tonsil, a neck lump,
features of hypopharyngeal cancer?
odynophagia, dysphagia, stertor, or referred otalgia.
features of nasopharyngeal cancer?
neck lump or unilateral conductive hearing loss
features of laryngeal cancer?
hoarse voice, stridor (if advanced), dysphagia, persistent cough, or referred otalgia
which laryngeal cancer has better prognosis
glottic
ix for head and neck cancers?
lesion biopsy
flexible nasendoscopy
USS/FNA
how is cancer staging done?
MRI/CT
PET-CT
when are cancers referred?
general mx of cancers?
moking and alcohol cessation.
Surgical resection +/- adjuvant radiotherapy or chemotherapy or primary radiotherapy +/- adjuvant chemotherapy
oral cancer mx?
Small tumours can undergo wide local excision +/- neck dissection
Advanced tumours should undergo surgical resection +/- flap reconstruction + neck dissection +/- post-operative radiotherapy +/- chemotherapy.
oropharyngeal cancer mx?
Small tumours of the tonsil can undergo surgical resection using Laser or Transoral Robotic Surgery +/- neck dissection or primary radiotherapy or both (if margin involved). More advanced tumours of the tonsil can undergo solely primary radiotherapy +/- adjuvant chemotherapy.
Small tumours at the tongue base can undergo surgical resection using Transoral Robotic Surgery with neck dissection or primary radiotherapy or both (if margin involved). Larger tumours at the tongue base can undergo primary radiotherapy +/- adjuvant chemotherapy.
supraglottic cancer mx?
Small tumours can undergo surgical resection using transoral laser microsurgery with bilateral neck dissection or primary radiotherapy +/- adjuvant chemotherapy.
Advanced tumours can undergo laryngectomy with post-operative radiotherapy +/- adjuvant chemotherapy or primary radiotherapy +/- adjuvant chemotherapy.
glottic cancer mx?
Small tumours can have surgical resection using transoral laser microsurgery with bilateral neck dissection or primary radiotherapy.
Advanced tumours can undergo laryngectomy with neck dissection and post-operative radiotherapy +/- adjuvant chemotherapy or primary radiotherapy +/- adjuvant chemotherapy.
subglottic cancer mx?
Tumours originating from the subglottis are very rare but treatment principles are similar to the glottis.
hypopharyngealc cancer mx?
Small tumours of the hypopharynx can undergo surgical resection using transoral laser microsurgery with neck dissection or primary radiotherapy +/- adjuvant chemotherapy
Advanced tumours should undergo laryngopharyngectomy +/- gastric pull up/jejunal free flap + neck dissection or primary radiotherapy +/- adjuvant chemotherapy
complication following cancer mx?
Dysphagia (secondary to pharyngeal/oesophageal stricture)
Pharyngocutaneous fistula (following laryngectomy)
Injury to the accessory, vagus, hypoglossal, or marginal mandibular nerves (following neck dissection), or chyle leak (following neck dissection)
Mucositis (early complication of radiotherapy) or xerostomia (complication of radiotherapy)
Chronic pain, persistent hoarse voice, or hearing loss (following chemoradiotherapy)
benign salivary gland tumours?
pleomorphic adenoma and Warthin’s tumour (papillary cystadenoma lymphomatosum).
malignant salivary gland tumours?
(from most to least common)
mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma, squamous cell carcinoma, and adenocarcinoma
RF for salivary gland tumours?
Direct radiation exposure
Epstein-Barr virus (EBV) infection
Smoking*
Genetic alterations (p53 mutations)
features of salivary gland tumours?
slowly enlarging mass, typically painless
malignant = facial nevre palsy, erythema + ulceration
pain = red flag
large = airway obstruction, dysphagia, or hoarseness
ix for salivary gland tumour?
Routine bloods (FBC, U&Es, and CRP)
USS + FNA
staging CT neck + thorax
mx of salivary gland tumours?
Excision via parotidectomy
Selective neck dissection will be performed for lymph node clearance
non surgical mx for salivary gland tumours?
Radiotherapy has been used as adjuvant treatment if non-resectale
indications for post-op radiotherapy?
(1) high-grade or advanced stage tumours
(2) residual neck disease
(3) recurrent disease
(4) adenoid cystic carcinoma
(5) close proximity to the facial nerve
(6) incomplete or close resection margin
early complications of salivary tumour resection?
Haematoma
facial nerve injury
sialocele
late complications of salivary tumour resection?
Frey’s syndrome can develop following a parotidectomy, whereby the autonomic fibres supplying the gland reform inappropriately; the stimulus to salivate results in an inappropriate response of redness and sweating.
First bite syndrome is a complication characterised by patient experiencing intense pain on taking the first few bites of a meal, which gradually improves as they eat.
what is sialadenitis?
inflammation of the salivary gland
most commonly affects parotid gland
aetiology of sialadenitis?
Infective (viral or bacterial, as discussed below)
Stones (60% of cause of sialadenitis)
Malignancy
Autoimmune, including Sarcoidosis*, Sjögren’s syndrome, systemic lupus erythematosus or Wegener’s granulomatosis
Idiopathic
common viral causes of sialadenitis?
mumps
coxsackie, parainfluenza, and HIV
common bacterial causes of saisladneitis
S.aureus
S. viridans, H. influenzae, and Strep. pyogenes.
features of sialadenitis?
painful swelling and tenderness of the gland
Pyrexia, lymphadenopathy, and erythema
purulent discharge
ix for sialadenitis?
Routine bloods (FBC, CRP)
Pus swabs
blood cultures
ultrasound-guided fine needle aspiration cytology
CT if deep space neck infection
mx of sialadenitis?
oral hydration and analgesia (including NSAIDs and paracetamol),
Artificial saliva
Antibiotics should be given if bacterial sialadenitis
abscess formation will warrant an incision and drainage.
what is sialothiasis?
calculi in the salivary glands or ducts
how do stones form in salivary gland/ducts?
ollowing the stagnation of saliva; they are typically composed of calcium phosphate and hydroxyapatite, as the saliva is rich in calcium
anatomy of parotid gland?
located superior to the angle of the mandible, the gland is superficial to the masseter muscle and drains (via Stensen’s duct) opposite to the upper second molar
anatomy of submandibular gland?
lying beneath the floor of the mouth in the submandibular triangle, it drains (via Wharton’s duct) into the floor of the mouth, beside the frenulum of the tongue
anatomy of sublingual gland?
located below the mucous membrane of the floor of the mouth, they are drained by multiple small ducts that empty either into Wharton’s duct or directly into the floor of the mouth
RF for sialolithises?
medication (such as diuretics, anti-cholinergics, or antidepressants), dehydration, gout, smoking, periodontal disease, and hyperparathyroidism
features of sialolithiasis?
intermittent facial swelling and pain, particularly associated with eating. Symptoms are usually unilateral.
ix for sialolithiasis?
ultrasound or plain film radiographs
sialography - gold standrad
mx of sialolithaisis?
conservatively with oral hydration, analgesia, and sialogogues, such as lemon juice or sour sweets, which promote saliva production
definitive mx of sialilithiasis?
Interventional radiology for direct extraction
surgery - transoral approach can be used if the stones are distal or a transcervical approach for more proximal stones
Sialoendoscopy is usually reserved for stones <5mm
extracorporeal shockwave lithotripsy, which is reserved for stones in the proximal duct
Salivary gland excision (most commonly submandibular gland excision) will be considered for patients with persisting symptoms which have failed conservative or medical management
complications of sialolithiasis?
recurrent infections leading to chronic sialadenitis.
