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Special Senses > The Throat and Neck > Flashcards

The Throat and Neck Flashcards

1
Q

where is the retropharyngeal space?

A

potential space anterior to pre-vertebral fascia and behind the pharynx, extends from the base of the skull to the mediastinum

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2
Q

presentation of a retropharyngeal abscess?

A

commonly in young children (6mnths to 6 yrs with peak at 3 yrs) and following an URTI, although abscess is a relatively rare URTI complication
usually infection due to spread from infected LNs following URTI, but penetrating pharyngeal trauma also a cause
commonly Group A beta haemolytic strep, also anaerobes and S.aureus
neck held rigid and upright with reluctance to move
systemically unwell, fever, irritable
airway compromise-stridor, resp distress
dysphagia/odynophagia
may be bulging of posterior pharyngeal wall
RP space widening on lateral X-ray
assoc. mortality due to airway problems and mediastinitis

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3
Q

how is a retropharyngeal abscess investigated?

A

blood cultures-guide Abx therapy
lateral neck radiograph-1st line in stable child
CT Neck with IV contrast-best imaging modality, see hypodense lesion, can determine vasc involvement
fine needle pus aspiration-send for histology and microbiology-always consider mycobacterium TB-do ziehl-neelsen staining

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4
Q

management of RP abscess?

A

secure a.way if any concerns-must assess degree of resp distress and avoid invasive investigations if very anxious child to avoid worsening risk of airway obstruction, continuous monitoring required
keep child NBM, insert IV cannula
IV Abx-clindamycin plus beta lactamase inhibitor e.g. clavulanic acid, stopped on pt clinical improvement/afebrile for 48hrs and followed with oral ABx-amoxicillin and clavulanic acid
surgery-incision and drainage, through intraoral incision or external cervical approach, if a.way obstruction or failure to improve after 24-36hrs Abx

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5
Q

what complications are we part. concerned with if pt has a parapharyngeal abscess?

A

involvement of CCA as located within the carotid sheath located within the parapharyngeal space*

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6
Q

how should all neck masses be investigated?

A

US guided fine needle aspiration and cytology (FNAC)
EXCEPT for pulsatile masses

(plus also not needed in child with obvious midline thyroglossal cyst which moves on tongue protrusion and swallowing, BUT do need USS to check for functioning thyroid tissue before excision!)

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7
Q

which muscles of the anterior cervical region are known as the infrahyoid muscles?

A 
also known as the strap muscles of the neck:
sternohyoid
omohyoid
sternothyroid
thyrohyoid
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8
Q

which 2 infrahyoid muscles does the thyroid gland lie deep to?

A

sternohyoid
and
sternothyroid

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9
Q

anatomical location of the thyroid gland?

A

sits in base of the neck, anterolateral to the lower larynx and upper trachea, deep to sternohyoid and sternothyroid muscles, and at C5-T1 vertebral level.
surrounded by fibrous capsule, dense CT attaching capsule to cricoid cartilage and superior tracheal rings, and a visceral portion of the pre-tracheal layer of deep cervical fascia-loose sheath.

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10
Q

blood supply to the thyroid gland?

A

superior and inferior thyroid arteries
superior originates from ECA
inferior originates from thyrocervical trunk branch of SCA

extensive anastomoses between R and L within gland, so potential collateral circulation between subclavian and ECAs.

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11
Q

thyroid venous drainage?

A

superior and middle thyroid veins, into the IJVs

inferior thyroid veins into the brachiocephalic veins

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12
Q

which intrinsic muscle of the larynx is NOT supplied by the recurrent laryngeal nerve?

A

cricothyroid

this is supplied by the external laryngeal nerve, a branch of the superior laryngeal nerve from the vagus nerve.

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13
Q

what proportion of adult neck lumps are malignant?

A

80%
in contrast to 20% in children-usually located posterior triangle

malignancy in adults commonly metastatic disease from SCC of head and neck, upper RT or upper GIT squamous carcinomas.

80% of paediatric neck lumps benign, and located in anterior triangle

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14
Q

1st line investigation for determining thyroid status of a patient?

A

TSH

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15
Q

indications for CT scanning the neck in patients with a thyroid mass e.g. goitre or a solitary nodule?

A

when suspicion of tracheal compression or retrosternal extension

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16
Q

how is cellular nature of a thyroid nodule determined?

A

ultrasound guided fine needle aspiration and cytology

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17
Q

1st imaging of choice in a thyroid mass?

A

neck USS-can determine if swelling cystic or solid, and if multiple nodules present

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18
Q

signs of thyrotoxicosis?

A

fine resting tremor
palmar erythema
thyroid acropachy-dermopathy assoc. with AI thyroid disease, involves soft tissue swelling and periosteal bone changes and clubbing.
tachycardia, irregular pulse-AF or SVT-regular
thin hair
TED-eye proptosis, lid lag
goitre
thyroid bruit
pretibial myxoedema-commonly non-pitting lower leg oedema

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19
Q

local problems of thyroid gland enlargement e.g. goitre or nodule?

A

tracheal compression-at level of VCs causing stridor

oesophageal compression, causing dysphagia

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20
Q

why is a multinodular goitre less of a concern than a solitary thyroid nodule?

A

solitary nodule more likely to be a thyroid cancer, of which most common type is a papillary adenocarcinoma which commonly presents in younger pts or where hx of neck irradiation.

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21
Q

types of thyroid cancer?

A

papillary adenocarcinoma
follicular carcinoma-tendency to metastasise to bones and lungs
medullary carcinoma-neoplasm of C-cells which produce calcitonin. typically seen in MEN, so must screen for other organ involvement in these syndromes. genetic component.
anaplastic carcinoma-typically older patients, poor prognosis.

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22
Q

management of thyroid adenoma?

A

no further tment after diagnostic hemithyroidectomy (1 lobe removed, usually with isthmus)

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23
Q

management of thyroid Ca?

A

diagnosis-FNAC, lesion US and CT staging
total thyroidectomy for papillary, follicular and medullary, followed by radio-iodine for papillary and follicular
anaplastic normally too far advanced for curative surgery.

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24
Q

thyroid surgery complications?

A

haemorrhage-surgical can be inserted during op, drain may be put in and left for 24 hrs in hemi, 48hrs in total, but this functions to aid healing process rather than control bleeding.
VC palsy-damage to 1 RLN can produce hoarse voice
a.way obstruction-bilateral VC palsy presenting with stridor, or may be secondary to haemorrhage*closing up after surgery sternothyroid and hyoid muscles brought together loosely so if bleeding less risk of airway compression
hypocalcaemia due to parathyroid gland damage

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25
Q

most common midline mass in children?

A

thyroglossal cyst-due to persisting thyroglossal duct that allowed thyroid descent from foramen cecum (between anterior 2/3 and posterior 1/3 of tongue) into the neck during embryological development

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26
Q

features of a thyroglossal cyst on examination?

A

located in neck midline, commonly below the hyoid and above the thyroid gland
moves on both swallowing and tongue protrusion

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27
Q

why might a child with a thyroglossal cyst complain of pain in neck?

A

cyst can become infected, which is assoc. with pain and swelling

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28
Q

management of a patient with a thyroglossal cyst?

A

tment is by excision, but this must follow an USS of the neck to look for normal thyroid gland further down the neck in case the cyst is the only thyroid tissue present-hence removal would cause cretinism.

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29
Q

differentials for midline neck lump in children?

A

thyroglossal cyst
dermoid cyst-submental swelling, dermal remnant occurring along lines of fusion in embryo, lined by epidermis, tend not to move on swallowing or tongue protrusion.
pyramidal lobe of the thyroid
LN enlargement due to infection or metastasis

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30
Q

most common isolated lateral neck lump cause in children?

A

branchial cyst

these are investigated with US guided FNAC to exclude necrotised LN from metastasis, and are excised completely

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31
Q

most common cause of multiple lateral neck lumps in children?

A

cervical lymphadenitis secondary to infection such as URTI e.g. tonsillitis-*painful anterior lymphadenopathy is 1 of the 4 centor criteria favouring more severe bacterial tonsillitis and increased likelihood of quinsy requiring 10 day penicillin V treatment.
multiple palpable non-tender nodes normal feature in many children

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32
Q

differential for bilateral parotid gland enlargement in a child?

A 
mumps viral infection
note can be unilateral
child has malaise and pyrexia
can be complicated by orchitis and encephalitis
symptomatic tment
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33
Q

what features might make you suspect a cervical LN TB infection?

A

a non-tender purple/red lump in the neck, that may be quite large due to TB node coalescence, and this may form a discharging sinus
most cases have assoc. pulmonary TB
may need node biopsy for histological diagnosis confirmation-caseating granuloma?
treat with normal TB drugs-rifampicin, isoniazid, pyrazinamide, ethambutol

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34
Q

why might a child being treated for a cervical LN TB infection be at risk of colour blindness?

A

treatment with ethambutol which can cause optic neuritis (retrobulbar)

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35
Q

usual location of a branchial cyst?

A

anterior to SCM in anterior triangle of the neck-level II, III or IV**

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36
Q

why might a branchial cyst become painful and swollen in a child with a URTI?

A

most of these cysts are lined with lymphoid tissue

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37
Q

medical therapy for hyperthyroidism?

A

symptom control with a beta blocker e.g. propranolol-rapid relief of tremor and tachycardia
carbimazole or propylthiouracil-inhibitors of thyroid peroxidase required for iodination of thyroglobulin, propylthiouracil should never be used 1st line-due to risk of severe liver injury UNLESS: 1st trimester of pregnancy, tment of thyroid storm or tment of those with minor reactions to carbimazole who refuse tment with radioiodine or surgery. if put into remission, must check TFTs at least annually. may be given to prepare patients before radioiodine or surgery.

38
Q

complications of a retropharyngeal abscess?

A 
tracheal compression
pharyngeal compression
aspiration pneumonia-content aspiration following abscess rupture
mediastinitis, pericarditis, tamponade
empyema
jugular vein thrombosis
carotid rupture-RP space bordered laterally by the carotid sheaths
osteomyelitis
39
Q

how can nasopharyngeal carcinoma affect the neck?

A

may present as unilateral or bilateral metastatic nodes in posterior triangle of neck (posterior to post. border of SCM)
note disease more common in those of S.Asian origin e.g. Chinese.
disease may cause of chronic rhinorrhoea, and glue ear in adults-*always be suspicious of this.

40
Q

what is risk with incision biopsy of neck lumps?

A

seeding malignant disease e.g. SCC onto the skin

so FNAC always preferred, but then may need excision biopsy if primary sites are not clear.

41
Q

what malignancy are patients with sjogren’s syndrome at increased risk of developing?

A

lymphoma, which develops within the parotid gland?

42
Q

common differential for bilateral tender enlargement of cervical LNs in young adult?

A

glandular fever (EBV)
presentation includes sore throat, fever and fatigue
presentation of acute HIV infection mimics this, but is followed with persistent lymphadenopathy, and may also present as a cystic swelling in parotid gland.

43
Q

causes of bilateral parotid enlargement?

A

sjogren’s syndrome-lymphocytic infiltration of glands
bulimia nervosa
mumps

44
Q

what may be palpated deep in the supraclavicular fossa which is not of concern?

A

cervical rib

45
Q

most common cause of midline neck lumps in adults?

A

thyroid lesions

46
Q

most common cause of lateral neck lump in adults?

A

metastatic malignant disease, usually SCC from a primary site in head and neck
if supraclavicular node involvement (worse prognosis) likely infraclavicular primary lesion e.g. gastric Ca.

47
Q

what term is used to describe impalpable LNs in metastatic disease where known primary malignant site, and which primary cancers commonly cause this in the neck?

A 
occult nodes (N0)
piriform fossa
supraglottic larynx
nasopharynx
tongue base
floor of mouth

prophylactic radiotherapy to neck should be considered to control the potential neck disease.

48
Q

if the primary lesion cannot be identified when LN metastatic disease in neck after thorough clinical examination, what other investigation may be useful?

A

PET scanning

49
Q

fixation of a LN to what structures in the neck implies that the metastatic disease is incurable?

A

skull base and brachial plexus

50
Q

what score is used to assist decision on whether antibiotics should be prescribed in primary care for a sore throat?

A

Centor criteria: tonsillar exudate, tender anterior cervical lymphadenoapathy/lymphadenitis, hx if fever, absence of cough.
presence of at least 3 suggests antibiotic treatment would be effective.

51
Q

when is immediate hosp admission required in sore throat presentation?

A

stridor or resp difficulty: resp distress, drooling, system very unwell, odynophagia, muffled voice-suspect acute epiglottitis-DO NOT examine throat, upper a.way obstruction.
severe suppurative complications e.g. RP abscess as risk of a.way compromise or abscess rupture
dehydration
signs of being profoundly unwell and unknown cause or rare cause suspected e.g. SJS-mouth ulcers, bullae formation and erosions, high fever, or yersinial pharyngitis-abdo pain with or without diarrhoea.
signs of being markedly systemically unwell and patient is at risk of immunosuppression,

52
Q

why might a patient with tonsillitis complain of abdo pain?

A

due to gut lymphadenitis

also * yersinial pharyngitis

53
Q

when if r/f to secondary care indicated for a tonsillectomy?

A

For a child if:
5 or more episodes of acute sore throat per year, documented by parent or clinician.
symptoms been occurring for at least 1 yr
sore throat episodes been severe enough to disrupt the child’s normal behaviour or day to day functioning.
r/f if child has guttate psoriasis which is exacerbated by recurrent tonsillitis.
r/f if child has hx of sleep apnoea, daytime drowsiness, and failure to thrive.

r/f adults if had 5 or more episodes per year of sore throat due to tonsillitis. The episodes should have been disabling and have prevented normal functioning.

54
Q

management of tonsillitis?

A

most cases viral and patients just need reassurance and advice-advise rest, drinking plenty of water-espec. if fever, and that if sore throat fails to improve or becomes worse over several days to come back-may be glandular fever (EBV). patient should improve within 1 week.
advise to seek urgent medical help if devlop breathing difficulty, muffled voice, drooling, stridor, dysphagia.
sucking ice lollies, throat lozenges may help
analgesia-paracetamol and ibuprofen
Abx role only in bacterial infection-phenoxymethylpenicillin (penicillin V) 10 day course, can do delayed prescribing strategy, use clarithromycin or erythromycin if pen allergic, for 5 days.
quinsy-need abscess drainage
if persistent consider tonsillectomy r/f

55
Q

causes of tonsillitis?

A

70% viral-rhinovirus, adenovirus, enterovirus, EBV
bacterial-group A beta haemolytic strep-strep throat
staph
strep pneumonia
h.influenzae
e.coli

56
Q

why should amoxicillin NOT be prescribed for a sore throat?

A

if the cause is glandular fever, patient will develop a widespread erythematous maculopapular rash.

*think glandular fever in teenagers, part. if tonsils covered with a membranous exudate, and may see petechial haemorrhages on palate.

57
Q

non-infectious causes of a sore throat that may be considered if pt has a sore throat for 3 or 4 wks?

A

GORD
smoking
alcohol
allergic rhinitis

58
Q

features that may suggest Ca e.g. oropharyngeal or hypopharyngeal e.g. pyriform sinus, in sore throat presentation?

A

hypopharyngeal-persistent, unilateral, well localised sore throat, vague discomfort ton swallowing, otalgia, neck lump
oropharyngeal-pt may complain of sensation of lump at back of the throat, neck mass, ulcer usually visible on examination.

?weight loss, smoking and alcohol hx

59
Q

presentation of quinsy (peritonsillar abscess)?

A

here pus forms between tonsil capsule and superior constrictor muscle
severe sore throat lateralised to 1 side, causing dysphagia
“hot potato” voice
trismus
ipsilateral otalgia and cervical adenopathy

examination-gross swelling of tonsil and base of uvula deviation away

60
Q

quinsy treatment?

A

drainage of abscess under LA
pareneteral Abx-penicillin
may do immediate tonsillectomy, or interval tonsillectomy

61
Q

what must patients with glandular fever be advised about in relation to sports?

A

avoid contact sports for 2-3mnths as EBV commonly causes hepatosplenomegaly so risk of rupture.

62
Q

complications of quinsy?

A

spread to deeper neck tissues-necrotising fasciitis
infection spread from parapharyngeal space to cause mediastinitis, pericarditis and pleural effusions
airway compromise-RARE
abscess recurrence
haemorrhage after tonsillectomy
death-can occur from aspiration, airway obstruction, erosion into major blood vessels or extension into mediastinum.

63
Q

most common cause of a chronic sore throat in adults?

A

chronic pharyngitis-often related to irritation from cigarette smoke, alcohol and acid reflux
chronic inflammation may also be due to post-nasal drip from chronic sinusitis

64
Q

why in relation to the adenoids is it unusual for glue ear to develop in adults?

A

glue ear common in children due to ET obstruction by the adenoids which hypertrophy up to the age of 6yrs, then gradually regress to an insignificant size by about 12 years.
therefore symptoms of adenoidal hypertrophy in adults must have nasopharynx examined-flexible rhinolaryngoscopy, to exclude a malignancy.

65
Q

likely cause of sudden onset pain within a thyroid lump?

A

bleed into a thyroid cyst

66
Q

indications for 2ww referral in presentation of a thyroid lump?

A

child with a thyroid nodule
unexplained hoarseness, or voice changes assoc. with goitre
painless thyroid mass enlarging rapidly over period of few weeks
palpable cervical lymphadenopathy

other potential red flags: FH of thyroid Ca or endocrine Ca-?medullary thyroid Ca inheritance and link to MEN
hx of previous irradiation or exposure to high environmental radiation
insidious or persistent pain lasting for several wks

67
Q

blood tests to order if medullary thyroid Ca is suspected?

A

basal plasma calcitonin and CEA

68
Q

what investigation is needed in all vocal cord palsy cases where hx and examination not diagnostic?

A

CT scan to image course of vagus and recurrent laryngeal nerves.

69
Q

where do 80% of salivary gland neoplasms occur?

A

parotid gland

70
Q

what proportion of parotid neoplasms are malignant in nature?

A

20%

71
Q

what are 80% of benign parotid neoplasms?

A

pleomorphic adenomas

72
Q

complications of a parotidectomy?

A

facial weakness-usually temporary and related to trauma and pressure close to nerve, but after SM gland surgery mandibular branch damage rarely recovers.
ear anaesthesia-great auricular nerve division, anaesthesia to inferior 1/2 of pinna and surrounding skin, always some residual defecit.
salivary fistula-overprod. of saliva from remaining tissue, need pressure dressings and suction drainage.
frey’s syndrome-gustatory sweating, possibly with facial flushing and heat, due to PNS fibre severing, espec. those of auriculotemporal nerve, destined for parotid, are rerouted to skin by growing along SNS fibres to sweat glands during their regeneration. may do tympanic nerve section if symptoms don’t settle spontaneously after 6mnths.
tongue weakness and anaesthesia-hypoglossal and lingual nerve trauma respectively.

73
Q

what proportion of SM gland neoplasms are malignant?

A

50%

contrast to 20% in parotid, and 80% in sublingual

74
Q

how does infection occurrence in parotid differ from that of SM gland?

A

SM gland infections 9 times more common than in parotid

75
Q

causes of acute sialadenitis?

A 
bacterial-usually staph, seen in dehydrated and IC patients
viral-paramyxovirus (mumps)
coxsackievirus
echovirus
HIV

chronic disease rare, but sometimes seen in TB, sarcoidosis, HIV and syphilis.

76
Q

presentation and management of sialolithiasis?

A

9 times more common in SM than parotid gland
pain and swelling, worse during meals
investigated with USS or sialogram
management: conservative-most will settle, may give analgesia, hydration and sialogogues-increase saliva flow rate e.g. pilocarpine-parasympathomimetic
endoscopy
radiological removal
surgery-intraoral removal of palpable stones, or salivary gland removal
complications: sialadenitis, abscess formation

77
Q

how does region of laryngeal carcinoma impact on symptom presentation?

A

supraglottic=dysphagia
glottis=dysphonia
subglottic=resp problems e.g. stridor

78
Q

why does supraglottic laryngeal Ca present late?

A

potential space for expansion

dysphonia late feature, may be dysphagia, resp problems or metastatic neck node-very rich decussating lymphatic supply

79
Q

supraglottic laryngeal Ca management?

A

usual primary site radiotherapy and neck nodes

if residual or recurrent disease then total laryngectomy and modified radical neck dissection

80
Q

most common malignant laryngeal Ca?

A

glottis laryngeal Ca
usually starts on free vibrating edge of true vocal cord-allows early presentation due to dysphonia
anterior spread to anterior commissure=poor prognosis as site close to cartilage-can be easy further spread to thyroid gland
if confined to cord then excellent prognosis as no lymphatic supply, BUT lateral spread to muscle may reach lymphatic channels.

81
Q

management of glottic carcinoma?

A

radiotherapy
laser surgery for selected early tumours
total laryngectomy with modified radical neck dissection in cases of residual or recurrent disease

82
Q

name for when malignant squamous tumour involves all 3 regions of larynx?

A

transglottic laryngeal carcinoma

emergency tracheostomy may be required due to resp difficulties

83
Q

over what time period where a patient is anticipated of requiring ventilation should a surgical or percutaneous tracheostomy be planned?

A

requiring ventilation for periods greater than 7-10 days

84
Q

important aspects of postop care of a tracheostomy?

A

regular physiotherapy to assist bronchial toilet
suction catheter to clear tracheal secretions
regular humidification and temp control to prevent dry crust formation-loss of normal air humidification carried out in the nose
ensure patients kept well hydrated so secretions not made thicker and so more likely to be retained and predispose to infection

85
Q

complications of a tracheostomy?

A 
immediate: haemorrhage-thyroid and anterior jugular veins, thyroid isthmus
air embolism
cricoid injury
surgical emphysema
pneumothorax
early: dysphagia-due to loss of subglottic pressure and presence of inflated tracheostomy cuff
tracheitis and tracheal crusting
atelectasis
tube blockage
tracheal erosion
late: tracheomalacia
laryngotracheal stenosis
decannulation problems
tracheocutaneous fistula/scar
tracheal erosion anteriorly-haemorrhage from brachiocephalic artery
aspiration and pneumonia
86
Q

NICE pathway for urgent (2ww) r/f for suspected laryngeal Ca?

A

people aged 45 or older with persistent unexplained hoarseness OR unexplained lump in neck.

87
Q

tracheostomy indications?

A

upper airway obstruction e.g. trauma, FB, infection, laryngeal tumour, facial fractures
impaired resp function e.g. head trauma causing unconsciousness
assist weaning from ventilatory support in patients on ITU
help clear secretions in upper airway

88
Q

at what are age are the tonsils at their largest?

A

by 2 years of age

start to decrease in size from this point, and often disappear by 8 years of age

89
Q

if a patient has a tracheostome, what should be considered in their management if giving the pt O2 therapy?

A

**tracheostome may be present post laryngectomy or if pt has a tracheostomy
if had laryngectomy, no point giving O2 by face mask, and need to place mask over the tracheostome.

90
Q

where do most benign parotid neoplasms affect?

A

the superficial lobe of the parotid gland

91
Q

why is facial nerve palsy associated with malignant parotid neoplasms?

A

the facial nerve runs through the parotid gland between the superficial and deep lobes and expansion within deep lobe will cause facial nerve compression.
any mass here tends to expand towards oropharynx causing medial tonsil displacement.

92
Q

tment of benign pleomorphic adenomas of the parotid gland?

A

superficial parotidectomy (as tumour usually in lobe superficial to facial nerve)

Special Senses (13 decks)

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