THROAT AND NECK Flashcards
Description of reteropharyngeal abscess
Anterior to the prevertebral fascia, behind the pharynx, is a potential space, the retropharyngeal space, where an abscess may form. This space extends from the base of the skull to the mediastinum.
clinical features of reteropharyngeal abscess
Commonly in young children, commonly after an URTI
Neck held rigid and upright with reluctance to move
Systemically unwell
Airway compromise
Dysphagia/Odynophagia
Widening of the retropharyngeal space on lateral X-Ray
Associated mortality due to airway problems & mediastinitis
investigations of reteropharyngeal abscess
CT neck
management of reteropharyngeal abscess
Secure airway if any concerns
IV antibiotics
Surgery - Incision & drainage
what is the anterior triangle
midline of the neck
lateral anterior border of SCM
Superior - lower border of the mandible
what is the posterior triangle
posterior - anterior trapezium
base - middle 1/3rd of clavicle
anterior - post border of SCM
features of peritonsillar abscess
severe throat pain, which lateralises to one side
deviation of the uvula to the unaffected side
trismus (difficulty opening the mouth)
reduced neck mobility
management of quinsy
needle aspiration or incision & drainage + intravenous antibiotics
tonsillectomy should be considered to prevent recurrence
what is secondary haemorrhage in tonsillectomy
Haemorrhage occuring 5-10 days post-tonsillectomy is referred to as secondary haemorrhage. In the majority of cases this is due to infection
post op complications of tonsillectomy
Pain
The pain may increase for up to 6 days following a tonsillectomy.
Haemorrhage
Haemorrhage is a feared complication following tonsillectomy. All post-tonsillectomy haemorrhages should be assessed by ENT.
Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre.
Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in around 1-2% of all tonsillectomies.
dry mouth for a few months
sensation of grittiness in her eyes
On examination she has a diffuse swelling of her parotid gland. There is no evidence of facial nerve palsy.
Sjogren’s syndrome
In which age group sjogrens common
post menopausal women
sarcoidosis symptoms
bilateral parotid gland swelling and symptoms of a dry mouth. On examination she has bilateral facial nerve palsies. This improved following steroid treatment.
pancreatitis and bilateral painful parotid enlargement
mumps
when to susupect mumps in young adults
young adult with parotid swelling and pancreatitis/orchitis/reduced hearing/meningoencephalitis suspect mumps.
which site of salivary gland is the most common for tumours
parotid gland
do benign salivary gland tumours invade structures such as the facial nerve
NO except Warthins tumours
Types of bening salivary gland tumours
Benign pleomorphic adenoma or benign mixed tumour
Warthin tumour (papillary cystadenoma lymphoma or adenolymphoma)
monomorphic adenoma
haemangioma
features of Benign pleomorphic adenoma or benign mixed tumour
Most common parotid neoplasm (80%)
Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components
Slow growing, lobular, and not well encapsulated, painless
Recurrence rate of 1-5% with appropriate excision (parotidectomy)
Recurrence possibly secondary to capsular disruption during surgery
Malignant degeneration occurring in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma
features of Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma)
Second most common benign parotid tumor (5%)
softer, more mobile and fluctuant (although difficult to differentiate
Most common bilateral benign neoplasm of the parotid
Marked male as compared to female predominance
Occurs later in life (sixth and seventh decades)
Presents as a lymphocytic infiltrate and cystic epithelial proliferation
May represent heterotopic salivary gland epithelial tissue trapped within intraparotid lymph nodes
Incidence of bilaterality and multicentricity of 10%
Malignant transformation rare (almost unheard of)
features of Monomorphic adenoma
Account for less than 5% of tumours
Slow growing
Consist of only one morphological cell type (hence term mono)
Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas
features of haemangioma
Should be considered in the differential of a parotid mass in a child
Accounts for 90% of parotid tumours in children less than 1 year of age
Hypervascular on imaging
Spontaneous regression may occur and malignant transformation is almost unheard of
types of malignant tumors
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
mixed tumors
acinic cell carcinoma
adenocarcinoma
features of mucoepidermoid carcinoma
30% of all parotid malignancies
Usually low potential for local invasiveness and metastasis (depends mainly on grade)
features of adenoid cystic carcinoma
Unpredictable growth pattern
Tendency for perineural spread
Nerve growth may display skip lesions resulting in incomplete excision
Distant metastasis more common (visceral rather than nodal spread)
5 year survival 35%
features of mixed tumors
Often a malignancy occurring in a previously benign parotid lesion
features of acinic cell carcinoma
Intermediate grade malignancy
May show perineural invasion
Low potential for distant metastasis
5 year survival 80%
features of adenocarcinoma
Develops from secretory portion of gland
Risk of regional nodal and distant metastasis
5 year survival depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvement
features of lymphoma
Large rubbery lesion, may occur in association with Warthins tumours
Diagnosis should be based on regional nodal biopsy rather than parotid resection
Treatment is with chemotherapy (and radiotherapy)
Diagnostic evaluation of salivary gland tumours
Plain x-rays may be used to exclude calculi
Sialography may be used to delineate ductal anatomy
FNAC is used in most cases
Superficial parotidectomy may be either diagnostic of therapeutic depending upon the nature of the lesion
Where malignancy is suspected the primary approach should be definitive resection rather than excisional biopsy
CT/ MRI may be used in cases of malignancy for staging primary disease
risk factors for salivary gland tumours
• Direct radiation exposure • Epstein-Barr virus (EBV) infection • Smoking* • Genetic alterations (p53 mutations) *Tobacco smoke has been associated with the development specifically to Warthins tumour
treatment for salivary gland tumours
- surgical resection
- benign - superficial parotidectomy
- malignant disease - radical or extended radical parotidectomy, facial nerve is included in the resection if involved.
neck dissection is determined by the potential for nodal involvement.
how does HIV affect the salivary galnds
Lymphoepithelial cysts associated with HIV occur almost exclusively in the parotid
Typically presents as bilateral, multicystic, symmetrical swelling
Risk of malignant transformation is low and management usually conservative
What is sjogrens
Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicca
90% of cases occur in females
Second most common connective tissue disorder
Bilateral, non tender enlargement of the gland is usual
Histologically, the usual findings are of a lymphocytic infiltrate in acinar units and epimyoepithelial islands surrounded by lymphoid stroma
Treatment is supportive
There is an increased risk of subsequent lymphoma
how does sarcoidosis affect salivary glands
Parotid involvement occurs in 6% of patients with sarcoid
Bilateral in most cases
Gland is not tender
Xerostomia may occur
Management of isolated parotid disease is usually conservative
DD for salivary gland tumours
- Sialoliathiasis
- Chronic sialadenitis
- Autoimmune disease
- Lymphoproliferative disorders
- DIAGNOSIS UNCERTAIN – HIV should be considered
what are the non surgical options for slaivary gland tumours
- Radiotherapy – adjuvant following surgery – higher grade tumours
o Malignant – resection margin is positive, hidtological features of an aggressive tumour
o Recurrent pleomorphic salivary adenoma
o Chemotherapy only for palliative care
early complications of surgery of salivary gland tumours
Early
Haematoma is an important post-operative complication. A rapidly expanding haematoma may cause airway obstruction, hence close observation of these patients post-operatively is paramount.
Facial nerve injury or sacrifice intra-operatively must be included in any consent for the resection procedures*. Transient facial nerve paresis resolves in 3-12 weeks. It is now common practice to use facial nerve monitoring during parotid surgery. During submandibular gland surgery, the marginal mandibular, hypoglossal and lingual nerve may also be injured.
*If injury of the facial nerve is noted intra-operatively, grafting with the greater auricular nerve can be performed if deemed suitable
early complications of surgery of salivary gland tumours
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. Salivary fistula is also a recognised complication.
DD for neck lumps
reactive lymphadenopathy lymphoma thyroid swelling thyroglossal cyst pharyngeal pouch cystic hygroma branchial cyst cervical rib carotid aneurysm
features of Reactive lymphadenopathy
By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness
features of lymphoma
Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon hodgkins lymphoma
There may be associated night sweats and splenomegaly
features of thyroid swelling
May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing
what is thyroglossal cyst
More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected
what is pahryngeal pouch
More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
symptoms of pharyngeal pouch
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough
halitosis
throat infections
what is cystic hygroma
A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years of age
transilluminate
Collection of dilated lymphatic sacs
what is a brachial cyst
An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood
what is cervical rib
More common in adult females
Around 10% develop thoracic outlet syndrome
what is carotid aneurysm
Pulsatile lateral neck mass which doesn’t move on swallowing
what is ludwig’s angina
cellulitis which occurs on the floor of the mouth of the patient. It is deadly, as it spreads in the fascial spaces of the head and neck. Due to the infection, the swelling that ensues from the inflammation begins to push the floor of the mouth upwards and blocks air entry.
risk factors for ludwig’s angina
immunocompromised ie IV drug user
poor dentition
Pericoronitis (inflammation surrounding a partially erupted wisdom tooth) can also predispose one to this
features for an EBV infection
monospot test positive
splenomegaly
features of ludwigs angina
dysphagia malaise fatigue pyrexial extensive swelling of her submental and submandibular lymph nodes. There is pharyngeal oedema and extensive erythema on the floor of her mouth, however, no exudation can be seen on the tonsils and there are no abscesses near the tonsils .
stridor
difficulty breathing
causes of salivary gland enlargement apart from cancer
acute viral infection e.g. mumps
acute bacterial infection e.g. 2nd to dehydration diabetes
sicca syndrome and Sjogren’s (e.g. RA)
what is bartonella infection
may occur following a cat scratch. The organism is intracellular. Generalised systemic symptoms may occur for a week or so prior to clinical presentation.
features of bartonella infection
symptoms of abdominal pain, lethargy and sweats. These have been present for the past two weeks. On examination she has lymphadenopathy in the posterior triangle.
What is found inside a branchial cyst
The cyst is filled with acellular fluid with cholesterol crystals and encapsulated by stratified squamous epithelium. Branchial cysts may have a fistula and are therefore prone to infection. They may enlarge following a respiratory tract infection.
branchial cyst on examination
unilateral, typically on the left side
lateral, anterior to the sternocleidomastoid muscle
slowly enlarging
smooth, soft, fluctuant
non-tender
a fistula may be seen
no movement on swallowing
no transillumination
DD neck lump in children
congenital: branchial cyst, thyroglossal cyst, dermoid cyst, vascular malformation
inflammatory: reactive lymphadenopathy, lymphadenitis
neoplastic: lymphoma, thyroid tumour, salivary gland tumour
diagnosis and Ix for branchial cysts
consider and exclude other malignancy
ultrasound
referral to ENT
fine-needle aspiration
management of ludwigs angina
airway management
intravenous antibiotics
ECG changes you see in hypocalcaemia
prolonged QT interval
ECG changes you see in hypercalcaemia
shortened ST segment
ECG changes you see in hypermagnesaemia
prolonged PR interval
ECG changes you see in hyperkalaemia
tall peaked T waves
complications of thyroid surgery
Anatomical such as recurrent laryngeal nerve damage.
Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
Damage to the parathyroid glands resulting in hypocalcaemia.
features of crohns
ulcer in oral cavity
weight loss
ulcer - noncaseating granulomata
cell type for pharngeal cancer
squamous cell carcinoma
risk facts for pharyngeal cancer
smoking
HPV
chewing tobacco
older age
causes of gingivial hyperplasia
phenytoin
ciclosporin
calcium channel blockers (especially nifedipine)
acute myeloid leukaemia
adenoid hypertrophy presentation
breathing problems sleep apnoea middle ear infection sinusitis OME
Tx for adenoid hypertrophy
1) nasal steroids
2) adenoidectomy
facts regarding parotid glans
80% of parotid tumours are benign
80% of benign tumours are pleomorphic adenomas
most common parotid lesion in children
haemangioma
most common parotid malignancy in adults
mucoepidermoid carcinoma
