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ENT > THROAT AND NECK > Flashcards

THROAT AND NECK Flashcards

1
Q

Description of reteropharyngeal abscess

A

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.

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2
Q

clinical features of reteropharyngeal abscess

A

 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

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3
Q

investigations of reteropharyngeal abscess

A

CT neck

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4
Q

management of reteropharyngeal abscess

A

 Secure airway if any concerns
 IV antibiotics
 Surgery - Incision & drainage

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5
Q

what is the anterior triangle

A

midline of the neck
lateral anterior border of SCM
Superior - lower border of the mandible

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6
Q

what is the posterior triangle

A

posterior - anterior trapezium
base - middle 1/3rd of clavicle
anterior - post border of SCM

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7
Q

features of peritonsillar abscess

A

severe throat pain, which lateralises to one side

deviation of the uvula to the unaffected side

trismus (difficulty opening the mouth)

reduced neck mobility

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8
Q

management of quinsy

A

needle aspiration or incision & drainage + intravenous antibiotics
tonsillectomy should be considered to prevent recurrence

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9
Q

what is secondary haemorrhage in tonsillectomy

A

Haemorrhage occuring 5-10 days post-tonsillectomy is referred to as secondary haemorrhage. In the majority of cases this is due to infection

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10
Q

post op complications of tonsillectomy

A

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.

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11
Q

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.

A

Sjogren’s syndrome

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12
Q

In which age group sjogrens common

A

post menopausal women

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13
Q

sarcoidosis symptoms

A

bilateral parotid gland swelling and symptoms of a dry mouth. On examination she has bilateral facial nerve palsies. This improved following steroid treatment.

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14
Q

pancreatitis and bilateral painful parotid enlargement

A

mumps

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15
Q

when to susupect mumps in young adults

A

young adult with parotid swelling and pancreatitis/orchitis/reduced hearing/meningoencephalitis suspect mumps.

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16
Q

which site of salivary gland is the most common for tumours

A

parotid gland

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17
Q

do benign salivary gland tumours invade structures such as the facial nerve

A

NO except Warthins tumours

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18
Q

Types of bening salivary gland tumours

A

Benign pleomorphic adenoma or benign mixed tumour

Warthin tumour (papillary cystadenoma lymphoma or adenolymphoma)

monomorphic adenoma

haemangioma

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19
Q

features of Benign pleomorphic adenoma or benign mixed tumour

A

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

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20
Q

features of Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma)

A

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)

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21
Q

features of Monomorphic adenoma

A

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

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22
Q

features of haemangioma

A

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

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23
Q

types of malignant tumors

A

Mucoepidermoid carcinoma

Adenoid cystic carcinoma

mixed tumors

acinic cell carcinoma

adenocarcinoma

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24
Q

features of mucoepidermoid carcinoma

A

30% of all parotid malignancies

Usually low potential for local invasiveness and metastasis (depends mainly on grade)

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25
Q

features of adenoid cystic carcinoma

A

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%

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26
Q

features of mixed tumors

A

Often a malignancy occurring in a previously benign parotid lesion

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27
Q

features of acinic cell carcinoma

A

Intermediate grade malignancy
May show perineural invasion
Low potential for distant metastasis
5 year survival 80%

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28
Q

features of adenocarcinoma

A

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

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29
Q

features of lymphoma

A

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)

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30
Q

Diagnostic evaluation of salivary gland tumours

A

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

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31
Q

risk factors for salivary gland tumours

A 
•	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
32
Q

treatment for salivary gland tumours

A
  • 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.

33
Q

how does HIV affect the salivary galnds

A

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

34
Q

What is sjogrens

A

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

35
Q

how does sarcoidosis affect salivary glands

A

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

36
Q

DD for salivary gland tumours

A
  • Sialoliathiasis
  • Chronic sialadenitis
  • Autoimmune disease
  • Lymphoproliferative disorders
  • DIAGNOSIS UNCERTAIN – HIV should be considered
37
Q

what are the non surgical options for slaivary gland tumours

A
  • 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
38
Q

early complications of surgery of salivary gland tumours

A

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

39
Q

early complications of surgery of salivary gland tumours

A

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.

40
Q

DD for neck lumps

A 
reactive lymphadenopathy
lymphoma
thyroid swelling
thyroglossal cyst
pharyngeal pouch
cystic hygroma
branchial cyst
cervical rib
carotid aneurysm
41
Q

features of Reactive lymphadenopathy

A

By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness

42
Q

features of lymphoma

A

Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon hodgkins lymphoma
There may be associated night sweats and splenomegaly

43
Q

features of thyroid swelling

A

May be hypo-, eu- or hyperthyroid symptomatically

Moves upwards on swallowing

44
Q

what is thyroglossal cyst

A

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

45
Q

what is pahryngeal pouch

A

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

46
Q

symptoms of pharyngeal pouch

A

Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

halitosis
throat infections

47
Q

what is cystic hygroma

A

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

48
Q

what is a brachial cyst

A

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

49
Q

what is cervical rib

A

More common in adult females

Around 10% develop thoracic outlet syndrome

50
Q

what is carotid aneurysm

A

Pulsatile lateral neck mass which doesn’t move on swallowing

51
Q

what is ludwig’s angina

A

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.

52
Q

risk factors for ludwig’s angina

A

immunocompromised ie IV drug user
poor dentition
Pericoronitis (inflammation surrounding a partially erupted wisdom tooth) can also predispose one to this

53
Q

features for an EBV infection

A

monospot test positive

splenomegaly

54
Q

features of ludwigs angina

A 
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

55
Q

causes of salivary gland enlargement apart from cancer

A

acute viral infection e.g. mumps
acute bacterial infection e.g. 2nd to dehydration diabetes
sicca syndrome and Sjogren’s (e.g. RA)

56
Q

what is bartonella infection

A

may occur following a cat scratch. The organism is intracellular. Generalised systemic symptoms may occur for a week or so prior to clinical presentation.

57
Q

features of bartonella infection

A

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.

58
Q

What is found inside a branchial cyst

A

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.

59
Q

branchial cyst on examination

A

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

60
Q

DD neck lump in children

A

congenital: branchial cyst, thyroglossal cyst, dermoid cyst, vascular malformation
inflammatory: reactive lymphadenopathy, lymphadenitis
neoplastic: lymphoma, thyroid tumour, salivary gland tumour

61
Q

diagnosis and Ix for branchial cysts

A

consider and exclude other malignancy
ultrasound
referral to ENT
fine-needle aspiration

62
Q

management of ludwigs angina

A

airway management

intravenous antibiotics

63
Q

ECG changes you see in hypocalcaemia

A

prolonged QT interval

64
Q

ECG changes you see in hypercalcaemia

A

shortened ST segment

65
Q

ECG changes you see in hypermagnesaemia

A

prolonged PR interval

66
Q

ECG changes you see in hyperkalaemia

A

tall peaked T waves

67
Q

complications of thyroid surgery

A

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.

68
Q

features of crohns

A

ulcer in oral cavity
weight loss
ulcer - noncaseating granulomata

69
Q

cell type for pharngeal cancer

A

squamous cell carcinoma

70
Q

risk facts for pharyngeal cancer

A

smoking
HPV
chewing tobacco
older age

71
Q

causes of gingivial hyperplasia

A

phenytoin
ciclosporin
calcium channel blockers (especially nifedipine)

acute myeloid leukaemia

72
Q

adenoid hypertrophy presentation

A 
breathing problems
sleep apnoea
middle ear infection
sinusitis
OME
73
Q

Tx for adenoid hypertrophy

A

1) nasal steroids

2) adenoidectomy

74
Q

facts regarding parotid glans

A

80% of parotid tumours are benign

80% of benign tumours are pleomorphic adenomas

75
Q

most common parotid lesion in children

A

haemangioma

76
Q

most common parotid malignancy in adults

A

mucoepidermoid carcinoma

ENT (15 decks)

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