Throat Conditions Flashcards
What is a retropharyngeal abscess?
Neck infection involving abscess in the space between the pre-vertebral fascia and constrictor muscles
Most commonly seen in children
What causes retropharyngeal abscesses?
Complication of URTI from:
- strep viridans
- strep epidermis
- staph aureus
Can also be trauma or foreign body
How do retropharyngeal abscesses present?
Spiking fever
Neck pain - especially on movement
Torticollis
Dysphagia and odynophagia –> drooling
!Airway compromise!
What is torticollis?
Abnormal, asymmetrical, twisted head position
What may be seen on examination with a retropharyngeal abscess?
Tonsillar swelling
Lymphadenopathy
Oropharyngeal swelling
What investigation may you carry out for a suspected retropharyngeal abscess and what would it show?
CT with contrast - ring enhancing lesion in retropharyngeal space
What are the risk factors associated with retropharyngeal abscess?
Diabetes
Dental Infection
FB ingestion
Trauma
What complications can arise from retropharyngeal abscesses?
Airway compromise
Mediastinitis
Pericarditis
CN9 + 12 palsy
How is a retropharyngeal abscess managed?
IV dexamethasone + nebulised adrenaline
IV Abx - ampicillin
Surgical drainage
Supportive therapy
What is Ludwig’s angina?
Cellulitis of the floor of the mouth
What causes Ludwig’s angina?
Follow dental infection in 90% of cases
Parapharyngeal abscess
Mandibular fracture
Cut/piercing in mouth
Submandibular salivary stones
How does Ludwig’s angina present?
Progress over hours
Drooling - dysphagia
Bilateral lower face swelling - mandible and neck
Elevation of the floor of the mouth
Posterior displacement of the tongue - can compromise airway
Painful neck area
How would you investigate Ludwig’s angina?
CT with contrast
+ dental x rays and chest imaging
How is Ludwig’s angina managed?
Airway management
Empirical IV Abx (Benpen + metronidazole)
Surgical incision and drainage
Give some differential diagnoses for neck lumps
Reactive lymphadenopathy Lymphoma Thyroid swelling Thyroglossal cyst Pharyngeal pouch Cystic hygroma Branchial cyst Cervical Rib Carotid aneurysm Sebaceous cyst Lipoma Salivary gland problems
If a patient presents with a history of general malaise but has a neck lump, what would be your primary differential?
Reactive lymphadenopathy
What history would indicate a neck lump is a lymphoma?
Rubbery painless lymphadenopathy
+- night sweats and splenomegaly
What feature of a neck lump would indicate it is a thyroid swelling?
Moves upwards on swallowing
What history would indicate a thyroglossal cyst?
Painful - if infected
Midline (between isthmus of thyroid and hyoid)
Move up with protrusion of tongue
Commonly <20yo
What history may indicate a neck lump is a pharyngeal pouch?
HALITOSIS
Usually older men
Represent herniation between thyropharyngeus and cricopharynxgeus
Gurgle on palpation
Usually not seen but if large then midline
Dysphagia, regurgitation, aspiration, chronic cough
How would a cystic hygroma appear?
Left side
Congenital lesion - most evident at birth, 90% before 2yo
What history indicates a branchial cyst?
Oval, mobile, cystic mass
Pain and redness
Between SCM and pharynx
Usually early adulthood
What is often noted about cervical rib?
More common in adult females
10% develop thoracic outlet syndrome
How may a carotid aneurysm appear?
Pulsatile lateral neck mass
Doesn’t move on swallowing
How does a sebaceous cyst appear?
Intradermal - quite superficial
Central punctum
What may make you think a neck lump is due to salivary gland issues?
Associated with eating
Fluctuant in size
May cross mandibular angle
What questions do you ask about for a neck lump?
Fever Malaise Night Sweats? Weight Loss? Swallowing okay? Voice change? Smoker Travel?
What investigations would you request for a neck lump?
FBC and ESR - generalised lymphadenopathy
Thyroid function tests
CXR - supraclavicular and >40yo
USS and fine needle aspiration if diagnosis unclear - NOT IF PULSATILE
What is the most common head and neck cancer? What cancers do “head and neck” cancers include?
Squamous cell carcinoma
Oral cavity
Pharynx
Larynx
What are the red flags for head and neck cancers?
Neck lumps Hoarse voice Oral Ulcer > 3 weeks Red/white oral patch Lip lump Stridor Dysphagia or odynophagia >3 weeks Unilateral throat discomfort >4 weeks Tooth mobility
What are the main risk factors for head and neck cancers/
Smoking Alcohol Poor dentition Poor diet - limited fruit, veg and fish GORD HPV16
How are head and neck cancers investigated?
Fine needle aspiration cytology
How are head and neck cancers staged?
TNM staging
Whats the difference between a thyroid nodule and goitre?
Goitre - enlargement of the thyroid gland - can be multiple nodules
Lump
- can be in a normal thyroid gland or a goitre.
- can be cystic, colloid, hyperplastic, malignant or oedematous
What TFT’s would you expect to see in a non-toxic goitre?
Normal
What thyroid conditions can cause raised TFT’s?
Grave’s disease
Toxic multi nodular goitre
What happens in toxic multi nodular goitres?
Autonomously functioning thyroid nodules secrete excess hormone
What thyroid conditions can cause low TFT’s?
Hashimoto’s
De Quervain’s thyroiditis
Riedel’s thyroiditis
What history would indicate de quervain’s thyroiditis?
Painful goitre
Raised ESR
Following URTI
What happens in acute suppurative thyroiditis?
Infection causing an abscess
What history may indicate Riedel’s thyroiditis?
Painless goitre
Fibrous tissue replace thyroid parenchyma
What are the red flags for thyroid lumps?
Stridor - same day referral In a child Voice changes Rapid enlargement over weeks Cervical lymphadenopathy History of radiation exposure
How would you investigate a thyroid lump?
Thyroid function tests
US guided fine needle aspiration
Hemithyroidectomy if in diagnostic doubt
What are the types of thyroid neoplasms?
Benign - adenoma (follicular cells) Malignant: - Papillary adenocarcinoma (70%) - Follicular carcinoma (20%) - Medullary carcinoma (5%) - Anaplastic carcinoma (5%)
What history is common in papillary adenocarcinoma of the thyroid?
Most common type of malignant thyroid neoplasm
Younger patients
History of neck irradiation
What may indicate a thyroid cancer is a follicular carcinoma?
Metastasise to bones and lungs
What is important to know about medullary carcinoma’s of the thyroid?
Neoplasm of C Cells - regulate calcitonin
Typically seen in MEN syndromes - screen other organs
Genetic component
What is important to know about anaplastic thyroid carcinoma?
Typically older patients
Poor prognosis - weeks/months by time of diagnosis
How are non neoplastic thyroid nodules managed?
Conservatively
Hemithyroidectomy if airway compression, patient preference or cosmetic reasons
Avoid thyroidectomy due to complications and lifelong thyroxine req.
How are neoplastic thyroid nodules managed?
Adenoma - diagnostic hemithyroidectomy
Carcinoma - total thyroidectomy
What complications are associated with thyroid surgery?
Post-operative haemorrhage
Airway obstruction - haemorrhage or vocal cord palsy
Vocal cord palsy
Hypocalcaemia
What are the salivary glands?
Parotid
Sublingual
Submandibular
Which salivary gland is normally affected by calculi?
Submandibular - 80%
What makes up most salivary calculi?
Calcium phosphate or calcium carbonate
70% radioopaque
How does sialiolithiasis usually present?
Colicky pain and post prandial swelling of the gland
How is sialolithiasis diagnosed?
Sialography - demonstrate site of obstruction
How is sialolithiasis managed?
Distal aspect of Wharton’s duct - remove orally
Other stones and chronic inflammation - gland excision
What ducts are connected to each salivary gland?
Parotid - Stensons duct
Submandibular - Wharton’s duct
Sublingual - duct of Rivinus
What is sialadenitis?
Infection of the salivary glands
Usually due to staph aureus tracking from oral cavity
What risk factors are associated with sialadenitis?
Decreased saliva or obstruction Dehydration Malnourishment Radiotherapy Drugs - antihistamines, beta blockers, diuretics
How is sialadenitis managed?
Abx - fluclox and metronidazole
Warm compress - encourage flow
Hydration
How does sialadnitis present?
Reduced saliva Bad taste in mouth - pus Pain Swelling Redness of skin
What is Sjogrens syndrome?
Autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces
May be primary or secondary to rheumatoid arthritis/other connective tissue disorders
Who is Sjogren’s more common in?
Females
What does Sjogren’s increase risk of ?
Lymphoid malignancy - 40-60fold increase
What are the main features of Sjogrens?
Dry eyes dry mouth vaginal dryness arthralgia Raynaud's Myalgia Sensory polyneuropathy Recurrent parotitis Renal tubular acidosis - usually subclinical
What antibodies are associated with Sjogrens
Rheumatoid Factor - nearly 100% of patients
ANA - 70%
Anti-Ro - 70% with primary sjogrens
Anti-La - 30% of primary sjogrens
What other investigations are indicated for suspected Sjogrens?
Schirmers test - filter paper near conjunctival sac to measure tear formation
Histology - focal lymphocytic infiltration
Hypergammaglobulinaemia
How is Sjogren’s managed?
Artificial saliva and tears
Pilocarpine - may stimulate saliva production
