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ENT > Neck Lump > Flashcards

Neck Lump Flashcards

1
Q

What questions do you want to ask when a patient presents with a neck lump?

A
  • Duration - when did it appear
  • Change in size
  • Associated features - pain/redness/discharge
  • Lumps elsewhere (armpit/groin&raquo_space; lymphoma metastasis)
  • Preceding symptoms: particularly coryzal/tonsillitis/pharyngitis (any recent infections/illness)
  • Recent travel - particularly to areas where TB is endemic
  • Contact with TB patients
  • Occupation - petrochemical wood industry
  • Exposure to radiation
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2
Q

What are red flag symptoms for the neck and throat?

A
  • Persistent sore throat
  • Hoarseness
  • Dysphagia
  • Odynophagia
  • Weight loss, fevers, night sweats, appetite loss
  • New unexplained lump
  • Ulceration in oral cavity >3 weeks
  • Red/red and white patch in oral cavity
  • Smoker or previous HPV
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3
Q

What examination would you do for a neck lump?

A
  • Neck exam
  • Oral cavity: inspect floor of mouth, tongue, cheek mucosa, dentition, gums and anterior tonsillar pillar (use light source)
  • Nasopharynx: fibreoptic endoscope
  • Oropharynx: head light and tongue depressor (make sure to check tonsillar fossae)
  • Larynx: fibreoptic endoscope, only in ENT clinic, if there are any persistent symptoms relating to the larynx e.g. dysphonia for >6 weeks then urgent referral to ENT
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4
Q

What would a neck lump in reactive lymphadenopathy feel like and how would you treat it?

A

Rubbery, non-tender and non-fluctuant lump, post-infection.

No red flag symptoms - doesn’t need to be removed and will continue to reduce in size over time, no further treatment.

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5
Q

What are investigations for a neck lump?

A
  1. 1st line: US, fine needle aspiration cytology (FNAC) (using US guidance)
  2. Incisional biopsy if FNAC doesn’t show anything
  3. CT - very useful
  4. Excision biopsy - should only be performed as part of wider dissection of all cervical lymph nodes. As in certain circumstances, like excision of a metastatic lymph node, has a detrimental effect on outcome.
  5. MRI - useful but not 1st line
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6
Q

What are the risk factors for squamous cell carcinoma of the head and neck?

A
  • Betel nut chewing - common in India/Asia and around Pacific, it is carcinogenic and one of the main causes of oropharyngeal cancer around the world
  • Alcohol
  • Smoking
  • Human Papilloma Virus (HPV) - responsible for emergence of head and neck cancers in much younger patients i.e. 20-40s
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7
Q

What are the steps for diagnosing head and neck cancer?

A
  • Panendoscopy + biopsy: examination under anaesthesia of pharynx, larynx and upper oesophagus, this is to find the primary site and obtain tissue for histological diagnosis
  • CT skull base to diaphragm to assess event of the primary tumour and to identify any regional or distant metastasis
  • MDT meeting
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8
Q

What other symptoms do you want to ask about in a presentation of hoarseness (dysphonia)?

A
  • Dysphagia
  • Odynophagia (pain on swallowing)
  • Weight loss
  • Heartburn or indigestion - GORD can cause inflammation of larynx and dysphonia
  • Postnasal drip or other nasal symptoms: excessive nasal discharge can cause dysphonia through excessive throat clearing
  • Systemic upset
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9
Q

What are the NICE guidelines for urgent referral 2 week wait of head and neck malignancy?

A
  • Hoarseness >6 weeks
  • Oral swellings >3 weeks
  • Dysphagia >3 weeks
  • Unilateral nasal obstruction, particularly when associated with purulent discharge
  • Unresolving neck masses >3 weeks
  • Cranial neuropathies
  • Orbital masses
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10
Q

What symptoms need to be referred to maxillofacial surgery?

A
  • All red or red and white patches of oral mucosa
  • Ulceration of oral mucosa persisting for >3 weeks
  • Unexplained teeth mobility not associated with periodontal disease
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11
Q

What would inflammation/neoplasia of the oropharynx cause?

A
  • Sore throat
  • Odynophagia
  • Dysphagia
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12
Q

What symptoms would lesions inside and outside the larynx cause?

A
  • Inside: dysphonia

- Outside: dysphonia by damage to recurrent laryngeal nerve or vagus nerve&raquo_space; paralysis of vocal folds

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13
Q

What are the common causes of dysphonia?

A
  • Overuse
  • Acute laryngitis
  • Chronic laryngitis secondary to reflux
  • Use of asthma inhalers
  • Smoking
  • SCC of larynx
  • Vocal cord palsy
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14
Q

Why should you examine the neck with dysphonia?

A
  • Lymphadenopathy: may be reactive to infection or neoplastic from metastatic spread of SCC
  • Lymphoma can cause generalised lymphadenopathy
  • Thyroid disease: benign thyroid disease is rarely associated with dysphonia, except malignant thyroid disease (invades recurrent laryngeal nerve)
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15
Q

What are risk factors for dysphonia?

A
  • Tobacco products - especially smokeless tobacco (risk factor for development of SCC in upper aerodigestive tract)
  • Excessive alcohol
  • EBV, HPV, GORD
  • Vocal abuse i.e. overuse + asthma inhalers are important, although benign
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16
Q

What are the differential diagnosis for vocal cord lesions?

A
  • Vocal fold polyp: benign inflammatory lesions of vocal fold and usually result from overuse. May settle with appropriate speech therapy but in resistant cases the polyp can be removed surgically using special instruments.
  • SCC of larynx: lobulated mass, potentially unilateral, can affect fold mobility and this suggests invasion of muscles and possibly cartilaginous skeleton of larynx. It is not uncommon for these lesions to produce keratin, giving them a white coloured film over the surface. Potential associated neck lump which would suggest metastasis.
17
Q

What is Reinke’s oedema?

A

Condition in which the vocal folds become very oedematous with accumulation of a gelatinous material within the vocal fold. It occurs most commonly in females and usually in smokers. The treatment is cessation of smoking, control of gastroesphageal reflux and in refractive cases incision of the vocal fold with evacuation of gelatinous material.

18
Q

What would be the next stage of investigation if FNAC confirms metastatic disease?

A
  • Biopsy (histology): allows diagnosis to be confirmed and provides important prognostic information (TNM staging)
  • Panendoscopy: examine thoroughly the upper aerodigestive tract and oesophagus when assessing the extent of any potential carcinoma. The oral cavity, nasopharynx, oropharynx, hypopharynx, larynx and upper oesophagus are examined using a rigid endoscope. Any lesions identified are then biopsied and specimens sent to histopathologists for assessment
  • MDT discussion
19
Q

What are the treatments for head and neck cancer?

A
  • Radiotherapy: can be used for curative intent or palliation
  • Surgical: resection of tumour
  • Chemotherapy: not usually curative, can be used to shrink a tumour down prior to surgery/radiotherapy
  • Palliative management: involves symptomatic control for patients who cannot be cured or decide not to have curative treatment
  • Rehabilitation: treatment of head and neck can result in significant problems including voice problems and swallowing problems - appropriate rehabilitation can help recovery of function.
20
Q

What are differentials for a lump in the midline of the neck?

A
  • Dermoid cyst
  • Cervical lymphadenopathy
  • Thyroid lump/goitre
  • Thyroglossal cyst
21
Q

What are causes of thyroid nodules?

A
  • Benign: follicular adenoma, hyperplastic nodules, thyroid cyst
  • Malignant: papillary carcinoma, follicular carcinoma, medullary carcinoma, anaplastic carcinoma, lymphoma (uncommon)
22
Q

What does grading on an US and FNAC scan mean?

A

The ‘U’ and ‘TH’ classifications refer to the likelihood of malignancy based on the ultrasound scan and FNAC scan respectively (out of 5). If both are grade 5 it is highly suggestive of malignancy.

23
Q

What are common causes of generalised thyroid swelling?

A
  • Physiological - pregnancy, puberty
  • Degenerative - multinodular goitre
  • Thyroiditis - most commonly Hashimoto’s thyroiditis
  • Grave’s disease
24
Q

What symptoms alongside a thyroid lump would make you suspicious of malignancy?

A
  • Stridor: inspiratory noise breathing and suggests narrowing of upper airway, only present when thyroid is large
  • Thyroid nodule in a child: this is rare so needs to be investigated urgently
  • Enlarged cervical lymph nodes: lymphadenopathy&raquo_space; malignancy
  • Rapidly enlarging painless thyroid mass: any mass showing rapid growth&raquo_space; malignancy
  • Unexplained hoarseness: presence suggests invasion of recurrent laryngeal nerve&raquo_space; malignancy
25
Q

What is the treatment for thyroid cancer?

A
  • Surgery (thyroidectomy): removal of neck lymph nodes may also be recommended, parathyroid glands may get damaged/removed (results in hypocalcaemia)
  • Radioactive iodine: post-operatively for larger tumours or those with unfavourable histological features/distant spread
  • Immunotherapy/external beam radiotherapy: role in management of inoperable/recurrent disease or distant disease that’s failed to respond to previous radioactive iodine therapy
  • Chemotherapy not used to treat thyroid malignancy
26
Q

What is a cystic hygroma?

A
  • Not infection or cancer
  • Congenital malformation - lump of tissue
  • Presents in babies usually
27
Q

What is a branchial cyst?

A
  • Presents in 2nd-3rd decade

- Often following URTI

ENT (8 decks)

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