9. Salivary Gland Tonsils

Question 1

What is involved in examination of the salivary ducts?

Answer 1

Bimanual palpation
Facial nerve function
Oropharynx

Question 2

Describe the suite of investigations most used in the dx of salivary gland disease?

Answer 2

FBC/UEC/LFT/RF/ANA/Anti rho/ACE

Sialogram
CT
MRI

Question 3

What are the three types of Infectious Parotitis?

Answer 3

Viral
Bacterial
TB

Question 4

What are the clinical features of infectious parotitis?

Answer 4

Hx/Symptoms 
Likely viral (mumps, tender bilateral enlarged parotids + trismus, Self limiting, supportive treatment at home, Can lead to serious complication = pancreatitis which can be very acute) 

(HIV, chronic enlargement, lymphoepithelial cysts)

(Coxsaki can also cause)

Bacterial (Staphylococcal)
TB always Ddx for any lump anywhere.
Red tender ulcerative mass = U/S

Question 5

What are the main causative organisms in viral infectious parotitis? Signs of Each?

Answer 5

Mumps

• Paramyxovirus
• Tender bilaterally enlarged and trismus
• Complications

HIV

• Chronic enlargement
• Lymphoepithelial cysts

Question 6

What are the main causative organisms in bacterial infectious parotitis? Signs of Each?

Answer 6

Staphylococcal

Elderly and immunocompromised

Question 7

What is Sjogren Syndrome?

Answer 7

AI disorder defined by periductal lymphocytes in multiple organs

40% have salivary gland involvement.

Question 8

How is Sjogren Syndrome classified?

Answer 8

Classified into
Primary Sjögren syndrome(sicca complex)
- Xerostomia, xerophtalmia and no connective tissue abnormality

Secondary Sjögren syndrome
= Associated with autoimmune diseases such as lupus erythematosus or rrheumatoid arthritis

Question 9

What is the Dx work-up for Sjogren Syndrome?

Answer 9

Work up – autoimmune screen (rheumatology really)

Question 10

What is Sialolithiasis?

Answer 10

Calculi in salivary ducts
Usually in mucous secreting gland 
80% in SMG
65% are radiopaque
Swelling on eating + pain

Question 11

What is the treatment for sialolithiasis? How is it Dx?

Answer 11

Removal under LA (most) or GA/ Resection of the gland (if recurrent, incision through neck)

Stitch behind the stone to make sure it doesn’t fall down before removing.

Dx using a sialogram, or a sialolscope (prof current mainly performs these, usually when not amenable to GA)

Question 12

What is the 80 rule in Salivary Gland Neoplasms?

Answer 12

80% n parotid, 80% these benign, 80% of benigns are pleomorphic adenomas.

Question 13

How does the Submandibular gland differ?

Answer 13

1/3 of tumours arising in the SMG malignant

Question 14

Who does salivary gland neoplasms commonly affect?

Answer 14

Generally in >60yo

Question 15

What are the two most common benign tumours of the salivary glands?

Answer 15

Pleomorphic

Warthins

Question 16

What are the characteristics of Pleomorphic Adenoma?

Answer 16

Painless, slowly enlarging, smooth masses

Peak incidence in 5th decade

Arise from intercalated and myopethelial cells

Pseudocapsule-pseudopodia

Carcinoma ex pleomarphic carcinoma

Facial Nerve Involvement only happens with malignant!

Recurrency v. hard to deal with as it occurs dispersed manner in small numerous growths

Question 17

What are the charateristics of Warthins Duct Tumour?

Answer 17

Adenolymphoma or cystadenoma
Male
10% bilateral
60-70yrs

Question 18

What is the Tx for Pleomorphic Adenoma?

Answer 18

Take all out if ≤55 as small percentage will become malignant.

In parotid lump Examine all skin of face as may be a mets from another CC

Question 19

What are the most common types of malignant salivary gland tumour?

Answer 19

Adenoid Cystic Carcinoma

Adenocarcinoma

Mucoepidermoid Carcinoma

Question 20

What are the characteristics of adenoid cystic carcinomas?

Answer 20

Occurs more frequently in minor salivary glands
Slow growing
Spreads along nerve sheaths

Question 21

What is the prevalence of adenocarcinomas?

Answer 21

3% parotid tumours and 10% SMG

Question 22

What are the characteristics of mucoepidermoid carcinoma?

Answer 22

Mainly parotid

Variable maligancy depending on degree of differentiation

Question 23

Describe the Staging of Salivary Gland Tumours?

Answer 23

T0-no clinical evidence of tumour

T1-6cm

Question 24

What is the treatment for Malignant Salivary Gland Tumours

Answer 24

Dependent on stage
Surgical
Adjuvant chemotherapy
Adjuvant Radiation

Question 25

What are the potential complication of salivary gland surgery?

Answer 25

Surgical Complications Facial nerve injury Haematoma Salivary fistula Freys syndrome

Question 26

What is the function of the Thyroid?

Answer 26

Increases protein catabolism Increases fat metabolism Increases gluconeogenesis, glycogenolysis Regulation of gut, skin and hair development

Question 27

Describe how you would assess the thyroid?

Answer 27

Hx Neck examination MNG/Diffusely enlarged/single nodule Compressive symptoms??? Thyroid status

Question 28

How might thyroid pathology present?

Answer 28

Diffuse enlarge goitre (unless compressive symptoms, management is endodrine, can occur psychological goitre esp in preg with no hypo/hyper function) Nodule, again come to ENT if compression problems, esp to airway.

Question 29

What investigations may indicate thyroid pathology?

Answer 29

``` TFTS Autoantibodies US Fine needle aspiration CT neck and thorax if retrosternal extension ```

Question 30

What are the malignant thyroid tumour features which may appear on U/S?

Answer 30

``` Hypoechoic Nodule Microcalcifications Irregular Border AP>TD Intranodular Flow ```

Question 31

What are the features of benign thyroid tumour which may appear on U/S

Answer 31

* Cystic * Peripherlal calcification * Peripheral vascularity * Hyperechoic ring around nodule

Question 32

What are the risk factors for malignancy of the thyroid?

Answer 32

Male/>45yrs/previous irradiation Assoc lymphadenopathy Systemic features Compressive symptoms? Difficulty breathing? Dysphonea (recurrent laryngeal nerve supplies the vocal chords) Any family history of thyroid cancer (MENS, any adrenal/other mens cancers), previous radiation ( childhood cancer?, Eastern Europe.

Question 33

Extending lymph nodes, systemic features (weight loss + fatigue) = ?

Answer 33

Suggests lymphoma as opposed to carcinoma as tc is slow growing and indolent , refere to haematology and full work up involveing ct, bloods,

Question 34

How are the possible results of FNA classified?

Answer 34

Type 1= Non dx, repeat Type 2 non-neoplastic Type 3 Worrying features but cells too scanty to qualify as type 4 Type 4 Suspicious of malignancy (75% but only 25% will be malignant) Type 5 Diagnositc of malignany All discussed as part of a MD team

Question 35

What are the characteristics of Papillary TC?

Answer 35

``` 75% Younger Irradiation Mulitfocal Cervical LN Spread ```

Question 36

What are the characteristics of Follicular TC?

Answer 36

20% Unifocal Haematogenous and lymphatic spread

Question 37

What are the characteristics of Anaplastic TC?

Answer 37

5.00%

Question 38

What are the characteristics of Medullary TC?

Answer 38

5% • C-cells • Night sWEATS • Lmphadenompathy

Question 39

What are the complications of Thyroidectomy?

Answer 39

Always divide into general/thyroidectomy specific Can also divide into intermediate, early delayed TS = Hypothyroidism, if total, synthetic hormone rest of life. Alos Hypoparathyroidism blood pressure cuff = wrist spasm = trusos? LOVE ASKING THESE Recurrent Laryngeal Nerve = Usually temporary (neuropraxic injury), Dysphonia, emergency trach if vocal chords shut, usually happens in extendive cancers. Haematoma = always stitch cutter by the bed, as any swelling will cause pressure of the airway, oedema of the larynx may still occur, call anaesthesis immediately. 3 layers to get to the haematoma Skin, plati Neck swelling post Thyroidectomy a favourite, if any midline lump comes up. ``` Scar Infection Haematoma Recurrent laryngeal nerve injury Unilateral-dysphonia Bilateral-airway obstruction Hypothyroidism Hypoparathyroidism ```