ENT Flashcards
1
Q
A 32 year old man presents with a 1 month Hx of offensive ear discharge from the left ear. Examination reveals a facial nerve palsy and there is an attic perforation of the tympanic membrane. What is the likely diagnosis?
A
Cholesteatoma
2
Q
An 82 year old woman presents with a one day Hx of a severely painful right ear, a right facial palsy and a vesicular rash around the right ear. What is the diagnosis?
A
Herpes zoster otitis - Ramsay Hunt syndrome
3
Q
What is an acoustic neuroma and what are the symptoms?
A
Slow growing neurofibroma arising from the acoustic nerve’s vestibular division
Ipsilateral tinnitus, sensorineural deafness, giddiness
4
Q
What are the most common variety of submandibular tumours?
A
Adenoid cystic
5
Q
What should be done to manage a patient with a suspected submandibular tumour?
A
Fine needle aspiration
CT
Surgery with node dissection
Radiotherapy
6
Q
What are symptoms of carotid body tumours?
A
Asymptomatic Dysphagia Hoarseness Stridor Weakness of the tongue Compression of vagus or hypoglossal nerves
7
Q
In which group of people are carotid body tumours more likely?
A
Those living at altitude
8
Q
What is the most common site for glandular calculi? Why?
A
Submandibular
High calcium content in saliva
9
Q
What is the treatment for submandibular duct calculi?
A
Opening warthins duct and milking stone along
Excision of gland
10
Q
What is the second most common parotid rumour?
A
Adenolymphoma/warthins tumour
11
Q
A 53 year old woman is seen in clinic reporting pain in left hand on exertion such as when she brushes her hair. At rest her pulses are palpable but they disappear after repeatedly elevating her arm. An X-ray is performed that confirms the diagnosis. What is it?
A
Thoracic outlet syndrome
12
Q
What is the definitive test for thoracic outlet syndrome?
A
Adsons test - palpate radial pulse on affected side with elbow fully extended
Patient rotate head to side being tested and extend neck
Abduct extend and laterally rotate the shoulder
Patient take deep breath and hold
Positive test - decrease in pulse vigor
13
Q
What is Roos test?
A
Patient raises arm to 90 degrees of abduction with arms fully externally rotated and elbows at 90 degrees flexion
Open and close hands for 3 mins
If unable to hold arms up or if pain /paraesthesia
Test for thoracic outlet syndrome
14
Q
A child puts a pea in his ear while having dinner and is taken to paeds ED by his father. Otoscopy shows a green object in the external auditory canal. What is the appropriate action to remove this?
A
Suction
15
Q
What are contraindications to syringing an ear?
A
Tympanic membrane perforation Vegetable matter Otitis media Otitis externa History of ear surgery Unilateral deafness
16
Q
Why is the hyoid bone resected with a thyroglossal cyst?
A
Prevent recurrence
17
Q
When is hemithyroidectomy performed for thyroid nodules?
A
Cytology of nodule is equivocal or when follicular cells are seen as follicular adenomas cannot be differentiated from follicular carcinomas by cytological assessment
18
Q
What operation is performed for thyroid cancer if there is spread to local lymph nodes?
A
Total thyroidectomy with central compartment node clearance
19
Q
What is the function of calcitonin?
A
Inhibits osteoclast function
20
Q
What can cause hair cell damage and therefore lead to sensorineural hearing loss?
A
Gentamicin toxicity Bacterial meningitis Skull fracture Noise exposure Presbycusis Genetic syndromes Hereditary deafness Acoustic neuroma
21
Q
What is otosclerosis and what type of hearing loss does it lead to?
A
Overgrowth of bone in the middle ear fixing the foot plate of the stapes at the oval window, leading to a conductive hearing loss
If present untreated for many years, the cochlear can become affected and a mixed loss results
22
Q
What are causes of a thyroid nodule? What should be done to investigate it?
A
Colloid cyst
Adenoma
Carcinoma
Fine needle aspiration
23
Q
What causes benign positional vertigo?
A
Degenerative inner ear changes that result in debris impacting on the hair cells giving rise to the sensation of movement
24
Q
What technique can be used to demonstrate the symptoms of benign positional vertigo?
A
Hallpike manoeuvre
25
How is benign positional vertigo best treated?
Inner ear physiotherapy
26
A 20 year old woman is referred to an ENT surgeon with recurrent epistaxis. No cause is found on nasal speculum examination and she is discharged. Four days later she is admitted to ED after massive haematemesis. What is the likely diagnosis? Why does this happen?
Hereditary haemorrhagic telangiectasia
Osler-weber-render syndrome
Fragile punctiform lesions on mucous membranes
27
A 29 year old singer is referred to ENT in a worried state as she has noticed her voice has become hoarse. Indirect laryngoscopy reveals small nodules on both vocal cords. What is the problem and how do you manage it?
Vocal cord nodules - keratin
Smaller nodules will disappear with voice rest
Larger ones need to be removed surgically
28
What is hysterical aphonia?
Hysterical reaction to some deep rooted psychological problem
Sudden onset
Failure to adduct the vocal cords
29
Levels of what hormone can be used to monitor for subclinical recurrence of medullary thyroid cancer after thyroidectomy?
Calcitonin
30
What are the 2 most common forms of thyroid cancer?
Papillary carcinoma 60%
| Follicular carcinoma 20%
31
What is medullary carcinoma of the thyroid?
Tumour of parafollicular cells (C cells) which are derived from neural crest
32
Which infectious agent is associated with the development of nasopharyngeal carcinoma?
Epstein Barr virus
33
What are presenting features of nasopharyngeal carcinoma?
```
Otalgia
Unilateral serous otitis media
Nasal obstruction/discharge/epistaxis
Cranial nerve palsies - III to VI
Cervical lymphadenopathy
```
34
What is the first line treatment for nasopharyngeal carcinoma?
Radiotherapy
35
What are possible 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
36
What are treatment options for Graves' disease?
Antithyroid drugs - carbimazole
Radio iodine
Surgery
37
A cachectic 77 year old woman is rushed into ED with acute dyspnoea. On examination she is exhibiting stridor and has an irregular form goitre. What pathological thyroid problem is likely present? What is the treatment?
Anaplastic carcinoma - rapidly growing hard thyroid
Emergency radiotherapy
Excision of thyroid isthmus with tracheostomy
38
What is pendred syndrome?
Genetic disorder leading to congenital bilaterally sensorineural hearing loss and goitre with euthyroid or mild hypothyroidism
39
A 60 year old woman from Derbyshire is seen with progressively enlarging mass on right side of neck. It has been present for 10 years and is now causing dyspnoea on exertion. What is the underlying pathology?
Multinodular goitre - iodine deficiency
40
What are the most common thyroid neoplasms?
Papillary tumours
41
Who gets papillary thyroid carcinoma?
Young and middle aged women
42
How is papillary carcinoma of the thyroid treated?
Resection followed by thyroxine suppression
43
How does papillary carcinoma of the thyroid spread?
Lymph nodes
44
How is follicular carcinoma of the thyroid treated?
Total thyroidectomy
| Radioiodine for mets
45
What are branchial cysts?
Congenital defects related to incomplete obliteration of the two or three branchial clefts which if left, get infected and form an abscess
46
What is done to manage branchial cysts?
Excised in continuity with its track, taking care of to damage adjacent structures such as facial nerve
47
Where can thyroglossal cysts form?
Anywhere from foramen caecum to thyroid isthmus, mostly infrahyoid
48
What is done to manage thyroglossal cyst?
Cyst excised in continuity with tract and body of hyoid to prevent recurrence
49
What is a cystic hygroma?
Hamartomas of jugular lymphatics
50
Why might a cystic hygroma enlarge quickly? Why is this a problem?
Haemorrhage
Develop secondary infection
Compress local structures
51
Which type of thyroid cancer may be familial?
Medullary thyroid carcinoma - c cells
| Can be associated with MEN or ret proto oncogene mutations
52
A 35 year old woman presents with a hard mass in her neck which is progressively enlarging. Her PMH includes sclerosing cholangitis. On examination there is a hard mass affecting both right and left lobes. What is the likely diagnosis?
Riedels thyroiditis - dense fibrous infiltrate associated with sclerosing cholangitis and mediastinal and retroperitoneal fibrosis
53
What type of lymphoma is thyroid lymphoma usually?
Non hodgkins B cell lymphoma
54
On the background of what disease can thyroid lymphoma occur?
Hashimoto's thyroiditis
55
A 65 year old lady presents to GP with recurrent bouts of deafness. A typical attack starts with a full feeling in the ear with tinnitus, which gradually increases in volume, followed by nausea, vomiting and rotational vertigo. What is the diagnosis?
Menieres disease - gradual increase in fluid in endolymphatic compartment of inner ear
56
How is otosclerosis treated?
Stapedectomy
57
A 35 year old man presents to GP with progressive bilateral hearing loss over 1 year. Rinne's test is negative and on examination the tympanic membrane is normal. His father had a similar problem at his age and required a hearing aid. What is the diagnosis?
Otosclerosis - progressive conductive deafness due to fixation of stapes in the oval window
58
What typically are swellings in the posterior triangle?
Lymph nodes
59
What are characteristics of thyroid swellings which allow them to be differentiated from other causes?
Move with degluition but not protrusion of the tongue
60
Give some differentials for a swelling in the neck which moves on degluition
Thyroid swellings
Thyroglossal cyst
Hyoid bursa
Median/pyramidal lobe of thyroid
61
What are your differentials for swellings in the neck with a cough impulse?
Pharyngeal pouch
Laryngeal pouch
Diverticula
Cystic hygroma
62
How do you treat sinusitis?
Amoxicillin, decongestants, steroid drops/spray, mucolytics, antihistamines, lavage
63
What is the most common cause of community acquired sinusitis?
Streptococcus pneumoniae and Haemophilus influenzae
64
When is a tonsillectomy considered for children?
History of recurrent tonsillitis causing them to miss significant time at school
5 episodes per year requiring time off and have seen a doctor to be classed as "recurrent tonsillitis"
65
What does petechiae on the palate suggest in the context of a sore throat?
Infectious mononucleosis or group A streptococcal pharyngitis
66
When is de Quervains thyroiditis commonly seen?
Young women following a flu like illness
67
How is de Quervains thyroiditis treated?
Self limiting
| NSAIDs
68
Who tends to get follicular carcinoma of the thyroid?
Females, mean age 50
69
How does follicular carcinoma of the thyroid differ from papillary?
Spreads haematogenously to the lungs
70
What is the most common cause of primary hypothyroidism?
Hashimotos disease
71
How is a diagnosis of hashimotos disease confirmed?
Biopsy
72
A 48 year old woman is seen in clinic. A referral letter from GP notes elevated TSH, low T4 and presence of antithyroid antibodies. She reports lethargy, dry skin, hair loss and weight gain. On examination she has a diffusely enlarged thyroid. What is the diagnosis?
Hashimotos disease
73
What is Reinkes oedema?
Recent strain on vocal cords - singers
| Strain causes subepithelial infiltration of interstitial fluid into vocal cords causing oedema
74
What does the tympanic membrane look like in acute otitis media?
Retracted initially, handle and short process of malleus more prominent
Pressure builds up, ear drum may become distended and bulge outwards
75
What is treatment for acute otitis media?
Broad spec abx to cover haemophilus and streptococci
Bed rest
Analgesia
76
When should grommet insertion be considered?
Persistent middle ear effusion or recurrent attacks of acute otitis media
77
What are some complications of thyroidectomy?
Bleeding
Recurrent and superior laryngeal nerve injury
Infection
Hypoparathyroidism - hypocalcaemia
78
How should you treat symptomatic hypocalcaemia secondary to total thyroidectomy?
IV calcium gluconate
79
How do you distinguish thyroid neoplasms from benign conditions?
History
Examination
USS
Fine needle aspiration cytology
80
What clinical and investigation features suggest subacute (de Quervains) thyroiditis?
Tender goitre
Hyperthyroidism
Raised ESR
Globally reduced uptake on technetium scan
81
What are the 4 phases of subacute (de Quervains) thyroiditis?
Phase 1: hyperthyroidism, painful goitre, raised ESR
Phase 2: euthyroid
Phase 3: hypothyroidism
Phase 4: thyroid structure and function returns to normal
82
What are causes of Thyrotoxicosis?
```
Graves' disease
Toxic nodular goitre
Acute phase of de Quervains thyroiditis
Acute phase of post partum thyroiditis
Acute phase of Hashimoto's thyroiditis
Amiodarone therapy
```
83
Which patients with sub clinical hypothyroidism need treating?
TSH >10
Thyroid autoantibodies positive
Other autoimmune disorder
Previous treatment of Graves' disease
84
What is an antithyroid drug titration regime for graves?
Carbimazole 40mg then reduced gradually to maintain euthyroidism
Continued for 12-18 months
85
What is a major complication of carbimazole therapy for Graves' disease?
Agranulocytosis
86
What is a block and replace regime for Graves' disease?
Carbimazole started at 40mg
Thyroxine added when patient is euthyroid
Treatment for 6-9 months
87
What are contraindications to radioiodine therapy for Graves' disease?
```
Pregnancy
Breast feeding
Age <16
Severe uncontrolled thyrotoxicosis
Thyroid eye disease (relative)
```
88
What is the most likely adverse effect of radioiodine therapy for Graves' disease?
Hypothyroidism
89
A 9 month old boy is referred to ENT as he has been noted to have stridor. He sometimes chokes when drinking or feeding. His head circumference has risen from the 50% at birth to the 98% centile and he has short limbs. What is the likely problem?
Achondroplasia associated with hydrocephalus (Arnold Chiari malformation) which in turn can be associated with vocal cord palsy
90
A 3 year old boy is brought to ED with stridor onset in last few hours and a barking cough. Over past 3 days he has been unwell with coryzal symptoms and ear temperature of 38.2. What is the diagnosis? What is the causative organism?
Croup
| Parainfluenza
91
What are local causes of chronic nasal discharge?
```
Nasal polyps
Chronic sinusitis
Chronic infected adenoids
Deviated septum
Foreign body
Nasal diphtheria
```
92
What are systemic causes of chronic nasal discharge?
```
Cystic fibrosis
Dismotile cilia syndrome
Allergy
Syphilis
Wegeners granulomatosis
Immune deficiency
Hypothyroidism
```
93
What are features of infectious mononucleosis?
```
Sore throat
Lymphadenopathy
Pyrexia
Malaise, anorexia, headache
Palatal petechiae
Splenomegaly
Splenic rupture
Hepatitis
Haemolytic anaemia cold agglutinins
Maculopapular rash if given amoxicillin
```
94
How is a diagnosis of infectious mononucleosis made?
Monospot test in second week of illness
95
What features of otitis externa make it more severe?
```
Red oedematous ear canal which is narrow and obscured by debris
Conductive hearing loss
Discharge
Regional lymphadenopathy
Cellulitis spreading beyond the ear
Fever
```
96
How is otitis externa managed?
Mild: topical acetic acid 2% spray
| More severe: 7 days of topical antibiotic with or without topical steroid
97
What are indications for abx in a sore throat?
```
Marked systemic upset
Unilateral peritonsillitis
History of rheumatic fever
Increased risk from infection: diabetes, immunodeficiency
3 or more centor criteria present
```
98
In which circumstances are antibiotics required for otitis media?
Symptoms lasting more than 4 days or not improving
Systemically unwell
Immunocompromise or high risk of complications due to comorbidity
Younger than 2 with bilateral symptoms
Otitis media with perforation and or discharge in canal
99
What antibiotics are prescribed for otitis media?
5 day course of amoxicillin
100
What is the management for otitis externa?
Topical antibiotic and steroid
If canal debris consider removal
If swollen, ear wick
101
What is Samters triad?
Asthma
Aspirin sensitivity
Nasal polyposis
102
What are features of nasal polyps?
```
Nasal obstruction
Rhinorrhoea
Sneezing
Snoring
Poor sense of taste and smell
```
103
What is the management of nasal polyps?
Refer to ENT for full examination, particularly if unilateral, bleeding
Topical corticosteroids
104
Which drugs can cause corneal opacities?
Amiodarone
| Indomethacin
105
Which drugs can cause optic neuritis?
Ethambutol
Amiodarone
Metronidazole
106
What can be used as a tumour marker for medullary thyroid cancer?
Calcitonin
| Originates from parafollicular cells
107
What is Ludwigs angina?
Cellulitic like infection of floor of mouth with gram positive strep pyogenes
108
What are the triad of symptoms in Ménière's disease?
Spontaneous vertigo
Sensorineural hearing loss
Tinnitus
109
What are complications of tonsillitis?
Otitis media
Quinsy
Rheumatic fever
Glomerulonephritis
110
What are the criteria for tonsillectomy?
Sore throats due to tonsillitis
Person has five or more episodes per year
Symptoms occurring for at least a year
Episodes are disabling and prevent normal functioning
111
What is Ménière's disease?
Idiopathic swelling of the membranous labyrinth
Endolymphatic hydrops
Usually unilateral, is progressive
112
What can be used as a tumour marker for papillary thyroid cancer?
Thyroglobulin
113
What is hutchinsons sign?
Presence of vesicular rash on the tip of the nose which is strongly predictive for ocular involvement in herpes zoster
114
What are neurological complications of Hashimoto's thyroiditis?
```
Cerebellar dysfunction/ataxia
Entrapment neuropathies - carpal tunnel syndrome
Dementia/myxoedema madness
Coma
Hashimoto's encephalopathy
```
115
What are associations of nasal polyps?
```
Asthma
Aspirin sensitivity
Infective sinusitis
Cystic fibrosis
Kartageners syndrome
Churg Strauss
```
116
What are features of nasal polyps?
Nasal obstruction
Rhinorrhoea
Sneezing
Poor sense of taste and smell
117
What are unusual features of nasal polyps which require further investigation?
Unilateral symptoms
| Bleeding
118
What is Samters triad?
Asthma
Aspirin sensitivity
Nasal polyposis
119
Which bugs most commonly cause sinusitis?
Strep pneumoniae
Haemophilus influenzae
Rhinovirus
120
What are predisposing factors for sinusitis?
Nasal obstruction: septal deviation or nasal polyps
Recent local infection: rhinitis or dental extraction
Swimming/diving
Smoking
121
What are features of sinusitis?
Facial pain: frontal pressure, worse on bending forward
Nasal discharge: thick and purulent
Nasal obstruction: mouth breathing
Post nasal drip: chronic cough
122
What is the management of acute sinusitis?
Analgesia
Intranasal decongestants
Oral abx for severe presentations: amoxicillin
123
Above what line on an audiogram is normal hearing?
20dB line
124
Why does a thyroglossal cyst move on tongue protrusion?
Connected with the foramen caecum at back of tongue
125
What is Mikulicz syndrome?
Chronic condition characterised by abnormal enlargement of glands in head and neck
Occurs in association with other disorders: TB, leukaemia, syphilis, hodgkins, sjogrens, SLE
126
Which procedure is used to excise a thyroglossal cyst?
Sistrunks procedure
| Small segment of hyoid bone is removed to gain access to cystic tract
127
What are features of cholesteatoma?
```
Foul smelling discharge
Hearing loss
Vertigo
Facial nerve palsy
Cerebellopontine angle syndrome
Attic crust seen on otoscopy
```
128
What is cerebellopontine angle syndrome?
```
Space occupying lesion causing:
Ipsilateral deafness
Nystagmus
Reduced corneal reflex
Vth and VIIth nerve palsies
Ipsilateral cerebellar signs
```
129
Which bug causes cat scratch disease?
Bartonella henselae
130
What are signs and symptoms of cat scratch disease?
```
Tender swollen lymph nodes near site of scratch
Malaise
Anorexia
Abdominal pain
Muscle and joint pains
Sweats
```
131
What is the management for a perforated ear drum?
Watch and wait- ent referral if persists beyond 6 weeks
Advise skin like structure will heal self like skin
Avoid getting water in ear to reduce chance of infection
132
Why should topical nasal decongestants not be used for prolonged periods of time?
Tachyphylaxis: increasing doses required to achieve same effect
Rebound hypertrophy of nasal mucosa may occur on withdrawal
133
What is the first line medication for treating otitis media if no improvement of symptoms after 2-3 days?
Amoxicillin 500mg TDS for 7 days
134
What are the most common causes of hearing loss?
Ear wax
Otitis media
Otitis externa
135
What are some complications of thyroid surgery?
Recurrent laryngeal nerve damage
Bleeding which can lead to laryngeal oedema and respiratory compromise
Hypocalcaemia due to parathyroid damage
136
What are causes of otitis externa?
Infection: staph aureus, pseudomonas, fungal
Seborrhoeic dermatitis
Contact dermatitis: allergic and irritant
137
What is the management of otitis externa?
```
Topical antibiotic or combined with topical steroid
If canal debris: removal
If canal is swollen: ear wick
Oral antibiotics if infection spreading
Swab
```
138
How long do grommets usually last?
6-12 months
139
What is the management of otitis media?
```
80% resolve within 3 days
Antibiotics not usually recommended: NNT = 3-7 (depending on measure of success), NNH = 3-10 (rash, diarrhoea – mainly children)
Analgesia:
Paracetamol NNT = 6
Ibuprofen NNT = 5
```
140
What are causes of earache?
```
Otitis media
Otitis externa
Boils and furuncles of canal and pinna
Trauma / foreign body
Referred pain: throat, teeth, neck
TMJ dysfunction
Less common: Mastoiditis, Cholesteatoma, Malignancy
```
141
What is the management of otitis externa?
Consider sending ear swab, ideally before starting antibacterial
Rarely may have fungal OE
Acetic acid spray / drops
Combined steroid and antimicrobial spray / drops: Consider ease-of-use
Appropriate analgesia
142
What are complications of otitis externa?
```
Malignant otitis externa: Elderly, diabetic patients most at risk, Often Pseudomonas spp. resistant to regular antibiotics, 50% mortality
Mastoiditis
Facial nerve (CN VII) palsy
```
143
What investigation should be done for a patient presenting with unilateral hearing loss, tinnitus and vertigo?
Urgent MRI via 2 week wait head and neck protocol
| Rule out acoustic neuroma
144
What are common ent causes of vertigo?
Labyrinthitis (usually viral)
Benign Paroxysmal Positional Vertigo
Ménière's disease
145
What is the management of labyrinthitis?
Self-limiting, Duration up to 3 weeks
May need vestibular sedative / antiemetic
Consider impact on work / caring: Fit to drive? Sick note?
Persistent or worsening symptoms demand ENT review
Vestibular rehabilitation therapy (VRT) in extreme cases
146
What causes BPPV?
Probable otolith in semicircular canal
147
How is a diagnosis of BPPV confirmed?
Dix-Hallpike provocation test, Check they didn’t drive here
148
How is BPPV managed?
Symptomatic treatment with betahistine, cinnarizine, prochlorperazine
Self-treatment with Brandt-Daroff exercises
Epley Manoeuvre
149
What is the management of nasal polyps?
Steroid nasal sprays
Adjust underlying asthma treatment
Surgical treatment
150
What is the management of allergic rhinosinusitis?
Allergen avoidance
Steroid nasal sprays
Antihistamine nasal spray: fexofenadine
151
What is the management for post nasal drip?
Avoid antigens
Antihistamine
Oral decongestant
Nasal steroids
152
What are causes of sore throat?
```
Pharyngitis / viral URTI
Tonsillitis
Glandular fever
Quinsy (peritonsillar abscess)
Thrush (oropharyngeal candidiasis)
Less common: Reflux, Rare infections – Herpes simplex, diphtheria, Thyroiditis, Oropharyngeal carcinoma
```
153
What is the management of quinsy?
Needs incision, drainage and IV abx
154
What investigations might you do for a sore throat?
```
Throat swab
FBC
Infectious mononucleosis test: monospot
Upper GI endoscopy; in absence of oropharyngeal pathology a trial of PPI often resolves problem
Biopsy
```
155
What is the centor criteria?
Adults and children >3y
1 point for each of the following:
Tonsillar exudate
Tender cervical lymph nodes
Fever
Absence of cough
Score 1: 2-23% chance of bacterial cause (GrpA Strep)
Score 4: 25-86% chance of bacterial cause
NICE: Antibiotics only if scoring 3 or more
156
What larynx presentations warrant a 2 week wait referral?
Aged 45 years and over with:
Persistent, unexplained hoarseness > 3 weeks
Unexplained, persistent sore throat > 3 weeks
Need nasendoscopy
157
What oral and oropharyngeal presentations warrant a 2 week wait referral?
Unexplained ulceration in oral cavity lasting more than 3 weeks
Assessed by a dentist/doctor as having a lump or erythroplakia on the lip/oral cavity consistent with oral cancer
Persistent, unexplained lump in neck > 3 weeks
158
What thyroid presentations warrant 2 week wait referral?
Unexplained thyroid lump
Will need TFTs, TPO, UE, Ca2+
May already have USS but this should not delay referral
159
What salivary gland presentations warrant a 2 week wait referral?
Persistent swelling in parotid / submandibular gland > 3 weeks
Examine for tenderness, congestion and history suggestive of sialolithiasis
160
What are causative organisms of otitis media?
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
161
When are antibiotics indicated for otitis media?
If persists beyond 4 days, Amoxicillin is the first line choice
162
What are common causes of pharyngitis?
```
Rhinovirus
Corona virus
Adenovirus
HSV
Streptococcus pyogenes (Group A Streptococci)
Group C and Group G Streptococci
```
163
How can the organism causing pharyngitis be detected?
Throat swab for culture
| Rapid Antigen Detection Test (RADT)
164
What are common causes of lumps in the neck?
```
Skin and Subcutaneous lumps
Lymph Nodes
Salivary Gland
Thyroid
Branchial Cysts
Laryngeal Cysts
Pharyngeal Pouches
```
165
What are the different lymph node levels of the neck?
Level 1: a submental, b submandibular
Level 2-4: deep cervical/internal jugular chain
Level 5: posterior triangle/spinal accessory nodes
Level 6: prelaryngeal/pre tracheal
Level 7: superior mediastinal nodes
166
What are the causes of lymphadenopathy?
Follicular (B cell): Bacterial Infection, RA, EBV (infectious mononucleosis), Toxoplasmosis
Paracortical (T cell): Viruses, Drugs, Dermatopathic
Sinus histiocytosis: Tumour Drainage, Other lesions e.g bruises
Granulomas: TB, fungi, Cat Scratch, Toxoplasmosis, Sarcoidosis, Crohn’s, Tumour Reaction e.g. SCC
Neoplastic: Primary (lymphomas), Secondary (metastases)
167
What is a granuloma?
Focus of chronic inflammation consisting of a microscopic aggregation of macrophages surrounded by a collar of lymphocytes
168
What are examples of benign salivary gland tumours?
Pleomorphic Adenoma
| Warthin Tumour
169
What is a pleomorphic adenoma?
Most common salivary gland tumour in major and minor salivary glands
Natural history: slow growing, usually asymptomatic
Histology: Innumerable patterns. Tumour that shows epithelial and myoepithelial elements mixed with a myxoid and chondroid
material
170
What is a warthin tumour?
2nd most common salivary gland tumour in parotid
Natural history: slow growing, link to cigarette smoking
Histology: Cystic structures lined by oncocytic epithelium within a lymphoid stroma
171
What are examples of malignant salivary gland tumours?
Adenocarcinomas: Mucoepidermoid, Adenoid Cystic
Lymphoma: MALToma (salivary gland), Other types (Within lymph nodes)
Secondaries (Parotid): Squamous cell carcinoma, Malignant melanoma
172
What is a mucoepidermoid carcinoma?
Most common malignant salivary gland tumour
Natural history: Firm, fixed and painless swellings
Histology: Contains epidermoid cells, intermediate cells andmucocytes. It can be cystic.
173
What is an adenoid cystic carcinoma?
<10% of salivary gland tumour
Natural history: Slow growing swelling. Numbness paresthesia or pain. It can cause facial or tongue weakness
Histology: Tubular cribiformand solid patterns of epithelial and
myoepithelial cells
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Where are salivary gland stones the most common?
Submandibular Gland due to stickier/more mucinous secretions - Sialolithiasis
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What cancer are Sjögren's syndrome sufferers at risk of?
MALT lymphoma in salivary glands
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What is Sjögren's syndrome?
Autoimmune disease that involves lacrimal and salivary glands
Dry eyes, dry mouth, enlargement of parotid glands. Positive
Schirmer test. Auto antibodies to Ro or La in serum
Histology: Lymphocytic infiltration of the gland with epithelial
differentiation in the parotid
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What are differential diagnosis for a single thyroid nodule?
Cyst
Multinodular Goitre +/- dominant hyperplastic nodule
Benign: Follicular Adenoma, NIFTP (non invasive follicular thyroid neoplasm with papillary like features)
Malignant: Papillary thyroid carcinoma (>70% of thyroid malignancies), Follicular thyroid carcinoma, Poorly Differentiated, Anaplastic, Medullary, Lymphoma, Metastases
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What results are given from a thyroid fine needle aspiration?
Thy1: Non diagnostic
Thy2: Benign features
Thy3a: Atypical cytology (5– 15% could be malignant)
Thy3f: Follicular lesion, (20 – 30% could be malignant)
Thy4: Suspicious for malignancy (60 – 75% could be malignant)
Thy5: Malignant (>97% are malignant)
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What is the difference in prognosis between different thyroid cancers?
Papillary: Good
Follicular: Minimally invasive – good, Widely invasive – worse
Poorly differentiated – about same as WI FC
Anaplastic – appalling, but presents differently
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Who is involved in the MDT for thyroid cancers?
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Pathology
Oncology
Radiology
CNS
SALT/Dietetics
Surgery
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39 year old male. Non smoker, non drinker. Presents with 2 months of enlarging left neck mass and increasing difficulty in swallowing. What investigations would you like?
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Flexible nasendoscopy
FNA
Contrast CT neck and chest
Contrast MRI
(PET CT if no obvious primary lesion)
Panendoscopy/biopsy
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What is the link between HPV and oropharyngeal squamous cell carcinoma?
Base of tongue and tonsils
Incidence of OPSCC has risen over the past 3 decades
Male to female ratio of 4:1
HPV16 >90% of cases
Oral sex is an established risk factor
Significantly better survival outcomes than HPV negative OPSCC
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59 year Old Female. Smokes 15 cigarettes per day. Presenting with 8 months of increasing dysphonia. What investigations would you like to order?
Nasendoscopy
Microlaryngoscopy
Biopsy
Imaging
