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Year 4 - SPC > ENT - Head and neck > Flashcards

Flashcards in ENT - Head and neck Deck (81):
1

What are the 3 divisions of the pharynx?

The pharynx is the upper part of the combined air and food passages - aero-digestive tract. It is divided into 3 parts - the nasopharynx, the oropharynx and the hypopharynx or laryngopharynx.

2

What are the boundaries of the nasopharynx?

The nasopharynx is between the base of the skull and the level of the hard palate. It contains the adenoids (in children) and the Eustachian tube.

3

Where is the oropharynx?

The oropharynx runs from the level of the hard palate down to the level of the vallecula - this is the junction between the base of the tongue and the epiglottis. The tonsils, base of the tongue, and the soft palate are all found in the oropharynx.

4

Where is the hypopharynx?

The hypopharynx extends between the level of the vallecula to the cricopharynx which is a muscular sphincter at the upper end of the oesophagus.

5

What are the 3 stages of swallowing?

Swallowing is a complex process requiring coordination of the muscles of the oral cavity, pharynx and larynx. Loss of function of any of these stages can cause potential aspiration and LRTI.

The 3 stages are:
1) oral phase
2) pharyngeal phase
3) oesophageal phase - food bolus passes through the oesophagus and into the stomach

6

What happens in the oral and pharyngeal phases of swallowing?

Oral phase - Mastication and partial digestion by salivary glands produces a food bolus which is shaped by the tongue. The tongue also pushes the bolus into the oropharynx.

Pharyngeal phase - muscles around the larynx close and push the food bolus into the oesophagus. These muscles are known as the pharyngeal constrictors. During this phase the larynx is elevated to protect the airway and lower respiratory tract.

7

How is the pharynx examined?

It is difficult to visualise the nasopharynx and hypopharynx without the use of a flexible endoscope. But the oropharynx can be easily examined using a light source and a tongue depressor.

8

What are the adenoids? Are they normally visible on examination?

The adenoids are a collection of lymphoid tissue. They are part of a circle of lymphoid tissue known as Waldeyer's ring that surrounds the entrance to the pharynx and respiratory tract. The other parts of the ring include the lingual tonsils on the base of the tongue and the pharyngeal tonsils.

Remember that the pharynx is divided into 3 parts - naso, oro and hypopharynx. The adenoids are located in the nasopharynx. They are not usually visible on examination of the oropharynx by direct vision because they lie behind the soft palate near the posterior openings (choanae) of the nose.

9

Symptoms of adenoid hypertrophy

- nasal obstruction/ rhinorrhoea
- mouth breathing/ hyponasal speech
- secretory otitis media (glue ear)/ acute otitis media
- snoring/ obstructive sleep apnoea

10

Why is adenoid hypertrophy associated with OME?

OME is otitis media with effusion or glue ear and is defined as symptoms caused by fluid collection in the middle ear for greater than 3 months. Gross enlargement of the adenoids causes obstruction of the Eustachian tube and pressure changes in the middle ear which can result in OME. If this occurs with a spread of infection to the middle ear along the Eustachian tube then an acute middle ear infection usually arises.

11

Do adults have adenoidal tissue?

Adenoids reach maximal size between the ages of 5-7 years and then regress. Adults have very little (if any adenoidal tissue) and the presence of nasopharyngeal masses in adults should be investigated further to exclude other pathology.

12

What are the main indications for adenoidectomy?

- airway obstruction caused by enlarged adenoids (often combined with tonsillectomy in obstructive sleep apnoea)
- OME - as an adjuvent procedure with grommet insertion in recurrent cases of glue ear

13

Contraindications for adenoidectomy

- bleeding disorders
- palatal abnormalities - palate must be palpated prior to the procedure to assess for undiagnosed submucal clefts
- recent URTI

14

Complications of adenoidectomy

- bleeding
- velopharyngeal insufficiency (i.e. nasal regurgitation). This is rare and usually short lived
- hypernasality - can be a significant problem if the patient has an undiagnosed palatal deformity. Air escapes through the nose during sleep

15

What patients get nasopharyngeal cancer?

Not all nasal obstruction in children is caused by adenoids. There are other causes such as nasopharyngeal cancer. This is rare in western populations and is more common in individuals who live in certain provinces of China.

EBV has been implicated in the aetiology.

All nasopharyngeal masses in adults as well as unilateral glue ear must be investigated for nasopharyngeal cancer.

16

Pharyngeal infection

Viruses normally infect the pharynx and acute pharyngitis is part of many upper respiratory tract infections including the common cold. Infection of the pharynx can cause enlargement of the tonsils - acute tonsilitis. This is one of the more common infections of children and young adults and a typical attack will last 3 to 7 days.

17

What are the main organisms implicated in acute tonsillitis?

- viruses
- pyogenic bacteria - e.g. haemophilus, pneumococcus, haemolytic strep

18

What are the main clinical features of acute tonsillitis?

- sore throat
- odynophagia (painful swallowing)
- fever
- malaise
- enlarged cervical lymph nodes
- enlarged red tonsils

O/E the tonsils are red, swollen and coated with pus. An important differential to think about is infectious mononucleosis (glandular fever), which has a similar appearance but with a more definite membrane over the tonsils and usually splenomegaly

19

What is the treatment for acute tonsillitis?

Treatment is controversial. Very enlarged tonsils that contribute to obstructive sleep apnoea are removed surgically together with the adenoids.

Most cases of tonsil infection (like most URTIs) are viral and will not respond to antibiotics. An acute sore throat is probably best treated with good analgesia and fluids. If an ongoing bacterial infection is suspected then a short course of antibiotics is sensible. Pen V is the first line choice.

Avoid amoxicillin or ampicillin if glandular fever is suspected because they cause the patient to develop a florid rash.

20

How should tonsillitis be investigated?

If infectious mononucleosis is suspected then an FBC and glandular fever screen (Paul-Bunnell or monospot test) can be helpful. A finding of raised monocyte count on white cell differential usually indicates glandular fever even if the glandular fever screen is normal.

FBC is also useful if there is suspicion of agranulocytosis - this can be a presentation of leukaemia.

Diptheria is very rare but in parts of the world where it is endemic a smear and culture is useful.

21

What are the outcomes of acute tonsillitis?

Most cases of tonsillitis will resolve spontaneously. However there are a few important complications to bear in mind:
1) Rheumatic fever - follows an attack of acute tonsilittis by streptococci leading to endocarditis

2) Glomerulonephritis - acute renal failure following streptococcal infection

3) Septicaemia - very rare, mostly immunocompromised patients

There are also some complications of local spread:
- Quinsy
- retropharyngeal abscess
- parapharyngeal abscess

22

What is Quinsy?

This is a collection of pus in the peri-tonsillar space just lateral to the tonsil. Quinsy occurs mainly in young adults and causes severe pain and dysphagia.

The patient needs to be admitted to hospital and the abscess drained surgically. It can then be treated with antibiotics.

23

Where does a retropharyngeal abscess occur?

This occurs most commonly in very young children - usually under 2. Pus collects in a lymph node between the vertebral column and the pharynx. It can quickly obstruct a childs airway and treatment is by surgical drainage under anaesthesia.

24

Parapharyngeal abscess

This is a collection of pus in the parapharyngeal space which is formed by the deep cervical fascia in the side of the neck. It can lead to mediastinitis and venous thrombosis.

25

What are the tonsils?

The tonsils are a collection of lymphoid tissue at the entrance to the pharynx on either side of the uvula (i.e. the palatine tonsils). There are also lingual tonsils at the base of the tongue. All of these, as well as the adenoids, are part of Waldeyer's ring which is a collection of lymphoid tissue that forms the first line of defence against infection.

The tonsils are lined with squamous epithelium that forms crypts that extend well into the body of the tonsils where pus and debris collect.

26

What diseases can affect the tonsils?

Infection - mostly viral, self limiting; sometimes bacterial (e.g. streptococcal), more severe and lasts longer

Obstruction - large tonsils contribute to airway obstruction, young children

Neoplasia - tonsil can be a site of malignant disease - squamous cell carcinoma of the oropharynx in adults and very rarely lymphoma or rhabdomyosarcoma in children where the presentation may be unilateral tonsils

Bleeding - haemorrhagic tonsillitis

27

Indications for performing tonsillectomy - what do the SIGN guidelines recommend?

- suspected malignancy
- bleeding
- oropharyngeal obstruction (OSA)
- recurrent tonsilitis (including complications), main reason

The SIGN guidelines recommend indications for tonsillectomy for recurrent sore throats in both children and adults are as follow:
- sore throats due to acute tonsillitis
- episodes bad enough to require time off work or school
- 7 or more episodes in 1 year, 5 or more in 2 consecutive years or 3 or more in 3 consecutive years

28

Is tonsillectomy a day-case procedure?

Tonsillectomy is painful but most cases are performed as a day case operation (i.e. the patient goes home the same day). The exception to this is children undergoing tonsillectomy for OSA. They should stay overnight for sats monitoring.

29

What is the main post op complication in tonsillectomy?

Bleeding.

It is also normal to have a granular, sloughed appearance of the tonsillar fossa after the operation. This is not an indication of infection and therefore the patient does not need antibiotics.

30

How can the larynx and trachea be injured?

1) penetrating wounds - e.g. gunshot or cut throat injuries
2) blunt trauma, especially RTC
3) inhaled flames or hot vapours
4) swallowed corrosive poisons
5) endotracheal tubes and inflatable cuffs

31

What are the key features of laryngeal and tracheal injury management?

Laryngeal and tracheal injury should always be suspected when there is damage to the neck. Crichotracheal separation may not be immediately obvious but can lead to asphyxia.

Fractures of the larynx will produce hoarseness and stridor and tracheostomy may be urgently required.

In the cases of cut throat, it may be possible to intubate through the wound prior to formal tracheostomy and laryngeal repair. The 2 priorities of treatment are:
1) to protect the airway by intubation or tracheostomy
2) to restore laryngeal function by careful repair of the injury

32

What commonly causes acute laryngitis in adults?

Acute laryngitis is more common in winter months and it usually caused by coryza (common cold) or influenza. Vocal over use, smoking and alcohol predipose to laryngitis.

33

What are the clinical features of acute laryngitis?

- aphonia (the voice is reduced to a whisper)
- dysphonia (pain of speaking)
- pain around the larynx

Examination by direct laryngoscopy shows the larynx to be red, swollen and with stringy mucus between the cords.

34

How is acute laryngitis treated?

1) total voice rest
2) inhalations with steam
3) no smoking
4) antibiotics are not usually required

35

What are the clinical features of acute laryngitis in children?

Acute laryngitis in children is usually caused by upper respiratory tract infection. This may lead to airway obstruction.

The child is:
- unwell
- harsh cough
- hoarse voice or aphonia

36

How should acute laryngitis in a child be managed?

The early stage will often respond to paracetamol and a steamy environment. If oedema develops within the limited space of the subglottis, stridor may occur. The combination of acute laryngitis and stridor = croup. If there is significant or worsening airway obstruction then the chid should be admitted to hospital.

37

What agent cause acute epiglottitis? What are the clinical features?

Acute epiglottitis is caused by Haemophilus influenza type B. It causes acute swelling of the epiglottis, which obstructs the laryngeal inlet. This is an emergency in children! The child can go from being well to dead in a few hours. It is now rare in the UK because of the HIB vaccine.

The child will become unwell with increasing dysphagia and a quack like cough. Stridor develops rapidly and the child prefers to sit up and leaning forwards to help their airway.

38

How is epiglottitis treated?

Children usually require hospitalisation, an ET tube and therapy with chloramphenicol. In adults it generally as a slower onset and offset and is not usually as severe.

39

What is laryngotracheobronchitis?

This condition occurs in children and is a generalised respiratory infection, probably viral in origin. As well as laryngeal oedema, there is production of thick secretions which block the trachea and airways.

It is of slower onset than acute epiglottitis and there is a harsh, croupy cough. Mild cases normally resolve on humidification with steam but severe cases may require ventilatory support.

40

What are the features of laryngeal diphtheria?

Diphtheria is now rarely seen in the UK. The child is ill and usually presents with the clinical picture of faucial diphtheria. Stridor suggests the spread of membrane to the trachea and larynx.

Rx:
- antitoxin
- general medical treatment for diphtheria
- tracheostomy may be required

41

When does chronic laryngitis occur?

Chronic laryngitis is more common in males than females. It is exaccerbated by:
- habitual shouting
- faulty voice production with excessive vocal use - e.g. teachers, actors, singers
- smoking
- alcohol
- chronic upper airway infection - e.g. sinusitis

The voice is hoarse and fatigues easily. There may be discomfort and a tendancy to want to clear the throat constantly. Examination shows the cords are thick and pink and the surrounding mucosa is often red and dry.

42

What is hyperkeratosis of the larynx?

Hyperkeratosis of the larynx is where the cords become covered in white plaques of keratinized epithelium, which may become florid. Histology shows dysplasia, which may progress to malignancy - the plaques should be removed for histology.

It may occur on top of chronic laryngitis.

43

What are vocal cord nodules?

These are more comon in children and result from excessive vocal use. The appearance is of a small, smooth nodule on the free edge of each cord composed of fibrous tissue covered in epithelium.

NB - any persistant hoarseness of voice should be considered malignancy until proven otherwise!

44

Name some benign tumours of the larynx?

Benign tumours of the larynx are rare and cause persistant hoarseness. The commonest tumours encountered are:
- papilloma - solitary or multiple
- haemangioma - almost exclusively in infants
- fibroma

45

What is the most common type of malignant laryngeal tumour?

Malignant tumours of the larynx are nearly always squamous cell carcinomas. Adenoid cystic carcinoma and sarcoma may also occur on very rare occassions.

46

What is the aetiology of malignant laryngeal cancer?

Malignant tumours are much more common in men than women (10:1), occuring exclusively in smokers. The peak age incidence is between 55-65 years, but it can occur in young adults.

The most common subtypes are:
- Glottic carcinoma (60%) - hoarseness is the main symptom which may persist for some months, only once it has spread from the larynx will earache, dysphagia and dyspnoea occur

- Supraglottic carcinoma (30%) - as well as producing a change in voice, this type of cancer metastasises early to the cervical nodes

- Subglottic carcinoma - this produces less hoarseness but increasing airway obstruction. It must not be mistaken for asthma or COPD.

47

How does laryngeal carcinoma spread?

Spread is local initially and proceeds:
- along the cord to the anterior commissure and onto the opposite cord
- upwards onto the ventricular band and onto the epiglottis
- downwards to the subglottis
- deeply into the laryngeal muscles, causing cord fixation

Lymphatic spread from glottic lesions occurs late, but occurs easily from supraglottic and subglottic sites to the deep cervical nodes.

Metastasis to the lung are also common.

48

How is laryngeal carcinoma diagnosed?

Every case of hoarseness should be examined by indirect laryngoscopy; malignant growths are usually seen easily. Diagnosis is confirmed by biopsy.

If a mass is found then a CXr is required because bronchial carcinoma may also be present at the same time. CT scanning of the larynx is often helpful in determining the extent of disease

49

What treatment options are available for laryngeal carcinoma?

1) External beam radiotherapy is often used. In a small tumour limited to one cord the 5 year survival rate is 80-90% and the patient retains the normal larynx

2) If there is extensive disease or if the disease returns after radiotherapy then total laryngectomy is required. The patient then has a permanent tracheostomy and will need to develop oesophageal speech.

50

What is the prognosis of laryngeal carcinoma?

Glottic carcinoma diagnosed early and treated effectively is virtually a curable disease. The later the diagnosis, the worse the prognosis. Never neglect hoarseness!

Supraglottic and subglottic tumours have a worse prognosis owing to the likelihood of of later development of symptoms and early lymph node spread.

About 10% of patients successfully treated for laryngeal carcinoma will develop carcinoma of the bronchus.

51

Describe the innervation of laryngeal muscles.

All the intrinsic muscles of the larynx, with the exception of the cricothyroids are supplied by the recurrant laryngeal nerves.

The cricothyroids act as tensors of the cords, are supplied by external branches of the superior laryngeal nerves.

52

What is Semon's law?

In a progressive lesion of the recurrant laryngeal nerves, the abductors are paralysed before the adductors. Thus, in incomplete paralysis, the cord will be brought to the midline by the adductors but in complete paralysis it falls away to the paramedian position.

Semons law is not fully understood but it may be explained by the fact that the adductor muscles are more powerful than the abductors.

53

What is the most likely differential diagnosis in acute facial palsy?

Bell's palsy is a diagnosis of exclusion - i.e. when all other causes have been excluded

54

What is important to check for on examination of a patient with an acute facial palsy?

Perform an otoneurological exam plus audiometry. Examine the neck for a parotid mass.
Determine whether the lesion is upper or lower motor neurone - upper motor neurone lesions spare the forehead. The vast majority of acute facial nerve palsies in younger patients are lower motor neurone. Try to grade the palsy (House-Brackmann classification).

55

Name some causes of a lower motor neurone facial palsy. How can they be excluded?

Cerebellopontine angle - typically acoustic neuromas
Middle ear - temporal bone fracture, acute otitis media, cholesteatoma
Parotid - malignant parotid neoplasms
Globally - Bells palsy, Ramsay Hunt, Lyme disease

Middle ear conditions can be excluded by a combination of history and otoscopic findings. Parotid pathology can be excluded by neck palpation. CP angle lesions cannot be excluded initially and if there is no complete resolution of symptoms within 3 months then an MRI is undertaken. Presence of pain and vesicles on the soft palate, tonsils or ear canal and drum are diagnostic of Ramsay Hunt syndrome. This is the sensory supply of the seventh nerve. Lyme disease can present with BILATERAL facial palsies with a history of exposure to Borrelia species. If all of these are normal then a diagnosis of Bells can be made.

56

In a patient with an acute facial palsy what is the single most important feature to note?

The single most important observation is whether the patient can cover the cornea when they try to close their eyes. The eye is most at risk from corneal damage with a facial palsy. Lacrimation may well be reduced as well.

57

What investigations should be undertaken in a patient who has acute facial nerve palsy?

A simple case of Bell's palsy requires no investigation except audiometry. If the palsy does not improve completely after 3 months, then an MRI is required to exclude an acoustic neuroma.

58

What are the treatment options for acute facial nerve palsy?

Corticosteroids have been demonstrated to improve the outcome from a facial palsy if begun within 2 weeks of onset. Antivirals may be beneficial. The most important aspect of treatment is corneal protection. If there is any doubt, the patient should be referred to the eye surgeon. In the meantime artificial tears and tape, to ensure the eye remains closed at night, should be provided.

59

What is the most likely differential diagnosis in an adolescent who presents with an acute sore throat?

Infectious mononucleosis (glandular fever) caused by Epstein-Barr virus.

60

What additional features in the history of glandular fever should you elicit?

Exclude recurrent tonsilitis. A history of tonsils swelling up with exudate during attacks that last between 5 and 7 days is more suggestive of tonsillitis than galndular fever. Constitutional symptoms are also present. Ask about contacts with similar problems.

61

What is the most important finding on examination in glandular fever?

Examine the oral cavity and tonsil region and palpate the neck. Large fleshy tonsils with an exudate encroaching on the soft palate may indicate infectious mononucleosis. Lymphadenopathy is often particularly severe and may extend from the neck to the rest of the body. Hepatosplenomegaly, pancreatitis and jaundice are rare complications.

62

What investigations should be undertaken in glandular fever?

Atypical lymphocytes (activated CD8 positive T lymphocytes) on a peripheral blood film strongly suggests EBV infection. Detection of the heterophile antibodies is the diagnostic test of choice. The antibodies react to antigens from phylogenetically unrelated species and agglutinate sheep red blood cells (the Paul-Bunnell reaction) and horse red blood cells (the Monospot test). Measurement of EBV specific antibodies may be necessary in the few patients with suspected EBV and negative heterophile antibodies.

63

What are the treatment options for infectious mononucleosis?

Most cases require no treatment. Corticosteroids are given if there is neuro- logical involvement (encephalitis, meningitis), when there is tonsillar enlarge- ment causing respiratory obstruction and if there is severe thrombocytopenia or haemolysis. Patients are advised to refrain from contact sports for 3 months after resolution of symptoms as there is an increased risk of hepatic or splenic injury if the liver or spleen is enlarged.

64

What is the likely differential diagnosis in a smoker with a continuous sore throat?

Squamous cell carcinoma of the pharynx.

65

What additional features in the history of a smoker with a continuous sore throat should you elicit?

Particular attention should be paid to the progressive nature of the sore throat, oral intake and respiratory symptoms, including cough, sputum and haemoptysis. The history suggests a supraglottic carcinoma in ltrating the muscle that causes pain on swallowing.

66

What is the important finding on examination of a smoker with a continuous sore throat and odynophagia?

Examine the oral cavity, neck and chest. If you can, undertake an endoscopic examination of the postnasal space, larynx and pharynx. The tonsil, supraglottic or laryngeal sites are the most likely. Ten per cent of smokers have more than one carcinoma in the aerodigestive tract. Oral examination may well not be conclusive. Examination of the neck will help stage the disease.

67

What investigations are most useful in a smoker with a continuous sore throat?

These patients require screening investigations including an FBC, liver function tests, ECG and chest radiograph. Special investigation may include imaging of the neck and chest with CT and MRI. Biopsy the lesion and stage the tumour under general anaesthesia.

68

In a patient with a lump in the throat and difficulty swallowing what is the most likely diagnosis?

In both cases the differential diagnosis is:
1) Globus pharyngeus - "lump in ones throat" - that is the persistent sensation of having phlegm, a pill or some other sort of obstruction in the throat when there is none

2) Neoplasm arising from either outside or within the oesophagus or pharynx (a pharyngeal pouch can cause dysphagia although the hallmark is regurgitation of food)

69

What should one look for in the examination of a patient with a lump in the throat or difficulty swallowing?

Palpate the neck – there is a physical sign called ‘Toynbee’s sign’. Move the laryngeal cartilages from side to side over the vertebral column. This produces crepitus in the normal individual and a post- cricoid carcinoma will lift the larynx forwards and crepitus is absent. This also occurs in foreign body or abscesses such as tuberculosis cold abscesses. Check for lymphadenopathy. In the ENT clinic, nasendoscopy with a exible endoscope may show pooling of saliva or an abnormality such as a space- occupying lesion. In patients with globus there is no abnormality.

70

What differentials should you consider in a patient with intermittent hoarse voice?

Intermittent hoarse voice is usually benign.
Vocal cord nodules, muscle tension dysphonia and laryngopharyngeal reflux are differentials to consider.

71

What additional features in the history would you want to elicit in a patient with intermittent hoarseness?

Ask about the nature of the job and when the hoarseness comes on. See whether the voice goes back to normal. If it is intermittent and comes on during the day, or during times of persistent voice use, it is almost certainly benign. Find out about hobbies such as singing. Ask about stress and the voice. Enquire about the symptoms of hiatus hernia and thyroid disease, and also whether the patient smokes or has chest disease such as asthma. Ask about nasal symptoms and snoring because this may dry the throat. Sinusitis is a rare cause of the problem and is often secondary to asthma and coughing.

72

What is the most important finding on examination of a patient with intermittent hoarseness?

Examination of the neck is usually uneventful. A exible nasendoscopy in the clinic may show how the vocal apparatus is working and whether there are any lesions on the vocal cords. Singers’ nodules are
a sign of vocal misuse and occasionally a unilateral vocal cord polyp may be found. Bilateral diffuse oedema suggests chronic persistent abuse but may be found in conditions such as thyroid disease. In patients with laryngopharyngeal reflux the posterior larynx appears in inflamed. Muscle tension dysphonia is a common problem in professional voice users and leads to insufficient adduction of the cords on phonation.

Investigation is rarely needed, but consider doing a FBC, TFTs and a CXR.

73

What are the treatment options for benign vocal hoarseness?

Vocal hygiene should be practiced, such as frequent drinks to keep the larynx moist (not alcohol). Refrain from smoking if the patient is a smoker. Trials have shown that speech and language therapy is effective. Surgery is occasionally needed in patients with hoarseness. If the patient has asthma, therapy may improve the voice but sometimes the irritation is the result of the inhalers, or Candida species, on the vocal cords.

74

A heavy smoker presents with continual hoarse voice. What is the most likely diagnosis?

Carcinoma of the nasopharynx/larynx.
Continuous hoarseness in a smoker is malignant.

75

What additional features would you want to elicit in a smoker with continuous hoarseness?

The history should be taken similar to that in the previous case. The smoking history is most important here. Progressive hoarseness that lasts longer than 6 weeks is most likely to be a neoplasm. Examination of the neck is often uneventful because secondary nodes rarely occur in a simple carcinoma of the larynx as it presents relatively early.

76

What investigations would be most useful in a patient with continuous hoarseness?

A neck and chest CT should always be taken because secondary neoplasm in the chest occurs in 10 per cent of patients, this also aids in staging the disease. Similarly, an FBC, U&Es and liver function tests, together with thyroid function tests, may be required before radiotherapy or surgery.

77

What are the treatment options for malignant causes of hoarseness?

Treatment depends on the TNM classification. Very small malignant squamous cell tumours can be removed with LASER once a biopsy has confirmed it. These patients should be followed up closely. The conventional treatment for small tumours is radiotherapy. However, this results in disability to the larynx and pharynx, with dryness and soreness as well as mucositis, and is best given in a fractionated regimen over a 6-week period rather than a shorter one. Larger tumours require surgery and radiotherapy. There is a move at present to more conservative surgery rather than laryngectomy and block dissection.

78

What is the most common cause of cervical lymphadenopathy?

Reactive, typically related to an underlying infection (acne, tonsilitis etc)

79

A lymph node of what size should be concerning?

A lymph node of >2cm is always concerning.
Painless neck lumps in Asians are frequently TB.
Painless neck lumps in Chinese adults are often postnasal space squamous cell carcinomas metastases.

80

How should painless neck swellings be investigated?

FNA of cervical lymphadenopathy should always be performed as this can direct further treatment. Cross sectional imaging can aid in determining the extent of disease and assist with diagnosis.

81

How is postnasal space carcinoma treated?

Treatment is by radiotherapy plus a neck dissection together with radiotherapy to the neck felds. A third of patients present with nasal symptoms, a
third with cervical metastases and a third with intracranial extension. This tumour can be particularly aggressive. It occurs in a younger age group and is associated with the Epstein Barr virus (EBV). Levels of the immunoglobulin IgA to EBV may indicate recurrent disease.