JC99 (ENT) - Infections and Tumors in Pharynx and Oral cavity

Question 1

Divide upper aerodigestive tract into anterior and posterior portions

Answer 1

Question 2

List salivary glands

Answer 2

o Parotid
o Submandibular
o Sublingual
o Minor salivary gland

Question 3

Outline history taking questions for pharyngeal or oral infections

Answer 3

HPI:
- Duration: acute (infection) vs. chronic (neoplastic)
- Symptoms:
Ear: Hearing loss, pain
Nose: Nasal obstruction, blood-stained discharge, epistaxis
Mouth: Loose denture, non-healing ulcers, mass, bloody saliva
Throat: Hoarseness, SoB, bloody sputum
Pharynx: Globus sensation, dysphagia, bloody saliva
Neck: Salivary glands, lymph node enlargement
- Constitutionals symptoms

Risk factors for cancer: e.g. smoking, alcohol, family history …etc

Comorbidities: fitness for surgery

Question 4

Risk factors for oral cavity cancers

Answer 4

• Smoking, alcohol
• Family history
• Betel nut (oral carcinoma)
• HPV (STD)
• Poor oral hygiene
• Previous radiation, malignancy
• Immunosuppression

Question 5

Outline P/E for oral and pharyngeal lesions

Answer 5

Oral:
 Systematic to all sub-sites
 Inspection and palpation (underlying mass/ induration (hardening))

Neck: mass and LN
 Location (region/ level)
 Shape + size (measure)
 Consistency
 Mobility
 Inflammation (skin surface)

Scalp/ skin
- Melanoma, Skin SCC

Question 6

Patient presents with Colicky postprandial glandular swelling and pain in mouth

Most likely dx?

Answer 6

Salivary duct stones

Question 7

2 benign mass in oral cavity

Answer 7

Benign mass:

• Salivary ductal stone (usually submandibular)
• Ranula (Sublingual gland)

Question 8

Salivary ductal stone

• Which gland most commonly affected
• Presentation
• Tx
• Complication

Answer 8

Glands: Submandibular (most common) > parotid > sublingual
Submandibular ducts tract against gravity + secretions more viscous = prone to precipitation and blockage

Presentation: Colicky postprandial glandular swelling and pain

Tx:

• marsupialization, calculus removal, submandibular gland excision
• Sialendoscopy

Complication: Sialadenitis (pus from ductal orifice, infection)

Question 9

5 major etiologies of oral ulcers and example of causes

Answer 9

Ulcers:
- Apthous

• Traumatic: Dental-related (e.g. sharp teeth, ill-fitting denture)
• Infective:
   Bacterial
   Viral: Herpes virus, EBV
• Systemic diseases
   Behcet’s disease
   Autoimmune (RA, SLE)
   Blood disease
• Malignant: irregular, rolled/everted edge, indurated, painless

Question 10

Benign tongue cancer ddx

Answer 10

Haemangioma: Bluish, compressible
Lipoma: Like fatty origin: soft, smooth
Papilloma: Small, around teeth
Giant cell tumor: Smooth, firm

Question 11

Ddx pre-malignant oral cavity lesions

Answer 11

Torus palatinus - bony outgrowth on hard palate
Torus mandibularis - bony outgrowth on lingual aspect of mandible
Leukoplakia - white patch on oral cavity mucosal membrane
Erythroplakia - erythematous patch with granular or nodular lesion, dysplasia without keratosis

Question 12

Torus palatinus

• Anatomical location
• Presentation
• Tx options

Answer 12

Anatomy:
 Bony outgrowth on hard palate
 Usually in midline, smooth mucosa even though irregular

Presentation:
 Pain
 foreign body sensation
 swallowing problem

Tx:
Surgical removal if symptomatic: Ulcer, affect denture, associated periodontal disorder

Question 13

Differentiating features of Torus palatinus vs cancer

Answer 13

Torus

• Normal overlying mucosa
• Does not extend or invade

Cancer

• Ulceration
• Extends inferiorly from nose, maxillary sinus (nasal symptoms)

Question 14

Torus mandibularis

• Morphology and anatomical position

Answer 14

Bony protuberance on the lingual aspect of the mandible (commonly between the canine and premolar areas)

Question 15

Ddx white patches in the mouth

Answer 15

Leukoplakis
Lichen planus
Oral Candidiasis
Linea alba (white mark from pressure, friction, trauma in mouth)

Question 16

Erythroplakia

Morphological features

Answer 16

 Erythematous patch
 +/- granular or nodular lesion
 Dysplasia without keratosis (red without surrounding epithelium)

Question 17

First-line investigations for pre-malignant lesions in oral cavity

Answer 17

Biopsy** to confirm malignancy

Wide base excision if malignant

Question 18

Parapharyngeal space tumor

• Clinical presentation
• Differentiating factor with parapharyngeal infection
• Benign or malignant

Answer 18

Clinical presentation:

• Asymptomatic due to space for expansion
• Incidental finding during URTI: swelling at tonsil/ peritonsil region

No trismus unlike quinsy

80% benign

Question 19

Presentation:

• Painless mass in mouth
• Persistent bleeding and ulcer that fails to heal
• Dysphagia
• Some dysarthria

Most likely dx

Answer 19

Ulcerative oral cavity cancer

• SCC
• Adenocarcinoma

Question 20

Presentation:

 Sore throat, odynophagia, dysphagia
 Muffled speech
 otalgia (referred pain)

Known HPV infection

Most likely Ddx

Answer 20

Oropharyngeal malignancy** HPV-related

 Epithelium: SCC
 Lymphoma tonsil and tongue base/ minor salivary gland

Acute tonsilitis
Acute epiglottitis
Ludwig angina

Question 21

Presentation

Sore throat 
Globus sensation and dysphagia 
Hoarseness 
Otalgia 
Known alcoholic 

Most likely Dx

Answer 21

Hypopharyngeal carcinoma (at level of hyoid to lower border of cricoid; between oral cavity and esophagus)

Question 22

Oral cavity cancers

• Subsites
• S/S, features of mass
• Histological types

Answer 22

Subsites: 
 Oral tongue (commonest)
 Buccal mucosa
 Floor of mouth
 Upper/ lower alveolus
 Hard palate
 Lip

S/S:

• Painless at first, painful when infiltrating nerve
• Bleeding
• Dysphagia
• Dysarthria (ankyloglossia due to size/ infiltration of hypoglossal nerve)

Mass features:

• Exophytic mass/ nonhealing ulcer
• Surrounding leukoplakia/ erythroplakia
• Loosen tooth +/- nonhealing tooth socket

Histological types 
ulcerative:
 SCC
 Adenocarcinoma
smooth :
 Lymphoma
 Minor salivary gland

Question 23

Oropharyngeal cancer

• Subsites
• S/S, features of mass
• Risk factors
• Histological types

Answer 23

Subsites: 
 Tonsil (commonest)
 Tongue base (need endoscope)
 Soft palate
 Posterior wall

S/S:

• Sore throat, odynophagia, dysphagia
• Muffled speech
• Referred otalgia
• Mass with ulceration, asymmetrical tonsils
• Trismus
• Cervical LN

RF:

• Smoking, Alcohol
• HPV (Oral sex)**

Histology:
- SCC or Lymphoma of tonsils/ minor salivary gland

Question 24

Hypopharyngeal carcinoma

• Subsites
• S/S
• RF
• Associated syndrome

Answer 24

Subsites:

1. Piriform fossa (60%)
2. Postcricoid (30%)
3. Posterior pharyngeal wall (10%)

S/S:
 Sore throat
 Globus, dysphagia
 Hoarseness -infiltrate recurrent laryngeal nerve)
 Otalgia
 Loss of laryngeal crepitus
 30% LN metastases

RF:(like CA esophagus):
 Alcohol
 Smoking

Associated syndrome: Paterson- Brown-Kelly syndrome

Question 25

Paterson Brown Kelly syndrome Define clinical features

Answer 25

triad of dysphagia, iron deficiency anemia, esophageal webs Examine koilonychias in nails Asso. high risk of CA hypopharynx

Question 26

First-line investigation for pharyngeal and oral cavity cancers

Answer 26

Investigation (10% risk of synchronous/ metachronous tumour esp smoking):  Panendoscopy (nasal cavity, nasopharynx, esophagus, trachea, bronchus etc.) + biopsy  Tonsillectomy or EUA (examination under anaesthesia) to look for malignancy + Bx  Ultrasound neck +/- FNAC (cell type)  CXR  CT/ MRI (tumor extent)  PET scan

Question 27

Typical histological types of Head and Neck Cancers

Answer 27

90% squamous cell carcinoma (SCC) nasopharynx: mostly undifferentiated nonkeratinizing NPC thyroid: mostly papillary thyroid cancer

Question 28

General treatment options for pharyngeal and oral cavity cancers

Answer 28

Early stage: Single modality:  Minimally invasive surgery (laser/robotic)  Elective neck dissection for nodal metastasis  Radiotherapy alone Late stage: Combined modality of treatment:  Surgery with adjuvant radiotherapy +/- chemotherapy  Concurrent chemo-irradiation

Question 29

3Rs principles for surgical treatment of pharyngeal and oral cancers

Answer 29

3Rs  Resect with adequate margins (frozen section to confirm clear resection)  Reconstruct to restore form and function (e.g. flap reconstruction)  Rehabilitation always – recover swallowing, voice and hearing with therapy

Question 30

Types of oral and pharyngeal reconstruction

Answer 30

Minimal invasion surgery: laser/ endoscopic/ robotic partial pharyngectomy +/- reconstruction Open major surgery with reconstruction: o Circumferential pharyngectomy + reconstruction o Total pharyngolaryngoesophagectomy (PLO) Flap reconstruction with microvascular anastomosis

Question 31

Ddx oral and pharyngeal infections

Answer 31

``` Acute tonsillitis Infectious mononucleosis Peritonsillar abscess (quinsy) Acute epiglottitis Ludwig angina Deep neck abscesses: Retropharyngeal, parapharyngeal abscesses ```

Question 32

Acute tonsillitis Causative pathogens

Answer 32

URTI Virus (esp children): - influenza, parainfluenza, - adenovirus, enterovirus, rhinovirus Bacteria: - ß-haemolytic strep (Streptococcus pyogenes) - Streptococcus pneumoniae, - Haemophilus influenzae Aerobic GPR: - Corynebacterium diphtheriae (vaccine) - Mycobacterium tuberculosis (chronic)) - Treponemia pallidum (syphilis) Candida (immunocompromised)

Question 33

Acute tonsillitis Clinical presentation

Answer 33

``` Symptoms  Sore throat, odynophagia  Muffled voice, hot- potato voice  Otalgia (glossopharyngeal nerve referred pain)  Systemic: abdominal pain, vomiting ``` ``` Signs  Fever  Hyperaemic tonsils with exudates/ pus (bilateral)  No/ minimal trismus ****  Tender cervical lymphadenopathy ```

Question 34

Acute tonsillitis First-line investigations and treatment options

Answer 34

Investigations: - CBC with diff: neutrophilia or lymphopenia patterns - Throat swab for C/ST Treatment: - Viral = rest, analgesics, fluid replacement, supportive - Bacterial = analgesics, penicillin, erythromycin

Question 35

Infectious mononucleosis - Demographic - Causative pathogen - Incubation period and prodromal period

Answer 35

Demographic  Acute infection  Young adult Causative: Epstein barr virus (EBV): Transmitted through saliva Incubation period: 5-7 weeks Prodromal period: 4-5 days

Question 36

Infectious mononucleosis Clinical presentation

Answer 36

``` Symptoms  Systemic: chills, aches  Respiratory: cough  Stomach: nausea, vomiting  Spleen: abdominal pain***  Central: fatigue, loss of appetite, malaise, headache  Visual: photophobia  Throat: soreness ``` ``` Signs:  Systemic: high fever  Spleen: enlargement  Throat: reddening  Tonsils: reddening, swelling, white patches  Lymph nodes: swelling ```

Question 37

Infectious mononucleosis First-line investigations and treatment options

Answer 37

Investigation: - CBC with diff - High WBC with mononuclear cell predominant - Blood smear - atypical lymphocytosis - Low plt - Deranged LFT and clotting - Positive MONOSPOT TEST Treatment: - Bed rest, analgesic, fluid replacement, supportive - AVOID AMPICILLIN, gives rubelliform rash over trunk

Question 38

Peritonsillar abscess/ quinsy - Anatomical nidus of infection - Causative pathogens

Answer 38

Anatomy: Collection of pus between tonsillar capsule & superior constrictor Mixed aerobic & anaerobic organisms:  Bacteroides  Peptostreptococcus

Question 39

Peritonsillar abscess Clinical presentation

Answer 39

``` Symptoms: Similar as tonsillitis  Sore throat, odynophagia  Muffled voice  Otalgia  Dysphagia, airway obstruction (dyspnea) ``` ``` Signs:  Fever  Unilateral peritonsillar swelling  Deviation of uvula  Trismus (spasm in muscles of mastication) ```

Question 40

Peritonsillar abscess/ quinsy - Treatment options

Answer 40

```  Analgesics  Fluid replacement*  Chart I/O  Transoral incision & drainage  antibiotics ``` Consider elective tonsillectomy (20% recurrence in smokers)

Question 41

Acute epiglottitis - Demographic - Causative organisms

Answer 41

ENT emergency (pediatric predominant) ``` Pathogens:  Haemophilus influenzae type b  β-haemolytic streptococci  Pneumococcus  Staphylococcus ```

Question 42

Acute epiglottitis Clinical presentation First-line investigation and treatment

Answer 42

``` Symptoms:  Sore throat, odynophagia  Hot potato voice, muffled Signs:  High fever  Tripod sign  Airway obstruction (inspiratory stridor)  Drooling ``` Secure airway immediately IV 3rd gen cephalosporins

Question 43

Ludwig angina - Anatomical location of infection - Origin of infection - Presentation

Answer 43

Severe inflammation/ abscess of floor of mouth, submental & submandibular space Dental origin bacteria S/S  Airway obstruction (stridor, dysphagia)  Trismus  Septic  Tender swelling at submental region  Superior, posterior displacement of tongue

Question 44

Ludwig angina First-line investigations and Tx

Answer 44

Secure airway Urgent head CT Surgical drainage + IV antibiotics Dental consultation for tooth abscess/ infection

Question 45

Deep neck abscess - Subsites - Causative organisms

Answer 45

``` Retropharyngeal abscess (paedi), Parapharyngeal abscess (masticator space, parotid space) ``` Causative organism: - Tonsillitis organisms: URTI viruses, B-hemolytic bacteria, Candida - Dental flora

Question 46

Deep neck abscess - Clinical presentation

Answer 46

Symptoms:  Sore throat  Neck swelling  Airway obstruction(dysphagia, dribbling) Signs:  Fever  Toxic  Head hyperextended, stiff  Airway obstruction (inspiratory stridor)  Neck swelling, infected retropharyngeal LN

Question 47

Deep neck abscess First-line investigations and treatment

Answer 47

Secure airway Urgent head CT Urgent ENT surgery: transcervical drainage, IV antibiotics Dental consultation for oral infections

Question 48

Complications of acute tonsillitis

Answer 48

Local (spread of infection):  Abscess formation: peritonsillar/ parapharyngeal/ retropharyngeal  AOM (acute otitis media) Systemic:  Immune-related hypersensitivity due to cross-reaction of Ab:  Acute rheumatic fever, rheumatic heart disease;  Acute glomerulonephritis (deposition of Ab- Ag in nephrons)  Septicaemia  meningitis, pneumonia

Question 49

Complications of infectious mononucleosis

Answer 49

 Sepsis (secondary bacterial infection)  Splenomegaly 50%  Hepatomegaly