surgery - ENT neck

Question 1

most common malignancy of head and neck?

Answer 1

SCC

Question 2

factors increasing incidence of oral cavity cancer?

Answer 2

immigration and betel quid chewing especially in the Indian subcontinent

Question 3

factors increasing incidence of oropharyngeal cancer?

Answer 3

Human Papillomavirus (HPV) in younger population

Question 4

RF for head and neck SCCs?

Answer 4

alcohol and tobacco use
HPV 16
betel quid
occupational wood dust or asbestos exposure
EBV infection
immunodeficiency
prior radiation

Question 5

premalignant condiitons to head and neck cancer?

Answer 5

leukoplakia
erythroplakia
oral lichen planus
actinic cheilitis

Question 6

non-specific features of head and neck cancer?

Answer 6

weight loss, night sweats, loss of appetite, or cervical lymphadenopathy

Question 7

features of oral cavity cancer?

Answer 7

odynophagia, dysphagia, tonsillar lump or an asymmetrical tonsil, a neck lump,

Question 8

features of hypopharyngeal cancer?

Answer 8

odynophagia, dysphagia, stertor, or referred otalgia.

Question 9

features of nasopharyngeal cancer?

Answer 9

neck lump or unilateral conductive hearing loss

Question 10

features of laryngeal cancer?

Answer 10

hoarse voice, stridor (if advanced), dysphagia, persistent cough, or referred otalgia

Question 11

which laryngeal cancer has better prognosis

Answer 11

glottic

Question 12

ix for head and neck cancers?

Answer 12

lesion biopsy
flexible nasendoscopy
USS/FNA

Question 13

how is cancer staging done?

Answer 13

MRI/CT
PET-CT

Question 14

when are cancers referred?

Answer 14

Question 15

general mx of cancers?

Answer 15

moking and alcohol cessation.

Surgical resection +/- adjuvant radiotherapy or chemotherapy or primary radiotherapy +/- adjuvant chemotherapy

Question 16

oral cancer mx?

Answer 16

Small tumours can undergo wide local excision +/- neck dissection

Advanced tumours should undergo surgical resection +/- flap reconstruction + neck dissection +/- post-operative radiotherapy +/- chemotherapy.

Question 17

oropharyngeal cancer mx?

Answer 17

Small tumours of the tonsil can undergo surgical resection using Laser or Transoral Robotic Surgery +/- neck dissection or primary radiotherapy or both (if margin involved). More advanced tumours of the tonsil can undergo solely primary radiotherapy +/- adjuvant chemotherapy.

Small tumours at the tongue base can undergo surgical resection using Transoral Robotic Surgery with neck dissection or primary radiotherapy or both (if margin involved). Larger tumours at the tongue base can undergo primary radiotherapy +/- adjuvant chemotherapy.

Question 18

supraglottic cancer mx?

Answer 18

Small tumours can undergo surgical resection using transoral laser microsurgery with bilateral neck dissection or primary radiotherapy +/- adjuvant chemotherapy.

Advanced tumours can undergo laryngectomy with post-operative radiotherapy +/- adjuvant chemotherapy or primary radiotherapy +/- adjuvant chemotherapy.

Question 19

glottic cancer mx?

Answer 19

Small tumours can have surgical resection using transoral laser microsurgery with bilateral neck dissection or primary radiotherapy.

Advanced tumours can undergo laryngectomy with neck dissection and post-operative radiotherapy +/- adjuvant chemotherapy or primary radiotherapy +/- adjuvant chemotherapy.

Question 20

subglottic cancer mx?

Answer 20

Tumours originating from the subglottis are very rare but treatment principles are similar to the glottis.

Question 21

hypopharyngealc cancer mx?

Answer 21

Small tumours of the hypopharynx can undergo surgical resection using transoral laser microsurgery with neck dissection or primary radiotherapy +/- adjuvant chemotherapy

Advanced tumours should undergo laryngopharyngectomy +/- gastric pull up/jejunal free flap + neck dissection or primary radiotherapy +/- adjuvant chemotherapy

Question 22

complication following cancer mx?

Answer 22

Dysphagia (secondary to pharyngeal/oesophageal stricture)

Pharyngocutaneous fistula (following laryngectomy)

Injury to the accessory, vagus, hypoglossal, or marginal mandibular nerves (following neck dissection), or chyle leak (following neck dissection)

Mucositis (early complication of radiotherapy) or xerostomia (complication of radiotherapy)

Chronic pain, persistent hoarse voice, or hearing loss (following chemoradiotherapy)

Question 23

benign salivary gland tumours?

Answer 23

pleomorphic adenoma and Warthin’s tumour (papillary cystadenoma lymphomatosum).

Question 24

malignant salivary gland tumours?

Answer 24

(from most to least common)

mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma, squamous cell carcinoma, and adenocarcinoma

Question 25

RF for salivary gland tumours?

Answer 25

Direct radiation exposure Epstein-Barr virus (EBV) infection Smoking* Genetic alterations (p53 mutations)

Question 26

features of salivary gland tumours?

Answer 26

slowly enlarging mass, typically painless malignant = facial nevre palsy, erythema + ulceration pain = red flag large = airway obstruction, dysphagia, or hoarseness

Question 27

ix for salivary gland tumour?

Answer 27

Routine bloods (FBC, U&Es, and CRP) USS + FNA staging CT neck + thorax

Question 28

mx of salivary gland tumours?

Answer 28

Excision via parotidectomy Selective neck dissection will be performed for lymph node clearance

Question 29

non surgical mx for salivary gland tumours?

Answer 29

Radiotherapy has been used as adjuvant treatment if non-resectale

Question 30

indications for post-op radiotherapy?

Answer 30

(1) high-grade or advanced stage tumours (2) residual neck disease (3) recurrent disease (4) adenoid cystic carcinoma (5) close proximity to the facial nerve (6) incomplete or close resection margin

Question 31

early complications of salivary tumour resection?

Answer 31

Haematoma facial nerve injury sialocele

Question 32

late complications of salivary tumour resection?

Answer 32

Frey’s syndrome can develop following a parotidectomy, whereby the autonomic fibres supplying the gland reform inappropriately; the stimulus to salivate results in an inappropriate response of redness and sweating. First bite syndrome is a complication characterised by patient experiencing intense pain on taking the first few bites of a meal, which gradually improves as they eat.

Question 33

what is sialadenitis?

Answer 33

inflammation of the salivary gland most commonly affects parotid gland

Question 34

aetiology of sialadenitis?

Answer 34

Infective (viral or bacterial, as discussed below) Stones (60% of cause of sialadenitis) Malignancy Autoimmune, including Sarcoidosis*, Sjögren’s syndrome, systemic lupus erythematosus or Wegener’s granulomatosis Idiopathic

Question 35

common viral causes of sialadenitis?

Answer 35

mumps coxsackie, parainfluenza, and HIV

Question 36

common bacterial causes of saisladneitis

Answer 36

S.aureus S. viridans, H. influenzae, and Strep. pyogenes.

Question 37

features of sialadenitis?

Answer 37

painful swelling and tenderness of the gland Pyrexia, lymphadenopathy, and erythema purulent discharge

Question 38

ix for sialadenitis?

Answer 38

Routine bloods (FBC, CRP) Pus swabs blood cultures ultrasound-guided fine needle aspiration cytology CT if deep space neck infection

Question 39

mx of sialadenitis?

Answer 39

oral hydration and analgesia (including NSAIDs and paracetamol), Artificial saliva Antibiotics should be given if bacterial sialadenitis abscess formation will warrant an incision and drainage.

Question 40

what is sialothiasis?

Answer 40

calculi in the salivary glands or ducts

Question 41

how do stones form in salivary gland/ducts?

Answer 41

ollowing the stagnation of saliva; they are typically composed of calcium phosphate and hydroxyapatite, as the saliva is rich in calcium

Question 42

anatomy of parotid gland?

Answer 42

located superior to the angle of the mandible, the gland is superficial to the masseter muscle and drains (via Stensen’s duct) opposite to the upper second molar

Question 43

anatomy of submandibular gland?

Answer 43

lying beneath the floor of the mouth in the submandibular triangle, it drains (via Wharton’s duct) into the floor of the mouth, beside the frenulum of the tongue

Question 44

anatomy of sublingual gland?

Answer 44

located below the mucous membrane of the floor of the mouth, they are drained by multiple small ducts that empty either into Wharton’s duct or directly into the floor of the mouth

Question 45

RF for sialolithises?

Answer 45

medication (such as diuretics, anti-cholinergics, or antidepressants), dehydration, gout, smoking, periodontal disease, and hyperparathyroidism

Question 46

features of sialolithiasis?

Answer 46

intermittent facial swelling and pain, particularly associated with eating. Symptoms are usually unilateral.

Question 47

ix for sialolithiasis?

Answer 47

ultrasound or plain film radiographs sialography - gold standrad

Question 48

mx of sialolithaisis?

Answer 48

conservatively with oral hydration, analgesia, and sialogogues, such as lemon juice or sour sweets, which promote saliva production

Question 49

definitive mx of sialilithiasis?

Answer 49

Interventional radiology for direct extraction surgery - transoral approach can be used if the stones are distal or a transcervical approach for more proximal stones Sialoendoscopy is usually reserved for stones <5mm extracorporeal shockwave lithotripsy, which is reserved for stones in the proximal duct Salivary gland excision (most commonly submandibular gland excision) will be considered for patients with persisting symptoms which have failed conservative or medical management

Question 50

complications of sialolithiasis?

Answer 50

recurrent infections leading to chronic sialadenitis.