The Throat and Neck

Question 1

where is the retropharyngeal space?

Answer 1

potential space anterior to pre-vertebral fascia and behind the pharynx, extends from the base of the skull to the mediastinum

Question 2

presentation of a retropharyngeal abscess?

Answer 2

commonly in young children (6mnths to 6 yrs with peak at 3 yrs) and following an URTI, although abscess is a relatively rare URTI complication
usually infection due to spread from infected LNs following URTI, but penetrating pharyngeal trauma also a cause
commonly Group A beta haemolytic strep, also anaerobes and S.aureus
neck held rigid and upright with reluctance to move
systemically unwell, fever, irritable
airway compromise-stridor, resp distress
dysphagia/odynophagia
may be bulging of posterior pharyngeal wall
RP space widening on lateral X-ray
assoc. mortality due to airway problems and mediastinitis

Question 3

how is a retropharyngeal abscess investigated?

Answer 3

blood cultures-guide Abx therapy
lateral neck radiograph-1st line in stable child
CT Neck with IV contrast-best imaging modality, see hypodense lesion, can determine vasc involvement
fine needle pus aspiration-send for histology and microbiology-always consider mycobacterium TB-do ziehl-neelsen staining

Question 4

management of RP abscess?

Answer 4

secure a.way if any concerns-must assess degree of resp distress and avoid invasive investigations if very anxious child to avoid worsening risk of airway obstruction, continuous monitoring required
keep child NBM, insert IV cannula
IV Abx-clindamycin plus beta lactamase inhibitor e.g. clavulanic acid, stopped on pt clinical improvement/afebrile for 48hrs and followed with oral ABx-amoxicillin and clavulanic acid
surgery-incision and drainage, through intraoral incision or external cervical approach, if a.way obstruction or failure to improve after 24-36hrs Abx

Question 5

what complications are we part. concerned with if pt has a parapharyngeal abscess?

Answer 5

involvement of CCA as located within the carotid sheath located within the parapharyngeal space*

Question 6

how should all neck masses be investigated?

Answer 6

US guided fine needle aspiration and cytology (FNAC)
EXCEPT for pulsatile masses

(plus also not needed in child with obvious midline thyroglossal cyst which moves on tongue protrusion and swallowing, BUT do need USS to check for functioning thyroid tissue before excision!)

Question 7

which muscles of the anterior cervical region are known as the infrahyoid muscles?

Answer 7

also known as the strap muscles of the neck:
sternohyoid
omohyoid
sternothyroid
thyrohyoid

Question 8

which 2 infrahyoid muscles does the thyroid gland lie deep to?

Answer 8

sternohyoid
and
sternothyroid

Question 9

anatomical location of the thyroid gland?

Answer 9

sits in base of the neck, anterolateral to the lower larynx and upper trachea, deep to sternohyoid and sternothyroid muscles, and at C5-T1 vertebral level.
surrounded by fibrous capsule, dense CT attaching capsule to cricoid cartilage and superior tracheal rings, and a visceral portion of the pre-tracheal layer of deep cervical fascia-loose sheath.

Question 10

blood supply to the thyroid gland?

Answer 10

superior and inferior thyroid arteries
superior originates from ECA
inferior originates from thyrocervical trunk branch of SCA

extensive anastomoses between R and L within gland, so potential collateral circulation between subclavian and ECAs.

Question 11

thyroid venous drainage?

Answer 11

superior and middle thyroid veins, into the IJVs

inferior thyroid veins into the brachiocephalic veins

Question 12

which intrinsic muscle of the larynx is NOT supplied by the recurrent laryngeal nerve?

Answer 12

cricothyroid

this is supplied by the external laryngeal nerve, a branch of the superior laryngeal nerve from the vagus nerve.

Question 13

what proportion of adult neck lumps are malignant?

Answer 13

80%
in contrast to 20% in children-usually located posterior triangle

malignancy in adults commonly metastatic disease from SCC of head and neck, upper RT or upper GIT squamous carcinomas.

80% of paediatric neck lumps benign, and located in anterior triangle

Question 14

1st line investigation for determining thyroid status of a patient?

Answer 14

TSH

Question 15

indications for CT scanning the neck in patients with a thyroid mass e.g. goitre or a solitary nodule?

Answer 15

when suspicion of tracheal compression or retrosternal extension

Question 16

how is cellular nature of a thyroid nodule determined?

Answer 16

ultrasound guided fine needle aspiration and cytology

Question 17

1st imaging of choice in a thyroid mass?

Answer 17

neck USS-can determine if swelling cystic or solid, and if multiple nodules present

Question 18

signs of thyrotoxicosis?

Answer 18

fine resting tremor
palmar erythema
thyroid acropachy-dermopathy assoc. with AI thyroid disease, involves soft tissue swelling and periosteal bone changes and clubbing.
tachycardia, irregular pulse-AF or SVT-regular
thin hair
TED-eye proptosis, lid lag
goitre
thyroid bruit
pretibial myxoedema-commonly non-pitting lower leg oedema

Question 19

local problems of thyroid gland enlargement e.g. goitre or nodule?

Answer 19

tracheal compression-at level of VCs causing stridor

oesophageal compression, causing dysphagia

Question 20

why is a multinodular goitre less of a concern than a solitary thyroid nodule?

Answer 20

solitary nodule more likely to be a thyroid cancer, of which most common type is a papillary adenocarcinoma which commonly presents in younger pts or where hx of neck irradiation.

Question 21

types of thyroid cancer?

Answer 21

papillary adenocarcinoma
follicular carcinoma-tendency to metastasise to bones and lungs
medullary carcinoma-neoplasm of C-cells which produce calcitonin. typically seen in MEN, so must screen for other organ involvement in these syndromes. genetic component.
anaplastic carcinoma-typically older patients, poor prognosis.

Question 22

management of thyroid adenoma?

Answer 22

no further tment after diagnostic hemithyroidectomy (1 lobe removed, usually with isthmus)

Question 23

management of thyroid Ca?

Answer 23

diagnosis-FNAC, lesion US and CT staging
total thyroidectomy for papillary, follicular and medullary, followed by radio-iodine for papillary and follicular
anaplastic normally too far advanced for curative surgery.

Question 24

thyroid surgery complications?

Answer 24

haemorrhage-surgical can be inserted during op, drain may be put in and left for 24 hrs in hemi, 48hrs in total, but this functions to aid healing process rather than control bleeding.
VC palsy-damage to 1 RLN can produce hoarse voice
a.way obstruction-bilateral VC palsy presenting with stridor, or may be secondary to haemorrhage*closing up after surgery sternothyroid and hyoid muscles brought together loosely so if bleeding less risk of airway compression
hypocalcaemia due to parathyroid gland damage

Question 25

most common midline mass in children?

Answer 25

thyroglossal cyst-due to persisting thyroglossal duct that allowed thyroid descent from foramen cecum (between anterior 2/3 and posterior 1/3 of tongue) into the neck during embryological development

Question 26

features of a thyroglossal cyst on examination?

Answer 26

located in neck midline, commonly below the hyoid and above the thyroid gland moves on both swallowing and tongue protrusion

Question 27

why might a child with a thyroglossal cyst complain of pain in neck?

Answer 27

cyst can become infected, which is assoc. with pain and swelling

Question 28

management of a patient with a thyroglossal cyst?

Answer 28

tment is by excision, but this must follow an USS of the neck to look for normal thyroid gland further down the neck in case the cyst is the only thyroid tissue present-hence removal would cause cretinism.

Question 29

differentials for midline neck lump in children?

Answer 29

thyroglossal cyst dermoid cyst-submental swelling, dermal remnant occurring along lines of fusion in embryo, lined by epidermis, tend not to move on swallowing or tongue protrusion. pyramidal lobe of the thyroid LN enlargement due to infection or metastasis

Question 30

most common isolated lateral neck lump cause in children?

Answer 30

branchial cyst | these are investigated with US guided FNAC to exclude necrotised LN from metastasis, and are excised completely

Question 31

most common cause of multiple lateral neck lumps in children?

Answer 31

cervical lymphadenitis secondary to infection such as URTI e.g. tonsillitis-*painful anterior lymphadenopathy is 1 of the 4 centor criteria favouring more severe bacterial tonsillitis and increased likelihood of quinsy requiring 10 day penicillin V treatment. multiple palpable non-tender nodes normal feature in many children

Question 32

differential for bilateral parotid gland enlargement in a child?

Answer 32

``` mumps viral infection note can be unilateral child has malaise and pyrexia can be complicated by orchitis and encephalitis symptomatic tment ```

Question 33

what features might make you suspect a cervical LN TB infection?

Answer 33

a non-tender purple/red lump in the neck, that may be quite large due to TB node coalescence, and this may form a discharging sinus most cases have assoc. pulmonary TB may need node biopsy for histological diagnosis confirmation-caseating granuloma? treat with normal TB drugs-rifampicin, isoniazid, pyrazinamide, ethambutol

Question 34

why might a child being treated for a cervical LN TB infection be at risk of colour blindness?

Answer 34

treatment with ethambutol which can cause optic neuritis (retrobulbar)

Question 35

usual location of a branchial cyst?

Answer 35

anterior to SCM in anterior triangle of the neck-level II, III or IV**

Question 36

why might a branchial cyst become painful and swollen in a child with a URTI?

Answer 36

most of these cysts are lined with lymphoid tissue

Question 37

medical therapy for hyperthyroidism?

Answer 37

symptom control with a beta blocker e.g. propranolol-rapid relief of tremor and tachycardia carbimazole or propylthiouracil-inhibitors of thyroid peroxidase required for iodination of thyroglobulin, propylthiouracil should never be used 1st line-due to risk of severe liver injury UNLESS: 1st trimester of pregnancy, tment of thyroid storm or tment of those with minor reactions to carbimazole who refuse tment with radioiodine or surgery. if put into remission, must check TFTs at least annually. may be given to prepare patients before radioiodine or surgery.

Question 38

complications of a retropharyngeal abscess?

Answer 38

``` tracheal compression pharyngeal compression aspiration pneumonia-content aspiration following abscess rupture mediastinitis, pericarditis, tamponade empyema jugular vein thrombosis carotid rupture-RP space bordered laterally by the carotid sheaths osteomyelitis ```

Question 39

how can nasopharyngeal carcinoma affect the neck?

Answer 39

may present as unilateral or bilateral metastatic nodes in posterior triangle of neck (posterior to post. border of SCM) note disease more common in those of S.Asian origin e.g. Chinese. disease may cause of chronic rhinorrhoea, and glue ear in adults-*always be suspicious of this.

Question 40

what is risk with incision biopsy of neck lumps?

Answer 40

seeding malignant disease e.g. SCC onto the skin | so FNAC always preferred, but then may need excision biopsy if primary sites are not clear.

Question 41

what malignancy are patients with sjogren's syndrome at increased risk of developing?

Answer 41

lymphoma, which develops within the parotid gland?

Question 42

common differential for bilateral tender enlargement of cervical LNs in young adult?

Answer 42

glandular fever (EBV) presentation includes sore throat, fever and fatigue presentation of acute HIV infection mimics this, but is followed with persistent lymphadenopathy, and may also present as a cystic swelling in parotid gland.

Question 43

causes of bilateral parotid enlargement?

Answer 43

sjogren's syndrome-lymphocytic infiltration of glands bulimia nervosa mumps

Question 44

what may be palpated deep in the supraclavicular fossa which is not of concern?

Answer 44

cervical rib

Question 45

most common cause of midline neck lumps in adults?

Answer 45

thyroid lesions

Question 46

most common cause of lateral neck lump in adults?

Answer 46

metastatic malignant disease, usually SCC from a primary site in head and neck if supraclavicular node involvement (worse prognosis) likely infraclavicular primary lesion e.g. gastric Ca.

Question 47

what term is used to describe impalpable LNs in metastatic disease where known primary malignant site, and which primary cancers commonly cause this in the neck?

Answer 47

``` occult nodes (N0) piriform fossa supraglottic larynx nasopharynx tongue base floor of mouth ``` prophylactic radiotherapy to neck should be considered to control the potential neck disease.

Question 48

if the primary lesion cannot be identified when LN metastatic disease in neck after thorough clinical examination, what other investigation may be useful?

Answer 48

PET scanning

Question 49

fixation of a LN to what structures in the neck implies that the metastatic disease is incurable?

Answer 49

skull base and brachial plexus

Question 50

what score is used to assist decision on whether antibiotics should be prescribed in primary care for a sore throat?

Answer 50

Centor criteria: tonsillar exudate, tender anterior cervical lymphadenoapathy/lymphadenitis, hx if fever, absence of cough. presence of at least 3 suggests antibiotic treatment would be effective.

Question 51

when is immediate hosp admission required in sore throat presentation?

Answer 51

stridor or resp difficulty: resp distress, drooling, system very unwell, odynophagia, muffled voice-suspect acute epiglottitis-DO NOT examine throat, upper a.way obstruction. severe suppurative complications e.g. RP abscess as risk of a.way compromise or abscess rupture dehydration signs of being profoundly unwell and unknown cause or rare cause suspected e.g. SJS-mouth ulcers, bullae formation and erosions, high fever, or yersinial pharyngitis-abdo pain with or without diarrhoea. signs of being markedly systemically unwell and patient is at risk of immunosuppression,

Question 52

why might a patient with tonsillitis complain of abdo pain?

Answer 52

due to gut lymphadenitis also * yersinial pharyngitis

Question 53

when if r/f to secondary care indicated for a tonsillectomy?

Answer 53

For a child if: 5 or more episodes of acute sore throat per year, documented by parent or clinician. symptoms been occurring for at least 1 yr sore throat episodes been severe enough to disrupt the child's normal behaviour or day to day functioning. r/f if child has guttate psoriasis which is exacerbated by recurrent tonsillitis. r/f if child has hx of sleep apnoea, daytime drowsiness, and failure to thrive. r/f adults if had 5 or more episodes per year of sore throat due to tonsillitis. The episodes should have been disabling and have prevented normal functioning.

Question 54

management of tonsillitis?

Answer 54

most cases viral and patients just need reassurance and advice-advise rest, drinking plenty of water-espec. if fever, and that if sore throat fails to improve or becomes worse over several days to come back-may be glandular fever (EBV). patient should improve within 1 week. advise to seek urgent medical help if devlop breathing difficulty, muffled voice, drooling, stridor, dysphagia. sucking ice lollies, throat lozenges may help analgesia-paracetamol and ibuprofen Abx role only in bacterial infection-phenoxymethylpenicillin (penicillin V) 10 day course, can do delayed prescribing strategy, use clarithromycin or erythromycin if pen allergic, for 5 days. quinsy-need abscess drainage if persistent consider tonsillectomy r/f

Question 55

causes of tonsillitis?

Answer 55

70% viral-rhinovirus, adenovirus, enterovirus, EBV bacterial-group A beta haemolytic strep-strep throat staph strep pneumonia h.influenzae e.coli

Question 56

why should amoxicillin NOT be prescribed for a sore throat?

Answer 56

if the cause is glandular fever, patient will develop a widespread erythematous maculopapular rash. *think glandular fever in teenagers, part. if tonsils covered with a membranous exudate, and may see petechial haemorrhages on palate.

Question 57

non-infectious causes of a sore throat that may be considered if pt has a sore throat for 3 or 4 wks?

Answer 57

GORD smoking alcohol allergic rhinitis

Question 58

features that may suggest Ca e.g. oropharyngeal or hypopharyngeal e.g. pyriform sinus, in sore throat presentation?

Answer 58

hypopharyngeal-persistent, unilateral, well localised sore throat, vague discomfort ton swallowing, otalgia, neck lump oropharyngeal-pt may complain of sensation of lump at back of the throat, neck mass, ulcer usually visible on examination. ?weight loss, smoking and alcohol hx

Question 59

presentation of quinsy (peritonsillar abscess)?

Answer 59

here pus forms between tonsil capsule and superior constrictor muscle severe sore throat lateralised to 1 side, causing dysphagia "hot potato" voice trismus ipsilateral otalgia and cervical adenopathy examination-gross swelling of tonsil and base of uvula deviation away

Question 60

quinsy treatment?

Answer 60

drainage of abscess under LA pareneteral Abx-penicillin may do immediate tonsillectomy, or interval tonsillectomy

Question 61

what must patients with glandular fever be advised about in relation to sports?

Answer 61

avoid contact sports for 2-3mnths as EBV commonly causes hepatosplenomegaly so risk of rupture.

Question 62

complications of quinsy?

Answer 62

spread to deeper neck tissues-necrotising fasciitis infection spread from parapharyngeal space to cause mediastinitis, pericarditis and pleural effusions airway compromise-RARE abscess recurrence haemorrhage after tonsillectomy death-can occur from aspiration, airway obstruction, erosion into major blood vessels or extension into mediastinum.

Question 63

most common cause of a chronic sore throat in adults?

Answer 63

chronic pharyngitis-often related to irritation from cigarette smoke, alcohol and acid reflux chronic inflammation may also be due to post-nasal drip from chronic sinusitis

Question 64

why in relation to the adenoids is it unusual for glue ear to develop in adults?

Answer 64

glue ear common in children due to ET obstruction by the adenoids which hypertrophy up to the age of 6yrs, then gradually regress to an insignificant size by about 12 years. therefore symptoms of adenoidal hypertrophy in adults must have nasopharynx examined-flexible rhinolaryngoscopy, to exclude a malignancy.

Question 65

likely cause of sudden onset pain within a thyroid lump?

Answer 65

bleed into a thyroid cyst

Question 66

indications for 2ww referral in presentation of a thyroid lump?

Answer 66

child with a thyroid nodule unexplained hoarseness, or voice changes assoc. with goitre painless thyroid mass enlarging rapidly over period of few weeks palpable cervical lymphadenopathy other potential red flags: FH of thyroid Ca or endocrine Ca-?medullary thyroid Ca inheritance and link to MEN hx of previous irradiation or exposure to high environmental radiation insidious or persistent pain lasting for several wks

Question 67

blood tests to order if medullary thyroid Ca is suspected?

Answer 67

basal plasma calcitonin and CEA

Question 68

what investigation is needed in all vocal cord palsy cases where hx and examination not diagnostic?

Answer 68

CT scan to image course of vagus and recurrent laryngeal nerves.

Question 69

where do 80% of salivary gland neoplasms occur?

Answer 69

parotid gland

Question 70

what proportion of parotid neoplasms are malignant in nature?

Answer 70

20%

Question 71

what are 80% of benign parotid neoplasms?

Answer 71

pleomorphic adenomas

Question 72

complications of a parotidectomy?

Answer 72

facial weakness-usually temporary and related to trauma and pressure close to nerve, but after SM gland surgery mandibular branch damage rarely recovers. ear anaesthesia-great auricular nerve division, anaesthesia to inferior 1/2 of pinna and surrounding skin, always some residual defecit. salivary fistula-overprod. of saliva from remaining tissue, need pressure dressings and suction drainage. frey's syndrome-gustatory sweating, possibly with facial flushing and heat, due to PNS fibre severing, espec. those of auriculotemporal nerve, destined for parotid, are rerouted to skin by growing along SNS fibres to sweat glands during their regeneration. may do tympanic nerve section if symptoms don't settle spontaneously after 6mnths. tongue weakness and anaesthesia-hypoglossal and lingual nerve trauma respectively.

Question 73

what proportion of SM gland neoplasms are malignant?

Answer 73

50% contrast to 20% in parotid, and 80% in sublingual

Question 74

how does infection occurrence in parotid differ from that of SM gland?

Answer 74

SM gland infections 9 times more common than in parotid

Question 75

causes of acute sialadenitis?

Answer 75

``` bacterial-usually staph, seen in dehydrated and IC patients viral-paramyxovirus (mumps) coxsackievirus echovirus HIV ``` chronic disease rare, but sometimes seen in TB, sarcoidosis, HIV and syphilis.

Question 76

presentation and management of sialolithiasis?

Answer 76

9 times more common in SM than parotid gland pain and swelling, worse during meals investigated with USS or sialogram management: conservative-most will settle, may give analgesia, hydration and sialogogues-increase saliva flow rate e.g. pilocarpine-parasympathomimetic endoscopy radiological removal surgery-intraoral removal of palpable stones, or salivary gland removal complications: sialadenitis, abscess formation

Question 77

how does region of laryngeal carcinoma impact on symptom presentation?

Answer 77

supraglottic=dysphagia glottis=dysphonia subglottic=resp problems e.g. stridor

Question 78

why does supraglottic laryngeal Ca present late?

Answer 78

potential space for expansion dysphonia late feature, may be dysphagia, resp problems or metastatic neck node-very rich decussating lymphatic supply

Question 79

supraglottic laryngeal Ca management?

Answer 79

usual primary site radiotherapy and neck nodes | if residual or recurrent disease then total laryngectomy and modified radical neck dissection

Question 80

most common malignant laryngeal Ca?

Answer 80

glottis laryngeal Ca usually starts on free vibrating edge of true vocal cord-allows early presentation due to dysphonia anterior spread to anterior commissure=poor prognosis as site close to cartilage-can be easy further spread to thyroid gland if confined to cord then excellent prognosis as no lymphatic supply, BUT lateral spread to muscle may reach lymphatic channels.

Question 81

management of glottic carcinoma?

Answer 81

radiotherapy laser surgery for selected early tumours total laryngectomy with modified radical neck dissection in cases of residual or recurrent disease

Question 82

name for when malignant squamous tumour involves all 3 regions of larynx?

Answer 82

transglottic laryngeal carcinoma emergency tracheostomy may be required due to resp difficulties

Question 83

over what time period where a patient is anticipated of requiring ventilation should a surgical or percutaneous tracheostomy be planned?

Answer 83

requiring ventilation for periods greater than 7-10 days

Question 84

important aspects of postop care of a tracheostomy?

Answer 84

regular physiotherapy to assist bronchial toilet suction catheter to clear tracheal secretions regular humidification and temp control to prevent dry crust formation-loss of normal air humidification carried out in the nose ensure patients kept well hydrated so secretions not made thicker and so more likely to be retained and predispose to infection

Question 85

complications of a tracheostomy?

Answer 85

``` immediate: haemorrhage-thyroid and anterior jugular veins, thyroid isthmus air embolism cricoid injury surgical emphysema pneumothorax ``` ``` early: dysphagia-due to loss of subglottic pressure and presence of inflated tracheostomy cuff tracheitis and tracheal crusting atelectasis tube blockage tracheal erosion ``` ``` late: tracheomalacia laryngotracheal stenosis decannulation problems tracheocutaneous fistula/scar tracheal erosion anteriorly-haemorrhage from brachiocephalic artery aspiration and pneumonia ```

Question 86

NICE pathway for urgent (2ww) r/f for suspected laryngeal Ca?

Answer 86

people aged 45 or older with persistent unexplained hoarseness OR unexplained lump in neck.

Question 87

tracheostomy indications?

Answer 87

upper airway obstruction e.g. trauma, FB, infection, laryngeal tumour, facial fractures impaired resp function e.g. head trauma causing unconsciousness assist weaning from ventilatory support in patients on ITU help clear secretions in upper airway

Question 88

at what are age are the tonsils at their largest?

Answer 88

by 2 years of age | start to decrease in size from this point, and often disappear by 8 years of age

Question 89

if a patient has a tracheostome, what should be considered in their management if giving the pt O2 therapy?

Answer 89

**tracheostome may be present post laryngectomy or if pt has a tracheostomy if had laryngectomy, no point giving O2 by face mask, and need to place mask over the tracheostome.

Question 90

where do most benign parotid neoplasms affect?

Answer 90

the superficial lobe of the parotid gland

Question 91

why is facial nerve palsy associated with malignant parotid neoplasms?

Answer 91

the facial nerve runs through the parotid gland between the superficial and deep lobes and expansion within deep lobe will cause facial nerve compression. any mass here tends to expand towards oropharynx causing medial tonsil displacement.

Question 92

tment of benign pleomorphic adenomas of the parotid gland?

Answer 92

superficial parotidectomy (as tumour usually in lobe superficial to facial nerve)