Throat Flashcards
(129 cards)
1
Q
Investigations for vocal cord palsy
A
- Chest X-ray
- Computed topography of the skull base to mediastinum (aortic arch) (to check entire course of recurrent laryngeal for lesions / trauma)
+/- USS thyroid
+/- Oesophagoscopy - HBA1C (diabetes)
- ACE-I levels (? Sarcoid)
- Mantoux text (TB)
Remember 1/3 idiopathic 1/3 neoplasia 1/3 iatrogenic / traumatic (surgery)
2
Q
Causes of unilateral vocal cord palsy
A
Left > affected than right as longer course, therefore more places for lesions to affect it
Generally:
* 1/3 Trauma (e.g to vocal cord via intubation or to recurrent laryngeal e.g. thyroid surgery, cartoid endarterectomy)
* 1/3 Neoplastic (e.g. Thyroid, bronchus, oesophagus etc.)
* 1/3 Idiopathic (likely viral neuritis)
Other:
- Infective (e.g Viral, Lyme disease, TB)
- Neurotoxins (mercury)
- Autoimmune (Sarcoid, RA, Crohn’s, PGA)
- Diabetes
- Thoracic lesions e.g aortic aneurysm, mitral stenosis etc
Pathology of:
- Recurrent laryngeal nerve (e.g. Iatrogenic - intubation/surgery, trauma, malignancy)
- Cricoarytenoid joint (e.g RA)
- Intrinsic muscle (e.g. myopathy, malignancy)
3
Q
Vocal cord palsy symptoms
A
- Breathy voice - adductor palsy
- Weak / hoarse voice - abductor palsy / compensated adductor palsy
- Stridor - bilateral palsy
- Difficulty swallowing
4
Q
Treatment for unilateral vocal cord palsy (3)
And, when would you surgically intervene and why at this time?
A
- Speech and language therapy
- Injections of fillers e.g teflon, colloid
- Surgical procedures to medialise the affected cord
Wait 6 months, as occasionally the contralateral cord could compensate for the palsy, and also to allow any viral cause to resolve.
5
Q
Symptoms of laryngomalacia
A
Number one cause of infant stridor (harsh inspiratory noises)
Mild tachypnoea
Choking and other feeding difficulties
Chest infections (aspiration)
**Snoring
Noisy breathing
Sleep-disordered breathing
Swallowing dysfunction
Nasal congestion
NORMAL CRY
6
Q
Laryngomalacia prognosis
A
90% resolve by 2 years
7
Q
Stridor characteristics in Laryngomalacia
A
High pitched
Crowing
Worse when crying and when supine
WILL HAVE NORMAL CRY
8
Q
Description of what you see on FNE with laryngomlacia:
A
An omega- shaped retroflexed epiglottis
Shortened aryepiglottic folds
Dynamic collapse of the supraglottic structures on inspiration
9
Q
Pathophysiology of laryngomalacia
A
Collapse of the supraglottic structures on inspiration causing stridor
10
Q
Treatments (mins 3) for laryngomalacia
A
Conservative:
MDT - paediatrics, dietician, SALT
Feeding advice / upright feeding position / thickened feeds / encouraging burping / paced feeds / treating any reflux to reduce laryngeal oedema
Oxygen administration
Surgery
- supraglottoplasty (e.g if failure to thrive)
- Aryepiglottoplasty (e.g. CO2 laser)
- rarely tracheostomy
11
Q
Investigations for larygomalacia (min 3)
A
Flexible nasal endoscopy
Laryngoytracheobronchoscopy
Polysomnography
12
Q
Embyological origin of Branchial cysts
A
Failure of **obliteration **of 2nd branchial cleft (by fusion of 2nd branchial arch and epicardial ridge)
13
Q
Branchial cleft cyst differentials?
A
Thyroglossal cyst
Reactive lymph node
Metastatic lymph node
Lymphoma
Cystic SCC
Carotid body tumour
Vascular malformation
Cystic hygroma
Ectopic thyroid tissue
Cat scracth disease
Atypical mycobacterium infection
14
Q
USS Neck of branchial cysts - findings: (5)
A
- Cystic
- Well defined
- Smooth outline
- Uniformly anechoic
- Posterior enhancement
*
15
Q
Aspiration of branchial cysts - findings:
A
- Viscous, turbid, yellow-green
- Cholesterol crystal on microscopy
16
Q
What is the workup for a head and neck cancer?
A
Tissue biopsy for histology
Imaging of lesion
- e.g. USS guided core biopsy or USS and EUA
Once CA known:
- CT/MRI (e.g. neck for surgical planning)
- CT Thorax for staging
- PET CT for distant mets / primary
17
Q
Neck lumps by location e.g. midline, anterior, posterior triangle, anywhere
A
Anywhere
- sebaceous cysts / other skin lesions
- Lymphadenopathy (reactive / malignant)
- Lymphoma
- Malignancy
- Infection (neck space/Ludwigs/dental abscess)
Midline
- Thyroglossal cysts
- Thyroid goitre / Cancer
- Dermoid cysts (fusion point, abocve hyoid, midline)
Anterior Triangle
- Branchial cysts (young adult, infected often, deep to junction of upper 1/3 and lower 2/3 SCM)
- Parotid lump (benign/malig/infective/stone)
- Submandibular lump (bening/malig/infective/stone)
Posterior triangle
- Cystic hygroma (low posterio triangle new born)
- Cartoid body tumour
18
Q
Treatment of thyroglossal cysts:
A
Conservative with long course abx and repeated aspiration can be used for infections
**
They should not be incised and drained because this
would result a persistent discharging sinus.**
Sistrunk procedure (removal of cyst, body of hyoid bone, wedge of tongue base)
19
Q
Risks of sistrunk procedure
A
Recurrence (2-8% if hyoid body excised)
Postoperative accumulation of infection or hematoma
may push the tongue base up into the airway and give rise to a ‘Ludwig’s’ angina type of airway emergency.
20
Q
Why do thyroglossal cysts form?
A
Failure of closure of the thyroglossal duct extending from the foramen cecum in the tongue to the thyroid’s location in the neck
….following migration of the thyroid gland from tongue base (foramen caecum) to its position in the neck
21
Q
Symptoms and presentatio of thyroglossal cysts
A
Most occur in children - mean 4yrs old, but adults can get
Midline (in 90%) swelling
Move upwards with tongue protrusion and swalling (attached to larynx)
Intermittent swelling, pain due to infection
Note left sided in 10%, right in 1%
22
Q
Investigation of thyroglossal cysts
A
Ultrasound scan
Radio-iodine uptake scan (Prior to excision as there may be active thyroid tissue in the cyst)
MRI
23
Q
What pathology is geneally found in midline between hyoid bone and cricoid cartilage?
A
Thyroglossal cyst
24
Q
Symptoms & signs acute tonsillitis
A
Odynophagia
Referred otalgia
Trismus
Drooling
Fever
Fatigue
Abdo pain (kids)
Vomiting (kids)
Enlarged tonsils, hyperaemic, pus in tonsillar crypts
Tender cervical lymphadenopathy
25
Treatment of tonsillitis
Analgesia (paracetamol - NOT aspirin, risk Reye's syndrome)
Fluid replacement (IV if necessary)
Antibiotics (if bacterial - Penicillin V (allergy: Clarithroymcin) or IV Benzylpenicillin, never Amoxicillin
Corticosteroids (more contraversial)
26
What is associated with aspirin in children and what is it:
Reye's syndrome: rapidly worsening brain disease associated with aspirin use post virally, generally in children
27
What type of reaction does amoxicillin cause in GF?
Type IV hypersensitivity - rash
28
Post tonsillectomy haemorrhage rates and the study/audit names
**NPTA (National Post Operative Tonsillectomy Audit 2005):**
Post operative haemorrhage for cold steel tonsillectomy - 1.3% (1% return to theatre rate)
Post operative haemorrhage rate (all techniques, adult + children) - 3.5% with 0.8% return to theatre.
**GIRFT (Getting it right first time 2019)**
Post operative haemorrhage rate (all techniques, adult + children) - 8% with 1.3% return to theatre.
29
Indications for tonsillectomy (min. 5)
Paradise Criteria & SIGN criteria
Recurrent quinsy
Recurrent severe tonsillitis for > 1 year
Treatment for obstructive sleep apnoea
Diagnosis of tonsillar malignancy with unilaterally enlarged tonsillar
7 or more documented, clinically significant, adequetely treated sore throats in the last year
5 or more (as above) in last 2 years
3 or more (as above) in last 3 years
30
Tonsillits differential diagnosis (min 3)
Glandular fever (EBV)
Diptheria
Agranulocytosis
Leukeamia
31
Most common organism bacterial tonsillitis
Group A Beta Haemolytic Streptococcus
32
Investigations for tonsillitis
FBC - (Neutrophilia = Bacterial, Leucocytosis > GF)
Monospot / Paul -Bunnell test
Throat swab
33
Define - Supraglottis, Glottis and Subglottis
Supraglottis – From inferior surface of the epiglottis to the vestibular folds (false vocal cords) including them to the superior surface of the true cords
Glottis – Contains true vocal cords and 1cm below them (opening between the vocal cords is known as rima glottidis)
Subglottis – From inferior border of the glottis to the inferior border of the cricoid cartilage.
34
Define laryngeal vestibule vs ventricle
Laryngeal Ventricle / sinus of Morgagni:
slitlike, mucosa-lined, space located between the true and false vocal cords.
Laryngeal vestibule:
The part of the laryngeal cavity lying between the laryngeal inlet and vocal folds.
35
Classification for H&N cancer?
8th Edition of the TNM classification for head and neck cancer
36
Symptoms of pharyngeal pouch (8)
Halitosis
Regurgitation
Dysphagia
Weight loss
Chest infections
Aspiration
Swelling of the neck (left sided usually)
Gurgling on palpation (Boyce's sign)
37
Epidemiology pharyngeal pouch
1:200,000 per year
38
Aetiology of pharyngeal pouch
Weakness at Killian dehiscence through the inferior constrictor between the thyropharyngeus and cricopharyngeus muscles of the infderior constrictor.
It’s a posterior pharyngeal pulsion (Zenker's) diverticulum through the pharyngeal mucosa.
39
Treatment options for pharyngeal pouch (4)
* Conservative
* Laser / diathermy myotomy (Dohlmann's procedure - divides the wall between the pouch and oesophagous)
* Endoscopic stapling (first line generally)
* Open surgical excision
40
Investigations for pharyngeal pouch
Flexible nasendoscopy
Contrast swallow
41
Complications from pharyngeal pouch surgery (10)
IMMEDIATE:
Primary haemorrhage
Surgical emphysema
Pneuomothorax
Injury to teeth
Oesophageal perforation
INTERMEDIATE:
Secondary haemorrhage (infection)
Hoarseness (recurrent laryngeal damage, permanent if divided)
Wound infection
Fistula
Mediastinitis
LATE:
Stricture
Recurrence
42
Causative agent of laryngeal papillomas?
HPV 6 and 11 (11 = moe aggressive disease)
43
Epidemiology of laryngeal papillomas
- peak incidence
- risk factors
- what dictates how aggressive disease is?
- can remission occur ?
Any age from birth to around age 5 (peal incidence 3-5).
Earelier age on onset = more aggressive disease
Remission can occur at any age
Maternal warts dsuring pregnancy a risk factor
44
Symptoms of laryngeal papillomas (3)
Hoarseness
Abnormal cry
Shortness of breath
Stridor (late)
45
Investigations for laryngeal papillomas
Microlaryngoscopy + tissue biopsy
46
Treatment for laryngeal papillomas
Surgical:
Microdebridement /cold steel excision or C02 laser ablation
If on both cords or at anterior commisure two operations 4 weeks apart are required to prevent web formation.
Adjuvant Medical (if px has > 4 procedures a year):
- Gardasil Vaccine (quadrivalent, given in 3 IMs)
- Antivirals e.g. Cidofovir (prevents HPV DNA synthesis) injected into lesion a number of times
- Alpha interferon
- indole-3-carbinol
(cabbage juice derivative) and immunostimulants.
47
Single laryngeal papilloma in and adult - management:
Liable to recur and become malignant
Remove at direct laryngoscopy.
Follow up for 5 years
48
Tracheostomy in laryngeal papillomas
Used rarely (as a last resort)
as risk of spreading disease distally
49
Risk factors for oral cancer
Smoking
Excessive alcohol consumption
Betel nut chewing
50
Investigations for oral cavity cancer
Biopsy
+/-Orthopantomogram (useful if ? mandible involved)
Staging CT head / neck / chest
MRI useful for soft tissue delineation
PET CT if concerns for occult spread
51
Treatment options for oral cavity cancer (3)
Palliation
Radiotherapy / Chemotherapy
Surgery - excision +/- neck dissection +/- reconstruction (e.g radial forearm free flap if T1/T2 / hemiglossectomy, free fibular if mandible resection)
52
Treatment options for oral cavity cancer (3)
Palliation
Radiotherapy / Chemotherapy
Surgery - excision +/- neck dissection +/- reconstruction (e.g radial forearm free flap if T1/T2 / hemiglossectomy, free fibular if mandible resection)
53
Symptoms of hypothyroidism (min 5)
Fatigue
Hair loss
Dry skin
Weight gain
Cold intolerance
Voice change
Muscle weakness
Decreased sweating
54
Symptoms hyperthyroidism (min 5)
Sweating
Anxiety
Weakness
Palpitations
Weight loss
Tremor
Insomnia
Hyperactivity
Diarrhoea
Oligomenorhoea
55
Causes of hypothyroidism (min 5)
Hashimotos thyroiditis (>com. developed world)
Iodine deficiency (>com. developing world)
Radiation
Thyroid surgery
Pituitary disease
Drugs e.g. Amiodarone
56
Investigations for hypothryoidism
TSH
Free T4
Antithyroid Peroxidase Antibodies
More thorogh:
TSH, T4
TSH Receptor Antibodies (which are directed against the TSH receptor causing stimulation of it)
Anti thyroglobulin antibodies (can be raised in Grave’s / Hashimoto’s - sign of autoimmune damage to thyroid)
Calcium
Calcitonin
CXR ? Retrosternal ? Trachea deviation ? Mets/Nodes
Flexible nasendoscopy to check vocal cords
USS +/- FNA
Radionucelotide scintigraphy to identify if a nodule is hot
Staging scans if necessary
57
Investigations for hyperthryoidism
TSH
Free T4
TSH receptor antibodies
More thorough:
TSH, T4
TSH Receptor Antibodies (which are directed against the TSH receptor causing stimulation of it)
Anti thyroglobulin antibodies (can be raised in Grave’s / Hashimoto’s - sign of autoimmune damage to thyroid)
Calcium
Calcitonin
CXR ? Retrosternal ? Trachea deviation ? Mets/Nodes
Flexible nasendoscopy to check vocal cords
USS +/- FNA
Radionucelotide scintigraphy to identify if a nodule is hot
Staging scans if necessary
58
Common causes hyperthyroidism
Graves disease
Toxic multinodular goitre
59
What's raised in Hashimotos and what's raised in Grave's
Hashimoto's
- AntiThyroid Peroxidase Antibodies
- Anti thyroglobulin antibodies (can be raised in Grave’s / Hashimoto’s - sign of autoimmune damage to thyroid)
- Anti-microsomal antibodies
Graves
- TSH Receptor Antibodies (which are directed against the TSH receptor causing stimulation of it)
60
Treatment for Hashimoto's
Levothyroxine
Nb. if severe hypothyroidism = medical emergency
61
Treatment for Grave's
Co-ordinated with endocrinologists:
Medical
- Beta blockers
- Thioamide drugs e.g carbimazole and radioactive iodine
Surgical
- Total thyroidectomy
62
Complications of thyroid surgery
Anatomical
- Recurrent laryngeal nerve damage (2%)
- External branch of superfical laryngeal nerve damage
- Damage to trachea
- Pneumothorax
Hormonal
- Tetany (hypoparathyroidism due to removal or bruising to parathyroid glands)
- Thyroid crisis
- Hypothyroidism
- Late recrrence thyrotoxicosis due to incomplete removal of toxic gland
Wound site
- haemorrhage (immediate / delayed - release staple/stitches, evacuate)
- Tracheomalacia (rare)
- Infection of wound
- Poor scar
63
Follow up care post thyroid surgery
Serum calcium 12 hours post op
(SGH seems to be within 6 hours post op and post op day 1)
Thyroid function check at 6 weeks to check contralateral lobe working
Check again at 3 months if issue at 6 weeks
Vocal cord mobility check (FNE) post op
64
Which signs are pathognomic of Grave's in a hyperthyroid patient?
Exophthalmos and nonpitting edema (pretibial myxedma)
65
Risk factors for Grave's
Genetic link > likely to suffer if family member has
Those with Autoimmune disease - T1DM, RA - more likely to suffer
Smoking
66
Risk factors for Hashimoto's
FH
Personal history of autoimmune disease
67
Pathophyisology of Grave's
Thyroid stimulating immunoglobulins (IgG) bind to TSH receptors on thyroid follicular cells which produce > T3/T4
Eye signs are due to ? the extaocualr muscles expressign a TSH receptor, are affected by the circulating IgG which results in fibrobklast activation > hypertrophy, adipogenesis > exopthalmos
68
Second most common cause hyperthyroidism
Toxic multinodular goitre
69
Indications for thyroid surgery
4 C’s
Compressive symptoms (Trachea / Oesophagous - Dysphagia / Stridor)
Cancer
Cosmetic
ToxiCOSIS
70
Signs / Symptoms of Hypocalcaemia
What is a common cause of it in an ENT setting?
CATS GO Numb
Convulsions / seizures
Arrhythmias
Tetany
Numbness in the hands and feet and around the mouth
ECG changes (prolonged QT)
Chostek sign may be positive with hypocalcaemia
(twitching of facial muscle ontapping on the side of the ear).
Thyroid / Parathyroid surgery
71
Emergency management of hypocalcaemia
STAT
> IV 10ml 10% calcium gluconate in 100ml NaCl / 1 hour
Followed by:
> Calcium infusion 40ml 10% in 500mls NaCl / 24hrs
> Start calcium supplements PO (Calcichew D3 forte) QDS 1 tabket
72
Rare causes of Goitre
Sarcoidosis
TB
Amyloid
HIV
can all cause Goitre
73
Large goitre, normal TFTs diagnosis?
Management?
Non toxic or multinodular goitre
(? Ensure not cancer or rare cause e.g. Amyloid, sarcoid, TB, HIV by testing for all of this?)
> USS FNA
> CXR for retrosternal extension and sarcoid and TB
> Bloods - CA, ACE-I, HIV
If is just the above generally no treatment unless becomes toxic / hypo or compressive symptoms or other 4 C's)
74
What is De Quervains Thyroiditis?
Subacute granulomatous thyroiditis
Secondary to acute viral illness e.g. URTI, Mumps, adenovirus etc.
Diffusely swollen, tender goitre
Transiet Hyperthyroidism and autoantibody production
Hypothyroidism
Then return to euthyroid
75
Elderly patient, long term Hashimoto's thyroiditis, Goitre has recently enlarged, what is the possible cause?
Hashimoto's Can degenerate into Lymphoma (B Cell, Non-Hodgkins)
76
Types opf thyroid cancer (5-7)
Papillary
Hürthle cell
Follicular
Medullary
Anaplastic
Thyroid sarcoma
Primary thyroid lymphoma is a type of non-Hodgkin lymphoma
77
Papillary Carcinoma
Description
Where metastasis to
Diagnosis
Histology
**Papillary Carcinoma**
> Common (60%)
> Commonest thyroid cancer in children
> Often MULTIFOCAL
Lymph mets common (cervical nodes)
< 10% have distant mets
Diagnosis
Thyroglobulin tumour marker
Accurately Dx on FNA (FNA, not a core biopsy
Histology:
Psammoma bodies (microcalcification)
Orphan annie nuclei (which appear uniform on staining and EMPTY)
Pappillary projections
Seldom encapsulated
78
**Follicular Carcinoma**
Description
Where metastasis to
Diagnosis
Histology
**Follicular Carcinoma**
20% of thyroid CAs
Rare in young (<30 yr old) pts
Haematogenous route common (lungs etcs)
Diagnosis
CANNOT Dx on FNA, therefore must perform hemi-lobectomy for histology
Histology:
macroscopically encapsulated, microscopically capsular invasion is seen
well-defined follicles containing colloid
Hurthle cell tumours (variation): prominent oxyphil cells and scanty thyroid colloid.
Dx actually made on invasion rather than histology because it looks so much like normal tissues (hence FNA no diagnostic)
79
**Medullary thyroid carcinoma**
Description
Where metastasis to
Diagnosis
Histology
**Medullary thyroid carcinoma**
~5% of all thyroid CAs
Familial in 20%
Can be MEN II (A&B) disease or Familial NON MEN disease or Sporadicially
If MEN 90% bilateral
Tumour of Parafollicular (C cells)
Lymphocytes predominant
Lymph AND Haematogenous spread
Poor outcome if not familial
**Diagnosis**
Calcitonin often raised
**Management**
Total Thyroidectomy + selective lymph node dissection
80
MEN I
MEN IIA
MEN IIB
What pathologies
MEN I
Pituitary adenoma
Parathyroid hyperplasia
Pancreatic tumours
MEN IIA
Medullary thyroid cancer
Parathyroid hyperplasia
Phaeochromocytoma
MEN IIB
Medullary thyroid cancer
Phaeochromocytoma
Marfanoid body habitus
Mucosal neuromas
81
Anaplastic Carcinoma
**Anaplastic Carcinoma **
10% of all Thyroid malig
Elderly women
Often superimposed on longstanding Goitre
Spindle cells
Rapid local invasion common
Very poor prognosis
82
**British Thyroid Association (BTA) "U" System**
U1: Normal - only FNAC if high risk
U2: Benign - only FNAC if high risk
U3: Indeterminate - FNAC
U4: Suspicious - FNAC
U5: Malignant - FNAC
83
Thyroid ultrasound appearance suspicious for malignancy (6)
* Solid hypOechoic
* Lobulated / irregular outline
* Microcalcification
* Intranodular vascularity
* Taller than wide axially (AP>ML)
* Characteristic associated lymphadenopathy
84
How are thyroid nodules classified on ultrasound and what is the grading system called?
**British Thyroid Association (BTA) "U" System**
**U1 (normal)**
no nodules
**U2 (benign)**
hyperechoic or isoechoic with a halo
cystic change with ring-down artifact (colloid)
microcystic or spongiform appearance
peripheral egg-shell calcification
peripheral vascularity
**U3 (indeterminate)**
solid homogenous markedly hyperechoic nodule with halo (follicular lesions)
hypoechoic with equivocal echogenic foci or cystic change
mixed or central vascularity
**U4 (suspicious)**
solid hypoechoic (compared with thyroid)
solid very hypoechoic (compared with strap muscles)
hypoechoic with disrupted peripheral calcification
lobulated outline
**U5 (malignant)**
solid hypoechoic with a lobulated or irregular outline and microcalcification
papillary carcinoma
solid hypoechoic with a lobulated or irregular outline and globular calcification
medullary carcinoma
intranodular vascularity
taller than wide axially (AP>ML)
characteristic associated lymphadenopathy
Size does not have a role in this grading system.
85
THY classification
**Thy 1**
Non-diagnostic
**Thy 2**
Non-neoplastic
**Thy 3a**
Neoplasm possible (atypical features)
**Thy 3f**
Follicular neoplasm
**Thy 4**
Suspicious of malignancy
**Thy 5**
Diagnostic of malignancy
86
How are thyroid FNA samples classified on cystology and what is the grading system called?
THY Classification
**Thy 1**
- Non-diagnostic
- US +/- repeat FNA
**Thy 2**
Non-neoplastic
Correlate with clinical and US findings
**Thy 3a**
Neoplasm possible (atypical features)
Further US +/- FNA
MDT discussion if Thy3a on repeat sample
**Thy 3f**
Follicular neoplasm
Diagnostic hemi-thyroidectomy
**Thy 4**
Suspicious of malignancy
Diagnostic hemi-thyroidectomy
**Thy 5**
Diagnostic of malignancy
Therapy appropriate to tumour type: usually surgery
87
What adjuncts are there post thyroidectomy for high risk tumours?
Post-operative radioactive iodine treatment is warranted in the management of high-risk thyroid tumours
88
What type of burns do button batteries cause and how?
The form a circuit when surrounded by bodily fluids, releasing strong alkali causing corrosive burns.
Can perforate oesophagus within 2 hours.
89
Investigations (3) for ingestion of button battery?
AP & Lateral soft tissue neck XR
Erect AP & Lateral CXR
Abdominal XR
90
Button battery at cricopharangeous - management?
Urgent rigid oesophagoscopy for removal
91
Radiological signs associated with FB in oesophagous (4)
Which fish bones are radiolucent vs radiopaque?
LAWS
Loss of cervical lordosis
Air fluid level
Widened pre-vertebral shadow (pre-vertebral soft tissue thickening)
Subcutaneous emphysema
Lucent - Mackeral, Trout, Pike
Opaque - Cod, Haddock
92
Management of FB in oesophagous
NBM
D/W anaesthist on call, theatre co-ordinator, ENT consultant on call and list for emergency oesophagoscopy and foreign body removal
93
Signs and symptoms of oesophagoeal perforation (6)
Severe chest pain
Haematemesis
Tachycardia
Tachypnoea
Pyrexia
Surgical emphysema
94
Management of oesophagel perforation
NBM
IV Abx
CXR
Rigid oesophagoscopy
Pass NG in theatre
Confirm placement
Commence feed when placement checked and satisfactory
95
Investigation for FB in oesophagous / airway
HX & clinical exam (oral / neck / chest / nasal exam)
FNE
AP & Lateral soft tissue neck XR
AP & lateral CXR
+/- AXR
If none found, but high clinical suspicion can consider CT
96
Management of a child who has inhaled a foreign body
A to E approach as per APLS
Assessning for any signs of airway compromise
15L high-flow oxygen on a non re-breath mask
+ nebulised adrenaline
+ heliox if available
Anaesthetic, paediatric and senior ENT support should be sought.
If in respiratory distress can deliver back blows > Abdominal thrusts > CPR is unresponsive
**Operative management:**
**Above the vocal cords**
Direct laryngoscopy
Magill forceps to remove
**Below the vocal cords e.g. right main bronchis**
Removal using
Rigid ventilating bronchoscope and optical forceps
97
Causes of respiratory distress in a child (7)
**Congenital **
- laryngomalacia in the infant
**Traumatic **
- vocal cord palsy, subglottic stenosis
**Infective **
- severe adenotonsillitis, acute epiglottitis, laryngotracheo- bronchitis (croup)
**Acquired **
- Foreign body ingestion
**Autoimmune **
- severe asthma
- Anaphylaxis
98
What can be used in laryngectomy patients to provide them with speech? (3)
And how do the work?
Blom-Singer valve (transoesophageal prosthesis)
- stoma occludedm air transmitted from trachea into oesophagus through prosthesis and then the throat which creates voice sound. Small valve prevents aspiration of food / fluids
Electrolarynx - handheld device put against neck produces monotone buzz which user articulates into speech
Oesophageal speech - swallowed air is regurgitated, vibrating neopharynx and articulated into speech
99
How does a transoesophageal prosthesis create speech and what is the valve's name?
Blom-Singer valve (transoesophageal prosthesis)
Stoma occludedm air transmitted from trachea into oesophagus through prosthesis and then the throat which creates voice sound. Small valve prevents aspiration of food / fluids
100
Indications for tracheostomy
**Obstruction:**
To secure airway compromised by obstruction (e.g tumour / trauma / burns / FB / infection)
**Protection:**
To secure an airway in a anticipation of compromise (e.g surgery / cancer / neuorligical disease / burns)
**Weaning:**
To faciliate ventilatory wean (reduces dead space)
**Pulmonary disease:**
- Severe OSA unresponsive to CPAP
- Aid removal of secretions / protect from aspiration
**Severe chest injury (flail chest):**
**As part of another procedure e.g. laryngectomy**
101
Types of tracheostomy tube and why you would use them:
Cuffed - to protect the lower aiway
Uncuffed - used for:
Children (to reduce subglottic stenosis)
Used to aid Vocalisation
(- patients who can protect their own airway, have an adequate cough reflex and most importantly can manage their own secretions e.g. GCS >8)
Fenstrated - allows air to pass to the glottis enabling speech, but encourage granulation formation > bleeding > aspiration risk
Unfenestrated - ??
102
Parts of tracheostomy tube
Size 8 is pretty standard
Introducer - to aid insertion of tracheostomy
Inner tube (fenestrated / unfenestrated) - aid cleaning of the tracheostomy
Balloon / cuff
103
Complicatons from tracheostomy
**Immediate **
- Damage to local structures (recurrent lareyngeal, cricoid, oesophagus, brachiocepahlic vein)
- Cardiac arrest
**Early**
- Bleeding
- Infection
- Pneumothorax
- Surgical emphysema
- Tube obstruction
- Tracheal necrosis
**Late**
- Subglottic stenosis
- Decannulation difficulties
- Tracheoesophageal fistula / Tracheocutaneous fistula
- Tracheoinommate fistula
- Scarring / Keloid
104
Post op management tracheostomy
Regular suction (pt unable to cough/clear)
Humidifcation of air to prevent drying of airway / crusts / infection
Inner tube change at 48hrs
Outer tube change at 5 days
(Should always be spare tube and dilater at bedside)
Writing pad / instructions on speaking if fenestrated trachy
Removal as soon as is feasible - Ptg must be able to tolerate spigot for full 24 hour period before removal, and then monitored as inpt for 48 hrs after
105
Oral pathology that could come up:
Oral candidiasis
Mucocele / Mucous retention cyst
Ranula
Apthous Ulcer
Traumatic Ulcer
Neoplasia (SCC)
Lichen Planus
Geographic tongue (erythema migrans)
Black hairy tongue
Frictional keratosis (e.g. linear, bilateral acoss buccal surface where teeth meet)
Leukoplakia
Erythroleukoplakia
Proliferative Verrucous leukoplakia
Palatal (Maxillary) Torus
Mandibular torus
Good article with images: https://www1.racgp.org.au/ajgp/2020/september/common-benign-and-malignant-oral-mucosal-disease
106
Lace like pattern on buccal mucosa - diagnosis, sign, Rx?
Reticular Lichen Planus
‘net-like’ pattern = Wickham’s striae
This is most commonly located on the buccal mucosa but can be found on the tongue and lip vestibule
Often asymptomatic
Rx
Leave if asymptomatic
Topical steroid (e.g. steroid mouth rinses)
Systemic Rx
107
Define leukoplakia, investigatons and management
Leukoplakia = descriptive term used to describe ‘white plaques of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer’ affecting the oral mucosa
As leukoplakia is a descriptive term
> Biopsy mandatory to establish the diagnosis.
Tissue diagnosis may range from benign (eg hyperkeratosis) to pre-malignant (dysplasia) to malignant (SCC).
108
Define erythroplakia, investigatons and management
Red patch of the oral mucosa or a red lesion that cannot be characterised clinically or pathologically as any other definable lesion or disease.
Erythroplakic lesion is of even greater cause for concern than a white leukoplakic lesion as there are studies showing an almost 90% rate of SCC/high-grade dysplasia when a tissue diagnosis is established.
Biopsy
109
What is a ranula and how is it treated?
A ranula is a mucus extravasation cyst involving a sublingual gland and is a type of mucocele found on the floor of the mouth.
Rx
- Nothing is aymptomatic and small
- Marsupialisation (open it into the oral cavity)
- Removal of sublingual gland
110
Red spots on tongue - possible diagnosis?
What are they and where else could they be found?
Hereditary Heamorhagic Telengectasia
Telengectasia =
Red spots on lips / tongue / mucous membranes
Telengectasia face
AVM
Lesions in the gut
111
Hereditary Heamorhagic Telengectasia
- Mode of inheritance
- Symptoms (6)
- Associatyed abnormalities (2)
Autosomal dominant
Epistaxis (> commons feature)
Telengectasia on face, nose & mucous membranes (mouth / (esp. the tongue / lips)
GI bleeding
Haemoptysis
CNS complications, cardiac and liver failure
Iron def anaemia
Lesions in the gut which can bleed
Arteriovenous malformations in the lungs, liver & brain / spine
112
Treatments for HHT when it affects the nose
Conservative
- monitoring, follow-up and surveillance
Medical
- Oestrogens or Progesterone
Surgical / Interventional
- Repeated local treatment (cautery may exacerbate bleeds, try adrenaline soaked balloons, TXA)
- Radiotherapy
- Sclerosants
- laser (argon or Nd-YAG)
- Septodermoplasty (replacement of area with skin graft)
- Modified Young's procedure (surgical closure of the nares)
113
Investigations for a patient with recurrent epistaxis and red spots on tongue?
? Hereditary haemorrhagic telengectasia
FBC
Iron studies
Genetic screening
CXR (?Lung AVMS visible)
Echocardiogram (?cardiac compromise)
MRI Brain (?AVMS)
114
Management options for hypopharyngal tumour
Depends on TNM stage:
Transoral laser microsurgery (TLM)
Chemoradiotherapy Laryngopharyngectomy
Palliative therapy / Best supportive care
115
Laryngeal cancer pathology:
90% SCC
116
Why does glottic carcinoma spread more slowly than other laryngeal tumours?
Glottic carcinoma spreads more slowly than other subtypes due to the relative lack of lymphatic drainage of the vocal cords.
117
How does the monospot test work and how diagnostic is it for EBV?
positive Monospot test is highly suggestive of glandular fever.
HETERO = opposite of MONO
The test detects heterophile antibodies produced by
humans in response to EBV infection.
sensitivity between 70-92 percent
specificity between 96-100 percent.
118
Complications of tonsillitis (6)
Peritonsillar abscess,
Inferior extension to medistinum
Para or retropharyngeal abscess
Septicaemia
Infective endocarditis Glomerulonephritis.
119
Complications of deep neck space infections
Septicaemia
Endocarditis
Pericarditis
Mediastinitis
Thrombosis of the great vessels of the neck
Pyopneumonitis
Bronchial erosion
Purulent aspiration pneumonia
Grisel syndrome - non-traumatic rotary atlantoaxial subluxation associated with a head and neck infection.
120
Symptoms of deep neck space infections
(5 key ones)
Stridor / Resp distress
Pyrexia
Drooling
Neck pain / stiffness
Dysphonia / voice change
Trismus
Odynophagia / Dysphagia
In children v. siumiliar to epiglotitis presentation: **poor feeding, irritability** plus the above
121
Treatmet of deep neck space infections:
Consult seniors (ENT Surgeon / Anaestethist / paediatrician anesthetist)
Secure airway if any concerns
IV abx / 02 +/- adrenaline nebulises / Fluids / Bloods / Cultures
Imaging:
CT with contrast most helpful
Lateral soft tissue XRs
Theatre for drainge usually
122
Discharging sinus anterior to SCM between the middle and lower 1/3?
second branchial cleft fistula
123
Branchial cleft pathology - describe the types and locations and which is most common?
**First branchial cleft anomalies (5-8%)**: seen above the level of the mandible near the external auditory canal within or close to the parotid gland.
* first branchial cleft cyst
* first branchial cleft fistula
* first branchial cleft sinus
**second branchial cleft anomalies (commonest by far: 90-95%):**
between the level of the mandible angle and the carotid bifurcation, deeper than the platysma and superficial layer of deep cervical fascia
* second branchial cleft cyst
* second branchial cleft fistula
* second branchial cleft sinus
**3rd and 4th are very rare**
3rd - infrahyoid neck
4th - infrahyoid neck, usually adjacent to the thyroid gland
5th - don't occur
124
Investigations for weeping sinus in neck
Fistulogram / Fistulorgraphy
USS
CT
125
Management of weeping sinus in neck
Likly 2nd branchial cleft sinus/fistula
Investigations
- Fistulogram / Fistulography
- +/-USS
- +/- CT
Abx
Analgesia
Then any of:
sclerosing agents;
excision of the fistulous tract
Pull through brachial fistulectomy
126
What will a fistulogram of a 2nd branchial cleft fistula show / what is the course of the tract?
Ssmooth tract extending from the external cutaneous opening at the lateral neck superomedially passing between the ECA and ICA over the hypoglossal nerve to the posterior pillar of the tonsillar fossa.
127
What syndrome is associated with 2nd branchial cleft fistula?
Branchio-oto-renal syndrome
128
Tonsillectomy - bleeding, what to tell patients
one in every five adults will need to stay in hospital for observation because of bleeding.
One in 100 people will need a second operation to stop the bleeding.
129
Pathology c FNA grading
FNA results may be described as:
C1: Inadequate sample (not enough cells for diagnosis)
C2: Benign (not cancer)
C3: Unusual, abnormal or uncertain but probably benign
C4: Suspicious and possibly cancer
C5: Cancer
