THROAT AND NECK

Question 1

Description of reteropharyngeal abscess

Answer 1

Anterior to the prevertebral fascia, behind the pharynx, is a potential space, the retropharyngeal space, where an abscess may form. This space extends from the base of the skull to the mediastinum.

Question 2

clinical features of reteropharyngeal abscess

Answer 2

 Commonly in young children, commonly after an URTI
 Neck held rigid and upright with reluctance to move
 Systemically unwell
 Airway compromise
 Dysphagia/Odynophagia
 Widening of the retropharyngeal space on lateral X-Ray
 Associated mortality due to airway problems & mediastinitis

Question 3

investigations of reteropharyngeal abscess

Answer 3

CT neck

Question 4

management of reteropharyngeal abscess

Answer 4

 Secure airway if any concerns
 IV antibiotics
 Surgery - Incision & drainage

Question 5

what is the anterior triangle

Answer 5

midline of the neck
lateral anterior border of SCM
Superior - lower border of the mandible

Question 6

what is the posterior triangle

Answer 6

posterior - anterior trapezium
base - middle 1/3rd of clavicle
anterior - post border of SCM

Question 7

features of peritonsillar abscess

Answer 7

severe throat pain, which lateralises to one side

deviation of the uvula to the unaffected side

trismus (difficulty opening the mouth)

reduced neck mobility

Question 8

management of quinsy

Answer 8

needle aspiration or incision & drainage + intravenous antibiotics
tonsillectomy should be considered to prevent recurrence

Question 9

what is secondary haemorrhage in tonsillectomy

Answer 9

Haemorrhage occuring 5-10 days post-tonsillectomy is referred to as secondary haemorrhage. In the majority of cases this is due to infection

Question 10

post op complications of tonsillectomy

Answer 10

Pain

The pain may increase for up to 6 days following a tonsillectomy.

Haemorrhage

Haemorrhage is a feared complication following tonsillectomy. All post-tonsillectomy haemorrhages should be assessed by ENT.

Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre.

Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in around 1-2% of all tonsillectomies.

Question 11

dry mouth for a few months
sensation of grittiness in her eyes
On examination she has a diffuse swelling of her parotid gland. There is no evidence of facial nerve palsy.

Answer 11

Sjogren’s syndrome

Question 12

In which age group sjogrens common

Answer 12

post menopausal women

Question 13

sarcoidosis symptoms

Answer 13

bilateral parotid gland swelling and symptoms of a dry mouth. On examination she has bilateral facial nerve palsies. This improved following steroid treatment.

Question 14

pancreatitis and bilateral painful parotid enlargement

Answer 14

mumps

Question 15

when to susupect mumps in young adults

Answer 15

young adult with parotid swelling and pancreatitis/orchitis/reduced hearing/meningoencephalitis suspect mumps.

Question 16

which site of salivary gland is the most common for tumours

Answer 16

parotid gland

Question 17

do benign salivary gland tumours invade structures such as the facial nerve

Answer 17

NO except Warthins tumours

Question 18

Types of bening salivary gland tumours

Answer 18

Benign pleomorphic adenoma or benign mixed tumour

Warthin tumour (papillary cystadenoma lymphoma or adenolymphoma)

monomorphic adenoma

haemangioma

Question 19

features of Benign pleomorphic adenoma or benign mixed tumour

Answer 19

Most common parotid neoplasm (80%)

Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components

Slow growing, lobular, and not well encapsulated, painless

Recurrence rate of 1-5% with appropriate excision (parotidectomy)
Recurrence possibly secondary to capsular disruption during surgery
Malignant degeneration occurring in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma

Question 20

features of Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma)

Answer 20

Second most common benign parotid tumor (5%)

softer, more mobile and fluctuant (although difficult to differentiate

Most common bilateral benign neoplasm of the parotid

Marked male as compared to female predominance

Occurs later in life (sixth and seventh decades)
Presents as a lymphocytic infiltrate and cystic epithelial proliferation
May represent heterotopic salivary gland epithelial tissue trapped within intraparotid lymph nodes
Incidence of bilaterality and multicentricity of 10%
Malignant transformation rare (almost unheard of)

Question 21

features of Monomorphic adenoma

Answer 21

Account for less than 5% of tumours
Slow growing
Consist of only one morphological cell type (hence term mono)
Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas

Question 22

features of haemangioma

Answer 22

Should be considered in the differential of a parotid mass in a child
Accounts for 90% of parotid tumours in children less than 1 year of age
Hypervascular on imaging
Spontaneous regression may occur and malignant transformation is almost unheard of

Question 23

types of malignant tumors

Answer 23

Mucoepidermoid carcinoma

Adenoid cystic carcinoma

mixed tumors

acinic cell carcinoma

adenocarcinoma

Question 24

features of mucoepidermoid carcinoma

Answer 24

30% of all parotid malignancies

Usually low potential for local invasiveness and metastasis (depends mainly on grade)

Question 25

features of adenoid cystic carcinoma

Answer 25

Unpredictable growth pattern Tendency for perineural spread Nerve growth may display skip lesions resulting in incomplete excision Distant metastasis more common (visceral rather than nodal spread) 5 year survival 35%

Question 26

features of mixed tumors

Answer 26

Often a malignancy occurring in a previously benign parotid lesion

Question 27

features of acinic cell carcinoma

Answer 27

Intermediate grade malignancy May show perineural invasion Low potential for distant metastasis 5 year survival 80%

Question 28

features of adenocarcinoma

Answer 28

Develops from secretory portion of gland Risk of regional nodal and distant metastasis 5 year survival depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvement

Question 29

features of lymphoma

Answer 29

Large rubbery lesion, may occur in association with Warthins tumours Diagnosis should be based on regional nodal biopsy rather than parotid resection Treatment is with chemotherapy (and radiotherapy)

Question 30

Diagnostic evaluation of salivary gland tumours

Answer 30

Plain x-rays may be used to exclude calculi Sialography may be used to delineate ductal anatomy FNAC is used in most cases Superficial parotidectomy may be either diagnostic of therapeutic depending upon the nature of the lesion Where malignancy is suspected the primary approach should be definitive resection rather than excisional biopsy CT/ MRI may be used in cases of malignancy for staging primary disease

Question 31

risk factors for salivary gland tumours

Answer 31

``` • Direct radiation exposure • Epstein-Barr virus (EBV) infection • Smoking* • Genetic alterations (p53 mutations) *Tobacco smoke has been associated with the development specifically to Warthins tumour ```

Question 32

treatment for salivary gland tumours

Answer 32

- surgical resection - benign - superficial parotidectomy - malignant disease - radical or extended radical parotidectomy, facial nerve is included in the resection if involved. neck dissection is determined by the potential for nodal involvement.

Question 33

how does HIV affect the salivary galnds

Answer 33

Lymphoepithelial cysts associated with HIV occur almost exclusively in the parotid Typically presents as bilateral, multicystic, symmetrical swelling Risk of malignant transformation is low and management usually conservative

Question 34

What is sjogrens

Answer 34

Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicca 90% of cases occur in females Second most common connective tissue disorder Bilateral, non tender enlargement of the gland is usual Histologically, the usual findings are of a lymphocytic infiltrate in acinar units and epimyoepithelial islands surrounded by lymphoid stroma Treatment is supportive There is an increased risk of subsequent lymphoma

Question 35

how does sarcoidosis affect salivary glands

Answer 35

Parotid involvement occurs in 6% of patients with sarcoid Bilateral in most cases Gland is not tender Xerostomia may occur Management of isolated parotid disease is usually conservative

Question 36

DD for salivary gland tumours

Answer 36

- Sialoliathiasis - Chronic sialadenitis - Autoimmune disease - Lymphoproliferative disorders - DIAGNOSIS UNCERTAIN – HIV should be considered

Question 37

what are the non surgical options for slaivary gland tumours

Answer 37

- Radiotherapy – adjuvant following surgery – higher grade tumours o Malignant – resection margin is positive, hidtological features of an aggressive tumour o Recurrent pleomorphic salivary adenoma o Chemotherapy only for palliative care

Question 38

early complications of surgery of salivary gland tumours

Answer 38

Early Haematoma is an important post-operative complication. A rapidly expanding haematoma may cause airway obstruction, hence close observation of these patients post-operatively is paramount. Facial nerve injury or sacrifice intra-operatively must be included in any consent for the resection procedures*. Transient facial nerve paresis resolves in 3-12 weeks. It is now common practice to use facial nerve monitoring during parotid surgery. During submandibular gland surgery, the marginal mandibular, hypoglossal and lingual nerve may also be injured. *If injury of the facial nerve is noted intra-operatively, grafting with the greater auricular nerve can be performed if deemed suitable

Question 39

early complications of surgery of salivary gland tumours

Answer 39

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. Salivary fistula is also a recognised complication.

Question 40

DD for neck lumps

Answer 40

``` reactive lymphadenopathy lymphoma thyroid swelling thyroglossal cyst pharyngeal pouch cystic hygroma branchial cyst cervical rib carotid aneurysm ```

Question 41

features of Reactive lymphadenopathy

Answer 41

By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness

Question 42

features of lymphoma

Answer 42

Rubbery, painless lymphadenopathy The phenomenon of pain whilst drinking alcohol is very uncommon hodgkins lymphoma There may be associated night sweats and splenomegaly

Question 43

features of thyroid swelling

Answer 43

May be hypo-, eu- or hyperthyroid symptomatically | Moves upwards on swallowing

Question 44

what is thyroglossal cyst

Answer 44

More common in patients < 20 years old Usually midline, between the isthmus of the thyroid and the hyoid bone Moves upwards with protrusion of the tongue May be painful if infected

Question 45

what is pahryngeal pouch

Answer 45

More common in older men Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles Usually not seen but if large then a midline lump in the neck that gurgles on palpation

Question 46

symptoms of pharyngeal pouch

Answer 46

Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough halitosis throat infections

Question 47

what is cystic hygroma

Answer 47

A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age transilluminate Collection of dilated lymphatic sacs

Question 48

what is a brachial cyst

Answer 48

An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx Develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood

Question 49

what is cervical rib

Answer 49

More common in adult females | Around 10% develop thoracic outlet syndrome

Question 50

what is carotid aneurysm

Answer 50

Pulsatile lateral neck mass which doesn't move on swallowing

Question 51

what is ludwig's angina

Answer 51

cellulitis which occurs on the floor of the mouth of the patient. It is deadly, as it spreads in the fascial spaces of the head and neck. Due to the infection, the swelling that ensues from the inflammation begins to push the floor of the mouth upwards and blocks air entry.

Question 52

risk factors for ludwig's angina

Answer 52

immunocompromised ie IV drug user poor dentition Pericoronitis (inflammation surrounding a partially erupted wisdom tooth) can also predispose one to this

Question 53

features for an EBV infection

Answer 53

monospot test positive | splenomegaly

Question 54

features of ludwigs angina

Answer 54

``` dysphagia malaise fatigue pyrexial extensive swelling of her submental and submandibular lymph nodes. There is pharyngeal oedema and extensive erythema on the floor of her mouth, however, no exudation can be seen on the tonsils and there are no abscesses near the tonsils . ``` stridor difficulty breathing

Question 55

causes of salivary gland enlargement apart from cancer

Answer 55

acute viral infection e.g. mumps acute bacterial infection e.g. 2nd to dehydration diabetes sicca syndrome and Sjogren's (e.g. RA)

Question 56

what is bartonella infection

Answer 56

may occur following a cat scratch. The organism is intracellular. Generalised systemic symptoms may occur for a week or so prior to clinical presentation.

Question 57

features of bartonella infection

Answer 57

symptoms of abdominal pain, lethargy and sweats. These have been present for the past two weeks. On examination she has lymphadenopathy in the posterior triangle.

Question 58

What is found inside a branchial cyst

Answer 58

The cyst is filled with acellular fluid with cholesterol crystals and encapsulated by stratified squamous epithelium. Branchial cysts may have a fistula and are therefore prone to infection. They may enlarge following a respiratory tract infection.

Question 59

branchial cyst on examination

Answer 59

unilateral, typically on the left side lateral, anterior to the sternocleidomastoid muscle slowly enlarging smooth, soft, fluctuant non-tender a fistula may be seen no movement on swallowing no transillumination

Question 60

DD neck lump in children

Answer 60

congenital: branchial cyst, thyroglossal cyst, dermoid cyst, vascular malformation inflammatory: reactive lymphadenopathy, lymphadenitis neoplastic: lymphoma, thyroid tumour, salivary gland tumour

Question 61

diagnosis and Ix for branchial cysts

Answer 61

consider and exclude other malignancy ultrasound referral to ENT fine-needle aspiration

Question 62

management of ludwigs angina

Answer 62

airway management | intravenous antibiotics

Question 63

ECG changes you see in hypocalcaemia

Answer 63

prolonged QT interval

Question 64

ECG changes you see in hypercalcaemia

Answer 64

shortened ST segment

Question 65

ECG changes you see in hypermagnesaemia

Answer 65

prolonged PR interval

Question 66

ECG changes you see in hyperkalaemia

Answer 66

tall peaked T waves

Question 67

complications of thyroid surgery

Answer 67

Anatomical such as recurrent laryngeal nerve damage. Bleeding. Owing to the confined space haematoma's may rapidly lead to respiratory compromise owing to laryngeal oedema. Damage to the parathyroid glands resulting in hypocalcaemia.

Question 68

features of crohns

Answer 68

ulcer in oral cavity weight loss ulcer - noncaseating granulomata

Question 69

cell type for pharngeal cancer

Answer 69

squamous cell carcinoma

Question 70

risk facts for pharyngeal cancer

Answer 70

smoking HPV chewing tobacco older age

Question 71

causes of gingivial hyperplasia

Answer 71

phenytoin ciclosporin calcium channel blockers (especially nifedipine) acute myeloid leukaemia

Question 72

adenoid hypertrophy presentation

Answer 72

``` breathing problems sleep apnoea middle ear infection sinusitis OME ```

Question 73

Tx for adenoid hypertrophy

Answer 73

1) nasal steroids | 2) adenoidectomy

Question 74

facts regarding parotid glans

Answer 74

80% of parotid tumours are benign 80% of benign tumours are pleomorphic adenomas

Question 75

most common parotid lesion in children

Answer 75

haemangioma

Question 76

most common parotid malignancy in adults

Answer 76

mucoepidermoid carcinoma