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Surgery for Finals Series: Head and Neck Lavandan Jegatheeswaran Ear Nose and Throat Surgery Core Surgical Trainee 1Social Medias Case 1 Question You are asked to review in GP, an 18 year old who reports a sore throat ongoing for 4 days. They are able to drink but find it painful to swallow food. They have tried paracetamol for the pain, but there seems to be little relief from it. They do report having on and off fevers but says this settles with the paracetamol. They have not experienced this before. A/ Patent E/ A. Tonsillitis B/ B. Quinsy (peritonsillar abscess) Sats 95% OA RR 17 C. Pharyngitis D. Uvulitis C/ D/ HR 101 Regular GCS 15 E. Don’t know BP 110/70 BM 8.0 CRT 4 seconds PEARL HS I + II + 0 Temp 37.0 Case 1 Answer What is the most likely cause? This is a classic presentation of tonsillitis. A. Tonsillitis Short acute history of a sore throat B. Quinsy (peritonsillar abscess) alongside the presence of enlarged C. Tonsillar stone erythematous tonsils which may or may not D. Uvulitis have exudate on them. E. Don’t know Quinsy’s tend to have normal appearing tonsils – it is an abscess in the peritonsillar space which displaces the tonsil medially and inferiorly thus making them look large. Tonsillar stones tend to painless but patients may report halitosis and it can predispose them to tonsillitis. Uvulitis tends to involve an enlarged erythematous uvula. Case 1 Explanation • Infection and inflammation of the tonsils • Clinical Features • Sore throat • Odynophagia • Fever • Referred ear pain • Hallitosis • Exudative tonsils • Common organisms • Group A B haemolytic strep • EBV • Coxsackie • HSV Case 1 Explanation • Centor Criteria for antibiotic prescribing in tonsillitis: • Patients with one or none of these criteria are unlikely to have GABS • Consideration of antibiotic prescription should be limited to patients with three or four criteria Case 1 Explanation • Tonsillectomy Criteria (SIGN guidance) Case 2 Question You are asked to see a 25 year old man who presents with an acute sore throat lasting for 4 days. He reports it feeling like his previous tonsillitis episodes however this time he reports his voice sounding more huskier than usual. He also reports an inability to swallow his saliva and an inability to open his jaw. What is your most likely differential? A/ Patent E/ A. Tonsillitis B/ B. Quinsy (peritonsillar abscess) Sats 99% OA RR 17 C. Pharyngitis D. Uvulitis C/ D/ HR 101 Regular GCS 15 E. Don’t know BP 110/70 BM 8.0 CRT 3 seconds PEARL HS I + II + 0 Temp 37.0 Case 2 Answer What is the most likely cause? The characteristic history of a patient who A. Tonsillitis reports a sore throat and is unable to open their B. Quinsy (peritonsillar abscess) jaw is indicative of a Quinsy. Patient may also C. Pharyngitis report voice changes and breathing difficulties (if the abscess tracks from the peritonsillar D. Uvulitis space into the parapharyngeal space) E. Don’t know The tonsils in this picture look to be of normal calibre. The pharynx and uvula doesn’t seem overly erythematous or swollen as would be expected in pharyngitis and uvulitis. Case 2 Explanation • Peritonsillar abscess – usually associated with recurrent tonsillitis, teenagers, male sex and smoking • Can cause severe airway difficulties – this is due to there being a potential space from peritonsillar space 🡪 parapharyngeal space 🡪 mediastinum • Examination involves: • Oropharyngeal exam • Fine nasendoscopy • Neck exam – for lymphadenopathy • Liverpool Peritonsillar Abscess Score • Management • IV dexamethasone stat – to improve trismus • Needle aspiration first line • Incision and drainage • Antibiotics • Difflam oral rinse • Analgesia • ?referral for tonsillectomy Case 3 Question You are asked to see a 3 year old boy who has presented with acute stridor. They are unvaccinated. Mother reports child initially had a sore throat and being off food and then suddenly deteriorated. He has been fit and well prior to this episode. The patient is drooling and seems unable to swallow. A/ Stridor E/ A. Croup B/ B. Quinsy (peritonsillar abscess) Sats 99% 15L RR 40 C. Epiglottitis D. Viral induced wheeze C/ D/ HR 101 Regular GCS 15 E. Don’t know BP 110/70 BM 8.0 CRT 3 seconds PEARL HS I + II + 0 Temp 37.0 Case 3 Answer What is the most likely cause? This is a paediatric emergency and it is vital A. Croup that senior support is available on hand. The B. Quinsy (peritonsillar abscess) classic picture of a tripodding unvaccinated C. Epiglottitis child with stridor and drooling is D. Viral induced wheeze synonymous with epiglottitis. E. Don’t know Stridor is associated with upper airway obstruction hence viral induced wheeze is not included as part of the differential. Quinsy’s can cause drooling but is unlikely to cause upper airway obstruction (unless there is tracking of the infection) Croup tends to cause a typical barking cough. Case 3 Explanation • Inflammation of the epiglottis • Incidence reducing due to introduction of Hib vaccine in children • Symptoms • Sore throat • Airway/breathing difficulties • Odynophagia • Stridor • Hoarse voice • Fever • Drooling • Can also be caused by strep pneumoniae, fungi, viruses (VZV and HSV), smoking and chemical burns Case 3 Explanation • Management • Senior support is required! • Do not aggravate the child • A-E approach – child may need to be intubated to allow treatment • IV antibiotics • IV dexamethasone • Most people recover in 1 week and can be discharged in 5-7 days Case 4 Question You have been asked to review a 10 year old boy in the ENT clinic. Mother reports that the child has had a prominent lump on their neck. It is in the midline and has not caused the patient any problems. Mother is worried that it might be a malignancy. O/E the lump moves upwards on sticking the tongue out and feels fluctuant. An USS is performed also. A. Cystic hygroma B. Thyroid cancer C. Branchial cyst D. Thyroglossal cyst E. Don’t know Case 4 Answer What is the most likely cause? A fluctuant painless cyst in the midline which A. Cystic hygroma moves on protrusion of tongue and swallowing B. Thyroid cancer implies that it is a thyrogossal duct cyst. The C. Branchial cyst patency of the embryonic duct to the back of the tongue results in movement of the cyst D. Thyroglossal cyst when the tongue is protruded. E. Don’t know Cystic hygromas and branchial cysts tend to be found lateral to the midline. This is a very young age for thyroid cancer to present. Case 4 Explanation • Failure of involution of the thyroglossal tract at birth • Tends to move on swallowing and sticking tongue out – due to patent embryonic duct • If left untreated: • Infected cyst • Thyroglossal duct cyst carcinoma • Generally papillary thyroid cancers – caused by ectopic thyroid remnants in the cyst • Thyroglossal fistula • Investigations • USS + FNA • Thyroid scan • TFTs • Management • Sistrunk procedure – involves removing central portion of hyoid bone • Avoid incision and drainage Case 5 Question You have been asked to review a 2 year old who has a lump on the left side of their neck. It is painless and fluctuant to touch. Mother reports it being there since birth but has presented today as she is worried that it is growing in size. There are no concerns about airway or feeding issues at present. A. Cystic hygroma B. Carotid body tumour C. Thyroglossal cyst D. Torticollis E. Don’t know Case 5 Answer What is the most likely cause? A slow growing painless fluctuant mass that A. Cystic hygroma is off midline in a child that is 2 years or less B. Carotid body tumour is usually a cystic hygroma. They are benign C. Thyroglossal cyst masses which can be left alone or removed D. Torticollis surgically for cosmetic purposes. E. Don’t know Carotid body tumours tend to present in adulthood and are rare in childhood. Torticollis is a twisting of the neck that causes the head to rotate and tilt at an odd angle. Thyroglossal cysts are midline in nature. Case 5 Explanation • Lymphatic malformation – most common in armpits and on neck • Almost all are diagnosed by the age of 2 years • Usually harmless – can be left alone • Removal usually occurs if cosmetic concerns, or impacting on breathing or feeding • Can be removed via surgery or sclerotherapy Case 6 Question Match the clinical presentation with the right thyroid pathology: 1. 80F presents with rapidly enlarging thyroid lump and has suddenly got a hoarse voice. She has lost 10kg in the past 2 months A. Medullary carcinoma 2. 25F presents with unilateral lump in thyroid and a lump in the neck. Histology shows Orphan Anne nuclei. She was in B. Papillary carcinoma Fukushima when the nuclear reactor failed. C. Anaplastic carcinoma 3. 60M presents with large lump in neck. He reports having night sweats and fevers as well as losing 5kg in the past month Follicular carcinoma unintentionally. He reports being more ill than usual these past few months E. Lymphoma 4. 40F presents with a unilateral lump in their thyroid. FNA shows a well differentiated carcinoma with some microinvasion into vasculature. 5. 30M presents with a thyroid lump. She recently had a right parathyroidectomy as she was suffering from hyperparathyroidism. Case 6 Answer 1. 80F presents with rapidly enlarging thyroidC. Anaplastic carcinoma lump and has suddenly got a hoarse voice. She has lost 10kg in the past 2 months 2. 25F presents with unilateral lump in thyroiB. Papillary carcinoma and a lump in the neck. Histology shows Orphan Anne nuclei. She was in Fukushima when the nuclear reactor failed. 3. 60M presents with large lump in neck. He E. Lymphoma reports having night sweats and fevers as well as losing 5kg in the past month unintentionally. He reports being more ill than usual these past few months 4. 40F presents with a unilateral lump in theiD. Follicular carcinoma thyroid. FNA shows a well differentiated carcinoma with some micro invasion into vasculature. 5. 30M presents with a thyroid lump. She A. Medullary carcinoma recently had a right parathyroidectomy as she was suffering from hyperparathyroidism. Case 6 Explanation • Papillary carcinoma – characteristic Orphan Anne nuclei and spreads by lymphatic invasion. Strong association with radiation exposure. Can usually get away with hemi thyroidectomy and selective neck dissection • Follicular carcinoma – Tends to affect those in 40 – 60. Prognosis worse as you get older. Spreads by invasion into vasculature. Requires total thyroidectomy if found • Lymphoma – classic B symptoms and poor immune function • Anaplastic carcinoma – worst kind of thyroid cancer to get. Rapid enlarging and highly aggressive. Most patients are palliated on diagnosis • Medullary carcinoma – sporadic or familial. Part of the MEN syndromes. Cancer of the C cells which release calcitonin Case 7 Question Match the clinical presentation with the right parotid pathology: 1. 75M presents with bilateral slow growing parotid lumps. He is a appearance of these lumps.therwise but is concerned about the A. Adenoid cystic 2. 15M presents with bilateral painful swollen parotid lumps. He is unvaccinated. He thinks he might have gotten this from kissing ainoma stranger in the club a few nights ago. He feels unwell B.d Pleomorphic adenoma reports fevers. He also thinks his testicles have swollen in size. 3. 60M presents with a large painful unilateral parotid lump. He ishin’s tumour noticed to have bad dentition. The lump is warm to touch and you think you can express pus through Stenton’s duct onD. Viral mumps palpation of the gland. E. Bacterial parotitis 4. 40F presents with a unilateral slow growing parotid lump. He is worried about the cosmetic appearance of this lump and wishes it to be removed. He reports it growing over a 10 year period. 5. 60M presents with a unilateral facial nerve palsy alongside a large fast growing parotid lump. He reports having lost 5kg of weight unintentionally. Case 7 Answer 1. 75M presents with bilateral slow growing parotid C. Warthin’s tumour lumps. He is a heavy smoker. He is well otherwise but is concerned about the appearance of these lumps. 2. 15M presents with bilateral painful swollen parotid lumps. He is unvaccinated. He thinks he might haveD. Viral mumps gotten this from kissing a stranger in the club a few nights ago. He feels unwell and reports fevers. He also thinks his testicles have swollen in size. 3. 60M presents with a large painful unilateral parotE. Bacterial parotitis lump. He is noticed to have bad dentition. The lump is warm to touch and you think you can express pus through Stenson's duct on palpation of the gland. 4. 40F presents with a unilateral slow growing parotid lump. She is worried about the cosmetic B. Pleomorphic adenoma appearance of this lump and wishes it to be removed. She reports it growing over a 10 year period. 5. 60M presents with a unilateral facial nerve palsy A. Adenoid cystic carcinoma alongside a large fast growing parotid lump. He reports having lost 5kg of weight unintentionally. Case 7 Explanation • Adenoid cystic carcinoma – fast growing unilateral parotid lump. Can cause facial nerve palsy due to direct invasion of the nerve. Facial nerve usually sacrificed in removal • Pleomorphic adenoma – Usually unilateral slow growing parotid lumps affecting those from 40-60 years. Higher risk than warthin’s tumour of becoming cancerous – usually advised to have superficial parotidectomy • Warthin’s tumour – most common bilateral parotid tumour. Associated with old men and smoking. Can leave them alone or cut it out • Viral mumps – causes bilateral painful swollen parotid lumps. Spreads via infected saliva droplets. Management involves rest, hydration and analgesia. Can lead to meningitis • Bacterial parotitis – usually caused by retrograde infection from mouth to parotid via Stenson’s duct. Can be caused by impacted stone – in which case sialography and stone removal required. Requires abx and warm compress of parotid alongside good oral care O O F Feedback & Instagram + 3FC N O Please complete feedback to receive CF slides! 3 NH O Cl CH3 CH OH CH 3 3 CH OH 3 3C CH3 HC O 3