[<) Question 1 of 34 x Bp © A 56 year old man presents with symptoms of nasal pain, anosmia and rhinorrhea. He has been well until recently and has worked as a wood carver for many years. What is the most likely diagnosis? Ameloblastoma Fibrous dysplasia Haemangiopericytoma Paranasal sinus cancer is strongly associated with wood work. Most cases require an ‘occupational exposure of greater than 10 years and are adenocarcinomas on histology. Most cases are ethmoidal in origin (Hadfield E. Ann R Coll Surg Engl. 1970 June; 46(6): 301319) | | Improve Diseases of nose and sinuses * Benign Tumours + Simple papillomas may be an incidental finding or present with obstructive symptoms Excision under general anaesthesia is sufficient management. * Transitional cell papillomas may be more extensive and produce obstructive symptoms. Erosion of local structures is a recognised complication. These lesions may rarely undergo ‘malignant transformation and therefore careful and complete excision is required, some cases may requite partial or total maxillectomy. + Pleomorphic adenomas of the maxillary sinuses are reported but are extremely rare, their symptoms typically include nasal obstruction and pain if the sinus is obstructed. Treatment is by complete surgical excision, the diagnosis is not infrequently made post operatively. + Benign osteomas may develop in the paranasal sinuses, the frontal sinus is the most frequent location of such lesions. Symptoms include; pain, thinorrhoea and anosmia. Most ‘osteomas may be observed if asymptomatic, sphenoid osteomas should be resected soon after diagnosis as enlargement may compromise visual fields. Many sinus osteomas can now be resected endoscopically, complete surgical resection is required. + Nasal polyps are benign lesions of the ethmoid sinus mucosa. Many patients may also have asthma, cystic fibrosis and a sensitivity to aspirin. Symptoms include watery rhinorthoea, infection and anosmia. The polyps are usually a semi transparent grey mass. ‘They are rare in childhood. Treatment is either with systemic steroids or surgical resection. ‘The latter should be combined with antral washout. Low dose, nasal, steroid drops may reduce the risk of recurrence.Malignant disease * Malignancies encountered in the nose and paranasal sinuses include; adenoid cystic carcinoma, squamous cell carcinoma and adenocarcinoma. * Adenocarcinoma of the paranasal sinuses and nasopharynx is strongly linked to exposure to hard wood dust (after >10 years exposure). * Adenoid cystic carcinoma usually originate in the smaller salivary glands. + The majority of cancers (50%) arise from the lateral nasal wall, a smaller number (33%) arise from the maxillary antrum, ethmoid and sphenold cancers comprise only 7%. * Signs of malignancy on clinical examination include loose teeth, cranial nerve palsies and lymphadenopathy. * Nasopharyngeal cancers are most common in individuals presenting from China and Asia and are linked to viral infection with Epstein Barr Virus. Radiotherapy and chemotherapy are the most commonly used modalities. lary sinusi ‘+ Common symptoms include post nasal discharge, pain, headache and toothache. + Imaging may show a fluid level in the antrum, ‘+ Common organisms include Haemophilus influenzae or Streptococcus pneumoniae, + Treatment with antral lavage may facilitate diagnosis and relieve symptoms. Antimicrobial therapy has to be continued for long periods. Antrostomy may be needed. Frontoethmoidal sinusitis, + Usually presents with frontal headache, nasal obstruction and altered sense of smell + Inflammation may progress to involve periorbital tissues. Ocular symptoms may occur and secondary CNS involvement brought about by infection entering via emissary veins. + CT scanning is the imaging modality of choice. Early cases may be managed with antibloties. More severe cases usually require surgical drainage. ‘Save my notes, Search ‘Search textbook, Q Google search on "Diseases of nose and sinuses" + Suggest link + Suggest media° Question 2 of 34 v B °o ‘A550 year old female presents with bilateral parotid gland swelling and symptoms of a dry mouth. (On examination, she has bilateral facial nerve palsies. This improved following steroid treatment. What is the likely underlying diagnosis? Pleomorphic adenoma e BIL Warthins tumour oe Sialolithiasis eo ‘Adenoid cystic carcinoma Sarcoid occurs bilaterally in 70% of cases and facial nerve involvement is recognised. Treatment |s conservative in most cases although individuals with facial nerve palsy will usually receive steroids with good effect. [« "9 | Improve Parotid gland clinical » Benign neoplasms Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should net invade structures such as the facial nerve. With the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion is in the Sth decade of life Benign tumour types Tumour type Features Benign pleomorphic Most common parotid neoplasm (80%) adenoma or benign Proliferation of epithelial and myoepithelial cells of the ducts and mixed tumor an increase in stromal components Slow growing, lobular, and not well encapsulated 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Warthin tumor (papillary Second most common benign parotid tumor (5%) cystadenoma lymphoma Most common bilateral benign neoplasm of the parotid ‘or adenolymphoma) 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 ‘rapped within intraparotid lymph nodes Incidence of bilaterality and multicentricty of 10% Malignant transformation rare (almost unheard of) Monomorphic adenoma Account for less than 5% of tumours Haemangioma Mi Types of malignancy Mucoepidermoid carcinoma Adenoid cystic carcinoma Mixed tumours: Acinic cell carcinoma Adenocarcinoma Slow growing Consist of only one morphological cell type (hence term mono) Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas ‘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 ignant salivary gland tumours 30% of all parotid malignancies Usually low potential for local invasiveness and metastasis (depends mainly on grade) 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% Often a malignancy occurring In a previously benign parotid lesion Intermediate grade malignancy May show perineural invasion Low potential for distant metastasis 5 year survival 80% 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Lymphoma 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) \gnostic evaluation + Plain x-rays may be used to exclude calculi + Sialography may be used to delineate ductal anatomy ‘+ FNACis used in most cases + Superficial parotidectomy may be elther diagnostic or 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 Treatment For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement. Other parotid disorders HIV infection + 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 Sjogren syndrome ‘+ 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 Sarcoid ‘+ 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 Tr &- @ @° Question 3 of 34 v 8 ©} ‘An 18 year old boy presents with pancreatitis. He has bilateral painful parotid enlargement. What Is the most likely underlying cause? Sialectasis Bacterial parotitis Mucoepidermoid carcinoma Sjogren's syndrome Ina young adult with parotid swelling and pancreatitis/orchitis/reduced hearing/meningoencephalitis suspect mumps. There is an association between Sjogrens syndrome and pancreatitis but the mean age of onset is 55. wo | 9 | Improve Parotid gland clinical * Benign neoplasms Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There Is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerve. With the exception of Warthins tumours, they are commoner in women than men, The median age of developing a lesion is in the 5th decade of life. Benign tumour types ‘Tumour type Features Benign pleomorphic Most common parotid neoplasm (80%) adenoma or benign Proliferation of epithelial and myoepithelial cells of the ducts and mixed tumor an increase in stromal components Slow growing, lobular, and not well encapsulated 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Warthin tumor (papillary Second most common benign parotid tumor (5%) cystadenoma lymphoma — Most common bilateral benign neoplasm of the parotid or adenolymphoma) Marked male as compared to female predominance Occurs later in life (sixth and seventh decades) Presents as a lymphocytic inflitrate 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) Monomorphic adenoma Account for less than 5% of tumours Haemangioma Mucoepidermoid carcinoma Adenoid cystic carcinoma Mixed tumours: Acinic cell Adenocarcinoma Slow growing Consist of only one morphological cell type (hence term mono) Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas ‘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 ignant salivary gland tumours 30% of all parotid malignancies Usually low potential for local invasiveness and metastasis (depends mainly on grade) 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% Often a malignancy occurring in a previously benign parotid lesion Intermediate grade malignancy May show perineural invasion Low potential for distant metastasis, S year survival 80% 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Lymphoma 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) Diagnostic evaluation * Plain x-rays may be used to exclude calculi * Sialography may be used to delineate ductal anatomy + FINACis used in most cases * Superficial parotidectomy may be either diagnostic or 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 Treatment For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical parotidectomy is performed. The facial nerve Is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement. Other parotid disorders HIV infection + 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 ‘Sjogren syndrome + Autoimmune disorder characterised by parotid enlargement, xerostomla 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 Sarcoid ‘+ 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3° Question 4 of 34 v Bp ©} ‘A583 year old man presents with a mass lesion slightly inferior to the tragus of his right ear. An FNA and USS are performed and a 2cm pleomorphic adenoma Is diagnosed. What Is the most appropriate course of action? USS guided core biopsy @e Radical parotidectomy QD [eciataeriee = Discharge MRI scanning of the region @ Pleomorphic adenoma of the parotid= surgical excision Pleomorphic adenomas a usually benign tumours. However, they will enlarge over time and a proportion can undergo malignant transformation. Therefore, all pleomorphic adenomas are excised and a superficial parotidectomy is generally the procedure of choice. The facial nerve is, preserved. More recently, there has been a move towards partial superficial parotidectomy. However, complete resection of the lesion is still mandatory. *@ | improve Parotid gland clinical * Benign neoplasms Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerve. With the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion is in the Sth decade of life. Benign tumour types Tumour type Features Benign pleomorphic Most common parotid neoplasm (80%) adenoma or benign Proliferation of epithelial and myoepithelial cells of the ducts and mixed tumor an increase in stromal components Slow growing, lobular, and not well encapsulated 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 iong periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma Warthin tumor (papillary Second most common benign parotid tumor (5%) cystadenoma lymphoma — Most common bilateral benign neoplasm of the parotid or adenolymphoma) 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) Monomorphic adenoma Account for less than 5% of tumours Haemangioma Malignant s Mucoepidermoid carcinoma Adenoid cystic carcinoma Mixed tumours Acinic cell Slow growing Consist of only one morphological cell type (hence term mono) Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas ‘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 ivary gland tumours 30% of all parotid malignancies Usually low potential for local invasiveness and metastasis (depends mainly on grade) 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) S year survival 35% Often a malignancy occurring in a previously benign parotid lesion Intermediate grade malignancy May show perineural invasion Low potential for distant metastasis 5 year survival 80%Adenocarcinoma 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 Lymphoma 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) jagnostic evaluation * Plain x-rays may be used to exclude calculi ‘+ Sialography may be used to delineate ductal anatomy + FNAG is used in most cases * Superficial parotidectomy may be either diagnostic or 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 Treatment For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical Parotidectomy Is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement. Other parotid disorders HIV infection + 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 ‘Sjogren syndrome + 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 epimyoepithellal islands surrounded by lymphoid stroma + Treatment is supportive + There is an increased risk of subsequent lymphoma Sarcoid * 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°o Question of 34 v B °o AAS year old man presents with a facial swelling. On examination, he has a swelling that lies inferolaterally to the nose. When the area is palpated, it feels like the underlying bone is cracking, What is the most likely diagnosis? Maxillary sinus cancer Qa @ Nasal polyps @Q @ Maxillary sinusitis Mucocele Ameloblastomas are rare tumours of the odontogenic epithelium. They are slow growing and expand with a rim of periosteum that surrounds them, Its the palpation and disruption of this layer that gives rise to the crepitus. | | Improve Diseases of nose and sinuses * Benign Tumours ‘+ Simple papillomas may be an incidental finding or present with obstructive symptoms. Excision under general anaesthesia Is sufficient management. ‘+ Transitional cell papillomas may be more extensive and produce obstructive symptoms. Erosion of local structures is a recognised complication. These lesions may rarely undergo ‘malignant transformation and therefore careful and complete excision Is required, some cases may require partial or total maxillectomy. + Pleomorphic adenomas of the maxillary sinuses are reported but are extremely rare, their symptoms typically include nasal obstruction and pain if the sinus is obstructed. Treatment is by complete surgical excision, the diagnosis is not infrequently made post operatively. * Benign osteomas may develop in the paranasal sinuses, the frontal sinus is the most frequent location of such lesions. Symptoms include; pain, rhinorthoea and anosmia, Most osteomas may be observed If asymptomatic, sphenoid osteomas should be resected soon after diagnosis as enlargement may compromise visual fields. Many sinus osteomas can now be resected endoscopically, complete surgical resection is required. ‘+ Nasal polyps are benign lesions of the ethmoid sinus mucosa. Many patients may also have asthma, cystic fibrosis and a sensitivity to aspirin. Symptoms include watery thinorrhoea, infection and anosmia. The polyps are usually a semi transparent grey mass, ‘They are rare in childhood. Treatment is either with systemic steroids or surgical resection. The latter should be combined with antral washout. Low dose, nasal, steroid drops may reduce the risk of recurrence.Malignant disease ‘+ Malignancies encountered in the nose and paranasal sinuses include; adenoid cystic carcinoma, squamous cell carcinoma and adenocarcinoma. ‘+ Adenocarcinoma of the paranasal sinuses and nasopharynx is strongly linked to exposure to hard wood dust (after >10 years exposure) ‘+ Adenoid cystic carcinoma usually originate in the smaller salivary glands. ‘+ The majority of cancers (50%) arise from the lateral nasal wall, a smaller number (33%) arise from the maxillary antrum, ethmoid and sphenoid cancers comprise only 7%. ‘+ Signs of malignancy on clinical examination include loose teeth, cranial nerve palsies and lymphadenopathy. ‘+ Nasopharyngeal cancers are most common in individuals presenting from China and Asia and are linked to viral infection with Epstein Barr Virus. Radiotherapy and chemotherapy are the most commonly used modalities. Maxillary sinusitis + Common symptoms include post nasal discharge, pain, headache and toothache. ‘+ Imaging may show a fluid level in the antrum. + Common organisms include Haemophilus influenzae or Streptococcus pneumoniae. ‘+ Treatment with antral lavage may facilitate diagnosis and relieve symptoms. Antimicrobial therapy has to be continued for long periods. Antrostomy may be needed. Frontoethmoidal sinusitis + Usually presents with frontal headache, nasal obstruction and altered sense of smell + Inflammation may progress to involve periorbital tissues. Ocular symptoms may occur and secondary CNS involvement brought about by infection entering via emissary veins. + CT scanning is the imaging modality of choice. Early cases may be managed with antibiotics. More severe cases usually require surgical drainage. Tr & Boe ‘Save my notes Search Search textbook GB Q Google search on “Diseases of nose and sinuses” Suggest lnk Suggest modia° Question 6 of 34 v P ° ‘A 4 year old is brought to the general practitioner by her mother. She has been distressed with ear pain for the past 14 hours. She is constantly touching and pulling at her ear. Whilst she Is sat in the waiting room her mother notices a discharge of foul smelling fluid from the ear, following which the pain resolves. What is the most likely cause? Otitis externa Cholesteatoma Mastoiditis Otosclerosis In young children acute suppurative otitis media Is a common condition. Rupture of the tympanic ‘membrane is a rare, but recognised complication. Disorders affecting the ear * Otitis externa Variant Cause ‘Acute Boil in external auditory meatus otitis externa Chronic Chronic combined infection in otitis the external auditory meatus extema usually combined staphylococcal and fungal infection Otitis media Variant Cause Features Features Acute pain on moving the pinna Conductive hearing loss if lesion is large When rupture occurs pus will flow from ear Chronic discharge from affected ear, hearing loss and severe pain rare Treatment Ear packs may be used Topical antibiotics Operative debridement may be needed in severe cases Cleansing of the external ear and treatment with antifungal and antibacterial ear drops TreatmentAcute Viral induced Most common in Antibiotics (usually suppurative middle ear children and rare in amoxycillin) otitis media effusions adults secondary to May present with eustacian tube symptoms dysfunction elsewhere (e.9. vomiting) in children Severe pain and sometimes fever May present with discharge if tympanic rupture occurs Chronic May occur with or Those without ‘Simple pars tensa perforations suppurative — without cholesteatoma may _may be managed non otitis media cholesteatoma complain of operatively or a myringoplasty Those without intermittent considered if symptoms cholesteatoma discharge (non. troublesome. have a perforation offensive) Pars flaccida perforations will of the parstensa Those with usually require a modified Those with cholesteatoma have radical mastoldectomy cholesteatoma —_impaired hearing and have a perforation foul smelling of the pars discharge flaccida Otosclerosis + Progressive conductive deafness + Secondary to fixation of the stapes in the oval window ‘+ Treatment is with stapedectomy and insertion of a prosthesis Acoustic neuroma * Symptoms of gradually progressive unilateral perceptive deafness and tinnitus * Involvement of the vestibular nerve may cause vertigo * Extension to involve the facial nerve may cause weakness and then paralysis, Pre auricular sinus * Common congenital condition in which an epithelial defect forms around the external ear * Small sinuses require no treatment * Deeper sinuses may become blocked and develop episodes of infection, they may be closely related to the facial nerve and are challenging to excise LED ESS° Question 7 of 34 v 5 © The parents of a 1 year old child are concerned after he develops a lump in his neck. On examination, there is a swelling in the subcutaneous tissue of the posterior triangle which transilluminates. What is the most likely cause? Branchial cyst Q Branchial sinus e@ iii = Lipoma eo @ Pharyngeal pouch This Is a classical description. Collection of dilated lymphatic sacs which are fluctuant and brilliantly transilluminable. Recurrence following surgical excision is not uncommon. 4 | | improve | Neck lumps * The table below gives characteristic exam question features for conditions causing neck lumps: Reactive By far the most common cause of neck swellings. There may be a lymphadenopathy history of local infection or a generalised viral illness Lymphoma Rubbery, painless lymphadenopathy The phenomenon of pain whilst drinking alcohol is very uncommon ‘There may be associated night sweats and splenomegaly Thyroid swelling May be hypo:, eu- or hyperthyroid symptomatically Moves upwards on swallowing Thyroglossal cyst 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 Pharyngeal More common in older men pouch 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Typical symptoms are dysphagia, regurgitation, aspiration and chronic ‘cough Cystic hygroma A congenital lymphatic lesion (Ilymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age ‘An oval, mobile cystic mass that develops between the stemnocleidomastoid muscle and the pharynx. Develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood Cervical rib More common in adult females Around 10% develop thoracic outlet syndrome Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing Save my notes ‘Search Search textbook. Q Google search on "Neck lumps" 4 Suggest ink + suggest media Dashboard £46448° Question 8 of 34 a Pp o ‘A.42 year old singer is admitted for a thyroidectomy. Post operatively the patient develops stridor and has difficulty speaking. What is the most likely underlying cause? Bilateral superior laryngeal nerve injury Unilateral recurrent laryngeal nerve injury Unilateral superior laryngeal nerve injury Hypoglossal nerve injury This patient has speaking difficulties as the cords lie in the paramedian position and so speech is difficult and breathing obstructed. | | imorove | Voice production * ‘There are 2 main nerves involved: ‘Superior laryngeal nerve (SLN) ‘+ Innervates the cricothyrold muscle Since the cricothyrold muscle Is involved in adjusting the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in: a. Abnormalities in pitch b. Inability to sing with smooth change to each higher note (glissando or pitch glide) Recurrent laryngeal nerve (RLN)/Inferior laryngeal nerve + Innervates intrinsic larynx muscles ‘a. Opening vocal folds (as in breathing, coughing) bb, Closing vocal folds for vocal fold vibration during voice use c. Closing vocal folds during swallowing a @ ©Qo Question 9 of 34 v B oO ‘A 40 year old professional singer is admitted for a right thyroid lobectomy. Post operatively, she is unable to sing high notes. Which of the following muscles is likely to demonstrate impaired function? Thyroarytenoid Posterior cricoarytenoid ‘Thyrohyoid Lateral cricoarytenoid ‘The most likely injury is to the superior laryngeal nerve which innervates the cricothyroid muscle. Since this tenses the vocal cords, singing high notes becomes a problem. | @ | improve Voice production * There are 2 main nerves involved: Superior laryngeal nerve (SLN) + Innervates the cricothyroid muscle Since the cricothyroid muscle is involved in adjusting the tension of the vocal fold for high notes. during singing, SLN paresis and paralysis result in’ ‘a, Abnormalities in pitch b. Inability to sing with smooth change to each higher note (glissando or pitch glide) Recurrent laryngeal nerve (RLN)/Inferior laryngeal nerve + Innervates intrinsic larynx muscles a. Opening vocal folds (as in breathing, coughing) . Closing vocal folds for vocal fold vibration during voice use . Closing vocal folds during swallowing Bis u- ii Tr By @ ©3° Question 10 of 34 v ~ ©o A50 year old women presents with a diffuse swelling in the region of her right parotid together with facial pain. On examination, she has a right sided facial nerve palsy. What is the most likely underlying cause? Pleomorphic adenoma = es) @ Warthins tumour eo Lymphoma eo Sarcoid eo Adenoid cystic carcinoma commonly infiltrates the facial nerve and may cause neuropathy and facial pain. | ot | improve Parotid gland clinical * Benign neoplasms Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerve. With the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion is in the Sth decade of life. Benign tumour types Tumour type Features Benign pleomorphic Most common parotid neoplasm (80%) adenoma or benign Proliferation of epithelial and myoepithelial cells of the ducts and mixed tumor an increase in stromal components Slow growing, lobular, and not well encapsulated 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Warthin tumor (papillary Second most common benign parotid tumor (5%) eystadenoma lymphoma Most common bilateral benign neoplasm of the parotid or adenolymphoma) 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) Monomorphic adenoma Account for less than 5% of tumours Haemangioma Slow growing Consist of only one morphological cell type (hence term mono) Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas ‘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 Malignant salivary gland tumours Types of malignancy Mucoepidermoid carcinoma Adenoid cystic carcinoma Mixed tumours: Acinic cell carcinoma Adenocarcinoma 30% of all parotid malignancies Usually low potential for local invasiveness and metastasis (depends mainly on grade) 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% Often a malignancy occurring in a previously benign parotid lesion Intermediate grade malignancy May show perineural invasion Low potential for distant metastasis 5 year survival 80% 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Lymphoma 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) iagnostic evaluation + Plain x-rays may be used to exclude calculi + Sialography may be used to delineate ductal anatomy + FNACis used in most cases ‘+ ‘Superficial parotidectomy may be either diagnostic or 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 Treatment For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical Parotidectomy is performed. The facial nerve is included in the resection if involved. The need for eck dissection is determined by the potential for nodal involvement. Other parotid disorders HIV infection ‘= 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 ‘Sjogren syndrome * 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 Sarcoid ‘+ Parotid involvement occurs in 6% of patients with sarcold * Bilateral in most cases + Gland is not tender + Xerostomia may occur + Management of isolated parotid disease is usually conservative Tr & @ ©° Question 11 of 34 v 5 © ‘A 4 year old child is brought to the clinic by his father. They are concerned because the child has been noted to have a small epithelial defect anterior to the left ear and is has been noted to discharge foul smelling material for the past 2 days. What is the most likely explanation? Otitis externa Oltitis media Cholesteatoma Long standing pars flaccida perforation Pre auricular sinuses that are deeper may accumulate secretions and produce foul smelling discharge. 6 | @ | Improve Disorders affecting the ear * Otitis externa Variant Cause Features Treatment Acute Boil in external auditory meatus Acute pain on. Ear packs may be used otitis moving the pinna Topical antibiotics externa Conductive Operative debridement hearing loss if may be needed in lesion is large severe cases When rupture occurs pus will flow from ear Chronic Chronic combined infection in Chronic discharge __Cleansing of the otitis _the external auditory meatus from affected ear, external ear and externa usually combined hearing loss and treatment with staphylococcal and fungal severe painrare antifungal and Infection antibacterial ear drops Otitis media Variant Cause Features TreatmentOtitis media Variant Acute suppurative otitis media Chronic suppurative otitis media Otosclerosis + Progressive conductive deafness Cause Viral induced middle ear effusions secondary to eustacian tube dysfunction May occur with or without cholesteatoma Those without cholesteatoma have a perforation of the pars tensa ‘Those with. cholesteatoma have a perforation of the pars flaccida Features Most common in children and rare in adults May present with symptoms elsewhere (e.9 vomiting) in children Severe pain and sometimes fever May present with discharge if tympanic rupture occurs ‘Those without cholesteatoma may complain of intermittent discharge (non offensive) Those with cholesteatoma have impaired hearing and foul smelling discharge * Secondary to fixation of the stapes in the oval window + Treatment is with stapedectomy and insertion of a prosthesis Acoustic neuroma + Symptoms of gradually progressive unilateral perceptive deafness and tinnitus * Involvement of the vestibular nerve may cause vertigo * Extension to involve the facial nerve may cause weakness and then paralysis. Pre auricular sinus + Common congenital condition in which an epithelial defect forms around the external ear * Small sinuses require no treatment + Deeper sinuses may become blocked and develop episodes of infection, they may be closely related to the facial nerve and are challenging to excise ‘Treatment Antibiotics (usually amoxycillin) Simple pars tensa perforations may be managed non operatively or a myringoplasty considered if symptoms troublesome. Pars flaccida perforations will Usually require a modified radical mastoidectomy<) Question 12 of 34 x n © ‘A78 year old man is referred to the clinic by his general practitioner. For many years he noticed a smooth swelling approximately 2cm anterior to the tragus of his right ear. Apart from being a heavy smoker he has no co-morbidities. What Is the most likely diagnosis? Pleomorphic adenoma ED Liposarcoma e ‘Adenocarcinoma oe None of the above e Warthins tumours are most common in elderly smokers. They have a relatively benign and indolent course. They are usually well circumscribed as illustrated below: oo |e | improve Parotid gland clinical * Benign neoplasms Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerveWith the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion is in the Sth decade of life. Benign tumour types ‘Tumour type Benign pleomorphic adenoma or benign mixed tumor Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma) Monomorphic adenoma Haemangioma Features 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 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 ‘Second most common benign parotid tumor (5%) 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 Iymph nodes Incidence of bilaterality and multicentricity of 10% Malignant transformation rare (almost unheard of) 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 Should be considered in the differential of a parotid mass ina 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 ‘Malignant salivary gland tumours ‘Types of malignancy Mucoepidermoid 30% of all parotid malignancies, carcinoma Usually low potential for local invasiveness and metastasis (depends mainly on grade)Adenoid cystic Unpredictable growth pattern carcinoma ‘Tendency for perineural spread Nerve growth may display skip lesions resulting in incomplete excision Distant metastasis more common (visceral rather than nodal spread) S year survival 35% Often a malignancy occurring in a previously benign parotid lesion Intermediate grade malignancy carcinoma May show perineural invasion Low potential for distant metastasis 5 year survival 80% Adenocarcinoma 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. Lymphoma 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) Diagnostic evalu * 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 or 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 Treatment For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement. Other parotid disorders HIV infection + 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 Sjogren syndrome ‘+ Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunetivitis 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 Iymphoma Sarcoid * Parotid involvement occurs in 6% of patients with sarcold * Bilateral in most cases * Gland is not tender + Xerostomia may occur ‘+ Management of isolated parotid disease is usually conservative Tr @ @ © Search Search textbook Q Google search on "Parotid gland clinicar* Suggest tink ‘+ Suggest media Dashboard SAR REAE EE 3<) Question 13 of 34 ¥ p ° ‘A 40 year old woman presents as an emergency with a painful mass undemeath her right ‘mandible. The mass has appeared over the previous week with the pain worsening as the lump has increased in size. On examination, there is a 4cm mass underneath her mandible, there Is no associated lymphadenopathy. What Is the most likely diagnosis? Submandibular gland cancer oe Carotid body tumour Papilloma of Whartons duct Carotid body aneurysm e ‘The sub mandibular gland is the most common site for salivary calculi, Patients will usually complain of pain, which is worse on eating. When the lesion is located distally the duct may be laid open and the stone excised. Otherwise the gland will require removal. Improve Neck lumps * The table below gives characteristic exam question features for conditions causing neck lumps: Reactive By far the most common cause of neck swellings. There may be a lymphadenopathy history of local infection or a generalised viral illness Lymphoma Rubbery, painless lymphadenopathy The phenomenon of pain whilst drinking alcohol is very uncommon There may be associated night sweats and splenomegaly Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically Moves upwards on swallowing Thyroglossal cyst 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 Pharyngeal More common in older men pouch Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles Usually not seen, but if large then a midline lump in the neck thatCystic hygroma Carotid aneurysm gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough ‘A congenital lymphatic lesion (Iymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age ‘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 More common in adult females ‘Around 10% develop thoracic outlet syndrome Pulsatile lateral neck mass which doesn't move on swallowing mo Save my notes | ‘Search Search textbook ‘Q Google search on ‘Neck lumps! Suggest link + Suggest media esas = £46 Dashboard<) Question 14 of 34 v Bb >) ‘A.43 year old lady presents with symptoms of chronic ear discharge and a right sided facial nerve palsy. On examination, she has foul smelling fluid draining from her right ear and a complete right sided facial nerve palsy. What is the most likely cause? Adenoid cystic carcinoma Acute otitis media Chronic sinusitis Cerebrovascular accident Foul smelling ear discharge and facial nerve weakness is likely to be due to cholesteatoma. The presence of a neurological deficit |s a sinister feature, oe | | improve | Facial nerve palsy * Sarcoid Cholesteatoma Basal skull fracture Facial nerve palsy is the most frequent neurological manifestation of sarcoid Affects right and left side with equal frequency, may be bilateral Typically resolves in up to 80% of cases Destructive and expanding growth of keratinised squamous epithelium Patients often complain of chronic ear discharge Infection with Pseudomonas may occur resulting in foul smell to discharge Aquired lesions usually arise from the Pars flaccida region of the tympanic membrane Surgical removal and mastoidectomy may be needed Recurrence rates of 20% may be seen following surgery History of head injury Presence of features such as Battles sign on examination Clinical presence of CSF leak strongly supports diagnosis, Assessment is by CT and MRI scan Prophylactic antibiotics should be given in cases of CSF leak° Question 15 of 34 x B °° AB year old boy with recurrent attacks of otitis media is suspected of developing a glue ear. If his sound conduction is tested, which of the following is most consistent with a unilateral middle ear effusion? t on the ipsilateral side Positive Rinne's test on the contralateral side Positive Webers and Rinnes tests on the ipsilateral side @ eo Negative Webers test only on the contralateral side Rinne’s test will localise to the affected side (ie. it is negative in conductive deafness). Ina positive Rinne's test sound heard by alr conduction Is better than that conveyed by bone conduction. Reduction of both air and bone conduction in equal measure is a feature of sensorineural hearing loss. | P| Improve Hearing Loss * Hearing loss may be conductive or sensorineural. To determine which is present patients will often require a formal assessment with pure tone audiometry. In the clinical setting Webers and Rinnes tests may be helpful in categorising various types of hearing loss. Webers and Rinnes Tests In anormal patient, the Weber tuning fork sound Is heard equally loud in both ears with no one ear hearing the sound louder than the other. A patient with symmetrical hearing loss will hear the Weber tuning fork sound equally well with diagnostic utility only in asymmetric (one-sided) hearing losses. In a patient with asymmetrical hearing loss, the Weber tuning fork sound Is heard louder in one ear versus the other. This clinical finding should be confirmed by repeating the procedure and having the patient occlude one ear with a finger; the sound should be heard best in the occluded ear. Rinne Weber without Test lateralisation Weber lateralises to left Weber lateralises to right Both ears Normal Sensorineural loss on right Sensorineural loss on left Alr>Bone Left Bone Conductive loss on left Combined loss on left > AirRight ‘Combined loss on right Conductive loss on right Bone> Air Both Bone Combined loss on right and Combined loss on left and > Air conductive on left conductive on right Next question BY a) ~ Save my notes, Search Search textbook B Q Google search on Hearing Loss" + sugost ink ++ Suagest media Dashboard 1 2 sv av sv ov 7 av ov iv uv 2 * By “uv 15 x 6 vww Senne ane ee: = . <- ‘A dentist treating a woman with rheumatoid arthritis for recurrent episodes of dental sepsis notices that both parotid and submandibular glands are symmetrically enlarged. What is the ‘most likely diagnosis? Mikulicz’s syndrome Alcoholism Liver cirrhosis Metastatic cancer Sjogren's is associated with autoimmune disorders. Mikulicz’s is similar but there is no sicca or arthritis. Improve Neck lumps * The table below gives characteristic exam question features for conditions causing neck lumps: Reactive By far the most common cause of neck swellings. There may be a lymphadenopathy history of local infection or a generalised viral illness Lymphoma Rubbery, painless lymphadenopathy The phenomenon of pain whilst drinking alcohol is very uncommon There may be associated night sweats and splenomegaly swelling May be hypo-, eu- or hyperthyroid symptomatically Moves upwards on swallowing Thy Thyroglossal cyst 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 Pharyngeal More common in older men pouch Represents a posteromedial hemiation between thyropharyngeus and cricopharyngeus muscles Usually not seen, but If large then a midtine lump in the neck that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration and chronic coughCystic hygroma A congenital lymphatic lesion (Iymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age Branchial cyst. 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 Cervical rib More common in adult females ‘Around 10% develop thoracic outlet syndrome Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing Bis @- Tr By @ @ Search Search textbook Q Google search on “Neck lump: Suggest Ink + suggest media Dashboard ee nd° Question 17 of 34 ¥ 6 ©} ‘A25 year old woman presents with a slowly enlarging mass on the side of the face. Clinical examination demonstrates that the mass is located in the tail of the parotid gland. There is no evidence of facial nerve involvement. What is the most likely cause? Sialolithiasis Adenocarcinoma Warthins tumour Oncocytoma Pleomorphic adenomas are the commonest tumours of the parotid gland and are often slow growing, smooth and mobile. Warthins tumours are typically found in elderly males and are composed of multiple cysts and solid components consisting of lymphoid tissue, Warthins ‘tumours are most often found in the tall of the parotid gland, but not in 25 year old females, ‘where a pleomorphic adenoma remains the most likely lesion. Improve Parotid gland clinical * Benign neoplasms Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerve. With the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion is in the Sth decade of life. Benign tumour types Tumour type Features Benign pleomorphic Most common parotid neoplasm (80%) adenoma or benign Proliferation of epithelial and myoepithelial cells of the ducts and mixed tumor an increase in stromal components ‘Slow growing, lobular, and not well encapsulated 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 Warthin tumor (papillary Second most common benign parotid tumor (5%) cystadenoma lymphoma Most common bilateral benign neoplasm of the parotid or adenolymphoma) 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) Monomorphic adenoma Account for less than 5% of tumours Haemangioma Slow growing Consist of only one morphological cell type (hence term mono) Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas 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 Malignant salivary gland tumours ‘Types of malignancy Mucoepidermoid carcinoma Adenoid cystic carcinoma Mixed tumours Acinic cell carcinoma Adenocarcinoma 30% of all parotid malignancies Usually low potential for local invasiveness and metastasis (depends mainly on grade) 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% Often a malignancy occurring in a previously benign parotid lesion Intermediate grade malignancy May show perineural invasion Low potential for distant metastasis 5 year survival 80% 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 Lymphoma 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) Diagnostic evaluation * Plain x-rays may be used to exclude calculi * Sialography may be used to delineate ductal anatomy + FINACis used in most cases ‘+ Superficial parotidectomy may be either diagnostic or 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 Treatment For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical Parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement, Other parotid disorders HIV infection ‘+ 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 ‘Sjogren syndrome + 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 Sarcoid + 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 18 of 34 ¥ ® °o ‘A'56 year old man presents with a painless swelling in the upper part of the anterior triangle of his neck. On examination a mass lesion involving the sub mandibular gland is identified. On CT scanning this is shown to be a solid lesion. There is no regional lymphadenopathy. Two fine needle aspirates have failed to be diagnostic. Which of the following is the most appropriate management option? Incisional biopsy of the mass Manage conservatively and repeat the CT scan in 6 months Sub mandibular gland excision and radical neck dissection Diagnostic excision of the superficial lobe of the submandibular gland There is a 50% risk that this lesion is malignant (in some series up to 70%). Therefore the gland should be excised entirely, At this stage a radical neck dissection is not justified. [oo | improve Submandibular glands- disease * Physiology The submandibular glands secrete approximately 800- 100m! saliva per day. They typically produce mixed seromucinous secretions. When parasympathetic activity is dominant; the secretions will be more serous. The parasympathetic fibres are derived from the chorda tympani nerves and the submandibular ganglion. Sensory fibres are conveyed by the lingual branch of the mandibular nerve. Sialolithiasis + 80% of all salivary gland calculi occur in the submandibular gland *+ 70% of the these calculi are radio-opaque * Stones are usually composed of calcium phosphate or calcium carbonate * Patients typically develop colicky pain and post prandial swelling of the gland * Investigation involves sialography to demonstrate the site of obstruction and associated other stones. * Stones impacted in the distal aspect of Whartons duct may be removed orally, other stones and chronic inflammation will usually require gland excision Sialadenitis * Usually occurs as a result of Staphylococcus aureus infection + Pus may be seen leaking from the duct, erythema may also be noted + Development of a sub mandibular abscess is a serious complication as it may spreadthrough the other deep fascial spaces and occlude the airway ‘Submandibular tumours * Only 8% of salivary gland tumours affect the sub mandibular gland * Of these 50% are malignant (usually adenoid cystic carcinoma) * Diagnosis usually involves fine needle aspiration cytology * Imaging is with CT and MRI * In view of the high prevalence of malignancy, all masses of the submandibular glands should generally be excised Tr gy @ © | Save my notes Search ‘Search textbook. Q Google search on “Submandibular glands- disease" Suggest Iink + Suggest media Dashboard 1% 2 av av 5 v ov 7 av ov ov uy 12) By3° Question 19 of 34 v p o ‘A 56 year old man presents with episodic facial pain and discomfort whilst eating. He has suffered from halitosis recently and he frequently complains of a dry mouth. He has a smooth swelling underneath his right mandible. What is the most likely underlying diagnosis? ee @ Stone impacted in Stensens duct Benign adenoma of the submandibular gland oe ‘Adenocarcinoma of the submandibular gland eo ‘Squamous cell carcinoma of the submandibular gland e2 ‘The symptoms are typical for sialolithiasis. The stones most commonly form in the submandibular gland and therefore may occlude Whartons duct. Stensens duct drains the parotid gland. [| improve | Submandibular glands- disease * Physiology The submandibular glands secrete approximately 800- 1000m! saliva per day. They typically produce mixed seromucinous secretions. When parasympathetic activity is dominant; the secretions will be more serous. The parasympathetic fibres are derived from the chorda tympani nerves and the submandibular ganglion. Sensory fibres are conveyed by the lingual branch of the mandibular nerve. Sialolithiasis + 80% of all salivary gland calculi occur in the submandibular gland *+ 70% of the these calculi are radio-opaque * Stones are usually composed of calcium phosphate or calcium carbonate + Patients typically develop colicky pain and post prandial swelling of the gland * Investigation involves sialography to demonstrate the site of obstruction and associated other stones + Stones impacted in the distal aspect of Whartons duct may be removed orally, other stones and chronic inflammation will usually require gland excision ladenitis, * Usually occurs as a result of Staphylococcus aureus infection + Pus may be seen leaking from the duct, erythema may also be noted + Development of a sub mandibular abscess is a serious complication as it may spread through the other deep fascial spaces and occlude the airway‘Submandibular tumours * Only 8% of salivary gland tumours affect the sub mandibular gland + Of these 50% are malignant (usually adenoid cystic carcinoma) + Diagnosis usually involves fine needle aspiration cytology + Imaging is with CT and MRI + In view of the high prevalence of malignancy, all masses of the submandibular glands should generally be excised, Next question > Biles &- ‘Save my notes Search Search textbook. Google search on “submandibular glands- disease” ++ suggest ink + suggest mecia Dashboard OaVausene " 12 13 14 415 PRiRa © R446 40 < Ce° Question 20fs¢ A 25 year old lady presents with a swelling located at the anterior border of the stemocleidomastoid muscle. The swelling Is intermittent and on examination itis soft and fluctuant. What is the most likely diagnosis? Thyroglossal cyst Infection with Bartonella eo @ tid body tumour oe @ oe Dental abscess Branchial cysts are remnants of the branchial cleft. They may become infected. « Improve Neck lumps * The table below gives characteristic exam question features for conditions causing neck lumps: Reactive By far the most common cause of neck swellings. There may be a lymphadenopathy history of local infection or a generalised viral illness. Lymphoma Rubbery, painless lymphadenopathy The phenomenon of pain whilst drinking alcohol is very uncommon There may be associated night sweats and splenomegaly ‘Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically Moves upwards on swallowing ‘Thyroglossal cyst 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 Pharyngeal More common in older men pouch 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 Typical symptoms are dysphagia, regurgitation, aspiration and chronic coughCystic hygroma A congenital lymphatic lesion (Iymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age Branchialcyst_ —_An oval, mobile cystic mass that develops between the sterocleidomastold muscle and the pharynx Develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood Cervical rib More common in adult females Around 10% develop thoracic outlet syndrome Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing erent Be ote) Search ‘Search textbook. Q Google search on ‘Neck lumps" “+ Suggest ink “F Suggest media Dashboard >Yoaanona ee° Question 21 of 34 x B °o A patient presents with a facial nerve palsy. This occurred following repeat excision of a facial lump. The histology report remarks on the biphasic appearance of the lesion and mucinous connective tissue. What is the most likely underlying lesion? | Peomemicatnane ‘Adenolymphoma Anaplastic carcinoma eo Schwannoma eo The histological features are as described with a classic biphasic (mixed stromal and epithelial elements), although benign local recurrence can complicate incomplete excision. As this is @ benign lesion direct extension into the facial nerve is unlikely to occur. Facial nerve injury can happen during repeat parotid surgery. Improve Neck lumps * The table below gives characteristic exam question features for conditions causing neck lumps: Reactive By far the most common cause of neck swellings. There may be a lymphadenopathy history of local infection or a generalised viral iliness Lymphoma Rubbery, painless lymphadenopathy ‘The phenomenon of pain whilst drinking alcohol is very uncommon ‘There may be associated night sweats and splenomegaly Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically Moves upwards on swallowing Thyroglossal cyst More common in patients < 20 years old Usually midline, between the isthmus of the thyroid and the hyold bone Moves upwards with protrusion of the tongue May be painful if infected Pharyngeal More common in older men pouch 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 Typical symptoms are dysphagi cough regurgitation, aspiration and chronic Cystic hygroma 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 Branchial cyst ‘An oval, mobile cystic mass that develops between the sternocleidomastold muscle and the pharynx Develop due to failure of obliteration of the second branchial cleft in ‘embryonic development Usually present in early adulthood Cervical rib More common in adult females ‘Around 10% develop thoracic outlet syndrome cari aneurysm Pulsatile lateral neck mass which doesn't move on swallowing Search ‘Search textbook Q Google search on "Neck lumps" “+ Suggest Ink Suggest media Dashboard rpeone SOO38 Question 22 of 34 v Bp So ‘A21 year old man presents with a unilateral facial nerve palsy after being hit on the head, On examination, he has a right sided facial nerve palsy and a watery discharge from his nose. What Is the most likely cause? Pleomorphic adenoma Cerebrovascular accident Occipital bone fracture Sarcoidosis Nasal discharge of clear fluid and recent head injury makes a basal skull fracture the most likely underlying diagnosis, } | Improve Facial nerve palsy * Sarcoid Facial nerve palsy is the most frequent neurological manifestation of sarcoid Affects right and left side with equal frequency, may be bilateral Typically resolves in up to 80% of cases Cholesteatoma Destructive and expanding growth of keratinised squamous epithelium Patients often complain of chronic ear discharge Infection with Pseudomonas may occur resulting in foul smell to discharge ‘Aquired lesions usually arise from the Pars flaccida region of the tympanic membrane Surgical removal and mastoidectomy may be needed Recurrence rates of 20% may be seen following surgery Basal skull History of head injury fracture Presence of features such as Battles sign on examination Clinical presence of CSF leak strongly supports diagnosis ‘Assessment is by CT and MRI scan Prophylactic antibiotics should be given in cases of CSF leakQuestion 23 of 34 v Bp eZ ‘870 year old lady presents with a painless neck lump. There is a mass noted beneath the stenocleldomastold muscle. There Is a long history and somewhat unkindly her husband remarked on her rather noticeable halitosis. What is the most likely explanation? Branchial cyst Branchial fistula Thyroglossal cyst Dental caries Usual history of regurgitation of undigested food or coughing at night. Associated with halitosis and throat infections, Neck lumps * The table below gives characteristic exam question features for conditions causing neck lumps: Reactive By far the most common cause of neck swellings. There may be a lymphadenopathy history of local infection or a generalised viral illness Lymphoma Rubbery, painless lymphadenopathy The phenomenon of pain whilst drinking alcohol is very uncommon There may be associated night sweats and splenomegaly Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically Moves upwards on swallowing Thyroglossal cyst More common in patients < 20 years old Usually midline, between the isthmus of the thyrold and the hyold bone Moves upwards with protrusion of the tongue May be painful if infected Pharyngeal More common in older men pouch 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 Typical symptoms are dysphagia, regurgitation, aspiration and chronic ouohcystic hygroma ‘Accongenital lymphatic lesion (Iymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age Branchial cyst 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 Cervical rib More common in adult females ‘Around 10% develop thoracic outlet syndrome Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing BlewW- ss s- Tr & wo Save my notes Search ‘Search textbook B Q Google search on ‘Neck lumps" + suggest nk + suggest media Dashboard 1 2 30v av sv ov ad°o Question 24 of 34 v Rp © A child is brought to casualty complaining of a headache and a sensation of pressure between the eyes. On examination, she is febrile with a smooth swelling overlying the superomedial aspect of the right eye. The eye is uncomfortable and there is a purulent discharge from the inner canthus. What Is the most likely cause? Maxillary sinusitis Nasal polyps Ethmoid sinus cancer Maxillary sinus cancer Ethmoidal sinusitis may spread to the periorbital tissues resulting in periorbital cellulitis. The superomedial distribution makes a maxillary sinusitis less likely. || imorove | Diseases of nose and sinuses * Benign Tumours ‘+ Simple papillomas may be an incidental finding or present with obstructive symptoms. Excision under general anaesthesia is sufficient management, ‘+ Transitional cell papillomas may be more extensive and produce obstructive symptoms Erosion of local structures is a recognised complication. These lesions may rarely undergo malignant transformation and therefore careful and complete excision is required, some cases may requite partial or total maxillectomy. + Pleomorphic adenomas of the maxillary sinuses are reported but are extremely rare, their symptoms typically include nasal obstruction and pain if the sinus is obstructed. Treatment Is by complete surgical excision, the diagnosis is not infrequently made post operatively. ‘+ Benign osteomas may develop in the paranasal sinuses, the frontal sinus is the most frequent location of such lesions. Symptoms include; pain, thinorrhoea and anosmia. Most ‘osteomas may be observed if asymptomatic, sphenoid osteomas should be resected soon after diagnosis as enlargement may compromise visual fields. Many sinus osteomas can now be resected endoscopically, complete surgical resection is required. ‘+ Nasal polyps are benign lesions of the ethmoid sinus mucosa. Many patients may also have asthma, cystic fibrosis and a sensitivity to aspirin. Symptoms include watery thinorthoea, infection and anosmia. The polyps are usually a semi transparent grey mass. They are rare in childhood. Treatment is either with systemic steroids or surgical resection, ‘The latter should be combined with antral washout. Low dose, nasal, steroid drops may reduce the risk of recurrence.Malignant disease + Malignancies encountered in the nose and paranasal sinuses include; adenoid cystic carcinoma, squamous cell carcinoma and adenocarcinoma. * Adenocarcinoma of the paranasal sinuses and nasopharynx is strongly linked to exposure to hard wood dust (after >10 years exposure). * Adenoid cystic carcinoma usually originate in the smaller salivary glands. The majority of cancers (50%) arise from the lateral nasal wall, a smaller number (33%) arise from the maxillary antrum, ethmoid and sphenold cancers comprise only 7%, * Signs of malignancy on clinical examination include loose teeth, cranial nerve palsies and lymphadenopathy. + Nasopharyngeal cancers are most common in individuals presenting from China and Asia and are linked to viral infection with Epstein Barr Virus. Radiotherapy and chemotherapy are the most commonly used modalities, Maxillary sinusitis + Common symptoms include post nasal discharge, pain, headache and toothache. + Imaging may show a fluid level in the antrum. + Common organisms include Haemophilus influenzae or Streptococcus pneumoniae. + Treatment with antral lavage may facilitate diagnosis and relieve symptoms. Antimicrobial therapy has to be continued for long periods. Antrostomy may be needed. Frontoethmoidal sinusitis * Usually presents with frontal headache, nasal obstruction and altered sense of smell * Inflammation may progress to involve periorbital tissues. Ocular symptoms may occur and secondary CNS involvement brought about by infection entering via emissary veins. + CT scanning is the imaging modality of choice. Early cases may be managed with antibiotics. More severe cases usually require surgical drainage Tr By Go ‘Save my notes ‘Search Search textbook B ‘Q Google search on “Diseases of nose and sinuses" + Suggest lnk Suggest media°o Question 25 of 34 x Be } ‘A 42 year old singer is admitted for a thyroidectomy. Post operatively she is only able to make a 40 years, as lumps in this age group may in fact be metastatic disease from oropharyngeal cancer. | Improve Neck lumps * The table below gives characteristic exam question features for conditions causing neck lumps: Reactive By far the most common cause of neck swellings. There may be a lymphadenopathy history of local infection or a generalised viral ines Lymphoma Rubbery, painless lymphadenopathy ‘The phenomenon of pain whilst drinking alcohol Is very uncommon ‘There may be associated night sweats and splenomegaly ‘Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically Moves upwards on swallowing Thyroglossal cyst 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 Pharyngeal More common in older men pouch Represents a posteromedial hemiation between thyropharyngeus and cricopharyngeus muscles Usually not seen. but if larae then a midline lumo in the neck thatgurgles on palpation ‘Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough Cystic hygroma 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 Branchial cyst An oval, mobile cystic mass that develops between the stemocleidomastold muscle and the pharynx Develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood More common in adult females Around 10% develop thoracic outlet syndrome Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing Save my notes Search Search textbook B ‘Q Google search on “Neck lumps" Suggest nk + suggest media Dashboard eee , OSEww ee ae eee - = as ‘A22 year old man presents with symptoms of lethargy and bilateral facial nerve palsy. On examination he has bilateral parotid gland enlargement. What is the most likely cause? Pleomorphic adenoma oe Cerebrovascular accident @2 Warthins tumour o) Adenoid cystic carcinoma Facial nerve palsy is the commonest neurological manifestation of sarcoid. It usually resolves. The absence of a discrete lesion on palpation Is against the other causes. |B | Improve J Parotid gland clinical * Benign neoplasms Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerve, With the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion is in the Sth decade of life. Benign tumour types ‘Tumour type Features Benign pleomorphic Most common parotid neoplasm (80%) adenoma or benign Proliferation of epithelial and myoepithelial cells of the ducts and mixed tumor an increase in stromal components Slow growing, lobular, and not well encapsulated 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 Warthin tumor (papillary Second most common benign parotid tumor (5%) cystadenoma lymphoma — Most common bilateral benign neoplasm of the parotid or adenolymphoma) 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) Monomorphic adenoma 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, myoepithellomas Haemangioma ‘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 Malignant salivary gland tumours ‘Types of malignancy Mucoepidermoid 30% of all parotid malignancies carcinoma Usually low potential for local invasiveness and metastasis (depends mainly on grade) ‘Adenoid cystic 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% ed tumours Often a malignancy occurring in a previously benign parotid lesion Acinic cell Intermediate grade malignancy May show perineural invasion Low potential for distant metastasis S year survival 80% Adenocarcinoma 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 Lymphoma 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) Diagnostic evaluation + 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 or 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 Treatment For nearly al lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement. Other parotid disorders HIV infection ‘+ 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 Sjogren syndrome ‘+ Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicea * 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 infitrate in acinar units and epimyoepithelial islands surrounded by lymphoid stroma + Treatment is supportive + There is an increased risk of subsequent lymphoma Sarcoid + 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 Se Tr a mw ©° Question 29 of 34 v Bp oS At which of the following time frames is secondary haemorrhage most likely to occur following tonsillectomy? a | - During the first 6 hours after surgery Between 6 and 12 hours after surgery @ Upon resumption of normal feeding oe Between 2 and 3 days post operatively Haemorthage in the first 24 hours after surgery is termed reactionary haemorrhage. Feeding does not increase the risk and may actually lower the risks of infection developing, | 9% | Improve Secondary haemorrhage after tonsillectomy * Haemorthage is a feared complication following tonsillectomy. Primary, or reactionary haemorthage 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, itis often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in 3% of all tonsillectomies. VD | _ Tr By wl @ Search Search textbook B Q Google search on “Secondary haemorrhage after tonsillectomy"° Question 30 of 34 v » ° A 34 year old lady presents with a long standing offensive discharge from the ear and on examination is noted to have a reduction in her hearing of 40 decibels compared to the opposite side. What is the most likely cause? Otosclerosis Acute otitis media Long standing perforation of the pars tensa Otitis externa The combination of long history, offensive discharge and hearing loss is strongly suggestive of cholesteatoma. +? Tl Disorders affecting the ear * Otitis externa Variant Cause Acute Boll in external auditory meatus otitis externa Chronic Chronic combined infection in otitis _the external auditory meatus externa usually combined staphylococcal and fungal infection, Otitis med Variant Cause Features Features Acute pain on moving the pinna Conductive hearing loss if lesion is large When rupture occurs pus will flow from ear Chronic discharge from affected ear, hearing loss and severe pain rare Treatment Ear packs may be used Topical antibiotics Operative debridement may be needed in severe cases Cleansing of the external ear and ‘treatment with antifungal and antibacterial ear drops. ‘TreatmentOtitis media Variant Acute suppurative otitis media Chronic suppurative otitis media Otosclerosis Cause Viral induced middle ear effusions secondary to eustacian tube dysfunction May occur with or without cholesteatoma Those without cholesteatoma have a perforation of the pars tensa Those with cholesteatoma have a perforation of the pars flaccida Features Most common in children and rare in adults May present with symptoms. elsewhere (e.g. vomiting) in children Severe pain and sometimes fever May present with discharge if tympanic rupture occurs Those without cholesteatoma may ‘complain of Intermittent discharge (non offensive) Those with cholesteatoma have Impaired hearing and foul smelling discharge * Progressive conductive deafness * Secondary to fixation of the stapes in the oval window + Treatment is with stapedectomy and insertion of a prosthesis Acoustic neuroma + Symptoms of gradually progressive unilateral perceptive deafness and tinnitus * Involvement of the vestibular nerve may cause vertigo * Extension to involve the facial nerve may cause weakness and then paralysis. Pre auricular ‘Treatment Antibiotics (usually amoxycillin) Simple pars tensa perforations may be managed non ‘operatively or a myringoplasty considered if symptoms troublesome. Pars flaccida perforations will usually require a modified radical mastoidectomy * Common congenital condition in which an epithelial defect forms around the external ear + Small sinuses require no treatment * Deeper sinuses may become blocked and develop episodes of infection, they may be closely related to the facial nerve and are challenging to excise°e Question 31 of 34 v p oO A 10 year old git! presents with epistaxis. From which of the following regions is the bleeding most likely to originate? Posterior nasal space Alar rim Cribriform plate None of the above Kiesselbachs plexus has an arterial supply derived from both the internal and external carotid arteries and is the commonest area for bleeding in idiopathic epistaxis. | | Improve ba Epistaxis * Usually trivial and insignificant but severe haemorrhage may compromise airway and pose a risk tolife Anatomy: Arterial supply * From internal and external carotid * An arterial plexus exists at Little's area and is the source of bleeding in 90% cases * Major arterial supply is from the sphenopalatine and greater palatine arteries (branches of the maxillary artery) * The facial artery supplies the more anterior aspect of the nose + Ethmoidal arteries are branches of the ophthalmic artery. They supply the posterosuperior nasal cavity ‘Venous drainage follows the arterial pattern + Primary idiopathic epistaxis accounts for 75% of all cases. + Secondary cases arise as a result of events such as anticoagulants, trauma and coagulopathy ‘+ Classification into anterior and posterior epistaxis may help to locate the source and becomes more important when invasive treatment Is requiredManagement + Resuscitate if required + Subject should sit upright and pinch nose firmly + Nasal cavity should be examined using a headlight + Simple anterior epistaxis may be managed using silver nitrate cautery. If difficult to manage then custom manufactured packs may be inserted + Posterior packing or tamponade may be achieved by passing a balloon tamponade device and inflating it. This Is indicated where anterior packing alone has failed to achieve haemostasis. + Post nasal pack patients should receive antibiotics ‘+ Fallure of these methods will require more invasive therapy. Where a vascular radiology suite Is available, consideration may be given to angiographic techniques. Direct ligation of the nasal arterial supply may also be undertaken. Of the arterial ligation techniques available, the endo nasal sphenopalatine arterial ligation procedure is most popular. erry [ save my notes Search Search textbook Go Q Google search on "Epistaxis" suggest lnk + uggest media Dashboard LOSE°o Question 32 of 34 v Bp Oo Which of the following does not cause parotid enlargement? Liver cirrhosis Myxoedema Tuberculosis Sjogrens syndrome Drugs commonly implicated in parotid gland enlargement include: Thiouracil,isoprenaline, phenylbutazone, high oestrogen dose contraceptive pills. [4 | | improve PA Parotid gland clinical Benign neoplasms Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There Is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerve. With the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion is in the Sth decade of life. Benign tumour types Tumour type Features Benign pleomorphic Most common parotid neoplasm (80%) adenoma or benign Proliferation of epithelial and myoepithelial cells of the ducts and mixed tumor an increase in stromal components Slow growing, lobular, and not well encapsulated 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 Warthin tumor (papillary Second most common benign parotid tumor (5%) cystadenoma lymphoma _ Most common bilateral benign neoplasm of the parotid or adenolymphoma) 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) Monomorphic adenoma 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, oncacytoma, myoepitheliomas Haemangioma 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 Malignant salivary gland tumours ‘Types of malignancy Mucoepidermoid 30% of all parotid malignancies carcinoma Usually low potential for local invasiveness and metastasis (depends mainly on grade) Adenoid cystic Unpredictable growth pattern carcinoma 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% Mixed tumours Often a malignancy occurring in a previously benign parotid lesion Acinic cell Intermediate grade malignancy carcinoma May show perineural invasion Low potential for distant metastasis S year survival 80% Adenocarcinoma _ 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 Lymphoma 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) Diagnostic evaluation * Plain x-rays may be used to exclude calcull * Sialography may be used to delineate ductal anatomy * FAC is used in most cases * Superficial parotidectomy may be either diagnostic or 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 Treatment For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical Parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement. Other parotid disorders HIV infection ‘+ 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 ‘Sjogren syndrome + Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunetivitis 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 Iymphoma Sarcoid * Parotid involvement occurs in 6% of patients with sarcold * Bilateral in most cases * Gland is not tender + Xerostomia may occur ‘+ Management of isolated parotid disease is usually conservative° Question 33 of 34 x 6 © ‘A.32 year old lady is referred to the clinic with recurrent infections and abscesses in the neck. On examination, she has a midline defect with an overlying scab, which moves upwards on tongue protrusion. What is the most likely diagnosis? Branchial cyst ‘Sebaceous cyst Dermoid cyst Thytoglossal cyst is always located in the midline as itis this route that the thyroid takes during its embryological descent. its connection with the foramen caecum means it wll move on tongue protrusion. oF Improve Neck lumps * ‘The table below gives characteristic exam question features for conditions causing neck lumps: Reactive By far the most common cause of neck swellings. There may be a lymphadenopathy history of local infection or a generalised viral iliness Lymphoma Rubbery, painless lymphadenopathy The phenomenon of pain whilst drinking alcohol is very uncommon There may be associated night sweats and splenomegaly Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically Moves upwards on swallowing Thyroglossal cyst. 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 Pharyngeal More common in older men pouch 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cystic hygroma Branchial cyst Cervical rib arotid aneurysm Bie &- [save ots Search ‘Search textbook Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough A congenital lymphatic lesion (Iymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age An oval, mobile cystic mass that develops between the sternocleidomastold muscle and the pharynx Develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood More common in adult females ‘Around 10% develop thoracic outlet syndrome Pulsatile lateral neck mass which doesn't move on swallowing ‘Q Google search on “Neck lumps" + Suggest lnk + suggest mecia SEER Dashboard°o Question 34 of 34 v Bp © ‘A 50 year old lady presents with symptoms of a dry mouth that has been present for the past few months. She also has a 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. What is the likely underlying diagnosis? Sarcoid @ Adenoid cystic carcinoma Pleomorphic adenoma e Lymphoma eo Most patients with Sjogrens present in the post menopausal years. Multi system involvement is ‘common Improve Parotid gland clinical * Benign neoplasms Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerve. \With the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion Is in the Sth decade of life. Benign tumour types ‘Tumour type Features Benign pleomorphic Most common parotid neoplasm (80%) adenoma or benign Proliferation of epithelial and myoepithelial cells of the ducts and mixed tumor an increase In stromal components ‘Slow growing, lobular, and not well encapsulated 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Warthin tumor (papillary Second most common benign parotid tumor (5%) cystadenoma lymphoma — Most common bilateral benign neoplasm of the parotid or adenolymphoma) 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) Monomorphic adenoma Account for less than 5% of tumours Haemangioma Malignant s: Types of malignancy Mucoepidermoid carcinoma Adenoid cystic carcinoma Mixed tumours: Acinic cell carcinoma Adenocarcinoma Slow growing Consist of only one morphological cell type (hence term mono) Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas 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 ary gland tumours 30% of all parotid malignancies Usually low potential for local invasiveness and metastasis (depends mainly on grade) 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) S year survival 35% Often a malignancy occurring in a previously benign parotid lesion Intermediate grade malignancy May show perineural invasion Low potential for distant metastasis Syear survival 80% Develops from secretory portion of gland Risk of regional nodal and distant metastasis S year survival depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvementLymphoma 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) .gnostic evaluation + Plain x-rays may be used to exclude calculi * Sialography may be used to delineate ductal anatomy ‘+ FNACis used in most cases ‘+ ‘Superficial parotidectomy may be either diagnostic or 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 Treatment For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement. Other parotid disorders HIV infection + Lymphoepithelial cysts associated with HIV occur almost exclusively in the parotid + Typically presents as bilateral, mutticystic, symmetrical swelling + Risk of malignant transformation Is low and management usually conservative Sjogren syndrome * 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 inflitrate in acinar units and epimyoepithelial islands surrounded by lymphoid stroma + Treatment is supportive + There is an increased risk of subsequent lymphoma Sarcoid + Parotid involvement occurs in 6% of patients with sarcoid * Bilateral in most cases * Glands not tender + Xerostomia may occur ‘+ Management of isolated parotid disease is usually conservative 5 a Tr By & oEMRCS 2021 EDITED BY OMER KAMAL AHMED A SUDANESE MEDICAL OFFICER AT ALGAZIRA CENTER FOT ORTHOPEDIC AND TRAUMA coobLugKV\ER K AHMET Wit tery tl