Thyroglossal cysts are benign cysts that form in the midline of the neck.

They can form anywhere along the remnant fo the Thyroglossal Duct, which gets from eh base of the tongue, to the sternal notch.

Many individuals shave a remnant of the Thyroglossal duct that persists at birth. The natural physiology is that the duct atrophies during development, but in some individuals this process does not occur.

For reasons that are not fully understood, some of those with a persistent duct will, later in life, go on to form a cyst within the duct.

The cysts are smooth, regular, painless, non-tender, fluctuant masses. They occur in the midline in the neck, and move on movements of the tongue. This helps them to be distinguished from other lumps in the neck which are not connected to the tongue, and thus do not move when the tongue is moved.

It is a very common exam question to have a lump in the neck that moves with swallowing!

Differentials

• Thyroid masses – e.g. goitre, nodule
• Inflamed lymph node – e.g. lymphoma
• Haematoma
• Sarcoidosis

References

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Otitis Media is an umbrella term that can refer to several subtypes of middle ear infection and inflammation; acute otitis media, otitis media with effusion, and chronic suppurative otitis media.

It is important to clinically differentiate these causes as their treatment is different.

Acute Otitis Media (AOM) is very common in children, and less commonly seen in adults. The cause is usually viral (rhinovirus, adenovirus, enterovirus, RSV). In bacterial cases, the cause is usually haemophilia influenzae or streptococcus pneumoniae – although the latter is much less common since the introduction of pneumococcus vaccination. It typically presents with a deep ear pain and a sensation of a blocked ear.

Otitis Media with Effusion (OME) – aka glue ear refers to chronic inflammation of the middle ear, with collection of fluid in the Eustachian tube. It is the most common cause of hearing problems in childhood and although most cases resolve spontaneously, elective surgery (placement of grommets) is required in many cases. It is typically a complication of an episode of acute otitis media.

Chronic suppurative otitis media (CSOM) is a chronic disorder with persistent rupture of the tympanic membrane and subsequent otorrhoea (ear discharge). It is the most disabling of all types of otitis media. It is very common in the developing world and in some Aboriginal and Torres Straight Islander populations in Australia. It is associated with permanent hearing loss and poor educational performance.

Acute Otitis Media (AOM)

AOM is a very common disorder, with most children experiencing at least one episode. Most common in younger children <3 years old. In children >3 years old OME is more common. Be aware that AOM is a risk factor for OME and may present as co-existing conditions.

Epidemiology

• 75% of children have had a test one episode by school age
• Peak incidence is between 6-18 months
• Increased risk associated with smoke exposure in the home
• Incidence in adults 0.25% per year
• More common in winter months – probably due to association with URTI

Presentation

• Ear pain
  • Usually resolve spontaneously if TM perforates
• Fever
• Irritability
• Lethargy
• URTI symptoms
• Discharge from affected ear (if perforated)

Examination

• The infection typically begins in the upper outer quadrant and spreads down the handle of the malleus. In the early stage, the tympanic membrane (TM) may remain translucent.
• In later stages, the tympanic membrane bulges and becomes very oedematous. Often there is pus behind the TM.
• There may occasionally be blister on the TM – this is known as bullous myringitis – and is typically exquisitely painful, with pain received when the blisters pop. This is usually indicative of viral infection.
• A red angry-looking TM, without bulging or pus does not confirm a diagnosis of AOM – and is commonly seen with URTI
• Ear effusion also does not confirm diagnosis of AOM. It is often present after previous AOM, and may represent OME (otitis media with effusion – see below)
• Red flags
  • Cellulitis of the outer ear or surrounding skin
  • Mastoiditis (tender mastoid, often with cellulitis looking ear and ear appears to be pressed forwards)
  • Headache
  • Facial palsy
  • Fever in child under 3 months old

Investigations

• No investigations are routinely required. Diagnosis is clinical
• If any suspected intracranial complications, CT or MRI may be performed

Complications

• Mastoiditis
  • Rare
  • Pain, tenderness and swelling behind the ear, often pressing the ear forwards
  • Requires urgent ENT admission for IV antibiotics and some cases may require surgical drainage
• Bacterial labyrinthitis
  • Causes severe vertigo and persistent pain and fevers

Management

• Analgesia
• Watchful waiting is suitable for most children
  • 60% will resolve within 24 hours
  • 80% will resolve within 4 days
  • Antibiotics will improve symptoms 12-24 hours sooner than without, but carry the risk of GI upset and resistance
• Antibiotics
  • There is much debate and differing clinical guidelines
  • Antibiotic of choice is amoxicillin 50mg/Kg/day in 2-3 divided doses for 5 days
    • Studies show a 5 day course is as effective as a 10 day course
  • Indications for immediate antibiotics
    • AOM in the only hearing ear
    • Cochlear implant – discuss with ENT – may require IV abx
    • In Australia – Aboriginal children
  • Consider immediate antibiotics for
    • AOM in both ears in children <2
    • Any case with perforated TM
  • Consider antibiotics at 48 hours if symptoms not resolving
    • Some UK guidelines suggest to do this is on day 5, rather than at 48 hours
    • Consider giving a delayed script at initial consultation
    • In practice – I discuss the facts with the parents – I explain 80% will get better without antibiotics in 4 days or less, and to persist with analgesia. If parents particularly keen for antibiotics I explain that they help children get better about 12-24 hours sooner, but carry risks as above. Most parents choose not to give the antibiotics after this advice
  • In perforation with discharge, consider also using topical antibiotics for 2-3 days
• If TM perforation – Follow-up in 2 weeks to re-assess the tympanic membrane to ensure it is healing
• If no perforation, but multiple episodes of AOM – consider review at 8 weeks to assess for effusion – note that the normal time frame for resolution of effusion is 8-12 weeks
• Consider non-urgent ENT review if:
  • >= 6 episodes in 12 months
  • Persisting OME for >3 months (bilateral) or >6 months unilateral

Otitis media with Effusion (OME)

Epidemiology

• Common between ages of 1 and 6
  • Prevalence at age 2 is about 20%
  • By age 7 this has fallen to about 8%
• The most common cause of acquired hearing loss
• By the age of 10, 80% of children will have had at least one episode

Aetiology

• Usually in winter
• Typically follows an episode of AOM
• Chronic colonisation of adenoids / adenoidal hypertrophy
• Cleft palate
• Male gender
• Daycare attendance in children
• Frequent URTI
• Smoker or parents who smoke
• Gastro-Oesophageal reflux
• Eustachian tube dysfunction
• Allergic rhinitis
• Barotrauma (after diving or flying)
• Chronic sinusitis / other sinus disease
  • Accounts for 66% of cases in adults
  • Rare in children

Presentation

Children

• Hearing loss
  • Reduced communication – e.g. mispronouncing words, delay speech, delayed progress at school
  • Likes to have TV volume loud
  • Asks for things to be repeated frequently
• Ear pain
• Balance problems (rare)
• Often bilateral

Adults

• Usually unilateral
• Hearing loss
• Sensation of fullness in the ear
• Popping sounds, cracking sounds, tinnitus
• Ear pain – often mild and chronic. Acute ear pain is rare
• Balance problems (rare, and not usually true vertigo)

Examination

• Opaque ear drum
• Loss of light reflex
• Indrawn or retracted TM – rarely can be bulging
• Bubbles in fluid behind TM / fluid level visible behind TM

Investigations

• Hearing test – shows a mild conductive hearing loss
• Significant if >25dB hearing loss
  • A 30dB hearing loss reduces conversational speech to the equivalent of a quiet whisper
• Pneumatic tympanogram may show immobile eardrum (not routinely performed

Prognosis

• Spontaneously resolves in most cases – up to 90% by 12 weeks
• 30% of children will have recurrent cases
• Up to 10% of episodes last >1 year
• In children with other pre-existing co-morbidities (e.g. deafness, visual problems, speech problems, social developmental delay) surgical treatment is indicated sooner
• Worse prognosis in recurrent cases

Management

• Reassure parents with verbal and written advice:
  • 90% of children have complete resolution within one year
  • No medication has been proven to be effective
  • Parental smoking increases the risk
• Tips for children with hearing loss
  • Look at child when speaking to them
  • Speak more slowly
  • Speak clearly
  • Speak more loudly
  • Turn off other sound sources (e.g. TV)
  • Encourage daily reading to assist with language development
• Medical treatments – have no proven benefit and are NOT recommended. This includes antibiotics, antihistamines, decongestants.
• Most cases resolve spontaneously
• Observe for 2-3 months (“active observation”)
• >50% will recover within 3 months
• Consider repeat hearing test in 3 months to confirm resolution of symptoms
• If remains symptomatic (e.g. with language development, or other symptoms) at 3 months, OR has reduced hearing at three months – refer for ENT assessment – for consideration for grommets
  • Many cases referred will have resolved by the time they see an ENT specialist!
  • High risk cases (such as Down Syndrome, cleft palate or other causes of developmental delay) should be referred sooner (do not wait 3 months)
  • Consider referral for any case bilateral OME at 3 months and for any case that is unilateral at 6 months and still persisting
• Surgical management 
  • Indications:
    • Persistent bilateral OME lasting >3 months, OR
    • Hearing loss >25dB in the best ear, OR
    • Language, education or social developmental delay
  • Both commonly used options – grommets and adenoidectomy reduce the duration of OME and improve hearing in the short-term – but by 6-9months most studies have shown no difference between surgical and non-surgically managed patients (i.e. the OME resolved anyway by this time in the non-surgical patients)
  • Grommets
    • First line surgical treatment
    • These are small plastic ventilation tubes, placed into the tympanic membrane which allow fluid to drain into the external ear canal
    • Proven to improve hearing loss
    • NOT proven to improve speech and language development over the “watch and wait” approach – no studies have ever assessed this effect
    • Risk of tympanosclerosis – although the clinical significance of this is uncertain
    • Usually done under GA, but can be done with local anaesthetic
    • By 6-9 months most studies show little benefit in comparison to those who didn’t undergo surgery
  • Adenoidectomy
    • Recommended if frequent URTIs are implicated
  • Laser Myringotomy
    • A incision made by laser into the tympanic membrane
    • Doesn’t require anaesthetic
    • Allows fluid to drain from the middle ear
    • Quick, safe and painless
    • However, the hole heals up within 3-4 weeks – which is not long enough to allow for clearance of OME. As such, it is rarely used
  • Adults
    • Need to have a more sister cause excluded first. If no cause is identified, often treated similarly to children

Complications

• There is only weak evidence for the link between OME and speech and language developmental delay – and even then the effect is only temporary
• Increased risk of psychological disorder – such as depression, anxiety and, in children, behaviour disorders

Prevention

• Influenza vaccination associated with reduced risk (between 2-9x reduced risk)
• Pneumococcal vaccination provides no benefit

Chronic Suppurative Otitis Media (CSOM)

A chronic inflammatory disorder of the middle ear, associated with frequent tympanic membrane perforation and associated otorrhoea (discharge from the ear).

It is very common in the developing world, and in Australia is seen frequently in Aboriginal and Torres Straight Islander populations (ATSI). CSOM is thought to cause 80% of hearing impairment world-wide.

The definition is not universally agreed upon – some guidelines suggest a minimum of 2 weeks of discharge, other suggest 6 weeks.

CSOM is caused by recurrent infection of the middle ear, resulting in ulceration and oedema of the mucosa with subsequent breakdown of the epithelial lining.

It can result in permanent hearing loss, is associated with poor school performance, and can cause cholasteoatoma – a destructive lesion affecting the base of the skull

Clinically, it is important to define the location of the perforation of the TM.

• “Safe” CSOM – occurs with perforation in the centre of the TM
• “Unsafe” CSOM – occurs with proration near the periphery of the TM. This predisposes to cholesteatoma

Epidemiology

• Affects about 1% of children and 0.5% of adults in the UK
• In some ATSI populations in Australia, affects up to 15% of children (down from 25% in 2001)
  • In one study, only 7% of ATSI children in the Northern Territory had normal ears. The rest had various forms of OM
• In the developing world, up to 60% of patients will develop permanent hearing loss as a result of CSOM
• CSOM is associated with poor educational performance

Aetiology

• Multiple episodes of AOM
• Living in crowded environment
• Daycare attendance
• Congenital cranial deformities
  • Cleft lip or palate
  • Down Sydnrome
  • Microcephaly
  • Many others

Presentation

• Chronic (>2 weeks) of ear discharge, usually on background of AOM
• Hearing loss in affected ear
  • May be associated speech development
• Usually NO fever and NO ear pain
• Red flags for urgent referral to exclude intracranial complications
  • Fever
  • Vertigo – suggest labyrinthitis which can lead to meningitis and encephalitis
  • Ear pain
  • Facial paralysis – suggests cholesteatoma

Examination

• External canal often oedematous
• Discharge in external canal
• Granulation tissue may be seen
• TM perforation
  • Beware the differentiation between “safe” (middle of TM perforation) and “unsafe” (periphery of CSOM perforation) CSOM. The latter may required more prompt imaging and referral due to risk of cholesteatoma
• It is usually fairly obvious that there is something very wrong with the TM and external canal!

Differentials

• Otitis externa
• Foreign body
• Impacted ear wax
• Cholesteatoma
• Wegeners granulomatosis
• Neoplasm

Investigations

• Swab for MC+S – usually not useful and not indicated
• Audiogram
  • Often shows conductive hearing loss
  • Mixed loss suggests more extensive disease
• CT scan is indicated in failed treatment or “unsafe” CSOM. Can show:
  • Cholesteatoma
  • Foreign body
  • Malignancy
• MRI more useful for suspected intracranial complications such as labyrinthitis or abscess

Complications

• Cholesteatoma
  • This is abnormal growth of skin within the ear canal, usually secondary to dysfunctional healing of the tympanic membrane (occasionally congenital). It is noncancerous, but is often locally invasive, and can invade the mastoid and the base of the skill. Nearly always requires surgical intervention
• Mastoiditis
• Chronic hearing loss
• Abscess formation
• Facial paralysis
• Labyrinthitis – potentially leading to meningitis or encephalitis
• Lateral sinus thrombophlebitis
• Tympanosclerosis

Management

• If any red flags (see presentation above) – urgent referral for admission under ENT
• Any other diagnosis of CSOM should be considered for non-urgent outpatient ENT assesment
  • Use of micro suction by an ENT specialist in clinic allows for better visualisation of TM
  • In the UK, NICE guidelines suggest all CSOM patients be referred to ENT
  • In Australia, advice differs. I have seen some places suggest that cases not responsive to topical antibiotics after 4 weeks should be referred
• Antibiotics – topical usually preferred
  • Topical quinolone thought to be most effective – e.g. ciprofloxacin
  • Aminoglycosides are frequently used – despite their risk of ototoxicity – because this is thought to be outweighed by the risk of CSOM (e.g. neomycin)
  • Common organisms are pseudomonas and staphylococcus aureus
  • Systemic antibiotica are reserved for cases that fail to respond to treatment – and often need to be given IV to obtain sufficient concentrations in the middle ear
• Topical steroids
  • Can reduce granuloma formation
  • Frequently used in combination with antibiotics (e.g. sofradex)
• Regular aural toilet (microscution) to remove debris from external ear canal
  • Antibiotics and aural toilet cure otorrhoea, but their effect on long-term healing of TM is not proven
• Removal of granulation tissue
• Keep the ear dry – avoid swimming (not good evidence but seems common sense)
• Surgery
  • Reserved for cases that have failed to respond to medical management
  • Myringoplasty  – repair of the TM – is the most commonly performed procedure
  • Mastoidectomy – various type of procedure – often required if cholesteatoma is present. The aim of the surgery is to remove all of the cholesteatoma to dry to ear canal and return function to the ear
  • Cochlear implants – can be used to retire hearing – but it is essential to ensure all disease is eradicated prior to the insertion

Prognosis

• Good in developed countries
• Can be fatal if left untreated – one study suggests it causes about 3-4,000 deaths annually worldwide
• Earlier onset is associated with worse developmental and educational prognosis

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Acute Otitis Media in Adults – patient.info
• Otitis Media with Effusion – Patient.info
• Otitis Media – Health Pathways
• Chronic suppurativee otitis media and cholesteatoma in Australia’s refugee population
• Managing Otitis Media – an evidence based approach – nps
• Acute otitis Media in Children
• Acute Otitis Media – RCH

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Acute otitis externa (AOE) is an infection of the external ear canal. It is a common presentation in general practice. It is occasionally known as “swimmer’s ear” due to the increased risk in swimming and other water sports, and sometimes “tropical ear” due to its association with humid climates.

It usually presents with ear pain and discharge. There are a wide range of causative organisms, and it is typically a multi-microbial  disorder – with many microbial species involved simultaneously.

Treatment typically involves topical antibiotics, and the majority of cases resolve within a few days.

More rarely, otitis externa is due to inflammation without infection. Typically these cases are chronic. Fungal causes can also cause a chronic illness which is very difficult to treat.

Epidemiology

• A very common problem presenting to GP practice – accounts for about 1% of all presentations to a GP surgery!
• 10% of the population will experience an episode in their lifetime
• 3% of cases will require specialist referral

Aetiology

• Water penetration of the ear
  • Frequent swimming or other water sports
• Humidity – more common in tropical locations
• Trauma to external ear canal
• Use of cotton wool buds for cleaning the ear
  • This reduces the amount of wax in the canal, which reduces the body’s natural defences
  • It may also cause micro trauma, predisposing to infection
• Use of hearing aids
• Ear canal foreign body
• Presence of external auditory exotosis
  • These are bony growths in the ear canal that appear, on otoscope, like small , rounded “mounds” arising from the wall of the external ear canal.
  • Common in surfers and other individuals who spend a long time in cold water
  • In severe cases, can completely obscure the TM
  • Wax and other debris becomes lodged behind them and leads to frequent and recurrent acute otitis externa
  • If severe, with recurrent infections, they should be surgically removed
  • Less severe cases can be left in situ
  • It is thought that the contact of cold water with the external auditory canal stimulates osteoblast activity – causing the lumps to grown – possibly as a mechanism to protect the TM from the cold

Pathology

Size and shape of the ear canal varies widely between individuals. Some patients are naturally predisposed due to the shape of their canal. The outer 1/3 is made of cartilage, whilst the inner 2/3rds is bony.

The ear canal is naturally self cleaning. The skin of the canal slowly migrates from the TM, along to canal and towards the external auditory meatus. This helps to keep the canal free of debris. Ear wax also helps, by forming an slightly acidic coating, which is toxic to pathogens. It also prevents water from reaching the skin surface. The outer part of the canal is protected by hairs which keep debris out.

Usually multiple organisms are involved. It is thought that water exposure alter the usual microbial balance found in the external ear canal. 90% of cases are bacterial and 10% are fungal.

Common causative organisms include:

• Pseudomonas
• Escherichia coli
• Staphylococci
• Enterobacter
• Candida

Chronic otitis media is more likely if there is underlying diabetes or immunosuppression and is typically due to a fungal organism (e.g. candida). Symptoms are typically the same as acute otitis media, and itch and discharge are common. On examination, black dots (fungal spores) may be visible in the external ear canal.

Presentation

• Ear pain
• Itching sensation in external ear canal
• Purulent discharge from external auditory meatus
• Pre-auricular (in front of the ear) lymphadenopathy
• Signs of more severe infection include:
  • Hearing loss
  • Discharge
  • Additional regional lymphadenopathy
  • Cellulitis around the ear
  • Fever
• Necrotising (malignant) otitis externa
  • A potentially life-threatening complication
  • Occurs when the infection has spread to the mastoid and temporal bones
  • Severe pain – out of proportion to other clinical signs
  • Typically occurs in older patients who are otherwise immunocompromised
  • Facial nerve palsy may also be a sign

Investigations

Consider investigations in recurrent infection, or cases not responding to first line therapy. Identifying the organism rarely changes management. False positives for fungi are common in partially treated cases.

• Swab of discharge for MC+S

Differentials Diagnosis

• Acute Otitis Media
• Foreign body
• Impacted wax
• Cholasteatoma

Management

• Aural Toilet
  • A method of cleaning the external canal. Usually performed by the medical practitioner at the time of diagnosis – for example, micro-suction, dry swabbing or gentle ear syringing
    • Be aware that ear syringing carries a risk of perforation of the tympanic membrane (TM), and is also contraindicated if TM perforation is already present. In some guidelines it is no longer recommended
  • Aural toilet lowers pH of the external canal – which helps increase the effectiveness of amino glycoside drops
• Ear wicking
  • A device inserted into the ear, impregnated with antibiotics and steroids
  • Usually requires ENT referral for placement
  • Should be changed every 2-3 days
• Acetic acid
  • As effective as antibiotics in mild cases
  • Less effective in severe cases
  • Generally, antibiotics are preferred
• Topical antibiotics are the mainstay of treatment e.g.:
  • “Sofradex” ear drops – a combination preparation with framycetin (an aminoglycoside containing neomycin – good Gram-positive and Gram-negative cover), gramicidin (an antibiotic compound containing multiple antimicrobial agents – mainly gram negative cover) and dexamthasone (a corticosteroid). Care should be taken if there is a risk of TM rupture, because aminoglycosides can disrupt healing of the TM and thus are contraindicated
  • Ciprofloxacin ear drops – first line is TM rupture suspected or proven
  • Prolonged use of antibiotics can cause a local contact sensitivity – which can mimic ongoing symptoms of otitis externa (itchy, painful, red looking canal on otoscopy)
  • Drops should be used for at least a week
  • Most cases resolve within 6 days
• Analgesia
  • Paracetamol or NSAIDs
  • NSAID’s may be slightly more effective
• Oral antibiotics
  • Can be used in cases with complications (such as TM rupture)
  • Indications include:
    • Systemic features
    • Pre-aurcilar lymphadenoapthy
    • Spreading infection – e.g. cellulitis of the ear
  • Usual antibiotic of choice is flucloxacillin (or erythromycin in penicillin allergy) – the most common causative organism in these case is staph. aureus. 
  • Several studies have shown that oral antibiotics are generally over-prescribed
• Indications for referral
  • Systemic symptoms – need urgent referral for possible IV antibiotics
  • Chronic cases
    • Consider use of topical clotrimazole drops if fungal infection is suspected
• Necrotising otitis externa
  • 90% of cases due to pseudomonas
  • Usually responds to oral quinolone – but may require up to 8 weeks of treatment
• Avoid swimming until symptoms have settled
• Avoid plugging the ear with cotton wool – some patients like to try this to prevent unsightly (and smelly) discharge, but can worsen the infection

Complications

• Temporary hearing loss
• Chronic otitis externa
• Cellulitis
• Necrotising otitis externa
  • May cause secondary sepsis

Prevention

• Avoid water getting into the external canal. Measure may include:
  • Use of ear plugs and / or cotton wool coated with vaseline when swimming
  • Keeping head above water wherever possible
  • Avoid swimming in dirty or polluted water sources
• Dry ears well after swimming and bathing
  • Recommended method is a tissue spear. This involves taking a tissue and twisting it into a tip with your fingers.
• Avoid putting anything into the ear canal – finger, cotton buds or other “cleaning” agents. The ear is remarkable good at cleaning itself!

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Acute Otitis Externa – afp
• Otitis externa (Swimmer’s Ear) – Better Health Channel – Victorian Government
• Otitis Externa – patient.info

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Salivary gland tumours are growths found in the salivary glands. The salivary glands include:

• Major (paired)
  • Parotid glands
  • Submandibular glands
  • Sublingual glands
• Minor
  • 600-1000 found beneath the mucosa of oral cavity and oropharynx.

These tumours can be benign or malignant, with parotid tumours less likely to be malignant than those in the submandibular, sublingual or minor salivary glands.

Epidemiology

Salivary gland tumours have an incidence of 1 in 100,000. They are slightly more common in women than in men and more common in adults. Tumours found in children are more likely to be malignant.

Malignant tumours of the salivary glands are rare. In the UK, malignant salivary gland tumours are responsible for 1 in every 100 cancers that are diagnosed.

Origin of salivary gland cancers:

• 80% in the parotid glands
• 10% in submandibular glands
• 10% in the sublingual and minor glands

Aetiology

Mainly idiopathic

Risk factors:

• Previous exposure to radiation
• Age (50s and 60s)
• Previous squamous cell carcinoma
• Human Papilloma Virus
• Smoking

Pathophysiology

Benign tumours:

• Pleomorphic adenomas
• Warthin’s Tumour

Tumours of variable malignancy :

• Mucoepidermoid tumours
• Acinic cell carcinoma

Malignant tumours :

• Adenoid cystic carcinoma
• Adenocarcinoma
• Carcinoma ex-PSA
• Low grade polymorphous cancers
• Lymphoma
• Squamous cell carcinoma (rare)
• Lymphoepithelioma (rare)
• Anaplastic carcinoma (rare)
• Metastatic tumours from elsewhere

Pleomorphic adenoma

These are the most common tumours of the salivary gland. They usually arise in the parotid gland and are derived from intercalated duct reserve cells. They are benign but have the potential to become malignant if left for many years (see Carcinoma ex-PSA). All the tumour cells most be removed during surgery to avoid recurrences.

Warthin’s Tumour

Warthin’s Tumour is also known as adenolymphoma, it is not, however, a type of lymphoma. It usually arises in the parotid gland, commonly the tail. It is more common in men (8:1) and occurs in older people. It may feel soft and cystic.

Mucoepidermoid tumour

These tumours can either be low-grade (well-differentiated) or high-grade (poorly differentiated). The better differentiated they are, the more slowly they grow and the more likely they are to be painless. Both tumour types will need resecting, but high-grade tumours will also require radiotherapy. They are derived from the epithelial cells of interlobar and intralobular ducts and are usually found in the parotid gland. They are more common in women than in men and are the most common type of salivary gland tumour in children.

Acinic cell carcinoma

This is a slow-growing tumour which develops in the acinar cells and is usually found in the parotid gland. It is more common in females.

Adenoid cystic carcinoma

This is the most common malignant tumour of the salivary glands. It grows slowly and spreads locally, but the long-term prognosis is poor. Recurrence is common and distant metastases can occur. It can infiltrate the nerves, causing pain and nerve palsies. It is derived from reserve epithelial cells of the intercalated ducts and can occur in any of the major or minor glands.

Adenocarcinoma

These develop in the epithelial cells of any of the major or minor salivary glands. They are rare but highly malignant and have a poor prognosis.

Carcinoma ex-PSA

These can develop from a benign pleomorphic adenoma, usually years later.

Low grade polymorphous cancers

These are rare and usually occur in the over-70s. They are seen in the minor salivary glands and grow slowly.

Lymphoma

These are non-epithelial tumours and are usually Non-Hodgkin’s Lymphoma.

Signs and symptoms

• A swelling in the face/neck which may be slow-growing (benign or low-grade) or rapidly-growing (malignant)
• If painless: more likely to be benign
• Facial palsy or nerve palsy: more likely to be malignant
• Lymph nose metastases may be felt on examination

Investigations

• Fine-needle aspiration
• Ultrasound/CT/MRI scan
• Chest X-ray (for another primary and/or metastases)
• Excisional biopsy (NB avoid incisional biopsy as seeding can occur, leading to recurrence)

Treatment

• Excision of benign tumours
• Malignant tumours require wide local excision and may need radiotherapy and excision of affected lymph nodes

Complications

Complications include neural involvement, causing pain and nerve palsies.

Complications of surgery:

• Facial nerve palsy
• Haematoma
• Salivary fistula (usually resolves with time)
• Frey’s Syndrome (the skin over the area of the parotid bed sweats when eating)

References

Corbridge RJ. Essential ENT. 2^nd ed. London: Hodder Arnold; 2011

Ellis H, Calne R, Watson C. Lecture Notes: General Surgery. 12^th ed. Chichester: Wiley-Blackwell; 2011

Munir N, Clarke R. Ear, Nose and Throat at a Glance. Chichester: Wiley-Blackwell; 2013

Nottingham School of Medicine Specials Handbook

www.macmillan.org.uk

www.cancerresearchuk.org

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1. Sensorineural
2. Conductive
3.  Mixed

Sensorineural hearing loss

• pathology in cochlear or CN VIII
• commonly due to irreversible loss of hair cells on organ of Corti
• Permanent hearing loss
• Audiometry; loss in the high frequencies

Conductive hearing loss

• pathology in outer or middle ear
• Commonly responds to surgery

Comparison

History Taking

References

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Tonsillitis is an acute inflammation of the tonsils, usually secondary to an infect. It is a common cause of sore throat, and a common reason for presentation to General Practice, and the Emergency Department.

Most cases are mild and self limiting, and will last less than 7 days.

More severe cases can result in inability to swallow and subsequent dehydration, and can require IV antibiotics, steroids and fluids.

Epidemiology and Aetiology

• 70% viral
• 30% bacterial
• 90% will recover within a week without treatment
• Common in children age 5-10 and young adults age 15-25
• Bacterial tonsillitis is most commonly cause by Group A streptococcus (aka “Strep Throat”). This is carried in normal healthy throats in the general population. Rates of carriage decline with age, from about 10% of under 14’s to <1% of over 45s.

Presentation and diagnosis

Sore throat!
Use the Centor Criteria to help decide if antibiotics are necessary. There is a 50% chance of the tonsillitis having a bacterial cause if:

• Pus on tonsils (tonsilar exudate)
• Pyrexia (temperature >38 degrees celsius)
• No cough
• Tender cervical lymph nodes

Antibiotics are recommended only for those scoring 4, or sometimes 3.

Investigations

Investigations aren’t usually necessary. You can to throat swabs for Group A beta-haemolytic streptococcus but this is an unpleasant procedure, results take several days, and often an individual can be a carrier without this being the cause of their tonsillitis. It is also unlikely to alter management, especially if you are using the censor criteria, as above.
Some advocate the use of rapid antigen testing from a throat swab, as this only takes a few minutes, but the evidence shows that it does not alter prescribing patterns, and so is probably not useful.

Treatment

• Mostly supportive – paracetamol and ibuprofen
• Avoid giving antibiotics unless four features above are present or if systemically unwell
• Avoid amoxicillin – as this causes a rash if the patient has glandular fever.
• Penicillin V (aka phenoxymethypenicillin) is typically used if they meet the criteria. A typical adult dose is 500mg QID
  • Erythromycin is a suitable alternative if the patient is penicillin allergic.
• Systemically unwell
  • IV Benzylpenicillin 1g stat
  • Steroids – e.g. IV dexamethasone 10mg – aiming to reduce tonsillar swelling
  • IV fluids
  • Check for peritonsillar abscess (see below)

Complications of Tonsillitis

• Ear pain – not always due to otitis media – can just be referred pain
• Otitis media – particularly in children
• Inability to swallow and resultant dehydration
• Quinsy – this is a peritonsillar abscess. Patients may have:
  • Assymetrical throat swelling
  • Severe throat pain / pain out of proportion with other clinical signs
  • Systemically unwell

Differentials

• Common cold – the common cold will cause similar features and in general practice a lot of patient may request or expect antibiotics. Use the Centor Criteria to decide and to justify your decision.
• ​Glandular fever – Epstein Barr Virus – aka infectious mononucleosis – typically presents in adolescents or young adults, but children can get it too. Rare in adults. Often accompanied by general malaise and tiredness. Can take several week to resolve, particularly the lethargy and treatment is only supportive.
  • Rarely, glandular fever can cause a ruptured spleen, or jaundice. Jaundice is usually mild and self-limiting, but the ruptured spleen can be life threatening. The spleen may become enlarged but is highly unlikely to rupture. You may want to ask patients to avoid contact sports or anything that puts them at risk of traumatic splenic injury.
  • In all instances of possible tonsillitis – AVOID AMOXICILLIN! If given glandular fever, amoxicillin can cause a nasty urticarial rash
• Epiglottitis – be wary – will require immediate acute admission. Listen for stridor and look out for any increased work of breathing

Tonsillectomy

In case of recurrent tonsillitis, tonsillectomy can be considered.

Tonsillectomy is less common than in past decades, but still routinely performed by ENT surgeons. The tonsils are important lymph nodes that help to fight infection of the upper respiratory tract, and are not ‘useless’ but in most people, can be safely removed.
Surgery is only used in recurrent cases of infection. The goal of surgery is to reduce the frequency of these infections.
There are strict NICE guidelines which stipulate tonsils can only be considered for removal if all four of the following conditions are met:

• >5 episode tonsillitis in one calendar year
• Symptoms ongoing for >1 year
• Episodes are disabling and prevent normal function
• Tonsillitis is known to be the cause of the sore throats!

Surgery is usually straightforward, but there is a risk of large haemorrhage, which can often occur several hours or days later (be aware when on call covering ENT wards as a foundation doctor!)

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Vertigo is the hallucination of rotation due to the abnormal stimulation of the hair cells of the vestibular system.

Vestibular System

Common Causes of Vertigo

Benign Paroxysmal Positional Vertigo

Pathology

Features

Dix Hall​pike Test

Epley Manoeuvre

Ménière’s Disease

Pathology

Features

Management

Vestibular Neuronitis

Features

Management

Acoustic Neuroma

Features

Management

References

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Examination of the neck is an important skills for assessing lumps and masses in the neck. Lumps in the neck are most commonly caused by the thyroid gland or the lymph nodes in the neck.

• Wash hands, check right patient, introduce yourself, get permission
• Ask the patient to sit up straight in a chair, and expose their neck down to the shoulders. You could ask them to look up a little bit. Remove any jewellery.

Inspection

• Hypothyroidism
  • Lethargic, disinterested
  • Bradycardia (radial pulse)
  • Alopecia
  • Ascites
• Hyperthyroidism
  • Sweaty – hyperthyroidism
  • Palmar erythema
  • General warmth
  • Thyroid acropachy – can cause swelling (perhaps clubbing) in the extremeties as a result of periosteal new bone formation as a result of Grave’s disease.
  • Onycholysis – painless separation of the nail from the nail bed – present in autoimmune thyroid disease (so can be hyperthyroid and hypothyroid?)
  • Tremor – place a piece of paper on the back of the hands and watch for tremor.
  • Tachycardia, and possibly irregular pulse. Patients with hyperthyroidism can have an irregular pulse as a result of atrial fibrillation. Hypothyroid patients have a very slow pulse.
  • Pre-tibial myxedema – can be found anywhere on the body, but often on the shins – a plaque-like thickening of the skin caused by Grave’s disease.
  • Night sweats

Inspect and palpate the face

Look for signs of hyperthyroidism (remember these only occur in Grave’s disease)

• Lid lag – this is where the eye-lid will not move as quickly as the eye downwards when the patient looks downwards.
• Proptosis
• General discomfort of eyes, oedema, grittiness
• Gynaecomastia
• Osteoporosis

Look for sig​ns of hypothyroidism

• Dry hair
• Dry skin (waxy skin)
• Puffy eyes
• ‘peaches and cream complexion’
• Deep voice
• Cold intolerance
• Loss of the outer parts of the eyebrows.
• Etc etc

Neck

Inspection

• The thyroid will ALWAYS elevate (if it is normal or abnormal).
• Anything attached to the cricoid cartilage will also move on swallowing
• Lymph nodes will probably not move on swallowing.
• Anything not attached to the thyroid or cricoid – lipoma, carotid body tumour, epidermal cyst.

Palpation

Identify the cricoid cartilage. Then palpate for masses first in the anterior triangle, then in the posterior triangle. Remember to check all the way down to the clavicles, and as far posteriorly as the trapezius. If you find a lump you should note its:

• Size
• Consistency – soft masses will tend to be fluid filled, and will often be lymph nodes. Hard nodular masses may be malignancy. Hard smooth masses may be enlarged organs or tissues
• Location
• Mobility – fixed masses are more likely to be malignant, and benign masses more likely to be mobile.
• Tenderness – a tender mass is more likely to be an acute infection or inflammatory problem.
•  Translumination may be of help to determine fluid filled lesions – which will transluminate.
• Pulsation – nothing should do this except the carotid – if a swelling does do this then it could be a carotid body tumour (chemodectoma).

Feeling specifically for the thyroid – it is not always that easy to feel. Start at the laryngeal prominence and move down to find the cricoid cartilage. The isthmus of the thyroid covers the 2^nd, 3^rd and 4^th tracheal cartilages, so try and feel this. Then try and feel the lobes of the thyroid. You can always ask the patient t swallow some water as you do this so you can feel for movement of the thyroid.  The lobes should be roughly no bigger than the patient’s thumb. The normal thyroid is often not palpable – the lobes could be tucked under SCM. Things of particular note are any lumps, and any irregularity between the two lobes.

Feeling for the lymph nodes – use a logical sequence! You should include:

1. Posterior auricular
2. Pre-auricular
3. Occipital
4. Cervical chain
5. Posterior cervical chain
6. Supraclavicular
7. Submandibular
8. Submental
9. Pharyngeal
10. Pre-tracheal

Auscultate the swelling

Percussion

Further Assessment

• TFT’s
• USS – find out if lump is solid or cystic
• Radioactive iodine to detect if nodule is hot or cold (if it is cold more likely to be malignant).
• Check reflexes – hyperthyroidism – hyperreflexia, hypothyroidism – hyporeflexia. In hypothyroidism, the ankle reflex is particularly delayed.
• Proximal myopathy in hyperthyroidism – ask the patient to put out their arms and then you try to push them down – if it easy to push the arms down, it suggests proximal myopathy.

References

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Mechanism

• C-spine                                                             -> cervical nerves 2 & 3
• Nose and sinuses                                             -> CN V
• Teeth                                                                 -> CN V
• Temporomandibular joint                                  -> CN V
• Oropharynx                                                       -> CN IX
• Larynx                                                               -> CN X
• Oesophagus                                                      -> CN X

Acute otitis externa

• Common associations with eczema
• Common after use of cotton buds
• Common in anything that increases humidity in the ear à ear phone use, swimming etc.
• 4 main causative agents; streptococcus, staphylococcus, pseudomonas and fungus (secondary fungal infection is common after initial overuse of antibiotics)
• Sx; itching and pain
• O/E;                                                                    
  • Red and tender ear canal                                                           
  •   Watery discharge                                                          
  •   Accumulation of debris + oedema à hearing loss
• Rx;                                                             
  • Topical antibiotic OR                                                           
  • Topical steroid drop OR                                                         
  • Antibiotic dressing (if canal severely swollen)                                                          
  • 1% hydrocortisone (for itching)

Acute otitis media

• Causes severe otalgia
• Upper respiratory tract infection
  • ascends via and blocks Eustachian tube
  • negative pressure in middle ear
  • exudates
  • otitis media with effusion (OME)
• N.B Mastoiditis is a severe possible complication
• Sx;                                                              
  • Pain (due to pressure in middle ear)
  • Hearing loss
  •   Disharge (if tympanic membrane ruptures) à reduced pain
  •   Imbalance (especially in adults)
• O/E;
  • Injected, congested and bulging ear drum
  • Hearing loss
  • Large tonsils ( + adenoids NB cannot see on normal examination of buccal cavity and pharynx)
  • Tympanometry shows no ear movement and produces a flat trace. (Tympanometry measures how the tympanic membrane moves in relation to an applied pressure and thus pressures in the middle ear can be calculated)
• Rx;
  • NSAIDs and analgesics
  • Systemic broad spectrum antibiotics
  • Decongenstants
  • Myringotomy and grommet insertion (if recurrent)
  • Adenoidectomy (if recurrent)

Ramsay Hunt Syndrome

• Infection of the facial nerve ganglion by herpes zoster (shingles)
• NB can cause permanent damage to facial nerve if not treated promptly
• Sx;
  • Otalgia
  • Facial palsy
  • Hearing loss
  • Imbalanced.      O/E;
  • Vesicles in ear canal and around pinnae.      Rx;
  • Systemic acyclovir

References

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• External meatus blocked by wax
• Presbyacusis

Sensorineural hearing loss

Presbyacusis

• Loss of hair cells on cochlear as increase in age
• Audiogram; High frequencies lost first, low frequencies stay in normal range, no increased air-bone gap
• Usually noticed clinically after 60
• Variability in degree of hearing loss and age of onset
• No treatment to prevent worsening
• Can cause significant social and work handicaps
• Aural hearing aids used to improve hearing

Idiopathic hearing loss

• Sudden deterioration of hearing. Ear may feel blocked
• Tinnitus and vertigo can be present
• Thought to be due to viral infection of vascular event
• Rx; bed rest and vasodilators

Noise exposure

Inflammatory diseases

• Measles, mumps, meningitis and syphilis can damage the cochlear

Ototoxic drugs

• Systemic aminoglycosides
• Cytotoxic agents
• Salicylates and quinine cause reversible damage
• Can cause hearing loss and imbalance as can affect cochlear and/or labyrinth.

Tumours

• Rare
• Tumours of CNVIII
• Causes progressive unilateral hearing loss and tinnitus
• Investigate with MRI
• Rx; surgical removal

Conductive hearing loss

Classified according to the anatomical location of the pathology
External auditory meatus

• Wax; removal by cotton buds usually impacts wax and worsens obstruction.
  • Rx; soften using sodium bicarbonate TDS or hydrogen peroxide then syringe or remove by blunt hook.
• Keratosis obturans; accumulation of desquamated skin which can erode the canal
• Exostoses; bony growths which occlude external meatus. Common in swimmers. No treatment needed unless causing problems.

Eardrum

• Perforation; traumatic or due to chronic otitis media.
  • Rx; either heal naturally or tympanoplasty carried out

Middle ear

• Discontinuity of ossicles
• Otosclerosis;
  • New bone growth in middle ear causes fusion of stapes footplate to oval window
  • Causes conductive hearing loss in young adults
  • Ear drum looks normal on examination
  • Often a family Hx
  • Pregnancy worsens symptoms
  • Rx; surgery or hearing aid

References

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