Head, neck and otorhinolaryngology

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CHAPTER 8 Head, neck and otorhinolaryngology

Scalp swellings 126
Facial swellings 127
Swellings in the neck 127
Oral disorders 134
Carcinoma of the upper aerodigestive tract 137
Disorders of the ear 141
Disorders of the nose 144
ENT emergencies 145

The majority of head and neck problems seen in a surgical clinic are usually lumps. Often it is difficult for the family doctor to decide whether the lump lies in the field of the general surgeon, ENT surgeon, dental surgeon or dermatologist. The conditions described in this chapter are those that one may expect to see in a general surgery clinic or in an ENT clinic. The speciality of otorhinolaryngology (ear, nose and throat – ENT) is diverse. A multidisciplinary approach is mandatory and involves allied professionals such as audiologists, speech and language therapists, dentists, specialist nurses and prosthetists. ENT surgeons possess a detailed knowledge of the anatomy of the head and neck and its related benign and malignant pathological conditions, and have developed a variety of surgical techniques to manage these. Head and neck cancers are discussed at diagnosis in the context of a multidisciplinary team.

Scalp swellings

These include sebaceous cysts, lipomas, papillomas, squamous cell and basal cell carcinomas and melanoma (→ Ch. 19). Other swellings of the scalp include those described below.

Cephalhaematoma

This is a subperiosteal haematoma. It occurs following birth trauma or direct injury in babies. The haematoma occurs beneath the periosteum and is limited by the suture lines. It usually resolves spontaneously.

Ivory osteoma

Osteoma of the outer table of skull is a smooth hard swelling, and skin moves over it freely. It is confirmed by radiograph. It is asymptomatic and should be left or excised if it enlarges.

Cock’s peculiar tumour

This is a suppurating sebaceous cyst with granulation tissue. It may be mistaken for a squamous cell carcinoma.

Facial swellings

These include boils, sebaceous cysts, dermoid cysts, squamous cell carcinoma, basal cell carcinoma, malignant melanoma (→ Ch. 19).

Swellings in the neck

A convenient classification of these is: superficial, lymph nodes and deep swellings (→ Table 8.1).

TABLE 8.1 Swellings in the neck

Superficial Sebaceous cyst
Lipoma
Dermoid cyst
Abscess
Lymph nodes
Deep  
Anterior triangle
Move on swallowing:

• thyroid
• thyroglossal cyst
• lymph node

Do not move on swallowing:

• salivary glands
• branchial cyst
• carotid body tumour
• carotid aneurysm
• sternomastoid ‘tumour’

Posterior triangle Cervical rib Subclavian artery aneurysm Pharyngeal pouch Cystic hygroma

The key to assessment and diagnosis of soft tissue neck swellings is careful history-taking, examination of the site, size and nature of the swelling (soft or firm, mobile or fixed, transilluminates, presence of a bruit). Fine needle biopsy is indicated for non-pulsatile masses. If the cytology is not definitive, then ultrasound core biopsy may be indicated if the imaging suggests it. The definitive investigation for soft tissue swellings is MRI.

In general, in patients over 45 years of age, assume a neck lump is metastatic malignant disease until proven otherwise.

Superficial

Superficial lumps include sebaceous cysts, lipomas, dermoids and infective lesions, e.g. boils and abscesses. A common site for lipomas is in the midline posteriorly at the level of the collar line (→ Ch. 19).

Lymph nodes

The majority of swellings in the neck, especially in children, are likely to be lymph nodes. The lymph nodes of the head and neck are basically arranged in two circles; an outer superficial one including submental, submandibular, preauricular, and occipital nodes; and an inner one surrounding the trachea and oesophagus and including the paratracheal and retropharyngeal nodes. Both the superficial and deep groups drain into a chain of deep cervical lymph nodes that surround the internal jugular vein. Lymph from there drains into the thoracic duct on the left and into the right lymphatic duct. The causes of cervical lymphadenopathy are shown in Table 8.2.

TABLE 8.2 Causes of cervical lymphadenopathy

Infection Local lesions on head and neck
Upper respiratory tract infection
Tonsillitis
Glandular fever
Toxoplasmosis
Tuberculosis
HIV
Cat-scratch disease
Malignancy
Primary:

• lymphoma
• lymphosarcoma
• leukaemia

Secondary:

• almost anywhere in the body, e.g. breast, lung, testis

Sarcoidosis  

Investigation of cervical lymphadenopathy

Clinical examination. Look for local lesions, e.g. scalp, face, neck, mouth, tonsil. A full general examination of chest, breast, abdomen, testes and lower limb is required. Check for axillary and inguinal lymphadenopathy. Check for hepatosplenomegaly.

• Hb, FBC, ESR, Paul–Bunnell, Toxoplasma screen, viral antibodies, HIV
• CXR for hilar nodes or primary lung tumour
• Laryngoscopy and examination of postnasal space
• FNAC
• Ultrasound guided core biopsy of node
• Excisional biopsy of node – if lymphoma suspected
• MRI or CT of the head and neck to examine nodes and look for possible primary
• Examination under anaesthetic by panendoscopy of nasopharynx, oropharynx, hypopharynx, larynx, trachea and upper bronchi, oesophagus and stomach and biopsy of suspicious areas and likely primary sites, i.e. nasopharynx, tongue base and the pyriform and tonsillar fossae.

Deep swellings of the anterior triangle

Swellings that move on swallowing

Thyroid

Swellings of the thyroid gland are dealt with in Chapter 11.

Thyroglossal cyst

This is an embryological remnant of the thyroid and may present as a fluctuant swelling in the midline of the neck. It may occur anywhere along the line of thyroid descent but is most common just above the body of hyoid bone and attached to it.

Symptoms and signs

Usually a painless, cystic swelling in the midline of the neck that moves on swallowing. It also moves on protrusion of the tongue. Occasionally may become infected, with pain, tenderness, and increased swelling.

Treatment

This is by excision.

Lymph node

Occasionally a lymph node may be attached to thyroid isthmus and this will move on swallowing.

Swellings that do not move on swallowing

Salivary glands: inflammatory

The parotid gland is included here, although only a part of the gland extends into the neck under normal conditions. In pathological conditions it may present with the swelling largely in the neck. The causes of swellings of the salivary glands are shown in Table 8.3.

TABLE 8.3 Swellings of the salivary glands

Inflammatory and infective Acute sialadenitis, e.g. mumps parotitis
Chronic sialadenitis, e.g. calculus, duct stenosis
Neoplastic
Benign:

• adenolymphoma
• pleomorphic adenoma

Malignant:

• adenocarcinoma

Autoimmune Mikulicz’s syndrome Sjögren’s syndrome

Acute sialadenitis

This is most common in the parotid gland and is due to epidemic viral parotitis of mumps. It is bilateral. Occasionally sialadenitis of both parotids and submandibular glands can be caused by poor oral hygiene, dehydration or duct obstruction by stone or stenosis. Acute bacterial sialadenitis is often unilateral.

Symptoms and signs

Sudden onset of pain and swelling over salivary glands. Made worse by eating. General malaise. Examination reveals redness, tenderness and swelling in the region of the gland.

Treatment

Viral parotitis – treat symptomatically with analgesics. Acute bacterial sialadenitis is treated by antibiotics, e.g. flucloxacillin. If an abscess forms, drainage is required. Recurrent parotitis should be investigated by sialography to exclude sialectasis and areas of duct stenosis.

Chronic sialadenitis

This is usually due to calculus in the duct or duct stenosis. Salivary calculi are composed of calcium or magnesium phosphate and are usually radio-opaque.

Symptoms and signs

Pain and swelling of the affected gland occur on eating and drinking. The swelling can be reproduced in clinic by putting lemon juice on the tongue. If the stone becomes impacted, the gland remains swollen. Infection and abscess formation may ensue. Inspect the duct orifice. In the case of submandibular calculi, the swelling may be seen in the duct in the floor of the mouth. Feel along the duct with a gloved finger in the floor of the mouth, palpating bimanually from the outside with the other hand. The calculus may be felt.

Investigations

• Plain radiograph
• ‘Floor of mouth’ view for submandibular calculi
• If no stone is seen, arrange sialogram.

Treatment

• Stone in the submandibular duct may be removed by incising directly over the stone into the duct in the floor of the mouth. The stone is extracted leaving the duct marsupialized.
• With duct stenosis, a ductoplasty (widening of the duct orifice) is carried out.
• For the stones in the gland itself, total (submandibular) or partial (parotid) removal of the gland is indicated.

Salivary glands: tumours

Salivary gland tumours are rare; 85% arise in the parotid gland, 8–15% in the submandibular gland, and 5–8% in the sublingual gland. Of these, the majority are benign and in the parotid, are usually pleomorphic adenomas. The minor salivary glands are submucosal around the oral cavity. In general, the smaller the gland, the more likely a neoplasm will be malignant.

Benign: Pleomorphic adenoma

Some 90% occur in the parotid. The old name of ‘mixed parotid’ tumour arose from the histological appearances of mixed element, i.e. epithelial, fibrous, myxomatous and ‘pseudocartilaginous’. The latter was, in fact, mucus. They are slow growing and may enlarge over many years. The tumour sends processes into the surrounding parotid tissue, thus explaining why shelling out (enucleation) of these lesions may leave tumour behind with a high recurrence rate. After many years (10–30 years of slow growth), some pleomorphic adenomas develop into invasive malignant tumours.

Symptoms and signs

Early and middle adult life. Painless swelling on side of face. Slow growing. Examination reveals a non-tender, diffuse swelling in the angle between the mandible and mastoid process. It may extend down into the neck and forward on to the cheek overlying masseter. Test the integrity of the facial nerve. Diagnosis is made on clinical history and examination.

Differential diagnosis

Parotitis, sebaceous cyst, lipoma, preauricular lymph node, tumour of ramus of mandible.

Treatment

Superficial parotidectomy, i.e. removal of the gland superficial to the facial nerve. Enucleation is associated with a high incidence of recurrence.

Complications

Facial nerve palsy either temporary or permanent. Salivary fistula – usually dries up spontaneously. Frey’s syndrome, i.e. facial flushing and sweating on eating, occurs in areas supplied by the auriculotemporal nerve.

The patient should be warned of these complications, especially the facial nerve palsy, prior to informed consent being obtained.

Benign: Adenolymphoma (Warthin’s tumour)

This is a cystic tumour that contains epithelial and lymphoid elements. It is benign.

Symptoms and signs

Middle and old age. More common in males. Slow-growing, painless swelling over angle of jaw. It is soft and well defined.

Treatment

Surgical excision. If patient is elderly and diagnosis is certain, these can be left alone. Recurrence is rare.

Malignant

Usually affects parotid and may arise in a longstanding pleomorphic adenoma. Mucoepidermoid tumours are primary squamous cell tumors of the parotid gland and are of variable grade.

Adenoid cystic carcinoma is associated with early perineural spread and skip lesions which normally requires adjuvant radiotherapy following removal of the gland and nerve branch. Patients may have a long latency period before haematogenous lung, liver or bone metastasis become clinically evident.

Symptoms and signs

The gland becomes hard, irregular and painful. Facial nerve palsy may develop.

Treatment

Radical parotidectomy with sacrifice of the facial nerve. Neck dissection may be required. Radiotherapy is of limited value. The prognosis is poor.

Secondary squamous cell carcinoma or melanomas of the head and upper aerodigestive tract may present with a lump in the parotid gland. These are treated with total parotidectomy and ipsilateral neck dissection.

Lymphomas may arise in the parotid gland. Surgery is confined to incisional biopsy prior to definitive oncological therapy.

Salivary glands: autoimmune

This is a slow painless enlargement of salivary glands. The glandular tissue is invaded by lymphocytes.

Mikulicz’s syndrome

This causes symmetrical enlargement of the salivary glands, both parotid and submandibular. There is involvement of lacrimal glands and a dry mouth (xerostomia).

Sjögren’s syndrome

This has the same symptoms as Mikulicz’s disease but in addition has keratoconjunctivitis sicca (dry eyes) and seronegative arthritis.

Treatment

No treatment may be required but steroids may help. Dry eyes may be treated with hypromellose drops (artificial tears).

Branchial cyst

This is a remnant of the second branchial cleft. It may be associated with a sinus or fistula.

Symptoms and signs

It appears in early adult life, usually with soft swelling but consistency varies with tension in the cyst and some may be firm. It occurs at the level of the junction of the upper third and lower two-thirds of sternomastoid, appearing from under the anterior border of that muscle. It may be associated with the branchial sinus that opens over the anterior border of sternomastoid at the junction of the middle and lower thirds of that muscle. The sinus may extend up between the internal and external carotid arteries and open as a fistula into the side-wall of the pharynx.

Differential diagnosis of a branchial cyst

This is a lymph node. Diagnosis can be confirmed by aspirating the cyst and examining the fluid under the microscope, when cholesterol crystals will be seen.

Treatment

Surgical excision of cyst, sinus or fistula tract.

Carotid body tumour

This is a chemodectoma; a slow-growing tumour arising from the carotid body at the carotid bifurcation. It is usually benign but rarely does become malignant. Pathologically, it is described as a ‘potato’ tumour because of the shape and consistency when it is cut.

Symptoms and signs

Age 40–60 years. Painless, slow-growing lump with transmitted pulsation. May be associated with fainting attacks from pressure on the carotid sinus.

Investigations

• CT scan
• Angiography: shows a tumour blush at carotid bifurcation with splaying of the bifurcation (this investigation has largely been superseded by CT scanning).

Treatment

Surgical excision. Large tumours may require carotid bypass grafting.

Carotid aneurysm

A true aneurysm is extremely rare. A false aneurysm may arise following penetrating trauma of the neck. A tortuous carotid artery appearing from under the anterior border of sternomastoid may give the impression of an aneurysm. Careful examination will reveal the tortuosity and lack of an expansile area.

Sternomastoid ‘tumour’

This is a swelling of the middle third of sternomastoid in neonates. It consists of oedematous and infarcted muscle.

Symptoms and signs

Neonates. Difficult birth, e.g. breech or forceps. Lump or torticollis. Pain on attempting to straighten neck. Head becomes turned to opposite side and tilted towards shoulder on side of lesion.

Treatment

Sternomastoid tenotomy.

Deep swellings of the posterior triangle

Cervical rib

This may cause neurological or vascular symptoms in the arm (→ Ch. 15). It is often asymptomatic. Occasionally the rib is palpable.

Symptoms and signs

Vascular symptoms, e.g. Raynaud’s phenomenon or venous thrombosis in the arm. Neurological symptoms, e.g. wasting of the small muscles of the hand (T1 myotome). Paraesthesia on the inner upper aspect of the arm in the dermatomal distribution of T1. May be a palpable lump in the supraclavicular fossa.

Diagnosis

• CXR to include thoracic inlet
• Count the ribs – if there are 13, there is a cervical rib.

Treatment

Excise the rib if causing symptoms.

Subclavian artery aneurysm

This is often just a poststenotic dilatation distal to a cervical rib. True aneurysms are rare. Treatment is by excision if symptomatic.

Pharyngeal pouch

This is a pulsion diverticulum of the pharynx occurring between the thyropharyngeus and cricopharyngeus muscles of the inferior constrictor, i.e. through Killian’s dehiscence. The swelling is thought to be due to formation of a high-pressure area at Killian’s dehiscence because of incoordination of the contraction of the two parts of the inferior constrictor of the pharynx.

Symptoms and signs

Middle or old age. Regurgitation of food on lying down. May develop aspiration pneumonia. Dysphagia due to pouch pressing on oesophagus. May gurgle on palpation. Halitosis.

Diagnosis

Barium swallow. Never endoscopy – the pouch may be perforated if the endoscope passes into it.

Treatment

Endoscopic diverticulotomy with external excision and cricopharyngeal myotomy if this is not possible.

Cystic hygroma

This is a collection of dilated lymphatic sacs that occur near the right lymphatic duct or thoracic duct in the lower part of the posterior triangle. They probably arise because of failure of the lymph channels to connect with main lymphatic drainage.

Symptoms and signs

Swelling in the lower part of the posterior triangle present at birth or occurring in the first few years of life. Soft, lobulated, fluctuant, compressible and brilliantly transilluminable.

Treatment

Surgical excision. Cyst walls are gossamer thin and rupture easily. Difficult to excise completely and therefore risk of recurrence.

Oral disorders

Stomatitis

Stomatitis is a general term used to describe inflammation of the lining of part, or the whole, of the mouth (→ Table 8.4).

TABLE 8.4 Causes of stomatitis

Local Ill-fitting dentures
Sharp teeth
Smoking
Local ulceration
Infections, e.g. herpes simplex, candida, Vincent’s angina
Trauma, e.g. chemical, thermal, irradiation
General
Haematological:

• leukaemia
• agranulocytosis
• anaemia
• vitamin deficiency B and C

Debilitating illness:

• cancer
• tuberculosis
• following major surgery

Symptoms of stomatitis

A sore dry mouth; mastication is painful. There may be painful cracking at the corners of the mouth.

Specific causes

Candida stomatitis

It is found in children and adults with debilitating disease, those on immunosuppressive drugs, and those with AIDS. It is also found in diabetics.

Symptoms and signs

Clinically small red patches appear which are then covered by a white membrane.

Investigations

• FBC
• Blood sugar
• Oral swab
• HIV test (if suspected and only after counselling).

Treatment

Nystatin mouth washes.

Vincent’s angina (acute ulcerative gingivitis)

It is caused by Borrelia vincentii (a spirochaete), and Fusobacterium fusiformis, which are Gram-negative anaerobes.

Symptoms and signs

Swollen, painful, inflamed gingiva. Ulcers develop which may spread to the tonsils and buccal mucosa. Other signs are bleeding, halitosis, cervical lymphadenopathy.

Investigations

Mouth swab.

Treatment

Penicillin, metronidazole.

Angular stomatitis (cheilosis)

Inflamed fissures at the corner of the mouth. The common cause is dribbling saliva at the corners of the mouth. It may occur in school-age children who lick the corners of the mouth. Treatment is aimed at adequate diet, improving oral hygiene, and local application of Vaseline.

General principles of management

History

Smoking, drugs, hot spicy foods, dentures, antibiotics.

Examination

Check dentures, check for sharp teeth, check general oral hygiene. Examine clinically for other signs of vitamin deficiency or haematological disease.

Investigations

• Hb
• FBC
• ESR
• Blood sugar
• CXR
• VDRL
• Mouth swab with film for fungus and culture and sensitivity for bacteria.

Treatment

Treatment is that of the underlying disease.

Ulcers

Traumatic

Caused by a sharp tooth or ill-fitting dentures. They heal rapidly when the causative agent is removed.

Aphthous

A small white deep painful ulcer, it may be solitary or multiple and heals spontaneously. Pain is relieved by local anaesthetic gel.

Herpes simplex

Multiple small painful ulcers of mouth or lips, they usually appear in debilitated patients. They may also appear as part of AIDS. Treat with topical acyclovir cream, oral or intravenous acyclovir.

Syphilitic

These are rarely seen. Chancre in primary, ‘snail track’ in secondary, and gumma in tertiary syphilis.

Tuberculous

These are rare, and usually found on the tongue. Painful ulcers with undermined edges, they are associated with advanced pulmonary tuberculosis.

Malignant

See below.

Leukoplakia

Leukoplakia may occur anywhere within the mouth but is common on the tongue. Areas affected by it appear thickened, white and may show cracks and fissures. Unlike Candida it cannot be rubbed off. It is a premalignant condition.

Cystic lesions of the lips and mouth

Mucous retention cyst

These occur on the inner surface of the lips and anywhere in the mouth where there are mucus-secreting glands. Obstruction to the duct causes the cyst.

Symptoms and signs

Painless cystic lesion. Pinkish grey. Transilluminates.

Treatment

Excision or it may burst spontaneously.

Ranula

A large mucus retention cyst of the floor of the mouth, it looks like a frog’s belly (ranula is Latin for frog). It occurs in children and young adults.

Symptoms and signs

A swelling in floor of mouth between symphysis menti and the tongue in the midline. Soft, fluctuant, transilluminates, bluish in colour.

Treatment

Complete excision or marsupialization.

Sublingual dermoid

Although congenital, these are rarely noticed before the age of 10. Usually midline, it results from inclusion of the ectoderm during fusion of mandibular processes.

Symptoms and signs

Swelling in floor of mouth. Usually painless. May present as ‘double chin’ if below mylohyoid. In the latter case it may be mistaken for a thyroglossal cyst.

Treatment

Excision or leave alone if diagnosis known.

Tonsillitis

The tonsils are mucosal-associated lymphoid tissue (MALT) lying in the space bounded by the anterior faucial pillars formed by the palatoglossus and the posterior faucial pillars formed by palatopharyngeus. Infection, most commonly viral (e.g. rhinovirus, adenovirus).

Symptoms and signs

The patient complains of a sore throat, difficulty in swallowing, earache and general malaise. Patients may be pyrexial. Bacterial tonsillitis (β-haemolytic streptococcus, staphylococcus, haemophilus influenzae) may present with pus on the tonsils (follicular tonsillitis) which is an indication for broad spectrum antibiotic therapy.

Investigations

• Throat swab
• Paul Bunnell test for infectious mononucleosis (glandular fever).

Treatment

Broad spectrum antibiotics if considered bacterial. Amoxicillin should not be given if infectious mononucleosis is suspected as it may be complicated by a rash.

Lymphoid neoplasias such as lymphoma and leukaemia should form part of the differential diagnosis of tonsillar enlargement.

Tonsillectomy

Tonsillectomy is not generally indicated in isolated episodes of tonsillitis. Recurrent bacterial tonsillitis, multiple quinsy or respiratory obstruction may necessitate removal. This is performed under general anaesthetic. An incision is made in the mucosa of the anterior faucial pillar and the tonsil dissected from its fossa. Bleeding may be prevalent from its inferior aspect where it merges with the base of the tongue. Postoperative bleeding may occur immediately or within 48 h of surgery, and warrant re-exploration, or may occur several days postoperatively, normally due to infection.

Carcinoma of the upper aerodigestive tract

The oral cavity

Squamous cell carcinoma may present as a lump or ulcer on the lips, in the mouth, or on the tongue. It spreads via the lymphatics to glands in the neck. It is usually a disease of the elderly and more common in males.

Predisposing factors

The six ‘Ss’: smoking, syphilis, sharp tooth, spirits, spices, sunlight. Alcohol and smoking have a synergistic effect on predisposition. These agents may predispose to chronic superficial glossitis, which results ultimately in leukoplakia, which then results in malignant change with frank carcinoma. Exposure to sunlight may predispose to carcinoma of the lip.

Carcinoma of the lip

Symptoms and signs

An ulcer that does not heal in those aged 60 years and above. More common in men than women. Preceded by leukoplakia, it may occur in pipe smokers. A non-tender ulcerative lesion, it may be associated with lymphadenopathy.

Investigations

Excision or incisional biopsy depending on size.

Treatment

Wide excision. Block dissection of neck if nodes involved. Radiotherapy.

Carcinoma of the tongue

Although it is more common in males, the incidence has been decreasing over the past 25 years. The incidence is stable in females but the overall incidence remains higher in the male. Most frequently it appears on the lateral margins of the anterior two-thirds of the tongue as a small warty growth, ulcer, or indurated fissured area. Initially painless it becomes painful when secondary infection occurs or invasion is deep into the tongue. Pain may be referred to the ear, being referred from the lingual branch of the trigeminal nerve, which supplies the tongue to the ear via the auriculotemporal nerve. If the tumour is extensive and is on the posterior one-third of the tongue, swallowing and speaking may be difficult.

Investigations

• Biopsy, incisional or excisional depending on size of tumour
• Panendoscopy and biopsy should be performed on patients with oral cavity tumours to exclude synchronous tumours (1–6% of patients).

Treatment

• Small tumours less than 1 cm can be treated by simple excision or brachytherapy.
• Larger lesions may be treated with radiotherapy or more extensive surgery, e.g. subtotal glossectomy and block dissection of neck (40% of patients have nodal involvement at the time of presentation, 20% bilateral disease). Occasionally this may require removal of part of the mandible with major plastic reconstruction.

Carcinoma of the floor of the mouth

Often these are extensive ulcerating tumours that may invade the floor of the mouth and extend into the root of the tongue and the gums. Spread to regional lymph nodes occurs early.

Investigations

• Biopsy
• CT scan.

Treatment

Wide excision, with or without mandibulectomy, with block dissection of the neck and plastic reconstruction. Radiotherapy may be the most appropriate treatment in some cases and can be given by either external beam or implants.

Prognosis

For small cancers of the lips, 5-year survival rates of 90% have been reported. However, overall carcinoma of the lip has a 5-year survival of over 60%. Tumours of the tongue and floor of the mouth have a poorer survival, being about 30% at 5 years.

Carcinomas can occur anywhere in the oral cavity in the buccal mucosa, retromolar trigone, alveolar ridge and hard palate.

Squamous cell cancer of the pharynx and larynx

The upper aerodigestive tract can be divided into the nasopharynx (from nasal choana anteriorly to soft palate inferiorly), oropharynx (from palatoglossus anteriorly, including posterior third of tongue and soft palate, to upper border of epiglottis), hypopharynx (from upper border of epiglottis superiorly to cricoid cartilage inferiorly, the larynx anteriorly).

Carcinoma of the nasopharynx

Rare in the Western population but a much higher prevalence in China. Predisposing factors include Epstein–Barr virus (EBV) and nitrosamine-containing foods, but less evidence of causative effects of tobacco and smoking. Local invasion can occur into sphenoid sinus, oropharynx, orbit or skull base.

Symptoms and signs

Patients often present late with enlarged nodes in the neck (often bilateral). Other symptoms include epistaxis, nasal obstruction, conductive deafness, otitis media, tinnitus, sore throat or CNIII–VI palsy.

Investigation

• MRI head and neck
• Panendoscopy and biopsy
• FNAC
• US guided core biopsy of lymph node.
• If lymphadenopathy of uncertain cause then polymerase chain reaction (PCR) of specimen can amplify and identify EBV DNA to support diagnosis of occult tumour.

Treatment

Chemoradiation is treatment of choice. Neck dissection if lymph nodes involved.

Carcinoma of the oropharynx

Most tumours are squamous in origin, however the higher density of lymphoid tissue means that higher proportions of lymphoma are found in this region. Local invasion can occur into sinuses, sphenoid,

Symptoms and signs

Patients often present late with enlarged nodes in the neck (often bilateral). Referred otalgia. CNIX or X palsy.

Investigations

• MRI head and neck
• Panendoscopy and biopsy.

Treatment

MALT lymphoma is radiosensitive. Early SCC treated with chemoradiotherapy. More advanced lesions may require surgical resection. Access can be difficult. Tumours on base of tongue may require exposure via a lip splitting, lateral pharyngotomy or mandibulotomy approach. Laryngeal wall tumours may require laryngopharyngectomy. Neck dissection is performed if involved nodes present or access required to vessels for free flap reconstruction. Tracheostomy is performed initially.

Carcinoma of the hypopharynx and cervical oesophagus

Hypopharyngeal carcinoma most frequently involves the pyriform sinuses, and when advanced, has a high rate of pulmonary metastatic spread.

Symptoms and signs

Dysphagia, CN IX referred otalgia. Palpable lymphadenopathy.

Investigations

• Barium swallow
• MRI head and neck
• Panendoscopy and biopsy.

Treatment

Chemoradiation is becoming treatment of choice. If early stage or chemoradiation has failed, then surgery is an option. Partial laryngopharyngectomy may be performed for small hypopharyngeal lesions, total laryngopharyngectomy if more extensive. Gastrointestinal continuity can be reconstructed with a gastric pull up, free radial forearm or free jejunal flaps. Pedicled pectoralis major flaps can be used for salvage cases or high anaesthetic risk. Neck dissection may be performed for microsurgical access or in presence of lymphadenopathy. Total oesophagectomy and gastric pull-up may be required for extensive oesophageal lesions.

Carcinoma of the larynx

Divided into supraglottic (above vocal cords), glottic (vocal cords – most common), subglottic (below vocal cords – rare).

Symptoms and signs

Voice change, hoarseness.

Investigations

• MRI head and neck
• Panendoscopy and biopsy.

Treatment

Dependent on site and size. Options include transoral laser ablation, chemoradiation, partial laryngectomy and closure or reconstruction with a free radial forearm flap, total laryngectomy. Elective neck dissection for supraglottic tumours, as >20% have occult metastatic spread to lymph nodes – rarely with glottic tumours.

Neck dissection

Removal of the lymph nodes draining the head and neck by block dissection of soft tissue between superficial and visceral/deep layers of deep cervical fascia.

Cervical nodal basin divided into levels I–VI (Sloan Kettering nomenclature):

I. Submental/submandibular nodes – triangle bounded by hyoid, mandible and posterior belly of digastric
II. Upper jugular – skull base to level of hyoid bone
III. Middle jugular – hyoid bone to level of cricoid cartilage
IV. Lower jugular – cricoid cartilage to clavicle
V. Posterior triangle – bounded by clavicle, sternomastoid, trapezius
VI. Anterior nodes.

Indications

Clinical or radiological evidence of lymph node secondaries from head and neck cancer. If no evidence of lymphadenopathy may be performed if high probability (arbitrarily >20%) of occult metastases, or if access to branches of the external carotid artery/internal jugular vein (IJV) required for microsurgical anastomosis in free flap reconstruction.

Classification

Traditionally, radical neck dissection removes levels I–V sacrificing the XI accessory nerve, internal jugular vein and sternomastoid muscle.

Modified radical neck dissection preserves one or more of these structures.

Selective neck dissection takes specific levels of drainage, e.g. supraomohyoid dissection (levels I–III), lateral (II–IV) – determined by likely levels of lymphatic spread from anatomic location of primary. Sentinel node biopsy helps to further define the locale of lymph node spread.

Extended neck dissection – Levels I–V plus other levels or non-lymphatic structures, e.g. parotid, anterior level VI.

Complications

Bleeding, pneumothorax, air embolus, carotid artery injury, cerebrovascular accident, carotid blow-out, skin flap necrosis, infection, marginal mandibular (VII), XI, XII, phrenic or lingual nerve injury, chyle leak.

Disorders of the ear

Otitis externa

Infection of the external auditory canal to the tympanic membrane. Infective causes include β-haemolytic streptococcus, Staphylococcus aureus, Pseudomonas aeruginosa, anaerobes or fungi, e.g. aspergillus. Skin allergies, swimming in dirty water, chemical irritants (e.g. shampoo, hairspray), foreign bodies (e.g. cotton buds) and diabetes predispose. Furunculosis can occur around an infected hair follicle.

Symptoms and signs

Pain, swelling and itching of pinna, discharge from the canal, conductive hearing loss.

Treatment

Topical antibiotic (gentamicin, chloramphenicol) and steroid eardrops normally lead to resolution. Malignant otitis externa can occur in diabetics leading to skull base destruction and cranial nerve palsy, therefore requires surgical debridement and parenteral antibiotics.

Acute otitis media

Common middle ear infection in infants and young children. Acute otitis media is associated with a middle ear effusion. Causative organisms viral or bacterial (Strep. pneumoniae, Haemophilus influenzae, Moraxella catarrhalis). Acute otitis media is often associated with an upper respiratory tract infection due to migration along the eustachian tube.

Symptoms and signs

Peak incidence at 6–15 months. Pain, fever, malaise, vomiting, red and bulging eardrums, pus discharge from perforated eardrum. Child is unlikely to report hearing loss.

Treatment

Most cases resolve spontaneously. Indications for antibiotic therapy are controversial. In general, if the child is under 2 years of age, pyrexial, or has evidence of purulent discharge prescribe antibiotics (co-amoxiclav). Otherwise consider delaying therapy for 2–3 days. Perforated eardrums should heal within 2–3 weeks.

Complications

Chronic serous otitis media (glue ear) can persist and hearing can become impaired. Audiometry is used to assess hearing loss. A child >3 years with bilateral OME (otitis media with effusion) may develop problems with language development and therefore myringotomy and insertion of grommets may be required. These small tympanic tubes equalize the pressure between the middle and external ear. Other complications include chronic suppurative otitis media, mastoiditis, labyrinthitis, meningitis, intracranial abscess.

Chronic suppurative otitis media (CSOM)

This can arise in cases of recurrent acute otitis media due to a cycle of inflammation, ulceration, infection and granulation tissue formation in the middle ear.

In ‘unsafe’ CSOM there is associated cholesteatoma (squamous epithelial implantation into the middle ear causing destruction of middle ear contents).

Symptoms and signs

Cheese-like, purulent or clear otorrhoea; hearing loss; swollen auditory canal, tympanic perforation with erythematous, oedematous middle ear mucosa beyond. Unsafe CSOM may also be complicated by labyrinthitis, cerebral sinus thrombosis and embolism, facial paralysis, vertigo, meningitis, intracranial abscess. May ultimately cause conductive deafness.

Investigations

• Audiometry – conductive hearing loss
• CT scan to identify cholesteatoma.

Treatment

Regular aural toilet. Topical antibiotic therapy and steroid therapy to control granulation. Surgery for failed medical therapy includes tympanomastoidectomy to clear the middle ear of disease, with a tympanoplasty to seal the perforated eardrum. If cholesteatoma is present then a classical or modified radical mastoidectomy may be indicated. In hearing loss, cochlear implants may be considered once disease eradicated.

Benign paroxysmal positional vertigo (BPPV)

Vertigo is the hallucination of movement and BPPV is the commonest form. It is caused by dislodged vestibular calcium carbonate particles (otoconia) entering the semicircular canals (particularly posterior canal) causing abnormal stimulus of the hair cells.

Predisposing factors

Labyrinthitis or head trauma.

Symptoms and signs

The patient feels the room moving around them, for about 10–20 s after rotational head movement or looking up.

Diagnosis

Can be precipitated and diagnosed by quickly moving a patient from sitting upright face forward, then rotating the neck laterally at 45°, then moving to a lying down position with the neck hyperextended 20° (Dix–Hallpike manoeuvre). Nystagmus after a latency of 5–10 seconds is positive for BPPV. The fast phase of the nystagmus is towards the affected ear.

Treatment

May resolve spontaneously over weeks or months; may respond to manipulations of the head (e.g. Epley or Semont manoeuvre).

Ménière’s disease

Inner ear condition of unknown cause. Associated with increased pressure in the endolymphatic sac; 1:100 incidence. Onset commonly at 20–50 years.

Symptoms and signs

Triad of vertigo, tinnitus and deafness. Progressive. Initial paroxysmal (minutes to hours’ duration) vertigo with nausea and vomiting. Tinnitus and transient hearing loss may develop. Periods of remission become more variable until the deafness and tinnitus becomes permanent. Later, the vertigo may resolve. Balance becomes difficult.

Investigations

With pure tone audiogram, balance and other specialized tests.

Treatment

• Vertigo attacks treated with prochlorperazine or cinnarizine
• Preventive treatment with betahistine and low dose diuretic may control symptoms
• Vestibular rehabilitation exercises
• White noise generators can help to mask the tinnitus
• Hearing aids for deafness.

Refractory treatment may require local gentamicin injection into middle ear, endolymphatic sac decompression, section of the vestibular nerve or labyrinthectomy.

Labyrinthitis

Inflammation of the labyrinths housing the vestibular system. Commonly viral in origin but may be a bacterial cause.

Symptoms and signs

Patient presents with vertigo, imbalance, nausea, vomiting and sometimes tinnitus or hearing loss. Vestibular neuritis (inflammation of CNVIII) presents in similar fashion but without the hearing loss.

Ramsay Hunt syndrome = Herpes zoster reactivation in geniculate ganglion of CNVII with external vesicular rash and facial nerve weakness. CNVIII affected as in close proximity. Symptoms may improve on lying down. Treat with acyclovir and steroids (prednisolone).

Treatment

Acute labyrinthitis treated symptomatically with prochlorperazine. If bacterial, then amoxicillin. Resolves within 8 weeks as brain compensates for changes in vestibular signalling. Uncompensated labyrinthitis may cause chronic symptoms. Additional treatment includes vestibular rehabilitation therapy (VRT) using eye, head and body exercises.

Deafness and hearing aids

Hearing loss can be conductive (CHL) or sensorineural (SNHL); congenital or acquired.

CHL is impairment of the airwave signal from the external ear to the cochlea. Acquired causes include foreign body, earwax (cerumen) impaction, cholesteatoma (see above) and benign tumours, e.g. glomus jugulare or haemangioma.

Otosclerosis

Otosclerosis is the commonest cause of CHL affecting 1% of the population in the third decade. This has a genetic predisposition and is caused by osteoblasts forming dense bone around the ossicles. The stapedial footplate can become involved and fixed to the oval window causing CHL. Patients can present with associated tinnitus and vertigo. Fine-cut CT scan and pure tone audiometry may confirm the diagnosis. Amplification hearing aids may improve function. Surgery is highly successful, involving removal and replacement of the stapes with a prosthesis (stapedectomy). However, it may not cure the tinnitus and there is a risk of deafness.

SNHL is the impairment of the transmission of the hearing signal after the cochlea. This may be caused by damage to the cochlea hair cells or CN VIII, e.g. due to trauma, surgery or acoustic neuroma. Congenital causes are numerous and may be syndromic (associated with other congenital anomalies) or non-syndromic. Positive family histories and known causative genetic mutations have been identified.

Prenatal cytomegalovirus, rubella virus or exposure to teratogens predispose, as does perinatal sepsis, administration of ototoxic medication (e.g. aminoglycosides), childhood meningitis or mumps.

Investigations

Neonates in the UK are routinely screened for audio-evoked brainstem response (ABR), looking for nerve signal activity to the brain in response to an audible stimulus. This does not distinguish between SNHL and CHL. Pure tone audiometry (PTA) can be used from age 4–5 and can distinguish.

Treatment

Ongoing cause of CHL caused by otitis media should be treated with, e.g. antibiotics, myringotomy, grommets. An amplification hearing aid may help in both CHL and SNHL to provide as much audio input as possible. Speech therapy can prevent delayed language development. Hearing aids may be bone-anchored (BAHA) in the case of a congenitally absent or malformed pinna. SNHL may be treated surgically with a cochlear implant. These are surgically implanted into the cochlear and convert sound frequencies into electrical impulses that stimulate the CN VIII.

Disorders of the nose

The nose can be examined using a headlight or head mirror, and nasal speculum. A nasendoscope can be used to examine the nasal cavity.

Nasal obstruction

May be caused by inserted foreign bodies, inflammation secondary to allergic rhinitis or infectious rhinosinusitis, nasal polyps, tumours, granulomas (sarcoidosis, Wegener’s granulomatosis, tuberculosis).

Foreign bodies are associated with a purulent discharge and swelling. May require examination and removal under general anaesthetic.

Infectious rhinosinusitis

Can be caused by viruses (rhinovirus, influenza, parainfluenza), bacteria (Haemophilus influenzae, Streptococcus, Staphylococcus) or fungi (aspergillus). Aggressive infection may spread to the orbit, skull base or intracranially, causing an intracerebral, extradural or subdural abscess. Changes in vision, conscious state, drowsiness, meningism or lateralizing neurological signs, indicate an urgent CT scan and subsequent definitive drainage.

Polyps

Polyps are pedunculated masses of oedematous mucosa that arise from the sinuses or the lateral nasal wall. They are most commonly idiopathic, but can be secondary to cystic fibrosis, asthma or aspirin sensitivity. They can be surgically removed or treated symptomatically with intranasal or systemic steroid therapy.

Tumours

Tumours of the sinuses are rare. They may present with epistaxis, and in adults are most commonly squamous cell carcinomas. These can present with recurrent epistaxis and chronic nasal obstruction. Nasopharyngeal cancer can present with nasal obstruction.

MRI and CT scans will help identify the extent of the tumour and help plan surgical resection after discussion in the MDT. Adjuvant chemotherapy and radiotherapy may be indicated.

Lesions of the maxilla may require access via a Weber–Ferguson incision – an incision extending vertically along lip philtrum, along the ipsilateral nasal-cheek margin (lateral rhinotomy) and along the eyelid-cheek margin. Partial or total maxillectomy may be required for clear margins and the orbital floor can be reconstructed with calvarial bone grafts, and the cavity including the hard palate filled with a prosthetic obturator or free microvascular muscle transfer, e.g. rectus abdominis (→ Ch. 19).

Ent emergencies

Epistaxis

Acquired causes of nose bleeds include local trauma, anticoagulants, massive transfusion, benign and malignant tumours, allergic rhinitis, liver and renal failure, and blood dyscrasias, such as primary and secondary thromobocytopaenia, lymphoma, leukaemia and aplastic anaemia. Congenital causes include hereditary haemorrhagic telangiectasia, haemophilia and von Willebrand’s disease.

Little’s area (anterior nasal septum) is the most common site of bleeding. Minor bleeds may cease with local pressure, topical application of local anaesthetic with adrenaline, or cautery with a silver nitrate stick.

Heavier bleeds can be packed with Merocel nasal tampons or a ribbon gauze layered within the nasal cavity. Posterior nasal bleeding may be controlled by passage of a Foley catheter into the nasopharynx and inflation of the balloon to apply pressure to the area. Uncontrollable bleeding may require urgent referral to the interventional radiologist for embolization or arterial ligation may be required.

In the case of heavy bleeding, the patient should be investigated for cause with full blood count and clotting studies. They may need resuscitation with fluids and blood products.

Nasal trauma

A simple ‘broken nose’ may be reducible by manipulation if managed within 2 hours of injury, after which swelling obscures the deformity. However, manipulation can be attempted at 10 days once the swelling has resolved and before the fractures have become too sticky.

Submucosal nasal septal haematomas require urgent incision and drainage to prevent cartilage necrosis and a resultant ‘saddle-nose’ deformity.

Nasal trauma with broadening of the distance between the medial canthi (telecanthus) implies a nasoethmoidal fracture which may require reduction and fixation, and should therefore be investigated with a CT scan. Any nasal trauma associated with a high-energy blow and other deformity (e.g. malocclusion, trismus, diplopia) should also be investigated with a CT scan.

Swallowed foreign body

Chicken or fish bones can become entrapped in the oropharynx. This may be in the palatine or lingual tonsils. The patient presents with drooling and a feeling of irritation at the back of the throat. These can be removed under local anaesthetic, using forceps.

Foreign bodies can become lodged in the hypopharynx, above the cricopharyngeal sphincter, sometimes causing dysphagia, pain and a change in the voice. Surgical emphysema around the neck would suggest perforation by a sharp body such as a bone. If suspected, an urgent barium swallow should be requested and endoscopy may be required for removal. In cases of perforation, there is a risk of mediastinitis and the patient should commence broad-spectrum i.v. antibiotics and be observed while ‘nil by mouth’.

Larger foreign bodies, such as marbles or coins swallowed by children may become trapped at the upper oesophageal sphincter and in extreme cases, may present with stridor and respiratory compromise. These may be radio-opaque and therefore an X-ray investigation is indicated.

Peritonsillar abscess (QUINSY)

The peritonsillar or quinsy abscess is an acute suppurative infection in the peritonsillar space following an episode of acute tonsillitis. Patients present with trismus and drooling with a foul smelling breath. It can cause necrotizing fasciitis, airway compromise and haemorrhage. The abscess is treated by incision and drainage under local, or occasionally general anaesthetic.

Deep infections of the neck

Acute peritonsillar infection or oropharyngeal foreign bodies may give rise to a deep neck abscess in the lateral parapharyngeal space between the deep and superficial cervical fascia, superior to the hyoid bone and anterior to the carotid sheath. These are treated by external incision and drainage with adjunctive antibiotic therapy. Children can be affected by a suppurative infection of the retropharyngeal nodes. Similar retropharyngeal abscesses can be seen in adults following endoscopy, intubation or oropharyngeal/middle ear infections. These present with sore throat, fever, dysphagia and neck pain. Urgent incision and drainage is recommended.

Acute epiglottitis

Caused by Haemophilus influenza type B, acute epiglottis is a potentially fatal infection presenting in children 2–7 years of age. Symptoms include stridor and dyspnoea – worse on lying supine, dysphagia and excessive drooling. The child sits upright and is distressed. Widespread vaccination has reduced the incidence of this, and it responds to amoxicillin therapy. On presentation, humidified oxygen should be administered. Direct laryngoscopy may cause life-threatening obstruction, and should only be performed by staff with the means to secure the airway. Orotracheal intubation may be difficult, and therefore needle cricothyroidotomy may be life-saving until a definitive airway can be established.

Acute hearing loss

Sudden deafness is most often conductive, caused by occlusion of the external ear canal by wax, foreign body or haematoma. Middle ear causes include perforation of the tympanic membrane caused by otitis media or direct trauma, and ossicle dislocation. Sensorineural hearing loss is most commonly idiopathic, probably viral or vascular in nature, but can also be secondary to acoustic trauma, barotrauma (in divers) or ototoxic drugs such as gentamicin. Associated vertigo or tinnitus would suggest a sensorineural cause. Care must be taken to exclude a retrocochlear cause such as acoustic neuroma. Inspection of the ear canal, tympanometry, pure tone audiogram and imaging with CT scan may be indicated to aid diagnosis. Treatment depends on cause.

Procedure

Open tracheostomy

This is a planned elective procedure, usually performed on a patient who is anticipated to require airway protection and ventilation for longer than 10 days. A tracheostomy reduces the dead space compared to an orotracheal tube, making gas exchange more efficient; reduces ulceration around the mouth and facilitates upper airway suction. A patient who is anticipated to need weaning from assisted ventilation over a long period will cope much better with a tracheostomy. Complications include bleeding, infection, tracheomalacia and tracheal stenosis.

• This is performed in an operating theatre with the patient under general anaesthetic, positioned supine with the neck extended and a sandbag between the shoulder blades.
• The intended tracheostomy tube is selected and the cuff checked for leaks and that the introducer fits inside the tube with ease.
• A 4 cm transverse skin incision is made one or two finger breadths above the sternal notch, below the palpable cricoid cartilage. Any anterior jugular vein is ligated and divided.
• Dissection through the superficial fascia proceeds in a longitudinal direction and the strap muscles (sternohyoid and sternothyroid) are separated from their counterparts.
• The isthmus of the thyroid gland is divided using bipolar diathermy to prevent bleeding. A self-retaining retractor is placed to visualize the trachea.
• The anterior trachea is dissected to visualize the underlying tracheal rings.
• The anaesthetist is informed that the trachea is about to be opened and they will advance the orotracheal tube caudally, moving the cuff away from the planned incision.
• The stoma is incised below the first tracheal ring, either as a longitudinal split or excised disc through the second, third and fourth rings.
• The introducer is made ready inside the tracheostomy with the cuff deflated and the anaesthetist deflates the orotracheal cuff and draws the tube in a cephalic direction until the tube is clear of the stomal opening. The introducer and tracheostomy tube are passed into the stoma and the introducer removed and the cuff inflated. This is then attached to the anaesthetic circuit.
• Breath sounds and chest expansion is checked bilaterally, and leaks excluded. If present, this may require a larger tube.
• The wound is partially closed with skin sutures around the tube, and the tube secured into place with the supplied neck tape or with sutures.

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