ENT Medicine and Surgery

Illustrated Clinical Cases

Jayesh Doshi, Manohar Bance, Simon Lloyd, Jayesh Doshi, Manohar Bance, Simon Lloyd

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315355955
• Edition: 1
• Topic: Medicina
• Subtopic: Teoria, pratica e riferimenti medici

This practical ENT reference guide includes over 100 clinical case scenarios, ranging from basic ENT issues to more challenging clinical cases, presented randomly as they would occur in real life. Each scenario includes thought-provoking questions followed by reasoned answers and is superbly illustrated with diagrams and high quality photographs.

This is an invaluable text for otorhinolaryngologists in practice and in training, from hospital-based surgeons preparing for higher examinations to established physicians for their continuing professional development.

HEAD AND NECK

CASE 1

QUESTIONS 1

A 39-year-old male presents with a 2-month history of right throat pain. There is no significant past medical history and he is a lifelong non-smoker who drinks 20 units of alcohol per week. Examination of the neck reveals a 1 cm right level II lymph node. Examination of the oropharynx reveals the following:

1. What is the likely diagnosis?
2. What are the major risk factors for this condition?
3. How would you investigate this patient?
4. Outline the T staging classification for this condition.
5. This patient has a TNM stage of T1, N1, M0. Outline the treatment options.
6. Should the N0 neck be treated in T1–T2 disease?

Answers 1

1. The right tonsil is enlarged and ulcerated – it is likely to be a squamous cell carcinoma.
2. Smoking, alcohol, human papilloma virus (HPV) and betel nut chewing.
3. Fine needle aspiration cytology (FNAC) of the neck node.
   Magnetic resonance imaging (MRI) of neck – to assess primary tumour and cervical metastasis.
   Computed tomography (CT) of thorax – for staging purposes.
   Panendoscopy and biopsy for definitive histological diagnosis, HPV testing of biopsy specimen.
   Tonsillectomy should not be carried out in the presence of obvious malignancy as this will limit the treatment option of future transoral laser surgery.
4. Tx: primary tumour cannot be assessed.
   T0: no evidence of primary tumour.
   Tis: carcinoma in situ.
   T1: tumour 2 cm or smaller in the greatest dimension.
   T2: tumour larger than 2 cm but 4 cm or smaller in the greatest dimension.
   T3: tumour larger than 4 cm in the greatest dimension.
   T4a: tumour invades the larynx, deep/extrinsic muscle of tongue, medial pterygoid, hard palate or mandible.
   T4b: tumour invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base or encases carotid artery.
5. As with all head and neck malignancies, this patient would be formally discussed at a multi-disciplinary team (MDT) where a treatment plan would be formulated. Early stage disease (T1–T2) should be treated with a single modality, which may be primary radiotherapy or transoral surgery and neck dissection. The transoral approach is preferred to open surgery and is associated with good functional outcomes. If treated surgically, selective neck dissection involves levels II–IV and possibly level I. If there is no disease evident in level IIa then Level IIb can be omitted. Chemotherapy is not routinely used in early-stage disease.
6. Occult neck metastases are present in 10%–31% of patients with T1–T2 disease and the treatment of a N0 neck remains a controversial topic. Those undergoing primary surgery can undergo a selective neck dissection and for patients treated with primary radiotherapy, prophylactic treatment of the neck is often advised. Sentinel lymph node biopsy is another option unless cervical access is required at the same time as primary surgery.
   These decisions should be discussed at the local MDT and based upon any national guidance, which varies from country to country.

CASE 2

QUESTIONS 2

1. What procedure is being carried out?
2. Describe the advantages and disadvantages for the different types of tubes that can be used with this procedure.
3. What are the indications for this procedure?
4. What are the advantages of tracheostomy compared to endotracheal intubation in the ventilated ITU patient?
5. What are the complications of tracheostomy?

Answers 2

1. Tracheostomy
2. There are a number of tracheostomy tubes available: cuffed tubes (non-fenestrated and fenestrated), uncuffed tubes (non-fenestrated and fenestrated), cuffed adjustable flange tubes and silver negus tubes. The majority of tubes have inner and outer tubes; the inner tube can be easily removed for cleaning without disturbing the outer tube.
   Fenestrated tubes enable patients to talk by allowing airflow to pass superiorly through the fenestrations and through the vocal cords. However, there is a risk of aspiration with fenestrated tubes and they should only be used in patients with a safe swallowing mechanism.
   Cuffed tubes prevent leaking of secretions around the tube into the lungs and provide an airtight seal to enable positive pressure ventilation. However, prolonged use of a cuff can cause trauma to the tracheal wall: tracheomalacia, tracheal stenosis and fistulation into the oesophagus.
   Cuff pressures should be checked regularly using a manometer. Most modern tubes have a high-volume, low-pressure cuff to minimise these risks.
   A cuffed adjustable flange can be useful in patients with deep neck.
   Silver negus tubes are uncuffed and only used in some long-term tracheostomy patients.
3. One of the most common reasons to undertake a tracheostomy is to bypass upper airway obstruction. This is usually carried out ...