Gerard Kelly MD MEd FRCS(Ed) FRCS(ORL-HNS) ENT surgeon 9th July 2017

1. ENT red flags The Leeds Teaching Hospitals NHS Trust • Gerard Kelly MD MEd FRCS(Ed) FRCS(ORL-HNS) • ENT surgeon • 9th July 2017

2. aims to discuss the ENT red flag symptoms and associated conditions which will present in general practice

3. objectives give a differential diagnosis for the symptoms of dysphonia dysphagia odynophagia define the NICE guidelines for hoarseness list the differential diagnosis for a nasal condition resulting in nasal obstruction with other symptoms such as bleeding, epiphora and cranial nerve palsies make a management plan for someone presenting with a salivary gland / thyroid / neck mass with reference to the potential diagnosis plan the treatment and investigate a patient presenting with a facial paralysis describe the management in primary care of a person presenting with a sudden hearing loss

4. topics hoarseness persisting for > 3 weeks dysphagia persisting for > 3 weeks unilateral nasal obstruction particularly when associated with purulent discharge epistaxis cranial nerve palsies epiphora unresolved neck masses for > 3 weeks sudden change in existing neck mass / thyroid swelling stridor associated with neck or thyroid swelling parotid / salivary gland lesions sudden hearing loss facial paralysis

5. first though... history in ENT

6. history ears otorrhoea otalgia itch hearing tinnitus balance noses nasal obstruction rhinorrhoea facial pain smell epistaxis post nasal drip throats dysphagia dysphonia odynophagia pain neck lumps weight loss

7. hoarseness

8. hoarseness NICE

9. laryngeal cancer cancers of the head and neck are the 9th most common tumours almost all are squamous cell carcinomas (except BCC of the skin of the face), the most common site of the tumour is the larynx, caused by smoking & alcohol treatment consists of treating the primary disease and treating metastatic disease metastatic disease is to the neck, hardly ever to the rest of the body treatment is by radiotherapy, chemotherapy, surgery or a combination of all 3 small tumours tend to be treated by radiotherapy large tumours by radical surgery and post operative chemo-radiotherapy

10. laryngeal cancer stage 1 90% will survive their cancer for 5 years or more after diagnosis Stage 1, one part of the larynx & vocal cords mobile, no spread nodes stage 2 60% will survive their cancer for 5 years or more after diagnosis Stage 2, has spread to another part of the larynx from where it started & vocal cords may be immobile, no spread to nodes  stage 3 almost 60% will survive their cancer for 5 years or more after diagnosis Stage 3,  growth not outside the larynx OR  vocal cord fixed OR the cancer may also have spread to a nearby lymph node (less than 3cm) stage 4 more than 40% will survive their cancer for 5 years or more after diagnosis Stage 4, spread outside the larynx eg thyroid or oesophagus, nodal spread (large and distant mets) http://www.cancerresearchuk.org/about-cancer/laryngeal-cancer/survival

11. laryngeal cancer as the most common site of cancer of the head and neck is the larynx and in the larynx the glottis is most common symptom is dysphonia or hoarseness

12. head and neck cancer the narrowest part of the airway is the glottis and such tumours can also result in stridor – noisy breathing from the airway stertor is noisy breathing from the mouth / throat / area above the glottis

13. dysphagia dysphagia is difficulty swallowing cancer of the larynx can extend into the pharynx and result in dysphagia but usually pain on swallowing ‘odynophagia’ cancer of the post cricoid area tends to cause dysphagia cancer of the oesophagus causes dysphagia

14. dysphagia the differential diagnosis of a patient with dysphagia (other than cancer) is: benign stricture, webs pharyngeal pouch dysmotility, motor disorders achalasia extrinsic compression (tumours, cervical osteophytes)

15. differential diagnosis? globus upper aerodigestive tract lesion laryngopharyngeal reflux disease ACE inhibitors cough variant asthma chronic rhinosinusitis

16. dysphagia the differential diagnosis of a patient with dysphagia (other than cancer) is: benign stricture, webs pharyngeal pouch dysmotility, motor disorders achalasia extrinsic compression (tumours, cervical osteophytes)

17. Pharyngeal pouch pharyngeal pouch (elderly) presents with dysphagia, regurgitation of undigested food, rarely a neck mass 100% seen on barium swallow endoscopic or open operation to remove may give left sided mass, with gurgling sensation or crepitus on palpation

18. unilateral nasal obstruction particularly when associated with purulent discharge epistaxis cranial nerve palsies epiphora

19. unilateral nasal obstruction particularly when associated with purulent discharge, epistaxis, cranial nerve palsies, epiphora sinister nasal lesions are rare, they include cancers (male 50-60y) 60% squamous cell cancers, 10% adenocarcinomas, adenoid cystic carcinomas, lymphomas, plasmacytoma, melanoma, olfactory neuroblastoma, sarcoma smoking HPV chemicals, wood & leather dust, nickel, chromium, formaldehyde

20. unresolved neck masses for > 3 weeks

21. neck lumps examination? examine the throat

22. neck disease

23. neck disease midline anterior triangle

24. neck disease lateral posterior triangle

25. neck disease levels 1 – 5 levels 1 to 5

26. neck disease levels 1 – 5

27. neck Lumps - Lymphatic drainage

28. midline thyroid gland submandibular salivary gland thyroglossal cyst midline dermoid ranula

29. lateral lymph node laryngocele branchial cyst pharyngeal pouch lymphangioma heamangioma carotid body tumour

30. thyroglossal cyst thyroglossal cyst (5 year old, 90% midline) thyroid gland develops from the floor of the primitive pharynx and migrates down in the neck moves on tongue protrusion excision with body of the hyoid bone

31. thyroglossal cyst excision Sistrunk procedure

32. midline dermoid epidermoid cyst (most common). Lined by squamous epithelium and contains cheesy keratinous material

33. ranula simple ranula. Retention cyst arising from a minor salivary gland in floor mouth. plunging ranula. Part of cystic hygroma.

34. laryngocele laryngocele (60 years, M:F = 5:1) lnlarged laryngeal saccule. Can be internal or external and appears on valsalva.

35. laryngocele

36. lymph nodes reactive primary malignancy secondary malignancy

37. branchial cyst branchial cyst (30 years, M:F = 3:2) probably arise from epithelial inclusions in a lymph node. Contain straw coloured fluid with cholesterol crystals. Most lie anterior to the sternomastoid in the upper third of the neck. ?second branchial arch derivative

38. branchial cyst

39. lymphangioma lymphangioma (3 types, 2/3rds present at birth) slimple lymphangioma. Capillary sized lymph vessels. Lips, tongue, cheek, floor mouth. cavernous lymphangioma. Dilated lymphatic spaces. Lips, tongue, cheek, floor mouth cystic hygroma. Cysts of various sizes mainly arise in the neck. Recurrence after excision 15%

40. haemangioma most common tumour of infancy 15-20% in head and neck masseter and trapezius 3F:1M 50% may involute spontaneously

41. carotid body tumour carotid body tumour (50 years, chemodectoma) slowly growing for years. One third present as parapharyngeal mass and push the tonsil medially. Pulsatile, refills after compression. diagnose by angiography. Excision in younger patients or radiotherapy.

42. vagal body tumour vagal body tumours (chemodectoma) slowly growing but more malignant potential than carotid body tumours and may invade the cranial cavity or cause cranial nerve palsies surgery required

43. benign head and neck disease most present as a lump management history examination where is it? tender, moves with swallowing, pulsatile, cystic, transilluminates, red

44. sudden change in existing neck mass / thyroid swelling

45. thyroid gland goitre cysts adenoma (papillary and follicular) carcinoma papillary and follicular medullary anaplastic and lymphoma

46. thyroid gland management now is examine ultrasound FNA decide on excision or not

47. stridor associated with neck or thyroid swelling

48. stridor associated with neck or thyroid swelling 999

49. salivary glands

50. history most present as a lump