Answer:

Singer’s nodes is a condition that usually affects professional voice users and screaming children’. Following either excessive or inappropriate use of the voice, the patient complains of hoarseness of voice and inability to reach high notes without extra effort. On indirect laryngoscopy white, symmetrical, sessile nodules are seen at the junction of the anterior third and posterior two thirds of the vocal cords. The nodules are less than 2 mm in size. Pathologically there is benign localised keratosis.
Treatments include;

• voice rest
• elimination of focal sepsis in the URT
• microlaryngoscopic excision if the problem persists despite voice rest
• speech therapy

Answer:

In children up to 60% of persistent parotid enlargement is caused by

• haemangioma,
• lymphangioma, and
• neurofibroma, where as these tumours are causes of parotid swelling in the adults.

Other causes of parotid enlargement in children are

• chronic sialdenitis,
• leukaemias, and
• lymphomas.

Answer: 

This an association of
a) oropharyngeal ulceration (aphthous type)
b) genital ulceration and
c) iritis.
In this idiopathic condition multisystem involvements is now recognised. Encephalitis and blindness are rare complications.
Steroids, azathioprine and cyclophosphamide may be used in the severe case.

Answer: 

This tumour has the synonyms of papillary cystadenoma lymphomatosum
and Warthin’s tumour. It accounts for 20% of the benign tumours of the parotid gland. It is a disease of the elderly and affects approximately 7 men to 1 woman.
Lymphoid element is prominent on histological examination and the tumour is believed to arise from a residue of salivary duct epithelium within an intraparotid lymph node.
As a rule, there is never malignant degeneration. Clinically, they may appear suddenly and fluctuate in size. These soft and cystic tumours are bilateral in 10% of cases.
Occasionally they are discovered as incidental findings during an operation on the neck. Treatment is usually with superficial parotidectomy to obtain a histopathological diagnosis. Fine needle aspiration biopsy may alter this treatment policy.

Answer:

1. Malignancy eg. Carcinoma of bronchus, oesophagus, thyroid and metastatic carcinoma of the nasopharynx
2. Surgical trauma eg surgery to thyroid, oesophagus and great vessels
3. Idiopathic
4. Inflammatory eg. Apical or mediastinal scarring due to Tuberculosis
5. Non-surgical trauma eg. Sharp and blunt injuries to the neck.
6. Miscellaneous eg. Connective disorders (rheumatoid arthritis), syphilis, thrombosis of subclavian vein
7. Stretching of the nerve eg. By an aortic aneurysm, non-malignant thyroid or parathyroid disease , an enlarged heart or lymph nodes.
8. Neurological

• Peripheral Neuritis eg. Diabetes, alcoholism, lead poisoning, viral.
• central and general neurological disorders eg. Cerebrovascular accident, syringomyelia, multiple sclerosis.

Answer: 

This is a cyst which develops in the line of a persistent thyroglossal duct which runs from the foramen caecum through or in front of the hyoid bone to the thyroid gland.
The thyroglossal cyst, the commonest cause of a midline cyst , usually presents in childhood.
No age group, however, is exempt. In the majority there is a painless midline mobile cyst which moves upwards on swallowing or protrusion of the tongue. Occasionally the cyst may be situated just lateral to the midline (usually left) and atypical presentation includes infection and fistulisation.
Treatment involves excision of the cyst plus the duct including the body of the hyoid bone.

Answer:

In glandular fever there may be a very prominent tonsillar enlargement such that the tonsils may even meet in the midline.
These tonsils are hard and this contribute to the symptoms of dysphagia and oral respiratory difficulty.

The managements includes:

• confirm the diagnosis
• admission to hospital if any complications develop
• most patients will breathe comfortably through the nose. Those patients with nasal obstruction may be helped with vasoconstrictor nasal drops or by insertion of nasopharyngeal airway
• steroids to reduce the tonsillar swelling
• The role of antibiotics is controversial. In the presence of a superadded infection they may be of use. Ampicillin should be avoided
• general support such as adequate hydration and oxygen if appropriate
• rarely a tracheostomy may be required.

Answer:

This is an air or fluid containing prolongation of the laryngeal saccule from the ventricle. It is believed that the saccule becomes encysted secondary to ostial obstruction. Should the cyst discharge then fluid is replaced by air in the sac. It is commoner in elderly men.
Most are unilateral and there is an association of increased incidence of laryngocoele with laryngeal carcinoma.

Laryngocoeles can be

1. External- herniating around or through the thyrohyoid membrane and presenting as a neck swelling which expands on coughing and empties on pressure
2. Internal- confined within the laryngeal framework
3. Combined external and internal.

A muffled and hoarse voice is usually present. Radiographic examination during the valsalva manoeuvre may demonstrate an air containing lesion.
Treatment of the internal type involves marsupialising the lesion endoscopically, where as the external approach and excision is required for the external type.

Answer:

Management may include:

1. Reassurance – Up to 20% of parotidectomy patients may complain of this
   symptom. The majority improve within 6 months
2. Topical therapy – The drying agents that are available in antiperspirants may be used to good effect, such as zinc oxide
3.  Anticholinergics – such as atropine or hyoscine have been used but the side
   effects are often worse than the condition and the results are poor
4. Surgical – The objective is to interrupt the parasympathetic fibres.
   i) re-evaluate the skin flap over the parotid
   ii) section of the auriculo-temporal nerve
   iii) perform a tympanic neurectomy and chorda tympanectomy
   iv) perform a middle cranial fossa geniculate ganglion and lesser petrosal nerve
   section. Of these the tympanic neurecttomy is at present the favoured method. The results, however, are not as good as might be expected.

Answer:

This common cause of a bilateral , often asymmetrical goitre, affects 9 females to 1 male.  The gland consistency varies from firm and glandular to obviously nodular.  History and examination suggest the diagnosis with confirmation by histology (usually from fine needle aspiration) which shows focal lymphocyte infiltration.  There is a gross elevation of thyroid auto-antibodies.  All ranges of thyroid function are seen; however, myxoedema is the usual outcome.  A normal T4 and T3 with a raised TSH is nearly pathognomonic of the condition.  Treatment with thyroxine usually prevents further growth of the goitre and may encourage shrinkage.  There is debate as to whether there is an increased incidence of neoplasia in Hasimoto’s disease.  At present this association is believed to be coincidental.

Answer:

About1 70% of thyroid carcinomas are papillary.  This is the commonest childhood thyroid cancer and not an unusual incidental post mortem finding. It occurs in any age group but has a peak incidence in the third and fourth decades (20- 40 years).  About 75% of patients are females. This rarely encapsulated tumour is usually infiltrating. 

Histologically, there are papillary projections into a variable colloid stroma with characteristics psammoma bodies. Up to 20% of tumours may be multifocal within the thyroid gland on simple examination, and histological examination may increase this number 90%.  

Presentation is usually with a solitary thyroid nodule although lymphatic metastases may be present.  Investigation with ultrasound and isotope scanning may be helpful.  Fine needle aspiration biopsy (FNAC) has a high diagnostic yield, with diagnostic accuracy of 94%, sensitivity of 85-95% and specificity of above 90%.  

In cases of doubt surgical exploration is required.  Total lobectomy, total thyroidectomy and functional neck dissection all have a place in the surgical management depending depending on the tumour extent.  

Metastatic disease can be diagnosed using a radioactive iodine scan and ablated with a therapeutic dose of radio-iodine.   Thyroxine is given to those patients post treatment both as replacement therapy and as TSH suppression.  

NB: There is evidence that differentiated thyroid carcinoma is TSH dependent.

Answer:

This is an autoimmune acquired disorder which causes skeletal muscle weakness and fatigue.

Under the age of 40 more women are affected while over that age males predominate. Peak age incidence depends on the presence of a thymoma.

It is associated with other autoimmune disorders. A serum IgG antibody binds acetylcholine post-synaptic receptor at the neuromuscular junction and interferes with normal neuromuscular transmission.

The muscle weakness is increased by exercise and may be exacerbated by pregnancy, stress or infection.  Specific muscle groups may be differentially affected.

Investigations include:

1. anti-acetylcholinesterase2 receptor antibody,  
2. striated muscle antibody,
3. edrophonium test,
4. electromyograpy and
5. anterior mediastinal radiology to identify those cases with an associated thymoma.

Treatment include:

1. anticholinesterae drugs (pyridostigmine or neostigmine)
2. prednisolone and azathioprine as second choice therapy
3. plasma exchange in the severely ill  
4. thymectomy and 
5. tracheostomy for severe breathing difficulties.

Answer:

Syringomyelia is a rare condition in which there is cavitation of the spinal cord extending over several segments. Damage occurs mostly to the anterior horn cells, spinothalamic and corticospinal fibres.

Syringobulbia is when cavitation extends into the medulla and pons. Predisposing factors include, congenital and acquired abnormalities at the foramen magnum such as basal arachnoiditis, posterior fossa tumours and intermedullary gliomas.

The usual presentation is between the ages of 10 and 30 and may be:

• with hand neurotrophic ulceration, weakness or wasting.
• dissociated sensory loss to pain and temperature in one or both arms with associated
  burning shoulder pain and painless destruction of the joints of the hand.
• cerivcal lesions above c5 may cause coarse rotatory nystagmus, vertigo, Horner’s
  syndrome and ataxia. The earliest features of syringobulbia may be sensory loss over the face, dysphagia and dysphonia. Investigation is with myelography, CT and MRI scanning.

Treatment is by surgical decompression at the the cranio- vertebral junction plus control of any secondary hydrocephalus.

Answer:

There is regurgitation of gastric juice into the lower oesophagus where the vulnerable squamous epithelium is injured. The reflux may be intermittent or persistent.

Reflux is caused by:

• incompetence of the lower oesophageal sphincter which may be congenital or acquired
  1) anatomical eg. Scleroderma
  2) physiological eg. Cigarette smoking
• increased intra abdominal pressure eg. Pregnancy
• hiatus hernia (sliding)
• obesity in which fat infiltration causes loss of the fundo-oesophageal angle
• vomiting.

Answer:

This disease is characterised by progressive degeneration of anterior horn cells, corticospinal and motor nuclei in the medulla. Although all parts of the motor system may be involved the disease may start in any area.

The most common presentation is upper limb wasting with lower limb spasticity where as within the head and neck pseudobulbar, or progressive bulbar palsy may be a feature of the disease.

The aetiology is unknown; progression is relentless; treatment does not alter the progression; males are affected more often than females; it is generally a condition of the elderly. Survival from the time of diagnosis is on average 3 – 4 years; prevalence is 5 per 100, 000.

Presentation is often insidious with diagnosis being considered when there is muscle wasting and fasciculation without associated sensory signs. The clinical diagnosis may be corroborated by EMG and muscle biopsy.

The major aspects of treatment are supportive to cope with increasing disability. Surgery may be considered for intractable aspiration.

Answer:

AJCC 8th edition:

• Tis – carcinoma in situ.  To-no evidence of primary tumour
• Tx – the minimum requirements to assess the primary tumour cannot be met
• T1a – tumour confined to the laryngeal surface of the epiglottis or to an aryepiglottic fold or to a ventricular cavity or to a ventricular band. 
• T1b – tumour involving the epiglottis and extending to the ventricular cavities or bands.
• T2 – tumour with extension to adjacent sites or to the glottis without fixation.
• T3 – tumour confined to the larynx but with fixation of cords and/or other evidence of deep invasion. 
•  T4 –  tumour extended outside the larynx.

Answer:

1.  Lymphatic obstruction to the tongue due to submandibular space disease
2.  Haemangioma
3.  Myxoedema
4.  Acromegaly
5.  Amyloid
6.  Cysts
7.  Actinomycosis
8.  Von Gierke’s disease
9.  Down’s syndrome
10.  Tumours of the tongue
11.  Angioneurotic oedema
12.  Pierre Robin ( relative macroglossia).

Answer:

This is a spastic paralysis which selectively involves the bulbar motor nuclei. The most common cause is a cerebral vascular accident. Other possibilities include;

• Multiple sclerosis (MS),
• Neoplasia, and
• Motor Neurone Disease (MND).

There is degeneration of the pyramidal fibres high in the brain stem. Owing to the rich bilateral innervation of the cranial nerve nuclei by the upper motor neurones from each cerebral hemisphere, a unilateral lesion of the pyramidal tract causes few and transitory signs within the cranial nerve territory (with the exception of the facial muscles).

In a bilateral lesion there is often a near complete paralysis of the muscles used in chewing, swallowing, and speaking. The effects are similar to bulbar palsy but without wasting or fasciculation.

• The tongue is slow moving.
• Speech is slurred and monotonous.
• The face is immobile and expressionless although facial emotional responses may be excessive, uncontrollable and inappropriate.
• The jaw jerk is increased.
• Gait may be tottery and shuffling.
• Inhalation pneumonia is the most frequent cause of death.

There is no curative treatment for this condition although in some cases surgery to protect the lower respiratory tract may be appropriate, e.g. Cricopharyngeal myotomy, Epiglottopexy or even Laryngectomy.

Answer:

1. Carotid angiography would be the investigation of choice.

Characteristic features are that of an egg-shell like mass displacing the internal carotid artery laterally and widening the bifurcation between internal and external carotid arteries

2. Urinary VMA to identify

• secreting carotid body tumours and
• associated secreting paragangliomas such as phaeochromocytoma

Answer:

Sleep apnoea is characterized by repetitive episodes of upper airway tract obstruction during sleep. There are at least 30 apnoeic episodes in both REM and non-REM sleep during 7 hours of un-sedated sleep.
In the following;

• the premature infant, apnoea > 20 seconds,
• an infant, apnoea > 15 seconds and
• an adult, apnoea > 10 seconds are considered pathological

Answer:

1. Peripheral / obstructive: 

• enlarged tonsils and adenoids
• nasal obstruction (deviated nasal septum, nasal pack)
• nasopharyngeal abnormalities (stenosis or incompetence)
• Pharyngeal obstruction
  i) lingual tonsil, vallecular cyst
  ii) abnormal deposits in the walls (obesity, myxoedema, acromegaly)
• laryngeal obstruction ( webs, polyps, cysts)
• craniofacial abnormalities (Treacher collin’s , Pierre Robin)

2. Central

• high altitude
• encephalitis
• brain stem disease
• ondine’s curse
• myxoedema
• supratentorial masses
• congestive cardiac failure

3. Some cases have a combined peripheral and central aetiology.

Answer:

1. Local:

• Chronic tonsillitis
• Quinsy
• Parapharyngeal abscess
• Suppurative cervical adenitis
• Acute suppurative otitis media

2. Systemic; particularly related Group A beta-haemolytic streptococcus: .

• Rheumatic fever
• Acute Glomerulonephritis
• Chorea
• Subacute bacterial endocarditis

Answer:

1. Smoking, particularly reverse smoking of cigar or cigarette. Chewing tobacco and betel nut. Pipe smoking is associated with lower lip squamous carcinoma
2. Spirits
3. Spices
4. Syphilis
5. Spikes (sharp tooth); ill-fitting dentures and sharp teeth causing irritation
6. Sunlight , particularly related to carcinoma of the lip
7. Avitaminosis
8. Plummer – Vinson syndrome

Answer:

• Lateral border – 85%
• Midline – 5% 
• Tip – 5% 
• Within – 5%

Answer:

• Nasogastric tube: This is a temporary solution and nutrition may be supplied through the tube. The problems of inhalation of saliva and complications of the tube occur
• Cuffed tracheostomy or nasotracheal tube is useful in the short term but not the long term due to complications. 
• Polytetrafluoroethylene (PTFE) cord injection. There is a place for this method in high vagal paralysis but it is not very effective.
• Cricopharyngeal myotomy
• Bilateral chorda tympani and tympanic nerve sections or radiotherapy to reduce saliva
• Gastrostomy
• Separate larynx and trachea by closure at the first tracheal ring and creation of a tracheostomy
• Epiglottopexy
• The vocal cords are sutured together and a tracheostomy created
• Tracheo-oesophageal anastomosis and tracheostomys 
• Total laryngectomy

Answer:

Advantages:

1. Avoids stab incision to drain Quinsy
2. Avoids interval tonsillectomy
3. Allows drainage of loculated pus behind the lower pole
4. Fewer attachments between tonsil and capsule

Disadvantages:

1. Rupture of the abscess and inhalation occurring during the induction of anaesthesia
2. Excessive haemorrhage from contralateral tonsillectomy
3. Infection may be spread in the opened tissue planes.

Answer:

This functional paralysis of the laryngeal adductors during phonation occurs most frequently in emotionally unstable individuals particularly in young women.
The aphonia is sometimes complete but more often the voice is reduced to a whisper. Onset and recovery are usually sudden.

The characteristic signs on indirect laryngoscopy are, failure of the cords to meet on attempted phonation, with a normal cough at which the glottis is seen to close.  .

Answer:

a). Control associated conditions of the nose and pharynx.

b). Control irritative factors such as associated sinus disease, smoke and dusty atmospheres.

c). Loosen and remove crusts by

1. inhalation of steam or menthol
2. laryngeal sprays such as 8.4% sodium bicarbonate or
   benzdyamine hydrochloride 0.15%

Answer:

a). CXR and ECG for signs of Cor pulmonale

b). Polysomnography which may include:

• ENG recording of eye movements
•  EEG
•  Strain gauges to chest and diaphragm
• A throat microphone to record airflow
• Continuous ECG for dysrhythmias
•  Transcutaneous PO₂ monitorings :