Complete ENT (Otorhinolaryngology) question bank — ear, nose, throat, larynx, airway & head-neck — in explanation-first exam-topper style, with 72 diagrams.
12chapters144questions77High-Yield
THE CONCEPT
A neck lump is a common presentation with a broad differential; a systematic approach based on location (midline vs lateral, level), age and characteristics guides diagnosis. The key task is to exclude malignancy (especially a metastatic node in adults).
Neck lump: differential by site
MIDLINE
thyroglossal cyst (moves w/ tongue)
thyroid (moves w/ swallowing)
dermoid / submental node
LATERAL
branchial cyst
lymph node
carotid body (pulsatile)
salivary / cystic hygroma
Adult >40 + persistent lateral node = metastatic until proven otherwise
A neck lump is approached by site: midline swellings (thyroglossal cyst, thyroid, dermoid) versus lateral swellings (lymph node — the commonest — branchial cyst, salivary gland, carotid body tumour, cystic hygroma). In an adult over 40, a persistent lateral neck node is treated as metastatic until proven otherwise.
DIFFERENTIAL BY SITE
Midline: thyroglossal cyst (moves with tongue protrusion/swallowing), thyroid swelling (moves with swallowing), dermoid, submental node.
Lateral: a lymph node (commonest — reactive, TB, lymphoma, metastatic); branchial cyst (upper third of SCM, young adult); salivary gland (parotid/submandibular); carotid body tumour (pulsatile, moves side-to-side not up-down); cystic hygroma (infant, posterior triangle, transilluminates).
APPROACH BY AGE
As a rule of thumb: in children/young adults, lumps are mostly congenital (thyroglossal, branchial, cystic hygroma) or inflammatory (reactive/TB nodes); in an adult over 40 with a persistent lateral neck node, assume metastatic squamous cell carcinoma (from a head-and-neck primary) until proven otherwise — also consider lymphoma.
ASSESSMENT & INVESTIGATION
WHY LOCATION AND MOVEMENT ARE SO INFORMATIVE
The reason a neck lump is approached first by its exact location and its movement is that these two features alone narrow the differential dramatically. Because the neck contains structures with characteristic positions and attachments, where a lump sits and how it moves often points to its origin before any investigation. A midline lump that rises when the tongue is protruded is almost certainly a thyroglossal cyst (tethered to the tongue base via its tract), whereas a midline lump that moves only with swallowing suggests a thyroid origin (the thyroid moves with the larynx). A pulsatile lateral lump at the carotid bifurcation that moves side-to-side but not up-and-down suggests a carotid body tumour (fixed to the artery). A lump at the upper third of the sternocleidomastoid in a young adult suggests a branchial cyst. Learning these positional and movement signatures turns a bedside examination into a powerful diagnostic tool, which is why they are emphasised so strongly.
WHY FNAC — NOT EXCISION BIOPSY — COMES FIRST
A crucial principle in evaluating a neck lump, particularly in an adult, is that fine-needle aspiration cytology (FNAC) is the first-line investigation, and an open excision biopsy of a possibly-malignant node must be avoided. FNAC is quick, safe, cheap and can distinguish reactive, tuberculous, lymphomatous and metastatic nodes without an operation. The danger of jumping to an excision biopsy of a suspected metastatic node is that cutting into it can seed tumour, disrupt the tissue planes and worsen the outcome of the definitive neck dissection, and it does not identify the primary anyway. The correct pathway when FNAC suggests metastatic squamous carcinoma is to search for the primary tumour by careful examination and panendoscopy, then plan definitive treatment. The one exception is suspected lymphoma, where an excision biopsy is needed because the diagnosis depends on the node's architecture. Understanding this sequence — FNAC first, find the primary, biopsy only for lymphoma — is central to managing the neck lump safely.
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DANGER / REMEMBER: Assessment: history (duration, growth, pain, systemic symptoms, smoking/alcohol, ENT symptoms), examination (site, consistency, mobility, pulsatility, movement with swallowing/tongue, a full head-and-neck examination, transillumination), and investigation — FNAC (the key first-line test), ultrasound (± guided FNAC), CT/MRI, and panendoscopy + biopsy of the primary if a metastatic node is suspected. The rule: a firm, persistent neck node in an adult is metastatic SCC until proven otherwise — find the primary (triple endoscopy), and do not perform an excision biopsy of the node first.
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CLINICAL PEARL: Neck lump — approach by site, age and characteristics; exclude malignancy. Midline: thyroglossal (moves with tongue protrusion), thyroid (moves with swallowing), dermoid. Lateral: lymph node (commonest — reactive/TB/lymphoma/metastatic), branchial cyst (upper SCM, young), salivary, carotid body (pulsatile), cystic hygroma (infant, transilluminates). An adult >40 + a persistent lateral node = metastatic SCC until proven otherwise → find the primary. FNAC = the key first investigation (not excision biopsy).
By age: children/young — congenital (thyroglossal/branchial/cystic hygroma) or inflammatory (reactive/TB). Adult >40 + persistent lateral node = METASTATIC SCC until proven otherwise (+ lymphoma).
Ix: history + full head & neck exam; FNAC = key first-line (NOT excision biopsy if metastasis suspected); ultrasound ± guided FNAC, CT/MRI; panendoscopy + biopsy of primary for a suspected metastatic node; excision biopsy only for suspected lymphoma.
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KEY POINTS TO REMEMBER
Approach a neck lump by site, age and characteristics; the priority is excluding malignancy.
Midline: thyroglossal cyst (moves with tongue protrusion), thyroid (moves with swallowing), dermoid.
Adult >40 + persistent lateral node = metastatic SCC until proven otherwise → find the primary (triple endoscopy).
FNAC is the key first investigation; avoid excision biopsy of a possible metastatic node (excision biopsy is for suspected lymphoma).
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat; Scott-Brown's Otorhinolaryngology.
THE CONCEPT
Tumours of the salivary glands (parotid, submandibular, sublingual, minor) are mostly in the parotid and mostly benign. A useful rule: the smaller the gland, the higher the chance of malignancy.
Major salivary glands
parotid
Stensen's duct → opposite upper 2nd molar
submandibular
Wharton's duct → floor of mouth
sublingual (floor of mouth)
~80% of tumours are in the parotid & ~80% of those are benign (pleomorphic adenoma)
The major salivary glands: the parotid (with Stensen's duct opening opposite the upper second molar), the submandibular (with Wharton's duct opening in the floor of the mouth) and the sublingual. About 80% of salivary tumours arise in the parotid and about 80% of those are benign.
DISTRIBUTION & TYPES
As a rule of thumb, about 80% arise in the parotid, ~80% of parotid tumours are benign, and ~80% of these are pleomorphic adenomas; the submandibular/minor glands have a higher proportion of malignancy.
Pleomorphic adenoma (mixed tumour) — the commonest salivary tumour (parotid); slow-growing, painless, mobile, firm; with a risk of recurrence (pseudopod capsule) and malignant transformation if long-standing. Treated by superficial parotidectomy (not enucleation).
Warthin's tumour (adenolymphoma) — the 2nd commonest benign; parotid; older men, smokers; may be bilateral; soft/cystic.
Mucoepidermoid carcinoma — the commonest salivary malignancy (and commonest in children).
Adenoid cystic carcinoma — commonest in submandibular/minor glands; perineural spread (pain, facial-nerve involvement), late lung metastases.
FEATURES, INVESTIGATION & MANAGEMENT
WHY THE FACIAL NERVE DOMINATES PAROTID SURGERY
A concept that dominates all parotid surgery is the intimate relationship of the parotid gland to the facial nerve, which runs through the gland dividing it into superficial and deep lobes. This anatomy explains several key points. First, a facial-nerve palsy in a patient with a parotid lump is an ominous sign strongly suggesting malignancy, because benign tumours displace but do not invade the nerve, whereas cancers infiltrate it. Second, the whole of parotid surgery is designed around identifying and preserving the facial nerve — a superficial parotidectomy removes the tumour with the superficial lobe while carefully dissecting out and protecting the nerve, since damaging it causes facial weakness. Third, it is why enucleation of a pleomorphic adenoma is avoided (it risks leaving tumour and recurrence) in favour of formal excision with a cuff of normal tissue. Appreciating that the facial nerve both signals malignancy when involved and governs the surgical approach is fundamental to understanding parotid tumours.
WHY THE '80% RULE' AND GLAND SIZE MATTER
The memorable 'rule of 80s' and the gland-size principle are worth understanding because they encapsulate the epidemiology and guide clinical suspicion. The rule — roughly 80% of salivary tumours are in the parotid, 80% of parotid tumours are benign, and 80% of these are pleomorphic adenomas — tells you that a parotid lump is most likely a benign pleomorphic adenoma, while still leaving a meaningful minority that are malignant. The complementary principle is that the smaller the gland, the greater the proportion of tumours that are malignant: a tumour of the parotid is usually benign, but one of the submandibular gland is more likely to be malignant, and one of a minor salivary gland (e.g. on the palate) more likely still. This means the index of suspicion for cancer rises as one moves from the parotid to the smaller glands, influencing how aggressively a lump is investigated and treated. These simple heuristics usefully frame the likelihood of malignancy at each site.
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DANGER / REMEMBER: A benign tumour is a slow, painless, mobile lump; sinister/malignant features are rapid growth, pain, a facial-nerve palsy (in the parotid — an ominous sign), fixation, skin involvement and nodes. Investigation is by FNAC and MRI/CT (extent, facial nerve) — avoiding incisional biopsy of the parotid (tumour seeding/facial-nerve injury). Management: benign parotid → superficial/total parotidectomy (preserving the facial nerve); malignant → parotidectomy (± nerve sacrifice if involved) + neck dissection + radiotherapy; submandibular → gland excision.
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CLINICAL PEARL: Salivary tumours — most in the parotid, most benign; rule: smaller gland → higher malignancy. Commonest = pleomorphic adenoma (parotid; slow, painless, mobile; recurrence/malignant change; treat by superficial parotidectomy). Warthin's (older male smokers, bilateral). Malignant: mucoepidermoid (commonest malignancy), adenoid cystic (submandibular/minor, perineural spread). Sinister signs: pain, facial-nerve palsy, rapid growth, fixation. FNAC + MRI; avoid incisional biopsy; parotidectomy preserving the facial nerve.
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KEY POINTS (viva)
Salivary tumours: ~80% parotid, ~80% of those benign, ~80% of benign = pleomorphic adenoma; smaller gland → higher malignancy risk.
Benign: pleomorphic adenoma (commonest; parotid; slow/painless/mobile; recurrence [pseudopods], malignant change → carcinoma ex-pleomorphic; superficial parotidectomy, NOT enucleation); Warthin's (adenolymphoma — older male smokers, may be bilateral, cystic).
FNAC + MRI/CT; avoid incisional biopsy; parotidectomy preserving the facial nerve (± neck dissection/RT for malignancy).
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat; Scott-Brown's Otorhinolaryngology.
THE CONCEPT
Cervical lymphadenopathy (enlargement of the neck lymph nodes) is the commonest neck swelling. Causes range from benign reactive nodes to serious disease (TB, lymphoma, metastatic cancer), so the approach must exclude malignancy and tuberculosis.
Cervical lymph-node levels
I
II
III
IV
V
VI
submental / submandibular
uppermidlowerjugular chain
posterior triangle
central
The level of a node helps point to the likely primary site
The cervical lymph-node levels (I–VI): level I (submental/submandibular), levels II–IV along the jugular chain (upper, mid, lower), level V (posterior triangle) and level VI (central). The level of an involved node helps point to the likely primary site.
NODE LEVELS & CAUSES
The node levels (I–VI: I submental/submandibular; II–IV the deep cervical/jugular chain; V posterior triangle; VI central) help point to the likely primary. Causes:
Infective — acute (bacterial/viral); chronic: tuberculosis (very common in India — matted nodes, cold abscess, sinus, caseation), infectious mononucleosis, HIV, cat-scratch, toxoplasmosis.
Neoplastic — lymphoma (Hodgkin/non-Hodgkin — rubbery, painless, multiple, ± B symptoms: fever, night sweats, weight loss); metastatic (hard, fixed — from a head-and-neck SCC, the level guiding the primary; or Virchow's node, from GI/lung).
ASSESSMENT
Assessment: history (duration, tenderness, systemic symptoms, TB contact, risk factors), examination (level, consistency, matting, a full head-and-neck examination), FNAC (the key test), ultrasound, CT/MRI, a TB work-up and blood tests. For a suspected tuberculous node — FNAC/AFB/culture; for a suspected metastatic node — find the primary (panendoscopy); for suspected lymphoma — an excision biopsy (the architecture is needed).
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CLINICAL PEARL: Cervical lymphadenopathy = the commonest neck swelling. Causes: reactive (commonest — tender, resolving); infective (TB — matted nodes/cold abscess, common in India; EBV, HIV); neoplastic (lymphoma — rubbery, B symptoms; metastatic — hard/fixed, head-and-neck SCC; Virchow's node = GI/lung). The node level guides the primary. FNAC = the key test (excision biopsy for lymphoma). An adult with a persistent hard node = metastatic until proven otherwise → find the primary.
WHY THE NODE LEVEL POINTS TO THE PRIMARY
A clinically valuable concept is that the level (position) of an enlarged cervical node helps localise the likely primary source, because lymphatic drainage follows predictable pathways. Different regions of the head and neck drain to specific node groups — for example, the oral cavity and face to the submandibular/submental nodes (level I), the oropharynx, larynx and thyroid to the jugular chain (levels II–IV), the nasopharynx to the upper deep cervical and posterior triangle, and — importantly — a node in the left supraclavicular fossa (Virchow's node) to abdominal or thoracic malignancy. So when a metastatic node is found, its level directs the search for the primary tumour to the regions that drain to it. This orderly relationship between drainage and node level is why the examining clinician notes exactly which level is involved, and it structures the subsequent panendoscopic search for an occult primary — making the node level far more than an anatomical curiosity.
WHY TUBERCULOSIS IS A KEY CONSIDERATION
In many parts of the world, and especially in India, tuberculosis is one of the most important causes of chronic cervical lymphadenopathy and deserves particular emphasis. Tuberculous nodes (scrofula) characteristically present as firm, initially discrete nodes that become matted together, may break down into a cold abscess (an abscess without the usual heat/redness of acute inflammation), and can discharge through the skin as a chronic sinus. Recognising this pattern is important because it is common, treatable and infectious, yet can mimic malignancy. The diagnosis is confirmed by FNAC (showing caseating granulomas), staining and culture for acid-fast bacilli, and evidence of TB elsewhere, and it responds well to standard anti-tuberculous therapy rather than surgery. Keeping tuberculosis high on the differential for a chronic neck node — particularly matted nodes or a cold abscess in an endemic area — prevents both missed diagnoses and the inappropriate surgical treatment of what is a medical disease.
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KEY POINTS (viva)
Cervical node levels: I submental/submandibular; II–IV deep cervical/jugular chain (upper/mid/lower); V posterior triangle; VI central. Level guides the likely primary.
Causes: reactive (commonest — tender/mobile/resolving); infective — acute + chronic (TB: matted nodes, cold abscess, sinus, caseation — common in India; infectious mononucleosis, HIV, cat-scratch, toxoplasmosis); neoplastic — lymphoma (rubbery, painless, multiple, B symptoms) and metastatic (hard, fixed — head & neck SCC; Virchow's node = GI/lung).
Ix: history + full head & neck exam; FNAC = key; ultrasound, CT/MRI; TB work-up (AFB/culture). Tuberculous → FNAC/AFB; metastatic → find primary (panendoscopy); lymphoma → EXCISION biopsy (architecture). Persistent hard adult node = metastatic until proven otherwise.
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KEY POINTS TO REMEMBER
Cervical lymphadenopathy = commonest neck swelling; approach must exclude malignancy and TB.
Node levels I–VI (I submental/submandibular, II–IV jugular chain, V posterior triangle, VI central) point to the primary.
Reactive (commonest, tender, resolves); TB (matted nodes/cold abscess — common in India); EBV/HIV.
Lymphoma (rubbery, painless, B symptoms); metastatic (hard, fixed — head & neck SCC; Virchow's node = GI/lung).
FNAC = key test; excision biopsy for suspected lymphoma; persistent hard adult node = metastatic until proven otherwise → find the primary.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Salivary calculi (sialolithiasis) are stones in the salivary ducts/glands, mostly in the submandibular gland, and a common cause of obstructive sialadenitis (inflammation of a salivary gland).
Submandibular calculus
mandible
submandibular gland
Wharton's duct → floor of mouth
stone
~80% of stones are submandibular (thick saliva, uphill duct,
usually radio-opaque)
Meal-time syndrome: painful gland swelling on eating
About 80% of salivary calculi form in the submandibular gland/Wharton's duct — favoured by its thick mucous saliva and its uphill duct against gravity — and are usually radio-opaque. Obstruction gives the 'meal-time syndrome' of painful gland swelling on eating.
SIALOLITHIASIS
About 80% of stones form in the submandibular gland/Wharton's duct — favoured by its thick mucous saliva, its uphill duct against gravity, and its longer duct — and are usually radio-opaque. The characteristic feature is the 'meal-time syndrome': painful swelling of the gland during/before eating (as saliva flow is obstructed), settling afterwards; it is recurrent and may become infected. Diagnosis is by palpation (a stone in the duct/floor of mouth), X-ray (radio-opaque), sialography, ultrasound, CT or sialendoscopy; management is conservative (hydration, sialogogues, massage, transoral removal if distal), sialendoscopy, or gland excision if recurrent/intraglandular.
SIALADENITIS
WHY STONES FAVOUR THE SUBMANDIBULAR GLAND
A frequently-examined point is why salivary stones form so much more often in the submandibular gland than the parotid, and it follows from the gland's anatomy and secretions. Three factors conspire: the submandibular saliva is thicker and more mucous (and more alkaline, with more calcium), making it more prone to precipitate and form stones; its duct (Wharton's duct) runs upward and forward, so saliva must flow against gravity, encouraging stasis; and the duct is long and its opening relatively narrow. Together these favour stagnation and calculus formation in the submandibular system. The parotid, by contrast, produces thinner serous saliva through a shorter, more favourably-angled duct, so parotid stones are much rarer (and, when they occur, more often radiolucent). Understanding these anatomical and secretory reasons explains the striking predominance of submandibular calculi and why a stone should be actively sought in a submandibular gland that swells at mealtimes.
WHY THE MEAL-TIME PATTERN IS DIAGNOSTIC
The characteristic 'meal-time syndrome' is so useful because it directly reflects the obstructive mechanism of a salivary stone. When a stone partially or completely blocks the duct, the surge of saliva produced in response to food (or even the sight/smell of it) cannot escape, so it backs up and distends the gland, causing painful swelling that develops around eating and then gradually subsides as the saliva slowly drains or is reabsorbed. This produces the classic history of a gland that swells painfully with meals and settles afterwards, recurring predictably. Because this pattern points so specifically to ductal obstruction, eliciting it in the history strongly suggests a salivary calculus (or stricture) and directs examination toward palpating the duct and imaging for a stone. The meal-time relationship is therefore a small but powerful diagnostic clue, and its presence in a submandibular swelling should prompt a search for a stone before other causes are considered.
THE BOTTOM LINE
Salivary calculi mostly form in the submandibular gland because of its thick saliva and uphill duct, causing the meal-time syndrome and obstructive sialadenitis, and are managed by removing the stone or, if recurrent, the gland; sialadenitis is otherwise acute bacterial, viral (mumps) or chronic.
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DANGER / REMEMBER:Sialadenitis may be: acute bacterial/suppurative (e.g. acute parotitis in a dehydrated/elderly/post-operative patient — Staph aureus — with a painful, swollen, tender gland, pus from the duct and fever; treated with antibiotics, hydration and sialogogues); viral (mumps — bilateral parotid); or chronic/recurrent (from obstruction — stone/stricture — or autoimmune Sjögren's). Abscess formation is a complication.
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CLINICAL PEARL: Salivary calculi — ~80% in the submandibular gland/Wharton's duct (thick saliva, uphill duct, radio-opaque) → 'meal-time syndrome' (painful gland swelling on eating). Diagnose: palpation, X-ray, sialendoscopy. Treat: hydration/sialogogues/massage, transoral removal or sialendoscopy; gland excision if recurrent. Sialadenitis: acute bacterial (parotid; dehydrated/post-op; Staph — antibiotics), viral (mumps), chronic (obstruction/Sjögren's).
Salivary calculi: ~80% in the submandibular gland/Wharton's duct (thick saliva, uphill duct; usually radio-opaque).
Meal-time syndrome: painful gland swelling on/before eating, settling afterwards; recurrent, may get infected.
Diagnose: palpation, X-ray, ultrasound, sialendoscopy; treat with hydration/sialogogues/massage, transoral removal or sialendoscopy; gland excision if recurrent.
Acute bacterial sialadenitis: parotid, dehydrated/post-op, Staph aureus; painful tender gland + pus from duct → antibiotics/hydration.
Also viral (mumps — bilateral parotid) and chronic (obstruction/Sjögren's) sialadenitis; abscess is a complication.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
An oesophageal foreign body is an object impacted in the oesophagus — common in children (coins) and adults (food bolus/bones/dentures). It lodges at the sites of anatomical narrowing and can be an emergency (obstruction, perforation).
SITES & OBJECTS
Cricopharynx (the narrowest, at C6, ~15 cm) — the commonest site.
The level of the aortic arch/left main bronchus (~25 cm).
The lower oesophageal sphincter/diaphragm (~40 cm).
Common objects: coins (children — commonest), button batteries (dangerous!), food bolus/meat, bones (fish/chicken) and dentures (adults).
FEATURES, INVESTIGATION & MANAGEMENT
WHY THE BUTTON BATTERY IS A SPECIAL EMERGENCY
Among all oesophageal foreign bodies, the button (disc) battery deserves special emphasis because it is uniquely and rapidly dangerous. Unlike an inert coin, a lodged battery generates a local electrical current and leaks alkaline contents, causing a liquefactive (caustic) burn of the oesophageal wall that can progress within hours to full-thickness necrosis and perforation, with catastrophic complications such as mediastinitis or an aorto-oesophageal fistula. This is why a suspected or confirmed oesophageal button battery is treated as an immediate emergency requiring urgent endoscopic removal — there is no place for a period of observation. On X-ray it can be recognised by its 'double-ring' or 'halo' appearance, distinguishing it from a coin. Because these small batteries are ubiquitous in toys and household devices and are easily swallowed by toddlers, awareness of their special danger — and the need for immediate action — is a critically important public-health and clinical message.
WHY DROOLING AND INABILITY TO SWALLOW SALIVA MATTER
A key clinical sign in oesophageal foreign body is the inability to swallow even saliva, with resulting drooling, because it signals a high-grade or complete obstruction that needs urgent action. When the oesophagus is completely blocked, saliva cannot pass into the stomach, so it pools and overflows as drooling — the patient reports that they cannot get anything, even their own spit, down. This is important for two reasons: it indicates a complete obstruction requiring prompt removal of the object (rather than watchful waiting), and the pooled saliva in a blocked oesophagus poses an aspiration risk to the airway. So a patient who is drooling and cannot swallow their saliva after ingesting a foreign body should be moved quickly toward endoscopic removal. Recognising this sign helps distinguish the urgent, completely-obstructed case from a partial obstruction that may allow a little more time, and it is a useful piece of clinical triage.
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DANGER / REMEMBER: Features: sudden onset after swallowing, dysphagia, odynophagia, drooling (unable to swallow saliva), a sensation of something stuck and retrosternal pain (with respiratory symptoms in children from airway compression). Complications are obstruction, mucosal injury, perforation (mediastinitis, surgical emphysema) and aspiration. A button battery is an emergency (electrical/caustic liquefaction necrosis → perforation — remove urgently). Investigation: X-ray (a radio-opaque object; the button battery shows a 'double-ring/halo' sign; fish bones are often radiolucent) and CT — avoiding barium if perforation is suspected or before endoscopy. Management: rigid/flexible oesophagoscopy under GA is definitive (urgent for button batteries, sharp objects, complete obstruction or airway compromise); a smooth object in the stomach may pass spontaneously (observe); treat any perforation (surgery, antibiotics).
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CLINICAL PEARL: Oesophageal foreign body — lodges at narrowings; the cricopharynx is the commonest site. Coins (children), food bolus/bones/dentures (adults). Dysphagia, drooling, retrosternal pain. A button battery = emergency (caustic/electrical necrosis → perforation) — remove urgently. X-ray (radio-opaque; fish bones often radiolucent; battery = halo sign); avoid barium if perforation suspected. Definitive: rigid oesophagoscopy under GA; watch for perforation/mediastinitis.
X-ray (radio-opaque; battery = halo sign; fish bones often radiolucent); avoid barium if perforation suspected.
Definitive treatment = rigid oesophagoscopy under GA; watch for perforation/mediastinitis; a smooth object in the stomach may pass.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
A thyroglossal cyst is the commonest congenital midline neck swelling, arising from a remnant of the thyroglossal duct (the thyroid's line of descent from the foramen cecum at the tongue base to the neck).
Thyroglossal cyst
tongue base
foramen cecum
hyoid
cyst
moves up ontongue protrusion
Midline; treated by Sistrunk operation (cyst + tract + central hyoid)
A thyroglossal cyst arises from the remnant of the thyroglossal duct (the thyroid's line of descent from the foramen cecum at the tongue base). It is a midline swelling that classically moves upward on protrusion of the tongue, and is treated by the Sistrunk operation (excising the cyst, the tract and the central hyoid).
FEATURES & MANAGEMENT
It is a midline (or just off-midline) cystic swelling, usually at/below the hyoid, that classically moves upward on protrusion of the tongue (and on swallowing) — owing to its attachment to the tract. It presents in children/young adults and may become infected or form a fistula. Investigation is by ultrasound (to confirm a normal thyroid is present — the cyst may contain the only functioning thyroid tissue) and thyroid function tests. Management is the Sistrunk operation (excision of the cyst, the tract and the central portion of the hyoid — which reduces recurrence).
A NOTE ON THE SISTRUNK OPERATION
The reason a thyroglossal cyst is treated by the Sistrunk operation rather than simple cyst excision is important and frequently tested. The cyst is connected by the thyroglossal tract, which passes intimately through (or very close to) the body of the hyoid bone up to the foramen cecum at the tongue base. If only the visible cyst is removed and the tract is left behind, the residual epithelial tract very commonly leads to recurrence. The Sistrunk operation therefore removes the cyst together with the entire tract and the central portion of the hyoid bone through which it runs, dramatically reducing the recurrence rate. This is a good example of how understanding the embryological anatomy — the line of descent of the thyroid — directly dictates the correct surgical procedure, and why simply 'removing the lump' is inadequate for a lesion with an embryological tract.
THE BOTTOM LINE
A thyroglossal cyst is the commonest midline congenital neck swelling, moving up on tongue protrusion, and is treated by the Sistrunk operation to remove the tract and prevent recurrence.
THE BOTTOM LINE
A thyroglossal cyst is the commonest congenital midline neck swelling, moving up on tongue protrusion, and is treated by the Sistrunk operation to remove the tract and prevent recurrence.
It is also worth noting that a thyroglossal cyst can occasionally become infected, presenting as a painful, red midline swelling, or discharge to form a thyroglossal fistula, and that — although rare — thyroid carcinoma can arise within one, which is another reason the cyst and its tract are excised and examined rather than merely drained.
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KEY POINTS TO REMEMBER
Thyroglossal cyst = commonest congenital midline neck swelling; from a thyroglossal duct remnant (foramen cecum to neck).
Midline cystic swelling (at/below the hyoid) that classically moves up on tongue protrusion (and swallowing).
May get infected or form a fistula; confirm a normal thyroid on ultrasound (cyst may hold the only thyroid tissue).
Treated by the Sistrunk operation (cyst + tract + central hyoid) to reduce recurrence.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
A branchial cyst is a congenital lateral neck cyst arising from remnants of the branchial (pharyngeal) apparatus (usually the 2nd branchial cleft).
Branchial cyst
sternocleido-mastoid
upper ⅓
cyst
at the junction of the upper⅓ and lower ⅔ of the SCM
In an older adult, exclude a cystic metastatic node
A branchial cyst (usually a 2nd-cleft remnant) presents as a smooth, fluctuant swelling at the junction of the upper third and lower two-thirds of the sternocleidomastoid, deep to its anterior border, in a young adult. In an older adult a 'branchial cyst' must be viewed with suspicion for a cystic metastatic node.
FEATURES & MANAGEMENT
It presents as a smooth, fluctuant, non-tender swelling at the junction of the upper third and lower two-thirds of the sternocleidomastoid (deep to its anterior border), in a young adult; it may enlarge after a URI or become infected. The fluid contains cholesterol crystals (on FNAC), and it may be associated with a branchial fistula/sinus. Management is surgical excision.
A NOTE ON THE MALIGNANT MIMIC IN OLDER ADULTS
The most important caution with a branchial cyst is that, in an older adult, an apparent 'branchial cyst' may in fact be a cystic metastatic lymph node and must not be assumed benign. Metastatic squamous carcinoma — particularly from an HPV-related oropharyngeal (tonsil/tongue-base) primary — characteristically produces cystic neck nodes that can closely mimic a branchial cyst in appearance and even on initial cytology. Treating such a lump as a simple congenital cyst risks a serious delay in diagnosing a cancer. This is why a truly congenital branchial cyst is expected in a young adult, whereas a new 'branchial cyst' appearing in a patient over about 40 is investigated for malignancy — with careful examination of the oropharynx, imaging and appropriate cytology/biopsy. Remembering that the branchial cyst has a dangerous malignant mimic in the older patient is the single most important clinical point about this otherwise benign congenital lesion.
THE BOTTOM LINE
A branchial cyst is a congenital lateral cyst at the upper sternocleidomastoid in a young adult, excised surgically, but in an older adult it must be viewed with suspicion for a cystic metastatic node.
THE BOTTOM LINE
A branchial cyst is a congenital lateral cyst at the upper sternocleidomastoid in a young adult, excised surgically, but in an older adult it must be viewed with suspicion for a cystic metastatic node.
It is also worth noting that a branchial sinus or fistula, representing a persistent tract of the branchial apparatus opening onto the lower neck skin, may accompany or occur instead of a cyst, and that such a discharging opening in the neck of a child similarly points to a branchial-arch anomaly requiring surgical excision of the whole tract.
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DANGER / REMEMBER: In an older adult, a 'branchial cyst' must be viewed with suspicion for a cystic metastatic node (e.g. from an HPV-related oropharyngeal cancer) — investigate accordingly.
Smooth, fluctuant, non-tender swelling at the junction of the upper 1/3 and lower 2/3 of the SCM (anterior border), in a young adult.
FNAC shows cholesterol crystals; may enlarge after a URI or get infected; may have a fistula/sinus.
Treated by surgical excision; in an older adult, exclude a cystic metastatic node (e.g. HPV oropharyngeal cancer).
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
A cystic hygroma (lymphangioma) is a congenital malformation of lymphatic vessels, presenting as a soft cystic neck swelling, usually in the posterior triangle, in infants/young children (often present at birth or by age 2).
FEATURES & MANAGEMENT
It is a soft, painless, fluctuant, compressible mass that classically brilliantly transilluminates; it can be large, may cause disfigurement or airway/feeding compression, and may enlarge with infection or haemorrhage. Investigation is by ultrasound/MRI (extent) and transillumination. Management is surgical excision (which can be difficult — it is infiltrative) and/or sclerotherapy (e.g. OK-432/picibanil, bleomycin), with observation for small lesions (some regress).
A NOTE ON WHY IT TRANSILLUMINATES
The characteristic sign that a cystic hygroma brilliantly transilluminates is diagnostically valuable and worth understanding. Because the lesion is a collection of thin-walled, fluid-filled lymphatic channels containing clear lymph, light shines through it readily — shining a torch against the swelling in a darkened room makes the whole mass glow, far more brightly than a solid or blood-filled lump would. This brilliant transillumination, together with its soft, compressible feel and its typical location in the posterior triangle of an infant, strongly suggests the diagnosis at the bedside. The sign is a nice example of how a simple, equipment-free clinical test can point to the nature of a swelling. It also helps distinguish a cystic hygroma from solid neck masses, which do not transilluminate, and reinforces the general principle that the physical characteristics of a neck lump — here its translucency — carry real diagnostic weight.
THE BOTTOM LINE
A cystic hygroma is a congenital lymphatic malformation of the posterior triangle in infants that brilliantly transilluminates and is treated by excision or sclerotherapy.
THE BOTTOM LINE
A cystic hygroma is a congenital lymphatic malformation of the posterior triangle in infants that brilliantly transilluminates and is treated by excision or sclerotherapy.
It is also worth noting that, because a cystic hygroma is infiltrative and interdigitates with surrounding structures such as nerves and vessels, complete surgical excision can be difficult and carries a risk of recurrence and injury, which is why injection sclerotherapy has become an important and often first-choice alternative, particularly for large or awkwardly-placed lesions.
A useful additional point is that the term 'cystic hygroma' is often used for the classic large multicystic neck lesion of infancy, while 'lymphangioma' or 'lymphatic malformation' is the broader term for these malformations of lymphatic vessels wherever they occur, so the two names refer to essentially the same underlying abnormality.
SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
A ranula is a mucous retention cyst/mucocele of the floor of the mouth, arising from the sublingual (or minor) salivary gland (obstruction/extravasation of saliva).
FEATURES & MANAGEMENT
It is a soft, bluish, translucent, cystic swelling in the floor of the mouth, to one side of the frenulum (resembling a frog's belly — 'rana'). A plunging (cervical) ranula extends/herniates through the mylohyoid muscle into the neck, presenting as a neck swelling. Management is excision of the ranula together with the sublingual gland (marsupialisation has a higher recurrence rate); a plunging ranula requires excision of the gland.
A NOTE ON THE PLUNGING RANULA
An important variant to understand is the plunging (cervical) ranula, because it explains how a lesion of the floor of the mouth can present as a neck swelling. Ordinarily a ranula is confined to the floor of the mouth, but if the extravasated mucus tracks backward and herniates through or around the mylohyoid muscle, it can descend (plunge) into the neck, presenting as a soft swelling in the upper neck that may have little or no obvious intra-oral component. Recognising this is important because such a neck swelling could otherwise be mistaken for another cystic neck lesion. The key to treatment, for both the simple and plunging forms, is that removing the associated sublingual gland (the source of the leaking saliva) is necessary to prevent recurrence — simply draining or marsupialising the cyst leaves the gland to produce more saliva and the ranula tends to return. Understanding its origin from the sublingual gland thus explains both the plunging variant and the rationale for gland excision.
THE BOTTOM LINE
A ranula is a mucous cyst of the floor of mouth from the sublingual gland, which may plunge into the neck, and is treated by excision of the ranula with the gland to prevent recurrence.
THE BOTTOM LINE
A ranula is a mucous cyst of the floor of mouth from the sublingual gland, which may plunge into the neck, and is treated by excision of the ranula with the gland to prevent recurrence.
It is also worth noting that the term ranula derives from the Latin for 'little frog', reflecting the translucent, bluish swelling in the floor of the mouth that resembles the underside of a frog's belly — a descriptive name that neatly captures the characteristic clinical appearance and aids recognition.
A useful additional point is that the choice of operation matters for recurrence: because simple marsupialisation (unroofing the cyst) leaves the offending sublingual gland in place, the ranula tends to recur, whereas excising the gland along with the cyst addresses the source of the leaking saliva and gives a much lower recurrence rate.
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KEY POINTS TO REMEMBER
Ranula = mucous retention cyst/mucocele of the floor of mouth from the sublingual (or minor) salivary gland.
Soft, bluish, translucent cystic swelling to one side of the frenulum (frog's-belly appearance).
Plunging (cervical) ranula herniates through the mylohyoid into the neck (presents as a neck swelling).
Rx: excision of the ranula with the sublingual gland (marsupialisation → higher recurrence).
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Mumps is an acute viral infection (the mumps virus, a paramyxovirus) causing parotid gland swelling (often bilateral), spread by droplets — the commonest cause of acute painful parotid swelling in children.
FEATURES, COMPLICATIONS & MANAGEMENT
There is painful swelling of the parotid(s) (bilateral, uplifting the ear lobe), fever, malaise and pain on eating, after an incubation of about 2–3 weeks.
A NOTE ON THE SYSTEMIC COMPLICATIONS
Although mumps is often thought of as a self-limiting childhood parotitis, its importance lies in its systemic complications, which can be serious and are the main reason for vaccinating against it. The virus is not confined to the salivary glands: it can cause orchitis in post-pubertal males (painful testicular inflammation that, if bilateral, may impair fertility), viral meningitis or encephalitis, pancreatitis, oophoritis and — relevant to ENT — sensorineural hearing loss, which is a recognised cause of acquired unilateral deafness. Because these complications can occur even in an otherwise mild case, and some (like deafness or subfertility) are permanent, prevention through the MMR vaccine is a public-health priority, and mumps remains a notifiable disease. Appreciating that mumps is a systemic viral illness with potentially lasting sequelae, rather than merely a swollen face, is the key learning point and underlines the value of immunisation.
THE BOTTOM LINE
Mumps is a viral parotitis whose importance lies in systemic complications such as orchitis, meningitis and sensorineural deafness, prevented by the MMR vaccine.
THE BOTTOM LINE
Mumps is a viral parotitis whose importance lies in systemic complications such as orchitis, meningitis and sensorineural deafness, prevented by the MMR vaccine.
It is also worth noting that the widespread use of the MMR vaccine has greatly reduced the incidence of mumps, so that a case today should prompt confirmation and notification, and that outbreaks can still occur in under-vaccinated communities, underlining the importance of maintaining high immunisation coverage.
A useful additional point is that the parotid swelling of mumps characteristically lifts the ear lobe upward and outward and fills in the hollow behind the angle of the jaw, a distribution that helps distinguish parotid enlargement from an enlarged cervical lymph node, which sits lower and behind the jaw.
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DANGER / REMEMBER: Complications include orchitis (post-pubertal males — subfertility), meningitis/encephalitis, pancreatitis, sensorineural hearing loss (a cause of acquired unilateral SNHL) and oophoritis. Diagnosis is clinical (± serology); management is supportive (analgesia, hydration, rest), and it is prevented by the MMR vaccine (it is a notifiable disease).
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KEY POINTS TO REMEMBER
Mumps = viral (paramyxovirus) parotitis; often bilateral parotid swelling; droplet spread; commonest acute painful parotid swelling in children.
Painful parotid swelling (uplifts the ear lobe), fever, malaise, pain on eating; incubation ~2–3 weeks.
SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Frey's syndrome is a complication of parotid surgery (or trauma) characterised by sweating and flushing of the pre-auricular/cheek skin during eating (gustatory stimulation).
MECHANISM, DIAGNOSIS & MANAGEMENT
The mechanism is aberrant regeneration: after parotidectomy, the severed parasympathetic (secretomotor) fibres of the auriculotemporal nerve (meant for the parotid) re-grow and connect instead to the sweat glands and vessels of the overlying skin — so salivary stimulation (eating) causes sweating/flushing rather than salivation. It appears weeks–months after surgery. Diagnosis is by Minor's starch-iodine test; management is antiperspirants (aluminium chloride), topical anticholinergics, botulinum toxin (effective) or, rarely, surgery.
A NOTE ON PREVENTION AND MANAGEMENT
A useful additional point about Frey's syndrome is that, being an understood and often preventable complication, it can be anticipated and managed in several ways. Because it results from the cut parasympathetic fibres reconnecting with skin sweat glands, placing a barrier between the raw parotid bed and the overlying skin at the time of surgery — for example an interpositional flap or graft — can reduce its incidence. When it does develop, it is usually diagnosed with Minor's starch-iodine test, which turns the sweating skin blue-black and maps the affected area. For treatment, many patients are only mildly bothered and need reassurance, while those troubled by it respond well to topical antiperspirants or anticholinergics and, most effectively, to injections of botulinum toxin, which block the aberrant cholinergic stimulation of the sweat glands. Understanding both the preventive strategies and this ladder of treatment rounds out the picture of a characteristic post-parotidectomy complication.
THE BOTTOM LINE
Frey's syndrome is gustatory sweating after parotidectomy from aberrant nerve regeneration, diagnosed by the starch-iodine test and treated effectively with botulinum toxin.
THE BOTTOM LINE
Frey's syndrome is gustatory sweating after parotidectomy from aberrant nerve regeneration, diagnosed by the starch-iodine test and treated effectively with botulinum toxin.
It is also worth noting that Frey's syndrome, although troublesome, is not dangerous, and that many patients need only reassurance once the harmless nature of the gustatory sweating is explained — with active treatment reserved for those in whom the sweating and flushing are socially distressing.
A useful additional point is that the interval between the parotid surgery and the onset of symptoms — typically several weeks to months — reflects the time needed for the severed nerve fibres to regenerate and reach the skin, so a patient developing gustatory sweating some months after a parotidectomy has the classic time course of Frey's syndrome.
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KEY POINTS TO REMEMBER
Frey's syndrome = gustatory sweating/flushing of the pre-auricular skin after parotid surgery/trauma.
Mechanism: aberrant regeneration — severed auriculotemporal (parasympathetic) fibres reconnect to skin sweat glands → eating triggers sweating instead of salivation.
Appears weeks–months post-parotidectomy; diagnosed by Minor's starch-iodine test.
SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
A carotid body tumour (chemodectoma/paraganglioma) is a rare, usually benign, slow-growing tumour of the carotid body (a chemoreceptor at the carotid bifurcation).
FEATURES & MANAGEMENT
It is a painless, slow-growing, pulsatile (transmitted) neck mass at the carotid bifurcation (upper neck), classically mobile side-to-side but not up-and-down (fixed to the carotid), sometimes with a bruit; it splays the carotid bifurcation. It may be familial/multiple and (rarely) functional (catecholamines).
A NOTE ON WHY BIOPSY IS AVOIDED
The most important safety point with a carotid body tumour is that it must not be biopsied, because it is highly vascular and sits directly on the carotid vessels. Attempting a needle or incisional biopsy risks serious, difficult-to-control haemorrhage, and it is unnecessary because the diagnosis can be made by imaging — characteristically CT or MR angiography showing a vascular mass splaying the carotid bifurcation (the 'lyre sign'). This is why any pulsatile mass at the carotid bifurcation, mobile side-to-side but not up-and-down, should raise the suspicion of a carotid body tumour and prompt imaging rather than biopsy. The same vascularity that makes biopsy dangerous also makes surgical removal a specialist vascular procedure carrying risks of stroke and cranial-nerve injury, often preceded by embolization to reduce bleeding. Remembering 'don't biopsy a pulsatile neck mass' is the key take-home message, mirroring the same rule applied to other vascular head-and-neck tumours such as the juvenile angiofibroma.
THE BOTTOM LINE
A carotid body tumour is a vascular paraganglioma at the carotid bifurcation, diagnosed by angiography (lyre sign) and never biopsied, and treated by specialist surgical excision.
THE BOTTOM LINE
A carotid body tumour is a vascular paraganglioma at the carotid bifurcation, diagnosed by angiography (lyre sign) and never biopsied, and treated by specialist surgical excision.
It is also worth noting that carotid body tumours may be familial and multiple, sometimes occurring as part of a paraganglioma syndrome, so a diagnosis in one patient may prompt screening for further lesions and consideration of a genetic cause, particularly in younger patients or those with a family history.
A useful additional point is that, because these tumours grow slowly and are usually benign, management is individualised: excision is favoured in younger, fitter patients to prevent progression and cranial-nerve involvement, whereas observation or radiotherapy may be preferred in the elderly or for surgically risky lesions, balancing the risks of intervention against those of the tumour.
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DANGER / REMEMBER: Investigation is by duplex ultrasound and CT/MR angiography (the 'lyre sign' — splaying of the internal and external carotids); biopsy is avoided (it is vascular — bleeding risk). Management is surgical excision (vascular surgery; risk of stroke/cranial-nerve injury) ± pre-operative embolization, with radiotherapy for unresectable disease.
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KEY POINTS TO REMEMBER
Carotid body tumour (chemodectoma/paraganglioma) = rare tumour of the carotid body (chemoreceptor at the carotid bifurcation).
Painless, slow-growing, pulsatile mass; mobile side-to-side but NOT up-down (fixed to the carotid); may have a bruit.
Ix: duplex ultrasound, CT/MR angiography ('lyre sign' — splayed carotids); do NOT biopsy (vascular — bleeding).
Rx: surgical excision (± pre-op embolization; risk of stroke/nerve injury); radiotherapy for unresectable disease.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.