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ENT: Neoplasms, Oral Cavity Lesions & Tonsil Disorders

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PART 1 - Benign and Malignant Neoplasms of the Nose and Paranasal Sinuses (PNS)

Key Clinical Points

• Unilateral nasal blockage, discharge, and bleeding are the classic presenting symptoms of nasal/sinus tumors.
• Almost 50% of sinonasal cancers arise on the lateral nasal wall; 33% in the maxillary antrum.
• Management of malignant sinonasal tumors requires a multidisciplinary team (ENT, maxillofacial, oncology).

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A. BENIGN TUMORS

1. Nasal Polyps

• Recurrent rhinitis leads to focal mucosal protrusions - polyps can reach 3-4 cm.
• Histology: edematous mucosa with loose stroma, hyperplastic/cystic mucus glands, neutrophil and eosinophil infiltrates.
• Despite an allergic appearance, most patients are NOT atopic; only 0.5% of atopic patients develop polyps.
• When large, they obstruct the airway and impair sinus drainage.
• Unilateral polyposis raises suspicion for antrochoanal polyp, inverted papilloma, or malignancy - early biopsy is recommended.

2. Antrochoanal Polyp

• Benign mucosal polyp arising in the maxillary antrum that prolapses into the nasal cavity and expands posteriorly into the nasopharynx.
• Relatively uncommon; dumbbell-shaped on imaging (antrum + choanal component).
• Treatment: surgical excision (Caldwell-Luc approach or endoscopic).

3. Osteoma

• Most commonly found in the frontal and ethmoid sinuses.
• Usually asymptomatic; found incidentally on imaging.
• If symptomatic (pain, obstruction, mucocele formation): surgical removal.

4. Inverted Papilloma (Schneiderian Papilloma)

• Benign but locally aggressive; presents as a unilateral polyp.
• Key features: HPV association; inverted growth pattern into underlying stroma.
• Important: has malignant potential (up to 10% undergo squamous cell carcinoma transformation).
• Treatment: complete surgical excision (medial maxillectomy); recurrence is common with incomplete removal.

5. Sinonasal Angiofibroma (Juvenile Nasopharyngeal Angiofibroma - JNA)

• Richly vascular tumor occurring almost exclusively in adolescent males.
• Classic presentation: recurrent epistaxis in a teenage boy.
• Arises from fibrovascular stroma of the posterolateral wall/roof of the nasal cavity.
• Histology: numerous vessels embedded in a dense collagenous stroma.
• Locally aggressive - can extend intracranially; recurrence rate ~20%; 9% can be fatal.
• Molecular: CTNNB1 mutations (encoding beta-catenin) in the majority of sporadic cases.
• Treatment: surgical removal, usually with preoperative embolization to reduce bleeding.

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B. MALIGNANT TUMORS

1. Squamous Cell Carcinoma (SCC)

• Most common malignant tumor of the nose and sinuses.
• Risk factors: tobacco, occupational exposure (wood dust, nickel, chromium).
• Late presentation is common due to the silent nature of the sinuses.

2. Esthesioneuroblastoma (Olfactory Neuroblastoma)

• Arises from the olfactory neuroepithelium of the cribriform plate.
• Presents with nasal obstruction, epistaxis, anosmia.
• Staged using the Kadish system (A: nasal cavity; B: PNS; C: beyond).
• Treatment: combined surgery + radiotherapy; chemo for advanced disease.

3. Sinonasal Papilloma - Malignant Transformation

• Inverted papilloma with associated SCC is treated with radical resection.

4. Adenocarcinoma

• Associated with wood dust exposure (particularly furniture workers).
• Arises predominantly in the ethmoid sinuses.

5. Nasopharyngeal Carcinoma (NPC)

• Associated with EBV, especially the undifferentiated type (WHO Type III).
• Endemic in East/Southeast Asia, North Africa.
• Presents with cervical lymphadenopathy (often first sign), nasal obstruction, epistaxis, unilateral serous otitis media (eustachian tube obstruction).
• Treatment: radiotherapy (primary modality) ± chemotherapy; surgery rarely curative.

6. Extranodal NK/T-cell Lymphoma (Nasal Type)

• Tumor cells harbor EBV.
• Primarily in males of Asian or Latin American descent (5th-6th decade).
• Necrotizing ulcerating lesions of the nose/upper airway.
• Rapidly fatal if untreated; localized cases may respond to radiotherapy.

7. Rhabdomyosarcoma

• Most common soft tissue sarcoma of the head and neck in children.
• Listed among sinonasal malignancies; embryonal type most common.

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PART 2 - Benign and Malignant Lesions of the Oral Cavity

Overview of Oral Cavity Diseases

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A. INFLAMMATORY/REACTIVE LESIONS

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B. ORAL MANIFESTATIONS OF SYSTEMIC DISEASE (Selected)

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C. PRECANCEROUS LESIONS

1. Leukoplakia

• White patch or plaque on oral mucosa that cannot be scraped off and cannot be classified as any other definable disease.
• Histology: ranges from simple hyperkeratosis to severe dysplasia or carcinoma in situ.
• Favored sites: buccal mucosa, floor of mouth, ventral tongue, palate, gingiva.
• Risk factors: tobacco (all forms), alcohol, betel/paan chewing (Asia), sunlight (lower lip).
• Malignant transformation rate: ~5-25% depending on dysplasia grade.
• Note: in India/Asia, chewing of betel quid/paan (areca nut, slaked lime, tobacco in betel leaf) is a major predisposing factor.

2. Erythroplakia

• Red, velvety patch on oral mucosa.
• More dangerous than leukoplakia: ~90% show severe dysplasia, carcinoma in situ, or minimally invasive carcinoma on histology.
• Intense subepithelial inflammatory reaction contributes to the red color.

Erythroplakia is clinically more sinister than leukoplakia - biopsy is mandatory.

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D. ODONTOGENIC CYSTS AND TUMORS

• Dentigerous (follicular) cyst - surrounds crown of unerupted tooth
• Radicular (periapical) cyst - most common jaw cyst; at root apex; sequel of dental caries
• Keratocystic odontogenic tumor (KCOT) - aggressive; lined by stratified squamous epithelium with parakeratosis; high recurrence rate
• Ameloblastoma - most common odontogenic neoplasm; locally aggressive but benign; arises from enamel organ remnants
• Epulis - generic term for a localized swelling on the gingiva (can be fibrous, giant cell, or pregnancy epulis)

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E. MALIGNANT LESIONS

Squamous Cell Carcinoma (SCC) of the Oral Cavity

• ~95% of head and neck cancers are SCC.
• Sixth most common malignancy worldwide; ~650,000 cases/year globally.
• Risk factors:
  • Tobacco + alcohol (classic, synergistic)
  • HPV-16/18 (especially oropharynx - up to 90% of tonsillar/base of tongue SCCs)
  • Betel nut/paan chewing
  • Actinic radiation (lower lip)
• Pathogenesis: TP53 mutations are most frequent; also CDKN2A, PIK3CA, NOTCH1, FAT1 loss-of-function mutations.
• HPV-negative vs HPV-positive: Different molecular profiles; HPV-positive tumors have better prognosis.
• Field cancerization: Years of carcinogen exposure leads to widespread mucosal damage, producing multiple independent primary tumors throughout the upper aerodigestive tract. New primaries develop at 3-7% per year - the highest rate among all malignancies.
• Prognosis: Early-stage (I/II): ~80% 5-year survival; Late-stage: ~20% 5-year survival. HPV-positive SCC has better long-term survival.

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PART 3 - Acute and Chronic Tonsillitis

Anatomy

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A. ACUTE TONSILLITIS

Etiology

• Most common causative organism: Group A beta-hemolytic Streptococcus (GABHS / Streptococcus pyogenes)
• Others: viruses (rhinovirus, echovirus, adenovirus, EBV, RSV), S. aureus, anaerobes
• Both viral and bacterial forms tend to resolve quickly without treatment

Clinical Features

• Short history of sore throat with fever
• Odynophagia (pain on swallowing)
• Examination: erythema of tonsils and posterior pharyngeal wall
• Exudates on tonsils (follicular tonsillitis - exudate from tonsillar crypts dotting enlarged tonsils)
• Tender jugulodigastric lymph node enlargement

Management

1. Symptomatic (first-line): analgesia + hydration
2. Antibiotics if no improvement within 48-72 hours, or if clinically severe from the outset:
   • Drug of choice: Benzyl penicillin (IV) or Phenoxymethylpenicillin (oral)
   • Avoid ampicillin/amoxicillin if EBV suspected (causes rash)
3. Corticosteroids (oral or IM) + antibiotics: expedite resolution of pain, especially in severe cases

Complications of Acute Tonsillitis

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B. PERITONSILLAR ABSCESS (QUINSY)

• Collection of pus lateral to the tonsil in the peritonsillar space
• Symptoms: severe unilateral sore throat, odynophagia, trismus (jaw stiffness), lymphadenopathy, muffled "hot potato" voice, uvular deviation to contralateral side
• Treatment:
  1. IV high-dose penicillin or cephalosporin
  2. Needle aspiration of pus (initial management of choice)
  3. Incision and drainage if aspiration fails
  4. Interval tonsillectomy if: recurrent quinsy on same side or history of recurrent tonsillitis

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C. RETROPHARYNGEAL ABSCESS

• Rare but serious; mainly in infants and children <5 years
• Infection tracks to lymphoid tissue between posterior pharyngeal wall and prevertebral fascia
• Features: systemically unwell child, airway compromise, neck abscess
• Diagnosis: CT scan
• Treatment: IV antibiotics first; incision and drainage (peroral approach, or external neck drainage) if pus confirmed; tracheostomy rarely needed
• Special: Tuberculosis-related RPA needs specific anti-TB treatment

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D. CHRONIC TONSILLITIS

• Results from repeated acute episodes; organisms include beta-hemolytic streptococci, anaerobes
• Features: Persistent or recurrent sore throat, halitosis, cryptic tonsils (debris-filled crypts), tonsillar scarring, mild cervical lymphadenopathy
• Histology: Reactive lymphoid hyperplasia, fibrosis of tonsillar tissue, bacterial debris in crypts

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PART 4 - Acute and Chronic Adenotonsillitis and Management

Adenoids (Nasopharyngeal Tonsil)

• Superior component of Waldeyer's ring
• Located at junction of roof and posterior wall of nasopharynx
• Physiologically enlarged in children (3-7 years); normally involute by adolescence
• Hypertrophy causes: nasal obstruction, snoring, sleep apnea, mouth breathing, "adenoid facies," hyponasal speech, and eustachian tube dysfunction (recurrent otitis media)

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Adenotonsillitis - Combined Disease

• Adenoidal hypertrophy + recurrent tonsillitis = adenotonsillitis
• Adenoid facies: open mouth, elongated face, crowded upper teeth, high-arched palate from chronic mouth breathing

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Indications for Tonsillectomy (Paradise/SIGN Criteria)

• Sore throats due to tonsillitis
• Episodes are disabling and prevent normal functioning
• Frequency threshold (any one of):
  • ≥7 episodes in the preceding year, OR
  • ≥5 episodes per year for each of 2 preceding years, OR
  • ≥3 episodes per year for each of 3 preceding years

• Obstructive sleep apnea (adenotonsillectomy is treatment of choice; improves in 90% of children, including behavior, growth, and development)
• Suspected malignancy (asymmetric tonsil with irregular/ulcerated surface)
• Recurrent quinsy (same side)

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Surgical Techniques for Tonsillectomy

• The Swedish National Tonsil Registry (37,530 patients) found cold steel dissection with ties had significantly lower bleed rates and less post-operative pain than energy-based techniques.
• The National Prospective Tonsillectomy Audit (NPTA) (UK, >50,000 patients) data guide current recommendations.

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Tonsillotomy (Partial Tonsillectomy)

• Removal of the bulk of tonsil tissue while leaving the capsule intact
• Used mainly for obstructive symptoms (OSA) rather than recurrent infections
• Lower pain and bleed risk than total tonsillectomy
• Recurrence of obstruction possible if residual tissue regrows

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Adenoidectomy

• Adenoidal hypertrophy causing nasal obstruction, mouth breathing, sleep apnea
• Recurrent/persistent otitis media with effusion (glue ear) - adenoidectomy ± grommets
• Recurrent rhinosinusitis

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Post-Tonsillectomy Hemorrhage

• Secondary hemorrhage is the most common (peak day 7-10).
• Management: IV antibiotics, re-exploration under GA if conservative measures fail.

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Key Takeaways Summary