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Throat 127
OSCE Counselling case
OSCE COUNSELLING CASE 2.15 –
A mother wonders when a child may
return to school after a tonsillectomy
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128 Ear, nose and throat (ENT)
Key concepts
Children have frequent viral respiratory infections.
Tonsillitis causing persistent school absences for at least 1 year should be considered before a
tonsillectomy is performed.
Adolescents may have infectious mononucleosis.
Smokers with sore throat and pain on swallowing may have a carcinoma.
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Throat 129
Answers
Clinical cases
CASE 2.16 –
Child with sore throat
A1: What is the likely differential diagnosis?
Tonsillitis
A2: What additional features in the history would you like to elicit?
As children have frequent sore throat, it is important to determine whether the symptoms are the result
of tonsillitis or simply a sore throat. This can be achieved by determining whether the tonsils swell up and
have exudate on them during an attack. Establish the length and frequency of the attacks; they should last
between 5 and 7 days and cause constitutional symptoms, and there should be six or more attacks a year
resulting in school absence. The vast majority of other sore throats are caused by viral infections. Appetite
may be affected intermittently and respiratory symptoms may also occur. Occasionally, there is obstructive
sleep apnoea in patients with snoring. Sleep apnoea occurs mostly below 4 years of age.
A3: What is the important nding on examination?
Conrm tonsillitis with examination of the oral cavity. Cervical lymphadenopathy may be palpated and is
frequent in children, particularly in the jugular digastric region.
A4: What investigations would be most helpful and why?
None is usually required.
A5: What are the treatment options?
As the vast majority of infections are viral, no treatment is required. Occasionally, bacterial tonsillitis
does occur and if the symptoms are particularly severe and prolonged a 5-day course of antibiotics,
such as amoxicillin, may be helpful. Tonsillectomy should not be recommended as the treatment unless
the child has had seven episodes of tonsillitis in 1 year, or ve episodes per year for 2 years, or three
episodes per year for 3 years.
CASE 2.17 –
Adolescent with acute sore throat
A1: What is the likely differential diagnosis?
Infectious mononucleosis (glandular fever) caused by Epstein-Barr virus
A2: What additional features in the history would you like to elicit?
A similar history should be taken to exclude recurrent tonsillitis. Concentrate on constitutional symptoms
and contacts with a similar problem.
A3: What is the important nding on examination?
Examine the oral cavity and tonsil region and palpate the neck. Large eshy tonsils with an exudate
encroaching onto the soft palate may indicate infectious mononucleosis. Lymphadenopathy is often
particularly severe and may extend from the neck to the rest of the body. Hepatosplenomegaly,
pancreatitis and jaundice are rare complications of the condition.
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130 Ear, nose and throat (ENT)
A4: What investigations would be most helpful and why?
FBC which usually shows a monocytosis, and serology for glandular fever
A5: What are the treatment options?
The vast majority require little more than symptomatic treatment. Patients are advised to refrain
from contact sports for 3 months after resolution of symptoms as there is an increased risk of
hepatic or splenic injury if the liver or spleen is enlarged. Occasionally, patients with severe airway
problems may require a course of oral steroids to reduce the lymphadenopathy but should be
managed in hospital. Very occasionally an urgent tonsillectomy is required for airway management.
CASE 2.18 –
Smoker with continuous sore throat
A1: What is the likely differential diagnosis?
Squamous cell carcinoma of the pharynx
A2: What additional features in the history would you like to elicit?
Particular attention should be paid to the progressive nature of the sore throat, oral intake and
respiratory symptoms, including cough, sputum and haemoptysis. The history suggests a supraglottic
carcinoma inltrating the muscle that causes pain on swallowing.
A3: What is the important nding on examination?
Examine the oral cavity, neck and chest. If you can, undertake an endoscopic examination of the
postnasal space, larynx and pharynx. The tonsil, supraglottic or laryngeal sites are the most likely. Ten
per cent of smokers have more than one carcinoma in the aerodigestive tract. Oral examination may
well not be conclusive. Examination of the neck will help stage the disease.
A4: What investigations would be most helpful and why?
These patients require screening investigations including an FBC, liver function tests, ECG and chest
radiograph. Special investigation may include imaging of the neck and chest with CT and MRI. Biopsy
the lesion and stage the tumour under general anaesthesia.
A5: What are the treatment options?
Depending on the tumour location and stage, radiotherapy or surgical resection and reconstruction are
potential options.
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Throat 131
OSCE Counselling case
OSCE COUNSELLING CASE 2.15 –
A mother wonders when a child may
return to school after a tonsillectomy
Advise that it is usual for a child to stay off school for 2 weeks after surgery. Emphasize that the area
has to heal and that there may be a secondary bleed as the slough comes away from the tonsillar fossa.
Infection makes this worse, so children should be kept at home during the recovery period. Eating and
drinking reduce the risk of infection as well.
REVISION PANEL
Recurrent tonsillitis is a common presenting complaint. Assessment requires conrmation that
tonsillitis is the underlying problem and determination of the number of episodes per year the
child is suffering.
Tonsillectomy can be a useful intervention if the underlying problem is recurrent tonsillitis and the
above-mentioned frequency criteria are met.
Glandular fever requires serology testing to conrm the diagnosis. It is typically a self-limiting
condition; however, recovery takes longer than bacterial tonsillitis.
A progressive dysphagia may well be the presenting complaint of a carcinoma. A full ENT
examination should be performed, including staging imaging.
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132 Ear, nose and throat (ENT)
DIFFICULTY IN SWALLOWING
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What should one look for in the examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.19 –
Lump in throat
A woman aged 45 presents with an intermittent feeling of a lump in the throat.
CASE 2.20 –
Problems with swallowing
A man aged 68 presents with continuous and progressive problems with swallowing. He is able to
swallow liquids but nds solids more difcult.
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Difculty in swallowing 133
OSCE Counselling case
OSCE COUNSELLING CASE 2.16 –
What advice would you give to a
patient with globus pharyngeus who
is concerned that he might have a
neoplasm?
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134 Ear, nose and throat (ENT)
Key concepts
Intermittent dysphagia with a constant weight is due to a benign condition.
Continual dysphagia with weight loss may be malignant.
Pain and discomfort are poorly localized in the embryological foregut and may present as a sensation
of a neck lump.
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Difculty in swallowing 135
Answers
Clinical cases
CASE 2.19 –
Lump in throat
CASE 2.20 –
Problems with swallowing
A1: What is the likely differential diagnosis?
In both cases the differential diagnosis is either
Globus pharyngeus – ‘lump in one’s throat’ – that is the persistent sensation of having phlegm, a pill
or some other sort of obstruction in the throat when there is none
Neoplasm arising from either outside or within the oesophagus or pharynx (A pharyngeal pouch can
cause dysphagia, although the hallmark is regurgitation of food.)
A2: What additional features in the history would you like to elicit?
Ask the same questions for both cases. Try to unravel whether there is a serious problem for the basis of
the complaint. Ask whether there has been any weight change or any symptoms of reux. Compression
and direct erosion may come from the thyroid gland and rarely from the thoracic cavity contents and
eventual ulceration. Smoking and alcohol consumption are risk factors for squamous cell carcinoma and
their usage should be determined.
A3: What should one look for in the examination?
Palpate the neck – there is a physical sign called ‘Toynbee’s sign’. Move the laryngeal cartilages from
side to side over the vertebral column. This produces crepitus in the normal individual and a post-
cricoid carcinoma will lift the larynx forwards and crepitus is absent. This also occurs in foreign body
or abscesses such as tuberculosis cold abscesses. Check for lymphadenopathy. In the ENT clinic,
nasendoscopy with a exible endoscope may show pooling of saliva or an abnormality such as a space-
occupying lesion. In patients with globus there is no abnormality.
A4: What investigations would be most helpful and why?
These include an FBC (sideropenic dysphagia). If a patient is severely dehydrated with neoplasm, urea
and electrolytes (U&Es) may be indicated. A barium swallow may show both reux and neoplasia, but
high lesions in the oesophagus do not show up well. Patients with globus should have breoptic gastro-
oesophagoscopy. Perform a direct endoscopy and biopsy under general anaesthesia if in any doubt. Any
tumour should be assessed, biopsied and staged.
A5: What are the treatment options?
The management depends on the nature of the underlying lesion and, for globus pharyngeus patients,
simple reassurance is often enough. Reux oesophagitis should be treated appropriately and is best
managed in general practice. Neoplasms require a combination of excision, reconstruction and
radiotherapy, or palliation.
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136 Ear, nose and throat (ENT)
OSCE Counselling case
OSCE COUNSELLING CASE 2.16 –
What advice would you give to a
patient with globus pharyngeus who
is concerned that he might have a
neoplasm?
Stress that intermittent problems are rarely serious and a stationary weight argues against a serious
problem. Say also that the endoscopy has almost certainly excluded a neoplasm. A hiatus hernia
and reux may cause a sensation of a lump in the neck. The primitive foregut extends to the
second part of the duodenum and takes its nerve supply with it – it is referred to the neck. Another
feature of reux is spasm of the cricopharyngeus sphincter. An explanation of these anatomical and
functional reasons will result in acceptance of the condition and hopefully its cessation.
REVISION PANEL
Diagnosing dysphagia and globus pharyngeus requires a constant vigilance to ensure the patient
does not have a neoplasm.
Patients who are smokers and drinkers are at increased risk of head and neck cancer.
If the patient has intermittent symptoms, is a non-smoker, does not drink alcohol, has no loss of
weight and examination is normal, globus pharyngeus is likely.
Any patient who deviates from the above ‘classic globus’ patient may benet from a direct
laryngoscopy and upper oesophagoscopy to exclude a carcinoma.
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