Salivary Stones

Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.

Definition

formation of calculi in ductal system of salivary glands

Epidemiology

M > F

age 40 – 70 yrs

Common-SMG: - 80 – 90% of stones 

10 – 20% of stones form in Parotid (Stensen's) duct / - 1% in sublingual duct

Aetiology

Uncertain, possible causes can be thought of as local and systemic factors

Systemic-

        dehydration- more viscous saliva 

        Systemic conditions as Sjogrens- 

Local

        Inflammation/ infection/ duct strictures / taruma- dentures                  

        Above leads top Stasis/ nidus formation

SMG Stones are More Common: Reasons

Anatomical Factors:

        - Duct is: - long & tortuous

        - large diameter 

        - angled against gravity 

        - narrow at ostium→ slower flow

Physiological Factors:

         - SMG Saliva is: - more viscous (higher mucus content)

         - more alkaline                  

         - higher in calcium & phosphate

Pathology of the Stones

SMG-hard stones (more Calcium) , Parotid soft stones (less Calcium)

Initial formation of organic gel, which becomes framework for deposition of salts 

Salts are mostly calcium phosphate & carbonate, (less Mg, Po4, Ammonia)

CLINICAL  (ASSESSMENT = history, examination, investigations)

- Recurrent post-prandial salivary colic (pain & swelling after eating)

- History of multiple cases of acute suppurative sialadenitis

- Bimanual palpation will reveal palpable stone intraorally in most cases

- More common SM stones will be noted along the floor of mouth

-Parotid stones might be noted at orifice of Stensen's duct or along its course

Investigations

US is a good first line investigation. Below is summary of other investigations.

XR

- Intraoral or occlusal views identify radiopaque stones - poor predictive value to do the reasons below

          - false postives-phleboliths, atherosclerosis of lingual artery, calcified cervical LN

           - false negatives-80% parotid stones are radiolucent

US

-Good predicative value in the hands of an experienced radiologist

-Difficulty distinguishing between stones and stenosis (both give a cone beam)

-Can see over the mandible well enough

Digital subtraction sialography

- Can detect radiolucent stones  as well, but not routinely done anymore

- Sensitivity of 95 – 100%

- Disadvantages: - invasive and difficult to perform

                         - side effects of contrast 

                        - contraindications: - stones in oral portion of Wharton's duct 

                                                        - active infection

CT scan-accurate

MRI

-can miss 2-mm to 3-mm calculi that cause no ductal dilatation

MR sialography of SMG duct with evoked salivation  - accuracy similar to Digital Sialography & superior to U/S

Sialendoscopy

-Can identify stenoses that may be associated with both stones. 

-Not routinely available in Melbourne

Treatment Overview

If presents with acute swelling +/- infection the treatment principles are to improve salivary flow and treat the underlying infection. 

- Keep well hydrated

-Massage back to front

-Chew sugar free gum- help salivate and reduce stasis

If there is an obvious impacted stone this could be removed by direct incision on to the duct or by papillotomy by an ENT surgeon.

More distal stones are difficult to remove intra orally. Also the SM duct has a close relation ship to the lingual nerve proximally. These should be treated either by sialendoscopy or in protracted cases removal of the affected gland. (note endoscopy is not routinely available in Melbourne)

  

Globus

Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.

Definition

persistent or intermittent sensation of a lump or foreign body in the throat for at least 12 weeks

Epidemiology

Up to 40 % of the population been affected at some stage

M=F, F seek help more

Mostly middle age

Aetiology

A Sinister (Minority)

Mass/tumour-Pharynx/ neck / thyroid

B Non Sinister (majority)

LPR (laryngo pharyngeal reflux)-direct irritation

GERD-leading to reflex CP spasm

Psychogenic

Osteophytes-cervical

CP spasm

Tonsil hypertrophy

 Oesophagus- oesophagitis, motility disorders

Taking a Hx

Take a clear hx to identify the likely underlying cause (first exclude a sinister cause)

A Symptoms of sinister pathology include

dysphagia/ food sticking in the throat

odynophagia

otalgia-referred pain

B Usual non sinister globus sensation is..

Midline

Improves when eating (ie patients can gain weight)

Non progressive, been there for months

No associated dysphagia or above symptoms

DD symptoms of non sinister causes

LPR/ GORD

Vomit taste in the throat

Dry Cough especially at night

May have heart burn (LPR can occur without  heartburn)

CP Spasm

Caffeine , alcohol intake, smoking, 

GORD- relate CP spasm

Psychogenic- Stress, anxiety

Osteophyte

May become evident on examination/ barium swallow

 
        Tonsils large

Examination

complete H&N exam- Oral cavity, oropharynx, neck, fiberoptic scope

Diagnosis & Rx

Hx and examination will help you identify and diagnose most sinister pathology. Most globus due to LPR is difficult to diagnose and below is a simple guideline

If sinister pathology on Hx or Exam-URGENT panedsocopy and biopsy

if no obvious sinister pathology/ benign globus symptoms

First step

omeprazole 40 mg BD (1/2 hr pre prandial) for 3 months

If stressed help with relaxation therapy

Stop Caffeine, ETOH, and likely other ppt

(if better its most likely reflux/ stress / CP spasm)

2nd Step-If not better

Barium swallow

(show osteophytes, motility disorders)

3rd step-Still non diagnostic

Gastroenterology RV

Oesophagoscopy / biopsies/ PH probes for PH nonitoring

Treatment

-If Sinister: Rx the sinister pathology

-Non Sinister/ Stress/ Caffeine / CP spasm : general RX as above

-If Osteophyte may need surgery-spinal surgeon

-If significant reflux despite rx fundoplication

Thyroid Mass

Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.

Outline
When a patient with a thyroid mass presents, 
    -First step is to see if it is goiter or a thyroid nodule.
    -Second step is to determine the risk of cancer with in 
    -Third step is to see if the patient is hyperthyroid or not
    -Forth is to determine if there are compressive symptoms- if so URGENT referral 

The examination should assist determine above four features

Investigations should be directed according to the findings




History
Is this a long standing mass, is the whole thyroid large or a nodule?
Is it an endemic goiter
Is it a toxic goiter



Is this a nodule the patient is presenting with
Is there is a risk of cancer
      Extremes in age (very young or older)
      Radiation exposure
      Family Hx of thyroid cancer

Hyper or Hypothyroid symptoms
Rare for a nodule to be cancerous if hyper hyperfunctioning
Are the symptoms of acute onset or longer standing


Are there compressive symptoms
      Breathing ?
      swallowing? if significant URGENT referral




Examination

First confirm its the thyroid (moves with swallowing) 
Determine if this is a goiter or a nodule

look for cancer
Any hard masses- Hard= risk of cancer (individual nodule or within a goiter)
Any neck nodes (nodes= cancer)


look for compressive features
if venous congestion positive Pemberton's test
Stridor-URGENT Referral


Look for hyperthyroid features 
Look for hypothyroid features




Investigations

-First line of test:TFT- Hyperthyroid

If hyperthyroid determine the cause (Graves, Toxic nodular goiter/ thyroditis)
    Endocrine review
    Anti thyroid medications 

-If hyperthyroid also do TC99 
    what we want to know is...is it a hot nodule (low risk) or a hot gland with a    cold nodule (High risk of cancer)
    If cold nodule need US and FNA (as below)

If Euthyroid and a nodule/ or a euthyroid goiter
   US-? suspicious features in nodules (i.e. calcification etc)
   if so FNA the risky nodules



Treatment Outline
If US FNA says benign- 95% it benign, need to repeat US +/- FNA in 6 months
If FNA is cancer- Total thyroidectomy plus pots op radioactive I if high risk
If inconclusive / follicular cells need hemithyroid- if cancer completion total T 

Assessment of the Vertigo Patient

Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.

Vertigo Definition

Illusion of Rotation due to asymmetry in neural activity between the L and R vestibular systems (Halmagi)

Taking a History

First familiarize your self with the specific features of the above 6 causes of vertigo. These are discussed in the later part. What helps tell these apart are the differences in their onset, length of the symptoms and associated features. 

History taking should be fairly directed ie “ do you feel light headed (not vertigo) or is the roof spinning around (true vertigo)”. How quickly does it come on, in a second or over long period. When it comes on does it last for hours/ or days  with out stopping, or only a few seconds but keeps coming back over days when you move for example?

Following are the main aspects of history

1 Characterize “dizziness”-is it true vertigo not light headedness, True vertigo has a clear sense of motion.

      If true vertigo determine if its central (central vertigo has neurological features) OR... Peripheral vertigo- know the specific features in history that characterizes each type of peripheral vertigo well (conditions discussed in the latter part)

 2  Following are the important aspects of history which helps you differentiate

                    Onset/ predisposing factors 

                    time course,    

                    temporal pattern

3  Associated symptoms (think of DDs) 

                  CNS symptoms-Central vertigo
                  Migraine features
                  Ear symptoms
              
                        

         Examination (the most important ones)

1 Nystagmus

   Central features- Vertical nystagmus, direction changing

   Peripheral features;  horizontal or in BPPV rotatory

2 Head pulsion test-only positive in peripheral vertigo, -ve in central vertigo types

        Get the patient to fixate on an object 2 m in front of him/ her

        keep the head Flexed down by about 3o degrees

        rapid flick-movement of the head to the right then repeat the same to   the left

       if the labyrinth is dysfunctional the eyes will not stay fixed on the object (ie eyes will move with the head and flick back)

       see the following video

       

       

3 Dix Hallpike

If symptoms suggest BPPV do Dix Hallpike to confirm. see the following video

4- Romberg

Balance depends on a tripod

         A the input from the eyes, 
         B the proprioceptors of feet and 
         C tone by the vestibular spinal tracts

stand pt with feed together/ or on cushions (proprioceptors are removed)

ask the pt to close the eyes- visual input is removed (ensure you are ready to catch them)

now the patient relies on their vestibular tone alone- if one side is affected they will sway to that side

note a cerebellar tumor will also have a positive Romberg, however with other central signs as follows

Look for central signs-

- Finger-nose test (dysmetria past-pointing, intention tremor) 

- Ataxia (heel-toe)

- Head Titubation

- Dysarthria

- Otological

- Neurological

- Visual

- Autonomic

        -Other cranial nerves affected

Vertigo Main Conditions

Vestibular Neuronitis

History

Onset: within minutes to hours) onset of severe, 

Time course:  24 hrs or more prolonged rotatory vertigo, nausea, and postural imbalance.

No Hearing Loss (helps differentiate from labyrinthitis)

NO central features

Examination

Peripheral vestibular signs
    Horizontal spontaneous nystagmus

    Head pulsion test is positive (indicates it is NOT a central process)

    Romberg positive to affected side 

No other neurological findings
NO evidence of a central vestibular lesion- no other neurological findings
No hearing loss

Treatment

Supportive

Rx-Steroids

Labyrinthitis

History
Onset:Over hours

Time course: Goes on for a day or more-then slowly subsides

Other: patient is very unwell-vomiting severely, and severe vertigo

          Sensory hearing loss in the affected ear (different from V neuronitis)

Examination

Peripheral signs i.e.
    Nystagmus- horizontal

    head pulsion positive

    Romberg positive- falls to affected side

also may have a middle ear infection

Sensory neural hearing loss

Rx

short course of vestibular sup presents i.e. Diazepam and Stemetil/ steroids

Stop after about 2 days- allow compensation

if middle ear infection- antibiotics

Meniere's Disease

Over diagnosed (vestibular Migraine)

History

Onset:Vertigo only hours, pt may feel unwell for days

Has associated features ; Aural fullness, Rumbling tinnitus , Hearing loss and vertigo

Examination

Peripheral vestibular symptoms as above ie

     Nystagmus- horizontal

     head pulsion positive

     Romberg positive- falls to affected side

BPPV

History

Very common condition

Onset-Short duration vertigo (seconds), with head movement, rolling in bed

Time course: Patient may call it days- as short duration episodes vertigo keeps  over many days- need to specifically ask this

Movement brings it on i.e. turning in bed- wakes up with vertigo, or turning the head

Examination

Positive Dixhallpike test to the affected ear (see the above clip)

Treatment

Epley manoeuvre (not medical treatment)

Vestibular Migraine (very common)

Usually comes on over minutes to hours

Usually lasts over a day

Has other migraine features i.e.

      Photophobia, Phonophobia

      may have an aura

      May have a headache not always

      responds to migraine medications

      can have other neurology i.e. ataxia, tinnitus, other cranial nerve/ neurology