Common Conditions of the Head, Neck and Throat Flashcards
56 year old man presents with slight cough and no other symptoms
“Doc, I have been smoking 20 per day and working on the roads for 38 years”
Identify the problem and what to examine
Left lateral neck mass
Most likely to be associated with the lympho-reticular system of the head and neck; these structures require examination
What is the basic arrangement of the lympho-reticular system of the head and neck?
1) Inner ring (Waldeyer’s ring): adenoids (pharyngeal), tubal, tonsils (palatine), lingual, pharyngeal bands
2) Outer ring (LN groups): submental, submandibular, jugulo-digastric (relationship to tonsils??), post-auricular, sub-occipital
3) Lymphatic chain associated with the great vessels of the neck and thoracic duct: jugulo-digastric LN group, jugulo-omohyoid LN group
56 year old man of Cantonese/SE Asian extraction presents with slight cough and no other symptoms
O/E: left lateral neck mass
Other Hx: 38 pack-year smoking Hx, retired construction worker
What are you particularly concerned about given the patient’s ethnic background?
Increased risk of nasopharyngeal cancer (which often drains to the posterior cervical triangle LN, and therefore can present with a lateral neck mass)
56 year old man presents with slight cough and no other symptoms
O/E: left lateral neck mass
Other Hx: 38 pack-year smoking Hx, retired construction worker
Likely sites of origin of pathology?
1) External: skin of head and neck (e.g. SCC or melanoma, given occupation Hx)
2) Internal: upper aero-digestive tract including tonsils, larynx, pharynx (given smoking Hx; don’t forget CXR to examine lungs)
3) Other: primary salivary gland pathology, thyroid differentiated tumours (esp papillary Ca), lymphoma, supraclavicular LN associated with visceral malignancy (Virchow’s node or Troisier’s sign)
Why is careful examination especially important in the patient presenting with a neck mass in the setting of possible malignancy?
Want to avoid an open neck biopsy to determine the site of origin of the malignancy; in most cases, careful examination will demonstrate this site (look in the mouth and at the skin of the head and neck especially)
What structures in the central anterior neck can be isolated on examination and how?
Hyoid: elevates with tongue protusion (can look for a thyroglossal duct cyst by performing this manoeuvre)
Larynx and contents of pretrachial fascia (including thyroid): elevate on swallowing
What important structures are in the lateral neck?
Carotid triangle
Structures deep to sternomastoid muscle
Neck examination
1) Inspection: central anterior neck (tongue protusion, swallowing), lateral neck, posterior cervical triangle
2) Palpation: anteriorly, posteriorly
3) Completion: mouth and tonsil inspection, examination of skin above the neck lesion
4) Consider further Ix: FNAC, CT neck/oral cavity/pharynx, CXR
How should the anterior neck be palpated?
Face to face with patient:
1) Palpate from zygomatic arches inferiorly (to include parotid glands)
2) “Outer ring” of LN groups including submandibular glands
3) Laterally flex the head towards the examining hand to palpate deep to the sternomastoid (lower section of great vessels and lympho-reticular chain); also palpate the carotid triangle (upper section of great vessels and lympho-reticular chain)
4) Palpate posterior triangle of the neck, charting the course of the accessory nerve
How should the posterior neck be palpated?
Standing behind the seated patient; fingers of examining hand naturally curl around the neck, and present the pads of the fingers in the correct position for examining the “outer ring” of LN groups (again) and the central anterior neck (hyoid, trachea, thyroid gland)
What should be looked for specifically on examination of the mouth and tonsils?
1) Inspect all oral mucosal sufaces including bucco-alveolar sulci, floor of the mouth and under the tongue
2) Use tongue depressor to properly inspect the tonsils (or tonsillar fossae)
3) Use a gloved finger to examine glosso-tonsillar sulci (both sides)
In what % of patients is the primary site of SCC origin in upper aero-digestive tract initially identified on diligent examination and simple Ix?
90%
What can FNAC help to identify?
SCC (skin or upper aero-digestive)
Melanoma
Papillary thyroid Ca
Nasopharyngeal Ca (possibly)
Why should CXR be considered in patient with a neck mass secondary to an identified malignancy?
Up to 5% chance of another SCC in the upper part of aero-digestive tract or a lower respiratory tract SCC
What is this? What is the relationship between this clinical finding and risk of SCC?
Leukoplakia
3% chance of SCC
What is this and what is it suspicious for?
Persistent mouth ulceration
Suspicious for malignancy, esp with other factors such as smoking, sun exposure (lips) and presence of a neck lump
What is this?
Quinsy (peri-tonsillar abscess)
What is this?
List the 3 principle causes of tongue base and floor of mouth swelling
1) Infective (usually spread from other head and neck fascial space source such as quinsy, neglected mandibular #, mandibular molar tooth root abscess
2) Malignancy
3) Haematoma
What is this?
Tonsillitis, likely due to infectious mononucleosis (more diffuse tonsillar coating)
What is the relationship between otalgia and CN IX and X?
Pain can be referred from anywhere in the sensory distribution of the glossopharyngeal nerve (oral cavity) or vagus nerve (larynx, pyriform fossae)
Likely Dx?
SCC of larynx
Likely Dx?
Paralysed vocal cord
What is this appearance of the larynx consistent with as an underlying cause of hoarseness?
GORD or LPR (laryngo-pharyngeal reflux)
Likely Dx?
Vocal nodules and polyps
What is the preferable site for tracheostomy?
Below 2nd tracheal ring
