H&N

Question 1

Gland anatomy

Answer 1

parotid: serous gland; supf/deep lobes; ostium 2nd upper molar; CN VII, ECA, LN

subM: mixed mucoserous; Wharton’s duct; papilla in mouth under tongue; CN V2/V3, facial artery

subL: smallest major gland; mucous; 10-15 ducts, direct into mouth or via Wharton’s

Question 2

Neck surface anatomy

Answer 2

trachea C5 to T4/5 (bifurcation); cricoid to sternal angle
thyroid gland: midline, below prominence, crosses inf to cricoid
hyoid bone C3; thyroid C3/4-C5; cricoid C6; arytenoid, corniculate, cuneiform
carotids: sternoclavicular joints, along SCM; bifurc C4

Question 3

midline DDx

Answer 3

thyroid: swallowing + Sx
thyroglossal cyst: swallowing + tongue
Ludwig’s angina: mouth floor cellulitis; Sx
sebaceous cyst: keratin ‘cottage-cheese’ filled, mobile
lipoma: soft mobile painless
lymph nodes: benign or malignant

Question 4

anterior DDx

Answer 4

branchial cyst: young adult, oval, ant upper SCM
laryngocoele: neck bulge
carotids: tumour or aneurysm; bruit
sebaceous cyst: keratin ‘cottage-cheese’ filled, mobile
lipoma: soft mobile painless
lymph nodes: benign or malignant

Question 5

posterior DDx

Answer 5

cervical rib: hard, immobile; ?thoracic outlet syndrome
branchial cyst: YA, oval, ant upper SCM
cystic hygroma: fluctuant, transillumination
pharyngeal pouch: hallitosis, regurg, elderly
pancoast tumour: Horner’s
sebaceous cyst: keratin ‘cottage-cheese’ filled, mobile
lipoma: soft mobile painless
lymph nodes: benign or malignant; superficial cervical (H/N), Virchow’s (GI), infraclavicular (breast)

Question 6

branchial cysts

Answer 6

congenital arch non-closure

present

Question 7

thyroglossal cysts

Answer 7

congenital; present in kids/adults
cyst/fistula: swelling +/- discharge; moves with swallow and tongue
Rx: excision including hyoid body (otherwise recurrence)

Question 8

thyroid masses DDx

suppression: carbimazole, propylthiouracil
Ca: excise/radioiodine/RDT
*RDT: worsens eye disease initially

Answer 8

goitre: diffuse (Graves, preggo, iodine deficiency) or nodular (?Ca, hypo/hyper switching)
benign adenoma: non-Fx or thyroxine (hot/cold nodules); unlikely malignant; suppression Rx
carcinomas: papillary (50%), follicular (25%), anaplastic (20%), parafollicular medullary (5%)

Question 9

pharyngeal pouch

Answer 9

elderly, halitosis, regurg, gurgle/bulge on swallowing, asp pn., weight loss, chronic cough

Question 10

Ludwig’s angina

Answer 10

mouth floor cellulitis, usually from dental infection
bilateral oedema (neck/mandible), dys/odynophagia, DOB, pain
potentially fatal
Rx: IV ABx, airway protection, ?drainage

Question 11

cystic hygroma

Answer 11

congenital lymphatic malformation
usually left triangle
fluctuant and transilluminates

Question 12

swallowing/Sx

Answer 12

oral phase (vol; tongue), pharyngeal; oesophageal

globus pharyngeus: relieved with swallow
pain
aspiration pneumonia
regurgitation and choking

Question 13

Salivary gland history questions

Answer 13

relation to meals
lumps, pain, trismus (pain on opening)
displaced tonsils (DDx: quinsy)
facial palsy
xerostomia: drugs (antiM/SANS), depp/anx, Sjogren's, RDT
arthritis and dry eyes

Question 14

viral SG infection

Answer 14

systemic, swelling, pain

Mump (paramyxovirus) commonest; HIV-associated

Question 15

sialadenitis

Answer 15

bacterial; systemic, pain, swelling (gland and mouth), pus;
RF: dehydration, old age, poor hygiene
Rx: ABx (HD), fluids, hygiene, sialogogues/citrus (flow)
complications: abscess (drain), chronic infection

Question 16

sialolithiasis

Answer 16

stones, usually from chronic infection
subM commonest (thick mucoserous)
postprandial pain and swelling, repeated infection, tender and swollen, ?palpable stone
Rx: XR +/- dye; PO fluids + sialogues (pass stone); fail/deteriorate = surgery

Question 17

Sjogren’s

Answer 17

multisystem AI disease; 1o/2o (CTD, SLE, scleroderma)
serostomia, keratoconjunctivitis, glossitis, stomatitis, no secretion, candidiasis, stones risk
diffuse parotid swelling
Dx: Bx, Schirmers (lacrimation), Carisson-Crittendon (saliva), Ag/HLA
Rx: symptoms (tear drops, steroids, parotidectomy)

Question 18

malignant SG

Answer 18

rapid growth, pain, CN VII palsy (Ca UPO!), LN mets
subL/subM > Parotid; SM/SL less common than parotid tumours but more likely malignant

adenoid cystic: commonest; 40-60y; 14% of parotid tumours; slow circ’d fibrous; poor prognosis
mucoepidermoid
adenocarcinoma: aggro; poor prognosis
lymphoma: NHL >HL; 50-70y; rubbery, rapid, B symptoms
mets: lung, breast, kidney, upper GI, melanoma, SCC

Question 19

benign SG

Answer 19

tumours 80-90% in parotid, 80-90% benign
slow, painless masses, no nerve palsy, smooth mobile mass

pleomorphic adenoma: commonest; transformation; cystic lobulated blue/grey
Warthin’s tumour/adenolymphoma: soft cystic mass, old men,

Question 20

infection vs. benign vs. malignant

Answer 20

inflammatory: systemic
benign: slow painless
malignant: fast, painful, nerve palsy, LN

Question 21

SG investigations and managemet

Answer 21

baseline bloods and cultures
FNAC + excision biopsy

excision: benign/low grade Ca
radical resection + RDT: high grade Ca
surgical risks: CN VII, haematoma, fistula, Frey’s syndrome (cross salivary and sweat)

Question 22

mouth features

Answer 22

leukoplakia and erythroplakia
tonsillar displacement/enlargemenr
ulceration
oedema/swelling
pus
halitosis
loose teeth

Question 23

leukoplakia

Answer 23

adherent white patches, often on tongue; sharp, defined, bright, raised
50-70yo, M>F (2x),

Question 24

erythroplakia

Answer 24

red patches or macpap rash, defined, soft/velvety
associated with leukoplakia and dysplasia
mouth floor, tongue, soft palate

Question 25

H/N Ca symptoms

Answer 25

growing mass; usually SCC; lymphoma, sarcoma, undiff, salivary gland
aSx, or pain, ulceration, bleeds, plakia, LN

local Sx: pain, paraesthesia, palsy, trismus, halitosis, otalgia, voice change/hoarse
other Sx: weight loss, dys/odynophagia, night sweats, anorexia, fever

Question 26

H/N Ca RF

Answer 26

RF: smoking, sun, chemicals, male, age, alcohol, radiation

Question 27

H/N Ix

Answer 27

history + exam
FNAC and biopsy (confirm)
CT/MRI neck
CXR/CT chest
baseline bloods + BM and TFT
ECG + nutritional status

Question 28

Tonsillitis

Answer 28

acute/recurrent bacterial: pain, odyno, systemic, lethargy
white exudate/slough, LA (jugulodigastric)
diphtheria, mono, strep pn/GAS, Hib (AOM)
!unilateral or >35yo
5/7 duration; hydration, analgesia, ?ABx (centor)
excision: 7/y, 2x 5/y, 3x 3/y, or quinsy (trismus)

mono = adherent exudate (bleed on peeling)
parapharyngeal abscess: life-threatening complication

Question 29

Pharyngitis

Answer 29

acute: viral, involves tonsils
chronic: specific (infection) or non-specific (irritant, lymphoid, inflammation)
odynophagia, otalgia, redness;, discomfort, red granular papules posterior wall
rarely systemic; ABx rarely helpful

Question 30

cervical LN

Other groups: subMa, subMe, pre/post auricular, occiptal, supra/infra clavicular

Answer 30

superficial: EJV, anterior SCM border;
- posterior/posterolateral scalp into deep cervical

deep: IJV, posterior SCM border; upper (jugulodigastric)/middle/lower (jugulo-omohyoid) groups;
- head and neck into jugular trunk/SCV

Question 31

Lymphadenopathy vs. malignancy

Answer 31

LA: painful, tender, inflammatory Sx

?Ca: >2/52, >1.5cm, firm/rubbery, fixed, B symptoms

lymphoma: rubbery, painless, fixed, B symptoms

2o (H/N): firm, fixed, painless, H/N Sx (e.g. dysphonia/dysphagia)