H+N (History taking, Clinical Examination + Investigations)

Question 1

What are the common presenting symptoms in H+N cases?

Answer 1

• Sore Throat
• Dysphonia - hoarseness
• Dysphagia
• Odynophagia
• Mouth/Throat Ulcer
• Neck Lump

Question 2

What should you ask in the Systematic Enquiry for H+N?

Answer 2

• Dysphagia
• Odynophagia
• Persistent sore throat
• Hoarseness/voice change
• Haemoptysis
• Unilateral nasal obstruction
• Otalgia
• Epistaxis
• New hearing loss

Question 3

What would you examine in a H+N examination?

Answer 3

• Neck
• Oral cavity
• Pharynx: nasopharynx, oropharynx, hypopharynx
• Larynx: supraglottis, glottis (vocal cords), subglottis
• Nose/Ears/Salivary glands

Question 4

How would you examine the LNs in a H+N examination?

Answer 4

• Trace a Z-shape from the submental to the submandibular nodes, down the anterior edge of the SCM muscle (II, III, and IV), then to the posterior triangle of the neck (V)
• Check the thyroid gland
• Then check Level VI LNs (pretracheal)

Question 5

How do you examine the Major Salivary Glands in a H+N examination?

Answer 5

• Parotid gland = overlying both cheeks
• Submandibular gland = below the jaw
• Sublingual gland = bimanual palpation underneath the tongue!

Question 6

Where would you auscultate for in a H+N examination?

Answer 6

• Thyroid gland - thyroid bruit

- Carotid bruit

Question 7

What does a Thyroid bruit indicate?

Answer 7

Grave’s Thyroiditis

Question 8

What does a Carotid bruit indicate?

Answer 8

Carotid Stenosis

Question 9

How do you examine the Throat in a H+N examination? What are normal laryngoscope findings?

Answer 9

• Indirect Laryngoscopy
• Fibreoptic Nasolaryngoscopy
• Rigid Laryngoscopy

Question 10

What is the initial first-line investigation for any pt presenting with a lump in the H+N area?

Answer 10

• Fine Needle Aspiration Cytology

Question 11

What is the initial first-line imaging for any suspicious neck lump?

Answer 11

• US scan

* NB. NOT the first-line investigation!!*

Question 12

What are the different investigations you can carry out as part of a H+N examination?

Answer 12

• FNAC
• CT/MRI/PET scan
• US scan
• Plain XR
• Contrast swallow
• Endoscopy

Question 13

How would you assess a pt. with a Neck Lump?

Answer 13

• > History:
• How Long?
• Site?
• Fluctuates?
• Sore?
• H+N symptoms?
• Systemic (“B”) symptoms?
• Travel?
• > Examination:
• Site
• Size
• Shape
• Sore
• Skin
• Stuck
• Soft

Question 14

Name some common Differential Diagnoses of a Neck Lump

Answer 14

• Vascular: aneurysm
• Infective/Inflammatory: reactive lymphadenitis, tonsillitis, salivary gland infection, HIV, TB, mononucleosis, abscess
• Traumatic: Neck Trauma
• Autoimmune: Grave’s disease
• Neoplastic: Benign (ie. salivary gland tumour, fibroma, lipoma), Malignant (ie. lymphoma, leukaemia, non-melanoma skin cancer, metastatic cancer, thyroid cancer)
• Congenital: Thyroglossal cyst, Brachial cyst
• Degenerative/Developmental: Laryngocoele, Cervical rib, skin cysts
• Endocrine/Environmental: thyroid enlargement/nodule

Question 15

What are the characteristics of a Reactive LN in the Neck?

Answer 15

• Oval
• Soft
• Smooth
• Mobile
• Tender

Question 16

What is the Differential Diagnosis of a benign swollen Salivary gland?

Answer 16

• Tumour ie. benign Pleomorphic Adenoma
• Inflammation - Parotitis
• Salivary gland stones

Question 17

What would you ask a pt. who has a hoarse voice?

Answer 17

• How long?
• Recent URTI?
• Persistent or Intermittent?
• Pain?
• Cough/Choking/Swallowing?
• Asthma/Rhinosinusitis/Reflux?
• Voice use? ie. singers, teachers
• Smoker?
• Medication? ie. inalers

Question 18

What is the Differential Diagnosis of a benign hoarseness?

Answer 18

• Nodules
• Cysts
• Vocal abuse
• Laryngitis
• Infection
• Smoking
• Reflux

Question 19

What would you ask a pt. with dysphagia?

Answer 19

• Solid vs. Liquid?
• > solid = obstructive or mechanical problem
• > liquid = neuromuscular problem
• Persistent/Intermittent?
• Pain?
• Where?
• > well-localised in neck
• > poorly localised lower down

Question 20

What is the initial investigation you would do for a pt. with Dysphagia?

Answer 20

Upper GI Endo!!

Question 21

What is the initial investigation you would do for a pt. with Dysphagia if a pharyngeal pouch is suspected?

Answer 21

Barium swallow!

Question 22

What are the most common causes of Dysphagia?

Answer 22

• Lumen: Foreign body
• Wall: Tumour, Stricture, Neuromuscular, Pouch
• Thyroid, Heart, Mediastinal mass

Question 23

What are the clinical features of FOSIT?

Answer 23

• FOSIT = Feeling Of Something In The Throat (Globus Pharyngeus)
• No dysphagia (“easier with food”)
• Not a red flag symptom
• Acid reflux “silent”
• usually due to Stress/anxiety

Question 24

What are the signs of a malignant neck lump?

Answer 24

• Round
• Firm
• Irregular
• Fixed
• Non-tender

Question 25

What are the causes of Airway Obstruction?

Answer 25

• Infection (ie. Quinsy)
• Tumour
• Foreign Body
• > dentures
• > children:cherry tomatoes, grapes hot dogs

Question 26

What are the clinical features of Airway Obstruction?

Answer 26

• Symptom = difficulty breathing

- Sign = stridor (noisy breathing) -> inspiratory, expiratory, biphasic

Question 27

What is the management of Airway Obstruction?

Answer 27

“ABC”

• humidified oxygen, steroids, adrenaline nebuliser
• secure the airway: intubate, FONA (cricothyroidotomy, tracheostomy)

Question 28

What is the management of Tonsillitis/Quinsy?

Answer 28

SIGN guidelines:

Offer Tonsillectomy if….

• Bacterial Tonsilitis (pus covering, neck nodes, fever, no cough)
• 6-7 attacks in 1 year (5/year over 2 years, 3/year over 3 years)
• Disrupting daily activities
• More than 1 quinsy (peritonsillar abscess -> pocket-filled pus between tonsils and the wall of the throat -> pushes uvula over to the opposite side)