H+N (History taking, Clinical Examination + Investigations) Flashcards
What are the common presenting symptoms in H+N cases?
- Sore Throat
- Dysphonia - hoarseness
- Dysphagia
- Odynophagia
- Mouth/Throat Ulcer
- Neck Lump
What should you ask in the Systematic Enquiry for H+N?
- Dysphagia
- Odynophagia
- Persistent sore throat
- Hoarseness/voice change
- Haemoptysis
- Unilateral nasal obstruction
- Otalgia
- Epistaxis
- New hearing loss
What would you examine in a H+N examination?
- Neck
- Oral cavity
- Pharynx: nasopharynx, oropharynx, hypopharynx
- Larynx: supraglottis, glottis (vocal cords), subglottis
- Nose/Ears/Salivary glands
How would you examine the LNs in a H+N examination?
- 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)
How do you examine the Major Salivary Glands in a H+N examination?
- Parotid gland = overlying both cheeks
- Submandibular gland = below the jaw
- Sublingual gland = bimanual palpation underneath the tongue!
Where would you auscultate for in a H+N examination?
- Thyroid gland - thyroid bruit
- Carotid bruit
What does a Thyroid bruit indicate?
Grave’s Thyroiditis
What does a Carotid bruit indicate?
Carotid Stenosis
How do you examine the Throat in a H+N examination? What are normal laryngoscope findings?
- Indirect Laryngoscopy
- Fibreoptic Nasolaryngoscopy
- Rigid Laryngoscopy
What is the initial first-line investigation for any pt presenting with a lump in the H+N area?
- Fine Needle Aspiration Cytology
What is the initial first-line imaging for any suspicious neck lump?
- US scan
* NB. NOT the first-line investigation!!*
What are the different investigations you can carry out as part of a H+N examination?
- FNAC
- CT/MRI/PET scan
- US scan
- Plain XR
- Contrast swallow
- Endoscopy
How would you assess a pt. with a Neck Lump?
- > History:
- How Long?
- Site?
- Fluctuates?
- Sore?
- H+N symptoms?
- Systemic (“B”) symptoms?
- Travel?
- > Examination:
- Site
- Size
- Shape
- Sore
- Skin
- Stuck
- Soft
Name some common Differential Diagnoses of a Neck Lump
- 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
What are the characteristics of a Reactive LN in the Neck?
- Oval
- Soft
- Smooth
- Mobile
- Tender
What is the Differential Diagnosis of a benign swollen Salivary gland?
- Tumour ie. benign Pleomorphic Adenoma
- Inflammation - Parotitis
- Salivary gland stones
What would you ask a pt. who has a hoarse voice?
- How long?
- Recent URTI?
- Persistent or Intermittent?
- Pain?
- Cough/Choking/Swallowing?
- Asthma/Rhinosinusitis/Reflux?
- Voice use? ie. singers, teachers
- Smoker?
- Medication? ie. inalers
What is the Differential Diagnosis of a benign hoarseness?
- Nodules
- Cysts
- Vocal abuse
- Laryngitis
- Infection
- Smoking
- Reflux
What would you ask a pt. with dysphagia?
- Solid vs. Liquid?
- > solid = obstructive or mechanical problem
- > liquid = neuromuscular problem
- Persistent/Intermittent?
- Pain?
- Where?
- > well-localised in neck
- > poorly localised lower down
What is the initial investigation you would do for a pt. with Dysphagia?
Upper GI Endo!!
What is the initial investigation you would do for a pt. with Dysphagia if a pharyngeal pouch is suspected?
Barium swallow!
What are the most common causes of Dysphagia?
- Lumen: Foreign body
- Wall: Tumour, Stricture, Neuromuscular, Pouch
- Thyroid, Heart, Mediastinal mass
What are the clinical features of FOSIT?
- 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
What are the signs of a malignant neck lump?
- Round
- Firm
- Irregular
- Fixed
- Non-tender
What are the causes of Airway Obstruction?
- Infection (ie. Quinsy)
- Tumour
- Foreign Body
- > dentures
- > children:cherry tomatoes, grapes hot dogs
What are the clinical features of Airway Obstruction?
- Symptom = difficulty breathing
- Sign = stridor (noisy breathing) -> inspiratory, expiratory, biphasic
What is the management of Airway Obstruction?
“ABC”
- humidified oxygen, steroids, adrenaline nebuliser
- secure the airway: intubate, FONA (cricothyroidotomy, tracheostomy)
What is the management of Tonsillitis/Quinsy?
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)
