Head and Neck

Question 1

If someone presents with headache, what 5 conditions do you want to consider?

Answer 1

1. Intracranial mass
2. Meningitis
3. Temporal Arteritis
4. SAH
5. Migraine

Question 2

NICE (2012) recommend referral in headaches in what conditions?

Answer 2

1. Worsening headache with fever.
2. Sudden-onset headache reaching maximum intensity within 5min (= thunderclap headache).
   
   1. Refer immediately to exclude subarachnoid but may also be caused by other intracerebral bleeding, cerebral venous sinus thrombosis, arterial dissection, pituitary apoplexy (SIGN).
3. New-onset neurological deficit or cognitive impairment.
4. Change in personality.
5. Impaired level of consciousness.
6. Recent head trauma (in last 3/12).
7. Headache triggered by cough, valsalva manoeuvre or sneezing.
8. Headache triggered by exercise.
9. Orthostatic headache (headache that changes with posture).
10. Symptoms suggestive of giant cell arteritis.
11. Symptoms and signs of acute narrow-angle glaucoma.
12. A substantial change in the character of a headache.

Question 3

Red flag symtoms for intracranial mass?

Answer 3

• Raised ICP - morning headache
• Focal neurological deficits
• Fits/faints/funny turns
• Vomiting
• Waking from sleep with headache.
• Double vision
• H/O cancer anywhere

Question 4

Red flag symptoms for Temporal Arteritis?

Answer 4

• Pain on eating (Jaw claudication)
• Acute duration
• Tender temporal arteries

Question 5

Red flag symptoms for SAH?

Answer 5

• Acute severe headache
• Sudden hit on the head
• Occipital (10% are SAH - most common is cervicogenic)
• Stiff neck
• N&V
• Photophobia
• Blurred/double vision

Question 6

What other 2 conditions, apart form SAH, have thunderclap headaches (Max intensity within 5 minutes)?

Answer 6

1. Cerebral venous sinus thrombosis
2. Cervical artery dissection

Question 7

Describe the 3 item test for Migraines.

(Sensitivity of 80% and Specificity of 70%)

Describe other symptoms

Answer 7

1. Acute unilateral pulsating and disabling headache
2. Nausea (75%)
3. Photophobia (85%)

Other symptoms:

• Phonophobia (75%)
• Vertigo (50%)
• Vomiting (30%)
• Aura (20%)

Question 8

Describe the red flag symptoms to ask about in eye problems?

Answer 8

• Visual acuity changes
• Diplopia
• Sudden onset pain
• Redness
• Floaters
• Facial pain
• Double vision

Question 9

What are the red flags for the nose?

Answer 9

• Epistaxis.
• Nasal obstruction, nasal discharge – with or without blood
• Facial pain
• Double vision

Question 10

What throat red flags should you screen for?

Answer 10

• Dysphagia
• Hoarseness >3w
• Long lasting cough (>3w)
• Long lasting sore throat (>3w)
• Lump in neck
• Persistent mouth ulcers (higher suspicion if age>45)
• Ask about alcohol or smoking history - increased risk of oral/laryngeal cancer.

Question 11

If someone has a dental swelling, what red flag symptoms should you discuss?

(Think PUSTULE)

Answer 11

• Pyrexia
• Unwell (tachycardia, tachypnoea, hypotension)
• Swelling (extra-oral)
• Tender
• Unable to swallow secretions (i.e. drooling)
• Limitation in opening
• Eye involvement (periorbital cellulitis)
• Speech problem

Refer all dental swellings - either abscess or malignancy.