Head and Neck Clinical Flashcards
What may present in a head and neck history?
Sore throat Dysphonia Odynophagia Moth/ throat ulcer Neck lump
Smoking/ Alcohol
Family History
What is important to remember about a full head and neck examination?
It includes an examination of the pharynx and larynx.
If you suspect problems then refer to ENT. They have the equipment to do this:
- Laryngoscopy
- Nasolaryngoscopy
What is bifid uvula an early manifestation of?
Cleft palate
What is the appearance of normal healthy vocal cords?
“Pearly white”
How should you prepare a patient for a head and neck examination?
Patient sitting in chair
Glass of water nearly - be prepared to examine the thyroid in full
Expose the neck down to the clavicles - undo the top buttons of a shirt
Ask the patient to remove any jewellery
How do you carry out an inspection in head and neck examination?
Lump: site, size, skin changes
Scars
Does the lump move?
- Tongue protrussion: thyroglossal cyst
- Swallowing: place glass of water in patients hands, hold in mouth then swallow
Describe the palpation in the head and neck examination
From front:
-Check the trachea
From back:
- Be gentle, watch for discomfort
- Use fingertips to elicit physical signs
Palpate the triangles (Z)
- Anterior triangle
- Posterior triangle
Determine lump characteristics
Examine thyroid in full
How do you examine the neck using the Z technique?
- Palpate from the chin backwards to below the ears
- Palpate down the anterior border of sternocleidomastoid to clavicle
- Move laterally along the clavicle and then up the posterior border of sternocleidomastoid
- Finish by palpating the back of the scalp for occipital lymph nodes
What can a thyroid bruit indicate?
Grave’s disease
What are the head and neck examinations?
FNAC CT/MRI/PET scan US scan Plain X-ray Contrast swallow Endoscopy
Explain FNAC in head and neck
With any lumps this is great.
If you find a lump on examination imaging is only going to tell you what you already know.
FNAC will tell you what exactly the lump is
What are the characteristics of a reactive lymph node?
Oval Soft Smooth Mobile Tender
What does a brachial cyst present like?
Usually young patients
Soft and non tender
Upper sternocleidomastoid
How do you identify a thyroglossal cyst?
Moves out with tongue
How would a patient present with duct calculi?
Pain and pressure when they are about to eat or are eating (pressure builds up as fluid produced but nowhere to go)
Will settle a while after eating
Should you worry about a pleomorphic adenoma?
They are benign
Can become malignant over the space of years so if the patient is young you may consider removal
Someone presents with hoarseness.
What questions should you ask them?
How long? Persistant or intermittent? Pain? Cough/Choking/Swallowing? Voice use? (do they sing etc) Asthma/Rhinosinusitis/Reflux? Smoker? Medication (inhalers etc may irritate)
What can cause hoarseness?
Nodules
- Will be present on both cords
- Singers with poor technique
Cysts
-Traumatic cyst or vocal cord polyp
Laryngitis
Smoking
Reflux
Laryngeal or lung cancer
What are the two most common treatment plans for laryngeal carcinoma?
Chemoradiotherapy - try to save the larynx
Laryngectomy - remove larynx and bring trachea up as stoma
will breath through tube for test of life
How would you suspect lung cancer in someone with hoarseness?
The larynx will look normal
Get them to speak
One cord (usually left) won’t be able to move.
Lung cancer nodes in the mediastinum are pressing on recurrent laryngeal nerve causing palsy
Nodes in mediastinum means cancer is inoperable
What kind of questions should you ask someone presenting wit dysphagia?
- What is difficult? (solids or liquids)
- Persistent or intermittent
- Getting worse?
- Pain?
- Where?
- –Neck better at localising obstruction
- –Lower down poorly localised, may be referred slightly
What can cause dysphagia?
Lumen = foreign body
Wall = Tumour, stricture, neuromuscular, pouch
Extra Luminal = Thyroid, Heart, Mediastinal mass
What is FOSIT?
“Feeling Of Something In Throat”
aka Globus Pharyngeus
Due to spasm of cricopharyngeus
Acid reflux
Stress/ anxiety
No dysphagia (“easier with food”)
What are the most common cancers of the head and neck?
90% squamous
What are the characteristics of a malignant neck node?
Round Firm Irregular Fixed Non-tender
What is stridor?
Noisy breathing
Inspiratory stridor comes from the level of vocal cords or above (emergency)
-Possible tracheostomy
Expiratory stridor = wheeze
-From lower down
Biphasic stridor = both inspiratory and expiratory
What infections may become an emergency?
Quinsy/ Peritonillar abscess
Infectious Mononucleosis (Glandular Fever) -Possibly cannot swallow at all
Neck space infections
Why should you do an ultrasound after a FNAC of a thyroglossal cyst?
To check if the thyroid is present where it should be or if the whole thing is in the cyst
Don’t want to remove the thyroid if its in the cyst -> hypothyroidism
What is the operation for a thyroglossal cyst?
Sistruck’s operation
take cyst out along with central portion of hyoid bone and tracts of cyst
This prevents it returning
What is the embryological origin of a thyroglossal cyst?
Foramen caecum
What signs would show a lymphoma?
B Symptoms:
- Poor appetite
- Weight loss
- Fever
- Profuse night sweats
Indicate both Hodgkin’s and and non Hodgkin’s lymphoma
How does quinsy (peritonsillar abcess) present?
Very like tonsillitis but location slightly different
May have difficulty opening jaw due to spread of infection to pterygoid muscles causing spasm
Drainage of cyst can improve many symptoms
What is laryngomalacia?
Floppy larynx
Tissues very soft in young child so tissue will flop covering larynx -> stridor
As the child grows the structures will stiffen and it should sort itself out
