History taking, clinical examination and investigations

Question 1

What symptoms should be asked for specifically in terms of head and neck during the history?

Answer 1

o	Sore Throat – how long for, constant or changing, alleviating factors?
o	Dysphonia - Hoarseness
o	Dysphagia – difficulty swallowing
o	Odynophagia – pain when swallowing
o	Mouth/Throat Ulcer
o	Neck Lump

Question 2

Whats the significance of a thyroid bruit?

Answer 2

Thyroid bruit (Grave’s thyroiditis) - Graves’ disease, also known as toxic diffuse goiter, is an autoimmune disease that affects the thyroid. It frequently results in and is the most common cause of hyperthyroidism. It also often results in an enlarged thyroid. A thyroid bruit is seen in Grave’s disease from a proliferation of the blood supply when the thyroid enlarges. While a TSH producing pituitary tumor could also cause this, it’s very rare so a thyroid bruit is often considered pathognomonic for Grave’s disease.

Question 3

Whats the significance of a carotid bruit?

Answer 3

Carotid bruit (carotid stenosis) - It may occur as the result of carotid artery stenosis (though some disagree); however, most carotid bruits, particularly those found in younger or asymptomatic patients, are not related to any disease and are termed “innocent carotid bruits”. A carotid bruit is unlikely to be heard if the stenosis occludes less than 40% of the diameter of the artery. Likewise, a stenosis of greater than 90% may not be heard, as the flow may be too low

Question 4

What investigations can be used on the head and neck?

Answer 4

FNAC – fine needle aspiration cytology, usually used in neck lumps
CT/MRI/PET scan – good to assess staging, finding metastases etc
US scan
Plain X-ray
Contrast Swallow – good for studies of the GI tract
Endoscopy – good for assessing mucosa
Can also transilluminate neck lumps

Question 5

What should be assessed when you take the history and examine a neck lump?

Answer 5

History
o	How long?
o	Site?
o	Fluctuates?
o	Sore?
o	H&N symptoms?
o	B symptoms-  Night sweats, weight loss and fever, typical of lymphoma
o	Travel?

Examine
o	Site
o	Size
o	Shape – oval (reactive lymph node) or round (cancer)?
o	Sore – cancer is usually not painful
o	Skin – any change in skin over lump?
o	Stuck – mobile is more likely to be benign
o	Soft

Question 6

How can you tell between a reactive lymph node and a cancer in the neck?

Answer 6

Shape – oval (reactive lymph node) or round (cancer)

Question 7

What are B symptoms?

Answer 7

B symptoms- Night sweats, weight loss and fever, typical of lymphoma

Question 8

Give some examples of neck lumps

Answer 8

Branchial cyst

Lipoma - a benign tumor composed of adipose tissue (body fat).

Thyroglossal cyst - a fibrous cyst that forms from a persistent thyroglossal duct.

Reactive lymph node – oval, soft, smooth, mobile and tender

Salivary gland tumours – pleomorphic adenoma

Salivary gland inflammation – parotitis

Salivary gland obstruction – duct calculus

Question 9

Describe the clinical features of a branchial cyst

Answer 9

Branchial cyst – found on the side of the neck, can occasionally have a fistula to the surface of the skin. Most branchial cleft cysts present as a smooth, slowly enlarging lateral neck mass that may increase in size after an upper respiratory tract infection. The fistulas, when present, are asymptomatic, but may become infected. Branchial cleft cysts are remnants of embryonic development and result from a failure of obliteration of one of the branchial clefts, which are homologous to the structures in fish that develop into gills.

Question 10

Describe a lipoma

Answer 10

Benign growth of adipose tissue

Usually small, smooth, moveable and painless

Question 11

Describe a thyroglossal cyst

Answer 11

A fibrous cyst that forms from a persistent thyroglossal duct.

Thyroglossal cysts can be defined as an irregular neck mass or a lump which develops from cells and tissues left over after the formation of the thyroid gland during developmental stages. Rarely develops into a cancerous tumour.

Characterised by moving when patient sticks their tongue out

Question 12

What type of neck cyst moves when a patient sticks their tongue out?

Answer 12

Thyroglossal cyst

Question 13

Describe the characteristics of a reactive lymph node

Answer 13

oval, soft, smooth, mobile and tender

Question 14

What should be asked when someone presents with hoarseness?

Answer 14

• How long?
• Persistent or Intermittent E.g. excessive voice use at work?
• Pain?
• Cough/Choking/Swallowing?
• Voice use?
• Asthma/Rhinosinusitis/Reflux?
• Smoker?
• Medication?

Question 15

List some possible causes of hoarseness

Answer 15

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

Also injury to recurrent laryngeal nerve

Question 16

From which pharyngeal arch does the recurrent laryngeal nerves arise from?

Answer 16

The recurrent laryngeal nerves are the nerves of the sixth pharyngeal arch.

Question 17

What does a difficulty in swallowing solids or a difficulty in swallowing liquids suggest?

Answer 17

• Difficulty with liquids suggests a neuromuscular problem

* Difficulty with solids suggests mechanical obstruction

Question 18

How can localisation in dysphagia help clinically?

Answer 18

Well localised - obstruction in neck

Poorly localised - obstruction lower down.

Question 19

How is dysphagia assessed?

Answer 19

Barium swallow

Question 20

What can cause dysphagia?

Answer 20

Lumen: foreign body

Wall: tumour, stricture, neuromuscular, pharyngeal pouch

Extra luminal: Thyroid, Heart, Mediastinal mass

Question 21

What is FOSIT?

Answer 21

Feeling of something in throat/ globus pharyngeus

Question 22

What is the most common cause of FOSIT?

Answer 22

Cricopharyngeus muscle spasm is the usual cause of sensation

Question 23

What are the clinical signs of a malignant neck node on examination?

Answer 23

o	Round
o	Firm
o	Irregular
o	Fixed
o	Non-tender

Question 24

What surgery is suggested for neck cancers?

Answer 24

Neck dissection

Flap reconstruction

Question 25

What are the different types of stridor?

Answer 25

Inspiratory stridor suggests a laryngeal obstruction

Expiratory stridor implies tracheobronchial obstruction

Biphasic stridor suggests a subglottic or glottic anomaly

Question 26

What are some common causes of airway obstruction/stridor?

Answer 26

Causes: Infection/Tumour/Foreign body e.g. dentures (always ask!), fruits such as grapes and cheery tomatoes common cause of airway obstruction in young children

Question 27

What is the last resort when trying to open up breathing in a patient?

Answer 27

Tracheostomy or Cricothyroidotomy

Question 28

What are the SIGN guideline for eligibility for tonsillectomy?

Answer 28

Bacterial Tonsillitis: (pus covering, neck nodes, fever, no cough)

6-7 attacks in 1 year (5 per year over two years, 3 per year over three years)

Disrupting daily activities

More than 1 quinsy (peritonsillar abscess)