Neck examination

Question 1

Inspection- what do you do and what do you look for?

Answer 1

-From front and side
-Inspect tongue and dentition with tongue depressor

Look for:

Systemic features cancer
-General appearance of pt (e.g ? cachexia)

Local features of cancer
-Any obvious lumps/swelling/asymmetry

Evidence previous surgery/treatment
-Scars or fistulae
-Post radiotherapy skin changes e.g. telangiectasia

Nerve palsy
-Any signs facial assymetry

Question 2

Palpation

Answer 2

-Warn pt you will palpate cheek and ask about any pain/tenderness
-Check temperature
-Feel for lumps around cheek/angle of jaw
-Intraoral examination
-Bimanual palpation of parotid
-Lymph nodes

Question 3

Assess facial nerve function

Answer 3

Test muscles systematically
-Temporal branch (occipitofrontalis) - ‘raise your eyebrows’
-Zygomatic branch (orbicularis oculi) -‘close your eyes tightly’
-Buccal branch (buccinator) - ‘puff out your cheeks’
-Marginal mandibular branch (orbicularis oris) - ‘show me your teeth’
-Cervical branch - ‘tense your neck muscles’ (platysma_)

Question 4

To complete examination

Answer 4

Examine submandibular gland
Perform full ENT examination
Triple assessment

Question 5

How would you describe a lump?

Answer 5

Site: unilateral or bilateral?
Size
Shape
Edges/surface
Consistency/nodularity
Fluctuance
Fixity/tethering

Question 6

Describe intraoral examination. ?where does parotid duct open?

Answer 6

-Look inside mouth and sweep gloved finger along inside of cheek to feel for any stones in parotid duct
-Parotid duct opens into papilla at the level of second upper molar
-Palpate parotid gland bimanually to fully assess for lumps or swelling

Question 7

Describe anatomy of parotid gland

Answer 7

Superior:
-zygomatic arch

Anterior
- masseter

Inferior:
-inferior border mandible

Posterior
-External ear + SCM

Question 8

Describe course of parotid duct

Answer 8

• It arises from the anterior surface of the gland, traversing the masseter muscle.
• pierces buccinator and opens within buccal vestibule at level of upper 2nd molar tooth (stensen’s duct)

Question 9

Describe blood supply to parotid

Answer 9

-Arterial: branches from external carotid via superficial temporal + posterior auricular arteries
-Venous: retromandibular vein

Question 10

Nerve supply to parotid:

Answer 10

-Sensory from auriculotemporal and great auricular nerves
-Parasymp: glossopharyngeal

Question 11

Name structures within substance of parotid gland:

Answer 11

For REAL (superficial to deep)

-Facial nerve: 5 branches divide within parotid
-Retromandibular vein (formed by union superficial temporal and maxillary)
-External carotid artery and terminal branches superficial temporal and maxillary arteries
-Branches greater auricular nerve
-Lymph nodes

Question 12

Rule of 80s used to describe tumours of parotid gland

Answer 12

-80% are benign
-80% are pleomorphic adenomas
-80% salivary gland pleomorphic adenomas occur in parotid
-80% parotid pleomorphic adenomas occur in superficial lobre

Question 13

Causes Parotid enlargement

Answer 13

Benign:
-Pleomorphic adenoma
-Warthin’s tumour
-Lymphangioma

Malignant:
-Adenoid cystic carcinoma
-Adenocarcinoma
-Lymphoma

Infection
-Viral e.g. HIV/mumpbs
-Bacterial e.g. staph

Inflamm:
-Autoimmune e.g. sjogren’s

Drugs
-Alcohol

Metabolic:
-Diabetes
-Cirrhosis

Question 14

What are complications associated with parotid gland surgery?

Answer 14

Specific:
-Facial nerve injury
-Frey’s (gustatory sweating)
-Spillage leading to reocurrance of disease
-Sinus/fistula

Question 15

How would you investigate parotid lump?

Answer 15

Triple assessment
-History + examination
-Imaging (CT/MRI)
-FNA

Question 16

Name blood supply to submandibular gland

Answer 16

Submental artery (from facial)
Lingual (from external carotid)

Question 17

What is the nerve supply to submandibular?

Answer 17

Parasympathetic fibres from facial nerve via chorda tympani + lingual nerve supply secretomotor function

Question 18

Describe where submandibular gland duct opening lies

Answer 18

Submandibular duct (Wharton’s duct) is approx 5cm long and opens lateral to lingual frenulum into sublingual papilla

Question 19

Lymph node chains

Answer 19

1. Start under the chin (submental lymph nodes), then move posteriorly palpating beneath the mandible (submandibular), turn upwards at the angle of the mandible (tonsillar and parotid lymph nodes) and feel anterior (preauricular lymph nodes) and posterior to the ears (posterior auricular lymph nodes).
2. Follow the anterior border of the sternocleidomastoid muscle (anterior cervical chain) down to the clavicle, then palpate up behind the posterior border of the sternocleidomastoid (posterior cervical chain) to the mastoid process.
3. Palpate over the occipital protuberance (occipital lymph nodes).
4. Ask the patient to tilt their head (bring their ear towards their shoulder) each side in turn, and palpate behind the posterior border of the clavicle in the supraclavicular fossa (supraclavicular and infraclavicular lymph nodes).

Question 20

Submandibular gland specific examination:

Answer 20

-Ask patient to put tongue to roof of mouth to determine relation of lump to myloyoid
-Divides superficial and deep lobes
-Test sensation and mobility of tongue to assess lingual and hypoglossal nerves

Question 21

Submandibular gland anatomy

Answer 21

-The submandibular gland is located within the anterior part of the submandibular triangle. The boundaries of this triangle are:

Superiorly: Inferior body of the mandible.
Anteriorly: Anterior belly of the digastric muscle.
Posteriorly: Posterior belly of the digastric muscle

-Two lobes, superficial and deep
-Superficial: outside oral cavity
-Deep: hooks around mylohyoid to enter oral cavity

Question 22

Submandibular gland relationship with nerves

Answer 22

Both the submandibular gland and duct share an intimate anatomical relationship with three principal nerves; the lingual nerve, hypoglossal nerve and facial nerve (marginal mandibular branch). The courses of these nerves are briefly outlined:

Lingual nerve: Beginning lateral to the submandibular duct, this nerve courses anteromedially by looping beneath the duct and then terminating as several medial branches. The terminal branches ascend on the external and superior surface of hypoglossus to provide general somatic afferent innervation to the mucus membrane of the anterior two-thirds of the tongue.
Hypoglossal nerve: Lies deep to the submandibular gland and runs superficial to hyoglossus and deep to digastric muscle.
Facial nerve (marginal mandibular branch): Exits the anterior-inferior portion of the parotid gland at the angle of the jaw and traverses the margin of the mandible in the plane between platysma and the investing layer of deep cervical fascia curving down inferior to the submandibular gland.

Question 23

Differentials for submandibular gland swelling

Answer 23

Inflammatory
-Lymphadenopathy/lymphangitis
-Ludwig’s angina

Tumours
-Pleomorphic adenoma
-Lymphoma

Developmental
-Ranula
-Dermoid cyst
-Cystic hygroma

Question 24

What is surface marking submandibular gland?

Answer 24

2-3cm anterior to anteiror border SCM

Question 25

What imaging would you use for suspected submandibular gland stone?

Answer 25

Ultrasound +/- siaglography

Question 26

What imaging would you use for suspected malignancy?

Answer 26

CT or MRI

Question 27

Management for salivary stone

Answer 27

-Conservative: Sialogogs, encourage fluids, bimanually massage duct to express stone
-Medical: nsaids
-Surgical: Sialotomy (under local if visible, gland excision if chronic