Neck examination Flashcards
Inspection- what do you do and what do you look for?
-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
Palpation
-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
Assess facial nerve function
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_)
To complete examination
Examine submandibular gland
Perform full ENT examination
Triple assessment
How would you describe a lump?
Site: unilateral or bilateral?
Size
Shape
Edges/surface
Consistency/nodularity
Fluctuance
Fixity/tethering
Describe intraoral examination. ?where does parotid duct open?
-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
Describe anatomy of parotid gland
Superior:
-zygomatic arch
Anterior
- masseter
Inferior:
-inferior border mandible
Posterior
-External ear + SCM
Describe course of parotid duct
- 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)
Describe blood supply to parotid
-Arterial: branches from external carotid via superficial temporal + posterior auricular arteries
-Venous: retromandibular vein
Nerve supply to parotid:
-Sensory from auriculotemporal and great auricular nerves
-Parasymp: glossopharyngeal
Name structures within substance of parotid gland:
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
Rule of 80s used to describe tumours of parotid gland
-80% are benign
-80% are pleomorphic adenomas
-80% salivary gland pleomorphic adenomas occur in parotid
-80% parotid pleomorphic adenomas occur in superficial lobre
Causes Parotid enlargement
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
What are complications associated with parotid gland surgery?
Specific:
-Facial nerve injury
-Frey’s (gustatory sweating)
-Spillage leading to reocurrance of disease
-Sinus/fistula
How would you investigate parotid lump?
Triple assessment
-History + examination
-Imaging (CT/MRI)
-FNA
Name blood supply to submandibular gland
Submental artery (from facial)
Lingual (from external carotid)
What is the nerve supply to submandibular?
Parasympathetic fibres from facial nerve via chorda tympani + lingual nerve supply secretomotor function
Describe where submandibular gland duct opening lies
Submandibular duct (Wharton’s duct) is approx 5cm long and opens lateral to lingual frenulum into sublingual papilla
Lymph node chains
- 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).
- 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.
- Palpate over the occipital protuberance (occipital lymph nodes).
- 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).
Submandibular gland specific examination:
-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
Submandibular gland anatomy
-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
Submandibular gland relationship with nerves
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.
Differentials for submandibular gland swelling
Inflammatory
-Lymphadenopathy/lymphangitis
-Ludwig’s angina
Tumours
-Pleomorphic adenoma
-Lymphoma
Developmental
-Ranula
-Dermoid cyst
-Cystic hygroma
What is surface marking submandibular gland?
2-3cm anterior to anteiror border SCM
What imaging would you use for suspected submandibular gland stone?
Ultrasound +/- siaglography
What imaging would you use for suspected malignancy?
CT or MRI
Management for salivary stone
-Conservative: Sialogogs, encourage fluids, bimanually massage duct to express stone
-Medical: nsaids
-Surgical: Sialotomy (under local if visible, gland excision if chronic
