Neck Lumps & Common ENT Conditions:

Question 1

What are the different levels of the neck?

Answer 1

Level 1- submandibular & submental region
Level 2- upper sternocleidomastoid region
Level 3- middle sternocleidomastoid region
Level 4- lower sternocleidomastoid region
Level 5- posterior triangle of neck
Level 6- anterior triangle of neck

Question 1

What are the 2 triangles of the neck?

Answer 1

Anterior triangle (digastric triangle, carotid triangle, muscular triangle)

posterior triangle (bounded by anterior border of trapezius, posterior border of sternocleidomastoid, and middle third of clavicle)

Question 2

What questions should you ask regarding a lump in a patient?

Answer 2

When did you first notice it?
What has happened to it since?
Ever had it before?
Any other lumps?
Any associated features?

Question 3

What important things are in the history that is relevant if the patient has lumps?

Answer 3

-Foreign travel e.g tuberculosis
-Pets e.g cat scratch disease
-Weight loss
-Night sweats
-Fever
-Pain with alcohol
-Smoking
-Alcohol

Question 4

What different things should you look for when examining a lump?

Answer 4

Site - know your head and neck anatomy!

Size - greater than 3-4cm is worrying

Shape

Surface - has it changed the colour/surface of skin?

Temperature

Tenderness

Mobile/fixed - does it move on swallowing?

Transillumination - does the lump glow when a light is held next to it?

Pause for pulsation

Colour

Margin

Relations

Nodes - involvement of any lymph nodes?

Question 5

What does the anatomical sieve consist of?

Answer 5

(Sieve = way of sorting what the pathological cause of the lump is)

Start from superficial to deep

-Skin
-Hair
-Fat
-Blood vessels
-Nerves
-Lymphatics
-Connective tissue
-Muscles
-Bone
-Special structures (thyroid, parotid, thymus)

(important for pathological diagnosis)

Question 6

What does the surgical sieve consist of and what is it important for?

Answer 6

It’s an approach to making a differential diagnosis based on the pathological process and it consists of:

-Congenital or acquired
-Traumatic
-Infective/inflammatory
-Neoplastic
-Metabolic/immune
-Drug
-Degenerative
-Vascular
-Iatrogenic
-Psychogenic

Question 7

What are some special investigations that you can do in terms of investigating a head or neck lump?

Answer 7

-Nasendoscopy (looking into nose/nasopharynx)

-Fine needle aspiration

-Imaging (DPT, ultrasound, CT, MRI, PET scan)

-Blood tests (FBC, LFT, bone screen, ESR, thyroid function, EBV, CMV, HIV, brucellosis, toxoplasmosis, glandular fever, cat scratch disease)

Question 8

What are the many different causes of cervical lymphadenopathy?

Answer 8

infective:
bacterial
local viral
general bacterial
general viral

neoplastic:
local metastatic
general

other:
Drugs eg phenytoin
Sarcoidosis - a chronic disease of unknown cause characterized by the enlargement of lymph nodes in many parts of the body

Question 9

What are some examples of lateral neck lumps?

Answer 9

-Epidermoid cyst
-Lipoma
-Fibroma
-Salivary glands
-Branchial cyst - usually in patients over 3rd decade. Patients in their 40’s be careful as it may not be a brachial cyst but a malignant metastases.
-Cervical rib - can cause vascular/nerve pain in arms
-Hyoid bone (normal anatomy misdiagnosed as pathology)
-Transverse process C1 & C6 (as above)
-Ectatic carotid artery
-Congenital torticollis

Question 10

What are some examples of common midline neck lumps?

Answer 10

-Thyroid gland pathology

-Parathyroid gland

-Dermoid cyst - usually presents in the Submental region

-Plunging ranula - cyst of the sublingual gland, whilst its getting bigger it can plunge through Mylohyoid muscle and present as a neck lump

-Thyroglossal duct cyst

Question 11

What is an axiom of diagnosing a lateral neck mass?

Answer 11

Any lateral neck mass in an adult is a metastatic deposit until proven otherwise.

Therefore investigations must be taken

Question 12

What does a branchial cyst (cervical lymphoepithelial cyst) look and feel like?

Answer 12

Usually presents as a lateral neck mass, anterior to the sternocleidomastoid muscle

Usually in late adolescence/early adulthood

It’s fluctuant and feels like it’s half fluid-filled

Generally treated by surgical excision

Question 13

Where does a thyroglossal duct cyst present and how can you diagnose it?

Answer 13

It’s a midline neck lump

It’s an embryological remnant cyst from where the thyroid first develops at the base of the tongue near the foramen cecum

Diagnosis: it is the only neck lump that moves with swallowing AND with protrusion of the tongue

Question 14

What does Ludwig’s angina look like?

Answer 14

Infective process
Emergency drainage needed/rapid referral
Can be fatal

Question 15

What common conditions affect the ear?

Answer 15

-Hearing loss
-Otalgia - pain in the ear
-Otorrhoea - discharge from the ear
-Middle ear infection
-Facial palsy
-Disorders of balance
-Tinnitus
-Foreign bodies

Question 16

What is a cholesteatoma?

Answer 16

An abnormal, noncancerous skin growth that can develop in the middle section of your ear, behind the eardrum.

It may be a birth defect, but it’s most commonly caused by repeated middle ear infections

Can cause smelly discharge from the ear

Question 17

From what different sources can pain be referred to the ear?

Answer 17

slides

Question 18

What steps should you follow to treat a patient with ear pain?

Answer 18

slides

Question 19

What is otitis externa?

Answer 19

Inflammation of the external auditory meatus

Question 20

What are some common causes of otitis externa?

Answer 20

Infective: Bacterial, fungal, viral

Reactive: Eczema, psoriasis

Question 21

What it otitis media with effusion?

Answer 21

Also known as glue ear and tends to affect children very commonly

It’s a Eustachian tube dysfunction

Question 22

What can glue ear cause?

Answer 22

It can lead to conductive hearing loss, learning difficulties, and speech delay, associated with cleft lip & palate

Question 23

When is urgent treatment needed in glue ear?

Answer 23

When you can see pus behind the tympanic membrane
Also put them on a course of antibiotics

Question 24

What common problems arise from the nose?

Answer 24

-Allergic rhinitis
-Nasal polyps
-Nasal infections
-Nasal septum
-Epistaxis - nose bleed
-Sinusitis

Question 25

What can be some causes of epistaxis?

Answer 25

-Hypertension

-Blood dyscrasias: von Willebrands, liver disease, haemophilia, thrombocytopenia

-Hereditary haemorrhagic telangiectasia

-Drugs: aspirin (NSAIDs), warfarin, steroids, clopidogrel, chemotherapy

-Trauma

-Rhinotillexis

-Nasal septum defects

-Neoplasms

-Inflammation: URTI, sinusitis

-Environmental: cold dry air, central heating

Question 26

What are some common conditions affecting the throat?

Answer 26

-Dysphonia - problems with the voice
-Stridor - narrowing of airway causing sound
-Sore throats
-Tonsils and Adenoids
-Dysphagia - difficulty swallowing
-Snoring and sleep apneoa

Question 27

What should a persistent sore throat with a changing voice, especially a hoarse voice longer than 2 weeks, be treated as?

Answer 27

Laryngeal cancer, until proven otherwise

Question 28

What are some causes of dysphagia?

Answer 28

Neuromuscular:
-Old age; bulbar or pseudobulbar palsy; MND; stroke; constriction of cricopharyngeus muscle

Obstructive (in lumen, wall, outside wall):
-Foreign body; carcinoma of pharynx; post-cricoid carcinoma, oesophagitis; carcinoma of oesophagus; invasion by carcinoma of lung; achalasia of the cardia