Session 1 ILOs - General organisation and cervical lymph nodes and neck lumps

Question 1

State the 2 major muscle groups of the head and neck and their nerve innervation

Answer 1

Muscles broadly divide into 2 groups:

1. Muscles of facial expression (most muscles)
   - Muscles are dilators or sphincters
2. Muscles of mastication (4 muscles)
   - Muscles act on the temporomandibular joint

Nerve supply:

1. Muscles of facial expression (most muscles)
   - Innervated by the Facial Nerve / Cranial nerve 7
   - Mainly MOTOR
   - Facial nerve passes through the parotid gland, damage can lead to facial nerve lesion
   - 5 extra cranial branches (To Zanzibar By Motor Car) - Temporal, Zygomatic, Buccal, Marginal mandibular and Cervical
2. Muscles of mastication
   - Innervated by the (mandibular branch of) Trigemial Nerve / Cranial nerve 5
   - Mainly SENSORY
   - 3 main sensory branches OOM - Ophthalmic, Maxillary, Mandibular PLUS motor innervation to muscles of mastication

Question 2

Describe the boundaries of the anterior, posterior and carotid triangles, identify their surface anatomy and the key anatomical contents

Answer 2

Anterior triangle:
Medial border - imaginary mid line
Lateral border - anterior border of the sternocleidomastoid
Superior border - inferior aspect of mandible
Contents: Infra-hyoid and supra-hyoid muscles, internal jugular vein, carotid artery and vagus nerve

Posterior triangle:
Medial border - posterior border of the sternocleidomastoid
Lateral border - trapezius
Inferior border - clavicle
Contents: External jugular vein, scalenes, subclavian artery and vein, brachial plexus and omohyoid

Carotid triangle = smaller triangle within the anterior triangle:
Medial border - omohyoid muscle
Lateral border - anterior border of the sternocleidomastoid
Superior border - diagastic muscle
Contents: Carotid sheath

Question 3

Explain the implications for the spread of deep neck space infections due to the compartmentalisation and boundaries of the cervical fascial planes

Answer 3

The concentric fascial layers create cylindrical compartments
- Creates deep neck spaces which can provide room for infection and spread of infection in certain directions

Deep neck spaces communicate with the mediastinum
- Can cause infections to spread inferiorly into the mediastinum = mediastinitis

Question 4

Outline 2 common pathologies which may give rise to lymphadenopathy (enlarged lymph nodes in the neck

Answer 4

2 main causes for lymphadenopathy:

1. Infection
   - Tender and mobile lump
2. Malignancy (either primary or secondary)
   - Primary feels rubbery and mobile
   - Secondary feels hard, matted and non-tender

Then need to take a full history, examine the area that the lymph node drains and examine other lymph nodes

Question 5

Describe the general location of the superficial and deep cervical lymph nodes plus the general areas of the head and neck that these drain

Answer 5

5 main superficial lymph nodes:
- Submental
- Submandibular
- Pre-auricular
- Post-auricular
- Occipital
Drain area generally above them (in lines)

3 deep lymph nodes:

• Jugulo-diagastic = drains tongue and tonsils
• Jugulo-omohyoid = drains thyroid, pharynx etc.
• Supra-clavicular

Question 6

List tonsils forming Waldeyer’s ring of lymphoid tissue and their location

Answer 6

Pharyngeal tonsil (adenoids)

• Roof of nasopharynx
• Common issue for children

Tubal tonsils (x2)
- Lateral wall of the nasopharynx

Palatine tonsils (x2)

• Lateral oropharynx wall
• Commonly referred to as ‘the tonsils‘

Lingual tonsil
- Posterior third of the tongue

Question 7

Describe common causes of neck lumps and the key symptoms and clinical examination findings associated with them

Answer 7

• Lumps within superficial fascia e.g. sebaceous cyst
• Inflammatory or infective lymph node
• Congenital lesions e.g. thyroglossal cyst or branchial cyst
• Thyroid pathology
• Primary or secondary malignancy
• Salivary gland pathology
  etc.

Question 8

Describe and recognise the red flags for neck lumps, which indicate concerning underlying pathology e.g. head and neck cancer

Answer 8

• Persists more than 6 weeks
• Fixed, hard, irregular
• Rapid growth
• Associated with general lymphadenopathy
• Associated symptoms e.g. night sweats, weight loss
• Persistent change in voice/hoarseness or difficulty swallowing