ENT - The Neck

Question 1

Describe the borders and content of the 3 main triangles of the neck.

Answer 1

Anterior triangle

• borders: mandible + midline + anterior SCM
• contains: muscles, carotid triangle, CN 7, 9, 11

Posterior triangle

• borders: clavicle + posterior SCM + anterior trapezius
• contains: muscles, EJV, subclavian vein, CN 11, cervical + brachial plexus

Carotid triangle:

• anterior SCM (post.) + superior belly omohyoid (ant.) + posteror belly digastric (sup.)
• contains: common carotid artery (+ bifurcation), carotid sinus, IJV, CN 10 + 12

Question 2

A father brings his 10yo son Ben to the GPs. Ben has a 4/7 Hx of tonsillitis. He says today the pain is much worse, more so on the left side, and that it hurts to talk (‘hot potato voice’.

O/E Ben is drooling, has difficulty opening his mouth but you can see swelling above the left tonsil. His temp is 39.
Name 2 possible diagnoses? How should he be managed?

Answer 2

Peritonsillar abscess (Quinsy)
or paraphaenygeal abscess (would see swelling around upper SCM)

1. Urgent ENT referral + admission to hospital.
2. high dose IV Abx e.g. CO-AMOXICLAV
3. single dose adjuvant steroid
4. surgical incision + drainage +/- immediate/interval tonsillectomy

Question 3

A mother brings a 3yo girl with difficulty breathing to ED. The girl has been unwell with a throat infection for 1 week, but has worsened since yesterday: refuses to eat due to pain, unable to move neck, SOB + stridor and temp of 39.

Name 2 possible diagnoses? How should she be assessed and managed for each?

Answer 3

Retropharyngeal abscess or epiglottitis

Retropharyngeal abscess:

1. secure airway if any concerns
2. high dose IV Abx e.g. co-amoxiclav
3. CT neck for definitive Dx
4. +/- surgical incision + drainage

Epiglottits:

1. do not examine/distress child (clinical diagnosis)
2. secure airway: direct rigid laryngoscopy + intubation in theatres
3. IV Abx e.g. cefotaxime/ceftriaxone
4. dexamethasone PO
5. extubation after 72hrs + oral Abx e.g. co-amoxiclav

Question 4

A 57yo man presents to ED with difficulty breathing, fever, mouth pain, trismus + drooling. He has been waiting for a dental appointment for 7/7 due to a tooth infection.
On bimanual paplation, a firm swelling of the floor of the mouth can be felt.

What is the likely diagnosis? How should he be assessed + managed?

Answer 4

Ludwig’s angina: infection of submandibular space.

Clincal Dx but can use CT neck to assess airway patency (airway compromise due to backward displacement of tongue) and presence of underlying dental abscess.

Mx:

1. secure airway if any concerns e.g. NPA, tracheostomy
2. high dose IV Abx e.g. co-amoxiclav
3. +/- surgical incision + drainage

Question 5

A 46yo man presents to the GP with a lump under his left jaw. It is usually painful during meals only. No other Sx.
What is the likely diagnosis and how would you investigate? What are the Mx options?

Answer 5

Sialolithiasis

Ix: USS + sialogram

Mx:
1. analgesia + hydration + gentle massage + sialogogues e.g. pilocarpine
2nd line:
2. endoscopic or radiological removal 
3. surgery

Question 6

A 70yo man presents to the GP with a painful lump under his left jaw + fever. O/E: his mucous membranes are dehydrated and a small amount of pus is visible in oral cavity with pressure on lump.

What is the likely diagnosis and how would you investigate? What are the Mx options?

Answer 6

Sialadenitis

Ix:

• FBC
• MC+S of exudate from duct
• USS or face X-ray: ID any sialoliths

Mx:
- Abx e.g. co-amoxiclav
- analgesia + hydration + gentle massage + sialogogues e.g. pilocarpine
+/- surgical drainage if abscess

Question 7

Where are salivary gland tumours usually located?

Answer 7

80% in parotid gland

Question 8

Are salivary gland tumours usually benign or malignant?

Answer 8

Benign:

• parotid gland: 80% benign, 20% malignant
• submandibular gland: 50/50
• sublingual glands: 20% benign, 80% malignant

Question 9

What is the most common type of salivary gland tumour? How should it be managed?

Answer 9

Pleiomorphic adenoma - surgical excision due to small risk of malignant transformation with time

Question 10

What are Warthin’s tumours?

Answer 10

Benign tumours of parotid gland, more common in elderly males. May be bilateral.

Question 11

Describe features suggest a malignant parotid gland tumour.

Answer 11

1. painful neck lump
2. facial n. palsy (nerve infiltration)
3. skin ulceration/fixation
4. lymphadenopathy

Question 12

Suggest possible complications of parotid gland excision.

Answer 12

1. infection + haemorrhage
2. permanent facial n. injury
3. Frey’s syndrome: gustatory sweating due to damage + inappropriate regeneration of PNS fibres of CN V3 to sweat glands (instead of parotid)
4. 1st bite syndrome: pain in parotid region with 1st bite of every meal due to sympathetic denervation of gland

Question 13

Name 3 structures that run through parotid gland.

Answer 13

1. facial n.
2. external carotid artery
3. retromandibular vein