Common Conditions of the Head, Neck and Throat Flashcards
56 year old man presents with slight cough and no other symptoms
“Doc, I have been smoking 20 per day and working on the roads for 38 years”
Identify the problem and what to examine
Left lateral neck mass
Most likely to be associated with the lympho-reticular system of the head and neck; these structures require examination
What is the basic arrangement of the lympho-reticular system of the head and neck?
1) Inner ring (Waldeyer’s ring): adenoids (pharyngeal), tubal, tonsils (palatine), lingual, pharyngeal bands
2) Outer ring (LN groups): submental, submandibular, jugulo-digastric (relationship to tonsils??), post-auricular, sub-occipital
3) Lymphatic chain associated with the great vessels of the neck and thoracic duct: jugulo-digastric LN group, jugulo-omohyoid LN group
56 year old man of Cantonese/SE Asian extraction presents with slight cough and no other symptoms
O/E: left lateral neck mass
Other Hx: 38 pack-year smoking Hx, retired construction worker
What are you particularly concerned about given the patient’s ethnic background?
Increased risk of nasopharyngeal cancer (which often drains to the posterior cervical triangle LN, and therefore can present with a lateral neck mass)
56 year old man presents with slight cough and no other symptoms
O/E: left lateral neck mass
Other Hx: 38 pack-year smoking Hx, retired construction worker
Likely sites of origin of pathology?
1) External: skin of head and neck (e.g. SCC or melanoma, given occupation Hx)
2) Internal: upper aero-digestive tract including tonsils, larynx, pharynx (given smoking Hx; don’t forget CXR to examine lungs)
3) Other: primary salivary gland pathology, thyroid differentiated tumours (esp papillary Ca), lymphoma, supraclavicular LN associated with visceral malignancy (Virchow’s node or Troisier’s sign)
Why is careful examination especially important in the patient presenting with a neck mass in the setting of possible malignancy?
Want to avoid an open neck biopsy to determine the site of origin of the malignancy; in most cases, careful examination will demonstrate this site (look in the mouth and at the skin of the head and neck especially)
What structures in the central anterior neck can be isolated on examination and how?
Hyoid: elevates with tongue protusion (can look for a thyroglossal duct cyst by performing this manoeuvre)
Larynx and contents of pretrachial fascia (including thyroid): elevate on swallowing
What important structures are in the lateral neck?
Carotid triangle
Structures deep to sternomastoid muscle
Neck examination
1) Inspection: central anterior neck (tongue protusion, swallowing), lateral neck, posterior cervical triangle
2) Palpation: anteriorly, posteriorly
3) Completion: mouth and tonsil inspection, examination of skin above the neck lesion
4) Consider further Ix: FNAC, CT neck/oral cavity/pharynx, CXR
How should the anterior neck be palpated?
Face to face with patient:
1) Palpate from zygomatic arches inferiorly (to include parotid glands)
2) “Outer ring” of LN groups including submandibular glands
3) Laterally flex the head towards the examining hand to palpate deep to the sternomastoid (lower section of great vessels and lympho-reticular chain); also palpate the carotid triangle (upper section of great vessels and lympho-reticular chain)
4) Palpate posterior triangle of the neck, charting the course of the accessory nerve
How should the posterior neck be palpated?
Standing behind the seated patient; fingers of examining hand naturally curl around the neck, and present the pads of the fingers in the correct position for examining the “outer ring” of LN groups (again) and the central anterior neck (hyoid, trachea, thyroid gland)
What should be looked for specifically on examination of the mouth and tonsils?
1) Inspect all oral mucosal sufaces including bucco-alveolar sulci, floor of the mouth and under the tongue
2) Use tongue depressor to properly inspect the tonsils (or tonsillar fossae)
3) Use a gloved finger to examine glosso-tonsillar sulci (both sides)
In what % of patients is the primary site of SCC origin in upper aero-digestive tract initially identified on diligent examination and simple Ix?
90%
What can FNAC help to identify?
SCC (skin or upper aero-digestive)
Melanoma
Papillary thyroid Ca
Nasopharyngeal Ca (possibly)
Why should CXR be considered in patient with a neck mass secondary to an identified malignancy?
Up to 5% chance of another SCC in the upper part of aero-digestive tract or a lower respiratory tract SCC
What is this? What is the relationship between this clinical finding and risk of SCC?
Leukoplakia
3% chance of SCC
What is this and what is it suspicious for?
Persistent mouth ulceration
Suspicious for malignancy, esp with other factors such as smoking, sun exposure (lips) and presence of a neck lump
What is quinsy? What are the signs and potential complications of quinsy?
Peri-tonsillar abscess
Signs: displaced uvula, unilateral swelling
Complications: potential spread to other fascial spaces, potential fatal sequelae (e.g. spread to tongue base, can spread further to become mediastinitis)
What is this?
Quinsy (peri-tonsillar abscess)
How does tonsilitis appear?
Follicular appearance (“strawberries and cream”)
When should tonsillectomy be considered for tonsillitis?
If recurrent bacterial tonsillitis (e.g. 6x in 1 year)
If OSA (esp in children)
What is this?
How does tonsillitis due to infectious mononucleosis appear?
More diffuse coating on tonsils
Other signs: hepatosplenomegaly, diffuse lymphadenopathy, impaired liver function
List the 3 principle causes of tongue base and floor of mouth swelling
1) Infective (usually spread from other head and neck fascial space source such as quinsy, neglected mandibular #, mandibular molar tooth root abscess
2) Malignancy
3) Haematoma
Why is tongue base and floor of mouth swelling so important? What Mx may need to be considered?
Importance due to possible fatal airway obstruction
Consider nasopharyngeal airway or tracheostomy
What is this?
Tonsillitis, likely due to infectious mononucleosis (more diffuse tonsillar coating)
When can ear pain be referred from the temporo-mandibular joint?
Anxiety (teeth clenching)
Poor molar support
Bruxism (involuntary clenching and grinding of the teeth)
Otalgia post-tonsillectomy
Likely cause?
Referred pain from the pharynx (CN IX)
Otalgia with persistent soft palate ulcer on same side
Likely Dx?
Oropharyngeal Ca (referred via CN IX)
Presentations which may be associated with otalgia
Post-tonsillectomy
Persistent soft palate ulcer on same side
Persistent hoarseness
Haemoptysis
Neck lump (in region of larynx)
(I.e. anything affecting the oral cavity, pharynx or larynx)
What is the relationship between otalgia and CN IX and X?
Pain can be referred from anywhere in the sensory distribution of the glossopharyngeal nerve (oral cavity) or vagus nerve (larynx, pyriform fossae)
List 4 possible causes of hoarseness
SCC of larynx
Paralysed vocal cord
Reflux of pepsin and acid
Vocal nodules
Likely Dx?
SCC of larynx
Likely Dx?
Paralysed vocal cord
What is this appearance of the larynx consistent with as an underlying cause of hoarseness?
GORD or LPR (laryngo-pharyngeal reflux)
Likely Dx?
Vocal nodules and polyps
Mx of emergency airway in hospital
1) Adrenaline: give 0.5mL if >40kg (0.01mL/kg) deep IM (ampoule 1:1000 contains 1mg of adrenaline per mL of solution in a 1mL glass vial; administered via deep IM and NOT IV route)
2) Secure airway: Guedel, nasopharyngeal tube, crico-thyroid puncture with two 19-guage needles, tracheostomy
When is tracheostomy preferred over crico-thyroid puncture?
Tracheostomy: medium and long term airway Mx
Crico-thyroid puncture: rapid airway patency
Why is a crico-thyroid puncture preferred over tracheostomy in the acute setting?
Rapid airway patency can be established by piercing the relatively blood crico-thyroid membrane, in contrast to the upper trachea where the relatively bloody thyroid isthmus often gets in the way
What is the preferable site for tracheostomy?
Below 2nd tracheal ring
List 2 indications for tracheostomy
Subglottic stenosis
Hoarseness from prolonged C-T membrane disruption
