Head and Neck Clinical

Question 1

What may present in a head and neck history?

Answer 1

Sore throat
Dysphonia
Odynophagia
Moth/ throat ulcer
Neck lump

Smoking/ Alcohol
Family History

Question 2

What is important to remember about a full head and neck examination?

Answer 2

It includes an examination of the pharynx and larynx.

If you suspect problems then refer to ENT. They have the equipment to do this:

• Laryngoscopy
• Nasolaryngoscopy

Question 3

What is bifid uvula an early manifestation of?

Answer 3

Cleft palate

Question 4

What is the appearance of normal healthy vocal cords?

Answer 4

“Pearly white”

Question 5

How should you prepare a patient for a head and neck examination?

Answer 5

Patient sitting in chair

Glass of water nearly - be prepared to examine the thyroid in full

Expose the neck down to the clavicles - undo the top buttons of a shirt

Ask the patient to remove any jewellery

Question 6

How do you carry out an inspection in head and neck examination?

Answer 6

Lump: site, size, skin changes

Scars

Does the lump move?

• Tongue protrussion: thyroglossal cyst
• Swallowing: place glass of water in patients hands, hold in mouth then swallow

Question 7

Describe the palpation in the head and neck examination

Answer 7

From front:
-Check the trachea

From back:

• Be gentle, watch for discomfort
• Use fingertips to elicit physical signs

Palpate the triangles (Z)

• Anterior triangle
• Posterior triangle

Determine lump characteristics

Examine thyroid in full

Question 8

How do you examine the neck using the Z technique?

Answer 8

• Palpate from the chin backwards to below the ears
• Palpate down the anterior border of sternocleidomastoid to clavicle
• Move laterally along the clavicle and then up the posterior border of sternocleidomastoid
• Finish by palpating the back of the scalp for occipital lymph nodes

Question 9

What can a thyroid bruit indicate?

Answer 9

Grave’s disease

Question 10

What are the head and neck examinations?

Answer 10

FNAC
CT/MRI/PET scan
US scan
Plain X-ray
Contrast swallow
Endoscopy

Question 11

Explain FNAC in head and neck

Answer 11

With any lumps this is great.
If you find a lump on examination imaging is only going to tell you what you already know.
FNAC will tell you what exactly the lump is

Question 12

What are the characteristics of a reactive lymph node?

Answer 12

Oval
Soft
Smooth
Mobile
Tender

Question 13

What does a brachial cyst present like?

Answer 13

Usually young patients
Soft and non tender
Upper sternocleidomastoid

Question 14

How do you identify a thyroglossal cyst?

Answer 14

Moves out with tongue

Question 15

How would a patient present with duct calculi?

Answer 15

Pain and pressure when they are about to eat or are eating (pressure builds up as fluid produced but nowhere to go)

Will settle a while after eating

Question 16

Should you worry about a pleomorphic adenoma?

Answer 16

They are benign

Can become malignant over the space of years so if the patient is young you may consider removal

Question 17

Someone presents with hoarseness.

What questions should you ask them?

Answer 17

How long?
Persistant or intermittent?
Pain?
Cough/Choking/Swallowing?
Voice use? (do they sing etc)
Asthma/Rhinosinusitis/Reflux?
Smoker?
Medication (inhalers etc may irritate)

Question 18

What can cause hoarseness?

Answer 18

Nodules

• Will be present on both cords
• Singers with poor technique

Cysts
-Traumatic cyst or vocal cord polyp

Laryngitis
Smoking
Reflux

Laryngeal or lung cancer

Question 19

What are the two most common treatment plans for laryngeal carcinoma?

Answer 19

Chemoradiotherapy - try to save the larynx

Laryngectomy - remove larynx and bring trachea up as stoma
will breath through tube for test of life

Question 20

How would you suspect lung cancer in someone with hoarseness?

Answer 20

The larynx will look normal

Get them to speak

One cord (usually left) won’t be able to move.

Lung cancer nodes in the mediastinum are pressing on recurrent laryngeal nerve causing palsy

Nodes in mediastinum means cancer is inoperable

Question 21

What kind of questions should you ask someone presenting wit dysphagia?

Answer 21

• What is difficult? (solids or liquids)
• Persistent or intermittent
• Getting worse?
• Pain?
• Where?
• –Neck better at localising obstruction
• –Lower down poorly localised, may be referred slightly

Question 22

What can cause dysphagia?

Answer 22

Lumen = foreign body

Wall = Tumour, stricture, neuromuscular, pouch

Extra Luminal = Thyroid, Heart, Mediastinal mass

Question 23

What is FOSIT?

Answer 23

“Feeling Of Something In Throat”
aka Globus Pharyngeus

Due to spasm of cricopharyngeus

Acid reflux
Stress/ anxiety
No dysphagia (“easier with food”)

Question 24

What are the most common cancers of the head and neck?

Answer 24

90% squamous

Question 25

What are the characteristics of a malignant neck node?

Answer 25

``` Round Firm Irregular Fixed Non-tender ```

Question 26

What is stridor?

Answer 26

Noisy breathing Inspiratory stridor comes from the level of vocal cords or above (emergency) -Possible tracheostomy Expiratory stridor = wheeze -From lower down Biphasic stridor = both inspiratory and expiratory

Question 27

What infections may become an emergency?

Answer 27

Quinsy/ Peritonillar abscess ``` Infectious Mononucleosis (Glandular Fever) -Possibly cannot swallow at all ``` Neck space infections

Question 28

Why should you do an ultrasound after a FNAC of a thyroglossal cyst?

Answer 28

To check if the thyroid is present where it should be or if the whole thing is in the cyst Don't want to remove the thyroid if its in the cyst -> hypothyroidism

Question 29

What is the operation for a thyroglossal cyst?

Answer 29

Sistruck's operation take cyst out along with central portion of hyoid bone and tracts of cyst This prevents it returning

Question 30

What is the embryological origin of a thyroglossal cyst?

Answer 30

Foramen caecum

Question 31

What signs would show a lymphoma?

Answer 31

B Symptoms: - Poor appetite - Weight loss - Fever - Profuse night sweats Indicate both Hodgkin's and and non Hodgkin's lymphoma

Question 32

How does quinsy (peritonsillar abcess) present?

Answer 32

Very like tonsillitis but location slightly different May have difficulty opening jaw due to spread of infection to pterygoid muscles causing spasm Drainage of cyst can improve many symptoms

Question 33

What is laryngomalacia?

Answer 33

Floppy larynx Tissues very soft in young child so tissue will flop covering larynx -> stridor As the child grows the structures will stiffen and it should sort itself out