Neck Lumps and Common ENT Conditions

• What are the 2 triangles of the neck?

  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)

  
• What are the different levels of the neck?

  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

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

  When did you first notice it?

  What has happened to it since?

  Ever had it before?

  Any other lumps?

  Any associated features?
• What important things are in the history that is relevant if the patient has lumps?

  Foreign travel e.g tuberculosis

  Pets e.g cat scratch disease

  Weight loss

  Night sweats

  Fever

  Pain

  Smoking

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

  Site- know your head and neck anatomy!Size- greater than 3-4cm is worryingShapeSurface- has it changed the colour/surface of skin?TemperatureTendernessMobile/fixed- does it move on swallowing?Transillumination- does the lump glow when a light is held next to it?Pause for pulsationColourMarginRelationsNodes- involvement of any lymph nodes?

  
• What does the anatomical sieve consist of?

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

  Start from superficial to deep

  SkinHairFatBlood vesselsNervesLymphaticsConnective tissueMusclesBoneSpecial structures (thyroid, parotid, thymus)(important for pathological diagnosis)
• What does the surgical sieve consist of and what is it important for?

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

  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)

  
• What are the many different causes of cervical lymphadenopathy?

  Is it an infective or neoplastic process?

  
• What are some examples of lateral neck lumps?

  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

  
• What are some examples of common midline neck lumps?

  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

  
• What is an axiom of diagnosing a lateral neck mass?

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

  Therefore investigations must be taken

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

  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

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


  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 theonlyneck lump thatmoves with swallowingANDwithprotrusion of the tongue

  
• What does Ludwig's angina look like?

  Infective process

  
  

  Emergency drainage needed/rapid referral

  
  

  Can be fatal

  
• What common conditions affect the ear?

  Hearing loss

  Otalgia - pain in the ear

  Otorrhoea - discharge from the ear

  Middle ear infection

  Facial palsy

  Disorders of balance

  Tinnitus

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

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

  
• What is a cholesteatoma?

  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

  
• What is otitis externa?

  Inflammation of the external auditory meatus

  
• What are some common causes of otitis externa?

  Infective:Bacterial, fungal, viral

  Reactive:Eczema, psoriasis
• What it otitis media with effusion?

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

  
  

  It's a Eustachian tube dysfunction

  
• What can glue ear cause?

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

  
• When is urgent treatment needed in glue ear?

  When you can see pus behind the tympanic membrane

  Also put them on a course of antibiotics

  
• What common problems arise from the nose?

  Allergic rhinitis

  Nasal polyps

  Nasal infections

  Nasal septum

  Epistaxis - nose bleed

  Sinusitis

  
• What can be some causes of epistaxis?

  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

  
• What are some common conditions affecting the throat?

  Dysphonia- problems with the voiceStridor- narrowing of airway causing soundSore throatsTonsils and AdenoidsDysphagia- difficulty swallowingSnoring and sleep apneoa
• What should a persistent sore throat with a changing voice, especially a hoarse voice longer than 2 weeks, be treated as?

  Laryngeal cancer, until proven otherwise
• What are some causes of dysphagia?

  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