Fwd: Bambury Tutorial on Head and Neck

Examination for the OSCEs

Examination of a lump Introduce yourself and ask is it alright to

examine the patient and to talk as you go along

Note the site of the lump Is there any tenderness State its size in approx cm State its shape- is it

circular/hemispherical

Examination of a lump What is the surface like?

is it smooth/ rough /craggy/ irregular Can you feel around the lump?

is it well circumscribed or is it diffuse Next test its fluctuance-

press on two areas of the lump and then with the other hand press a third area. If the first two areas bulge outwards that is positive for fluctuance -beware lipomas

Examination of a lump Is it pulsatile?

is this the lesion itself or is it the proximity to an artery. Check to see if it’s expansile as is the case with aneurysms

Is it compressible? press down on the lesion and see if it

disappears. Does it reappear when pressure is released-? Vascular malformation

Examination of a lump Is it reducible?

lesion disappears on pressure and does not reeappear spontaneously on releasing pressure.

Next step feel for origin of the lump. Is it attached to the skin- (sebaceous cyst BCC) or the underlying tissue- move the lump itself. Is there skin tethering? Is it tethered to the

underlying muscle- tense the muscle and ask the patient to resist movement- lump will be less easy to feel and less mobile

Examination of a lump Look at and feel the overlying skin

is there any ulceration Is the surrounding tissue

erythematous /discoloured Next check for the appropriate lymph

nodes

Examination of the neck In the case of the thyroid……… Introduce etc…… Expose the neck appropriately INSPECT- can you see any visible

lump/swelling. State what you see. Ask the patient to take a sip of water

and tell them to hold it in their mouth until you ask them to swallow

Examination of the neck Ask them to raise their head and

swallow. Does the swelling move on swallowing.

Now ask them to stick out their tongue. Does the swelling move upwards on protrusion of the tongue- suggestive of a thyroglossal cyst

Examination of the neck PALPATE- Stand behind the patient after

explaining what you are about to do. Feel for a swelling. Ask the patient is it sore first. Ask the patient to take a sip of water and with your hands over the swelling ask them to swallow it- does it move upwards on swallowing

Ask them to stick out their tongue. Does the lesion move upwards?

Examination of the neck Describe the lump as we have outlined

earlier. Take your time and outline all the previous criteria

In the case of the lymph nodes check all areas in the neck appropriately. Know the names of each set including-

Examination of thyroid status Introduce yourself. Explain to patient

what you are about to do. Expose the patient appropriately. In this

case open shirt/ blouse to expose base of neck

You need to know the signs associated with Hyper/hypothroidism or else you’re wasting your time on this one!

Examination of thyroid status Inspect. Look at the patient sitting in the

chair. Is there a tremor, signs of muscle wasting weight loss-Hyper

How about signs of Hypothyroidism periorbital puffiness Mywoedema facies

Look for a goitre/signs of previous operation

Examination of thyroid status

Examination of thyroid status Look at the eyes

In hyperthroidism look for exophthalamus-bulging of eyelids Lid retraction- ask the patient to keep head still

and follow your finger up and down In hypothyroidism

look for thinning of the hair Loss of lateral third of eyebrows

Examination of thyroid status Move to the hands-

Feel the pulse, Irregular fast

Check for acropachy soft tissue swelling of digits, joint enlargement and clubbing of fingers

Examination of thyroid status Check the hands for signs of

Hypothroidism Dry cool pale Puffiness Is she bradycardic

Examination of thyroid status Move onto the full thyroid lump

examination After this tell the examiners you’d like to

ask the patients a few questions. Ask about weight, bowel movements,

changes in appearance, palpitations

Differential diagnosis of a neck Lump Lymphoma Thyroid lump-diffuse if diffuse goitre, thyroid

nodule, unilateral swelling of one lobe Branchial cyst Thyroglossal cyst Pharyngeal pouch Carotid body tumour Cystic hygroma Sebaceous cyst Dermoid cyst

Branchial cyst

Branchial cyst Remnant of second branchial cleft Occurs at anterior border of

sternocleidomastoid muscle Painless swelling- painful if becomes infected Complications-

branchial fistula- discharges intermittently. External opening occurs between the lower 2/3rds of s/c/m- connects with oropharynx-swallowing accentuates the external opening

Branchial sinus- external opening but upper end is obliterated

Branchial cyst O/E

Smooth surface well circumscribed not pulsatile fluctuant compressible Overlying skin normal Fixed to deep structures

Treatment Surgical excision as will always become infected

Pharyngeal pouch A diverticulum of the pharynx occuring

between the fibers of the the inferior constrictor muscle.( Killian’s dehiscence)

More common in older men Symptoms

Regurgitation of undigested food Dysphagia Nocturnal coughing,choking May get aspiration pneumonia

Pharyngeal pouch O/E

Nontender Situated below thyroid(usually on left) Smooth surface, indistinct edges\not pulsatile

fluctuant Is compressible but not reducible Arises from deep structure relatively immobile Overlying skin is normal

Pharyngeal pouch Investigations- barium swallow

Pharyngeal pouch Treatment Surgical excision

Incise along inferior s/c/m Dissect out pouch which is prepacked with

gauze for easier identification Excise neck of pouch Dohlman’s procedure-

Endoscopic inversion and oversewing of pouch

Carotid body tumour Rare tumour of chemoreceptors of

carotid body Malignant potential Painless 40-60 years May be associated with TIAs secondary

to pressure

Carotid body tumour O/E

Non tender lump Anterior triangle of the neck Round hard solid Not fluctuant Skin moves over it freely Can be moved side to side but not up and down No movement on swallowing or protrusion of the

tongue Overlying skin is normal

Carotid body tumour Investigations

Digital subtraction angiography Treatment

Surgical excision may become malignant or grow in size making it

more difficult to excise

Thyroglossal cyst A patent thyroglossal dust The duct begins at what will become the

foramen caecum of the tongue and guides the thyroid gland into position. Usually becomes obliterated.

Remember it hooks around the hyoid bone making excision difficult

Thyroglossal cyst Age group 15-30 usually Painless usually May become infected O/E

Midline of the neck Spherical smooth well circumscribed Fluctuates Not pulsatile compressible or reducible Tethered to deep structures moves side to side only Moves on swallowing and extending the tongue

Thyroglossal cyst Investigations-ultrasound Treatment-

Surgical excision with sacrifice of the middle third of the hyoid bone

Triangles of the neck Basic anatomy need to be known if you

get a neck examination Anterior triangle

Borders Midline Posterior border of the s/c/m Ramus of mandible

Anterior triangle Contents

Suprahyoid muscles(s,m,g/hyoids) Strap muscles(t,s,s) Recurrent and external laryngeal Nerves Vagus nerve CCA bifurcation IJV Thyroid gland parathyroid submand gland trachea

oesophagus

Posterior triangle Borders

Anterior Post border of s/c/m

Posterior Ant border of trapezius

Inferior clavicle

Posterior triangle Contents

Muscle-levator scapulae, scalene medius Spinal accessory nerve Trunks of brachial plexus Lymph nodes-occipital supraclavicular Subclavian artery