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128
CHAP TER5 The front oftheneck
Useful questions and what
tolookfor
Cough (chronic/ severe)
Askabout
• Post- nasal drip and nocturnalcough
• Full cardiac and respiratory history
• Recent URTI/ sorethroat
• Heartburn
• Change invoice
• Occupation
• Otalgia/ discharge/ irritation
• Diseases of the external auditory canal (e.g.wax)
• Medications (especially ACE inhibitors).
Lookfor
• Full cardiorespiratoryexam
• Neckmasses
• Examine fauces/ cords for ulcers, infection, granuloma,etc.
Diculty breathing (stridor)
(See also E Chapter 8.)
Askabout
• Onset and duration
• Constant vs intermittent
• Dysphagia, drooling, hoarseness, airway, bleeding, weight loss,
odynophagia, cough (barking cough), sleep pattern (snoring,
daytime somnolence), choking (GORD, foreignbody)
• Recent URTI, fever, cough, sorethroat
• Allergy
• Recent trauma, caustic ingestion
• Previous air way surger y
• Medications (medicine allergies, ACE inhibitors)
• History of sarcoidosis, connective tissue disorders, granulomatous
diseases, asthma, cardiac and pulmonary problems
• Complete perinatal history in infants and feeding diculties
(regurgitation, worse with feeding).
Lookfor
• Assess airway/ respirations/ cyanosis
• Oral cavity (macroglossia, tonsillar hypertrophy or infection)
• Cranialnerves
• Trachea midline, goitre, palpable laryngeal fractures
• Examine tracheal stoma (if relevant)
• Cutaneous lesions (haemangiomas)
• Na soseptal deformities, nasalmasses
• Chest (cardiorespiratory)
• Consider laryngoscopy/ bronchoscopy depending oncause.
USEF UL QU ESTI ONS AND WHAT TO LOOKFOR
Diculty swallowing (dysphagia)
(See also E Chapter 8.)
Askabout
• Onset and duration
• Progressive orstatic
• Diculty initiating a swallow
• Coughing/ choking, frequent chest infections
• Weightloss
• Gurgly or wet voice after swallowing
• Odynophagia.
Lookfor
• Complete neurologicalexam
• Examine fauces/ cords/ chest
• Neck masses.
Foreign body ingestion and aspiration
Askabout
• Description of objec t (if sharp may need retrieval)
• Dysphagia
• Pain (mouth, throat, chest, abdomen)
• Fever
• Choking, stridor
• Wheezing, hoarseness.
Lookfor
• Airway patency
• Assess chest and abdomen
• Examine neck/ fauces/ cords (but avoid manipulation).
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Haemoptysis (coughing upblood)
Askabout
• Full cardiac and respiratory history
• Quality of blood (fresh/ streaks/ clots)
• Recent URTI/ sorethroat
• Change invoice
• Weightloss
• Occupation
• Smoking
• Medications.
Lookfor
• Full cardiorespiratoryexam
• Neckmasses
• Examine fauces/ nose/ postnasalspace.
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CHAP TER5 The front oftheneck
Hoarse voice/ loss ofvoice
Askabout
• Onset and duration
• Time cour se, periodicit y (morning hoarseness with GORD
and evening hoarseness with voiceabuse)
• Voiceabuse
• Recent URTI, fever, sore throat,cough
• Smoking or alcoholabuse
• PMH of neuromuscular disorders, hypothyroidism
• Previous lar yngeal trauma, surgery, or airway manipulation
• Odynophagia, dysphagia, aspiration, weight loss, hearing loss,
heartburn.
Lookfor
• Assess perceptual quality of voice (pitch, loudness)
• Neckmasses
• Thyroidmasses
• Indirect or direct laryngoscopy (vocal fold motion, lesions, and
competence)
• Complete neurologicalexam.
Injuries
Askabout
• When it occurred/ mechanism of injury (blunt/ penetrating)
• Other injuries
• Progression of symptoms since time ofinjury
• Hoarseness
• Pain
• Haemoptysis
• Diculty swallowing
• Odynophagia
• Haematemesis.
Lookfor
• Airway obstruction
• Signs of blood loss/ active bleeding
• Other injuries
• Site and estimate depth (root of neck can also involve the chest
andarm)
• Lacerations, bubblingwounds
• Haematomas— ?pulsatile
• Subcutaneous emphysema/ lar yngeal crepitus
• Diminishedpulses
• Neurological impairment (Horner’s syndrome, brachial plexus,
spinal cord,CNs)
• Peripheral pulses (distal carotid, supercial temporal, brachial)
andbruit.
USEF UL QU ESTI ONS AND WHAT TO LOOKFOR
Lumps and swellings
Askabout
• Onset, duration, and progression
• Painful/ painless
• Recent URTI, toothache/ carious teeth, sinus infection, otitis media,
or other head and neck infection
• Exposure to pets and other animals
• Recent tr avelabroad
• Previous excision of skin or scalp lesions/ malignancies
• Smoking and alcoholabuse
• Fever, postnasal drip, rhinorrhoea, otalgia, night sweats, weight
loss, malaise, dysphagia, hoarseness.
Lookfor
• Assess character oflump
• Solitar y versus multiple
• Overlying skin (e.g. erythematous, blanching, stulas, induration,
necrotic)
• Head and neck exam for primar y malignancies (nasopharynx, oral
cavit y, base of tongue, tonsillar fossa, nasal cavity, exter nal ear
canal, scalp, thyroid, and salivary glands) or infections
• Other lymphatic sites (e.g. inguinal, axillary, supraclavicular)
• Examine chest, liver and spleen.
Pain onswallowing (odynophagia)
(See also E Chapter 8.)
Askabout
• Onset and duration
• Precipitating factors
• Diculty breathing
• Sorethroat
• Haemoptysis/ haematemesis.
Lookfor
• Examinechest
• Neckmasses
• Examinefauces
• Complete neurologicalexam.
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132
CHAP TER5 The front oftheneck
Examination ofthe front oftheneck
In order to examine the neck thoroughly (usually a lump or lumps), the
patient must be comfortable and the neck relaxed as much as possible.
They must be sitting upright with their neck fully exposed, so that you
can see the clavicles fully (Figure5.1).
When examining the neck consider also the surrounding structures
(especially the mouth, teeth, throat, and sk in) for infections and tumours.
These may need to be examined aswell.
Look
Star t by st anding back and simply observing the patient from the front
and then the lateralviews.
• Is there an obvious lesion/ lump (see later in topic)?
• Does the ear lobe stick out (parotid swelling)?
• Get the patient to drink some water (if not an emergency)— does the
lump move on swallowing (attached to the tongue or upper airway)?
• Get the patient to stick out their tongue. If a lump moves up it will be
attached to it somewhere (classically seen in thyroglossal cysts).
• Is the over lying skin aected (tethered or a discharging sinus)?
• Look at the scalp, face, and in the mouth — are there any lesions that
could cause inammatory or metastatic lymphadenopathy?
• Is there evidence of systemic disease (e.g. anaemic, cachexia ,
thyroid)?
Figure5.1 Examinatio n of the n eck is best done sta ndin g behi nd the p atient.
EXAMIN ATION OF THE FRONT OF T HENEC K
Feel
Examine as many necks as possible until you are familiar with what is
‘normal’. All necks have irregularities, palpable lumps, depressions, etc.,
which are normal ndings (for instance, you can often feel prominent
submandibular glands in the elderly). Only when you are familiar with the
normal are you likely to pick up abnormal ndings. There are dierent
ways to examine the neck. Some clinicians feel both sides simultaneously
for asymmetry, others feel each side in turn — that way you can laterally
ex the neck and feel deep into the submandibular tr iangle. Try both
and decide for yourself but don’t throttle the patient! Beware of putting
pressure on bilateral prominent carotid bodies simultaneously. This can cause
vagal stimulation and induce vasovagal syncope in elderly patients.
Standing behind the patient, gently but rmly rest your ngertips under
the lower border of the mandible under the chin. Palpate the submental
area moving back to the submandibular areas, feeling for abnormal or
painful masses. In some patient s the submandibular gland hangs lower
than normal. This is sometimes referred to as a ‘ptotic’ submandibular
gland. It is commonly found in elderly patients and can often be confused
with an enlarged lymph node. Feel along the side mandible as well as
below, lymph nodes are commonly found in the lower face (the buccofacial node), but should be considered as par t of the neck . Palpate the
depression behind the r amus, below the ear lobe — an important site
for parotid swellings. Follow on by feeling down the anterior border of
the SCM to the sternal notch, and then staying in the midline move back
superiorly to the submental area where you started. Palpate the posterior triangle behind the SCM, the supraclvicular areas, and the occipit al
scalp. After laterally exing the neck, gently grab the SCM and tr y to feel
deep to it— this is an important and often missed area of examination. It
is where many lymph nodeslay.
Assessingalump
If there is a lump,note:
• Site
• Size
• Shape
• Surface
• Temperature
• Tethering
• Transillumination— cystic hygromas (congenital cavernous
lymphangioma) transilluminate brilliantly
• Colour
• Consistency
• Pulsatile
• Auscultation— listen over the mass with a stethoscope. Is there
abruit?
133
134
CHAP TER5 The front oftheneck
What are you feelingfor?
Lymph nodes are part of the immune system and are often enlarged
when ghting infections. Infected lymph nodes tendtobe:
• Firm
• Tender
• Enlarged
• Warm.
Inammation can spread to the overlying skin, causing erythema.
Untreated, the node can become necrotic, resulting in abscess formation. Following infection, lymph nodes can sometimes remain permanently enlarged, but are usually non- tender, small (<1 cm) and have a
rubberyfeel.
Malignant nodes areoften:
• Firm
• Non- tender
• Adherent
• Fixed to the surrounding tissues.
The location of the lymph node may help to determine the site of malignancy. Diuse, bilateral involvement suggests a systemic malignancy (e.g.
leukaemia) or infection, while those localized on one side are more likely
associated with a local problem.
Other important ‘lumps’ to consider include the thyroid and submandibular glands and the tail of the parotid (just below the ear lobe). In thin
necks the hyoid bone can sometimes be palpable, as well as the carotid.
Useful investigations
Laborator ytests
A complete blood count with dierential is usually required for any infective, inammatory, systemic, or neoplastic pathologies.
Monospot, puried protein derivative ( TB), HIV testing, cat- scratch,
toxoplasmosis, mumps titres, and Epstein– Barr virus serolog y are commonly required in the assessment of lymphadenopathy.
Thyroid function tests should be taken for any thyroid lump or
enlargement.
Plainlms
These may be required to identif y some foreign bodies. ACXR by itself
may overlook small object s. Air trapping is a clue to the presence of
radiolucent foreign bodies. Consider a CXR and soft tissue neck in both
anteroposterior and lateral views, to locate the foreign body. The trachea is wider on the anteroposterior direction, whereas the oesophagus is wider on a later al projection. Mediastinitis, haemothor ax, and
pneumothorax are worrying signs. These require further evaluation and
urgent referral. Beware:most sh bones and non- metallic objects are radio-
lucent and therefore may not be seen onX- ray.
USEFUL INVESTIGATIONS
Orthopantomography (OPT)— this is required in the assessment of
lymphadenopathy or swelling in the upper neck. Dental infections are a
commoncause.
A cervical spine X- ray may show a bony cervical rib or prominence of
the anterior tubercle of the 7th cervical vertebra (with a brousband).
CT/ M RI
CT is the diagnostic test of choice to evaluate laryngeal fractures (hyoid
bone, thyroid, and cricoid cartilage).
CT/ MRI of the neck provides greater dierentiation of abscess, neo-
plasms, vascular lesions, haematomas, or congenital abnormalities. The
chest may need to be included depending on the suspected pathology
or injuries.
Angiography
This may be required urgently following trauma (penetrating injuries). If
bleeding is active, selective embolization may be necessar y.
Angiography is also occasionally undertaken in the assessment of vas-
cular swellings (alternatively computed tomography angiography (CTA)
or magnetic resonance angiogr aphy (MRA) may be per formed).
Direct visualization techniques
• Fibreoptic nasopharyngoscopy (laryngoscopy). This can assess airway
patency, visualize endolaryngeal lacerations, laryngeal oedema,
and haematomas. It can also assess vocal fold mobilit y, supraglottic
structure, and be used to examine a tr achealstoma.
• Rigid oesophagoscopy. This requires admission and general
anaesthesia. It is usually indicated for foreign bodies that remain in
the oesophagus for >2days and lar ge objects in the oesophagus.
Batteries need immediate retrieval.
• Rigid bronchoscopy. This requires admission and general anaesthesia.
Because this involves sharing the airway, anaesthesia is complicated.
It may sometimes be needed in an emergent airway crisis.
• Flexible bronchoscopy can be under taken in awake, cooperative
patients. It enables visualization of the upper airway.
Ultrasound
This is useful in dening cystic or solid masses. When combined with
Doppler it denes vascular lesions. It may also be used to look for calculi
in the submandibular gland orduct.
Fine- needle aspiration
Fine- needle aspiration (FNA) can provide uid for culture and sensitivity
and is of ten used for discrete nodules or non- resolving masses suspicious
for malignancy (>2 cm, non- tender, asymmetric neck masses). Open
(incisional) biopsy of suspicious lumps carries a risk of tumour seedling and
should not be performed.
135
136
CHAP TER5 The front oftheneck
Miscellaneous investigations (in outpatients)
• Videostroboscopy:used to examine vocal fold mucosa for anatomical
defec ts, mechanical disturbances and vocal fold mucosal wave
dynamics.
• Acoustic analysis:measures fundamental frequenc y, pitch period
uctuations or jitter, amplitude uctuations or shimmer.
• Aerodynamic studies:these measure the mean transglottal air ow
rate, glottal resistance, and subglottal pressure.
• Perceptual testing:assesses the qualitative rating of voice features.
• Laryngeal electromyography(EMG).
• Modied barium swallow and oesophagram:for oesophageal
pathology, reux, aspiration, and vascular abnormalities.
• Pulmonary function tests and ow– volume loops:identify level of
obstruction and assess for intrinsic lung disease.
• Magnied air way (uoroscopy):a dynamic evaluation of airway,
assesses vocal fold motion.
• Sialography:this visualizes ductal anatomy (stones, trauma, stulas,
Sjögren’s disease). It is contraindicated in acute infections.
fInjuries tothe front oftheneck
Applied anatomy ofthelarynx
The larynx is a semi- rigid structure consisting of a horseshoe - shaped
hyoid bone and collection of small cartilages connected by brous tissue.
It contains the vocal cords, ‘supraglottic’, and ‘subglottic’ spaces. The
‘paraglottic’ space lies between the lining mucosa and car tilages. This
space is potentially very distensible from bleeding and oedema. The
cricoid car tilage lies below the lar ynx and is the only complete ring in
the respirator y tract. Airow through a tube varies in a way similar to
Poiseuille’s law:ow=pπr4/ 8ln, (where p is the pressure, r is the radius
of the tube, l is its length, and n is the coecient of viscosity). Small
changes in the radius (e.g. from swelling/ oedema) can therefore have
profound eects on the ow of air through the lar ynx. This is important at the vocal cords, the narrowest part of the upper air way, where
the mucosa can swell considerably. The hyoid bone is most commonly
fractured following at tempted strangulation. A fracture separating the
cricoid from the trachea is referred to as laryngo- tracheal separation and
is most commonly due to a clothesline- type injury.
Zones oftheneck
The neck is divided into threezones:
• Zone Iis located below the cricoid car tilage.
• Zone II is between the cr icoid cartilage and the angle of mandible.
• Zone III is located above the angle of the mandible.
Injuries in zones Iand III may require evaluation with CT or angiography
as surgical exploration is dicult and risky. Zone II injuries may require
CTA, MRA, oesophagoscopy, bronchoscopy, barium swallow, ultrasound, or angiography depending on the injuries suspected.
INJU RIE S TO THE FRON T OF THEN ECK
Symptoms of neckinjury
• Laryngotr acheal injury:hoarseness, stridor, airway obstr uction,
subcutaneous emphysema, pain, haemopt ysis. The recurrent
laryngeal ner ve may also be injured.
• Oesophageal or hypopharyngeal injury:dysphagia, odynophagia,
haematemesis, subcutaneous emphysema.
• Vascular injur y:shock, haematoma, diminished pulses, stroke
(hemiplegia).
• 5 – 15% of aerodigestive injuries are asymptomatic (may be missed).
Initial considerations
Neck trauma can be potentially life- threatening. Generally in penetrating
injuries/ lacerations, if the platysma muscle has not been breached, there
is a low risk of ser ious injur y. Therefore, never explore a neck wound under
local anaesthetic if you think it is deep to the platysma. Many impor tant
underlying str uctures are at risk, especially when the injury is at the root
of the neck. Pharyngoesophageal injury is often missed and requires a high
index of suspicion to diagnose.
Blunt trauma to the front of the neck has a higher risk of laryngeal
fractures than penetrating injuries. Paediatr ic laryngeal fr actures are rare
because of the elasticity of cartilage and higher position of the larynx in
the neck. But signicant swelling can still occur. Common causes of injury
include:
• MVCs
• Sports (e.g. martial arts and racket spor ts)
• Assaults, knifewounds
• Attempted suicide
• Inhalation of smoke, hot air, orsteam.
Types ofinjury that may occur following
blunttrauma
• Oedema/ haemorrhage. Oedema rapidly occurs particularly after
ther mal inhalation. Early intubation is often necessar y.
• Fractured larynx. In young patients, the larynx is elastic and tends to
ex. In older patients the calcied cartilages tend to fracture.
• The hyoid bone is commonly fractured following attempted
strangulation or hanging. Fractures may lacerate pharyngeal mucosa.
• The trachea can be avulsed from the cr icoid cartilage (lar yngo-
tracheal separation) most commonly from a clothesline- type
injury. Total separation is usually r apidly fat al— the trachea retracts
substernally and the larynx migrates superiorly. However, with
partial separation, the airway may remain patent, although it is still at
highrisk.
• Surgical emphysema of the neck and face may be seen after
penetrating or blast injuries.
• Carotid injur y is uncommon but can result in delayed dissection or
rupture.
• Oesophageal injur y is uncommon but rupture and mediastinitis may
occur. It is an injur y that is often not considered.
• Cervical spine injury should also always be considered.
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