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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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338
NECK LUMPS
The GP overview
A lump in the neck usually means just one thing to a patient: Cancer. is is rarely the cause in
practice, and a careful examination and explanation can be more anxiolytic than a bucket-load
of benzodiazepines. Occasionally, further investigation is needed. For a more detailed analysis
of ‘Swollen glands’, including cervical glands, see the ‘Swollen glands’ section.
Differential diagnosis
COMMON
reactive lymphadenitis due to a local infection
prominent normal lymph nodes
goitre
sebaceous cyst
thyroglossal cyst
OCCASIONAL
thyroid carcinoma
branchial cyst
pharyngeal pouch
cervical rib
primary lymphoma or secondary neoplastic metastasis
RARE
tuberculosis of cervical lymph nodes (king’s evil; scrofula)
actinomycosis
carotid body tumour or aneurysm
sarcoidosis
cystic hygroma
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NECK LUMPS 339
Ready reckoner
Lymphadenitis Normal nodes Goitre Sebaceous cyst Thyroglossal cyst
Tender Ye s No Possible No No
Other symptoms Yes No Possible No No
Moves with swallowing No No Ye s No Yes
Midline No No No Possible Yes
Fixed to skin No No No Ye s No
Possible investigations
LI KE LY: TFTs if thyroid swelling.
POSSIBLE: FBC, ESR/CRP, CXR.
SMALL PRINT: yroid ultrasound, radioisotope studies, barium swallow, biopsy.
TFT in all cases of thyroid enlargement: May reveal hypo- or hyperthyroidism.
FBC and ESR/CRP in persistent enlarged nodes: Check WCC and investigate further if
abnormal or if ESR/CRP high.
CXR: May reveal primary lung carcinoma, lymphoma, or other more obscure pathologies.
yroid ultrasound and/or radioisotope studies if lump felt within the thyroid – usually
arranged by endocrinologist aer referral.
Barium swallow: To conrm and outline a pharyngeal pouch.
Biopsy: Specialist procedure to establish nature of a persistent, suspicious neck lump.
TOP TIPS
Establish the patient’s concerns – cancer fear is common with this symptom.
Unless the lump is obviously suspicious, employ the ‘diagnostic use of time’ – a judicious
delay oen resolves the problem, or it may reveal the true diagnosis.
Children with normal or reactive neck glands are oen presented by anxious parents. Take
time to explain the nature of the problem to properly allay fears and prevent inappropriate
repeat attendances.
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340 SYMPTOM SORTER
A neoplastic-type lymph node enlargement – usually involving a single, gradually enlarging
and non-tender node – without any obvious cause should be referred urgently for detailed
ENT assessment.
Dysphagia with a neck lump is a serious symptom unless associated with a transient sore
throat. Further investigation by endoscopy is necessary.
Beware of a hard swelling developing rapidly in the thyroid – carcinoma must be excluded.
NOTES:
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341
SORE THROAT
The GP overview
is presenting symptom is the king of superlatives in general practice. It is the commonest – the
average GP will see about 120 cases each year – the most over-treated, the most controversial and
usually the most mundane. It is also probably the most welcome, as consultations are oen short,
even when self-management is explained rather than a prescription given.
Differential diagnosis
COMMON
mild viral pharyngitis (with URTI)
tonsillitis/streptococcal pharyngitis (‘strep throat’)
glandular fever
quinsy (peritonsillar abscess)
oropharyngeal candidiasis
OCCASIONAL
GORD
glossopharyngeal neuralgia and cervicogenic nerve root pain
trauma: foreign body or scratch from badly chewed crispy food
other viral or bacterial infections (e.g. Vincent’s angina, herpangina, herpes simplex,
gonorrhoea, HIV infection)
aphthous ulceration
acute or subacute thyroiditis
RARE
cardiac angina
carotidynia
blood dyscrasia (including iatrogenic)
epiglottitis
diphtheria
oropharyngeal carcinoma
retropharyngeal abscess
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342 SYMPTOM SORTER
Ready reckoner
Mild viral ‘Strep throat’ Glandular fever Quinsy Oropharyngeal
candidiasis
Cervical lymphadenopathy Possible Ye s Ye s Ye s No
Purulent throat No Ye s Possible Possible No
High fever No Ye s Ye s Ye s No
Unilaterally swollen No Possible No Ye s No
URTI symptoms Ye s No No No No
Possible investigations
LI KE LY: None.
POSSIBLE: roat swab, FBC, Paul–Bunnell test.
SM A L L PR I N T: Blood glucose and HIV, upper GI endoscopy, biopsy, cardiac investigation (all
secondary care).
roat swab: Use is controversial, mainly because of low specicity and sensitivity. Practical
use only in persistent sore throat or treatment failure.
FBC: May show atypical lymphocytes in glandular fever; also will reveal any underlying
blood dyscrasia.
Paul–Bunnell test for glandular fever if malaise and fatigue persist.
Blood glucose and HIV: To rule out diabetes and HIV infection in severe, recurrent or
persistent cases.
Upper GI endoscopy may be necessary to diagnose GORD.
X-ray/laryngoscopy: If suspicion of foreign body.
Cardiac investigation: In rare case when referred symptoms cause pain in throat.
Biopsy of suspicious lesions important to investigate possible malignancy.
TOP TIPS
Consultations for severe sore throats usually boil down to a decision whether or not to
prescribe antibiotics. ere is no easy or reliable way to distinguish clinically between
bacterial and viral causes, so the situation becomes an exercise in pragmatism, though the
Centor or FeverPAIN criteria may help. Even in ‘true’ streptococcal throats, antibiotic
treatment probably only reduces the duration of symptoms by about 24 hours and is unlikely
to inuence the likelihood of complications.
Mild sore throat with an URTI is usua lly just one of a ‘package’ of symptoms presented, along
with rhinorrhoea, cough, headache and so on. e cause is invariably viral and antibiotics
have no role to play.
roat swabs only help management in obscure or persistent cases (and even then usually
contribute little).
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SORE THROAT 343
In adolescents and young adults whom you decide to treat with antibiotics for ‘strep throat’,
explain that the symptoms can also be caused by other infections such as glandular fever.
is will help maintain the patients’ condence in you if they return with the sore throat
persisting aer the course of antibiotics.
Remember that this apparently trivial symptom can occasionally herald a serious problem.
In particular, enquire about medication (the rst sign of drug-induced agranulocytosis may
be a sore throat).
A true foreign body stuck in the throat will lodge in the supraglottic area and may not be
seen orally. Refer if in doubt.
Admit if any suspicion of epiglottitis – and do not examine the throat.
Consider a possible underlying problem (such as diabetes or immunosuppression) in the
younger patient with oropharyngeal candidiasis which has no obvious cause.
uinsy can cause a respiratory obstruction. Never attempt conservative management, but
admit for surgical drainage.
Florid ‘tonsillitis’ is unusual in the middle-aged or elderly – consider investigations for a
blood disorder or oropharyngeal carcinoma.
NOTES:
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344
STIFF NECK
The GP overview
e most common causes of acute neck stiness are benign and easily managed in general
practice. However, this symptom causes disproportionate panic in parents of febrile children
thanks to extensive media coverage of meningitis. is anxiety can spill over into adult illness
behaviour, with the result that a troublesome but harmless symptom may be misinterpreted as
the harbinger of serious pathology.
Differential diagnosis
COMMON
acute torticollis
cervical spondylosis
viral URTI with cervical lymphadenitis
whiplash injury
meningism due to systemic infection (e.g. pneumonia)
OCCASIONAL
tension/stress (common, but usually causes an ache or muscle tenderness rather than sti ness)
other forms of arthritis (e.g. rheumatoid [RA] and ankylosing spondylitis)
abscess in the neck
hysteria
intracerebral haemorrhage
cerebral tumour (primary or secondary)
RARE
meningitis
vertebral fracture
bone tumour (primary or secondary)
atypical infections: tetanus, leptospirosis, sandy fever, psittacosis
brain abscess
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STIFF NECK 345
Ready reckoner
Torticollis Cervical spondylosis URTI Whiplash Meningism
Other symptoms No Possible Ye s Possible Ye s
Recurrent No Yes No Possible No
Enlarged lymph nodes No No Ye s No Possible
Neck asymmetrical Ye s Possible No Possible No
Fever No No Ye s No Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, Paul–Bunnell test, ESR/CRP, rheumatoid factor, HLA-B27.
SMALL PRINT: Bone biochemistry, X-ray cervical spine, bone scan, other hospital-based tests.
FBC and Paul–Bunnell: In unresolved or resistant URTI, check these parameters if
glandular fever suspected.
ESR/CRP, rheumatoid factor and HLA-B27: Will help in the diagnosis of possible RA and
ankylosing spondylitis in the young and middle-aged with unresolving neck stiness.
Neck X-ray: For possible fracture (at hospital); of limited value in cervical spondylosis –
symptoms do not correlate well with X-ray ndings. May reveal serious bone pathology, but
bone scan more useful for this.
Bone biochemistry: Consider this if bony secondaries or myeloma are possible diagnoses.
Hospital-based tests: ese might include lumbar puncture (for meningitis) and scans for
cerebral lesions.
TOP TIPS
Neck tenderness due to cervical lymphadenopathy in an URTI is innitely more common
than meningitis, but is oen misreported as ‘neck stiness’.
Only advise so collars in the majority of sti necks for a maximum of 48 hours. ough
comfortable, they tend to delay resolution. Instead, suggest adequate analgesia, heat and
mobilisation.
Warn patients with whiplash injury that symptoms may take many months to settle
completely – this saves repeated futile and frustrating consultations.
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346 SYMPTOM SORTER
Meningococcal petechiae are usually a late sign and can be missed unless the febrile child
with a sti neck is undressed and examined.
Pain and stiness may be the only symptoms of vertebral fracture or subluxation, which can
occur without cord involvement – signicant trauma merits A&E referral.
underclap headache preceding neck sti ness suggests subarachnoid haemorrhage – admit
straight away.
Consider serious bony pathology if pain and stiness are relentless and wake the patient at
night – especially if there are other worrying symptoms, or the patient has a past history of
carcinoma.
Pain onset in whiplash is usually delayed. Immediate onset may mean signicant bony injury.
NOTES:
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347
STRIDOR IN CHILDREN
The GP overview
Acute stridor is a very frightening experience for both child and parents. e respiratory eort
can lead to hyperventilation, making things worse. ‘Dicult’ or ‘noisy’ breathing in a child quite
commonly leads to a request for an out-of-hours visit in winter. e usual cause is viral croup,
producing mild, harmless stridor – but serious cases do occur. A calm exterior and a methodical
approach are the keys to eective management.
Differential diagnosis
COMMON
viral croup (laryngotracheobronchitis)
acute epiglottitis
acute laryngitis
acute airways obstruction: foreign body (small toy, peanut)
laryngeal paralysis (congenital: accounts for 25% of infants with stridor)
OCCASIONAL
laryngomalacia
laryngeal trauma
bacterial tracheitis
pseudomembranous croup (staphylococcal)
upper airway burn
RARE
laryngeal stenosis
laryngeal tumours (papilloma, haemangioma) and mediastinal tumours
laryngeal oedema (angioneurotic: oedema also present in other tissues)
anomalous blood vessels (e.g. double aortic arch)
diphtheria
retropharyngeal abscess
https://t.me/med1917
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