Fwd: Bambury Tutorial on Head and Neck


Published on

---------- Forwarded message ----------
From: UCD PAEDS <ucdpaeds@gmail.com&gt;
Date: 2009/2/12
Subject: Fwd: Bambury Tutorial on Head and Neck
To: ucdgrad09@gmail.com

---------- Forwarded message ----------
From: Henning L. Stokmo <helangen@gmail.com&gt;
Date: Wed, Feb 11, 2009 at 7:07 PM
Subject: Bambury Tutorial on Head and Neck
To: ucdpaeds@gmail.com

Published in: Health & Medicine
1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Fwd: Bambury Tutorial on Head and Neck

  1. 1. Examination for the OSCEs
  2. 2. Examination of a lump <ul><li>Introduce yourself and ask is it alright to examine the patient and to talk as you go along </li></ul><ul><li>Note the site of the lump </li></ul><ul><li>Is there any tenderness </li></ul><ul><li>State its size in approx cm </li></ul><ul><li>State its shape- is it circular/hemispherical </li></ul>
  3. 3. Examination of a lump <ul><li>What is the surface like? </li></ul><ul><ul><li>is it smooth/ rough /craggy/ irregular </li></ul></ul><ul><li>Can you feel around the lump? </li></ul><ul><ul><li>is it well circumscribed or is it diffuse </li></ul></ul><ul><li>Next test its fluctuance- </li></ul><ul><ul><li>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 </li></ul></ul>
  4. 4. Examination of a lump <ul><li>Is it pulsatile? </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>Is it compressible? </li></ul><ul><ul><li>press down on the lesion and see if it disappears. Does it reappear when pressure is released-? Vascular malformation </li></ul></ul>
  5. 5. Examination of a lump <ul><li>Is it reducible? </li></ul><ul><ul><li>lesion disappears on pressure and does not reeappear spontaneously on releasing pressure. </li></ul></ul><ul><li>Next step feel for origin of the lump. </li></ul><ul><ul><li>Is it attached to the skin- (sebaceous cyst BCC) </li></ul></ul><ul><ul><li>or the underlying tissue- move the lump itself. </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  6. 6. Examination of a lump <ul><li>Look at and feel the overlying skin </li></ul><ul><ul><li>is there any ulceration </li></ul></ul><ul><li>Is the surrounding tissue erythematous /discoloured </li></ul><ul><li>Next check for the appropriate lymph nodes </li></ul>
  7. 7. Examination of the neck <ul><li>In the case of the thyroid……… </li></ul><ul><li>Introduce etc…… </li></ul><ul><li>Expose the neck appropriately </li></ul><ul><li>INSPECT- can you see any visible lump/swelling. State what you see. </li></ul><ul><li>Ask the patient to take a sip of water and tell them to hold it in their mouth until you ask them to swallow </li></ul>
  8. 8. Examination of the neck <ul><li>Ask them to raise their head and swallow. Does the swelling move on swallowing. </li></ul><ul><li>Now ask them to stick out their tongue. Does the swelling move upwards on protrusion of the tongue- suggestive of a thyroglossal cyst </li></ul>
  9. 9. Examination of the neck <ul><li>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 </li></ul><ul><li>Ask them to stick out their tongue. Does the lesion move upwards? </li></ul>
  10. 10. Examination of the neck <ul><li>Describe the lump as we have outlined earlier. Take your time and outline all the previous criteria </li></ul><ul><li>In the case of the lymph nodes check all areas in the neck appropriately. Know the names of each set including- </li></ul>
  11. 12. Examination of thyroid status <ul><li>Introduce yourself. Explain to patient what you are about to do. </li></ul><ul><li>Expose the patient appropriately. In this case open shirt/ blouse to expose base of neck </li></ul><ul><li>You need to know the signs associated with Hyper/hypothroidism or else you’re wasting your time on this one! </li></ul>
  12. 13. Examination of thyroid status <ul><li>Inspect. Look at the patient sitting in the chair. Is there a tremor, signs of muscle wasting weight loss-Hyper </li></ul><ul><li>How about signs of Hypothyroidism </li></ul><ul><ul><li>periorbital puffiness </li></ul></ul><ul><ul><li>Mywoedema facies </li></ul></ul><ul><li>Look for a goitre/signs of previous operation </li></ul>
  13. 14. Examination of thyroid status
  14. 15. Examination of thyroid status <ul><li>Look at the eyes </li></ul><ul><ul><li>In hyperthroidism look for </li></ul></ul><ul><ul><ul><li>exophthalamus-bulging of eyelids </li></ul></ul></ul><ul><ul><ul><li>Lid retraction- ask the patient to keep head still and follow your finger up and down </li></ul></ul></ul><ul><ul><li>In hypothyroidism </li></ul></ul><ul><ul><ul><li>look for thinning of the hair </li></ul></ul></ul><ul><ul><ul><li>Loss of lateral third of eyebrows </li></ul></ul></ul>
  15. 16. Examination of thyroid status <ul><li>Move to the hands- </li></ul><ul><ul><li>Feel the pulse, </li></ul></ul><ul><ul><ul><li>Irregular </li></ul></ul></ul><ul><ul><ul><li>fast </li></ul></ul></ul><ul><ul><li>Check for acropachy </li></ul></ul><ul><ul><ul><li>soft tissue swelling </li></ul></ul></ul><ul><ul><ul><li>of digits, joint </li></ul></ul></ul><ul><ul><ul><li>enlargement </li></ul></ul></ul><ul><ul><ul><li>and clubbing of fingers </li></ul></ul></ul>
  16. 17. Examination of thyroid status <ul><li>Check the hands for signs of Hypothroidism </li></ul><ul><ul><li>Dry cool pale </li></ul></ul><ul><ul><li>Puffiness </li></ul></ul><ul><ul><li>Is she bradycardic </li></ul></ul>
  17. 18. Examination of thyroid status <ul><li>Move onto the full thyroid lump examination </li></ul><ul><li>After this tell the examiners you’d like to ask the patients a few questions. </li></ul><ul><li>Ask about weight, bowel movements, changes in appearance, palpitations </li></ul>
  18. 19. Differential diagnosis of a neck Lump <ul><li>Lymphoma </li></ul><ul><li>Thyroid lump-diffuse if diffuse goitre, thyroid nodule, unilateral swelling of one lobe </li></ul><ul><li>Branchial cyst </li></ul><ul><li>Thyroglossal cyst </li></ul><ul><li>Pharyngeal pouch </li></ul><ul><li>Carotid body tumour </li></ul><ul><li>Cystic hygroma </li></ul><ul><li>Sebaceous cyst </li></ul><ul><li>Dermoid cyst </li></ul>
  19. 20. Branchial cyst
  20. 21. Branchial cyst <ul><li>Remnant of second branchial cleft </li></ul><ul><li>Occurs at anterior border of sternocleidomastoid muscle </li></ul><ul><li>Painless swelling- painful if becomes infected </li></ul><ul><li>Complications- </li></ul><ul><ul><li>branchial fistula- discharges intermittently. External opening occurs between the lower 2/3rds of s/c/m- connects with oropharynx-swallowing accentuates the external opening </li></ul></ul><ul><ul><li>Branchial sinus- external opening but upper end is obliterated </li></ul></ul>
  21. 22. Branchial cyst <ul><li>O/E </li></ul><ul><ul><li>Smooth surface </li></ul></ul><ul><ul><li>well circumscribed </li></ul></ul><ul><ul><li>not pulsatile fluctuant compressible </li></ul></ul><ul><ul><li>Overlying skin normal </li></ul></ul><ul><ul><li>Fixed to deep structures </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Surgical excision as will always become infected </li></ul></ul>
  22. 23. Pharyngeal pouch <ul><li>A diverticulum of the pharynx occuring between the fibers of the the inferior constrictor muscle.( Killian’s dehiscence) </li></ul><ul><li>More common in older men </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>Regurgitation of undigested food </li></ul></ul><ul><ul><li>Dysphagia </li></ul></ul><ul><ul><li>Nocturnal coughing,choking </li></ul></ul><ul><ul><li>May get aspiration pneumonia </li></ul></ul>
  23. 24. Pharyngeal pouch <ul><li>O/E </li></ul><ul><ul><li>Nontender </li></ul></ul><ul><ul><li>Situated below thyroid(usually on left) </li></ul></ul><ul><ul><li>Smooth surface, indistinct edges ot pulsatile fluctuant </li></ul></ul><ul><ul><li>Is compressible but not reducible </li></ul></ul><ul><ul><li>Arises from deep structure relatively immobile </li></ul></ul><ul><ul><li>Overlying skin is normal </li></ul></ul>
  24. 25. Pharyngeal pouch <ul><li>Investigations- barium swallow </li></ul>
  25. 26. Pharyngeal pouch <ul><li>Treatment </li></ul><ul><li>Surgical excision </li></ul><ul><ul><li>Incise along inferior s/c/m </li></ul></ul><ul><ul><li>Dissect out pouch which is prepacked with gauze for easier identification </li></ul></ul><ul><ul><li>Excise neck of pouch </li></ul></ul><ul><ul><li>Dohlman’s procedure- </li></ul></ul><ul><ul><ul><li>Endoscopic inversion and oversewing of pouch </li></ul></ul></ul>
  26. 27. Carotid body tumour <ul><li>Rare tumour of chemoreceptors of carotid body </li></ul><ul><li>Malignant potential </li></ul><ul><li>Painless </li></ul><ul><li>40-60 years </li></ul><ul><li>May be associated with TIAs secondary to pressure </li></ul>
  27. 28. Carotid body tumour <ul><li>O/E </li></ul><ul><ul><li>Non tender lump </li></ul></ul><ul><ul><li>Anterior triangle of the neck </li></ul></ul><ul><ul><li>Round hard solid </li></ul></ul><ul><ul><li>Not fluctuant </li></ul></ul><ul><ul><li>Skin moves over it freely </li></ul></ul><ul><ul><li>Can be moved side to side but not up and down </li></ul></ul><ul><ul><li>No movement on swallowing or protrusion of the tongue </li></ul></ul><ul><ul><li>Overlying skin is normal </li></ul></ul>
  28. 29. Carotid body tumour <ul><li>Investigations </li></ul><ul><ul><li>Digital subtraction angiography </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Surgical excision </li></ul></ul><ul><ul><li>may become malignant or grow in size making it more difficult to excise </li></ul></ul>
  29. 30. Thyroglossal cyst <ul><li>A patent thyroglossal dust </li></ul><ul><li>The duct begins at what will become the foramen caecum of the tongue and guides the thyroid gland into position. Usually becomes obliterated. </li></ul><ul><li>Remember it hooks around the hyoid bone making excision difficult </li></ul>
  30. 31. Thyroglossal cyst <ul><li>Age group 15-30 usually </li></ul><ul><li>Painless usually </li></ul><ul><li>May become infected </li></ul><ul><li>O/E </li></ul><ul><ul><li>Midline of the neck </li></ul></ul><ul><ul><li>Spherical smooth well circumscribed </li></ul></ul><ul><ul><li>Fluctuates </li></ul></ul><ul><ul><li>Not pulsatile compressible or reducible </li></ul></ul><ul><ul><li>Tethered to deep structures moves side to side only </li></ul></ul><ul><ul><li>Moves on swallowing and extending the tongue </li></ul></ul>
  31. 32. Thyroglossal cyst <ul><li>Investigations-ultrasound </li></ul><ul><li>Treatment- </li></ul><ul><ul><li>Surgical excision with sacrifice of the middle third of the hyoid bone </li></ul></ul>
  32. 33. Triangles of the neck <ul><li>Basic anatomy need to be known if you get a neck examination </li></ul><ul><li>Anterior triangle </li></ul><ul><ul><li>Borders </li></ul></ul><ul><ul><ul><li>Midline </li></ul></ul></ul><ul><ul><ul><li>Posterior border of the s/c/m </li></ul></ul></ul><ul><ul><ul><li>Ramus of mandible </li></ul></ul></ul>
  33. 34. Anterior triangle <ul><li>Contents </li></ul><ul><ul><li>Suprahyoid muscles(s,m,g/hyoids) </li></ul></ul><ul><ul><li>Strap muscles(t,s,s) </li></ul></ul><ul><ul><li>Recurrent and external laryngeal Nerves </li></ul></ul><ul><ul><li>Vagus nerve </li></ul></ul><ul><ul><li>CCA bifurcation IJV </li></ul></ul><ul><ul><li>Thyroid gland parathyroid submand gland trachea oesophagus </li></ul></ul>
  34. 35. Posterior triangle <ul><li>Borders </li></ul><ul><ul><li>Anterior </li></ul></ul><ul><ul><ul><li>Post border of s/c/m </li></ul></ul></ul><ul><ul><li>Posterior </li></ul></ul><ul><ul><ul><li>Ant border of trapezius </li></ul></ul></ul><ul><ul><li>Inferior </li></ul></ul><ul><ul><ul><li>clavicle </li></ul></ul></ul>
  35. 36. Posterior triangle <ul><li>Contents </li></ul><ul><ul><li>Muscle-levator scapulae, scalene medius </li></ul></ul><ul><ul><li>Spinal accessory nerve </li></ul></ul><ul><ul><li>Trunks of brachial plexus </li></ul></ul><ul><ul><li>Lymph nodes-occipital supraclavicular </li></ul></ul><ul><ul><li>Subclavian artery </li></ul></ul>