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E.N.

T GUIDE FOR MEDICAL STUDENTS:


NECK EXAMINATION
Dr. Giovanni Henry
ENT Resident
2016

OUTLINE

Introduction

Taking a good History

Equipment

Examination

Investigations

Presentation of findings

Management

INTRODUCTION

Doctors frequently encounter neck masses in adult and paediatric patients. A


careful medical history should be obtained, and a thorough physical examination
should be performed.

I believe you will have an outstanding experience and look forward to sharing information
about our specialty with you.

My aim is to motivate you to be dedicated to the highest level of patient care and seek
further education well beyond this presentation.

IMAGINE THIS

you are the new intern at a busy hospital or department. You are asked to see a patient
that your consultant is planning to take to the operating theatre for elective surgical
intervention tomorrow. Your resident tells you to see the patient then leaves without giving
you his phone number.

EQUIPMENT

BEFORE YOU PROCEED

Start first with examination of yourself as the doctor. The way you dress, speak,
mannerisms

Confidence level, background knowledge, experience of others

Takes Planning

JUST A FEW POSSIBLE PHYSICAL EXAMINATION


SCENARIOS

(Usually) a Thyroid

Cervical Lymphadenopathy

Lymphoma

Laryngectomy

Submandibular Gland

Parotid Mass

Many others

THE EXAMINATION ROOM

You must be aware of your environment, the patient and your examiners. from the moment
you or your patient walks into the room.

Try to anticipate the next move but do not skip important steps

Approach the patient in a step wise manner

Time is of the essence

EXAMPLE

Introduce yourself as.

Ask his or her name

Position and adequately expose your patient

Ask how comfortable they are

Shake hands

Although you may be tempted to rush through the examination

proceed in a calm but purposeful manner

NOW IN IN THE REAL WORLD


1.

You would start by Taking a history

2.

Examining the patient

3.

Order relevant investigations

4.

Offer alternative treatment options

5.

Explain possible Complications of the intervention being done

6.

Explain Each step to your patient

WHY DO WE PROCEED IN THIS MANNER?

Optimizes patient care

Prevents confusion

Reduces mistakes

Prevents litigation

HOWEVER IN THE MBBS EXAMINATION

You may be asked to examine a patient first. Then answer questions or volunteer
information
OR

describe and interpret a picture

Radiograph or Scan

Usually within a certain time

LISTEN

To your patient: they may be trying to tell or hint to you something or they could be
hoarse

Listen to your Examiner: do what is asked. They may ask you to skip a certain
maneuvers or simply proceed straight to just examining the neck.

Mention briefly what you would do or should do

REMEMBER

Do not be combative with your examiner. There is always another patient or station

But if you are confident in your answer. Explain yourself politely. STAND FIRM IN YOUR
CONVICTION

Remember there is more than one way or technique

Keep an open mind

Each examiner may have particular nuances or idiosyncrasies.

THE ACTUAL EXAMINATION

YOU HAVE LESS 5 MINS EXAMINE THIS PATIENT


GO!!

WHAT ABOUT GENERAL INSPECTION??

Painful Distress?

Respiratory Rate?

Anxious?

Diaphoretic?

Cachexia

DO I REALLY NEED TO INSPECT PERIPHERIES &


DO ALL THESE CLINICAL TEST?

It Depends. Certainly in clinical practice you should.

It is better to know the complete exam than to take short cuts

However In the exam there might be limited time

if the patient looks toxic , by all means

If the patient appears euthyroid, checking the pulse or simply mentioning a few negative
signs may be all that is required

To be safe, let your examiner stop you or cut off your examination. Just remember, you
must to be able to DEFEND each action you make

SHOULD ASK THE PATIENT TO SWALLOW

But why?

SHOULD I ASK ALL PATIENTS TO STICK OUT


THEIR TONGUE?

Debatable

Why?

CHECKING FOR PROPTOSIS

PALPATION OF THE NECK

Ask about neck Pain

Palpate one side at a time

Describe the features while you examine

Examine along the anterior and posterior cervical chains

Ask to swallow again

Feel for thrill

WHAT ARE YOU CHECKING FOR?

Site

Size

Shape

Surface

Consistency

Tenderness

Associated Lymph nodes!

Thrill

PERCUSSION &
AUSCULTATION

If the mass is retrosternal and you have time

Percuss over the Sternum.

Listening for Bruits over the neck . Why?

WHAT NEXT?

So youve examined the patient and presented your findings.

Ask yourself these questions:


1.

Based on my clinical findings, What is THIS particular patient most likely to have?

2.

What else could this neck mass be?

3.

From your list of differentials which would be the most significant/dangerous diagnosis

( i.e. a diagnosis that you would definitely not want to miss or a diagnosis you would want to
rule out because of significant morbidity or mortality that it might cause)

MAYBE YOU NEED MORE INFORMATION

In order to proceed:

I would first like to take


a detailed history

WHAT SHOULD I ASK ABOUT MY EXAMINATION


POINTS TO A THYROID MASS

Demographic information & duration

Toxic Symptoms

Compressive Symptoms

Constitutional

Symptoms that may be Indications for surgery

Risk factors

Family history, Social History

Medications

WHAT IF IT ISNT A THYROID MASS?

Demographics

Age Size duration- Neoplasia

Painful or painless

Constitutional symptoms: fever, weight loss

Hoarseness

Dysphagia

Odynophagia, otalgia

Relation to meals

Can you think of any Other symptoms?

ADDITIONAL HISTORICAL INFORMATION

A history of smoking, heavy alcohol use, or previous radiation


treatment increases the likelihood of malignancy.

Recent travel,

trauma to the head and neck,

insect bites,

exposure to pets or farm animals suggests an inflammatory or infectious


cause for a neck mass.

HOW WOULD YOU CONFIRM THIS DIAGNOSIS?


Clinical Investigations

Haematological?

Radiological?

Cytology/ Histopathological?

PRINCIPLE OF ORDERING INVESTIGATIONS


1.

What investigation should I order initially

2.

Is it the Best investigation

3.

Is it affordable, inexpensive

4.

Is it easily accessible

5.

Least invasive to more invasive

6.

Is it necessary

HAEMATOLOGICAL

PLAIN RADIOGRAPH

CHEST XRAY

ULTRASOUND

COMPUTED TOMMOGRAPHY

NUCLEAR IMAGING: THYROID SCAN

MAGNETIC RESONANCE IMAGING

CYTOLOGIC FEATURES :
PAPILLARY THYROID CANCER

CYTOLOGY: FOLLICULAR NEOPLASM

MEDULLARY THYROID CARCINOMA

ANAPLASTIC CARCINOMA

NECK LYMPH NODE LEVELS

OTHER INVESTIGATIONS

Laryngoscopy

Electrocardiograph ECG

PET SCAN

SCITIMIBI SCAN

DISCUSSION

Treatment

Complications

Management of complications

Post operative managment

TREATMENT

Medical management

Conservative

Radioiodine Ablation

Surgical

Chemotherapy

Radiotherapy

Palliative

POST OPERATIVE

COMPLICATIONS:

ANAESTHETIC OR SURGICAL: EARLY or LATE

COMMON POST OP BEDSIDE TEST:

Chvostek
Trosseou Sign
Cranial Nerve Testing

INSPECTION OF THE MOUTH

THE END